Harvey V. Fineberg, M.D. , Ph.D.
This week, the president says he is facing the hardest decision of his career: when to reopen the nation’s economy. Governors face the same dilemma for their states.
Five Principles:
First, stop the debate about a date. Instead, focus on the conditions under which we can safely and sustainably resume more nearly normal economic and social activity.
Second, because the pandemic is playing out at various stages and impact in different geographic locales, expect different states, counties and cities to be ready at different times.
Third, coordinate allowable activity across adjacent, interactive jurisdictions, whether across state borders or metropolitan areas.
Fourth, adapt as deeper scientific understanding, a new vaccine or other preventives, and demonstrably effective treatments come online. What matters is not the mere passage of time, but how conditions change on the ground at different points of time.
And finally, be prepared to rachet up or rachet down as conditions demand.
The pace and timing of opening various geographic regions and types of economic activity should follow from meeting five conditions:
1. Timely, accurate, local monitoring of the spread of infection. Each community needs to know how many have already been infected, how many are newly infected, and what are the distributions and risk factors. Tracking hospital and ICU admissions are important, but they are a lagging indicator of infection. Timely information will require a combination of PCR tests for viral RNA and antibody tests for previous exposure. Repeated stratified samples can track changes in a community over time. Pooled PCR test protocols can extend the reach of limited reagents. Strategies such as PCR tests of sewage in urban areas can give an early warning of the presence of infection in the community. Special attention should be given to groups at elevated exposure, such as health workers, first responders, and residents in congregate living facilities such as nursing homes, dormitories and military barracks.
2. Local capacity to contain new cases and treat the sick. The fundamentals for control of infectious diseases such as COVID-19 are well-known: detect, isolate and treat cases, trace contacts, and separate those exposed from those not known to have been exposed. Widespread physical distancing has helped suppress spread; we do not yet know whether it has been enough to squelch the outbreak or only slowed the pace of spread. We need to restore an adequate national reserve of ventilators and provide enough personal protective equipment to meet the need. After the inadequate number of tests, the most serious shortfall in disease prevention is inadequate capacity to trace contacts and promptly quarantine those at increased risk of infection. It would be wise to fund local health departments to hire and train needed staff and to put the CDC in charge of building contact-tracing capacity nationwide. These efforts can build on the high-tech partnership recently announced between Apple and Google.
3. Number of new cases diminished to a containable and manageable level. When the detection system signals that individuals are becoming newly infected, the growth cannot be allowed to exceed local capacity for containment and for clinical care, or the epidemic escalates out of control. It makes a big difference whether you begin with a background rate of 10 new cases or 100. If you have capacity to manage and trace contacts of up to 300 cases, for example, a rise from 10 to 270 is still containable, but a proportional rise from 100 to 2700 puts containment out of reach. The number of cases must be brought down to a low enough number to remain containable, and treatment facilities need to have enough capacity to cope, should the number of cases start to rise.
4. Conditions in each place of work, business, or school that protect the health of employees, customers, students and visitors. Any school, business, public venue or workplace intending to re-open should ask what it can do to arrange its internal environment and procedures to reduce the risk of transmission of respiratory viruses. Should all who enter have temperature checked and wear masks? Are hand cleaners readily accessible? Can cleaning of frequently touched surfaces be enhanced? Are in-person meetings necessary? Can employees work, or customers sit, at a safe distance from one another? Should lunchroom schedules be adapted to minimize the number of persons with whom each interacts? Can increases in air exchange, improved filtration and installation of germicidal UV lighting alter the likelihood of airborne transmission? A myriad of approaches, systematized by the Occupational Safety and Health Administration and specific to each business sector, could contribute to suppressing the risk of spread. Resumption of economic activity does not mean doing things the same way as before the time of coronavirus.
5. Choices that balance risk and benefit in deciding where and when to return to more nearly normal activity. Risk of spread of a respiratory virus such as SARS-CoV-2 depends on (1) physical proximity, (2) number of persons interacting, (3) duration of exposure, (4) nature of activity, and (5) the physical environment. A lunch restaurant with ample space between tables and 50 patrons where you leave after 60 minutes is lower risk than an indoor sporting event, with 15,000 cheering fans, that lasts two-and-a half hours. Economically, different functions have a range of direct and indirect benefits. For example, for many reasons, it would be important to re-open schools with close monitoring. It is harder to see the risk-benefit balance favoring an immediate return to mass musical or sporting events. In general, it makes sense to start with high-benefit, low-risk activity and defer those activities with lower overall economic impact and higher risk. These are the kinds of judgments that would guide smart decisions on a sequential, stepwise, monitored re-start of the economy.
This approach is the surest way to attain sustained resumption of economic activity and avoid a whipsaw back to total shutdown. When and where the five conditions are in place, the date to re-start the economy will have arrived.
Harvey V. Fineberg, M.D., Ph.D., is president of the Gordon and Betty Moore Foundation. He chairs the The National Academies of Sciences, Engineering and Medicine’s Standing Committee on Emerging Infectious Diseases and 21st Century Health Threats and also chairs the board of the Science Philanthropy Alliance. The views expressed are those of the author and do not necessarily represent the views of any organization with which he is affiliated.
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