Coronavirus advice from abroad: 7 lessons America’s governors should not ignore as they reopen their economies

Originally published by ProPublica

Memo to America’s Governors:

From: ProPublica

Subject: Restarting the Economy

After insisting that he had absolute power to decide when to reopen the American economy, President Donald Trump has turned over to all of you what he initially called “the biggest decision I’ve ever had to make.”

Trump is often guilty of hyperbole, but he’s right in this case. Figuring out how and when to let people go back to work during an outbreak of life-threatening disease is the most consequential decision any of you will ever face. You’ve already seen the stakes in New York, New Jersey and Michigan. Get this wrong and thousands of people in your state will die. As the presidential election campaign heats up, count on the president to blast you for high unemployment rates in your state (you lifted restrictions too slowly) or clusters of deaths (you went too far, too soon).

To help you and your aides think about this decision over the next few weeks, we’ve interviewed experts and frontline officials from Italy, Germany, Spain, Singapore, Taiwan and South Korea. While they differ on the details, their views formed a startlingly united consensus of what’s needed:

• Massive, ongoing testing to detect where the disease is spreading,

• a real-time ability to trace contacts of those infected and isolate them,

• a willingness of people to wear masks in crowded public spaces,

• reserves of personal protective equipment (PPE) and other equipment for hospital workers to handle any surge in cases,

• and reliable, easily administered blood tests to find out the number of people who have been infected. If they work well, such tests could eventually be used to identify people with immunity who could work at higher-risk jobs.

We also asked American experts whether states can meet all or most of these benchmarks. Their answers coalesced around a single point: None of you are close to being ready.

There were differences among the people we interviewed about tactics and strategy. Some saw promise in the smartphone-based tools that would allow disease detectives to quickly find people with whom an infected person was in close contact. Others doubted that a critical mass of Americans would ever let the government track their movements, whatever promises were made about privacy.

One theme emerged again and again. Experts from across the world said it’s crucial to correctly interpret the recent drop in the rate of hospitalizations and deaths reported by New York City, ground zero for the epidemic. This result was achieved only by a month of slamming the brakes on the economy and banning the most basic interactions (and pleasures) of human society.

The bad news, they said, is that everything we’ve been through so far has merely allowed us to reset the clock to mid-January, when the virus was already seeded in many parts of America and we were on the cusp of the biggest public health crisis in a century. Allow people to return to offices, streets, malls and mass transit without a well-thought-out plan, and you stand a substantial chance of triggering a second wave of infections.

Reopening is essential to save the economy, they said, but don’t kid yourself: The new normal will look nothing like the old normal. Until there’s a vaccine or a reliable treatment, you and your states will be living and working very differently, constantly at risk from a wave of disease that could overwhelm your hospitals. You may borrow ideas from Asia and Europe that would have been unimaginable a few months ago: Isolating infected people from their families in hotels, requiring masks for everyone on a bus or subway, ordering restaurants to seat people at every other table, limiting certain jobs to people who have proven immunity to the virus.

“We have to all acknowledge that we will have to live with Corona for at least a year and probably two or three years,” said Dr. Ansgar Lohse, a professor at University Medical Center in Hamburg and co-author of a paper that sets out a “flexible, risk-adjusted strategy” for reopening commerce in Germany.

“All of our societies will have to adapt to this challenge, and this will be different in different societies,” Lohse said in an interview. “Even in a country like Germany, we will have to regionally and locally and also probably seasonally adapt to this tragedy.”

America’s continuing inability to roll out widespread testing means you’re flying blind on the most pivotal questions. How many people in your state have already had the virus? The percentage is almost certainly in single digits, but there may be pockets in which more significant numbers of people have been exposed and have immunity.

You can assume that upwards of 90% of your state remains vulnerable to infection from a single sneeze or cough by someone standing or sitting near them. A single highly contagious person in a crowded space can start a chain of disease that quickly encompasses dozens if not hundreds of people.

“It’s like after a forest fire,” said Jerome Kim, director general of the International Vaccine Institute in Seoul. “There are still embers and warm spots on the ground. If you drop a gallon of gas on top of that, the fire will restart.”

1. Build an army of contact tracers

Without exception, every expert we talked to stressed the imperative of being able to know exactly where the virus is spreading. That sounds incredibly obvious and basic, but comes with demanding logistics that few — if any — states are able to carry out right now.

By now, we know that the virus has been relentlessly effective at spreading itself through a population because people are highly contagious in the first few days of their illness, often before they start to experience symptoms. The only way to track the spread of the virus, then, is to maintain a massive army of “contact tracers” who can track down the contacts of anyone who tests positive.

Places that have been most successful in slowing the spread of the virus, such as Hong Kong, South Korea and Singapore (at least initially), have been relentless in tracking down the contacts of every infected person, testing them and then instructing people who aren’t infected to self-isolate and monitor their own symptoms.

“It usually takes four or five people over three days to do one full contact trace, on average,” said Andy Slavitt, former head of the Centers for Medicare and Medicaid Services during the Obama administration. California, which has a population of 40 million people, could need anywhere from “several thousand to 20,000” contact tracers, depending on the number of cases and how fast the virus is spreading, Slavitt said.

Wuhan, China, a city of 11 million, employed more than 9,000 contact tracers, split into 1,800 teams of five. In Shenzhen, a city just across the border from Hong Kong in southeastern China, contact tracers had identified 2,842 close contacts of coronavirus patients and found that 88 were infected, as of mid-February, according to a World Health Organization report. That’s only 3%. But imagine what would have happened if all 88 had continued wandering around the city for the next several weeks.

Technology has been used by some countries to supplement the detailed human interviews. In South Korea, the government swept up everyone’s cellphone and credit card information and used it to identify anyone who came physically close to an infected person.

Kim, the director general of the International Vaccine Institute in Seoul, is a former officer in the U.S. Army’s Medical Corps who has lived in Seoul for five years. He said the South Korean government has combined 21st-century technology and old-fashioned shoe leather to trace contacts.

The initial outbreak of the virus was brought into the country by members of a church that had a branch in Wuhan, where the epidemic began in December. Soon, Korean authorities noticed that new cases were being seeded by international travelers, so they instituted a system in which people arriving from certain countries were met at the gate, tested and told to begin quarantine. A tracking app was put on their phones and over the next two weeks, they were asked to provide daily reports on their health. Authorities made at least one in-person visit to make sure they were healthy and following the rules.

Korean law gives health officials access to anyone’s credit card purchases and cellphone location data during an outbreak, allowing disease trackers to identify and alert anyone who crossed paths with an infected person.

Here in the U.S., our legal framework and historic commitments to civil liberties preclude us from doing anything like this. Apple and Google are adding features to the operating systems of their smartphones so that they will create an encrypted record of every other phone you encounter. The system, which would require users to opt in, will use the Bluetooth technology that connects phones to cars, wireless headphones or speakers. People who test positive for COVID-19 can enter that information into their phone, and any users in recent contact with them will be alerted. It’s hard to say how many people would ultimately agree to participate, but if it’s less than a large percentage of the population, as is likely, the app probably won’t be of enormous use.

Our reporting suggests that few major cities or states are yet prepared to do contact tracing at scale. New York City’s health department did not respond to a request for comment on the question of how many disease detectives it employs, but The Daily News reported last month that the city was hoping to triple the number from 50 to 150. The New York State Department of Health wouldn’t say how many contact tracers it currently has, noting that it is “actively working on a plan to greatly expand capacity at local and state levels to perform contact tracing.” Massachusetts has said it is hiring and training 1,000 workers.

Given the number of line cooks, waiters, airline flight attendants, mall employees and factory workers who are now unemployed, you might consider creating a contact tracing version of the WPA, the Depression-era employment program that bolstered society with projects like public roads, buildings, parks and art. Given that all of you are required to balance your budgets every year, paying the salaries of all these new public health workers is going to have to come out of your already-strapped budgets.

2. Be prepared to test constantly

We know you’re sick of hearing about it, but our experts agreed that the inability to do widespread testing for the virus is the central reason it has spread so widely in the U.S.

As you look toward reopening, testing is going to be just as important. There are two types of tests, and you’ll need both of them at a massive scale.

You’re already familiar with the first test, the one used to diagnose an active infection. While more and more have become available, there are still nowhere near enough. If you go to a system of contact tracing as described above, you’re going to need to test every single close contact of every infected person, not just those who are showing symptoms.

In Italy, much has been made of the contrast between how the epidemic unfolded in Lombardy, a region of about 10 million, and neighboring Veneto, which has almost 5 million. Lombardy was the hottest of Italy’s hotspots, accounting for about 11,581 of the country’s estimated 22,745 deaths. Veneto, by contrast, has had only about 1,026 deaths, reflecting a very different approach to testing and tracing. Relatively early, authorities locked down the town of Vo Euganeo and began widespread testing of everyone, regardless of whether they had symptoms of the virus. The suspicion, later proven correct, was that asymptomatic carriers were spreading the disease. Carriers and their close contacts were isolated for 10 to 15 days.

Different numbers have been thrown around for what sort of diagnostic test capacity the U.S. would need to fully reopen. Dr. Scott Gottlieb, the former commissioner of the U.S. Food and Drug Administration under Trump, has suggested testing everyone who visits a doctor, which would mean about 3.8 million tests per week. Slavitt, the former CMS administrator under Obama, calls for 10 million tests a week.

We are nowhere near that capacity right now (we’re currently at about 1 million a week, according to the COVID Tracking Project), due to shortages in the supply chain for all aspects of testing.

It’s not just a lack of test kits, but also chemicals needed to run the tests, called reagents, collection tubes, swabs and other equipment like pipettes, explained Scott Becker, chief executive officer of the Association of Public Health Laboratories. “Many labs aren’t just running one instrument with one extraction platform and one kit, they’re using multiple, because it’s like whack-a-mole. When you run out of reagents for this one, you switch to that one,” Becker said.

One of the key indicators that you are testing widely enough is the rate at which people test positive. If a significant percentage of tests keep finding COVID-19, it means you’re likely still reserving tests for people with obvious symptoms and likely missing those who are asymptomatic.

“If you’re at 15%, 20%, then you’re not testing enough,” according to Dr. Farzad Mostashari, former National Coordinator for Health IT for the U.S. Department of Health and Human Services.

Mostashari says a 5% positive rate would be appropriate as one metric for reopening, but he cautioned: “You have to be testing the right population. You can’t be like, I’m only testing asymptomatic basketball players and the positivity rate is less than 5%. It has to be everyone, including people coming in with cough and fever, and you still have that low positivity rate.”

A second test just coming online could be a game changer. It’s a blood test that measures whether you’ve been exposed to the disease and developed antibodies against it.

With many diseases, like chickenpox, the presence of antibodies means you’re immune and can’t get the disease a second time. Here’s the issue, and it’s not a trivial one: This novel coronavirus is such a new organism, we don’t yet know if the antibodies from the first infection protect you against a second one. Furthermore, with the FDA rushing to green-light tests and lowering the bar for validation, it’s unclear how accurate many of these diagnostics are.

Let’s say the accuracy of these tests is ultimately validated by scientists and it is established that a certain level of antibodies guarantees immunity, at least for a while. It would then be possible to give people a quick blood test that would allow them to return immediately to work.

One thing to keep in mind: While the models differ on specific numbers, all agree that coronavirus has so far infected just a small percentage of the more than 320 million people in America. Hundreds of millions of people nationwide, and the vast majority of your state’s citizens, still have no defense against this disease. This will be true until a vaccine is widely available, which probably won’t happen for more than a year, if we’re lucky.

3. Isolate people with suspected infections from their families

This is a really tough one. It goes against everything your constituents treasure in our family-centered society. That said, what we’ve learned in Italy, Taiwan and now our country is sobering.

In New York, health authorities’ initial approach to someone with a fever and dry cough was to send them home to “self-isolate” in a single room for 14 days. (There weren’t enough tests to confirm diagnoses in these cases.)

In many cases, the result was disastrous. The disease spread to the entire family, sometimes sickening multiple generations.

It turns out that the average American, when asked to turn a room of their home or apartment into a sealed zone, falls well short of perfection.

Yes, the person being quarantined is told to spend every waking (and nonwaking) hour behind closed doors, eat food left on a tray outside their door, and use a separate bathroom. But that goes against a lot of fundamental facts of life. Some people share single-room apartments. Many don’t have two bathrooms. And not everyone is meticulous about wiping down door handles or wearing gloves and masks when they wash dishes. The result, visible in city after city, has been horrifying stories about first one parent, then a second parent, then the children ending up dead or ill from sequential infections.

Separating people from their families for 14 days is a very tough thing to do. It would be massively unpopular. But if you look at what worked and didn’t in Taiwan, Italy and Singapore, you can see why this is so essential.

Sergio Romagnani, an immunologist at the University of Florence, said the traditional, multigenerational closeness of Italian families played a role in spreading the disease. “In Italy, there is a lot more mixing of young people and elderly relatives,” he said. “Kids have a lot of contact with their grandparents, and in this case that caused deaths.”

Romagnani noted that authorities in Tuscany had begun putting infected people in hotels, which would ordinarily be filled with people visiting one of the world’s most beautiful tourist destinations. “It’s a good idea,” he said. “The hotels make some money since they are all closed. And you have isolation, which is necessary.”

Dr. C. Jason Wang, director of Stanford University’s Center for Policy, Outcomes and Prevention, said Taiwan has been a leader in isolating infected people from their families. The government pays hotel owners as much as $200 a night to house people under quarantine, providing three meals a day, a book to read and a stipend roughly equivalent to a young person’s daily salary. Anyone caught breaking quarantine faces a massive fine.

Wang said Taiwan learned from the 2003 outbreak of SARS, when people who were forced to isolate thought they were being jailed, and ran away. “We learned that when you put people in quarantine, you need to be very nice to them.” Now, patients are checked by health workers three times a day. “If a person gets sick, their symptoms worsen, they will make sure they get care,” he said.

While in the U.S., it may be impossible to force people to isolate away from their homes, “I think you can say, ‘Hey, wouldn’t you like to protect your family, and we prepared a nice room at the Hilton for two weeks for you, and you don’t need to pay for it.’ and you know, hopefully people will,” said Slavitt, who is now hosting a new podcast about the pandemic, “In the Bubble.”

Slavitt added that to pull this off, the federal government would need to provide funding to help pay for hotels.

Here’s some incentive for you: Xihong Lin, a Harvard biostatistician, and colleagues in China found that when the outbreak began in Wuhan, the average person was infecting 3.86 other people. When the city closed businesses and imposed the sorts of social distancing measures that we now have in New York and California, the number of people infected by each person dropped to 1.26, which is good, but not good enough. (You need to get below 1 to get things under control and even consider restarting the economy.) When China got really tough, locking down every resident, isolating suspected cases in dorms and hotels and vigorously tracing contacts, it dropped to 0.32. Here’s Lin’s webinar on the group’s findings, if you’re curious to learn more.

4. Protect, protect, protect health care workers

If we are lucky enough to get the infection rate below epidemic levels in New York and elsewhere, there are still going to be people who get infected.

One of the lessons from Wuhan and Italy is that you have to be utterly meticulous about protecting doctors and nurses. If you don’t, the hospitals become a vector for infection and you lose the frontline people you need to treat the sick.

There’s another problem with not protecting your doctors and nurses: If you need them to handle a second wave of infections, even a smaller one, they may stop coming to work. Many are showing up right now out of a sense of duty and mission. But none of these people signed up for their profession with the idea that they would be risking their lives on a minute-by-minute basis. These are not combat infantry troops, and if they don’t believe they have appropriate personal protective equipment, there’s every reason to believe that some of them will simply quit.

While the Chinese have revised their numbers more than once, leading to some hesitation over how much we can trust their reporting, there are still lessons we can learn from their experience. As of late February, the joint WHO-China mission reported 2,055 cases of COVID-19 among health care workers, the vast majority, 88 percent, were at hospitals in Hubei province where the outbreak began. It appears that after the initial disaster in Wuhan, in which a doctor who raised the alarm died, the hospitals figured out what they needed to do to protect their medical workers.

This story describes how Johns Hopkins doctors consulted with Chinese colleagues about best practices. Wuhan hospitals, after being hit with a wave of deaths and infections, asked staff members to check that each other’s gear was being used correctly. They worked four-hour shifts to prevent fatigue. A committee helped support the children and elderly parents of the health care workers.

The past few weeks have already inflicted a powerful psychological blow on your state’s health care workers. To bolster their morale and keep them at work, you need to make a commitment to protecting their health. That means stockpiling an enormous supply of gowns, N95 masks, gloves and goggles. This is not optional. If you don’t have enough equipment set aside, don’t even think about restarting the economy. Lose the trained health care workers and it’s game over.

Obviously, this stockpile should also include ventilators, oxygen, the drugs needed for intubation and all the other stuff that should have been waiting in reserve back in January when we had our first bite at this apple. But you know that already.

5. Normal is not the goal

One question we asked the experts we interviewed is: What would it take to put 5.4 million people back on the New York City subway every day? Invariably, they all said: masks.

Masks, especially when we’re talking about home-made ones, are not going to be perfect at preventing infection, but they can help reduce transmission. “Face masks are the only option in situations where social distancing can not be practiced,” said Lohse, from University Medical Center in Hamburg.

In Madrid, police handed out masks for riders on public transit as Spain announced a partial return to work in certain sectors of the economy, including heavy industry and construction, on April 13.

“We would probably go with Austria in forcing the population to wear masks more widely, maybe in retail outlets, maybe in factories,” said Gabriel Felbermayr, president of the Kiel Institute for the World Economy and economic advisor for Chancellor Angela Merkel’s government, talking about what Germany’s plans for reopening its own society.

“We should have learned right away from the Asian experience, that was a huge mistake,” said Romagnani, in Florence. “But in the beginning, our authorities actually told people not to wear masks. They said, ‘Masks don’t do anything.’ Well, they were saying that because they didn’t have enough masks. They feared a stampede to buy them. They worried about price-gouging.”

In the United States, our surgeon general initially did much the same thing, tweeting on Feb. 29 that masks are “NOT effective in preventing general public from catching #Coronavirus.” This week, Gov. Andrew Cuomo ordered New York residents to wear face coverings in public whenever social distancing is not possible.

The international experts’ responses were a reminder that your goal isn’t to get back to a pre-pandemic way of life, but instead to employ whatever tools it takes to keep transmission as low as possible while restarting your economy. Things like masks, temperature checks and maintaining a six-foot distance are new concepts for the U.S., and many of your constituents are going to find them weird, uncomfortable and unappealing. It’s worth your time helping them understand why these measures are so necessary, because you’ll save lives.

One aspect of returning to normal is certain to arise in the coming months: Do you reopen schools? Early reports that COVID-19 can endanger only older people with other serious health problems have been demolished as the virus spread across the globe. The numbers are tiny, but infants, toddlers and teenagers have died from this disease. School closings, of course, were seen as a way of protecting older people, the assumption being that kids with mild or asymptomatic cases would infect their teachers, parents or grandparents.

Taiwan is one of a handful of countries in the entire world that have kept their schools open. In February, it adopted rules that require closing any school for 14 days if two or more cases are detected.

Singapore’s Dr. Li Yang Hsu, said reopening schools is a plausible step. Hsu noted that countries tracing the “index,” or initial case, in a disease cluster have found few instances that trace to school-age children, “which is unusual for a respiratory virus.”

Hsu, program leader of infectious diseases at the National University of Singapore’s Saw Swee Hock School of Public Health, said in an email that recent studies “seem to suggest that the impact of school closures is far less compared to other physical distancing measures. Therefore, provided nothing changes, the general conditions,” for resuming school “would be similar to that of reopening mass transit and other services.”

6. Keep your eyes peeled for the second wave

The initial success stories in fighting COVID-19 — Singapore, Hong Kong, South Korea — all saw a rise in cases in March. Nearly all of these involved travelers who brought the infection from other countries and came into contact with locals. Remember, even once you get the number of new cases caused by each infected person below 1, you still have a population largely composed of people with no immunity, so you have to maintain constant vigilance to keep the rate low.

We’re going to need a national system of the sort we should have had in the first place. Epidemiologists call it sentinel surveillance, and what it used to mean was that we would watch out for people with flu-like symptoms for signs of a new pandemic-type illness like H1N1.

Even though we knew the coronavirus was coming, and even though epidemiology experts wanted to start sentinel surveillance in major cities like Seattle, New York and San Francisco by early February, it never happened because the CDC bungled the design of the tests. Your state will need to get this right. Not only do we need to be testing constantly, but we should also be using all the tools we can to pick up any suspicious patterns of flu-like illness, whether that’s Google searches or heightened temperatures on web-linked thermometers, besides the traditional surveillance apparatus that public health departments already have.

Here’s the tough reality for people hoping to go back to the old normal and, say, sit in a stadium and watch Tom Brady try to defy Father Time as a Tampa Bay Buccaneer: There are some things — no, there are a lot of things — in which the crowds are too large and tightly packed to be safe. NASCAR races? Baseball stadiums packed with 50,000 people? NBA playoffs? Ballet? Broadway? Hard to imagine putting that many people close together without a vaccine or unimpeachable proof that people have antibodies that make them immune. (You’d still have to find an impossible-to-counterfeit, non-transferrable form of ID so that only fans with antibodies would be admitted to large events. Good luck figuring out how to do that.)

It’s sad to say this, but until there’s a way to verify immunity, or a vaccine, you can’t allow visitors back into nursing homes. The elderly are just too vulnerable, and we’ve seen over and over how the virus just tears through those settings.

You should keep an eye on Wuhan. The extra hospitals are closed, the extra 40,000 health care workers have gone home, and the city is slowly going back to work. If there’s no second wave in Wuhan, this might just work out. On the other hand, if the virus kicks up again despite everything they’ve done and are doing, hitting that restart button becomes a lot more complicated.

7. Clear communication is critical

There are an array of political skills that get you elected governor in America. Some of you built reputations as nuts-and-bolts technocrats, good at getting things done but not given to stirring oratory. Others have a gift for explaining complicated issues in ways that can move ordinary people to action. Several of you have run for president.

One thing that came through in many of our interviews around the world was the importance of communicating clearly and consistently about the actions you take. China was able to take draconian steps to contain the Wuhan outbreak because it is a single-party state with virtually unlimited powers.

You will need comparable levels of commitment from your citizenry, but will have to achieve it through persuasion rather than coercion.

Manuel Gimenez, the minister of Economy and Employment for the regional government of Madrid, said that Spanish leaders were able to articulate reasons for one of the strictest lockdowns in the world in a country where congregating in cafes, restaurants and large family groups is an ingrained cultural tradition.

For more than 45 days, Gimenez said, his 3-year-old and 8-month-old have not left his family’s 650-square-foot apartment, adhering to rules that require all children to remain indoors. Adults are permitted to go only to the nearest grocery store or pharmacy; exercising outdoors or walks for leisure are prohibited, and police have been enforcing the rules aggressively. Although at first there were complaints about people crowding parks and driving en masse to summer homes, over all the response has been remarkably disciplined.

“What the Spanish government has done is send a series of messages preparing citizens for each phase of the response and the restrictive measures. This isn’t China,” said Miquel Porta, an epidemiologist at the Hospital del Mar in Barcelona. “In Spain, we had to communicate, accustom people to the idea of a lockdown, and create consensus. You can’t do what a dictatorship can do. The idea was disseminated that we are not staying home for ourselves. We are doing it for our fellow citizens.”

“The Spanish people have reacted well with great solidarity and even humor,” Porta said. “People shopping for the elderly, people singing on balconies. The media and the people have approved of the fact that scientists are telling them there is a certain amount of uncertainty and lack of knowledge in this crisis. Nobody is clear on how this is going to evolve.”

Stanford’s Wang said Taiwan learned this lesson in the wake of the country’s widely criticized response to SARS, a coronavirus that flared in Asia in 2003 but was ultimately brought under control and did not become a global pandemic.

“In a democracy, we need to build trust and confidence so that when you say something to people, they’ll trust you and do what you say,” said Wang. “The communications part is critical and that’s what Taiwan did after SARS.”

As governors, you’re going to have to persuade voters to do things they won’t like at a moment of unparalleled partisan rancor, record unemployment, disarray in your state’s traditional media outlets and divisions among eminent scientists. Inevitably, you’re going to be using imperfect data to strike a balance between the possible loss of lives and the certain loss of jobs that keep food on the table of your state’s citizens. Remember when you thought battling the legislature and balancing the budget was hard?

This is much, much harder, and the clashing messages from the national level complicate things even more. The good news is that you have a better feel for your state’s character and quirks than any federal bureaucrat and are best equipped to figure out what your citizens can tolerate. Trump was right about one thing. These are the biggest decisions you’ll ever make. Good luck.

Christian Salewski contributed reporting.