The No. 1 question: What about testing? Public health experts, business leaders and elected officials all agree that widespread testing is needed on a scale many orders of magnitude greater than what is being done. Testing can’t be limited to patients with symptoms; surveillance testing of people without symptoms is necessary to detect the true spread of covid-19 in communities.
Without such testing, no one can be certain that areas reporting few cases don’t have others that have simply gone undetected. A criterion for safe reopening is a reliable downward trajectory of infections. That requires mass testing.
Testing should also be available to everyone who needs or wants it. Rapid tests have been developed that provide results within minutes. Reasonable reopening scenarios include testing of employees and students before they return to work and school. This means millions of tests must be available every day so that there can be a staggered return for the most essential workers, followed by gradual return of other employees and students. So far, 3.5 million tests have been administered across the country. Instead of continually growing, testing availability has plateaued in recent weeks. The guidance issued Thursday does not specify the much higher level of testing needed or how states can accomplish the sort of dramatic ramp-up that will entail.
Second, what is the federal government’s role? States have sought federal assistance to secure tests, ventilators and personal protective equipment for health-care workers, but there is still no national strategy for obtaining these needed supplies. The absence of a federal plan is a major contributor to the health-care system’s continuing state of crisis.
The guidelines call for a robust public health infrastructure to conduct contact tracing. This is key to moving from societal-level mitigation to containment on an individual level. When case numbers are low enough in a community, workers can identify each new positive case, trace every person the infected individual came into contact with during their infectious period, and isolate and quarantine those affected. This outreach is time- and labor-intensive, but it can be done by people with a basic level of public health training. Various proposals have suggested that students or those currently out of work be deployed for tracing.
Tracing could require a workforce of as many as 300,000 people. The guidelines do not outline a federal role, but a national program to recruit, train and deploy these workers makes infinitely more sense than 50 state programs with differing protocols and procedures.
As things stand, it’s unclear whether the federal government intends to invoke any enforcement authority over states that do not abide by the guidance. Although the president initially said that the decision to reopen was entirely under his authority, this new guidance was framed as a voluntary measure. The spread of infections illustrates that diseases do not respect state or national borders. Premature reopening of one state affects neighboring states and could spark a second wave of infections that affect the entire country. It should be clear whether the federal government would exert authority if states make decisions that run counter to the guidance.
Third, will there be tolerance for multiple rounds of shutdowns if — more likely, when — reopening results in increased infections? Social distancing has been effective in reducing transmission, but some increase is expected when the restrictions are eased. New outbreaks are likely, and some won’t be contained by contact tracing and isolation alone.
Assuming that there is sufficient testing to detect such upticks in real time, would states be willing to reimpose restrictions? Given the protests in states just this week, and the continued refusal of some officials to order lockdowns, it’s unclear whether the country could consistently resume widespread distancing and closure. Will there be consistent messaging from the White House to support such a public health imperative?
It is possible to reopen the United States safely. Data and evidence show how to do so. We must have widespread, accessible testing to assess, predict and prevent the next hot spots. The public health infrastructure must be in place to transition from a society-wide lockdown to individual, case-based tracing. And our health-care system must be stable, not overwhelmed amid a surging crisis.
The Trump guidance gets our country only part of the way to the goal. It’s not so much a reliable road map as suggestions based on inexact data. Already, Texas has announced that it will be reopening parts of its state; others are expected to follow. Without more clarity, urgently, reopening under the conditions proposed would almost certainly result in new waves of infections and deaths. All the sacrifices Americans have already made would be in vain.
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