With unemployment claims ballooning to 22 million people, the coronavirus lockdown took an uncomfortable turn for state governors on Wednesday. Workers and small business owners clogged the streets of Lansing, Michigan, near the capitol, blaring car and truck horns, and waved signs calling on Governor Gretchen Whitmer to allow businesses to open up. Smaller protests took place in Virginia, Kentucky, Ohio, North Carolina and Utah.
The angry outburst came just as the nation teeters on what the computer models say is the "peak" of the COVID-19 outbreak. According to most calculations, the death toll, after rising with terrifying steepness for several weeks, should be flattening out and soon starting to drop. "The worst is over," said New York Governor Andrew Cuomo earlier this week.
Reality, though, seems to have other ideas. New Jersey, supposedly on the downward slope, reported 362 deaths on Thursday, the biggest single-day increase. Governor Phil Murphy said the death toll, at 3518, surpasses the number of state residents who died in World War I.
Despite the lack of clarity, reopening is on everybody's mind. President Donald Trump announced Thursday, "We are in the next front of our war, which we are calling, 'Opening Up America Again.'" Governors on both coasts are hammering out plans to lift restrictions on businesses. Governor Gavin Newsom of California said any plans to open the state would be "guided by science and data."
One thing is clear: regardless of whether the lockdown ends next week or next year, the virus will be waiting on the other side. A lockdown only delays the virus' progress through the population. It's designed to keep the burden off emergency rooms and intensive care units and buy time. The relevant question in considering how and when to lift the lockdown is not how to prevent deaths, but rather how to prevent too many deaths all at once.
Several private studies have laid out frameworks for a plan, and the governors are no doubt fashioning their own. There is a consensus that life will not go back to normal until scientists figure out how to defang the virus—with a vaccine, or treatments that keep the acutely ill from dying on ventilators, or both. New treatments will take months to roll out and a vaccine is at least a year away. How, then, do we negotiate the coming months?
Most plans present a post-lockdown scenario in which life wouldn't exactly be normal but would still be an improvement on lockdown. People would wear masks when they go outside, some businesses would reopen with social-distancing precautions, large gatherings would be forbidden and bars would stay closed. Baseball season might reopen, but teams would play to empty stadiums. Former FDA Commissioner Scott Gottlieb, an author of a report published by the American Enterprise Institute, told Vox that it would look like a "gradual reintroduction of activity."
As social interactions increased, of course, the virus would begin to make a comeback. Epidemiolgist Marc Lipsitch of Harvard and his colleagues recently performed a computer analysis of how SARS-CoV-2 was likely to behave after lockdown is lifted, which the journal Science published on Tuesday. The authors found that loosened restrictions would almost certainly produce a rebound later in the year. A false sense of security during the summer months in northern states such as New York and Michigan, where the virus might be less active during the summer heat, could lead to a spike in cases in the autumn or winter that's even more severe than the one we're only now recovering from.
To avoid another catastrophe, doctors would use contract tracing to jump on small outbreaks before they turn into big ones. Contact tracing would require PCR tests to detect the presence of the virus in patients' blood, and serological tests to measure the presence of antibodies, an indication of whether or not a patient has immunity. The monitoring would have to be done at the local level, which means tests would have to be cheap, plentiful and quick. Paul Romer, a Nobel laureate and professor at New York University, calls for administering tests to every person in the country every two weeks—more than 20 million tests per day.
Testing on that scale is not going to happen anytime soon. Tests are only now being rolled out and it will be "at least weeks before there are results for more than a handful of places," said Lipsitch at a press conference.
Without testing and tracing, the only tool available to keep the outbreak in check is social distancing. Lipsitch's team explored scenarios for controlling the rebound with social-distancing measures alone. No one wants a permanent lockdown, so they also ran their computer models on a strategy of intermittent lockdowns. Public health officials would monitor the prevalence of the virus in the population at large and, as the number of infected people reached a certain threshold, social distancing rules would once again go into effect. A lockdown in March and April might give way to a few months of relative freedom, but then it would be time for a second lockdown, and eventually a third and a fourth and so on.
Without a vaccine or effective treatments, a strategy of on-again, off-again lockdowns would have to continue through 2022 before enough people carried antibodies to the virus to protect the most vulnerable, known as herd immunity.
It sounds awful—and it might not even work. Without adequate testing, public health officials would have to use indirect metrics, such as hospitalizations, to assess at what point a new lockdown is needed. This would hamper their ability to recognize a spike quickly enough to avoid another catastrophic increase in COVID-19 cases. Would politicians listen and act in time to close down businesses? Would the public accept and abide by these recurring rounds of restrictions?
The recent of experience of Singapore doesn't bode well. In the early days of the pandemic, Singapore, which arguably has the best health care system in the world, managed to avoid severe social distancing through a program of comprehensive testing and rigorous contact tracing. Still, it lost control of the outbreak. Last week, it had to resort to closing businesses and reducing social contact. If Singapore can't keep its economy open with a robust system of testing and monitoring, can the U.S.?
The lack of alternatives to social distancing makes charting a realistic course from lockdown to normalcy exceedingly difficult. Until scientists can come up with some other intervention—a vaccine, a treatment, a drastic expansion of ICU capacity—it looks like social distancing is going to be a way of life for a while.