If there's one thing people agree on, even as they debate the government's coronavirus response, it is this: We can't do this forever.
The nationwide shutdowns, the home quarantines, hospital shortages, layoffs, deaths and infections. All seemingly without end. So what exactly is our next step?
Concerned about the nation's halting, uncoordinated response — which has featured a patchwork of state-by-state, competing and at times contradictory decisions — health experts are rushing to offer their own long-term strategies to combat the virus and edge America closer back to normal.
Their proposals come as the White House's current 15-day guidelines on social distancing are set to expire early this week, with President Trump suggesting he might loosen them soon to help the economy. What he decides could have sweeping effects on his presidency and the lives of millions across the country. His comments of late about reopening parts of the country by Easter, which is April 12, have worried outside experts it might raise infections and the U.S. death count.
In response, epidemiologists and infectious disease specialists, as well as former top agency officials, have put out their own ideas — in preprint papers online, by Twitter and in op-eds. In a recent flurry of proposals, a consensus of sorts has begun to coalesce around several key ingredients for an American strategy to move forward while minimizing human and economic casualties. They include mounting a large-scale contact tracing effort, widespread testing, building up health care capacity before easing restrictions, making future quarantines more targeted, and allowing those who have recovered and have some immunity to go back to work.
The latest proposal, which has not been previously reported, is a 19-page plan with a step-by-step timeline, with clear benchmarks states and regions would need to meet to safely move forward to the next step. The plan was published Sunday by the American Enterprise Institute. Its lead author — Scott Gottlieb, former Food and Drug Administration commissioner in the Trump administration — has been acting as an informal adviser to the White House and has shared the paper with administration officials. His collaborators include Mark McClellan, a former FDA commissioner from the George W. Bush Administration; Caitlin Rivers, an epidemiologist at Johns Hopkins Center for Health Security, and other leading policy experts and infectious disease specialists.
"People feel anxious about the future, and you need to have milestones to show people how their lives are going to improve," Gottlieb said in an interview late Saturday. "The goal is to outline a plan that will allow a gradual return to a more normal way of life without increasing the risk" that the outbreak will resurge.
Road map for coming months
Many economists and health experts say there is no way to restart the economy without addressing the underlying problem of the coronavirus. As long as the pandemic continues, the markets will be in turmoil and businesses will struggle to stay open, they say.
"The question is once you take your foot off the pedal, what happens then?" said Michael Osterholm, director of University of Minnesota's Center for Infectious Disease Research and Policy. Osterholm, Gottlieb and others stressed lifting restrictions too soon could be disastrous.
Like others, Osterholm has argued in op-eds and interviews that instead of giving false reassurances and deadlines, the White House should tell people the hard truth about the current situation and a coherent strategy they can work toward. "The social distancing, being stuck at home, the deaths we're going to be seeing. People want to know what it's for. That there's a plan."
Similarly, the road map Gottlieb's group outlined stresses the need to move away from the current decentralized system and "toward more coordinated execution of response."
The report was co-written by Lauren Silvis, an attorney who was Gottlieb's chief of staff at the FDA, and was reviewed by prominent experts including Thomas Inglesby of the Hopkins Center for Health Security and Trevor Bedford, a computational biologist at Fred Hutchinson Cancer Research Center.
The plan divides coming months into four phases and sets "triggers" for states to move from one phase to the next. Given the uneven spread and stages of outbreak, not all states would move through the phases at the same time. While the overall peak of the epidemic may occur in late April or early May, the timing may be different in different states. New York, the current epicenter, may see a decline in infection rates as other states have an increase.
With most of the nation in phase one of the epidemic, the goal should be a sharp increase in hospital critical care beds and an increase of testing to 750,000 people a week to track the epidemic — a number Gottlieb said could be achieved in the next week or two. For a state to move to phase two, it should see a sustained reduction in new cases for at least 14 days, and its hospitals need to be able to provide care without being overwhelmed.
"The reason we set it at 14 days is that's the incubation period of the virus," said Rivers, of Johns Hopkins. "That way you know the downward trend is certain and not because of a holiday or blip or some other delay in reported cases."
States moving into phase two would gradually lift social distancing measures and open schools and businesses, while increasing surveillance. The key goals thereafter would be accelerating the development of new treatments and deploying tests to determine who has recovered from infection with some immunity and could rejoin the workforce.
Phase three occurs when the nation has a vaccine or drugs to treat covid-19 in place and the government launches mass vaccinations. Phase four involves rebuilding the nation's capacity to deal with the next pandemic by building up its scientific and public health infrastructure.
Moving beyond lockdowns
Trump has repeatedly returned to strategies of bans and movement restriction. On Saturday, Trump indicated he might announce a federally mandated quarantine on the tri-state region, forbidding people to leave parts of New York, New Jersey and Connecticut.
His comments prompted questions about whether it was feasible or legal. New York Gov. Andrew M. Cuomo (D) called a quarantine "preposterous," while New York Mayor Bill de Blasio said he wasn't "sure what the president means."
It was unclear whether Trump was seriously considering the New York-area quarantine or whether it was an off-the-cuff pronouncement. Two White House officials said the idea was spurred by a conversation Saturday morning with Florida Gov. Ron DeSantis who complained about people from New York pouring into his state. Aides spent the day warning the president against it, explaining it would be impossible to enforce and could create more complications, said the officials, who spoke on the condition of anonymity. Saturday evening, Trump tweeted that a quarantine wouldn't be necessary, and instead the Centers for Disease Control and Prevention issued an advisory against unnecessary travel in the three states.
For weeks, World Health Organization officials have stressed such lockdowns are helpful only for slowing the virus and buying time to deploy more targeted and comprehensive measures, which the United States has not done.
Mike Ryan, head of emergency programs for WHO, urged countries to focus on finding and isolating infected people and their contacts. "It's not just about physical distancing, it's not just about locking down," he said at a recent news briefing.
Proposals from many experts for a U.S. strategy have similarly stressed the importance of large-scale contact tracing — a cornerstone for successful efforts in countries including South Korea and Singapore.
In the past, some epidemiologists viewed contact tracing on a large scale both impractical and unhelpful once an outbreak has become widespread in a community. But as countries have shown its success against this coronavirus, that thinking has changed.
In a paper last week and interviews, Marc Lipsitch, an epidemiologist at Harvard University, suggested while contact tracing is "impractical now in many places," it could become practical once the numbers have gone down and testing has gone up. He said it also "could alleviate the need for stringent social distancing to maintain control of the epidemic."
South Korea had already honed this ability during an 2015 outbreak of the deadly MERS coronavirus. Singapore deployed its police force to do the work, drawing on digital footprints with security camera footage and credit card records.
In the United States, however, that task falls to county health departments, which have been weakened by decades of budget cuts and lack the staffing and ability to mount such a response. Rapidly building up that capacity — either with community volunteers or short-term hires — will be crucial in coming months, said Rivers, of Johns Hopkins. "If you build capacity up and bring cases down, it starts looking a lot more possible."
Getting the White House to listen
Many proposals are also tackling the problem of the tanking economy. The Gottlieb-Johns Hopkins plan, for example, calls for widespread use of blood tests to identify people who have had the infection and now are immune — called serology testing. People who are immune could return to work, or take on high-risk roles in the health care system and help people, especially the elderly, who are in quarantine.
Serology tests have not been deployed on such a large scale, although in Africa, during the Ebola outbreaks, survivors often were the ones who provided care, watched over the children of sick patients and buried the dead.
But the one looming challenge unaddressed by most proposals and op-eds is how to get such detailed plans adopted by the White House, whose response has been weighed down by infighting and leadership ping-ponging among Trump, Pence and health advisers including Anthony S. Fauci and Deborah Birx.
Pence said Saturday the covid-19 task force would bring its recommendations to Trump in the coming week on whether to ease social distancing and reopen the economy.
Health officials and scientists involved in the federal response, especially from the CDC, have fought to be heard while straining to avoid offending Trump, who bristles at being publicly contradicted, undercut or overshadowed by praise for ideas or people beside himself, according to people who spoke on the condition of anonymity about sensitive deliberations.
"While the president has said he'd like to open the country up in weeks not months, we're going to be bringing that data forward to him," Pence said in an interview with Fox News. "Ultimately, the president will make a decision that he believes is in the best interest of all of the American people."
On Thursday, Trump unveiled a plan of his own, though scarce in detail. He said he planned to help communities ease their restrictions and reopen for business by using "robust" surveillance and categorizing counties across America into three "risk levels" — low, medium and high. Specifics on how that plan might work, White House officials said, may be announced in coming days.
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