What will reopening America look like?

When and how to reopen the economy and other aspects of society in the United States continues to be debated, with federal and state officials all releasing outlines for phased-in plans for breaking from stay-at-home orders and temporary closures of numerous businesses.

The Hastings Center, a bioethics research institute, brought three experts on health policy, public health and ethics together April 21 to discuss balancing the ethical considerations with the economic imperatives for the country during an online discussion, “Re-Opening the Nation: What Values Should Guide Us?”

Discussing those trade-offs were:

• Zeke Emanuel, MsC, MD, PhD, vice provost for global initiatives and chair of the Department of Medical Ethics and Health Policy, University of Pennsylvania
• Danielle Allen, PhD, professor at Harvard University and director of Harvard’s Edmond J. Safra Center for Ethics
• Mildred Z. Solomon, president, The Hastings Center, and professor of global health and social medicine, Harvard Medical School.

Here are five key insights into their discussion:

1. Demand for services may not immediately spike after reopening

Emanuel noted that there is evidence that many people reduced mobility and began social distancing before shelter-in-place orders were issued by state governments, suggesting that many were hesitant about risking infection just to shop or go out to eat.

“Maybe being cooped up for a while is going to change people’s responses and make them more daring and less risk averse, but I have a feeling that … if you open up businesses, you’re probably not going to get the rush of economic activity that is anticipated.”

2. Replacing “stay at home” with “testing, tracing and supported isolation”

Allen detailed a number of approaches to reopening society, previously noted in the Safra Center’s “Roadmap to Pandemic Resilience” report, which point to testing, tracing and supported isolation as keys to the reopening of the United States in the weeks and months to come.

To Allen, the suggestion of trying to attain a “herd immunity” through rapid infection is a form of “surrender,” because the rapidity and severity of COVID-19’s progression is a threat to countless lives and many of the institutions the nation will rely on as society reopens.

“We have a job of social protection to do here, as well as the job of protecting individual lives,” Allen said. “The key job is actually to secure institutions … so they can deliver health, so that they can deliver a sound and prosperous economy,” making health and economic prosperity intrinsically aligned. This approach was labeled as a “mobilize and transition” approach.

The Safra Center report also outlined a “freeze-in-place” approach, which largely reflected the beginning of stay-at-home orders in hopes of halting the disease long enough to reopen, and then reapply social distancing orders as needed. The downside to such an approach, Allen noted, is that reopening, closing and reopening puts a great burden on businesses because of the uncertainty of whether another lockdown period will occur, again disrupting operations.

“What the economy needs, in order to deliver for the health system, is to be able to know that we’re going to be able to open up and stay open,” Allen said. “So instead of freezing the economy, leaving it just as it was and just tiding people over, the job is to actually drive … some significant recomposition of the economy to deliver the infrastructure that we need.”

That sentiment echoes the larger recommendation of the report, in that:
Between now and August, we should phase in economic mobilization in sync with growth in our capacity to provide speedy, sustainable testing, tracing and warning, and supported isolation and quarantine programs for mobilized sectors of the workforce, or TTSI. We do not propose a modest level of TTSI intended to supplement collective quarantine as a tool of disease control. Rather we recommend a level of TTSI ambitious enough to replace collective quarantine as a tool of disease control. TTSI should replace stay-at-home.

3. Avoiding a “stop-and-start” repetition depends on testing

Emanuel contends that testing infrastructure is a top consideration for relaxing social distancing and reopening a large number of businesses, but he — along with Paul M. Romer, writing in The Atlantic — estimates that about 2 million tests a day is the minimum number needed to control the spread of COVID-19.

The question remains whether a “stop-and-start” — in which the country must reimpose closures due to a resurgence in COVID-19 cases — can be avoided. “This open/close, open/close rollercoaster situation” may be inevitable in some parts of the country but perhaps not nationwide, Emanuel contends. “We have to recognize that and be prepared for it,” so that there can be better long-term planning for businesses.

Allen agrees that the 2-million-tests-a-day rate is likely necessary for a successful reopening of the country, but that there are two ways to get there. “The supply chain has two pathways for ramping up testing,” Allen said. “One is maximizing the capacity of the existing supply chain.” The other is something called an “innovation pathway,” in which simpler protocols — spit kits replacing nasal swabs, for example — allow for megalabs to rapidly transform the throughput processing of testing. It also depends on eliminating choke points in that process, such as:

• The need for PPE among sample collectors
• Transporting samples as biohazardous waste
• The need for reagents to purify RNA in samples.

“If our ambition is high enough, we absolutely decrease the need for closing repeatedly,” Allen said.

4. Testing focus should shift to asymptomatic populations

While the role of serological testing — to measure antibodies present in the blood of people who have recovered from COVID-19 — has its place, Emanuel said the most important testing remains in testing for COVID-19.

Serological testing “is not essential to the prevention of spread, and we need to reorient our testing regime away from diagnosing people who are symptomatic,” Emanuel said, pointing out that Centers for Disease Control and Prevention (CDC) testing guidelines remain unchanged in the past month. “If you want to contain a spread, you need to focus on testing people who are asymptomatic,” he added. “We have evidence that between 25% and 60% of the people who get this virus are asymptomatic, and they may unwittingly be spreading this around and causing real havoc.”

Allen echoes Emanuel’s sentiments on getting updates on testing guidance, comparing it to the updates to guidance on use of masks. “Originally, the guidance was really aimed at rationing … it’s time to change the guidance and ramp up the supply,” Allen said. “We really do need to test the asymptomatic [populations] … so that we can stop the spread of COVID-19.”

5. Big tech will help contact tracing, but it requires trust

The increase in testing will then lay a foundation for two stages of contact tracing, according to Allen. “Manual contact tracing, the gumshoe part of it, is a really important piece,” Allen noted, and that it then allows for technology and apps to “support and extend” the capacity of manual contact tracing.

The manual process will rely heavily on community health organizations to recruit and train contact tracers to identify anyone who was in close proximity to an infected individual and get them tested. From the tech perspective, areas with high usage of smartphones with Bluetooth capability and GPS location service enabled could then rely on individuals to use apps on their smartphones to have a degree of tracking where they’ve been and understand if they may have been in contact with someone infected with COVID-19.

But obtaining buy-in for such apps means that the apps must come from someone users trust. “There’s a group in American society that is very suspicious of the government and don’t want them to have data on us,” Emanuel said, as well as a segment of the population that’s “very suspicious of big tech.”

He said that for widespread adoption, individuals need to know that their data won’t be merged with other data, and that it will not be commercialized. He also said that users need assurances that the data is destroyed when the public health use for the data has ended.

Allen added that such apps should only store the data on a user’s device, and that “tokens” can be produced and shared with other phones in the vicinity or that can connect with the broader GPS system to ensure privacy protection. “There are things that we can do to build out a system so that it can be functional in this privacy-protective way,” Allen said.

Other voices

Writing for Medpage Today, Karen L. Paddock, MD, a board-certified pediatric anesthesiologist with Sutter Health in Sacramento, Calif., encourages expanded testing among essential workers and “careful lifting” of stay-at-home orders as new molecular testing for COVID-19 is rolled out for “all healthcare providers and patients in hospitals,” followed by phased expansion of tests to the food industry, grocery workers and then to the broader public.

Additional resources

• MGMA COVID-19 Recovery Center
• MGMA COVID-19 Federal Assistance and Advocacy Center