Amid Coronavirus, Experts Question When It's Safe To Go Back to Work, Lockdown Had No 'Exit Strategy'

Texas Lt. Gov. Dan Patrick, who at 69 would be relatively vulnerable to the ravages of COVID-19, offered on Monday to make the ultimate sacrifice. He said he'd be "all in" for lifting the nation's lockdown and getting Americans back to work. The next day, President Donald Trump floated a date. "I would love to have the country opened up and just raring to go by Easter," Trump said on Fox News town hall on Tuesday. The next day, Trump declared Texas a "major disaster."

Public health officials were aghast at talk of ending restrictions just as the first wave of COVID-19 cases was hitting New York City, threatening to overwhelm its hospitals. But the fundamental question of when and how to lift the nation's shelter-in-place strategy is legitimate. Deaths in the U.S. are expected to peak in about 3 weeks, a consultant to the Centers for Disease Control said Wednesday. What happens then? What's the plan?

There are good reasons to lift the lockdown, provided it can be done safely, as soon as possible. The severe disruption to the economy affects rates of poverty and unemployment and adds to stress, all of which exacts a toll on public health, particularly on people who live paycheck to paycheck. The longer that disruption goes on, the more difficult it will be for the economy to climb back. At some point, a lockdown may become counterproductive—but where that point lies is difficult to quantify.

Lifting restrictions too soon or too abruptly, on the other hand, will almost certainly trigger a second spike in infections, which could be just as deadly as the first. When too many patients fall ill at once, hospitals are overwhelmed and many of the sickest go without treatment, as has been happening in Italy and may happen soon in New York City. Stopping COVID-19 is out of the question—it's too highly transmissible, and herd immunity, when a high enough percentage of the population is immune, takes time to develop.

Knowing when to lift the lockdown is difficult in part because so little is known about the COVID-19 virus, which first arose in humans only a few months ago, and testing is woefully inadequate in the U.S. As a result, policymakers are working in the dark, says John Ioannidis, an epidemiologist at Stanford. He questions whether some aspects of the U.S. lockdowns are doing more harm than good. For instance, school closings, by sending kids home with their parents, might wind up increasing infections among older, more vulnerable members of the population. "In the absence of data on the real course of the epidemic," he wrote in StatNews last week, "we don't know whether this perspective was brilliant or catastrophic."

This lack of knowledge is one reason health officials were so alarmed by President Trump's Easter timetable. Epidemiologist David Katz argued in an op-ed in The New York Times that the least vulnerable members of the population—those under 60 with no health conditions—might be able to go back to work sooner rather than later, and might develop herd immunity that protects the vulnerable. (It's not clear, though, that patients develop immunity to the virus.) Still, Katz tweeted that an "arbitrary 'back to business' deadline is dangerous folly."

The World Health Organization is now drafting guidelines for nations to lift their lockdowns. Any plan to return the nation to work must be supported by data, says epidemiologist David Heymann, head of the WHO's Scientific and Technical Advisory Group for Infectious Hazards. His group is studying measures taken in Asia and Europe and plans to issue a report in a week or two. (The group is currently working with no input from the U.S.) Although many Asian countries, having lived through the SARS outbreak in 2002, were better equipped with diagnostic tests to handle the COVID-19 crisis, they also face a challenge in making the transition to some kind of normalcy. "Most countries don't have an exit strategy," says Heymann.

Although the report isn't yet complete, Heymann shared some of the main points. Once lockdown has blunted the first wave of the outbreak, he says, the idea is to consider unlocking certain sectors of the economy slowly, all the while measuring the virus's response to the loosening of restrictions. If infections rise precipitously, health systems would have to jump on them to avoid a resurgence of the disease. Before taking any measures, he says, a risk assessment would have to be made. If, say, offices are going to reopen, how much virus-swapping is likely to take place on the buses and trains and around the water cooler? And will that activity prompt a second spike in cases?

An essential element of such a plan, he says, is a surveillance system that gives health officials an accurate view of how many people are infected at any one time. (That much is clear from the rise of COVID-19 infections in Amazon warehouses.) Prolific testing is key. It's not enough to know how many people have COVID-19 in a particular city or state; health officials need to know what percentage of the population is carrying the virus, and how they're distributed among cities and counties. That kind of data calls for random testing of populations, the way pollsters sample public opinion. It would have to be able to distinguish outbreaks at a local level to identify pockets of infection before they balloon.

Heymann and other experts will be paying close attention to what happens in China in the weeks ahead. China has already tamped down its first wave of COVID-19 infections, using draconian measures of social distancing. But it recently lifted some restrictions on industry. It's too soon to know what effect it will have, but it should provide useful information for the U.S. and Europe.

Another element to a back-to-work strategy will be figuring out how to protect older people and those with underlying health issues, who are most vulnerable to COVID-19. If the number of cases can be kept at a low simmer, it would free up hospital resources for those who most need it. Eventually, a vaccine and herd immunity—if it turns out that people develop an immunity to the COVID-19 virus after illness—may keep new infections low.

With the right policy, before long at least some people will be able to go back to work without putting Dan Patrick's life in danger.