We need an exit strategy – now!

Data indicates the U.S. is achieving the goal it set out to accomplish.  The national objective was as follows:

The United States’ immediate and primary objective in response to the COVID-19 pandemic is to compress the peak of infections (commonly called “Flattening the Curve”) in order to avoid denying critical care to the afflicted as a result of insufficient hospital staffing, hospital beds, Intensive Care Unit (ICU) beds, and ventilators.  Social distancing is the primary strategy to achieve this objective.

Data tracking indicates the curve of COVID-19 illness is flattening in many countries of Europe and in the United States.  In the U.S., hospital beds, ICU beds, and ventilator capacity are meeting need and improving as the number of patients requiring these services is declining and options for treatment expand. Production of personal protective equipment and ventilators is increasing to meet need.  Care capacity to treat infected patients is increasing as hospitals reallocate resources, old hospitals and other spaces are converted to active service, field hospitals are opened, and hospital ships are deployed.

The U.S. objective stated above assumed a very high risk that healthcare capacity would be exceeded responding to the SARS-CoV-2 virus that causes Coronavirus Disease 2019 (COVID-19).  Models indicated the virus would spread wider and faster than other viruses, its symptoms would be more debilitating, and it would be more deadly than other viruses.   The models were just that – MODELS. 

Post-COVID-19 research and analysis will determine how accurate those predictive models were.  For now, gratitude is in order that the virus impact is less severe than was originally predicted.  Whether that results from our social distancing strategy, or the virus is just not as vicious as predicted, or seasonal weather change is having the same impact on SARS-2 as it does on many other viruses is fodder for another day.  For now, cautious victory can be declared, and cautious and prepared gradual rescinding of many social distancing restrictions can begin.

Maintaining social distancing to the extent it is currently in practice can cause tremendous social harm.  The “Disaster Distress Helpline” at the Substance Abuse and Mental Health Services Administration last month saw call volume increase 9 times over March 2019 and officials are warning of a national mental health crisis.   The National Suicide Prevention Lifeline set a record last month for call volume.  Those saved and sustained by addiction programs such as AA and NA are at greater risk of relapse despite attempts to move support online.  The United Nations this past weekend called for “urgent action to combat the worldwide surge in domestic violence.”

The social distancing strategy is negatively impacting U.S. economic activity.  Some estimates indicate up to $10 trillion of  $20 trillion in U.S. annual economic activity could be lost.  This suppression of economic activity cannot be sustained without damaging families economically and creating dangerous social ills.   The longer the suppression continues the greater the potential damage and more difficult the recovery.   Vulnerable low wage hourly earners without benefits will suffer the most economically.  The National Multifamily Housing Council reports only 69% of tenants paid any rent between April 1-5 as compared to 82% the previous year.  Small businesses will struggle to survive.

The Department of Labor reported 4/3/2020 the unemployment rate rose to 4.4% from 3.5% in March.  An additional 1.7 million lost their jobs.   The Labor Force Participation Rate, a measure of the percentage of Americans 16 and older who are working or looking for work, sank to 62.7 from 63.4.   On April 4 Labor reported 6.6 million jobless claims had been submitted in the past week with 16.8 million filings over a three week period - yet another very concerning historical record.  

The U.S. economy is fast approaching 20 million job losses through April as predicted by economists.  Many states have more stringent rules in effect – in some cases into June.  Goldman Sachs estimates the unemployment rate will rise to 15% and GDP drop 9% in the first quarter and an additional 34% in the second quarter.  James Bullard, President of the Federal Reserve Bank of St. Louis, said the unemployment rate could reach 30% and GDP drop 50%.

These predictions are not inevitable.  Change in policy can diminish the impact and duration of these very scary numbers just as social distancing may have changed the course of COVID-19.

 

A gradual reduction of social distancing must begin – soon.   This does not mean all restrictions lifted immediately on a given date.  As Dr. Anthony Fauci recently said, “this isn’t like a light switch on and off…It’s a gradual pulling back on certain of the restrictions to try and get society a bit back to normal.

There must be built into any plan the ability to change direction and delay dates of implementation. Military planners call this maneuver space. A gradual lifting of restrictions can reflect regional differences of COVID-19 status. 

One way to structure reduced social distancing is by industry as defined by the Bureau of Labor Statistics.  There could be a progression of implementation across industries.  Dates here are nominal for purposes of demonstrating one possible time progression example:

• April 20:  Health Services, Natural Resources and Mining, Construction, Manufacturing, Trade Transportation and Utilities (much in these sectors remains operational already)
• April 27:  Information, Financial, Professional and Business Services (again, much in this category remains operational through work at home)
• May 04:   Retail Trade (Does not include Leisure and Hospitality and Travel)
• May 11:   Education Services (K-12 only)

Leisure, Hospitality and Travel will require the greatest caution and hence the most detailed consideration.  Some leisure, such as outdoor park and trail enjoyment can be opened almost immediately with common sense planning.   

Places of social gathering in large numbers may take a few to several months before restrictions are fully lifted.   Large social gatherings must also be considered in time dimension.   There are large social gatherings that take place in one space of time, such as a sporting or entertainment events. Another example would be the expected return of the churn of restaurants and bars.

Transitioning will not be easy.  The U.S. population is bombarded daily with headlines that are frightening.  We have also become a risk averse nation that thinks all risk can be eliminated.  It cannot.   It will be difficult to step forward in  uncertainty and fear.  Psychological barriers may be the most difficult to overcome.

Politicians may exercise excess caution.  They do not want to be wrong.   They do not want to be seen as making a mistake.  They will need encouragement and courage to exercise leadership in this transition.  Pointing fingers of blame for past responses and actions based on imperfect information is folly.  Better to begin a transition from social distancing and conduct a stem-to-stern rigorous analysis of the COVID-19 pandemic to build resilience and strength to fight the next battle.  There will be other viruses/infections and possibly worse.  We cannot shut down our economy every time a model says a virus could be very bad.

Many current personal practices of hygiene and contact should be encouraged to continue.   For example: hand washing and cleaning surfaces; avoiding handshaking; avoiding casual hugging of friends and acquaintances; and avoiding closed spaces to avoid potential dense virus presence. (Go outside as often as possible and open windows in the home and office whenever possible as the weather improves!)

Cautious optimism is warranted, but there will be much more suffering and additional death.  Each of those cases is a personal tragedy for families.  There can be no diminishing the agonizing loss many have and will suffer.  The U.S. must continue to take all necessary action to restrict virus spread and mitigate effects, but the COVID-19 risk must be balanced against the severe decrease in economic activity and social engagement that have their own major risks.

Mission creep is a tendency we must avoid.  Our objective was never to eliminate the virus.  Our objective was never to eliminate infections.  Our objective was never to eliminate all risk.  None are possible. 

A new offensive strategy against the virus may be necessary.    We must accept that all risk cannot be eliminated and focus on managing and mitigating risk and building public health capacity.  Rather than broad public restrictions on movement and gathering we could shift to a more targeted offensive strategy against spread with increased testing, sampling, targeted surveillance, and tracing.  Vulnerable populations such as elder care facilities and poor communities with populations traditional suffering  from higher levels of underlying disease would receive increased focus . 

This is going to be hard.  But we must do it.  The first step is to make a plan of transition.  It must reflect true risk as we know it now, not at as it was predicted in early models and provide a timeline for transition.  Hopefully, we will begin that process very soon and united.