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In late February, as the coronavirus pandemic data continued to develop, I began making calls to friends and family to prepare them. I told them to get ready to bend over for three months. For many, it was hard to believe that a virus that we couldn’t see much evidence about, less understand, would require us to shut down our economy.
I also spoke to CEOs and governors, urging them to close nonessential businesses and issue orders to stay home to stop the spread of the virus. Other public health advocates called for the same, and fortunately government and business leaders responded. Their actions saved hundreds of thousands, if not millions, of lives and spared American hospitals the horrors of care rationing. Closing was the correct policy at the time.
As circumstances have evolved, so has my thinking. We survived the increase in hospitalized cases and suffered immense economic trauma. The full crash made sense weeks ago. But the situation is changing and more data is now available on the virus to inform our next steps. The choice before us is not to completely block or reopen completely. Many argue as if those were the only options.
As a doctor, I firmly believe that the main objective of our reopening strategy should be to maximize the number of lives saved. But virus mitigation can take many forms, from effective to excessive. Extreme forms of mitigation can have diminishing returns. Projections of the death toll from the current economic shutdown are often politically motivated, but the effects on human life are real.
In late April, the United Nations World Food Program reported that 250 million people could face hunger as a result of the economic impact of Covid-19. In the United States, local food banks are already congested with record wait times. There are other serious consequences of continuing to stay-at-home orders and prolonging the financial disruption. Deferred health care, mental health problems, domestic violence, and one of the largest pre-Covid-19 public health problems in the United States, loneliness, are magnified by shelter in the home. The economic and public health damage associated with accommodation has yet to be fully measured.
At the same time, the coronavirus will persist. We must be careful how we reopen, so as not to discount human life in the race for prosperity. That would worsen already troubling trends, given that Covid-19 disproportionately affects disadvantaged communities that depend on public transportation and in congested living conditions. Our path to reopen should protect high-risk people. The current “normality”, with its economic anxiety, dizzying unemployment and social isolation, cannot continue: we must work towards a new status quo until a therapeutic product is available and mass produced.
So what does a new and more secure status quo look like? It looks different in different parts of the country. Not all reopens are the same. Areas with continuous outbreaks or increasing cases should postpone nonessential activity, and those with a decreasing trend in cases should participate in some basic practices.
We need universal masking. China gives the first advance of a reopened society after a strong wave of the virus. And although the Chinese Communist Party has not been honest about its handling of the coronavirus, Chinese doctors and citizens have been largely transparent. I recently called some prominent Chinese doctors to ask why they think the infection is being controlled in most of their country. In their clinical judgment, they believe that the main reason is universal masking.
I have worn a mask most of my adult life as a surgeon, and I had been skeptical that masks played an important role in fighting this pandemic. Most masks do not have the seal and filtration to protect us from inhaling the coronavirus. But that is not the only way they work. Masks reduce the transmission of aerosol droplets to others and to surfaces that others can touch. They protect your mouth and nose from drops from others, and prevent you from touching your nose and mouth.
Spend more time outside. Since April, we have learned a lot about indoor and outdoor coronavirus transmission. At first, we closed parks and told people to stay indoors. But since then, studies have shown that being outdoors with adequate distance carries a lower risk of contracting the infection than being indoors. These findings have implications for restaurants and other businesses and activities that outdoor areas can use. Yoga and other physical activities should be resumed when possible. Similarly, instead of inviting someone to your home for lunch, consider eating in your garden or park six feet away.
Companies must adapt. A busy consumer-oriented industry has already demonstrated how it is feasible to adapt to a virus mitigation approach. Most grocery stores have been operating safely during the pandemic. Many do this by limiting the number of shoppers in a store, requiring masks, spacing alternate lines and registers, installing plexiglass protectors, incessantly cleaning and discontinuing some services like self-service salad bars. Supermarkets have strict policies that workers with symptoms do not report to work, and some continue to pay them to avoid creating a financial incentive not to disclose symptoms. By adhering to distance and hygiene standards, these companies have shown that even at the peak of the pandemic, they can operate without becoming contagion hot spots. These practices should be extended to small businesses. If a business like a cruise ship or a game room is not feasible to operate with strict spacing, masks, and impeccable hygiene, then that business must remain closed until it is safe to reopen.
We must prioritize the protection of nursing homes. Throughout April, several studies using antibody tests found that asymptomatic infections are 10 to 20 times more common than previously observed, reducing the actual case fatality rate. The data also taught us that young, healthy Americans have a death rate similar to seasonal flu. Deaths among the young and healthy are rare. (In fact, community immunity against seasonal viruses is often achieved through younger people who develop antibodies.) About a third of all Covid-19 deaths in the United States occurred among nursing home residents. In New Jersey, half of all deaths have been among residents or long-term care workers. Nursing homes are often understaffed and are last in line when it comes to obtaining the necessary resources.
Nursing homes should not be allowed to house any Covid-19 patients unless the facility has isolation rooms and sufficient protective equipment, and tests all employees and residents for coronavirus at least twice a week. Additionally, hospitals should be banned from transferring Covid-19 patients to nursing homes, a common transmission vector that has caused outbreaks in recent weeks.
Protect high-risk people. The data shows that those with pre-existing medical conditions like diabetes, lung disease, or a weakened immune system are among the most vulnerable. Depending on the degree of their risk and the prevalence of the virus in the region, we must advise these high-risk people, especially the elderly, to avoid interactions with others until the risk of transmission is extremely low. This approach aligns with the White House return-to-work roadmap that houses high-risk individuals through Phase 3, even when many companies are reopened.
These practices will help optimize public health until there is a therapeutic solution or until the virus mutates to a less virulent form. In addition to saving lives now, mastering these strategies will save lives this fall if this virus demonstrates a seasonal pattern similar to that of other coronaviruses.
At first, we didn’t know what we were dealing with. But now that we have better information, we should use a more surgical approach to fight the virus and minimize damage.
Marty Makary M.D., M.P.H. (@MartyMakary) is a professor of health policy at the Johns Hopkins School of Public Health and author of “The Price We Pay.”
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