In late February, as data on the coronavirus pandemic continued to unfold, I started making calls to friends and family to prepare them. I told them to get ready to hunker down for three months. For many then, it was hard to believe that a virus we couldn’t much see evidence of, less understand, would require us to shut down our economy.
I also spoke with C.E.O.s and governors, urging them to close nonessential businesses and enact stay-at-home orders 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 rationing care. Shutting down was the right policy at the time.
As circumstances have evolved, so has my thinking. We have survived the surge in hospitalized cases and suffered immense economic trauma. The full lockdown made sense weeks ago. But the situation is changing, and more data on the virus are now available to inform our next steps. The choice before us isn’t to fully lock down or to totally reopen. Many argue as though those are the only options.
As a physician, I firmly believe that the primary goal of our reopening strategy should be to maximize the number of lives saved. But virus mitigation can take many forms, ranging from effective to excessive. Extreme forms of mitigation can have diminishing returns. Projections of the death toll produced by 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 may face starvation as a result of the economic impact of Covid-19. In America, local food banks are already congested with record wait times. There are other serious consequences of continuing stay-at-home orders and prolonging economic disruption. Deferred medical care, mental health problems, domestic violence and one of the biggest pre-Covid-19 public health problems in the United States — loneliness — are all magnified by in-home sheltering. The economic and public health harm associated with sheltering is yet to be fully measured.
At the same time, the coronavirus will persist. We must take proper care in how we reopen, lest we discount human life in the race to prosper. That would worsen already troubling trends, given that Covid-19 disproportionately affects disadvantaged communities dependent on public transit and in congested living conditions. Our path to reopen should protect those at high risk. The current “normal,” with its economic anxiety, skyrocketing unemployment and social isolation, can’t carry on — we should work toward a new status quo until there’s an available, mass-produced therapeutic.
So what does a new, safer status quo look like? It looks different in different parts of the country. Not all reopenings are created equal. Areas with continuing outbreaks or rising cases should postpone nonessential activity, and those with a declining case trend should engage in some basic practices.
We need universal masking. China gives the earliest preview of a reopened society after a harsh wave of the virus. And while the Chinese Communist Party has not been honest about its coronavirus handling, Chinese doctors and citizens have largely been transparent. I recently called some prominent Chinese doctors to ask why they believe the infection is being controlled in most of their country. In their clinical judgment, they believe the main reason is universal masking.
I’ve worn a mask most of my adult life as a surgeon, and I had been skeptical that masks would play a large role in fighting this pandemic. Most masks don’t have the seal and filtration to protect us from inhaling the coronavirus. But that’s not the only way they work. Masks reduce aerosolized droplet transmission to others and to surfaces that others may touch. They protect your mouth and nose from the droplets of others, and they prevent you from touching your nose and mouth.
Spend more time outside. Since April, we’ve learned a lot about indoor versus outdoor transmission of the coronavirus. Early on, we closed parks and told people to stay inside their homes. But studies have since shown that being outdoors with appropriate distancing carries a lower risk of getting the infection than being indoors. These findings have implications for restaurants and other businesses and activities that are able to use outdoor areas. Yoga and other fitness activities should resume outside when possible. Similarly, instead of having someone to your home for a meal, consider having a meal in your yard or at a park, six feet apart.
Business must adapt. One busy consumer-facing industry has already demonstrated how adapting to a virus-mitigation approach is feasible. Most grocery stores have been safely operating through the pandemic. Many are doing so by limiting the number of shoppers in a store, requiring masks, spacing out lines and alternating registers, installing plexiglass guards, cleaning incessantly and discontinuing some services like self-serve salad bars. The grocers have strict policies for workers with symptoms to not report to work, and some continue to pay them to avoid creating a financial incentive to not disclose symptoms. By adhering to distancing and hygiene standards, these businesses have proved that even at the peak of the pandemic, they can operate without becoming hot spots of contagion. These practices should be expanded to smaller businesses. If it’s not feasible for a business such as a cruise ship or an arcade to function with strict distancing, masks and impeccable hygiene, then that business should remain closed until it’s safe to reopen.
We must prioritize safeguarding nursing homes. Throughout April, several studies using antibody testing found that asymptomatic infections are 10 to 20 times more common than previously observed, lowering the true case fatality rate. The data also taught us that young, healthy Americans have a fatality rate similar to that of the seasonal flu. Deaths among those young and healthy are rare. (In fact, community immunity from seasonal viruses is often achieved through younger people developing antibodies.) About one-third of all Covid-19 deaths in America occurred among nursing home residents. In New Jersey, half of all deaths have been among long-term-care residents or workers. Nursing homes are often short-staffed and the last in line when it comes to getting needed resources.
Nursing homes should be not be allowed to house any Covid-19 patient unless the facility has isolation rooms and sufficient protective equipment, and tests all employees and residents for the coronavirus at least twice a week. Moreover, hospitals should be prohibited from transferring Covid-19 patients to nursing homes, a common transmission vector that has caused outbreaks in recent weeks.
Protect those at high risk. The data show that those with pre-existing medical conditions such as diabetes, lung disease or a weakened immune system are among the most vulnerable. Based on the degree of their risk and the prevalence of the virus in the region, we should advise these high-risk individuals, particularly the elderly, to avoid interactions with others until the risk of contagion is extremely low. This approach aligns with the White House’s return-to-work road map that shelters high-risk individuals until Phase 3, even as many businesses are reopened.
These practices will help optimize the health of the public 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.
Early on, we didn’t quite know what we were dealing with. But now that we have better information, we should use a more surgical approach to fight the virus to minimize the 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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