As coronavirus infections rise across the United States, public health experts widely agree it's time for a drastic step: Every state in the nation should now issue the kind of stay-at-home orders first adopted by the hardest-hit places. And while most states will probably not need to keep the rules in place for months upon months, many health specialists say the lockdowns will need to be kept up for several weeks.
Yet among these same experts, there is debate when it comes to the natural next question: What strategy can be deployed after the lockdowns are lifted?
Here's the breakdown of what health experts are saying about each issue.
The arguments for enacting a lockdown
We'll start with the call for a nationwide lockdown. On this point, "there is no question about it," says Juliette Kayyem, a former assistant secretary of homeland security who is now faculty chair of the homeland security program at Harvard's Kennedy School of Government. "We are seeing community spread in every state. You need the nation to shut down."
In fact, state officials should have taken this action at least 10 days ago, argues Ashish Jha, director of the Harvard Global Health Institute, one of a number of public health professionals who for weeks have been urging states to be more aggressive.
"At this point, there's really no good excuse for any state official not to have these policies in effect," says Jha.
He notes that when the virus is left unchecked, it infects people at an exponential rate. Each sick person passes it on to something like two to three others — who then spread it to the next two to three people, and so on, such that a single case quickly leads to thousands.
Social distancing dramatically slows this process by reducing opportunities for people to interact face-to-face and infect each other. Evidence from China, northern Italy and, most recently, New York — the U.S.'s current hot spot — suggests that even after the virus has spread widely, strict social distancing can eventually bring the number of new infections down.
But, says Jha, "if you wait until the disease is out of control in your community you're going to have to implement those social distancing policies for much, much longer," to stop the upward spiral of new infections.
Moreover, adds Jha, "you're still going to have to deal with the fallout of all the people who got very sick and ended up overwhelming the health care system. Many of them will end up dying because of that delay."
So far 13 states have enacted the strictest combination of restrictions — closures of all nonessential business as well as a prohibition on all gatherings — according to an analysis by the Kaiser Family Foundation.
Many other states have opted for measures that are weaker — for instance, declining to shut businesses, and limiting their prohibitions on gatherings to groups of more than 10 or even 50 people. Some states have no statewide limitations whatsoever on either gatherings or business operations other than restaurants. These states include Arizona, Arkansas, Florida, Georgia, North Dakota and Utah.
In several of them, the number of people with positive tests for the coronavirus is relatively low: no more than several hundred, compared with the tens of thousands now infected in New York.
Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases and a key leader of the administration's COVID-19 response, said, in an interview with NPR on Thursday, that a "uniform" nationwide shutdown is not warranted because of the variation in rates of infection across states.
"I mean, obviously, you always keep an open mind that you might have to revert to something like that," said Fauci. "But there are regions of the country where rather than shut down, we should be doing ... containment."
Fauci then described a strategy of seeking out and identifying people with symptoms, testing them, isolating those who have the virus and tracing their contacts. Later Thursday, President Trump released a letter to U.S. governors stating that his administration would soon be issuing guidelines to determine which states could ease up on social distancing and follow such a containment approach.
This is also essentially the strategy that many public health experts hope the U.S. can ultimately pivot to in areas where the number of infections is low.
But Jha and others maintain that right now, the U.S. lacks the testing capacity to do containment this way. In fact, says Jha, the U.S. is still so behind on testing that it's impossible to know whether a low number of official cases in a particular city or state isn't actually masking a brewing hotspot.
In the interview with NPR Fauci conceded that, "to be honest, we don't have all that data now uniformly throughout the country to make those determinations."
In the meantime, health experts such as Jha argue that even places with low numbers of confirmed coronavirus cases should operate on the assumption that there may be a substantial amount of transmission in their midst that is going undetected.
In Arizona, for example, more than half of those who have been tested have been found to have the coronavirus. That's a troubling sign, says Jha. "One thing we know is that if more than 10 to 15% of your tests are positive, you are probably not testing enough. You want to be testing a lot of people because that's how you capture all the positive cases."
Arizona's status is particularly concerning to Jha because the state has a larger-than-average share of older residents – and the virus kills older people at vastly higher rates.
Two other states with less stringent social distancing rules where the trend also seems worrisome, he says, are Florida and Texas. "These are places that are likely going to end up seeing big increases in their numbers of very, very sick people. And we'll have wished that they had taken a pause much earlier," says Jha.
In Florida more than 300 people have already been hospitalized with COVID-19 – one of the highest totals in the country, according to data compiled by the COVID tracking project, a volunteer group of journalists, scientists, and other data specialists. Yet Florida Gov. Ron DeSantis has resisted calls to issue a statewide shelter-in-place order even as several counties have adopted their own versions.
Florida's ratio of confirmed coronavirus cases to its overall population also now appears to be at a level similar to that of New York's barely 10 days ago. And this is the case in nearly 20 other states as well.
So why aren't all states rushing to put their residents under effective lockdown? One reason may be mixed signals coming from the Trump administration about how necessary or urgent these measures are.
Fauci's comments to NPR are only the latest example. On March 16, the president issued guidelines urging all Americans to work from home if possible and to avoid gatherings of more than 10 people as well as discretionary travel and eating out. But the guidelines were proposed for a period of just 15 days — which means they expire on March 31.
In recent press conferences, the president has also repeatedly decried the economic and social cost of extreme social distancing and said he remains hopeful that by Easter — which is April 12 — the measures may no longer be needed in many locations.
Technically, the power to enact social distancing rules lies with state authorities. But they often take their cues from the federal government.
Jha, who has been fielding calls from a number of governors weighing tighter restrictions, says another reason for their hesitancy is uncertainty over the end game. "They want to know when can they un-pause. What are the criteria they're going to be able to use to go back to normal?"
In other words, what is the strategy post-lockdown?
On this point, there is a wider range of views among public health experts. Here's a sampling.
Test, trace and isolate
Both Kayyem, the former homeland security official, and Jha stress that extreme social distancing is a temporary measure. The aim is to keep the number of infections across the United States low while authorities ramp up sufficient hospital beds and testing capacity to pivot to a stage two strategy that sounds a lot like the "containment" effort Fauci spoke of. There would be widespread testing to identify and isolate positive cases and their contacts. South Korea has demonstrated some success with this model.
Kayyem warns that any shift to this approach will likely take place gradually and at a different pace for different regions. "This does not happen in a day," she says. "The lights don't go on at the same time everywhere. We have to think of the recovery as much more fluid."
And she adds that even after movement restrictions are lifted, it's likely there will be flare-ups of COVID-19 infections in particular states or cities. This will require reimposition of extreme social distancing measures there, says Kayyem, likening the approach to "a game of whack-a-mole."
'We're really in a big dilemma'
Marc Lipsitch, a professor of epidemiology at Harvard, is less optimistic. He says his group's models of how the virus spreads suggest that as soon as a freeze on movement is lifted, cases would rise so rapidly that "we'll spend much more time in freeze mode."
But he recognizes that this is a problematic conclusion. It would be devastating to keep large swaths of the country in lockdown for the roughly 18 months it's expected to take until a vaccine can be developed, he says. And the pain would not just be economic. The resulting poverty would lead to widespread deprivations and even death.
On the other hand, says Lipsitch, without broad movement restrictions, tens of thousands and even potentially millions of Americans will die of COVID-19 — not to mention those with other illnesses and health emergencies who may suffer because of the breakdown of the health care system.
"I think the unfortunate fact is that the two options we know about are both essentially unacceptable," says Lipsitch. "I think we're really in a big dilemma."
Accept the inevitable and start making the hard choices
Michael Osterholm, director of University of Minnesota's Center for Infectious Disease Research and Policy, also worries that a phase two test-and-isolate strategy may not be feasible. But his view stems from his conviction that the U.S. will never be able to build enough testing capacity.
Osterholm notes that the chemical reagents needed to run coronavirus tests are already in short supply. Over the coming weeks and months, worldwide demand will only exacerbate the problem.
"We are literally within three to four weeks into the complete implosion of testing in this country," says Osterholm. "So don't plan an extensive national effort around testing, only to find out in a couple of weeks we can't even do it."
Instead, says Osterholm, the U.S. should face up to the likelihood that throughout the entirety of the outbreak, there will be shortages of not just testing but also of most other necessary medical supplies. By failing to acknowledge this reality now, he says, the U.S. is wasting valuable time needed to make the hard choices about how to soften the blow when the inevitable wave of cases washes over.
For instance, he says, officials will need to find less-than-ideal, but creative ways to reduce the need for supplies such as protective equipment for health workers. One option, he says, would be to place infected patients in massive wards such that doctors and nurses don't need to keep putting on and taking off the protective gear.
Osterholm says the U.S. also needs to think of ways to protect the elderly and other populations that are especially vulnerable to the virus, even as we accept that much of the rest of the population will get infected.
He does not discount the difficulty of trying to cocoon elderly people.
"Do I think that it will stop all people from getting infected in that age group? No," says Osterholm. "But I do think that's our best chance at reducing the number of cases that present to our health care systems."
As unpalatable as all this may sound, says Osterholm, compared with the test and isolate strategy that others are championing, his approach is at least realistic."I don't want the impossible becoming the enemy of the doable," he says, "and I think that that's where we're at right now."
But like so many other public health experts, Osterholm too, argues that a nationwide freeze is absolutely necessary right now.
It's the only way, he says, that the U.S. can buy enough time to put in place a plan for the onslaught that's coming.