Trump could do a lot more.
President Donald Trump has given up on a coordinated federal response to the coronavirus pandemic, preferring to juke the states and argue that the country is overcounting deaths (even though the data pretty clearly demonstrates that the opposite is true).
What’s frustrating about this is that although the pandemic presents difficult policy problems, they are not insurmountable. Multiple countries have suppressed the coronavirus and brought domestic cases down to zero. America’s leading biological and social scientists say there is plenty the US can do here, too.
New: President Trump has complained to advisers about the way coronavirus deaths are being calculated, suggesting the real numbers are actually lower — and a number of his senior aides share this view, according to sources w direct knowledge. w @sam_baker https://t.co/n9Fs6J8oSi
— Jonathan Swan (@jonathanvswan) May 6, 2020
We’re just not trying. We’re not doing things that have worked in Asia, and we’re also not trying bold new ideas that American experts have dreamed up. We’re underresourced in combating the virus but have millions of people unemployed. And we’re worried about the economic toll of social distancing, but we’re not enacting economic relief measures that are equal to the scale of the problem.
Here are seven ideas collected from the work of dozens of experts in multiple fields that, if combined, would attack the pandemic from multiple directions simultaneously — aiming to make it safer and more sustainable to go about our lives, speed the development of a vaccine, reduce caseloads to manageable levels, and alleviate economic suffering.
1) Masks for all
Wearing masks is really important for reducing coronavirus transmission. A study by a team of five researchers out of Hong Kong and several European universities calculates that if 80 percent of a population can be persuaded to don masks, that would cut transmission levels to one-twelfth of what you’d have in a mask-less society. Widespread use of masks is likely part of the reason Japan’s coronavirus outbreak has been mild thus far, and grassroots mobilization starting with masks is almost universally seen as part of the Hong Kong success story.
For the broad population, the key fact is that while wearing a mask does little to protect the wearer from the risk of getting infected, it does a lot to prevent the risk that the wearer spreads the virus to other people. Consequently, an interdisciplinary Yale team featuring biologists, medical doctors, economists, and public health specialists calculates that “the benefits of each additional cloth mask worn by the public are conservatively in the $3,000-$6,000 range due to their impact in slowing the spread of the virus.” And the benefits of professional-grade masks for health care workers may be even higher.
The big problem is that, months into the crisis, the US continues to be afflicted by shortages of N95 respirators for medical personnel, never mind ordinary Americans. The situation has improved since early March, but not by nearly enough.
A huge barrier to increasing production of either kind of mask is that nobody knows how long high levels of demand will last. Prestige Ameritech, a Texas-based company and the largest American manufacturer of surgical masks in the United States, thought the surge in demand associated with the H1N1 flu pandemic in 2009 would be a godsend. But in a recent NPR interview, co-owner Michael Bowen recalls that efforts to scale up rapidly during that crisis nearly killed the company.
“We hired a lot of people and ramped up,” he told NPR’s Mary Louise Kelly. “And then we nearly went bankrupt afterward. We laid off 150 people and nearly went out of business. You know, it’s not like flipping on a switch. It’s building machines. It’s hiring people. It’s training people. That’s the issue.”
Caleb Watney from the R Street Institute and Alec Stapp from the Progressive Policy Institute suggest avoiding this situation with an idea that will recur several times on this list: The federal government should agree to pay above the pre-crisis market rate and guarantee that it will buy lots of masks and lots of respirators for an extended period. That gives business owners confidence to invest. The risk is that the country ends up “wasting” money on unneeded equipment if things end up going better than expected. But surplus equipment can be stockpiled so the US doesn’t get caught short in the next pandemic, or can be donated to lower-income countries that don’t have the financial capacity to engage in massive purchase guarantees.
2) Accelerate vaccines on all fronts
The science of developing safe and effective vaccines is difficult. But over and above the scientific issues, the process of demonstrating that a vaccine is safe and effective to the satisfaction of the Food and Drug Administration is time-consuming. We can speed it up.
A conventional phase three trial involves recruiting a very large sample of test subjects. Some of them get a vaccine (the safety of which has already been demonstrated in smaller trials), and the rest get a placebo. Then they’re told to go out and live life as usual, including normal efforts to not get sick. Because it’s fairly unlikely that any particular person will get sick on any particular day, it takes months to gather statistically meaningful information about the vaccine’s effectiveness. If it is effective, then you need to start manufacturing doses that will inevitably be scarce at first — short-term demand is sky high, but nobody wants to invest in manufacturing facilities that will be mostly idle in a year.
Bioethicist Nir Eyal, epidemiologist Marc Lipsitch, and vaccine specialist Peter G. Smith advocate speeding up that process with human challenge trials.
In a challenge trial, you deliberately expose the test subjects to the virus, allowing you to obtain data much faster and get away with a smaller number of participants. The downside is that a large share of people in your placebo group are going to get sick, and if the vaccine proves ineffective, people in your treatment group will get sick too. But the advocacy group 1 Day Sooner has lined up thousands of potential volunteers, and with reasonable safety measures — such as making sure you enroll young people with healthy hearts and lungs — the risks are relatively low and the benefits of speed are immense.
But there is still the problem of manufacturing. Bill Gates advocates spending billions of dollars to manufacture promising vaccines before they’re approved. This means money will be wasted on making doses of vaccines that turn out not to work. The upside is that many doses could be available soon after approval does come, saving many lives and carrying huge economic benefits. A team of economics professors — Susan Athey, Michael Kremer, Christopher Snyder, and Alex Tabarrok — pushed this logic even further, calling on the US government to create an advance market commitment that guarantees “to spend about $70 billion on new vaccines — enough to make direct investments to support capacity installation or to repurpose capacity and to pay, say, $100 per person for the first 300 million people vaccinated.”
The idea is that it’s hard to anticipate logistical snags and supply-chain bottlenecks. But if you commit in advance to spend lavishly on buying the finished product, you ensure that businesses start thinking now about how to create large-scale production and win the race to get those doses flowing.
3) More and smarter testing
South Korea had one of the biggest Covid-19 outbreaks early on, but it rapidly developed enough testing capacity to identify and isolate positive cases. In China, authorities have responded to the identification of six new cases in Wuhan with a crash program to test up to 11 million people in 10 days, by some accounts — after which all positive cases, whether symptomatic or not, can be isolated.
Widespread testing makes the pandemic much easier to manage. The Trump White House recognizes this implicitly, and it’s able to function with a reasonable approximation of normalcy precisely because the president, the vice president, and their top aides are all tested frequently. Because of that, White House staffers are reasonably certain they’re not infected and thus can do their work and even travel around the country. And thanks to frequent testing, if someone does become infected, they’ll be isolated rapidly and the epidemic won’t spread (as happened just last week with one of Trump’s personal valets and Vice President Mike Pence’s press secretary).
Paul Romer is an economist rather than an epidemiologist, but some calculations he’s made help illustrate the power of widespread testing. In a simulation that you can see for yourself on Romer’s website, he shows the virus could successfully be repressed by testing every American once every two weeks and isolating the positive cases, even with no additional contact tracing or social distancing. In fact, it works even if you posit that the test returns false negatives 20 percent of the time.
In the real world, the US is nowhere near doing 20 million tests per day. It’s also not forced to rely on tests as the sole countermeasure against the coronavirus. But the country should increase its testing capacity nonetheless.
A secondary problem, as Romer has explored in tandem with bioethicist and medical doctor Zeke Emanuel, is that could be testing the wrong people. The vast majority of current Covid-19 testing in the US is being used for diagnostic purposes, to tell if someone who’s sick is infected with the virus. This may have made sense in February, when lots of people had the sniffles and few people had Covid-19. But right now, you don’t need a test if you’re sick; rather, you should stay home and self-isolate — unless you’re worried you might need to be hospitalized, in which case you need a pulse oximeter to test your blood oxygen levels, not an RNA test for the virus.
Romer and Emanuel argue that as the US does more tests, it should “focus them on the people most likely to spread Covid-19, not sick patients.”
As my family’s dedicated grocery shopper, I am more likely to spread Covid-19 than my wife is. But I’m less likely to spread it than the people who work in the supermarkets, who in turn are less likely to spread it than the people who work in hospitals. For any given volume of tests, the priority should be on ensuring detection of cases among people who, if they are positive, are very likely to spread the infection to large numbers of other people. That will get us the most “bang for the buck” in terms of reducing infections. Then, as test capacity grows, more people can be tested.
Shifting from diagnostic testing to surveillance testing also helps with the problem of scaling up tests.
“Imagine a world in which the only way to get a soda is to get your doctor to write a prescription,” Romer writes. “It costs $20 per can. Your insurance company pays. The economy produces about 100,000 sodas each day. If you lived in this world, do you think you could get people to scale up the production of soda to a level of millions of cans per day? It would be a challenge, but not because it is hard to produce and distribute soda.”
His point is that for all the talk about specific bottlenecks to testing — swabs, reagents, etc. — the underlying malady is that the diagnostic business model doesn’t give anyone a real way to get paid for solving the problems of massively increased test capacity. A team of Rutgers researchers has received emergency FDA approval for a saliva-based test that doesn’t require swabs or trained health care personnel. But “no one has proposed a way to pay the researchers at Rutgers, or their peers in comparable laboratories located throughout the United States, for the tests they could supply.”
As in the PPE and vaccine cases, guaranteed purchase could make a huge difference. The federal government should be willing to pay for tens of millions of tests per day for a year. If America’s labs never get to that point, then at least we tried. And if the country ends up suppressing the virus surprisingly quickly and end up with too many tests, then it’s a small price to pay.
4) Hire more contact tracers
Romer’s idea of suppression through mass testing is an appealing theoretical construct.
But real-world suppression success stories have relied on a mix of ample testing with robust contact tracing. Asian countries, including Singapore and Korea, have been doing this with a variety of digital tools as well as old-fashioned elbow grease. The basic idea is that if someone working in, say, food delivery gets sick, you want to quickly track down everyone they’ve been in contact with — coworkers, household members, customers — because you know those people are at elevated risk for infection.
This basic kind of work has long been ongoing in the United States, but it’s mostly focused on HIV and other sexually transmitted infections. Dealing with Covid-19 would require doing it on a much larger scale. The Center for Health Security at Johns Hopkins recommends hiring 100,000 people to do this work for state and local agencies. Tom Frieden, a former director of the CDC, is calling for 300,000 tracers. That’s a lot of people, and it would cost a lot of money to pay them. But millions of people have lost their jobs recently in the United States, so it’s not as though the labor is genuinely unavailable.
The sheer scale of the pandemic, though, makes this daunting.
“I tend to be somewhat on the pessimistic side about contact tracing as a general control strategy,” Lipsitch told reporters on a call last week. “What we are pretty sure about is that contact tracing works well when you have relatively few cases, you have the resources to do it, and when you have even fewer cases that are unknown.”
None of that currently applies in the US. But the key point about contact tracing is that, as with testing, you gain benefits on the margin. We’re a very long way from Romer’s 20 million tests per day, but every additional test performed helps get a handle on the outbreak, especially if the US is able to be intelligent about whom it tests. And every additional contact tracer lets us be more intelligent about how we use our tests. Working in tandem, more testing and more tracing can slow the spread of the disease. And they’d be even more effective if the country did more to isolate people who do test positive.
5) Halt household spread
Another thing detailed contact tracing would let us do is speak more definitively to the question of how it is that people get sick in the first place. Right now we can’t do that, but we can look at studies from Asian countries that have done more extensive contact tracing and learn from them.
Muge Cevik, a virologist at the University of St. Andrews, did a helpful roundup of research from Asian countries, and paper after paper emphasizes that the attack rate within households is extremely high. A lot of people, in other words, are getting sick from roommates or family members.
New York Gov. Andrew Cuomo’s look at his state’s data paints a similar picture. Even though there’s an obvious sense in which people doing “essential” jobs are at elevated risk, older people who are staying home actually account for a larger share of cases.
New data from New York state suggests that new cases are not primary occurring among people working in essential services but among older people at home. Although, one might need to be careful with this. pic.twitter.com/ea152QkONJ
— Nate Silver (@NateSilver538) May 6, 2020
People staying home aren’t getting sick by magic, and transmission among people who are leaving the house is critical to keeping the epidemic running. But a key reason even serious social distancing efforts only bring case volumes down very slowly is that the virus spreads so easily inside households, meaning that one infection picked up at work could swiftly into two or three or four at home.
Current CDC guidelines call for infected people to “stay in a specific room and away from other people and pets in your home” and “use a separate bathroom.”
This is not practical in many cases. Not everyone has a large house and some people need ongoing care and attention. It also appears that the coronavirus could be spreading effectively through ducts, so it’s not clear that the CDC’s ideas would work even if rigorously applied. Regardless of the exact reason, the statistics signal it’s not working in practice.
Successful virus suppression strategies in Asian countries have all relied on one form or another of quarantining sick people (and sometimes their close contacts) outside the home so that transmission chains end sooner.
6) Let people go outside
Even as the federal government does too little to suppress transmission of the virus and as many jurisdictions seem excessively eager to reopen businesses that could potentially be dangerous for transmission, significant swaths of the country are living through outdoor space closures that are not necessarily well-grounded in evidence.
In Washington, DC, where I live, all the city-run parks are closed, along with the National Arboretum, Kenilworth Aquatic Gardens, and Fort Circle Park. Maryland has closed access to all beaches. And there seem to be endless rounds of wrangling on social media about whether too many people are out in this or that park in this or that city on a nice day.
Outdoor air is not magic, and it is possible to inhale droplets from another person’s mouth outside. But the evidence seems to indicate that outdoor transmission is not, in practice, a huge problem. A detailed study of public outdoor spaces in Wuhan, China, found “undetectable or very low” levels of virus everywhere they looked. A study of more than 1,000 confirmed Covid-19 cases in other Chinese cities could only document one case of outdoor transmission.
Former FDA chief Scott Gottlieb has stated that he wants states to encourage more business and social activity to happen outdoors.
Studies suggests activities held outdoors as temperatures warm pose lower covid risk than those done in confined indoor spaces. As we re-open, states should look to ease rules to allow more recreational, religious, and business activities to occur outside. https://t.co/6AVfr4TiMi
— Scott Gottlieb, MD (@ScottGottliebMD) May 6, 2020
Whether or not one goes that far, a few things seem clear:
- Outdoor transmission of the virus should not be a primary concern.
- Spending time in outdoor recreation is, in general, a healthy thing for people to do.
- Restricting access to outdoor spaces makes the remaining ones more crowded and therefore could be counterproductive.
- It’s better for people to follow social distancing guidelines rather than flout them, but if they do break the rules or skirt the edges, it’s likely safer to do it outside rather than inside.
Last but by no means least, letting people go outside can be helpful because it helps make restrictions on activities more socially and psychologically bearable. Current political debate has featured a fairly overwhelming emphasis on the idea of “opening up the economy,” but the government could actually do an enormous amount to cushion the economic blow by spending more money. But fiscal stimulus can’t replace the mental health benefits of fresh air and sunshine.
7) Just spend the damn money
The recommendations on this list add up to a few hundred billion in total spending. That’s both a lot of money and a drop in the bucket compared to what Congress has already appropriated for coronavirus relief efforts. Given that the country could be contemplating a procession of five-figure death toll week over week, the case is strong for simply spending whatever it takes on genuinely useful suppression measures.
The bigger issue comes in the opposite direction.
There is a perception, rightly or wrongly, that social distancing measures are inflicting horrendous pain on the economy and state governments are feeling intense pressure from business owners to lift restrictions. In reality, it’s far from clear that the restrictions (rather than the pandemic itself) are the actual economic problem. Regardless, the view of many leading economists is that there is a better way to alleviate economic problems: Spend more money.
Right now, the interest rate the federal government pays on its bonds is less than the expected rate of inflation. This means that even as debt reaches eye-popping levels, it’s actually relatively affordable for the government to go deeper into debt, and there’s little reason to let financial concerns per se stop the country from doing what’s right for public health.
Claudia Sahm, a macroeconomist with the Washington Center on Equitable Growth and a former staff economist at the Federal Reserve, emphasizes that Congress “must commit to stay the course and provide relief until we are all back on track,” which means “a trigger based on economic conditions to determine when the relief can be phased out” rather than an arbitrary time limit.
There are two big buckets where more money would be helpful. One is Sahm’s longstanding proposal to simply send money to everyone on a regular basis as long as economic help is needed. The second major bucket of need is fiscal help for state and local governments that don’t have the federal government’s borrowing power. Despite Senate Majority Leader Mitch McConnell’s efforts to characterize this as a “blue state bailout,” all states like having money. If GOP-dominated states don’t want to use their extra money to finance state spending, they can always cut taxes. The point is, there’s little reason for states to be running out of money when the federal government can borrow in essence for free.
Last but by no means least, we need to do something to support America’s small businesses. The Paycheck Protection Program is too complicated and prescriptive to work. In a policy brief for the Economic Innovation Group, Adam Ozimek and John Lettieri propose giving zero-interest loans equal to up to the lesser of $5 million or 200 percent of 2019 operating expenses. This could help ensure that no business with a realistic long-term future needs to close due to a pandemic-related fall in demand, meaning that restrictions could stay in place as long as is prudent without jeopardizing entrepreneurs’ livelihoods or imperiling the long-term structure of the American economy.
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