Smart Reopening

Coronavirus Roundup, Part 3

How can you be smart in a "dumb reopening"?

When the state and local government lockdowns were first announced, I referred to Stein's Law: "If something cannot go on forever, it won't." The lockdowns can't go on forever, so they're already being lifted, partially and piecemeal. But as I warned in the last installment, we're not getting a "smart reopening" with testing and contract tracing. We're getting a "dumb reopening," in which lockdowns were not used as a transition to a better system. We took the pain of economic closure without the full gain of a system to contain the spread of the virus.

This leaves us, as individuals, free to make more decisions about what we're going to do or not do—so we had better figure this out based on the best information available. What should we do?

Isolate the Vulnerable

One of the lines we're hearing about coronavirus is that we should isolate the vulnerable while letting the young and healthy go about their lives. That sounds like good advice—but those who give it tend not to acknowledge how hard it is to implement.

If we were to isolate the vulnerable, for example, might we send the very elderly and infirm to special care facilities—in other words, to nursing homes? Yet those are the places that have been notably un-isolated. One of the signatures of this pandemic is that between a third and half of all deaths have resulted from COVID-19 tearing through nursing homes.

That's partly because nursing homes, by their nature, contain the highest density of those who are at top risk of dying from the virus: older people with pre-existing health problems. But it also highlights the inherent problem with isolating them. The old folks who live in nursing homes are cared for by young people who do not live in nursing homes. If a disease is running rampant through the rest of society, it is going to make its way into nursing homes by way of gardeners, cooks, nurses, and so on. Moreover, because they have pre-existing health problems, nursing home patients are also going back and forth to hospitals, which are seeing a lot of COVID-19 patients and have become hot spots for infection.

This leads health-care analyst Philip Klein to question what "isolate the vulnerable" even means.

Nursing homes have been the hardest-hit places, with tens of thousands dying as the virus has spread like wildfire among the vulnerable populations there.... Removing the elderly from these facilities would run counter to the strategy of isolation. If they came home to live with grown children, for instance, they'd be exposed to individuals who would be, under the reopening strategies, participating in society.

Sharing a household, by the way, is one of the the strongest mechanisms for spreading the virus. If one person in a household is going out into the big, bad world and gets the virus, then everybody gets it. That takes us back to Klein's point.

The United States has 51 million people over 65. There are 103 million people with high blood pressure, over 100 million with obesity, and 34 million have diabetes. Now, you can't simply add up all of these numbers, as some people will fit into multiple categories. But were you to add up everybody who fit into at least one of these categories (or who had different underlying health conditions) and then take into account those who are in regular contact with somebody who fits into these categories, the pool of people who could simply go back to normal under this 'isolate the vulnerable' strategy dwindles considerably.

What this does mean, though, is that there is a lot to be accomplished by doing a better job of isolating the nursing homes. Jim Geraghty criticizes the responses of state governments.

You could make a strong argument that the country's deadly coronavirus problem is largely a nursing home problem, dangerous everywhere but far more prevalent in a half-dozen or so of the country's more heavily and densely populated states. What's more, many of these states enacted coronavirus response policies that likely put nursing and assisted-living home residents at higher risk for infection....

Right now, a lot of people really want to believe that as bad as the coronavirus outbreak is, the consequences have been mitigated by good decisions made by governors like Gavin Newsom, J. D. Pritzker, Gretchen Whitmer, Tom Wolf, Phil Murphy, and Andrew Cuomo. But those governors, whatever their other strengths, all presided over state governments that served their nursing homes and assisted living facilities poorly—either through an inability to provide protective equipment (Illinois), insufficient attention (Pennsylvania), or by sending recovering but still contagious patients back into buildings with lots of other vulnerable elderly (California, Michigan, New Jersey, and New York).

An overview in The Atlantic emphasizes poor funding.

"If you're looking for the perfect scenario for a virus to pass quickly through a population and kill a lot of them, look no further than a publicly funded nursing home." Most of Canterbury's residents, as is the case in many nursing homes, pay through Medicaid, which provides the facilities with limited reimbursement. That underfunding means that many residents live in cramped quarters, forced to share bedrooms and bathrooms, which can make limiting the spread of infection difficult....

But the most consequential deficiency of America's long-term-care system could be that the country's most vulnerable people are being cared for by workers who are themselves extremely vulnerable—a dynamic that has contributed to the rapid spread of the virus.... Certified nursing assistants and personal-care aides, whose jobs involve close-contact tasks like bathing and feeding, are some of the lowest-paid health-care workers in America. Many hold multiple jobs to make ends meet, which increases both their exposure to the virus and the chances that they'll pass it to a resident.

The takeaway comes from health-care-policy professor David Grabowski: "Nursing-home residents aren't getting half of our resources or half of our attention, yet they account for roughly half the deaths."

How does this influence how you act? Well, for one thing, this is a reason to maintain a high level of social distancing, not as an alternative to isolating the vulnerable, but as a way of doing so.

Chain Reactions

Jack Wakeland has been trying to talk me into walking you through the mathematics of how infection risk accumulates in a pandemic, and he gave me a very detailed and extremely interesting analogy to nuclear chain reactions in the core of a nuclear power plant. Maybe I'll go into all of that some other time, but for now I'm going to cruelly disappoint Jack and act like a humanities major by reducing it all to a literary metaphor, because I like the idea of comparing a contagion to radiation—particularly because this is something people are thoroughly trained to be scared of.

Every interaction you have with another person is potentially like another act of fission in the core of a nuclear reactor: you get could get hit and the particles you emit could hit others, and so on in an expanding chain reaction. That's exactly how contagion works. I mentioned in the last installment the story of contact tracers following up on a single individual who went out for an evening at Seoul's nightclubs. Here's the follow-up to that story.

More than 22,000 people have now been traced and tested in connection with the outbreak of COVID-19 at nightclubs in Seoul. 119 people are infected so far. 76 were people who visited the clubs. 43 were secondary infections.

That's from one guy going bar-hopping—and note that more than a third are "secondary infections," one step removed from the original.

The more interactions between people and the closer they get to one another, the higher the level of infectious "radiation," so to speak—the higher the presence of the virus among the people moving around you in the world, and the greater the speed with which it transmits. Living in a low-radiation world is going to be safer, both for you and for those you care about, than living in a high-radiation world. That's why maintaining as much social distancing as possible is still going to be a good idea.

The upshot is that "isolating the vulnerable" does not imply we can just end social distancing for the young and healthy, because social distancing by the young and healthy is an important way of helping to isolate the vulnerable, by reducing the intensity of the ambient "radiation" of infection in the outside world.

Similarly, people have complained that the canceling of elective procedures in hospitals (a policy that is now being lifted as the worst of the fist wave passes) will have its own cost in lives, since serious conditions may go undetected. But elective procedures are, by definition, those that are not believed to be urgently necessary. The higher death toll is probably going to come from more serious problems, such as heart attacks, for which people voluntarily choose not to go the hospital because they are afraid of getting infected. It's not a totally irrational fear, either. In the early days of coronavirus in the UK, for example, hospitals were hot spots and the main centers of transmission. Social distancing that keeps the transmission of the virus at a lower level will make hospitals safer places to go for those who do have urgent need of them—which might be you or someone you love.

Yet not all social distancing has an equal impact. This virus transmits much more easily in some circumstances than in others.

Café Society

As they say in business jargon, you start by picking the low-hanging fruit—making the easy and obvious changes that will produce a high reward.

A lot of people have been recommending a biology professor's very good overview of the science on this. I recommend you read it, and I'll echo some of the results here.

In the case of social distancing, the low-hanging fruit is the great outdoors. From the beginning of this pandemic, the evidence has indicated that the virus does not spread easily outdoors. You just aren't in close enough contact for the airstream coming out of an infected person's lungs to send an infectious dose of the virus into your lungs. That happens mostly from "close and prolonged contact," usually in an enclosed space. This is why the biggest hotspots right now, behind nursing homes and households, are prisons and meat-packing plants. (Meat-packing plants have the additional disadvantage of being refrigerated, which prevents spoilage of the meat but also helps preserve the virus.)

Transmission outdoors and in open spaces, particularly where people can maintain a good social distance, is relatively unlikely. Hence, Maryland just announced that it is lifting restrictions on "golfing and tennis, outdoor fitness instruction, recreational fishing and hunting, recreational boating, and horseback riding."

Restriction on parks and beaches were not completely crazy. The problem is that when people go to the beach, they don't just go to the beach. They stop to fill their gas tanks, go to the store to pick up food, crowd next to each other in the parking lots, and—this is probably the biggest problem—need to use public restrooms. They end up in enclosed spaces next to other people and making contact with surfaces recently used by others. Remember when I said earlier that every interaction raises the general "radioactivity" level.

Yet with a lot of precautions to address those problems, outdoor spaces can be regarded as relatively safe.

It is still very unclear whether warmer weather will cause the threat from the virus to recede, as it does with the ordinary flu. Results in tropical locations like Singapore, or the spread of COVID-19 to new hot spots in South America, indicate that we won't get a summer respite. But the warm weather will help in one respect: it will make it possible to move a whole range of activities outdoors.

Many restaurants have actually managed to make it through the shutdowns by offering carryout food. (Places built around carryout have flourished. For Papa John's, "April was the strongest sales month in the company's history.") But one suburb of Chicago is converting part of its downtown into a pedestrian mall that restaurants can fill with widely spaced outdoor seating. Cincinnati is doing it on an even larger scale.

I suspect we might see shops opening up outdoors, too, throughout the summer, as a way for retailers to reopen with a relative degree of safety. We are going to become a café society, out dining al fresco on the streets, for as long as the weather permits.

The Work-from-Home Utopia

What are the worst places to be for the transmission of the virus? Large gatherings, like concerts and conferences, are an exceptionally bad idea. These are super-spreader events and will almost certainly remain banned. This is also, in my opinion, the clearest legitimate use of the government's quarantine power. If they could shut down the theaters because of the plague in Shakespeare's time, we can do it now. Until we either have a vaccine or a highly effective test-and-trace system, holding large events is inherently reckless.

This will hit a relatively small portion of the economy very hard. Hotel chains and airlines will be in trouble. Cruise ship have gone dormant and will remain so until there is a vaccine or a highly effective treatment. Musicians, actors, and athletes are all going to either lose a year of work or will have to take big steps to adapt—going online, finding ways to perform in widely spaced outdoor venues, or holding sports events broadcast from empty stadiums. Movie theaters were already on the ropes, facing competition from big high-definition TVs and online streaming. They will have to stay closed for a while and may not survive, unless Jeff Bezos buys them out.

The venues that are also dangerous, but harder to do without, are indoor restaurants and offices.

Two diagrams have been going around to illustrate this. One showed the spread of COVID-19 through a restaurant in China, driven by the airflow from an air conditioner. This is a virus spread by micro-droplets of water exhaled from the lungs, which can hang around in enclosed spaces and sometimes move through ventilation systems. The other chart shows the spread of COVID-19 through a South Korean call center, where workers were talking all the time and packed closely together with no barriers between their desks.

I've already mentioned how restaurants are adapting by offering carryout or serving customers outdoors. As for offices, one of the silver linings of this pandemic is that it just might be the thing that finally kills the "open plan" office. Or maybe they'll just have cubicles with higher walls.

The fact that this virus spreads in office buildings—including the White House—also implies that working from home is going to be normalized, not just for the few weeks of this initial shutdown, but for the duration. As someone who has worked this way for many years, I regard this as the ideal and will refer you to my somewhat subversive recommendations for how to do it.

Public transportation is another potential source, and the notoriously crowded New York City subways have been blamed for the outbreak in New York—though there is some controversy about the actual extent of the effect. Seoul, for example, has kept its extensive commuter system running throughout this crisis with the benefit of intensive cleaning. This might be a bit too much to expect from the New York City Transit Authority.

The New York Times has a helpful infographic that uses cellphone data to measure which kinds of businesses tend to be most crowded and have customers linger the longest.

The bad news: you probably won't be going back to the gym, a place where people tend to spend a long time breathing heavily and touching surfaces that others have recently contacted.

The good news: "The existence of super-spreader businesses might seem like bad news. In fact, it means that most of the disease-spreading risk generated by the economy is concentrated in a small portion of it—-which means that we can resume a lot of economic activity with minimal risk." That seems a bit too complacent to me. It's getting to the point where I now know a few people who have contracted this locally, even after taking some precautions. So the risk is not quite that "minimal." But more economic activity will be possible.

They're Terribly Comfortable. I Think Everyone Will Be Wearing Them in the Future

What about masks? There is some controversy over how much difference they make, particularly the homemade cloth versions we're all getting because we need to save the good stuff for the hospitals.

Outdoors, for the all reasons we've discussed, masks are mostly irrelevant and are not usually required. Indoors, they might make a difference, but the consensus is that they do more to protect others from you, by catching your coughs and sneezes, than to protect you from others—an idea rather memorably illustrated here.

This is still a good reason to wear them, and at any rate, loudly refusing to wear one does not make you Rosa Parks or a GI storming the beach at Normandy. It just makes you kind of a jerk. I think Jonah Goldberg has pegged it: This is the fight you pick when you regard the culture war as an end in itself, permanent, self-perpetuating, and drawing everything into its framework.

Compared to everything else that is happening right now, requiring you to wear a mask in indoor spaces is the least intrusive, least inconvenient thing anyone can ask. If it only makes a small difference in preventing you from getting infected, every little bit helps, and it certainly is not a sacrifice.

School's Out Forever

The biggest inconvenience many of us have to face is having the kids home from school. I won't call it a sacrifice, because I love them. But it can be a challenge, and I'm also mindful that, as much as we try to do over Zoom or by home-schooling, my kids would be better off being able to go to their school.

So when I hear the suggestion that children not only are far less susceptible to becoming ill from coronavirus but are also far less likely to transmit it, this is the one piece of information I really want to be true. If kids are not spreaders of this disease (as opposed to just about every other disease on the planet), then summer camps can open and school can restart in the fall.

Matt Ridley recently made that suggestion.

In sharp contrast to the pattern among the elderly, children do not transmit the virus much if at all. A recent review by pediatricians could not find a single case of a child passing the disease on and said the evidence "consistently demonstrates reduced infection and infectivity of children in the transmission chain." One boy who caught it while skiing failed to give it to 170 contacts, but he also had both flu and a cold, which he donated to two siblings. Children appear to have ACE2 receptors, the cellular lock that the coronavirus picks, in their noses but not their lungs.

But Ridley wrote this as part of a larger piece describing how much we don't know about this new virus, and I'm afraid he forgot his overall message for a bit. I've been trying to track this down, and I have concluded that the data is just not there yet.

Ridley wrote this in response to some early reports in the British media indicating that kids are in the clear. But in response to those reports, the Royal College of Pediatricians and Child Health felt the need to clarify.

A number of media reports, citing RCPCH, have incorrectly suggested that children cannot transmit COVID-19. This is not the RCPCH position, nor is it based on evidence.

Our own research and evidence summary explicitly states that the evidence about children in transmitting the virus remains unclear, in particular given the number of asymptomatic cases.

Moreover, there are some new studies that sound a lot less promising.

In one study, published last week in the journal Science, a team analyzed data from two cities in China—Wuhan, where the virus first emerged, and Shanghai—and found that children were about a third as susceptible to coronavirus infection as adults were. But when schools were open, they found, children had about three times as many contacts as adults, and three times as many opportunities to become infected, essentially evening out their risk.

Based on their data, the researchers estimated that closing schools is not enough on its own to stop an outbreak, but it can reduce the surge by about 40 to 60 percent and slow the epidemic's course.

Moreover, COVID-19 has proven to be a strange disease with a lot of varied and unpleasant effects. One of them is a syndrome that seems to be hitting kids who have had coronavirus infections, but on a delay.

[D]octors in Westchester County are now warning that some kids presenting with this 'pediatric multisystem inflammatory syndrome' are not showing symptoms until as long as six weeks after exposure to the virus....

Dr. Ofori said some patients have developed heart problems and low blood pressure that led to shock. He explained that some had been diagnosed with COVID-19 2-3 weeks before these symptoms developed.

"Whether the underlying condition is COVID-19 or the body's response to COVID-19 is not known at this time. While it is too early to definitively say what is causing this we believe it is important to alert the public as to what we are seeing" he said.

This is still fairly rare, but we have an understandably lower tolerance for health risk for children.

This is one of the big remaining unknowns, and it bears close watching. Don't get your hopes too high. It looks to me as if opening the schools on any kind of large scale will happen after we contain the spread of the virus everywhere else, not beforehand.

Not getting our hopes up seems to be a good note on which to introduce a discussion of coronavirus treatments.

The Toolbox

One of the problems we've had in gauging the prevalence, the deadliness, the risks, and the potential treatments for COVID-19 is the fact that, in an attempt to speed up the science, a lot of scientific papers have been released early, in a "preprint" form. This "pandemic research exceptionalism," combined with a huge amount of interest from non-scientists (many of whom overrate their ability to evaluate the science), has led people to latch onto a series of dubious claims that end having to be downgraded or retracted.

We can speed up some of this science, but not that much. Time will be needed for critical review, more sophisticated analysis, and more and better data. So don't get too excited by the latest glimmer of hope for a radically accelerated vaccine or a miracle cure.

A good Washington Post overview describes the growing "toolbox" of treatments that doctors are developing.

The menu of treatment options, tried singly and increasingly in combination, includes the blood plasma of COVID-19 survivors, a rich source of antibodies that may help neutralize the virus; drugs to suppress the body's own immune response, which some believe goes into hyperdrive as it tries to fight an invader; anticoagulants, which decrease the risk of deadly clots, and finally, antivirals, such as remdesivir, the Gilead Sciences drug that recently won approval for emergency use from the Food and Drug Administration.

Randomized clinical trials are necessary to confirm early anecdotal data, with the results probably months away. But doctors say they believe they are seeing some positive results from these and other things they have learned through trial and error these past 10 weeks....

While doctors are still a long way from having a full picture of the virus and its effects, "it is a different world today," said David Reich, a cardiac anesthesiologist and president of Mount Sinai Hospital in New York City.

So far, one of the main focuses for treatment has been taming the "cytokine storm" that is believed to be the cause of the most severe reactions, and finding effective preventive treatment for this could knock down the fatality rate to a much lower level. That still leaves the question of how such treatments will affect the long and brutal recovery process that many survivors face.

I am, as you know, an optimist. For the most part, our political leaders have fallen down on the job, which I hope was not a surprise to you. But we will find way to adapt and survive this, by reducing the deadliness of the disease, by reducing its opportunities for it to transmit, and by finding ways to do our work and engage in commerce more safely.

Remember that this is a "dumb reopening." We haven't earned this reopening the way some other countries have, by containing the virus, so you will need to compensate by following your own extra layer of precautions. I hope I've given you some of the information you need to make your own personal reopening a smart one.

Be careful out there.