U.S. Can’t Beat Coronavirus, But Americans Can Cope With It
(Bloomberg Opinion) -- Lots of Americans have been disappointed by the inability of their leaders to speedily deploy the tools public-health experts prescribed to contain the spread of the coronavirus: mass testing, contact tracing and isolation of people who are infected. As states ease life-saving lockdowns that devastated the economy, it’s reasonable to wonder whether the U.S. is catching up, or whether there are other ways to prevent a recurrence of the public-health emergency that struck in March. To find out, the economist and Bloomberg Opinion columnist Michael R. Strain spent a few hours this week with Dr. Scott Gottlieb, his colleague at the American Enterprise Institute and a physician, investor and public-health specialist who led the U.S. Food and Drug Administration for two years ending in 2019. His forecast was sobering but far from hopeless. These are excerpts of their conversation.
Michael R. Strain: The U.S. has partially reopened without adequate test-trace-isolate capability. What is the second-best strategy? It surely isn’t simply to hope for the best.
Scott Gottlieb: Some states have been implementing pretty good programs to do testing and contact tracing. No state has the optimal system in place, but we will probably never have the optimal system. I think states have made a lot of progress.
In addition, we’re hopefully going to benefit from reopening during the summer. We don't know how significant that's going to be, but cases should come down. We may have nothing more than a slow burn through the summer, as happened in 2009 with the H1N1 “swine flu” pandemic. Then, we weren't social distancing and we didn't cancel the baseball season and we were going about our normal lives. H1N1 emerged in March and April, became epidemic, spread all the way into June, and then in July and August it sort of collapsed. Now granted, H1N1 was less contagious than the coronavirus, but it demonstrated what we believe, which is that respiratory diseases don't spread efficiently in the summertime.
MRS: So maybe we catch a break with the weather. But where does that leave us in the fall?
SG: I think that sets up challenges for the fall. We're going to have enough virus circulating when we head into the fall that it's going to set up the potential to ignite. But by then, adequate screening and contact tracing should be there, even if we aren’t there right now. The funding's there. It's not like we're going to get caught off guard. The only reason we wouldn't have what we need by the fall is if we're not taking the steps that we should be over the next two, three months.
MRS: But not every state will take those steps over the next few months, right? Many won’t?
SG: Some states won't, but I think a lot of states will. We're going to have multiple new testing systems authorized and on the market by the fall. Each one will be able to handle 1 to 2 million tests per week. And you’ll have the tests we are currently relying on, which could grow to 500,000 tests per day. So we should have the testing we need by the fall.
We’ll also be able to do pooled samples using next-generation sequencing. We can literally pool 50, 100 or 1,000 employees, test the pool once, and if you get a hit, then you go back and screen each individual person.
MRS: Everybody just spits in a cup?
SG: Everyone spits in a cup and you pour the cups together. Yeah. And literally that's what you would do, you'd do spit tests. So that’s a long way of saying that we're going to have massive screening capacity. The challenge in the fall isn't going to be the ability to run a test, it’s going to be the ability to collect the samples.
MRS: What do you mean?
SG: I think there are going to be a lot of places that are going to have an installed base of testing equipment that probably aren't going to want to test people. Pharmacies aren't going to want to bring testing into the pharmacy, because they're going to be worried that it will discourage customers from going into the pharmacy. Physicians might not want to test in their offices because they're going to be worried about the implications of having a Covid-positive patient in an office environment, where the public health authorities might say, you now have to shut down your office for 24 hours and do a deep cleaning and test your entire staff. And so you might see Covid testing sort of relegated to certain Covid-only testing sites. And if that's the case, we're going to be limited in the ability to collect samples.
Going into the fall, we're not going to have enough places that can easily collect samples so that we're testing not just people who are symptomatic, but we're also making testing so easy that even people who are asymptomatic or who have a runny nose are going and getting swabbed. Because if we really want to be able to detect outbreaks at a local level and target those interventions very well to prevent large outbreaks that are going to shut down states, we have to be testing people who aren't feeling sick or are only mildly symptomatic.
The only way to do that is to push testing into the community and make it exceedingly easy to get tested. We have to figure out how to get testing into work sites and places of residence. For example, we should be testing nursing homes on a regular basis and the people who work there. So that's the challenge for the fall.
MRS: So let’s say we have better testing, but we don't have contact tracing up and running as we should.
SG: Not every state is investing in this. And it’s breaking down a little bit along political fault lines where you see some of the northeast states and California investing in very aggressive case-based interventions. And other states are viewing this through a political lens where some of these case-based interventions are perceived as government overreach. And an argument that I've heard is that with so much coronavirus in circulation anyway, you're going to end up tracing everyone, and so it's just going to be very intrusive. I don't think that's true. I think we have the potential to keep up with this. South Korea kept up with it. Singapore kept up with it. Japan, to some extent, is keeping up with it.
And they didn't do it by interrogating their entire population. So I think we have the potential to get infection rates down to a level that we can actually use contact tracing to try to reduce spreading. You're never going to capture all the infections. But if you can capture even a sizable share of them, that might be enough to prevent an epidemic. It's a layer of protection.
MRS: Tell me about the other layers.
SG: One layer of protection is social distancing and the things we're asking people to do: wash your hands, wear a mask, be mindful of your social interactions, maybe shrink down your social circle a little bit, try to go shopping once a week instead of three times. U.S. health officials have suggested that if everyone does one less visit to the grocery store every week, that can have a profound impact on the risk of spread.
MRS: Other layers?
SG: We're probably going to limit gatherings in the fall. People won't be traveling as much. People won't have large conferences. We're still going to Zoom into meetings. So all of that will have an impact. And then you layer on top of that more testing and contact tracing for a large minority of cases. There's no one thing that's a silver bullet. It's all going to be layers of protection. And what we're doing is, we're not trying to end Covid-19. We're never going to fully contain it, not in a country as big, diverse and noncompliant as the U.S. And so what we're looking to do is prevent states and cities from having to shut down for long periods.
MRS: Let me ask you a naive question. If instead of shutting down the country in March, if we had just required everybody to wear a mask, would that have been effective?
SG: I think we should have implemented masks earlier than we did. I think one of the concerns about implementing masks was there was a worry that it was sending a mixed message if we were telling people to socially isolate, but then by telling them to wear a mask, you were giving sort of a counter-message. You were saying, "On one hand don't go out, on the other hand go out, but wear a mask." Masks do have value now, though their value was more limited earlier when less infection was circulating.
MRS: So are masks the best second line of defense?
SG: I think that the best second line of defense for individuals is to try to limit contact with people, within reason. There are things you can do to shrink your social circle. Avoid unnecessary trips. Be mindful of your hygiene with respect to spreading a respiratory pathogen.
The other important ingredient is going to be what employers do. Certain employers have the capacity to de-densify the workplace. Certain employers don't. And for the employers that don't — meat-processing plants, manufacturing floors, grocery stores — they need to think about how to provide protective equipment to employees, to create distancing at work, how to not have people congregate in break rooms, but stagger breaks, change the workflow, and how to provide testing in the workplace.
What they're trying to guard against is the risk that a single introduction into a place of employment leads to an outbreak where 100 people get infected. And that should be a solvable challenge. Employers are going to play a big role here because a lot of the spread is going to be not just in social gatherings, but places of employment.
There are other things you can do, especially in the summer and heading into the fall. You can move activities outdoors, gym classes outdoors, restaurants outdoors, religious services outdoors. We should be doing that now because there's ample evidence that the risk of transmission in outdoor settings is much lower than the risk of transmission in indoor settings. Studies that have looked at clusters of infections almost universally found that they started indoors.
MRS: What about schools? Should they stay closed?
SG: I think there will and should be an attempt to open schools in the fall. I don't think schools are going to remain closed until we get a vaccine. We should recognize that, yes, we're going to have outbreaks, we're never going to get this fully contained, but we'll have the tools to identify the outbreaks and take mitigation steps on a local level.
MRS: So should we not have closed schools this spring?
SG: Looking back at what we did with the current population-based mitigation, where we closed the entire country, there were parts of the country that weren't that affected by Covid-19. Now we know where they were. The problem was that we couldn't identify them at the time. We didn't have adequate screening in place to know where it was spreading, and so we didn't have the ability to say, "We should do the mitigation here, and we don't have to do it there." Going into the fall, we should have that ability. You're going to want to group kids in smaller groups. You're not going to want to have everyone go out for recess. You might go to a four-day week and then have kids distance-learn for a day to de-densify the school.
MRS: It sounds like what you're saying is that the best second line of defense behind testing and tracing involves common-sense measures that institutions can take to reduce density, that individuals can take to reduce social contact, and that governments can take to use the better testing capability we'll have in the fall for more information about where outbreaks are happening to shut them down before they get out of control.
SG: Not shut them down, but implement local measures to try to ring-fence infections.
MRS: Let me step back from specific measures and ask you about culture. Masks have been subsumed by the partisan culture wars in a way I find very troubling. How important is culture in all this? A political culture of transparent communication? A political culture that trusts experts? A broader culture that finds individual citizens concerned about the common good?
SG: I don't know where this divide's going to be. I think at the end of the day, most governors aren't going to want their state to be the state that ends up being engulfed in infection in the fall. Most governors are going to act responsibly and the responsible thing is to try to put in place interventions, whether it's through testing or case-based interventions, to prevent small outbreaks from becoming large outbreaks. We really don't have another line of defense. We don't have a vaccine, we don't want to go back to closing all the businesses and schools, and so the only other line of defense is these interventions.
MRS: So let me ask it maybe more pointedly: Do you think that if we roll into the fall and there's a big campaign to get people to wash their hands every two hours and wear masks, do you think that enough people will do that, that it will actually have an impact on the rate of spread?
SG: Well, I don't know why you're focusing on washing your hands every two hours, but setting that aside — I guess as an economist you have to assign metrics to things — I think if we roll into the fall and people are being very conscious in their own social interactions, their hygiene, limiting activity within reason, businesses take measures to do that, schools take measures to do that, I think if we do all those things, and I think we will, on an aggregated scale that's going to have an impact.
This is a highly infectious bug. There's a lot of infection around the world. I don't think this is just going away. This is the eighth coronavirus that's going to circulate. It's hard to envision that this is just going to get extinguished from humanity. It's a coronavirus. It's pretty contagious.
MRS: Okay, I've got a little math in this next one. According to my back-of-the-envelope calculation, the coronavirus is costing the U.S. economy roughly $85 billion per week in lost economic output. Given that, are we under-investing in therapeutics? Shouldn't we be pumping money into every therapeutic and every vaccine that could possibly be effective, manufacturing 100 million doses of each even though we may not need that many and even though most of those therapeutics and vaccines would end up not working? Wouldn't it be worth the cost of just having them, to avoid the economic calamity that we're currently in?
SG: I'm not sure that more money, per se, is going to tip the balance there. The thing that's limiting the availability at this point is just the time it takes to scale up manufacturing and conduct the proper trials.
MRS: So the binding constraint isn't money. The binding constraint is the number of sick people needed to run trials.
This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.
Michael R. Strain is a Bloomberg Opinion columnist. He is director of economic policy studies and Arthur F. Burns Scholar in Political Economy at the American Enterprise Institute. He is the author of “The American Dream Is Not Dead: (But Populism Could Kill It).”
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