Perhaps by the time you read these words, Colorado’s count of COVID-19 cases will, one hopes, have plateaued or even be falling. There will be mounting political pressure to open Colorado and the country back up. With the exceptions of the intrepid health care workers, farm and grocery workers, warehouse workers, delivery people, municipal employees, and staff deemed essential, we will have been cooped up for more than a month.
It’s been hard. The economy is in lousy shape. We’re restless, anxious, and, even if we’re busy, somehow bored. Who wouldn’t, deep in his or her heart, want to see physical distancing, also known as social distancing end?
Deep in his heart, Glen Mays, chair of the Department of Health Systems, Management and Policy at the Colorado School of Public Health, would love to see social distancing end. So would his colleague Dr. Lisa Miller, a professor of Epidemiology and the former State Epidemiologist at the Colorado Department of Public Health and Environment. But both agreed that we still must heed not the heart but the head.
“We’re seeing signs of social distancing being effective in slowing the progression of the disease, but given the lag time, it’s important to keep these policies in place for long enough that we can make sure we’re not overwhelming the hospital system and health care workers,” Mays said.
Added Miller: “I think it’s important for people to understand that it’s not going to get back to the way things used to be for a considerable period of time.”
Political noise and our own hearts’ desires to the contrary, Mays and Miller’s voices echo the consensus among public health experts all the way to the top. Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases put it bluntly on April 10: “Now is no time to back off.”
Okay, then: when?
“When” will depend. That’s an irksome answer, particularly considering that the coronavirus’s spread is driven by exponential math, and math is typically about as concrete as science can get. But in the case of the coronavirus, the unknowns make its math more like wet cement.
A host of unknowns contribute to that squishiness. How far has the virus spread? What percentage of contagious people show no symptoms at all or symptoms mild enough that the coronavirus doesn’t enter the self-diagnostic equation? How effective has physical distancing been? How is the virus actually transmitted? How will changes in seasons affect transmission? What’s the nature of the immunity of those who have recovered? How long might immunity last? How old is the population? What health problems do they have already?
These are all inputs to the models that policymakers in Colorado and everywhere outside of Antarctica are relying on to help them make decisions about “when.” Uncertainty about the inputs listed above makes those models less useful (technical term: “garbage in, garbage out”). Both Miller and Mays mentioned George Box’s famous quip: “All models are wrong, but some are useful.”
What the useful models are now telling us (this one from the Colorado School of Public Health team led by the school’s Dean, Dr. Jonathan Samet, being a great example) is that physical distancing works, but that soon after we stop distancing, COVID-19 infections will ramp back up. That’s inevitable once a highly contagious disease unfamiliar to billions of immune systems sinks its hooks into 210 countries and territories. The question is, then, how to manage that ramp-up in a way that balances the freedom of movement of the majority against the freedom from critical-care treatment of the minority.
In the United States, the answers may differ state-by-state, city-by-city, town-by-town. Miller described each state as its own laboratory, with different demographic makeups, population densities, travel patterns, weather, and so on. Colorado, she says, is unique in that it has a major urban corridor along the Front Range, but also sparsely populated communities in the plains and in the mountains. But then, she adds, those same mountain towns are a global attraction. And so Eagle County—home to Vail and Beaver Creek resorts—now has four times the per capita coronavirus case count as Denver and about the same number of confirmed cases as Boulder and Larimer counties combined.
“The diversity of our state and the different regions of our state are things we need to think about,” Miller said.
That said, public health experts agree on the big picture of how we’ll open our doors and our economy back up again. It will happen slowly and carefully, through what Mays called “selective relaxation” of physical-distancing rules. Among the ideas: friends and families may get together in small groups. Small businesses restart with limitations, with telework remaining a mainstay. Lots of shift work. Restaurants and bars open with tables far apart. Gyms could open but limit client numbers. There will be tough calls, such as with hair salons and barber shops. How do you maintain your distance when you’re cutting someone’s hair?
Mass gatherings – concerts, shows, megachurch services, sporting events, festivals – are probably out of the question in the near-term.
“I think, considering the risk-benefit tradeoff, it’s going to preclude moving forward with those kinds of events until we’ve got a major breakthrough in prevention, treatment, or vaccination or some combination of them,” said Mays, who is not alone with that take.
Even such a limited opening will demand continued, extraordinary precautions. “No masks” may be added, tacitly or explicitly, to those “no shirts, no shoes, no service” signs, and the people providing the services will wear them, too. Compulsive handwashing and frequent deep cleans will be de rigueur. Those at higher risk may need to continue to physically distance: in Colorado, those confirmed to have coronavirus over the age of 70 are at least 22 times more likely to end up hospitalized than those younger than 30. Those with COPD, cardiovascular disease, hypertension, and diabetes look to be at greater risk. If reopening indeed hinges on balancing hospital resources and economic reopening, how will policymakers take such demographic facts into account?
More importantly, opening back up in any real way will depend on public-health action of unprecedented scale. That action will include the three prongs of testing, contact tracing, and, based on those findings, testing of contacts and limited isolation.
“Increased testing linked with more targeted contact tracing is going to be an incredibly important part of the long-term strategy for managing this pandemic,” Mays said.
This is a proven combination for taking the bite out of epidemics, Miller says. Contact tracing could be augmented by cell-phone location technology and the mass-hiring of people to help with contact tracing.
For contact tracing to work, though, we will need much more testing. Yet testing will have its limits. South Korea, considered the gold standard as far as COVID-19 testing, has tested less than 1% of its population, Mays says.
“They’re still doing risk-based testing – testing the people who are likely to have been exposed. That’s probably the most realistic path for us,” he said. “I don’t think it’s feasible to get to a situation where we’re testing 25% or 50% of the population, over and over.”
Another factor that will play into the answer to the question of “when” will be antibody testing, Mays says. Such blood tests, which are just now being rolled out, can establish whether someone has antibodies related to a COVID-19 infection he or she has recovered from – and thus can be assumed to have at least some immunity for some period of time.
Taken together, the answer to “when,” in Colorado and elsewhere, will depend on what we learn – and how fast we learn it – about many other questions related to COVID-19 and the SARS-CoV-2 virus that causes it. Miller and Mays are optimistic that – given the global scope of the disease, the extreme motivation to beat it back, and the legions of smart people focusing on various aspects of the virus and the disease and then sharing what they’ve learned – we should know more about the coronavirus and how to control it, faster, than we have about any pathogen, ever.
“We’re learning every single day,” Miller said.
She is hopeful that a vaccine will come, and that therapies to keep the disease from progressing as aggressively – many of them are already being tested – will come before vaccines. Such therapies should reduce the number of and length of hospitalizations, take pressure off the health care system, and enable the acceptance of more societal opening.
And don’t forgot, a proven approach in combatting the coronavirus is the one we’re living with now. The curve is indeed flattening; physcial distancing works. That’s good news, because we may need to do it again.
“Our collective actions – and our collective pain – is having a tangible effect on this virus,” Mays said. “We may have to selective put the brakes back on. It’s good to know that the brakes work so we can reapply them as needed, hopefully on a more precise basis going forward.”
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