U.S. faces long road to reopening amid COVID-19 crisis

The American Enterprise Institute, in collaboration with faculty from the Johns Hopkins Center for Health Security, released a report on March 28 titled "National Coronavirus Response: A Road Map to Reopening." While most of the world struggles to address the immediate challenges of the COVID-19 crisis, the report offers a guide for navigating the entirety of the pandemic, including both recommendations for adapting our public health strategy and milestones for deciding when and how officials should relax physical distancing measures.

Crystal Watson, a health security expert, is one of the co-authors of the report, along with her colleague Caitlin Rivers, both senior scholars at the Center for Health Security. Watson's research focuses on public health risk assessment, crisis and risk-based decision making, public health and health care preparedness and response, biodefense, and emerging infectious disease preparedness and response.

Johns Hopkins responds to COVID-19

Coverage of how the COVID-19 pandemic is affecting operations at JHU and how Hopkins experts and scientists are responding to the outbreak

Watson, who is also an assistant professor in the Department of Environmental Health and Engineering at the Johns Hopkins Bloomberg School of Public Health, sat down Friday afternoon to discuss the report and how the weeks and months ahead might unfold.

Your report was published four days after President Donald Trump announced on national TV that he'd love to have the country opened up by Easter. Is the report a kind of response to that?

It was in response to the president and state and local officials saying that we need to relax social distancing measures because they're hurting the economy. In outbreaks, there is always a tension about whether we should take measures that limit economic activity even if they're good for public health, but we've never been in a situation where we've used these measures in such a wide way. We know the physical distancing measures are having a severe economic impact, along with the virus itself. At the same time we need to realize that if we let up on them too soon, it will contribute to many more deaths, and we will have wasted our time and sacrifice. That feels unconscionable to me. So we felt a need to provide input and guidance to officials about what the guidelines should be.

You recommend a phased approach for managing the pandemic. Can you walk us through the phases?

Right now we're in Phase I, the "slow the spread" phase. The goals are to reduce transmission, increase testing, and ensure the health care system can safely treat people. We already have physical distancing measures in place in most areas of the country—and preliminary data from Washington, and perhaps New York, are beginning to show that viral spread is slowing. We need to massively scale up our diagnostic testing capacity. We need to build capacity at hospitals—beds, ventilators, protective equipment—and create facilities for people with the illness to recover in isolation if they are unable to stay at home. We need cheap, fast diagnostic tools for use at bedside, a serological test that can help gauge rates of infection and immunity, and a new national surveillance system and data infrastructure for tracking and analyzing COVID-19.

We're really flying blind right now. If we get through this first surge and learn that only 5% of the population has been infected, we may take different actions in Phase II than if 50% of the population has been infected and has immunity.

It's a huge list of tasks to accomplish.

If we truly want to safely reduce these physical distancing measures, this is what we need to do.

What do you see as the biggest challenge directly ahead of us?

More testing platforms are coming online every week, so I do think we can build up testing capacity while we're in Phase I. Building our capacity for contact tracing is going to require a massive public health workforce upgrade. We're going to look at South Korea, which has done a really good job with contact tracing, and try to understand how we can extrapolate their system to the United States. We might reach for retired medical personnel, or it might be an opportunity to employ people who've been laid off. I think contact tracing skills are teachable, and I do think we can train up a workforce. At Hopkins there are people working with the Baltimore City Health Department to do some of this. We need to take that up to a national level. We need a national vision and federal guidance for how state and local health departments can expand their workforce to enable case-based intervention—finding all cases and tracing the contacts of each case to break chains of transmission.

I also think it is possible to improve our capacity to provide hospitals with adequate supplies and ventilators. But expansion of the health care workforce is going to be the biggest challenge in Phase I since it's something we can't do quickly. It takes a long time to train doctors and nurses.

What milestones have to be reached before you recommend relaxing physical distancing measures—and when do you think we'll reach those milestones?

We recommend that no state relax physical distancing until it sees a sustained reduction in cases for at least 14 days, its hospitals can safely treat all patients without resorting to crisis standards of care, and it's able both to test all people with COVID-19 symptoms, and conduct monitoring of confirmed cases and their contacts.

As for when this will happen, it's really hard to know. We're going to have a tough April. May will also be tough. After that, hopefully we'll see things loosen up. Everything depends on how well we use this opportunity to prepare and build our capacities. If we can hold out for a while and focus on preparing ourselves for the next phase, we'll save lives.

Image caption: Crystal Watson

You call Phase II the "reopening phase." What will this reopening look like?

Physical distancing measures have to be stepped down in a concerted and careful fashion. In Phase II, schools, universities, and businesses may begin to reopen (albeit in a modified way to reduce opportunity for transmission)—but teleworking should continue where convenient, and social gatherings should continue to be limited to fewer than 50 people wherever possible. Opening schools is a tough one because having kids in school, as we've seen with flu, could be a driver of infection. I don't think it's an on/off switch. Maybe we send kids on alternating days—we have to be creative. And we'll need to constantly reevaluate our measures based on data and be ready to adjust our approach. We will have to revert to Phase I if there's a surge in cases.

People need to realize that there are still going to be things we can't do for a while. Large gatherings won't take place for a long time—large stadiums won't be full. There are going to be somewhat more permanent changes in our society until we have a vaccine or other therapeutics that can be used for prevention or treatment. That's when we can go to Phase III.

In Phase III, all restrictions can be lifted?

Yes. Once a robust surveillance system is in place, coupled with widespread testing and a robust ability to implement tracing, isolation, and quarantines—and we've got the therapeutics or vaccines—we can return to some semblance of normal life. At that point we need to focus on rebuilding our readiness for the next pandemic. This is a huge event, but it's not the only virus that could cause a pandemic—and it's not the worst case scenario we've thought about. The cycle of panic and neglect is definitely a problem in this field. There will probably be another neglect phase, but we need to take what we've learned and make some real changes.

What are the changes you see as essential to prepare for the next pandemic?

We need to be able to surge our health care capacity. We need to build our ability to create new vaccines for novel viruses within months, not years. We need to integrate new technologies into many areas of epidemic response, including surveillance, diagnosis, and treatment. We need preparedness for public health emergencies to be a priority of the White House, with a permanent office dedicated to this issue. We were caught flat-footed by this pandemic and we need to never be in that position again.

Did you ever imagine a pandemic unfolding in the United States like this?

My colleagues and I have thought a lot about pandemic preparedness. Many of the problems we anticipated are things we are seeing now. Even so, there are many situations and events unfolding now that I couldn't imagine before this pandemic. What it's taught me is we need to think big.