Coordinated and Evidence-Based Easing of Social Distancing Restrictions That Centers Equity and Justice is the Only Way to Save Lives and Protect the Poor During the COVID-19 Pandemic
Point 1: Social distancing measures are working to mitigate the spread of the virus despite the uncoordinated federal response that has led to the current outbreak.
The initial handling of COVID-19 response by the United States federal government was reckless and uncoordinated resulting in a much larger outbreak and unnecessary loss of life. Despite this, communities, public health officials, health care workers, service workers, and families, rose to the challenge. Our country has peacefully adapted to one of the most extreme upheavals to our social and economic life in the past 100 years. Over the course of less than two months, the nation shut down schools and many industries to avoid loss of life on a mass scale from the COVID-19 pandemic. Without these extreme measures, thousands more of our beloved neighbors, friends, and family members would have died from this virus and the health care system would have been overwhelmed. The staggering inequities we are witnessing among poor communities [1] and communities of color [2] would have been even worse. While much damage has been done and many lives lost, the sacrifices that we have all made have prevented the worst-case scenarios.
Now we stand at a crossroads. As we enter the next stage of this pandemic, there is still no vaccine. There will probably not be widespread access to a vaccine until late 2021 or 2022. Until then, we have important decisions to make about when and how to ease social distancing restrictions. Doing so prematurely without a real plan for monitoring and responding to future outbreaks and a coordinated strategy that centers the needs of the poor and most marginalized communities is irresponsible, and will have long-standing health, social and economic consequences. Furthermore, moving too quickly without the proper safeguards will prolong the pandemic, make the country less likely to rebound from this crisis, and deepen existing inequities.
Point 2: The federal government and many states have begun to ease social distancing restrictions and “reopen the economy” with no legitimate scientific basis for assertions that it is safe to do so.
On April 30, 2020, the federal guidelines on social distancing expired, leaving decisions about reopening economies (i.e., allowing or requiring workers in certain sectors to return to work with or without recommended safety protections) to the discretion of the states. By May 1, 2020, more than a dozen states partially opened their economies and six states had plans to reopen within a week. [3] Leading public health experts agree that this form of “patchwork” reopening by states is counter-productive and will undermine all of our efforts to date to contain the virus and mitigate its spread within the population. Furthermore, no legitimate scientific basis exists for how the White House and states like Georgia are reopening certain industries. For instance, the White House’s guidelines for Opening Up American Again [4] prioritize businesses such as “movie theaters” and “sporting venues.” Meanwhile, in Georgia, where the number of cases continues to rise [5] the governor prioritized reopening businesses such as hair salons and massage services. These types of jobs require close contact making it implausible if not impossible for workers or clients to maintain a 6-feet distance from one another, directly contradicting national public health guidelines.
These actions of the president and some Republican governors are irresponsible and reckless. They exploit low-wage workers, treating them as guinea pigs for determining how risky it is to reopen without adequate PPE, adequate access to free health care for all, workers’ rights, testing, contact tracing and isolation. Most of these workers are not receiving hazard pay and have few options to opt out of working if they feel unsafe in these jobs because many are non-unionized jobs and reside in states with very weak workers’ rights and protections. Furthermore, if they quit because they fear for their safety or need to take care of children or sick loved ones, they will not receive unemployment benefits. The position of these workers is impossible, and it’s a travesty.
Point 3: Any plans for reopening must be coordinated, evidence-based and must center on equity and justice.
Public health experts agree that actions to reopen U.S. society must be driven by proven public health strategies led by the best available data. Dr. Tom Frieden, former director of the Centers for Disease Control and Prevention and President and CEO of Resolve to Save Lives outlines four criteria that must be in place in order to ease social distancing restrictions and safely and responsibly reopen the economy: 1) widespread testing of the population including both diagnostic and surveillance tests; 2) isolation of all infected people in safe, humane conditions; 3) identification of everyone who has been in contact with infected individuals (“contact tracing”); and 4) quarantine of all contacts for 14 days in safe, humane conditions. [6]
Additionally, we must ensure that there are pre-approved triggers (e.g. surges in cases, health care capacity) in place that govern the reintroduction of stay-at-home orders. The recommendations above are in contrast to guidelines from the White House [7], which would reactively monitor tested cases and sick people. We must be proactive, not passive, in the approach to tackling the spread of COVID-19 by also monitoring asymptomatic transmission in communities and not doing so conveniently or selectively.
Equity and justice for the most marginalized segments of the population must be centered in reopening strategies. Testing, treatment, and safe and humane isolation facilities must be made universal for high-risk populations, including individuals in homeless shelters and senior housing, as well among poor communities and communities of color with longstanding structural factors that lead to higher rates of community transmission and death. The country must provide adequate income protections, economic relief, paid sick leave, personal protective equipment and ensure safe, humane working conditions for all workers. Safety demands rapid reduction in the numbers of people held in congregate settings such as jails, prisons and detention centers so that incarceration does not become a death sentence. Unless these provisions are guaranteed by each state, the federal government gaps in access and care will widen among these groups and inequities in transmission and deaths will get worse.
Point 4: The country and most states are not ready to ease social distancing restrictions.
Based on these considerations, we are ill-prepared as a country to reopen the economy. Recent research from Harvard University estimates that in order to safely reopen the economy, the country needs to move from testing only those who are sick to widespread testing in the general population in order to monitor the spread of the virus. Specifically, to reopen the United States by mid-May, between 500,000 and 700,000 tests must be performed every day, which is a daily minimum of about 152 tests per 100,000 people. [8] Currently, the entire country of 328 million people is only performing about 150,000 tests per day. [9] With the exception of a few states (e.g. Rhode Island), all states remain severely limited in their testing, falling far short of recommended guidelines. [10][11] Decisions to reopen any state cannot be made with incomplete data. Furthermore, with the exception of a few states (e.g. Massachusetts) [12], no state has demonstrated that they have the capacity and public health infrastructure for contact tracing, supported isolation of sick individuals, and effective quarantine for the general population or among high risk groups. Finally, all COVID-19 federal legislation to date falls woefully short of the economic relief needed to address the short- and long-term economic hardship of the poor, overlooking the necessity of guaranteed access to workers protections, healthcare and economic relief for the most marginalized.
Point 5: Long-term consequences for nation and marginalized communities.
We know from past pandemics that countries that acted swiftly and aggressively, were able to rebound quickly following a pandemic. Furthermore, episodic opening and reopening is bad for businesses due in part to a level of uncertainty that many businesses cannot adjust to. Researchers from Harvard offer a roadmap to reopening which is based on a massive scale up of testing, reaching 5 million tests per day by early June to help ensure a safe social opening. This number will need to increase to 20 million tests per day by mid-summer to fully re-mobilize the economy, paired with contact tracing and supported isolation and quarantine. At this scale of case identification, the number of new infections could be safely managed, the sick cared for and the economy reopened. [13] But reopening the economy too soon will lead to more widespread transmission and the loss of life. Health care systems in many parts of the country are already overwhelmed and many more are ill-prepared to handle the surge in cases that will inevitably occur. This will ultimately lead to more deaths in these areas of the country. Poor communities and communities of color will be disproportionately impacted. Until we have a vaccine, there is no path to returning to business as usual. Any reopening strategy must include a new strategy for honoring (with hazard pay and benefits) and protecting the dignity of workers (i.e. truly protected work conditions, protecting the livelihoods of those who protest dangerous work conditions).
Conclusion
The COVID-19 pandemic has changed our world. It has exposed the many fault lines created by prioritizing profit over people: low wages, lack of worker protections, millions without health insurance or access to health care. This is why the US is experiencing a massive outbreak. There is no safe way to “turn on the economy” by turning back the clock. No one wants to see people become ill with COVID-19 among those standing side by side in protest of “stay at home.” But logic suggests this will happen. The cost of prematurely re-opening of various businesses will be measured in lives lost. There is a way forward, but this is not the way. The way forward is to take action based on proven public health strategies and the best available data, to ensure that all communities are protected, cared for, and provided with the economic means to survive, and that equity and justice are central to all of our efforts.
Notes
- Chen JT, Krieger N. Revealing the unequal burden of COVID-19 by income, race/ethnicity, and household crowding: US county vs ZIP code analyses. Harvard Center for Population and Development Studies Working Paper Series, Volume 19, Number 1. April 21, 2020. https://tinyurl.com/ya44we2r
- The color of coronavirus: COVID-19 deaths by race and ethnicity in the U.S. https://www.apmresearchlab.org/covid/deaths-by-race.
- https://www.nytimes.com/interactive/2020/us/states-reopen-map-coronavirus.html
- https://www.whitehouse.gov/openingamerica/#criteria
- https://www.nytimes.com/interactive/2020/04/24/opinion/coronavirus-covid-19-georgia-reopen.html
- Frieden T, Shahpar C, McClelland A, and Karpati A. (2020, April). Box It In: Rapid Public Health Action Can Box In Covid-19 and Reopen Society. Resolve to Save Lives, Retrieved from https://preventepidemics.org/coronavirus/resource/box-it-in/
- https://www.whitehouse.gov/openingamerica/#criteria
- ROADMAP TO PANDEMIC RESILIENCE, Harvard University Center for Ethics
- https://www.nytimes.com/interactive/2020/04/17/us/coronavirus-testing-states.html
- https://www.statnews.com/2020/04/27/coronavirus-many-states-short-of-testing-levels-needed-for-safe-reopening/
- https://www.nytimes.com/interactive/2020/04/17/us/coronavirus-testing-states.html
- https://www.bostonglobe.com/2020/04/25/metro/way-out-inside-ambitious-mass-coronavirus-contact-tracing-effort/
- Roadmap to Resilience, Harvard University Center for Ethics