With the stay-at-home advisory in Massachusetts set to expire May 18, Governor Charlie Baker has signaled he’s considering letting some businesses open.
As much as we would like to see Massachusetts open for business after it was shut down to slow the spread of the coronavirus, we don’t believe the state will be ready to reopen on May 18. To make opening safe and sustainable, the state needs to strengthen four pillars of COVID-19 prevention that remain shaky today and maintain these pillars in the coming months as the Commonwealth implements a smart, flexible, phased plan to open the economy.
The curve has not yet been crushed — it’s just a plateau. Although there have been recent signs that the first wave of infections is peaking, COVID-19 deaths continued to hover between 120-140 per day for the week of May 3, with spikes over 200. Hospitalizations and ICU admissions also held relatively constant, at 10 percent of the peak recorded on April 27. The number of confirmed infections per day — in the 1,200-3,000 range in recent days — is not as meaningful as deaths and hospitalizations, since the number of cases is a function of how many tests were conducted. Such testing has bounced around from a high of 15,652 on May 3 to a low of 6,290 just three days later.
These data show that Massachusetts is in a holding pattern. The prevention measures put in place, including closures of schools and nonessential businesses as well as social distancing, have stopped the coronavirus from overwhelming public health systems in the state, but it’s still far from crushing the curve. Implementation of social distancing has been inconsistent and the enforcement of critical actions, such as the universal use of face masks, has been toothless, leading to persistent community spread of the virus.
To reopen safely, hospitalizations and deaths need to decline for 14 consecutive days, while testing capacity needs to increase to the point where less than 5 percent of tests come back positive. These triggers for reopening are recommended in expert guidelines that ensure that downward trends in deaths and hospitalizations are durable and that testing is strong and comprehensive enough to catch any flares in new infections. Massachusetts is still far from meeting these criteria.
Every day that businesses remain closed costs at least $250 million to the state’s economy and increases desperation for workers and businesses that need income to survive. This is a terrible trade-off — your livelihood or your life — that we do not have to accept.
Massachusetts can crush COVID-19 and open the economy at the same time, but only if it doubles down to meet the 14-day criteria by plugging the leaky holes in current prevention efforts. State and local governments must:
- Strictly enforce the rules around social distancing and mask-wearing — the lack of enforcement and ambivalent signals from government officials have weakened the impact of these rules and needlessly increased infections. Reports to Boston 311 show that social distancing is weakening as the weather improves, movement away from home is increasing, and mask use is inconsistent. When fines are announced, but not enforced evenly, people will not take these advisories seriously.
- Protect first responders and essential workers to reduce community spread. A recent walk through Boston’s streets revealed that some first responders continue to work without masks, although a quarter of Boston firefighters have been exposed to COVID-19. This is dangerous and sets a poor example for the public. Some customers also continue to enter stores without masks, imposing risk to cashiers, shelf stockers, and other essential workers. Evidence is mounting that even where social distancing rules are in place, much of the community spread is occurring in grocery stores and other essential businesses.
- Ramp up regular testing of high-risk employees and most vulnerable populations, including those without symptoms. Up to 60 percent of infected people may be asymptomatic yet still infectious. Current CDC and state guidelines prioritize testing only for people displaying symptoms. New guidelines must be issued in Massachusetts so that we can aggressively find those infected, whether they display symptoms or not. Expanded testing must target those at highest risk of getting infected and transmitting COVID-19 to others because of their occupations and living conditions. More mobile testing units are urgently required to make it easy for such people to test where they work and live.
- Build up contact tracing capacity and couple it with comprehensive social and income support to help infected and exposed people to self-isolate safely. Expanded testing is good but not enough. Many of those reached by the Massachusetts Contact Tracing Collaborative, which has been highly touted by Baker, will need supportive counseling, alternative housing, food, and special financial assistance to enable them to quarantine safely and avoid infecting others. Bridge shelters such as the Quality Inn Hotel in Revere, for self-isolation of infected residents of Chelsea and other nearby communities, remain largely empty right now, suggesting that the current support to those being asked to quarantine is not adequate to overcome their fears of losing their jobs, being cut off from their families, and even of being deported because of their immigration status.
Once the triggers for reopening have been met, Massachusetts should proceed cautiously. The phasing of the reopening of the state economy should be based on the answers to four key questions: What is the risk that the work activity in question will cause new infections of employees, customers, and their family members? How essential is the particular business sector to our lives? What is the share of Massachusetts employment and income generated by the specific business sector? What is the ability of employees in that sector to work remotely?
Taking these four factors into account, lower-risk businesses that can safely manage the flow of workers and customers, including retail stores and museums, could open with strict rules to maintain physical distance and enforce the use of masks. Public transportation systems will have to ensure adequate capacity on trains and buses to allow for social distancing while still protecting the health of transport employees and riders.
The effect of the first wave’s reopening will have to be carefully monitored, with businesses prepared to adjust their operating rules and possibly be shut down again if COVID-19 cases begin to rise.
If the first wave is successful, a second group of businesses, including restaurants, salons/spas, gyms, and theaters could open, again with strict rules for physical distance and sanitation. The success of the first wave would give customers more confidence to eat out again and go to the movies, albeit while wearing masks.
The third and final wave would be venues with the highest level of risk, such as sports stadiums and music concerts.
During these openings, businesses will have to test employees frequently, and the state will need to sample a wide swath of the population, using sentinel testing to monitor community spread so that it is ready to swiftly surround and snuff out localized COVID outbreaks.
This phased approach to opening the economy is captured in parts of the plan put forward by the Massachusetts High Technology Council. It needs to be adopted by the governor’s Reopening Advisory Board when it announces its plan.
Our state ranks third in the country in COVID-19 deaths and has more cases and deaths than Canada, a country with five times our population. Rather than comparing ourselves with New York or New Jersey, we should be emulating the performance of Germany and Hong Kong, or the state of Washington, which have kept deaths low by prioritizing prevention as well as treatment.
Massachusetts cannot afford to get this reopening wrong. It cannot shut down the economy again and incur economic damage and the further loss of life.
To prevent another COVID-19 surge, state and local leaders and all Massachusetts citizens need first to focus on “muscular” prevention, now that the need for hospitalization is easing, including enforcing social distancing and the use of masks at all times until there is a vaccine. Choosing health or an open economy is a false choice — we can’t have one without the other. We’ve learned the hard way during the initial outbreak, when the country failed to take meaningful action for weeks, what needs to be done to save lives and reduce pressure on our front-line health workers. We must apply to the future what we learned from our past mistakes. There are no excuses for not doing everything that we can going forward, by wearing masks and keeping our distance, to ensure that reopening is a success.
Shan Soe-Lin is managing director of Pharos Global Health Advisors and a lecturer in global health at the Jackson Institute for Global Affairs at Yale University. Robert Hecht is president of Pharos Global Health Advisors and a clinical professor of epidemiology at the Yale School of Public Health.