As COVID-19 cases have risen in Massachusetts and around the country, a public still hearing the echo of “flatten the curve” has begun bracing for — and dreading — a potential wintertime shutdown.
So far, though, elected officials, including Governor Charlie Baker, have largely resisted saying if they would issue a new round of stay-at-home orders. And, increasingly, public health experts say they might not need to.
“Lockdown is a blunt measure that impacts the whole population,” said Natalia Linos, executive director of the FXB Center for Health and Human Rights at Harvard University. “We know that we will have pockets of outbreaks, and if we are able to quickly identify those pockets and shut them down, then we can prevent the situation where we have widespread exposure" that leads to wider lockdowns.
Avoiding that scenario is fairly straightforward: Test as many people as possible; locate the source of outbreaks and trace and quarantine those who have been exposed to the virus; target high-risk settings with public health restrictions and prioritize keeping open settings that serve public interest, such as schools.
In Massachusetts, even as many in the scientific community express concern about rising numbers of infections and hospitalizations, few call for a return to spring or summer restrictions. But, experts warned, a lighter-touch approach will only be effective if Baker and other officials work hard to keep the public informed, united, and compliant.
“Communication is an important part of showing people that the governor is looking at the numbers and responding to them,” said Dr. Sarah Fortune, chair of the department of immunology and infectious diseases at Harvard T.H. Chan School of Public Health. “There’s a huge tension between giving people so much information that it compromises others’ privacy and giving them enough information that they are able to feel safe.”
For the public, the scientific thinking away from total shutdowns may seem confusing, as sheltering in place remains the most visible and familiar way to limit COVID-19′s spread.
A World Health Organization official, Dr. David Nabarro, encountered this disconnect earlier this month when he advocated for a “middle path” approach to controlling the pandemic. “We really do have to learn how to coexist with this virus in a way that doesn’t require constant closing down of economies, but at the same time in a way that is not associated with high levels of suffering and death,” Nabarro said in an interview with British news source The Spectator.
Some, including President Trump, took Nabarro’s comment to mean that shutdowns were never justified. But scientists argue that the viability of a “middle path” is proof that staying home in March, April, and May worked.
“In the spring, we just didn’t even know what was going on. . . . You really have no other option at that point other than to just shut everything down,” said Helen Jenkins, a Boston University epidemiologist. “You then use that time while you’re shut down,” Jenkins said, to learn more about how a new virus spreads and then get to work tracking and containing it.
"We’ve learned a lot since March when we implemented these shutdowns,” said Dr. Leana Wen, an emergency physician and visiting professor at the George Washington University’s Milken School of Public Health, “including about what are the targeted measures that we can apply that would have less of an impact on the economy and still have a significant impact on reducing infections.”
Experts said we have also learned that shutdowns carry significant consequences of their own — not only for the economy, but also for public health. Many people suffer from isolation, and those who have health care needs unrelated to COVID-19 may be afraid of going to the doctor or unable to access their usual services.
Shutdowns remain an important tool if COVID-19 spread becomes rampant and hospitals risk being overrun, but scientists say we need not reach that point again.
Public adherence to behaviors that minimize risk can help contain outbreaks, said Wen, who prior to her post at George Washington served as Baltimore’s city health commissioner. She noted that some reports suggest that private gatherings of friends and family, not unsafe workplaces or public settings, are primarily driving the current surge in COVID-19 cases across the United States.
“Policy interventions can only go so far. At some point, we need individuals to do their part,” she said.
While public health strategies that avoid economy-wide shutdowns have their merits, they are not a guaranteed solution, experts said. Just as shutdowns did not entirely prevent community spread or deaths, neither would more targeted containment strategies.
And Shawnita Sealy-Jefferson, a social epidemiologist at Ohio State University, said the movement toward targeted closures continues to disenfranchise high-risk communities.
“Large numbers of people have died, and the majority of people who have died have been people of color. I see this push against shutdowns as being an economic one, and it’s not really thinking about the potential cost in terms of lives that are lost,” said Sealy-Jefferson, the incoming chair of the American Public Health Association’s epidemiology group. “The people who are dying most are not being centered in the decisions about how we address spikes in the number of cases.”
“If every segment of our population had a similar rate of deaths, we would not even be having this conversation. Everything would be shut down,” she said.
Some experts were less certain that avoiding lockdowns would result in public health disparities.
“For the lockdowns, we know that there’s a variability in individuals that can work from home and those that can’t,” said Sam Scarpino, a Northeastern University epidemiologist. That variability, he explained, leaves people of color and essential workers more exposed to the virus. Moreover, the economic costs of shutting down are felt most deeply by those already facing financial precarity.
At the same time, Scarpino said that keeping businesses open heightens the risk of exposure for workers such as restaurant employees. “With outdoor dining, I can’t get these images out of my head of people not putting their mask on when the server comes to the table,” he said.
Ultimately, Scarpino said, a pandemic response that avoids shutdowns must grapple just as seriously with inequality issues as heavy-handed measures.
Experts also said an effective containment strategy will require officials to work harder than ever to build public trust and awareness — an area where some said Massachusetts leaders have room for improvement.
“We’re still not hearing specific information from the governor’s office on where cases are coming from," Scarpino said. “Either [contact tracing] is not happening well enough, or we’re not being told enough about them.”
Earlier this week Baker noted the state already releases weekly data on contact tracing, and said most new cases in Massachusetts have been traced to social gatherings — especially among young adults.
“We continue to follow a lot of the information that we get from the contact tracing folks with regard to not just outbreaks, but also just contagion generally,” he said.
Still, Scarpino and others said Massachusetts residents will only feel safe — and will do their part to limit the spread of COVID-19 — if they know which high-risk settings to avoid. The public also deserves to know more about how the governor makes decisions, said Linos, the director of Harvard’s FXB Center.
The public demands “consulting with more impacted groups, feeling like decisions are being made with all the trade-offs being thought about, not just our economy," she said. "Are women leaving the workforce because they have to stay home with their kids? Are Black and brown communities being harmed disproportionately?”
“What people demand is clarity," Scarpino said. “It’s important for the public health community to be able to talk honestly about trade-offs."