America needs to close down

The US is losing the fight against Covid-19. The only way to win quickly is closing down.

The past few six months have been an American experiment with Covid-19: Can the country keep bars, restaurants, gyms, and other businesses open while fighting the virus with milder measures, including some social distancing and widespread masking?

Six months after spring shutdowns ended, the answer is clear: The milder approach isn’t working.

The US surpassed 100,000 daily new coronavirus cases on November 4, and it’s gone on to regularly break new records for coronavirus cases ever since — with the most recent high exceeding 180,000 on Friday. Hospitalizations have skyrocketed to their highest level of the pandemic, leaving a growing number of hospitals around the US, from Arizona and Texas to Ohio and Tennessee, nearing or at capacity. And deaths are climbing: now above 1,000 a day once again, with a growing likelihood that the country will surpass 2,000 or even 3,000 a day in the coming weeks and months — on top of the more than 246,000 Covid-19 deaths that America has seen so far.

Unlike the spring outbreak, the current disaster isn’t isolated to the New York City area and a few other states. It’s truly national: Every state now has more than 4 daily new coronavirus cases per 100,000 people, the standard for having Covid-19 under control. And some states now breach 100 daily new cases per 100,000 — which was unthinkable months ago. That’ll make it much harder to respond to outbreaks, as states dealing with their own crises won’t be able to, as they did in the spring and summer, send reinforcements of doctors and nurses to support other places.

“This is the worst we’ve seen it,” Saskia Popescu, an infectious disease epidemiologist, told me.

The coronavirus’s explosive growth has occurred before Thanksgiving, Christmas, and New Year’s are set to bring friends and family together in large gatherings that could turn into super-spreading events. It’s also largely before colder weather in most of the US pushes people into poorly ventilated indoor spaces where the virus has an easier time spreading. The country is hitting records before experts believe Covid-19 cases stand to shoot up even further.

With the milder measures failing us, it’s clear what needs to happen: To avert possibly hundreds of thousands of deaths in the months before a vaccine becomes widely available, the US needs to close down once again. That means temporarily shuttering in-person, indoor services at nonessential businesses, particularly bars and restaurants; restricting larger gatherings, including in private homes; and encouraging, or outright mandating, people to stay home as much as possible — only going out for food, work, exercise, health care, and other basics needs — and limit their social interactions to their own households.

Some places are already taking steps in this direction, like New Mexico, Oregon, Chicago, and El Paso, Texas. But for this to work, it has to be much more widespread — so it becomes more likely the entire country can stop the spread.

This doesn’t mean locking down in the same way many places did in the spring. Since then, we’ve learned a lot about what works and doesn’t, and can apply those lessons accordingly — keeping outdoor spaces like parks open, for example.

It also shouldn’t mean simply abandoning individuals and businesses hurt by closing down. In the spring, Congress passed economic aid for workers and businesses to ease the suffering that a lockdown involved. Experts widely agree that, if closing down is necessary again, Congress should make similar moves — from boosting unemployment insurance to offering financial aid, even a bailout, to the businesses most affected. This wouldn’t just ease people’s economic suffering, but make closing down more bearable and, as a result, more sustainable.

No one wants this to be true. I don’t want this to be true. The experts I spoke to were divided on whether such aggressive restrictions are necessary. Jen Kates, director of global health and HIV policy at the Kaiser Family Foundation, echoed others who argued the US could still do a much better job with testing, tracing, and masking. “I think there are other ways to accomplish this without having to go [to a lockdown],” Kates said.

But we’ve now seen again and again what happens when countries try to keep indoor businesses in particular open as cases remain elevated or go up. Unlike many countries in Europe, Asia, and Oceania, the US never truly suppressed cases, outside of a handful of states, largely because it moved to reopen so quickly. That’s left the country in a vulnerable position as we barrel to what may be the worst Covid-19 outbreak the country will ever see.

Our World in Data

Time is running out. With the coronavirus, the infections that are happening right now take weeks to show up in hospitals or morgues. That means that the horrifying numbers we see right now are actually signals from the past, like data that took time to reach our eyes. The present reality is likely much worse, and we’ll see it in record hospitalizations and deaths in the coming weeks. That makes the problem all the more urgent, forcing us to race to avert an even worse future than we might have expected.

The flipside is the finish line for this pandemic has never been clearer. This month, we saw reports that we really might have a highly effective vaccine coming soon. Mass distribution is still likely months away — possibly until the spring of 2021 or later — but, finally, we have some idea of how and when this all might end.

First, though, the US has to get through a fall and winter that could be the worst of Covid-19. Closing down again increasingly seems like the best way to ensure more of us make it through that finish line.

Closing down can stop the spread

In March through May, much of America, under federal guidance to do so, locked down. That led both cities and states to impose variations of stay-at-home orders, which closed down public locations and businesses — except those deemed “essential,” such as grocery stores and pharmacies. People were advised or mandated to stay home, not socialize with people in other households, and avoid large gatherings.

It worked. A Health Affairs study found government-imposed social distancing measures reduced the growth rate of coronavirus cases, particularly the longer measures remained in place. A study in The Lancet produced similar results. A study from the Centers for Disease Control and Prevention of Delaware found its lockdown, paired with contact tracing and a mask mandate, contributed to 80-plus percent drops in coronavirus cases, hospitalizations, and deaths by the summer.

A more pessimistic working paper published by the National Bureau of Economic Research found that, while lockdowns reduced Covid-19 cases, their effect might have been limited because people were already voluntarily staying home at the time. But that still means the concept of people social distancing and limiting their interactions is still effective. (That differs from the situation today, where increasingly fewer people are voluntarily distancing.)

Lockdowns have also clearly worked in places that have seen resurgences of Covid-19. In September, Israel suffered what was the worst Covid-19 outbreak in the world at the time. The country first tried milder, more targeted measures — and after they failed, imposed a lockdown. And despite some public opposition, it worked to massively reduce cases from October to this month.

Our World in Data

Notably, more European countries, including France, Germany, and the UK, have also closed down again in recent weeks after trying milder measures, which failed to stop massive spikes in cases over the past couple of months. The European efforts have already seen some success, with cases starting to drop or at least grow more slowly with the new restrictions in place.

There’s a historical example that applies to the US, too: During the 1918 flu pandemic, many places shut down certain indoor venues and large gatherings to constrain the disease. Deaths plummeted. When the measures were lifted, deaths increased again, and only came down once the measures were reimposed.

Take the experience of St. Louis: In this chart, the dotted lines represent excess flu deaths and the black and gray bars show when social distancing measures were in place. The peak came after the measures were lifted, and the death rate fell only after they were reinstated.

JAMA

America, right now, is essentially in that in-between space. The vast majority of states have reopened, at least partially, or are reopening right now, even as cases continue to increase. Most states, even those hit very hard in the spring like New York, now let people gather in indoor spaces, such as restaurants, bars, and places of worship, in which the coronavirus can spread easily due to poor ventilation and close contact with others.

As states have reopened, officials across the country have argued other measures, like physical distancing, masking, and aggressive testing and tracing, can keep coronavirus cases down.

It’s true all these measures work to reduce coronavirus cases, based on a growing body of research and real-world evidence. But these approaches don’t seem to be working as well as many hoped.

Part of it is an adherence problem, in which people simply aren’t social distancing and masking. In some states, an increase in larger gatherings, such as house parties, has led to more Covid-19 cases. Rates of masking in public can drop below 75 or even 70 percent in some states, and the real rates are likely lower since people may not be honest with survey takers about their mask use. Fifteen states still don’t have mask mandates at all.

There’s also some natural tension between reopening and measures like social distancing and masking. People who work in retail and other service industries, for example, may not always be able to social distance from people, or avoid interacting with people who aren’t wearing masks — issues that these workers may have little control over if they want to keep their jobs. In some settings, masking and social distancing are in practice impossible, like in restaurants and bars where people are often cramped for hours and have to take off masks to eat or drink.

The other problem is the milder approaches don’t seem to work well enough when cases are already high or rising. Consider contact tracing: The idea is “disease detectives” can contact people who are positive for the coronavirus to get them to isolate, find out their close contacts, and get those close contacts to quarantine. But that is simply much harder when there are more than 100,000 new cases a day — it requires much more staff, time, and resources. Even the best teams may not be able to keep up with exponential spread.

Crystal Watson, a senior scholar at the Johns Hopkins Center for Health Security, estimated that contact tracing becomes difficult at 10 daily new cases per 100,000 people. The US is now at more than four times that, and some states are past 10 or even 15 times that threshold.

New York has a lot of testing, a contact tracing program, a mask mandate, and strongly recommends social distancing. But it’s still seen its cases spiral as it’s reopened more and more. Since the state allowed indoor dining to reopen in New York City in September, with parts of the state reopening before that, cases have spiked from a weekly average of 800 a day to more than 4,400. Indoor dining doesn’t explain the whole increase, but it’s reflective of a wider reopening that measures like masking simply haven’t been able to keep up with.

All of that suggests that social distancing, masking, testing, and tracing can keep cases low, at least for a time. But to get Covid-19 cases down, the country simply needs to close down.

We need to do more than close down

Ashish Jha, dean of the Brown University School of Public Health, recalled a recent conversation with a Democratic governor about controlling the coronavirus. When Jha suggested closing down indoor dining, the governor immediately responded: “What else do you have?” The recommendation wasn’t even worth considering.

“This is where states are,” Jha said. “I just don’t see any political appetite for a lockdown.”

If anything, the country is by and large moving in the opposite direction. Many people are preparing to celebrate Thanksgiving, Christmas, and New Year’s with family and friends — after celebrating other holidays, like Labor Day and Halloween, in large gatherings. There are reports of people refusing to get tested so they don’t have to call off work if they test positive. States are, again, continuing to reopen or letting places stay open, including risky indoor spaces like bars and restaurants. The federal government has even allowed cruise ships to start up again, after they became big hotspots for the coronavirus in the spring.

Adherence to existing mandates and guidelines, meanwhile, is spotty. Some experts argued: If we can’t get people to mask up, can we really get them to close down? “I could describe it as a fantasy,” Kumi Smith, an epidemiologist at the University of Minnesota, told me. “I don’t know what political and cultural stars would have to align for, really, Americans everywhere to appreciate the gravity of the situation and make a lot of personal sacrifices.”

But this could also be flipped into an argument for another stay-at-home order: If people aren’t going to voluntarily social distance and make sacrifices, the government could try to force their hand.

There are real downsides to closing down. Throughout the pandemic, people have reported more mental health problems, and drug overdose deaths have increased. There are massive economic problems, with the spring lockdown producing record-shattering unemployment filings (in the millions) and likely increases in poverty only averted by the CARES Act passed by Congress.

The effects of the lockdown were also unequal. While wealthier people in office jobs could largely transition to working from home, lower-income workers either lost their jobs as their employers shut down or were effectively forced to work in “essential” workplaces. A Nature study, looking at cellphone data, found that mobility during the spring lockdown dropped significantly more in higher-income communities than in their lower-income counterparts.

“It just doesn’t feel equitable to me,” Stefan Baral, a physician epidemiologist at Johns Hopkins University, told me. “There’s a tremendous number of interventions we could be doing to break transmission chains and to support people and empower them” — without, he argued, closing down and all the negative consequences that could produce.

But many of these problems could be mitigated with more action by Congress. Just like the CARES Act made the spring lockdown more bearable for many, more economic aid could in the coming months, too.

Experts have many ideas for how this could work. Some of that could simply mean a repeat or extension of the CARES Act, like the unemployment benefits that have expired or are set to expire at the end of the year. Another round of stimulus, including paychecks to Americans, could make potentially losing sources of income more tolerable. Businesses that are forced to close, such as bars and restaurants, and their employees could be made whole with a bailout or another form of financial aid. If people lose health insurance as they lose jobs, Congress could boost support for safety net programs like Medicaid or COBRA.

Many of these programs could help or even explicitly target lower-income communities to ease economic disparities, too.

This is not only important for the economy and people’s financial well-being, but for slowing the spread of the coronavirus as well. People are more likely to follow orders or guidance to stay home and not reopen businesses if they can actually afford it — and the country needs people adhering to rules and recommendations for any of this to work.

And closing down again doesn’t have to mean a full-on lockdown like many countries did in the spring. Since then, we’ve learned some places, particularly the outdoors, are fairly safe. Keeping as many of those venues as possible open could, at least in warmer climates, help ease people’s pain as other places close. Admittedly, this will be less helpful in the northern parts of the country, though the option of a park in the cold weather is better than nothing at all.

A key mistake made during the spring lockdown is that the US didn’t use the time it bought productively. Instead of building a national testing and tracing system, President Donald Trump’s administration punted the issue down to the states. Congress and state officials should take steps to ensure things go differently this time around — building up testing and tracing regimes, and full cooperation between states’ systems, to keep the US safe as cases are, hopefully, suppressed closer to zero.

In addition, all levels of government could use the time to prepare for widespread vaccine distribution. With some data showing we might get a highly effective vaccine soon, now is the time more than ever to make sure that hundreds of millions of Americans can and will get vaccinated. That means setting up distribution networks, including dealing with likely transportation hurdles if vaccines require extremely cold temperatures to store. It means making sure that Americans are persuaded to get a vaccine, given polling showing half of US adults, or more, are currently skeptical of getting one.

Crucially, the bulk of this work must come from Congress and the White House. A big reason that states aren’t closing down right now is because they simply don’t have the resources or reach, especially as they deal with an economic downturn, to offer enough financial support to individuals and businesses hurt by new restrictions. The federal government does.

The good news: If the country does this right, it could come out of widespread closures later in the winter or spring with a visible finish line to the pandemic. If coronavirus cases are successfully suppressed, a test-and-trace system keeps new cases low, and vaccine distribution is ready to go, we could be looking at a much better, more normal spring than we saw in 2020.

To put it another way: As painful as closing down again might be, it may only have to last a few months at most — to carry as many Americans as possible through the finish line, and end this pandemic with more lives saved.

The alternative, at the current rates of spread, is we go through the winter and into the spring with a widespread scourge that kills possibly hundreds of thousands of Americans and, ironically, impedes our ability to reopen more of the economy as much of the public remains terrified of going out while cases are high and it takes months to roll out a vaccine. (There’s historical evidence for this: A preliminary study of the 1918 flu pandemic found the US cities that took stronger measures against outbreaks saw quicker economic recoveries.)

Everyone wants to go back to normal. As unpopular as closing down may be right now, it’s how we can do it sooner rather than later.