416. How Do You Reopen a Country?

Gina Raimondo, the governor of Rhode Island, speaks about the struggles her state is facing due to the COVID-19 pandemic. She is obsessed with finding ways to safely reopen the economy, but the situation remains challenging. The majority of Rhode Island is struggling, with a large number of people having filed for unemployment. Raimondo is considering metrics based on science and fact to guide the reopening process so that if another outbreak occurs, a whole state shutdown can be avoided. The situation is not unique to Rhode Island, and elected officials worldwide are facing similar dilemmas. The challenge is to minimize the impact of the pandemic on people's health and the economy.

The 1918 pandemic killed around 675,000 people in the US, and the second wave was the deadliest. As governors weigh the risks of when and how to reopen the economy during the current Covid-19 pandemic, strategies are being discussed to mitigate the risk. Former heads of the Centers for Disease Control and pandemic forecasters are amongst those addressing the issue, along with economists proposing possible solutions, such as a weekly lottery to incentivize people to get tested. Rhode Island Governor, Gina Raimondo, remembers the chaos in the first few weeks of the pandemic before banning large gatherings and closing schools which was initially met with resistance. While there has been pain and hardship, her state has never had extreme spikes in cases and their healthcare system has not been overwhelmed.

Rhode Island Governor, Gina Raimondo, defends her decision to intercept cars with New York license plates during COVID-19 outbreaks, citing concerns over the high rate of infection in neighboring states and requests from Rhode Islanders. However, she admits singling out one state was a mistake and would treat everyone equally in retrospect. Raimondo emphasizes the importance of data and relying on public health advisors to make informed decisions, while also being willing to adapt as information changes. As she works on a strategy for restarting the economy, Raimondo acknowledges the challenges of doing so without adequate testing and data available, but stresses the need for politicians to be flexible and open to changing plans.

The reopening of society will need to be phased, with social distancing measures being in place for at least the next year until a vaccine is available. Even as crowds increase over time, handwashing, mask-wearing, and social distancing will remain necessary. The reopening of schools poses a particularly tough challenge due to the age of the custodians and teachers often being over 50 or 60 years old. Pandemic management comes in three phases: early detection, mitigation, and suppression. The heroic efforts of China in containing the outbreak at its epicenter were not replicated globally, leading to the mitigation phase of slowing down rather than stopping the spread of the virus through social-distancing measures.

Mitigating the spread of COVID-19 involves both social distancing and maintaining essential services, which is a delicate balance that many are struggling with. The next phase of the pandemic involves recovery, but there is uncertainty about whether a second wave of the virus will occur. Experts agree that testing, contact tracing, and isolation strategies are key to exiting lockdowns sensibly, but achieving this is challenging with a disease that is still largely unknown. Novel coronavirus attacks the body in ways that top doctors and scientists are still trying to understand. This uncertainty is reminiscent of previous pandemics such as the AIDS outbreak. To prepare for the next phase of the pandemic, communities must focus on testing, contact tracing, and isolation strategies while being mindful of the potential for a second wave.

The emergence of Covid-19 and the current experience of health workers with a lack of protective equipment is reminiscent of the early days of AIDS. Both diseases initially arose in an environment of complacency, where previous successes against infectious diseases created a false sense of security. While different countries have responded differently to the pandemic, some finding success in broad-based shutdowns and contact tracing, others pursuing herd immunity, the best overall approach remains unclear. However, the success story of New Zealand, which brought community-based transmission to near zero through a broad-based shutdown, offers hope. Balancing individual privacy and civil liberties with effective contact tracing remains a challenge.

Contact tracing is a vital tool to contain the spread of COVID-19. The best middle ground or compromise for contact tracing involves consumer choice and opting in rather than forcing people. It requires providing incentives and ensuring the security of personal information. While some states have started to lift lockdown restrictions, others face protests and political leaders trying to balance public health and economic concerns. Leaders must communicate the importance of following the rules to control anxiety and move towards reopening. Scientists worldwide are working towards creating a vaccine for the virus, which could take up to 10 years. In the meantime, we must take things slow, stay patient, and follow protocols to end the pandemic.

Developing a vaccine for Covid-19 requires a longer testing period for protection and safety concerns, but with a public-health threat of this scale, norms may be adjusted to accelerate things. Producing enough vaccine for equitable access among all people who need it is monumental and unprecedented in history. The absence of a vaccine or therapeutic calls for reducing the spread of the virus through testing, which is key to reopening the economy. Despite testing progress, multiples of more than 2,000 tests per day are needed before that can happen. The search for treatment or vaccine for Covid-19 is unpredictable, but history provides examples such as Polio having a vaccine while there is still no HIV vaccine but therapeutics have made AIDS no longer a fatal disease.

Economists can play an important role in guiding policy decisions and tradeoffs during the exit from quarantine, given their expertise in balancing economic activity and life and death tradeoffs. Lack of widespread testing has been identified as a major challenge for developing a sensible plan, with the need to scale up investment to address the $16-19 billion daily loss to the economy. Reliable estimates of Covid prevalence, including pregnant moms in hospitals, are important for making informed decisions. Collaboration between economists and policymakers is crucial, with the need to reach out to relevant parties in the Hill, Senate, House, executive branch, and HHS for effective decision-making.

A pair of Dartmouth researchers have proposed random testing of 10,000 people to predict the number of Covid-19 cases. The two types of tests available are diagnostic, which looks for the virus, and the antibody test, which looks for the body's reaction to the virus. However, the accuracy of the antibody test is questionable, and the F.D.A. has granted emergency authorization for over 60 versions of Covid tests, most of which are diagnostic. The lack of testing is due to a disrupted medical-supply chain, and the science behind immunity through antibodies is unclear. False positives and negatives and the unknown protective nature of antibodies complicate the interpretation of the test results. Therefore, it is essential to understand the meaning of the antibody tests before deciding who should be tested and when.

To effectively ramp up COVID-19 testing, the federal government needs to set a single, high payment rate for all parties in the healthcare system, with prices aligned to the social value of testing. The scale of externalities associated with testing demands stronger financial incentives, with much capital needed to scale up testing. If the economy is losing billions of dollars daily, investing $250 billion in testing looks reasonable and necessary. However, payment rates alone won't increase the supply of test kits. Supply chain problems must also be addressed, particularly in the production of tests and necessary materials. Investing in ramping up testing could help restart the economy earlier, saving roughly $500 billion.

The Defense Production Act provides an opportunity for the government to steer private firms into producing necessary supplies such as re-agents and swabs for Covid-19 testing. Boosting testing production and delivery is crucial, especially with existing hospital systems under strain. Pharmacies offer an existing infrastructure with 67,000 locations available in comparison to 5,500 hospitals. Pharmacists, who have the same years of training as physicians, manage complex and dangerous medications and dosing. However, pharmacists are not considered healthcare providers due to a quirk in the Social Security Act. Policymakers could tap into the existing pharmacy network and redefine the role of pharmacists as healthcare providers to aid in Covid-19 testing delivery.

Pharmacists are trained healthcare professionals who play a vital role in improving patient outcomes by monitoring and adjusting medications. However, they are often overtrained and underutilized due to limited funding for healthcare, and regulatory barriers prevent them from being compensated for their work. Despite being authorized by the US Department of Health and Human Services to administer Covid-19 tests, regulations remain a barrier to pharmacists in various states, with California currently forbidding pharmacists from conducting Covid-19 tests. To address this issue, there needs to be an exception made to allow pharmacists to administer Covid-19 tests as they are a viable resource and can significantly increase testing capacity in the state while complying with established safety guidelines. This decision will ultimately improve healthcare accessibility and affordability for the people of California.

Pharmacists can play a key role in containing the COVID-19 infection by offering screening, advice, self-management, self-care guidance, quarantine directions, and referrals into the healthcare system. However, the incentive problem of actually getting people to take the tests is a major challenge. Even if we had millions of tests available to administer, the chances of getting people to take them voluntarily are low. People need to be compelled to take these tests, but this is a classic case of a negative externality, where the costs of not taking the test are borne by others. Economists can help solve this problem and create incentives for people to take the tests regularly, which is essential for a smooth and safe exit from quarantine.

Economist Steve Levitt believes incentivizing people to take Covid tests could be solved by internalizing the externality. By paying people in the form of a large lottery, such as his proposed Pandemillions, people without symptoms could be motivated to take the test. Those who test positive would receive a payment of $2,000 per week to stay at home, further incentivizing them to get tested. Levitt believes the costs of paying people to stay at home and taking the test would be insignificant compared to the impact of the disease. However, the challenge will be preventing people from cheating to gain favourable results for the lottery. Levitt suggests that incentivizing people to get tested and stay home is a practical approach to controlling the pandemic.