A Detailed Plan for Getting Americans Back to Work

A Detailed Plan for Getting Americans Back to Work

by Amitabh Chandra , Mark Fishman and Douglas Melton - April 01, 2020

Millions of Americans - especially those who have been most impoverished by the forced shutdown due to the Covid-19 pandemic - want to return to work. But with the Trump administration now urging Americans to stay at home until May 1 and the likelihood that a vaccine against the disease won’t be widely available for 12 to 18 months, how can we safely make that happen?

There is a way. Several similar approaches have been proposed by others such as Paul Romer of New York University and Alan Garber of Harvard and Ezekiel Emanuel of the University of Pennsylvania. In this article, we build on them, offering ideas for how individual states can carry them out. Our hope is that this plan will allow people to begin to return to work depending on local conditions. We do not offer a set date for reopening the economy; rather, we specify a minimum set of conditions to be satisfied before the economy of a given state can be reopened, and a path to reopening it once these conditions are met.

Our proposal requires the following conditions to exist before reopening a state’s economy:

• The state is over the peak of the current wave.
• Health systems in specific regions agree that they have the resources and personnel available to deal with smaller but inevitable second waves of disease. Our proposal does not work if the delivery system is stretched to capacity or beyond and recognizes that some communities will be unable to open because of limited capacity.
• The availability of sufficient testing capability to identify both those who still have an active infection and those who have evidence of prior infection. There needs to be an unrestricted availability to perform both tests, ideally through point-of-care tests and backed up by centralized testing. We emphasize testing over temperature-taking; although taking individuals’ temperatures is inexpensive and easy to use it is too insensitive to detect people who may be transmitting the virus.
• The widespread availability of personal protection equipment, including protective masks, not only for health care workers but also for returning workers, along with continued practice of social distancing. There has been rapid innovation in such equipment, and some may prove to be more effective than N-95 masks, which need to be fitted and were invented to protect people from industrial particulate pollution, not virus transmission.

If these conditions are met, we propose allowing people to return to work who have recovered from the virus, have demonstrable immunity, are under age 65, and have no complicating medical conditions. The first group includes those with asymptomatic and previously symptomatic patients who are now virus-free. The second includes those who test negative for current infection, a test that would need to be repeated at regular intervals. Both categories would need to be verified.

Our approach can be flexibly adjusted to the situation in different U.S. locations, which is essential. Each location will have distinctive conditions in terms of medical conditions, the availability of resources for health care delivery and maintenance, testing capabilities, population demographics, and business priorities. Given that these factors will be fluid, the task of staging business re-openings in a safe and thoughtful manner will be complex. We suggest that governors set up specific advisory structures - perhaps including a coronavirus “czar” - to help make and enforce decisions.

That said, any proposal to return to work before widespread immunity in the population has been achieved - either by prior infection or immunization - has risks that could lead to a second wave of infection. For example, we currently do not know how long patients who appear to have recovered from the virus continue to shed the virus and remain infectious. Nor do we know how long antibodies protect the patients.

We also do not know if the apparently high rate of serious illness and mortality is real or whether it reflects the limitation on testing to those already fairly ill. It is possible that, once we have sufficient tests to examine the broad population at large, we find that many more folks have been infected but haven’t shown symptoms. This would mean that the severity of illness is lower than currently believed, and that “herd immunity” - the point at which so much of a population is immune to the disease because they’ve had it or have been vaccinated against it that it can’t easily be transmitted to others - is is building and becoming protective. This will help to inform the rapidity with which resumption of business can occur.

Here’s how our approach would work in practice.

Testing. We would have to confirm that people returning to work do not have a current infection or that they do have antibodies that confer immunity to the virus (indicating prior infection). Most current tests for active infection are based on assays for viral DNA that require multiple cycles of heating and cooling. They are limited in availability and time-consuming to perform. But newer tests, even some using paper strips (similar to pregnancy tests), are being developed.

If needed, testing could be performed in open-air parking lots by public health authorities. Such testing should not happen inside hospitals or use limited hospital resources. Any new cases would need to be immediately quarantined, as would the contacts of the infected person. This requires a non-trivial allocation of resources, but is the price of reopening the economy.

Certification. Patients receiving clearance to work would receive an electronic certification - for example, a certification that resides on a phone app that provides a time-bound certification of their status. The certification should be time-bound because virus-negative patients can still get the virus.

Return to work.  Employers would verify this certification for returning employees. Airlines, restaurants, retailers, and grocery stores could require it as a condition for customers and suppliers to conduct business with them. Neighbors and relatives could require it as a condition to socialize. Certified-to-work employees would be required to work with full mask protection, possibly in shifts, and they would need to adhere to social distancing practices, such as not shaking hands or sharing utensils to serve food. These restrictions could be modified over time.

Implementation and fine-tuning. Each state governor should consider appointing a specific group and potentially a “czar” whose job would include verifying the assumptions behind this approach, operationalizing its implementation, and being responsible for restoring normalcy when the time is right. The czar will also need to deal with the complex issues of travel between states.

Each state should determine the answer to the following 10 questions:

1. At the local level, are health care providers sufficiently resourced to cope with a second wave of cases? How will they signal their readiness?
2. Which test kits will the state rely on? The test kits should be robust and certified by the Food and Drug Administration (FDA). They should not have unacceptable rates of false negatives for the virus or false positives for virus antibodies.
3. Are sufficient numbers of these test kits available to assay regularly for active and prior infection?
4. How and where will testing be done?
5. How will the state denote folks who had been tested? And how frequently should testing for virus negativity be performed?
6. How will the state enforce the quarantine of those newly infected and their contacts? Would there be point-of-care testing at patients’ homes backed up by centralized confirmation, especially of active infections?
7. Who will pay for testing and certification?
8. How will the state issue certification while not getting entangled in immigration law?
9. Who will be responsible for restoring a shutdown if this approach falters?
10. How will the availability of new treatments modify the approach above?

These determinations are different from the related enterprises of understanding the basic science behind virus replication, finding treatments for it, and building ventilator capacity.

To summarize, the date for reopening the economy depends on three constraints - health care capacity, testing capacity, and certification capacity - which vary by state and time, but do not depend on the condition of the economy. This may seem strange, but the economy will be even worse if it is restarted prematurely, which, in turn, means that a pre-specified or national date for reopening the economy should be avoided.

A local solution will require intense collaboration involving governments, hospitals, schools, employers, and scientists. It will be critical for population health but also strengthen communities long after the reopening - which would be strong medicine for a battered economy.

April 3, 2020 — Editor’s note: This piece has been updated to reflect Paul Romer’s affiliation.

Amitabh Chandra is the Edith Zimmerman Professor of Public Policy and the director of health policy research at the Harvard Kennedy School of Government and the McCance Professor at Harvard Business School. He codirects Harvard’s MS/MBA joint-degree program in the life sciences and is an elected member of the National Academy of Medicine.