When and How Will We Get to the New Normal?

When will things get back to “normal?” When we are able to give the vaccine to most of the population by the end of summer in 2021. In the meantime, we have to manage the next 12–15 months in a way that minimizes infections and impacts on our economy. Collectively, we have transitioned from the initial shock and denial phase to the anger and sadness phase. Some of us have come to accept the temporary new normal and are doing everything we can to mitigate and suppress the contagion.

Dyson invented a new type of ventilator and has started production. Tesla built 1000 ventilators in a week and donated them to LA and NYC hospitals already. Various supply chain experts are sourcing masks and other personal protective equipment (PPE), while some people are sewing masks for themselves and the local nursing homes. Apple and Facebook looked in their warehouses and found a bunch of masks from when they stockpiled after the H1N1 flu in 2009 to donate to the hospitals that are struggling to source enough masks. Every scientist is theorizing new treatments and getting them into clinical trials. Scientists are also working quickly to develop more accurate, faster testing. Software developers are making tools and apps to trace the virus and make predictions. The rest of us are self-isolating at home as much as we can to “flatten the curve” as we exercise our social responsibility while protecting ourselves.

The government signed into law a few major pieces of legislation to help us through. Two weeks of emergency sick leave is now mandatory for small and medium sized businesses (companies over 500 employees are exempt from this law). FMLA now includes all businesses with less than 50 employees as well — it did not before. 80% of American adults will get a $1200 check soon. Each kid gets $500. It’s phased out for higher-income people. There are lots of loan options for small businesses. The SBA offers an interest rate 3.75%, and some states offer even lower interest rates. Some landlords are not charging rent for a month or two. Water is being turned back on for some households that could not pay their water bill.

All of these social safety nets and kind gestures will help us get through this crisis. This is great for the initial phase as we all grapple with the incredible situation. Now, we need to move to a “new temporary normal,” one in which we can re-engage in our economy. To do this, we need to implement a few key changes:

• Mass testing
• Isolating the sick
• Trace and quarantine sick contacts
• Quarantine travelers

Step 1. We need to have easily accessible, free testing.

This testing would need to be more accurate than our current method. Our current testing uses PCR (polymerase chain reaction), which looks for a chunk of the virus’s genetic code. It’s very specific when it finds the code — meaning that there are very few false positives. Unfortunately, if the swab did not dip into the right chunk of mucus in someone’s nose or throat, then it may not grab the virus that’s there. So it has a high rate of false negatives — anywhere from 20–40% of tests incorrectly do not detect viruses. This is why some people miraculously recover (test negative) but then test positive again. It’s simply a testing error. People who recover from COVID-19 will test negative on PCR because there are no more virus particles to detect.

Statistically, one in four people who have COVID-19 will have a negative PCR test. It’s incredibly inaccurate, so many doctors have to rely on their intuition to recommend patients self-isolate even with a negative test. Abbott Labs recently announced a five-minute PCR test, but they do not list the sensitivity at all, recommending that all negative five-minute tests be followed up with their longer test that is more accurate. A five minute test is great for screening at an airport or emergency room triage. My cynical side thinks it’s a sneaky way to upsell two tests for every patient.

Once someone has symptoms, a few other options become available to look for COVID-19. A CT scan is able to find characteristic changes in the lungs of someone who has COVID-19 symptoms. Even when the PCR test is negative, a CT scan can sometimes find the disease. It’s potentially a more accurate (sensitive) way to diagnose COVID-19 for someone who’s sick during this epidemic. We should be doing more CT scans while waiting for the antibody test to become widely available. A CT scan in this country can range $500-$1500. In other countries, a simple chest CT can be under $100. If we standardize the chest CT cost for COVID-19 screening, it can be a great test that’s potentially more accurate than the PCR test. The government-funded free test is the PCR, not a CT, so this is underutilized as a diagnostic test.

The final option that will be available soon is an antibody test. When your body starts to fight off the virus, it produces two types of antibodies: IgM and IgG. This ten-minute test will check for both types via a finger stick (a drop of blood from your finger like when someone checks their blood sugar). IgM type antibodies are produced within 2–4 days of the fever and can be detected for about a month. IgG antibodies are produced in a more mature immune response, starting about a week into the illness and lasting for years. When you get a vaccine, your body’s production of IgG provides long-lasting immunity. This test will show up positive even after your body has gotten rid of the virus, in contrast with the PCR test. Plus, this antibody test will find the people who never had symptoms, such as kids, even when they’ve had the disease. While this test is more reliable (sensitive) than the PCR, it requires someone to have been sick for a few days to show up positive. The other downside is that it may cross-react with other coronaviruses, so it is less specific — it has more false positives.

The antibody test is being made in a town in Colorado. They plan to test the entire county of 8,000 people — whether they had symptoms or not, whether they tested positive on PCR or not. Correlation of the PCR test to the antibody test will tell us a lot about how accurate both tests are and how many people were sick but never exhibited symptoms. This is a huge unknown right now, and it would be fantastic to know these results from a scientific standpoint. It makes a huge difference if kids catch the virus but never have symptoms (but can still transmit) versus if kids just don’t even catch the virus. This can tell us when we can reopen schools.

To identify the people who are sick, we need to go through a stay-at-home/essential-businesses-only period where we wait for anyone who is infected to come down with a fever. Those people should be tested, confirmed, and given strict isolation orders. After that, all stores (and other places where lots of people may interact) should scan employees and visitors for fevers. Anyone with a fever should be referred for testing. While we would like to believe that sick people would self-refer for testing, we aren’t naive. There will be at least 10% who won’t (scared, oblivious, or just ornery), so we must subject everyone to mass fever screening and follow up testing.

Step 2. Once we have widespread reliable testing, we can find the people who are sick and keep them in strict isolation.

Right now, we are essentially quarantining everyone in multiple states because we don’t know who is sick with the coronavirus. If we strictly isolate just the sick, then the rest of us can go back to work and go back to school.

There are a few ways to isolate someone with COVID-19. While most people will happily comply with staying home when sick (as long as they are paid), there will be a few who won’t. The few who can’t follow the rules will cause too much of a burden, so this non-enforced home quarantine/isolation is not good enough. We must have strict enforcement with jail time consequences.

In some countries, the method of enforcing isolation is to ask the sick person to use an app on a smartphone to verify that they are home. The app would ask you to send location information at all times, sometimes requiring a picture or voice verification to make sure that you did not just leave your phone at home. It would of course have geofencing, face recognition, and voice recognition to help with automation. Surveillance operators would not only notify police to enforce the quarantine but also walk people though when to go to the hospital or to help with their mental health. This is far more effective and will help keep honest people honest. Far fewer people will break isolation. It’s important to note that a month of isolation can be really hard on anyone.

The final method, which I hope we don’t have to do, is for the government to book a hotel and have the National Guard tend to the sick. Moving the sick to a monitoring area ended up happening in some areas of China because it was really hard for a family living in a small apartment to isolate the sick person. They didn’t have two bathrooms, so the sick person ended up transmitting the virus to the rest of the family, who still interacted with the outside world. In fact, 2 out of 3 cases in China were close-contact transmissions, rather than catching the virus at public places.

In the US, lower-income families often only have one bathroom as well. COVID-19 can cause nausea and diarrhea in some people, which transmits the virus, just like coughing. If we start to find that there is a lot of in-family transmission in certain areas with a widespread outbreak, moving the sick people to a hotel/inn/motel/extended-stay-suite may be necessary to stamp out continued transmission within a community. Plus, it would help with the struggling travel industry. Ultimately, the cost of isolating ten people in a hotel for a month ($100 x 30 days x 10 people = $30,000) would still be less than one person in a hospital for two weeks. ($2500 x 14 days x 1 person in a normal hospital bed, not ICU = $35,000). Under certain circumstances, having patients check into a hotel rather than staying at home with the rest of their family sharing a bathroom and kitchen is actually cheaper for our economy.

Economists can best advise who to pay for this, and public health officials can work out the details of food service, in-room monitors (in case someone needs to go to the hospital), and subsequent decontamination. The National Guard can provide not only enforcement but logistics support and transportation. It may not make sense in every case, but this should be an option for really badly-hit areas to control spread. In these communities, security may become a concern. Having Guard presence may also help to keep order.

Step 3. All contacts of the people who are ill must be traced, informed, and kept in home quarantine.

This is where the smartphone app would be really handy to keep someone home for 14 days. Tracing and quarantining contacts is the only way to keep the disease from continuing to spread.

There are plenty of gig workers who can help with the administrative job of contact tracing. We need to ramp up hiring temporary government workers to do contact tracing and quarantine enforcement via technology. It’s like the temporary status for the census. The temporarily displaced retail workers can get a temporary job helping to get this epidemic under control. We just need someone at the top to lead it. If the federal government isn’t up for it, States can take it into their own hands. We wouldn’t need to send out another set of stimulus checks if people are employed.

Contact tracing and quarantines aren’t new. These are standard for any outbreak, but we don’t have the manpower in our public health departments right now. We need a massive war-like effort to hire people to do this. The good thing is, the soldiers would simply be administrative workers, organized, compassionate, and compliant.

We must not stigmatize people in isolation or quarantine.

It must be viewed as a sacrifice the quarantined individual is making for the rest of us to be safe. We should fully support them with quality food, shelter, and internet (entertainment). The local paper can write feel-good articles about how many people completed their quarantine and how they plan to celebrate.

Step 4. All travelers from high-risk regions (including high-risk domestic areas such as New York City) should also undergo a 14-day home quarantine.

Some countries have implemented required quarantines for every single traveler. As the disease makes its way around the world, we will need to exercise this precaution as well. Americans would be allowed to go home, with a quarantine app. For visitors like tourists or business travelers, a government controlled hotel at major ports of entry would be helpful. The public-private partnership of a hotel quarantine is really a win-win from an economic point of view.

Speaking of hotels, some front-line healthcare workers are staying in hotels so they do not bring the virus home. Again, from a purely economic point of view, hospitals paying for hotels (via government tax write-offs) is cheaper than doctors or nurses quitting or suddenly retiring because they simply don’t want to deal with the logistics of keeping their family safe. They are putting their own lives on the line; they shouldn’t have to endanger their own families. For the government, supporting hazard pay or housing the front-line healthcare workers is cheaper than degraded medical care.

Mass testing, case-isolation, contact-traced quarantine, and travel restrictions will suppress the epidemic.

It already works in South Korea, Taiwan, Singapore, and China. I believe that the major cities currently under siege would support these simple steps. For the rest of the country to get on board with the isolation and quarantine concepts, they may need to also experience the illness. Once everyone knows someone personally connected to them with COVID-19, I think we’ll all be on the same page. This should happen by the end of April, when even small towns in middle America will have a bad case requiring hospitalization.

It hits you at a visceral level when you have an exposure and worriedly look up the mortality rate for your age group, finally realizing that no, you’re not okay with a 1% chance of actually dying. It’s all too easy to say to someone else that the chances are low, but when you have a close call, then it becomes real. It will become real for most people by the end of April.

Data published a week ago shows that even if young people don’t die with good medical care, a huge percentage of them still need to be hospitalized. Here is the chart from CDC’s March 26th MMWR report. 14–30% of people 20–65 years of age required hospitalization. This is much more than I or anyone else had expected. It finally makes sense to me why some countries (that seem to care more about economic output than compassion for its citizens) made such an investment in building out emergency hospitals to suppress the disease. If we overwhelmed the medical system, working-age people would die. Any economist can tell you that’s devastating.

This March 26th CDC report really changes the calculus for when people can work again. The only way for us to get the economy back is to completely suppress this disease. If we can keep the virus at bay, then we can resume some of our daily routines.

If we let the coronavirus slowly spread, continually killing and keeping our hospitals at capacity, we won’t ever feel safe enough to get back to normal. We won’t be able to take the subway, resume schools, go to church, or participate in group sports. We’ll have periods of being able to work and periods when we have to restrict to essential businesses only again. This uncertainty will make it impossible for businesses and individuals to plan long-term, and our economy will suffer greatly.

If we work together to actively isolate, trace, and quarantine, then we can have far more certainty for our lives and our economy. There may be occasional outbreaks, but these would be quickly contained, and only the small number of people involved would be isolated or quarantined. As our testing capabilities improve, active, continual suppression will become the obvious course of action for our nation. By late April, our government (either federal or state) will start implementing the four steps I outlined above. By the end of May, the caseload will begin to decline around the country. We will all breathe a sigh of relief at the end of Spring.

• Shock (March — April 2020) — fear and economic instability
• Definitive actions for suppression (May — July 2020) — implement widespread testing, strict case isolation, trace and quarantine contacts, travel restrictions (international and domestic)
• Active, continual suppression (August 2020 — April 2021) — continued commitment to minimum social distancing and all suppression techniques
• Vaccination phase (May — August 2021) — most vulnerable population begins the vaccinations
• Resumption of “new” normal (September 2021 — end of 2022) — bills become due, government assistance phases out

Over the summer, we will manage to completely suppress the disease and get nearly everyone back to work. It’s not because the virus has a huge seasonal variation, but because we are effectively containing it. We may be able to have some kids summer camps, but with pretty strict restrictions such as daily fever screening. Local team sports may start up again, but also with crowd size restrictions, which will gradually loosen. Currently, we are restricted from gatherings of more than 10 people around the nation. Over the summer, we may be able to have church services of up to 100 people at a time if we do a good job with suppression. Mass transit, grocery stores, restaurants, and bars will still have recommended social distances, and we’ll feel safer because they do, even if we grumble about it.

School will resume in the fall, again with strict precautions, particularly for international students who may be asked to arrive early for 14 days of quarantine before school starts. Employees who are sick will still be asked to stay home. Elective medical procedures may be scheduled again. We can go to the mall, but we may have to walk through thermal scanners at the entrance, especially in large metropolitan areas. We’ll have our trick-or-treating, election (with a lot of voting-by-mail), and holiday family get-togethers. However, we may not have huge events like the pictures with Santa at the mall or professional sporting events. What we now consider invasions into our privacy will be viewed more like a safety measure and social contract, plus social media already knows everything anyway.

When you read predictions, does it make you more confident about how to plan your life for the next few months? If so, then you know how businesses would feel having a reliable game plan. Knowing what to expect, while knowing that there will be some set-backs along the way, frees people from worry. We need to get to that stage as a country. The only way to feel confident is to really quash down the number of cases so our hospitals can get back to near-normal function. We have to get to where we quickly identify, isolate, and quarantine contacts. We need to do this in every single town, small or large. The science and technologies soon available will get us there. If we all fully commit, we can do this!