Required Minimum Public Health Steps to Open Society and Economy after Spatial Restrictions to  Overcome the COVID-19 Pandemic:

Everyone wants the pandemic to end. Everyone wants the closings, spatial isolation, staying-at-home and economic collapse to end. But the COVID-19 disease operates on the rules of viruses, not our popular vote. If we don’t understand how viruses spread and what it takes to end the risk then we will keep repeating the flare up/isolations/economic collapse/renewed deaths and hospitalizations cycle followed by an illusory search for normal. Hope for a return to a fair and resilient world must be based on the application of what we know about science, public health and fairness. We cannot continue to praise our frontline staff and bemoan the deaths of our neighbors if we do not institute policies that change how our nation, region or city confronts illness and a broken health system.

These steps are essential components of an effective program of opening up US society at the local and state levels from the restrictions implemented to save lives and flatten the curve of COVID-19. They are affordable and necessary to minimize the potential for new spikes of illness which would require new or renewed restrictions.

1. Without a vastly expanded capacity for testing we simply don’t know if we are making progress and if a loosening of restrictions will succeed. Without massive and sustained testing we will not identify people who need to self-quarantine or who need treatment. Without testing so that we know who tests positive for COVID-19 we will have people continuing to spread the virus to others. Unless the testing is free, people who are at risk will not use the tests. While the deficit in testing varies widely by state, the most reasonable estimates are that we need to be doing more than 3 million more tests each week. If positive tests are more than 3% of total tests we are not reaching enough people. In the US we are seeing 20% of people tested being positive.
2. The pandemic treatment can be expensive and will include not only hospital and intensive care but also out-patient medical and mental health as well as addiction services and PTSD care. Covering everyone, including people who are not documented, for the full range of care that is needed because of the pandemic is the only way to get around the reluctance of people to use services for fear of the cost and the bureaucratic complications that many of our current health plans impose.
3. We have seen the extraordinary extent of disparate treatment by, race, class, gender and other groupings. Everyone is now clear that people of color, ethnic minorities, the elderly, people living without stable homes, the LGBTQ community all suffer disproportionate levels of illness and death. What we need is to document these cases and develop a database sufficient to understand what characteristics, co-morbidities, exclusions are most associated with increased vulnerability. The data exist in hospital records, state and local government databases and a host of mapping and health reform databases maintained by philanthropy. They must be put together in a usable form and states must require that data be submitted in a timely and complete fashion.
4.  Without contact tracing we will not be able to intelligently loosen restrictions or prevent and monitor any possible flare-ups. We now know that there is an urgent need for hundreds of thousands (one often quoted estimate is 300,000) new public health workers. The Federal government is being lethargic and minimalist in its approach. We must force the Federal government to fund the training and maintenance of these workers. There are existing models for training programs so that these new public health workers can build careers of agile and smart service that assures family sustaining incomes and conditions of safety and health in their own work. We do not want to create another profession of frontline workers who live in poverty while doing high risk work.
5. Prisons and nursing homes as well as other high density and congregate care institutions subject residents to high risk. There is an urgent need to make these settings less dense immediately. We then need to assure adequate trained staff, increased active testing and isolation capacity. There are numerous critiques of the ways in which we provide congregate housing. While critiques of prisons and critiques of nursing homes or shelters may be very different they share a characteristic of high vulnerability and preventable mortality and morbidity. As an immediate strategy we need to have an active program monitoring these settings for the benefit of residents, their loved ones and frontline staff. This must be accompanied by an expedited process of rethinking how such institutional care is provided to improve quality, control cost and reduce exclusion.
6. Even with careful planning and an active program of taking the initiative for public health there will be times at which flareups happen or are threatened. When that happens our goal must be to reduce the flareups which may require re-instituting some restrictions. Planning such policies also allows us to have a public discussion of both the importance of maintaining sound prevention policies and if necessary implementing public health protections and restrictions in response to the flareups.
7. We have seen that there is a clear market failure in the provision of PPE. We have inadequate production and a chaotic market that drives up the costs for everyone while not getting PPE to the places where it is needed. A national program of production, reliable supply chains (domestic and international), stockpiling and emergency distribution is essential to meet needs of this pandemic and future public health needs in the US and elsewhere.
8. Without federal support for these extraordinary problems we will see cuts in programs essential to minimize vulnerable populations’ exposure to this virus and a range of preventable health problems. Local and state governments have suffered a huge loss of revenue at the same time they are experiencing huge additional expenditures to meet the challenges of the pandemic. Unlike the federal government most state and local governments are required to develop and maintain balanced budgets. To meet that challenge there will be increased unemployment and further shredding of essential safety net programs which will in turn increase the vulnerability of populations to many levels of disease. National organizations of governors and mayors have estimated the federal support they need to be made whole. This is an urgent issue because most state and local governmental budgets have to be in place by June 30 or September 30.
9. This pandemic has shown the frailty of our hospital system. While we have some hospitals that are still profitable we also have a network of safety net and rural hospitals that are in danger of collapse. A federal program to provide funding to these hospitals accompanied by a commitment by the hospitals to serve their communities is needed to provide care now and to guarantee a future of service.

There will also need to be special legislation and funding to help the tens of millions of our neighbors whose often frail economic security has been shattered by the collapse of our economy. Defending the economic security of all of our people is not in conflict with rational public health. Working together we can emerge healthier, more knowledgeable and less polarized. That is what will end the threat of the pandemic. Nothing less.