What’s the Plan?

How long is this going to last? As terrible as a pandemic would be, is averting it really worth a new Great Depression? What is the endgame?

As a pandemic loomed, the country moved in remarkably short order from shrug to shutdown. Understandably, some are already questioning the wisdom of this move, noting how little information we’re acting on and the devastation the shutdown is already wreaking on the economy. The New York Times grants shutdown skepticism the frisson of “taboo.”

Much of this skepticism still misunderstands just how devastating the pandemic would be — not only in lives lost but in damage to the economy. The skeptics are wrong in the near term. For now, we have no other choice. But they are right that this cure cannot be tolerated for long. And they are right too that there is no consensus on when the shutdown will have achieved its aim, or on when the benefits will no longer outweigh the costs.

In conversations this week with public health experts, policymakers, journalists, friends, and family, I have heard a wide range of views on what needs to happen for the shutdown to end and when we will get there, from “two or three weeks, until everyone can get tested,” to “12 to 18 months, until there’s a vaccine.” Notably, nobody seemed to be aware of the vision articulated by national leadership — 15 days of shutdown to slow the outbreak, then we’ll reassess.

We urgently need a better understanding of why the shutdown is necessary, under what conditions it will be relaxed, and what we all must do to achieve that transition. The present uncertainty imperils not only the economy but the effort against the pandemic. We must have a plan now.

Many still do not grasp how bad the pandemic could be. An unfortunate narrative has developed: Since deaths will mostly be among the old and infirm, most of us will be fine. We thus face a wretched choice between saving vulnerable lives and saving the economy.

This choice is false, and misunderstands the damage the pandemic would inflict, both to human lives and to the economy.

Projections of the number of Americans who will die without mitigation range from the hundreds of thousands to 2.2 million. The reality of so many lives lost — more than all the soldiers we have lost in all the wars we have fought — is not something modern Americans can grasp.

As unimaginable as these deaths would be, we may be erring by focusing on them. It is possible that 20 million Americans would need hospitalization. And while the available evidence is fragmentary, in New York and Italy there are reports that half of those hospitalized are of working age. Millions of American workers now idle but healthy could instead fall gravely ill.

Crucially, even the “low” fatality rate assumes that the sick receive medical treatment. If the health care system is overwhelmed, many of those in the 99 percent — the young, the healthy, the “most of us” — will die. We are already seeing this reality play out in Italy, where doctors are now choosing whom they can’t treat, and the fatality rate so far is 8 percent — compared to 1 percent in South Korea, where the outbreak has been contained within the health care system’s capacity.

Worse still, deaths from everything other than coronavirus would also boom, as care would be scarce for everyone. The coronavirus dead would disproportionately be doctors and nurses, further crippling the health care system at the moment of peak need. This again is already the case in Italy.

We also still do not know with confidence that all survivors fully recover. Though there is precious little data available, initial reports suggest that some recovered patients have reduced lung capacity, which on a mass scale would entail enormous long-term social and economic costs.

We could go on with this analysis, but it is enough to say that an unchecked pandemic would not just mean the loss of beloved grandparents; it would mean mass illness and the collapse of the health care system. This in turn would mean economic and social collapse.

It is not possible to place meaningful estimates on the true economic cost of this scenario, except to say that there is good reason to believe it would be worse than the current shutdown. We simply do not have a good frame through which to view this future. Our world is too different from 1918 for the Spanish flu pandemic to offer much guidance.

The shutdown, then, is our only option — for now. Its purpose is to slow the disease as much as possible while we rapidly develop other options. A refrain from public health experts I spoke to this week is the lack of vision from federal leaders. We are stuck together on a rudderless ship.

The most urgent task for the president and national leaders is to articulate the purpose of the shutdown, what it aims to achieve, and how we will know when we have. The current answer — “15 days to slow the spread” — is arbitrary and unpersuasive. The question is not How many more weeks or months? but Under what conditions can we relax blanket national closures?

Various answers suggest themselves. We might say that the shutdown can end when the case curve bends: That is, when new daily confirmed cases peak and decline. We might also look for the share of tests returning positive to steadily decline, suggesting that testing is finally widespread enough to capture most cases. Perhaps most importantly, we might look for a peak and decline in Covid-19 hospitalizations and deaths.

Some such set of specific conditions needs to be offered by federal leadership and broadly understood by the public. Why are we doing this? How will we know when we’ve won? “Flatten the curve” has already sunk in, but it is not enough.

The shutdown is not a plan; it is a hasty but necessary retreat. Its purpose must be to shrink cases, and ramp up our infrastructure, enough to switch to more targeted suppression measures.

We already have a gold standard for fighting epidemics: early identification of symptomatic patients, contact tracing, isolation of those infected and exposed, and widespread random sampling of the population to detect new outbreaks among unidentified contacts. Only by identifying and isolating the sick can the healthy get back to work.

The crucial lesson is that we need not endure mass closure for the duration of the pandemic. We are only stuck doing it now because we were caught with our defenses down, failing to implement the normal methods early enough.

This is not a hypothetical point: South Korea managed to control its outbreak without ever resorting to mass closures. It did so through a combination of massive testing, rigorous contact tracing, and isolation of the infected. Not only were people with symptoms tested and quarantined, but authorities went through considerable effort to track down people who may have been in contact with the sick and test them as well.

We may need to borrow methods from South Korea, Israel, and Singapore, which have accepted a level of surveillance that is incompatible with the “old normal” of American life, but which may need to be tolerated for a year or two if we are to lift the shutdown. It is urgent for our national leadership to offer a clear vision of what the “new normal” of post-shutdown life will look like, how we will balance its requirements against civil liberties, and how we will achieve it as quickly as possible.

Many now speak of a “victory mindset”: We are at war and must stand together as a nation, like England during the Blitz. If that is true, national leaders and the public must be united in a clear understanding of what counts as victory, when we will know we’ve achieved it, and what each of us must do and sacrifice.

As we near the end of the shutdown’s first week, public resolve seems firm. But without a clear vision from our leadership, the problem is not so distant as a shutdown lasting a year and half, but a backlash arriving much sooner. Conversely, we can endure the pain and hardship of this phase for much longer if we all know how it will end.

The problem in the near term is not whether the plan for victory is too costly. It is whether we have a plan at all. The chief priority of our leadership must be to offer us this vision before the end of the shutdown period they have defined — a week from now — arrives.