Singapore's knocking it out of the park in their approach to COVID-19 and they still ended up having to succumb to lockdown.  The united states is nowhere near their game and we're already trying to reopen.  We've got to scale up our response to this virus; that's the topic of this week's healthcare triage.
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Many experts are beginning to coalesce around a set of benchmarks that could determine when it might be safe to reopen parts of the country but even though most areas of the United States are nowhere near achieving the gals necessary to do so, there has been a push to relax social distancing soon, and many states have begun to at least partially reopen, most without meeting recommended benchmarks.
Even more alarming, some experts say even those still not achieved goals aren't close to enough.  It appears that it may be time to think bigger.
Natalie Dean and assistant professor of biostatistics at the University of Florida said to me, and i'm quoting; "These are unprecedented times, and so we need to think on a scale that would previously be considered unimaginable."
The cautionary tale at the moment is sinapore.  For weeks public health officials enviously lauded it's response to COVID-19.  Singapore officials have been screening and quarantining all travelers from outside the country since the beginning of the pandemic.  Their contact tracing is second to none.  Every time they identify an infection, they commit to determining its origin in two hours.  They post online where identified infected people work, live and have spent time so that potential contacts can be identified.  They enforce quarantines and isolation of such contacts, with criminal charges for those who violate orders.  
And yet, a few weeks ago they put the entire country into lockdown.  All migrant workers were confined to their compounds for at least two weeks.  Citizens may leave their homes, but only to buy food or medicine, or to exercise.  Anyone who breaks the rules, including spending time with anyone not in their household can be imprisoned, fined the equivalent of seven thousand dollars in the United States, or both.  What Singapore is doing Dwarfs what most are discussing in the United States; it's present circumstances bode poorly for our ability to remain open for a long time.
Ezekiel Emanuel vice provost of global initiative at the university of Pennsylvania said to me; "There's just no way that we're going to be able to keep most of the country open through the year.  If Singapore can't do it, I don't imagine how we think we can.  As I have said, this is going to be a roller coaster with multiple waves of opening and partial re-closings necessary."
There are plans that aim higher.  Given the United States goverment's limited and lagging response to date the idea of a hugely ambitious project may seem inplausable.   But the cost of another future shut down is so high that previously unfathomable ideas may be worth considering.  
One of those ideas comes from Nobel prize winning economist Paul Romar and involves testing seven percent of the population each day.  We covered the details of his plan last week, so go check that out if you haven't already.
Other ambitious ideas can be found in a plan for the center of American Progress, written by doctor Emanuel and colleges.  Part of the proposal is an enormous information technology monitoring system.  It would call for all Americans to download apps to their phones that would monitor where they go and whom they get near, which would allow contact tracing to be done near instantaneously.  Everyone could sign in electronically before using public transportation, entering large buildings or school or gathering in groups above a certain number.  They even propose requiring the app to be downloaded in order to receive test results.  In an ideal situation, it would run in the background, regardless of whether users signed in.  Of course, such a system would be considered a large intrusion of privacy and it's not clear it's even politically feasible, or even legal!  Aditionally, not every American has a smart phone.  
Meridith Mctone, scientific director of policy lab, and an assistant professor of pediatrics at the university of Pennsylvania school of medicine says we may need to get away from testing to more grass roots approaches like community surveillance.  
As detailed in a policylab policy review, such surveillance could relax our need for active testing.  It would be more reliant on passive systems, like monitoring electronic medical records or traditional infection monitoring systems to pick up signals for outbreaks, like increased visits to doctors or emergency rooms for respiratory illnesses.  Surveillance could also involve a participatory approach, like asking patients to be tested before clinic visits, or to enter symptoms on web based tracking platforms, or to regularly check their temperatures at home.  Thermometers would be ubiquitous, and could even be linked to the internet for reminders and reporting.  If such systems work well, we don't need to capture an entire population to detect a signal.  We could identify hot spots, telling us where to do more focused testing.  Such testing could even be done by pooled samples, in such an approach, areas would have their individual samples combined together for testing, which saves resources.  If it is clear, everyone is safe!  If an infection is found, then again more focused testing could be done on the individuals in the pool.
The policy review also highlights the benefits of improving workplace safety especially in high risk areas like child care, school, and healthcare enviroments.  To making infection control more robust and infection control easier to acomplish. 
Not everyone thinks we need to aim quite that high.  Catelyn Rivers an author of the American enterprise institute report on reopening the nation and an epidemiologist at the john hopkin's center for health security said to me, and i'm quoting; "While Singapore is adding in some community mitigation measures, they've been able to successfully keep levels of infection under control for months, and they're still only seeing one to two hundred infections a day, which is far fewer than we are.  A case based approach is still the best way to move forward, and while it's possible that some areas may have to revert to staying home, I don't think that's inevitable.  Of course, we should still prepare for that with economic aid that can quickly snap into place if that needs to happen so that there's much less disruption than this time."  Of course, when I got that quote the numbers in Singapore were lower; they've gone up higher since then.
In a city state of five point seven million people, in an area the size of Indianapolis, Sinapore has had a hundred and forty people dedicated to contact tracing, working in conjunction with the police.  A little over a month ago it could test two thousand people each day.  That's the equivalent of testing about a hundred and fifteen thousand people in the United States.  We were testing barely a tenth of that amount at the same time.  
Singapore has always provided free testing and medical care for all citizens; more recently it distributed reusable face masks to everyone.  Officials were careful, while stores and restaurants were open people were told to keep at a distance from one another.  Gatherings of more than ten people were considered inadvisable.  
All of this is to say that people in Singapore have been operating in an environment that looks like what we might hope to create as we reopen- with safeguards beyond what we are probably going to achieve.  And yet Singapore is in lockdown now.  
It's not clear how tolerant the United States will be of another national pause; if Americans failed to comply the results could be disasterous.  Preventing a second lock down could be even considered a long term investment.
Professor Gregg Gonsalves a Professor of epidemiology and law at Yale said to me; and again i'm quoting, "Our trajectory right now does not give me hope.  Social distancing is happening in only a patchwork across the United States.  The next phase needs a massive national mobilization not seen since World War two, with dramatic scale up of the production of tests for the virus and its antibodies the commodities we need to do these tests, from long stemmed swabs to RNA extraction kits and the personal protective equipment to keep those conduction the tests safe.  We also need a huge new cadre of people to do these tests, trained and deployed across the country."  And he added Thats the First step.
All of this sounds expensive but consider the cost of a shut down is trillions of dollars; we clearly don't want to do this again.  As Mr. Roamer says if it costs a couple Hundred Billion to avoid it that may still be a relatively low price to pay.  
Hey if you found this episode useful you might find these other episodes useful where we also answer your questions about COVID-19.  And if you can, like and subscribe down below, it really helps and also support the show in any way you can through Patron.com/healthcaretriage.  It's harder than normal to keep this going in the pandemic, and again, as much as you CAN.  We really appreciate your support, it helps to keep this coming out.  We would like to especially thank your research associates Joe Sevits, James Glasgow and Joshua Gister and of course our surgeon admiral Sam.