Everyone wants to know when we're going to be able to leave our homes and open up the United States again.  It's a hot topic.  It's also the topic of this week's Healthcare Triage.

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So when will we reopen the country? That's unfortunately the wrong way to phrase it.  What we should be asking is "how will we know when we should reopen the country?"

Any date that's currently being thrown around is just being pulled out of the air - it's just a guess! Americans have been reactive - often without data, and often too late.

A lot of what we're doing is because we saw bad things happening in Europe or even in New York City, and everyone's trying to prevent that from happening where they live.

That's why we're all sheltering in place.  We want to avoid getting there, and we don't have the tests to know where the hotspots really are, so therefore all of us have to act as one, and all of us do the same thing.

We're not gonna all reopen at the same time either.  Some cities or states will be able to reopen sooner than others.  A recent report from the American Enterprise Institute, written by Scott Gottlieb and colleagues offers up some helpful guideposts to help us figure out when it might be that some places can open up.

The first goalpost is that hospitals in any area have to be able to take care of all the cases of coronavirus that might show up without any fear of being overwhelmed.  Other cities and states worry they could be headed towards where New York is, and they need to make sure that they have enough doctors and nurses and respiratory therapists and ventilators and beds to make sure that they can take care of all the cases of COVID-19 that might show up without fear they might not have capacity and have to turn people away.

That's the most immediate bar we have to clear to even talk about reopeing.  And it's the one that most of us have been focused on for a while.  It's all we talk about when we mean "flattening the curve".  Almost nowhere in the United States has gotten over that peak yet - even by the time you see this video - and if some have, they're JUST doing it.  So, we're just getting there, barely.

The second goalpost is that an area needs to be able to test ANYONE who has symptoms at all.  So, Doctor Gottlieb and colleagues estimate that in order to do this, by modeling and looking at past flu symptoms, they think that we'd need capacity at peak to be able to test about 750,000 people in a week.  There are times, of course, that we might need to test even more.

I talked to Doctor Mark McClellan, who's a professor at Duke University, and also one of the authors of that study.  Here's what he said:

"The 750,000 number should be viewed as a reasonable expectation for when we haven't been having any major pockets or regional outbreaks to manage...

...If more testing to help contain outbreaks and potential outbreaks is needed, which seems very plausible, especially early on, the number would need to be significantly larger...

...We'll also have to do some surveillance of people without symptoms, especially in higher-risk settings."

The national estimate – which is that really big number – really doesn't matter as much as a local areas capability to test anyone with symptoms at all. And I mean anyone and get the results in a timely manner.

That's the only way we can achieve the third goalpost. And that goalpost is: The state is able to conduct monitoring of confirmed cases and contacts.

A robust system of contact tracing and isolation is really the only way to prevent outbreaks from happening again. Every time someone tests positive the public health infrastructure has to be able to figure out where they got infected, find out everyone that they've been in contact with, notify them, and get them to quarantine pretty much immediately.

This is a big lift, other countries are doing way better than we are, some of them are using things like cell phone tracking to immediately go back and look who's been near the person who's now been identified as being infected. It's not clear we can do those things in the United States for a variety of political, ideological and ethical reasons, but it is important to at least think about it.

Building the infrastructure and capacity to do all of that contact tracing and figure out who's been where and exposed to whom will take time, money, and resources to set up we are woefully behind on that.

And the fourth goalpost is that there must be a sustained reduction in the number of cases for at least 14 days.

Because it can take up to 14 days for people to show that there are infected after they've been infected, there are a lot of cases out there, that are already there, that we just don't now about. And we need to make sure that we give enough time for those cases to show up.

Only by waiting 14 days and seeing cases go down every day every day will we have a good sense that we've really got a handle on  this, and things are starting to get under control.

If we do suppression well cases should reduce in an exponential fashion just as they rose. It's impossible, though, to set benchmarks and numbers for what every state needs to achieve because how low they need to get will be very depended on what is their capacity to do contact tracing and isolation.

If they can only do contact tracing and isolation for a very small number of cases, then they need to only see a very small number of cases every day, so they can be sure that they can actually follow them all out.

Exchanged emails with Caitlin Rivers – another author of the study – and an epidemiologist at the Johns Hopkins center for health security. She said to me: "We wanted to suggest criteria that would allow locations to safely and thoughtfully begin to reopen but what looks like exactly will vary from state to state. We therefore included some flexibility for jurisdictions to tailor these criteria to their local context." 

It's important to understand that these four criteria are a baseline. They're the floor. Lots of epidemiologists think we need a lot more. For instance some point to serological testing, or the ability to look at people's blood to see if they built up antibodies, which can tell us if people have already been exposed and recovered, and perhaps even have some immunity.

It will give us a much better sense of how many people in a community have been infected overall rather than knowing who's infected right this second. Serological testings can also be much cheaper, and much faster, and much easier to administer than the tests we are using right now – PCR tests – to figure out who's currently sick.

Exchanged emails with Greg Gonzales – an epidemiologist at Yale University – who's a bit more pessimistic. Here's what he said: "I'd feel better if we had serological testing, and could preferentially allow those who are antibody positive and no longer infectious to return to work first. The point is, though, that we are nowhere even near accomplishing any of these criteria. Opening up before then will be met with a resurgence of the virus." He added: "That's the thing that keeps me up every night." It's also the thing that keeps me up every night.

Until we get our vaccine, or really effective treatment, focusing on these criteria and checking how close we are to achieving them is the best way to move forward, and to talk about when, and how we might begin to reopen up parts of society.

It'll also help stop us from pulling dates out of the air and giving Americans false hope about when we might approach a more normal way of life. By focusing on these goals and directing our efforts to achieving them, we can get a much better sense of when, and how we might be able to reopen up a little bit.

[Outro]
Hey, did you enjoy this episode? You might enjoy this other episode where we answer you're questions about Corona virus and hopefully give you some good information. It also always helps if you like and subscribe down below, and another good way to support the show especially now is at https://www.patreon.com/healthcaretriage, cause we rely on your help to help make the show bigger and better even as we try to  figure out this brand new run, and how we're taping and it's not even in the studio anymore. We'd especially like to thank our research associates Joe Sevits and James Glasgow and, of course, our Surgeon Admiral Sam.