In the last couple days the President has started itching again open up the economy again in the near future. So there’s more chatter about setting a date. We’ve also seen continuing bottlenecks and debates about the quality and availability of testing. But both of these discussions miss the reality of the situation we’re in and what we need to focus on right now. So I want to return to some points I made at dinner time last night on Twitter. Put simply, we won’t be able to get back to even a semi-normal social and economic life until we have a system in place that will prevent us from rapidly falling right back into a cycle of more outbreaks, lockdowns, deaths in the tens of thousands and economic shocks.
A robust system of testing is the critical necessary condition for that. But in itself it’s not at all sufficient. We will need a system of mass surveillance testing to give us real time visibility into the current prevalence of the disease and keep numbers low enough to make contact tracing at a vast scale possible. Without this kind of data and early warning system our society will be like a plane flying in a cloud bank with all the instruments on the blink.
With that happy image let’s define a few terms and concepts.
We are getting the first signs that severe social distancing is working and that we are seeing a peak or plateau of the epidemic in the early hotspots. But we need to see the course of this crisis in three parts.
First is the initial outbreak which we hope we’re getting some handle on. But there won’t be a return to a real normal until there’s a widely available vaccine or very effective treatments for COVID-19. All evidence suggests a vaccine is a good year away. That means that in the best case scenario we face what I’ll call Phase Two of the crisis – a lengthy period after the initial outbreak in which the challenge will be to get back to an Interim New Normal until vaccines or treatments come online. The third phase will be the arrival of an effective vaccine that can finally in some sense end at least the epidemiological crisis. So Phase One: Initial Outbreak. Phase Two: Sustaining an Interim New Normal. Phase Three: Vaccines and/or robust Treatments arrive and the crisis ends.
Another key concept: Testing isn’t all the same. One form of testing is diagnostic, tests you give to a particular person to guide their treatment. The other is surveillance testing, testing to measure and manage the prevalence of the disease in the community at large. The physical tests themselves may be the same. And in many cases a particular test may be administered for both diagnostic and surveillance purposes. But they are quite different in concept and in terms of planning. This is why the calls you hear to get enough tests so that everyone who wants one can have one misses the point. Anyone who feels sick should be able to get a test. But in itself that doesn’t solve our central, national problem.
With those concepts and definitions in hand, let’s say it simply: You can’t go back to even a semblance of normal economic and social life until you have an integrated, national system of surveillance testing in place that will give us a good shot at avoiding a rolling series of outbreaks and lockdowns for another year. A great system in one state and a crappy one next door won’t cut it.
So how do you do that? A lot of really smart, expert people are figuring that out right now. But some building blocks are clear. The first is building a robust and vast system of testing across the country, both testing for infection and testing for antibodies (blood tests which show antibodies and likely immunity). You also need a system of data collection and analysis that allows all those tests to be analyzed to granularly measure the prevalence and possible spread of the disease, both nationally and on the local level. This likely means some amount of random, voluntary testing of people who appear well. This is the only way you’ll know in time if the disease is moving toward another breakout. You also need to keep the scale of infection low enough that contact tracing of new infections is at all possible. When you’ve got a New York scale outbreak contract tracing isn’t remotely feasible.
We’re a country of 330 million people, with a highly infectious disease on our hands. Conventional contact tracing alone with armies of disease detectives probably isn’t up to the challenge, at least not on its own. That is why there’s already extensive discussions of using big data and geolocation tracking on cell phones to do some of this work at scale. A lot of that discussion has focused on taking something China did with mobile applications and adapting it to our social mores and laws. Put simply, you download an app. You say you’re healthy. If you get sick and test positive you tell the app. The app has recorded your movements over the last two weeks and a lot of other peoples. Once I test positive, the people who’ve been in close proximity to me get alerted and told they should get tested. It’s all anonymized. So it doesn’t say ‘Hey, Josh tested positive.’ You just know you should go get tested, probably not for the first time. This is a very blunt instrument version of contact tracing. But unlike conventional contact tracing which operates with disease detectives, phone calls and interviews it can potentially be done at scale and almost instantaneously.
Clearly we need to address a host of questions about who controls that data, what uses it’s put to, what happens to it once the crisis is over. But some version of this is probably necessary to make a partial return to normal economic and social life.
This morning Ezra Klein published a look at a number of the proposed plans for this Phase Two/Interim New Normal and he found all of them almost totally unworkable. They all involve levels of technical capacity, privacy intrusion and political will that seem almost fantastical. But as he rightly notes, we’ll either do one of these plans or all stay in our houses for a year or engage in the truly fantastical approach of going about life as usual while hundreds of thousands of Americans are dying and our national health care system collapsing around us. The reality is that we’ll likely get some mix of all three. But knowing the alternatives helps focus our attention not on the seeming impossibility of these strategies but the fact that we need to get down to the business of planning and implementing them.
We are currently in the mix of what is likely (hopefully) the most painful phase of this crisis. But it’s also probably the simplest. Everybody who can stays at home and limits human contact as much as possible while hospitals use every resource to save as many lives as possible. Phase Two is much more complicated. It is what everyone involved in any sort of public policy needs to be focusing on right now. Unfortunately the federal government has shown very, very little ability to mount any kind of coherent, national response. And the President is focused on finding a date and calling an all clear as soon as possible. Asked about this yesterday, he denied the problem, telling CNN’s Jim Acosta that more testing will be great but actually won’t be necessary.
President Trump clearly has no idea of the need for mass surveillance testing to reopen the economy, or even what it would involve. pic.twitter.com/yGLWr2ObBb
— Josh Marshall (@joshtpm) April 9, 2020
Needless to say this is a big problem. It’s where all of our attention should now be focused. Our society, at least in any form we want to contemplate, can’t survive the alternatives.