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Lesson From Singapore: Why We May Need to Think Bigger Lesson From Singapore: Why We May Need to Think Bigger
(32 minutes later)
Many experts are beginning to coalesce around a set of benchmarks that could help 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 goals necessary to do so, there has been a push to relax social distancing soon.Many experts are beginning to coalesce around a set of benchmarks that could help 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 goals necessary to do so, there has been a push to relax social distancing soon.
Even more alarming, some experts say even those still-not-yet-achieved goals aren’t close to enough. It appears that it may be time to think bigger.Even more alarming, some experts say even those still-not-yet-achieved goals aren’t close to enough. It appears that it may be time to think bigger.
“These are unprecedented times, and so we need to think on a scale that would previously be considered unimaginable,” said Natalie Dean, an assistant professor of biostatistics at the University of Florida.“These are unprecedented times, and so we need to think on a scale that would previously be considered unimaginable,” said Natalie Dean, an assistant professor of biostatistics at the University of Florida.
The cautionary tale at the moment is Singapore. For weeks, public health officials have been enviously lauding its response to Covid-19.The cautionary tale at the moment is Singapore. For weeks, public health officials have been enviously lauding its 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.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, in the last week, they’ve put the entire country into lockdown. All migrant workers are 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 $7,000 U.S., or both.And yet, in the last week, they’ve put the entire country into lockdown. All migrant workers are 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 $7,000 U.S., or both.
What Singapore was doing (more on that below) dwarfs what most are discussing in the United States. Its present circumstances bode poorly for our ability to remain open for a long time.What Singapore was doing (more on that below) dwarfs what most are discussing in the United States. Its present circumstances bode poorly for our ability to remain open for a long time.
“There’s just no way that we’re going to be able to keep most of the country open through the year,” said Ezekiel Emanuel, vice provost of Global Initiatives at the University of Pennsylvania. “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’s just no way that we’re going to be able to keep most of the country open through the year,” said Ezekiel Emanuel, vice provost of Global Initiatives at the University of Pennsylvania. “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.”
Given the U.S. government’s limited and lagging response to date, the idea of a hugely ambitious project may seem implausible. But the cost of another future shutdown is so high that previously unfathomable ideas may be worth considering. Here are a few:Given the U.S. government’s limited and lagging response to date, the idea of a hugely ambitious project may seem implausible. But the cost of another future shutdown is so high that previously unfathomable ideas may be worth considering. Here are a few:
The Romer plan of maximum testing.The Romer plan of maximum testing.
Paul Romer, a Nobel-winning economist and N.Y.U. professor, proposes that 7 percent of the population be tested each day. If put on a rotating schedule, that would mean everyone would be tested roughly once every two weeks.Paul Romer, a Nobel-winning economist and N.Y.U. professor, proposes that 7 percent of the population be tested each day. If put on a rotating schedule, that would mean everyone would be tested roughly once every two weeks.
He argues that even if there are plenty of false negatives, if we committed to isolating everyone with a positive test, we could keep the vast majority of Americans out and about in normal life. All told, that would mean 150 million tests a week.He argues that even if there are plenty of false negatives, if we committed to isolating everyone with a positive test, we could keep the vast majority of Americans out and about in normal life. All told, that would mean 150 million tests a week.
Critics will argue that’s impossible. We cannot even seem to manage a million a day. They say we lack the materials, as well as the reagents for chemical analysis, the delivery infrastructure and the machines to run so many tests.Critics will argue that’s impossible. We cannot even seem to manage a million a day. They say we lack the materials, as well as the reagents for chemical analysis, the delivery infrastructure and the machines to run so many tests.
Mr. Romer is not dissuaded. “I’ve been focused on a single idea my whole career, that just because something is unfamiliar doesn’t mean it’s impossible,” he said. “Building interstate highways, scanning every book, going to the moon — these were all outrageous ideas at one time. But if we put enough resources and our minds behind it, we are able to make the impossible possible.”Mr. Romer is not dissuaded. “I’ve been focused on a single idea my whole career, that just because something is unfamiliar doesn’t mean it’s impossible,” he said. “Building interstate highways, scanning every book, going to the moon — these were all outrageous ideas at one time. But if we put enough resources and our minds behind it, we are able to make the impossible possible.”
His plan would rely less on contact tracing and isolation, since everyone would be tested regularly, and this might make infection control easier in many parts of the country. Contact tracing requires significant infrastructure and is hard to do well.His plan would rely less on contact tracing and isolation, since everyone would be tested regularly, and this might make infection control easier in many parts of the country. Contact tracing requires significant infrastructure and is hard to do well.
“We spend something like $700 billion a year to protect us against military threats,” he said. “We are at greater risk from a biological threat at the moment than any military threat. We should be prepared to spend at least a hundred billion a year not only to protect us against this virus, but any potential new viruses that could threaten us in the future.”“We spend something like $700 billion a year to protect us against military threats,” he said. “We are at greater risk from a biological threat at the moment than any military threat. We should be prepared to spend at least a hundred billion a year not only to protect us against this virus, but any potential new viruses that could threaten us in the future.”
The Center for American Progress plan that leans on monitoring via your phone.The Center for American Progress plan that leans on monitoring via your phone.
Other ambitious ideas can be found in a plan from the Center for American Progress, written by Dr. Emanuel and colleagues. 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 instantaneously. Everyone could sign in electronically before using public transportation, entering large buildings or schools 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.Other ambitious ideas can be found in a plan from the Center for American Progress, written by Dr. Emanuel and colleagues. 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 instantaneously. Everyone could sign in electronically before using public transportation, entering large buildings or schools 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.
“If we could do real-time contact tracing based on a person’s phone and GPS signals, and alert people that they have been exposed to a Covid-19 positive person,” that would greatly ease the containment strategy, he said.“If we could do real-time contact tracing based on a person’s phone and GPS signals, and alert people that they have been exposed to a Covid-19 positive person,” that would greatly ease the containment strategy, he said.
Of course, such a system would be considered a large intrusion on privacy, and it’s not clear it is politically feasible — or even legal. Additionally, not every American has a smartphone.Of course, such a system would be considered a large intrusion on privacy, and it’s not clear it is politically feasible — or even legal. Additionally, not every American has a smartphone.
The PolicyLab focus on universal community-level surveillance.The PolicyLab focus on universal community-level surveillance.
Meredith Matone, scientific director of PolicyLab 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.Meredith Matone, scientific director of PolicyLab 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.
“A more realistic and useful approach would focus much more on surveillance, monitoring communities more than individuals,” she said.“A more realistic and useful approach would focus much more on surveillance, monitoring communities more than individuals,” she said.
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.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.
Updated June 22, 2020Updated June 22, 2020
A commentary published this month on the website of the British Journal of Sports Medicine points out that covering your face during exercise “comes with issues of potential breathing restriction and discomfort” and requires “balancing benefits versus possible adverse events.” Masks do alter exercise, says Cedric X. Bryant, the president and chief science officer of the American Council on Exercise, a nonprofit organization that funds exercise research and certifies fitness professionals. “In my personal experience,” he says, “heart rates are higher at the same relative intensity when you wear a mask.” Some people also could experience lightheadedness during familiar workouts while masked, says Len Kravitz, a professor of exercise science at the University of New Mexico.A commentary published this month on the website of the British Journal of Sports Medicine points out that covering your face during exercise “comes with issues of potential breathing restriction and discomfort” and requires “balancing benefits versus possible adverse events.” Masks do alter exercise, says Cedric X. Bryant, the president and chief science officer of the American Council on Exercise, a nonprofit organization that funds exercise research and certifies fitness professionals. “In my personal experience,” he says, “heart rates are higher at the same relative intensity when you wear a mask.” Some people also could experience lightheadedness during familiar workouts while masked, says Len Kravitz, a professor of exercise science at the University of New Mexico.
The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth.The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth.
The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave.The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave.
So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.
Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.
A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.
The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.
States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.
Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.
If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)
If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.
If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested.If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested.
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’s clear, everyone is safe. If an infection is found, then — again — more focused testing could be done on the individuals in the pool.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’s clear, everyone is safe. If an infection is found, then — again — more focused testing could be done on the individuals in the pool.
The PolicyLab review also highlights the benefits of improving workplace safety, especially in high-risk areas like child care, school and health care environments, to make infection control more robust and surveillance easier to accomplish.The PolicyLab review also highlights the benefits of improving workplace safety, especially in high-risk areas like child care, school and health care environments, to make infection control more robust and surveillance easier to accomplish.
Revisiting Singapore’s strengths.Revisiting Singapore’s strengths.
Not everyone thinks we need to aim quite that high. Caitlin Rivers, an author of a recent American Enterprise Institute report on reopening the nation and an epidemiologist at the Johns Hopkins Center for Health Security, said: “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.”Not everyone thinks we need to aim quite that high. Caitlin Rivers, an author of a recent American Enterprise Institute report on reopening the nation and an epidemiologist at the Johns Hopkins Center for Health Security, said: “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.”
In a city-state of 5.7 million people in an area the size of Indianapolis, Singapore has had 140 people dedicated to contact tracing, working in conjunction with the police. A month ago, it could test 2,000 people each day. That’s the equivalent of testing about 115,000 people in the U.S. We were testing barely a tenth of that amount then.In a city-state of 5.7 million people in an area the size of Indianapolis, Singapore has had 140 people dedicated to contact tracing, working in conjunction with the police. A month ago, it could test 2,000 people each day. That’s the equivalent of testing about 115,000 people in the U.S. We were testing barely a tenth of that amount then.
Singapore has always provided free testing and medical care for all citizens; more recently, it distributed reusable face masks to everyone.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, and gatherings of more than 10 people were considered inadvisable.Officials were careful. While stores and restaurants were open, people were told to keep at a distance from one another, and gatherings of more than 10 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.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 would be of another national pause. If Americans failed to comply, the results could be disastrous. Preventing a second lockdown could even be considered a long-term investment.It’s not clear how tolerant the United States would be of another national pause. If Americans failed to comply, the results could be disastrous. Preventing a second lockdown could even be considered a long-term investment.
“Our trajectory right now does not give me hope,” said Gregg Gonsalves, a professor of epidemiology and law at Yale. “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 II, 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 conducting the tests safe. We also need a huge new cadre of people to do these tests, trained and deployed across the country.”“Our trajectory right now does not give me hope,” said Gregg Gonsalves, a professor of epidemiology and law at Yale. “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 II, 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 conducting the tests safe. We also need a huge new cadre of people to do these tests, trained and deployed across the country.”
“And that’s the first step,” he added.“And that’s the first step,” he added.
All this sounds expensive. But consider that the cost of a shutdown is trillions of dollars. We clearly don’t want to do this again. As Mr. Romer says, if it costs a couple of hundred billion to avoid it, that may still be a relatively low price to pay.All this sounds expensive. But consider that the cost of a shutdown is trillions of dollars. We clearly don’t want to do this again. As Mr. Romer says, if it costs a couple of hundred billion to avoid it, that may still be a relatively low price to pay.