Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.
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AMA Chief Experience Officer Todd Unger speaks with the director of the Edmond J. Safra Center for Ethics, Danielle Allen, MD, on updates regarding COVID-19 including a proposed plan to open the country safely amid the COVID-19 pandemic that would have the country full up and running by August 2020.
Learn more at the AMA COVID-19 resource center.
Transcript
Unger: Hello. This is a special edition of the American Medical Association's COVID-19 update. Today we're discussing a proposed plan for reopening the country safely amid COVID-19. I'm joined today by Dr. Danielle Allen, director of Harvard University's Edmond J Safra Center for Ethics in Cambridge, Massachusetts. I'm Todd Unger, AMA's chief experience officer in Chicago.
Dr. Allen, you and a team of experts have outlined a plan called the Roadmap to Pandemic Resilience that would have the country fully back up and running by August. Can you give us first some background on the team that put this together and how you all came together?
Dr. Allen: Sure. Thanks so much for having me, Todd. I really appreciate the conversation. I direct something called the Edmond J. Safra Center for Ethics at Harvard. We've been around for more than 30 years, and we're broadly in the space of ethics and public affairs. In our earlier years, we did spend a lot of time on bioethics. It's still an area we do work in.
One of our earliest fellows was Ezekiel Emanuel, probably somebody well known to your community. So when the COVID situation was ramping up, I started paying attention to his writing about rationing. And so I reached out to him at a certain point to say, "Zeke, how could an ethics center like mine help? What are the hard problems that people are stuck on?"
And his answer was that the thing that people were having the hardest time thinking about was how to weigh health objectives and goals in relationship to economic objectives and goals.
So we took that and we ran with it, basically. We built a huge multidisciplinary team drawing on experts at the public health school here at Harvard, the Chan School of Public Health, but also trying to integrate that public health expertise with economic expertise. Our core principle was the need to integrate expertise across domains and try to come to a picture that could align what we needed from a health perspective with what we needed from an economic perspective.
So my co-lead is an economist named Glen Weyl, he was at the University of Chicago early in his career and is now at Microsoft. Other economists like Rajiv Sethi have also been working hard in the traces here. We have had people in public health, like Meredith Rosenthal, Larry Gostin has been a big help. We've consulted repeatedly with people like Mary Travis Bassett and Marc Lipsitch at the Chan School. So our authors are really from the spaces of law, policy, economics and so forth. We have always tried to dig into, pull public health experts into our conversations so that we can have the most informed, integrated understanding possible.
Unger: And I don't get to use this word much, but you would definitely call this an audacious plan. The key premise being, we're not going to get through this successfully with social distancing alone. There's a much bigger program, in your words, that needs to take place. So can you tell us about the key pillars of your roadmap?
Dr. Allen: Absolutely. So I think the thing to recognize is that the most powerful tool that the public health community has in its toolkit for responding to a pandemic is collective stay at home orders. And they're extremely effective. They can stop the disease in its tracks, and we should all be extremely grateful for that. We needed to use those tools without any question.
At the same time that that was the case, however, they have this profoundly devastating economic impact. And so it seems as if the biggest question you have to ask is what's a tool of equivalent power to collective stay at home orders that can actually stop the disease in its tracks and keep the economy open?
That was the hard question. And yes, the answer to that is ambitious and audacious, but actually it's no more ambitious or audacious than national collective quarantine, master relevant scale of comparison. The ambitious, audacious plan is testing, tracing and supportive isolation at massive scale. So, big enough to actually decelerate the disease.
So the goal of our modeling, our mathematical modeling, is to have testing at such levels that you could actually achieve an R of .75 and decelerate the disease continuously over time, not need repeated applications of collective social distancing.
I will say that the plan is one that will become challenging to implement in the sense that, once prevalence gets too high, the plan is not really a viable plan as a sole tool of disease control, which is how we developed and designed it. So it's really a tool that is the scale that you need when prevalence is getting into territory of one percent maybe a bit above one percent. But once prevalence is over that, then it's still a tool you need to contribute to controlling the disease, but it can't be a sole tool.
Unger: I know in the plan, and this is not a matter of whether we can do it, but how.
Dr. Allen: Yes.
Unger: Why don't we talk a little bit about what does it take to make a plan of this scale a reality?
Dr. Allen: The thing is it really takes asking that how question, just as you said, not asking can we, but just simply asking how. Because the fact is there's no law of physics that has to be broken to be testing in millions of people per day sort of rates. We know how to make tests. We even have ways of simplifying the testing process. We can work really aggressively and invest aggressively in switching from throat and nasal swabs to saliva-based tests for example and put a viral de-activator in the test tube, and you no longer have a biohazard that you have to transport. And the whole testing process becomes much simpler and faster. That's what we need is I really sped up, simplified testing process.
So there's no law of physics that has to be broken. The challenges are organizational. They are coordination from a market or economic point of view. And then, of course, they're also political. Because the kind of coordination that we need is both about activating that supply chain to ramp up capacity in the existing supply chain as well as innovate new forms of testing to simplify the supply chain, and that kind of coordination will work best with some sort of support activation from the federal government.
So that's one piece. And then we also of course need coordination to actually administer testing programs and contact tracing programs. And that's really state and local governments, municipal governments, county public health officials, things like that. And there, the challenge is really that, for many places this would be to run testing and contact tracing programs on a scale they've never done before. So we need a lot of help building up readiness frameworks, helping people have plug and play organizational approaches to doing this so that they can do it quickly.
Unger: So in your plan, you lay out some pretty aggressive numbers in terms of the numbers of tests that we would want to be seeing in June and July and a prioritized approach to doing that. Can you give a little more context on that?
Dr. Allen: Absolutely. So, the first thing to recognize as we think about reopening the economy is that actually the economy is open, 40% of the workforce has not been under stay at home orders because they are part of the essential workforce. Health care workers are the biggest part of that, the most obvious piece of that, but also, it's public safety officers and a variety of other roles. So 40% of our workforce has had the virus circulating relatively freely, and we really owe it to that workforce that they should be fully integrated in testing, tracing and supportive isolation programs first.
The good news is, if we could actually achieve that, then we've actually already stabilized 40% of the population and also that part of the population where the disease is circulating at the highest rates. So our plan is a phased reopening plan where the first thing you want to do is really build out testing, tracing and supported isolation programs for the health care workforce and other parts of the essential workforce, and then begin to phase in other parts of the economy as well, supporting them as they're coming back online also with testing, tracing and supportive isolation programs.
Unger: I noticed in the plan, you hear a lot of people saying obviously we're going into the summer and so the timing is different but get the schools back open. I know that's the last rollout in your plan. What's that about?
Dr. Allen: It's critical that schools reopen, and that, in some sense, I feel like the fall is kind of drop-dead date for all of us to get this right. And I think one of the hardest things about this problem has been the interaction between schools and the economy. So, one of the things we've all discovered through this crisis is that schools are our childcare structure. They are what make it possible for the workforce to be at work. And so there is a close relationship between these two things.
We try to bridge that with our phased approach by including childcare workers in the early phase of sectoral rollout so that there would be childcare provision with people who are doing childcare also being tested, being part of testing programs so that people can go back to work. So if you see childcare as a part of that essential workforce, that does begin to open up the economy.
And then, since it's summer, it does give schools more time. And places like schools, congregate settings, have a lot of work to do to reorganize recreational practices. So, in that regard, schools, colleges, universities, they need the time over these next few months to really rethink how they do business on a basic daily level. So, that's the final phase is with the schools.
Unger: Do you have any sense of the cost of executing the plan?
Dr. Allen: We do. And, actually, again here it's really important to compare the massively ramped up testing, tracing and supportive isolation, or TTSI, as we like to call it, to the cost of collective stay at home orders. So, collective stay at home orders as a tool for disease control are costing us $350 billion a month. So, a testing, tracing and supportive isolation program costs $15 billion a month. So, we should have done this two months ago, basically. I wish we'd done it two months ago. We can still do it. We should still do it. It would make a huge difference if we were able to do it. And that's really the trade off, $350 billion for collective stay at home orders or $15 billion for testing, tracing and supportive isolation.
Unger: Well, on that note, there has been a lot of pressure to reopen the country quickly. You have certain states that are moving at a more aggressive pace than others. What do you see as the consequences of reopening too soon or in an uncoordinated way?
Dr. Allen: We really are, in our plan, focused on opening in such a way that we can stay open. We are really trying to figure out how to ward off second and third waves. The reason for this is very straightforward. Businesses, if they're truly going to come back online, need to plan with clarity about the fact that they won't have to face repeated shutdowns. So, that kind of uncertainty is a real negative drag on the business environment.
So the economy itself needs a way of reopening where it will stay open. So that's the message that we've been trying to share with governors. It's not enough to reopen because you will face a second wave if you haven't taken steps to try to achieve disease control within your state. The most powerful tool for disease control, notice I've been saying, is the TTSI tool. It's important also to look at other tools, which are about things like the de-densification in public transport. So adding more subway cars in contexts where that's relevant or adding more buses to bus lines, changing infection control practices throughout all workforce sectors or opening up retail on a drive through only basis for the next period of months.
So I do want to say that TTSI is not the only tool. I think at this point we really all have to be looking at what the package of tools is that will broadly permit us to control the disease, decelerate its rate of transmission.
Unger: If our viewers want to take a look at the entire plan, is there a place they can go to do that?
Dr. Allen: Sure. So, at our website, ethics.harvard.edu, the homepage to take you right to the Roadmap for Pandemic Resilience.
Unger: Thank you so much, Dr. Allen for being here and for reviewing your important work on how we can reopen the country safely.
Dr. Allen: Thank you.
Unger: That is obviously at top of mind for everyone.
Dr. Allen: Absolutely.
Unger: That's it for today's COVID-19 update. For more resources on COVID-19, you can go to the AMA COVID resource center at ama-assn.org/COVID-19. Thanks for joining us.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
