Opening America: Should we really have to choose between economic revival and human life?

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Let me tell you a story about Francisco, a recent patient under my care in one of New York City’s hardest-hit hospitals. Suffering from severe COVID pneumonia, he gasped for air as I tried to exude empathy underneath the cold appearance of my head-to-toe, blue protective equipment. Carefully placing a breathing tube into his airway, I connected his lungs to a machine by a single plastic lifeline. Hoping also to bring life back into his weakly pumping heart, I fervently pushed syringes of epinephrine into his veins. As my own adrenaline levels spiked in the chaotic symphony of beeping alarms, for a brief moment, I took stock of my surroundings: faded wallpaper outlining once-hanging art, an abandoned bookshelf with post-it notes still attached, and a placard featuring an unfamiliar name tightly glued to the door. I realized then that, only weeks before, this “intensive care room” was actually a repurposed hospital administrator’s office.

When we talk about “reopening America,” I don’t think about friends laughing over mimosas at brunch or theme parks packed with excited kids; I think of emergently resuscitating Francisco in a makeshift ICU bed in a hospital pushed to its limits under the care of physicians like me who dropped everything to fight in the trenches of the New York City COVID battle. If states aren’t careful, it won’t be a matter of if this situation iterates in other corners of the country—it’s a matter of when.

We certainly need a responsible plan to reopen, but should we really have to choose between economic revival and human life? I believe we can have both. Right now, many states across the country are reopening while blatantly ignoring key virus metrics, ICU utilization trends, and insufficient testing capacity.  Unfortunately, at a time when public health experts are needed the most, their recommendations are increasingly sidelined in favor of shortsighted policies aimed at sparking temporary financial growth. But what if stricter reopening strategies actually mean more lives saved and greater long-term economic prosperity?

Thankfully these waters are not entirely uncharted, and history tells us we may be demonizing the wrong culprit.  Evidence from the 1918 Spanish Flu suggests that economies are inherently stifled by pandemics themselves, not necessarily by public health containment measures.  With widespread global illness, consumer confidence and spending plummet.  This drives a reduction in manufacturing, productivity, and labor supply. A century ago, cities that intervened earlier and more aggressively did not perform worse economically, and, if anything, grew faster after the pandemic’s ravishing subsided. Granted, the 1918 Spanish Flu is not a perfect model because the COVID-19 mortality rate is lower, and we now live in a world with a more complex global supply chain and greater reliance on telecommunications.  Nevertheless, getting out of this vicious cycle hinges on virus containment as a primary solution.

We can also learn from Sweden, infamous for encouraging “common sense” social distancing guidelines instead of a mandatory lockdown—restaurants, gyms, shops, and schools have remained open. The country will still lose up to 10% GDP this year, according to the Swedish Central Bank. But that’s not all they lost; nearly 30% more Swedes died compared to years past. The Swedish Finance Minister and a chief economist in Stockholm both acknowledged this financial despair.  Compared to other nations, one official commented, Sweden would fare “somewhat better,” but “the difference is marginal.”  So even in the modern world, premature reopening as an attempt to save the economy is a recipe for a lose-lose situation.

As an anesthesiologist who has seen the worst this disease can do, I strongly advocate for states adhering to a phased reopening. Advancement between phases should depend on firm gating criteria and states should also be prepared to backtrack into a lockdown when numbers veer in a dangerous direction. However, the Centers for Disease Control comprehensive guide for reopening America was initially rejected and reprocessed into a diluted version—further evidence that expert recommendations are being silenced.

A more robust conversation needs to be had around the distribution of tests. The Rockefeller Foundation National Testing Action Plan puts forth an ambitious blueprint of administering 3 million tests per week in the U.S., gradually increasing to 30 million weekly.  Meanwhile, Wuhan concocted an impressive plan to test 11 million people in a 10-day window, following a resurgence in cases after the province reopened; the U.S. has only recently broached this number of total tests over three months. In a state like New York, where testing capacity is at 100%, we’ve seen a 58% decrease in cases over two weeks, in contrast to Alabama’s 56% growth over the same period with a testing capacity of only 52%. Both states are partially reopened, but the radical difference in viral containment is directly associated with access to an accurate test.

Having spent the last eight weeks as a first responder in New York City hospitals, I regard any reopening plan that does not meet the following criteria as unconscionable. First and foremost, COVID-19 tests must be ubiquitous and virus metrics need rigorous assessment. Next, PPE should be available in abundance; every morning, I still plead for a new N95 mask from locked hospital corridors, indicating supplies remain far from adequate. Third, we must integrate a response to the secondary ramifications of COVID-19, namely, the emerging mental health crisis resulting from burnout amongst essential workers, and the long-term health conditions that patients like Francisco will suffer when removed from a ventilator.

I feel for the small business owner, the restaurateur, and the concert venue eager to host customers, foodies, and audiences again. But lessons from the 1918 Spanish Flu, pitfalls of the current Swedish model, and also as the WHO warn us, premature reopening will devastate our economy far more than a stir-crazy desire to watch society spring back into place. In a story we’ll likely tell our grandchildren with somber reflection, our biggest cities and national landmarks cleared out seemingly overnight. Our reopening strategy cannot, by necessity, transpire with the same haste.

Ajit Rai is an anesthesiologist and interventional pain physician and can be reached at his self-titled site, Ajit Rai MD.

Image credit: Shutterstock.com

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