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With the US economy taking a battering from COVID-19 lockdowns, President Donald Trump wants states to get back to business as soon as possible.
Measures taken by many states including stay-at-home orders and business closures are credited with slowing the spread of the coronavirus and saving lives, but that has come with a high economic cost.
“We must have a working economy, and we want to get it back very, very quickly, and that’s what’s going to happen,” Trump said on April 16. That day, the White House released guidelines for “Opening Up America Again,” intended to help state and local officials judge when it’s safe to start relaxing social distancing rules.
But in a departure from his administration’s own reopening plan, the next day Trump tweeted “LIBERATE MINNESOTA!” followed by similar tweets about Michigan and Virginia — calling out states with Democratic governors under lockdowns and apparently giving his approval to activists who have taken to the streets to protest stay-at-home orders.
The White House’s criteria for states to start reopening their economies have three components: They should have seen a decline in COVID-19 cases for 14 days; reports of symptoms that might represent undiagnosed COVID-19 should have been in decline for the same period; and hospitals should have enough capacity to handle cases without operating in crisis mode and have a “robust testing program” for health care workers.
But the criteria don’t explicitly include a provision for widespread population testing and tracing of the contacts of people who test positive — which many experts say is crucial.
“You need an infrastructure of an adequate number of tests and you need contact tracing,” Ezekiel Emanuel, vice provost of global initiatives at the University of Pennsylvania and a former health policy adviser to the Obama administration, told BuzzFeed News. “Those are absolutely essential for going forward.”
The easiest of the White House criteria to assess is the two-week decline in the number of new reported cases of COVID-19 per day. To help you judge how close your state is to meeting that goal, BuzzFeed News has plotted the trajectory of new cases for each US state and territory.
New COVID-19 cases per day
Because delays in reporting cases can cause spikes and dips in the data, this chart plots the daily average number of new cases recorded over the preceding seven days to show a smoother trajectory. The vertical axis has a logarithmic scale, which makes the difference between 10 and 100 take up the same height on the chart as the difference between 100 and 1,000. That makes it easier to see the trajectories for the states with fewer cases, which would otherwise be clustered together at the bottom of the chart.
We have highlighted the worst-affected state, New York, the most populous, California, and the three states targeted in Trump’s tweets, plus two states that were badly affected early in the COVID-19 epidemic: Washington and Louisiana. Other states and territories are shown in gray. You can search for any state, including those already highlighted, by using the box at the top of the chart — start typing its name or use the dropdown menu, and the state’s trajectory of new cases will appear in black.
Few states currently have a clearly declining trajectory of new cases. Of those targeted by Trump’s “liberate” tweets, Michigan has seen a decline since seeing a peak in the number of new cases around April 7. New cases in Minnesota and Virginia have continued to rise.
While some states may decide on relaxing their COVID-19 restrictions individually, others — including Michigan and Minnesota — have joined regional alliances to coordinate their plans.
This chart shows the trajectory of new cases for these regional groupings. The Western group comprises California, Oregon, and Washington; the Midwest group includes Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, and Wisconsin; and the Northeast group is Connecticut, Delaware, Massachusetts, New Jersey, New York, Pennsylvania, and Rhode Island.
The Western grouping has seen a slight decline in new cases. On April 14, California Gov. Gavin Newsom warned state residents against expecting a rapid return to normal, even after restrictions start to be lifted. “You may be having dinner with a waiter wearing gloves, maybe a face mask, dinner where the menu is disposable, where ... half the tables in that restaurant no longer appear, where your temperature is checked before you walk into the establishment,” he said.
Some experts question whether a decline in the number of new cases is the best measure for deciding whether to reopen, however. Emanuel said that a declining trajectory of new cases may not be enough to safely relax restrictions, if the number of cases is still high.
Computational epidemiologist Maia Majumder of Harvard University warned that daily counts of new cases may be an unreliable indicator of whether the epidemic is subsiding, given differences in the extent of testing from state-to-state and over time.
Across the nation, the number of tests being conducted each day seems to be plateauing or even declining, according to data collected by the COVID Tracking Project. This means that a decline in the number of new cases in some states could reflect a falloff in testing, rather than a real decline in transmission of the coronavirus.
“New deaths per day might be the better metric to watch, given that deaths from COVID-19 are less likely to be misclassified,” Majumder told BuzzFeed News by email. (There are also concerns that deaths may have been undercounted, and states are taking different positions on whether to count people presumed to have died as a result of COVID-19 without a positive diagnosis.)
In addition to a decline in new cases, a second White House criterion suggests that states should wait for a 14-day decline in reports of symptoms that might represent undiagnosed COVID-19 cases. But those numbers may also be difficult to reliably assess.
The CDC’s FluView surveillance program each week calculates the percentage of outpatient consultations for a sample of health care providers in each state that involve patients reporting a fever and a cough or a sore throat without a known cause other than influenza. Those numbers likely include some people who actually have COVID-19. But the pandemic may have changed the way in which people seek medical help, potentially biasing the numbers. The CDC has warned that its surveillance systems “are currently being affected by recent changes in health care seeking behavior, including increasing use of telemedicine.”
The White House’s third criterion addresses the need for hospitals to be able to cope with treating COVID-19 patients, including robust testing of health care workers. This criterion suggests using antibody tests to reveal who has been infected and beaten off the virus, which could help identify workers who may have some immunity.
But meeting this goal will also be difficult: Few of the available tests have been approved for use by the FDA and their accuracy is far from guaranteed. It’s also unclear whether having antibodies against the coronavirus will give people complete immunity.
The White House criteria are broadly similar to other recommendations made to state governors by public health experts. On April 17, the Center for Health Security at Johns Hopkins University released a report co-authored by former FDA commissioner Scott Gottlieb that also suggested states should consider starting to reopen their economies after the number of new cases has declined for at least 14 days.
In addition, it suggested states must have the ability to test, at minimum, all people with COVID-19 symptoms, be able to safely care for all patients and provide personal protective equipment for health care workers. Finally, the report said that states must be able to trace contacts of all new cases — which may require tens of thousands of workers to conduct this laborious work across the country.
The White House guidelines don’t include a provision for widespread testing and contact tracing as an explicit criterion for starting to reopen a state’s economy. Instead, this is included under a separate heading of “Core State Preparedness Responsibilities.”
Although the guidelines put responsibility for testing and contact tracing onto the states, the slow rollout of testing across the nation has widely been blamed on bureaucratic obstacles imposed by the federal government and the distribution of faulty test kits manufactured by the CDC.
Experts consulted by BuzzFeed News urged states to concentrate on improving their capacity for testing before relaxing their COVID-19 restrictions. “I don’t think there’s a responsible expert out there that thinks we’ve done enough testing,” Emanuel said.
Emanuel wants to see testing expanded to people without symptoms who may be spreading COVID-19, including essential workers like grocery clerks and bus drivers who could infect many people. Exact estimates differ, but asymptomatic cases may make up as much as 25% of total cases, according to CDC director Robert Redfield.
Both the White House and Center for Health Security guidelines call for a phased reopening of facilities including schools, restaurants, and other businesses. But it’s still unclear which aspects of the current restrictions are doing the most to limit transmission of COVID-19.
That means states should carefully monitor the effects of reopening to see which moves cause transmission to ramp up again and which have relatively small effects, according to Jessica Metcalf, a demographer at Princeton University who studies the dynamics of infectious disease.
“One of the big questions is which pieces of social distancing policies are having the largest effects,” Metcalf told BuzzFeed News. “Amazingly, we don't really know.”
Learning which policies have the biggest effect in limiting viral spread is important because most experts predict that we may need several cycles of social distancing and relaxation of these controls before an effective vaccine is developed and it becomes safe to go back to something resembling normality.
“We just can’t squander any opportunity to learn,” Metcalf said.