County officials need to take the lead on addressing the Governor’s six indicators and transitioning out of the COVID-19 statewide stay at home order.
On Tuesday, Governor Newsom released a planning framework for gradually replacing the statewide stay at home order with less disruptive public health measures. He acknowledged that the collateral costs of the stay at home order were significant and that the transition into this next phase was inevitable. But he refused to commit to a specific timeline. Instead, the Governor identified six key “indicators” that should be used as a framework to assess our ability to transition into the next phase of the pandemic, which he acknowledged will require us to live with the virus until we acquire immunity.
The Governor’s framework raises two fundamental questions: First, are his “indicators” more accurately viewed as “to dos?” For example, we do not need more data to tell us that we need to “prevent infection in people who are at risk for more severe COVID-19.” Instead, we need to be developing and implementing social distancing and public health measures that are carefully tailored to protect this demographic. If viewed as “to dos,” then I agree with five of the six indicators the Governor has identified (I do not believe the development of therapeutics should be viewed as any sort of indicator or task, as I explain below).
The second key question raised by these indicators is: Which level of government should be doing this work? As I previously suggested, I believe it is our Counties. With the exception of certain “baseline” guidance per Governor Newsom (or “minimum standards,” in my vernacular) – such as bans on large gatherings — most of the tasks the Governor identified must be carried out at the local level because that is where the rubber meets the road on COVID-19 – testing, healthcare capacity, social distancing given demographics and density, and early warning of an uptick in infections or hospitalizations. The Governor acknowledged this dynamic in his press conference when he repeatedly emphasized that “localism is determinative.”
In light of the Governor’s comments, I have reorganized his 6 indicators into a 5-Point “To Do” List for each County. When a County has checked off each of these items, it should transition out of the stay at home order and into the next phase of the pandemic. Even if Counties are unwilling to lead, they must be ready to follow given the Governor’s increasing concerns over the order’s negative “impact[s] on the economy, poverty, and overall health care in California.”
The COVID-19 “To Do” List for Each County
1. Develop Social Distancing and Public Health Plans for Protecting the Most Vulnerable
The CDC has determined that older adults (> 65) and people of any age with serious underlying medical conditions appear to be at much higher risk for severe illness and hospitalization from COVID-19. Accordingly, each County will need public health and social distancing orders to protect these vulnerable populations. These measures could include ongoing stay at home orders for the most vulnerable paired with business regulations that require merchants to establish dedicated hours and procedures for protecting these individuals when they leave their homes. These policies should be fairly easy to develop as many Counties were moving in this direction when the statewide stay at home order was issued.
2. Develop Social Distancing and Public Health Plans for Businesses, Childcare Facilities, and Schools
In addition to measures designed to protect the most vulnerable, Counties will need to develop policies for businesses of every sort, including childcare facilities (because many people will not be able to return to work with the schools closed unless there is alternate childcare available). These policies will likely have two components: (1) a mechanism for staggering the resumption of businesses by category over time; and (2) social distancing (including reduced patron capacity limits) and hygiene requirements for various business types (for both employees and customers in some cases). Here too, these policies should be fairly easy to develop — Counties could partner with their Chambers of Commerce and local business associations to accelerate the process.
Counties certainly do not need to condition their transitions out of the stay at home order upon a plan for re-opening their schools. Rather, local school districts and private schools should be independently assessing relevant conditions (e.g., numbers of COVID-19 cases in school-aged children, students among the most vulnerable, students who cannot participate in remote learning, students who depend on school meals, and staff and faculty among the most vulnerable) and determining whether to (1) re-open in May (as is happening in Denmark, Germany, and Austria), (2) remain closed for the school year, but re-open for certain summer programs, or (3) remain closed until August. Once they decide on their course of action, local school districts and private schools should begin planning for their transition, including the adoption of social distancing, reduced capacity, and health and hygiene measures to protect students, faculty, and staff.
3. Ensure the Local Healthcare System has the Capacity for Additional COVID-19 Hospitalizations
We already know the State has substantial unused hospital capacity for COVID-19 patients. But the same must be true at the local level before a County lifts its stay at home order. In addition to modeling, one guide for answering this question would be to assess hospitalization levels from roughly March 14th to March 31st if a County was implementing significant public health measures before the statewide stay at home order was issued. If a County had unused capacity (hospital beds, ICU beds, ICU equipment, and personal protective equipment) for confirmed and suspected COVID-19 patients during this period, it should have adequate capacity to manage admissions under a gradual and carefully crafted transition out of the stay at home order.
4. Develop a Plan for Improved Testing and Isolation Measures
No one disputes that testing can and should be improved across California. But this must be done with clear goals, reasonable expectations, and confidence in statistical methods (the State is “guided by science and data”) given the limited financial and staffing resources available at the State and County levels. Today, the two critical goals for testing should be: (1) test everyone with serious COVID-19-like symptoms and return results in less than 48 hours to improve early isolation measures and better predict healthcare capacity demands; and (2) as Counties implement increasingly less disruptive public health measures, they should develop and implement a program for randomly sampling a small percentage of the population at regular intervals to improve early warning and isolation capabilities and assess the ongoing trajectory of the pandemic. Such a program could be developed with support from the State, in partnership with other Counties, or in partnership with research institutions and private laboratories.
5. Ensure Early Warning and “Snap Back” Capabilities
Each County will need to develop a plan for carefully monitoring the trajectory of the virus and “snapping back” to a stay at home order if it detects a true surge in infections that could overwhelm its healthcare capacity. This plan should have three components: (1) monitoring the number of positive tests for people exhibiting serious COVID-19 symptoms to identify any sustained and substantial increases over a 3-5 day period; (2) monitoring confirmed and suspected COVID-19 hospital admissions to ensure that substantial increases over a 3-5 day period are detected; and (3) monitoring the percentage of positive tests in random samples once the random testing program has been in place for a reasonable period of time. With such a monitoring program in place, these three sources of data should provide a County with ample warning of a rapid change in the trajectory of the virus and enable it to snap back to a stay at home order to prevent the uncontrolled growth of the virus.
Notwithstanding the Governor’s position, I do not believe that developments in therapeutics – treatments that reduce the severity and duration of COVID-19 symptoms – should be included on this list. The development of therapeutics does not tell us anything about the trajectory of the virus or the success of our public health measures. Moreover, the development of therapeutics lies entirely outside the State’s control – the pharmaceutical industry and the federal government determine whether and when these treatments become available. For these reasons, I do not believe that therapeutic developments are relevant for deciding when to transition out of the stay at home order. That said, I do believe that if proven therapeutics are introduced, this should dramatically accelerate our return to something more closely resembling normalcy because of our ability to deliver improved healthcare outcomes to more people.
Let the Transition Begin
COVID-19 hospitalizations continue to plummet in California. The purpose of the statewide stay at home order has been achieved. Out of an abundance of caution, Governor Newsom has elected to continue the stay at home order while creating a planning framework for transitioning to the next phase of the pandemic – a framework based on the principle that “localism is determinative.” This is a call to action for our Counties. They should heed it and immediately begin the process of transitioning from the stay at home order to our new normal – carefully-crafted and effective public health and social distancing measures that are less disruptive and far less costly. We can see the light. Now let’s get to the end of the tunnel.
Be safe. Stay healthy.