COVID-19: 50 Suggestions for Reopening the Economy in a Responsible Way

COVID-19 poses a very serious threat: Many more people could die, either from COVID-19, the disease caused by the coronavirus, or from other conditions that could not be properly treated because hospitals are running at or over capacity due to the influx of COVID-19 patients. 

The current strategy that many Western countries follow to deal with the problem is to try to ‘flatten the curve’. In practice flattening the curve requires extreme forms of social distancing and shutting down large sectors of the economy. This too, however, has severe negative consequences: Tens of millions of people could lose their jobs, businesses will go under, retirement accounts lose value etc. All these developments are likely to cause significant health, social, psychological and institutional problems.

At this point it is not obvious that the ‘flatten the curve’ strategy is effective. Judging from results in South Korea, Japan, Taiwan, Singapore, Sweden and other countries, shutting down the economy may not be necessary to deal with the virus in a harm-minimizing way. And looking at countries such as Italy, on lockdown since March 9, it may not even be sufficient.

In addition, when it comes to reducing mortality rates the strategy has severe limits: Unless a vaccine and/or effective treatment is found in record time, a lockdown is not going to stop the virus. It will just distribute the deaths from the virus over a longer period of time. The lockdown is only intended to prevent the additional deaths that could result from hospitals being overloaded.

At the same time, this strategy is likely to cause a significant number of additional deaths due to the before-mentioned severe economic, social and psychological consequences of the lockdown itself. 

But what is the alternative? Are there effective ways to contain the pandemic or at least reduce the number of deaths as much as possible without imposing a lockdown?

First note that shutting down large parts of the economy is incredibly costly, almost unfathomably so. A lockdown means that large parts of the economy simply stop producing. That means billions of dollars worth of goods and services that could have been created are now not being created. Moreover, the stimulus packages intended to enrich politically connected corporations at the expense of everybody else cushion the blow of shutting down the economy are incredibly expensive too, and it will quickly become simply impossible to compensate people for lost wages and revenue if the lockdown continues for much longer.

This means that it is worthwhile to spend considerable sums of money on measures that could help to end the lockdown sooner rather than later.

With this in mind, below are some ideas for how to responsibly end the lockdown and reopen public life. This document will continue to be updated.

[Please note that this document is written by somebody with no expertise in any of the relevant areas. It is purely intended as a starting point for much needed discussion and research. Corrections, suggestions etc are very welcome at @koenswinkels or kmswinkels@gmail.com. Please share and feel free to use any content, with or without attribution. 
For an alternative take on the COVID-19 crisis, see this interview with prof Knut Wittkowski who argues not just that the lockdown cure is worse than the disease but that the disease is not as big a problem as commonly thought and that a lockdown makes the disease itself worse.] 

Reopen Public life

Allow both essential and non-essential businesses as well as other public spaces to reopen, under the following conditions: 

1. Masks: Everyone should wear masks when outside and in public spaces. While it is true that a mask does not offer 100% protection against getting infected or infecting others it is highly likely that if a large enough percentage of the population starts wearing masks a lot fewer people will become infected. To the extent that shortages of masks remain, give the best masks (eg N95) to medical professionals and allow all other masks to be sold or handed out to the public. Also encourage people to make their own DIY masks. DIY masks are still a lot better than nothing. Also keep reminding the public that wearing a mask is only effective if they keep practicing the other healthy habits.
2. Healthy habits: Continue to encourage frequent & thorough hand washing, no hand shaking; washing grocery packaging; no face touching etc.
3. No Crowds: Events with big crowds should be cancelled and the organizers should be partially compensated. Professional sports leagues can resume but in empty arenas & with continuous testing (and maybe group-quarantining) of players, staff etc.
4. Clean Spaces: Require public spaces (stores, government buildings, public transport etc) to disinfect their facility frequently and thoroughly. Inspect often: Fine at a first violation, close at a second. Financially reward businesses that pass inspections. To minimize the potential for abuse and to ensure quality control all inspections should be video recorded.
5. Humidity Control: Humidity is likely a key factor in how well the virus is transmitted. Specifically, a humidity level between 4,6 and 5,4 g/kg seems to be the most conducive to transmission. Research this in more detail and in the meantime, wherever humidity control is possible, aim for levels between 6 and 7 g/kg.
6. No Singing: There are good theoretical reasons and empirical examples to think that an ideal situation for the virus to spread is one wherein multiple people are singing in a closed space. The forceful breathing action of singing disperses a relatively high number of viral particles into a room, which makes it more likely that others get infected and that they receive a large viral dose, which likely increases the severity of the disease. So for the time being, cancel events where people sing, especially in closed spaces, with poor ventilation. In nursing homes activities involving song should be cancelled.
   
7. Bars & Restaurants: In restaurants and bars wearing masks is obviously a problem, so while servers and other staff should wear face masks, customers should not have to. To decrease the risk of transmission the maximum capacity of restaurants and bars should be reduced significantly so that customers are not too close to one another. Establishments should be partially financially compensated for the reduction in revenue. In addition, encourage the use of glass or plastic dividers. 
8. Outdoors: People should be encouraged to go outdoors (sunlight, fresh air & exercise are good & infection risk minimal). Parks and other spaces should be open but with more limited capacity than usual. Green spaces that are currently unused or underused should be made available and their use promoted.
9. Travel Bans: [this section requires more research: proceed with caution] Travel bans may be significantly less effective at containing a pandemic than is often thought. Specifically, once significant community transmission already exists within a region or country, travel bans may delay the spread of the virus by a few days or weeks but they will not avoid further spread. Screening prospective travellers for COVID-19 symptoms and banning those that do exhibit symptoms will still be useful to some extent. In some circumstances it could also make sense to require travellers to take a COVID-19 test before being allowed in. If a community is not yet hit by the virus, draconian travel bans —i.e. banning just about everybody from entering— that isolate the community from affected regions could work better but the more the rest of the world is already hit by the virus the more severe the negative economic and social consequences of such bans will be.
   

Vulnerable people

The goal is to take extra care protecting vulnerable people during the outbreak until we are well past the peak of the first wave. If the rest of the population can more or less continue their daily lives and the economy can keep going, more resources will be available to spend on protecting the vulnerable. And to the extent that a larger percentage of the rest of the population builds up immunity this too will help to protect vulnerable groups later on.

10. Self-Quarantine: Vulnerable people should continue to self-quarantine and be provided with all the care and services they need. Unless very strict protocols to prevent infection can be established, do not let vulnerable people quarantine in the same home as other family members unless those family members 1) tested negative and 2) are also self-quarantining: The infection risk is simply too high when people live in close quarters with each other —like they do in homes, nursing homes & hospitals. This is a major reason why in the absence of pervasive testing putting everybody —instead of just vulnerable people— on lockdown may make the problem worse.
11. Carers: Carers who tested positive for antibodies for the virus should be the first choice to assist vulnerable people as they have little to no risk of infecting others or getting infected themselves. Strict measures to prevent infection (eg use of personal protective equipment) should nonetheless continue.
12. Outdoors: Opportunities for vulnerable people to be outdoors should be created as much as possible. At the very least encourage open windows for fresh air. 
13. Quarantine but not Isolate: Strongly encourage ways in which people in self-quarantine can interact with loved ones and others without exposing them to risk. Pay special attention to people with few or no relatives (people with antibodies can play an important role here too). 
14. Nursing homes: The risk of infection is high in nursing homes. And given the population those infected will tend to have a considerably worse outcome than the general population. So a lot of additional resources need to be invested in preventing infection in these settings. 
15. Prisons: The risk of infection is very high in prisons too, although the average outcome of the illness will tend to be less bad than in nursing homes. Still, invest a lot of money in providing prisons and prisoners with the soap and other disinfection materials they need, and develop rigorous protocols for disinfecting shared spaces. Also strongly consider releasing non-violent offenders deemed to be low risk if they have tested negative for the virus. If prisoners test positive, they should go to designated sections of the prison that are isolated from the rest of the prison.
16. Vitamin D: Vulnerable people should be encouraged to take vitamin D supplements to compensate for reduction in exposure to sunlight. Vitamin D seems to reduce risk of lung infections and there is little to no downside in taking it as a supplement.

Testing & Tracking 

To get a much better understanding of the spread of the virus, how deadly it is, how contagious it is and how many people already have immunity (based on the unproven but plausible assumption that people can't get reinfected), and to be able to contain new outbreaks as quickly as possible we need a lot of testing and tracking.

17. Small Random Samples: Quickly test a small random (as random as possible) sample of the population (maybe 2,000 people) for a) the virus (who has it?) & b) antibodies (who had it?)
18. Mass Testing: Encourage everyone to get tested for the virus and for antibodies. Make tests available at home, in drive-throughs, in stores, in government buildings etc. Make tests free. Consider paying people to get tested.
19. Genetic Sequencing Tests: Wherever available, use tests that let you test someone for all known and unknown pathogens in one go.
20. On-Site Waiting for Test Results: Keep people who are getting tested on-site until the results are in (use tests that give results within hours not days) to prevent infected people from going back home and infecting others on the way or at home.
21. Antibodies Certificates: Issue certificates to people who test positive for antibodies so that these people can be used for jobs that carry a significant risk of getting infected or infecting others. Suspend this practice the moment there is persuasive evidence that a person can be infected a second time.
22. Share Results: Encourage sharing of test results in anonymized form in freely accessible databases.
23. Guarantee Free Treatment: To encourage testing and treatment guarantee that nobody who tests positive and who does not have insurance will have to pay for their treatment.
24. Pay for Missed Work: To encourage testing and treatment also guarantee that people who test positive and need treatment or quarantining will be paid at least 75% of their lost wages (the lower the income the higher the compensation percentage).
25. Tracking: Conduct detailed interviews with anyone who tests positive about who they have been in contact with in the past few weeks. Then contact as many of those people as possible and strongly encourage or incentivize them to get tested too. Also see to what extent it is possible to use cell phone location data of those who test positive to determine where they may have been infected and who they may have infected. Share all this data in anonymized form in freely accessible databases.
26. Volunteer Contact Tracers: Find a lot of volunteers to help with contact tracing. Make the forms they use as idiot-proof as possible so that more people are able to help.
27. Create Red and Green Zones: Based on the data gathered from testing and contact tracing locations (neighborhoods, towns, cities, regions) can be labeled as being at low (green zone) or high (red zone) risk of the virus spreading. Such maps could inform the public in their travelling choices and the lifting of restrictions on locations could be informed by/based on this data.
28. Track Hospital Capacity: To get a better sense of how the crisis is impacting hospital capacity, strongly incentivize hospitals to publish up to date numbers on use of hospital beds, in particular ICUs, and publish the results in freely accessible databases.

Treatment

The goal is to treat patients as quickly and effectively as possible with the means currently available while also reducing the risk of infecting other people and without overloading hospitals.

29. Telemedicine as First Point of Contact: To avoid spreading the virus people who suspect they have COVID-19 should NOT go to their GP but instead first contact a special COVID-19 hotline where an initial screening is done and people are separated into mild, moderate and severe. Once this pandemic is over this same model could also be used every flu season: It is a bad practice to make flu patients go to their GPs and make them wait with other (typically vulnerable) patients in the same confined space. SO set up specific flu hotlines and flu clinics.
30. Avoid Hospitalization: The vast majority of COVID-19 cases are mild. To reduce pressure on hospitals only those patients who need specialized medical equipment and care (ventilators) should be hospitalized. If symptoms are deemed mild to moderate, care for patients should be provided at home or in special facilities. These patients need to be constantly monitored to see if their symptoms (especially fever, lungs and oxygen levels) worsen. They should not live in the same house or facility as non-infected people unless the risk of infection is very low (for example, due to adherence to strict protocols).
31. Visits: Every effort should be made to create protocols and other safety measures that allow close relatives to safely visit patients who are hospitalized, not just for comfort and companionship but also because loved ones can alert nurses when something is wrong.
32. BLS, ALS, RNs and NRs: Te reduce the workload of nurses and to improve patient comfort consider using volunteers (preferably those with antibodies) with relevant qualifications (BLS, ALS, RNs and NRs) to help in hospitals (doing simple tasks but also alerting nurses when something is wrong).
33. Strict Separation: To prevent COVID-19 patients from infecting other people in hospitals, they should be treated only in designated COVID-19 areas of a hospital that are fully isolated, or in specially created new facilities.
34. Telemedicine: To reduce the burden on hospitals and to prevent the spread of the virus by people making unnecessary trips provide as much COVID-19 and non-COVID-19 medical care online as is reasonably possible. But don’t overdo it. Don’t risk reducing in-person medical care by so much that it has deleterious consequences for patients’ health.
35. Expand Right-to-Try: Allow not just terminally ill patients to opt for experimental treatment. Encourage experimental treatment as long as data is continuously shared. Reserve the right to intervene if a jury of experts randomly selected from a larger pool of experts determines the treatment is too risky.
36. Hydroxychloroquine and Chloroquine: Medical professionals in many different locations around the world appear to be having considerable success using hydroxychloroquine and chloroquine (but other evidence is less encouraging). Encourage all medical professionals to seriously consider this as their first choice for treatment. Strongly encourage sharing of data and reconsider use if results are disappointing.
37. Proning instead of Ventilators: Ventilators can be a lifesaver, but they also can do considerable damage to patients and the survival ratio of people on ventilators is shockingly low. Some doctors have success with using an alternative: Proning. Proning involves the patient taking oxygen and then rolling onto their sides or on their bellies, to quickly have oxygen levels in their blood to normal levels. More patients using the proning technique instead of having to go on a ventilator also reduces the burden on hospital staff. 
38. Pre-registration: To prevent P-hacking strongly encourage doctors and researchers to pre-register their research setups.

Innovation

We need innovation in testing, treatment, vaccines, preventon, disinfection methods for consumer, commercial, transportation and industrial use, and many other solutions for the various problems the pandemic and our efforts to contain it have created. And we need them fast. Rather than a top-down government directed approach we should encourage bottom-up innovation. The goal is to harness the expertise, creativity and resources present throughout society. 

39. Permissionless innovation: Switch from a precautionary principle framework to a permissionless innovation framework. Instead of having to first prove that a specific innovation is safe (a long, expensive and bureaucratic process) the burden of proof should be on those who wish to prevent or stop the introduction of that innovation.
40. Tort Law & Common Law: To curb excesses and prevent recklessness within a framework of permissionless innovation, use tort law, common law, class action activity, property laws, contract law and other tools. (p. 122)
41. Voluntary variolation: One possible way to create herd immunity fast is through voluntary variolation: There is strong evidence for the thesis that viral dose affects illness severity: Deliberately infecting volunteers with very small doses may make them immune without causing them to be ill. Once immune such people can be used to care for vulnerable groups and in general, to the extent that a virus is likely to infect a large part of the population anyway, deliberate low dose infection may significantly reduce severity of illness and deaths. And there are other potential benefits.
42. Controlled Human Challenge Trials: To speed up the development and rollout of vaccines, replace Phase 3 testing of vaccine candidates with a setup wherein volunteers who are previously uninfected, and at high risk of infection but low risk of complications or mortality receive the vaccine candidate (or a placebo) and after an interval to permit an immune response to the vaccine are administered a controlled exposure to the virus.
43. Research Airborne Transmission: Recent anecdotal evidence suggests the risk of airborne transmission is higher than usually thought. It is very important to know if this is so. Prioritize research into this issue.
44. Research Immunity: It is crucial to know whether people who’ve had the virus become immune or could get infected a second time. Prioritize research into this issue.
45. Research History of the Virus: Test people who experienced unusual kinds of pneumonia in late 2019 for antibodies for the virus to see if the virus has not been around outside of China for considerably longer than usually thought. This knowledge would affect the accuracy of model projections (specifically, it would mean we are further along the curve than projected).
46. International Cooperation: Encourage the sharing of ideas, research and personnel between countries. Cut as much red tape as possible. Provide 1-year visas to foreign scientists, researchers, entrepreneurs etc who have a sponsor or some party (university, business, investor, research institute etc) that will vouch for them, no (or few) questions asked. Also encourage scientists to go abroad to learn from the experiences in other countries, and share their expertise with those countries.
47. Subsidize Data Sharing: Find ways to incentivize the sharing of useful data (without incentivizing sharing of useless data).
48. Prizes: Create prizes for scientific and technological breakthroughs that might otherwise not be sufficiently financially rewarded. Jury members are randomly selected from a larger pool of relevant experts.
49. Continue Production: PPE and medical equipment such as ventilators will continue to be important and the risk of shortages remains. Continue producing such equipment and train staff to use them. To the extent that is possible, innovate so that e.g. ventilators and other devices become easier to use so that people can be trained relatively quickly to operate them in an effective and responsible manner. This additional capacity of equipment and staff will be useful for the future even if they turn out to be unnecessary in this pandemic.

Accountability 

50. Shame and Punishment: Fire the authorities who failed to properly prepare us for this pandemic, who hindered private efforts to develop and distribute tests and other equipment, who spread misinformation such as telling the public it was OK to go to big events or that wearing masks is not effective. At the very least publicly shame them, relentlessly.
51. Suspend Salaries: Give politicians and officials skin in the game. They should not receive salaries as long as the lockdown continues. If e.g. 10% of the lockdown is lifted they should get back 10% of their salary, if 50% is lifted they get 50% of their salary and so on. Cut their pay immediately if the number of infections (or deaths) starts to go back up by some percentage. 
52. Get Rid Of Bad Models and Bad Modelers: Models play a huge role in preparing for and responding to a pandemic. But models are often way off. Continue to closely monitor the accuracy of a model’s predictions. If a model continues to generate predictions that prove inaccurate and there are no good ways to adjust the model so that it provably leads to improved accuracy, discard the model and stop listening to the modelers. Don’t let them get away with the excuse “Oh, our projections were off because our approach worked and people practised social distancing better than expected”: The models that already took into account social distancing were off. Way off.
53. Not the New Normal: Encourage a strong sentiment among the public but also in government that all intrusive measures (restrictions, privacy-invasive measures) should be ended as soon as possible, that this is not a new normal, and that we only had to resort to these emergency measures because of the spectacular failure of government to prepare us properly for this pandemic. We should be much better set up to limit the damage future pandemics can do, putting effective measures & systems in place that threaten neither our civil rights nor our economic life. The data that was gathered during this pandemic should have been as anonymized as possible and once the emergency is over, any data that could not be properly anonymized should be destroyed & tracking apps should be removed. Start insisting on specific plans to return to normalcy right now.