Saving lives or saving the economy? Reopening doesn’t have to be an all-or-nothing proposition

May 13, 2020
Boston Globe
By Larry Edelman and Shirley Leung, Globe Staff

As Massachusetts prepares to follow other states down the uncertain path of lifting coronavirus restrictions, the clamor of competing messages grows louder: Moving too fast will bring a surge in deaths. Moving too slowly will bury the economy.

The debate over when to reopen will continue to rage between public health leaders, politicians, and business owners. But just as important is how. A growing number of scientists, economists, and business leaders have eschewed all-or-nothing thinking as they map out approaches to a new normal with COVID-19 until there is a vaccine.

Among the strategies: Maintain a stay-at-home advisory for seniors, and limit family access to nursing homes, because the elderly are most vulnerable to infection. Allow older employees to work at home even as younger colleagues return to the office. Permit more outdoor restaurant dining, because it’s safer than breaking bread indoors, and loosen restrictions on small social gatherings like backyard barbecues while still barring large crowds at concerts and sporting events.

“We can’t keep doing this 100-percent stay-at-home, extreme physical distancing indefinitely, but we also can’t go back to business as usual at this point. There has to be some middle ground,” said Julia Marcus, an epidemiologist and assistant professor at Harvard Medical School. “Now is the time to figure out what the middle ground is.”

In any reopening, scientists and economists agree that testing, tracing, and social distancing measures are paramount in keeping the virus under control. Selective lockdowns and restrictions come with their own trade-offs: they are hard to implement, even harder to enforce, and the downsides may be difficult to offset.

If the people over the age of 70, for example, need to be isolated for a prolonged period, will they need new services and programs? If an employer signals to older workers to stay home, is that a form of discrimination? If restaurants are restricted to outdoor dining or by capacity, how can businesses make money?

Lawrence Mayor Dan Rivera — who is on Governor Charlie Baker’s reopening advisory board, which is expected to deliver a plan on Monday — said members of the group are mindful of striking a balance between public health and business interests.

Rivera said reopening “is not a binary choice. . . . We are a society that put a man on the moon. We have to be able to take care of this problem.”

A group of MIT economists began looking at how best to restart commerce and wondered whether the country really faces a stark choice between saving lives and saving the economy. That led to a report published last week that focused on developing policies differentiated by age — young (20 to 44), middle-age (45 to 65), and old (65 and up). The conclusion: Combining a protective lockdown of those 65 and older with lesser restrictions on younger adults could decrease both deaths and economic harm.

One of the coauthors, Michael Whinston, said such a measure could “reduce deaths by 33 percent while reducing economic losses by 35 percent. The point is, with targeted policies the available options just get much, much better.”

Virus-related deaths have been concentrated in the older population. In Massachusetts, for example, people 80 or older have accounted for 15 percent of COVID-19 cases, but two-thirds of the deaths. People 60 to 69 have accounted for nearly 10 percent of deaths.

Whinston said protecting seniors would go a long way to preventing more deaths and allow the rest of the population to emerge sooner from their homes. Think of it as the difference between heating your entire home with an old-fashioned thermostat, or in zones with a smart thermostat. A zoned system lets you be comfortable at far less cost by targeting heat where and when you need it.

“With the right kinds of policies, the choices don’t have to be so grim,” said Whinston.

Helen Jenkins, an epidemiologist and assistant professor of biostatistics at Boston University, said the MIT idea sounds “very appealing in theory,” but she wonders about the logistics of locking down one age group.

Still, Jenkins said that reopening the economy does not have to be an “either-or” and that society will need to be “creative and innovative” in how to live before a vaccine arrives.

Even before the MIT paper, the concept of protecting some groups had surfaced in recommendations and protocols. Georgia was among the first states to reopen its economy in late April, yet Governor Brian Kemp kept the stay-at-home order for the elderly population and medically fragile in place until mid-June. In Ohio, Governor Mike DeWine is strongly recommending the elderly take extra precautions as others go back to work. In Massachusetts, Governor Charlie Baker highlights in his four-phase reopening plan how there will be “limitations” placed on a “vulnerable population.”

Employers are also looking to bring back employees based on age as a way to reduce infection. A recent report by the Massachusetts High Technology Council highlights a phased approach starting with young workers in the first wave, while keeping staff who are 60 and older working from home as long as possible.

But one big obstacle is that more than 36 percent of people 65 and older are in the workforce, according to the US Bureau of Labor Statistics, and many can’t work remotely, change jobs, or afford to retire.

Another challenge is that many older people live in multigenerational households with children, grandchildren, and extended family members. In many cases, segregation from younger relatives isn’t possible.

“We live together,” said Margaret Morganroth Gullette, a resident scholar at Brandeis University’s Women’s Studies Research Center and author of “Ending Ageism, or How Not to Shoot Old People.”

“There are midlife people who take care of older people. There are grandparents taking care of children,” she said.

In its report, the High Tech Council suggests young workers living in multigenerational households in COVID-19 hot spots consider alternative living arrangements. Telling people to live elsewhere to contain a virus would have been outlandish before the pandemic. Now here and elsewhere hotels have been converted into isolation facilities for people who have coronavirus but cannot safely isolate at home. Rather than shutting down much of the economy, government, for example, could provide housing in hot spots.

Similarly, in protecting seniors, government could create special hours for them to walk in public parks, just as grocery stores set up special shopping hours during the pandemic.

Bain Capital cochair Steve Pagliuca, who helped lead the tech council’s research on reopening the economy, said it’s possible to create a safe return but everyone bears some responsibility.

“This is a systemic problem and we need to solve it with a systemic response,” said Pagliuca. “You need a thoughtful, phased approach and you have to monitor where you are based on the spread factor, and then push forward or pull back based on the trend.”

Indeed, on Wednesday Baker sounded another note of caution, saying it would be “incredibly irresponsible” to open the economy all at once. He has warned he would issue another stay at home order if the virus flares up again.

Age is not the only demographic factor to consider.

A recent working paper by epidemiologists at the Harvard Center for Population and Development Studies found that during the early stages of the outbreak the mortality rate climbed higher in Massachusetts locales with larger concentrations of poverty, people of color, and crowded housing. It’s the same kind of health disparities that researchers have long found among racial, ethnic, and economic groups.

“It’s not just age” that puts people at risk, said Nancy Krieger, a professor of social epidemiology at the Harvard T.H. Chan School of Public Health and an author of the COVID-19 report. “It’s also racial and economic inequities in living and working conditions. It’s both — not either-or.”

Until a vaccine is available, it’s inevitable some workers — in high-volume stores, for example, or health care facilities, or restaurants — will be at greater risk than those who can work at home or in low-density offices.

And then there are nursing homes. More than 60 percent of COVID-19 deaths in Massachusetts have been tied to long-term-care facilities, according to state data. Residents were often infected by staff, many of whom are poorly paid, work multiple jobs, and lack access to sufficient personal protection equipment.

Making these facilities safer will require “more money, better monitoring, and better pay,” said Morganroth Gullette of Brandeis.

It may also require tighter controls on family visits until testing is widespread and routine, and more is understood about immunity among people who have already had the virus.

Like other scientists, Marcus, the infectious disease doctor at Harvard, worries about reopening the economy too soon. But it’s not too soon to think about life after quarantine. In a recent article published in the Atlantic, Marcus wrote that “quarantine fatigue is real,” adding that “what Americans need now is a manual on how to have a life in a pandemic.”

Marcus urges policy makers and public health experts to help the public differentiate between lower risk and higher risk activities. Being in enclosed crowded settings, for example, is more dangerous than hanging out outdoors with a few friends.

That means redesigning outdoor and indoor spaces to reduce crowding, for example, or increasing ventilation, and promoting physical distancing. Cities could close down streets to allow for more outdoor recreation or dining.

“I don’t think there’s a way to do it with risks completely eliminated,” Marcus said in an interview, but there is a “way that reduces risk as much as possible.”