Years ago, anthropologist Margaret Mead was asked by a student what she considered to be the first sign of civilization in a culture.
The student expected Mead to talk about fishhooks or clay pots or grinding stones. But no. Mead said that the first sign of civilization in an ancient culture was a femur (thighbone) that had been broken and then healed.
Mead explained that in the animal kingdom, if you break your leg, you die. You cannot run from danger, get to the river for a drink or hunt for food. You are meat for prowling beasts. No animal survives a broken leg long enough for the bone to heal.
A broken femur that has healed is evidence that someone has taken time to stay with the one who fell, has bound up the wound, has carried the person to safety and has tended the person through recovery. Helping someone else through difficulty is where civilization starts, Mead said.
“We are at our best when we serve others. Be civilized.”- Ira Byock.
Exactly 300 years ago, in 1721, Benjamin Franklin and his fellow American colonists faced a deadly smallpox outbreak. Their varying responses constitute an eerily prescient object lesson for today’s world, similarly devastated by a virus and divided over vaccination three centuries later.
As a microbiologist and a Franklin scholar, we see some parallels between then and now that could help governments, journalists and the rest of us cope with the coronavirus pandemic and future threats.
Smallpox strikes Boston
Smallpox was nothing new in 1721. Known to have affected people for at least 3,000 years, it ran rampant in Boston, eventually striking more than half the city’s population. The virus killed about 1 in 13 residents – but the death toll was probably more, since the lack of sophisticated epidemiology made it impossible to identify the cause of all deaths.
What was new, at least to Boston, was a simple procedure that could protect people from the disease. It was known as “variolation” or “inoculation,” and involved deliberately exposing someone to the smallpox “matter” from a victim’s scabs or pus, injecting the material into the skin using a needle. This approach typically caused a mild disease and induced a state of “immunity” against smallpox.
Even today, the exact mechanism is poorly understood and not much research on variolation has been done. Inoculation through the skin seems to activate an immune response that leads to milder symptoms and less transmission, possibly because of the route of infection and the lower dose. Since it relies on activating the immune response with live smallpox variola virus, inoculation is different from the modern vaccination that eradicated smallpox using the much less harmful but related vaccinia virus.
The inoculation treatment, which originated in Asia and Africa, came to be known in Boston thanks to a man named Onesimus. By 1721, Onesimus was enslaved, owned by the most influential man in all of Boston, the Rev. Cotton Mather.
Known primarily as a Congregational minister, Mather was also a scientist with a special interest in biology. He paid attention when Onesimus told him “he had undergone an operation, which had given him something of the smallpox and would forever preserve him from it; adding that it was often used” in West Africa, where he was from.
Inspired by this information from Onesimus, Mather teamed up with a Boston physician, Zabdiel Boylston, to conduct a scientific study of inoculation’s effectiveness worthy of 21st-century praise. They found that of the approximately 300 people Boylston had inoculated, 2% had died, compared with almost 15% of those who contracted smallpox from nature.
The findings seemed clear: Inoculation could help in the fight against smallpox. Science won out in this clergyman’s mind. But others were not convinced.
Stirring up controversy
A local newspaper editor named James Franklin had his own affliction – namely an insatiable hunger for controversy. Franklin, who was no fan of Mather, set about attacking inoculation in his newspaper, The New-England Courant.
One article from August 1721 tried to guilt readers into resisting inoculation. If someone gets inoculated and then spreads the disease to someone else, who in turn dies of it, the article asked, “at whose hands shall their Blood be required?” The same article went on to say that “Epidemeal Distempers” such as smallpox come “as Judgments from an angry and displeased God.”
In contrast to Mather and Boylston’s research, the Courant’s articles were designed not to discover, but to sow doubt and distrust. The argument that inoculation might help to spread the disease posits something that was theoretically possible – at least if simple precautions were not taken – but it seems beside the point. If inoculation worked, wouldn’t it be worth this small risk, especially since widespread inoculations would dramatically decrease the likelihood that one person would infect another?
Franklin, the Courant’s editor, had a kid brother apprenticed to him at the time – a teenager by the name of Benjamin.
Historians don’t know which side the younger Franklin took in 1721 – or whether he took a side at all – but his subsequent approach to inoculation years later has lessons for the world’s current encounter with a deadly virus and a divided response to a vaccine.
You might expect that James’ little brother would have been inclined to oppose inoculation as well. After all, thinking like family members and others you identify with is a common human tendency.
That he was capable of overcoming this inclination shows Benjamin Franklin’s capacity for independent thought, an asset that would serve him well throughout his life as a writer, scientist and statesman. While sticking with social expectations confers certain advantages in certain settings, being able to shake off these norms when they are dangerous is also valuable. We believe the most successful people are the ones who, like Franklin, have the intellectual flexibility to choose between adherence and independence.
Truth, not victory
Perhaps the inoculation controversy of 1721 had helped him to understand an unfortunate phenomenon that continues to plague the U.S. in 2021: When people take sides, progress suffers. Tribes, whether long-standing or newly formed around an issue, can devote their energies to demonizing the other side and rallying their own. Instead of attacking the problem, they attack each other.
Franklin, in fact, became convinced that inoculation was a sound approach to preventing smallpox. Years later he intended to have his son Francis inoculated after recovering from a case of diarrhea. But before inoculation took place, the 4-year-old boy contracted smallpox and died in 1736. Citing a rumor that Francis had died because of inoculation and noting that such a rumor might deter parents from exposing their children to this procedure, Franklin made a point of setting the record straight, explaining that the child had “receiv’d the Distemper in the common Way of Infection.”
Writing his autobiography in 1771, Franklin reflected on the tragedy and used it to advocate for inoculation. He explained that he “regretted bitterly and still regret” not inoculating the boy, adding, “This I mention for the sake of parents who omit that operation, on the supposition that they should never forgive themselves if a child died under it; my example showing that the regret may be the same either way, and that, therefore, the safer should be chosen.”
A scientific perspective
A final lesson from 1721 has to do with the importance of a truly scientific perspective, one that embraces science, facts and objectivity.
Inoculation was a relatively new procedure for Bostonians in 1721, and this lifesaving method was not without deadly risks. To address this paradox, several physicians meticulously collected data and compared the number of those who died because of natural smallpox with deaths after smallpox inoculation. Boylston essentially carried out what today’s researchers would call a clinical study on the efficacy of inoculation. Knowing he needed to demonstrate the usefulness of inoculation in a diverse population, he reported in a short book how he inoculated nearly 300 individuals and carefully noted their symptoms and conditions over days and weeks.
The recent emergency-use authorization of mRNA-based and viral-vector vaccines for COVID-19 has produced a vast array of hoaxes, false claims and conspiracy theories, especially in various social media. Like 18th-century inoculations, these vaccines represent new scientific approaches to vaccination, but ones that are based on decades of scientific research and clinical studies.
We suspect that if he were alive today, Benjamin Franklin would want his example to guide modern scientists, politicians, journalists and everyone else making personal health decisions. Like Mather and Boylston, Franklin was a scientist with a respect for evidence and ultimately for truth.
When it comes to a deadly virus and a divided response to a preventive treatment, Franklin was clear what he would do. It doesn’t take a visionary like Franklin to accept the evidence of medical science today.
But some find science-by-press-release troubling.
Anti-inflammatory oral drug colchicine improved COVID-19 outcomes for patients with relatively mild cases, according to certain topline results from the COLCORONA trial announced in a brief press release.
Overall, the drug used for gout and rheumatic diseases reduced risk of death or hospitalizations by 21% versus placebo, which “approached statistical significance.”
However, there was a significant effect among the 4,159 of 4,488 patients who had their diagnosis of COVID-19 confirmed by a positive PCR test:
- 25% fewer hospitalizations
- 50% less need for mechanical ventilation
- 44% fewer deaths
If full data confirm the topline claims — the press release offered no other details, and did not mention plans for publication or conference presentation — colchicine would become the first oral drug proven to benefit non-hospitalized patients with COVID-19.
“Our research shows the efficacy of colchicine treatment in preventing the ‘cytokine storm’ phenomenon and reducing the complications associated with COVID-19,” principal investigator Jean-Claude Tardif, MD, of the Montreal Heart Institute, said in the press release. He predicted its use “could have a significant impact on public health and potentially prevent COVID-19 complications for millions of patients.”
Currently, the “tiny list of outpatient therapies that work” for COVID-19 includes convalescent plasma and monoclonal antibodies, which “are logistically challenging (require infusions, must be started very early after symptom onset),” tweeted Ilan Schwartz, MD, PhD, an infectious diseases researcher at the University of Alberta in Edmonton.
The COLCORONA findings were “very encouraging,” tweeted Martin Landray, MB ChB, PhD, of the Big Data Institute at the University of Oxford in England. His group’s RECOVERY trial has already randomized more than 6,500 hospitalized patients to colchicine versus usual care as one of the arms of the platform trial, though he did not offer any findings from that study.
“Different stage of disease so remains an important question,” he tweeted. “Maybe old drugs can learn new tricks!” Landray added, pointing to dexamethasone.
A small open-label, randomized trial from Greece had also shown less clinical status deterioration in hospitalized patients on colchicine.
“I think this is an exciting time. Many groups have been pursuing lots of different questions related to COVID and its complications,” commented Richard Kovacs, MD, immediate past-president of the American College of Cardiology. “We’re now beginning to see the fruit of those studies.”
The COLCORONA announcement came late Friday, following closely on the heels of the topline results from the ACTIVE-4a, REMAP-CAP, and ATTACC trials showing a significant morbidity and mortality advantage to therapeutic-dose anticoagulation in non-ICU patients in the hospital for COVID-19.
COLCORONA was conducted remotely, without in-person contact, with participants across Canada, the U.S., Europe, South America, and South Africa. It randomized participants double-blind to colchicine 0.5 mg or a matching placebo twice daily for the first 3 days and then once daily for the last 27 days.
Participants were ages 40 and older, not hospitalized at the time of enrollment, and had at least one risk factor for COVID-19 complications: age 70-plus, obesity, diabetes, uncontrolled hypertension, known asthma or chronic obstructive pulmonary disease, known heart failure, known coronary disease, fever of ≥38.4°C (101.12°F) within the last 48 hours, dyspnea at presentation, or certain blood cell abnormalities.
It had been planned as a 6,000-patient trial, but whether it was stopped for efficacy at a preplanned interim analysis or for some other reason was not spelled out in the press release. Whether the PCR-positive subgroup was preplanned also wasn’t clear. Key details such as confidence intervals, adverse effects, and subgroup results were omitted as well.
While a full manuscript is reportedly underway, “we don’t know enough to bring this into practice yet,” argued Kovacs.
Some physicians also warned about the potential for misuse of the findings and attendant risks.
Dhruv Nayyar, MD, of the University of Toronto, tweeted that he has already had “patients inquiring why we are not starting colchicine for them. Science by press release puts us in a difficult position while providing care. I just want to see the data.”
Angela Rasmussen, MD, a virologist with the Georgetown Center for Global Health Science and Security’s Viral Emergence Research Initiative in Washington, agreed, tweeting: “When HCQ [hydroxychloroquine] was promoted without solid data, there was at least one death from an overdose. We don’t need people self-medicating with colchicine.”
As was the case with hydroxychloroquine before the papers proved little efficacy in COVID-19, Kovacs told MedPage Today: “We always get concerned when these drugs are repurposed that we might see an unintended run on the drug and lessen the supply.”
Citing the well-known diarrheal side effect of colchicine, infectious diseases specialist Edsel Salvana, MD, of the University of Pittsburgh and University of the Philippines in Manila, tweeted a plea for use only in the trial-proven patient population with confirmed COVID-19 — not prophylaxis.
The dose used was on par with that used in cardiovascular prevention and other indications, so the diarrhea incidence would probably follow the roughly 10% rate seen in the COLCOT trial, Kovacs suggested.
In the clinic, too, there are some cautions. As Elin Roddy, MD, a respiratory physician at Shrewsbury and Telford Hospital NHS Trust in England, tweeted: “Lots of drug interactions with colchicine potentially — statins, macrolides, diltiazem — we have literally been running up to the ward to cross off clarithromycin if RECOVERY randomises to colchicine.”
Years ago, anthropologist Margaret Mead was asked by a student what she considered to be the first sign of civilization in a culture. The student expected Mead to talk about fishhooks or clay pots or grinding stones.
But no. Mead said that the first sign of civilization in an ancient culture was a femur (thighbone) that had been broken and then healed. Mead explained that in the animal kingdom, if you break your leg, you die. You cannot run from danger, get to the river for a drink or hunt for food. You are meat for prowling beasts. No animal survives a broken leg long enough for the bone to heal.
A broken femur that has healed is evidence that someone has taken time to stay with the one who fell, has bound up the wound, has carried the person to safety and has tended the person through recovery. Helping someone else through difficulty is where civilization starts, Mead said.”
“We are at our best when we serve others. Be civilized.”
– Ira Byock.
Anthony Fauci, the nation’s top infectious diseases expert, said Tuesday that he has serious doubts about Russia’s announcement that it has a vaccine ready to be used for the novel coronavirus.
“Having a vaccine and proving that a vaccine is safe and effective are two different things,” Fauci said during a panel discussion with National Geographic.
Putin said that the vaccine went through clinical testing and that it had proven to offer immunity to the deadly disease, which has infected more than 20 million people worldwide, according to a Johns Hopkins University database.
However, phase three trials for the drug have reportedly not been completed, triggering skepticism from international health experts about its usefulness.
Fauci, the director of the National Institute of Allergy and Infectious Diseases and a key member of the White House coronavirus task force, said that he had seen no evidence supporting Putin’s position.
“I hope that the Russians have actually, definitively proven that the vaccine is safe and effective. I seriously doubt that they’ve done that,” he said, adding that Americans need to understand that the process for gaining vaccine approval requires safety and efficacy.
More than 100 possible vaccines are being developed around the world as part of efforts to offer immunity protection for the coronavirus. Moderna, in collaboration with the National Institutes of Health, launched a phase three trial for a vaccine in July, making it the first U.S. candidate to reach that stage.
Fauci has said that he’s “cautiously optimistic” that a COVID-19 vaccine will be ready by the end of the year. He told a House committee on July 31 that he was encouraged by everything he’s seen in the early data but that “there’s never a guarantee that you’re going to get a safe and effective vaccine.”
The World Health Organization said Tuesday that it was monitoring Russia’s progress in developing a COVID-19 vaccine. Progress in combating the virus “should not compromise safety,” the health agency said.
Former Food and Drug Administration Commissioner Scott Gottlieb echoed Fauci’s skepticism earlier Tuesday, noting in a tweet that Russia has been behind disinformation campaigns related to the pandemic.
“Today’s news that they ‘approved’ a vaccine on the equivalent of phase 1 data may be another effort to stoke doubts or goad U.S. into forcing early action on our vaccines,” he said.
Russia is reportedly planning to offer its COVID-19 vaccine to medical personnel as soon as this month. It will be made available to the general public in October, according to Reuters.
Over the past months, the country and the economy have radically shifted to unchartered territory. Now more than ever, we must reexamine how we spend health care dollars.
While the COVID-19 pandemic has exposed challenges with health care in America, we see two overarching opportunities for change:
1) the under-delivery of evidence-based care that materially improves the lives and well-being of Americans and
2) the over-delivery of unnecessary and, sometimes, harmful care.
The implications of reallocating our health care spending to high-value services are far-ranging, from improving health to economic recovery.
To prepare for coronavirus patients and preserve protective equipment, clinicians and hospitals across the country halted non-urgent visits and procedures. This has led to a substantial reduction in high-value care: emergency care for strokes or heart attacks, childhood vaccinations, and routine chronic disease management. However, one silver lining to this near shutdown is that a similarly dramatic reduction in the use of low-value services has also ensued.
As offices and hospitals re-open, we have a once in a century opportunity to align incentives for providers and consumers, so patients get more high-value services in high-value settings, while minimizing the resurgence of low-value care. For example, the use of pre-operative testing in low-risk patients should not accompany the return of elective procedures such as cataract removal. Conversely, benefit designs should permanently remove barriers to high-value settings and services, like patients receiving dialysis at home or phone calls with mental health providers.
People with low incomes and multiple chronic conditions are of particular concern as unemployment rises and more Americans lose their health care coverage. Suboptimal access and affordability to high-value chronic disease care prior to the COVID-19 pandemic was well documented As financially distressed providers re-open to a new normal, hopeful to regain their financial footing, highly profitable services are likely to be prioritized.
Unfortunately, clinical impact and profitability are frequently not linked. The post-COVID reopening should build on existing quality-driven payment models and increase reimbursement for high-value care to ensure that compensation better aligns with patient-centered outcomes.
At the same time, the dramatic fall in “non-essential care” included a significant reduction in services that we know to be harmful or useless. Billions are spent annually in the US on routinely delivered care that does not improve health; a recent study from 4 states reports that patients pay a substantial proportion (>10 percent) of this tab out-of-pocket. This type of low-value care can lead to direct harm to patients — physically or financially or both — as well as cascading iatrogenic harm, which can amplify the total cost of just one low-value service by up to 10 fold. Health care leaders, through the Smarter Health Care Coalition, have hence called on the Department of Health and Human Services Secretary Azar to halt Medicare payments for services deemed low-value or harmful by the USPSTF.
As offices and hospitals reopen with unprecedented clinical unmet needs, we have a unique opportunity to rebuild a flawed system. Payment policies should drive incentives to improve individual and population health, not the volume of services delivered. We emphasize that no given service is inherently high- or low-value, but that it depends heavily on the individual context. Thus, the implementation of new financial incentives for providers and patients needs to be nuanced and flexible to allow for patient-level variability. The added expenditures required for higher reimbursement rates for highly valuable services can be fully paid for by reducing the use of and reimbursement for low-value services.
The delivery of evidence-based care should be the foundation of the new normal. We all agree that there is more than enough money in U.S. health care; it’s time that we start spending it on services that will make us a healthier nation.
Despite a raft of data suggesting that wearing face masks (in conjunction with hand washing and social distancing) is effective in preventing person-to-person transmission of the coronavirus, the practice is still a partisan political issue in some places even as new cases continue to rise.
A new review published in The Lancet looked at 172 observational studies and found that masks are effective in many settings in preventing the spread of the coronavirus (though the results cannot be treated with absolute certainty since they were not obtained through randomized trials, the Washington Post notes).
Another recent study found that wearing a mask was the most effective way to reduce the transmission of the virus.
90% of Americans now say they’re wearing a mask in compliance with the CDC’s recommendations, up from 78% in April, according to a new poll conducted by NORC at the University of Chicago for the Data Foundation.
But despite the conclusive research and what seems to be a public consensus, masks remain a divisive subject.
As new coronavirus cases surge in Arizona, where cases have jumped 300% since the beginning of May, for instance, Governor Doug Ducey has not made it mandatory to wear masks in public, and in Orange County, California, officials on Friday rescinded a mask mandate after public backlash, even as cases rise; when cases peaked in April, on the other hand, New York made wearing a mask mandatory when people could not socially distance from others, and other states passed similar restrictions.
Part of the politicization of masks may have to do with resistance to heavy-handed government mandates, which in this case could cause people who are already skeptical of wearing face coverings to dig in their heels.
Lindsay Wiley, an American University Washington College of Law professor specializing in public health law and ethics, told NPR last month that stringent mask requirements “can actually cause people who are skeptical of wearing masks to double down.” And in turn, that “reinforce[s] what they perceive to be a positive association with refusing to wear a mask … that they love freedom, that they’re smart and skeptical of public health recommendations.”
Masks have also become a heavily politicized issue in recent weeks: Senate Majority Leader Mitch McConnell (R-Ky.) last month voiced his support of mask wearing in public, for instance, in contrast to President Trump and other GOP leaders who have portrayed masks as a sign of weakness. Trump infamously refused to wear a face mask as he toured a Ford facility in Michigan last month. When asked about the mask, he said that he wore one in private but “didn’t want to give the press the pleasure of seeing it.” House Speaker Nancy Pelosi has voiced her support for the practice: “real men wear masks,” she said earlier this month.
A video posted to Twitter on Friday showed a street in New York City’s East Village that was packed with people ignoring social distancing guidelines, most of whom were not wearing masks, drew widespread criticism. “When there’s a new spike people will blame the (masked) protests, but it’s really gonna be maskless crap like this,” one Twitter user wrote.
New York Governor Andrew Cuomo even weighed in on the scene. “Don’t make me come down there,” he tweeted.
On Friday, the Bureau of Labor Statistics will release employment numbers for April that are expected to show a tragic and historic increase in unemployment. Consensus estimates anticipate more than 20 million jobs lost and an unemployment rate of 16 percent—a figure that may well be an underestimate given that millions of people may not be looking for jobs, effectively exiting the labor force and reducing the labor force participation rate. Moreover, state-level unemployment claims data show that this economic pain is being felt across the country, with sharp rises in joblessness in every state. And Thursday’s jobless claims release suggests that job losses have continued at high levels since the April unemployment survey was taken.
While the immediate cause of this spike in joblessness is, of course, the necessary stay-at-home orders and social distancing measures taken to respond to the crisis, the rise in unemployment—and how long it lasts—cannot be separated from choices made by the Trump administration. In understanding the state of the economy, as well as what comes next, the following three elements of this crisis must be understood:
- The economic crisis we are facing—and the economic pain we expect in the months ahead—is the result of a failed public health response. The Trump administration ignored early warnings, misled the public, and made the coronavirus crisis worse. The fact that the administration bungled the testing regime early on in the crisis meant that the United States could never contain the virus, as other countries such as South Korea, New Zealand, and Taiwan have done. As a consequence of that failure, the United States has had to engage in social distancing that has meant economic shock in order to avoid significantly greater levels of infections and deaths. The depth and scope of the economic pain being felt is a consequence of the administration’s delayed response and complete failure take leadership during this crisis.
- The administration’s inability to put in place appropriate public health measures going forward—combined with its insistence that efforts to contain the virus should be lifted in the absence of those measures—is likely to not only prolong the public health crisis but also extend the economic pain. Rather than provide workers, businesses, and families the confidence that they can return to activity safely, the administration is taking steps that try to ignore the risk of infection, such as absolving employers of responsibility for worker safety through a liability shield or forcing workers to return to work even when they have concerns about their health. In this environment, we are likely to see decreased demand for some time to come because people will have little confidence in individual state reopening strategies disconnected from science—as we are already seeing across the country.
- By rejecting efforts that would support families, workers, and communities during this crisis, the administration and its allies in Congress are putting us on a path for continued double-digit unemployment even after the pandemic finally ends. Indeed, the Congressional Budget Office (CBO) projects that the unemployment rate—absent additional action—will be near 10 percent at the end of 2021, several months after they project social distancing as a result of the health crisis abates. By opposing efforts to provide sufficient aid to states and localities; relief to families and unemployed workers; and assistance to those struggling the most, President Donald Trump, Majority Leader Mitch McConnell (R-KY), and their allies are insisting on making this extended period of double-digit unemployment a reality.
There is an alternative path, however: Taking the necessary steps to address the public health crisis and ensure that people can go back to work safely and doing what is needed to address the immediate economic pain and avoid prolonged unemployment. As Congress and the administration consider an additional stimulus package, they should put in place necessary public health protections while providing robust aid to families, workers, and communities for as long as the crisis lasts. This will allow us to avoid double-digit unemployment from being a devastating reality for American families for the next year and a half or more.
Public health failures has driven unemployment up
The rise in unemployment over the past two months is a direct consequence of the public health crisis—one that could have taken a far less severe toll under an administration that had been better prepared for it and that had approached it more wisely. The Trump administration has failed to develop an evidence-based plan to end the coronavirus crisis. Instead, its mismanagement has resulted in widespread fear and uncertainty as to when it might be appropriate to reopen parts of the economy. President Trump did not take the pandemic seriously when cases first emerged in the United States; his administration failed to use the month of April—when the nation was largely shut down—to ramp up the testing, contact tracing, and other pieces necessary for the public health response. And now, Trump is pushing states to reopen too soon. Before people feel comfortable enough to once again venture out of their homes and reengage in work and other economic activities, we need to ensure the country has developed the necessary health infrastructure to allow us to gradually reopen our economy without sparking a second wave of infections.
The economic crisis cannot end until public health crisis is solved
The Trump administration and its allies are arguing that the way to solve the economic crisis is to open up the country, ending stay-at-home orders and engaging in aggressive efforts to force business to return to normal. But in the absence of public health measures that actually allow activity to return safely, the administration’s strategy appears to be one of “ignore and press on,” with potentially devastating results for workers and communities. This strategy includes:
- Pushing communities to lift stay-at-home orders and other public health measures before sufficient testing, tracing, isolation and ongoing surveillance is in place
- Forcing workers back on the job, even without sufficient personal protective equipment or workplace safety protections—whether by removing unemployment insurance for those who are recalled to unsafe situations or through executive actions such as those taken for the meatpacking industry
- Proposing to absolve employers of the responsibility to keep workers and communities safe through blanket immunity from liability—a measure that would do nothing to keep workers safe or build confidence in economic reopening
These steps reflect an acceptance of elevated risks of transmission, and ultimately, death. And despite the president’s rhetoric, it will make it less likely that the economy can return faster.
First, it is clear that the public isn’t going to feel safe to return to normal economic activity absent additional public health measures. A recent Washington Post-University of Maryland poll found that “67 percent say they would be uncomfortable shopping at a retail clothing store, and 78 percent would be uncomfortable eating at a sit-down restaurant.” These results were similar both in states that had loosened restrictions and those that had not and is consistent with other data. As long as people are anxious that returning to normal activities could put them at risk of contracting the virus, the economy will be unable to recover.
Second, a strategy that fails to put in place the necessary protections against spreading the virus will increase transmission among the public, and especially workers, in ways that may force additional shutdowns and prolong the period of public health crisis. In sum, prolonged public health crisis equals a prolonged state of economic distress—extending the number of months with a job market like April’s. The best approach—an approach adopted by other countries who are faring better both with their health outcomes and their economic impacts—is a national plan to fight the virus that is based on testing, tracing, and isolation.
After the pandemic ends, double-digit unemployment will persist under the current course
The CARES act provided large, necessary relief to most Americans, including assistance for workers, families, and small businesses. But this assistance will run out before the economic emergency is behind us, forcing the economy into unnecessarily prolonged hardship.
Indeed, the measures in the CARES Act both leave important gaps and will expire long before the economy is expected to return to normal. States and localities are facing extreme budget shortfalls. If action is not taken before state budget deadlines on July 1, states are likely to begin implementing layoffs of teachers and first responders and service cuts in the coming months that will cause additional job loss. Expanded unemployment insurance benefits expire at the end of July, removing an important lifeline for those out of work. While the direct payments in the CARES Act provided important assistance to families, the $1,200 per person payment will not be enough to sustain households through a prolonged crisis. The initial Paycheck Protection Program (PPP) support for small businesses has run out, and a second round of funding may soon run out too. And in important areas such as housing, food assistance, child care, and health coverage, among others, the CARES Act failed to do enough to address the hardship being felt today, let alone over a prolonged crisis—even as it provided generous aid to corporations.
As a result, under baseline projections—those that assume no further action on the part of the government—double-digit unemployment is expected to be a feature of the economy for at least the next year and a half. As noted above, the CBO estimates that the unemployment rate will remain near 10 percent at the end of 2021—many months after they predict that social distancing due to the pandemic itself ends.
Yet the Trump administration and congressional Republicans have indicated that they are prepared to accept this reality, or at best, offer solutions that do nothing to shift it. White House economic adviser Kevin Hassett said that another round of coronavirus relief legislation might not be necessary, and chief economic adviser Larry Kudlow said on Sunday that nothing has been decided yet and that “there’s kind of a pause period right now” and that “we will wait and see.” Senator McConnell has dismissed state and local aid as a “blue state bailout,” despite pain being felt in all states.
To the extent the administration or its allies have signaled a desire to act, they have focused on measures that would be woefully insufficient to address the economic challenges we face. Aside from the liability shield, Trump has signaled a push for poorly targeted corporate tax cuts or a payroll tax cut that would fail to benefit those who are out of work. An illustrative example of Trump’s approach is his call for removing limits on corporate deductions for meals and entertainment—effectively allowing companies to deduct expenses for sports tickets, golf trips, or visits to casinos—which would provide a benefit to corporations and their wealthiest executives but do little to help put money in the hands of those who need it.
A better path: a response that meets the public health and economic challenge
As it considers another package to address this crisis, Congress has the opportunity to take a path that rejects double-digit unemployment as a lasting feature of this crisis. The approach Congress should take would allow economic activity to restart safely and ensure that, as the economy restarts, we are actually getting people back to work rather than accepting a recession that keeps millions unemployed.
First, that requires a sufficient public health response. The purpose of stay-at-home orders in the first place was to suppress transmission to low levels and buy time to put in place extensive testing and contact tracing programs, but we have yet to meet those goals. Nationally, we still need to increase our testing capacity and reach at least 500,000 tests a day; scale up contact tracing—both manually and by apps that meet privacy standards—in order to isolate people who test positive as well as their contacts; and have in place a far more robust disease surveillance system.
And second, it requires an economic response that offers relief that both addresses immediate pain that families, small businesses, and communities are facing and is sufficient to build back to a stronger economy.
In particular, the package must be:
- At a scale necessary to address the crisis. We need to pursue a fiscal response that is proportional to both the public health and economic threat posed by COVID-19. The economic consequences of this crisis are staggering. Children are going hungry; households are piling massive debts; millions of homeowners are delaying their mortgage payments; small businesses in hard hit states received fewer loans than others; minority small business owners are struggling to stay open; and state and local governments are preparing for significant layoffs of teachers and first responders in the absence of federal aid. Action needs to be sufficiently large to both address the immediate hardship that families are facing and get the economy back to work. This big push for aid has to be coordinated at the national, state, and local levels. An important lesson form the Great Recession was that austerity at the level of states and localities was a key factor in delaying economic recovery for years, since states were in austerity mode from 2008 until 2012, contributing to lower GDP growth. And, in contrast to concerns raised by some congressional Republicans—concerns that were absent during the passage of nearly $2 trillion in tax cuts in 2017—we have the fiscal capacity to respond robustly, especially with interest rates near zero. Indeed, evidence suggests that increased fiscal stimulus may increase fiscal sustainability.
- Sustained for the duration of the crisis. Relief must be sustained, automatic, and available with certainty for as long as it is needed. We should learn from the Great Recession, when stimulus was insufficient and removed too soon. During that crisis, unemployment insurance expired for many workers long before the crisis had passed; fiscal aid ended long before state and fiscal budget cuts ceased being a drag on the recovery. Key measures to support the economy, such as unemployment insurance, state and local aid, and direct relief to families, should automatically extend for the duration of the economic crisis—ensuring that we are providing sufficient relief and necessary stimulus as long as is needed to support a robust recovery.
- Targeted to all the areas where Americans are feeling economic hardship. There is no silver bullet that will bring the economy back. We need a multilayered attack that addresses the root cause of the problem—the spread of the virus—and ameliorates its symptoms in the form of hardship for families, workers, small businesses, and communities. Building off the CARES Act, additional aid needs to make sure it is reaching those who have been excluded. That requires ensuring that aid is more completely available—for example, ensuring that immigrant families can access needed relief or closing loopholes that prevent workers from having access to paid leave. It also means providing much needed assistance in areas such as food assistance, child care, housing, and for people with disabilities—areas that would both address concentrated harm and support the economy going forward. Finally, the package should be designed so that—rather than exacerbating structural problems in our economy that benefited corporations over workers—it puts us on a path for a stronger economy once the crisis ends.
The administration and its allies appear content to accept a prolonged period of public health and economic harm that is a result of the mismanagement of the COVID-19 crisis to date—essentially condemning the nation to a greater toll from the virus itself and a much longer period of economic distress. It must be clear that the harsh reality of the April jobs report—and the much broader pain that has been felt over recent weeks—was the result of both failed policy decisions and mismanagement. By the same token, we have the choice going forward as to whether we accept further pain or take steps that would both keep people healthy and get Americans back to work.