Philadelphia’s recent explosion in confirmed coronavirus cases pushed city officials to increase restrictions starting Nov. 20 and lasting through Jan. 1. While some hail the bans on indoor dining, indoor gatherings, and attendance at some public spaces as necessary to public health, others question their efficacy given that they’re tough to enforce and many people are struggling with pandemic fatigue.
Two public health experts debate: Are COVID-19 “lockdowns” the right response to control the growing pandemic?
By Amy Carroll-Scott
You don’t have to be an epidemiologist to assess your own health risks. For many, this means balancing perceived risks with the severity of consequences. Of course, risk assessment looks very different from person to person. In the case of seat belts or helmets, some people choose personal freedom over preventing injury or death. As a society, we largely support individual choices, believing they don’t affect anyone but the risk-taker. We are, after all, a culture of personal freedoms.
Which brings us to the COVID-19 restrictions the Philadelphia Department of Public Health is enacting Friday. As a working mother of school-aged kids, I, too, dread the debilitating impacts of restrictions on our work, school, social and mental health, and the economic well-being of beloved neighborhood businesses. But I support these “Safer-at-Home” restrictions that some view as a “lockdown.” Here’s why.
First, individual behaviors are not working to control COVID transmission in the U.S. Part of this failure is the absence of federal coordination of or investment in our usual epidemic responses, such as clear messaging, widespread testing, contact tracing, and regional surveillance. Indeed, Japan has avoided lockdowns by avoiding the three C’s: closed spaces, crowded places, and close-contact settings. An existing culture of mask-wearing didn’t hurt, either. Had we successfully practiced COVID-safe behaviors and kept cases down, we may not be facing restrictions on our personal freedoms today.
Second, individual COVID behaviors are not just individual — they impact the common good, a term I wish I heard more. With a disease this infectious and deadly, if you contract COVID and spread it to others, you are putting your family, your neighbors, that person at the grocery store, and your local first responders and ICUs at risk. If individuals cannot adopt the three C’s and mask-wearing, the only solution left in such a crisis is to close or limit the places where COVID is known to spread, such as large gatherings and close-contact settings such as theaters, gyms, and indoor dining.
Third, those who always bear the disproportionate burden of poor health — the elderly, those living in poverty, and minority groups — are also at increased risk for COVID and its economic impacts. Our long history of segregating minority groups and the poor into underserved urban neighborhoods has created the perfect storm of COVID risks, including crowded housing conditions, reliance on public transportation, and a higher proportion of residents working in hourly, low-wage jobs (trackable via the COVID-19 Vulnerability Data Dashboard from our team at the Drexel Urban Health Collaborative).
These residents are more likely to be frontline workers caring for the elderly, delivering your food, and assisting patients in lower-paying hospital jobs. They contract COVID at higher rates and have worse outcomes, including dying at higher rates. We know we can’t control this pandemic without controlling it in these communities.
Finally, I don’t consider such restrictions a true “lockdown.” These are targeted restrictions that allow many industries to continue to operate and should have less financial impact than the March stay-at-home order. They are temporary until we can get cases back under control.
As family and friends ask what I think about these restrictions, I wonder if perhaps it does help to have epidemiological training to appreciate the public health necessity of such restrictions. And I say: Come on, Philadelphia! Let’s show the country that we can do this — for our neighbors, frontline workers, most vulnerable communities, and health-care system — and get us all safely to the vaccines now within reach.
Amy Carroll-Scott, Ph.D., MPH, is an associate professor at Drexel University’s Dornsife School of Public Health and Urban Health Collaborative.
By Steven M. Albert
The U.S. COVID pandemic now exceeds 11 million cases and has surpassed a quarter-million deaths. We will soon see 200,000 new cases and 1,500 deaths daily. These rates make the old weekly benchmark of 50 cases per 100,000, which Pennsylvania once used to define “red” conditions requiring lockdowns, a distant memory.
Will lockdowns lower incidence? Possibly, but it depends on their extent, consistency, duration, and most importantly, compliance, not to mention economic and mental health support for many people restricted to their homes. If these cannot be delivered reliably, more severe lockdowns may not add much to policies that restrict gatherings and require face coverings. Paradoxically, part of the current surge may be due to restrictions introduced too early and removed too quickly.
“Lockdowns” cover wide terrain. Are we talking about restrictions on restaurants and bars (50% occupancy, takeout only, de-densified outdoor seating, early closings), travel limitations, required testing and quarantine when crossing state lines, bans on in-home gatherings of more than 10 people? The greater their extent, the harder to enforce. A survey reported earlier this month suggested that 40% of Americans plan Thanksgiving gatherings of more than 10 people without distancing or advance quarantine.
Any one-size-fits-all approach to restrictions is inappropriate because of geographic variation in the pandemic. As of Nov. 16, Pennsylvania’s COVID-19 Early Warning Monitoring System showed as much as a 10-fold difference across counties in new cases per 100,000, from 556 in Mifflin to 270.4 in Philadelphia to 55 in Forest County. Fine-tuning restrictions to local incidence may be the best strategy.
Ensuring consistency is also difficult. Should the same restrictions apply to casinos and churches, to restaurants that have indoor and outdoor seating vs. only indoor seating? Consider also the range of occupations considered “essential” across states. We haven’t come up with widely accepted standards for restricting activity, making any kind of single policy unlikely, if not unworkable.
Duration and timing are also essential. Moving too quickly to lockdown can squander commitment to an almost impossibly demanding regimen. Then, relaxing lockdown restrictions too soon can actually intensify transmission. The resurgence of cases we see now may be a consequence of this too early too soon, too draconian approach. One modeling study suggests that lockdowns should remain in place for at least 60 days, followed by a gradual relaxation of restrictions and return to work and school to avoid a resurgence.
“Community-specific quarantines” may be a better route. Curfews and restrictions on commerce should be locally targeted and linked to effective supports, such as economic aid, along with appropriate testing and tracing. Areas with out-of-control transmission, or on the brink of explosive growth, will likely require lockdown measures. Elsewhere, less severe measures may be enough. Consider this choice of strategies in the current phase of the epidemic: closing preschools from Thanksgiving through the end of the year (lockdown), or suspending classes for 10-14 days after the Thanksgiving holiday to allow infections to become clear, isolating families as appropriate, and allowing resumption of classes when possible (community-specific quarantine). The latter is reasonable given the importance of preschool for families.
If we can return to lower levels of community incidence, and if we are able to respond to inevitable local outbreaks with efficient testing, tracing, and isolation, we should be able to stave off more severe lockdowns. This would allow a more flexible and tolerable community quarantine. If this middle ground strategy fails, however, communities will likely need to move to more severe restrictions.
Steven M. Albert is the chair of the department of behavioral and community health sciences at the University of Pittsburgh.