Today, Connecticut begins the long, winding process of reopening. Were kicking off a new series on Steady Habits to explore some of the most challenging questions as it plays out.

Date: Wednesday, May 20, 2020

Its May 20, which means the reopening process in Connecticut is underway. Thousands of workers across the state will return to their workplaces as some businesses resume their operations. It comes as the state has seen a steady decline in coronavirus-related hospitalizations in recent weeks, and dramatically increased its testing capacity.

Still, some say more time may have been needed, including one of our guests this week.

Dean Sten Vermund of the Yale School of Public Health and Dr. Tom Tsai of the Harvard Global Health Institute talk with John Dankosky on the inaugural episode of our new reopening series on Steady Habits.

Listen to the episode using the player above or read an edited transcript of the conversation below.

DANKOSKY: If youre listening on the day we drop this episode, May 20th, you will note its the day the states been targeting for a partial reopening of state businesses. Now, to this point, only businesses considered essential have been operating in Connecticut. And thats meant a lot of people are out of work and a big part of our economy is suffering. The phased reopening is being done based on meeting goals for testing and a reduction in the transmission of coronavirus. And as youll hear, the state is making some progress. So that means pretty soon youll be able to eat in restaurants again. But only if you eat outside, and only if not that many of you are in the restaurant. And frankly, your waitress will be wearing a mask. And it probably doesnt sound like a whole lot of fun. You might, though, have been looking forward to getting a haircut. I mean, I dont know about you, but Ive been getting these kind of homemade haircuts for the last couple months.

My wifes been doing as well as she possibly can, but I could use to go back to the barber. But thats going to have to wait because this week, Governor Lamont pushed when salons could open up until June to coincide with the neighboring state of Rhode Island. Other businesses are being told now that theyll have to wait until later in June. Some businesses feel like, well, this pace is too slow. We want to open up more quickly. Others say give us more time and public health experts to kind of split on when to reopen different parts of the economy. So on this episode, two views from the public health sphere, from Dr. Tom Tsai from the Harvard Global Health Institute. And first from Sten Vermund. Hes dean of the Yale School of Public Health. Now, his colleague, Dr. Albert Ko, who has been helping to lead Connecticuts effort to reopen the economy. Vermund told me hes been pleased with the states response so far.

VERMUND: Im happy that the governor and legislature havent tried to move too quickly. Just two weeks ago, we had 440 patients in Yale New Haven Hospital with coronavirus. And now we have 240. Thats clear progress and were clearly on the downswing. But thats still a lot of patients and a lot of people got infected last week. So we are prudent and I think thats good. I also feel like, you know, opening up some industries, some businesses can be done expeditiously. Others may have to wait a little bit.

DANKOSKY: When we talk about this phased in nature of the reopening of our economy, some businesses going back, others taking a little bit longer. From a public health standpoint, are there certain benchmarks that you feel the state needs to meet before we start to open up restaurants? And what are what are some of those guide points that we have to hit?

VERMUND: Well, over a month ago, we had federal guidance that I thought was very thoughtful, 14 days of steady, declining case numbers. And that is a rule of thumb that was evaluated by the folks who do the mathematical modeling and forecasting. And they had reason to recommend that a two week span, because that would suggest that the wave of transmission was moving on, shall we say. And its a shame that states have ignored that guidance, because I think that would have been much more prudent. Georgias whats highlighted the news. I dont have any special knowledge about Georgia, but certainly judging from the news, they were especially aggressive at reopening. And Im not so sure that was such a good idea. Texas seems to have had a surge now. Maybe thats just a pocket or maybe its going to be more generalizable. But I dont think that you can be penny wise and pound foolish. Opening up too early and substantially risking another wave will simply disrupt the entire point of this shutdown to begin with. So I do feel like were in a good position now to thoughtfully reopen the state in stages. Other parts of the state that are considerably lower risk than other parts. And we can be more liberal in opening them. And we can also take a look at the big three. This is physical distancing, hand and face hygiene and mask use. And theres a lot we can do when we adhere to those big three.

DANKOSKY: I think my big question, though, comes with some of the the social aspects of of this crisis and how weve seen human behavior around these various milestones that were hitting. When the states start to open up, and a state like Connecticut which is I think we can all agree more thoughtfully doing it then Georgia starts to open up a bit more, youll start to see what I think you and I both might have witnessed over this past weekend. You had a couple sunny days. You get more people out and about. Maybe we get more people going to the stores that are open, not wearing masks. Theres almost a social effect of saying, well, were past this certain point and now were going to start to open up. Do you fear from a public health standpoint that people are going to take the message that things are fine and we dont have to be as vigilant as we have been for the past two or three months?

VERMUND: That is a challenge for the policymakers, political leaders, journalists, public health officials, academics. We need to impress upon people that a declining rate is not a zero rate. And if we continue to have transmission of the virus in the state of Connecticut, which we expect to well into the summer, it is highly prudent to physically distance, use masks and be aggressive with hand hygiene. Its not asking very much. Thats not a huge burden. If I can go to the movies and be a few seats away, lets be honest, most the movies I go to are not jam packed anyway. So its a matter of the movie theater owner being thoughtful in sort of the hot cross bun seating arrangement and making a bit of an educational effort to please sit in the seat where you see a mark and youll distribute people in the theater and people will be safer. Its not so difficult to sit in a theater and wear a mask, and its not so difficult to use the hand sanitizer that the clever theater owner will place conveniently at the entrance and exit and the bathroom.

DANKOSKY: But let me just stop you, because I think what were all though, noticing that there will probably be some theater owners, there will probably some bar owners, when bars are able to open up, that arent going to be so thoughtful. And there will be some places where people will crowd in as though its Mardi Gras and we just have had been locked up and cant wait to go party. Im wondering how much of a problem you see from a potential transmission standpoint, increased contact over the summertime as people begin to get into situations where, frankly, the businesses or the individuals themselves are not being that thoughtful?

VERMUND: Well, I think that the Department of Public Health and some of us in public health academia can be helpful. If our data in the state suggests that our problem is exceedingly low at the time, then liberalization is not unreasonable. If there is little to no transmission, then one might resume normal behavior, much as we do outside of flu season. Were much more cautious about hygiene in flu season than we are at the rest of the year. And maybe we should always be that cautious, but we arent. And so if the circumstances are highly favorable, liberalization is fine. But if we continue to have transmission, then were just inviting another wave. If were too relaxed and and we dont take those precautions and were going to open up the state. The governors aside of this, theres a broad consensus across the state that when we hit that sort of two week declining span, there is good reason to believe that the wave of transmission that washed over us from New York City will have largely dissipated. And until we know for sure, it is a fools errand to ignore physical distancing, handwashing and mask use. I honestly think we owe it to each other as denizens of our state to try to keep each other safe.

DANKOSKY: Even though its a small state, do you do you feel, though, because New York City has been the hot spot in the United States, maybe in the world, that Fairfield County and surrounding areas are in a little bit of a different situation than than Hartford County or the or the eastern part of the state?

VERMUND: I do believe they are, yes. They have business and social intimacy with New York City, far greater than any other part of the state. Their home of Stamford and Greenwich, which were hit right away very hard. And theres just no question that it was due to the tied by the hip kind of relationship theyve got with New York City. So I was disturbed seeing the evening news yesterday by folks in New York City, not bothering with masks, not bothering with any kind of distancing in some of the bars. And itll be interesting to see what Mayor de Blasio does about that, because we do have a tradition in public health of getting tough with people if theyre unsafe and theyre threatening the health of the community. It is it is true in all 50 states that an active tuberculosis patient who refuses therapy can be incarcerated and treated for two weeks until theyre no longer infectious to others.

And nobody sees that as a violation of individual liberty because theres a point at which that individuals irresponsible behavior threatens me. Its similar to running a red light or are driving recklessly or driving under the influence. We dont hesitate to enforce these things. And all of a sudden, public health people are saying, well, Im not so sure that that persons behavior is a risk to me. So I just all let it pass. But I think we should remind people courteously and in a cordial and reasonable way. Would you mind wearing a mask? Could you use that hand sanitizer? Could you stay a couple feet away, a couple more feet away? Thats not unreasonable. And I do it with people. I try to do it in a way thats friendly and supportive. And Im getting away with it without having my face smashed in so far. And I think if we do that with each other and set up a different kind of social contract that we agree to try to protect each other, then perhaps well be better off.

DANKOSKY: I want to ask you about this. The social contract or social compact? I think its such an important point and theres two questions I want to ask about it. One is that that is a slightly different thing than an enforcement mechanism, right? If theres a mechanism that says we cannot tolerate people without masks going into a certain establishment or we cannot tolerate someone who we know is actually a carrier of this virus being out in public, were going to incarcerate them. Thats a very different thing than us all getting together in deciding that were gonna take care of each other. Can you just parse those two things out for us? Because I believe that the social compact is a wonderful idea, but it may be a utopian idea in the America that we live in currently.

VERMUND: Good point. Now that weve been in a bit of a plateau of a peak of infection, there have been more rigorous regulations. The governor has required mask use to go into a store. A friend of mine was at a store the other day that was doing, you know, you were ordering in advance and then they would bring it to you and you could even pay in advance. And they had the six foot distancing of people. There was one gentleman in the whole line who wasnt wearing a mask and the store owner refused to serve him. And he got all upset, but the store owner said the governor has said that you have to wear a mask. Im not serving people who dont wear a mask. And everybody in the line cheered the store owner. Nobody took the side of the one person out of six or seven who refused to wear a mask because it was sociopathic. It was anti-social behavior. It was not a reasonable point of view. And as the gentleman left, my friend told me that he he mumbled, Oh masks dont help anyway. Which is simply untrue. So, you know, we do have a problem with people who dont want to do what they feel is inconvenient it for them. And these are not the people who are helpful in a pandemic.

DANKOSKY: The last thing for you, sir. Where do you think we need to get to in terms of testing in the state for us to more fully open back up? Because we hear from so many health experts that without an expanded and increased testing, were not going to be able to take those next steps toward more liberalization.

VERMUND: So if Im a store owner and I want to protect all my employees and my clients, I would like to get my employees tested for the antigen, meaning for the virus, before they return to work. So I might ask them to go to the CVS or other drivethrough or whatever is available my community and get a test. I think I would reimburse them for the costs of the test, because I would want to incentivize them to get that test. And then I would know that I have a returning workforce, none of whom is infectious to others. And they will stay uninfected the same way the health workers stay uninfected, which is use of personal protective equipment. In this case, were only asking for handwashing and masks and distancing, and that would protect my business. I will not then end up in the newspaper as a place that had a coronavirus case because Im going to lose a lot of business as soon as people see that my employees have gotten ill. And so I think its mutually self-interested. Its good for the business. Its good for the client. And having that ability to test people as they come back into group settings would be a powerful tool.

DANKOSKY: And do you think that theres some magic in the state number of wanting to get 40000 tests a week?

VERMUND: Others have done that calculation. I havent double checked it, but my colleague Albert Ko was happy with that number and I think hes done the research. One of my other colleagues, Forest Crawford, is working with the state. I dont think hes actually on the advisory group, but hes consulting the advisory group and I think theyre coming up with those numbers with his assistance. I believe that tens of thousands of tests that we could definitely quite to be needed because we may not think of ourselves as a large state, but there are three and a half million of us. If you take a million children out of the equation for the need for testing, you still have a couple of million people. And thats a lot of people.

DANKOSKY: So were starting a series this week called Reopening Connecticut. And we wanted to go outside the state for some perspective. Dr. Tom Tsai is from the Harvard Global Health Institute. Theyve been taking a close look at testing for coronavirus and how that can be used as a gauge for loosening restrictions on businesses. I asked him what hes looking for states to do as they consider how to reopen.

TSAI: The most important things to focus on as we look forward to next few weeks in terms of reopening is making sure that we continue to test broadly and counterintuitively the need for testing may actually increase as you reopen despite lower cases, because the reason for testing is going to change. Over the last several months, weve been really focused on just diagnosing COVID-19, basically testing patients with symptoms and confirming that they had coronavirus infection. But as we move towards reopening, were moving from a paradigm of diagnosis to one of screening and surveillance. So we need to get the tests out of the hospital and really into the communities and be able to adequately perform testing, contact tracing and supported isolation.

So I think there are two key metrics we need it will be looking at and state governors should be looking at as you move from looking at just the structural indicators of whether or not we have enough tests to now actually measuring our processes for testing and for reopening. That means we need to be measuring the number of people who are actually being traced through contact tracing. Among those, the number of people who are actually being tested because we have to make sure were testing those contacts in order to cast a wide enough net to get our arms around infection. The second part is to make sure that our tests are coming back at a fast enough rate so we can actually inform behavior. If testing is supposed to increase peoples confidence in the health care system, in society and in the economy, they cant wait four to five days for a result to come back. Thats four to five days of being self-isolated at home, unsure if you have the coronavirus and unsure if you may have inadvertently affected your friends, families or loved ones. So we really also need to be measuring the turnaround time. And ideally, that needs to be, you know, below 48 hours, below 24 hours if we have to make sure that the tests are immediately actionable.

DANKOSKY: How close do you think we are toward getting the right number of tests done, toward getting that turnaround time so that we can have the sorts of impact that youre looking for?

TSAI: I think were heading in the right direction. In Massachusetts, the governor recently announced a testing threshold, a target of 45000 by July and 75000 by December. I think similarly, Connecticut and other states have also increased their testing goals for the next few weeks to months. But, you know, Connecticut still has a test positive rate thats close to about 10 percent. And we need to be making sure that states like Connecticut are continuing to drive down the test positive rate.

The way to think about this is its not enough to make sure your car is going slower, going 10 miles per hour versus 60 miles per hour. The goal is to bring that car to a stop. So we have to actively be applying the brakes, actively decelerating and slowing down. And the quality of that is the test positive rate, continue to decrease and decrease in a fast enough rate. Thats what we know that the infection rate is going down, that fewer and fewer people are being infected. So a lot of progress has been made. I think were heading in the right direction, especially as states begin to move into phase reopening. There is an even more important need for continued vigilance around all the things that work. You know, that includes universal masking, physical distancing and really minimizing unnecessary social contact and exposure again. Because even though the infection has slowed down, its not over yet. And theres always a chance that if we take the lid off that things could bubble over again.

DANKOSKY: What conditions might make it easier for the virus to come back in another wave, to bubble back over again? I mean, if you if you look at a phased reopening like this, what could go wrong in a state like Massachusetts or Connecticut that would they would have the numbers start to head in the wrong direction again?

TSAI: We know that the virus tends to be spread easiest in close settings, indoor settings where theres not a lot of air circulation, but theres a lot of high frequency and high duration of contacts. So, you know, these are things like factories and plants. You know, weve seen how rapidly clusters can emerge and some of these meat packing or food processing plants. So thats why we have to be even more vigilant going forward to make sure that were testing, but also redoing repeated surveillance testing of nursing home residents and nursing home workers, testing any visitors. Now, the same goes for prisons. The same goes for new workplaces. You know, as they open, that may be sort of that higher risk.

So I think its really a focusing of the vulnerable populations or underserved communities. And the way this works is its a snowball effect if youre testing widely in these vulnerable populations, not only protecting the high-risk individuals, but if you actually following through with not just testing, but contact tracing for each new case, youre testing at least five to 10 additional individuals. And some of those may be new cases. And then you go contact tracing those individuals so that this becomes a snowball where, you know, one test becomes 10 tests, becomes 100 tests. And thats how you do sort of a targeted surveillance thats both screening the population, but also, you know, following the epidemiologist for the disease through contact tracing. And thats the way to move forward is by making sure that we can identify some of these cases early enough before they become, you know, emerging as huge clusters of cases.

DANKOSKY: The states are really only starting to ramp up their contact tracing efforts. Do you think that enough has been done at the state level in order for us to feel confident that we can start to go back to work? Because were testing more people, obviously, but still, those numbers are relatively low compared to what public health experts would have wanted. And now we seem to be just slowly ramping up contact tracing. I guess Im just wondering, Doctor, if weve if weve done enough so far to give you confidence.

TSAI: I think weve made a good start in lots of states, but I think we could be doing better. We always can be doing better. The goal of testing and the contact tracing is to make sure that we are creating confidence in the society and the public and the economy to safely reopen. And the best way to create that confidence is to make sure were testing broadly. I mean, think about, you know, your confidence in going back to work or bringing children back to school would be many fold higher if you know that you didnt have coronavirus, your child didnt have coronavirus, their teachers didnt have coronavirus, your colleagues have coronavirus. So, you know, I dont think were there yet. But thats the degree of confidence we need to be building in society. And the only way to do that is to be making sure that were testing broadly. And the only way to make sure we are testing broadly is to make sure that were actually doing adequate contact tracing. So I think weve made an important start.

We want the states hiring contact tracers. In Massachusetts, over 10,000 phone calls have been made to potentially exposed contacts. But I think thats just stage one. You know, step one. Where we really need to be moving is making sure those 10,000 individuals all get tested. I think thats where we need to be looking beyond just the number of tests as our metric for success and start measuring how effective our policies are, how effective our processes are. Thats where we need to be looking at the number of tests per contact, the turnaround time per test. These are second order metrics that will shine some light on how well the phase reopening plans are actually being implemented, because that will tell us whether or not ultimately were improving the outcomes for the public, which is decreasing the number of COVID-19 cases.

DANKOSKY: If you were on the line with Ned Lamont, the governor of Connecticut, and he asked you, Is it time to start a phased reopening, to start some businesses going back as early as the 20th of May, some others starting as early as June 1st? what would you tell him? I mean, do you think that we are going about this too quickly or not quickly enough? Do you think that were doing it just about right?

TSAI: So Im just looking at the numbers and in Connecticut so I have no skin in the game, being a resident in Massachusetts. By looking at the numbers in Connecticut, the positive rate seems to be stabilizing around 10 percent. Thats good, but not good enough. I want to see that drop below 10 percent and keep dropping. The number of positive tests has also stabilized, but I want to see it continue to go down. So, you know, the good news that the number of tests has increased over the last several weeks in Connecticut. So, again, I think there are some there are some early signals. Want to make sure that what were seeing are truly signals and not noise. So I think it may still be too early for Connecticut. But whats more important than dates is that our deadline should be driven by the data. So we shouldnt hold ourselves to specific dates.

But what we should really be holding ourselves accountable to is what the data show us. The data shows that the number of cases continues to go down at the positive rate is not just stable, but continues to go down below 10 percent. Number of deaths continue to go down and our number of tests continue to go up. All these, you know, signs have been are pointing the right direction that the pandemic is truly slowing down. I think thats a point where the phased reopening approach is important. The second part I would tell Governor Lamont is that just as important as to the goals, the gating criteria for moving to phase one, is how do we measure how was success in phase one looks like? Because if we see that rise in cases during phase one, how do we hold ourselves accountable for having made the right policy decisions? We wont even be making sure that the state of Connecticut, and that goes for every state in the Union, needs to have very transparent metrics on what success or failure looks like in terms of phase reopening because our lives that are at stake.

So we need to be making sure that we are very clear about what the goalposts are and we hold ourselves accountable to those moving forward. We cant have, you know, sort of moving targets. You know, there needs to be something that we work towards to during phase one for reopening. And if we meet those, great, move on to the next phase. But we all seem to know what happens if we dont meet those and we may have to reinstitute some forms of social distancing or even though double down on even more testing in order to be able to contain the pandemic. So its the the response is what Ive been seeing in a lot of the state plans. And I think thats incredibly important because that transparency is whats going to breed accountability, which is whats going to breed confidence in our public health system and our economy as well.

DANKOSKY: For the last couple months, we went from thinking that maybe if we elbow bumped instead of shook hands, that would be OK. And then we started to distance ourselves a little bit more. And then there was a lockdown and then more and more things shut down. And weve been only really essentially increasing the amount that we have distanced from each other and protected ourselves and each other. And now with this phased reopening, there seems to be a sense in society that weve turned a corner and that the behavior is going to start heading in the other direction. And I guess from a public health standpoint, Im wondering if it worries you that even if the testing gets up to a certain point, even if our metrics look good, we are sending a signal that things are back to normal and so that people who have heretofore been acting a lot differently than they ever have are going to go back to acting exactly the way they were in January of this year.

TSAI: There is no normal. The new normal is this brave new world that were in now. It is no longer ever going to look like December 2019. Now, this is a once in a generation, once in a lifetime pandemic. And what the public needs to realize is that, you know, it was actually easy to do one really big thing. Well, the big thing was staying at home. Now we have do lots of small things well. You know, masking, physical distancing, making sure we get tested, you know, making sure we answer the phone if we get contact traced, you know, following the guidelines at work. You know, were at school. You know, all these things are really hard to do well and to have this complete cultural change than just doing the one big thing while staying at home. So I think the next few months are actually going to be very challenging and difficult.

But, you know, Im confident that, you know, residents of Connecticut, as in every other state, you know, get it. People understand, you know, their friends, family members whose lives have been lost in this. People understand the tragedy and the depths of this pandemic. So my hope is that people will continue to translate, you know, that level of concern into their everyday practice, because its not just, you know, going back to the way things were. You know, this is a new world that were sort of reopening to and thats a world that requires vigilance. But the important thing to understand is that everybody has a role to play, that in this new world means that everybody has a sense of control because you are responsible for breaking your link in the chain. And when you do that, youre not just helping some hypothetical person across the country. Youre helping your friends, your family, your loved ones for potentially being infected.

So I think theres a credible role for individual responsibility on that. I think thats the message we have to focus on going forward.

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