BY ARPIT GUPTA AND JONATHAN M. ELLEN
As New York City passes through the worst of the coronavirus pandemic, it is not too soon to think about a strategy to reopen the economy and exit from the current state of lockdown. Given its important role in the national economy—in 2018, the city’s economic output accounted for 5% of the nation’s gross domestic product—it is imperative to enable New Yorkers to return to work when it is safe to do so. This will require real reassurance. Recent polling suggests that Americans remain cautious about returning to normal activities. We can’t force people to endanger their lives, so having concrete steps to preserve safety can build trust, which will be critical to future success.
This public-health crisis, along with the economic crisis in its wake, is especially challenging for New York City. Skilled professionals and tourists, for instance, are drawn to the city from around the world for its rich array of services and amenities; now they stay at home, with businesses shuttered. One example: the nearly 450,000 residents working in leisure and hospitality account for more than $65 billion of the metro area’s GDP. This pandemic means that most of them are out of work and living with uncertain futures. Unsurprisingly, shuttering vast swaths of the world’s largest urban economy blows a hole in city hall’s budget, with tax revenues expected to run nearly $10 billion below projections.
An exit strategy should involve two components. The first is a series of measures to mitigate the risks of infection as much as possible. The second is a staged approach to opening to help protect vulnerable populations.
Mitigating the Risk of Infection
Some measures should be mandatory; others, such as centralized isolation, should be voluntary. But for each measure, the city should mobilize resources to help facilitate compliance and voluntary participation. In cases where the city requires business establishments to observe certain rules as a condition of reopening, the city should minimize bottlenecks, perhaps by developing a web platform on which businesses can sign an agreement signaling that they will observe the public-health measures. The city might also give firms that reopen a safe legal harbor: businesses that affirmatively agree to and do follow the city rules are protected from, for example, being sued for the spread of the virus. The measures to mitigate risk should include:
The single most important component of a strategy to exit the current “stay-at-home” lockdown is to continue ramping up testing, as Paul Romer has emphasized. Reasonably accurate mass testing is the only way to ensure that we can identify many Covid-19 cases—including asymptomatic cases—and quickly isolate those who test positive from the rest of the population. Businesses could reopen on the condition that their employees receive regular testing, as determined by NYC’s Department of Health and Mental Hygiene (and, as explained below, ideally conducted in coordination with contact-tracing programs for those who test positive for Covid-19).
To help make such an increase in testing expansion feasible, former FDA commissioner Scott Gottlieb has suggested bringing testing machines on site for large employers. New York State could also enroll small businesses in collaborative testing programs.
Many experts have highlighted the value of masks for other coronaviruses comparable with Covid-19 (aka SARS-CoV-2) and the large potential gains from mass mask use. While these benefits are potentially quite large, the costs are fairly minimal, which should push us toward prudential measures to require masks (as, indeed, many American cities did during the last flu pandemic in 1918). To start, requiring homemade masks is sufficient.
Masks are essential when people use public transit, are out in public, or are in crowded workplaces. The goal is to limit the spread of infection from individuals who have the virus but are asymptomatic. Businesses can be regularly inspected to ensure that employees wear masks in the workplace and that there are sufficient sanitation breaks for hand-washing and hand-sanitizer use (perhaps as part of normal health inspections, or through self-certification, subject to severe penalty). Over time, the wearing of a mask will likely become ingrained as accepted, and expected, behavior.
Masks can be made from fabric and other materials available at home, in order to reduce the demand on surgical masks, which may be in short supply for some time to come and should be prioritized to meet the needs of essential workers, such as health-care workers, first responders, transit workers, and grocery-store workers. However, important bottlenecks remain in the production and distribution of masks. These should be addressed through a coordinated response by businesses and government.
Daily Workplace Temperature Checks
Partnerships with large local property owners could help establish temperature checks at workplaces. Infrared mass temperature detectors should also be installed at airports, train stations, and other public places. Temperature checks rely on the fact that many Covid-19 cases present with fever. To be sure, this measure is not perfect—fever is not a universal symptom, and asymptomatic individuals may still spread the disease without a fever. Still, the effort to reopen the economy must layer many protective elements to limit the spread of infection as much as possible, and temperature checks act as an additional protocol designed to catch some symptomatic cases. Daily temperature checks are now routine in Ohio, and temperature checks are also common across many Asian countries to help detect individuals with fever. People should also be made aware of other common Covid-19 symptoms—including loss of smell and eye pain.
Social Distancing in the Workplace and Throughout the City
Employers should make efforts to ensure that workers can remain at least six feet apart and avoid mingling in crowds. However, the city also has a role to play. Given its population density and the inevitability of crowds along sidewalks, New York City must increase pedestrian space. Oakland, California, has already opened up 74 miles of streets to pedestrians.
With the lockdown, traffic congestion has declined, and New York City streets have fewer parked cars; also, many residents have left the city. This presents an ideal opportunity to open more streets for pedestrians, who can more easily maintain social distancing while walking, running, biking, and otherwise enjoying the outdoors.
However, cars have also taken advantage of lower street volume to engage in risky speeding, and some cities are seeing increased traffic deaths. Governor Andrew Cuomo and City Council Speaker Corey Johnson have advocated opening streets to lower density and to relieve pressure on parks, which are growing increasingly crowded as the spring weather improves.
Early in April, New York City opened a tiny 0.06% of the city’s street space to pedestrians as a trial, but hastily ended it a few days later. Mayor Bill de Blasio defended this action, citing demands on police officers for manning the intersections of the closed streets. However, cities such as Oakland have managed to open streets to pedestrians without requiring a police presence to barricade traffic. A priority could be areas that the organization Transportation Alternatives has highlighted—the NYC Marathon route, Summer Streets on Park Avenue, streets regularly closed for block parties and street fairs, and a focus on places not within walking distance of parks. On April 27, the mayor announced plans to open 40 miles of streets to pedestrian traffic over the next month.
For years, New York has sought to keep e-bikes off city streets. The mayor has temporarily suspended the crackdown. That suspension should also continue, as electric bicycles offer an important transit option for delivery workers and ordinary residents.
Contact tracing has long been a key method for controlling the spread of an infectious disease. Identifying infected persons through testing, treating them, and then finding, testing, and treating their contacts are the core components. In the case of COVID-19, there is no proven treatment. Until there is, isolation replaces treatment.
Contact tracing is labor-intensive and requires trained outreach workers. The city’s current contact-tracing workforce, in the New York State Department of Health and the NYC Department of Health and Mental Hygiene, is likely inadequately staffed to meet the needs. Hiring and training will need to be undertaken in New York, as it has in other states. For example, Massachusetts has already hired 1,000 contact tracers. 
Information technology can supplement standard contact tracing. Mobile phone data can be used to identify at-risk individuals who have been in close physical contact with those who have been confirmed positive. Recently, Apple and Google have launched a partnership to build out contact-tracing capacity. Numerous other applications have also been developed for this purpose. While such measures will remain opt-in because of privacy concerns, they should be encouraged by the New York State Department of Health and the NYC Department of Health and Mental Hygiene. Employers and insurers can take also a lead in allowing opt-in tracing. This will help identify clusters of infections and prevent a resumption of the exponential spread that the city experienced in March.
Centralized Isolation Sites
The current practice is to encourage individuals who test positive to remain at home and isolate themselves as much as possible from people who live with them. But infectious people who remain at home inevitably risk infecting family members and others with whom they share housing.
The alternative would be to create central isolation areas, organized by the NYC Department of Health and Mental Hygiene, for individuals who test positive for the viral infection. Such practices have been imposed in China with purportedly great success in reducing disease transmission rates. While the U.S. is not likely to make isolation measures mandatory, it is possible to offer this as an option to individuals who would like to take measures to protect roommates and family. Wisconsin and Florida have opened voluntary isolation centers.
While New York has recently signed contracts to provide hotel rooms for Covid-19 patients, hospitals would still have to discharge patients before they can shelter in these hotels. Centralized isolation is most effective to limit spread among patients with lighter symptoms, who would not ordinarily be admitted to the hospital upon testing positive.
Some workers who are released to return to work, even in the riskiest tier, will share housing with family or roommates. If those workers or their roommates become infected, a centralized isolation option can help reduce the risk that they spread the disease to others.
Staged Approach to Opening
To help manage the risk of transmission, the city should consider opening in stages rather than all at once. These stages, or risk tiers, should rely on specific thresholds, based on quantitative measures, or rules, to determine de-escalation or possible re-escalation. The process for determining movement between risk tiers can follow a proposal for the American Enterprise Institute by Scott Gottlieb and a group of other experts. In the context of the current situation in the United States: the trigger for relaxing stay-at-home orders—moving to a lower risk tier—is when there is a sustained reduction in cases over 14 days, sufficient advances in testing capacity to test everyone, and sufficient capacity in the health system to handle additional cases if necessary. The broad point is that as risks fall, based on observable facts such as the rates of infection and hospitalization rates, the city can gradually reopen. If caseloads start increasing at a rapid pace (doubling over three to five days), stay-at-home orders would be reinstituted. Once caseloads continue to decrease, the city can move in stages toward reopening.
Importantly, age-based guidelines are featured in several plans to reopen the economy. These guidelines are based on research on New York cases, suggesting that the frequency of hospitalization for symptomatic cases among individuals aged 55−66 is over four times that of individuals aged 19–44. These numbers escalate to greater than a 10-fold increase in hospitalization risk for those aged 65–74, and an enormous 66 times increase among those older than 75.
It is also important to note that implementing an exit strategy from the current lockdown status in New York cannot take place in a vacuum. Because New York City shares commuting flows with neighboring states, testing efforts and health measures need to be coordinated with multistate reopening efforts. What follows is a rough sketch of what the stages would look like, based on various levels of risk.
In this stage, which represents the highest risk to people and establishments, New York City would release to work only individuals younger than 45. The city can also issue strong guidance against returning to work for people of any age who have comorbidities (such as diabetes, hypertension, cancer, and pregnancy)—and make it illegal for employers to force such individuals back to work. The logic is that older workers and those with preexisting conditions have substantially higher rates of hospitalization and death.
Estimates suggest that about 36.9% of New York’s population is high-risk because of advanced age or comorbidities, but the fraction among the working-age population is smaller. For this reason, reopening with younger and healthier workers should allow businesses to start with a substantial share of their workforce.
Firms should also stagger office-worker shifts to the extent possible, as well as remain cautious about how many healthy, low-risk workers they call back to the workplace. Companies could be required to categorize workers by the necessity of their in-person work and allow those for whom in-person work is less essential to continue working from home or rotate with similar workers the days that they do go to the office.
In stage 1, the highest risk tier, schools, malls, entertainment venues, restaurants (open only for takeout and delivery), religious buildings, and the like should continue to remain shut. So, too, would Broadway theaters, Madison Square Garden, and Coney Island remain shuttered. These types of establishments allow for the continual mixing of different populations, presenting a strong risk for spread. Nonessential public meetings should also be banned. Public transportation such as buses and subways would remain open because of their role in transporting essential workers, as long as all passengers and drivers are required to wear masks.
More individuals can go back to work, including individuals under the age of 65 with no comorbidities. So, too, can jobs be opened in an increased range of businesses.
In Stage 2, establishments such as cafés, barbershops, retail stores, and restaurants can reopen with limited capacity and appropriate social-distancing measures. These establishments employ considerable numbers of New Yorkers, provide valuable dining and other services, and prudential measures here can further limit contact. New York State can help establish working groups, for each sector, to help coordinate mitigation efforts and reopening plans. For example, the New York State Restaurant Association could help develop protocols for the appropriate amount of physical distancing, hygiene measures, and other guidelines necessary for safe operation. Most offices should reopen with staggered work hours.
However, establishments in which people typically congregate in close quarters, such as schools and entertainment venues (e.g., Broadway shows), would remain closed.
In this, the lowest risk tier, establishments such as gyms, entertainment venues, and schools remain closed—as they offer the greatest risk of infectious spread through contact with numerous individuals. However, most retail and offices are open—subject to coordination with relevant industry-level bodies. Based on available data, individuals over 65 will remain at risk for severe infection, if exposed to the virus, until there is a vaccine. However, it is assumed that, at this stage of opening, the health-care system is not at risk of being overwhelmed and that individuals over 65 should have the option to return to work and have the personal liberty to risk exposure to the virus.
While ending stay-at-home orders and moving to reopen the economy sounds like a simple task, its success will depend critically on whether people feel safe and secure enough to resume normal activities. The best way to ensure the rebuilding of that trust is to take as many steps as possible to mitigate health risks and open the economy carefully and slowly. As the U.S. city most affected by the coronavirus, New York City faces unique challenges—how to ensure against a future outbreak and how to successfully revive an economy that has been battered by this pandemic. This crisis will likely leave scars that last for years to come. A forceful but measured process to lift restraints is critical.
Arpit Gupta is an adjunct fellow at the Manhattan Institute and an assistant professor of finance at New York University’s Stern School of Business.
Jonathan M. Ellen, MD, a pediatrician, epidemiologist, and public-health academician, is the former CEO of Johns Hopkins All Children’s Hospital.
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