When will social distancing end? When will life return to “normal”? And what will it take to get there?

Scott Gottlieb is a physician and public health expert who served as President Donald Trump’s first FDA commissioner, where he was the rare Trump appointee to win plaudits from both the left and the right. Now he’s a resident fellow at the American Enterprise Institute where he’s emerged as a leading voice on the coronavirus response.

Gottlieb is one of the lead authors of a comprehensive roadmap for what it would take to end social distancing and reopen the American economy. The report divides the coronavirus response into four distinct phases (the US is currently in phase one, which requires the strictest social distancing measures) and documents key “triggers” that states need to meet if they want to advance to a phase with less intense social distancing and a somewhat normal economy. It’s exactly what the country needs right now: a specific proposal for what comes next that can actually be analyzed and debated.

Two themes drive this conversation. First, what are the challenges to simply getting out of lockdown? Why doesn’t the US have enough tests yet? What’s stopping it from making more? And second, what does the world look like out of lockdown but before a vaccine is discovered? What’s being imagined here isn’t a return to normal, either socially or economically, but a kind of limbo that it’s not clear America has the political will to sustain and that has few answers for the most vulnerable among us.

You can listen to our full conversation by subscribing to The Ezra Klein Show, available on Apple Podcasts, Spotify, Stitcher, or wherever you get your podcasts. A transcript of our discussion, edited for length and clarity, follows.

Ezra Klein

Many of us are living under lockdown right now, but we remember what normalcy is like. And I think the expectation for many of us is that when lockdown ends, normalcy is what returns. Are we going back to normal any time soon?

Scott Gottlieb

I don’t think there’s going to be a binary point in time when we just return to what we were doing. I think world history is permanently altered by this episode.

As long as this pathogen is circulating in the background and we don’t have a vaccine and very effective therapeutics, this is going to alter the way we live and do business. Some of it is going to be subtle. You’ll see businesses advertising deep cleanings. People aren’t going to shake hands as much anymore. Wearing masks in public is going to become more fashionable in Western societies.

Some of it’s going to be more profound. I don’t think the marginal customer for a stadium or a concert or a cruise ship is coming back soon. I think people are going to be more circumspect about travel, particularly international travel. Businesses are going to be more circumspect about bringing together large groups of people. So you’re going to see a change in the way we live, in the way we do business.

The question is: Can we get back to our normal level of economic activity with that kind of profound, pervasive change in the way we operate? It may be hard. That’s why I talk about the “80 percent economy.”

Ezra Klein

Your plan divides the coming months into four phases and then it establishes triggers for states to move from one phase into the next. Tell me about those triggers.

Scott Gottlieb

What we tried to do with the report was create really identifiable milestones and then tie policy decisions to those milestones. One of the very clear milestones that we identify is that 14 days after you have a sustained reduction in new cases, you can start to reopen the economy. You can start to lift stay-at-home orders and allow certain businesses to go back to work in a staggered fashion while still implementing certain restrictions.

But you also need to have the health care capacity to treat everyone. And you need the capacity to test everyone who may present with symptoms of coronavirus. Those were the three milestones that we identified for when you would make a decision to reopen the economy.

Ezra Klein

I think people understand the social distancing part of phase one. But are we doing enough on the testing and health care side of things in states like California and New York and Washington that are in intense lockdown? Is the huge economic sacrifice being made by the people locking down being matched by a true mobilization on the supply side?

Scott Gottlieb

We’re doing a lot to increase testing capacity, but we’re going to hit an upper limit. Getting from 100,000 tests to a million tests is going to be a lot easier than getting from a million tests to 1.5 million tests. The reason is that what we’ve done so far is take platforms and labs that already existed and made them available for coronavirus testing. That’s why we’ve been able to increase testing. By the end of this week, we’ll probably be at a million tests a week in terms of capacity. Next week, we’ll build on that.

But getting to the point where you have a 2-3 million test capacity per week — which is probably where you need to be initially as you do this transition — is going to be very hard. We’ve tapped out the available platforms and now we’re dependent upon creating new platforms and new supply chains to fuel those platforms. We’re approaching an upper limit in spare capacity. The question is how fast can Abbott and other companies build new testing platforms? And how fast can LabCorp and Quest scale up new labs that didn’t exist before? That’s a harder exercise.

When will we get there? I don’t think we’re gonna get there by May. I think that we’re still going to be under-testing relative to what is optimal from a public health standpoint. I think we have the ability to get there by September, but we need to be doing a lot of things right now to invest in that. Congress is going to need to ultimately act.

Ezra Klein

I’ve been looking at every one of the plans people have released for how to get the economy back up and running. Your plan, the Center for American Progress plan, the Harvard Safra Center plan, Paul Romer’s plan for mass testing. One thing I see in all of them is massive scaled-up testing. You talk about a couple of million a week. Some of those plans talk about a couple of million a day. Romer’s plan talks about 22 million a day.

So a huge question in all this seems to me to be: What are the constraints on how rapidly we can build up testing?

Scott Gottlieb

What we did up until now is stand up existing labs — we got them working on coronavirus tests. Now we’re going to be at a constraint in terms of not having available platforms. We’ve got to build more machines to actually run the tests. Building that hardware takes time. Deploying that hardware takes time.

The other limiting factor is the testing supply chain. It’s not the machines that we might not be able to build. We’re not going to have enough reagents or enough plastic tips to pipette samples, or enough plastic cartridges to put the samples in. We’re actually running short of swabs to swab people’s noses. It’s all the low-margin commodity products in the testing supply chain that we’re now having problems obtaining. That’s the weak link in the supply chain. We never envisioned being in shortage of swabs for nasal pharyngeal swabs or reagents. That’s what’s happening now.

Ezra Klein

Is this a situation where the resources exist and they need to be directed and mobilized through some kind of central planning, say the Defense Production Act? Or is this something where even if you put into play that level of aggressive direction, you still couldn’t get the resources you need to make this work?

Scott Gottlieb

I don’t know how much you can just create new manufacturing for some of these commodity products because the starting materials are the weak link in the supply chain. Even if you had extra manufacturing for, let’s say, N95 masks, the actual ingredient that goes into making those masks is manufactured outside the US — it would be hard to scale a new manufacturer for that. That’s what’s in shortage right now.

With respect to the point of care tests that I think we’re going to need, those are made by companies like Abbott and Becton Dickinson. And those companies control their entire supply chain. They make their own swabs, their own pipette tips, their own cartridges, and the toaster-sized box. That’s a supply chain that could be scaled a little more easily because they control it.

Ezra Klein

I want to talk about what your plan called the “comprehensive Covid-19 surveillance system.” On the one hand, you’ve got widespread and rapid testing. But then there’s what you call the “national sentinel surveillance system.” This is a way you can check the background rate of infection and do contact tracing. And there’s a lot of discussion about whether you could do IT-based contact tracing where people download an app — which seems to be happening to some degree in Taiwan.

This seems to me to be another area where at scale really helps. But the idea that every American is going to download an app that lets the government or some company trace who they’ve been near and who they’ve touched would require a very big cultural shift, especially in a moment of low trust in politics or corporations. Can you talk a bit about what a robust contact-tracing regime could look like and what you think the obstacles to getting there might be?

Scott Gottlieb

I don’t think we’re going to get to that kind of an app in the United States and I don’t think we should be doing that. I think where technology could be very helpful, though, is when it comes to case-based interventions and self-isolation.

If we end up identifying people when they have mild disease or asymptomatic disease, then we can ask them to voluntarily self-isolate or we can enforce that self-isolation. I think we should be asking people to self-isolate and enforcing it. Simply asking for voluntary compliance with self-isolation may not be enough. But we could use tools to enforce that self-isolation as opposed to public health workers to make it more efficient: text messaging people every day and asking, are you home? That would be the least invasive. Or requiring them to download an app and tracking their phone to make sure they haven’t physically separated from their phone.

The flip side of this is that you don’t want to impose restrictions that alienate individuals or make people concerned about their privacy. If you do, then you’re gonna discourage people from going out and getting tested and self-identifying when they have coronavirus. That’s the last thing you want. You want people to be encouraged to get tested and identified and diagnosed with coronavirus.

We need to balance whatever we impose against not discouraging people from actually getting tested. Where that line is is a debate we need to have. When people are identified as being positive with coronavirus, what do we ask them to do?

Ezra Klein

In the report, when you say we need to massively scale contact tracing, what does that look like?

Scott Gottlieb

At a basic level, it’s what states like Massachusetts are doing right now. They’re hiring 1,000 public health workers to do contact tracing. When they identify people with an infection, they’ll interview them. They’ll talk to them about who they might have been in contact with. They’ll trace down those individuals. They’ll ask them if they have signs or symptoms of coronavirus. They may ask them to get tested. They may ask some of them to self-isolate for a period of time, depending on the level of exposure and the likelihood that they could have could be infected. That’s the traditional boots on the ground work of public health.

We don’t have the capacity to do that at scale right now. We’ve underinvested in public health infrastructure for years. If there was a large outbreak in a city it would very quickly overwhelm the capacity of any city’s public health infrastructure to do that at scale. So we need to build that out. Now, you can use technology with respect to the case-based interventions in the self-isolation to augment. But you can’t use technology to augment all of it. Ultimately, you need people doing this work.

Ezra Klein

That brings us to the triggers for moving to phase two. If there’s a sustained reduction in cases for at least 14 days in a state, the state’s hospitals can safely treat all patients requiring hospitalization, the state is able to test all people with Covid-19 symptoms and is able to conduct active monitoring of confirmed cases and their contacts, your plan says that the state can begin to reopen and move into phase two.

Tell me what you think will reopen when we go state by state. I don’t think you mean that you can have an NBA game again. So if you manage to get to phase two, what kind of economy are we looking at? What is opened and what isn’t?

Scott Gottlieb

I think it’s going to be a gradual reintroduction of activity. You’ll probably lift the stay-at-home orders, but you’ll tell people to wear a mask if they go out for a period of time. You’ll allow certain businesses to go back to work, but you’ll tell businesses that they have to put certain restrictions in place to try to reduce the number of people who congregate together — basically maintain some social distancing in the workplace. You want to reduce human-to-human interaction as much as possible while having a functioning economy, allowing people to reengage in normal activity.

What’s going to be last to be introduced? It’s going to be places where a lot of people crowd indoors for purely entertainment purposes: bars, venues, concerts, clubs — things like that are going to be the last to open up.

Ezra Klein

What about those who are especially vulnerable to coronavirus — the elderly, the immunocompromised, those with lung damage. What kind of normalcy returns for them, if any? Or are they in a position of essentially self-isolation until there is a vaccine?

Scott Gottlieb

There’s a difference between what the government requires you to do and what you choose to do. I think there might be guidance that people who are in a vulnerable position with respect to this virus should avoid going out for a longer period of time. You’re not going to be pulling people’s licenses in the street and checking their age, but there might be some strong recommendations as certain individuals delay their reintroduction. I think people who are older or vulnerable are going to make decisions to limit their activity. That’s why I talk about the 80 percent economy.

Ezra Klein

What you’re saying is that for the many people who are especially vulnerable, this is going to be a rough year. The most vulnerable among us are going to have to follow these restrictions through the fall; at the same time, everyone else is going to be moving around in a way that makes them more of a health threat.

I think about this myself. If social distancing is lifted because San Francisco or California has managed to make it to phase two, it becomes more dangerous for me to go see my parents because I’ve been in contact with more people. So in a perverse way, as the rest of the country becomes less isolated again, the people who are the most vulnerable might become yet more isolated because the folks who were being careful before now pose a higher risk.

Scott Gottlieb

I think the things that could really tip that balance is a very aggressive health monitoring system and a testing regime where you’re testing so many people on a daily basis for coronavirus that you’re likely to surface an outbreak when it’s only hundreds of cases, not thousands. If you can demonstrate that to people, it’s going to inspire a lot of confidence and people will feel fairly comfortable going out again. But if you don’t have that in place, your risk can be quite high and nobody knows it. That’s an uncomfortable position. If that’s the situation in perpetuity, people are going to be more reluctant to go out.

Ezra Klein

Phase three, which is a much more normal phase of life, works off of the development of vaccines and therapeutics. Where do you think we are on that front and what do you think is plausible in terms of therapeutics, let’s say, by the end of the year?

Scott Gottlieb

We’re not going to have a vaccine by the end of the year. We need to assume that a vaccine may be two years away. So we need other technology. If you look at what could be available by the fall, it’s a small subset of drugs. I would be focusing attention and resources on working aggressively with those manufacturers to try to pull those products through the development process and understand whether they are safe and effective.

What are those drugs? One is an antiviral drug — it inhibits viral replication. And it’s pretty far along. There’s data available right now that suggests that it’s active. A lot of doctors are using it. The other products are therapeutic antibodies. These are basically biotech manufactured antibodies — the same kind of antibody your body would produce if it is exposed to the virus in order to fight the virus if you’re exposed again.

That’s an attractive product for a number of reasons: First, it can be used as a treatment early in the disease. It can also be used as a prophylaxis — as a bridge to a vaccine. You might be able to give a monthly injection or bi-monthly injection to people that would prevent them from getting infections. You can use that for frontline health care workers. You can use it for TSA agents or food handlers who are coming into contact with a lot of people and more likely get infected and then spread the infection. You can use it in the contacts of someone who is sick to prevent them from getting sick. That could be a very attractive drug.

The combination could be very effective if you can have both of those by the fall: a treatment to help people who are infected and an antibody that can help prevent infection in those who are exposed. That’s a pretty potent combination.

The biggest obstacle is going to be manufacturing them at scale. That’s something we could solve for right now. We should be working on how we’re going to make investments to help these companies scale up manufacturing and get to large commercial scale manufacturing in time for the fall so that if one of them does work, we’re able to turn on the spigot and produce millions of doses a month. That’s the kind of position you want to be in.

There was money set aside in a recent congressional bill that set aside upwards of 10 billion dollars to do just this. That needs to be implemented. The companies need to be aware of it and pursue those opportunities. You need the agencies working to stand that up so that all has to happen. That’s the kind of thing I think we should be focused on right now.

Ezra Klein

In phase three you also talk about using serological surveys to determine population immunity. I’ve seen conflicting reports on whether people who’ve gotten coronavirus are immune. What is your best guess on that? If we had that serological testing, would it even matter?

Scott Gottlieb

Serological testing is important for understanding where the virus has been and who’s been exposed. It could be important for decisions about returning to work in certain professions where there’s gonna be high exposure like police officers or EMT workers or doctors and nurses. But by and large, what we’re going to find is that a very small percentage of the population has actually been exposed to this virus. If you talk to the modelers and the experts, they say anywhere from 1 to 5 percent of the US population has probably been exposed to this virus already.

If you look at the data coming out of Europe where they’re already using serology, it’s in the 5 percent range. So the idea that 30 or 40 percent of the population has had this virus is going to turn out not to be the case. It’s going to turn out to be a small percentage of the population — certainly in the single digits — that have the level of antibodies needed for immunity. And it’s not going to be enough to create herd immunity. It’s also not going to be enough to have this pool of people that can just return to work.

Ezra Klein

One of the things that worries me going forward is it has been hard enough to get states into phase one — not every state is there, even as we speak. Then if you move into phase two, I think there’s going to be a lot of relief. But something that is planned for in your proposal — and that we’re seeing in other places like Singapore — is that you may have to bounce back and forth between phase one and phase two for a while.

A president who clearly wants to get out of phase one as quickly as possible is not going to be excited in an election year about reestablishing it. It seems that the obstacles to being able to dance back and forth are very high. But if we don’t, we could end up back in a very, very difficult situation. I’m curious how you think about these obstacles.

Scott Gottlieb

I think there will be political obstacles, not just at a national level but at a local level as well. Ultimately these decisions are going to be made by mayors and governors — and that’s going to be hard because being the city that shuts down activity while the rest of the country is humming is not going to be in your best interest.

If you look at the history of this outbreak and this epidemic, Seattle should have taken more aggressive steps earlier. They kept the activity humming along far longer than they should have. That would have been the first city to really start to shut down economic activity and you saw a reluctance to do it.

So I think that’s going to be a challenge when you have outbreaks in cities: At what point do cities pull the trigger and start to shut down economic activity, not just to prevent spread in their cities but also to prevent spread more broadly in the United States?

This is going to be hard at a national level. But I’m more worried about the local decision-making and people being reluctant to take steps that could serve the national interests but maybe serve their local interests not quite as well.

You can listen to the full episode by subscribing to The Ezra Klein Show on Apple Podcasts, Spotify, Stitcher, or wherever you get your podcasts.

Further reading/listening:

For more on this topic, I looked at not just the AEI plan but three others for this piece. I thought immersing myself in the plans to reopen the economy would be some comfort. Boy, was I wrong.

Also, Matt Yglesias and I discussed the AEI plan and three others on this episode of The Weeds last week.

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