We spoke to frontline experts from around the globe and have compiled a list of recommendations for reopening U.S. states. Their consensus? It’s tough to find policies that simultaneously save lives and livelihoods.

This article was first published on Saturday, April 18, 2020 in ProPublica.

By Stephen Engelberg, Caroline Chen and Sebastian Rotella

After insisting that he had absolute power to decide when to reopen the American economy, President Donald Trump has turned over to all of you what he initially called “the biggest decision I’ve ever had to make.”

Trump is often guilty of hyperbole, but he’s right in this case. Figuring out how and when to let people go back to work during an outbreak of life-threatening disease is the most consequential decision any of you will ever face. You’ve already seen the stakes in New York, New Jersey and Michigan. Get this wrong and thousands of people in your state will die. As the presidential election campaign heats up, count on the president to blast you for high unemployment rates in your state (you lifted restrictions too slowly) or clusters of deaths (you went too far, too soon).

To help you and your aides think about this decision over the next few weeks, we’ve interviewed experts and frontline officials from Italy, Germany, Spain, Singapore, Taiwan and South Korea. While they differ on the details, their views formed a startlingly united consensus of what’s needed:

• Massive, ongoing testing to detect where the disease is spreading,
• a real-time ability to trace contacts of those infected and isolate them,
• a willingness of people to wear masks in crowded public spaces,
• reserves of personal protective equipment (PPE) and other equipment for hospital workers to handle any surge in cases,
• and reliable, easily administered blood tests to find out the number of people who have been infected. If they work well, such tests could eventually be used to identify people with immunity who could work at higher-risk jobs.

We also asked American experts whether states can meet all or most of these benchmarks. Their answers coalesced around a single point: None of you are close to being ready.

There were differences among the people we interviewed about tactics and strategy. Some saw promise in the smartphone-based tools that would allow disease detectives to quickly find people with whom an infected person was in close contact. Others doubted that a critical mass of Americans would ever let the government track their movements, whatever promises were made about privacy.

One theme emerged again and again. Experts from across the world said it’s crucial to correctly interpret the recent drop in the rate of hospitalizations and deaths reported by New York City, ground zero for the epidemic. This result was achieved only by a month of slamming the brakes on the economy and banning the most basic interactions (and pleasures) of human society.

The bad news, they said, is that everything we’ve been through so far has merely allowed us to reset the clock to mid-January, when the virus was already seeded in many parts of America and we were on the cusp of the biggest public health crisis in a century. Allow people to return to offices, streets, malls and mass transit without a well-thought-out plan, and you stand a substantial chance of triggering a second wave of infections.

Reopening is essential to save the economy, they said, but don’t kid yourself: The new normal will look nothing like the old normal. Until there’s a vaccine or a reliable treatment, you and your states will be living and working very differently, constantly at risk from a wave of disease that could overwhelm your hospitals. You may borrow ideas from Asia and Europe that would have been unimaginable a few months ago: Isolating infected people from their families in hotels, requiring masks for everyone on a bus or subway, ordering restaurants to seat people at every other table, limiting certain jobs to people who have proven immunity to the virus.

“We have to all acknowledge that we will have to live with Corona for at least a year and probably two or three years,” said Dr. Ansgar Lohse, a professor at University Medical Center in Hamburg and co-author of a paper that sets out a “flexible, risk-adjusted strategy” for reopening commerce in Germany.

“All of our societies will have to adapt to this challenge, and this will be different in different societies,” Lohse said in an interview. “Even in a country like Germany, we will have to regionally and locally and also probably seasonally adapt to this tragedy.”

America’s continuing inability to roll out widespread testing means you’re flying blind on the most pivotal questions. How many people in your state have already had the virus? The percentage is almost certainly in single digits, but there may be pockets in which more significant numbers of people have been exposed and have immunity.

You can assume that upwards of 90% of your state remains vulnerable to infection from a single sneeze or cough by someone standing or sitting near them. A single highly contagious person in a crowded space can start a chain of disease that quickly encompasses dozens if not hundreds of people.

“It’s like after a forest fire,” said Jerome Kim, director general of the International Vaccine Institute in Seoul. “There are still embers and warm spots on the ground. If you drop a gallon of gas on top of that, the fire will restart.”

1. Build an Army of Contact Tracers

Without exception, every expert we talked to stressed the imperative of being able to know exactly where the virus is spreading. That sounds incredibly obvious and basic, but comes with demanding logistics that few — if any — states are able to carry out right now.

By now, we know that the virus has been relentlessly effective at spreading itself through a population because people are highly contagious in the first few days of their illness, often before they start to experience symptoms. The only way to track the spread of the virus, then, is to maintain a massive army of “contact tracers” who can track down the contacts of anyone who tests positive.

Places that have been most successful in slowing the spread of the virus, such as Hong Kong, South Korea and Singapore (at least initially), have been relentless in tracking down the contacts of every infected person, testing them and then instructing people who aren’t infected to self-isolate and monitor their own symptoms.

“It usually takes four or five people over three days to do one full contact trace, on average,” said Andy Slavitt, former head of the Centers for Medicare and Medicaid Services during the Obama administration. California, which has a population of 40 million people, could need anywhere from “several thousand to 20,000” contact tracers, depending on the number of cases and how fast the virus is spreading, Slavitt said.

Wuhan, China, a city of 11 million, employed more than 9,000 contact tracers, split into 1,800 teams of five. In Shenzhen, a city just across the border from Hong Kong in southeastern China, contact tracers had identified 2,842 close contacts of coronavirus patients and found that 88 were infected, as of mid-February, according to a World Health Organization report. That’s only 3%. But imagine what would have happened if all 88 had continued wandering around the city for the next several weeks.

Technology has been used by some countries to supplement the detailed human interviews. In South Korea, the government swept up everyone’s cellphone and credit card information and used it to identify anyone who came physically close to an infected person.

Kim, the director general of the International Vaccine Institute in Seoul, is a former officer in the U.S. Army’s Medical Corps who has lived in Seoul for five years. He said the South Korean government has combined 21st-century technology and old-fashioned shoe leather to trace contacts.

The initial outbreak of the virus was brought into the country by members of a church that had a branch in Wuhan, where the epidemic began in December. Soon, Korean authorities noticed that new cases were being seeded by international travelers, so they instituted a system in which people arriving from certain countries were met at the gate, tested and told to begin quarantine. A tracking app was put on their phones and over the next two weeks, they were asked to provide daily reports on their health. Authorities made at least one in-person visit to make sure they were healthy and following the rules.

Korean law gives health officials access to anyone’s credit card purchases and cellphone location data during an outbreak, allowing disease trackers to identify and alert anyone who crossed paths with an infected person.

Here in the U.S., our legal framework and historic commitments to civil liberties preclude us from doing anything like this. Apple and Google are adding features to the operating systems of their smartphones so that they will create an encrypted record of every other phone you encounter. The system, which would require users to opt in, will use the Bluetooth technology that connects phones to cars, wireless headphones or speakers. People who test positive for COVID-19 can enter that information into their phone, and any users in recent contact with them will be alerted. It’s hard to say how many people would ultimately agree to participate, but if it’s less than a large percentage of the population, as is likely, the app probably won’t be of enormous use.

Our reporting suggests that few major cities or states are yet prepared to do contact tracing at scale. New York City’s health department did not respond to a request for comment on the question of how many disease detectives it employs, but The Daily News reported last month that the city was hoping to triple the number from 50 to 150. The New York State Department of Health wouldn’t say how many contact tracers it currently has, noting that it is “actively working on a plan to greatly expand capacity at local and state levels to perform contact tracing.” Massachusetts has said it is hiring and training 1,000 workers.

Given the number of line cooks, waiters, airline flight attendants, mall employees and factory workers who are now unemployed, you might consider creating a contact tracing version of the WPA, the Depression-era employment program that bolstered society with projects like public roads, buildings, parks and art. Given that all of you are required to balance your budgets every year, paying the salaries of all these new public health workers is going to have to come out of your already-strapped budgets.

2. Be Prepared to Test Constantly

We know you’re sick of hearing about it, but our experts agreed that the inability to do widespread testing for the virus is the central reason it has spread so widely in the U.S.

As you look toward reopening, testing is going to be just as important. There are two types of tests, and you’ll need both of them at a massive scale.

You’re already familiar with the first test, the one used to diagnose an active infection. While more and more have become available, there are still nowhere near enough. If you go to a system of contact tracing as described above, you’re going to need to test every single close contact of every infected person, not just those who are showing symptoms.

In Italy, much has been made of the contrast between how the epidemic unfolded in Lombardy, a region of about 10 million, and neighboring Veneto, which has almost 5 million. Lombardy was the hottest of Italy’s hotspots, accounting for about 11,581 of the country’s estimated 22,745 deaths. Veneto, by contrast, has had only about 1,026 deaths, reflecting a very different approach to testing and tracing. Relatively early, authorities locked down the town of Vo Euganeo and began widespread testing of everyone, regardless of whether they had symptoms of the virus. The suspicion, later proven correct, was that asymptomatic carriers were spreading the disease. Carriers and their close contacts were isolated for 10 to 15 days.

Different numbers have been thrown around for what sort of diagnostic test capacity the U.S. would need to fully reopen. Dr. Scott Gottlieb, the former commissioner of the U.S. Food and Drug Administration under Trump, has suggested testing everyone who visits a doctor, which would mean about 3.8 million tests per week. Slavitt, the former CMS administrator under Obama, calls for 10 million tests a week.

We are nowhere near that capacity right now (we’re currently at about 1 million a week, according to the COVID Tracking Project), due to shortages in the supply chain for all aspects of testing.

It’s not just a lack of test kits, but also chemicals needed to run the tests, called reagents, collection tubes, swabs and other equipment like pipettes, explained Scott Becker, chief executive officer of the Association of Public Health Laboratories. “Many labs aren’t just running one instrument with one extraction platform and one kit, they’re using multiple, because it’s like whack-a-mole. When you run out of reagents for this one, you switch to that one,” Becker said.

One of the key indicators that you are testing widely enough is the rate at which people test positive. If a significant percentage of tests keep finding COVID-19, it means you’re likely still reserving tests for people with obvious symptoms and likely missing those who are asymptomatic.

“If you’re at 15%, 20%, then you’re not testing enough,” according to Dr. Farzad Mostashari, former National Coordinator for Health IT for the U.S. Department of Health and Human Services.

Mostashari says a 5% positive rate would be appropriate as one metric for reopening, but he cautioned: “You have to be testing the right population. You can’t be like, I’m only testing asymptomatic basketball players and the positivity rate is less than 5%. It has to be everyone, including people coming in with cough and fever, and you still have that low positivity rate.”

A second test just coming online could be a game changer. It’s a blood test that measures whether you’ve been exposed to the disease and developed antibodies against it.

With many diseases, like chickenpox, the presence of antibodies means you’re immune and can’t get the disease a second time. Here’s the issue, and it’s not a trivial one: This novel coronavirus is such a new organism, we don’t yet know if the antibodies from the first infection protect you against a second one. Furthermore, with the FDA rushing to green-light tests and lowering the bar for validation, it’s unclear how accurate many of these diagnostics are.

Let’s say the accuracy of these tests is ultimately validated by scientists and it is established that a certain level of antibodies guarantees immunity, at least for a while. It would then be possible to give people a quick blood test that would allow them to return immediately to work.

One thing to keep in mind: While the models differ on specific numbers, all agree that coronavirus has so far infected just a small percentage of the more than 320 million people in America. Hundreds of millions of people nationwide, and the vast majority of your state’s citizens, still have no defense against this disease. This will be true until a vaccine is widely available, which probably won’t happen for more than a year, if we’re lucky.

3. Isolate People With Suspected Infections From Their Families

This is a really tough one. It goes against everything your constituents treasure in our family-centered society. That said, what we’ve learned in Italy, Taiwan and now our country is sobering.

In New York, health authorities’ initial approach to someone with a fever and dry cough was to send them home to “self-isolate” in a single room for 14 days. (There weren’t enough tests to confirm diagnoses in these cases.)

In many cases, the result was disastrous. The disease spread to the entire family, sometimes sickening multiple generations.

It turns out that the average American, when asked to turn a room of their home or apartment into a sealed zone, falls well short of perfection.

Yes, the person being quarantined is told to spend every waking (and nonwaking) hour behind closed doors, eat food left on a tray outside their door, and use a separate bathroom. But that goes against a lot of fundamental facts of life. Some people share single-room apartments. Many don’t have two bathrooms. And not everyone is meticulous about wiping down door handles or wearing gloves and masks when they wash dishes. The result, visible in city after city, has been horrifying stories about first one parent, then a second parent, then the children ending up dead or ill from sequential infections.

Separating people from their families for 14 days is a very tough thing to do. It would be massively unpopular. But if you look at what worked and didn’t in Taiwan, Italy and Singapore, you can see why this is so essential.

Sergio Romagnani, an immunologist at the University of Florence, said the traditional, multigenerational closeness of Italian families played a role in spreading the disease. “In Italy, there is a lot more mixing of young people and elderly relatives,” he said. “Kids have a lot of contact with their grandparents, and in this case that caused deaths.”

Romagnani noted that authorities in Tuscany had begun putting infected people in hotels, which would ordinarily be filled with people visiting one of the world’s most beautiful tourist destinations. “It’s a good idea,” he said. “The hotels make some money since they are all closed. And you have isolation, which is necessary.”

Dr. C. Jason Wang, director of Stanford University’s Center for Policy, Outcomes and Prevention, said Taiwan has been a leader in isolating infected people from their families. The government pays hotel owners as much as $200 a night to house people under quarantine, providing three meals a day, a book to read and a stipend roughly equivalent to a young person’s daily salary. Anyone caught breaking quarantine faces a massive fine.

Wang said Taiwan learned from the 2003 outbreak of SARS, when people who were forced to isolate thought they were being jailed, and ran away. “We learned that when you put people in quarantine, you need to be very nice to them.” Now, patients are checked by health workers three times a day. “If a person gets sick, their symptoms worsen, they will make sure they get care,” he said.

While in the U.S., it may be impossible to force people to isolate away from their homes, “I think you can say, ‘Hey, wouldn’t you like to protect your family, and we prepared a nice room at the Hilton for two weeks for you, and you don’t need to pay for it.’ and you know, hopefully people will,” said Slavitt, who is now hosting a new podcast about the pandemic, “In the Bubble.”

Slavitt added that to pull this off, the federal government would need to provide funding to help pay for hotels.

Here’s some incentive for you: Xihong Lin, a Harvard biostatistician, and colleagues in China found that when the outbreak began in Wuhan, the average person was infecting 3.86 other people. When the city closed businesses and imposed the sorts of social distancing measures that we now have in New York and California, the number of people infected by each person dropped to 1.26, which is good, but not good enough. (You need to get below 1 to get things under control and even consider restarting the economy.) When China got really tough, locking down every resident, isolating suspected cases in dorms and hotels and vigorously tracing contacts, it dropped to 0.32. Here’s Lin’s webinar on the group’s findings, if you’re curious to learn more.

4. Protect, Protect, Protect Health Care Workers

If we are lucky enough to get the infection rate below epidemic levels in New York and elsewhere, there are still going to be people who get infected.

One of the lessons from Wuhan and Italy is that you have to be utterly meticulous about protecting doctors and nurses. If you don’t, the hospitals become a vector for infection and you lose the frontline people you need to treat the sick.

There’s another problem with not protecting your doctors and nurses: If you need them to handle a second wave of infections, even a smaller one, they may stop coming to work. Many are showing up right now out of a sense of duty and mission. But none of these people signed up for their profession with the idea that they would be risking their lives on a minute-by-minute basis. These are not combat infantry troops, and if they don’t believe they have appropriate personal protective equipment, there’s every reason to believe that some of them will simply quit.

While the Chinese have revised their numbers more than once, leading to some hesitation over how much we can trust their reporting, there are still lessons we can learn from their experience. As of late February, the joint WHO-China mission reported 2,055 cases of COVID-19 among health care workers, the vast majority, 88 percent, were at hospitals in Hubei province where the outbreak began. It appears that after the initial disaster in Wuhan, in which a doctor who raised the alarm died, the hospitals figured out what they needed to do to protect their medical workers.

This story describes how Johns Hopkins doctors consulted with Chinese colleagues about best practices. Wuhan hospitals, after being hit with a wave of deaths and infections, asked staff members to check that each other’s gear was being used correctly. They worked four-hour shifts to prevent fatigue. A committee helped support the children and elderly parents of the health care workers.

The past few weeks have already inflicted a powerful psychological blow on your state’s health care workers. To bolster their morale and keep them at work, you need to make a commitment to protecting their health. That means stockpiling an enormous supply of gowns, N95 masks, gloves and goggles. This is not optional. If you don’t have enough equipment set aside, don’t even think about restarting the economy. Lose the trained health care workers and it’s game over.

Obviously, this stockpile should also include ventilators, oxygen, the drugs needed for intubation and all the other stuff that should have been waiting in reserve back in January when we had our first bite at this apple. But you know that already.

5. Normal Is Not the Goal

One question we asked the experts we interviewed is: What would it take to put 5.4 million people back on the New York City subway every day? Invariably, they all said: masks.

Masks, especially when we’re talking about home-made ones, are not going to be perfect at preventing infection, but they can help reduce transmission. “Face masks are the only option in situations where social distancing can not be practiced,” said Lohse, from University Medical Center in Hamburg.

In Madrid, police handed out masks for riders on public transit as Spain announced a partial return to work in certain sectors of the economy, including heavy industry and construction, on April 13.

“We would probably go with Austria in forcing the population to wear masks more widely, maybe in retail outlets, maybe in factories,” said Gabriel Felbermayr, president of the Kiel Institute for the World Economy and economic advisor for Chancellor Angela Merkel’s government, talking about what Germany’s plans for reopening its own society.

“We should have learned right away from the Asian experience, that was a huge mistake,” said Romagnani, in Florence. “But in the beginning, our authorities actually told people not to wear masks. They said, ‘Masks don’t do anything.’ Well, they were saying that because they didn’t have enough masks. They feared a stampede to buy them. They worried about price-gouging.”

In the United States, our surgeon general initially did much the same thing, tweeting on Feb. 29 that masks are “NOT effective in preventing general public from catching #Coronavirus.” This week, Gov. Andrew Cuomo ordered New York residents to wear face coverings in public whenever social distancing is not possible.

The international experts’ responses were a reminder that your goal isn’t to get back to a pre-pandemic way of life, but instead to employ whatever tools it takes to keep transmission as low as possible while restarting your economy. Things like masks, temperature checks and maintaining a six-foot distance are new concepts for the U.S., and many of your constituents are going to find them weird, uncomfortable and unappealing. It’s worth your time helping them understand why these measures are so necessary, because you’ll save lives.

One aspect of returning to normal is certain to arise in the coming months: Do you reopen schools? Early reports that COVID-19 can endanger only older people with other serious health problems have been demolished as the virus spread across the globe. The numbers are tiny, but infants, toddlers and teenagers have died from this disease. School closings, of course, were seen as a way of protecting older people, the assumption being that kids with mild or asymptomatic cases would infect their teachers, parents or grandparents.

Taiwan is one of a handful of countries in the entire world that have kept their schools open. In February, it adopted rules that require closing any school for 14 days if two or more cases are detected.

Singapore’s Dr. Li Yang Hsu, said reopening schools is a plausible step. Hsu noted that countries tracing the “index,” or initial case, in a disease cluster have found few instances that trace to school-age children, “which is unusual for a respiratory virus.”

Hsu, program leader of infectious diseases at the National University of Singapore’s Saw Swee Hock School of Public Health, said in an email that recent studies “seem to suggest that the impact of school closures is far less compared to other physical distancing measures. Therefore, provided nothing changes, the general conditions,” for resuming school “would be similar to that of reopening mass transit and other services.”

6. Keep Your Eyes Peeled for the Second Wave

The initial success stories in fighting COVID-19 — Singapore, Hong Kong, South Korea — all saw a rise in cases in March. Nearly all of these involved travelers who brought the infection from other countries and came into contact with locals. Remember, even once you get the number of new cases caused by each infected person below 1, you still have a population largely composed of people with no immunity, so you have to maintain constant vigilance to keep the rate low.

We’re going to need a national system of the sort we should have had in the first place. Epidemiologists call it sentinel surveillance, and what it used to mean was that we would watch out for people with flu-like symptoms for signs of a new pandemic-type illness like H1N1.

Even though we knew the coronavirus was coming, and even though epidemiology experts wanted to start sentinel surveillance in major cities like Seattle, New York and San Francisco by early February, it never happened because the CDC bungled the design of the tests. Your state will need to get this right. Not only do we need to be testing constantly, but we should also be using all the tools we can to pick up any suspicious patterns of flu-like illness, whether that’s Google searches or heightened temperatures on web-linked thermometers, besides the traditional surveillance apparatus that public health departments already have.

Here’s the tough reality for people hoping to go back to the old normal and, say, sit in a stadium and watch Tom Brady try to defy Father Time as a Tampa Bay Buccaneer: There are some things — no, there are a lot of things — in which the crowds are too large and tightly packed to be safe. NASCAR races? Baseball stadiums packed with 50,000 people? NBA playoffs? Ballet? Broadway? Hard to imagine putting that many people close together without a vaccine or unimpeachable proof that people have antibodies that make them immune. (You’d still have to find an impossible-to-counterfeit, non-transferrable form of ID so that only fans with antibodies would be admitted to large events. Good luck figuring out how to do that.)

It’s sad to say this, but until there’s a way to verify immunity, or a vaccine, you can’t allow visitors back into nursing homes. The elderly are just too vulnerable, and we’ve seen over and over how the virus just tears through those settings.

You should keep an eye on Wuhan. The extra hospitals are closed, the extra 40,000 health care workers have gone home, and the city is slowly going back to work. If there’s no second wave in Wuhan, this might just work out. On the other hand, if the virus kicks up again despite everything they’ve done and are doing, hitting that restart button becomes a lot more complicated.

7. Clear Communication Is Critical

There are an array of political skills that get you elected governor in America. Some of you built reputations as nuts-and-bolts technocrats, good at getting things done but not given to stirring oratory. Others have a gift for explaining complicated issues in ways that can move ordinary people to action. Several of you have run for president.

One thing that came through in many of our interviews around the world was the importance of communicating clearly and consistently about the actions you take. China was able to take draconian steps to contain the Wuhan outbreak because it is a single-party state with virtually unlimited powers.

You will need comparable levels of commitment from your citizenry, but will have to achieve it through persuasion rather than coercion.

Manuel Gimenez, the minister of Economy and Employment for the regional government of Madrid, said that Spanish leaders were able to articulate reasons for one of the strictest lockdowns in the world in a country where congregating in cafes, restaurants and large family groups is an ingrained cultural tradition.

For more than 45 days, Gimenez said, his 3-year-old and 8-month-old have not left his family’s 650-square-foot apartment, adhering to rules that require all children to remain indoors. Adults are permitted to go only to the nearest grocery store or pharmacy; exercising outdoors or walks for leisure are prohibited, and police have been enforcing the rules aggressively. Although at first there were complaints about people crowding parks and driving en masse to summer homes, over all the response has been remarkably disciplined.

“What the Spanish government has done is send a series of messages preparing citizens for each phase of the response and the restrictive measures. This isn’t China,” said Miquel Porta, an epidemiologist at the Hospital del Mar in Barcelona. “In Spain, we had to communicate, accustom people to the idea of a lockdown, and create consensus. You can’t do what a dictatorship can do. The idea was disseminated that we are not staying home for ourselves. We are doing it for our fellow citizens.”

“The Spanish people have reacted well with great solidarity and even humor,” Porta said. “People shopping for the elderly, people singing on balconies. The media and the people have approved of the fact that scientists are telling them there is a certain amount of uncertainty and lack of knowledge in this crisis. Nobody is clear on how this is going to evolve.”

Stanford’s Wang said Taiwan learned this lesson in the wake of the country’s widely criticized response to SARS, a coronavirus that flared in Asia in 2003 but was ultimately brought under control and did not become a global pandemic.

“In a democracy, we need to build trust and confidence so that when you say something to people, they’ll trust you and do what you say,” said Wang. “The communications part is critical and that’s what Taiwan did after SARS.”

As governors, you’re going to have to persuade voters to do things they won’t like at a moment of unparalleled partisan rancor, record unemployment, disarray in your state’s traditional media outlets and divisions among eminent scientists. Inevitably, you’re going to be using imperfect data to strike a balance between the possible loss of lives and the certain loss of jobs that keep food on the table of your state’s citizens. Remember when you thought battling the legislature and balancing the budget was hard?

This is much, much harder, and the clashing messages from the national level complicate things even more. The good news is that you have a better feel for your state’s character and quirks than any federal bureaucrat and are best equipped to figure out what your citizens can tolerate. Trump was right about one thing. These are the biggest decisions you’ll ever make. Good luck.

Christian Salewski contributed reporting.

We talked to a doctor about what hospitals in the throes of the coronavirus epidemic could learn from far less developed hospital systems in times of crisis and came away with three main points.

By Lydia DePillis

As New York City strains under COVID-19 cases and health care workers scramble for every bit of equipment they can get, hospitals are starting to look less like part of a wealthy country’s medical system and more like the makeshift clinics in disaster zones or the developing world. In those places, experts say, doctors need to think about care differently: managing resources to best serve all the patients who will need help over the duration of a crisis, even if it means not being able to save every person to walk through the door.

Dr. Sean Runnels is an associate professor at University of Utah Health and a working anesthesiologist who manages the supply room for his department. The wave of coronavirus cases hasn’t really hit yet in Salt Lake City, but he’s been stocking up on as much equipment as he thinks will be needed for sedating patients if they need to go on ventilators. Already, Runnels says he’s noticed normal supply ordering patterns breaking down, as hospital administrators working from home try to prepare for a potential flood of COVID-19 patients.

What’s happening in cities overwhelmed with COVID-19 cases reminds him of the year he spent based in Guinea working for Mercy Ships, a nonprofit that deploys floating hospitals to African countries with little surgical capacity, and the subsequent two years he spent in Rwanda training clinicians. We talked about what American cities in the throes of the coronavirus epidemic could learn from places with far less developed hospital systems in times of crisis, and came away with three main points.

This interview has been edited and condensed for clarity.

You need more than a ventilator to save someone’s life.

I worked for three years in Africa and really came to appreciate how complex an ICU is. You’ve got the ventilators, that’s the thing that you can see. But all the little pieces have to be sourced, someone has to clean it, someone has to order the cleaning solution, someone’s got to write the protocol to train the person that cleans it. It’s this really complex ecosystem, and each of the pieces of the ecosystem are required for the thing to work. Everyone’s focused on producing more ventilators, but the real capacity is the smallest thing in that ecosystem.

I worked for Mercy Ships, and we would get donations of all sorts of stuff, but if we got a donation of an odd-sized tube that doesn’t hook to our anesthesia circuits, it’s just stuff we have to move around. That’s something I’ve taken to heart with our system. If we start sourcing from all over the place, we’ll just create more chaos. I think we’re better off trying to strengthen our normal supply chains. If we get overloaded while the chains are weak, that’s a problem.

You are only viable if your health care workers are healthy.

Running medical systems in under-resourced environments is completely different. In some sense it would be better to have the health minister for Rwanda, Agnes Binagwaho, come show us what to do, because they were very intentional about capacity. I was never allowed to walk into a room and examine a patient unless I had gloves on. If we didn’t have gloves that day, we didn’t have a clinic. They completely understood that the real risk was to get your providers sick, because they’re actually the system. The machines and drugs and everything we do, they enable all of those things to work. As soon as you take out your providers, then you end up in a death spiral. You and your mortality jumps from 1% to 10%.

If you’ve got 200 ventilators, but you only have enough personal protective equipment to keep enough providers well to take care of 100 ventilators, then that’s your capacity. If you exceed it, you end up with these horrific rates of sickness. And then you end up with morale problems, and the system works less efficiently because those teams are now broken up.

The rule No. 1 in a resource-constrained system is keep your providers healthy.

Sometimes you have to make a decision to give up on a patient for the greater good of the system. And that’s hard.

When I was in Rwanda, I ran an anesthesia department and took care of keeping the system safe for the new American providers for the first three months before they knew what they were doing. You would say: “OK, I know in America we can save this child. But [here] if we try to deliver medical care, are we just prolonging the suffering and depleting resources?” I would have people turn around and visualize the 10,000 babies that were coming in the next few years, and say, “All right, I’ve got to balance this life in front of me with the lives of those that are coming.”

The shift internally they have to go through is from that heroic archetype of the doctor-patient relationship to “my most important relationship is to my colleagues and the system because that’s what’s going to take care of these people in the future.”

I went through it in Africa. It’s an incredibly painful experience, and there’s no road map for it. The worst thing you can have to do as a doctor is going to be not do everything for the patient in front of you. And yet that’s exactly what you have to do.

Low on essential supplies and fearing they'll get sick, doctors and nurses told ProPublica in-person care for coronavirus patients has been scaled back. In some cases, it's causing serious harm.   

This article was first published on Thursday, April 10, 2020 in ProPublica.

by Joshua Kaplan, Lizzie Presser and Maya Miller

Every morning, between 7 and 8, at Long Island Jewish Medical Center in Queens, several coronavirus patients are pronounced dead.

It's not that more people die at the beginning of the day, according to two medical providers at the hospital. But as a new shift arrives, doctors and nurses find patients who have died in the hours before and went undetected by a thin overnight staff.

Health care workers at several New York hospitals say they aren't entering patient rooms as often as usual. They say they are worried for their safety and are trying to conserve scarce personal protective equipment. And they say there are simply too many critically ill patients to provide the sort of continuous monitoring that should be standard.

"People haven't been seen in several hours overnight," a medical provider at Long Island Jewish said. "And when the morning team comes on, the person is sicker, or dead."

Across the city in Brooklyn, a similar ritual plays out each morning at Maimonides Medical Center, according to two doctors at the hospital. As the day shift begins, so does the blare of alarms: a patient's heart has stopped and they need to be resuscitated. "We hear the overhead speakers say, 'Code 3, Tower 7, Patient Room 732, Bed 1.' Then there will be another one. And another one," a doctor at Maimonides said.

"Normally there are so many steps we would take to keep a close eye on them," the doctor said. "But we're so swamped with patients coming in that we can't keep up."

In New York City, the epicenter of the virus, the surge in COVID-19 patients has overwhelmed many hospitals, forcing some health care workers to rethink and at times forgo certain essential safeguards.

In interviews, doctors and nurses at nine hospitals told ProPublica that to ensure they have enough PPE, like sterile gowns and masks, and to keep themselves from contracting the virus, hospital staff are not consistently providing the level of attention needed, and that lapses in care are imperiling COVID-19 patients, whose health can deteriorate very quickly.

The hospitals themselves insisted this wasn't so, saying their staff members have enough PPE and asserting that efforts to conserve equipment and protect staff weren't affecting patient care.

The pressures that front-line staff are reporting reveal what appears to be a disconnect between official policy and the decisions being made each day in beleaguered hospital wards. From hospital to hospital, the concerns raised and accounts provided were remarkably similar.

Some of the hospital workers interviewed by ProPublica said that in scaling back the level of care, they have missed important changes in patients' conditions they would ordinarily catch. One Brooklyn nurse said she and her colleagues have accidentally let patients' medicine bags run empty. And at another hospital in Brooklyn, a doctor said that last weekend, a 46-year-old patient took off his oxygen mask to go to the bathroom. No one noticed. They later found the man dead on the bathroom floor.

At many hospitals, when a patient "codes" — meaning their hearts or breathing have stopped — the response has slowed, too. In normal times, a team would rush into the room, scrambling to assess the patient and perform CPR. Now just a couple people go in, and often only after they stop to put on protective gear.

Hospital staff said they've had to adapt standards and come up with stopgaps. A doctor in Manhattan said he has taken to instructing patients, from outside their rooms, on how to change their own oxygen settings: The doctor stands outside the glass window, calls the patients over the phone, tells them how to turn on the oximeter, hook it up to their finger, read the knob on the machine, dial down the rate of oxygen and turn the monitor to face the window. "But you're talking to someone who is sick and who doesn't know how these machines work," the doctor said.

In New York City, more than 21,000 people have been hospitalized with COVID-19. Staff are stretched thin caring for so many critically ill patients, and some nurses are being asked to monitor up to 16 people at a time. The strain is exacerbated by a shortage of PPE.

Without sufficient equipment to feel safe, staff say they need to limit their exposure to the virus. They also want to limit how many supplies they go through. On Sunday, the president of SUNY Downstate Medical Center announced that the hospital was running out of gowns and would turn to garbage bags and rain ponchos.

One nurse at a Manhattan hospital said nurses are using N95 masks for up to 11 days, and getting a new one is always a struggle. In typical times, they wouldn't even go from one patient's room to another without changing masks. Now, they're scolded if they ask for more before their current mask is visibly dirty. Some of their colleagues have started deliberately ripping the mask's cord so their bosses have to give them a new one.

This week, a nurse employed by Maimonides started a GoFundMe campaign to raise money to buy her colleagues PPE. "We are in dire need of constant PPE to help us do our job safely & diligently," she wrote. (After she was contacted by ProPublica for comment, she took down the fundraiser. Last weekend, a nurse in Newark was suspended after using GoFundMe to buy PPE.)

A spokeswoman for Maimonides said the availability of PPE should not be a factor in patient care there. "We have had sufficient inventory of PPE to protect our staff and patients from the beginning of the pandemic. This is evident by our decision to mask our staff in our emergency room in the very early stages of the pandemic, followed by masking our entire hospital workforce soon thereafter. We did institute preservation-of-PPE guidelines for staff to reduce waste."

In response to the idea that patients code especially often during morning shift change, she said, "It is our experience that codes take place around the clock and are not clustered around any specific time."

A spokesperson for Northwell Health, the health care network overseeing Long Island Jewish, told ProPublica: "The claim that there has been a surge of deaths between 7 and 8 a.m. as a result of staffing shortages is blatantly false and disputed by our critical care specialists who have been on the front lines of this pandemic. ...The e-ICU staff remotely monitor patients' vital signs and alert on-site staff to any changes in patients' conditions. ... About 80% of COVID-positive patients within LIJ are not in intensive care but their pulse oximeters (the device that monitors oxygen saturation of a patient's blood) are checked regularly throughout the day and night."

"I strongly disagree with the assessment that we are lacking PPE," the spokesperson also said.

Hospital staff describe being put in an excruciating position. They are risking their lives and working tirelessly for their patients, and they've told reporters they're pained by not being able to give the quality of care they're used to. But they've seen their colleagues get sick and they don't want to bring the virus home to their families. And they know that if they fall ill, they wouldn't be able to care for patients at all. "Everyone has seen some otherwise healthy, young person die," said the provider at Long Island Jewish. "And they don't want that to be them."

Dr. Leigh Vinocur, spokesperson for the American College of Emergency Physicians, told ProPublica that coupled with PPE shortages, the highly contagious virus can force hospitals into a difficult calculus. "Of course, we want to do what's best for the patient, and in this situation we have to cut corners that we wouldn't usually," she said. "But the alternatives are losing half your workforce. Using all your resources on one patient, doing everything, everything, using all your PPE."

A Vital Loss of Precision

Critical care demands vigilance and precision. "It is the most meticulous part of medicine," Vinocur said. "You're managing every little vital sign. ... You're literally managing the physiology of the patient."

For the sickest coronavirus patients, hospital staff control everything from the patient's breathing to their kidney function. In normal times, providers say, patients this sick would have continuous, one-on-one monitoring, so that every change is noticed and acted upon. But now, providers say that sort of attention is impossible.

In a standard ICU, patient monitors are hooked up to a central system, so it's easy to track everyone's vital signs from afar. But in hospitals overwhelmed by COVID-19 patients, non-ICU floors have been converted into intensive care units, and they don't always have enough continuous oxygen monitors to check patient levels remotely. Instead, staff members check levels the old-school way. "Someone walks around the floor with an oxygen monitor, checks your oxygen in that moment in time and then walks away," the Long Island Jewish provider said. "And then no one checks it until the next person comes by — which is usually every four to six hours."

In order to contain infection, many hospitals keep the doors to patients' rooms closed, and doctors at Maimonides said that for some rooms, it's impossible to see inside. "And that's so scary," a second doctor at the hospital said, "because you'll walk in and a patient will be half on the bed and half on the floor."

A man with COVID-19 was recently admitted to a third hospital in Brooklyn and asked a doctor how long it was before he could leave. Before her shift ended, the doctor told him that he required oxygen, and he'd need a few days to recover. When she returned to work the next morning, she learned that the patient had taken a turn for the worse. He was on a high-concentration oxygen mask, at 15 liters per minute, the last step before intubation for COVID-19 patients.

Before the virus, doctors would check on patients on such a high oxygen setting every hour. But no doctor had evaluated this patient overnight and nurses had only checked his vital signs every four hours, the resident said.

That morning, the doctor found that he was taking 37 breaths per minute, a dangerously rapid rate. He was drowsy and sweating and gasping. "His breathing was going to stop at any moment," she said. The resident raced to the ICU to arrange an intubation. "I didn't want him to code and have a brain injury," she said. The patient needed a ventilator, but it would be another four hours before one became available.

Even in units where it's easy to check patients' vitals without entering their room, infrequent contact can mean other important changes fall through the cracks. For patients on ventilators, nurses must manage several crucial medications, and without frequent contact, it can take too long to realize that an IV bag needs to be replaced. The IV pumps have alarms to alert staff when the bags are running low, but since patients' doors are closed, nurses can't always hear them.

"That's happened to me, where it's like, 'Oh my fentanyl's out.' And I didn't notice," a nurse at Brooklyn Hospital Center said. "We're seeing that quite a bit. ... No one's letting their IV bags go completely dry for an extended period, I don't think. But you'll look at the monitors and say, 'Dude, do you see that your patient's blood pressure is super low?'"

Brooklyn Hospital Center did not respond to requests for comment.

"Patient Care Is Suffering"

Many of the medical staff interviewed said routine standards of care have also been neglected as hospitals switch into crisis mode. "If someone has a leaking stool bag, are you going to go in and change it every hour?" the Manhattan nurse asked. "No. You're not going to expose yourself."

It's unclear how, exactly, hospitals' legal obligations to patients have changed during this crisis. On March 23, New York Gov. Andrew Cuomo issued an executive order, as part of broader disaster emergency efforts, that temporarily limits liability for health care workers. The order modifies existing law to provide that many medical professionals are immune from civil liability for injury or death as a direct result from their actions or omissions, unless gross negligence can be proved. The wording, though, is vague. Inside the hospital, there's still uncertainty about the changes, according to a clinical administrative staff member at a hospital in Queens. And though some legal experts believe the order applies to hospitals, they are not explicitly written into the order. "There's still a lot up in the air, regulatory-wise," the clinical administrator said.

Front-line heath care workers have been sending incident notes to the clinical administrator, who has flagged fatal cases in the state's online tracking system, though there has been little time for follow-up.

Several doctors said that efforts to conserve PPE can affect a patient's care most when they are rapidly deteriorating. The Manhattan doctor explained that before COVID-19, if someone called a rapid response — meaning that a patient was at risk of losing a pulse within minutes — "all of us would rush into the room and there would be multiple moving parts to maximize the care and assess the situation quickly." Now, the policy is that the first person to get into the room makes the assessment. No one else from the medical team can enter, only a COVID-19 hospitalist and intensivist, when they arrive.

Recently, the doctor said, he was summoned for a rapid response for one of his patients, and when he got to the room, he found that a nurse was already inside. He had to stand outside and talk to her through the window: "Does this patient have a pulse?" he asked. The nurse said no. Before the coronavirus, the team likely would have started CPR. Instead, the doctor waited in the hall for the COVID-19 intensivist and hospitalist. They came within two minutes and decided to forgo CPR, as the patient, who was on dialysis, had a bad prognosis and CPR increases everyone's exposure. Still, if a doctor had been the first in the room, the doctor might have decided to start compressions immediately. "A nurse is not going to make that decision on their own."

As they do their best to take care of their patients, doctors and nurses feel that their hands are tied. "We're trying really hard to do our jobs and help people, but it's a really fine line. We're not being protected. We don't have the right equipment. Nurses are getting sick," the Brooklyn Hospital Center nurse said. "What do you expect? Patient care is suffering."

Olga Matievskaya raised more than $12,000 to buy and distribute protective gear for her colleagues, who say they felt inadequately protected against COVID-19.

This article was first published on Tuesday, April 7, 2020 in ProPublica.

By Marshall Allen

Olga Matievskaya and her fellow intensive care nurses at Newark Beth Israel Medical Center in New Jersey were so desperate for gowns and masks to protect themselves from the coronavirus that they turned to the online fundraising site GoFundMe to raise money.

The donations flowed in — more than $12,000 — and Matievskaya used some of them to buy about 500 masks, 4,000 shoe covers and 150 jumpsuits. She and her colleagues at the hospital celebrated protecting themselves and their patients from the spread of the virus.

But rather than thanking the staff, hospital administrators on Saturday suspended Matievskaya for distributing "unauthorized" protective gear.

Across the country, front-line medical providers and hospital administrators are butting heads about precautions against the coronavirus pandemic. Clinicians are being told to reuse or go without necessary supplies even when treating patients infected with COVID-19. That goes against the way they've been trained. Some doctors and nurses now say they are being instructed not to speak to journalists and disciplined for doing so or taking action to protect themselves.

Matievskaya spoke to ProPublica last week about the fundraising campaign. She said she had been able to purchase most of what the nurses needed on eBay. She did not criticize her administrators, and after her suspension she declined to comment. But four other Newark Beth Israel nurses spoke to ProPublica on the condition of anonymity about the dire shortage of gear.

All four said their administration has failed to provide the supplies they need to protect themselves and patients. Two of them work in the intensive care unit, which houses the sickest patients. The other two work in other areas of the hospital. They said Matievskaya showed leadership to keep people safe where their hospital administration has not. "There was no information distributed" about not being allowed to purchase supplies for others on staff, one of the nurses told ProPublica.

The hospital told ProPublica in a statement that Matievskaya's suspension ended Monday. "No employee is allowed to distribute unauthorized medical supplies within the hospital," the statement said. "The nurse in question was temporarily suspended for inappropriately distributing unauthorized medical supplies, against this policy."

The hospital said it ensures clinicians have the supplies they need by following guidance from the U.S. Centers for Disease Control and Prevention for reusing gear. "We are working 24-hours a day, 7-days a week to ensure that the appropriate PPE gets to the right staff, at the right time," the hospital said in its statement.

It did not answer questions about what would become of the supplies purchased through the campaign or whether other nurses who participated in the fundraising might be subject to discipline.

The confrontation at Newark Beth Israel may foretell what's coming in other cities. Northern New Jersey, just outside New York City, is one of the nation's hotspots, with more than 41,000 confirmed COVID-19 cases as of Monday. As of Thursday, the 665-bed hospital had housed 196 COVID-19 patients, according to an internal communication to hospital staff. Hospitals across the country have shortages of protective equipment, according to a report published Monday by the Office of Inspector General for the U.S. Department of Health and Human Services.

Aline Holmes, a clinical associate professor at the Rutgers School of Nursing, said she didn't know the details of the case but was "very surprised" to hear of Matievskaya's suspension. Hospital administrators are telling clinicians to reuse supplies, she said, which violates typical infection control standards. Suspending a nurse for obtaining protective equipment "doesn't make any sense," Holmes said.

"That just seems counterintuitive and really not a good message to send to your staff," Holmes said. "The staff have a right to protect themselves. If the hospital can't provide the necessary supplies, they have a right to do what they need to do. They're caring for the sickest patients in the hospital right now."

The situation is changing by the day as Newark Beth Israel acquires and runs through its supplies. But the four nurses told ProPublica that they have often not been given the N95 respirator masks the CDC has recommended to protect themselves from the virus. One of the ICU nurses said for at least one shift she received a regular surgical mask, which in her opinion is "like putting a paper towel over your face."

Some nurses outside the intensive care unit have been given a single surgical mask in a brown paper bag that they're expected to use for an entire week, one nurse said. Nurses at other hospitals around the country have made similar statements.

The shortage of gowns has also been a big problem, the nurses said. There should be enough to discard a gown after each interaction with an infected patient. But the shortage of gowns has required staff to leave the same gown hanging by the door of an infected patient's room and reuse it throughout a shift. In at least one case no gowns were available, one nurse said, so the staffer had to use a combination of a patient gown and bedsheet to treat an infected patient.

Some nurses in the intensive care unit have been caring for COVID-19 and non-COVID-19 patients on the same shift, the nurses said. So if they're not properly protected, the nurses said, they could pick the infection up on their masks or clothing in one room and carry it to the other. The nurses said they have heard of hospital staff testing positive for COVID-19, but they don't know where they picked it up and the facility's administration doesn't make any total numbers known. "We are spreading it, and we are getting it," one of the nurses said of the coronavirus.

The nurses said the situation is especially desperate because the hospital performs organ transplant operations, and those patients have compromised immune systems. A ProPublica report about the quality problems in the heart transplant program last year led to action by regulators. The hospital made the corrections required by the federal and state regulators, it said in a statement. The FBI also investigated the hospital as a result of the story, but the agency declined to comment Monday.

The nurses said some of the non-COVID-19 patients are heart and lung transplant recipients.

"We understand this is what we signed up for," one ICU nurse told ProPublica. "Just provide us with sufficient (protective equipment) so we can give these patients the optimal care that they need, and so we aren't contaminating others or ourselves."Bottom of Form

In some cases, nurses and administrators have disagreed about what is needed to keep them safe. The intensive care nurses said they have asked for jumpsuits, the overalls that cover their entire outfit. But administrators have told them such equipment isn't required, they said.

The intensive care nurses said they are directed to call a "command center" when they need more supplies. But when they reach out, "You get yelled at sometimes," one of the nurses said.

The hospital did not respond when ProPublica asked for an explanation of the various conditions described by the nurses.

But Dr. Matthew Schreiber, the hospital's chief operating officer, said in a brief phone conversation that the hospital has the personal protective equipment "that the staff require, which is at times not the same as the (protective equipment) that people want to have. There's lots of items people may bring from somewhere else."

Francis Giantomasi, an attorney who serves as the chairman of the hospital's board of trustees, said the problem isn't a lack of money. Newark Beth Israel had $186 million in net assets, according to its 2017 tax forms. It paid its chief executive officer Darrell Terry more than $1.4 million in salary and compensation, the documents show.

Gowns and masks and other critical gear "are in short supply everywhere and needed by everyone," Giantomasi said. "That's a serious, troubling, undeniable reality."

Darryl Young suffered brain damage during a heart transplant at Newark Beth Israel and never woke up. But, hardly consulting his family, doctors kept him alive for a year to avoid federal scrutiny.

One of the nurses said that if the hospital can afford to pay its CEO so well, then it should be able to go on eBay itself and purchase supplies for the staff.

In its statement the hospital blamed the problem on the way supplies are distributed. "No one person, institution, or hospital can independently correct this global supply shortage," it said.

Chris Neuwirth, assistant commissioner of the New Jersey Department of Health, said he feels that New Jersey is as prepared as it could have been. The 9/11 terrorist attacks, Superstorm Sandy and other events gave the emergency infrastructure a head start, he said. Meetings with hospital leaders began in early February. But the scope and magnitude of the coronavirus pandemic is beyond what emergency managers and public health officials could have anticipated, he said. When the crisis subsides, he predicted, there will be a reassessment of the stockpiles and what hospitals and health departments need to do in order to be prepared.

Holmes, the Rutgers professor, said hospital administrators need to step up and lead the providers on the front lines by communicating and building trust. If the staff members don't trust the administration, they might refuse to risk their lives and the health of their families, she said. They might stay home, she said.

Medical providers will not forget how administrators treated them when the COVID-19 pandemic is over, said Dr. Zubin Damania, a Stanford-trained physician who is now a popular social media personality known as ZDoggMD. Damania has more than 1.6 million Facebook followers and is pushing for clinicians to reform American health care. He said he is getting more than 250 private messages a week from doctors, nurses and other health care providers, lamenting the lack of protective equipment and unclear communication and intimidation they're getting from their administrators. In Mississippi, two doctors were reportedly fired for speaking out about coronavirus safety. A similar case was reported in Washington state.

"There's so much distrust, and it's all borne out of poor coordination of leadership that should know better," Damania said.

Caroline Chen contributed reporting.