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So we clearly dropped the ball on this infection. Our constitution is a primary difference between the United States and governments that have been more successful in dealing with the pandemic. In the United States, due to its constitutional structure, the primary responsibility for public health rests with the states. In the ordinary course of daily life, this is not a problem, but in extraordinary times, such as a global pandemic, decisive national action is necessary. States and the federal government can activate emergency powers to expand their ability to protect the life and health of citizens.

When enacted, the resulting emergency government powers are sweeping, including halting business operations, restricting freedom of movement, limiting civil rights, and commandeering property. A primary concern with these orders is the state overstepping their authority when it is not necessary. However, in the COVID-19 epidemic, we have the opposite problem: the federal government has done too little. What should our society and our government learn from other countries' successful mitigation efforts? Here are some possible suggestions.

1. First, the stay-at-home orders need to continue until infection rates drop for at least 14 days. We need to get the incidence of infection low enough in the community that the risk of transmission to the still mostly susceptible population is small enough to allow more interaction between people. I do believe that these orders need to be more sharply focused. It is nonsensical for counties where there are only a few cases to be locked down because other areas of the state are seeing large numbers of infections. The one major caveat to this is that testing must be available so that there is an accurate assessment of the spread of COVID-19.
2. Everyone in the population, when out in indoor public spaces, needs to wear a mask. A recent study models the effect of wearing a surgical or homemade mask while in public spaces. There is also an excellent press article about the research. These scientists do a careful analysis and build a model to determine the effect of wearing a mask on the spread of the infection. Many different types of masks will work, including cloth ones. If 80% of a population begins wearing masks before day 50 of an epidemic, it can bring the infectivity rate low enough to stop the spread of disease. The most important effect of wearing a mask is preventing those who are sick from spreading it to others. In other words, wearing the mask protects others, not you. However, if everyone does it, the spread of the diseases becomes unsustainable. One of the most important findings of the model was that mask-wearing is more effective than stay-at-home orders. Most parts of the US are still in the early days of the epidemic and can implement this plan. I worry, however, that too many Americans will not follow this advice.
3. Testing has to increase to the level that anyone who needs a test can get tested. Testings must include routine surveillance of all healthcare workers, anyone with potential symptoms, and their recent contacts. Tests must be available to everyone who fits the case description of COVID-19, not just those with severe illness. Widespread testing will give a better understanding of disease incidence. The good news here is that testing capacity in the US is increasing and surpassing the need in some places. For example, Wisconsin currently can perform 15,000 tests a day, yet doctors are only ordering 3,000 to 4,000.
4. Ideally, those with moderate illness should be quarantined in locations away from others. While self-quarantine is possible for those who have enough room in their homes, patients in crowded living conditions (e. g., dorms, apartment buildings, prisons) need to have alternative accommodations to prevent the spread of illness.
5. A contact tracing mechanism must be developed and deployed. The ones used in China and South Korea are probably not compatible with the attitudes and laws about privacy in the United States. However, groups are developing other solutions that can achieve the same goal without the invasion of privacy the current solutions entail. Both Apple and Google announced that their phones would have this capability by mid-May of 2020. Unfortunately, a misguided obsession with privacy rights, in my opinion, is polluting this effort. Both Google and Apple are refusing to allow these apps to record locations so that detailed routes and times of ill individuals can be cross-matched against others. This kind of detail is essential for public health departments. It is especially ironic considering the massive amount of information Facebook and Google collect on users of their systems.

If we had implemented these five steps, we could have bought more time for scientists to develop effective treatments and, eventually, a vaccine. Marcel Salathé (an epidemiologist) & Nicky Case (a programmer and artist) lay out a compelling case to guide the future reaction. I encourage you to read their analysis. Our country acted too late to take advantage of many of these measures. However, the rapid development of vaccines helped to protect people from serious illness and death for those who took them.

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