For the last several days, President Donald Trump has become increasingly vocal in his opposition to the social distancing policies that state and local governments have put in place to slow the spread of the COVID-19 pandemic, citing concerns about their business impact. This position is utterly reckless and contradicts the universal consensus of public health and infectious diseases experts. It also ignores the reality that allowing further spread of COVID-19 will result in more damaging and longer-term economic impact than continuing with social distancing. State and local governments must continue to lead in this crisis; measures that may seem overly disruptive remain essential to protect people’s health.
The United States is still in the early stages of this pandemic. For this reason, it may seem to some as though social distancing rules are unnecessary, overly onerous, or not working. In fact, evidence from other countries shows that social distancing interventions can slow the spread of COVID-19. Beyond the international evidence of social distancing’s effectiveness, there is promising data from states that were early adopters of key social distancing policies, including bans on large gatherings and closing bars and restaurants. Together, these case studies should reassure state and local governments that they are continuing on the correct path.
Social distancing and the spread of COVID-19
Mass testing allows officials to utilize up-to-date and localized data on the disease spread, including identifying asymptomatic individuals who can then isolate themselves before they further spread the virus. In the absence of widespread testing, however, the centerpiece of the public health response to COVID-19 is social distancing. The goal of social distancing is also to prevent contagious people from coming into close contact with healthy people in order to “flatten the curve”—slowing down the spread of the virus—which in turn helps to avoid a spike in cases that overwhelms the health care system. To lessen the chances of catching COVID-19, experts recommend that people stay at least six feet away from each other. Social distancing policies include telework and business and school closures.
Social distancing works, but it takes time to generate results. Even before social distancing completely eliminates transmission of the virus, it can still slow the transmission of the virus, ensuring that health care systems have adequate time to ramp up capacity to respond to the pandemic. For this reason, when evaluating social distancing results, it is critical to remember that the United States is still comparatively in the early stages of this pandemic. China’s first cases appeared in early December; the first case in the United States was identified in mid-January. The total number of reported cases in the United States has exceeded 62,000, with more than 800 people dying from the disease. Due to the lack of testing, we know that many more people have contracted COVID-19, and the virus will continue to spread to some degree in coming weeks.
New cases will continue to be diagnosed during periods of social distancing efforts for two reasons. First, even successful, aggressive “stay-at-home” orders do not stop all transmission. Individuals will still need to leave their homes for necessities such as food, and workers with essential jobs will continue to go to work. Both of these present opportunities for new transmissions, and relatively more lax social distancing practices will be less effective than stay-at-home orders. Second, the public health benefit of social distancing will not be felt until communities had these policies in place for the entire incubation period’s worth of time. Many individuals who contracted COVID-19 in the weeks before the start of social distancing will not be diagnosed until they begin to show symptoms, which can take up to 14 days.
Reducing asymptomatic transmission is the primary goal of social distancing. However, asymptomatic transmission is the more difficult form of transmission to monitor without widespread testing, which is currently unavailable in the United States. With these caveats, we will likely begin to see some clearer flattening of the curve in some areas in early April. Many states and localities began aggressively responding to the pandemic in the latter half of March, and the first statewide stay-at-home order, in California, was issued on March 19. With studies suggesting that patients are no longer contagious around 10 days after they start showing symptoms, this creates a 12 to 24 day delay between when social distancing begins and curve flattening is likely to show itself in the data.
The first coronavirus case in the United States was confirmed on January 21, 2020, in Washington state. The patient had traveled to Wuhan, China. By March 18, there was a confirmed case in all 50 states and the District of Columbia. States have implemented different social distancing requirements with varying levels of enforceability. By the afternoon of March 14, 14 states, the District of Columbia, and at least seven major cities or counties had implemented bans on gatherings, with an additional 19 states recommending the cancellation of large events. In the following days and weeks, other states, cities, and counties strengthened and implemented additional measures.
Evidence from other nations
South Korea and Italy are two of the nations with some of the greatest numbers of cases. These countries show how two completely different approaches to addressing the pandemic in its early stages can dramatically change the spread of the disease. Of course, many of the policies implemented by other countries may not be appropriate for adoption in the United States, but these case studies still illustrate the importance of social distancing.
South Korea
South Korea has had one of the earliest and most robust responses to the coronavirus pandemic. The impact of these policies is clear—with a case fatality rate of just more than 1 percent, the nation has one of the lowest fatality rates globally. Just one week after confirming its first case, South Korean government officials urged companies to mass produce testing kits. With enough supplies to do so, the government has proven its commitment to test often and quickly. The government “opened 600 testing centers designed to test as many people as possible, as quickly as possible” and minimize contact to prevent further infection. Some of these testing designs were innovative, including 50 drive-through centers and a chamber resembling “a transparent phone booth.”
South Korea has taken a unique approach to surveilling its citizens to contain the spread of the coronavirus, aided by a loosening of privacy laws during a 2015 outbreak of MERS that allows the government to access people’s personal data. The government monitors bank card, cell phone location, and CCTV data to identify people who may have come into contact with known cases and ensure they get tested. It also implemented an extensive emergency alert system that texts residents with reports of activity of nearby citizens who tested positive. These tactics have helped the government “locate coronavirus clusters, investigate the path of infection, quickly isolate those involved, and warn the public about trouble spots to avoid.”
Widespread testing, coupled with access to data on patients and paths of infection, has allowed social distancing measures to be used even more effectively than in other affected countries. For example, the government introduced an app that sets off an alarm if quarantined people leave their home. Live, app-based information about infected people nearby allows residents to avoid hotspots of infection. Furthermore, Gyeonggi Province, which includes Seoul, required public-use businesses to take precautions to mitigate risk of infection, including disinfecting and ventilating their premises; maintaining maximum distance between customers; and keeping a list of all visitors and their contact information.
Less than a week after a series of new infections in late February that peaked on February 29, the number of new cases in South Korea were halved. Within four days, it halved again—and again the next day. While these measures would not be an appropriate course of action in the United States, they have been effective at flattening the curve in South Korea.
Italy
Italy is one of the nations that COVID-19 has hit the hardest. As of March 24, Italy had nearly 70,000 positive cases—second only to China. This large number of cases is especially concerning given Italy’s relatively old population. The first cases in Italy were confirmed on January 31, resulting in the nation closing its air traffic to and from China. After this, it was nearly a month until Italian officials took further action to slow the spread of the disease, imposing travel restrictions in the northern region of Lombardy as well as closing schools in major cities nationwide on February 23.
In March, the Italian government imposed several additional measures meant to slow the spread of COVID-19. It ordered all schools and universities closed and sporting events to be held behind closed doors. A few days later, the government announced a forced quarantine for the Lombardy region, and then expanded the quarantine to the entire nation the next day. The Italian government ordered all shops, bars, and restaurants closed on March 11 and ordered all nonessential businesses closed on March 22.
As with the United States, however, different regions and provinces acted at different paces in Italy. Codogno, a small town outside of Milan where the first case of the coronavirus was confirmed in the nation in mid-February, demonstrates the effectiveness of swift and early social distancing, according to The Wall Street Journal. Local authorities told residents not to leave their homes except for emergencies and sealed the town off from the rest of Italy. While Codogno residents stayed home, life in the nearby city of Bergamo carried on as usual until the entire region of Lombardy—which includes Bergamo and Codogno—was placed under lockdown on March 8. In the week following, during which Codogno residents had been social distancing for roughly a month compared to just days for Bergamo residents, the number of overall cases had increased by nearly 76 percent in Bergamo compared to 21 percent in Lodi, the province that took early action and includes Codogno.
Unfortunately, the national social distancing measures were largely implemented too late to avoid significant spread of COVID-19 and resulting deaths. Italy has a death rate of more than 7 percent, over double the global average, and its total death toll of over 6,800 people is more than twice that of China, despite China’s population being around 20 times larger. It does appear that these measures are starting to take effect, however. Both deaths and new cases slowed recently, according to Italy’s Civil Protection Department.
Emerging evidence from early acting states and localities
Because the spread of COVID-19 in the United States is more recent than in Asia and Europe, evidence of the impact of social distancing also lags behind other nations. However, because some state and local officials adopted social distancing policies in mid-March—well before the federal government acted—there are early signs that the virus is potentially flattening or spreading more slowly in Kentucky, the San Francisco Bay Area, and in Washington state.
Kentucky vs. Tennessee
Throughout the crisis, Tennessee’s response has lagged behind that of Kentucky, from both a policy and communication standpoint. Kentucky Gov. Andy Beshear (D) recommended against large gatherings on March 11, while Tennessee Gov. Bill Lee (R) did not issue similar guidance until March 13. Gov. Beshear recommended school closures on March 12, while Gov. Lee did not issue a similar guidance until March 16, the following Monday. Gov. Beshear issued an executive order restricting restaurants and bars to carryout, delivery, and drive-through sales on March 16. Gov. Lee, on the other hand, did not issue a similar executive order until March 22, nearly a week later. Gov. Beshear issued an executive order on March 22 requiring all nonessential businesses to close. Gov. Lee has yet to issue a similar order, and neither state has issued a stay-at-home order.
The consistent difference in approach from the states has resulted in measurable difference in transmissions. While both states found similar numbers of positive COVID-19 cases at first, Kentucky’s aggressive actions have slowed the transmission of the virus in the state early in the outbreak. This early slowing will likely prove critical to ensuring a positive response. Data from the COVID Tracking Project show that Kentucky’s positive cases have increased much more slowly than Tennessee’s, even when accounting for differences in testing capacity and population.