What’s the most likely process for returning our country to something near “normal” in the wake of Covid-19? One reasonable hypothesis is put forward by Tomas Pueyo. In a series of three articles, he makes the case that it won’t be quick and it won’t be smooth. He provides a framework for thinking about how to deal with the pandemic, based on “the hammer” (initial severe restrictions) and “the dance” (detecting and containing subsequent smaller outbreaks).

Pueyo is a Stanford MBA and marketer at a Silicon Valley startup. He is not an epidemiologist, which has led to some criticism, and his writings are not published in peer-reviewed scientific journals, but his thoughtful analysis and his gift for turning Covid-19 statistics into easy-to-understand graphics has caused tens of millions of people to read his articles.  

Pueyo writes that the US lost its early opportunity to contain the virus. As a result, it had to impose severe restrictions (“the hammer” of Pueyo’s writings). The only way forward will be limited lifting of the restrictions, followed by intermittent outbreaks as the virus (still circulating in some locations) finds new victims. Those outbreaks will cause local imposition of restrictions again. The waves of lifting and re-imposing restrictions is what Pueyo calls “the dance”. The dance will continue until the majority of the population is immune—either via vaccination or because they have survived a case of Covid-19.

The three articles. Although Pueyo initially published his analyses as short Facebook posts, the overwhelming response prompted him to collect them into three articles which he posted on the publishing website Medium.com over a period from March 10 to April 1. Each of the article titles below is a link to the full article.

March 10: Coronavirus: Why You Must Act Now. The first of Puyeo’s three influential Covid-19 articles is called “Coronavirus: Why You Must Act Now”. It compares the rise of Covid-19 in the US to the corresponding data from China and other countries. Based primarily on death counts (the most reliable data available in the US), Pueyo argues that the amount of infection in the US has been vastly understated because there has been so little testing. He argues in favor of Italy-style lockdowns for the whole nation, and he gives guidelines for how quickly that is needed.

March 19: Coronavirus: The Hammer and the Dance. This article has become Pueyo’s best-known piece. It outlines how the future may play out, with the initial lockdown period (“the hammer”) followed by many months of “the dance”, with intermittent and local lockdowns. He explains why many of the variables in the Covid-19 fatality rate are still unknown, how to think about them, and why ICUs could be overwhelmed in the short term if we don’t “flatten the curve”. The aggressive curve-flattening requires “the hammer” of heavy social distancing for a period of weeks. (Fortunately, in most parts of the US, much of that curve-flattening seems to have been done soon enough to protect the health-care system from collapse.)

Relaxing the constraints requires rigorous testing and contact-tracing of anyone who tests positive. Then, testing of the contacts is required to make sure they aren’t infected, followed by quarantine if they are. Temporary local lockdowns may also be needed. This is “the dance”, and it is what China and South Korea have had to do to control their outbreaks. We don’t have the infrastructure to do the testing and tracing in the US yet, but we need it urgently.

April 1: Coronavirus: Out of Many, One. The third article outlines the steps the federal government and the states should be taking. In particular, Pueyo argues that the effort requires federal coordination and it cannot be left entirely to the states. Otherwise, less restrictive states will serve as virus reservoirs, re-infecting their neighbors, and states will fight over access to medical equipment. Puyeo also provides an economic analysis of intervention, which suggests that strong measures hurt the economy more initially but pay off in the longer term.

If you are interested in this topic, you’ll want to read the articles yourself. I have barely scratched the surface of the information they contain.

The hammer and the dance at Kendal. At Kendal, and to a large degree in Pennsylvania more broadly, we are currently enduring Pueyo’s “hammer.” Let’s assume that Pueyo is correct in his description of the ensuing “dance”. That would mean that Covid-19 would remain circulating, in scattered locations and at a low level, for months to come. There might not be cases in our immediately vicinity; but once the Kendal rules are loosened, the virus could be brought in by staff, visitors, contractors, delivery personnel, or residents returning from trips off campus.

How would we protect ourselves under those circumstances? This is just speculation, but I could imagine testing as potentially the key issue determining what the rules will be. As soon as reliable and rapid testing for active Covid-19 cases is available, it would be possible to test staff, contractors, visitors, and returning residents before they enter the campus. In the case of a positive test of a staff member or contractor, their Kendal contacts could be traced and tested. In the case of residents testing positive on return from an extended trip, they could go into immediate quarantine. (Testing on return from a short shopping trip might not be practical, because the quantity of virus might be too low to be detectable in the first hours of an infection.)  Perhaps the campus could be put back into full lockdown whenever there is a positive case. Visitors testing positive would be turned away immediately.

What kind of test would be needed at Kendal? The testing scenario outlined above could only happen with a quick (i.e. a result in a few minutes) test that checked for an active infection. So far, none of the tests I have read about meet that requirement.

There are promising candidates for a different type of rapid test, one for the presence of antibodies (showing that someone has recovered from Covid-19 and therefore is probably immune to re-infection). But that type of test would be of limited value here. For residents that turned out to have the antibodies, that test would relieve some of the anxiety about shopping and other off-campus travel. Likewise, staff who had the antibodies would present less of a threat to the residents. But those of us without antibodies (probably the vast majority) would not learn anything useful from the test.

It is possible that a readily available test for active cases, even if it is not quick, could support campus-wide testing of all residents. That could provide enough certainty to allow some restrictions to be lifted. For example, perhaps the Center could reopen, small gatherings might be permitted, and masks could be left at home—until someone tests positive, at which point a period of lockdown would again be called for.

Without testing, does the status quo continue? In the absence of some kind of testing, it is hard to see how our present “lockdown” restrictions could be relaxed in any significant way. We are operating on the assumption that Covid-19 could sneak into Kendal, and we need our social distancing, masks, meal delivery, and all the other restrictions to keep the virus from spreading if it does arrive. Without widespread testing, we won’t know if we have any cases; and if we don’t know that, we can’t afford to let down our guard.

As I say, this is all speculation. We’ll have to wait and see how this plays out. But until we can all be vaccinated it seems to me that some level of restriction will be needed. And until testing for active cases of Covid-19 is readily available, our current severe restrictions may need to continue. Who knows when the appropriate tests will be available? And a vaccine, from what I read, is at least a year away.