#10 Things to do before easing the COVID-19 Lockdown

In the last few hours, and almost three weeks after the lockdown, individual and collective resistance is beginning to falter and we read, from many quarters, requests for the urgent reopening of the country and the resumption of economic, social activities and personal freedoms. Yet, those who propose the suspension of the lockdown and a series of legitimate economic measures to deal with the damage generated by the suspension of activities, apart from rare and disorderly exceptions, do not outline a real "plan B" that allows us to emerge from the emergency by guaranteeing:
a) that a new surge in the epidemic does not appear soon,
b) a significant reduction in individual risk and the protection of the most exposed categories;
c) the possibility of hospitalization for COVID-19 for all citizens.
Asking for reopening is more than legitimate and, allow me, even obvious to argue. Without a doubt, it is more difficult, especially without previous cases to refer to apart from Wuhan and South Korea, with their respective exceptions, to outline Plan B. But this, I don't think there can be any doubt about it, is the real question to resolve without having to imagine living the next few months - even when, hopefully soon, the so-called epidemiological peak will have passed - in the nightmare of being infected or of infecting. Of going (or not going) with fear to the cinema, the theatre, the beach or the supermarket with the nightmare of becoming biological bombs for our loved ones.
The containment results that we will hopefully achieve in the next two weeks will be obtained mainly thanks to social distancing and lockdown.
But what will we do afterwards to prevent the considerable increase in risk from happening again in the same way, once again threatening the capacity of the National Health System and the possibility of treatment for all? 

# The precautionary principle
So where can we start without certain scientific references? Without a real theory?
Epidemiological mathematical models are certainly a starting point, we have already shared some reflections in previous posts, I am sharing a new one that suggests (in the figure below and in the link below) what to do to ease the lockdown and keep the epidemic "under control" with R0<1.
However, a series of reasonable things, in compliance with the precautionary principle that we have invoked many times for other environmental and social risks, and strategies (also reasonable) adopted with evident success in China and South Korea, can only be put in place before thinking about any form of reopening or easing of the lockdown. Actions which, when science understands their effectiveness but is unable to understand and measure or rigorously control their effects, albeit positive, calls "best practice".
If the epidemiological prediction models are correct, until the vaccine we will not be able to consider ourselves safe, we will not be able to be certain that the days we are experiencing will not be repeated. So, in the long months that distance us from the end of the COVID-19 emergency, we can implement many actions to reduce the risk of each of us and the most fragile people and restart the country.
I tried to summarize them in 10 actions, you will forgive me for the extreme synthesis adopted and for certainly having forgotten some that are being added day after day:

#1 Ensure PPE for medical and healthcare personnel, law enforcement agencies and public officials
We must know certain times to ensure that medical, healthcare personnel, law enforcement, public officials and all other categories most at risk are equipped with Personal Protective Equipment (PPE) that protects them and us from possible contagion. But even this first action, although widely shared, is not, at this moment and for the next few weeks, guaranteed. We need millions of PPEs per day that we don't have yet. 

#2 Equip all citizens with masks and disinfectants
They told us in recent weeks that only symptomatic or asymptomatic people who thought they might have been infected because they had been in contact with COVID-19 positive people should wear masks. Reasonable suggestion without masks for everyone, without masks for healthcare workers and the categories most at risk and in a general lockdown situation.
Suggestion no longer reasonable when we ease lockdown; in fact this is the precaution, certainly not a "regime", most evidently adopted in China and Korea and in many other eastern countries.
But when will they be available to everyone? Emergency Commissioner Arcuri says that we will be able to produce and purchase around 100 million masks per month. Perhaps they will be fine for the staff referred to in point #1, but they certainly will not be able to satisfy 60 million Italians potentially at risk. Not to mention the disinfectants that have completely disappeared from supermarkets.

#3 Provide equipment for intensive care and drugs after the enormous effort made by the Regions
Ensure that each Region, with respect to the efforts made to increase beds for hospitalizations, sub-intensive therapies and intensive therapies, is equipped with all the necessary equipment (helmets, respirators, etc.) and drugs to fight COVID-19.
The news coming from various quarters, especially from the southern regions of the country, does not appear comforting in this regard. 

#4 Install thermal scanners and PPE in factories, main stations and airports
Install all devices that allow us to monitor and limit the extension of the epidemic and the emergence of new outbreaks.
Certainly, as other countries have done before us, it is essential to equip ourselves with thermal scanners and PPE in factories, main stations and airports.
Are we sure we are already doing it? And when will it take to cover the whole country? 

#5 Prepare a temporary law to allow the tracing of infected patients for health purposes
It is urgent to prepare a law that allows the tracking, through software and wearable technologies - for exclusive health purposes (i.e. the data must be able to be read only by healthcare personnel) and for a defined period -, of the movements of positive patients in order to secure, with preventive isolation, all the people with whom the infected have potentially been in contact and which guarantees their absolute quarantine.
I have read from several places that there are APPs that allow such tracking to be carried out without completely compromising privacy, in the sense that the data all remains in the smartphone and can only be read by healthcare personnel in the event of confirmed infection of the user.
Many talk about the South Korea model; if we want to apply it, if we believe that it can be a useful best practice, we must immediately start preparing a new law. 

#6 Develop the IT platform that manages the technology referred to in the previous point
It is evidently necessary to develop, test and train, very quickly, the platform and healthcare personnel for this purpose. There is no information on this matter.

#7 Keep the HUBs where the epidemic spreads closed
It is clear that tracing makes sense if the people with whom one has potentially been in contact are small in number, it is not feasible when contacts can be hundreds or thousands or when there is no possibility of reconstructing the chain of infections because users are unable to use tracking technologies (children, for example). Therefore, it is clear that activities that take place in schools, universities, courts, arenas, shopping centers, etc. – which, in epidemiological terms, we could define as HUBs for the spread of the epidemic – should remain closed for as long as possible.
Let me tell you, most modeling studies converge on this point.

#8 Enact regulations to ensure safe social distancing
Promulgate a series of regulations that oblige all businesses that reopen to guarantee the distance of at least one meter between customers and between customers and merchants. I mean that it is necessary to define precise rules to be respected, which also include the modification of the current access spaces to public and commercial establishments.
I haven't read anything about it at the moment.

#9 Define a broad campaign of swabs on a certain statistical basis and seriological screening on the population
Define a large population screening campaign as soon as possible to try to do at least three things:
1) prevent quarantines and, consequently, contain the spread of the infection;
2) best estimate the possible number of asymptomatic people and understand how much the virus has affected individual communities overall and, then, the entire population;
3) anticipate the diagnosis of the infected to give them the entire spectrum of treatment possibilities.
On this point, compared to the total Italian population, we are very far from the objectives taking into account the speed of spread of COVID-19. It would be necessary for as many analysis laboratories (including private ones) to get to work and to quickly experiment with new COVID-19 positivity testing systems that are faster than the current ones.
They are trying, as we read from various sources, but we have no indication of timing in this regard.
Another fundamental issue is to develop, as soon as possible, serological tests (based on the development of antibodies to COVID-19) to understand who has already had the disease asymptomatic (with the consequent obvious benefits for the resumption of work activities of individuals in greater safety).

#10 Organize systems and a protection network for the weakest groups
If all the nine previous actions were achieved quickly and allowed us to ease the lockdown as soon as possible, there would remain a very high risk for the categories of elderly people and those with more or less serious co-pathologies (of which there are many, taking into account that these also include hypertension, atrial fibrillation, diabetes, etc.).
It is necessary to provide, and in some cases design, individual protection and insulation systems. I am referring to the physical, but also psychological, strengthening of quarantine measures for these at-risk categories. But also to strengthen the social volunteering network, equipping it with all the PPE, to help these categories in elderly centers, in hospitals, in home isolation. Yes, because in Korea and China they have adopted social isolation measures in hotels and specifically dedicated facilities, not only confining them to homes where life is, inevitably, promiscuous.
The Israeli model (whose epidemiological curve is also growing rapidly in these hours and it will be possible to evaluate its effectiveness only in a few weeks) of keeping men and women at work until the age of 55 is a strategy that involves enormous organizational complexity in a country, like Italy, in which working, family and social life is highly promiscuous. Furthermore, and not to be overlooked, Israel is one of the most technologically and organizationally advanced countries in the world.
I can't imagine how such a model could be implemented. But even on this, for now, we only hear words, no real program.

# Plan B to ease the lockdown
Knowing and guaranteeing the implementation times of these 10 best practices can lead us to easing the lockdown and understanding when and how to do it. The rest is obvious. We all want to get out and get back to normal.
A gradual reopening program, with continuous monitoring of results and improvement of actions, is the most reasonable solution possible. Reopening the country without the certainty of being able to preventively implement at least 8/10 of the actions suggested above, in my opinion, could be a disaster, nullifying everything we are doing while respecting the various Prime Ministerial Decrees.
I tried to collect ideas, ideas, reflections. If you have other suggestions, let's try to write plan B together, add them to the post, and then send it to our Government representatives.

# The highest mountain. (Personal considerations)
There are principles like mountains, and saving a life is the highest mountain. I have no doubt about this. And I also ask my dearest friends who, with intellectual honesty, fear further violations of rights and freedoms in this crisis situation, and who express legitimate fears as well, I ask you to reflect on this.
I would have given, as I imagine you too, everything to save my father from illness; just as many of us have fought for years, with immense pain, for ourselves and for our loved ones, trying to snatch even one more day of light.
The distance between the abstract fear of contagion and the disease (because this thing here, allow me to call it less euphemistically disease and not war), between personal risk and objective risk, between fragility and superomism, between courage for oneself and that to be given to others, is the same between those who are, at this moment, in a hospital bed and those who are at home writing on their smartphone in front of a good cup of tea. Only in this distance can we try to measure the highest mountain. Believe me.

Writing about inherent risk percentages is reasonable. But only if the risk is a personal choice that does not inevitably become the risk for another. And this seems simple enough to share. But a risk of 0.5% or 1% is individually very high when compared to that of any other pathology or human activity. It is easy to verify this from the data available online. We talk about permissible risks when we have at least two orders of magnitude lower. However, there is no need to consult the Internet, just watch the national news for what is extraordinarily happening in the North of the country and understand what the difference is between 0.5% and 0.005%.
It's true that we cannot avoid the inevitable, but we have a duty to try to save as many lives as possible and keep everyone safe. Yes, everyone. Even those over a cup of tea. Because no one is safe. Because each can infect the other. Because anyone can end up in intensive care in a few hours, without a system of rigid and clear protection rules to be respected in the coming months.
Minimizing the risk means, without too many mincing words, respecting the Italian Constitution which in art. 32 provides for the "protection of health as a fundamental right of the individual and interest of the community, and guarantees free treatment to the indigent."

Everything else, when you still have time in front of you, you can find it again, like the freedoms that are precluded today, earnings at a standstill, studying less effectively, movement certainly reduced, fun to a minimum... The history of men is accompanied by the strength to get up again. To roll up your sleeves and start again. But this opportunity must be given to each of us. In the same way as those who are in factories, hospitals, pharmacies, as well as all the others who will be potentially fragile when they reopen.
And in the coming weeks it will be decided how to do it. Any mistake will have serious consequences. It won't have the lightness of our posts on FB or our thoughts. Wrong, hasty actions, worse still dictated by material or, cynically, electoral impulses, will put thousands of lives at risk. Let's all reflect very carefully because the sum of all these posts, when it becomes a common feeling or belief, will no longer have the same lightness as it does now.

I appeal above all to you friends because we are, in some way, a social and cultural elite compared, unfortunately, to many other sections of the population who are struggling more than us in these times in more difficult conditions. A strong elite because it is distant from the front line at the moment. Strong because economically and socially solid, in these times. Strong because it is structured in logical thinking. Strong also because it has minimal freedom of movement (compared to those who live in a few square meters) such as to allow the construction of plan B at a distance. So strong, therefore, that we can make a rational contribution in a moment of collective disarray that could occur when on April 3rd or 20th they tell us to still stay at home (I obviously hope that it isn't necessary). The appeal is to maintain clarity and rigor in choosing priorities.
I remain firmly convinced that the highest mountain is always Schindler's and that "whoever saves one life saves the whole world".

Armando Di Nardo