After enduring weeks of coronavirus lockdowns, more than 100 million travellers in China flocked to key tourist sites this week, while businesses including barbershops, nail salons and shopping malls reopened in parts of the United States.
Families separated by strict physical-distancing rules in Italy reunited for the first time in two months, and Spaniards rushed out of their homes to exercise after being cooped up for seven weeks.
In Germany, churches, museums and some schools opened their doors, while in Nigeria, the cities of Abuja and Lagos came to life after a month-long shutdown; the streets once again clogged with cars and minibuses.
With the new coronavirus exacting an economic toll unseen since the Great Depression of the 1930s – wiping out millions of jobs and raising the spectre of unrest and hunger – governments around the world are trying to chart a way out of prolonged lockdowns and beginning to phase out restrictions. But without a vaccine or widespread testing to identify and stamp out new clusters, health experts warn some leaders are taking a “gamble” that could result in a new surge of infections and deaths.
“We are in uncharted territory,” said Dr Annelise Wilder-Smith, professor of emerging infectious diseases at the London School of Hygiene and Tropical Medicine. “Governments are having to strike a balance between this virus and the negative impacts of lockdowns on societies, including economic downturns, societal strife and mental health concerns … No one is totally ready to lift lockdowns.”
Indeed, researchers at the UK’s Oxford University, in a note published on May 1, say no countries fully meet the World Health Organization’s (WHO) criteria to safely ease shutdowns.
Key among the agency’s six guidelines is controlling transmission to the level of sporadic or clusters of cases. That translates to less than 50 cases a day and sustained decrease in rates of infections. Second is bolstering health sector capacity to contain future outbreaks, through widespread testing, rapid and effective contact tracing, as well as adequate infrastructure to support extended isolation and quarantine for positive cases and their contacts.
The Oxford study says only a handful of countries and territories come close to meeting the WHO measures. They include Taiwan and South Korea, which did not impose nationwide shutdowns but controlled the virus’ transmission with early and rapid test, trace and quarantine campaigns.
Also ranked high on these two measures is China, which imposed a strict lockdown, deployed an army of contract tracers and utilised mass surveillance to contain its outbreak. And despite suffering a historic economic slump, authorities in Beijing only began lifting lockdown measures after daily infections fell and stayed for weeks at about 100 cases. That was in late March. In recent days, China’s cases have fallen to single digits, most of them involving travellers from overseas.
But many hard-hit nations in Europe – including Spain, Italy and France – are moving to gradually reopen their economies despite continuing to record more than a 1,000 daily cases. The figures, however, mark a significant drop from peaks of between 4,000 and 7,000 daily cases in these countries.
Germany, notable in Europe for keeping deaths low, said its aim is to keep the rate of infections below a replacement rate of one-for-one, so that cases fall over time and do not overwhelm the healthcare system.
The number of infections in Germany remained in the hundreds this week, but health authorities say the country’s outbreak is manageable as the reproduction rate is 0.71, meaning 100 infected people pass the virus on to 71 others.
“In Europe, the governments and the people have decided containment is not possible. We mitigate, we keep it under control, but we cannot totally contain it,” said Wilder-Smith. “The intent is now to live in a compromised situation, where you live with this virus and try to find a balance between the economic standstill and the cases and deaths.”
She added: “There’s no right and wrong, it’s about what you want. China said we want containment, and Europe said we want to find a balance between the virus and the economic downturn.”
The United States is taking a different path.
Concerned by record job losses and egged on by US President Donald Trump, about half the country’s 50 states have begun to lift restrictions despite rising infections.
With more than a million confirmed cases, the US is the worst-hit country in the world. Some 75,000 people have already died and one model by Trump’s administration is projecting a rapid rise in daily infections and the doubling of deaths to 3,000 by June 1.
Wafaa El-Sadr, professor of epidemiology at Columbia University, said easing curbs in some states while the US remained in the grip of the pandemic was a “risk and a gamble” as “epidemics don’t know borders”.
“A major Achilles heel for many states in the US is the availability of sufficient testing capability,” she said. “Another challenge is the urgent need for a large cadre of health workers poised to do the hard work of going out into communities to expand testing, do case and contract tracing.”
The US has so far conducted 7.5 million tests in total, but a Harvard University study estimates five million tests a day by June and 20 million a day by July would be necessary for a return to normal life. The Johns Hopkins University estimates the US needs to add an extra 100,000 contact tracers nationwide to keep the virus in check.
Dr Hadi Halazun, assistant professor of cardiology at Weill Cornell Medicine in New York City, blamed the US’s shortfall partly on the lack of guidance and coordination at the national level.
“I don’t see any leadership,” he said. “There has been very little federal guidance or a unified national strategy… There is a lack of awareness in many big cities. For people in places where the pandemic hasn’t struck as hard, it’s difficult to fathom what doctors are seeing inside the hospitals here in New York City.”
It began lifting lockdown measures in late April despite continuing to record more than 1,000 cases on a daily basis. President Hassan Rouhani on April 22 called reopening the economy, already struggling under US-imposed sanctions, a “necessity for the country”.
For Iranian leaders, keeping the lockdown in place risks protests such as those seen in November last year when tens of thousands took to the streets over economic hardship. The demonstrations posed the biggest challenge to the country’s rulers in decades, but were swiftly quelled.
“There is fear that an economic meltdown in the wake of the coronavirus crisis could result in renewed protests. Bread revolts, basically, by the lower classes who are disproportionately affected,” said Ali Fathollah-Nejad, a visiting fellow at the Brookings Doha Center.
In parts of Africa, officials and experts say the rising spectre of starvation is making prolonged lockdowns untenable.
In Nigeria, where millions live on daily wages, the lockdowns in Lagos and Abuja have left many without money to buy food. The pandemic has also caused the price of oil, Nigeria’s main export, to plunge, adding to the country’s financial woes.
President Muhammadu Buhari, announcing the phased and gradual opening of the key states, said: “No country can afford the full impact of a sustained lockdown, while awaiting the development of vaccines.”
Since easing restrictions this week, Nigeria has seen a surge in cases. Experts say the true spread of the virus is not known, as the country of 200 million has conducted fewer than 20,000 tests in total.
South Africa, which won praise from the WHO for its strict lockdown, is also beginning to ease restrictions as economic hardship worsens. There was looting in some areas during the shutdown, as well as violent protests over undelivered food aid.
Infections and deaths remain comparatively low on the continent, with a total of 50,000 cases and more than 2,000 deaths. But the WHO said on Thursday as many as 190,000 could die on the African continent in the coming 12 months without containment measures.
COVID-19, the respiratory illness caused by the new coronavirus, “could become a fixture in our lives for the next several years unless a proactive approach is taken by many governments in the region”, said Matshidiso Moeti, WHO chief for Africa.
But with lockdowns unsustainable, African countries need to come up with other strategies, wrote Salma Abdalla and Sandro Galea at the Council on Foreign Relations.
African governments and donors need to further invest in rapid testing, contact tracing and isolation. This can help isolate those with the disease quickly, limiting its spread, they said. A second proposal suggested targeted physical-distancing guidelines aimed at protecting those who are at high risk, such as those more than 70 years of age.
“The United States and Europe have failed at implementing testing widely, but time here is on Africa’s side,” they said.