Wintry mix spreads across Minnesota

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As the U.S. wades deeper into a brutal fall surge of the coronavirus, Americans are living under a 

 of restrictions aimed at curbing the exponential rise of COVID-19.

California has resorted to a curfew. Other states — including 

 — have moved to partial lockdowns, shuttering sectors of the economy and limiting social gatherings. Quite a few states are trying to find a middle ground that staves off the economic pain of closing businesses altogether and ordering people to stay home. 

But given the unrelenting advance of the virus, can these varied approaches make a difference? Or is it delaying the inevitable return to the sweeping lockdowns of the springtime?

"It's really hard to slow it down once it gets going like this," says 

, professor at the University of Maryland School of Public Health. "That's when these awful draconian measures come into play."

 that any kind of national lockdown is off the table. 

 to President-elect Joe Biden has even pushed back on using the term "lockdown" to describe what many states did during the spring and has indicated that would be too heavy-handed a response. 

So for the dark weeks ahead, the scattershot approach to the pandemic — where each state or region is left to sort out the trade-offs — will likely define the U.S. public health response.   

"We're going to see a sputtering of shutdowns in the same way that we saw only haphazard shutdowns in March, April and May," says 

, a professor at Harvard T. H. Chan School of Public Health, who has advocated for a nationwide rapid testing program. 

"My concern is this is going to lead to the worst of all options, where we're going to have massive economic destruction and the virus is barely going to be dented at a national level." 

To see a place that's returned to strict lockdown, look to New Mexico.  

Calling it a "matter of life and death," Gov. Michelle Lujan Grisham 

 residents to shelter-in-place on Nov. 16, and closed all "non-essential" businesses for two weeks (this does not include big box retailers). 

, an assistant professor at the School of Public Health at Indiana University. 

It's the simplest, most blunt tool to break the chain of transmission, which reduces the probability of people getting infected and lightens the load on the health care system. 

"That's the whole purpose of it," Bento says. 

Much has changed since the spring, but evidence shows those lockdowns were quite effective.

For example, Delaware's stay-at-home order dramatically changed the course of the state's outbreak, after being implemented in mid-April. That policy decision, along with a mask mandate and contact tracing, led to an 88 percent reduction in COVID-19 hospitalizations and a 100% drop in mortality from late April to June, according to a 

 that, in many places, shelter-in-place orders and closing restaurants, bars and entertainment venues, did substantially slow the spread of the virus. 

"The lockdown as a strategy, if implemented absolutely correctly, in an ideal utopian world, would be very effective," says 

, professor of biostatistics and epidemiology at the University of Michigan School of Public Health. 

But aggressive lockdowns crush the economy and are tremendously difficult to sustain without a well-coordinated national strategy and a strong safety net. 

"What we learned from April is that blanketed, blind lockdowns cannot be withstood for a long period of time," says Bento. "People get fatigued and they get desensitized about the risks." 

A major shortcoming of the U.S. spring approach was not only the patchwork of different policies, but also that restrictions were 

. And many states did not have enough testing and contact tracing in place to stomp out outbreaks that lead to wider community spread, according to a recent modeling 

Ultimately, the decision to shut down parts of the economy is political and hinges on how much disease and death states are willing to tolerate. Parts of the Midwest and West have reached staggering 

 of infection, yet have not gone into lockdowns or substantially curtailed businesses. Some 

What else works? A surgical approach based on local data 

In many states, there is hope that dialing up targeted restrictions can avert broad shutdowns and in some places that may be feasible.

The targeted approach is not easy to pull off, either.

Ideally, the restrictions are coordinated, based on local data gleaned from contact tracing that show when and where most people are getting infected in that region, Bento says.

"The goal is to do it surgically with the least economic and social pain," says 

, an assistant professor in the Department of Epidemiology of Microbial Diseases at the Yale School of Public Health. 

Gonsalves says there is no "boilerplate" list of restrictions to avert a full lockdown, but there are obvious places to start, like businesses that lead to people crowding inside together for long periods of time.  

He says states that have scaled up testing and kept the virus in check are in a better position to quell the rising case numbers, but, in other parts of the country, these more circumscribed strategies can falter. 

"For places in the Midwest and the Upper Plains where the virus is sort of everywhere, it's going to be very hard to use testing to target our interventions," Gonsalves says. 

Lacking local data, communities can learn from research and the experience of their neighbors. Here's what research and experts say about the effectiveness of common restrictions and mandates. 

There's unanimous support for these among researchers. It's 

 curb the growth of the virus, and even some 

, such as Iowa's and North Dakota's, who spent much of the pandemic 

 to issue one, have relented as their hospitals near crisis. More than a 

 states still don't have universal face mask mandates.

Experts have mixed views on these. In states like New York and Massachusetts, late-night curfews are aimed at the most high-risk settings, including restaurants and bars. Much of 

 is now under a curfew between 10 p.m. and 5 a.m. State health officials 

 that will cut down on nighttime social activities, when people let their guard down and may spread the virus. 

Ohio's curfew baffled some public health experts: "I haven't met a single public health official who thinks these types of curfews/10pm shutdowns will be particularly helpful," 

 at Kent State University, in reaction to Ohio's curfew.

This kind of curfew may help bring down cases in the short-term, says Indiana University's Ana Bento, but would need to be in place long-term to truly decrease transmission.

 Research shows superspreading events play an 

 role in the transmission of the coronavirus, including 

. Some states, especially those that have resisted closing businesses, have enacted measures limiting the size of such gatherings or banning them outright.  

 to contradict their other policies. Indiana has 

 religious services from its rule on crowd limits, even though 

This appears to be the "single, most effective social distancing order," according to preliminary 

 found that reopening full-service restaurants was "particularly risky," along with fitness centers and places of worship. Using cell phone location data from the Chicago area, the researchers showed that capping maximum occupancy at 20% in these most high risk settings could cut down new predicted infections by 80%. 

But some experts say limiting the numbers of people is probably not enough when people are indoors, where the risk of catching the virus goes up substantially. 

"We should certainly shut down restaurants and bars first before anything else," says Don Milton, "Not just cutting back, but shutting them down."

 This is a particularly contentious measure. Recent 

 as initially feared and may be able to stay open safely, but there are still substantial risks if there is rampant community spread. After keeping schools open for a fraction of students, New York City has again halted in-person learning because the city has surpassed a COVID positivity rate of 3 percent — a threshold agreed upon by the teachers union when schools restarted. 

For all these restrictions, says Bento, there could be "race to contact" when the policies are relaxed and people are eager to start interacting again.

"While these work short-term, if they aren't implemented for a long enough time to truly decrease transmission, once they are relaxed there will be a rebound of cases," she says.

With the virus spreading at record speed, it's still far from clear that even data-driven, tailored approaches will work, given the enormous reach of the virus and the coming holiday travel season.

Ultimately it's like there's a fire raging, but you're only able to douse the spot fires and wait for help.

"We are putting out fires as they happen," says Bento. "This is not a long term solution." 

She and other experts say what's really needed is widely accessible rapid testing, a robust system of contact tracing and eventually the vaccine.  

, but the pandemic is moving at a breathtaking pace and the health care system is already starting to buckle under the growing number of patients. 

Some public health experts say the U.S. may not be able to afford to wait for those interventions to be ramped up.  

"I do think a shelter-in-place order is probably what we really need right now," says Columbia University epidemiologist 

NPR's Nurith Aizenman contributed to this report.

This story was published as part of a partnership with 

Health

COVID-19

Will Stone

Author

The U.S. added more than 1 million cases in the past week. More than 85,000 people are hospitalized. Some states may have no choice but to lock down again. Others are trying a "surgical approach."

Are more lockdowns inevitable, or can other measures stop the surge?

Go Deeper.

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