The deadliest month in American history was an October during a global pandemic.
In 1918, after waning through the long summer, Spanish flu came roaring back to claim nearly 200,000 lives, just in that one month, just in the United States. Until recently, this second-wave surprise — it was the worst of three to hit the country between 1918 and 1919, most likely because a rare mutation made the virus more deadly — was a bit of obscure medical trivia. But as our current pandemic enters its ninth month, armchair epidemiologists have been wringing their hands over it.
Coronaviruses have little in common with influenza viruses. (For one thing, coronaviruses mutate less frequently, and almost never in ways that make them deadlier). But we’re grasping for comparisons because we are living in a fog right now.
It’s not the same fog-of-war fog that we experienced in early spring, when airports were flooded in panic, every inanimate object seemed capable of infecting us and nobody could agree on if or when to wear a mask. Things seem much calmer now. But they also remain deeply uncertain. Will we get a safe, effective vaccine? A new president? More and better testing? How will these things change the course of the pandemic? What if they don’t?
To be sure, some progress has been made. Rapid antigen tests are finally being deployed, mask-wearing is common in many places, and doctors have grown much more adept at treating the virus’s victims. Thanks to a small roster of drugs and a better understanding of when and how to ventilate Covid-19 patients, Ashish Jha, dean of Brown University’s School of Public Health, estimates that people infected today are roughly 30 percent to 50 percent less likely to die of the virus than they would have been in March or April.
But government ineptitude, rampant misinformation and outright lies from our own president are still thwarting efforts to stomp the virus out. We are logging nearly twice as many cases nationally as we did in late spring. And the death toll will soon surpass 200,000. Elderly people and low-income, front-line workers, coming especially from communities of color, make up a disproportionate share of those deaths, meaning that we have done a bad job of protecting our most vulnerable.
It’s tough to say how autumn will go, let alone winter. Mathematical models have proven unreliable in part because they are based on previous experience, and when it comes to the novel coronavirus, there is none: Other coronaviruses have leapt into humans, but none have ever caused a pandemic.
Scientists also still don’t have enough data to form a full picture of the crisis. The Harvard epidemiologist Marc Lipsitch says his efforts to predict how many Covid-19 patients would need intensive care were stymied by a lack of basic information about their average hospital stay. Other experts have noted that there’s no way to tell how many cases are being found through contact tracing as opposed to clinical diagnostics.
A recent report on risk factors from the Centers for Disease Control and Prevention involved just 314 people and concluded that eating at a restaurant or being exposed to a someone with the coronavirus might increase your risk of developing Covid-19. “It’s insane that eight months into a global pandemic we still don’t have this kind of basic information,” Mr. Lipsitch says. “It makes for a lot of guesswork.”
But there are ways to think about the future of this pandemic — and some are more useful than others.
Second Waves, Magic Thresholds
Let’s set aside the wave analogy. Michael T. Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota, says that it’s far more accurate to think of the pandemic as a forest fire. We have suppressed it in some places, but we have not put it out completely. “It’s going to keep burning as long as it has wood,” he says. “In this case, wood is humans that are susceptible to infection.”
It’s safe to assume that case counts will rise in the coming months, as colder weather forces more people indoors (in the North, at least) and as more students and teachers return to in-person schooling. Colleges are already grappling with outbreaks, and infected students are already returning home to seed a further spread in their own communities.
“Case counts could start spiking just a few weeks from now,” Peter Hotez, the dean of the National School of Tropical Medicine at the Baylor College of Medicine in Texas, told me. “The most rigorous predictions are that we head into November with 220,000 deaths.” And if pandemic-fatigued families travel to spend the holidays together, it will get worse in late fall and winter.
It’s tough to say whether the nation will reach or surpass the grim peaks of the summer, when we were seeing 65,000 to 70,000 new cases every day. Hopeful policymakers have speculated that fall outbreaks will be less severe, because many communities are at or approaching the herd immunity threshold — the point at which enough people have become immune to the virus that it can no longer spread easily. But there are several problems with this hypothesis.
First, we don’t really know how durable immunity to the virus might be. Most scientists think it’s likely that it lasts anywhere from several months to a year. But doctors have confirmed a few cases of repeat infection and, in at least one of them, the second infection proved more severe than the first.
Second, herd immunity is not a magical doorway that will take us back to the before-times. “People think once we hit this number we can all go to the bar because now it’s over,” Dr. Jha says. “But it doesn’t work like that.” It’s hard to know what the threshold even is (most experts put it at around 60 percent or higher, though some argue it could actually be much lower) and difficult to say when a population has crossed it. But even then, the virus would only slow down, not stop.
Third, most experts agree that, whatever the threshold proves to be, no country in the world is there yet. Even if some of the hardest hit communities — in Corona, Queens, for example — are partly protected, antibody tests indicate that, overall, just 10 percent to 12 percent of Americans have been infected with the virus to date. If SARS-CoV-2 is a forest fire, it still has a lot of wood to burn through.
That’s true even in Sweden, where officials skipped complete lockdowns, presumably enabling more people to interact, catch SARS-CoV-2 and develop immunity to it. The resulting death toll was one of the highest in the world, but proponents argue that the pain was worth it because the country’s fatality rate is now tumbling. A precipitous decline in deaths indicates that herd immunity has been reached, they argue.
But critics say that many of those deaths were avoidable, and that case counts and death tolls could easily surge again when control measures are lifted, (the country still enforces strict social distancing in some indoor spaces), or even if they are not.
“The thing about fires is that they don’t burn everywhere equally at the same time,” Dr. Osterholm says. “Even where they rage, they still miss patches of vulnerability, just by chance.”
Vaccines, Tests, Treatments
Let’s start with the good news: Doctors and scientists are optimistic about two new drugs — REGN-COV-2 and LY-CoV555, both of them monoclonal antibodies — that could be available in the coming months. The hope is that, combined with other advances in the treatment of Covid-19, these medications will help keep patients out of the hospital and off ventilators, which would in turn help prevent hospitals from being overrun, even if infection rates match or surpass those of previous peaks.
The federal government’s main focus, however — its entire strategy, in fact — has been to develop a coronavirus vaccine. Anywhere from one to several could be authorized for use by the end of this year. But their rollout will be fraught and none of them will be a panacea.
For starters, the first vaccines to cross the finish line may not work that well. To get approved by the Food and Drug Administration, the shot only has to “reduce the severity of illness,” and only in half of the people who take it. Even if one of the dozen or so current candidates meets that standard, and even if manufacturers manage to clear the many expected supply chain hurdles (including for syringes, glass vials and vaccine ingredients), a vaccine that only works on half the population would still leave a lot of people vulnerable.
The president is pressuring the Food and Drug Administration to move quickly — asserting that a vaccine will be ready before the election, even though the government’s own scientists insist that that’s not feasible. The struggle has stirred fears that health officials will circumvent the normally robust vaccine approval process to bolster the president’s re-election bid, and those fears are already undermining the vaccine’s chances of success. “At this point, people are going to be suspicious even if the data is great,” the University of Washington epidemiologist Dr. Carl T. Bergstrom says. “And it’s going to take a lot of work to overcome that.”
When we do have a vaccine, the first batches will likely (and rightly) go to front-line workers, then to the elderly, especially in nursing homes. It could take a year or more before the average person is able to get a shot. (The early vaccines will probably require boosters, which also lengthens the timeline because it means twice as many have to be produced for the same number of people.) And because children haven’t been included in any clinical trials, it’s unclear when or how they might be deemed eligible for vaccination.
That means that mask-wearing and social distancing will remain essential, and we’ll need to keep using the same tools scientists have been clamoring for all along: surveillance testing, contact tracing and quarantine.
Testing remains a mixed bag. On one hand, our woeful shortages could soon be resolved. “I really think testing is going to be a lot better by late fall,” Dr. Jha tells me. “I’m nervous to say that, because I’ve thought it before and been wrong. But this time around I’m actually optimistic.” More rapid antigen tests and new genome sequencing tests should start to clear the regulatory process in the next month or so, he says. By January there should be enough capacity to regularly screen students, teachers and essential workers.
On the other hand, we’re failing to make almost any use of the testing data we already have. As The Atlantic recently reported, “thousands if not tens of thousands” of rapid antigen tests are almost certainly being administered every single day, but almost none of them are being logged in any public health database, which means they are not being used to track potential outbreaks or to inform state or local policies. Meanwhile, only a few states, like New York and Massachusetts, are even trying to pair robust testing with robust contact tracing. And there is still no federal funding to help people who test positive or have been exposed and need to isolate.
For proof that rigorous testing and tracing can make a difference, compare New York City with Madrid. Both are international hubs with expansive public transit that suffered large outbreaks in March, were forced to shut down by April, and had their case counts under control by June. But New York has kept its case counts exceedingly low since then, while Madrid now has one of the highest counts in Europe. The difference? New York City tested many more people and hired many more contact tracers. (It was also much slower to reopen: Madrid’s restaurants were at 60 percent capacity in June; New York’s are just opening now for indoor service, at 25 percent.)
The Coming Election
Some members of the Trump administration are already discussing the pandemic in the past tense. So if the president wins re-election, the federal response is unlikely to change. We’ll continue relying on individual states, cities, schools and businesses to manage the crisis on their own until a vaccine curbs the virus.
Mistrust between the White House and the nation’s leading scientific institutions is likely to persist. In just the past several days, political appointees have been accused of interfering with C.D.C. reports and the president has chastised the agency’s director for saying that a vaccine would not be widely available until late next year and that masks were the public’s best defense in the meantime (though a vast majority of scientists agree with both statements).
Mr. Trump’s newest scientific adviser, a neuroradiologist with no experience in infectious diseases, has argued that it is not the federal government’s job to stop the pandemic. He has advocated strategies that he says are meant to protect the most vulnerable, but would also enable the virus to spread more broadly. Critics say the approach is deeply flawed, and will only increase the toll of preventable deaths. “It doesn’t work for the same reason that it doesn’t work to have a peeing section in the swimming pool,” Dr. Jha says. “We all live in the same society. Nursing homes need workers. Workers need to use transit and shop in stores.”
It’s common to say that viruses don’t care about political parties. And it’s true that no matter the outcome of the election, we’ll probably still be dealing with rampant misinformation and a Congress and country as divided as they have ever been. But it’s also reasonable to expect some changes in the coronavirus’s prospects under a Democratic administration.
Mr. Biden is already building a team of advisers to deal with the pandemic if he is elected, and he has vowed to do most of the things that Mr. Trump refuses to. For example, he will encourage states to implement mask mandates, coordinate testing at the national level, and rejoin the World Health Organization.
He could also restore integrity to the nation’s scientific institutions. “I think if Biden wins, we’ll start to see the F.D.A. and C.D.C. exert scientific consensus again,” Dr. Bergstrom says. “And from there, I think, a more sensible, coordinated federal response will take shape.”
Your Fall and Winter Plans
It depends on where you live. Different communities will experience outbreaks at different times, based partly on weather (in the North, colder weather will drive us indoors; in the South, people will be outside more, as the summer humidity burns off), and partly on individual levels of vigilance.
As localized outbreaks are detected, shutdowns will be needed. Restrictions on everything from nursing home visits to haircuts to large indoor gatherings will have to be implemented. The scope and duration of these measures will depend on how quickly health officials respond, which in turn depends on the area’s testing and contact tracing abilities. They will also depend on how faithfully individuals abide by such edicts.
Offices will probably not look anywhere close to normal until at least next summer, if not next fall. Neither will schools. Students who are returning without incident now may find themselves stuck at home come November or December. On the flip side, students whose schools are scrambling today may end up with steady in-person instruction through the winter months, if their districts develop better testing strategies and communication plans.
“I am telling my kids not to be surprised if they are home from December through February,” Dr. Jha says. “But I also think things could get much better by late February into March.”
When it comes to the holidays, most Americans will be in the same boat. Halloween may be just fine: Some health departments have advised against it, but trick-or-treating is a largely outdoor event, many costumes come with masks of their own, and fomite transmission (where the virus is contracting by touching inanimate objects like plastic pumpkins) is much less of a concern than scientists originally thought. With the right precautions (maybe skip the haunted house), it should be safe to ring those doorbells.
But Thanksgiving and Christmas will be difficult for many. Large indoor gatherings, especially with people who have travelled from afar, will continue to pose a risk that no family testing strategy can eliminate. Even if you test negative and quarantine before you leave, you can still contract the virus while on route, and become contagious without realizing it.
“I think the holidays are going to be a hard, lonely time for a lot of people,” Dr. Jha says. “But I also think, hopefully, it’s a time when we will start to see a light at the end of the tunnel.”