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The coming months of the pandemic could be catastrophic. The U.S. still has ways to prepare.
In April 13, Robert Redfield, the director of the U.S. Centers for Disease Control and Prevention, appeared on the Today show and assured viewers that the worst was nearly behind us. It had been a month since the last gathering of fans in an NBA arena; a month since the fateful week when Americans began panic-buying bottled water and canned beans. The segment’s host, Savannah Guthrie, was broadcasting from home in upstate New York. With the light of a makeshift camera reflecting in her glasses, she asked Redfield to address reports that we could be facing another three weeks of social distancing. “We are nearing the peak right now,” Redfield told her. “Clearly we are stabilizing in terms of the state of this outbreak.”
By July, the number of daily cases had doubled. The death total had shot past 100,000. As Redfield looked ahead, his tone became more ominous. The fall and the winter, he said in an interview with the Journal of the American Medical Association, “are going to be probably one of the most difficult times that we’ve experienced in American public health.”
It is now widely accepted among experts that the United States is primed for a surge in cases at a uniquely perilous moment in our national history. “As we approach the fall and winter months, it is important that we get the baseline level of daily infections much lower than they are right now,” Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, told me by email. For the past few weeks, the country has been averaging about 40,000 new infections a day. Fauci said that “we must, over the next few weeks, get that baseline of infections down to 10,000 per day, or even much less if we want to maintain control of this outbreak.”
This may be the most salient warning he has issued at any point in the pandemic. Cutting an infection rate as high as ours by 75 percent in a matter of weeks would almost certainly require widespread lockdowns in which nearly everyone shelters in place, as happened in China in January. That will not happen in the United States. Donald Trump has been campaigning for reelection on just the opposite message. He has promised that normalcy and American greatness are just around the corner. He has touted dubious treatments and said at least 34 times that the virus will disappear. This disinformation is nearing a crescendo now that the election looms: Trump has been teasing a vaccine that could be available within weeks.
The cold reality is that we should plan for a winter in which vaccination is not part of our lives. Three vaccine candidates are currently in Phase 3 clinical trials in the U.S., and the trials’ results may arrive as early as November. But even if they do—and even if they look perfect—it would not mean that a vaccine would be widely available. On Wednesday, Redfield said in a congressional hearing that a vaccine was unlikely to be widely available until summer of next year, if not later. Fauci may be even less optimistic. He told my colleague Peter Nicholas that if the clinical trials go well, it could mean a few million doses could be available by early 2021. By the time we got to 50 million to 100 million doses, he estimated, “you’re going to be well into 2021.” If each person needs two doses, as many experts expect, that would be enough to vaccinate roughly 11 percent of the population.
The virus is here to stay. At best, it would fade away gradually, but that would happen after, not before, the winter. The sooner we can accept this, the more we can focus on minimizing the losses of the bleak and grisly coming months. Some of our fate is now inevitable, but much is not. There are still basic things we can do to survive.
Some of the physical elements of winter weather make viruses more difficult to escape. The coronaviruses that cause the common cold reliably peak in winter months, as do influenza viruses. There is some mystery as to why. It seems partly due to the air: Viruses travel differently in air of different temperatures and humidity levels. In typical summer weather, the microscopic liquid particles that shoot out of our mouths don’t travel as efficiently as they do in dry winter air.
Cold weather also drives us inside, where air recirculates. “As things get colder, activities and people will start moving indoors, and unfortunately that’s going to increase transmission risk, and the risk of super-spreading events,” Tom Ingelsby, the director of the Center for Health Security at Johns Hopkins, told me. The public-health directives that have allowed many businesses to reopen in recent months—by opening windows and doing as much as possible outdoors—will no longer be feasible in regions where temperatures plunge as the days grow short.
Winter days also wear on our body’s defense mechanisms. When people become more sedentary, our immune systems become less vigilant, and our overall resilience flags. Symptoms of depression, too, tend to run high in winter. This year these symptoms will be accompanied by restrictions on social life and concerns for health and economic security, leaving us physiologically vulnerable. “There is a growing sense of behavioral fatigue, and a real need for segments of the population to get back to work,” says Albert Ko, the chair of the department of epidemiology of microbial diseases at Yale School of Public Health. “I think the resurgence is going to be worse than what we’ve seen in the summer.”
Isolated people may feel especially compelled to travel and gather at the holidays, even though those gatherings may be perilous. They could lead to bigger spikes in COVID-19 cases than some states saw after Memorial Day and July 4, when people who insisted on gathering could generally do so outdoors. The winter holidays often involve multigenerational gatherings for prolonged periods indoors—preceded and followed by interstate travel. This is a worst-case combination during a pandemic.
“A lot of what we’re expecting about what might happen this winter comes from previous pandemics,” says Stephen Kissler, a research fellow at the Harvard School of Public Health. Flu pandemics tend to travel in waves, and often the first fall and winter waves are the worst. There are striking similarities so far between the current pandemic and the 2009 influenza pandemic, Kissler told me. “There was patchy transmission in the spring, in New York City and some other places, but then there was a unified wave that hit the entire country. It started right around now, the beginning of September.”
In a typical cold-and-flu season, many of us are protected—or partially protected—by antibodies to circulating viruses. But with COVID-19, the number of people with antibodies is still low. Even in the cities hardest hit by the disease, it seems that roughly 85 percent of people are still without antibodies. And if the immunity these antibodies confer is incomplete or short-lived, the number could effectively be even higher. This goes against the president’s allusions to how we might safely defeat the virus with “herd immunity.”
Winter has already hit some places in the Southern Hemisphere hard. South Africa has seen a surge in COVID-19. Melbourne has been locked down due to a winter resurgence. The U.S. fell prey to our sense of exceptionalism in the early stages of this pandemic. We watched idly as the virus spread in China and Iran, South Korea and Italy, and only after it was circulating widely among us did we begin to accept that we were not somehow immune. If we cling to that fiction, we are setting ourselves up to be unprepared once again.
This is not inevitable. There’s still time to break out of the patterns of thinking that have brought the U.S. to the point of leading the world in deaths and economic losses. There are basic measures we can take to mitigate and prepare. I’ve been worried about this winter since last winter, so over the past few months I’ve spoken with dozens of experts about what can be done. Here is a distillation of the recurring recommendations. None of them should be revelatory. But that’s precisely the point.
“Outbreak responses are chess, not checkers,” says Stephen Thomas, the chief of the infectious-disease division at the State University of New York Upstate. We are playing against a tiny, inanimate ball of genetic material. We are not winning, because we are thinking short-term, moving in only one direction, and not seeing the entire board.
Do not waste your time and emotional energy planning around an imminent game-changing injection or pill in the coming months. A pandemic is not a problem that will be fixed in one move, by any single medication or a sudden vaccine. Instead, the way forward involves small, imperfect preventive measures that can accumulate into very effective interventions. Groups of practices that minimize the spread of disease are sometimes known as prevention bundles. Our COVID-19 bundle includes important drugs, such as dexamethasone and remdesivir, which seem to help certain patients in specific situations. It also involves behaviors, too, such as distancing and masking. “Any action you take has the potential for numerous secondary and tangential benefits,” Thomas said.
A vaccine will be part of our bundles, hopefully before too long. But it will not instantly eliminate the need for everything else. If we can accept that masks will be a part of our lives indefinitely, we can focus on improving their effectiveness and making them less annoying to wear, Yale’s Ko said. “And it’s not just the design of masks themselves; we can come up with more innovative ways to promote face-mask use.” For one thing, they could be made more ubiquitous by employers and state agencies. Governments could even, as Luxembourg’s did, send masks to everyone by mail.
Plan for More Shutdowns
America’s “reopening” process is going to be less an upward line toward normalcy and more a jagged roller coaster toward some new way of life. In July, California ordered businesses and churches in some counties to again halt indoor activities after the state saw a rise in positive tests and admissions to intensive-care units. In August, the University of North Carolina sent students home barely a week after they had arrived. These sorts of moves shock the system if it relies on uninterrupted forward progress. Everyone will be better prepared if we plan for schools to close and for cities and businesses to shut back down, even while we hope they won’t have to.
“Many workplaces that have reopened don’t have clear guidelines as to when they will consider shutting back down or reducing capacity in buildings,” Kissler told me. Every place that’s reopening should assume that it might have to navigate further closures. “Having clear triggers for when and how to pull back would help us avoid what happened this spring, where everything shut down in a week,” Kissler said. “It was utter chaos. I’m afraid that scenario will play out again. We have the opportunity to avoid that.”
Live Like You’re Contagious
Even if you’ve had the virus, plan to spend the winter living as though you are constantly contagious. This primarily means paying attention to where you are and what’s coming out of your mouth. The liquid particles we spew can be generated simply by breathing, but far more by speaking, shouting, singing, coughing, and sneezing. While we cannot stop doing all of these things, every effort at minimizing unnecessary contributions of virus to the air around others helps.
Along with masking and distancing, time itself can effectively be another tool in our bundles. It’s not just the distance from another person that determines transmission; it’s also the duration. A shorter interaction is safer than a longer one because the window for the virus to enter your airways is narrower. Any respiratory virus is more likely to cause disease if you inhale higher doses of it. If you do find yourself in high-risk scenarios, at least don’t linger. Fredrick Sherman, a professor at the Mount Sinai School of Medicine, recommends that if someone near you coughs or sneezes, “immediately exhale to avoid inhaling droplets or aerosols. Purse your lips to make the exhaling last longer. Turn your head fully away from the person and begin walking.”
Even as it gets colder, continue to socialize and exercise outdoors when possible—even if it’s initially less pleasant than being inside. It’s worth thinking about sweaters, hats, and coats as protective measures akin to masks. During the holidays, don’t plan gatherings in places where you can’t be outdoors and widely spaced. This may mean postponing or canceling long-standing traditions. For a lot of people, that will be difficult and sad. For some, it will be a welcome relief. In either case, it’s better than sending a family member to the ICU.
Build for the Pandemic
This is an overdue opportunity to create and upgrade to permanently pandemic-resistant cities, businesses, schools, and homes. Now is the moment to build the infrastructure to keep workers safe, especially those deemed essential. Poor indoor air quality, for example, has long been a source of disease. Businesses can minimize spread by making ventilation upgrades permanent, as well as enshrining systems that let people work from home whenever possible. “We should be decreasing the density of indoor spaces as much as possible through telecommuting, shifting work schedules, changing work or school flows to spread people out,” the Center for Health Security’s Inglesby said. Instead of being ordered to take down temporary street dining areas, restaurants might build roofs over them to bear ice and snow, and accommodate space heaters.
Keeping people safe will save us economically: If restaurants, shops, offices, schools, and churches offer only indoor options, then they can expect attendance and business to suffer even further—either because of legally imposed limits to capacity or because people don’t feel safe going out. Building for pandemics also extends beyond physical infrastructure, to child care for workers, public transit, safe housing and quarantine spaces, and supply chains for everything from masks to air filters to pipette tips. We could make sure that sick people have places to go to seek care, and that they aren’t compelled to spread the virus by basic financial imperatives.
Hunt the Virus
Developing fast and reliable ways to detect the coronavirus will become only more crucial during the winter cold-and-flu season. Symptoms of the flu and other respiratory diseases can be effectively indistinguishable from early and mild symptoms of COVID-19. Natalie Dean, a biostatistician at the University of Florida, told me that testing will be needed to identify real cases and assure others in schools and workplaces that their coughs are not due to COVID-19. Being able to distinguish who among the sniffling masses truly needs to quarantine for two weeks will be vital to keeping essential workers safe and present.
The flu vaccine will be useful in helping to prevent a disease that can look very similar to COVID-19. But returns to normalcy in the coming year will depend on advancements in testing for the coronavirus itself. As of now, PCR tests, the most widely used forms of diagnostic testing, are not suited for efficient, massive-scale screening. They cannot identify every infection reliably enough, and are too resource-intensive to use as a comprehensive surveillance system. Some experts hope that November will be a watershed month for new ways of testing, as numerous novel point-of-care tests should have come to market by then. These will theoretically allow for on-premises testing at schools, offices, and polling stations—with results obtained in minutes. There are already concerns about the accuracy of such tests, but if they work well, they would be the most effective tool in our bundle. Results would ideally be coordinated nationally, with real-time tracking, to inform precise and minimal shutdowns.
All of these measures are contingent on reconceptualizing how this pandemic ends. They depend on common facts and clear information. There will be no fireworks or parades, only a slow march onward. Whether technological advances can help us chip away at the spread and severity of this disease will depend on how we use, distribute, and understand them.
Throughout the pandemic, America’s most significant barrier to this progress has been Donald Trump. Since February, he has depicted his response to the virus as a success by minimizing the threat. He has exaggerated and lied about treatment options, about the availability of tests, and about the importance of preventive measures such as masks. This week, after Redfield testified that a vaccine would not be widely available until mid-to-late 2021, Trump contradicted him and said Redfield was “confused.”
Trump’s insistence that normalcy is on the horizon trades long-term safety for short-term solace. Under his administration, the agencies that typically ensure the accuracy and proper usage of medical products like tests and vaccines—the FDA and the CDC—have been weakened and politicized. In August, the White House urged a rewrite of CDC guidelines to discourage testing asymptomatic people who have had high-risk exposures to people with COVID-19. This week, The New York Times reported that this happened over the objections of CDC scientists. In the coming months, “direct to consumer” sales of COVID-19 tests are expected to further clutter the information landscape. It will be up to the FDA to ensure that they work. Tests and vaccines will be worthless if the public can’t or simply doesn’t trust them.
The lack of a scientific basis for a shared reality—and a willingness to accept that reality—continues to be America’s greatest weakness in this pandemic. This is all the more reason to prepare ourselves for the months ahead. Build emotional reserves where you can. Make concrete plans for how to isolate and quarantine; to maintain access to credible information; to get medical care quickly. Consider simple ways to help your communities. The process will serve you well, no matter how bad winter gets. Offer to help friends and family care for children. Ask yourself what you can do, right now, for the people who would be burdened most by new waves of illness. Do you have neighbors who wouldn’t be able to get out at all? Do you have elderly relatives who would be totally alone? “If you can teach them how to use Zoom right now,” Kissler advised, “that might be easier to do while we can still do it in person.”
This story was originally published in The Atlantic. Subscribe to the magazine's newsletters.
James Hamblin, M.D., is a staff writer at The Atlantic.