We are in the early innings of an historic and catastrophic pandemic. The world has not seen anything on the scale of the COVID-19 pandemic scale since at least 1918. Best estimates are that so far only about 5-10% of the U.S. population has yet been infected — meaning that 90-95% of us are still susceptible. We have a long way to go before the pandemic, our response to it, and the cascading consequences from it are behind us.
As of July 20, 2020, there have been over 3.7 million confirmed US cases from COVID-19 and 140,000 deaths. These numbers account for about a quarter of the worldwide total. But these are very substantial undercounts. Serologic (antibody) testing and other careful studies in which everyone is tested, such as the cruise ships, suggests the true number of infections may actually be 10 times higher than the number of confirmed cases. Furthermore, routine monitoring of all death certificates in the country shows a large and unprecedented spike in deaths during the first four months of the pandemic — 50% larger than the number of confirmed COVID deaths.
Presumably, these other deaths are also related to the pandemic, either deaths due to COVID infections that were never tested, or people who did not seek medical care for unrelated problems because of the pandemic. But as bad as this sounds, it could have been so much worse.
Initial epidemiological forecast modeling from Imperial College London in March indicated that without any public health intervention to suppress the epidemic, the United States could expect more than 2.2 million deaths over the first 100-day wave. This model assumed a slightly higher fatality rate than is now the consensus, but the basic message was right. The difference between that model and where we are today was the remarkable success of the unprecedented effort at “flattening the curve” by slowing down transmission. Literally, millions of lives have been saved! But not without cost.
The difference between [initial forecasts] and where we are today was the remarkable success of the unprecedented effort at “flattening the curve” by slowing down transmission. Literally, millions of lives have been saved! But not without cost.
First is the cost to the economy from shutting down businesses, high unemployment, and cessation of so much economic activity. The second cost is the prolongation of the outbreak. As expected, flattening the curve also stretched out the curve. The goal was to tamp down the number of cases enough that the healthcare system would not collapse and we would have time, among other things, to develop systems for testing and contact tracing so that when we started to relax the mitigation efforts we would be able to rapidly identify and isolate cases, find those who have been exposed, and have them self-quarantine. Evidence-based criteria were established to guide a careful and gradual re-opening process. In states where these criteria have been faithfully followed, there has not been a large spike in cases.
Around the world, most countries have responded in the same way as the United States — with mask wearing, social distancing, teleworking, closing of high density businesses, cancelling large gatherings, and in most countries, some form of temporary lockdown or stay-at-home order. Most countries saw the same success as the United States did initially.
What is different, however, is the degree to which many other countries took advantage of the time the lockdowns bought them. Many countries have been able to implement robust nationwide testing and contact tracing programs and have had very high compliance rates with mask wearing and social distancing. This has enabled many to gradually reopen safely including schools, restaurants, and businesses. Most of Europe, China, South Korea, Vietnam, Singapore, Taiwan and many other places are successfully managing COVID-19 cases and reopening their economies.
But reopening is a delicate process. Public health officials must be extremely vigilant in looking for and responding to new cases. Governors and mayors, with the strong and unequivocal support of the federal government, must be willing to take the measures needed to pause or reverse the reopening. Some increase in cases is bound to occur when people begin to interact more, but if the requisite public health, public policy, and messaging groundwork has been laid, new cases or small outbreaks can be manageable. That is what success looks like in a pandemic like this.
Until there is a widely accepted, reasonably effective vaccine, these public health interventions are all we have to prevent the uncontrolled, explosive spread of the virus.
Over the last 15 years, the United States has been the world’s leader in pandemic preparedness. The strategies that other countries are using successfully were developed by our CDC. There is no excuse for the United States to be the poster child for how not to respond to a pandemic.
Going forward, the only way we can safely reopen our economy is to have most people wear masks, maintain distance, and avoid crowds, coupled with ubiquitous testing that reports results in hours not days and efficient contact tracing.
Going forward, the only way we can safely reopen our economy is to have most people wear masks, maintain distance, and avoid crowds, coupled with ubiquitous testing that reports results in hours not days and efficient contact tracing. If we do these things, we can reopen schools and business with appropriate modifications and get people back to work.
If, on the other hand, we are not successful in these efforts, cases will soar, hospitals will become overwhelmed and governments will have no choice but to impose lockdowns again — an outcome nobody wants.
Getting most people to follow the guidelines will require strong leadership from the top of government and a concerted risk communications campaign. The public service announcements now airing from health departments are good but not sufficient. We need to convince people that it is in their own enlightened self-interest to work together to stop the spread of the virus. Over the last 20 years there has been a lot of research into risk communication. Now is the time to put all that has been learned into practice. We should have messages from doctors, elected leaders, country music stars, hip-hop artists and elite athletes all reinforcing the message that the only way out of our current terrible situation is through common action: wearing masks, maintaining distance, and avoiding crowds.
Eric S. Toner, MD, is a Senior Scholar with the Center for Health Security and Senior Scientist of Environmental Health and Engineering at the Bloomberg School of Public Health at Johns Hopkins University.