The Coronavirus in America: The Year Ahead - The New York Times - 0 views
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More than 20 experts in public health, medicine, epidemiology and history shared their thoughts on the future during in-depth interviews. When can we emerge from our homes? How long, realistically, before we have a treatment or vaccine? How will we keep the virus at bay
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The path forward depends on factors that are certainly difficult but doable, they said: a carefully staggered approach to reopening, widespread testing and surveillance, a treatment that works, adequate resources for health care providers — and eventually an effective vaccine.
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The scenario that Mr. Trump has been unrolling at his daily press briefings — that the lockdowns will end soon, that a protective pill is almost at hand, that football stadiums and restaurants will soon be full — is a fantasy, most experts said.
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They worried that a vaccine would initially elude scientists, that weary citizens would abandon restrictions despite the risks, that the virus would be with us from now on.
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Most experts believed that once the crisis was over, the nation and its economy would revive quickly. But there would be no escaping a period of intense pain.
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Exactly how the pandemic will end depends in part on medical advances still to come. It will also depend on how individual Americans behave in the interim. If we scrupulously protect ourselves and our loved ones, more of us will live. If we underestimate the virus, it will find us.
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More Americans may die than the White House admits.
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The epidemiological model often cited by the White House, which was produced by the University of Washington’s Institute for Health Metrics and Evaluation, originally predicted 100,000 to 240,000 deaths by midsummer. Now that figure is 60,000.
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The institute’s projection runs through Aug. 4, describing only the first wave of this epidemic. Without a vaccine, the virus is expected to circulate for years, and the death tally will rise over time.
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Fatality rates depend heavily on how overwhelmed hospitals get and what percentage of cases are tested. China’s estimated death rate was 17 percent in the first week of January, when Wuhan was in chaos, according to a Center for Evidence-Based Medicine report, but only 0.7 percent by late February.
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Various experts consulted by the Centers for Disease Control and Prevention in March predicted that the virus eventually could reach 48 percent to 65 percent of all Americans, with a fatality rate just under 1 percent, and would kill up to 1.7 million of them if nothing were done to stop the spread.
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A model by researchers at Imperial College London cited by the president on March 30 predicted 2.2 million deaths in the United States by September under the same circumstances.
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China has officially reported about 83,000 cases and 4,632 deaths, which is a fatality rate of over 5 percent. The Trump administration has questioned the figures but has not produced more accurate ones.
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The tighter the restrictions, experts say, the fewer the deaths and the longer the periods between lockdowns. Most models assume states will eventually do widespread temperature checks, rapid testing and contact tracing, as is routine in Asia.
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In this country, hospitals in several cities, including New York, came to the brink of chaos.
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Only when tens of thousands of antibody tests are done will we know how many silent carriers there may be in the United States. The C.D.C. has suggested it might be 25 percent of those who test positive. Researchers in Iceland said it might be double that.
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China is also revising its own estimates. In February, a major study concluded that only 1 percent of cases in Wuhan were asymptomatic. New research says perhaps 60 percent were.
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The virus may also be mutating to cause fewer symptoms. In the movies, viruses become more deadly. In reality, they usually become less so, because asymptomatic strains reach more hosts. Even the 1918 Spanish flu virus eventually faded into the seasonal H1N1 flu.
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The lockdowns will end, but haltingly.
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it is likely a safe bet that at least 300 million of us are still vulnerable.
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Until a vaccine or another protective measure emerges, there is no scenario, epidemiologists agreed, in which it is safe for that many people to suddenly come out of hiding. If Americans pour back out in force, all will appear quiet for perhaps three weeks.
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The gains to date were achieved only by shutting down the country, a situation that cannot continue indefinitely. The White House’s “phased” plan for reopening will surely raise the death toll no matter how carefully it is executed.
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Every epidemiological model envisions something like the dance
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On the models, the curves of rising and falling deaths resemble a row of shark teeth.
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Surges are inevitable, the models predict, even when stadiums, churches, theaters, bars and restaurants remain closed, all travelers from abroad are quarantined for 14 days, and domestic travel is tightly restricted to prevent high-intensity areas from reinfecting low-intensity ones.
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In his wildly popular March 19 article in Medium, “Coronavirus: The Hammer and the Dance,” Tomas Pueyo correctly predicted the national lockdown, which he called the hammer, and said it would lead to a new phase, which he called the dance, in which essential parts of the economy could reopen, including some schools and some factories with skeleton crews.
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Even the “Opening Up America Again” guidelines Mr. Trump issued on Thursday have three levels of social distancing, and recommend that vulnerable Americans stay hidden. The plan endorses testing, isolation and contact tracing — but does not specify how these measures will be paid for, or how long it will take to put them in place.
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On Friday, none of that stopped the president from contradicting his own message by sending out tweets encouraging protesters in Michigan, Minnesota and Virginia to fight their states’ shutdowns.
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China did not allow Wuhan, Nanjing or other cities to reopen until intensive surveillance found zero new cases for 14 straight days, the virus’s incubation period.
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Compared with China or Italy, the United States is still a playground.Americans can take domestic flights, drive where they want, and roam streets and parks. Despite restrictions, everyone seems to know someone discreetly arranging play dates for children, holding backyard barbecues or meeting people on dating apps.
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Even with rigorous measures, Asian countries have had trouble keeping the virus under control
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But if too many people get infected at once, new lockdowns will become inevitable. To avoid that, widespread testing will be imperative.
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Reopening requires declining cases for 14 days, the tracing of 90 percent of contacts, an end to health care worker infections, recuperation places for mild cases and many other hard-to-reach goals.
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Immunity will become a societal advantage.
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Imagine an America divided into two classes: those who have recovered from infection with the coronavirus and presumably have some immunity to it; and those who are still vulnerable.
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“It will be a frightening schism,” Dr. David Nabarro, a World Health Organization special envoy on Covid-19, predicted. “Those with antibodies will be able to travel and work, and the rest will be discriminated against.”
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Soon the government will have to invent a way to certify who is truly immune. A test for IgG antibodies, which are produced once immunity is established, would make sense
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Dr. Fauci has said the White House was discussing certificates like those proposed in Germany. China uses cellphone QR codes linked to the owner’s personal details so others cannot borrow them.
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As Americans stuck in lockdown see their immune neighbors resuming their lives and perhaps even taking the jobs they lost, it is not hard to imagine the enormous temptation to join them through self-infection
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My daughter, who is a Harvard economist, keeps telling me her age group needs to have Covid-19 parties to develop immunity and keep the economy going,”
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It would be a gamble for American youth, too. The obese and immunocompromised are clearly at risk, but even slim, healthy young Americans have died of Covid-19.
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The virus can be kept in check, but only with expanded resources.
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Resolve to Save Lives, a public health advocacy group run by Dr. Thomas R. Frieden, the former director of the C.D.C., has published detailed and strict criteria for when the economy can reopen and when it must be closed.
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once a national baseline of hundreds of thousands of daily tests is established across the nation, any viral spread can be spotted when the percentage of positive results rises.
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To keep the virus in check, several experts insisted, the country also must start isolating all the ill — including mild cases.
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“If I was forced to select only one intervention, it would be the rapid isolation of all cases,”
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In China, anyone testing positive, no matter how mild their symptoms, was required to immediately enter an infirmary-style hospital — often set up in a gymnasium or community center outfitted with oxygen tanks and CT scanners.
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There, they recuperated under the eyes of nurses. That reduced the risk to families, and being with other victims relieved some patients’ fears.
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Still, experts were divided on the idea of such wards
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Ultimately, suppressing a virus requires testing all the contacts of every known case. But the United States is far short of that goal.
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In China’s Sichuan Province, for example, each known case had an average of 45 contacts.
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The C.D.C. has about 600 contact tracers and, until recently, state and local health departments employed about 1,600, mostly for tracing syphilis and tuberculosis cases.
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China hired and trained 9,000 in Wuhan alone. Dr. Frieden recently estimated that the United States will need at least 300,000.
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There will not be a vaccine soon.
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any effort to make a vaccine will take at least a year to 18 months.
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the record is four years, for the mumps vaccine.
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for unclear reasons, some previous vaccine candidates against coronaviruses like SARS have triggered “antibody-dependent enhancement,” which makes recipients more susceptible to infection, rather than less. In the past, vaccines against H.I.V. and dengue have unexpectedly done the same.
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A new vaccine is usually first tested in fewer than 100 young, healthy volunteers. If it appears safe and produces antibodies, thousands more volunteers — in this case, probably front-line workers at the highest risk — will get either it or a placebo in what is called a Phase 3 trial.
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It is possible to speed up that process with “challenge trials.” Scientists vaccinate small numbers of volunteers, wait until they develop antibodies, and then “challenge” them with a deliberate infection to see if the vaccine protects them.
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Normally, it is ethically unthinkable to challenge subjects with a disease with no cure, such as Covid-19.
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“Fewer get harmed if you do a challenge trial in a few people than if you do a Phase 3 trial in thousands,” said Dr. Lipsitch, who recently published a paper advocating challenge trials in the Journal of Infectious Diseases. Almost immediately, he said, he heard from volunteers.
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The hidden danger of challenge trials, vaccinologists explained, is that they recruit too few volunteers to show whether a vaccine creates enhancement, since it may be a rare but dangerous problem.
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if a vaccine is invented, the United States could need 300 million doses — or 600 million if two shots are required. And just as many syringes.
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“People have to start thinking big,” Dr. Douglas said. “With that volume, you’ve got to start cranking it out pretty soon.”
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Treatments are likely to arrive first.
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The modern alternative is monoclonal antibodies. These treatment regimens, which recently came very close to conquering the Ebola epidemic in eastern Congo, are the most likely short-term game changer, experts said.
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as with vaccines, growing and purifying monoclonal antibodies takes time. In theory, with enough production, they could be used not just to save lives but to protect front-line workers.
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Having a daily preventive pill would be an even better solution, because pills can be synthesized in factories far faster than vaccines or antibodies can be grown and purified.
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Goodbye, ‘America First.’
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A public health crisis of this magnitude requires international cooperation on a scale not seen in decades. Yet Mr. Trump is moving to defund the W.H.O., the only organization capable of coordinating such a response.
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And he spent most of this year antagonizing China, which now has the world’s most powerful functioning economy and may become the dominant supplier of drugs and vaccines. China has used the pandemic to extend its global influence, and says it has sent medical gear and equipment to nearly 120 countries.
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This is not a world in which “America First” is a viable strategy, several experts noted.
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“If President Trump cares about stepping up the public health efforts here, he should look for avenues to collaborate with China and stop the insults,”
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If we alienate the Chinese with our rhetoric, I think it will come back to bite us,” he said.“What if they come up with the first vaccine? They have a choice about who they sell it to. Are we top of the list? Why would we be?”
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Once the pandemic has passed, the national recovery may be swift. The economy rebounded after both world wars, Dr. Mulder noted.
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In one of the most provocative analyses in his follow-up article, “Coronavirus: Out of Many, One,” Mr. Pueyo analyzed Medicare and census data on age and obesity in states that recently resisted shutdowns and counties that voted Republican in 2016.
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He calculated that those voters could be 30 percent more likely to die of the virus.
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In the periods after both wars, Dr. Mulder noted, society and incomes became more equal. Funds created for veterans’ and widows’ pensions led to social safety nets, measures like the G.I. Bill and V.A. home loans were adopted, unions grew stronger, and tax benefits for the wealthy withered.
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If a vaccine saves lives, many Americans may become less suspicious of conventional medicine and more accepting of science in general — including climate change
