April, May, and beyond, Part 2: What do we do about the big picture?
In my last post I outlined what I think is coming over the next few months.(1) In the short term, we have implemented sufficient social distancing in much of the U.S. such that most areas will see a peak in COVID-19 cases and deaths sometime in April/May followed by a gradual decline in daily cases and deaths. Shortly after the peaks, our elected officials and public health departments will start getting substantial pressure to relax social distancing measures and let things get ‘back to normal.’ Unfortunately, the decline in COVID-19 cases we hope to see in a few months is not the end of the pandemic — it’s just the first wave. Until the majority of the population (50-80%) is immune from natural COVID-19 infection or a vaccine, we will need to continue to manage our response carefully. We cannot just go back to our prior lives.
If we ignore the past, we will repeat it. If we relax social distancing willy-nilly once we’re past this first peak, we’ll see a resurgence in cases within 2-3 weeks and a resurgence in deaths in 3-6 weeks. Then we can go back to the current social distancing, until we pass the next peak, and again, and again.
We can choose to go through this chaotic see-saw that will lead to more deaths and more social and economic disruption until we get a vaccine, or with work and collaboration, we can figure out another path.
The options we don’t want
We don’t want to let the COVID-19 pandemic run its course unchecked. The number of deaths would be substantial (probably more than 100 million globally) and the human, social, and economic impacts would be tremendous.(2) While this approach would probably lead to the pandemic being over in about 6 months, I think it’s obvious why we don’t want to take that route.
We could go in the opposite direction and double down on everything we’re doing already — implement even stricter social distancing, declare fewer businesses ‘essential’ — until we get a vaccine. This would be quite effective at preventing new infections and there would be many fewer deaths, but our economies would probably collapse and all the other critical aspects of our lives would fall apart. This is not a route we want either.
We have to find the middle ground between these two extremes. It’s clear that COVID-19 is going to be running our lives in some form or fashion for months, probably years, and we have to figure out a way to do more than just survive during this time. Thriving might be beyond what we can manage for the next year or two but we can do better than just holding on by the skin of our teeth.
A way forward
We have numerous tools that we are using (e.g., social distancing, school closures, travel restrictions, face masks, etc.) and others that we haven’t explored yet (e.g., digital contact tracing, stricter enforcement of isolation and quarantine orders, immunity passports). When considering which of the tools we should keep using, sometimes the answer is obvious. Encouraging everyone to wash their hands regularly and wear cloth masks has minimal negative impacts and is probably helpful, so those should continue. Healthcare workers have more exposure to COVID-19 than anyone else, so reserving N95s, surgical masks, and other personal protective equipment for healthcare workers until we have ample supplies ensures that we have the capacity to handle a second wave when it happens. This should also continue.
When we consider community-level interventions, the next steps are less clear. School closures are one good example of the challenges. Children generally have worse hygiene than adults and often transmit viruses easily (as any parent with kids in daycare knows). On the other hand, children are less likely to get severe COVID-19 infection which may impact their likelihood of passing this particular virus on to others. We also know that keeping schools closed has substantial negative impacts on society. Not only are children not learning, many are losing access to food and other necessary resources, and many parents are unable to work if their kids aren’t in school. So perhaps reopening schools is a logical place to start as we figure out how to move forward.
But there remain many unanswered questions. If we decide to reopen schools, do we start with elementary schools, middle schools, or high schools, or maybe daycare instead? Do we reopen all schools nationwide at the same time or in one limited area? Do we allow after-school sports or clubs? What about the teachers and students who have high-risk medical conditions and shouldn’t be exposed to COVID-19? Is there sufficient hand sanitizer to supply all the classrooms? Should teachers wear masks in the classroom? There are no clear answers to most of these questions but they all need to be resolved before we can take the next steps.
Every single intervention we have implemented, and new ones that we’re starting to consider, has a similar set of questions that need to be answered before we can determine what’s next. For every measure we consider rolling back, we must consider the following:
How much impact does the measure have on decreasing COVID-19 infections? (the benefits)
How large are the negative impacts of the measure on humans, psychologically, socially, and economically? (the harms)
What are the alternatives and the associated benefits and harms of those? Have those been tried in other areas and to what effects?
How do the benefits, harms, and alternatives compare to other measures we’re considering rolling back? (e.g., school closures versus restaurant closures)
What is the best timeline and what are the best geographic areas to apply the change to? Can we do a trial run for a limited time or in a limited area to see what happens?
What could be done to minimize the potential increase in COVID-19 transmission that results from rolling back some aspects of social distancing?
Are we prepared for a surge in cases if we do this? Are our hospitals ready with sufficient staff and equipment? Do we have enough public health workers to investigate cases and monitor contacts? Is there sufficient testing? Can areas that remain more restricted provide surge capacity to the area doing the trial run?
How will we continue to protect people who are at high risk of severe COVID-19 illness?
Can we capture the data from the experience so that it can be used to inform future decisions?
Are we prepared to reinstitute the measure if it doesn’t go well?
Many researchers are already tackling these questions through modeling (Prem et al, Ferretti et al, Anderson et al, Ferguson et al to identify a few) and some have proposed specific quantitative methods to guide the decision making process, but much of the time we are going to be experimenting. That is not a comfortable place to be. It means moving slowly and carefully, and being prepared to make mistakes. Mistakes will not be trivial -- they will lead to deaths. This is not completely avoidable and we all need to recognize that our way forward from here is not an easy one.
This approach requires close and careful coordination among scientists, elected officials, communities, and businesses to determine how to move forward. It also requires that we as community members support these plans, do our part in them, and forgive our leaders and ourselves when we make mistakes.
Coming next: What can we do as individuals?
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1) I’m primarily writing from the perspective of the U.S. although the basic principles and concepts I discuss apply to almost every country.
2) To help wrap your head around the scale of that, consider this. As of April 5, approximately 1.2 million people have been infected worldwide. Even if we assume that’s off by a factor of five because of insufficient testing, that’s still less than 0.1% of the world’s population. In an unchecked COVID-19 pandemic, we expect 50-70% of the world to get infected — we have barely even dipped our toe in that pool.