When will this all be over?!?

This post will attempt to answer the following questions:

1. Is this almost over?
2. What has to happen to get us back to normal?
3. When will that be?

There has been some encouraging news lately about the number of new cases of coronavirus in the US. There seems to have been a leveling off of new cases, certainly a result of the social distancing and lock down measures we all have been enduring. This by no means is a sign that we are out of the woods. We need to see sustained declines in new cases for a few weeks before we can breathe easier. The problem we all are feeling acutely is that, even as the social distancing becomes more effective it also becomes more painful. There are already reports of people starting to rebel and defy the restrictions which will likely be an increasing problem as things drag on. The restrictions cannot last forever and need to be eased at some point but this raises questions of how and when.

The main problem is that the virus will not be eradicated. It is still going to lurk on surfaces and in noses around the world, perhaps passed around among the asymptomatic. The upper estimates are that 10% of the population has been infected leaving 90% vulnerable and nowhere near the necessary numbers to lead to herd immunity. As you surely remember, this virus is highly contagious and spreads like wildfire faster than you can say quarantine. It can go from hundreds to hundreds of thousands in a very short period of time (for an explanation of how this happens read this). This means that, if restrictions are not eased correctly and intelligently, we’ll be right back where we started in short order. Current estimates are that it would take about three weeks to be back in full strength if we slip up. Even if the return to normal is done well it is certain that there will be flare ups periodically. This has been referred to as “The Hammer and The Dance“. We are currently dealing with being struck by the strict restrictions of the hammer but will need to start dancing with this virus until a vaccine is available.

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This means that, if restrictions are not eased correctly and intelligently, we’ll be right back where we started in short order.

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The goal then is for there to be sound public policy that eases restrictions in a way that ameliorates the economic pain while keeping the resurgences of the virus under control. There are a few steps that need to be put in place before we can go back to our lives safely.

The first, and probably most important, is testing that is sufficient in quantity and reliable in accuracy. There needs to be testing to identify who is sick and who is immune (I explained the different types of testing previously). Testing will be vital because we need to quickly identify who is sick so we can isolate them and quarantine their contacts. We also need antibody testing to determine who is immune to help us identify who was infected previously and hopefully impervious to reinfection. Implicit in better testing is more research to clarify how and for how long immunity lasts. When we reach a certain percentage of the population that has been infected we can rely on herd immunity to allow us to be more lenient with restrictions.

Better testing will hopefully also lead to better identification and modeling to allow us to have focused isolation efforts as opposed to the shotgun approach we have now. It will prevent hospitals from becoming overwhelmed by identifying sick hospital workers who, if out, could lead to major staffing shortages and who also can act as vectors for the spread of the disease. I have outlined a suggestion for how to help bring people back to work safely and this idea is starting to spring up in various forms around the globe. As we stand currently there is not nearly enough testing to prevent a major resurgence. We still don’t have accurate information about the prevalence of the disease. The most recent guidelines from the White House endorse more testing, isolation, and contact tracing but do not specify how these measures will be implemented, paid for, or how long it will take to be put in place.

Next, we need better treatment. We need to know as doctors how best to treat this condition. Which drugs work for which populations. Which ventilator strategies work best in each situation. If we can figure out how to get folks off of ventilators and out of the hospital faster and more safely it will allow the hospitals to treat more patients without getting overwhelmed.

Finally there needs to be a better logistical plan. We continue to have problems with adequate supplies of necessary medications and personal protective equipment. We are not only short on potential treatments for the virus itself but are also running out of other crucial medications we use in the ICU. When we don’t have access to these medications it becomes harder to effectively treat patients which leads to more deaths and longer time taking up valuable hospital beds.

The best-case scenario would be one where an army of testers and trackers would be deployed. It has been estimated that we will need up to 300,000 (the CDC now has 600). Data would be closely monitored for spikes in cases. This would then lead to targeted short term isolation with the strictest measures confined to direct contacts. We would all keep safe distances and still wear masks to help as well but would return to work to start the economy up again. Restrictions could then be turned off and on the way we respond to hurricanes or other trackable natural disasters. This would continue until a safe and effective vaccine is available at which time this nightmare will be behind us and we can start rebuilding.

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The worst-case scenario is one where we haphazardly release people back to normal life in an uncoordinated and unconditional manner.

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The worst-case scenario is one where we haphazardly release people back to normal life in an uncoordinated and unconditional manner. The virus would then spread exponentially again overwhelming our hospitals and necessitating another draconian lockdown which would be catastrophic economically, medically, and psychologically for everyone. Our hospitals and nursing homes are already running on fumes with nothing in the reserve tank. Fatality rates depend heavily on how overwhelmed hospitals get. Currently several New York hospitals are on the verge of total chaos.

We really need to get this right. Other countries around the world are figuring this out but it seems that compliance on the necessary scale goes against our American cultural DNA that favors liberty and rugged individualism. This has led to us falling behind the world in our response with disastrous results. We are now the epicenter of this global crisis with no signs of that changing any time soon. We have a patchwork state centered response without clear coordinated leadership and it’s just not working. Somebody needs to right the ship.

Until that happens we all must continue to do what we are doing to halt the spread. The good news is that it is making an impact, for now…

For more read

• Our Pandemic Summer from The Atlantic.
• When and How to Reopen from former CDC director Dr. Thomas Frieden
• The Coronavirus in America: The Year Ahead from the New York Times