The rise in Covid-19 cases and deaths in America during the summer is the result of a toxic mix of factors: reopening of states, block fatigue, and a season typically filled with holidays and holidays like Memorial Day and 4th July. People gathered and celebrated at home: bars, restaurants, friends and families. Millions of people have fallen ill and tens of thousands have died.
This fall, experts fear it will happen again: States are lifting restrictions, people are anxious to get back to normal, and Thanksgiving and Christmas are coming. America may be on the verge of repeating the same mistakes, which would risk yet another rise in the Covid-1
Coronavirus cases have already increased since mid-September. On September 12, the United States hit a recent low in the seven-day case average of around 35,000. As of September 26, it was back to nearly 45,000. The surge doesn’t appear to be led by any particular state – although some, like the Dakotas, are doing pretty badly – but rather it ramps up across much of the country all at once. (Greater testing capacity is likely to detect more cases as well.)
Part of the problem is that America has never really suppressed its Covid-19 cases to begin with. Think of a disease epidemic like a bushfire – it will be really hard to contain the virus when there are still flames raging in parts of the forest and small embers pretty much everywhere. The country always risks a riot at every step towards reopening and every inability to take precautions seriously.
Consider Florida. This month, the state reopened bars and, more recently, restaurantsdespite the high risk of these interior spaces. The last time Florida opened bars, in June, experts said the establishments were largely responsible for the massive Covid-19 outbreak in the summer. As Florida reopens now, it has about two to three times the number of Covid-19 cases it had in early June, and its test-positive rate suggests that there are likely still many cases missing. The state is blowing on the flames while its most recent fire is nowhere near extinguished.
This is, in fact, what much of the country is doing as it rushes to reopen schools, especially colleges and universities, and risky indoor spaces. Along with the recent Labor Day celebrations, experts fear this is already leading to a new wave of Covid-19 cases.
President Donald Trump, for his part, has encouraged swift reopening. From his “TO FREE” Tweets in the spring of his recent requests to reopen schools, Trump has continued his efforts to bring society back to normal even as the coronavirus continues to spread and kill people in the United States.
Autumn and winter threaten to make things worse. Schools will continue to reopen. The cold in the northern parts of America will push people back indoors, where the virus spreads much more easily than in the open air. Families and friends will get together for the holidays. A flu season could put a strain on the health system.
States are once again starting to reopen more widely as officials face pressure from companies to reopen indoor dining before colder temperatures make outdoor activities less viable. Experts fear that Americans as a whole will grow weary of social distancing now that the country is more than six months away from its battle against Covid-19.
“This time it’s less excusable,” Crystal Watson, senior scholar at the Johns Hopkins Center for Health Security told me. “We have an example of what happens when we reopen this type of business for indoor activities.”
The good news is that there is still time for action. Cities, states and the country as a whole could again take social distances seriously. They may require masks where they are not already mandatory. They could close bars and restaurants, backing these activities with a bailout, to prioritize keeping K-12 schools open while reducing other risks. Colleges and universities could ease the demands for in-person teaching or at least take aggressive testing and tracking measures to mitigate the risks of causing further Covid-19 outbreaks.
Without these steps, autumn and winter epidemics could end worse than summer and potentially spring as well. This could mean not only more infections and deaths, but also another setback in America’s hopes of returning parts of life closer to normal.
“If you do things right, you can do them,” Cedric Dark, an emergency medicine physician at Baylor College of Medicine, told me. “If you do them wrong, you’ll get cases.”
We keep making the same mistakes
After spring epidemics hit the northeastern United States, much of the country, led by conservative states like Arizona, Florida and Texas, has gone on with aggressive reopening. The problem, experts said, is that many of these places have never suppressed their Covid-19 outbreaks. As epidemiologist Pia MacDonald of RTI International told me at the time, many states “never got to the plate.” Case counts continued to rise and states still continued to reopen.
This created an environment that made COVID-19 much easier to spread. If community transmission is already in progress, one person is simply more likely to infect another. Add more spaces where infections are very likely – especially neighboring interior spaces like bars and restaurants – and the risk can be greatly increased.
Today, the United States appears to be heading in the same direction. Although cases have declined overall since late July, they have stabilized at – and recently started to rise – a point that was still above the peak of Covid-19 cases in the spring (partly, but probably not entirely, attributable to to further tests). Yet many states are proceeding with reopening once again.
So MacDonald is now repeating the same thing he told me this summer: “We never got to low enough levels [of Covid-19] to begin with in most places. “
Of particular interest is the indoor dining in restaurants and bars, which are reopening at various levels across the country. Experts define these settings as perhaps the worst imaginable spaces for the spread of Covid-19: people are close to each other for long periods of time; cannot wear masks while eating or drinking; the air cannot dilute the virus as it can outdoors; and alcohol could cause people to let their guard down even further. It has been a recognition of all these risks that has led many states to downsize and close indoor restaurants and bars during the summer outbreaks.
This time, however, there is another big variable: schools are reopening. Some places have even reopened, or planned to reopen, schools alongside indoor bars or restaurants, making it difficult to separate the effects of both and potentially aggravate new outbreaks.
There have already been reports of outbreaks in K-12 facilities, where students and teachers can potentially transmit the coronavirus to each other in the classroom. But there’s still a lot we don’t know about how younger children, particularly in elementary schools, spread the virus.
Some experts have raised more serious concerns about colleges and universities. Students at these institutions aren’t just potentially spreading the coronavirus in their classrooms, though this is likely to happen to some degree. They also show up in indoor bars, clubs and restaurants, party in dorms, and drink a lot more than they should.
“College kids are college kids,” Carlos del Rio, executive associate dean of Emory University School of Medicine, told me. “This is what I always tell every university president I speak to: you can make all the plans you want, but in the end it is what happens outside of your plans that matters.”
The good news, for now, is that infections in colleges and universities distort young people and that young people are less likely to suffer from major complications, including deaths, from Covid-19. This helps explain, along with general improvements in treatment, why daily Covid-19 deaths have still been declining since August (although they are still more than 700 per day in the US).
But young people can still get seriously ill and die from the coronavirus – and if enough of them get infected, that could result in higher death tolls eventually. Even if that doesn’t happen, young people will likely interact with their teachers, parents, and grandparents at some point, potentially infecting them. This could produce another summer-like result: outbreaks began first among youth groups, but eventually spread to older populations who were more susceptible to disease and death.
After the summer peaks, Brown University School of Public Health principal Ashish Jha said to me, “I was like, ‘Okay, now we’ve all been through this – every part of the country: the South, the West, the Midwest, the Northeast. There is no more denial that it will work, because there has been this long denial while it has been there but not here. ‘”Yet, he said,” we are starting to see it again. “
He added: “At this point, I feel like I clearly no longer understand why our country cannot learn its lessons and why we keep repeating the same mistakes.”
Autumn and winter are coming
For months, experts feared that autumn and winter would lead to more outbreaks, citing, as a contributor, the reopening of schools. This appears to be happening now, as cases begin to creep in nationwide, with outbreaks reported in primary schools, colleges and universities across the United States.
But things could still get worse.
People are bound to get more tired with social distancing and the pandemic more generally as time goes on. As the months have passed since the last huge wave of Covid-19 in the United States, people are more likely to convince themselves that it’s safe out there. If this happens, more people may end up going out and putting themselves in dangerous situations, infecting each other along the way.
At the same time, colder temperatures, particularly in the northern parts of the United States, will more likely drive people indoors, where the virus is much more likely to spread thanks to poor ventilation. (On a plus side: this could have the opposite effect in the southern parts of the country, where temperatures will become less unbearably hot, so the outdoors may actually become more tolerable.)
As Thanksgiving begins, followed by Christmas, Hanukkah, and New Year’s Eve, families and friends are likely to gather from all over the country. This includes college and university students, who may be returning home from Covid-19 hotspots to their dorms or classrooms.
If you put it all together, there is a real risk of a truly nationwide Covid-19 epidemic. As people gather from across the country and return home and school, they risk carrying the disease beyond local and state borders. This could lead to a much more dispersed – and possibly larger – coronavirus outbreak than the US has seen so far.
“People will bring it back over Thanksgiving, over Christmas, over the winter holidays,” Dark said. “This is a disease that has an incubation period of up to two weeks. So it’s not really safe to say, ‘Okay, I’ll go home and come back.’… By the time you develop symptoms, you’ve already exposed your parents. “
Additionally, another flu season in the fall and winter could put a strain on health systems, hindering hospitals’ ability to treat patients with Covid-19 and potentially contributing to more deaths.
There are reasons to think it won’t go that bad. Perhaps since so many people have already fallen ill in the United States, there will be enough community immunity, as long as there is enough social distancing and masking, to mitigate the spread. Maybe people won’t stop taking precautions after seeing 200,000 deaths from Covid-19 in the United States. Perhaps social distancing and COVID-19 cloaking will keep another flu season at bay, as seemed to be happening in the Southern Hemisphere.
But there is a risk. And the numbers are already going in the wrong direction.
“The next issue in the fall is likely to increase a lot,” Michael Osterholm, director of the Center for Infectious Disease Research and Policy, told me. “Probably well over 65,000, 70,000”, the previous peak of the summer. “I think this fall will be the biggest peak of all.”
We still have time to act
None of this set in stone. Experts have repeatedly told me that the US still has time to act before we see a repeat of the summer or worse.
None of the ideas for preventing this are shocking or new. These are all things people have heard before: more testing and contact tracking to isolate infected people, quarantine their closest contacts, and implement broader restrictions if needed. More masking, including mandates in the 16 states that don’t yet have one. More careful and gradual reopening.
This is what has worked in other countries, from Germany to South Korea to New Zealand, to contain the outbreaks. That’s what the studies support: as a review of the research published in The Lancet found, “the evidence shows that physical distance of more than 1m is highly effective and that face masks are associated with protection, even in non-health settings.”
It is also what worked in the United States. After suffering massive epidemics in the spring, states like New York and Massachusetts have suppressed the coronavirus with such policies. Cities, such as San Francisco, have avoided nasty epidemics entirely with similar efforts. Individual universities, such as the University of Illinois Urbana-Champaign campus, have also seen promising early results with aggressive testing and tracking. (The federal government would ideally be in charge of all of this, but Trump has generally directed the pandemic to states to resolve it.)
“There is no mystery as to what causes new cases,” Nahid Bhadelia, an infectious disease physician and medical director of Boston University School of Medicine’s Special Pathogens Unit, told me. “We have to make compromise choices.”
Much of the problem goes back to a careful reopening process. For this, some experts have indicated a budget model. The goal is to keep the spread of the coronavirus low enough so that each new infection does not always lead to more infections, causing the country to slip to zero cases over time. In other words, the goal is to keep the actual reproduction number, or R0 or Rt in scientific jargon, below one. Within that limited budget of an R0 or Rt of less than one, states can try to reopen some places but not all.
Anything that reopens will add to the infection rate. Some places can have minimal, even negligible effects, such as parks. Some are bigger threats, like indoor bars and dining. And some may carry potentially high risks but still seem worth it to the community for their social benefits, like schools.
The goal, then, is to balance a reopening – do it slowly, making it possible to see the effects of each additional step – to make sure that outbreaks don’t get out of hand. Ultimately, it may be necessary not to open indoor bars or lunches, perhaps ever, so that schools and other socially crucial places can open. At the same time, the government could offer closed businesses a bailout or other financial support.
“For us, as a society, to be able to send children to school, we have to make difficult decisions and sacrifices in other areas,” Jorge Salinas, an epidemiologist at the University of Iowa, told me. “We can’t have it all.”
Other steps could also help build a larger budget. More testing, tracking, and masking, for example, could further reduce the infection rate in a community, regardless of what else is going on.
By striking this balance, the country can not only avoid more infections and deaths, but potentially an epidemic can become so severe that it requires another lockdown. Although experts all agreed that there is currently no political appetite for a blockade, a massive increase in the fall and winter could leave the United States with no other choice. Israel, for example, closed its doors until early October at the earliest after experiencing a massive increase in cases.
The reality is that the United States is likely not to return to normal until it defeats the virus through a vaccine or similar treatment, a process that could take months or years, even after a vaccine is proven safe and effective, as the country and the world are to scale to increase distribution to actually achieve sufficient levels of immunity within the population.
But maybe the United States will continue to get away with it, or worse. The country has already shown a much higher tolerance for Covid-19 cases and deaths than the rest of the developed world. Trump, for his part, seems pleased with that – recently stating that the coronavirus “affects virtually no one” and shows no interest in changing his non-intervention approach.
If that holds up, America could suffer tens of thousands of more predictable and preventable deaths, on top of the 200,000 Covid-19 deaths it has already seen.