Urban Mirror

By Michael T. Osterholm and Mark Olshaker (Foreign Affairs)

In our essay “Chronicle of a Pandemic Foretold,” for the July/August issue of Foreign Affairs, we described the struggle against COVID-19 in terms of a baseball game and estimated that the United States was in about the third inning of a nine-inning contest. At this point, however, it may be more helpful to shift to an altogether different analogy. The unfolding story of the pandemic is a three-act play, in which the country is now midway through the second act.

The first act saw the disease spread from China to the rest of the world and to a woefully unprepared United States. The second witnessed Americans tire of restrictions and effectively surrender to the pandemic. Infection rates across the country soared during the summer and will likely rise again in the autumn as schools and universities reopen. To truly get the novel coronavirus under control, the United States must do what it has not done so far: impose real and stringent lockdowns across the country for roughly two months. Controlling the spread of the disease in this way will save lives ahead of the eventual end of this drama in the pandemic’s final act—the arrival of a safe, effective vaccine.

THE CURTAIN RISES
Act I opened in late 2019 with the emergence in China of a novel coronavirus that spread throughout much of the world with breathtaking speed and effect. Nations and regions faced the challenge in different ways and with varying levels of success. After a horrendous start, for example, Italy managed to get transmission substantially under control by imposing a near-complete shutdown of the northern part of the country. In the United States, both New York City and New York State saw catastrophic levels of infection that overwhelmed the entire health-care system. It is difficult to forget the images of refrigerated trailers sitting outside hospital emergency rooms to accommodate the dead. But under the leadership of Governor Andrew Cuomo—and thanks to a coordinated state public health response—New York locked down to get the number of cases to a manageable level and then maintain the low numbers, turning a disaster into a model for the rest of the United States.

The issue of testing loomed over Act I. Some Asian nations that had experience with SARS began widespread testing of possible cases early and therefore were able to do contact tracing and largely control viral transmission. The United States did not do that. The White House denied the potential seriousness of the coronavirus (allegedly in a bid to prevent “panic”), while the Centers for Disease Control and Prevention (CDC) developed a test for national use that was faulty, leaving the virus difficult to track and making case isolation and contact tracing ineffective as a means to control transmission. That forced the country onto a much more disruptive path: an attempt to control and mitigate the virus’s effects through a national lockdown of all nonessential personnel.

The price was steep, with millions of jobs lost, schools closed, and all public events and gatherings officially canceled. In mid-April, the United States was seeing 32,000 new cases a day. But a month later, that figure had dropped to 22,000 and Americans felt they had turned a corner, that the pandemic was subsiding and the battle was won.

THE DISTANT PEAK
Act II of this drama began around Memorial Day weekend in late May. Pandemic fatigue had set in. Americans seemed to collectively declare, “We’re done,” taking any decrease in daily case counts or deaths as a sign that the virus had been curtailed. The warm-weather months drew people into social settings, and the White House and a host of pundits encouraged this natural yearning to get back to business—and leisure—as usual. The administration and its allies posited a zero-sum choice between continuing to slow transmission of the disease and saving the economy. In fact, the country had the fire only under limited control, and if you stop fighting a fire at that point, it will naturally flare up again and continue to burn.

By July 20, with people resuming socializing in large groups, the country’s daily new case count shot up to more than 66,000. It should be noted that the many protests that followed the death of George Floyd in late May did not contribute much to the spread since the demonstrations occurred outdoors, where the virus rapidly dissipates in the air. The spring weekend beach gatherings of young people, by contrast, led to more serious transmissions because revelers often ended up indoors, particularly in close and crowded confines such as bars and houses.

The rate of daily new cases dipped to a little over 42,000 by the end of August, largely because of major containment efforts in California, Florida, Georgia, and Texas. As encouraging as that was on the face of it, the United States was still seeing about 1,000 COVID-19-related deaths per day, hardly a victory by any standard. Americans can expect these crests and troughs in new infections to continue, with each successive peak higher than the one before, until either an effective vaccine becomes widely available or herd immunity is established in the population through person-to-person transmission.
Herd immunity is often discussed but widely misunderstood. Each infectious disease has a different threshold for what percentage of a given population must be immune before the rate of transmission begins to drop. For a highly infectious agent transmitted through the air, such as measles, that percentage can be as high as 95 percent. For COVID-19, most public health infectious disease experts estimate it to be between 50 and 70 percent. One theory holds that the best way to approach the virus is to try to achieve herd immunity as quickly as possible through natural infection so everything can get back to normal, while protecting the older and most vulnerable people. This is the method seemingly employed by Sweden. Its transmission and mortality rates were significantly higher than those of neighboring Denmark and Norway, but the country does not appear to be substantially closer to reaching herd immunity than its Scandinavian neighbors, all of which are still far short of the threshold. Moreover, there is emerging evidence that exposure to the virus may confer only temporary immunity, possibly as brief as several months. And achieving herd immunity—if that is even possible—would only slow transmission, not halt it.

By the most liberal estimates, only about ten to 12 percent of the U.S. population has been infected thus far and, as Sweden’s experience has shown, reaching the threshold will be a long-drawn-out process that could result in the deaths of more than two million Americans. As it is, with about four percent of the world’s population, the United States has racked up about a quarter of all confirmed COVID-19 fatalities. The country failed to protect vulnerable populations, as witnessed in the many outbreaks in nursing homes and extended-care facilities. The virus has also taken a toll on young and healthy individuals; even some with mild or asymptomatic variants of the disease have become “long haulers,” who experience a range of symptoms, including chronic fatigue and cardiac and respiratory issues, weeks or months after getting infected.

SHUT IT DOWN
Herd immunity is a distant and unrealistic prospect, but Americans still have the opportunity to mitigate the suffering and death caused by the disease. The reality is that the only way for the United States to get through Act II with low levels of morbidity and mortality is through more complete lockdowns than were previously implemented in areas with high incidence of infection. Currently, the upper Midwest is the “hottest” area in the country for community-wide transmission, but other areas will see increasing case totals deeper into the fall. The aim at this point, quite simply, should be to cut transmission of the virus as much as possible until the creation and distribution of an effective vaccine.

Such lockdowns should last six to eight weeks with a goal of reaching no more than one new case per day per 100,000 people. This low rate is necessary for testing and contact tracing to have any meaningful effect. Once that rate is achieved, however, local officials will be able to adjust lockdown measures more accurately and with the flexibility the pandemic demands. If the White House and federal government will not lead, which is unfortunately likely under the current administration, the governors of each state, in coordination with their neighboring states, must take the initiative themselves. Some might think this is unrealistic, but New York has been able to maintain this low rate of new infections for the past three months.

Stringent lockdowns, of course, would depend on the continued labor of essential workers, a category we estimate to be no more than 35 percent of the workforce and possibly less. What about other workers? As part of its broader anti-COVID-19 strategy, the federal and state governments should compensate both individual workers and small businesses that suffer substantial or irreparable economic loss as a result of lockdowns. Such support negates the false choice between public and economic health. If carried out successfully, the near-complete shutdowns would be not open-ended but limited in time. And the government has the means to prop up adversely affected workers and businesses. As Minneapolis Federal Reserve Bank President Neel Kashkari outlined in an op-ed in The New York Times cowritten with one of us (Osterholm), this fiscal obligation could be covered by the money most Americans who have not lost income are saving by not spending as much during the pandemic—the personal savings rate of Americans has grown from eight percent in January to 20 percent in August. Domestic savings can fund investment in the national economy, a concept that should work equally well in other developed nations. Banks, whose holdings have been boosted by the additional savings, could loan the money necessary for protecting jobs and businesses; Americans would essentially be repaying themselves rather than taking the more traditional route of incurring foreign debt. We believe many people would support a more robust lockdown if they understood that they would not suffer financially. Such a subsidy will actually save money in the long term by preserving jobs and small businesses.

The alternatives to serious lockdowns are insufficient. In areas where the disease is still rampant, masks and physical distancing alone will not get the job done. Business as usual for another six to eight months—until an effective vaccine is widely available—will send current rates of transmission even higher, especially as schools and colleges reopen. By the middle of September, some universities had already canceled in-person classes owing to widespread transmission on campus. Consider how much pain, suffering, and death Americans have endured so far, with no more than ten to 12 percent of the population infected. The next phase could be overwhelming and make Americans look back with nostalgia at the time when new infection rates were still under 100,000 per day.

A DIFFICULT DENOUEMENT
The final act will begin when—and if—one vaccine or more becomes broadly available. A vaccine will eventually bring this long drama to an end, but it will raise a whole new set of questions. Will enough Americans be willing to take it, given our national schizophrenic view of vaccines and science in general? How effective will a vaccine be, and how long will it confer immunity? What will the rules be for approving the vaccine, in the United States and the rest of the world? Who should, or will, get it first? There has been little official or public discussion about answers to these important questions.

It would be dangerous if a possible vaccine became politicized, either to achieve power, prestige, and influence for the country that produces it or to gain partisan advantage within the United States. Many in the public health sphere are afraid that a vaccine will be made available for use before it has been demonstrated to be safe and effective. Never before has the authority and confidence in U.S. government scientific institutions been so undermined by real or perceived political pressure from the White House. At the beginning of September, the CDC directed localities to prepare for the distribution of a vaccine in two months, at the beginning of November, right around the time of the presidential election. One possible mechanism for this expedited rollout would require the president to direct the Food and Drug Administration or the secretary of the Department of Health and Human Services to grant Emergency Use Authorization for a vaccine candidate that looks promising but has not been through the entire validating process.

There is indeed an inescapable tension between wanting a vaccine as soon as possible to prevent further transmission of the disease (and the resulting illnesses and deaths) and taking the necessary time to produce a safe vaccine, whose efficacy and effects on people of various ages and health situations are well understood. But public health and political officials should be extremely wary of any attempt to grant Emergency Use Authorization to a vaccine that hasn’t completed phase three trials, the final and most rigorous stage in which the product is tested over a broad range of thousands of subjects. In most instances in which such authorization is granted, it is for extremely sick or even dying patients. In this case, it would be granted to administer a vaccine to healthy people before the formula is perfected and before any potential negative effects have been documented. In 1955, one company’s production of the original Salk polio vaccine turned out to be defective, causing 40,000 cases of polio. Ten children died. In 1976, a rush to produce a vaccine against a perceived threat of swine flu left approximately 450 recipients with Guillain-Barré Syndrome paralysis.

One of the key reasons for a full phase three review, which includes at least 30,000 test subjects in a double-blind administration (meaning neither the subject nor the administrator knows who has been given the vaccine and who has been given a placebo), is to determine the vaccine’s impact and effects, positive and negative, on a range of different risk groups. What might be safe and effective for young adults, for example, might be ineffective or even harmful for seniors or those with certain underlying conditions. It is also possible that the effect on children could be different or unpredictable. These results will probably take months to sort out. Even more troubling, present plans do not call for either children or the elderly to be included in the phase three test group. Moreover, the first vaccines for this virus probably won’t be home runs (to go back to baseball analogies for a moment) like the smallpox, polio, and measles vaccines. They are more likely to be singles and doubles like the annual influenza vaccine, which in a good year is about 50 percent effective. Americans won’t be going back to the “old normal” anytime soon.

The best outcome in Act III will be the development and distribution of the vaccine as quickly and widely as possible, without shortcuts on safety or testing for effectiveness. The U.S. government should establish and publicize the criteria by which a vaccine will be considered ready for wide-scale public use as well as make clear which groups of people will receive the vaccine first. A proven safe and effective vaccine should first be given to physicians, hospital personnel, and first responders; then to essential workers with underlying risks for serious disease; and after that, to children so that they can stay in school.

But right now, the United States should just be trying to get through the rest of Act II—the coronavirus winter—and hold out until the arrival of a vaccine-enabled spring. It must impose severe lockdowns to truly curb the spread of the disease. New York has shown it can be done. It remains to be seen whether the rest of the country possesses the collective grit and determination to follow suit. A happy ending to this drama will very much be determined by how Americans decide to craft the rest of this current act.

MICHAEL T. OSTERHOLM is Regents Professor and Director of the Center for Infectious Disease Research and Policy at the University of Minnesota. ARK OLSHAKER is a writer and documentary filmmaker. (Courtesy/with thanks: Foreign Affairs)