America Is Trapped in a Pandemic Spiral

https://www.theatlantic.com/health/archive/2020/09/pandemic-intuition-nightmare-spiral-winter/616204/

America Is Trapped in a Pandemic Spiral - The Atlantic

As the U.S. heads toward the winter, the country is going round in circles, making the same conceptual errors that have plagued it since spring.

Army ants will sometimes walk in circles until they die. The workers navigate by smelling the pheromone trails of workers in front of them, while laying down pheromones for others to follow. If these trails accidentally loop back on themselves, the ants are trapped. They become a thick, swirling vortex of bodies that resembles a hurricane as viewed from space. They march endlessly until they’re felled by exhaustion or dehydration. The ants can sense no picture bigger than what’s immediately ahead. They have no coordinating force to guide them to safety. They are imprisoned by a wall of their own instincts. This phenomenon is called the death spiral. I can think of no better metaphor for the United States of America’s response to the COVID-19 pandemic.

The U.S. enters the ninth month of the pandemic with more than 6.3 million confirmed cases and more than 189,000 confirmed deaths. The toll has been enormous because the country presented the SARS-CoV-2 coronavirus with a smorgasbord of vulnerabilities to exploit. But the toll continues to be enormous—every day, the case count rises by around 40,000 and the death toll by around 800—because the country has consistently thought about the pandemic in the same unproductive ways.

Many Americans trusted intuition to help guide them through this disaster. They grabbed onto whatever solution was most prominent in the moment, and bounced from one (often false) hope to the next. They saw the actions that individual people were taking, and blamed and shamed their neighbors. They lapsed into magical thinking, and believed that the world would return to normal within months. Following these impulses was simpler than navigating a web of solutions, staring down broken systems, and accepting that the pandemic would rage for at least a year.

These conceptual errors were not egregious lies or conspiracy theories, but they were still dangerous. They manifested again and again, distorting the debate around whether to stay at home, wear masks, or open colleges. They prevented citizens from grasping the scope of the crisis and pushed leaders toward bad policies. And instead of overriding misleading intuitions with calm and considered communication, those leaders intensified them. The country is now trapped in an intuition nightmare: Like the spiraling ants, Americans are walled in by their own unhelpful instincts, which lead them round and round in self-destructive circles.

“The grand challenge now is, how can we adjust our thinking to match the problem before us?” says Lori Peek, a sociologist at the University of Colorado at Boulder who studies disasters. Here, then, are nine errors of intuition that still hamstring the U.S. pandemic response, and a glimpse at the future if they continue unchecked. The time to break free is now. Our pandemic summer is nearly over. Now come fall, the season of preparation, and winter, the season of survival. The U.S. must reset its mindset to accomplish both. Ant death spirals break only when enough workers accidentally blunder away, creating trails that lead the spiraling workers to safety. But humans don’t have to rely on luck; unlike ants, we have a capacity for introspection.

The spiral begins when people forget that controlling the pandemic means doing many things at once. The virus can spread before symptoms appear, and does so most easily through five P’s: people in prolonged, poorly ventilated, protection-free proximity. To stop that spread, this country could use measures that other nations did, to great effect: close nonessential businesses and spaces that allow crowds to congregate indoors; improve ventilation; encourage mask use; test widely to identify contagious people; trace their contacts; help them isolate themselves; and provide a social safety net so that people can protect others without sacrificing their livelihood. None of these other nations did everything, but all did enough things right—and did them simultaneously. By contrast, the U.S. engaged in …

1. A Serial Monogamy of Solutions

Stay-at-home orders dominated March. Masks were fiercely debated in April. Contact tracing took its turn in May. Ventilation is having its moment now. “It’s like we only have attention for only one thing at a time,” says Natalie Dean, a biostatistician at the University of Florida.

As often happens, people sought easy technological fixes for complex societal problems. For months, President Donald Trump touted hydroxychloroquine as a COVID-19 cure, even as rigorous studies showed that it isn’t one. In August, he switched his attention to convalescent plasma—the liquid fraction of a COVID-19 survivor’s blood that might contain virus-blocking antibodies. There’s still no clear evidence that this century-old approach can treat COVID-19 either, despite grossly misstated claims from FDA Commissioner Stephen Hahn (for which he later apologized). More generally, drugs might save some of the very sickest patients, as dexamethasone does, or shorten a hospital stay, as remdesivir does, but they are unlikely to offer outright cures. “It’s so reassuring to think that a magic-bullet treatment is out there and if we just wait, it’ll come and things will be normal,” Dean says.

Other strategies have merit, but are wrongly dismissed for being imperfect. In July, Carl Bergstrom, an epidemiologist and a sociologist of science at the University of Washington, argued that colleges cannot reopen safely without testing all students upon entry. “The gotcha question I’ve handled most from reporters since is: This school did entry testing, so why did they get an outbreak?” he says. It’s because such testing is necessary for a safe reopening, but not sufficient. “If you do it and screw everything else up, you’ll still have a big outbreak,” Bergstrom adds.

This brief attention span is understandable. Adherents of the scientific method are trained to isolate and change one variable at a time. Academics are walled off into different disciplines that rarely connect. Journalists constantly look for new stories, shifting attention to the next great idea. These factors prime the public to view solutions in isolation, which means imperfections become conflated with uselessness. For example, many critics of masks argued that they provide only partial protection against the virus, that they often don’t fit well, or that people wear them incorrectly. But some protection is clearly better than no protectionAs Dylan Morris of Princeton writes, “X won’t stop COVID on its own is not an argument against doing X.” Instead, it’s an argument for doing X along with other measures. Seat belts won’t prevent all fatal car crashes, but cars also come with airbags and crumple zones. “When we layer things, we give ourselves more wiggle room,” Dean says.

Several experts I’ve talked with have been asked: What now? The question assumes that the pandemic lingers because the U.S. simply hasn’t found the right solution yet. In fact, it lingers because the familiar solutions were never fully implemented. Despite claims from the White House, the U.S. is still not testing enough people. It still doesn’t have enough contact tracers. “We have the playbook, but I think there’s a confusion about what we’ve actually tried and what we’ve just talked about doing,” Dean says. A successful response “is never going to be one thing done perfectly. It’ll be a lot of different things done well enough.” That resilience disappears if we create…

2. False Dichotomies

A world of black and white is easier to handle than one awash with grays. But false dichotomies are dangerous. From the start, COVID-19 has been portrayed as a disease that mostly causes mild symptoms in people who quickly recover, and occasionally causes severe illness that leads to hospitalization and death. This two-sided caricature—severe or mild, sick or recovered—has erased the thousands of “long-haulers” who have endured months of debilitating symptoms at home with neither recognition nor care.

Meanwhile, as businesses closed and stay-at-home orders rolled out, “we presumed a trade-off between saving lives and saving the economy,” says Danielle Allen, a political scientist at Harvard. “That was foolishness of the most profound degree.” The two goals were actually aligned: Epidemiologists and economists largely agree that the economy cannot rebound while the pandemic is still raging. By treating the two as opposites, state leaders rushed to reopen, leading a barely contained virus to surge anew.  

Now, as winter looms and the pandemic continues, another dichotomy has emerged: enter another awful lockdown, or let the virus run free. This choice, too, is false. Public-health measures offer a middle road, and even “lockdowns” need not be as overbearing as they were in spring. A city could close higher-risk venues like bars and nightclubs while opening lower-risk ones like retail stores. There’s a “whole control panel of dials” on offer, but “it’s hard to have that conversation when people think of a light switch,” says Lindsay Wiley, a professor of public-health law at American University. “The term lockdown has done a lot of damage.” It exacerbated the false binary between shutting down and opening up, while offering …

3. The Comfort of Theatricality

Stay-at-home orders saved lives by curtailing COVID-19’s spread, and by giving hospitals some breathing room. But the orders were also meant to buy time for the nation to ramp up its public-health defenses. Instead, the White House treated months of physical distancing as a pandemic-ending strategy in itself. “We squandered that time in terms of scaling up testing and contact tracing, enacting policies to protect workers who get infected on the job, getting protective equipment to people in food-processing plants, finding places for people to isolate, offering paid sick leave … We still don’t have those things,” says Julia Marcus, an infectious-disease epidemiologist at Harvard Medical School and regular Atlantic contributor. The country is now facing the fall with many of the same problems that plagued it through the summer.

Showiness is often mistaken for effectiveness. The coronavirus mostly spreads through air rather than contaminated surfaces, but many businesses are nonetheless trying to scrub and bleach their way toward reopening. My colleague Derek Thompson calls this hygiene theater—dramatic moves that appear to offer safety without actually doing so. The same charge applies to temperature checks, which can’t detect the many COVID-19 patients who don’t have a fever. It also applies to the porous and inefficient travel bans that Trump and his allies still tout as policy successes. These tactics might do some good—let’s not conflate imperfect with useless—but they cause harm when they substitute for stronger measures. Theatricality breeds complacency. And by emphasizing solutions that can be easily seen, it exacerbated the American preference for …

4. Personal Blame Over Systemic Fixes

SARS-CoV-2 spread rapidly among America’s overstuffed prisons and understaffed nursing homes, in communities served by overstretched hospitals and underfunded public-health departments, and among Black, Latino, and Indigenous Americans who had been geographically and financially disconnected from health care by decades of racist policies. Without paid sick leave or a living wage, “essential workers” who earn a low, hourly income could not afford to quarantine themselves when they fell ill—and especially not if that would jeopardize the jobs to which their health care is tied. “The things I do to stay safe, they don’t have that as an option,” says Whitney Robinson, a social epidemiologist at the University of North Carolina at Chapel Hill.

But tattered social safety nets are less visible than crowded bars. Pushing for universal health care is harder than shaming an unmasked stranger. Fixing systemic problems is more difficult than spewing moralism, and Americans gravitated toward the latter. News outlets illustrated pandemic articles with (often distorted) photos of beaches, even though open-air spaces offer low-risk ways for people to enjoy themselves. Marcus attributes this tendency to America’s puritanical roots, which conflate pleasure with irresponsibility, and which prize shame over support. “The shaming gets codified into bad policy,” she says. Chicago fenced off a beach, and Honolulu closed beaches, parks, and hiking trails, while leaving riskier indoor businesses open.

Moralistic thinking jeopardizes health in two ways. First, people often oppose measures that reduce an individual’s risk—seat belts, condoms, HPV vaccines—because such protections might promote risky behavior. During the pandemic, some experts used such reasoning to question the value of masks, while the University of Michigan’s president argued that testing students widely would offer a “false sense of security.” These paternalistic false-assurance arguments are almost always false themselves. “There’s very little evidence for overcompensation to the point where safety measures do harm,” Bergstrom says.

Second, misplaced moralism can provide cover for bad policies. Many colleges started their semester with in-person teaching and inadequate testing, and are predictably dealing with large outbreaks. UNC Chapel Hill lasted just six days before reverting to remote classes. Administrators have chastised students for behaving irresponsibly, while taking no responsibility for setting them up to faila pattern that will likely continue through the fall as college clusters inevitably grow. “If you put 10,000 [students] in a small space, eating, sleeping, and socializing together, there’ll be an explosion of cases,” Robinson says. “I don’t know what [colleges] were expecting.” Perhaps they fell prey to …

5. The Normality Trap

In times of uncertainty and upheaval, “people crave a return to familiar, predictable rhythms,” says Monica Schoch-Spana, a medical anthropologist at the Johns Hopkins Center for Health Security. That pull is especially strong now because the pandemic’s toll is largely invisible. There’s nothing as dramatic as ruined buildings or lapping floodwater to hint that the world has changed. In some circles, returning to normal has been valorized as an act of defiance. That’s a reasonable stance when resisting terrorists, who seek to stoke fear, but a dangerous one when fighting a virus, which doesn’t care.

The powerful desire to re-create an old world can obscure the trade-offs necessary for surviving the new one. Keeping high-risk indoor businesses open, for example, helps the virus spread within a community, which makes reopening schools harder. “If schools are a priority, you have to put them ahead of something. What is that something?” says Bill Hanage, an epidemiologist at Harvard. “In an ideal world, they would be the last to close and the first to open, but in many communities, casinos, bars, and tattoo parlors opened before them.” A world with COVID-19 is fundamentally different from one without it, and the former simply cannot include all the trappings of the latter. Cherished summer rituals like camps and baseball games have already been lost; back-to-school traditions and Thanksgiving now hang in the balance. Change is hard to accept, which predisposes people to …

6. Magical Thinking

Back in April, Trump imagined the pandemic’s quick end: “Maybe this goes away with heat and light,” he said. From the start, he and others wondered if hot, humid weather might curb the spread of COVID-19, as it does other coronavirus diseases. Many experts countered that seasonal effects wouldn’t stop the new virus, which was already spreading in the tropics. But, fueled by shaky science and speculative stories, people widely latched on to seasonality as a possible savior, before the virus proved that it could thrive in the Arizona, Texas, and Florida summer.

This brand of magical thinking, in which some factor naturally defuses the pandemic, has become a convenient excuse for inaction. Recently, some commentators have argued that the pandemic will imminently fizzle out for two reasons. First, 20 to 50 percent of people have defensive T-cells that recognize the new coronavirus, because they were previously exposed to its milder, common-cold-causing cousins. Second, some modeling studies claim that herd immunity—whereby the virus struggles to find new hosts, because enough people are immune—could kick in when just 20 percent of the population has been infected.

Neither claim is implausible, but neither should be grounds for complacency. No one yet knows if the “cross-reactive” T-cells actually protect against COVID-19, and even if they do, they’re unlikely to stop people from getting infected. Herd immunity, meanwhile, is not a perfect barrier. Even if the low thresholds are correct, a fast-growing and uncontrolled outbreak will still shoot past themPursuing this strategy will mean that, in the winter, many parts of the U.S. may suffer what New York City endured in the spring: thousands of deaths and an untold number of lingering disabilities. That alone should be an argument against …

7. The Complacency of Inexperience

When illness is averted and lives are spared, “nothing happens and all you have is the miracle of a normal, healthy day,” says Howard Koh, a public-health professor at Harvard. “People take that for granted.” Public-health departments are chronically underfunded because the suffering they prevent is invisible. Pandemic preparations are deprioritized in the peaceful years between outbreaks. Even now, many people who have been spared the ravages of COVID-19 argue that the disease wasn’t a big deal, or associate their woes with preventive measures. But the problem is still the disease those measures prevented: The economy is still hurtingmental-health problems are growing, and educational futures have been curtailed, not because of some fearmongering overreaction, but because an uncontrolled pandemic is still afoot.

If anything, the U.S. did not react swiftly or strongly enough. Nations that had previously dealt with emerging viral epidemics, including several in East Asia and sub-Saharan Africa, were quick to take the new coronavirus seriously. By contrast, America’s lack of similar firsthand experience, combined with its sense of exceptionalism, might have contributed to its initial sloppiness. “One of my colleagues went to Rwanda in February, and as soon as he hit the airport, they asked about symptoms, checked his temperature, and took his phone number,” says Abraar Karan, an internist at Brigham and Women’s Hospital and Harvard Medical School. “In the U.S., I flew in July, and walked out of the airport, no questions asked.”

Even when the virus began spreading within the U.S., places that weren’t initially pummeled seemed to forget that viruses spread. “In April, I was seeing COVID patients in the ER every day,” Karan says. “In Texas, I had friends saying, ‘No one believes it here because we have no cases.’ In L.A., fellow physicians said, ‘Are you sure this is worse than the flu? We’re not seeing anything.’” Three months later, Texas and California saw COVID-19 all too closely. The tendency to ignore threats until they directly affect us has consigned the U.S. to …

8. A Reactive Rut

In March, Mike Ryan at the World Health Organization advised, “Be fast, have no regrets … The virus will always get you if you don’t move quickly.” The U.S. failed to heed that warning, and has repeatedly found itself several steps behind the coronavirus. That’s partly because exponential growth is counterintuitive, so “we don’t understand that things look fine until right before they’re very not fine,” says Beth Redbird, a sociologist at Northwestern. It’s also because the coronavirus spreads quickly but is slow to reveal itself: It can take a month for infections to lead to symptoms, for symptoms to warrant tests and hospitalizations, and for enough sick people to produce a noticeable spike. Pandemic data are like the light of distant stars, recording past events instead of present ones. This lag separates actions from their consequences by enough time to break our intuition for cause and effect. Policy makers end up acting only when it’s too late. Predictable surges get falsely cast as unexpected surprises.

This reactive rut also precludes long-term planning. In April, Michael Osterholm, an epidemiologist at the University of Minnesota, told me that “people haven’t understood that [the pandemic] isn’t about the next couple of weeks [but] about the next two years.” Leaders should have taken the long view then. “We should have been thinking about what it would take to ensure schools open in the fall, and prevent the long-term harms of lost children’s development,” Redbird says. Instead, we started working our way through a serial monogamy of solutions, and, like spiraling army ants, marched forward with no sense of the future beyond the next few footsteps.

These errors crop up in all disasters. But the COVID-19 pandemic has special qualities that have exacerbated them. The virus moved quickly enough to upend the status quo in a few months, deepening the allure of the hastily abandoned past. It also moved slowly enough to sweep the U.S. in a patchwork fashion, allowing as-yet-untouched communities to drop their guard. The pandemic grew huge in scope, entangling every aspect of society, and maxing out our capacity to deal with complexity. “People struggle to make rational decisions when they cannot see all the cogs,” says Njoki Mwarumba, an emergency-management professor at the University of Nebraska at Omaha. Full of fear and anxiety, people furiously searched for more information, but because the virus is so new, they instead spiraled into more confusion and uncertainty. And tragically, all of this happened during the presidency of Donald Trump.

Trump embodied and amplified America’s intuition death spiral. Instead of rolling out a detailed, coordinated plan to control the pandemic, he ricocheted from one overhyped cure-all to another, while relying on theatrics such as travel bans. He ignored inequities and systemic failures in favor of blaming China, the WHO, governors, Anthony Fauci, and Barack Obama. He widened the false dichotomy between lockdowns and reopening by regularly tweeting in favor of the latter. He and his allies appealed to magical thinking and steered the U.S. straight into the normality trap by frequently lying that the virus would go away, that the pandemic was ending, that new waves weren’t happening, and that rising case numbers were solely due to increased testing. They have started talking about COVID-19 in the past tense as cases surge in the Midwest.

“It’s like mass gaslighting,” says Martha Lincoln, a medical anthropologist at San Francisco State University. “We were put in a situation where better solutions were closed off but a lot of people had that fact sneak up on them. In the absence of a robust federal response, we’re all left washing our hands and hoping for the best, which makes us more susceptible to magical thinking and individual-level fixes.” And if those fixes never come, “I think people are going to harden into a fatalistic sense that we have to accept whatever the risks are to continue with our everyday lives.”

That might, indeed, be Trump’s next solution. The Washington Post reports that Trump’s new adviser—the neuroradiologist Scott Atlas—is pushing a strategy that lets the virus rip through the non-elderly population in a bid to reach herd immunity. This policy was folly for Sweden, which is nowhere near herd immunity, had one of the world’s highest COVID-19 death rates, and has a regretful state epidemiologist. Although the White House has denied that a formal herd-immunity policy exists, the Centers for Disease Control and Prevention recently changed its guidance to say that asymptomatic people “do not necessarily need a test” even after close contact with an infected personThis change makes no sense: People can still spread the virus before showing symptoms. By effectively recommending less testing, as Trump has specifically called for, the nation’s top public-health agency is depriving the U.S. of the data it needs to resist intuitive errors. “When there’s a refusal to take in the big picture, we are stuck,” Mwarumba says.

The pandemic is now in its ninth month. Uncertainties abound as fall and winter loom. In much of the country, colder weather will gradually pack people into indoor spaces, where the coronavirus more readily spreads. Winter also typically heralds the arrival of the flu and other respiratory viruses, and although the Southern Hemisphere enjoyed an unusually mild flu season, that’s “because of the severe precautions they were taking against COVID-19,” says Eleanor Murray, an epidemiologist at Boston University. “It’s not clear to me that our precautions will be successful enough to also prevent the flu.”

Schools are reopening, which will shape the path of the pandemic in still-uncertain ways. Universities are more predictable: Thanks to magical thinking and misplaced moralism, the U.S. already has at least 51,000 confirmed infections in more than 1,000 colleges across every state. These (underestimated) numbers will grow, because only 20 percent of colleges are doing regular testing, while almost half are not testing at all. As more are forced to stop in-person teaching, students will be sent back to their communities with COVID-19 in tow. “I expect this will blow up outbreaks in places that never had outbreaks, or in places that had outbreaks under control,” Murray says. Further spikes will likely occur after Thanksgiving and Christmas, as people who yearn to return to normal (or who think that the country overreacted) travel to see their family. Despite that risk, the CDC recently dropped its recommendation that out-of-state travelers should quarantine themselves for 14 days.

But many of the experts I spoke with thought it unlikely that “we’ll have cities going full New York,” as Bergstrom puts it. Doctors are getting better at treating the disease. States like Massachusetts, New York, and New Jersey have managed to avoid new surges over the summer, showing that local leadership can at least partly compensate for federal laxity. A new generation of cheap, rapid, paper-based tests will hit the market and make it easier to work out who is contagious. And despite the spiral of bad intuitions, many Americans are holding the line: Mask use and support for physical distancing are still high, according to Redbird, who has been tracking pandemic-related attitudes since March. “My feeling is that while things are going to get worse, I’m not sure they’ll be catastrophic, because of situational awareness,” Bill Hanage says.

Meanwhile, Trump seems to be teeing up a vaccine announcement in late October, shortly before the November 3 election. Moncef Slaoui, the scientific head of Operation Warp Speed, told NPR that it’s “extremely unlikely” a vaccine will be ready by then, and many scientists are concerned that the FDA will be pressured into approving a product that hasn’t been adequately tested, as Russia and China already have. Many Americans share this concern. A safe and effective vaccine could finally bring the pandemic under control, but its arrival will also test America’s ability to resist the intuitive errors that have trapped it so far. Vaccination has long been portrayed as the ultimate biomedical silver bullet, separating an era when masks and social distancing mattered from a world where normality has returned. This is yet another false dichotomy. “Everyone’s imagining this moment when all of a sudden, it’s all over, and they can go on vacation,” Natalie Dean says. “But the reality is going to be messier.”

This problem is not unique to COVID-19. It’s more compelling to hope that drug-resistant bacteria can be beaten with viruses than to stem the overuse of antibiotics, to hack the climate than to curb greenhouse-gas emissions, or to invest in a doomed oceanic plastic-catcher than to reduce the production of waste. Throughout its entire history, and more than any other nation, the U.S. has espoused “an almost blind faith in the power of technology as panacea,” writes the historian Howard Segal.* Instead of solving social problems, the U.S. uses techno-fixes to bypass them, plastering the wounds instead of removing the source of injury—and that’s if people even accept the solution on offer.

A third of Americans already say they would refuse a vaccine, whether because of existing anti-vaccine attitudes or more reasonable concerns about a rushed development process. Those who get the shot are unlikely to be fully protected; the FDA is prepared to approve a vaccine that’s at least 50 percent effective—a level comparable to current flu shots. An imperfect vaccine will still be useful. The risk is that the government goes all-in on this one theatrical countermeasure, without addressing the systemic problems that made the U.S. so vulnerable, or investing in the testing and tracing strategies that will still be necessary. “We’re still going to need those other things,” Dean says.

Between these reasons and the time needed for manufacturing and distribution, the pandemic is likely to drag on for months after a vaccine is approved. Already, the event is exacting a psychological toll that’s unlike the trauma of a hurricane or fire. “It’s not the type of disaster that Americans specifically are used to dealing with,” says Samantha Montano of Massachusetts Maritime Academy, who studies disasters. “Famines and complex humanitarian crises are closer approximations.” Health experts are burning outLong-haulers are struggling to find treatments or support. But many Americans are turning away from the pandemic. “People have stopped watching news about it as much, or talking to friends about it,” Redbird says. “I think we’re all exhausted.” Optimistically, this might mean that people are becoming less anxious and more resilient. More worryingly, it could also mean they are becoming inured to tragedy.

The most accurate model to date predicts that the U.S. will head into November with 220,000 confirmed deaths. More than 1,000 health-care workers have died. One in every 1,125 Black Americans has died, along with similarly disproportionate numbers of Indigenous people, Pacific Islanders, and Latinos. And yet, a recent poll found that 57 percent of Republican voters and 33 percent of independents think the number of deaths is acceptable. “In order for us to mobilize around a social problem, we all have to agree that it’s a problem,” Lori Peek says. “It’s shocking that we haven’t, because you really would have thought that with a pandemic it would be easy.” This is the final and perhaps most costly intuitive error …

9. The Habituation of Horror

The U.S. might stop treating the pandemic as the emergency that it is. Daily tragedy might become ambient noise. The desire for normality might render the unthinkable normal. Like poverty and racismschool shootings and police brutalitymass incarceration and sexual harassmentwidespread extinctions and changing climate, COVID-19 might become yet another unacceptable thing that America comes to accept.

 

 

 

 

Covid-19 cases are rising, but deaths are falling. What’s going on?

https://www.vox.com/2020/7/6/21314472/covid-19-coronavirus-us-cases-deaths-trends-wtf

Coronavirus cases are rising, but Covid-19 deaths are falling ...

By the time coronavirus deaths start rising again, it’s already too late.

There is something confounding about the US’s new coronavirus spikes: Cases are rising, but the country is seeing its lowest death counts since the pandemic first exploded.

The numbers are genuinely strange to the naked eye: On July 3, the US reported 56,567 new Covid-19 cases, a record high. On the same day, 589 new deaths were reported, continuing a long and gradual decline. We haven’t seen numbers that low since the end of March.

When laypeople observe those contradictory trends, they might naturally have a follow-up question: If deaths are not increasing along with cases, then why can’t we keep reopening? The lockdowns took an extraordinary toll of their own, after all, in money and mental health and some lives. If we could reopen the economy without the loss of life we saw in April and May, then why shouldn’t we?

I posed that very question to more than a dozen public health experts. All of them cautioned against complacency: This many cases mean many more deaths are probably in our future. And even if deaths don’t increase to the same levels seen in April and May, there are still some very serious possible health consequences if you contract Covid-19.

The novel coronavirus, SARS-Cov-2, is a maddeningly slow-moving pathogen — until it’s not. The sinking death rates reflect the state of the pandemic a month or more ago, experts say, when the original hot spots had been contained and other states had only just begun to open up restaurants and other businesses.

That means it could still be another few weeks before we really start to see the consequences, in lives lost, of the recent spikes in cases. And in the meantime, the virus is continuing to spread. By the time the death numbers show the crisis is here, it will already be too late. Difficult weeks will lie ahead.

Even if death rates stay low in the near term, that doesn’t mean the risk of Covid-19 has evaporated. Thousands of Americans being hospitalized in the past few weeks with a disease that makes it hard to breathe is not a time to declare victory. Young people, who account for a bigger share of the recent cases, aren’t at nearly as high a risk of dying from the virus, but some small number of them will still die and a larger number will end up in the hospital. Early research also suggests that people infected with the coronavirus experience lung damage and other long-term complications that could lead to health problems down the road, even if they don’t experience particularly bad symptoms during their illness.

And as long as the virus is spreading in the community, there is an increased risk that it will find its way to the more vulnerable populations.

“More infected people means faster spread throughout society,” Kumi Smith, who studies infectious diseases at the University of Minnesota, told me. “And the more this virus spreads the more likely it is to eventually reach and infect someone who may die or be severely harmed by it.”

This presents a communications challenge. Sadly, as Smith put it, “please abstain from things you like to benefit others in ways that you may not be able to see or feel” is not an easy message for people to accept after three-plus months in relative isolation.

But perhaps the bigger problem is the reluctance of our government to take the steps necessary to control the disease. Experts warned months ago that if states were too quick to relax their social distancing policies, without the necessary capacity for more testing or contact tracing, new outbreaks would flare up and be difficult to contain.

That’s exactly what happened — and now states are scrambling to reimpose some restrictions. Unless the US gets smarter about its coronavirus response, the country seems doomed to repeat this cycle over and over again.

 

Why Covid-19 deaths aren’t rising along with cases — yet

The contradiction between these two curves — case numbers sloping upward, death counts downward — is the primary reason some people are agitating to accelerate, not slow down, reopening in the face of these new coronavirus spikes.

The most important thing to understand is that this is actually to be expected. There is a long lag — as long as six weeks, experts told me — between when a person gets infected and when their death would be reported in the official tally.

“Why aren’t today’s deaths trending in the same way today’s cases are trending? That’s completely not the way to think about it,” Eleanor Murray, an epidemiologist at Boston University, told me. “Today’s cases represent infections that probably happened a week or two ago. Today’s deaths represent cases that were diagnosed possibly up to a month ago, so infections that were up to six weeks ago or more.”

“Some people do get infected and die quickly, but the majority of people who die, it takes a while,” Murray continued. “It’s not a matter of a one-week lag between cases and deaths. We expect something more on the order of a four-, five-, six-week lag.”

As Whet Moser wrote for the Covid Tracking Project last week, the recent spikes in case counts really took off around June 18 and 19. So we would not expect them to show up in the death data yet.

“Hospitalizations and deaths are both lagging indicators, because it takes time to progress through the course of illness,” Caitlin Rivers at the Johns Hopkins Center for Health Security told me late last week. “The recent surge started around two weeks ago, so it’s too soon to be confident that we won’t see an uptick in hospitalizations and deaths.”

The national numbers can also obscure local trends. According to the Covid Tracking Project, hospitalizations are spiking in the South and West, but, at the same time, they are dropping precipitously in the Northeast, the initial epicenter of the US outbreak.

And a similar regional shift in deaths may be underway, though it will take longer to reveal itself because the death numbers lag behind both cases and hospitalizations. But even now, Alabama, Arizona, Florida, Nevada, South Carolina, Tennessee, Texas, and Virginia have seen an uptick in their average daily deaths, according to Covid Exit Strategy, while Connecticut, Massachusetts, and New York have experienced a notable decline.

There are some reasons to be optimistic we will not see deaths accelerate to the same extent that cases are. For one, clinicians have identified treatments like remdesivir and dexamethasone that, respectively, appear to reduce people’s time in the hospital and their risk of dying if they are put on a ventilator.

The new infections are also, for now, skewing more toward younger people, who are at a much lower risk of dying of Covid-19 compared to older people. But that is not the case for complacency that it might superficially appear to be.

 

Younger people are less at risk from Covid-19 — but their risk isn’t zero

For starters, younger people can die of Covid-19. About 3,000 people under the age of 45 have died from the coronavirus, according to the CDC’s statistics (which notably have a lower overall death count than other independent sources that rely on state data). That is a small percentage of the 130,000 and counting overall Covid-19 deaths in the US. But it does happen.

Moreover, younger people can also develop serious enough symptoms that they end up having to be hospitalized with the disease. Again, their risk is meaningfully lower than that of older people, but that doesn’t mean it’s zero.

There can also be adverse outcomes that are not hospitalization or death. Illness is not a zero-sum game. A recent study published in Nature found that even asymptomatic Covid-19 patients showed abnormal lung scans. As Lois Parshley has documented for Vox, some people who recover from Covid-19 still report health problems for weeks after their initial sickness. Potential long-term issues include lung scarring, blood clotting and stroke, heart damage, and cognitive challenges.

In short, surviving Covid-19, even with relatively mild symptoms, does not mean a person simply reverts to normal. This is a new disease, and we are still learning the full extent of its effects on the human body.

But even if we recognize that young people face less of a threat directly from the coronavirus, there is still a big reason to worry if the virus is spreading in that population: It could very easily make the leap from less vulnerable people to those who are much more at risk of serious complications or death.

 

The coronavirus could easily jump from younger people to the more vulnerable

One response to the above set of facts might be: “Well, we should just isolate the old and the sick, while the rest of us go on with our lives.” That might sound good in theory (if you’re not older or immunocompromised yourself), but it is much more difficult in practice.

“The fact is that we live in communities that are all mixed up with each other. That’s the concern,” Natalie Dean, a biostatistics professor at the University of Florida, says. “It’s not like there’s some nice neat demarcation: you’re at high risk, you’re at low risk.”

The numbers in Florida are telling. At first, in late May and into early June, new infections accelerated among the under-45 cohort. But after a lag of a week or so, new cases also started to pick up among the over-45 (i.e., more at-risk) population.

“The rise in older adults is trailing behind, but it is starting to go up,” Dean said.

Anecdotally, nursing homes in Arizona and Texas — the two states with the most worrisome coronavirus trends right now — have seen outbreaks in recent weeks as community spread increases. The people who work in nursing homes, after all, are living out in the community where Covid-19 is spreading. And, because they are younger, they may not show symptoms while they are going to work and potentially exposing those patients.

As one expert pointed out to me, both Massachusetts and Norway have seen about 60 percent of their deaths come in long-term care facilities, even though the former has a much higher total fatality count than the latter. That would suggest we have yet to find a good strategy for keeping the coronavirus away from those specific populations.

“There is so far not much evidence that we know how to shield the most vulnerable when there is widespread community transmission,” Marc Lipsitch, a Harvard epidemiologist, told me.

That means the best recourse is trying to contain community spread, which keeps the overall case and death counts lower (as in Norway) and prevents the health care system from being overwhelmed.

 

Health systems haven’t been overwhelmed — but some hospitals in new hot spots are getting close

Arizona, Florida, and Texas still have 20 to 30 percent of their ICU and hospital beds available statewide, according to Covid Exit Strategy, even as case counts continue to rise. While some people use those numbers to argue that the health systems can handle an influx of Covid patients, the experts I spoke to warned that capacity can quickly evaporate.

“Let’s keep it that way, shall we?” William Hanage at Harvard said. “Hospitals are getting close to overwhelmed in some places, and that will be more places in future if action isn’t taken now. Also ‘not overwhelmed’ is a pretty low bar.”

Hospital capacity is another example of how the lags created by Covid-19 can lull us into a false sense of security until a crisis presents itself and suddenly it’s too late. Because it can take up to two weeks between infection and hospitalization, we are only now beginning to see the impact of these recent spikes.

And, to be clear, hospitalizations are on the rise across the new hot spots. The number of people currently hospitalized with Covid-19 in Texas is up from less than 1,800 on June 1 to nearly 8,000 on July 4. Hospitalizations in Arizona have nearly tripled since the beginning of June, up to more than 3,100 today.

And the state-level data doesn’t show local trends, which are what really matter when it comes to hospital capacity. Some of the hardest-hit cities in these states are feeling the strain, as Hanage pointed out. Hospitals in Houston have started transferring their Covid-19 patients to other cities, and they are implementing their surge capacity plans, anticipating a growing need because of the trendlines in the state.

Once a hospital’s capacity is reached, it’s already too late. They will have to endure several rough weeks after that breach, because the virus has continued to infect more people in the interim, some of whom will get very sick and require hospitalization when there isn’t any room available for them.

“We’re seeing some drastic measures being implemented right now in Texas and Arizona along those lines: using children’s hospitals for adults, going into crisis mode, etc.,” Tara Smith, who studies infectious diseases at Kent State University, told me. “So it shows how quickly all of that can turn around.”

And, on top of Covid-19, these health systems will continue to have the usual flow of emergencies from heart attacks, strokes, accidents, etc. That’s when experts start to worry people will die who wouldn’t otherwise have. That is what social distancing, by slowing the spread of the coronavirus, is supposed to prevent.

 

We don’t have to lock down forever — but we have to be smart and vigilant

Lockdowns are extraordinarily burdensome. Tens of millions of Americans have lost their jobs. Drug overdoses have spiked. There has been a worrying increase in heart-related deaths, which indicates people who otherwise would have sought medical treatment did not do so during the worst of the outbreak this spring.

But we cannot will the coronavirus out of existence. Experts warned months ago that if states reopened too early, cases would spike, which would strain health systems and put us at risk of losing more people to this virus. That appears to be what’s starting to happen. And it may get worse; if the summer heat has suppressed the virus to any degree, we could see another rebound in the fall and winter.

So we must strike a balance, between the needs of a human society and the reality that most of us are still susceptible to an entirely novel pathogen that is much deadlier and more contagious than the flu.

That means, for starters, being smarter about how we reopen than we have been so far. There is strong evidence that states were too cavalier about ending stay-at-home orders and reopening businesses, with just a handful meeting the metrics for reopening laid out by experts, as Vox’s German Lopez explained.

“What I’ve seen is that reopening is getting interpreted by many as reverting back to a Covid-free time where we could attend larger group gatherings, socialize regularly with many different people, or congregate without masks,” Kumi Smith in Minnesota said. “The virus hasn’t changed since March, so there’s no reasons why our precautions should either.”

To date, most states have opened up bars again and kept schools closed. Lopez made a persuasive case last week that we’ve got that backward. One of the most thorough studies so far on how lockdowns affected Covid-19’s spread found that closing restaurants and bars had a meaningful effect on the virus but closing schools did not.

That study also found that shelter-in-place orders had a sizable impact. While those measures may not be politically feasible anymore, individuals can still be cautious about going out — and when they do, they can stick to outdoor activities with a small number of people.

Masks are not a panacea either, but the evidence is convincingly piling up that they also help reduce the coronavirus’s spread. Whether a given state has a mandate to wear one or not, that is one small inconvenience to accept in order to get this outbreak back under control.

And, really, that is the point. While the current divergence between case and death counts can be confusing, the experts agree that Covid-19 still poses a significant risk to Americans — and it is a risk that goes beyond literal life and death. We know some of the steps that we, as individuals, can take to help slow the spread. And we need our governments, from Washington to the state capitals, to get smarter about reopening.

It will require collective action to stave off the coronavirus for good. Other countries have done it. But we have to act now, before we find out it’s already too late.