Missouri will do that on Monday allow concerts resumed for the first time since the state’s start-up order began in early April. Yes, concerts, where people usually pack together and breathe the same air. Apparently, the Missouri government believes it will be safe for those present to be six feet apart.
It’s not just concerts: under the leadership of Governor Mike Parson, all companies in the state can do that resume operations, provided that employees and customers keep their distance. (The exception: St. Louis remains closed.) Meanwhile, the number is new daily positive cases is still rising in Missouri.
What is happening in Missouri is beginning to happen in many parts of the country, even though most states are still failing, as this interactive New York Times shows, to meet the White House criteria for doing so: a downward trajectory over a two-week period, along with greater testing capacity.
It is understandable that states want to open up. The pandemic has led to a painful and scary economic downturn; unemployment has risen to 14.7 percent. There is also an emotional toll on social distance: How many people have seen their family for months, are seriously lonely, or are they desperate for physical contact?
But is the public health situation really so different from when the blockades started in March? According to epidemiologists, no. While the situation varies from place to place, it now generally doesn’t seem like the best time for Americans to get close to each other again. There are three main reasons:
- Nationally, the outbreak peaked or reached a plateau. But there is still a lot of infection.
- Although the toll of the pandemic is enormous, more than 76,000 have been registered deaths in the United States from May 8 – the vast majority of the population is still not infected, has no immunity, and is fully susceptible.
- This virus is fundamentally very contagious, sneaky and deadly. That is as true as ever.
- The US has wasted lockdown time: it needs more testing, more contact tracking, targeted isolation of the infected, and the quarantine of their contacts. More research is also needed into social distance to know which relaxed measures are safe.
Epidemiologists’ predictions for what will happen next are grim. “If we open up and do exactly what we did in March, we’ll see a huge increase in the number of cases,” said Eleanor Murray, an assistant professor of epidemiology at Boston University School of Public Health. “We are going back to that same exponential trajectory.” That, in turn, will increase the capacity of a health care system that is already brutal financial and psychological blows from the first wave.
It is possible based on new projections from Columbia University, that state opening will lead to an increase of 10,000 new cases or more by June.
It may not happen. But the risk is there. “What we’re going to see is an unfortunate natural experiment underway,” said Jeffrey Shaman, an infectious disease model at Columbia University. “For the states that are lifting and reopening the restrictions, we are going to see if they can do it without blowing the virus on their faces. … actually they are playing Russian roulette.”
1) America is still at the peak of the epidemic. Cases are flat at best.
Overall, however, “cases have increased and reached a plateau,” said Stephen Kissler, who designs mathematical models of disease outbreaks at Harvard. “That hides a lot of changes. … And so really, we are in a phase of some sort of attempt to play the pandemic, and it will continue for a while.”
Removing restrictions during a plateau means releasing people into an environment where “there are now more people with an infection than ever before,” said Murray. “Instead of starting with one or two cases in each city [as might have been the case in March], we start with hundreds of cases or thousands of active cases in each city. “
On March 20, there were around 5,000 confirmed daily new cases of Covid-19 in the United States (although the actual number was probably much higher). Since the beginning of April, at least 20,000 to 30,000 new cases have been reported every day in the US, as the virus is multiplying in an increasing number of people.
Cases continued to drop slightly, but it is important to remember that outside of NY-NJ-CT cases * do * not * fall. pic.twitter.com/LB17L585rx
– The COVID tracking project (@ COVID19Tracking) May 8, 2020
“People keep talking about the second wave and we’re not through the first wave, ” said Tara Smith, an epidemiologist in Kent State. Cases “have not been handled significantly anywhere except in New York City.”
Still, the White House plans to open things up again requires a “downward trajectory of documented cases within a 14-day period.” We are nowhere near there, nationally or locally in most places.
The number of new cases may slowly start to decrease. However, the number of cases is still very high.
Another way to look at covid19’s declining positivity across the country. Daily tests are increasing, positive cases remain largely flat, and the positivity rate is declining. We are testing more to find the same number of cases, suggesting that the epidemic’s density may decrease. pic.twitter.com/maMYuiG2n8
– Scott Gottlieb, MD (@ScottGottliebMD) May 7, 2020
Infectious disease modelers Teresa Yamana, Sen Pei and Jeffrey Shaman at Columbia University recently has prepared three forecasts that are useful to reflect on what may happen in the coming weeks.
In one scenario, there is no change: states don’t open and we keep what we do now. Nationally, cases and deaths are decreasing from the current plateau.
In a second scenario, the contact rate has increased by 10 percent in all counties and cities in states that open up. That means Americans see an average of 10 percent more people than during lockdown. Yamana, Pei and Shaman find that the number of cases would rise to 43,353 cases a day by the end of June, compared to about 28,000 cases a day in early May.
The third scenario is similar to the second one, but the contact rate is increased by 10 percent every week after opening, “which means people start saying, okay, everything is fine, [and] they are becoming more smug, ”says Shaman. And then, according to the model, new cases jump to 63,330 cases per day.
In the second and third scenarios, mortality rates may even decrease across the country in May. But a new wave of death would be imminent and the toll would rise again in June and increase all month.
These projections are only the best estimates of what could happen. It’s hard to know what people will actually do: will they increase their contacts by 10 percent or more? Maybe not. But who wants to know?
2) Many people are still vulnerable
Another major reason this doesn’t go away: While there are more than a million confirmed cases in the US, very few people are generally infected in the country. “It’s not like we’re well on the way to building some kind of population-level immunity,” said Natalie Dean, a biostatistician at the University of Florida.
There have been some serological studies to assess how many people in a given area have antibodies (molecules that the body produces in response to an infection) for the virus that causes Covid-19.
These studies “weren’t always of the best quality,” says Dean (more on that here), “but in the end, they say fairly consistently that we’re still in the single numbers.” That is, less than 10 percent of the United States is still infected. This photo looks different in the worst affected areas. In New York City, as many as 21.1 percent of the population may have contracted the infection, according to one serological examination performed by the state.
That sounds like a large percentage, and it is, but it doesn’t come close to the level required for herd immunity – if there are enough people with immunity, the infestation begins to die out naturally. “About 60 percent [immune] roughly is when you start to see changes, “said Caitlin Rivers, an epidemiologist at the Johns Hopkins Center for Health Security. “And we don’t want to get there, just to be clear.”
It would also take a long time to get there: a recent study in Science found it it would take until 2022 for the US to achieve herd immunity in a way that would also avoid overwhelming hospitals. And any road to herd immunity would die many, many people who die.
Even if one city, or one community within one city, achieves herd immunity, that’s still not enough. The US is a huge, sprawling nation. A bag of herd immunity in Queens, New York isn’t going to help end an outbreak in Nebraska.
“My own estimate would be in the US that we have probably infected 10 to 20 million people to date,” said Shaman. ‘That’s not much.’ There are 328 million people in the country, most of whom are still vulnerable.
3) The biology of this virus makes it formidable
A quick overview of the basic reproduction number, or R0, for this coronavirus: without surgery, each infected person can infect an average of two or three others. That is a recipe for exponential growth. “If left to its own devices, given its nature and how efficiently it transfers from person to person, we would expect 50 to 70 percent of the world’s population to become infected within a one to two year period,” said Shaman.
It has not been left to its own devices. We have tried to control it with good hygiene, quarantine and social distance. Still, this virus is a sneaky little bastard – it spreads silently and survives on some surfaces. It takes an average of five days for a person to show symptoms after being infected, but it can last up to 14 days (most flu symptoms appear after one to four days). During that time, some people can spread the virus to others before they know they are sick.
This incubation period is enough to lure some communities into a false sense of security. Cases may decrease and any policy change will not be visible in infection rates for several weeks (provided people are tested).
“It can be really awful trying to pretend that everything is back to normal,” says Sarah Cobey, a scientist who studies epidemics and immunity at the University of Chicago, when initial social distances diminish and we become complacent. The virus can cause between 0.5 and 1 percent of the people it infects. That figure is also large and small. It is large enough to cause a million deaths or more in the United States if no precautions are taken.
4) We have no plans to stop the spread and to learn from reopenings
Lockdowns were always a blunt measure.
“We had to go that route because we didn’t have any other tools,” said Murray. The outbreak was too widespread and America’s capabilities were too low to test aggressively for the virus and detect the contacts of those it touched. “What we should have done while in the lockdown was build that capacity. … I think we’re seeing people get sick of lockdown right now, but [do we] are those other tools really ready for use? ‘
We do not. On May 1, a Harvard analysis found that more than half of the states are not performing enough Covid-19 tests to safely reopen. Without testing, we cannot know where the virus is and to whom it can spread. Testing is crucial to shift lockdowns to a smarter, more focused strategy: identify all new cases, isolate them, then figure out who may have been in contact with those people and quarantined them.
“Experts say the US needs 500,000 tests a day, on the low side, to tens of millions, on the high side, to fully control the coronavirus outbreak,” said Vox’s German Lopez. “Based on the COVID tracking project, the US performed approximately 260,000 tests per day on average in the first week of May – just over half the minimum.” Also lagging: programs to train and deploy contact tracers, to ensure that one case of Covid-19 doesn’t turn into thousands.
Testing is not only necessary to diagnose the sick; it is necessary for surveillance and to answer important scientific questions.
It seems clear that when people are in confined indoor spaces with a lot of people – like in meat packaging plants, dormitories, nursing homes, office buildingsor homeless shelters – the virus thrives. But what about a small barber shop, where both clients and hairdresser wear masks? It is not without risk, but the risk is difficult to quantify. As well as the risk of transmission in children and from children to adults.
As states open up, they are essentially conducting experiments to see which policies lead to new cases and which don’t.
Hopefully, scientists and local health departments have the right studies to track the results. “But what I’m really afraid of is that many areas aren’t even set up to learn from their own mistakes and successes,” says Cobey. This work includes not only diagnostic tests of Covid-19, but also post-infection tests to see if a person has developed antibodies to Covid-19.
“I’m really afraid that by June 1 or June 15, after we’ve seen a few weeks to a month of this [state openings], that our cases will rise – and even worse, that we may not see them because … we are maxed out with our test capacity, ‘says Smith. The first sign that the openings have failed could come when hospitals return to see many critically ill people – meaning a significant new wave is already underway.
There is plenty of potential for chaos: an area can alleviate limitations and, because of pure luck (or seasonal factors mixed with luck) may not see an increase in cases. It could boast of his success. Then another area could adopt the same policy and be doomed.
The future is uncertain. But the choice to reopen, and when, is something we can control.
There is a lot of uncertainty in the future. But we do have some control. Lifting social distance restrictions is now sparking a new wave of infections. “We can choose when the second wave occurs,” says Cobey. Why choose now?
This is just the health issue of not rushing to open again. There is also an economic one. If the U.S. creates a situation in which more people will fall ill and lead the spikes in the coming weeks, will that really save restaurants and small businesses – or just set them up for an even longer period of decline? On the other hand, will people go out and patronize companies again, even if they are allowed? We’ll have to see.
Yes, the country can pursue a twofold goal: to protect lives and protect the economy. But opening too quickly can tip the balance too far toward death and the burden on the health system without really helping the economy.
“We have to set our goals very clearly, and we must be serious that opening up our economy is at the expense of a certain number of Covid diseases associated with Covid deaths,” said Kissler. “There is no good way for it.”
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