The past few weeks have revealed the worst and the best in human responses to the coronavirus crisis from the supermarket hoarders clearing the shelves to the neighbourhood groups organising help for elderly and vulnerable people.
When it comes to the pharmaceutical companies, how should we judge their response? They, after all, hold the key to ending the pandemic. Yet in one vital respect their behaviour has more in common with the supermarket hoarders than the neighbourhood groups.
Our exit strategy from the global lockdown depends on the development of an effective vaccine, as is well-known. A huge effort is under way to find such a vaccine, but we cannot afford to wait the 18 months it might take.
In the meantime, as the death toll increases, doctors are desperate for treatments that would lessen the impact of the virus, by shortening the infection, reducing its severity and in that way saving lives. There is now a global hunt for a coronavirus drug. But it is a fight against time. The focus is therefore on existing treatments already proved to be safe for other diseases which will need less testing and be easier and quicker to manufacture in quantity.
Scores of trials are under way around the world. The World Health Organization has identified four of the most promising therapies including an HIV combination treatment, an anti-malarial and a drug developed but never used against Ebola - for testing in a global trial launched last month. But we cannot pause the search while waiting for the results. The need for new effective agents is too great.
The best way to identify candidate drugs is to use artificial intelligence (AI) to crunch huge quantities of data to find the ones that might work. Major AI companies are putting their immense computing power at the service of scientists engaged in this hunt.
But they are being hampered: because some pharmaceutical companies are failing to share all of the data on potential candidate treatments that they hold. Like toilet roll profiteers, they are keeping it stashed in their digital attics and cellars where others cannot get at it, on the grounds that it is commercially confidential.
It was the open sharing of data around the world that allowed scientists to map the genome of the SARS-CoV-2 virus at unprecedented speed, working across institutional, commercial and international boundaries in a unique collective effort against a common global enemy. We now urgently need all pharmaceutical companies to set aside their individual commercial ambitions and join a similar collective effort to identify, test, develop and manufacture treatments to curb the disease.
There is a precedent. Last June, 10 of the worlds largest pharmaceutical companies including Johnson & Johnson, AstraZeneca and GlaxoSmithKline announced they would pool data for an AI-based search for new antibiotics, which are urgently needed as antibiotic-resistant bacteria have proliferated across the world, threatening the growth of untreatable disease.
That historic agreement was made possible by the development of a secure, blockchain-based system that allows an algorithm to search rival companies data with full traceability but without revealing commercial secrets to competitors. The advantage of using blockchain is that companies can trust the code rather than their partners.
AI researchers at the Massachusetts Institute of Technologys J-Clinic, who trained a neural network to predict which molecules will have antibiotic properties, announced in February that they had found a new compound which works against 35 different types of bacteria. They named it halicin, after the AI system in 2001: A Space Odyssey.
AI is now being harnessed across the globe in the hunt for a coronavirus treatment, from Hong Kong to Israel to the UK and US. Last month the worlds fastest supercomputer, the IBM Summit, identified 77 compounds as potential candidates. Last week an AI platform run by Gero, based in Singapore, identified six drugs already approved for human use in other conditions which could help combat Covid-19. Meanwhile, Thomas Siebel, the billionaire head of C3.ai, a Californian artificial intelligence company, announced a public-private consortium including Princeton, Carnegie Mellon University, MIT, the Universities of California, Illinois and Chicago, as well as C3.ai and Microsoft, which will provide scientists with funding and access to some of the worlds most advanced supercomputers in the search for solutions to the pandemic.
However, no matter how great the computing power or how advanced the software design, results from these initiatives will depend ultimately on the data fed into them. Without full access to comprehensive data, the scientists will be fighting with one hand tied behind their backs.
All pharmaceutical companies must unlock their chemical libraries so candidate drugs can be identified, and trials to test the most promising treatments begin as soon as humanly possible. We cannot wait. Lives depend on it.
Prof Ara Darzi is a surgeon and director of the Institute of Global Health Innovation at Imperial College London. He is a former Labour health minister
Disclaimer: This post is from GomerBlog, a satirical site about healthcare.
CDC officials announced Tuesday that they believe the new vaccine currently under development aimed at controlling the rapidly spreading SARS-CoV-2 virus -- responsible for causing COVID-19 -- will be approved and ready to be utterly rejected by those in the anti-vaccination (anti-vax) movement by next year.
"This is an exciting development," said Eric Polsky, director of the CDC's Novel Vaccination Program, "and we will work tirelessly to ensure all anti-vaxxers have the opportunity to decline, refuse, and reject this potentially life-saving vaccine as early as possible."
The announcement has many in the anti-vaccination movement excited, including a local woman present at the press conference, who noted, "I just get such a thrill from ignoring mountains of scientific evidence at the danger of threatening the world around me, and the chance to do that by yet again opting out of a critical vaccine is just delightful."
At press time, officials noted conspiracy theories about the not-yet-developed vaccine containing mercury were spreading on Twitter.
Last Updated March 31, 2020
A doctor wearing a face mask looks at a CT image of a lung of a patient at a hospital in Wuhan, China. AFP via Getty Images hide caption
A doctor wearing a face mask looks at a CT image of a lung of a patient at a hospital in Wuhan, China.
Updated on March 17 at 6:43 p.m. ET:
Thousands of people have now died from COVID-19 the name for the disease caused by the coronavirus first identified in Wuhan, China.
According to the World Health Organization, the disease is relatively mild in about 80% of cases.
What does mild mean?
And how does this disease turn fatal?
The first symptoms of COVID-19 are pretty common with respiratory illnesses fever, a dry cough and shortness of breath, says Dr. Carlos del Rio, a professor of medicine and global health at Emory University who has consulted with colleagues treating coronavirus patients in China and Germany. "Some people also get a headache, sore throat," he says. Fatigue has also been reported and less commonly, diarrhea. It may feel as if you have a cold. Or you may feel that flu-like feeling of being hit by a train.
Doctors say these patients with milder symptoms should check in with their physician to make sure their symptoms don't progress to something more serious, but they don't require major medical intervention.
But the new coronavirus attacks the lungs, and in about 20% of patients, infections can get more serious. As the virus enters lung cells, it starts to replicate, destroying the cells, explains Dr. Yoko Furuya, an infectious disease specialist at Columbia University Irving Medical Center.
"Because our body senses all of those viruses as basically foreign invaders, that triggers our immune system to sweep in and try to contain and control the virus and stop it from making more and more copies of itself," she says.
But Furuya says that this immune system response to this invader can also destroy lung tissue and cause inflammation. The end result can be pneumonia. That means the air sacs in the lungs become inflamed and filled with fluid, making it harder to breathe.
Del Rio says that these symptoms can also make it harder for the lungs to get oxygen to your blood, potentially triggering a cascade of problems. "The lack of oxygen leads to more inflammation, more problems in the body. Organs need oxygen to function, right? So when you don't have oxygen there, then your liver dies and your kidney dies," he says. Lack of oxygen can also lead to septic shock.
The most severe cases about 6% of patients end up in intensive care with multi-organ failure, respiratory failure and septic shock, according to a February report from the WHO. And many hospitalized patients require supplemental oxygen. In extreme cases, they need mechanical ventilation including the use of a sophisticated technology known as ECMO (extracorporeal membrane oxygenation), which basically acts as the patient's lungs, adding oxygen to their blood and removing carbon dioxide. The technology "allows us to save more severe patients," Dr. Sylvie Briand, director of the WHO's pandemic and epidemic diseases department, said at a press conference In February.
Many of the more serious cases have been in people who are middle-aged and elderly Furuya notes that our immune system gets weaker as we age. She says for long-term smokers, it could be even worse because their airways and lungs are more vulnerable. People with other underlying medical conditions, such as heart disease, diabetes or chronic lung disease, have also proved most vulnerable. Furuya says those kinds of conditions can make it harder for the body to recover from infections.
"Of course, you have outliers people who are young and otherwise previously healthy who are dying," Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, told NPR's 1A show. "But if you look at the vast majority of the people who have serious disease and who will ultimately die, they are in that group that are either elderly and/or have underlying conditions."
Estimates for the case fatality rate for COVID-19 vary depending on the country. But data from both China and Lombardy, Italy, show the fatality rate starts rising for people in their 60s. In Lombardy, for instance, the case fatality rate for those in their 60s is nearly 3 percent. It's nearly 10 percent for people in their 70s and more than 16 percent for those in their 80s.
Del Rio notes that it's not just COVID-19 that can bring on multi-organ failure. Just last month, he saw the same thing in a previously healthy flu patient in the U.S. who had not gotten a flu shot.
"He went in to a doctor. They said, 'You have the flu don't worry.' He went home. Two days later, he was in the ER. Five days later, he was very sick and in the ICU" with organ failure, del Rio says. While it's possible for patients who reach this stage to survive, recovery can take many weeks or months.
In fact, many infectious disease experts have been making comparisons between this new coronavirus and the flu and common cold, because it appears to be highly transmissible.
"What this is acting like it's spreading much more rapidly than SARS [severe acute respiratory syndrome], the other coronavirus, but the fatality rate is much less," Fauci told 1A. "It's acting much more like a really bad influenza."
What experts fear is that, like the flu, COVID-19 will keep coming back year after year. But unlike the flu, there is no vaccine yet for the coronavirus disease.
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A medical worker administers a COVID-19 test at a facility in Camden, N.J., on Wednesday. Matt Rourke/AP hide caption
A medical worker administers a COVID-19 test at a facility in Camden, N.J., on Wednesday.
The new coronavirus is killing hundreds each day and swamping hospitals around the world. But catching the disease does not mean you will end up in the ICU.
"There are many patients that are fine and that are at home," says Michelle Ng Gong, the chief of critical care medicine at the Montefiore Health System in New York City. Those who don't need a hospital make up "I would dare say, in fact, the vast majority of people," she says.
Doctors like Gong are seeing many dozens of patients walk through their doors each day, and they're getting a better idea of who is at risk for severe illness. Here's their advice for what to watch out for if you think you or a loved one might have COVID-19.
Know who's at high risk of developing complications
Anyone can be made very sick by the coronavirus, but there are risk factors that increase your chances of developing serious disease.
By far the biggest factor is age. Data from several nations suggest that hospitalization and death rates rise in people older than 60. Those stats seem to be borne out by what Gong is seeing on the ground in New York City. "We've seen over and over again that our elderly patients are faring poorly," she says.
Additionally, there are a number of other health conditions that also put a person at risk. According to recent data from the Centers for Disease Control and Prevention, diabetes is a leading factor as is cardiovascular disease. Those two diseases often go hand-in-hand with obesity, and that means heavier people should also be vigilant, says Daniel Griffin, chief of the division of infectious disease for ProHEALTH Care Associates, a group of physicians that serves the New York City area.
Because COVID-19 is fundamentally a respiratory disease, anyone with lung ailments also needs to be careful. Asthma, chronic obstructive pulmonary disease and emphysema are all risk factors, the CDC says.
Finally, patients who have undergone transplants or who are immunocompromised can also get into trouble, Gong says. "It's particularly difficult with regards to being able to control the disease," she says.
Some symptoms are more worrisome than others
Fever and dry cough are among the most common symptoms of COVID-19, and by themselves, they don't require immediate medical attention. Additionally, Griffin says, many patients may experience gastrointestinal problems such as diarrhea or loose stools.
But Griffin says other symptoms early on in the illness could spell trouble later. In particular, he says, experiencing shortness of breath, significant headache, abdominal pain and severe fatigue in the first few days of illness all appear to be signs that a patient may be in for a tough fight to beat COVID-19.
Trouble with breathing, eating and drinking are all red flags, Gong says. "Those are all cause for you to consider calling a physician and seeing if you need to be evaluated for admission."
Griffin says one easy way to check breathing is to monitor how many breaths somebody takes a minute. "If they're starting to breath 24, 26, 30 times a minute, those are the high-risk people," he says.
Anyone who is worried should call their doctor rather than visit. "We're doing a lot more telehealth medicine," says Pavan Bhatraju, an assistant professor of medicine at the University of Washington. "Patients should use that as a resource."
Be vigilant, especially as the illness drags into the second week
A unique and unfortunate feature of COVID-19 is that some patients who are starting to feel better suddenly take a turn for the worst. The downturn usually comes between five to seven days into the illness.
A recent study by Bhatraju found that patients who need intensive care tend to arrive at the hospital around this time in the progression of their illness, and their deterioration can be extremely rapid. He says he's seen patients that "initially were just requiring a little bit of oxygen in 24 hours they're on a ventilator."
Doctors are still unsure what causes these late turns for the worse, but it may be the body's own immune system overreacting to the disease.
"We're all still trying to figure it out," Gong says. "But it does seem like some subset of these patients, they have a resurgence of an inflammatory response."
Regardless, if a week or so into the illness a high fever returns or a person suddenly feels short of breath, they should seek help immediately.
If you're not too sick, you may be better off at home
"As a general rule, people should stay out of the hospital if they don't need to be in the hospital," Gong says. "Fortunately, most cases of COVID seem to be able to be managed at home."
According to the CDC, the most important thing to do if you're sick at home is to quarantine yourself from others in your household. That may mean living in a separate room from loved ones or avoiding common spaces. When around other people, the CDC recommends wearing a face mask or scarf to reduce the chance of sickening others, and always try to keep six feet apart.
In terms of self-care, Gong says acetaminophen (Tylenol) and cold compresses can help with fever, and she sometimes recommends trying to sleep on your stomach to open up the lungs.
Beyond that, Griffin says the same remedies we use for other viral illnesses like the flu will also work for COVID: "Warm beverages, stay hydrated, take it easy, continue to eat healthy foods," he says. "You know, all the things your mother and grandmother probably told you."
Over a normal two-week period wed expect around half a million U.S. workers to file claims for unemployment insurance. Over the past two weeks weve seen almost 10 million filings. Were facing an incredible economic catastrophe.
The question is whether were ready to deal with this catastrophe. Alas, early indications are that we may be handling fast-moving economic disaster as badly as we handled the fast-moving pandemic thats causing it.
The key thing to realize is that we arent facing a conventional recession, at least so far. For now, most job losses are inevitable, indeed necessary: Theyre a result of social distancing to limit the spread of the coronavirus. That is, were going into the economic equivalent of a medically induced coma, in which some brain functions are temporarily shut down to give the patient a chance to heal.
This means that the principal job of economic policy right now isnt to provide stimulus, that is, to sustain employment and G.D.P. It is, instead, to provide life support to limit the hardship of Americans who have temporarily lost their incomes.
There is, to be sure, a strong risk that well have a conventional recession on top of the induced coma; more on that in subsequent columns. But for now, the focus should be on helping those in need.
Paul Krugmans Newsletter: Get a better understanding of the economy and an even deeper look at whats on Pauls mind.
The good news is that the $2 trillion CARES Act (Coronavirus Aid, Relief, and Economic Security Act) Congress passed last week does, on paper, provide a lot of economic life support. The bad news is that it looks as if it could be weeks, maybe even months, before serious amounts of money flow to those who need aid right now.
Journalists keep referring to the CARES Act as a stimulus package, but mainly its disaster relief. The best piece of the legislation which, by the way, Democrats forced unwilling Republicans to include is a major enhancement of unemployment benefits. Not only will laid-off workers get much more than they normally would, but many workers who werent previously covered by unemployment insurance, such as freelancers and independent contractors, are supposed to receive full benefits.
The legislation also provides loans to small businesses loans that will be forgiven, that is, turned into straight subsidies, if businesses use the money to maintain their payrolls.
Both of these programs are very good ideas. The trouble is that both are having a hard time getting started and time is one thing millions of distressed Americans, many of whom were already living on the edge, dont have.
On unemployment benefits: State unemployment offices, already overwhelmed by the surge in applications, arent ready to disburse these extra benefits, and may not be ready for quite a while a disastrous delay for families already in dire financial straits.
Small business loans are also facing a crippling lag in processing, with potential borrowers either unable to complete the forms or being told that they will have to wait three weeks. Furthermore, for some reason the federal government, instead of lending money directly, is channeling small-business lending through private banks and the banks are complaining that they have yet to receive crucial guidelines and that the administration is setting unworkable requirements.
In other words, it may be a long time before the economy starts getting the life support it needs right away.
And even when workers and businesses finally get the promised aid, the CARES Act doesnt provide remotely enough money to state and local governments, which are seeing revenues plunge and expenses soar. This is likely to force big cuts in government services precisely when theyre needed most.
So what do we need right now? First, we need an all-hands-on-deck effort to resolve the bottlenecks that are holding up unemployment benefits and small-business loans.
The obvious parallel here is to the crash of healthcare.gov when the Affordable Care Act was first going into effect; things looked terrible at first, but an Obama administration expert task force, working around the clock, resolved the problems more quickly than anyone imagined possible, and new enrollments ended up exceeding expectations.
I dont see any reason, in principle, a similar effort couldnt rescue the CARES Act. But heres the thing: Were talking about the Trump administration, which disdains expertise of every kind, and in which every effort somehow ends up being directed by Jared Kushner.
Second, we need another relief bill to fill the holes in the CARES Act, especially inadequate aid to state and local governments.
But will Republicans be willing to provide that aid? Donald Trump is talking, as he has many times before, about a giant infrastructure bill. But Senate Republicans are notably unenthusiastic. And while going big on infrastructure is a good idea, right now its less pressing than providing aid to states facing huge budget gaps.
And going back to the bill that Congress already passed: Im fairly sure that well eventually get the kinks worked out. But when youre losing six million jobs a week, eventually isnt good enough.
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So if epidemiological models dont give us certaintyand asking them to do so would be a big mistakewhat good are they? Epidemiology gives us something more important: agency to identify and calibrate our actions with the goal of shaping our future. We can do this by pruning catastrophic branches of a tree of possibilities that lies before us.
Epidemiological models have tailsthe extreme ends of the probability spectrum. Theyre called tails because, visually, they are the parts of the graph that taper into the distance. Think of those tails as branches in a decision tree. In most scenarios, we end up somewhere in the middle of the treethe big bulge of highly probable outcomesbut there are a few branches on the far right and the far left that represent fairly optimistic and fairly pessimistic, but less likely, outcomes. An optimistic tail projection for the COVID-19 pandemic is that a lot of people might have already been infected and recovered, and are now immune, meaning we are putting ourselves through a too-intense quarantine. Some people have floated that as a likely scenario, and they are not crazy: This is indeed a possibility, especially given that our testing isnt widespread enough to know. The other tail includes the catastrophic possibilities, like tens of millions of people dying, as in the 1918 flu or HIV/AIDS pandemic.
Read: The curve is not flat enough
The most important function of epidemiological models is as a simulation, a way to see our potential futures ahead of time, and how that interacts with the choices we make today. With COVID-19 models, we have one simple, urgent goal: to ignore all the optimistic branches and that thick trunk in the middle representing the most likely outcomes. Instead, we need to focus on the branches representing the worst outcomes, and prune them with all our might. Social isolation reduces transmission, and slows the spread of the disease. In doing so, it chops off branches that represent some of the worst futures. Contact tracing catches people before they infect others, pruning more branches that represent unchecked catastrophes.
At the beginning of a pandemic, we have the disadvantage of higher uncertainty, but the advantage of being early: The costs of our actions are lower because the disease is less widespread. As we prune the tree of the terrible, unthinkable branches, we are not just choosing a path; we are shaping the underlying parameters themselves, because the parameters themselves are not fixed. If our hospitals are not overrun, we will have fewer deaths and thus a lower fatality rate. Thats why we shouldnt get bogged down in litigating a models numbers. Instead we should focus on the parameters we can change, and change them.
Every time the White House releases a COVID-19 model, we will be tempted to drown ourselves in endless discussions about the error bars, the clarity around the parameters, the wide range of outcomes, and the applicability of the underlying data. And the media might be tempted to cover those discussions, as this fits their horse-race, he-said-she-said scripts. Lets not. We should instead look at the calamitous branches of our decision tree and chop them all off, and then chop them off again.
Sometimes, when we succeed in chopping off the end of the pessimistic tail, it looks like we overreacted. A near miss can make a model look false. But thats not always what happened. It just means we won. And thats why we model.
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But what is most worrisome is the racial disparity in prior health conditions that exist in the United States. As Bloomberg reported about a study of the deaths in Italy: Almost half of the victims suffered from at least three prior illnesses, and about a fourth had either one or two previous conditions. More than 75 percent had high blood pressure, about 35 percent had diabetes and a third suffered from heart disease.
According to the Centers for Disease Control and Prevention, high blood pressure is most common in non-Hispanic black adults (54 percent), and black people have the highest death rate from heart disease.
As for diabetes, the 2015 National Medical Association Scientific Assembly, held in Detroit, where my friend died, delivered these stark statistics:
African-American patients are more likely than white patients to have diabetes. The risk of diabetes is 77 percent higher among African-Americans than among non-Hispanic white Americans. The rates of diagnosis of diabetes in non-Hispanic African-Americans is 18.7 percent compared to 7.1 percent.
The group went on to say that in 2006, African-Americans with diabetes were 1.5 times more likely to be hospitalized and 2.3 times more likely to die from diabetes than non-Hispanic whites.
In addition, many Southern states refused to expand Medicaid under the Affordable Care Act, and there is a rural hospital crisis in this country. But that crisis is compounded in the South, where, as the magazine Facing South points out, the rural areas have higher poverty rates, higher mortality rates, and lower life expectancies than other rural regions of the country.
This all worries me, because I take a lesson from the H.I.V./AIDS crisis. In the beginning, it was largely seen as a New York and San Francisco problem affecting white men who were gay. Over the decades, treatments became available, and those cities saw their new infection rates plummet.
But the disease remained very much alive, particularly in the South, particularly among black people, where it has reached epidemic proportions. In the United States, more than 40 percent of people living with H.I.V. and 40 percent of people with new infections are black, according to the C.D.C., and African-American men accounted for three-quarters of new H.I.V. infections among African-Americans in 2016, and 80 percent of these were among African-American gay and bisexual men.
A person waits in line to get tested for the COVID-19 virus at Brooklyn Hospital Center on Tuesday. Angela Weiss/AFP via Getty Images hide caption
A person waits in line to get tested for the COVID-19 virus at Brooklyn Hospital Center on Tuesday.
A new analysis from the Centers for Disease Control and Prevention finds that people with chronic conditions including diabetes, lung disease and heart disease appear to be at higher risk of severe illness from COVID-19.
The report finds 78% of COVID-19 patients in the U.S. requiring admission to the intensive care unit had at least one underlying condition. And 94% of hospitalized patients who died had an underlying condition. The analysis is a preliminary snapshot based on data from about 7,000 cases in the U.S. and about 200 deaths.
"These results are consistent with findings from China and Italy," the CDC researchers conclude in a report published in the MMWR, the Morbidity and Mortality Weekly Report, on Tuesday. These findings "highlight the importance of COVID-19 prevention in persons with underlying conditions," the paper concludes.
Among COVID-19 patients admitted to the ICU, 32% had diabetes, 29% had heart disease and 21% had chronic lung disease, which includes asthma, COPD and emphysema. In addition, 37% had other chronic conditions including hypertension or a history of cancer.
The report includes a snapshot of cases among children and teenagers, and it adds to the evidence that people of all ages are vulnerable to infection.
The analysis concludes that about 23% of the COVID-19 cases were among children and teens (under age 19). But only a small number of these young patients were known to be hospitalized. The CDC documented 48 hospitalizations among this age group. Eight young patients were sick enough to be admitted to the ICU. (The report does not distinguish within the 0-19 age group).
Keep in mind, this snapshot is preliminary. "The analysis was limited by small numbers and missing data because of the burden placed on reporting health departments with rapidly rising case counts," the researchers write. And the picture could change as more data becomes available.
Overall, this report bolsters the evidence that people with chronic disease may be hit hardest by COVID-19 in terms of severity of symptoms and complications. But it's important to note that about 60% of cases evaluated in this analysis were among people who did not have documented chronic conditions. Healthy, younger people can be vulnerable, too.
As we've reported, a prior analysis, also based on preliminary data, found that nearly 40% of people hospitalized in the U.S. were 55 years old and younger. And 20% were people ages 20-44.
Imagine you are in a small boat far, far from shore. A surprise storm capsizes the boat and tosses you into the sea. You try to tame your panic, somehow find the boats flimsy but still floating life raft, and struggle into it. You catch your breath, look around, and try to think what to do next. Thinking clearly is hard to do after a near-drowning experience.
You do, though, realize two important things: First, the raft is saving your life for the moment and you need to stay in it until you have a better plan. Second, the raft is not a viable long-term option and you need to get to land.
In April 2020, the storm is the Covid-19 pandemic, the life raft is the combination of intense measures we are using to slow the spread of the virus, and dry land is the end to the pandemic.
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The U.S. is still in the clambering-into-the-life-raft phase of responding to Covid-19, and thinking clearly about what to do is still difficult. This confusion has made it hard to appreciate two facts: One is that social distancing combined with scaling up testing, production of medical equipment, and other countermeasures are essential and must be replicated across the country, intensified, and continued. The other is that if these measures have the desired effect of reducing the number of new cases accumulating each day, they provide only a temporary solution.
We still need to find a way to bring the pandemic to a permanent conclusion.
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Several countries in Asia controlled their epidemics before a majority of the population was infected. Some, like Taiwan and Singapore, did so by containing infections from the start. Others, like China and Korea, did so only after large outbreaks. The control they have reached is only a life raft, not dry land, because unless there have been extraordinarily high levels of infection that were so mild as to go unnoticed, most people in these countries remain susceptible to infection.
Viruses do not remember they were previously under control and will resurge when restrictions are lifted. Just look at what happened in 1918, when cities that had cracked down on the transmission of influenza lifted their restrictions and flu transmission rose again. Mathematical models of Covid-19 by our group and others that incorporate these lessons show that, in the short term, social distancing and other interventions can reduce the impact of the virus. But the same models show that when these interventions are eased, the problem returns.
Lets be clear. With something like Covid-19 there is the first peak, and theres the whole epidemic. For the first peak, the evidence so far points to a worrisome possibility of overwhelming our intensive care units even with the degree of social distancing weve achieved as were seeing in New York City. But every bit we slow and flatten the curve will make that less likely and less dramatic, if and when it happens.
It is very possible that after this first wave subsides, we will still have a largely susceptible population, though that depends on how well the social distancing works. Effective treatments and increased ICU capacity could reduce the demand for critical care, lightning the load on the health system, but again, these measures only delay things.
If the SARS-CoV-2 virus has a contagiousness of three, meaning every case infects three other people, then we wont get to the end of the epidemic until two-thirds of the population has become immune by infection or by vaccination. Successful control of the first peak of infections could leave a majority (perhaps a large majority) of the U.S. population still susceptible to the virus.
There are several broad ideas for how to get to dry land, which is widespread immunity in the population. But each has enormous problems.
One way is to let up on social distancing soon and let the epidemic run its course. That would lead to many deaths and completely overwhelm health care systems around the country. Another way is to maintain intense social distancing until there is a vaccine but the arrival of a vaccine is uncertain and, absent a miracle, will likely take more than a year. Meanwhile, society and the economy would suffer.
If the first wave really is controlled, another option would be to try multiple rounds of social distancing: instituting it to bring the epidemic under control then letting up, perhaps only in certain areas, to allow cases to occur and immunity to accumulate gradually in the population, and then again introducing another round of social distancing. Our model of this process shows that it would take multiple rounds and would be challenging to accomplish without errors that lead to ICU overload. It would also be difficult to maintain the political and social will to implement this.
The most ambitious approach would be to intensify social distancing and scale up testing until we have the ability to know about nearly every case of Covid-19, trace his or her contacts, and control the spread of the disease one case at a time. This, though, is hard to envision. Even though Singapore detected the infection early, Covid-19 has stretched the islands public health system to the limits, and our public health system has not had the practice and the resources devoted to stopping a pandemic that Singapore has invested since it faced down severe acute respiratory syndrome (SARS) in 2003. And continued risk of imported cases of Covid-19 from elsewhere in the world or even from other parts of the country would lead us in this best-case scenario to restrict and intensively screen travelers for an extended period.
As epidemics and responses to them are local, the scenario in one part of the U.S. could differ from that in another. A report from the Institute for Disease Modeling suggests that even Seattles relatively prompt response may have only slowed the spread of the infection and it may see a single-peaked epidemic with much of the population infected, despite social distancing efforts. If accurate, recently reported fever data from a networked thermometer company that illness rates may be coming down, not just growing more slowly, then we may see a second peak once social distancing efforts are lifted.
Clearly, we need more testing to understand each regions epidemic trajectory.
A vaccine is ultimately our best hope, but that is in the future many months away, if not a year or more, in the rosiest scenarios.
Whatever path we choose and it may be a mix of paths in different parts of the country, as the local epidemics and responses are so varying we should be working overtime to make use of the time we buy with social distancing. That means:
Despite the near-drowning of hospitals and intensive care units weve observed in many countries, and may soon witness in the U.S., we must think clearly and understand that getting through the first phase of this pandemic only gets us into the life raft, not to dry land.
Marc Lipsitch is professor of epidemiology and director of the Center for Communicable Disease Dynamics at the Harvard T.H. Chan School of Public Health, where Yonatan Grad is an assistant professor of immunology and infectious diseases.
