Imagine that in one year, the number of people who died in the United States doubled. That is what Imperial College London’s bleakest estimate is in its March 16 report on the likely outcomes of the coronavirus pandemic. It projects that without government-scale interventions, the pandemic could kill 510,000 individuals in Britain and 2.2 million individuals in the United States (about 2.75 million Americans die in a typical year). With stronger US interventions, that figure is halved.
These projections were sufficiently shocking to completely and quickly change the tone of President Trump and his Coronavirus Task Force. The president shifted from denial and confidence in an easy solution to recommending social distancing and reducing any gathering to fewer than 10 people.
More shocking was the report’s recommendation for how to address the pandemic and avoid the trauma of another 2 million deaths. The report recommends suppression, which entails “social distancing of the entire population, home isolation of cases, and household quarantine of their family members” and the addition of school and university closures and potentially more drastic measures. Most shocking is that these drastic measures would have to be sustained until a vaccine is available, which the report estimates could be approximately 18 months from now — or longer.
It appears that the US government is attempting to adopt the suppression strategy. Many states are complying. California has required its 40 million citizens to shelter in place. Other states have closed restaurants, schools, and other businesses and canceled conferences and conventions. However, a sustained suppression of the outbreak for the next year and a half is unlikely to occur. As the beaches of Florida attest, many states and localities are not taking the pandemic seriously and are failing to institute effective social distancing measures, much less home isolation.
If full suppression of the virus doesn’t happen, what will? One possible trajectory that has played out in previous pandemics is a roller coaster-like progression of cases, with restrictions lifting after the first wave of cases begins to decline, followed by a second, smaller wave in fall. During the second wave, social distancing measures and other restrictions may be reinstated, and after these are lifted, diminishing waves may follow until a vaccine is developed. This second-wave effect was observed in some cities during the 1918 influenza and the 2003 SARS outbreak.
The second rebounding wave is likely to happen, ironically, as a result of successful social distancing during the first wave. After the number of cases initially begins to decline and restrictions are lifted, a large portion of the population who practiced social distancing will have no immunity and will therefore be susceptible to the virus when they begin interacting with others again.
The only way to prevent this is by maintaining social distancing measures even after the cases drop until a vaccine or some prophylactic medication is available, hence the estimated 18-month period.
In order for this to work, local governments across the entire country will have to step up and implement sufficient social distancing measures. While the vast majority of states have closed schools, the remaining states need to follow suit now. There also needs to be unified messaging from public leaders, particularly at the federal level. Officials should promote adherence to federal guidelines. And looking forward to the next 18 months, the federal government will need to come up with longer-term economic support for those who cannot work.
These steps will not be easy but must be taken to minimize the loss of human life. Even pursuing a less stringent strategy like mitigation could still lead to an excess of over one million deaths in the United States, according to estimates from Imperial College London. In addition to increased deaths from COVID-19, the report warns of the potential for even greater mortality if health systems are overwhelmed. Without adequate control measures, health will suffer for not just the people with the virus but for everyone who relies on the health care system.
Cathy Zhang is a senior research fellow at the Department of Medical Ethics and Health Policy at the University of Pennsylvania. Dr. Ezekiel Emanuel is vice provost of Global Initiatives and codirector of the Healthcare Transformation Institute Perelman School of Medicine and the Wharton School at the University of Pennsylvania. He is also senior fellow at the Center for American Progress and venture partner at Oak HC/FT.
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