The coronavirus is spreading from America’s biggest cities to its suburbs, and has begun encroaching on the nation’s rural regions. The virus is believed to have infected millions of citizens and has killed more than 34,000.
Yet President Trump this past week proposed guidelines for reopening the economy and suggested that a swath of the United States would soon resume something resembling normalcy. For weeks now, the administration’s view of the crisis and our future has been rosier than that of its own medical advisers, and of scientists generally.
In truth, it is not clear to anyone where this crisis is leading us. More than 20 experts in public health, medicine, epidemiology, and history shared their thoughts on the future during in-depth interviews.
“We face a doleful future,” said Dr. Harvey V. Fineberg, a former president of the National Academy of Medicine.
He and others foresaw an unhappy population trapped indoors for months, with the most vulnerable possibly quarantined for far longer. They worried that a vaccine would initially elude scientists, that weary citizens would abandon restrictions despite the risks, that the virus would be with us from now on.
“My optimistic side says the virus will ease off in the summer and a vaccine will arrive like the cavalry,” said Dr. William Schaffner, a preventive medicine specialist at Vanderbilt University medical school. “But I’m learning to guard against my essentially optimistic nature.”
Most experts believed that once the crisis was over, the nation and its economy would revive quickly. But there would be no escaping a period of intense pain.
Exactly how the pandemic will end depends in part on medical advances still to come. It will also depend on how individual Americans behave in the interim.
More Americans may die than the White House admits
COVID-19, the illness caused by the coronavirus, is arguably the leading cause of death in the United States right now. The virus has killed more than 1,800 Americans almost every day since April 7, and the official toll may be an undercount.
By comparison, heart disease typically kills 1,774 Americans a day, and cancer kills 1,641.
Yes, the coronavirus curves are plateauing. There are fewer hospital admissions in New York, the center of the epidemic, and fewer COVID-19 patients in intensive care units. The daily death toll is still grim, but no longer rising.
The gains to date were achieved only by shutting down the country, a situation that cannot continue indefinitely. The White House’s “phased” plan for reopening will surely raise the death toll no matter how carefully it is executed. The best hope is that fatalities can be held to a minimum.
“All models are just models,” Dr. Anthony S. Fauci, science adviser to the White House coronavirus task force, has said. “When you get new data, you change them.”
The lockdowns will end, but haltingly
No one knows exactly what percentage of Americans have been infected so far — estimates have ranged from 3 percent to 10 percent — but it is likely a safe bet that at least 300 million of us are still vulnerable. Until a vaccine or another protective measure emerges, there is no scenario, epidemiologists agreed, in which it is safe for that many people to suddenly come out of hiding.
“There’s this magical thinking saying, ‘We’re all going to hunker down for a while and then the vaccine we need will be available,’” said Dr. Peter J. Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine.
In his wildly popular March 19 article in Medium, “Coronavirus: The Hammer and the Dance,” Tomas Pueyo correctly predicted the national lockdown, which he called the hammer, and said it would lead to a new phase, which he called the dance, in which essential parts of the economy could reopen.
Every epidemiological model envisions something like the dance. Each assumes the virus will blossom every time too many hosts emerge and force another lockdown. Then the cycle repeats. On the models, the curves of rising and falling deaths resemble a row of shark teeth.
Surges are inevitable, the models predict, even when stadiums, churches, theaters, bars, and restaurants remain closed, all travelers from abroad are quarantined for 14 days, and domestic travel is tightly restricted.
Immunity will become a societal advantage
Imagine an America divided into two classes: Those who have recovered from infection with the coronavirus and presumably have some immunity to it; and those who are still vulnerable.
“It will be a frightening schism,” Dr. David Nabarro, a World Health Organization special envoy on COVID-19, predicted. “Those with antibodies will be able to travel and work, and the rest will be discriminated against.”
Already, people with presumed immunity are very much in demand, asked to donate their blood for antibodies and doing risky medical jobs fearlessly.
Soon the government will have to invent a way to certify who is truly immune. A test for IgG antibodies, which are produced once immunity is established, would make sense, said Dr. Daniel R. Lucey, an expert on pandemics at Georgetown Law School. Many companies are working on them.
The virus can be kept in check, but only with expanded resources
The next two years will proceed in fits and starts, experts said. As more immune people get back to work, more of the economy will recover.
But if too many people get infected at once, new lockdowns will become inevitable. To avoid that, widespread testing will be imperative.
Fauci has said “the virus will tell us” when it’s safe. He means that once a national baseline of hundreds of thousands of daily tests is established across the nation, any viral spread can be spotted when the percentage of positive results rises.
But diagnostic testing has been troubled from the beginning. Despite assurances from the White House, doctors and patients continue to complain of delays and shortages.
There will not be a vaccine soon
Even though limited human trials of three candidates — two here and one in China — have already begun, Fauci has repeatedly said that any effort to make a vaccine will take at least a year to 18 months.
All the experts familiar with vaccine production agreed that even that timeline was optimistic. Dr. Paul Offit, a vaccinologist at the Children’s Hospital of Philadelphia, noted that the record is four years, for the mumps vaccine.
Researchers differed sharply over what should be done to speed the process. Modern biotechnology techniques using RNA or DNA platforms make it possible to develop candidate vaccines faster than ever before. But clinical trials take time, in part because there is no way to rush the production of antibodies in the human body.
Also, for unclear reasons, some previous vaccine candidates against coronaviruses like SARS have triggered “antibody-dependent enhancement,” which makes recipients more susceptible to infection, rather than less.
Treatments are likely to arrive first
In the short term, experts were more optimistic about treatments than vaccines. Several felt that convalescent serum could work.
The basic technique has been used for over a century: Blood is drawn from people who have recovered from a disease, then filtered to remove everything but the antibodies. The antibody-rich immunoglobulin is injected into patients.
The obstacle is that there are now relatively few survivors to harvest blood from.
Having a daily preventive pill would be an even better solution, because pills can be synthesized in factories far faster than vaccines or antibodies can be grown and purified.
But even if one were invented, production would have to ramp up until it was as ubiquitous as aspirin, so 300 million Americans could take it daily.