When will this end?

In the upcoming months, there will be intense pressure to relax social distancing, get back to work, and let your children run outside. And never return. For at least a week. Tension over when to open sectors of the economy will explode into a ThunderDome Death Match between politicians, economists, and medical experts.

Expect government officials and pundits to make a lot of noise about reopening sectors of the economy this month. Even though we have not yet reached the beginning of the end of the COVID pandemic. Even though in less connected cities and towns, we haven’t even reached the end of the beginning.

It might be helpful to think of social distancing as the country being on a ventilator. Meaning a life-saving intervention that is currently the only thing keeping us from a complete national medical catastrophe. There may be signs that the country (patient) is on the upswing. And that the most life-threatening period has passed. But would you ever want a loved one taken off a ventilator before a medical expert gave the okay? Even if your favorite politician thought she looked pretty good? The same should go for social distancing. Just as most doctors have a good idea of what would happen to a patient if taken off a ventilator too early, the scientists who study infectious disease patterns for a living can provide a pretty good picture of what will happen if we prematurely let up on social distancing.

Because, just to be clear, COVID will not just naturally disappear as the weather warms. Some of you may recall that the spring wave of the 2009 H1N1 influenza pandemic peaked in June in the United States. That does not mean that COVID will also peak in June. H1N1 has different transmission dynamics and was introduced later into the US, so there is no reason to expect COVID to follow the same curve. But it’s a potent reminder that novel pandemic viruses do not behave like seasonal viruses and are perfectly capable of causing severe outbreaks during warm weather.

This doesn’t mean we shouldn’t put economic considerations into the equation. If the ventilator for your loved one cost $1 trillion a day, you might decide to take the risk even if your doctor advised against it. The point is just that the economic considerations should be scrupulously and ethically weighed against well-calculated risks on both sides. It shouldn’t come down to a politician noticing a little improvement in a patient’s vital signs and deciding enough is enough.

The upshot is that, politics aside, everyone should be mentally prepared for intense social distancing to continue at least through the spring. But, the good news is that as we learn more about the virus, we can be more strategic about how we go about social distancing and hopefully improve our quality of life. The more we understand how the virus transmits, the more we can cut needless paranoia and allow ourselves new little freedoms.

For example, this is purely a hunch, but I think it’s possible that we’re going to find that talking is going to be important in the spread of the virus. We tend to focus on coughing and sneezing, but one of the things that makes COVID so dangerous is that it is transmitted early in the infection cycle. The 2003 SARS virus mostly spread to other people after a person had already been sick for a while. Same thing for Ebola. COVID is very different in that it spreads readily right at the onset of early symptoms, and to some degree even before symptoms. This makes it much harder to control. And suggests that while sneezing and coughing certainly helps transmission, talking may also contribute to transmission at those early stages of infection. In which case, better understanding of this could inform exactly how we go about social distancing. It could be that extended periods of talking with someone, even at a properly social-distanced 6 feet away, could be far riskier than opening a box of delivered groceries. (By the way, 6 feet is a good baseline number to shoot for in grocery stores, but is not entirely protective — the Washington State choir outbreak suggested that people singing loudly might shoot virus a lot farther than 6 feet and infect each other).

But the point is we still have a long way to go in understanding the virus and what activities put you at most risk for infection. So there is cause to be optimistic that even if social distancing continues into the summer, that greater knowledge of how the virus transmits could at least tell us how to do social distancing right and with less stress and uncertainty.

When we start to think about reopening parts of the country, it will be useful to look closely at how things play out first in Asia. A few months ago, I was able to be pretty confident in my early predictions about the arrival and intensity of COVID not because have great foresight, but because Asia (and later Italy) provided a vivid roadmap in real-time of how the virus was behaving, and it was obvious that America had no special sauce that would lead us to follow a different trajectory. If anything, America was less prepared. Since Singapore and other Asian countries that initially managed COVID far better than the US have already started to reopen society, we can get another sneak preview of how things are playing out. So far, their struggles with resurgences of COVID outbreaks as economies reopen sends a pretty clear message of how fraught reopening society is even in places where the virus has been brought under control and where intensive testing is available. This seems to be because, as long as there is trade and movement with other areas with high COVID activity, there are too many opportunities to import new cases. This will be particularly difficult in a country as large and heterogenous as the United States. It will be particularly interesting to see whether countries like New Zealand and Iceland can successfully reopen sectors of the economy in the upcoming months, as these would be the best candidates given their gold-medal responses to controlling COVID through high testing and early, intensive controls as well as innate geographical advantage as islands.

What seems to be most frustrating to people right now is the uncertainty about the future. The darn models keep changing. But the models aren’t changing. Human behavior is changing. The original models with really bad projections were based on what would happen if we didn’t do social distancing. New models have lower projections because they include current levels of social distancing. That doesn’t mean the original models were wrong. The models project much lower numbers because this is a virus with exponential growth potential, so changes in human contact patterns have really pronounced effects on the trajectory.

So why can’t models be smart and incrementally increase social distancing parameters as the number of cases and death increase, since this is how humans would naturally respond to a building threat? Because a smart model requires uniformly smart humans. And anyone who has been following the news knows just how much variability there has been in the responsiveness of leaders at different levels of US government, from the White House down to mayors of small towns. So instead models have to be updated manually according to real-world human behavior. If social distancing relaxes, the models will get updated again and show things getting worse.

The models also have a lot of uncertainty because they are only as good as the data fed into them. And, at least in the United States, the underlying data is unfortunately not so good. For a country that is a global leader in biomedical research, there will be a long reckoning at some point in the future about why our testing flopped.

This is what happens when testing flops:

1. We are always chasing the epidemic from behind. Localities still seem to still be under the impression that they don’t need to do anything until a positive case pops up. But at our slow pace of testing, by the time even a single positive case is detected, the virus is already transmitting like wildfire in a community.
2. We don’t know fundamental characteristics about COVID transmission, and these are needed to inform any decisions to relax social distancing. Things like how many people are asymptomatic or mild cases, and how important are they in overall transmission. Things like how much transmission occurs within households versus in the community. For all you parents out there, things like how important are children in transmission, and what would happen if we reopened schools?
3. Not testing mild or asymptomatic cases means we don’t know how many people actually have had the virus. Those numbers you see of lab-confirmed cases are just a fraction of the real number. And therefore we don’t know what proportion of the American population will be immune in the upcoming months. In theory, the greater the number of people who are immune, the lower the rate of transmission in the community (Re) and the sooner we begin to relax social distancing. It becomes very difficult to model the effect of reopening sectors of the economy without a baseline estimate of existing immunity in the population and well as individual-level knowledge of

There are certainly blockbuster events that could accelerate the reopening of society. If a new or existing therapeutic is proven to be effective (with the emphasis on proven). If a vaccine becomes available at some point in 2021. A high-quality antibody test would be very useful in determining who has been infected and is now immune (I mention high-quality because serological tests often have too many false-positives or false-negatives to actually inform policy).

I do want to emphasize that the COVID pandemic will officially end at some point, likely in 2021. That does not mean that the virus will be eradicated from the human population. It just means that through natural infection or vaccination, there will be enough herd immunity* that the virus is controlled. It remains to be seen whether the coronavirus behaves like an influenza virus, recurring in seasonal epidemics that affect the global population and vary in intensity year-to-year. Or whether it is more like a measles virus, causing intense outbreaks in localized pockets where vaccination levels are low. The answer will depend on the effectiveness of the vaccine and the evolutionary rate of the virus, specifically in the spike protein on the exterior of the virus that will be targeted by human antibodies. [You would think we would have a little more baseline knowledge of how coronaviruses evolve year-to-year in humans, since there are at least four strains that circulate widely and cause common colds in humans (e.g., HKU-1, OC43). But since they don’t tend to kill people, there’s not much funding for research.]

So the upshot is that social distancing is not the new normal. The COVID pandemic will eventually end and we will eventually see the return of baseball and senior bingo nights. And, if we have the political will, it is possible that, after decades of underfunding pandemic research and preparedness, we will be better prepared next time.

*Note that we do not know how long natural immunity to the virus lasts. It is likely that people who are infected with COVID and recover will have strong immunity to it for at least several months, probably longer. In terms of opening society back up and improving quality of life, having a proportion of the country that is known to be immune would be extremely helpful logistically. But if we don’t test enough, there will be many people who are immune but don’t know it.