It is a daunting proposition — a coronavirus-tinged world without a foreseeable end. But experts in epidemiology, disaster planning and vaccine development say embracing that reality is crucial to the next phase of America’s pandemic response. The long-term nature of covid-19, they say, should serve as a call to arms for the public, a road map for the trillions of dollars Congress is spending and a fixed navigational point for the nation’s current, chaotic state-by-state patchwork strategy.
With so much else uncertain, the persistence of the novel virus is one of the few things we can count on about the future. That doesn’t mean the situation will always be as dire. There are already four endemic coronaviruses that circulate continuously, causing the common cold. And many experts think this virus will become the fifth — its effects growing milder as immunity spreads and our bodies adapt to it over time.
For now, though, most people have not been infected and remain susceptible. And the highly transmissible disease has surged in recent weeks, even in countries that initially succeeded in suppressing it. Left alone, experts say, it will simply keep burning through the world’s population.
“This virus is here to stay,” said Sarah Cobey, an epidemiologist and evolutionary biologist at the University of Chicago. “The question is, how do we live with it safely?”
Combating endemic diseases requires long-range thinking, sustained effort and international coordination. Stamping out the virus could take decades — if it happens at all. Such efforts take time, money and, most of all, political will.
Americans have only started to wrap their heads around the idea, polls show. U.S. leaders and residents keep searching for a magic bullet to bring the pandemic to an abrupt end: Drugs that show even a hint of progress in the petri dish have sparked shortages. The White House continues to suggest summer’s heat will smother the virus or that it will mysteriously vanish. A vaccine — while crucial to our response — is not likely to eradicate the disease, experts say. Challenges to vaccination are already becoming clear, including limited supply, anti-vaccine opposition and significant logistical roadblocks.
Meanwhile, some states are rushing headlong into reopening their economies. Even those moving more cautiously haven’t developed tools to measure what’s working and what isn’t — a crucial feature for any prolonged scientific experiment.
“It’s like we have attention-deficit disorder right now. Everything we’re doing is just a knee-jerk response to the short-term,” said Tom Frieden, former director of the Centers for Disease Control and Prevention. “People keep asking me, ‘What’s the one thing we have to do?’ The one thing we have to do is to understand that there is not one thing. We need a comprehensive battle strategy, meticulously implemented.”
People also keep talking of returning to normal, said Natalie Dean, a disease biostatistician at the University of Florida. But a future with an enduring coronavirus means that normal no longer exists. “As we find different ways to adapt and discover what works, that’s how we’re going to start reclaiming parts of our society and life,” she said.
An urgent intermission
America now finds itself in a moment of transition. Infections are declining in some states, even as they rise in others with worrisome emerging hotspots.
What’s missing during this interlude, experts say, is a sense of urgency.
Arriving at this moment of transition required countrywide shutdowns, soaring unemployment and devastating blows to our economy and mental health. All that effort was supposed to buy us time to think, plan and prepare, said Irwin Redlener, director of Columbia University’s National Center for Disaster Preparedness.
“What’s concerning is that I don’t see any signs the federal government has learned any lessons and is doing anything differently to prepare for the next waves,” he said.
Leaders desperately need to shift their response from short-term crisis management to long-term solutions, he and other experts say.
Communities should be thinking about installing doors that don’t require grasping a handle, and re-engineering traffic signals so pedestrians don’t have to push crosswalk buttons, said Eleanor J. Murray, an epidemiologist at Boston University.
In coming years, robots and automated lines could become ubiquitous in meatpacking plants, which have experienced some of the country’s worst outbreaks. Families may have to make diagnostic tests routine ahead of visits to grandparents. Once-mocked office cubicles of a bygone era may become the rage again, replacing open-floor plans now found at many companies. Paid sick time might become a necessity for jobs of all types. And heading to work while under the weather may no longer be seen as an act of admirable American can-do spirit but instead a threat to co-workers and the bottom line.
More immediately, states should be using this time to craft quick-response systems and protocols. With hundreds of cities and counties reopening, think of each as a mini laboratory yielding valuable data on what will work against the virus in coming years. But most still lack the tools to capture that data, said Cobey, the University of Chicago epidemiologist, whose models have been used by Illinois leaders.
The metrics being employed by states remain crude: daily number of deaths, hospitalization rates and confirmations of cases long after people show symptoms. All lag behind the actual transmission of the coronavirus by at least one to three weeks.
“We desperately need better data and fast. It blows my mind that we still don’t have it,” Cobey said.
What’s needed are more sophisticated testing strategies, say experts, that could serve as canaries in the coal mine — increasing our speed and ability to detect surges in the virus. States could select certain populations or areas to test extensively. They could establish a handful of sites that test only patients who have developed symptoms in the last four days, to increase sensitivity to sudden increases in transmission.
“You need testing strategies that allow you to put on brakes quickly enough to stop surges,” said Cobey, who has pleaded with state leaders to implement such strategies.
Another idea researchers have proposed is universally testing pregnant women to measure the asymptomatic spread of the virus — among people who have been infected but don’t show symptoms. The women could be an ideal sample testing population because they already visit hospitals for delivery and maternity checkups.
One hospital in New York tested every pregnant woman who came in to deliver and found 15 percent had the coronavirus. Most of those testing positive — 88 percent — showed no symptoms, a sign of how crucial such testing could be.
Living long-term with the virus also means addressing the mental health effects. There’s an assumption among many leaders, experts say, that increases in depression and anxiety are a temporary problem that will eventually disappear along with the virus.
But for some people, the trauma, fear and stress will accumulate and fester like a wound if left unaddressed, said Paul Gionfriddo, president of the advocacy group Mental Health America. “The psychological recovery is going to be as important as economic and logistical parts of this.”
‘Prevention always sounds easy’
America’s yearning for a quick fix has turned in recent days toward a vaccine, now being portrayed as a solution that will quash the virus once and for all.
But the world has achieved that only once, with smallpox — a measure of just how difficult it is for vaccines to wipe out diseases. And it took nearly two centuries after the discovery of a vaccine — and an unprecedented international effort — to vanquish smallpox, which stole hundreds of millions of lives.
Eventually, many experts believe this coronavirus could become relatively benign, causing milder infections as our immune systems develop a memory of responses to it through previous infection or vaccination. But that process could take years, said Andrew Noymer, a University of California at Irvine epidemiologist.
Barney Graham, deputy director of the federal government’s Vaccine Research Center, said emerging plans for vaccination are already stretching as far out as a decade.
“I’m thinking about things in different stages or eras,” Graham said. “We had a discussion this morning about what can be ready before this winter of 2021, what could be ready for 2021-2022, and what kind of regimen or vaccine concepts would we want after this has settled into a more seasonal virus.”
The success of those vaccines will hinge on distribution — a complicated, logistically fraught process.
In the first few years of a vaccine, global demand will far outstrip what manufacturers are able to supply. Roughly 60 to 80 percent of the world’s population needs to be inoculated to reach herd immunity — that point when enough people have become resistant to a virus that it has difficulty spreading widely. Without international agreements worked out beforehand, the short supply could devolve into bidding wars, hoarding and ineffective vaccination campaigns.
In the United States, the crucial job of distribution will depend on federal and local health departments, which have already shown signs of limited capacity and competence amid this pandemic. As a preview to the chaos that might ensue, the U.S. government’s rollout of the first and only treatment for covid-19, remdesivir, has been described by hospitals as confusing, unfair and lacking transparency.
“We also assume that everyone will want the vaccine because of the devastation this virus has caused, but that’s a big assumption,” said Howard Koh, a top U.S. health official during the 2009 H1N1 flu pandemic. “Prevention always sounds easy, but it’s not.”
America already has vaccines for measles and the seasonal flu, which can be deadly. And yet the health-care system struggles every year to convince people to get those shots.
Looking further down the road, many top experts believe it’s critical that U.S. leaders start planning for the next pandemic now — even as they contend with this one — because of the short attention span and lack of political and public support for preparedness the country has shown in past decades.
“We’ve seen this story so many times before,” Koh said. “As soon as the crisis is over, people will go back to whatever is the new normal and they will move on.”
Our future selves
The struggle to get people to think long-term, of course, is not new to public health.
We know that smoking can kill us. Yet, it is still responsible for 1 of every 5 deaths in the United States.
“The problem is people putting the present ahead of the future,” said Frieden, who led the CDC from 2009 to 2017.
To bridge the divide between present and future, the CDC launched an ad campaign during Frieden’s tenure in which former smokers showed in graphic detail the consequences of lighting up: the removal of their jaw. Having to speak through an electronic voice box. The emotional devastation to their families.
The campaign caused more than 16.4 million people to try to quit smoking between 2012 and 2018 and about 1 million to quit for good, the CDC estimates. “We found a way to show them their future selves,” said Frieden, now president and CEO of a health initiative called Resolve to Save Lives.
The challenge in this pandemic is few such shortcuts remain to push U.S. leaders and the public into forward-thinking actions. The CDC has been sidelined by the White House and blocked from holding public briefings. Meanwhile, the Trump administration has made clear its priority is restarting the economy.
Increasingly, leading experts believe many Americans won’t make the shift toward long-range thinking until the virus spreads more widely and affects someone they know.
“It’s like people who drive too fast. They come upon the scene of an accident, and for a little while, they drive more carefully, but soon they’re back to speeding again,” said Michael T. Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy.
“Contrast that with people who have lost someone to drunk driving,” he said. “It mobilizes them and becomes a cause for them. Eventually, everyone is going to know someone who got infected or died from this virus.
“That’s what it may take.”