Tough time on the horizon: What the winter of pandemic will look like

The deadliest month in American history was an October during a global pandemic. In 1918, after waning through the long summer, Spanish flu came roaring back to claim nearly 200,000 lives, just in that one month, just in the United States. Until recently, this second-wave surprise — it was the worst of three to hit the country between 1918 and 1919, most likely because a rare mutation made the virus more deadly — was a bit of obscure medical trivia. But as our current pandemic enters its ninth month, armchair epidemiologists have been wringing their hands over it.

Coronaviruses have little in common with influenza viruses. (For one thing, coronaviruses mutate less frequently, and almost never in ways that make them deadlier). But we’re grasping for comparisons because we are living in a fog right now. It’s not the same fog-of-war fog that we experienced in early spring, when airports were flooded in panic, every inanimate object seemed capable of infecting us and nobody could agree on if or when to wear a mask. Things seem much calmer now. But they also remain deeply uncertain. Will we get a safe, effective vaccine? A new president? More and better testing? How will these things change the course of the pandemic? What if they don’t?

To be sure, some progress has been made. Rapid antigen tests are finally being deployed, mask-wearing is common in many places, and doctors have grown much more adept at treating the virus’s victims. Thanks to a small roster of drugs and a better understanding of when and how to ventilate COVID-19 patients, Ashish Jha, dean of Brown University’s School of Public Health, estimates that people infected today are roughly 30 per cent to 50 per cent less likely to die of the virus than they would have been in March or April.

But government ineptitude, rampant misinformation and outright lies from our own president are still thwarting efforts to stomp the virus out. We are logging nearly twice as many cases nationally as we did in late spring. And the death toll will soon surpass 200,000. Elderly people and low-income, front-line workers, coming especially from communities of color, make up a disproportionate share of those deaths, meaning that we have done a bad job of protecting our most vulnerable.

It’s tough to say how autumn will go, let alone winter. Mathematical models have proven unreliable in part because they are based on previous experience, and when it comes to the novel coronavirus, there is none: Other coronaviruses have leapt into humans, but none have ever caused a pandemic. Scientists also still don’t have enough data to form a full picture of the crisis. The Harvard epidemiologist Marc Lipsitch says his efforts to predict how many COVID-19 patients would need intensive care were stymied by a lack of basic information about their average hospital stay. Other experts have noted that there’s no way to tell how many cases are being found through contact tracing as opposed to clinical diagnostics.

A recent report on risk factors from the Centers for Disease Control and Prevention involved just 314 people and concluded that eating at a restaurant or being exposed to a someone with the coronavirus might increase your risk of developing COVID-19. “It’s insane that eight months into a global pandemic we still don’t have this kind of basic information,” Lipsitch says. “It makes for a lot of guesswork.” But there are ways to think about the future of this pandemic — and some are more useful than others.

Let’s set aside the wave analogy. Michael T Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota, says that it’s far more accurate to think of the pandemic as a forest fire. We have suppressed it in some places, but we have not put it out completely. “It’s going to keep burning as long as it has wood,” he says. “In this case, wood is humans that are susceptible to infection.” It’s safe to assume that case counts will rise in the coming months, as colder weather forces more people indoors (in the North, at least) and as more students and teachers return to in-person schooling. Colleges are already grappling with outbreaks, and infected students are already returning home to seed a further spread in their own communities.

“Case counts could start spiking just a few weeks from now,” Peter Hotez, the dean of the National School of Tropical Medicine at the Baylor College of Medicine in Texas, told me. “The most rigorous predictions are that we head into November with 220,000 deaths.” And if pandemic-fatigued families travel to spend the holidays together, it will get worse in late fall and winter.

It’s tough to say whether the nation will reach or surpass the grim peaks of the summer, when we were seeing 65,000 to 70,000 new cases every day. Hopeful policymakers have speculated that fall outbreaks will be less severe, because many communities are at or approaching the herd immunity threshold — the point at which enough people have become immune to the virus that it can no longer spread easily. But there are several problems with this hypothesis.

First, we don’t really know how durable immunity to the virus might be. Most scientists think it’s likely that it lasts anywhere from several months to a year. But doctors have confirmed a few cases of repeat infection and, in at least one of them, the second infection proved more severe than the first.

Second, herd immunity is not a magical doorway that will take us back to the before-times. “People think once we hit this number we can all go to the bar because now it’s over,” Dr Jha says. “But it doesn’t work like that.” It’s hard to know what the threshold even is (most experts put it at around 60 per cent or higher, though some argue it could actually be much lower) and difficult to say when a population has crossed it.

But even then, the virus would only slow down, not stop. Third, most experts agree that, whatever the threshold proves to be, no country in the world is there yet. Even if some of the hardest hit communities — in Corona, Queens, for example — are partly protected, antibody tests indicate that, overall, just 10 per cent to 12 per cent of Americans have been infected with the virus to date. If SARS-CoV-2 is a forest fire, it still has a lot of wood to burn through.

That’s true even in Sweden, where officials skipped complete lockdowns, presumably enabling more people to interact, catch SARS-CoV-2 and develop immunity to it. The resulting death toll was one of the highest in the world, but proponents argue that the pain was worth it because the country’s fatality rate is now tumbling. A precipitous decline in deaths indicates that herd immunity has been reached, they argue.

But critics say that many of those deaths were avoidable, and that case counts and death tolls could easily surge again when control measures are lifted, (the country still enforces strict social distancing in some indoor spaces), or even if they are not. “The thing about fires is that they don’t burn everywhere equally at the same time,” Dr Osterholm says. “Even where they rage, they still miss patches of vulnerability, just by chance.”