Here’s the one thing every health expert I’ve spoken to agrees on: No one knows the trajectory that Covid-19, the disease caused by the coronavirus, will take in the US. The difficulty in modeling it reflects the fact that the question being asked isn’t just epidemiological, it’s social and political: Can social trust and solidarity replicate faster than the virus?
Let’s break that down. By this point, many of us are familiar with the two numbers that define coronavirus coverage: the reproduction rate and the case fatality rate. In other countries, the coronavirus’s reproduction rate has been around 2.5 — that is to say, absent extreme quarantine measures, each infected person transmits the disease to 2.5 people. The case fatality rate seems to be around 1 percent — about one out of 100 of those infected with the coronavirus die, and those deaths are concentrated among older and immunocompromised people.
But these numbers aren’t intrinsic properties of the virus. They reflect the way the disease interacts with social institutions and behaviors. The replication rate falls amid social distancing and rises with recklessness — in South Korea, a single person led to more than 1,000 infections by refusing testing and going to religious services and brunches.
Similarly, the case fatality rate multiplies if health systems are overwhelmed and falls if social distancing and quarantine measures keep the elderly safe from the disease. In Wuhan, China, the World Health Organization (WHO) found a case fatality rate of 3.4 percent — a terrifying number.
But health experts now believe that reflected the collapse of the local health system, not just the virulence of the disease. “It seems clear that a lot of the fatalities in Wuhan reflected an overwhelmed health system where critically ill patients had to receive substandard types of care,” says Jennifer Nuzzo, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health. This video is an excellent visualization of how that works:
What all this means is that replication and lethality rates reflect other variables that are harder to measure and model: our willingness to trust in and to sacrifice for each other.
The coronavirus curve versus the social trust curve
To see why, run some numbers. Adam Kucharski, an expert on the mathematics of contagion, calculates that if each Covid-19 case leads to 2.5 more infections over five days, then a single case leads to 244 more cases over the course of a month. But if social distancing measures hold that to 1.25 new infections for every case, that’s only four new cases over the course of a month — which also means the cases that do emerge will be less lethal because health systems won’t be as overwhelmed.
Let’s play this out. As of Monday afternoon, there were 4,115 confirmed cases in the US, though testing failures ensure the true number is much higher. Still, let’s use 4,115 as a base. If you keep the assumption that each case creates 2.5 more cases over 5 days, then after 30 days we’ll have 7,564,000 cases. With a 1 percent death rate, that means more than 75,000 deaths — the equivalent of 25 9/11s — in 30 days.
But if social behavior cuts the replication rate to 1.25 and — due to higher health system capacity and more effective quarantining of the elderly — the case fatality rate to 0.5 percent, then after 30 days there will only be a bit more than 533,000 cases and 2,665 deaths. That loss of life would remain tragic, but more than 72,000 lives would be saved.
Here’s the catch: These measures are far more effective if implemented, well, now. “One of the particularly tough things about this infection is you get this delay of about a month between exposure and death,” Kucharski told me. “By the time people are taking it seriously, even if you stop transmission completely, you still likely have another three or four weeks of hospitals filling up.” In other words, you need to stop the disease before the health system is visibly overwhelmed, not after.
But implementing radical and rapid social distancing before the crisis is undeniable requires two resources in short supply: social trust and social solidarity.
Let’s start with trust. We’re being asked to upend our social and economic lives based on ... what? The chance that a virus few people currently have and none of us can see will explode? “When you’re feeling well and you don’t see it around you, the idea of giving up social support systems and connections and things that bring you joy is very hard,” says Nuzzo.
Eventually, the epidemic’s toll will be pervasive, and people will accept emergency measures as a necessary response. But by then, we will be past the point of containment. To act now — when it would be most effective — requires that we believe the scientists, journalists, and politicians warning us of a future we can’t yet see or feel. To do that, we need to trust them.
But we are a society operating in the midst of a collapse in social trust. Already, a gap is emerging between how Democrats and Republicans view the disease, with 68 percent of Democrats fearing that someone in their family could contract the virus and only 40 percent of Republicans saying the same.
This could just reflect geography — Democrats are likelier to live in urban centers where the disease is already present — but it could also reflect what Republicans are hearing from President Trump and allied media outlets. Fox, in particular, has downplayed the threat, though the network seems to be trying to reverse course, taking Fox Business anchor Trish Regan off the air for dismissing coronavirus as “another attempt to impeach the president.” Similarly, it’s good news that after weeks of repeatedly downplaying the crisis, Trump has begun conveying more urgency and seriousness in his statements.
But if social trust is thin, social solidarity is nearly nonexistent. As sociologist Eric Klinenberg writes, “social solidarity, or the interdependence between individuals and across groups ... [is] an essential tool for combating infectious diseases and other collective threats.” It’s solidarity that both persuades and permits us to sacrifice for each other. It’s social solidarity that “keeps us from hoarding medicine, toughing out a cold in the workplace or sending a sick child to school.” It’s solidarity that convinces us to pass policies like paid leave and universal health care, which make it possible for low-wage workers to stay home from work and go to the doctor when they’re feeling sick. But America is alone among rich nations in refusing to guarantee paid leave or health coverage. We were lacking in social solidarity before the pandemic, and we are suffering for it now.
“If we’re asking people to make sacrifices, society can’t ask them to make them alone,” says Tom Inglesby, director of the Center for Health Security at Johns Hopkins University. “It’s not right. And not only is it not right, it won’t work.”
To put it bluntly, social distancing and social solidarity are flip sides of the same coin: Absent the kinds of policies that emerge from social solidarity, social distancing isn’t economically or psychologically possible.
Making social distancing possible
Social distancing is being framed as a moral act: work from home, avoid restaurants, cancel gatherings — or be shamed. But for many, the calculation is more wrenching; the sacrifices they’re being asked to make will be painful, even ruinous.
Restaurant, bar, and shop owners may see their businesses collapse if they close or operate at half-capacity for weeks on end; service sector employees don’t get paid for the days they cannot come into work or the appointments that get canceled; parents are being asked to somehow work and entertain housebound children; people are canceling weddings they have planned for years or delaying nonessential medical care in the face of mounting pain and anxiety.
We are not a society in which social policy encourages or reflects solidarity. The economic support bill the House approved over the weekend tries to temporarily patch some of these holes, but it’s a wan effort. The paid leave provisions in the House bill only cover about half of the workers who would need it, for instance.
More ambitious plans exist. Reps. Ro Khanna (D-CA) and Tim Ryan (D-OH) have proposed legislation that would send a check of between $1,000 and $6,000 to every American who made less than $65,000 last year. Sen. Mitt Romney (R-UT) has discussed sending $1,000 to every adult. Jason Furman, the former head of the White House Council of Economic Advisers, has proposed a credit of $3,000 per adult and $1,500 per child. It would be straightforward to guarantee small businesses cheap loans and tax relief so they can survive lengthy closures. But we haven’t done any of that yet.
When I spoke with Kucharski, he said something that knocked the wind out of me. “At the moment, it seems the only way to sustainably reduce transmission are really severe, unsustainable measures.”
What he meant was this: The kind of top-down, state-enforced quarantines we see in China or Italy can only be enforced for so long. In Northern California, where I live, six counties have announced “shelter in place” regulations, closing most businesses through at least April 7. Extreme measures like that will slow contagion, but at some point, it won’t be possible to grind the majority of economic activity to a halt. Businesses will reopen. People will visit their families, their friends. If we do so carelessly, the virus will roar back.
Unsustainable measures can buy necessary time, but they only help if we use that time to build a sustainable response. We need to use that time, in other words, to make sure social trust and solidarity begin to reproduce faster than the virus itself.
What comes next on coronavirus is up to us, not the disease. But we must act fast.