While a lot of attention is currently going to President Donald Trump’s Covid-19 diagnosis, experts warn that the rest of the country should prepare for a potential coronavirus surge in the coming weeks and months of fall and winter.
The surge of Covid-19 cases and deaths in America over the summer resulted from a toxic mix of factors: states reopening, lockdown fatigue, and a season typically filled with vacations and holidays like Memorial Day and the Fourth of July. People gathered and celebrated indoors — at bars, restaurants, and friends’ and family’s homes. Millions of people got sick, and tens of thousands died.
This fall, experts worry it will all happen again: States are rolling back restrictions, people are eager to get back to normal, and Thanksgiving and Christmas are coming up. America may be on the verge of repeating the same mistakes, which would risk yet another surge in the Covid-19 epidemic.
Coronavirus cases have already trended up since mid-September. On September 12, the US hit a recent low in its seven-day case average of around 35,000. As of October 4, it was up to almost 44,000. The recent increase doesn’t seem to be driven by any one particular state — though some, like the Dakotas and Wisconsin, are doing quite badly — but rather upticks across much of the country all at once. (Increased testing capacity is likely detecting more cases, too.)
Part of the problem is America never really suppressed its Covid-19 cases to begin with. Think of a disease epidemic like a forest fire: It’s going to be really difficult to contain the virus when there are still flames raging in parts of the forest and small embers practically everywhere. The country always risks a full blaze with each step toward reopening and with each failure to take precautions seriously.
Consider Florida. Last month, the state reopened bars and, more recently, restaurants, despite the high risk of these indoor spaces. After Florida previously opened bars, in June, experts said the establishments were largely to blame for the state’s massive Covid-19 outbreak in the summer. As Florida reopens now, it has roughly two to three times the number of Covid-19 cases that it had in early June, and its high test positivity rate suggests it’s still likely missing a lot of cases. The state is fanning its flames while its most recent fire is nowhere near extinguished.
This is, in effect, what much of the country is doing now as it rushes to reopens schools, particularly colleges and universities, and risky indoor spaces. Coupled with recent Labor Day celebrations, experts worry that’s already leading to a new increase in Covid-19 cases.
Trump, for his part, has encouraged rapid reopenings. From his “LIBERATE” tweets in the spring to his recent demands that schools reopen, Trump has pushed forward with his efforts to return society to normal even as the coronavirus keeps spreading and killing people in the US. Indeed, Trump’s cavalier attitude toward the virus, as he attended big campaign rallies and refused to wear a mask, likely got him sick too.
The fall and winter threaten to make things much worse. Schools will continue to reopen. The cold in northern parts of America will push people back inside, where the virus has a much easier time spreading than the outdoors. Families and friends will come together for the holidays. A flu season could strain the health care system further.
States are once again starting to reopen more widely, as officials face pressure from businesses to reopen indoor dining before colder temperatures make outdoor activities less feasible. Experts worry that Americans as a whole will get even more fatigued with social distancing, now that the country is more than seven months into its battle against Covid-19.
“It’s less excusable this time,” Crystal Watson, senior scholar at the Johns Hopkins Center for Health Security, told me. “We have an example of what happens when we reopen these types of businesses for indoor activities.”
The good news is there’s still time to act. Cities, states, and the country as a whole could take social distancing seriously again. They could require masks where they aren’t already mandated. They could close bars and restaurants, supporting these businesses with a bailout, to prioritize keeping K-12 schools open while reducing other risks. Colleges and universities could ease demands for in-person teaching or at least embrace aggressive testing-and-tracing measures to mitigate the risks of causing further Covid-19 outbreaks.
Without these steps, the fall and winter outbreaks could end up worse than the summer and potentially even the spring. That could mean not just more infections and deaths but yet another setback in America’s hopes of getting parts of life closer back to normal.
“If you do things the right way, you can do them,” Cedric Dark, an emergency medicine physician at the Baylor College of Medicine, told me. “If you do them the wrong way, then you’re going to get cases.”
We keep making the same mistakes
After the spring outbreaks hit the northeastern US, much of the country, led by Republican leaders in states like Arizona, Florida, and Texas, moved forward with aggressive reopenings. The problem, experts said, is many of these places never suppressed their Covid-19 outbreaks. As epidemiologist Pia MacDonald at RTI International told me at the time, many states “never got to flat.” Case counts continued to climb, and states continued to reopen anyway.
This created an environment that made it much easier for the coronavirus to spread. If there’s already some community transmission going on, then it’s simply going to be more likely that one person will infect another. Add more spaces in which infections are very likely — particularly close indoor spaces like bars and restaurants — and that risk can be increased dramatically.
Today, the US seems to be heading in the same direction. While cases have fallen overall since late July, they plateaued at — and recently started rising from — a point that was still higher than the peak of Covid-19 cases in the spring (partly, but likely not entirely, due to more testing). Yet many states are moving forward with reopening once again.
So MacDonald is now repeating the same thing she told me this summer: “We never got to low enough levels [of Covid-19] to start with in most places.”
Of particular interest is indoor dining at restaurants and bars, which are reopening at varying levels across the country. Experts characterize these settings as perhaps the worst imaginable spaces for Covid-19 spread: People are close together for long periods of time; they can’t wear masks as they eat or drink; the air can’t dilute the virus like it can outdoors; and alcohol could lead people to drop their guards further. It was a recognition of all these risks that led many states to scale back and close indoor dining and bars back during their summer outbreaks.
This time, though, there’s another major variable: Schools are reopening. Some places have even reopened, or set plans to reopen, schools alongside bars or indoor dining — making it hard to separate the effects of either and potentially compounding new outbreaks.
Already, there have been reports of outbreaks in K-12 settings, where students and teachers can potentially transmit the coronavirus to each other in the classroom. But there’s still a lot we don’t know about how younger kids, particularly in elementary schools, spread the virus.
Some experts raised graver concerns about colleges and universities. Students in these institutions aren’t just potentially spreading the coronavirus in their classrooms, although that’s likely happening to some degree. They’re also showing up at bars, clubs, and indoor restaurants, partying at dorms, and drinking a lot more than they should.
“College kids are college kids,” Carlos del Rio, executive associate dean of the Emory University School of Medicine, told me. “That’s what I always tell every university president I talk to: You can make all the plans you want, but at the end of the day, it’s what happens outside your plans that matters.”
The good news, for now, is that infections in colleges and universities will skew younger, and younger people are less likely to suffer major complications, including deaths, from Covid-19. That helps explain, along with general improvements in treatment, why daily Covid-19 deaths have still trended down since August (although they’re still at more than 700 a day in the US).
But young people can still get seriously ill and die from the coronavirus — and if enough of them get infected, that could show up in higher death tolls eventually. Even if that doesn’t happen, young people will likely interact with their teachers, parents, and grandparents at some point, potentially infecting them. That could produce yet another outcome that would look similar to the summer: The outbreaks started among young groups but eventually spread to older populations who were more susceptible to illness and death.
After the summer surges, Brown University School of Public Health dean Ashish Jha told me, “I was like, ‘Okay, now we’ve all been through this — every part of the country: the South, the West, the Midwest, the Northeast. There’s no denialism anymore that will work, because there’s been this long denial while it’s been there but not here.’” Yet, he said, “we’re starting to see this again.”
He added, “I, at this point, feel like I clearly no longer understand why our country can’t learn its lessons and why we keep repeating the same mistakes.”
The fall and winter are coming
For months, experts have worried that the fall and winter would lead to more outbreaks, citing, as one contributor, the reopening of schools. That seems to be happening now, as cases start to creep up nationwide, with reported outbreaks in K-12 schools, colleges, and universities around the US.
But things could still get worse.
People are bound to get more fatigued with social distancing and the pandemic more broadly as time drags on. As months pass since the last huge wave of Covid-19 in the US, people are more likely to convince themselves it’s safe out there. If that happens, more people could end up going out and putting themselves in dangerous settings, infecting each other along the way.
At the same time, colder temperatures, particularly in the northern parts of the US, will more likely push people indoors, where the virus is much more likely to spread due to poor ventilation. (One upside: This could have the opposite effect in southern parts of the country, where temperatures will get less unbearably hot, so the outdoors may actually get more tolerable.)
As Thanksgiving rolls around, followed by Christmas, Hanukkah, and New Year’s, families and friends will likely come together from around the country. That includes college and university students, who could come home from Covid-19 hot spots back in their dorms or classrooms.
If you put this all together, there’s a real risk of a truly nationwide Covid-19 outbreak. As people come together from all over the country and return to home and school, they risk carrying the disease across local and state borders. That could result in a much more dispersed — and perhaps larger — coronavirus epidemic than the US has seen so far.
“People will bring this back during Thanksgiving, during Christmas, during winter break,” Dark said. “This is a disease that has an incubation period of up to two weeks. So it’s not really safe to say, ‘Okay, I’m going to come home, and come back.’ … By the time you develop symptoms, you’ve already exposed your parents.”
On top of all that, another flu season this fall and winter could strain health care systems, hindering hospitals’ abilities to treat Covid-19 patients and potentially contributing to more deaths.
There are reasons to think it won’t get so bad. Maybe since so many people have already gotten sick in the US, there will be enough community immunity, as long as there’s enough social distancing and masking, to mitigate spread. Maybe people won’t ease up on proper precautions after seeing more than 200,000 Covid-19 deaths in the US. Perhaps social distancing and masking for Covid-19 will hold off another flu season, as seemed to happen in the Southern Hemisphere.
Or maybe Trump’s Covid-19 diagnosis could signal to the country that this is still a serious problem.
But there’s a risk. And the numbers have already headed in the wrong direction.
“The next number in the fall is likely going to shoot way up,” Michael Osterholm, director of the Center for Infectious Disease Research and Policy, told me. “Likely well beyond 65,000, 70,000,” the summer’s previous peak. “I think this fall is going to be the biggest spike of all.”
We still have time to act
None of this set in stone. Experts told me again and again that the US still has time to act before it sees a repeat of the summer or worse.
None of the ideas to prevent all of this are shocking or new. They’re all things people have heard before: More testing and contact tracing to isolate people who are infected, get their close contacts to quarantine, and deploy broader restrictions as necessary. More masking, including mandates in the 17 states that don’t have one. More careful, phased reopenings.
This is what’s worked in other countries, from Germany to South Korea to New Zealand, to contain outbreaks. It’s what studies support: As a review of the research published in The Lancet found, “evidence shows that physical distancing of more than 1 m is highly effective and that face masks are associated with protection, even in non-health-care settings.”
It’s also what’s worked in the US. After suffering huge outbreaks in the spring, states like New York and Massachusetts have suppressed the coronavirus with such policies. Cities, such as San Francisco, have avoided bad outbreaks entirely with similar efforts. Even single universities, like the University of Illinois Urbana-Champaign campus, have seen promising early results with aggressive testing and tracing. (The federal government would ideally be in charge of all of this, but Trump has by and large punted the pandemic down to the states to resolve.)
“There’s no mystery about what causes new cases,” Nahid Bhadelia, an infectious diseases physician and medical director of the Special Pathogens Unit at Boston University School of Medicine, told me. “We have to make trade-off choices.”
Much of the issue comes back to a careful reopening process. For this, some experts pointed to a budget model. The goal is to keep the spread of the coronavirus low enough that each new infection doesn’t always lead to more infections, making it so over time the country slides to zero cases. In other words, the goal is to keep the effective reproduction number, or R0 or Rt in scientific parlance, below one. Within that limited budget of an R0 or Rt lower than one, states can try to fit some places to reopen but not everything.
Everything that reopens will add to the infection rate. Some places may have tiny, even negligible effects, such as parks. Some are bigger threats, like bars and indoor dining. And some may carry potentially high risk but still seem worth it to the community for their social benefits, like schools.
The goal, then, is to balance out a reopening — doing it slowly, making it possible to see the effects of each extra step — to make sure outbreaks don’t get out of control. Ultimately, it may require not opening bars or indoor dining, perhaps ever, so schools and other more socially crucial places can open. At the same time, the government could offer shuttered businesses a bailout or other financial supports.
“For us, as a society, to be able to send children to school, we have to make tough decisions and sacrifices in other areas,” Jorge Salinas, an epidemiologist at the University of Iowa, told me. “We can’t have it all.”
Other steps, too, could help build a bigger budget. More testing, tracing, and masking, for example, could reduce the infection rate in a community further, regardless of what else is going on.
By striking this balance, the country can not only avoid more infections and deaths but also potentially avoid an outbreak from getting so bad that it necessitates another lockdown. While experts all agreed that there’s zero political appetite for a lockdown right now, a massive surge in the fall and winter could leave the US with no other option. Israel, for example, has shut down until early October at the earliest after seeing a massive increase in cases.
The reality is that the US will likely not go back to normal until it vanquishes the virus through a vaccine or similar treatment — a process that could take months or years, even after a vaccine is proven safe and effective, as the country and world scale up distribution to actually reach sufficient levels of immunity within the population.
But maybe the US will continue muddling along, or worse. The country has already shown a much higher tolerance for Covid-19 cases and deaths than the rest of the developed world. Trump, for his part, seems content with that — recently stating that the coronavirus “affects virtually nobody” and showing no interest in changing his hands-off, minimizing approach.
If that holds, America could suffer tens of thousands more predictable, preventable deaths, on top of the almost 210,000 Covid-19 deaths it’s already seen.