The months ahead will be difficult. But the medical cavalry is coming, and the rest of us know what we need to do.
On March 16, back when White House news conferences were still deemed safe to attend, President Donald Trump stood before reporters and announced that drastic nationwide restrictions — in schools, workplaces, our social lives — were needed to halt the coronavirus.
The guidelines, "15 Days to Slow the Spread," were accompanied by a grim chart. Based on a prominent model by London's Imperial College, the chart illustrated with a sinuous blue line how many Americans might die if nothing were done to protect the public's health.
The line rose sharply as the estimated deaths went up, then drifted slowly down until finally, at the far right end of the graph, the number of new cases reached zero. Our national nightmare would end by October 2020 — that is, right about now. Along the way, if no action was taken, about 2.2 million Americans would die. Dr. Deborah Birx, one of Trump's science advisers, referred to the graph as "the blue mountain of deaths."
Clearly, the pandemic has not ended. So far some 215,000 Americans have lost their lives to the coronavirus, and reliable estimates suggest that the number could reach 400,000. Health experts agree that, with stronger leadership, the death toll would have been far lower.
Nonetheless, there is a collective accomplishment here worth acknowledging. In the Imperial College report, the authors underscored that their worst-case estimate would almost certainly not be realised, thanks to human nature: "It is highly likely that there would be significant spontaneous changes in population behaviour even in the absence of government-mandated interventions."
That prediction proved true, as millions of Americans agreed, however reluctantly, to accept the sacrifices involved in shutting down parts of the economy, keeping distance from one other and wearing masks.
In the day-to-day fights over reopening schools or bars, it is easy to forget that there was a time when the idea of cancelling large public gatherings — the St. Patrick's Day Parade, the NCAA's March Madness basketball tournament — did not seem remotely necessary. That there was a time when leading health officials said that only sick people and hospital workers needed to wear masks.
Today, and despite the president's own resistance, masks are widely accepted. Various polls show that the number of Americans who wear them, at least when entering stores, went from near zero in March to about 65 per cent in early summer to 85 per cent or even 90 per cent in October. Seeing the president and many White House staffers stricken by the virus may persuade yet more Americans to wear masks.
The slow but relentless acceptance of what epidemiologists call "non-pharmaceutical interventions" has made a huge difference in lives saved. The next step is pharmaceutical interventions.
Some are already modestly successful, such as antiviral drug remdesivir and steroids like dexamethasone. But in the near distance are what Dr. William Schaffner, a preventive medicine specialist, has called "the cavalry" — vaccines and monoclonal antibodies. They are likely to be far more effective.
Since January, when I began covering the pandemic, I have been a consistently gloomy Cassandra, reporting on the catastrophe that experts saw coming: that the virus would go pandemic, that Americans were likely to die in large numbers, that the national lockdown would last well beyond Easter and even past summer. No miracle cure was on the horizon; the record for developing a vaccine was four years.
Events have moved faster than I thought possible. I have become cautiously optimistic. Experts are saying, with genuine confidence, that the pandemic in the United States will be over far sooner than they expected, possibly by the middle of next year.
That is still some time off. Experts warn that this autumn and winter may be grim; indoor dining, in-classroom schooling, contact sports, jet travel and family holiday dinners may all drive up infections, hospitalisations and deaths. Cases are rising in most states, and some hospitals already face being overwhelmed.
Even if the cavalry is in sight, it is not here yet. To prevent deaths reaching 400,000, Dr. Anthony Fauci has warned, "We all need to hunker down."
We know what to do
The final death toll from Covid-19 will depend both on how we behave going forward and how quickly innovations arrive.
Already the United States is faring much better than it did during the Spanish influenza — the worst pandemic to hit the country to date and the one to which this one is often compared. It began in early 1918 and did not completely fade away until 1920, when herd immunity arrived, at the cost of 675,000 lives. The country's population at the time was 103 million, so that toll is equivalent to 2 million dead today.
Pandemics don't end abruptly; they decelerate gradually, like supertankers. The Centers for Disease Control and Prevention has estimated that about 10 per cent of the US population has been infected. As that figure grows, and as people begin to get shots after a vaccine is approved, transmission should slow.
Every Covid survivor and every vaccine recipient will be a broken link in the chains of transmission. There have been rare cases of people becoming infected twice; this happens even with chickenpox. But scientists assume that almost everyone who recovers from Covid cannot get or transmit the virus, at least for many months. Even by spring, we will not be entirely safe, but we probably will be safer.
In the interim, as the pandemic runs its course, the percentage of infected people who die from the virus has been falling. The reasons are many.
The average age of each new person infected is almost 30 years lower than it was in March. Fraternity brothers may be reckless, but few older Americans are.
Nursing homes have become better at protecting their wards. The death rate per nursing home resident in states that were hit by the virus in late summer is about one-quarter the rate in the northeastern and southern states that were hit first.
Simple interventions like pulse oximeters are detecting pneumonia before it becomes life-threatening. Steroids like dexamethasone have lowered the number of deaths among hospitalised patients by about one-third. Rolling patients onto their stomachs and delaying ventilator use also helps.
Each lesson learned saves lives.
Winter is survivable
Another good omen: Although in the spring health experts were fearful that a bad winter flu season could send thousands of patients to hospitals, all competing for ventilators and medical attention, the possibility of a "twindemic" of coronavirus and influenza now seems far less likely.
Flu is "seeded" in the United States each year by travellers from the Southern Hemisphere after the winter there ends. But this year their flu season was almost nonexistent — because they were socially distancing and, in some countries, wearing masks. And in this country, flu shots became available earlier than usual; so many Americans are rushing to get inoculated that spot-shortages are developing. If flu does arrive, those shots and our masks should blunt it.
Another intervention that might make a big difference is monoclonal antibodies.
Two weeks ago, most Americans had no idea what they were. Now, Trump is touting them as his "miracle cure" and, whether or not he is ultimately cured, monoclonals are famous.
That attention could speed up their clinical trials, which had been delayed. (Many patients declined to volunteer, preferring to not risk being given a placebo when instead they could receive convalescent plasma, which Trump was promoting in August.)
But experts believe that the antibodies could prove far more effective than plasma. Last year, in the Democratic Republic of Congo, monoclonal antibody cocktails proved 90 per cent effective at saving Ebola victims from death.
But this approach has limitations. It is believed to work only if administered soon after infection, and monoclonal antibodies are hard to produce and expensive, at least at the moment. If the treatment becomes popular, demand will quickly outstrip supply, forcing health officials to make hard choices.
Early testing in animals and humans suggests that a dose a fraction the size of the one that Trump received can protect an uninfected person against the virus. If that finding holds up, the antibodies could be used like a fast-acting vaccine, lasting just a month or so but providing a crucial "bridge" to the arrival of the new vaccines.
Such a treatment could protect people at highest risk, such as health workers and nursing home residents. Or, in a "ring vaccination" strategy, antibodies could be given to the household contacts of known cases. Ring vaccination was how smallpox was defeated.
But the number of doses will initially be limited, and choosing to use antibodies for prophylaxis over treatment may be may be frowned upon by medical ethicists.
Engaging warp speed
Sometime in the next three months, health experts say, the FDA is likely to begin granting approval to vaccines now in the works.
Despite the chaos in day-to-day politics and the fighting over issues like masks and lockdowns, Operation Warp Speed — the government's agreement to subsidize vaccine companies' clinical trials and manufacturing costs — appears to have been working with remarkable efficiency. It has put more than US$11 billion into seven vaccine candidates, and the FDA has said it will approve any one that is at least 50 per cent effective at preventing infection or reducing its severity.
Moncef Slaoui, Operation Warp Speed's chief scientific adviser and a former pharmaceutical executive who has overseen the development of 14 vaccines, has said repeatedly that he expects some of the candidates that he picked to have 75 per cent to 90 per cent efficacy and at least two to win approval by early January.
By then, Slaoui has estimated, the factories under contract will have produced enough vaccine for 30 to 40 million people and then another 80 to 90 million people every month after that. Assuming nothing goes wrong, he said, there will be enough doses for all 330 million Americans to be vaccinated by June. Bill Gates, who is not part of Operation Warp Speed but works with it to develop vaccines for the world's poor, has agreed with that timetable.
There will inevitably be distribution problems, but the military is standing by to help. The chief operating officer of Operation Warp Speed is Gen. Gustave F. Perna, a logistics specialist.
Vaccine scepticism may fade
Some health officials fear that when a vaccine arrives, many Americans will be reluctant to take it. Indeed, about half of Americans have told pollsters that they feel this way. Nonetheless, I believe that hesitancy may dissipate, if no major safety problems emerge as the first few million Americans are inoculated.
The last time the nation faced a moment like this was in the 1950s, when polio vaccine became available. For years, parents had lived in fear of the virus, as they saw children die, living in iron lungs or walking with braces on withered legs. When the Salk vaccine became available in 1955 — and again in the 1960s when it was replaced by the Sabin vaccine — Americans lined up in droves to receive it.
The demand for polio vaccine survived even the horrifying Cutter Incident of 1955, in which a bad batch of 200,000 Salk doses from Cutter Laboratories in Berkeley, California, partially paralysed 260 children and killed 10.
I have seen a similar trend as I covered the polio eradication drives in Pakistan and Nigeria. When a disease is actually tearing through a population, vaccine hesitation collapses. Even in the face of persistent rumours that polio vaccines would make their daughters sterile, mothers in Pakistan who had seen other children crippled defied their husbands and imams and sneaked their own children off to be vaccinated. Even in the most resistant areas, such as those controlled by the Pakistani Taliban or Boko Haram, vaccination campaigns attracted parents by setting up "health camps" that offered a dozen vaccines, polio just one among them.
No vaccine is 100 per cent safe.
"The most effective one may have the greatest risk if it stimulates the immune system enough to create the risk of autoimmune disease," said Dr. George D. Yancopoulos, an immunologist and founder of Regeneron Pharmaceuticals. "There will be some risk-benefit calculations to make."
But the alternative to being vaccinated is to risk a nearly 1 in 100 chance of death, as well as unquantifiable but still worrying threats of heart disease, lung damage and even brain damage. Not to mention the prospect of being unable to return to work, having to home-school one's children for years and not eating in a restaurant, flying on an airplane or watching a movie in a theater without the spectre of anxiety.
Those are strong motivations to take a chance on a vaccine, especially if one's friends and relatives have had it and fared well.
The whole world must be safe
In September, actress Jennifer Garner conducted an entertaining interview with Fauci on her Instagram feed, during which she asked when it would be safe to attend live theater again.
"The end of 2021 or maybe even the middle of 2021," he replied.
By then, he explained later, so many Americans would be vaccinated — or immune by virtue of having survived an infection — that it would be safe to sit unmasked in a crowded theater.
Until then, masks and caution are our best alternative. If we rigorously protect ourselves and each other, we can starve the virus of new hosts until our national epidemic finally evaporates.
Then we must help other countries get vaccines too; until they are protected, we cannot venture beyond our borders as tourists or business travelers nor can others come here. No country can be forgotten; charitable motives aside, their tourists fill our hotels.
We will have competition — or help, if we take a generous view of a global effort. China claims to already have five vaccines in phase 3 trials, and Russia is already marketing its vaccine abroad, although it has not even conducted a phase 3 trial.
Many economists think our national recovery will be rapid, like those that followed the first and second world wars, rather than what followed the financial crashes of 1929 and 2008. China, having beaten the virus, has a growing economy again. Among Americans who have not lost their jobs, personal savings are at record levels. Despite loan defaults in this recession, banks are flush with cash and, if need be, can borrow from their thriving Asian counterparts. When the moment is safe, loans to revive restaurants, hotels and other small businesses should flow.
In the interim, as we hunker down, Congress must find ways to ensure that millions of Americans who are out of work do not go hungry or get evicted.
And once the pandemic is over, one more mission lies ahead: to make sure this does not happen again. We must search for the viruses in nature that are most likely to infect us and spend the billions of dollars necessary to create vaccines and designer antibodies against them.
So that next time we are ready.
Written by: Donald G. McNeil Jr.
Photographs by: Emiliano Ponzi
© 2020 THE NEW YORK TIMES