How America’s Covid-19 epidemic ends

The US still has a chance to tame its coronavirus outbreak. But time is running out.

The world is finally looking at a real end to the Covid-19 pandemic. But in the US, it now looks more likely than ever that things will get much, much worse before they get better.

On the one hand, the vaccine news so far is great — suggesting that the coronavirus vaccines will be more effective than most of the experts expected. On the other hand, Covid-19 cases, hospitalizations, and deaths in America keep rising. Thanksgiving likely made things worse (but hasn’t yet shown up in the numbers). Christmas, New Year’s Eve, and other holidays in December will likely bring new potential superspreading events.

So I asked public health experts: How exactly does this all end? What can we expect in the next few weeks and months of Covid-19?

They said America faces two potential scenarios in the next few weeks:

1) The worst Covid-19 surge yet: With cases regularly coming in above 200,000 a day, Covid-19 hospitalizations topping 100,000, and deaths now above 2,000 a day, things are already quite bad. But it could get worse: Between public fatigue, holiday celebrations, and states keeping risky indoor spaces like restaurants and bars open, the death toll could climb well past 3,000 a day in the future — surpassing the initial spring outbreak. This time the outbreak may be truly national, and the public and leaders may not act, or at least not do enough. So the outbreak could remain bad and even worsening until deep into 2021, with the carnage ending only when a vaccine is widely distributed.

2) A less bad outbreak: It’s possible the public or different levels of government, seeing these concerning trends, will snap into action, renewing efforts to socially distance and enforce mask-wearing. This seems like more and more of a long shot in the near term, but even if it takes root after the holidays, it could mitigate much of the potential damage. That wouldn’t end America’s Covid-19 outbreak, but it could at least make it a little better in the months remaining before vaccination.

Regardless of which two of these scenarios plays out, a vaccine will eventually arrive. The rollout will be slow, as different local, state, and federal agencies and health care systems set their priorities in the next few months for who will get the vaccine first. And how fast it plays out will depend on many questions we don’t currently know the answers to: Will the public embrace the vaccine? Will governments and health care systems truly be ready to distribute it? Will the vaccine stop not just serious disease but transmission of the virus too?

Eventually, enough Americans should be vaccinated that Covid-19 will be far less prevalent — and many of our lives will go back to normal. The end of Covid-19 is coming. It may even be mere months away.

But this, experts say, makes the prospect of a continuously bad outbreak in the next few weeks and months before a vaccine is widely distributed even worse.

“We prescribe so much of the power and authority of this pandemic to the virus,” Michael Osterholm, director of the Center for Infectious Disease Research and Policy, told me. “We forget sometimes that, in the end, most of us hold that power and authority ourselves. And what we do with our behavior — how we, in a sense, swap air with neighbors, colleagues, friends, people we don’t know — will dictate what happens.”

We now can see a finish line. We just have to hold out for a bit longer to make sure more people make it there, with our actions dictating which of the two scenarios the US deals with in the months to come.

Scenario 1: America’s Covid-19 outbreak will likely get much worse

Right now, America appears to be on track for an outbreak that surpasses the spring surge. Already, the country is seeing more cases and hospitalizations than ever before, and deaths are starting to near or hit record highs as well. “Close to 3,000 deaths per day — I mean, that’s one 9/11 every day,” Carlos Del Rio, executive associate dean of the Emory University School of Medicine, told me. “In the short term, I see a lot of problems, I see a lot of pain.”

Experts say it’s likely inevitable the numbers will get worse soon. On Thanksgiving week, the country set pandemic-era records for airplane travel. As families and friends gathered, they in effect hosted superspreading events — spending a lot of time close together, not wearing masks, and largely in indoor areas where bad ventilation made it easier for the virus to glide from person to person.

But the full effects of these gatherings won’t show up in all of the counts for cases, hospitalizations, and deaths for weeks or potentially months, because the coronavirus takes time to cause symptoms, hospitalizations, and deaths — although we’ll likely start seeing at least cases rise as a result soon.

Meanwhile, local and state governments have kept open businesses that perpetually produce superspreading events. The research has pinned a lot of spread to bars and indoor dining — where people hang out close together for long periods of time, without masks, in poorly ventilated indoor areas — but most states have kept businesses open even as cases, hospitalizations, and deaths have climbed to record levels. As long as these places remain open, and as long as the public continues going to them, the US’s epidemic stands to get worse and worse.

State governments have also been slow to take other precautions. As it stands, 13 states still don’t have mask mandates — even though face coverings and mandates have been shown in the research to help combat Covid-19.

“In the next one to three months, I do not anticipate us turning the corner dramatically,” Pia MacDonald, an epidemiologist at the research institute RTI International, told me. “If people don’t change their plans [for the holidays] significantly, I anticipate an acceleration of the number of new cases.”

Every state is now reporting more than — and usually well above — 4 cases per 100,000 people per day, a standard for out-of-control outbreaks. With so much virus out there, just about the whole country is vulnerable to an increase in gatherings and risky behavior over the holidays.

Given this, experts expect that 3,000 deaths a day, surpassing the peak of spring outbreaks, is very likely, if not inevitable, and could be only the beginning.

“If you see another surge on Christmas, it’s a surge on top of a surge that we’re in right now,” Amesh Adalja, senior scholar at the Johns Hopkins Center for Health Security, told me. “There’s just so much burden of infection.”

Hospitals will also be increasingly strained, potentially to the point they can no longer take more patients. The consequences there aren’t just bad for Covid-19 — all the gains we’ve made with treatment will vanish if a hospital can’t treat the patient — but other kinds of diseases and conditions that will go untreated as health care systems no longer have the space necessary to see patients.

Preventing all of this will require a radical shift in what the public and leaders are doing right now. Otherwise, the toll of cases, hospitalizations, and deaths will continue to climb, with widespread distribution of a vaccine remaining the only way out.

Scenario 2: The US’s Covid-19 epidemic is less bad

The worst scenario is not inevitable. With government and public action, the worst of Covid-19 could be avoided in the coming weeks and months.

Different levels of government could encourage people to stay home and close down risky spaces. Short of that, the public could take its own steps to mitigate the spread of Covid-19 — voluntarily social distancing and masking, whether they’re required to by mandate or not.

“It’s really in our hands,” Osterholm said. “European countries have demonstrated that when you take these actions, you can drive the case numbers down substantially.”

At this point, things are bad and likely going to remain bad for at least several weeks. But how the public and leaders react could make things less bad in the weeks and months after. That could bend the curve of infections, hospitalizations, and deaths — potentially saving a lot of lives.

This wouldn’t take new, groundbreaking strategies, but instead the kinds of policies we’ve all heard about throughout the pandemic. Government leaders could institute lockdowns, stay-at-home orders, or, short of that, require risky indoor spaces to close down. They could do more to encourage or mandate masking, and enforce those mandates. They could build up systems for testing and contact tracing (though how much the latter can help is limited, as there are simply too many cases for tracers to keep up with).

“Public health measures to close indoor environments now would probably take a couple of weeks to have an effect,” Crystal Watson, senior scholar at the Johns Hopkins Center for Health Security, told me. “But that’s, in the grand scheme of things, pretty quick.”

And the public could embrace proper precautions, regardless of whether they’re mandated. “We have seen that in the past,” Watson said. But, she cautioned, government guidance and restrictions are likely still necessary “to make a real difference.”

A key player here is the federal government. It’d be much easier for people to follow the precautions if they’re given economic aid to make up for lost income and revenue as they social distance, potentially losing jobs and temporarily closing businesses. With cities and states facing massive budget gaps because of the weakening economy, only the federal government has the resources to provide relief to Americans.

Other places have proven this can work. In the face of big second waves, both Israel and, more recently, Europe have shown that renewed action against Covid-19, either by partly closing down or locking down entirely, can reduce the spread of the coronavirus. (Though Israel has seen cases start to rise again as the country eased restrictions.)

Our World in Data

America could follow a similar path. It’s just a matter of getting the public and its leaders to act.

Still, the reality is none of this seems particularly likely. Cases, hospitalizations, and deaths are still trending up. Even as the Centers for Disease Control and Prevention advised against travel during Thanksgiving, more than 9 million Americans flew around the holiday — setting records for air travel during the pandemic. Local and state governments have, by and large, shown little sign of changing course from mostly reopening after the spring and summer outbreaks. Congress hasn’t passed a stimulus bill as the economy has worsened, with discussions at best slowly progressing.

But maybe as things get truly horrifying — as more hospitals start to hit capacity and turn away patients because they simply can’t do more — something will change. It might take the epidemic getting worse to get the public and leaders to make it better, but that would be an improvement compared to a continuous climb to a worse and worse situation.

A vaccine will arrive — but it will take months to roll out

Right now, it seems certain we’ll get an effective vaccine soon. But it’s not like we’ll all wake up one day, get vaccinated at once, and throw a parade about the end of Covid-19. It will be a months-long process, with certain populations — health care workers, nursing home staff and residents, the elderly, people with conditions that make them vulnerable to the virus, and essential workers — getting the vaccine first.

“This is going to be the largest mass vaccination campaign that the US has ever attempted,” Watson said.

So it really matters whether we get a continuously worsening epidemic or a less bad outbreak in the coming months. Will the US be distributing vaccines while suffering the worst outbreak so far, one that continues to worsen? Or will it be distributing vaccines as daily cases and deaths are coming down, making the situation less chaotic and horrifying?

Experts emphasize a simple point here: A vaccine can’t, obviously, prevent the infections and deaths we’ve already had. But if we just get more people to the point where they get a vaccine, then a lot of lives could be saved.

Beyond that, there are different factors that will play into just how quickly a vaccine gets out to the public:

1) Are different levels of government truly ready to distribute a vaccine? This will be a massive project — some experts compared it to a New Deal — that involves building up infrastructure, transportation and storage means, data gathering, and communications campaigns. That will require a lot of support, both in time and money, from all levels of government. (Some officials say states need $8.4 billion to do this work. So far, they’ve gotten $340 million.)

2) Are health care systems ready? Getting a vaccine out to possibly more than 300 million Americans within months will be unlike anything health care systems have done. It’ll require technologies many systems don’t have, from refrigeration to transportation; a lot of staffing at a time when more health care workers are burned out by the pandemic; and very careful communication to patients about what the vaccine entails, including the need to return for a second dose as long as a Covid-19 vaccine requires two doses.

3) Is the public receptive to a vaccine? The more recent surveys show at least a third of the public is resistant to getting a Covid-19 vaccine. If that holds, it could stifle a vaccine’s ability to crush the coronavirus. There’s wide consensus among experts that a proactive communications campaign is needed to persuade the public to obtain a vaccine and, crucially, set expectations about potential side effects to ward off a possible backlash.

4) Does a vaccine only protect from disease, not transmission? Right now, the data shows that some vaccines could be more than 90 percent effective against Covid-19. But the data only shows the vaccine can stop serious illness at a rate of 90-plus percent, not that it can stop transmission by 90-plus percent. The vaccine may not stop infections much, if at all — maybe people don’t get as sick, but they can still carry the virus and spread it to others. So a lot more people, perhaps close to the whole country, would have to get vaccinated to stop Covid-19 for certain, instead of the lower threshold that herd immunity requires.

5) Are there any other hiccups? Perhaps people will consistently fail to get both doses, making the vaccine less effective. Maybe some places will be totally unprepared, even as some or most parts of the US are doing a good job getting the vaccine out there. A rare, scary side effect could pop up as millions of people get vaccinated, leading to a backlash against the vaccine. Maybe a vaccine will only offer protection for a few months, requiring people to get new doses even more often. None of these things are guaranteed to happen, but they would create new problems.

6) Could there be positive developments? Maybe it will turn out that the US is, as a whole, ready to distribute the vaccine. Maybe the vast majority of the public will embrace getting vaccinated as the epidemic gets worse and the data for the vaccine improves. Maybe new vaccines will come out requiring just one dose and with easier transportation requirements. All of this could speed up how quickly the country gets vaccinated.

How all of these factors, and surely more that we don’t even know of yet, play out will decide how long this process takes. Experts are confident there’s an end in sight to the Covid-19 epidemic in the US, but the question is how long into 2021 — or even 2022 and beyond — Americans have to wait before crossing that finish line.

So this will take a while. We have many decisions to make before then that could save a lot of lives — or cause potentially tens of thousands more people to get sick, hospitalized, and die.