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It's Time to Hunker Down

A devastating surge is here. Unless Americans act aggressively, it will get much larger, very quickly.

Two children look out a window

John Moore / Getty

The end may be near for the pestilence that has haunted the world this year. Good news is arriving on almost every front: treatments, vaccines, and our understanding of this coronavirus.

Pfizer and BioNTech have announced a stunning success rate in their early Phase 3 vaccine trials—if it holds up, it will be a game changer. Treatments have gotten better too. A monoclonal antibody drug—similar to what President Donald Trump and former Governor Chris Christie received—just earned emergency-use authorization from the FDA. Dexamethasone—a cheap, generic corticosteroid—cut the death rate by a third for severe COVID-19 cases in a clinical trial.

Doctors and nurses have much more expertise in managing cases, even in using nonmedical interventions like proning, which can improve patients' breathing capacity simply by positioning them facedown. Health-care workers are also practicing fortified infection-control protocols, including universal masking in medical settings.

Our testing capacity has greatly expanded, and people are getting their results much more quickly. We may soon get cheaper, saliva-based rapid tests that people can administer on their own, itself a potential game changer.

Read: The vaccine news that really matters

The Centers for Disease Control and Prevention has finally acknowledged that aerosol transmission happens and that ventilation is important. The initial bungled messaging and science around masks was unfortunate, but things have turned around; the CDC has even publicized how masks can help protect the wearer from infection, as well as lower the chances of onward transmission. The importance of clusters and super-spreading is more widely appreciated, maybe partly because of the highly publicized White House cluster, which is still simmering.

We have reasons to celebrate, but—and you knew there was a but—a devastating surge is now under way. And worse, we are entering this dreadful period without the kind of leadership or preparation we need, and with baseline numbers that will make it difficult to avoid a dramatic rise in hospitalizations, deaths, and potential long-term effects on survivors.

Almost every day, America is breaking new records in confirmed cases: They are up 40 percent from just one week ago. These cases are not confined to a region or a state; the whole nation is in the midst of a terrible surge. So, too, is much of Europe, where country after country is experiencing record numbers of cases.

This is not a "casedemic"—the false notion that we just have better testing and detection, without any real change in the underlying risk for illness and death. It's true that we missed a lot of cases in the spring because we didn't have enough tests, and that we are catching more of them now. But it's not just confirmed cases that are on the rise. The United States is also experiencing a steep increase in hospitalizations, as well as about 1,500 reported deaths a day; those are the highest numbers since mid-May, and they are still rising sharply. Trevor Bedford, a scientist at the Fred Hutchinson Cancer Research Center, in Seattle, calculates that more than 2,000 deaths a day may already be baked in for early December, meaning that even if we stopped every new infection from now on, we'd still see that many people die per day in just a few weeks among those already infected.

Read: 'No one is listening to us'

The Pfizer-BioNTech vaccine—or Moderna's vaccine—may be available in the United States to health-care workers and other high-priority people as early as the end of this year. But it won't be distributed widely until well into 2021, even in the best-case scenario—and the Pfizer vaccine needs two doses, about 21 days apart. Those promising monoclonal antibodies, too, are in very short supply. The president was one of fewer than 10 people to receive the treatment outside of a clinical trial. Even if the drug works as well as we hope, the 300,000 doses that Eli Lilly has agreed to deliver will not be enough when they finally arrive, probably toward the end of this year, when we have 150,000 positive cases a day, and still rising. Dexamethasone availability is excellent, but deaths are climbing despite its widespread use, because it helps address only one of this disease's complications.

We have little reason to count on the authorities for leadership that has the precision and scale we need. The outgoing president has refused to concede the election and has launched a flurry of frivolous lawsuits to muddy the transition, thereby making the odds of an effective federal response over the next few months less likely.

All of this means we desperately need to flatten the curve again before hospitals nationwide are overrun. Utah, Illinois, Minnesota, Colorado, and other states are already reporting that hospitals and intensive-care units are at or near capacity. The bottleneck for medical care isn't just lack of space, or even equipment, which we may be able to increase, but staff—trained nurses and doctors who can attend to patients, and who cannot be manufactured out of thin air. During the spring crisis in the New York tristate area, health-care workers from around the country rushed to the region, buttressing the exhausted medical workforce. With a nationwide surge, doctors and nurses are needed in their hometown hospitals.

If fewer people can be admitted to hospitals because of lack of space, patients won't benefit from our improved clinical management of COVID-19. We may give back some of our gains in the mortality rate. We may also see deaths rise from other causes: Fewer nonurgent but important surgeries, more overworked medical staff, and overburdened emergency rooms could all contribute to worsening health outcomes for many other viruses that peak in winter months, like influenza, as well other ordinary medical conditions.

This seasonality is not a huge surprise, which makes our lack of preparation even more tragic. The 1918 flu pandemic saw an earlier, milder wave in the spring; a lull in the summer; and a deadlier surge starting in the fall. Other coronaviruses endemic to us are also sharply seasonal, tending to peak in winter. This may be because the humidity and temperature conditions of fall and winter favor the virus more. It may also be because we spend more time indoors during the winter. Most likely, it's a combination, along with other factors (less vitamin D? less light?). Whatever the causes, public-health experts knew a fall and winter wave was a high likelihood, and urged us to get ready.

But we did not.

The best way to prepare would have been to enter this phase with as few cases as possible. In exponential processes like epidemics, the baseline matters a great deal. Once the numbers are this large, it's very easy for them to get much larger, very quickly—and they will. When we start with half a million confirmed cases a week, as we had in mid-October, it's like a runaway train. Only a few weeks later, we are already at about 1 million cases a week, with no sign of slowing down.

Americans are reporting higher numbers of contacts compared with the spring, probably because of quarantine fatigue and confusing guidance. It's hard to keep up a restricted life. But what we're facing now isn't forever.

It's time to buckle up and lock ourselves down again, and to do so with fresh vigilance. Remember: We are barely nine or 10 months into this pandemic, and we have not experienced a full-blown fall or winter season. Everything that we may have done somewhat cautiously—and gotten away with—in summer may carry a higher risk now, because the conditions are different and the case baseline is much higher.

Read: How we survive winter

When community transmission is this high, every kind of exposure is more dangerous. A gym class is more likely to have someone who is infectious. Workplaces will have more cases, meaning more employees will unknowingly bring the virus home. More people at the grocery store will be positive. A casual gathering of friends may be harder to hold outdoors. Even transmission from surfaces may pose a higher risk now, because lower humidity levels may improve the survivability of the virus.

Plus, the holidays are upon us, which means a spike in gatherings of people who do not otherwise see one another. Such get-togethers, especially if they are multigenerational, can spark more outbreaks. I take no joy in saying this, but all of this means that any gathering outside one's existing quarantine pod should be avoided for now—especially if it is indoors. Think of it as a postponement and plan to hold it later. Better a late Christmas than an early medical catastrophe. Pods should not expand unless absolutely necessary. Order takeout instead of dining indoors. Make game night virtual. Shop in bulk, so you can do fewer trips to the store. It's not the right time for wedding receptions or birthday parties.

Young people present one of the biggest challenges. Many colleges are ending school and sending students home, for what could be a country-wide super-spreader event. That age group—young adults—is especially dangerous; although they can get infected, they are less likely to get very sick, so they don't stay put the way sick people would. That means they pose a great risk to their more vulnerable parents and other older relatives as they go about their lives. Ideally, colleges should offer the students already on campus the option to stay in the dorms over winter break, and those who live in off-campus housing should consider staying put. If they do go home, the students should quarantine for the recommended two weeks to the greatest degree possible.

It might also be time for ordinary people to consider using higher-quality masks (N95s and KN95s)—something that public-health experts have long recommended. This is especially true for low-wage workers, a disproportionate number of whom are people of color and have to work indoors; older people, and anyone who works with them; and people with preexisting conditions that put them at higher risk. Ideally, we'd have a significant aid package, allowing businesses to remain closed and workers to stay home as much as possible, while also increasing workplace standards through better ventilation and masks. Tragically, that doesn't seem to be in the cards.

On the plus side, though, it's now possible for ordinary people to purchase higher-quality masks, which suggests that the dire shortage of the spring is over. It's still wise to avoid hoarding; most people don't need that many, and this surge will put a fresh strain on the supplies. As long as they are put on and taken off carefully (use hand sanitizer before and after), such masks are reusable after being left in a paper bag or breathable container for at least five days, which means as few as five are enough to rotate through a typical work week for people who work with others—especially indoors.

All of this is unpleasant, but the alternative is much worse. There is a Turkish saying for times like these, when we can see a light at the end of the tunnel: "Time passes quickly if we can count the days until the end." We are no longer in the open-ended, dreadful period of spring 2020, when we did not know if we'd even have a vaccine, whether any therapeutics would work, and whether we'd ever emerge from the shadow of this pandemic. We can see the cavalry coming, but until it's here, we need to lock ourselves down once again.