Since the novel coronavirus exploded in the United States, it’s been linked to the deaths of over 150,000 Americans and infected over 4.5 million, though the real numbers are likely higher.
It sabotaged an historically bustling economy, shut down many forms of basic professional and social interaction, killed beloved friends and family members, and popularized terrifying terms like “super-spreader.”
It also, predictably, became a political and ideological fault-line—exposing a spectacularly unprepared national health system and a willingness to vilify even century-old public health principles, sparking a national outbreak unlike any other in the world.
The entire planet has learned a lot about the deadly disease since those decisive early months: how not to treat it, how it spreads, some of the damage it can cause in the longer term, how it affects children, and much more.
But if the American failure to contain COVID-19 has never been clearer—the U.S. has more cases than Brazil and India combined—what should a devastated and enraged population be expecting next? Will hot zones in the South and West that replaced early outbreaks in the Northwest and Northeast keep getting hotter? (Hot zones will more likely continue to cycle around to new locations.) Will a furious—and deeply politicized—hunt for a vaccine actually pay dividends? (Probably, but too soon to tell for sure.) Would a Joe Biden administration appreciably change the game? (Depends on what outbreaks look like in January 2021.)
Here’s what we do know.
As a bevy of experts all told The Daily Beast this week, “all this”—the lockdowns, shifting hot spots, and surges in deaths and hospitalizations that threaten local health systems—will probably last about two to three years total. By then, humanity may have come to better coexist with the virus. People will die from it less often, and will have returned to healthier social and economic lives thanks to a dynamic set of tools. Those might include some combination of vaccines, non-pharmaceutical interventions, new testing technology, therapies, and even a potentially new administration willing to provide more consistent messaging and guidance that doesn’t undermine public health experts.
Of course, that last part is tougher to predict.
But there’s no longer much serious discussion about how to “eliminate” the virus—at least in the short term. Infectious disease experts say they are no longer sure that’s even possible.
“Epidemics have taught us that there won’t be a magic bullet,” said Lawrence Gostin, director of the O’Neill Institute for National and Global Health Law at Georgetown University.
The best-case scenario, Gostin and others agreed, must include a vaccine. But there are plenty of questions about what that will look like, according to Dr. David Rubin, the director of PolicyLab at Children's Hospital of Philadelphia. Who gets it? How well will it work? How quickly will it be deployed? What side effects will it have?
“Even in the best-case scenario, it wouldn’t be here until sometime after the new year,” said Rubin, suggesting its rollout could be “messy” given the notoriously rocky state of diagnostic testing in the United States, which has exposed supply-chain and other woes.
Until then, scientists will likely continue to improve and expand on the existing experimental treatments—like Remdesivir, convalescent plasma, and dexamethasone—to treat cases of the virus. Many experts interviewed by The Daily Beast this week said they’re still holding out hope for a prophylactic that could serve as a preventative measure, like PrEP does for HIV.
Even the technology around testing has shown signs of progress in recent weeks.
But the next years of the pandemic will also be shaped by political leadership. Social distancing, mask mandates, business closures, economic assistance, messaging, hygiene, quarantines, isolation, and mass congregations are all in various ways subject to the whims of local, state, and federal elected officials.
“We are at a crucial decision point,” said William Haseltine, president of the global health think tank ACCESS Health International, who recently chaired the U.S.-China Health Summit in Wuhan, where the virus likely originated. “Right now we have 150,000 people dead, and it’s up to us to decide if we are going to have 300,000 or 400,000 or 500,000 or 600,000 or more. And that depends on what we do now. If we behave as we have in the past, especially in many of our states, there is no telling what the end in sight is.”
“We also have 100 days before the election,” said Haseltine. “A new administration is very likely to have the right leadership and messaging. Our current president is not just not slowing the infection, he’s actually accelerating the virus.”
“No other country has our situation,” said Haseltine. “You need a calming, persuasive voice for a national leader.”
Of course, the development of new and effective vaccines, therapies, and testing technologies are not a given. There’s a darker timeline out there where promising research stalls.
“Worst-case scenario would be, bottom line, we can’t get a vaccine that works, therefore it’s off the table,” said Dr. Robert Kim-Farley, a medical epidemiologist and infectious disease expert and professor at the UCLA Fielding School of Public Health. “It’s doubtful that would happen, but it’s theoretically possible.”
Just as grim, he said, is a world where “immunity wanes after two or three months and the second infections are just as bad or worse than the first one.”
In that nightmare scenario, he continued, “You’d have it everywhere going on rising and only falling where control measures are put into place, cycling around the world.” More distancing and mask mandates and restrictions and lockdowns as the only way out, in other words.
Immunity is one of the bigger, scarier unknowns, acknowledged Kim-Farley.
“We’re in the dark on that,” he explained. “Right now we still just don’t know how long it lasts.”
“We’re only six months in here, and what we’ve observed is that there’s likely some short or medium-term immunity from this virus, but we can’t say a year out if reinfection can happen then,” Kim-Farley continued. “It’s not just whether people get sick again, but for people who do, will it be as severe or will it just be a cold?”
“What would be terrifying is if we see a round of people getting it a second time and having a similar—or worse—severity,” said Kim-Farley.
There are horrifying anecdotes floating around about just that—including in Montgomery, Alabama, where a man in his fifties recently contracted the infection at a reopened restaurant in the area and died about three weeks later, as The Daily Beast reported. The man first got sick with COVID-19 while traveling in Europe in February, recovered, and then tested positive for antibodies.
But last week, an extensive report from The New York Times dove into the question of reinfection, finding that many such anecdotes instead may have been cases of drawn-out illness. Nearly a dozen experts who study viruses told the paper that there has been no actual evidence of reinfection. “I haven’t heard of a case where it’s been truly unambiguously demonstrated,” said Marc Lipsitch, an epidemiologist at the Harvard T.H. Chan School of Public Health, in an interview with the paper.
For Rubin, of PolicyLab, the Alabama story is the stuff of “nightmares.” But he and others say there’s legitimate precedent for a second infection becoming more severe than the initial illness. He cited dengue fever, when a first case “primes” the immune system for a second one.
Dr. Arnold Monto, a professor of epidemiology and global health at the University of Michigan who has advised both the World Health Organization and the Defense Department on communicable diseases, concurred with that possibility, also citing dengue fever. He called this theoretical possibility “the elephant in the room.”
“The bottom line here is that we have to have better observational studies to examine these questions in larger numbers,” said Monto.
That possibility is even more alarming, considering the long-term damage the novel coronavirus may be doing to the heart, the central nervous system, and the lungs in many patients.
“That’s what makes this winter so scary,” said Rubin. “There is clearly a pathway here where immunity wanes and we hit the winter and we’re not just infecting naive individuals, we’re infecting people a second time around.”
On that score, said Kim-Farley, “The best thing to say about that is that we still don’t know.”
But even in the worst scenario without new vaccines and therapies, other countries have shown that mass testing, contact-tracing, draconian closures, quarantines, social distancing, and mask-wearing can work to control the virus.
Without a vaccine, said Haseltine, “The only real way to end it is the way the Chinese did. Every day the Chinese are teaching us how to do it, and here we’re deliberately choosing not to do that.”
To be clear, all of the experts interviewed for this article believe a vaccine, better treatments, and better testing are all likely on the horizon. They just may not be available until at least 18 months from now.
In between the best and worst case scenarios, then, lies the brutal reality of the current culture wars in the United States. It’s a climate in which some politicians refuse to wear masks. Where people in yoga pants are caught on viral videos berating business owners for refusing them entry. Where state leaders threaten to sue major cities for imposing mandates and restrictions to curb the virus. And where a booming disinformation movement has raised legitimate questions about how much of the population would even willingly take an effective vaccine.
But even in that messy reality, there will—in all likelihood—be bright moments of hope, of breakthroughs and recoveries, of sunlight.
“We’ll continue to see hospitalizations and deaths from COVID for the rest of our lifetimes,” said Gostin. But they will be less frequent and less severe, he argued.
And after that? Well, things may be more hopeful.
“What followed the great influenza pandemic 1918?” asked Gostin. “The Roaring Twenties.”