The Path to Normal
By Nayyer Ali MD
Two months into a national shutdown that has cratered the economy and forced us to spend too much time at home, there is still only a murky sense of how we get back to “normal”. Trump wants America to go back to work immediately so that the economic debacle can be turned around in time to salvage his reelection chances. But what is the path back to normal? What needs to happen to get there?
The entire purpose of staying at home was to stop the runaway exponential spread of the Corona Virus. New York City barely averted catastrophe, and yet still 20,000 people died, almost 0.2% of the population of New York, in just a few weeks. Hospitals were overwhelmed, and the state had to pull every lever to ensure adequate medical supplies and vital equipment like ventilators did not run out.
Even outside New York, hot spots of infection occurred in New Orleans and Detroit and other large cities. But the stay-at-home orders have worked. We did not have a national catastrophe with half a million dead. The death toll is currently about 100,000, which is bad enough though the daily death toll has declined from 2,500 to about 1,000.
This decline reflects the fact that we are not spreading the virus in an accelerating fashion. In medicine, the number we concentrate on is called the R0, which is the average number of new infections a sick person spreads the disease to. During runaway growth this was over 3, but we have now pushed it down to about 1. What this means is that the total number of infected people is not rising, but to bring the number down sharply we would have to push the R0 to 0.5 or less, which is what the Chinese did. We are not even trying to do that. Instead, the individual states are starting to relax their restrictions, which means that infections may actually start to rise.
The ideal goal over the last two months of staying at home was to stand up enough testing capacity, and recruit thousands of people to do contact tracing, which would then allow us to control the spread of the virus. If we can rapidly identify who is infected, and then track down and test all those they have had close contact with, we can smash this epidemic. That is what South Korea did. Unfortunately, there has not been a national strategy to do this, each state has been on their own.
At this point we are doing about 350,000 tests per day, which is much better than two months ago, but we need to do probably twice that number to get ahead of this, and combine it with contract tracing everywhere.
We could safely allow people to do outdoor activities as long as it does not involve large crowds. But crowded indoor situations are still unsafe. The single most important item is for everyone in public to wear masks. Even if they are not medical masks, even cloth masks provide partial protection. A mask protects the wearer from getting virus into their lungs, but even more important, it catches the infectious aerosols released by a sick person and keeps them from spreading into the room. Studies suggest that we could collapse transmission of the virus if 80% of the population wore masks all the time. If children wore masks and were spread out in classrooms then it should be safe to restart public schools in the fall.
Two medical treatments are becoming more widely available and they should have some impact as we get a better sense of how effective they are in the real world. First is remdesivir, an antiviral drug made by Gilead which has been shown to be effective in treating Corona virus pneumonia. At this point, we don’t know how effective it is in the hospital. Same goes for the other treatment, the transfusion of convalescent plasma from a recovered patient into a sick one. This moves the antibodies the recovered patient has into the sick patient and likely works to overcome the infection. The critical question is whether either of these treatments prevent moderately sick patients from going on to be very sick and needing a ventilator or dying. We should get a good answer to that in the next few months. Both these therapies are still in short supply, but the drug and plasma supplies should get much better in the next 90 days.
Even with all these strategies, the economy will remain depressed. It is only the free flow of funds from Congress and the Federal Reserve which has prevented widespread bankruptcies, foreclosures, poverty, evictions, and suffering despite unemployment shooting up to over 15%. The only real way we get back to normal is when a vaccine becomes available. On that front there is some good news.
Two different vaccine groups, one at Oxford University and another at the American company Moderna, have reported good preliminary results with their candidate vaccines. There are over 70 different vaccine projects underway around the world, but these two are probably in the lead. Both products appear to work. But we still need to prove that the vaccines are safe and effective, and that is going to take several more months of clinical trials. It is unclear if either group will seek to do a challenge trial with their vaccine using volunteers as a way to demonstrate efficacy faster than with a traditional vaccine trial. Deliberately exposing volunteers to the virus will answer the question much faster, but there are obvious ethical issues even if the volunteers give their consent. If the world is very, very lucky we could have a vaccine approved for use before the end of this year. But mass vaccination will likely not occur till first few months of 2021. That will be a very joyous day for America and the world. Hopefully we can produce billions of vaccine doses in a few months.
