This month, the United States reached a record number of coronavirus cases, with an average of a hundred and fifty thousand new cases per day and the highest number of patients hospitalized since the pandemic began. Unlike in the initial surge, in the spring, which saw enormous outbreaks in urban centers such as New York, the virus is now tearing through the entire country. The onset of winter weather and the mass migration of people travelling to celebrate the holidays are likely to lead to both more cases and new shutdowns. Death rates remain lower than they were in the spring, but the country is likely to reach a death toll of two hundred and fifty thousand within days, which approaches the number of Americans killed in combat during the Second World War.
I recently discussed the state of the pandemic with Céline Gounder, an infectious-disease specialist and epidemiologist at Bellevue Hospital and N.Y.U.’s Grossman School of Medicine. She is the host of the “Epidemic” podcast and a member of the Biden-Harris transition team’s COVID-19 advisory board. During our conversation, which has been edited for length and clarity, we discussed how public-health professionals should approach their messaging this winter, the continuing importance of “flattening the curve,” and the challenges of planning the next Administration’s coronavirus response.
Why exactly have things got so bad again? Is it people not wearing masks? Is it activities that we shouldn’t be doing? Was it inevitable? How do you understand it?
I think the No. 1 reason is that the weather is getting cooler and people are spending more time indoors. There’s no question that that is a big factor. We typically do see colds and the flu increase during this time of year, and the coronavirus is very similar in that it’s another respiratory viral illness. So this is something we have been predicting. We have been saying it’ll slow down a little bit, relatively speaking, over the summer, but it will not go away, and then it will surge again in the fall and winter, and that’s precisely the pattern that we’re seeing now. The other thing is that it’s become very clear that social gatherings, whether they are in restaurants or at home, are major drivers of this in terms of the transmission.
So this would be some combination of people letting their guard down and government policies not being strict enough in terms of the restaurant angle.
The challenge with restaurants is that you cannot eat and drink with a mask on, and if you are indoor-dining you also have the loss of ventilation, and you’re in close proximity with other people. So restaurants and bars, at least indoors, are really some of the worst places from the perspective of transmission. In terms of the bigger picture, I’ve heard a lot of people say things like “Well, I trust so-and-so about spending time with them or maybe celebrating the upcoming Thanksgiving holiday with them.” And I think it’s really important to understand that the coronavirus hitches a ride on our trust and our love for our family and friends. It’s actually the people we trust most whom we’re most likely to infect and who are most likely to infect us, because we’re not going to take those same precautions with the people we love and trust.
How do you combat that? What’s the message?
Despite there being vaccines that are now about to emerge from the pipeline and that will soon have emergency-use authorizations—likely in the next month or so, between the Pfizer vaccine and the Moderna vaccine—it’s still going to be a long road ahead before those are widely available to the general public. So we’re really going to have to focus on the basics of public-health control here—that’s mask wearing, social distancing, outdoors versus indoors, testing and contact tracing. And, with respect to masks, masks are cheap, highly effective, and they do not shut down the economy. They’re really as close to a vaccine as anything that we have available to us right now. And, unfortunately, they have been politicized. The way I think about masks is that masks are like toilet paper. This should not be a political statement. This is really a basic hygienic measure.
When we saw a surge in the spring, it was pretty clear that there were some failures from the federal government, such as a lack of testing. Are there some large-scale structural failures going on right now that are exacerbating this? Or is it more matters of messaging, and things like that?
Well, messaging has really been a problem in terms of what the current Administration has been saying and communicating to the public throughout the pandemic. You mentioned testing, and this current Administration has really discouraged testing, because it really did not want to see and did not want the public to know what was truly happening with coronavirus transmission and the scale of the problem. The challenge is that it is impossible to contain an invisible enemy, and the problem with the coronavirus is that many of the infections are asymptomatic or mildly symptomatic, so people have no or few symptoms. So what we are seeing in hospitals, in terms of people getting really sick and dying, is really the very tiny tip of the iceberg. Even though many, many people are getting sick and dying, there are far, far more who are getting infected and transmitting the virus. The only way to see what are essentially invisible infections is to massively scale up testing. So the message should have been: get tested. That has been a major failure. We also talked about masks, and that has also been a major failure of communication.
Is a lack of testing still a problem in your mind?
Yeah. We still need to scale up our testing. In New York, for example, as the positivity rate has gone up, and people have become aware that there is increasing coronavirus transmission in New York City, people have been seeking out testing at higher rates. And what we have found is that some of the testing centers have had very, very long lines, which then discourages people from going and also results in longer turnaround times. So we really do need to be scaling up testing dramatically across the country, and doing so in a way that we have short turnaround times, ideally within twenty-four hours, because this information needs to be actionable. You need to know that you’re infected so that you can go into isolation, so that you’re not transmitting to others. If you have to wait a couple days, a lot of people will keep on doing what they would normally do and will not change their behavior until they have a positive test result. And, by that time, you’ve already done the bulk of your transmitting to others. So it’s really defeating the purpose not to have widely available, conveniently available testing with short turnaround times.
What do you think we’ve learned about school closures and school openings, and how should we view what we’ve learned in the context of things getting much worse across the country?
I think, big picture, we have moved from what I would call coronavirus control 1.0 to coronavirus control 2.0. In the spring, we were not a hundred-per-cent sure how much of this was spread through droplets versus airborne transmission versus direct contacts. So now we have a much better understanding of that. This is clearly a respiratory virus, first and foremost. And, in terms of schools, we’ve also learned that younger children really do not seem to be major transmitters to adults. We’re not entirely sure why that is, although we have some theories. But what that means is that, while the risk is not zero, the risk of keeping kids—especially younger kids—in school was probably overestimated in the beginning. We can now really make it safe for younger students, twelve and under, to be back in school, especially if we institute safety measures like social distancing, mask wearing, ventilation.
Having kids in school is what I would call one of the more essential services, and it’s relatively low risk. So, recently, Governor Gretchen Whitmer announced new restrictions in Michigan, and you’ll note that—based on what we’ve learned, where schools have the ability to provide those safety measures—they’re keeping schools for younger kids open. They’re closing high schools and colleges to in-person learning, because that’s riskier. Another example of understanding transmission better: they’re closing group classes in gyms but, where the appropriate safety measures are in place, leaving open the option of individual exercise at a gym. They are leaving open outdoor dining and takeout but closing indoor dining. So we can be a lot more targeted and measured than we were in the beginning, when we were much more blunt.
That was going to be my next question, which is what we learned about shutdowns and what we can do differently this time, because it seems like people are probably going to be less willing to take necessary measures.
Yeah. I think the key is that you need to be as targeted as possible, and you need to explain the science behind it. In New York City, we saw a surge of coronavirus in the last couple months in certain neighborhoods—in Brooklyn, for example. And we took a very geographically targeted approach, on the basis of Zip Codes, to really scale up testing, ramp up contact tracing, and close certain places that seemed to be contributing to transmission. We were able to take that much more geographically targeted approach because we had the surveillance data.
