OVERVIEW
The emerging picture of the coronavirus pandemic is not good. Despite a clamor in some quarters to return to normal, the situation will likely continue to be quite protracted, costly, disruptive, and deadly even with strong measures in place. Attempts to rapidly return to a normal that is never coming back will likely result in the deaths of hundreds of thousands or millions in the United States alone. There will be secondary and tertiary fallout from this crisis that will last for years or more. Now is the time to start thinking in terms of your 3-year plan for personally weathering World War C and engaging collectively to defeat SARS-CoV-2 once and for all. Neither the personal nor collective challenges will be easy, but they are addressable.
UPDATED INFORMATION ABOUT HOW DANGEROUS THIS VIRUS IS
Lethality
Since the beginning of the coronavirus pandemic, there have been drastically conflicting media reports about how deadly COVID-19 really is. While there were initial estimates of lethality being somewhere between 0.6% and 3.4% in early March [1], a recurrent theme has been prominent voices claiming that the virus is really “orders of magnitude” less deadly [2]. Beyond armchair epidemiologists claiming “it’s just the flu bro,” and right-wing media chronically mocking concerns [3] to the detriment of their viewers [4], the US Surgeon General also downplayed risks [5] and Elon Musk got into full ‘cave rescue’ mode [6] contributing to the narrative that the virus is much less deadly than initially believed. Unfortunately, we now know that these views are wrong.
It is extremely likely that the overall Infection Fatality Ratio (IFR) is consistently greater than 0.5% and probably between 0.5% and 2.0% depending on other human, resource, and contextual factors. The emerging consensus is that an IFR of roughly 1% is probably a good, evidence-based, estimate with which to make plans and projections about the pandemic’s impact. The evidence for a 1% IFR comes from several sources: the Diamond Princess cruise ship, actual deaths in New York City, actual deaths in Bergamo, a recent study in Austria, and a recent study out of France. These four different countries plus a cruise ship paint a clear picture that is also roughly in alignment with previous studies in China and my own parameter estimates for Michigan.
New York City (NYC) has been hit hard by COVID-19 [7]. It has also been the site of seroprevalence surveys (tests that try to determine what percentage of the population has already been infected and might be immune as a result). Based on the combination of hard data in terms of excess mortality [8] and percentage seropositive, Dr. Trevor Bedford has estimated the IFR at roughly 1% [9]. Even while it might sound “totally insane” [10] to shut down large swaths of the country over a 1% risk, Dr. Carl Bergstrom reminds us that: “If the mortality rate is 1 percent, we’re looking at 2 million deaths, which is unprecedented in our nation’s history and unimaginable [11].”
Similar to NYC, Bergamo has been hit extremely hard by COVID-19 [12]. Recent research using data science methods found that 0.57% of the entire population died [13]. That is roughly 6 in every 1,000 residents died, not just 6 in 1,000 of those infected or potentially infected. While the demographics of Bergamo are different than those of the US overall, this is more data in support of 0.5% as a floor to the IFR, with the upper bound being considerably higher in certain at-risk populations or in scenarios where healthcare resources are overwhelmed or depleted.
While exact numbers can get hazy real fast when resources are overwhelmed and frontline healthcare workers are busy trying to save lives and not get bogged down in documentation and experimentation, we do have one accidental experiment where there was intensive monitoring and meticulous study: the Diamond Princess cruise ship. Based on the current numbers for the Diamond Princess [14] the IFR there is likely between 1.83% and 1.98%. While the demographics of cruise ship passengers and staff are different from those of the US or other nations, they do allow us to confirm that it is unlikely that there is some large percentage of asymptomatic individuals already harboring immunity and likely to drive down the IFR [15]. When taking into account the demographic composition of the Diamond Princess, and time-delays in information availability, the IFR for a general US population appears to be 1.3% with a confidence band that ranges from about 0.4% to 3.6% [16]. Again the 0.5% to 2.0% IFR range, with about 1% being typical, is supported by this research.
In April, both France and Austria released findings in support of the above. In Austria, the Ministry of Science launched a prevalence study and found that only about 0.33% of the population (or about 28,500 people) had been had been infected as of April 6th [17]. If we go 18 days out from the 6th (the typical time from infection to death, assuming most caught by the study were early) or 9 days out from the 6th (half of the typical time from infection to death assuming those caught by the study were randomly distributed) we get 508 deaths and 384 deaths respectively [18]. Since we now have numerators and denominators, we can estimate the IFR at 1.78% and 1.35% respectively, again within the 0.5% to 2.0% range. In France, a study out of the Institut Pasteur found: "The overall probability of death among those infected (the Infection Fatality Ratio, IFR) is 0.53% (95% CrI: 0.28-0.88)... Our estimate of overall IFR is similar to other recent studies that found values of between 0.5%-0.7% for the Chinese epidemic...” [19]. Note this study is NOT describing a situation where resources are chronically overwhelmed for weeks and months on end. If we were to let this virus run wild, minimum IFR will be 0.5% [20], but it could range as high as 2.0%, though again 1% seems a reasonable middle estimate across a range of differing conditions.
While lethality is important in understanding the danger posed by a virus, the propensity to replicate and spread is also critical. Some viruses are extremely lethal such as MERS, but are really bad at spreading and so kill relatively few people. In order to understand the complete threat picture with regard to SARS-CoV-2 / COVID-19, we will need to know how easily this lethal disease spreads in typical conditions.
R0 and Attack Rate
While there is still some debate on the topic of what the exact basic reproduction number (R0) for SARS-CoV-2 is, we know it is at least moderately high. The New York Times has a pretty good explainer on R0 [21], but in essence it is a measure of how many additional people an infected person will go on to infect. Anything under 1.0 and the epidemic is slowing down. Anything above 1.0 and the epidemic is growing. As an example the R0 for the 1918 Pandemic strain was between 1.4 to 2.8 [22]. SARS-CoV-2 was initially thought to have an R0 of 2.2 to 2.7, but may have an R0 as high as 5.7 [23]. This means that this coronavirus will spread very quickly and efficiently if left unchecked. With an R0 of about 3, the virus could go on to infect 80% of the population. Even with some pretty intense interventions (masks, moderate social distancing, massively scaled contact tracing, etc.), we may only drop the attack rate to about 45% [24]. This seems confirmed by real world data from South Korea [25]. At the other extreme it is possible that up to 90% of the population could be infected in a case of epidemic overshoot [26]. Given these two facts, it is very possible that 45% to 90% of the United States will ultimately be infected with SARS-CoV-2.
A SECOND WAVE IS ALL BUT ASSURED
Given what we now know about SARS-CoV-2, it seems probable that we are still at the beginning of the pandemic. Whether through continued viral spread while in lockdown, leaders electing to prematurely end social distancing measures, or large percentages of the population eventually resisting rules designed to reduce the spread of the virus, I believe that we will see a second (likely larger) wave of infections and deaths. Even accounting for the likelihood of 150,000 dead by August 2020 [27], I am convinced that we are nowhere near the ultimate peak of this pandemic. This is admittedly an educated guess, but the general notion is shared by the Director of the CDC [28], Dr. Fauci [29, 30], and Bill Gates [31]. If we do not seriously prepare for a lethal resurgence of the coronavirus, “we could be in for a bad fall and a bad winter” [32].
In order to continue suppression of the virus, “prolonged or intermittent social distancing may be necessary into 2022” [33] a situation that I find to be unlikely to be voluntarily maintained by increasingly restless segments of the US population. Historically, we know that there has been resistance to protracted non-pharmacological interventions [34]. We also know that even politicians that are considerably at odds with the current protesters are feeling pressured [35].
Given these facts and what I know of human behavior, my current bet is unfortunately on social distancing collapsing at some point and the US experiencing a surge of infections that, while somewhat attenuated, will begin to approach the casualties of a minimal intervention scenario. To spell that out explicitly: given what we know of IFR (0.5% +) and effective attack rate (45%+), in this scenario minimum dead in the US would be 750,000 and could easily be in the millions. My best guess for a peak in such a runaway scenario would be the week of December 13th 2020, but this extremely speculative. In short, if we open up prematurely, we are still basically facing the same picture we were looking at in February, just with the can kicked down the road a little bit further.
THIRD FOURTH AND ADDITIONAL WAVES ARE POSSIBLE
As if the aforementioned aspects of the pandemic were not distressing enough, there is still an unclear picture with regard to the degree of immunity conferred by a previous infection with SARS-CoV-2. Emerging data is calling into question even the fundamental possibility of herd immunity (enough people getting infected and developing subsequent immunity such that the pandemic dies out on its own). A study out of China suggests that it is possible that 30% of those infected never developed high levels of SARS-CoV-2 antibodies [36]. It is unclear if this is due to weak or nonexistent acquired immunity or to the virus being cleared via other processes. Elsewhere, a decreasing immune response has been documented at about 60 days out from infection [37]. If these findings do indeed point to weak and/or decaying immune responses, it may be the case that vaccines or herd immunity will not defeat this pandemic. It may be the case that SARS-CoV-2 becomes endemic and instead of 45% to 90% of the population getting the virus, we may be looking at 200% to 300% infections rates (on average people will get it 2 or 3 times over the course of their lives). Any scenarios that might play out in this direction would be truly chilling.
MORE THAN JUST THE VIRUS
Beyond the direct impact of the virus in terms of death or extended disability (SARS and MERS left some survivors altered for years afterwards), I believe that there will be at least an additional 18 months of political, economic, social, and supply chain disruption after the resolution of the pandemic. There are a range of systemic and long-accumulating vulnerabilities that are about to come to a head in the US. Some already have, but many of the cracks are still obscured from common view by various forms of whitewashing. Political stratification across age cohorts, challenges with voting in a pandemic, issues with civil engagement, truth decay and the rapid escalation of deep fake capabilities, the machinations of other nation states with regard to commodities pricing and currency denomination, longstanding fiscal and monetary policies, supply chain elasticity, location of manufacturing capabilities, cultural transitions, demographic transitions, environmental factors, displaced persons, and compromised federal structure are about to unleash a perfect storm (the Metacrisis).
ECONOMIC
Employment
Unemployment is skyrocketing to historic levels and economist Miguel Faria-e-Castro at the Federal Reserve Bank of St. Louis has estimated that we will see unemployment in excess of 32% within weeks [38]. If true, 1 in every 3 people you know will be unemployed before summer. If things escalate much beyond that, we will be deep in uncharted territory.
Housing
Housing prices in many markets will likely crash as short-term rentals such as Airbnbs fueled by debt go from being revenue generators to expensive millstones [39] and long-term rentals are no longer an enticing investment when the 1 in 3 renters are already missing payments [40]. Add in the demographic transition of the Baby Boomers looking to downsize, offset their losses in equity markets, or dying as a result of the virus, and the value of houses is not looking good.
Various Industries
Other aspects of the economy have been behaving in truly bizarre ways. Oil contracts traded negative for the first time in history, and while there is a complicated explanation for why this was the case [41], this is also probably one of the first canaries in the coalmine for an upsetting of the dominant global order largely in place since WWII [42]. Integral and systems thinkers were warning about systemic problems prior to the pandemic [43] and the coronavirus seems to have only exacerbated and accelerated the move towards greater disequilibrium.
Industries too numerous to list will be profoundly disrupted for years [44] or rendered obsolete. Things as seemingly typical as a dinner and a movie may never ever be the same again [45]. Las Vegas has already been transfigured [46].
Supply Chain
As the vexation over toilet paper has demonstrated [47], many of our supply chains have very little elasticity. Systems designed to optimize for just-right/just-in-time delivery are revealing their inherent vulnerabilities. These issues will not be easily or rapidly addressed [48]. While there were some additional stores in the meat supply chain at the start of the pandemic [49], they are starting to be diminished [50] and industry leaders are sounding the alarm [51].
As of right now, I am assuming that one way or another the economic, employment, housing, and supply chain situation will be highly unusual and stressful through about January of 2023 when a new (and likely very different) normal will begin to coalesce.
MENTAL HEALTH
None of what has been described so far includes the emerging psychological problems either currently present or likely to unfold in the coming years. The US has already been grappling with rising suicide rates for 2 decades, but this pandemic is likely to exacerbate this trend [52]. Domestic violence will likely spike [53] and already strained relationships [54] stressed by shelter-in-place measures will likely lead to increased divorces in the near future [55] in the US as they already have in China [56]. The scope of general mental health distress is quite widespread with 72% of adults in the US describing their lives as being disrupted 45% of adults reporting that their mental health had been negatively impacted due to worry and stress over the virus [57]. In my opinion this is likely an underestimate as the poll these numbers are based on is from early April, before weeks of additional stress. If I were to hazard a guess, I would say that the number of adults currently in mental health distress is probably somewhere between 50% and 75%, though this estimate may be biased by the fact that I live in a hot zone. When factoring in the mass psychological trauma that would be inflicted by potentially witnessing more deaths than all of the US wars in all of history combined here at home and all in a brief period of time, it is easy to see how the mental health aftereffects of this pandemic will be profound for hundreds of millions in the US.
NEAR-TERM PERSONAL PREPARATIONS
So what to do? As I had previously figured, there may be a brief May/June/July decrease in cases as the effects of social distancing begin to bear fruit, but before infections increase again from either the next wave or the outright discontinuation of all non-pharmacological measures whatsoever. In this time, we will need to prepare for the very real possibility of the most brutal November, December, and/or January of our lives. I hope, HOPE, that what I am writing is shot through with errors and wrong. I also need to look clear-eyed at the situation. It is possible that the resources we in the US have on hand in late August or early September will be the resources we have to make it through until February. While power/lights/heat etc. will probably still be on, I do not know what the situation will be with regard to any other regularly relied upon consumables. Even if they are available, going out to acquire them will be risky.
You will want to acquire or make a supply of masks for each of the members of your household. Wear masks on all outings beyond your own home or yard. You will also probably want to acquire or make face shields for the members of your household or at least anyone likely to go into more crowded areas (stores, work, etc.). There is emerging evidence that face shields appear to significantly reduce the amount of inhalation exposure to droplet-spread respiratory viruses and face shields should probably be included as part of strategies to reduce transmission in public [58]. Fortunately, face shields can be very cheaply and easily made with common household materials [59, 60].
COLLECTIVE INTERVENTIONS REQUIRED
There are only a few ways out of this pandemic and none of the feasible ones are going to be easy [61]. The pandemic will only end if and when: an effective vaccine is produced and administered at scale, an effective pharmacological treatment is found that defangs the lethal virus, the pandemic runs out of new hosts to infect, or an aggressive testing and contact tracing effort is mobilized. A vaccine could easily be 18 months away, if one is ever even viable. Pharmacological measures are (to date) less than spectacular; some of them probably do something, but not enough to dramatically curtail the death toll. The virus could run out of new hosts to infect due to rapidly burning through the population, but this reckless strategy would almost certainly leave millions dead and could still fail. That leaves only testing, tracing, and isolating as a viable strategy.
It is probable that we will need 100,000 to 300,000 contact tracers in the US in order to bring the virus to heel. We currently have fewer than 8,000 [62]. Instead of getting the army of contact tracers that we need, the cynic in me says we will probably end up getting a buggy tech solution instead (created by non-experts). I am afraid that I might be right about this [63]. I am seriously hoping that the states take a leadership role here. While the states will probably end up creating a patchwork replete with sizable gaps, they will at least be moving towards the goal.
Realistically, what might this look like? In an ideal situation, it looks very much like South Korea: aggressive contact tracing, strong community buy in, ubiquitous masks, and life continues with only moderate disruption and a sense of comradery, though in a mildly eerie way. In a really bad situation, federal, state, and local authorities either drop the ball or are overwhelmed and no superman emerges from tech (or worse they somehow make everything way more difficult by mixing up positives and negatives in a database somewhere), and we have comparable losses to an unmitigated scenario. We have the opportunity to make this our finest hour or a demoralizing quagmire where we start counting the dead in Vietnams per month.
In the optimistic scenario, someone assumes leadership. What might that look like? Here is one off-the-wall solution: convert the US Census into a fully-mobilized national contact tracing team. Every door-to-door census taker just asks a few extra questions:
“Are you or anyone in your household sick?” If yes, “Have you been tested for COVID-19?” “Would you like to be?” / give local testing number. If no, ask a basic set of 5 symptom questions. If meets criteria, give local testing number.
The Census workers do the leg work and hand off to state or local health departments for follow-up with the identified possible cases. Will it catch all? No. Could someone make this happen in a week? Yes. Are there other solutions out there? Totally. Right now, though, I feel like I did when I saw the flooded bus yards after Hurricane Katrina. Basic leadership says man the buses, pick up people, and move both out of harm’s way. No one bothered. Lives lost. Property destroyed. Poor leadership is an existential risk.
AFTER
Traditional, Modern, and Postmodern meaning structures and institutions will all crack and fail during this pandemic to some degree. We will all emerge profoundly different people. It will be qualitatively different just being alive. Depending on who we are when we exit this, we may have the opportunity to build back better. We may finally get what it means to think intergenerationally and act immediately.
The shadow of the US has always been community and collectivism. When we are at our best, we make free, individual, commitments to a greater purpose. When we are at our worst, we over focus on the individual to each individual’s ultimate disadvantage. Maybe, just maybe, we can thread the needle and dynamically balance individual and collective goods and lay the foundations for a better everything for both ourselves and the countless billions of humans that will come after us.
So there it is. What comes next is on us.
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