Almost exactly 300 years ago, in May of 1720, the goods-laden merchant ship Grand-Saint-Antoine arrived in Marseille, France, having earlier made port in plague-infested Cyprus. It had recently attempted a stop in Livorno, Italy, but officials there refused it entry. As it happened, Marseille had formed a Sanitation Board in 1580 at the end of the previous plague outbreak and with it, a well-established comprehensive quarantine system for inbound ships. Said system called for members of the board to examine a ship’s crew and cargo for signs of infection, and to review the ship’s log to determine if the ship had visited known sites of plague. Ships were quarantined at “lazarets”: well-appointed quarantine stations where crews could wait out their quarantine periods for a clean bill of health, to varying degrees of severity based on their condition.
Marseille had been warned by health authorities in Livorno about the ship’s conditions and the death of multiple sailors: the typical protocol would be to reroute the ship to be burned, along with its highly valued goods. But the merchants of Marseille wanted the goods on the ship, the owner of the ship just so happened to be the deputy mayor of Marseille, and the great Beaucaire medieval fair was mere weeks away, so greed won out and the ship was allowed to dock and sell its infected cargo.
The plague spread relentlessly, though slowly at first. Authorities attempted to quarantine those infected as quickly as they could, but cases continued to crop up and it soon overwhelmed the city. 50,000 of the city’s 90,000 inhabitants would perish over the next two years.
In a sense, it feels a bit like we are heading towards a similar, though less deadly (at least by percent) fate. People are social creatures. We can only spend so much time separated, or loosely connected by video chat before we start to scratch and claw at the door to go out. And while over 67,000 Americans have tragically succumbed to Covid-19, our ability to flatten the curve in many parts of the country because of our early interventions creates a level of abstraction that’s very difficult for most people to square:
Things don’t seem so bad here! We’re not NYC! Let’s get back to business!
And so, once more unto the breech, dear friends. Georgia has decided to throw open the doors to commerce, even in the absence of the metrics (two weeks of declining cases, as one example) called for in the nationwide guidelines, with several other states following close behind. There’s already video a-plenty of people in Atlanta going about their business, most of them not wearing masks and getting way too close to one another. (Even the people in the engraving of the Plague of Marseille pictured above are wearing masks!)
What happens next is going to be instructive: Georgia will either have a hard and fast acceleration of cases that takes shape over the next 2–4 weeks, and we’ll be discussing how they are in a hell of their own making come June 1, or, well, they won’t. At least not quite yet. Our efforts to flatten the curve have been unevenly applied nationally and so it’s difficult to determine if different states are experiencing the benefits of those efforts, or if they’re just at different stages of the breakout.
I have to believe that multiple weeks with extremely limited travel, closed restaurants, closed large venues, and a general willingness from the public to stay apart from each other has had a material impact on the spread of the virus. But it has certainly not been enough to kill it off outright, and so while community spread may have been significantly reduced, unfortunately that is far from the same thing as “eliminated”. A small handful of active cases undetected among us spreading the virus anew is all it will take for states to alight again and restart the cycle. It will simply take longer, and we’ll instead be having this conversation deeper into summer, or heading into fall.
It should be noted that the broad goal of “flattening the curve” is essentially this outcome: buying time to prepare with better testing, better understanding, perhaps better treatments, and most importantly, better hospital capacity. It is not, per se, to reduce the total count of people infected. It’s merely to draw those infections out. That being said, education and steps towards mitigation can help people continue to follow best practice to avoid infection, and, importantly, we can focus efforts on the worst environments for spread, like prisons, meatpacking plants, and nursing homes.
People are getting restless. Businesses are getting restless. That’s understandable. This, plainly, sucks. But while the virus may be slowing, it is ever-indefatigable in its march forward. It doesn’t particularly care about your political beliefs or how restless you are. The US is still adding between 25,000–30,000 cases per day. It’s still out there. And we are nowhere near close to the exposure levels needed to attain herd immunity, even if you were to presume some of the serology survey models correct stating our actual infection rates as closer to 10x-20x the confirmed counts.
I’ve heard the argument made that, if the serology tests are anything to go by, then the true mortality rate for the virus is really closer to “just” 0.1% to maybe 0.2% for people under 50. This was a preamble to a call to essentially ease back to normal, with special considerations made for the elderly and especially nursing facilities. The idea being, 0.1% is the fatality rate of the flu, and we live with that, don’t we? And again, it may come to that in a sense, but this is a macabre form of fatalism and a disregard for the good that flattening the curve and buying that time and establishing better standards can do, and importantly, the lives those actions can take.
A key distinction here is not purely the fatality rate. It’s also the attack rate: how infectious the virus is, and how likely you are to catch it in a given year. The flu infects around 40M people in the US every year, and kills around 40,000 per year, on average. (Some years are worse than others; the year before last was closer to 80,000 — a particularly bad year.) We have a vaccine for the flu, which, while not 100% effective, and in fact sometimes as low as 25%-30% effective, significantly stems the spread and severity of influenza. The flu is also different because humanity is familiar with it, and our immune systems are familiar with it.
We have no immunity for Covid-19, until we catch it. (And even then, we don’t yet know how consistently, or for how long.) We have no vaccine for Covid-19. And so, for us to achieve the necessary 60%-70% infection rate for herd immunity to kick in, we’re talking 90 million people between the ages of 19–54 infected in the US, and 90,000 deaths from that cohort alone, in a best case scenario. That excludes the much higher risk groups older than that, where we’re likely to see dramatically more fatalities.
So how do we move forward without staying in place while we wait for a vaccine? First and foremost is getting the public to understand the importance of wearing masks when out and about, even (and really, especially) if you’re asymptomatic. Masks help prevent those who don’t know they have the virus from spreading it so readily. They are vital to halting the transmission. Testing capacity is also vital. Incredible amounts of testing capacity will bring with it the ability to identify nascent hotspots as they first start forming, and, coupled with strong contact tracing, may allow us to grab hold of the situation by quarantining people quickly, and most importantly, only if they’re actually infected. This is a lot more manageable than just preemptively quarantining anyone you may have come into contact with.
We also need to establish strong protocols to keep the most at-risk populations safe. Protocols for nursing/assisted living facilities will need to verge on the draconian, unfortunately, but there’s really no other way forward. This virus is killing nursing home populations at absurdly high rates: in some cases, as many as half of a facility’s residents. So that means we need the ability to test every resident, limit their non-necessary travel, and repeatedly and regularly test all staff and visitors. The Abbott Labs rapid tests will be instrumental here as they can test on-site in minutes, but if we’re able to develop a rapid test based on saliva instead of a nasal or nasalpharyngeal swab, that will be a huge boon to the ease of use and reluctance we’ll otherwise see from the population about having the “back of their eyeballs scratched”, as my wife put it.
I’m hopeful we see the testing infrastructure start to take shape over the next month or so. I fear that the states opening early will see a fairly aggressive rebound, but it may take long enough to show itself that we grow more and more complacent, thinking maybe we’ve beat this thing, or it wasn’t as bad as we feared. We’ll allow the compassion fatigue of nightly news stories and our desire to claw back some normalcy drive us to let our guard down. And then we’ll be unprepared for how bad things get in the fall and winter. This isn’t a sprint. It’s a marathon. This is our whole year. This is probably a significant part of all of next year. Even as we start on a path back to a modified “normal,” it’s important to remember that the virus isn’t dead, it’s not gone, and we still don’t have a good protocol to treat it. We only have distance, masks, and washing our hands to prevent its spread. (And perhaps an assist by the summer weather.)
Most importantly, this is a case to be made for empathy and for recognition of how other people are losing their loved ones, and not waiting for it to directly impact you to care about it. First and foremost, this is not just happening to other people or people in other countries, far away from you. The impact of the virus is happening everywhere. As I’ve said before, if you don’t know someone who has lost a loved one to the virus, it’s likely that you will soon. That’s why these measures are especially important as we start to reopen and ease back into things. Don’t let your guard down just because you see everyone out and about without masks on. Avoid large crowds. Wear your masks. And be very careful about potentially exposing the at-risk people in your life. Limit your visits with them, and make sure they have everything they need.
We’ll get through this. If there’s one prevailing characteristic about humanity, it’s its indomitable spirit. We’ll continue to research and innovate. I have confidence we’ll develop a vaccine one way or another. But in the shorter term, our goal is to strike a balance that lets us get back some of our daily lives without needlessly shortening the lives of others. And for that, we must resist the temptation towards complacency.