By Ruth Reader
Last week, in an op-ed, Vice President Mike Pence made a highly misleading claim: There is no “second wave” of coronavirus in the United States, he wrote, and the Trump administration is winning the war against “the invisible enemy.”
Epidemiologists mostly agree on the first point—although not for the reason that Pence gave.
“He was completely right that we’re not in the second wave,” says Ashish Jha, Director of the Harvard Global Health Institute. “This is not a second wave, because we’re still in the first wave.”
At the national level, the number of new cases seemed to peak in April and decreased throughout May. But in fact, much of the decline was driven by the New York metropolitan area, previously the epicenter of the U.S. outbreak. In states that neglected social-distancing guidelines, the coronavirus continued to spread.
Now, confirmed cases of COVID-19 are rising in 26 states, weeks after parts of the country began to reopen. Hotspots including Arizona, Texas, and Florida are reporting thousands of new infections. On Wednesday, the country recorded its highest single-day total of new cases: 38,115.
We spoke to four epidemiologists to get a better understanding of America’s ongoing battle with coronavirus. The overall consensus was chilling: Despite more than 2.3 million confirmed infections and 120,000 deaths, few states are taking the necessary steps to halt the spread of the virus. A recent University of Washington study expects more than 200,000 people in the U.S. will lose their lives to COVID-19 by October 1.
“We may feel like we’re done with the pandemic,” says Jha, “but the pandemic, unfortunately, is not done with us.”
The Wave Fallacy
The concept of virus “waves” can be useful in epidemiology. Certain infectious diseases do exhibit seasonality, such as influenza, which tends to spread between fall and winter, with an initial spike in December and then a much larger one in February. There were also noticeable waves in the “Spanish flu” pandemic, which featured at least three distinct peaks in the United States. The second, more deadly wave hit in the fall of 1918.
It’s possible that COVID-19 will follow a similar trajectory. Research suggests that warmer weather—especially combined with mask-wearing—is correlated with reduced transmission. As the return of cold weather forces more people inside, making social distancing harder, scientists expect that cases will rise. “There’s no question in my mind that the number of cases will start climbing just from people spending more time indoors,” predicts Jha.
But seasonal factors are just one part of the picture. Government policies, travel restrictions, social distancing, and mask-wearing have significant effects, too—and they all interact in complex, unpredictable ways. Particularly in the United States, where every region has different health policies, it is hard to say where one wave ends and another begins.
“The second wave is, as far as I’m concerned, a suspicious concept,” says Dr. Ali Khan, former director of the Office of Public Health Preparedness and Response at the CDC and author of The Next Pandemic. “COVID-19 is not influenza, it’s Ebola,” he continues, referring to the hemorrhagic fever that periodically terrorizes sub-Saharan Africa.
The comparison is an instructive one. As with Ebola, he says, new cases don’t necessarily indicate a second wave but rather an incidence of “failed public health, where you have lost the chain of transmission and have been unable to get the condition taken care of.”
Khan points to China, a country that reported zero cases of COVID-19 for three weeks and then discovered an outbreak of 183 new infections. “Everybody’s going ‘look at China’s second wave!'” he says. “And I’m going, really? A hundred cases among 1.3 billion people? Second wave? I don’t think so.”
Perhaps a better metaphor for the spread of COVID-19 is illustrated by the virus itself. Under a microscope, MERS-CoV looks like a smooth, round particle studded with clubbed spikes of various lengths. Like the virus, the lifecycle of the coronavirus pandemic is likely to feature numerous spikes of differing duration and intensity. For epidemiologists, it’s vital that the public have clear expectations for how the virus circulates—and what it will take to stop it.
Unfortunately, politics has muddled the national conversation about coronavirus. Many state governors, eager to reopen their economies, seized on declining cases in May to justify loosening restrictions at the end of last month. Some have been encouraged by studies that underscore the disinfecting power of sunlight. Others have effectively given up on the idea of containment altogether.
Public health officials appreciate that countries cannot remain locked down forever. An alternative strategy proposes alternating periods of virus suppression and relaxation until a vaccine is available, keeping transmission at manageable levels without strangling local economies. One study, backed by the European Union, suggests countries impose strict rules for 50 days, followed by 30 days of less intense mitigation tactics that allow people to shop, dine, and work. If and when cases begin to rise again, restrictions could be put back in place.
But America’s “first wave” of coronavirus never ended—and in some states is only just beginning. While the New York area began to crush the curve, driving the national trend downward, a surge of new cases was being detected across the South and Southwest. This week, that number hit a new high in the U.S., surpassing the single-day record set in late April.
“People have used the word plateau. I find the word plateau to be inadequate,” says Dr. Khan. “We have been unable to attain containment of this disease. Now we’re rolling back down the hill.”
The Long Haul
Experts largely agree on the goals for virus suppression. “Until we have safe and effective vaccine that everyone takes, what needs to happen is we try and sustain this low level of transmission, which I think is a balancing act,” says Wafaa El-Sadr, an infectious disease specialist at Columbia University. She says that will involve wearing masks and limiting social contacts consistently. But she worries that, thanks to disinformation like Pence’s op-ed, public health messaging has become politicized.
“There’s this pitting of public health against economic health, but we don’t want to pit those against each other,” she says. It’s vital that people are able to get back to work, she says, but they need to wear face coverings and keep an appropriate distance from colleagues. “We need these public health measures, we need to sustain them as much as possible until we have a vaccine,” she says.
Most of the recommendations from epidemiologists are simple: Wash hands frequently, wear masks when out in public, and only leave the house if you have to. “It’s all about, what can you do to reduce risks?” says Jha.”
In the absence of federal leadership, however, states have been left to fend for themselves—leading to a patchwork of regional protocols that can vary substantially. New Yorkers, for instance, are required to wear masks when they are not able to put six feet of distance between themselves and others. Coloradans are only required to wear face coverings if they are essential workers. In Arizona, the governor only recently allowed local governments to mandate masks—and many people are ignoring the rules altogether.
“We’ve got to get away from thinking about first and second wave and instead think about what is really happening on the ground,” says Steffanie Strathdee, associate dean at University of California San Diego School of Medicine and author of The Perfect Predator, a book about antibiotic-resistant superbugs.
But tracking the virus has proved more challenging than it should be. Both Georgia and Florida, among other states, have both been accused of fudging or misrepresenting their coronavirus data. At the federal level, President Trump has said repeatedly that he would like to do less testing in order to find fewer cases. His administration reportedly plans to end funding for many COVID-19 testing sites this month.
Experts like Strathdee say it’s imperative that the CDC require states to report new cases in a specific and uniform way, so that the public can respond accordingly. That, she says, could help people to better understand the epidemiology of the virus as a series of spikes rather than a single wave. And she still holds onto hope that U.S. politicians will adopt a more aggressive national strategy, including contact tracing, which has helped to contain the virus in parts of East Asia and Europe.
“Let’s face it, this virus is not going away,” she sighs. “It’s going to get worse before it gets better.”