Is the pandemic over, or as the kids in the back seat might put it: are we there yet?
If in Sweden, the answer is apparently: yes – albeit a very begrudging and tentative yes, encumbered by doubts, caveats, and aspersions from the camp prone to parlaying the valid arguments for lockdown into moral superiority. While it’s true we can’t know for sure that Sweden is safely thus, and permanently out of the pandemic woods, things certainly look good there. Case counts are negligible and have been for a while; there is no excess demand on the medical system; and in the absence of lockdown, the entire population has potentially been exposed to one degree or another.
Despite the vituperations of doom directed at Sweden from the start for their lack of lockdown, their mortality per million population is lower than more than a dozen other countries, among those the U.S., the U.K., Spain, Chile, Brazil, Italy, and Belgium. How Sweden fared relative to many other countries cannot be determined until their pandemic experience is over as well. Sweden may yet move to a ranking better than many more places around the world.
Because ideology and dogma are easy to catch but hard to release, even at the invitation of evidence, expect to see high profile doubts about Sweden’s success for quite some time yet. While this will foment uncertainty about the status of the pandemic, and while that uncertainty will be amplified by ardent expostulations of opposing opinion- for now, it looks as if it is over, or nearly over, over there.
If in New Zealand, the answer is a decisive: no. That country is among those at the opposite extreme, with early and rigorous lockdown that precluded any meaningful level of population exposure. Where a population has no exposure, and thus no immunity, they are like dry tinder- and virus in circulation is like sparks on the wind. The Kiwis, and others around the world with comparable approaches, are living the difficulties of that now: when they poke their noses out, case clusters ensue- and they are obligated to lock down again.
But what about here in the United States?
I don’t know, and neither does anyone else. We can’t tell yet. That shouldn’t be too surprising, given the reticence to sign off on even Sweden.
For many reasons, we won’t be able to tell whether the pandemic is over for a while. Perhaps that’s unsatisfying, but there is hope in the notion that the pandemic could be over here- and we would not yet know it. I recommend you hang on to that hope if it appeals to you, while I talk us through the reasons for the uncertainty.
First this context: some weeks back, I proposed that that pandemic could very well be over in the U.S. by or about October 1. Since that date is coming in fast and hot (literally here in Connecticut, where the late September temperatures have frequently, and very abnormally, been above 80 degrees; as well as figuratively), it’s time for me to take stock. Was I right, or wrong?
By way of reminder, I was not making a “prediction.” I was just extrapolating.
New York City and the surrounding area (the so-called “Tri-State Region”) locked down too late to prevent a major COVID surge, now infamous around the world. I did my small part to help address that surge on the clinical front lines, and have played a larger role closely following our regional trends and referencing them in my commentaries: a spike in cases, hospitalizations, and deaths; a plateau; and then a decline. The process took a matter of weeks, and the toll of COVID (i.e., hospitalizations, complications, deaths) in this part of the country has been massively lower ever since.
By and large, case counts fell consistently here, but that has changed recently with the combination of large, new assemblies- notably, students on college campuses- and far more testing (although still too little) than we did those months ago when the surge hit New York City. But the recent elevations in cases are overwhelmingly in young people, and are unassociated with any apparent surges in hospital demand, severe illness, or death.
In other words, we are simply doing a far better job now than earlier of finding clinically trivial cases of COVID19.
As I noted in a recent, prior column- getting to the end of COVID successfully involves high case counts but low casualty counts (until or unless there is a highly effective, very safe, mass produced, uniformly distributed, and universally accepted vaccine). High case counts without elevated casualty counts is a good thing, as viral transmission burns itself out without causing harm, while leaving herd immunity behind. The Northeast looks to be there now, including the Orthodox Jewish community recently making the news. I have personal correspondence from there telling me that large assemblies without protection are now routine (the elderly and frail remain more careful), and while asymptomatic cases are being found with surveillance testing- hardly anyone is getting sick. This is very different from the early going.
The rest of the United States, or much of it (the areas around Seattle and Detroit are likely exceptions), seemed to lock down before there was wide circulation of SARS-CoV-2. So, instead of experiencing their “first wave” in February, March, and April- these other areas experienced it when they “returned” to the world prematurely and haphazardly from lockdown. That occurred mostly over the summer months, July and August.
Transposing the timeline for surge, crest, and dissipation of the wave seen in NYC and the northeast to the rest of the country – extrapolation, not prediction- suggested a nationwide “end” to the pandemic by or about October 1, and here we are.
So, again, time for the question: was my extrapolation right, or wrong? Is the pandemic effectively over (or nearly so) in the United States now, or not?
My answer is: I don’t know.
No one can know yet, through the infodemic fog we have propagated. Some may say they know it is over, and many more are apt to say they know it is not. But such certainty in either direction is largely dictated by hype over dispassionate analysis, dogma over data, and/or ideology over epidemiology. All of that is just more of the same noisy nonsense that got us into this mess.
The COVID pandemic in the United States could, for all intents and purposes, be over- and we would not know for some time. Let me explain that, in three parts:
(1) what does “over” mean?;
(2) why the pandemic may NOT be over;
(3) why the pandemic COULD be over- and we wouldn’t know.
I will then try to sum up where we are now, and what we should be doing about it.
To start, we need an operational definition of “over” or “end” to be able to know and agree whether or not we in the U.S. are “there yet.” When I offered my initial extrapolation, I provided one: when the impacts of SARS-Co-V-2 recede into the “background noise” of our prevailing epidemiology.
I realize now that is not detailed enough, but it does capture the spirit of “over” fairly well. Without a pandemic, roughly 8000 people die daily in the United States, so “over” does not mean no deaths- it must only mean no more deaths than usual. This is a critical consideration, because pandemic hype and incessant news coverage of every pandemic casualty to the exclusion of all others have made it seem that absent COVID, no one in the United States would otherwise die. Average life expectancy in the U.S. is roughly 78.6 years, so the high toll of COVID among those over age 80 is in a group at high risk of death from other causes in the absence of any pandemic. Close to 3 million people die in the U.S. every year of miscellaneous causes, most of those occurring in old age. Roughly 650,000 people die annually here- that’s about 1800 deaths a day- from heart disease alone. Poor diet quality kills more than 500,000 of us prematurely every year.
No deaths is not a realistic epidemiologic goal. We are mortal, and with or without a pandemic- we die. Most of those daily deaths are, of course, among older people, so the pandemic is over when both the number of deaths, and their distribution, are much as they were before SARS-CoV-2 found us.
The definition of “over” does not require zero circulating virus either. If that were required to rule out a pandemic, we would have dozens or even hundreds of concomitant pandemics, because there are that many pathogens circulating in our population at any given time, from gonorrhea to adenovirus, coxsackie virus to chlamydia, salmonella to herpes simplex, Lyme disease to hepatitis C- and innumerable others- some deadly, some not. If we went out looking for these and other infections among asymptomatic people, we would find them, too.
That would not be a reason to announce a bounty of new pandemics. Rather, it means that zero cases is not a reasonable or realistic threshold once a pathogen has gained access to the human population and taken up residence among us.
In other words, if we test for SARS-CoV-2 among apparently healthy people without symptoms, and find it in some number of them, it does not mean, by itself, that the pandemic is persisting. It just means that SARS-CoV-2 is now part of our epidemiology, and never going away- any more than gonorrhea or salmonella or cholera or hepatitis C (or A, or B, for that matter)- will ever go away completely. Keep in mind that only one infectious disease to date, among thousands, has ever been fully eradicated once human transmission was established: smallpox. Every infection other than smallpox has persisted at some level in human populations after first establishing our species as a suitable host. We may expect the same of SARS-CoV-2.
To conclude: if we want to know when the pandemic is over, we need a reasonable definition of what “over” will mean. It should not mean zero asymptomatic cases; that’s an absurdly high bar. It should mean no unusual impact on the rates and patterns of hospitalization, mortality, severe illness, or long-term complications.
Are we THERE yet?
My extrapolation about October 1 may have been wrong, and for potentially more than one reason.
All extrapolations require certain assumptions, minimally that the empirical data are reliable, and that they pertain to the comparison group as well as the index group. In this case, New York City and the Northeast are the index group- the rest of the country, the comparison.
The official U.S. response to COVID was, as I have noted, a master class in dysfunction and ineptitude; your basic train wreck. On that basis, and on the basis of seroprevalence research, and more- I inferred that exposure levels in New York City during the surge were quite high, somewhat Sweden-like, albeit by accident rather than design. But maybe individuals, taking matters into their own anxious hands, did much better?
Perhaps many more of us here in the Northeast than I realized managed to hide ourselves away from the virus from the start until now, including in New York City. Perhaps “personal” approaches to lockdown greatly ‘trumped’ (pun intended) the national…lack of anything resembling rational guidance, cogency, or plan.
If so, that suggests many fewer of us here have already been exposed than I thought; many more of us remain vulnerable; and many more are subject to exposure, infection, and perhaps complications now…not having been exposed during the earlier surge.
This all pertains to the rest of the country, but in reverse. The rest of the country- or most of it- avoided the early surge. But perhaps many fewer blundered out of lockdown prematurely or indiscriminately than I perceived. Perhaps throughout the U.S., the numbers of the unexposed and vulnerable remain much higher now than they seem, because individuals protected themselves even when their federal government failed them.
Again, if we think of circulating SARS-CoV-2 as sparks on the wind, and those of us with no prior exposure, no immunity, and thus high vulnerability as dry tinder- then a lot of dry tinder means the danger of conflagration is not over.
This scenario is possible, but not probable. I don’t think it is correct- but I am obligated to concede it could be. A lot of data argue against it; let’s turn now to those data, and the happier conclusions they imply.
The first, best argument against the above scenario of on-going vulnerability to COVID at a high level is the most flagrant: death.
As I write this, the COVID death toll in the U.S. is reported as just less than 210,000. That is a terrible figure, and I hate writing it- but that’s what it is. That translates to 633 deaths per million in the entire U.S. population, and that rate per million is considerably higher than Sweden’s 582 per million.
Per the argument I made in that prior column, the death toll in the United States implies that (a) SARS-CoV-2 is much more lethal if you are American than if you are Swedish, and (b) exposure in the U.S. is vastly greater than we have documented. If “b” is not true, and if the U.S. has more deaths per million than Sweden despite vastly less overall exposure, it indicates the virus is orders of magnitude more deadly to Americans than Swedes, which is, in a word: absurd.
If the U.S. has already experienced a higher mortality toll per million than a country that defended minimally against population-wide exposure, it suggests that we, too, have likely had something near to population-wide exposure. That, in turn, suggests that most of those vulnerable to severe COVID infection have already succumbed.
Maybe many more Swedes than Americans avoided exposure to COVID, despite the lack of lock down. That, too, is highly implausible: attempted lockdowns would have actually increased overall exposure. If true, the case for lockdowns is much ado about worse than nothing. Maybe SARS-CoV-2 does prefer killing Americans to Swedes, but this is also unlikely. The only likely interpretation of our mortality burden is that many tens of millions of us in the U.S., and perhaps even most of us- have been exposed already.
Per the math I did last time, U.S. mortality figures, the known infection fatality rate of SARS-CoV-2 around the world, and seroprevalence data- all suggest that at least 70 million or so Americans have been infected to date. We know that 50% or more of us have native resistance to this germ to one degree or another, based on prior coronavirus exposures, so if 70 million have been infected, it suggests that 140 million or more of us have been exposed. And, finally, we may reasonably expect that native resistance is at about the same 50% prevalence among those not exposed so far. If 140 million Americans have been exposed, the unexposed population would be (330 million – 140 million), or 190 million people. If 50% of that group has native resistance to SARS-CoV-2, that’s about 95 million. If we add these- 140 million exposed with or without infection, plus 95 million with native resistance not yet exposed- we have 235 million “immune” to one degree or another. That is 235 million out of 330 million, or 71% of the population.
There’s more, of course.
We are finding more cases in the U.S. now because we are testing vastly more people than we did at the start. Most of the cases we are finding now are young, generally healthy people with minimal to no symptoms- cases we would have systematically overlooked at the start of the pandemic. These are occurring not just in data tabulations and national news, but in my own social circles. I am hearing routinely from friends and family about testing turning up asymptomatic cases in schools and on sports teams, and inviting quarantines, consternation, and chaos.
As we find ever more of the mild cases we have overlooked to date, the gap between case counts and casualty counts (i.e., hospitalizations and deaths) is widening. That is, as noted, a good thing, and suggests…the pandemic could be over, or ending, and we would not know it based on case counts.
There is still more. What about reinfection?
We have learned recently that reinfection by SARS-CoV-2 is possible, but in a good way. Mild infection the first time around results in some degree of immunity, but not measurable levels of IgG antibodies. In other words, the milder the original infection or exposure, the less “discernible” the immunity it leaves behind; this was well elaborated in a paper out of Iceland published in the New England Journal of Medicine.
The result is that a second infection, months later, can occur- but encountering partial immunity, it is apt to be even milder than the first. Accordingly, some, perhaps many, or maybe even most of these “new” cases we are now capturing on college campuses around the country could be reinfections, among young people who had mild infections months ago. Since we sent college students home after the virus was circulating in the U.S., and we did not test them- this is far from implausible. We don’t know.
The medical system in the U.S. is generally no longer overwhelmed by COVID. There are states where ICU occupancy is high, but to be honest- I was not tracking ICU occupancy by state before the pandemic, so I am not sure what normal looks like for Alabama or Kentucky.
Also of note, hospitalization for COVID- and especially ICU admission- is generally a matter of weeks, so hospital counts now are a product of what the virus was doing in the population a month or more ago, not what it is doing now. Deaths, too, follow a delay- often occurring weeks after exposure. Even Sweden, which is reporting no new cases, continues to report an extremely low rate of new COVID deaths, as those severely infected many weeks ago finally lose their struggle with this pathogen.
Declines in hospitalization and deaths are already visible in the U.S., and that’s encouraging- but such declines will lag behind the termination of pandemic viral transmission by some number of weeks. The pandemic could be well and truly over- and we would still be tallying these. Similarly, burn victims may die long after the fire has burned out. It is no less tragic, of course- but it does not mean the fire isn’t out.
Along with the epidemiologic data, there is a component of personal experience to append here. Famously, we are all six degrees of separation from Kevin Bacon. Whatever the veracity of that, we are certainly all connected to networks, and at the start of the pandemic- mine was impacted. There were cases of COVID infection, hospitalizations, and even deaths among friends and family; among friends of family; among family of friends; among friends of friends. I have had no such intrusion into my extended network for several months now. I hear about new, asymptomatic cases routinely, as noted- but I have not heard of a new, severe case in a long time. I was also hearing routinely about overwhelming clinical burdens from my front-line colleagues, and that, too, has disappeared. Such personal anecdotes are not a substitute for formal epidemiologic surveillance, but they are a meaningful addendum to it.
All of which suggests: it might be over, and we just wouldn’t know it yet. We certainly wouldn’t agree about it, because agreement has been expunged- temporarily, we may hope- from the American character.
There is, of course, the worry of pandemic waves. Maybe it is over now, but it will come back. Maybe it will come back even in Sweden. That, presumably, is what a “second wave” portends.
This concern emanates from some expert sources I respect and admire, and is predicated on prior pandemic experiences. But it really does not appear to fit our situation. Influenza, our primary source of pandemic lessons, seems to display variable transmission by season as a matter of routine. COVID19 has not done so, circulating robustly over summer months among any population exposing itself.
SARS-CoV-2 was circulating in the United States as early as December, 2019. In other words, this is already a four-season experience: the latter weeks of Fall, 2019; Winter, 2019-2020; Spring, 2020; Summer, 2020; and now, we are back into fall. Viral transmission did not wane during any of that, so why should it wax as the calendar repeats the cycle?
I see nothing to suggest it will- although that, of course, does not prove it will not. But it is encouraging.
Whatever “waves” we have seen to date are waves of our own devising, born not of vicissitudes in viral behavior, but in our own. Where we hid away from the virus before exposure, transmission rates were low. Where we exposed ourselves en masse, transmission rates were high. Where we cycled these patterns by place or time, the pattern of contagion corresponded.
As best I can tell, the virus isn’t making waves; we are making the waves.
All pandemics end. This one will, too. Maybe it has in select locations, and we just don’t know it yet.
When it does end in any given location, how will we know? Will it end with a bang, a whimper, or something else altogether? Will it end in the morning or afternoon? Will it end on a given Tuesday, or Thursday- or will it end during a given week, month, or season? Will it end on some global C-Day, or at many different times in many different places?
We know it will end- and that in some places, it may have ended already. But since we don’t know the rest, knowing just when the pandemic has effectively ended in any given place will prove far more challenging than any hopes for champagne and confetti might foster.
As I write this, I honestly don’t know if the pandemic is over or not here in the United States. But I am willing to take a stand in a rather lonely place, no doubt subject to excoriations, and say: it could be. I am hoping it is over, or nearly so, and think you reasonably can do the same.
But while I sanction that shared hope, I far more adamantly espouse a platform of humility. From the start, the COVID infodemic has done more damage to us all than the virus itself, and the singular toxin in that contagion has been unwarranted certainty. Some have been far too certain of viral devastation, justifying unprecedented societal disruptions. Some have been far too certain of this pathogen’s insignificance, justifying lethal denial.
Certainty based on uncertain information may be the greatest danger.
Let’s be hopeful, but not certain. At some point, the evidence that the pandemic is over will be incontrovertible- and we will all be living in the aftermath. That won’t be today, even if the pandemic actually ended yesterday where you are.
During this time of transition, be careful. Take all relevant precautions, especially with regard to those in higher risk tiers. I do not think we should have chaos and quarantine every time a young, healthy person tests positive for asymptomatic infection- but I do think those cases should stay carefully away from their octogenarian loved ones, or loved ones with heart disease.
Be careful, be hopeful, and wait. Some things can only be seen clearly, and known reliably, through the medium of hindsight.
The end of a pandemic is one of those.
David L. Katz, MD, MPH, FACPM, FACP, FACLM, is the Founding Director (1998) of Yale University’s Yale-Griffin Prevention Research Center, and former President of the American College of Lifestyle Medicine. He has published roughly 200 scientific articles and textbook chapters, and 15 books to date, including multiple editions of leading textbooks in both preventive medicine, and nutrition. He has made important contributions in the areas of lifestyle interventions for health promotion; nutrient profiling; behavior modification; holistic care; and evidence-based medicine. David earned his BA degree from Dartmouth College (1984); his MD from the Albert Einstein College of Medicine (1988); and his MPH from the Yale University School of Public Health (1993). He completed sequential residency training in Internal Medicine, and Preventive Medicine/Public Health. He is a two-time diplomate of the American Board of Internal Medicine, and a board-certified specialist in Preventive Medicine/Public Health. He has received two Honorary Doctorates.