There may be two to four more rounds of social distancing before this is over. Here’s what to expect.
By Ezekiel J. Emanuel, Susan Ellenberg and Michael Levy
Food-distribution workers observed social distancing as they listened to Mayor Muriel Bowser of Washington speak about the city’s response to the coronavirus on Monday.Credit...Jacquelyn Martin/Associated Press
In the last few days, most Americans, even President Trump, have come to terms with the need for social distancing. Though they feel fine, they are staying home and developing new routines — killing time baking, binge-watching, figuring out how to home-school their kids. It took far too long for Americans to accept how serious the coronavirus is.
Now that we’ve finally taken the necessary measures in many places to close schools, offices, restaurants and other businesses, people are asking: How soon will it all be over? Two weeks? Four weeks? When can we go back to normal?
Unfortunately, normal is a long way off. We need to be thinking in terms of months, not weeks.
We need to stop picturing that ubiquitous “flatten the curve” chart and start imagining a roller coaster.
Social distancing works. As China, South Korea and other countries have demonstrated, it is possible to slow the spread of the virus and limit how many people are infected at one time.
This will keep hospitals from being overwhelmed with patients, so that those who are sick can be treated competently and compassionately. It will also give researchers time to work on developing vaccines and medications that could reduce the severity of the virus and save lives.
No one knows for sure how long social distancing will have to last to reduce the spread to near zero. But if South Korea and China are appropriate exemplars, we’ll need to stay apart now for at least eight weeks, and maybe more.
China locked down Wuhan and other cities in Hubei province on Jan. 23. Today, provincial officials are reporting few or no new cases of the virus. Just a few days ago, they closed the last of their 16 makeshift emergency hospitals. Consequently, restrictions are easing. Schools and offices are slowly opening. People are beginning to go out and see other people.
That timeline suggests that your kids are not going back to school on April 1. Nor are you returning to the office or catching a movie anytime soon. Plan for social distancing at least until mid- or late May, and be thankful if it eases off earlier.
What can we expect when Americans slowly emerge from their homes? Like much about this novel virus, we don’t know for sure. A likely scenario is that there will be subsequent waves of the disease. That’s what happened in Denver in the 1918-19 influenza pandemic and in Toronto during the 2003 SARS outbreak. Over the next few months, South Korea, China and other countries will generate some relevant evidence to show how this might play out.
Many people desperately hope that warmer, more humid weather will decrease the transmission of this coronavirus. But the reality is that influenza and most cold viruses wane in the summer in part because so many people catch them in the winter. Humans have never been infected with this coronavirus before, so there is no acquired immunity. At this point we have woefully little evidence to suggest a seasonal reprieve.
We assume that people who are infected and then recover, whether they develop symptoms or not, will most likely become immune and will not transmit the virus in the future. (Though it is possible, as with other types of coronavirus, that mild infections might not provide full immunity in the short term or lifelong immunity.)
The irony of successful social distancing is that fewer will develop immunity. That means that social distancing 2.0, 3.0 and, who knows, maybe even 4.0 will very likely have to occur.
The next round of social distancing will be activated more rapidly, because officials — and the public — will be more prepared. It should also be shorter, because we can assume that most of the people who were initially infected are likely to be immune next time around. But it will still disrupt people’s lives and the economy.
We will still have canceled conferences and sporting events. People will not frequent restaurants and will not travel. The service industry will be severely curtailed. And it’s going to happen again and again.
Maybe the best analogy is pumping a car’s brakes on an icy road. Either doing nothing or slamming on the brakes leads to an accident. So we pump the brakes — pushing on the brakes, then easing up, and then applying them again — and after three or four times we slow down enough to stop.
When will the coronavirus be tamed like influenza, if not conquered like smallpox? A vaccine would need to be administered to an estimated 45 percent to 70 percent of the population — at least 145 million people — to stop the spread of the virus. If we are lucky, and an effective vaccine is quickly developed, this could happen by the fall of 2021.
It might even be sooner if researchers can come up with an effective treatment that, in addition to preventing deaths, reduces the infectiousness of each case. One antiviral drug, remdesivir, has shown promise in treating monkeys infected with a similar coronavirus, and is being studied in humans. Trials of other drugs will begin soon. Again, if we are lucky, these trials may identify one or more effective treatments in four to five months.
The alternative to this roller coaster would be even more drastic. It would require sustaining social distancing until there are no more cases whatsoever and then closing borders to all travelers — no contact with the outside world — for 18 months or more. While the United States and many other countries, like Denmark and Germany, have instituted travel bans, sealing the country off for over a year until a coronavirus vaccine is discovered seems implausible. But who knows. If the situation becomes dire enough, the previously impossible could become inevitable.
On a positive note, each time the virus resurges after social distancing is relaxed, it will do so more slowly. But the flattened curve we are all hoping for — the one that is so critical to our health care infrastructure — will not actually be flat. It is more likely to be a series of ascents and descents, with dampened oscillations. So all of us — health care workers, policymakers and American citizens — need to get ready for a bumpy ride.
Ezekiel J. Emanuel is the chairman of the department of medical ethics and health policy at the University of Pennsylvania, where Susan Ellenberg is a professor of biostatistics and Michael Levy is a professor of epidemiology.
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