I’ve been studying headlines lately and I find many of them hilarious in their combination of absolute certainty, an assumption that the information presented is unknown yet essential to everyone, and pronouncements of inevitable doom unless you do whatever the article advocates.
“The one number you should pay attention to right now.”
“I lived through the 1918 pandemic and a nuclear winter. This pandemic will be worse unless you do this right now.”
“The next pandemic wave will be so much more stupendously worser than anything you can possibly imagine, unless you do this right now.”
My goal today is to assess where we’ve been, give my current impression of things, and what are possible future scenarios. I pronounce with absolute certainty that I cannot state with certainty what might have been or predict the future.
I am not proposing any public health policies; I’m simply presenting what I think the data tells us. Humility in all things (especially science and medicine) is extraordinarily important, but is in short supply these days.
What could have been?
How bad the last few months has been is pretty apparent to me. A natural follow up question is how bad could it have been? A colleague forwarded an article from the journal Nature which attempted to quantify an answer. You can review the paper if you want all the specific numbers, but I’ll summarize the article’s conclusion: large scale policies substantially slowed the growth of the pandemic. Some questions are too complex and hypothetical to allow any conclusion more specific than “Well, duh!” (That is my reaction to this article.) The article provides good evidence that local, state and national policies had substantial effects on reducing the growth and impact of the pandemic. The data is interesting but I think stating anything more specific is problematic.
Where are we now?
I wish we had a nice map with a big red dot that says “You Are Here.” Because wherever “Here” is keeps changing. What follows below is my humble attempt to say where I think we are. I’m going to use national data as it is the easiest to grab and compare. But what is far more important is what is going on in your community.
Generalization #1
Some states in the U.S. have just gone through the initial outbreak of a pandemic while others appear to still be in the initial outbreak. To fully understand this, we need to have the right comparisons. The average number of new daily cases in several states is at their highest since the beginning of the pandemic. That statement is true but misses the point. We have much more testing available now so seeing larger numbers of “known” cases is not surprising. For example, the U.S. is averaging about 20,000 new cases and 800 deaths due to COVID-19 each day. Perhaps the “true” number of new cases each day back in early April was 40,000 or 50,000 but there is no way to know because we didn’t have enough tests. However I “think” the amount of testing available in most states is not substantially different this week compared to four weeks ago, and in several states there is a clear trend of increasing cases. Thankfully the impact on the health care systems in those states has not reached a crisis (and hopefully won’t).
Generalization #2
Twenty thousand new cases a day “feels” large. To put this number in perspective we have approximately 16,000 car accidents per day in the U.S.
The approximate 800 daily deaths due to COVID-19 is about twice as many deaths per day caused by any one of the following: accidents, chronic lung disease, stroke or alzheimer’s. But it is about half as many deaths per day due to either heart disease or cancer. There’s also no serious infectious disease that even comes close to being as common as COVID-19. I am not saying that COVID-19 is worse than some things or better than others, I am just providing context.
Based on the above data I conclude with the highly scientific statement that COVID-19 is pretty damn common. If the virus were a car, then in March it was a Ferrari racing on the Autobahn, and now it’s a Honda Accord on cruise control on the interstate.
Generalization #3
Although temperature, humidity and multiple other factors affect COVID-19 transmission, the available data indicates the effect of these variables is relatively minor. COVID-19 transmission is so common right now that I would not count on this virus being seasonal in the same way we consider influenza seasonal. We need much more data over a year or more, however, to draw a firm conclusion.
What will be?
A large second wave like what was seen in the 1918 influenza pandemic is possible, but is only one of several possibilities, none of which are predestined. There could be a big second wave, or the virus could sort of simmer along and eventually diminish, or there could be a series of peaks and troughs, or some combination of one or more of these. All of us would be thrilled to see this virus burn itself out after the first outbreak, but I think that an unlikely scenario.
This virus— and the resourcefulness of microbes in general — humbles me enough that I think it unlikely the virus stays at relatively low activity levels even in those locations currently with a “handle” on things. There are simply too many human interactions that will not disappear; we cannot expect to permanently keep this virus at bay. To quote the character Ian Malcolm from Jurassic Park: “Life finds a way.”
As always I leave you with some hopeful analysis. Although I think a new virus as contagious as COVID-19 in such a large and susceptible population has a lot more road to travel, we have a tremendous capacity to slow that car down by wearing masks, keeping our distance, washing our hands, and not venturing out if we are sick. In addition, the state of medicine and technology makes 2020 radically different from 1918. And I remain optimistic that multiple vaccines will be developed, serving as effective roadblocks to this most awful of race cars.
Stay safe, and go make some lemonade.
The Infectious Pharmacist 
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