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15 November 20
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FOCUS: Dhruv Khullar | The Pandemic's Winter Surge Is Here
Dhruv Khullar, The New Yorker
Khullar writes: "The numbers are rising. Our leaders must react quickly to prevent unnecessary deaths."
urope’s second wave built slowly, starting in midsummer. At that time, charts comparing coronavirus cases in America and Europe highlighted the inadequacy of the U.S. response; there were days on which individual American states recorded more new infections than the entire European continent. But in July, cases in Spain started to tick upward, and in August the numbers in France began rising. By September, Spanish covid-19 deaths had increased by a factor of ten, and France, for the first time, had recorded more than ten thousand new coronavirus cases in a single day. “We do have a very serious situation unfolding before us,” Hans Kluge, the W.H.O. regional director for Europe, warned. Spikes soon followed in the U.K., Italy, Germany, and other countries. The virus, once confined to a few hotspots, was everywhere.
At first, European governments tried to avoid a return to the restrictions they’d used in February. But, as the virus filled I.C.U.s, they realized that they had no choice. This month, the United Kingdom entered a second national lockdown, with bans on gatherings of more than two people. In France, only schools, factories, and essential businesses remain open. Germany has announced “lockdown light,” with heavy restrictions on bars, restaurants, gyms, and theatres. These measures seem to have come too late: Europe now accounts for nearly half the world’s new coronavirus cases. “They opened up much too fast,” Mitchell Katz, the president and C.E.O. of N.Y.C. Health + Hospitals, the largest public-hospital system in the U.S., told me. Over the summer, Europeans took vacations and went to bars and clubs, facilitating viral spread; genetic analyses suggest that travel to and from Spain, in particular, may have contributed significantly to the resurgence of infection. “The only way you can open up to that level is if you eradicate the virus,” Katz said. “And the only way you can eradicate the virus with today’s tools is if you’re a totalitarian government or on an island.”
Almost every flu pandemic since the eighteenth century has come with a second wave; the fall of 1918 was far deadlier than the spring. Today, as the Northern Hemisphere steps deeper into autumn and more activity moves indoors, the spread of the coronavirus is, predictably, accelerating. America is again following Europe’s lead. In the last week of October, the U.S. recorded more new coronavirus cases than it has at any point during the pandemic; there have been days in November on which more than a hundred and thirty thousand people have been found to be newly infected. A few states—Wisconsin, North Dakota, Iowa—have among the highest per-capita infection rates in the world. The new surge has no epicenter. Infection records are being set in more than half of U.S. counties, and large swaths of the Midwest and mountain West are struggling with skyrocketing hospitalizations. On many days, more than a thousand Americans are now dying of covid-19—a number that is certain to rise, since deaths lag behind infections by several weeks.
The mortality rate for the virus has fallen substantially since the start of the pandemic, probably because of improvements in care and a shift in viral demographics: many of the newly infected are young. But a lower death rate combined with a vast rise in infections will still create profound suffering. One model predicts that, by the end of the year, two thousand Americans could be dying from covid-19 each day. The American death toll could reach four hundred thousand by January. Speaking about the coming winter with the Washington Post, Anthony Fauci concluded that the U.S. is “in for a whole lot of hurt.” The challenge now, for citizens and leaders, is to shift from anticipating the winter surge to recognizing that it is already here.
The character of the winter surge changes depending on where you live. Over the course of the pandemic, the virus has moved inexorably from cities to rural areas. Today, many first-wave epicenters, including New York City, New Jersey, and Massachusetts, have successfully suppressed the virus and are now working to prevent a second surge. Less populous states, such as Utah, Wisconsin, and the Dakotas, muddled through over the summer, accepting a certain level of infection without imposing significant restrictions—but they are now losing control, and face unprecedented waves of infection with limited resources.
In early April, when things were bad in the Northeast but mostly O.K. elsewhere, I got to know Tony Edwards and Scott Aberegg, two doctors from Utah who had flown to New York City to help when the pandemic was at its peak. A few weeks later, they flew back to Utah, where their hospital was preparing for its own covid-19 deluge. The surge didn’t immediately materialize: they returned to “Mundane May,” as Aberegg called it. But then Memorial Day festivities set off a rise in cases, which peaked in the middle of July. Utah’s hospitals were generally able to manage, so Gary Herbert, the state’s governor, declined to issue a statewide mask mandate, instead deferring to local leaders. A mask requirement put in place by the mayor of Salt Lake City, where the majority of Utah’s cases were concentrated, was enough to keep viral spread within limits.
As summer turned to fall, however, the virus began to spread more aggressively. In August, Salt Lake County started logging around two hundred new cases per hundred thousand people each day—a level of growth at which many public-health experts argue against in-person schooling. (A Harvard report discourages it at an infection rate above twenty-five cases per hundred thousand people.) Schools for all ages opened anyway; in the month afterward, the rate of viral growth more than tripled, and Utah set new records for coronavirus hospitalizations. According to officials, parents at some schools created an informal “Mom Code,” agreeing among themselves not to get their children tested in an effort to keep statistics low. In one Salt Lake City suburb, a high school switched to remote learning only after seventy-seven students had been diagnosed, and one teacher had been hospitalized and put on a ventilator.
Schools opened when viral spread was already high, then failed to close as cases rose further: it seems likely that this combination created an overwhelming coronavirus surge, driven largely by high-school and college students. By mid-September, people aged fifteen to twenty-four had the highest rate of infection of any demographic in Utah, accounting for more than a quarter of new coronavirus cases and prompting officials to develop a targeted public-health campaign. (“You’re so over it. . . . But if you wanna stay at school, you gotta avoid the Rona!”; “#ronalert, #avoidtherona.”) Tensions persist between parents who believe schools must remain open and those who think they should have closed long ago. Lindsay Keegan, an epidemiologist at the University of Utah, cited so-called pandemic fatigue as a key factor driving the aversion to new restrictions. “Early on, covid was a new and terrifying and unknown problem,” she told me. “People were willing to stay home, lock down, and do everything they could to prevent spread of the virus. But humans have a hard time staying activated against prolonged crises.”
For months, as the numbers climbed, Utah’s governor acknowledged reality without acting on it. In the summer, Herbert said that, although he “strongly” supported mask-wearing, he was concerned that mandating mask use would create “divisive enforcement issues.” When anti-mask protesters gathered outside the home of Angela Dunn, the state’s epidemiologist, Herbert called their actions “disgraceful.” He has also communicated about the virus in increasingly personal and forthright terms, citing his daughter and granddaughter, both of whom caught the virus; one hasn’t regained her sense of smell three months later, and the other has lost weight owing to nausea. “Our hospitals cannot keep up with Utah’s infection rate,” he tweeted, last month. “You deserve to understand the dire situation we face. We have seen this in Italy. We have seen this in New York. We could see this in Utah if things do not change.”
Even so, it was only on Sunday, November 8th—after his Lieutenant Governor won the gubernatorial election—that Herbert, whose term ends in January, declared a state of emergency, issuing a statewide mask mandate “for the foreseeable future” and putting into place temporary limits on social gatherings and extracurricular activities. (Schools can continue in-person instruction.) For public-health officials, the orders are welcome, but, Keegan warned, Utah is “way behind. You have to remember that the infection curve is symmetric. It’s going to be a while before we get things under control, even if we start now.”
Russell Vinik, the chief medical operations officer at the University of Utah Health, told me that his hospital is running at about ninety per cent of its I.C.U. capacity; on some days, it’s over one hundred. More coronavirus patients are arriving than are being discharged, and so the university has opened a surge I.C.U. staffed by clinicians working overtime, sometimes in new roles. “This is sustainable for a short period of time,” Vinik said, “but not for very long.” Still, he went on, “I don’t see this tide turning until we have a major change in public perception. We haven’t had that yet. For the most part, people are still just going about their lives.”
When describing the quality of treatment their patients receive, clinicians speak in terms of “standards of care.” As grim as the current situation is, Vinik’s hospital has been able to hold to its usual standard. If more patients arrive, that will become difficult. Vinik told me that there are at least two major changes to the standard of care that he hopes desperately to avoid. The first, which he calls “contingency standard,” takes effect when the volume of new patients so overwhelms the I.C.U. staff that clinicians trained in other specialties must be brought in. “These are great doctors, but they’re not used to caring for acutely ill patients with respiratory disease,” Vinik said. “That’s not ideal, but it’s the best we could do.” Next is “crisis standard,” at which I.C.U. care must be rationed. Recently, a group of hospital leaders briefed the governor on the “decision tree” they would use while rationing: they would first take into account various clinical measures—blood pressure, mental status, liver and kidney function, need for oxygen, and so on—and then, in the case of a tie, favor younger patients over older ones, giving preferential treatment to pregnant women, who, according to the guidelines, “represent two lives.” “Crisis standard is something none of us are prepared to enact,” Vinik concluded. “If we’re forced to make those decisions, it will be the most heinous thing that any of us has ever had to do.”
Utah’s experience mirrors that of many states where the virus is surging. This week, eighteen states reported record numbers of coronavirus hospitalizations. Shortages of I.C.U. beds have forced hospitals across the country to build surge units. In Idaho, where hospitalizations increased by nearly fifty per cent in late October, a third of the state’s I.C.U. beds are occupied by covid-19 patients. In Wisconsin, which continues to break infection records, an astonishing thirty per cent of those tested are positive, and hospitals are running at ninety per cent capacity.
The geographic expansiveness of the surge may be its defining characteristic. In normal times, patients across the mountain West are routinely transferred between states, or from rural areas to big cities. Now, with the virus consuming the entire region, many small, rural hospitals have found themselves unable to move critically ill patients to larger medical centers, which are themselves overwhelmed. During the spring, clinicians from around the country poured into New York City, the country’s singular epicenter, to help; today, Western states are competing for a limited number of clinicians, who must be hired through agencies. Staff shortages are further exacerbated by infections. At one point in October, a hundred and forty staff members at a single hospital in Minot, North Dakota were quarantined; more than ten per cent of the staff at a hospital in Rupert, Idaho, was sick. In Wisconsin, five per cent of coronavirus cases are estimated to have occurred among health-care workers.
In many states, efforts to combat the virus have been hampered by disputes between public-health leaders and politicians. Hospital administrators have pleaded with elected officials to introduce stronger restrictions, only to be denied or dismissed; their appeals have been met with half measures and, at times, hostility. A mask mandate was recently introduced in Bismarck, North Dakota, but it will not be enforced and carries no penalties. (North Dakota’s governor recently announced that, due to staff shortages, asymptomatic, coronavirus-positive health-care workers could continue caring for patients; he has not, however, issued a statewide mask mandate.) In Idaho, a local health board rescinded a mask mandate even as cases surged in the area. “I agree we have a problem with the virus,” one official said. “At the same time, I object to the mandate the board passed because it restricts people’s right of choice.” Greg Abbott, the governor of Texas, which has recorded more coronavirus cases than any other state, criticized a recent lockdown in El Paso—a city where covid-19 patients are filling hospital beds and the test-positivity rate is more than twenty-two per cent. The state’s attorney general has filed a motion to stop the “unlawful lockdown order.”
What’s to come for the small cities and rural counties where covid-19 is now surging? Unable to navigate the politics of the virus, many are now careening toward disaster. An irony of the pandemic is that leaders’ desire to avoid or delay government action means they’re often forced to introduce more severe restrictions in desperate circumstances. “If you introduce measures early, you have a chance at avoiding the more stringent ones,” Keegan said. “If you wait until you don’t have enough beds or doctors, you have to impose more drastic lockdowns.” Hospital systems that might have been able to cope with the virus are now finding themselves isolated and overwhelmed. Tens of thousands of people will soon die preventable deaths.
Early epicenters like New York City face a different challenge: preventing a second wave. In April, ambulances shrieked through New York’s streets, doctors worked for weeks without respite, and mobile morgues were parked outside hospitals; the city sometimes recorded more than eight hundred deaths in a single day. Since then, however, New York has done a remarkable job of controlling the virus by means of a public-health infrastructure which is now a source of cautious optimism.
Early on, New York’s response was marred by bureaucratic rivalries. Many observers have said that the city’s mayor, Bill de Blasio, and the state’s governor, Andrew Cuomo, allowed their antagonism to delay action in March, when the virus was spreading across the city unchecked; some have questioned the Mayor’s decision, in May, to shift responsibility for contact tracing from the city’s health department—which has historically performed tracing for other infectious diseases, such as H.I.V. and tuberculosis—to the public hospital system, N.Y.C. Health + Hospitals. (The city’s health commissioner, Oxiris Barbot, resigned in August in part because of the move.)
But the N.Y.C. Test & Trace Corps now operated by the hospital system is working at a high level of effectiveness. Initially, tracers had trouble reaching many of those who tested positive; some wouldn’t answer their phones, and others refused to provide contacts. Ted Long, the physician who runs the program, introduced changes. The Corps made more of an effort to hire the majority of its tracers from affected communities—“Building trust is the key variable in getting people to participate,” Long said—and began sending them to patients’ homes. It made sure that, when rapid tests were administered in the system’s clinics, tracers were in the room when patients were given their result. Soon, the program was reaching more than ninety per cent of those who tested positive, and getting information about contacts for nearly eighty per cent of all cases. Another key, according to Mitchell Katz, is a surfeit of capacity. “We’re not stretched, we could deal with way more cases if we had to,” Katz said. “That means we can be very persistent with each one.” Not long ago, Katz received an angry e-mail from a New Yorker who’d tested positive. The man complained about how many times he’d been contacted. “He said that we’d filled up all the space on his voice mail and how terrible it was,” Katz said. “I thought, ‘That’s great!’ ”
The city has also built support systems for those who need to isolate. Tracers call every day; food and medications are delivered to those in need; and some people are offered telehealth services or legal help to stave off eviction. “We’ll even walk your dog,” Long said. The city has signed a contract with Wag!, a company that offers on-demand pet-care services. For those who aren’t able to isolate safely at home, it provides free hotel rooms. “And not a dump where you worry about your possessions being stolen,” Katz said. “These are nice.” Today, ninety-eight per cent of New Yorkers who complete the city’s intake process report compliance with their coronavirus isolation.
In the late nineteen-nineties, a biostatistician named Martin Kulldorff wrote a program called SaTScan, which allowed epidemiologists to sift through vast amounts of data and identify cancer clusters. Today, Kulldorff is best known as one of the authors of the Great Barrington Declaration, the widely criticized herd-immunity-through-mass-infection manifesto that has been cynically embraced by the Trump Administration. SaTScan, on the other hand, has been vital to New York City’s efforts. “It’s one of the jewels of our response,” Dave Chokshi, the city’s health commissioner, said. In the two-thousands, SaTScan was adapted to work for infectious diseases, such as legionella and salmonella; now, it helps officials spot outbreaks of the coronavirus. “Think of it as a very, very early warning system for disease activity,” Demetre Daskalakis, the city’s deputy health commissioner, told me. “The parcels of land we create for administrative purposes don’t capture how diseases actually transmit,” he went on. But SaTScan “doesn’t say, ‘Uh oh, this Zip Code,’ or, ‘Uh oh, this census tract is blowing up.’ ” Instead, it constructs a heat map based on a block-by-block assessment of where tests are coming back positive. If a cluster is identified, the health department shifts advertisements and robocalls to the area, distributes masks, and encourages residents to get tested, either at existing centers or mobile and pop-up testing sites, which can be set up as soon as the next day. To get the word out, the health department works with faith leaders from churches and synagogues.
In October, Governor Andrew Cuomo announced a similar “micro-cluster” strategy for all of New York State. (Previously, restrictions were focussed more broadly, by county or region.) Cuomo has said that the data used to categorize neighborhoods is “so specific that we can’t show it because it could violate privacy conditions.” Every ten days, neighborhoods are classified into red, orange, or yellow zones. In red zones, which generally have positivity rates above three per cent, you can’t eat at restaurants even outside, schools are online only, mass gatherings are prohibited, only essential businesses are open, and fewer than ten people are allowed in houses of worship. As the positivity rate falls, restrictions are loosened. In an orange zone, for instance, schools remain online, but restaurants can serve meals outdoors; in a yellow zone, in-person schooling is allowed with mandatory weekly testing, and indoor dining is permitted at reduced capacity. For now, these systems seem to be working. New York State performs more tests per capita than many countries we think of as having stellar pandemic responses, including South Korea and Germany. More than fifty thousand New Yorkers across the city are tested each day, and results are generally available within forty-eight hours. Although the state has recorded over half a million coronavirus cases in total—more cases than all but three states—it has among the lowest per capita rate of infection in the nation.
And yet daily case counts in New York City are rising. Since the middle of October, they’ve increased by forty per cent. Poor neighborhoods with larger households, in particular, are struggling to keep the virus at bay. The test-positivity rate, which has hovered around two per cent, has at times risen to eight per cent in parts of Queens and Brooklyn. Like the rest of the country, New York City has struggled with pockets of resistance to public-health rules; in Borough Park, for example, anti-mask protesters have taken to the streets, and rising case-loads have led Chokshi and other health officials to engage local leaders. In recent weeks, the neighborhood, which became a “red zone” in October, has had a test-positivity rate as high as ten per cent. Although citywide deaths remain under twenty a day—far lower than the level in the spring—they have also started to rise. The weather is cooling, forcing people inside; schools are in session, and many workers have returned to offices, stores, restaurants, and construction sites. For much of the past week, New York City has recorded more than a thousand daily cases—nearly twice as many as last month, and its highest total since the spring. In a news conference on Monday, de Blasio said the city was “dangerously close” to a second wave. On Wednesday, Cuomo announced a ten p.m. curfew for bars and restaurants across the state, and limited private gatherings to ten people.
Will New York end up locked down again, like London, Paris, Berlin, and other European cities? It’s possible that New Yorkers’ recent experience with the pandemic’s devastation, combined with their knowledge that the virus is circulating widely across the country, could help it escape that fate. New Yorkers have among the highest rates of mask-wearing in the United States; compared to other Americans—even those in large cities, such as Los Angeles—they are more likely to self-isolate and avoid big gatherings. Surveys have shown that they are more supportive of limits on social and economic activity, including stay-at-home orders, the closure of non-essential businesses, and restrictions on indoor dining. “Our most successful intervention has been New Yorkers’ attitudes,” Katz told me. “We don’t have a lot of folks questioning what needs to be done. The credit for our success so far goes to people.”
But even with public buy-in, it won’t be easy for New York City to stem the rise in cases that’s begun. The city’s density makes it particularly vulnerable to the pandemic’s simple, ruthless logic: more contact means more infection. Its vulnerability necessitates not just constant surveillance but swift action. Already, the city has blown past the two-per-cent test-positivity threshold that the mayor set for stopping indoor dining; even so, restaurants continue to serve food indoors. Density is not destiny: New York may stay open this winter. But, for that to happen, a lot has to go right.
What comes next for the country as a whole? The election of Joe Biden promises a course correction for America’s pandemic strategy, beginning in January. In the meantime, Donald Trump remains President, and the country sits on a precipice. There is already no avoiding the deaths that will follow this month’s rise in coronavirus infections. But the trends that led to that rise may very well continue and intensify. The rural states that have lost control of the virus may hold to their perilous trajectories; the first-wave epicenters fighting to keep it suppressed may grow overwhelmed as the weather cools. In this bleak scenario, millions more Americans—in states big and small, red and blue—will contract the virus, and hundreds of thousands will die. We will experience the deadliest months in modern American history.
Alternatively, mayors, county executives, state legislatures, and governors can act decisively. They could take a clear-eyed view of the virus—of its contagiousness, its evasiveness. From this perspective, the restrictions recently re-imposed across much of Europe look less like signs of failure and more like indications of responsiveness. As cases rise, early and aggressive action—however unpopular—will save lives. The first signs of spread may be the only warnings we get.
The fundamentals of effective pandemic response are the same today as they were when the crisis started. We know the drill. Unless we put mitigating measures in place, the coronavirus will spread, and sooner than we expect it will get out of control. The only way to avoid mass death is to move quickly and decisively, flattening the curve through masks, distance, testing, tracing, and lockdowns until a vaccine and therapies can avert the suffering caused by covid-19. Passivity is the enemy. The winter surge is here; we decide what happens next.
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