Coronavirus: The new normal

This blog is the text of a YouTube live talk given by our Center’s Director, Gavin Yamey, on June 12, 2020.

Hello and thank you so much for joining this YouTube live conversation today on Coronavirus: The new normal. My name is Gavin Yamey, I’m a Professor of Global Health and Public Policy at Duke. I direct the Center for Policy Impact in Global Health in the Duke Global Health Institute.

To give you a little bit of my background: I’ve had a rather eclectic career—I’m a physician who then became a health journalist who then became a public health researcher—and today I try and wear all three hats at the same time in my work on global health policy. Global health policy essentially means trying to achieve large scale change in the health of the population, particularly the health of the poorest and the marginalized.

Even before COVID-19 hit, our Center was working on pandemic preparedness.

In particular, we had done a lot of research on what the world needed to do to get a proper preparedness system in place—one that was “fit for purpose” in quickly shutting down a global outbreak. We had done research on two kinds of preparedness:

National preparedness—a prepared country has a strong system for detecting an outbreak, isolating infected people, tracing and testing their contacts, communicating public health messages, and so on.  Part of this national preparedness is also having strong leaders who adopt science-based policies, and a strong health delivery system with no financial barriers getting in the way of people seeking medical help.

The second kind is global preparedness, by which I mean a set of activities that need to happen across all countries—you could call these activities “international collective action for health.” These are transnational actions that benefit all nations—like developing vaccines, treatments, and diagnostics to control outbreaks; generating and sharing knowledge worldwide on what works to control pandemics; and having a strong global outbreak surveillance system.

Obviously, the COVID-19 pandemic has shown that this system worked in some ways and in some countries, but not universally, and certainly it did not protect the most vulnerable, as I’ll talk about today.

I do want to just say right at the outset that one of the many tragedies of COVID-19 is that our research at Duke showed that it would have cost relatively little to put both a national and global preparedness system in place.

COVID-19 has caused an immense human and economic toll—worldwide, around 400,000 deaths and a predicted $2 trillion in economic loss in 2020 alone. Yet we could have put a decent national and global pandemic preparedness system in place for just $10 billion a year.

I’ll say that again: $2 trillion in losses, compared with what would have been a $10 billion annual investment. Hopefully in the Q&A, we’ll get a chance to discuss why the world didn’t prepare adequately.

So, I’m going to talk for around 30 minutes, then I’ll answer questions. I’ll address 4 topics. First, I’ll discuss what the “new normal” looks like and what it will take to end the pandemic. Second, in this new normal, I’ll discuss how can we live as safely as possible. Third, as you may know, I’ve written several columns in TIME magazine, the British Medical Journal, and other venues on the astonishingly poor U.S. response to COVID-19 and I want to explain how the U.S. became the epicenter of the global epidemic. Finally, I’ll touch on some of the longer-range policy questions surrounding the new coronavirus, like protecting the vulnerable and protesting in this pandemic era.

The new normal

So where are we today?

The number of new daily cases is flattening or falling in some countries. In many nations, including here in the U.S., lockdowns have been lifted. All this may give the impression that the pandemic is over.

In fact, the number of new daily cases worldwide hit a new high just a few days ago—136, 405 new cases on Sunday June 7. Most of those new cases were in the Americas, South Asia, and South Africa, the new epicenters of the pandemic.  Clearly the pandemic is still raging.

This is a new, highly contagious virus, and most people remain susceptible to infection.

While we don’t have a perfect crystal ball, I believe there is enough scientific information to be able to say: it is extremely unlikely that the pandemic will end unless we get a vaccine.

The only way that the disease will stop spreading is when the world reaches herd immunity—the world, and not just one country.

Herd immunity is when a high enough percentage of the population—a herd—becomes immune to an infectious disease by having antibodies against that infection.

For COVID-19, that percentage is probably around 70%.

Now there are two routes to herd immunity. The first is if a large number of people become infected with COVID-19, recover, and have antibodies against becoming infected again. But there are at least two reasons why herd immunity is unlikely to be reached in this way.

  • First, we still don’t know whether people who’ve recovered have full, lasting immunity.
  • Second, the percentage of people who’ve been infected and recovered is much too low to achieve herd immunity. The surveys that have been done so far make this very clear. Nationwide surveys in Spain and France for example, which were very hard hit by COVID-19, suggest that only around 5% of the population have antibodies.

So, the vast majority of the world is still susceptible to becoming infected.

Which brings us to the second route to herd immunity: developing COVID-19 vaccines.

Efforts to develop COVID-19 vaccines have been on the fastest trajectory in history, though I still believe it could take years before we see mass global deployment of a vaccine. After all, the fastest vaccine developed in history tool 4 years, the mumps vaccine.  Still, we are seeing rapid progress. On January 12, 2020, China shared the genetic code of SARS-CoV-2, the virus that causes COVID-19, and just 63 days later, the first human trial began in Seattle, USA on March 16, 2020. That’s fast. Two days later a trial in China kicked off.

Today there are 133 vaccine candidates being tested, including 10 in human trials. It’s fantastic that we have so many candidates because there is a very low rate of success when it comes to vaccine development. Very few of these 133 candidates will make it through the development pipeline all the way through to launch—most will fail at any earlier stage. But there are decent odds that a handful will make it.

But even if we can develop a safe, effective vaccine by perhaps 2021 or 2022, as many scientists think may be possible, there’s no guarantee right now that it will actually reach everyone who needs it.  And by that, I mean everyone worldwide.

There’s a serious risk that rich countries will monopolize the vaccine, leaving poor countries behind. Such behavior by rich countries would not only be immoral but disastrous to their own health and economic recovery too, and the selfishness would upend our global efforts to shut down the pandemic once and for all. If there’s still viral transmission anywhere on the planet, there’s a risk that this could lead to viral transmission everywhere again. So just protecting your own country won’t be enough.

We’ve already seen rich nations, like the U.S., try and do deals with vaccine manufacturers to ensure that Americans get the vaccine first. This kind of vaccine arms race won’t cut it.

We need to put a plan in place now to make sure that everyone worldwide who needs the vaccine will be able to receive it, free at the point of care.

What would the basics of a plan look like?  Our research team has argued that there must be 3 key components.

  • First, is sharing of knowledge. Companies that develop safe, effective vaccines must share the know-how with manufacturers worldwide. No sole manufacturer on earth will be able to single-handedly make enough vaccine. The manufacturing of any successful vaccine will need to be globalized as quickly as possible. Most of the funding for COVID-19 vaccine development is coming from us, as taxpayers. It’s only fair, I believe, that in return for receiving this public funding, vaccine developers should share the patent—placing it in an open access patent pool—and should support the necessary technology transfer arrangements to manufacturers worldwide. COVID-19 vaccines should be a global public good.
  • Second, the world needs to club together and collectively buy vaccines for distribution worldwide.  All nations should pay into this buying pool according to their means—the rich would pay the most, the poorest would pay nothing. The idea is to buy billions of doses for the world.
  • Third, this global supply needs to be distributed in ways that maximize public health impact and that are equitable and fair. It would make sense, for example, within a country for the initial doses to go first to health workers and the medically vulnerable before giving doses to the wider population. And countries that have an uncontrolled epidemic will clearly need doses more urgently.

But we also need to be honest with people: getting a vaccine that we know is effective and safe will take time. If we try and hurry this process and roll out an unsafe vaccine that causes harm, this will threaten our efforts to end the pandemic.

In this sense, I think it is deeply unfortunate that the Trump administration is calling the U.S. vaccine effort “Operation Warp Speed.”

The anti-vaccination movement commonly claims that vaccines are rushed to market without proper testing, and anti-vaxxers are already pushing the idea that the COVID-19 vaccine will be dangerous. I think the name Operation Warp Speed gives fodder to the anti-vaccination movement. We need to build the public’s trust right now, to ensure that at least 70% of people agree to be vaccinated.

Living as safely as possible

Predictions are hard, but I suspect we’re a few years away from having herd immunity. Which means that the new normal is about living as safely as possible with the virus.

Countries that successfully controlled their epidemics are showing us the way. After “crunching the curve,” if you have an excellent test and trace system in place, and you are doing surveys to look out for possible hot spots of infection, then you can gradually reopen your economy.

Again, the key is being able to put out any small fires quickly. And recognizing who is the most vulnerable.

South Korea is rightly hailed as one of the countries that did the best in controlling COVID-19.

They quickly developed a free test, rolled it out nationwide including via drive-through testing centers, and they used a world class contact tracing system with GPS to identify and isolate cases and quarantine those exposed. Their leaders communicated brilliantly with the public, and brought citizens along with them.

In early May, they started loosening social distancing because there were only a handful of new cases per day. But then they had a cluster of new cases linked to nightclubs in the Itaewon district of Seoul. They were able to put out this fire by closing bars and nightclubs again and doing aggressive contact tracing.  They conducted 65,000 tests. New daily cases fell again to the single digits. This is what the new normal looks like in a country that has been a success story: cycles of easing of restrictions, then tightening again to put out mini-fires.

The key is to get the virus under control first, which means at a bare minimum seeing new daily cases falling for at least 14 days, putting mass testing and contact tracing in place, and readying the health system for any future resurgences.  Then you can gradually reopen, with people still socially distancing and wearing masks, and then tightly monitor what happens using local data to pinpoint where any new flare-ups might be happening.

One helpful metric to monitor progress is R0, the basic reproductive number. It’s the number of new infections that stem from a single case. If a person has an infection and passes it to two people the R0 is 2.

Here can you see that the R0 for COVID-19 is 2-3. On average, each person infected with the new coronavirus will, on average, infect 2-3 people in a susceptible population.  That’s higher than seasonal flu but lower than SARS or measles.

For COVID-19, when the R0 has fallen to below 1, it suggests that the number of cases is shrinking, which gives you more confidence in carefully opening up the economy. An R0 above 1 indicates that the number of cases is growing, so you’d need to reinstate control measures.

An even more valuable metric is Rt, the effective reproduction number. R0 tells you a disease’s potential.  But once you put in place control measures—stay-at-home orders, for example—the actual or “effective” transmission rate, Rt, can be lowered. So Rt is the virus’s actual transmission rate at a given time, t.

Denmark is a good example of a country that used Rt in monitoring what happened after schools re-opened. Its lockdown, including school closures, was on March 12. These measures crunched the curve and the Rt fell to 0.7. When schools re-opened on April 15, there was some nervousness when the R0 crept up to around 1, but then it fell back again and so schools have stayed open.

The key is that Denmark was watching carefully, and had a system in place to respond if the Rt went over 1 again. Again, that’s what a “new normal” looks like in a nation that’s been effective in tackling COVD-19.

I’m addressing this issue of safety primarily from big picture here, in terms of what public health officials need to be doing to monitor cases and spot flare-ups.  But there’s also plenty of specific, science-based guidance on how to reopen schools in as safe a way as possible. In Denmark, for example, children are kept in small groups or “cocoons” with no mixing between them. These groups arrive at and leave school at separate times, they eat their lunch separately, and are taught by just one teacher.  All these steps minimize the risk of transmission.

The U.S response

So that’s where we are. But I think it’s also important to consider where we have been. I want to counter the perception that some people might have that the pandemic was inevitably going to hit the U.S. hard and there’s nothing we could have done about it. That’s false. There’s a reason that the U.S. has the largest number of cases and deaths in the world. This catastrophe was preventable, as the experience of other countries shows.

It’s now almost 5 months since the World Health Organization, the WHO, told every country worldwide to get ready for transmission of the new coronavirus. To be precise it was January 23rd when the WHO said this to all nations:

“Be prepared for containment, including active surveillance, early detection, isolation and case management, contact tracing and prevention of onward spread.”

 What we see looking back is that countries followed highly divergent paths.

Clearly, some countries followed this clear advice from the WHO. Their leaders adopted a science-based approach, communicated the risks to their citizens, and got ahead of the virus. They were able to keep their national death rate low through mass testing; isolation of infected people; tracing, testing, and quarantining their contacts; issuing stay-at-home orders; advising people to wear masks; and getting their health care facilities ready to handle any surge in cases, including giving high quality personal protective equipment to health workers.

So, if you look at a world map showing the death rate, that is, the number of deaths per million of the population, you see a patchwork pattern—some countries did well to keep their death rates very low. In Europe, for example: Austria, Germany, and Greece. In the East Asia and Pacific region: Australia, China, Hong Kong, Mongolia, New Zealand, Singapore, South Korea, Taiwan, and Thailand.

Vietnam, with a population of 96 million, has suffered no reported deaths at all. None.

Countries that acted early and effectively on the available information were clearly able to avoid the worst of the pandemic. Deaths were not inevitable.

Those that did not act early, like the US, Brazil, Russia, and the UK, now have the highest numbers of cases in the world. They have uncontrolled epidemics.  If you look at these four countries, you may conclude that the men who lead them share a particular leadership style, they share a particular view of international cooperation, and they share similar attitudes towards science.

I remain deeply worried about the U.S. because we still don’t have a nationally coordinated, robust, aggressive response to COVID-19. We are now the epicenter of the pandemic. We have almost 30% of the world’s cases, but only 4% of the world’s population. In 20 states, new daily cases and are rising. In at least 8 states, hospitalizations are rising. We haven’t even ended our first wave.

Our death rate is over 100 times higher than China’s. Let that sink in: The death rate from COVID-19 in the U.S. is 100 times greater than it is in China, where the virus first emerged in humans and where the Trump Administration claims the blame should lie for letting the U.S. epidemic get out of hand.

How did we get here? With my colleague Gregg Gonsalves, an activist and public health researcher at Yale, I recently wrote an editorial in the BMJ titled Donald Trump: A Political Determinant of COVID-19. A very subtle title.

It was incredibly depressing writing this piece. We went back to document every mis-step that the Trump administration made that led to the current U.S. catastrophe. While countries like South Korea heeded the advice of the WHO and listened to scientists, Trump failed to act. He downplayed the threat, falsely reassured the public, and denigrated science.  He touted bizarre ideas like injecting household disinfectants to treat COVID-19.  He refused to wear a mask. He urged his supporters to “liberate the states” from their state-at home orders, and they willingly followed his advice, marching with guns but without masks to their state capitols to demand they be able to get haircuts and go to the beach.

The federal government should have been getting ready: putting mass testing and contact tracing in place, producing personal protective equipment for essential workers, setting up clear chains of command between the federal and state governments. It did none of these things. The Trump administration dithered on social distancing.

So, for at least 6 weeks, from late January to mid-March, the virus was given a free pass to spread nationwide.  This was the worst public health failure in a century and I think any other president, Republican or Democrat, would have done better.

Although the situation has improved, there is still little sign that the federal government is mounting the kind of urgent, nationwide, coordinated approach that is needed to reverse current trends.

The White House coronavirus testing czar, Admiral Brett Giroir, is standing down, and there are no plans to replace him, even though the U.S. is woefully short of the number of daily tests that are needed to safely end social distancing.

While we are now conducting almost 500,000 tests daily, Harvard researchers concluded that somewhere in the range of 1-10 million daily tests are needed.

Similarly, there is nowhere nearly enough contact tracing in place to keep the U.S. epidemic under control. If we assume that five contact tracers are needed for every daily new case (a conservative estimate), only eight states have sufficient tracers.

And we have a patchwork of varying state policies and often-contradictory messaging about safety measures, including face masks and social distancing, which may well amplify the harms to human health and the economy resulting from the much-delayed initial response.

Some longer-range policy questions

So where do we go from here?

I think the most important thing to say is: we desperately need to protect those who are most vulnerable.

The virus has disproportionately ravaged Black and Latinx communities in the U.S. Research has clearly shown the many reasons why—structural racism; the legacy of slavery; the pervasive injustice of red-lining, the grotesque practice of outlining neighborhoods with sizable Black populations in red ink on maps as a warning to mortgage lenders; worse access to health care; worse living conditions; lack of health insurance; and, of course, much greater exposure to the virus.

I’m a privileged white professor who has had the luxury of working from home. But who has been delivering the mail, caring for elderly people in nursing homes, driving the buses, working in meatpacking or Amazon warehouses, and caring for the sick? Disproportionately it’s been Black and Latinx Americans. And too often they have not been given the personal protective equipment they need, like N95 masks and face visors.

We’ve also seen horrific outbreaks in nursing homes, prisons, and jails. Those who are in ICE or juvenile detention centers or are on the streets are all at high risk.  We’ve seen awful outbreaks in Native American communities.

We need to protect all vulnerable populations—not just because it’s the right thing to do, the just thing to do, the ethical thing to do, but it makes us all safer. Again, an outbreak anywhere can become an outbreak everywhere.  Look at Singapore, another country that did brilliantly at controlling its epidemic. But its initial mass testing forgot a key group: its 200,000 migrant workers who mostly live in packed dorms, 10-20 people per room. The result? An outbreak among these workers.

That’s why prison health is public health. Homeless health is public health. Migrant health is public health.

I think the most important word right now is solidarity. To keep the pandemic at bay while we wait for a vaccine, we all need to do our part. I want to talk about solidarity as individuals and solidarity as a community.

In a pandemic situation, the decisions we make as individuals do not just affect us, but have direct consequences on our communities, especially the most vulnerable among us. You may think it’s OK to just take a personal risk by not wearing a mask in public, but when you do that, you’re putting others at risk, including vulnerable people.

So, it’s been concerning to see how sound, evidence-based public health advice has been politicized.  When President Trump refuses to wear a mask, he’s sending a damaging message to his followers.  He’s implying that protecting yourself is a sign of weakness. Whether we are Republicans, Democrats, or Independents, we should be heeding safety messages, like the 3 Ws: wear a mask in public, wash your hands, wait 2 meters away.

As a community, we’ll need a new kind of social movement, what Greg Gonsalves and his colleague Amy Kapczynski [KAPCHINSKI] have called a “new politics of care.” This movement should be about solidarity in pushing local, state, and federal leaders to protect the most vulnerable; to ensure that Black, Latinx, and Native communities get access right now to free testing and can be supported if they need to isolate or quarantine, such as with rent and food assistance; to provide universal health coverage and universal sick pay; and to ensure that everyone can get the vaccine when it becomes available.

I wanted to close with one final reflection on the “new normal.” And that’s the new normal of protests against racial injustices.

When the pandemic first hit, I don’t think anyone would have predicted that we’d also see some of the largest worldwide mass protests in history—the protests in support of Black Lives Matter. Black Americans have died of COVID-19 at three times the rate of white Americans, yet testing centers have favored white communities. Black Americans die of common diseases like heart disease, diabetes, cancers, and asthma at much higher rates than white Americans. On top of this festering wound of racial disparity in health, the police and armed vigilantes have been assassinating Black Americans day after day after day. 1 in 1000 Black men and boys in the US will be killed by the police. This week alone, two Black trans women were found dead, presumably murdered, garnering no media coverage.

In the inspirational protests against these injustices, protests that I don’t see going away any time soon, I see demands for the new kind of “politics of care” that I was talking about. Now that gives me hope.

At the same time, we can’t pretend that from the point of view of the pandemic, protests are risk-free. Of course, there’s a risk of viral transmission. But the messages are the same: reduce the risk to yourself and others. For example, wear a mask, use noisemakers instead of yelling, stay distant or in your own cocoon of people, and wash your hands.  The police need to stop putting people at risk—they must stop using tear gas and pepper spray, they must stop kettling crowds, and they must stop forcing people into prolonged close contact by jailing them. They need to start handing out masks rather than shooting rubber bullets.

The wonderful Elie Mystal, justice correspondent for The Nation, said it so well:

Get your “hypocrisy” takes out of my face. Protesters should wear masks. The police should stop beating the masks off them. And MLK did not die so white people could get a tan at the beach during a pandemic.

People are taking to the streets to protest a different kind of pandemic that has lasted 400 years. So safer protesting will also, I hope, be part of the new normal.

Thanks for listening so far. I want to thank my team at the Center for Policy Impact in Global Health and also Michael Penn, Communications Director at the Duke Global Health Institute, for all their help and support in the work we’ve done on COVID-19. So now it’s time to answer a few questions.

About the Author:

Gavin Yamey (tweets @GYamey) is Director of the Center for Policy Impact in Global Health, Duke Global Health Institute.