Humans can beat COVID-19 because viruses are simplistic. They can’t move anywhere without assistance. Leave them outside in the open air for very long, and many will disintegrate. All they know is how to multiply. The problem, of course, is that the coronavirus is adept at this singular task, and as countries such as the United States have tried to loosen lockdowns and other restrictions, they’ve been jarred by the pandemic’s latest swells.
After months of plateauing at 20,000 to 30,000 new cases per day nationwide, U.S. numbers are rising sharply in 30 states, and overrun medical centers are scrambling to free up beds. In Houston, Texas, where daily cases have surged from 300 to 1,300 in two weeks, health-care workers are moving adult patients to children’s hospitals in a desperate bid to keep up with the surges. Other states are facing similar challenges.
“We are quickly reaching that critical level of capacity in ICU beds and ventilators in hospitals in the worst-hit areas,” says Purnima Madhivanan, an infectious disease epidemiologist and associate professor at the University of Arizona in Tucson. “Right now, I think the only thing we can think about is at least starting with harm reduction.”
Harm reduction refers to public health tools and practices—such as needle exchange programs or safe sex with condoms—meant to lessen danger rather than expecting universal compliance to rigid guidance. This approach acknowledges that risk levels vary by person and setting, and solutions should be tailored for those individual scenarios.
With the coronavirus, harm reduction techniques include convincing people to wear masks for the riskiest scenarios, such as crowded spaces, but relaxing those guidelines in places where people can stay at safe distances, such as parks. These approaches can go beyond decisions made by individuals, and the principles have already guided some nations and states, including New Zealand, South Korea, and New York State, toward successfully beating back the coronavirus.
“We were stuck, maybe six weeks ago, in this false binary between staying at home indefinitely and going back to business as usual,” says Julia Marcus, an epidemiologist and professor at Harvard Medical School in Boston, Massachusetts who has pushed for expanding harm reduction during this crisis. “Risk isn't binary, and we can't expect people to stay home forever, to abstain from social contact forever.”
More than half a dozen epidemiologists, virologists, and psychologists contacted by National Geographic agree, and said that struggling governments can win their COVID-19 wars—and perhaps avoid further lockdowns—through more unified planning and messaging, steeped with harm reduction. They say much of America’s inabilities to waylay COVID-19 stem from humans ignoring our essential advantages over the virus: communication, cooperation, and compromise.
“The countries that have succeeded have been the ones that have had real political and public will unite,” says Jeffrey Shaman, an epidemiologist at Columbia University's Mailman School of Public Health, whose lab is modeling hospital burden during the crisis. None of these experts believe the COVID-19 war is lost, but government leaders, news media, scientists, and the general public need to shift their mindsets and messaging, because if the virus is victorious, the devastation will be several times worse than what we’re seeing now.
On Thursday, the U.S. Centers for Disease Control and Prevention said it believed 5 to 8 percent of the U.S. population—roughly 26 million people—has already been infected with the coronavirus. Though CDC chief Robert Redfield didn’t provide data, his claim mirrors what similar surveys have revealed: Outside of New York City, the hardest-hit epicenter on the planet, total infections are still relatively low. Even assuming that every infection mentioned by Redfield creates lasting immunity—which isn’t necessarily the case—exposure to the virus would need to expand tenfold in most parts of the U.S. to establish herd immunity. (Read why the U.K. backed off on achieving herd immunity through infection alone.)
In other words, the virus still has abundant room to keep spreading. But harm reduction can help stop that from happening. Here’s how.
Since the beginning of its outbreak, the U.S. has relied on two options: mitigation via draconian stay-at-home orders, and containment of the virus’s spread via testing, self-isolation, and contact tracing. This dual strategy is a bit like using either a chainsaw or a scalpel to build Ikea furniture. It isn’t flexible enough to adapt to the ever-surprising coronavirus, and it’s easily derailed by misinformation.
For one, governors and news outlets have repeatedly cited adults under 50 as the main cause of the newest surges in COVID-19 cases. But young adults have made up about 25 percent of COVID-19 hospitalizations in U.S. surveys every week since early March, suggesting their infection rates haven’t ballooned tremendously. In Texas, one of the fastest growing hot spots, the share of infections among young adults was 50 percent before stay-at-home orders began lifting on May 1, and it has only grown by 3 percentage points since then. Likewise in Maricopa County, home to Phoenix and Arizona’s COVID-19 epicenter, the share of cases among young adults has increased only 15 percent.
“When you look at all of the pieces, it kind of makes sense that that's the age group that will have the highest rates,” Madhivanan says, given the U.S. workforce skews younger. “Infection rates at the beginning of any outbreak are always concentrated in younger, more active age groups with higher social contact rates...They're the essential workers. They are the working class...They are the ones required to be physically at their jobs.”
Yet simultaneously, public messaging tends to tell younger groups that they’ll be spared from COVID-19 symptoms and its worst outcomes, which isn’t quite right. No rigorous studies support the claim that younger people are more likely to be asymptomatic. On June 25, the CDC expanded its list of people at risk of severe COVID-19 to include all adults—rather than just those over 65—with the caveat that risk increases with age. And while deaths are more common among the elderly, clinical reports from hard-hit places such as New York City and China show people under age 50 often suffer serious consequences from COVID-19 and remain hospitalized for as long as members of older generations.
Young people have always been a part of this crisis, but conveying their risks and roles in this pandemic is difficult, which has bred confusion.
“What they need to appreciate is that they are part of a process of the dynamics of an outbreak,” Anthony Fauci, director of the U.S. National Institute of Allergy and Infectious Diseases, said before the U.S. House Energy and Commerce Committee on June 23 when asked about how to get younger adults to comply. “Getting back to normality is going to be a gradual step-by-step process and not throwing caution to the wind.”
The problem is getting the message just right, because mixed signals can harm people’s abilities to adhere to public health advice. Research shows that conflicting messages can cause mental hardship, and in the absence of credible and consistent information, people often hear what they want to hear and become prone to seeking misinformation.
“When there's an absence of consistent messaging from authorities, many rumors and conspiracy theories can fill the void, and that makes it very difficult for people to figure out what it is that they should do,” says Roxane Cohen Silver, a UC Irvine professor of psychological science.
Her lab has shown how relentless news cycles that focus too heavily on the negatives, such as those around the 2014 Ebola crisis or mass shootings, can collectively traumatize the public and even elicit symptoms of post-traumatic stress. Though more research is needed, such signs are emerging with COVID-19, including with “doomscrolling,” the binging of worrisome media posts. Cohen Silver’s team warned in May that both the media and health experts have a role to play in delivering practical advice about the pandemic’s risks without amplifying hysteria and confusion.
“I would encourage people to monitor the amount of time that they're engaged with the media to make sure that they're checking trustworthy authoritative sources,” Cohen Silver says.
30 million tests or bust?
Testing is one arena where a clear message could help, but it has taken time to find the right path for the U.S. Early flaws with the CDC’s COVID-19 kit caused the country to fall behind on diagnosing new cases, the equivalent of trying to end a fire without water. This spring, one report from well-regarded researchers assembled by the Rockefeller Foundation called for “a dramatic expansion” from one million tests per week to three million tests per week over the course of two months. Combine this testing of roughly one percent of the U.S. population with “high-precision” contact tracing, and the foundation predicted that parts of the economy could restart.
However, that approach would require 70 percent of contacts complying with quarantine, says Crystal Watson, a senior scholar at the Johns Hopkins Center for Health Security who wasn’t part of the report. If the epidemic grows too big, contact tracing can’t be successful, and without adequate contact tracing, the Rockefeller report says the nation would need to reach 30 million tests per week to control COVID-19 without a vaccine. The report dubbed it the “1-3-30 plan.”
According to the COVID Tracking Project, the U.S. crossed the three million mark in early June, after hovering near the tally since mid-May. And yet, cases are surging again. What went wrong?
“Yeah, we have had far too much testing, testing, testing mantra without really understanding what that accomplishes,” says Michael Osterholm, director of the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota and a coauthor of the 1-3-30 plan. “We need to put less emphasis on the number of tests that are conducted in a given region, and ask ourselves what tests are needed.”
Here’s where harm reduction can come into play again. Even the best diagnostic tests run the risk of yielding a false positive result, so if a city, state, or nation tests too many random people in the general public, you might end up quarantining the wrong people. Rather than test blindly, the highest priorities should be seeking out individuals who have symptoms of possible COVID-19 disease as quickly as possible and processing their tests faster, so the right cases can enter quarantine sooner. That’s how places like New York, South Korea, and the European Union beat back their outbreaks.
“I am deeply worried about approaches that assume we are going to test people who either have no symptoms or no epidemiologic criteria for testing,” says Jennifer Nuzzo, an epidemiologist who leads the Johns Hopkins Testing Insights Initiative at the Center for Health Security.
Nuzzo wants more than three million tests per week to root out COVID-19 from the most at-risk populations, such as by instituting universal and regular testing at nursing homes, prisons, and jails. But 30 million tests per week would be impractical, she says, because there are only so many labs in the country that can process the samples.
“To me, if we have to do that level of testing, it represents a bit of a failure … because that will mean that we have let the epidemic grow to the point where it's just wildly uncontained,” she says.
The better benchmark for monitoring progress, she says, is test positivity, or what percentage of tests come back positive. The World Health Organization recommends that before places reopen, they need to record a test positivity percentage below 5 percent for at least 14 straight days, as many countries with subsiding outbreaks have done. When places go above this line, it becomes harder to keep COVID-19 from hopping from group to group. Too much positivity can also mean an outbreak is expanding uncontrollably, and because medical centers tend to prioritize patients with the most serious symptoms, more of the milder cases will go unnoticed, worsening the spread.
But rather than follow the World Health Organization’s benchmark, which was decided by an international panel of top experts, the CDC and the White House said that states can start reopening after falling below 20 percent test positivity. “It's outrageously high,” Nuzzo says. Of the 30 states with cases surging right now, 16 have test positivity rates above 5 percent, and others in this unfortunate group are trending upward too.
Trickle-down public health
The world has made huge strides in understanding the coronavirus, but these conclusions take time. Scientists went from being unsure about face masks to fully supporting them in a few months. Their mindsets are also shifting on a “second wave”—a concept originally borrowed from the history of influenza pandemics. From an epidemiological perspective, true waves will dissipate on their own without much human intervention, but the coronavirus is not following that traditional pattern.
“I don't see this as a wave anymore. Waves are outdated. We have peaks and valleys,” says Osterholm, whose center laid out these scenarios in April.
Such observations have yielded evidence-based interventions that can restrict the coronavirus to low levels, buying time for the development of a vaccine or the other remedies needed to wrangle COVID-19. Yet, flaws in messaging are threatening this progress. Few people noticed two weeks ago when the CDC released thorough guidelines on dining out, because the public health agency has largely disappeared from public view. Mask hesitancy has also crept into the public conversation due to political divides.
“The bottom line is it really is about leadership,” says Aileen Marty, a professor at Florida International University who has served as an infectious disease advisor on the local, national, and international levels. All of the experts interviewed for this story agreed on this point, but also said responsibility lands not only at the very top with the White House, but also on Congress and its control of health agency funds and veto overrides, governors and their abilities to coordinate counties and cities, and everyone else down the ladder.
None of the experts believe a second lockdown is inevitable, but the U.S. has returned to the dangerous prospect of overwhelming hospitals, which prevents routine services from going forward. Much of the COVID-19 relief aid expires in July, and our return to enclosed environments where the disease thrives is beckoning as summer creeps toward autumn.
“The reality is the virus doesn't care,” Shaman says. “It's just going to do what it does.”
Editor’s note: This story has been updated to correct the daily new cases for Harris County, Texas.