What America wants is a way out. COVID-19 has killed 175,000 people in the United States, more than the number of Americans who died in every military conflict since the Korean War—combined. Thirty million are out of work, with many at risk of losing their homes. Millions of students can’t attend school while many who do face risks and quarantine.
After six months of the worst public health crisis in a century, health experts across the country say the U.S. is perfectly capable of mounting a comeback if it embraces reality and taps its potential for ingenuity.
First, we must knuckle down and accomplish the obvious: Continue social distancing and strive for universal mask use. Close high-risk spaces, such as churches, bars, and casinos. Spend time outdoors. Limit crowds. Wash our hands. Build up contact tracing. Do that, and the U.S. could go from 40,000 new infections a day to "the number of new cases you could count on your fingers and toes," Andy Slavitt, President Barack Obama’s former acting administrator of the Centers for Medicare and Medicaid Services, tells National Geographic.
“There’s no big secret—it’s not highly mysterious,” Slavitt says. “You can break the back of this thing if you do that." With concerted effort, we could get there in six weeks, he adds.
But given national failures thus far, many experts are also pushing for a new way forward based on innovation—specifically, cheaper, faster tests that millions could take at home every day. We’re still just beginning that process, as such rapid tests exist but either lack government approval or need medical oversight. The infrastructure for mass deployment exists, too, if the government or a company chooses to use it.
As a testament to the ease of production and the bureaucratic restrictions, Abbott Laboratories has newly announced plans to produce 50 million rapid tests per month by October. The company says the test costs $5 and takes 15 minutes. But it still requires a nasal swab and can only be administered by a health-care professional such as a pharmacist or a school nurse. The person in question must also have symptoms and a prescription. You can't just take the new test on your own.
For now, Americans must accept hard truths. We must keep modifying our behavior—all of us—to stop COVID-19 fatalities. The virus will keep disrupting normal life until a vaccine is developed and distributed in mass quantities, or unless we take a completely new approach to testing. That might not happen for months, or a year, perhaps longer. Just how significantly and how long our routines are upended depends in good measure on how much of the basics we follow right now. (If COVID-19 vaccines become mandatory, here’s how it might work.)
“As long as you have any member of society, any demographic group, who's not seriously trying to get to the end game of suppressing this, it will continue to smolder and smolder and smolder,” Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, told Harvard University’s T.H. Chan School of Public Health during a webcast on August 5.
That, of course, has been the case all along.
Stepping past square one
After a spring spent driving cases down, the U.S. squandered its summer. We reopened the economy, and the novel coronavirus SARS-CoV-2 resurged, particularly across the South and West, which had largely been spared early on. Mississippi just last week found virus cases in schools in 71 of 82 counties, and multiple universities reversed decisions to hold in-person classes, some after outbreaks emerged on campus.
“None of this is surprising,” says Jeremy Konyndyk, a health-care policy fellow at the Center for Global Development. “All of it was predicted. That’s the infuriating thing. It’s not like, Gosh, we did things right, and they didn’t work out.”
No shortage of critiques have outlined our initial failings. Supply chains did not secure necessary medical gear, including the personal protective equipment badly needed among health-care workers. States emerged too aggressively from lockdowns. Tests took a week or more to deliver results, making them too slow to effectively trace who else an outbreak may have hit. Political leaders frequently doled out contradictory and confusing guidance.
And they still are. Just this week, the Centers for Disease Control and Prevention, reportedly under pressure from the White House, issued new guidance: people who fear they’ve been exposed to the coronavirus but remain asymptomatic need not get tested. Outside health officials have been united in their alarm.
“We should be doing more testing, not less,” says Janet Baseman, an associate dean at the University of Washington’s School of Public Health.
Her colleague, vice dean Jared Baeten agrees. “This change makes no sense…Tracking and responding absolutely requires testing exposed persons—so if they have infection they can be headed off from spreading it. We need more testing, not less—period.”
In fact, while the country’s politicians are fighting and divided, health-care leaders remain remarkably consistent on what needs to be done. In a dozen interviews with nongovernmental experts; in recent presentations by Fauci; in a new report from Johns Hopkins University; in social media posts from ex-government officials, from Obama’s CDC director to President Donald Trump’s former head of the U.S. Food and Drug Administration—the message varies little if at all.
The first steps are the most crucial, but ostensibly have been the most difficult: wearing masks and staying apart.
“We’re aiming for a situation where, with appropriate social distancing and mask-wearing, we’re able to restart critical components of the economy without seeing surges,” says Hilary Godwin, dean of the University of Washington School of Public Health. “What we learned is some types of activities may not be possible during this extended period of time—not just until we have a vaccine, but until we have [widespread] immunity.”
Large gatherings, particularly indoors, are among the activities that will have to wait. Where alcohol or shouting or singing is involved, “those are recipes for superspreading events,” Godwin says. (Here's what 'airborne coronavirus' means, and how to protect yourself.)
Johns Hopkins’ Center for Health Security recently issued a 10-point plan to reboot America’s virus response. Its first item declared masks an essential civic responsibility—one that should be mandated where necessary. Evidence makes clear that face coverings dramatically reduce the odds of transmission. But “not all people are convinced of [mask] utility and importance,” says Caitlin Rivers, assistant professor of epidemiology at Johns Hopkins and lead author of the report.
The reason isn’t a mystery. “The average person is not following, eating, sleeping, and breathing this,” says Konyndyk. Rather than following all the minutiae from the latest science, “they look to cues from people they trust. And there is a whole segment of the right-wing ecosystem that is echoing skepticism about masks.”
While three-quarters of Americans say they support mask use, health-care experts have struggled to reach the naysayers. “I lived through 9/11 and invading Iraq and tying the yellow ribbon around the tree and coming together for our country,” says Colleen Kraft, associate chief medical officer at Emory Hospital in Atlanta. “I was never prepared for the public to be resistant to health interventions.”
Much of the skepticism starts at the top, with a voice whose power is hard to overstate. After President Trump spent months ridiculing face coverings and repeatedly refusing to wear a mask himself, many conservative state officials followed suit. By midsummer, though, even some Trump supporters were shifting in the face of tragedy. “I have ZERO incentive to spread fear about this virus,” Republican Mississippi governor Tate Reeves tweeted in July as he begged constituents to mask up. “It loses us money, makes my job harder, and puts me in a terrible spot. It’s never popular to ask people to sacrifice. There is only one reason for me to share these graphic warnings: trying to prevent mass death.”
Health experts knew altering Trump’s stance could spark a sea change. In July, even after many businesses began expecting customers to wear face coverings, Southern grocery chain Winn Dixie had announced it would not. But just hours after Trump tweeted a picture of himself in a black mask and called wearing them “patriotic,” Winn Dixie reversed course, announcing its own requirement. (A spokesman told the Washington Post the company was merely listening to customers—not Trump.)
Trump’s continued unwillingness to don a mask since then signaled to many that he did so only grudgingly. On August 12, shortly after a call with Trump, a county sheriff in central Florida actually prohibited his deputies from wearing masks—and ordered the public to remove them in department office buildings.
Progress, slowly, is being made. While 34 states now have mask mandates, two of the three states with the summer’s highest new cases per capita—Florida and Georgia—still do not.
Bending the curve with masks and distance
Masks and social distancing are so important because they act as vital relief valves, taking pressure off hospitals and testing centers.
At the pandemic’s outset, hospitals became beset with supply issues, facing shortages of everything from beds and ventilators to paper gowns and IV poles. Some have since retooled their practices, turning, for example, to washable gowns and reusable masks. And though competition for personal protective equipment remains high, hospitals are better prepared now to handle surges.
Test sites, though, are another matter. Standard COVID-19 tests can require up to 30 components—from tubes and stoppers to reagents and instruments in the lab. Nasal swabs, for example, largely came from one supplier in Italy at a time when that country was roiling with outbreaks. The White House encouraged labs to set up faster alternatives, but the lack of a national strategy still left states competing for supplies.
Shutdowns bought time, but with reopening, cases exploded anew, putting renewed pressure on testing facilities. “When you have that type of surge, [states and labs] need more stuff,” says supply chain expert Nicolette Louissaint, executive director of Healthcare Ready.
When labs slow down, results get delayed, and the holdups snowball even in states where case counts are low. Suddenly, “it’s hard to dig out from the backlog,” says Eric Blank, chief program officer for the Association of Public Health Laboratories.
If mask mandates and distancing can drive down cases, that cuts demand for test supplies, expediting results. That, in turn, makes it possible to track who else infected people might have exposed. “There’s not enough contact tracing in anybody’s wildest dreams given what we’re facing now,” Blank says.
And a nimble testing response can be crucial to tamping down outbreaks. Just ask Erik Johnson and Geoffrey Gottlieb.
On a weekend in late June, Johnson, the 21-year-old president of the University of Washington’s interfraternity council, took a call while driving. Several fraternity residents felt sick. At the same time, Gottlieb, an infectious disease physician who oversees campus outbreaks, heard from workers at a test facility that carloads of students had shown up seeking COVID-19 tests.
In dorms or group houses with shared bedrooms, bathrooms, and communal kitchens, COVID-19 can be devastating. But the region had health teams in place, given Washington State was the region where the U.S. pandemic started. By Monday, a pop-up test site appeared near the campus’s Greek Row, and more than a thousand students were tested in four days. Results often came back in just 12 hours. Students with the virus were isolated in frat houses. Testing and tracing continued for weeks. By August, 154 students, many of whom had been renting space in fraternity houses for the summer, had tested positive, but the number of new cases had started trailing off.
“I wouldn’t say it’s over, but we’ve knocked it down significantly,” Gottlieb says.
The incident shook up many students. Asked what he’d tell young people around the country, Johnson didn’t hesitate: “Don’t be a vector for transmission.”
The case for rapid tests
No matter how hard health advice gets pushed, some people may choose to ignore it. Just last week, across the state from Johnson, fraternity parties at rival Washington State University helped drive another spike in cases among young adults. Overcoming resistance to wearing masks and social distancing will take national resolve. But Harvard University epidemiologist Michael Mina thinks even the most skeptical among us would be more willing to embrace a simple at-home test as a way of keeping the virus in check, especially if it could tell them if they’re positive in just 15 minutes.
“Wearing a mask for some people is onerous,” he says. “But when you’re sitting at home in your underwear brushing your teeth, people drop their issues.”
Several companies already make such tests, but regulations set by the FDA are keeping them out of your medicine cabinet. Under FDA guidance for emergency authorization, the standard diagnostic tests, which involve polymerase chain reaction, or PCR, aim to be 95 percent accurate when it comes to identifying SARS-CoV-2 and must be conducted in a lab. At-home tests, so far, cannot be approved through these channels and also sacrifice some accuracy for the sake of being more convenient. But for Mina and others, an at-home test could be one thousand times less sensitive than conventional PCR and still be a huge advantage to controlling COVID-19.
These rapid COVID-19 tests could serve a purpose similar to at-home pregnancy tests—as an early warning.
Such tests could aid the return to normal life, even in coronavirus hot spots. Imagine being able to easily check if you have COVID-19 each morning or every other day. If done consistently, many people would test positive even before they actually became contagious, which would help interrupt community transmission. That could be helpful when up to 40 percent of coronavirus carriers never show symptoms, and unlike PCR tests, these at-home strips could be made and distributed cheaply, at a price of between $1 to $5 each.
Mina says the FDA is not close to approving these tests, but he adds, “I think we’re gaining ground.”
For such an idea to work, the government or a private company would likely need to help foot the bill, because mass production would cost billions of dollars but may not be lucrative in terms of profits. Some health experts propose employing the Defense Production Act, which compels—and compensates—companies to make items during a crisis. (The act has been triggered already in 2020, for emergency production of N95 masks and ventilators.) After FDA approval, Mina says production could begin immediately, and it would take only six weeks or so to ramp up to sufficient levels.
Many health experts applaud the concept. Jared Baeten, vice dean of public health at the University of Washington, is a fan of masks and avoiding crowds, but “if we could implement rapid easy testing that is frequent and everywhere, that would be a total game-changer.”
With or without such an innovation, Baeten says, we can do better. We just need to really want to. The fact that infections have already risen, fallen, resurged, and then tapered off is an indication that people are willing to change behavior, he says. For now, we have to “keep nudging each other.”