When Are Things Going to Get Back to Normal?

Well, when WILL things get back to normal?

Lots of folks have recently asked me to weigh in on that.

It's complicated.

It is not going to happen all of the sudden.  Like, say, turning on a light switch just as soon as we get a vaccine or an effective therapeutic.

In fact, we are going to be living with the consequences of Covid-19 for quite some time, while things gradually improve.

But it will get worse before it starts getting better.

That is my prediction, anyway.

My rationale?  

There are a combination of factors - some good and some bad -  that will impact us in our immediate future...  Factors that will produce a very rocky and turbulent period of 12-18 months (maybe more) for us.

First, the Good News
Here are a few of the positive things about our current situation (supporting references are hyperlinked):
  • Medical professionals have recently learned quite a bit about how to treat people with Covid-19 and will discover even better therapeutic practices over the next six months or so.  Death rates have plummeted recently, at least partially as a result of the increasing effectiveness of medical care for Covid patients.  So, if you do get it, your chances of survival have increased significantly.  And they will be even better later in the year.
  • Researchers have already found two therapeutic treatments that seem to be effective in treating very sick patients (remdesivir, an anti-viral and dexamethasone, a steroid).  In addition, there is a huge pipeline of  647 compounds currently in development, with at least 5 of them being anti-virals in the final phases of testing.  We'll surely be benefiting from this work with new drugs in the next 3-6 months.
  • Vaccine trials so far seem to indicate some good news.  There are currently at least 15 different proposed vaccines in clinical trials, followed by another 24 candidates in pre-clinical or research phases.  Sinovac, a Chinese company, has recently shown the presence of neutralizing antibodies in human subjects as part of a phase 2 study of their vaccine candidate - this is key finding that bodes well for an effective vaccine.  Acquired immunity against the virus is not a sure thing yet, but it appears to be an increasingly likely possibility.
  • There is increasing talk in the technical community about T-cell activity towards Covid-19.  The human immune system is extraordinarily complicated (I published an over-simplified description of it in a previous blog post) and T-cells are an important part of it.  If the medical community can figure out how to leverage T-cells more directly against Covid-19 (in addition to antibodies, which are produced by B-cells), it would be a big advance. You can read more about that here if you are interested.  
  • Antibody therapy, using serum drawn from convalescent patients or manufactured artificially by techniques such as monoclonal antibodies, could very well serve as a bridge for folks such as essential workers who know they will be exposed to the virus until a vaccine is available.  This kind of therapy can also hasten the recovery of people infected with the virus.
Now for the Bad News 
There are quite a few things to worry about (supporting references are hyperlinked):
  • Anybody not living under a rock knows that the virus is currently raging in as many as 40 states right now.  Florida, Arizona, Texas and southern California are currently in a particularly dire state as of today (July 13, 2020).  All indicators are up significantly all across the south: Test positivity rates, hospitalization, and death rates.  These states are accumulating a HUGE number of cases.  This represents an enormous reservoir for the virus, and it will take a long time for it to be drawn down. 
  • In the meantime, the virus won't respect state lines, and WILL return to the Northeastern US, including Maryland. It is just a question of time, and there is absolutely nothing that will stop it.  My guess is that as the weather turns colder and people are more restricted to indoors is when it will get back to dangerous levels locally.  Think October or November.  Maybe sooner.
  • We will be wearing masks in indoor locations for the foreseeable future, probably at least 12-18 months.  They are effective in reducing transmission of the virus, but only if a vast majority uses them.  Adoption of universal mask-wearing will happen quicker in some localities than others, but the virus will eventually teach all of us that they must be worn. At least until a good portion of the population gets vaccinated. 
  • The vaccine will come, but it will be late.  It is excessively optimistic to expect a vaccine will be made available in volume before 2021.  My guess for the absolute earliest that you will be able to stroll on down to the local CVS and get a shot will be sometime in the second quarter in 2021.  It will be worth the wait though... demonstrating something is safe and effective for billions of people is not a small undertaking, and will require phase III trials featuring tens of thousands of people for many months.  Not to mention all of the logistics of ramping production to hundreds of millions of Americans. 
  • (Ed. Note: added on 7/14)  The medical community is discovering long term health impacts due to Covid-19, even in asymptomatic patients.  It is clear now that some portion of folks that have cleared the disease will continue to have problems due to blood clots (e.g. strokes, embolisms) as well as long-lasting cardiac damage and cardiovascular problems.  Longer term lung damage (such as scarring) and neurological issues have also been reported.  There is a likely scenario where our health care system continues to be burdened well into the future, treating patients that have recovered from Covid.
  • This is the only 'politically tinged' point I will make, skip it if you'd like to: We (in the US) are at an extreme disadvantage in successfully and quickly dispensing with the virus.  Our federal government has been grossly negligent in managing the virus and not stepping up to all of the essential roles when something is declared a Federal Emergency.   There is no strategy.  The science and medical advice for managing such a pandemic is not only being ignored, it is being actively campaigned against by our president.  Mask-wearing has been turned into a political statement, primarily as a result of (lack of) leadership from the top.  Tens of thousands of people will lose their life as a result.  There is an inevitable comparison to the way that Covid-19 is being managed by countries in Europe vs. the US (with similarly sized populations and land areas) which certainly proves the point (see the figure below).
7 Day Moving Average of New Coronavirus Cases:  March through June 2020

My Crystal Ball
So, I'll go out on a limb and give you my thoughts on a roadmap for our immediate future. (I fully recognize that this post might not age well, these predictions are very difficult to make and invariably will contain some inaccuracies, so take this with a grain of salt.)
  • 3Q 2020 - Covid-19 shuts down most of the southern US.  Some states open schools, but many parents refuse to send their kids due to the prevalence of the virus.  
  • 4Q 2020 - Covid-19 returns to the Northeastern US, including Maryland.  Several Northeastern states go back into a partial lockdown.  Two or three more therapeutic drugs are approved for use in treating Covid-19, perhaps even one prophylactic treatment such as a monthly injection of monoclonal antibodies for front line workers.  Several vaccine candidates are in large scale phase III trials at this point.  Officials will be reluctant to approve until proven safe and effective which could take quite a while.  Emergency use authorization will be granted early (perhaps in December) for inoculation of front line health care workers.
  • 1Q 2021 - Volume production ramp-up could easily take a whole quarter before vaccines start to make it into the channel.  We will also continue our learnings on how the human immune system responds to vaccines (and infections) and whether the resulting immunity is complete (and long lasting).
  • 2Q 2021 - Vaccine widely available.
  • 3Q 2021 - If we are lucky, we can achieve herd immunity early in the third quarter of 2021.  

Consequences
There will be many consequences to our daily lives until herd immunity is achieved (probably through a vaccine):
  • Hospitals will periodically surge with Covid-19 patients, and we will start to regularly see overcapacity conditions as the epidemic progresses.  The result will be a temporary but significant degradation of medical care in various local areas.
  • Large events such as full sports stadiums and big concert venues will be impractical to produce and will be mostly suspended until 'herd immunity'.  Various forms of on-line entertainment (and sports with no live audiences) will take its place in the interim.  
  • Restaurants and bars won't have a viable business model other than takeout and outdoor dining - many will go bankrupt.  
  • Several 'Covid - friendly' businesses (such as Amazon and Netflix) will thrive, but the airline, hospitality and travel industries will be under extreme financial pressure and will consolidate.  
  • City living will come under pressure as people who can afford it will flee to the suburbs.  Urban real estate will be under negative price pressure for quite a while (especially commercial real estate).  
  • The federal government will need to continue to provide economic stimulus of various types throughout the period to keep our economy afloat.  Increasing inflation late in the year 2021 is a likely result.  
  • US citizens will be quarantined from travel (possibly until at least 2Q 2021) to the vast majority of countries in the world.  This might be one of the biggest consequences of our comparative inability to manage the virus.  And it will have a dramatic impact on our economy.
  • Oh, and the stock market?  It may very well continue to go up (or not). It is impossible to predict, and lots and lots of money has been made since the bottom on March 23rd. But I wouldn't have my life savings invested there right now, when it buckles, it will happen very quickly.  And it will buckle.  Eventually.
And then... another virus emerges in a wet market somewhere in the Far East and the cycle begins again.  Only this time we will be prepared... we've seen this movie before so:
  • People will immediately start wearing masks and social distance again, which will significantly slow the virus.  Just like it did this time in Taiwan.  And Hong Kong.  And New Zealand.  Next time, thankfully, the US will be added to that list.
  • We (hopefully) will have a m-RNA platform for vaccines.  As soon as we know the genetic sequence of the virus, a vaccine can be quickly approved and produced.
  • We will have an increased arsenal of anti-viral drugs that can be bought to bear quickly.
  • Our medical practices for treating highly contagious respiratory viruses will have improved even more by then, reducing the mortality rate significantly.
And then things will, indeed, get back to normal.  Some time in 2021 is my guess.

One More Thing
I may end up looking very silly 6 months from now, with all these dire predictions, when the virus 'just goes away' like Donald Trump said it is going to do.  

And you know what? I hope to God that Trump is right and I end up eating crow.

Until then, please stay safe and for heaven's sake, please use your mask.




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