How The Next Few Months of COVID Might Go In the United States

Originally published to friends and family on 1/11/21. Lightly updated.

Good afternoon —

Please consider this a friends and family INI-themed note about how the next few months might go with regard to COVID, considering the current facts on the ground, and extrapolating, with restraint, from there. I urge you to read to the bottom.

This will be a brief but important update, not unlike the private conversations I had with many of you in February and early March before things really took off.

A reminder, like those early conversations, that I’m not a doctor, a scientist, an epidemiologist, a public health worker, a policymaker, or a journalist — but I’ve built a high degree of trust among folks in those disciplines for a broad, objective analysis of all of the moving pieces, incorporating an understanding of why people and societies do what they do, and for humbling myself before their expertise.

This note is not comprehensive and represents the generalist perspective of a single moment in time, today, when it was sent to you. Please keep this in mind. Much of this information will be out of date in a week.

Finally, please understand that, like my climate work, I would like nothing more than to be wrong about any and all of this, and would be the first to shout it to the rooftops.

I am happy to answer any and all questions from a generalist perspective, but will not be engaging in anything regarding politics or what’s happened before today.

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Let’s get started.

First things first: per the Constitution, Trump’s term expires at 12:00 PM on January 20th, and President-elect Biden must simply take the oath of office immediately thereafter, anywhere of his choosing.

But before I get to what Biden can and will hopefully do, right away and long-term, I want to caveat everything by reminding you that humanity has never experienced anything like this, and as such, we’ve also never had to respond to anything like this.

We’ve learned a lot, we’ve made enormous progress in so many areas (like mortality, transmission, and masks), but please keep this in mind.

This isn’t to say everyone’s doing the best they can, but a lot of folks are, and you, reader, can only control what you can control. You can, of course, spend some of that control by calling your federal and state Congresspeople to advocate for more action in all capacities, and I encourage you to do so, but simply ranting against the machine isn’t going to get any of us anywhere. Save your energy. We’ll need it.

On January 20th:

Biden will treat the virus as a national security threat.

His incoming administration is filled with incredibly talented, curious, and proven humans. They are already coordinating with all 50 states and existing territories, which is obviously complex. They are hoping to stand up federally run mass vaccination centers, and send mobile units to hard to reach areas, and to finally use the Defense Production Act to speed up vaccine, rapid test, and PPE production.

They currently plan to release all doses of whatever vaccines are available whenever they’re available instead of holding doses back for a 2nd round (hoping that people will still come back for the 2nd dose).

This is complicated and important, because we don’t have any data on how long the partial immunity from a single dose will last. To be clear: you must get the 2nd dose. More on that below.

Understand also that the slow rollout has mostly not been because of availability, though we need to produce many more vaccines and faster, but because of logistical complications that many smart folks spoke openly about in months prior.

Let’s start with the good news:

Much of the US is *currently* dug out of the dark days of late fall when it seemed like everywhere was getting crushed by new cases, hospitalizations, and deaths. Enjoy it.

Immunity from an infection carrying an average-to-significant viral load may last years. To be clear: you should not let yourself get infected instead of getting the vaccine. COVID may not kill you, but the long-term health implications for millions are already devastating. You do not want this, under any condition. Vaccines bring relative immunity without that risk.

But cases are on the rebound, or will be soon, for a few reasons:

1. Excessive country-wide and state-wide travel over Thanksgiving, Christmas, and New Year’s. Do not travel.

2. Black and Brown Americans — the people who hold many of the frontline jobs the rest of us don’t do — continue to suffer from pre-existing health and living conditions: congested living with zero health care and cardiorespiratory conditions particularly sensitive to COVID.

Until we pay those people to stay home, they have to work and the virus will find hosts. These people do not have Zoom jobs or enough income to not work.

3. While a smaller percentage of cases, your “pods” are significantly less safe than you think they are. If you’re not doing a fully transparent audit of each pod member’s external contacts, every single week, you’re exposing yourselves.

4. Quarantine exhaustion. I get it, you get it, we all get it. But the virus doesn’t care.

You might say — "but my pod has held up this entire time, we haven’t gotten sick, and cases are relatively low, for now, in our area. I’m suffering from isolation, my kids are suffering, my parents are suffering. Plus, vaccines are coming!"

And I understand that. You’re not wrong.

Regarding those vaccines:

1. The two vaccines currently approved for use in the US are a revolutionary technology but require very specific (and expensive) storage and distribution practices. This, for now, limits availability and distribution points.

2. With luck, one to two more traditional vaccines requiring less expensive and specific storage methods will be approved in the coming weeks, and perhaps more after that. As of today, about 700,000 people a day are getting their first dose — double the week before, but that needs to be about 3 million a day.

3. The two current vaccines are approved for ages 16 and 18 up. Testing is underway on children younger than that, on breastfeeding women, and folks with auto-immune conditions.

4. Partial immunity does not kick in for 7 days after you get the first shot. Full immunity not until a week after the 2nd shot.

5. To be crystal clear, and this is very important to understand — we do not know, yet, whether getting the full vaccine dose (two shots) of either vaccine also prevents *transmission* to another person. To simplify: you must still wear a mask after you are vaccinated. Only you are protected by your vaccine.

6. State health departments, while nowhere near perfectly run or organized entities upon themselves in a regular year, have long been underfunded and poorly staffed, and states didn’t receive vaccine infrastructure funding until two weeks ago.

To be clear: states cannot run deficits, like the federal government. To simplify: when they’re out of money, they’re out of money, and most have been out of money for a while now, and building up this vaccine infrastructure is very expensive.

7. Are the current vaccines safe? As far as we can tell, they’re very safe from severe reactions. Just 11 people out of every million have suffered from anaphylactic reactions. That’s 10x the rate of anaphylactic reactions from flu shots, but is still 11 reactions out of every 1 million doses given.

However: If you have a history of allergic reactions and/or anaphylaxis, you should not get the shot. More info on that here.

8. Everyone else needs to get the shot to protect yourself, and cut down on the number of available hosts for the virus.

And here’s why (please please please read this section):

1. The virus has inevitability mutated into a few new strains. This isn’t abnormal, this is what viruses do, given time. There is an adage to remember with regard to viruses: “What doesn’t kill you will mutate and try again later."

2. The most prominent (so far) of these mutations so far is called B.1.1.7. It’s the one that originated in the UK, which doesn’t matter to you, but if you look at what’s happening in the UK and Ireland this month, you’ll get a brief understanding of what we’re dealing with.

3. As far as we know, B.1.1.7 is *not* more lethal than the original strain, and *should* respond to current vaccines. That’s great.

4. However, and if you take nothing else away from this note, please understand this: As far as we can tell, and while still uncertain, B.1.1.7 is 30-60% more transmissible than the original strain of this virus.

What does that mean in real life?

Imagine the current strain in a social situation, without masks.

Considering how many people have already been affected in most communities, and the average transmission rate for communities taking reasonable precautions, a person infected with SARS-CoV-2 (the original strain) would probably infect 1 other person.

But B.1.1.7 cases, on the other hand, seem to increase (as far as we can tell so far) 10-fold every three weeks.

That means one (1) B.1.1.7 case takes three weeks to become 10, and three weeks later, it could be 100. Three weeks after that, it’s 1000. Three weeks after that, it’s 10,000. Three weeks after that, it’s 100,000 — all in just three and a half months or so.

These are early estimates used to paint a picture, but it’s a picture I hope will help you understand the severity of what’s coming.

And this is where I want to emphasize that I’ve been sitting on this email for about a week because I have become incredibly sensitive to all of your mental health, and my own. Not unlike in February, delivering analysis like this brings me sorrow.

But if nothing else, it’s vitally important you set your expectations for the months to come.

With all things considered — how it established it already may be, existing travel habits, existing personal quarantine practices, exhaustion, existing mask wear, the anticipation of vaccines “curing” the nation and thus relaxed personal health measures, Biden taking office, state by state decision making, colleges coming back, weather — B.1.1.7 may very become the dominant strain in the US, despite how many people have already been infected.

And if it does, it could ravage this country and make 2020 seem like child’s play.

Getting the B.1.1.7 strain will most probably not make you any sicker, but vastly more people will get it, and thus vastly more people will suffer and die.

Our medical professionals and support staff are well past exhausted, and anguished. We were short 150,000 nurses pre-COVID. We simply do not have the resources to deal with this. But we could, soon.

A extensively more comprehensive and faster vaccine rollout will help, daily cheap paper tests will help, and we will get to a place where we manage this virus like we do the flu, but you should prepare yourself for the virus to be everywhere, and soon and for the next few months to be crippling.

Only the strictest quarantine measures combined with vaccines and mass testing and tracing, can prevent this from happening. You can’t control vaccine rollouts or testing and tracing (other than complying or volunteering yourself). None of us are exempt from the requirements to be as safe as possible, nor the most valuable public health requirement of all in America: the requirement to find ways to support those in our communities who can’t stay home, or to find ways to pay them to do so.

So where are we going?

Look today to Los Angeles, the UK, and Ireland. B.1.1.7 isn’t behind all of the growth and destruction of life in those places, but it’s a growing part of it, and they haven’t seen the worst yet.

There are two parallel stories to track:

On the one hand, a new federal direction couldn’t come at a better time, at our darkest time. When the baseline for support and direction is nothing, anything is better, and I’m confident the federal response will be truly massive, if not perfect. Vaccine rollouts will continue to grow and grow in size. More people will be made safe, a strange direction after a year of hiding and suffering.

On the other hand, in those early 2020 conversations, I very reluctantly mentioned to many of you that there was a chance that — all things considered, and that, really, is my bread and butter -- we’d see a million American deaths when all was said and done.

I’m very sad to report that despite the vaccine race (arguably the most significant accomplishment in human history), and despite the personal measures you’ve all taken, and what the new federal administration may do, that we will most likely reach that number by the end of calendar 2021.

4000 Americans are dying a day and this may be the low point for the first half of 2021. If we get 4000 deaths a day down to 1500 a day averaged out over the rest of the year (and we will), that’s still another half million deaths to go. And many, many more who are infected but do not die will suffer for years.

Both of these things can be true, though I’d obviously hope the first to become the dominant narrative. But hope is not a plan.

I cannot urge you enough to buckle down, even more than you have. I cannot urge you to get your vaccine at the first available opportunity (and after our frontline workers). I cannot urge you enough to seek mental relief and to build lasting habits to carry you through this. I cannot urge you enough to support your local, state, and federal governments in paying frontline workers to stay home until we get to herd immunity, which by now might require 80-85% of the population inoculated, one way or the other.

The personal and societal outcomes have always been about the choices we make, individually and together, and then how successful the virus is simply comes down to math. Millions of Americans have no choice but to expose themselves -- to make and deliver our food, stock our groceries, teach our children, work in our stores, drive our buses, fight our fires, deliver our mail, live with three generations of family — and they are going hungry and are having their water turned off, during a pandemic. They should be the first in line as these new mass vaccination centers. We should make every effort to help them understand that the vaccines are safe and can protect them and their loved ones. We need not only logistics, but marketing and empathy.

We can and must do better, but before we do, we have to understand the context for the situation at hand. I hope this has been a helpful version of that.

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Please excuse any errors in the above. There is much I’ve consciously left out because I didn’t feel it was actionable, or specific to your situations.

I’ve done my best to triangulate from the most reputable resources available to me at this moment, but I am just a generalist who asks informed questions from the smartest people in the world, and then tries to convert my knowledge into a practical analysis that’s helpful for every day people to each make change for themselves, and the world around us.

— Quinn