The risks of reopening too quickly, explained.
It’s the season, it seems, for proclaiming premature victory in the war against Covid-19.
Texas Gov. Greg Abbott (R) all but declared the Covid-19 pandemic to be over on Tuesday afternoon: He announced he was lifting the mask mandate he put in place last summer and rolling back pandemic-related restrictions so businesses could return to full operations.
“Texas is OPEN 100%,” Abbott tweeted. “EVERYTHING.”
I just announced Texas is OPEN 100%.
I also ended the statewide mask mandate.
— Greg Abbott (@GregAbbott_TX) March 2, 2021
A few minutes later, Mississippi Gov. Tate Reeves (R) announced that he’d be doing the same thing, ending the mask mandate ended and fully reopening businesses (though K-12 schools would still be under certain limitations). Reeves said that, as a conservative, he’d always been reluctant to have government mandates in place, but he’d felt it was necessary. Now, as more people are vaccinated and cases decline from the winter peak, he says he’s putting the responsibility back in people’s hands. If you get infected with Covid-19, there would be a hospital bed available to you in Mississippi, Reeves pledged — though you should try not to get infected.
But while the announcements from red-state governors have drawn most of the attention, blue states have also trumpeted similar moves recently. New York Gov. Andrew Cuomo has in recent weeks permitted restaurants to open for indoor dining and movie theaters to start screenings again, at a limited capacity. San Francisco will soon allow indoor dining, and museums and theaters will open their doors again.
The optimism reflected in these reopening plans is understandable. Cases and hospitalizations are down significantly from their winter peak. More than 50 million people have gotten at least their first dose of a Covid-19 vaccine.
But they might also be premature, experts warn, especially when taken to an extreme, as in Texas and Mississippi. Texas currently has 11.2 percent of its Covid-19 tests coming back positive, a rate that suggests significant community spread. The state is also seeing a high number of daily new cases per capita, as is Mississippi, another troubling indicator of the virus’s saturation.
“We risk another rebound of cases if people act like it’s over,” Tara Smith, a public health professor at Kent State University, told me. “I’m worried about complacency as cases decrease — it seems we haven’t yet learned the lessons of the pandemic, that if you start trying to return to ‘normal’ too soon, cases creep back up again.”
Some modulation in our precautions makes sense. The people most vulnerable to Covid-19 are also the ones getting most of the vaccines; the Biden administration announced this week that more than half of Americans over 65 have received at least one dose. People should know that it’s safe for small groups of vaccinated people to congregate (as the Centers for Disease Control and Prevention recently said) and the warming weather should permit more outdoor activities, which experts say are safer. State and local governments, with guidance from the feds, are trying to figure out how to safely resume in-person instruction in schools.
But hasty reopening while a large number of people are still unprotected means a higher likelihood of persistent spread and more cases, which inevitably lead to more hospitalizations and deaths. More spread also presents opportunities for the new, more infectious variants to spread and develop.
“We are in the race between the virus/variants and vaccines,” Wafaa El-Sadr, a Columbia University epidemiologist, told me, “and the future depends on the scale up of vaccination and prevention of transmission to avoid evolution of new variants.”
To borrow her metaphor, we may be in the final stretch of the race — but we aren’t across the finish line. The country is entering a fraught period for pandemic policy, as complacency from lower caseloads and the urge to reopen could given the virus one last chance to surge before there is widespread immunity.
Why experts are worried about states reopening too quickly
The improvement in America’s Covid-19 outbreak over the past few weeks is significant.
Texas is down from averaging about 23,000 daily cases in mid-January to 7,700 today. About half as many people are in the hospital now as there were six weeks ago. Mississippi has seen its numbers fall to roughly the same degree
Nationwide, the trends have been downward — but that progress may be slowing. The number of new cases has barely budged over the past week: The daily average for new cases was 68,038 on February 23 and was 65,468 on March 2. Hospitalizations are still falling at a steady pace (down 29 percent over the past two weeks), but they may soon start to plateau too if cases do. Current case numbers are still at about the same level as the summer surge last year.
And the ongoing loss of life is still at a level most people would have considered unacceptable as recently as last fall, before the terrible winter surge, with 2,000 deaths still being reported on average every day. The Biden administration is now saying the US will have enough vaccines for every adult by May, but at a 2,000-deaths-per-day pace, that would mean by the end of May another 175,000 deaths would be added to the 515,000 already dead if fatalities plateau at current levels.
“Each time we’ve reached a new and unprecedented surge in this epidemic, we quickly normalize it,” Kumi Smith, an epidemiologist at the University of Minnesota, told me. “It’s understandable to want to take comfort in seeing a downward-trending line. But if you pan out to what trends in hospitalizations and deaths have looked like over the past year, it’s clear that we’re still at a very worrying place.”
By the metrics valued by experts, most US states still have widespread outbreaks. A test positivity rate of 3 percent or less is considered the threshold for keeping coronavirus spread under control; 40 states have a positive test rate higher than that. Or, looking at new cases per capita, the New York Times’s tracker says that 13 states — including Texas and New York — as well as DC have a high number of new cases and the number is staying high.
As the new virus variants, which appear more infectious, continue to become more dominant, the risk is that spread could accelerate again before the country has time to vaccinate enough people to reach herd immunity. (The goal is generally 75 percent of people vaccinated or more; about 15 percent of Americans have gotten at least one dose to date, and, going by confirmed cases, about 10 percent of Americans have already been infected with Covid-19, though the real number is probably higher than that.)
That would mean more severe illnesses and more deaths. Sustained spread also creates the natural petri dish from which other variants could emerge.
The possible scenarios vary pretty widely, based on my conservations. It could be that seasonality and increased protection for the most vulnerable leads to a spring in which, yes, there are still outbreaks among younger populations (which probably means more cases of “long Covid,” experts say, and an increase in hospitalizations) but deaths continue to tail off. And once the younger cohorts start to get vaccinated, severe illness continues to disappear and even the people who do get sick are able to recover at home.
But a worst-case scenario looks more like this, according to Bill Hanage at Harvard: The B.1.1.7 variant (which is more virulent and transmissible) continues to emerge, as do the P.1 and B.1.351 variants (which can reinfect people with prior immunity). The vaccine rollout slows, and the virus starts surging again.
Under this scenario, Hanage says, “large outbreaks result in younger age groups who remain unvaccinated. They are especially concentrated in people with risk factors for exposure, like the ‘essential workers’ who are still denied PPE and get hit hard all over again. This is made worse by inequities in vaccine distribution.”
How to prevent this stage of the US outbreak from being any worse than necessary
The effect of these restriction rollbacks remains to be seen. Reeves said that local governments in Mississippi could reestablish their own mandates if they thought it was best for their communities. Businesses would be allowed to maintain restrictions if they so choose. The governor portrayed his action as delegating the responsibility to cities, businesses, and individuals. But the state would no longer be the primary enforcer. Abbott likewise urged Texans to be safe, even as he rolled back the state’s pandemic rules.
Already, mask adherence varies, even within a state. About 95 percent of people surveyed in urban Harris County, Texas, say they wear masks most or all of the time when they go out in public, according to Carnegie Mellon University’s Delphi Group. In Abilene, a small city in the middle of the state, the number is closer to 85 percent.
The compulsion to give people outlets to escape quarantine and to allow businesses to begin recouping is understandable and even desirable. We are in fact living in a new reality: Cases have dropped 82 percent among nursing home residents since vaccinations began.
As Zeynep Tufekci argues in the Atlantic, the message to the public should be that some activities are safe (outdoors, masked, distanced) and restrictions should be targeted to actual risk (don’t close playgrounds, maybe do close or restrict mass indoor gatherings). Clear guidance for vaccinated people on what they should or shouldn’t do is another way to allow people to take advantage of the real improvements in the fight against the pandemic without inviting another surge.
The worst outcomes — deaths and hospitalizations — should continue to drop as more people gain protection, so long as these new variants aren’t allowed to run wild because some stop taking precautions just because a state mask mandate is no longer technically in place.
The country is on the verge of another inflection point in the pandemic. But what distinguishes this from the prior ones is the Covid-19 vaccines. They can accelerate a safer end to Covid-19, if we give them time to work.
“The difference is that we now have the promise of the vaccines,” El-Sadr told me. “The optimism associated with the vaccines has changed the calculus.”
Sign up for The Weeds newsletter. Every Friday, you’ll get an explainer of a big policy story from the week, a look at important research that recently came out, and answers to reader questions — to guide you through the first 100 days of President Joe Biden’s administration.