Three Scenarios for How This Ends

On a recent episode of Social Distance, Ed Yong joins to discuss how the coronavirus outbreak will play out in the United States.

Editor’s Note: The Atlantic is making vital coverage of the coronavirus available to all readers. Find the collection here.

The question on everyone’s mind is this: When will things go back to normal?

My answer is never. The world is changed forever: No matter how deeply affected you are—medically, financially, emotionally, or otherwise—there is no going back.

But the decisions we make about how to proceed now are extremely consequential, and the potential outcomes before us are vastly different.

My colleague Ed Yong laid those out last week in a story headlined “How the Pandemic Will End.” The day after its release, he sat down (remotely) to talk with me and our colleague Katherine Wells about what he found out in the course of reporting.

What follows is a transcript of our conversation. You can also listen to the full episode of Social Distance here:

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This conversation has been edited and condensed for clarity.

Katherine Wells: It feels like we’re asking how this will end, but has it even started yet?

Ed Yong: I definitely think we’re not even close to the worst of it yet, sad to say. Cases are growing. We’re already seeing health-care workers and hospitals being overwhelmed, and those signs will become worse and more abundant as the coming days and weeks press on.

We need to steel ourselves for things getting worse, while at the same time also preparing and fighting for measures that might make things better.

It’s always perilous to look far into the future, especially for something as fast-moving as this. But I think there are two reasons why it’s important right now.

First, the choices we make immediately, not in the usual timeframes of crises, like within days or weeks—I mean literally right now—those choices are going to have a huge difference on how well the country fares in the future.

Secondly, even people who have been thinking about pandemics had not anticipated some of America’s failures. If we are to have any hope of averting the worst-case scenarios, we need to become much better about imagining the worst and the best possible futures.

Wells: So it’s important to think about the end now, because we have some control over it.

Yong: Absolutely.

Wells: Both of you have been talking for months, if not years, about this being a possibility. Did you anticipate how this would go? What’s been surprising to you?

Yong: I think it was very clear that a pandemic was inevitable—

Wells: It wasn’t clear to me! I’ve got to say this has been a big shocker.

James Hamblin: You should listen to Episode 1.

Yong: Right, okay. Well, I wrote a piece in 2018 about pandemic threats for The Atlantic. That is not the only piece that was out there. That a catastrophe of this kind would happen was absolutely inevitable. But that being said, I and everyone else I spoke to, almost to a person, thought that the United States was better prepared than it has proven to be. It has so substantially underperformed. It is still, I think, hard for people to believe.

Wells: Well, what about you? Is it hard for you to believe?

Yong: I think the extent to which the United States has flinched in the face of this virus has been truly surprising. The view that I found most helpful in framing the national posture toward this crisis came from a man named Ron Klain, who was the so-called Ebola czar, the man who coordinated America’s response to the West African Ebola outbreak of 2014. He pointed out that if you look at the countries that have done a really good job handling this pandemic—places like South Korea, Taiwan, Hong Kong—not only did those countries do specific things like widespread testing, but it’s also not a coincidence that a lot of them had firsthand experience with SARS in 2003. That, I think, is important.

The countries that have some experience of what a very fast-moving, possibly pandemic respiratory virus can do to a population have a sense of how to react. It’s like a legacy of medical know-how and a sort of national readiness that I think we in America and perhaps a lot of other industrialized countries just simply lacked. Ron said, and I think very rightly, one of the most common sentences uttered in America today is “I’ve never seen anything like this before.” And that is not something that someone in Hong Kong would have said. That inexperience goes back to what I was saying about the failure of imagination.

Wells: Why do we have this failure of imagination? I understand some of the steps that could have been taken to prevent us from getting to this point. But why?

Yong: I think there’s two ways of looking at it. One is that no country can be fully prepared for a thing like this. It’s just too sudden, too rare, too quick. So what preparedness really involves is being ready to spring into action when something like this happens. That is one of the ways in which we failed this time around: for the lack of testing, for the lack of coordinated leadership, for all of that. Most people I’ve spoken to who think about public health and preparedness talk about this concept of cycles of panic and neglect. So guess which one we’re in now.

Wells: That sounds a lot like my day-to-day.

Yong: Right, right. [Laughs.] It’s our inability to think past a timescale that is typically the timescale of an electoral cycle that really hurts us when dealing with some of the massive systemic issues that face society today, whether it’s planning for a pandemic or averting climate change. It’s the same problem. This is one of the things I wanted to deal with in the piece. Can we break that cycle? Are we doomed to forever repeating it?

Wells: What’s the answer, yes or no? Did you figure it out? Are we doomed to repeat it?

Yong: The pessimist, and maybe the realist, in me is not hopeful. I look at this pandemic unfolding right now, and I’m worried about the short-term deaths and losses that will ensue. But even now, I’m already worried about, like, five years from now—whether we’ll just slide back into the same vulnerable situation. The only reason I have for thinking that might not be the case is a sort of perverse one, and it’s that this catastrophe is really bad. It is on a scale that has affected all of the country, maybe all of the world, in a way that past disasters just have not.

Wells: There’s no compartmentalizing it.

Yong: There’s no compartmentalizing it. Absolutely. That might be the thing that shakes us out of this cyclical complacency.

Hamblin: It seems like when we put a defense frame on this, we are able to play into this same notion that … we have an enormous military. We put almost all of our money into the military, and I feel like most of our military and defense system is exorbitantly erred toward the worst possible scenario. Except for here.

Yong: Yeah, I totally agree with that. The disproportionate scale of spending in those two sectors in military defense versus public health is really striking. I do wonder if that is a thing that will change in the future. This event has been compared by many people I’ve spoken to something like 9/11. If anything, it is more significant than that. 9/11 was not mandatorily confining people to their homes. And if that caused such profound change in the nation’s posture, such a radical shift toward counterterrorism as the No. 1 American priority and [toward] terrorists as the No. 1 American fear, maybe this will do the same for public health and for pandemics as the possible threat.

Everything boils down to what lessons are allowed to take hold over the next few months and, realistically, what happens in the election of this November. The way America reacts to that—whether it is seeing the enemy correctly, I think, as the disease or whether incorrectly as the bearers of those disease—will radically influence the nation’s foreign policy and its posture to the rest of the world going forward.

Hamblin: You envision three scenarios for how this ends in your piece. I was wondering if you could quickly run through those.

Yong: The first of the three outcomes is the unlikely one, where every country simultaneously controls their individual epidemics and the whole pandemic is closed down. It needs to be total and synchronous. That is just so unlikely right now, given how much certain places are struggling.

The second option is that the virus does more or less what the last flu pandemic, of 2009, did, which is just sweep through the world, burn through the existing population. Some people die. People who survive become immune for a time. The virus can’t find enough hosts to spread efficiently, and it just fizzles out. The cost of this scenario would be astonishingly terrible. We come back to this issue of imagination. I think some people are not quite grasping just how costly this scenario would be. Millions of deaths either from the virus or from people who can’t be treated for the usual set of heart attacks, strokes, all the rest, because hospitals can’t deal with the virus. It means our health-care system and our health-care workforce will just collapse for the duration of the pandemic and perhaps some time after as it needs to recover. It means doctors will start making choices like: Do I let this patient die because that one might have a better chance of survival? This would be such a moral and medical catastrophe. I just dread to think what this scenario actually would entail.

Hamblin: We are already rationing in terms of tests and masks inside hospitals. Doctors are getting orders not to wear masks except in very specific situations, even though in an ideal world right now I would have everyone who comes into a hospital get tested and get a mask every day. And [that’s] in addition to in New York being told, “If you’re feeling sick, just stay home if you can.” The advice is always “consult your doctor” and “go to the emergency room if you feel sick.” But no. So we’re in the early stages. I hope it doesn’t get the point you’re talking about. I’m sort of trying to play that out and how it would be handled in specific areas. Like, especially in some rural hospitals, it seems inevitable there’ll be at least some stories where an ICU just has to turn people away who clearly needed ICU care.

Yong: And that goes to … some of this future is kind of baked into place already because the virus has this long fuse to it. It takes a long time for the infections to actually show up and then for the worst of those infections to play their course. To an extent, the future is a little set. The present is about mitigating the extent of the problems going forward, alleviating some of the signs that we’re already starting to see.

And then the final option, which I think is the best but also the most complicated, is that we play this protracted game of whack-a-mole with the virus over the course of at least a year, if not two, until a vaccine can be made, which means that people in different cities, states, countries try to stamp out their individual outbreaks, bring the virus under control.

At which point perhaps social-distancing measures can be relaxed. The virus may come back. It almost certainly will come back. But if we play the sort of adaptive game, like, on and off again, it gives us time to do things like ready enough protective equipment, roll out widespread testing, start developing antivirals, develop tests to work out who might have standing immunity to the virus. All of those things can be done, but we have to get past the first wave and then we have to ready ourselves for kind of a long game.

Wells: So just tell me if I’m getting this right. There are three options to how this could end. One is basically We missed our chance, which is squash it early.

Yong: That’s right.

Wells: Option two, what some people are seriously proposing right now, is just to let it run its course. That would mean horror on a scale that is difficult to imagine, and that we certainly haven’t seen in our lifetimes, probably not in generations. The scale of the horror and death would be—talk about a failure of imagination. I definitely can’t imagine how that would happen.

Yong: Nor can I, really.

Wells: So obviously that’s bad. And the third, which is the course we’re on, is that we do this cyclical stamping-out of outbreaks in a scattered way, but we put the brakes on it enough that the horror is limited until we can get a vaccine.

Yong: Yes, that’s exactly it. That third solution is about spreading things out over time, minimizing the spikes that would overwhelm hospitals, and just buying ourselves enough time that more permanent countermeasures can be developed.

Wells: So it seems like even within the third scenario, there’s a wide range of how that could go, right?

Yong: Right. Yeah.

Wells: And I’m wondering how you both think that our failure of imagination is going to play into that. We’re all anxious to get back to life, because we have such intolerance for what’s happening right now. But it’s because we cannot imagine how bad it could be.

Yong: These couple of weeks are going to be challenging, because people will start getting bored of social distancing. They’ll start wondering why all this is necessary. Meanwhile, cases will still continue to climb. So it’ll be a weird disconnect between people feeling like they’ve been subjected to weird, draconian measures they don’t understand that also seem not to be doing anything, because they won’t have any immediate effect on the trajectory of the epidemic. And you will see pressure being placed on Trump and on leaders both national and local to lift these restrictions, to allow the economy to get back to normal, to allow people to return to their jobs and reopen their businesses.

At least for now, it’s clear from every health expert I’ve spoken to that it’s really important to stay the course. We need this time. It’s an unenviable position, but there’s not really a choice, given where we’ve got to. And if those measures are enough, if we can get past that first wave, then we can start being cleverer and more precise and subtle, I think. But that requires a lot of the other things that we’ve talked about to be in place: the protective gear, the widespread testing, the serology tests to work out who has some degree of immunity. Those things need to happen before we start releasing our foot off the brakes. You can’t do that in a situation where doctors have no masks or where people are using trash bags instead of gowns. It would be bad. It would be very bad.

Wells: You both do this thing that I want to ask you about, where I feel like you’re not saying the thing. “It would be bad” is such an undersell. And I know you’re displaying basic professionalism. But it’s not that it would be bad. I mean, this is horrific. And sorry, I don’t mean this in an accusatory way. I think it’s an actual curiosity of mine: Like, even you, as a journalist who has been covering this and knows intimately what could happen, like, is part of this too horrific to say out loud?

Yong: No, it’s not that. I have two views of that. Firstly, any people currently in my inbox would disagree with you that I have been too restrained in my description of the future events. But even now, panic does no one any good. I don’t want people to panic. I want people to understand the gravity of the situation. So the piece I wrote talks about the various scenarios at play—the numbers that they might involve and what absolutely must happen with some urgency. I can use as many superlatives as I’d like, as many graphic adjectives as I can pull out of my thesaurus. And I don’t think that’s going to be the thing that makes a difference. I think part of the response that I’ve had to this piece that I’m grateful of is that it’s deliberately written so that it’s not about inducing panic, but nor is it about offering false assurance. It’s about calmly but accurately taking people through what might and what will happen and saying, “Here are our choices.” That’s what I want to leave people with. We still have options. We still have things we can do to avert the worst-case scenarios. Here is what the worst-case scenario is like. Here is how to get out of it. And I think that’s all you can do. People can work out the scale of it for themselves by looking at the descriptions of it. I think that a citizenry that is informed but not despairing is one that is more likely to take action than one that is running around thinking that the sky is going to fall on their heads. I want people to feel appropriately alarmed, but also empowered.

Wells: Hey Ed, I have one more question for you and then we’re going to let you go. Can you tell me about giraffes? Do you remember giraffes?

Yong: In the Before Times were giraffes. Okay. Giraffes are the tallest animals in the world. They are just faintly ridiculous. They have adapted to a life of verticality in ways that are just sort of hard to wrap your head around. One of my favorite [pieces of] giraffe trivia is that the skin on the legs is incredibly tight, kind of like compression socks, to stop blood from pooling at the bottom of the legs.

Wells: Giraffes have built-in compression socks!

Yong: Giraffes have built-in in compression socks.

Hamblin: It's nice to momentarily think about something beside the virus.

Yong: I know, right?

Hamblin: I don’t remember when the last time I did that was.

Wells: Giraffes are amazing. Let us remember: There may be a pandemic, but giraffes still exist. Don’t forget that. Check out Ed’s piece on giraffes. Ed is our resident expert on pandemics, how the world ends, and also giraffes. So check out all of his writing. Read Ed’s piece on giraffes because it’s amazing. And they’re still out there. They don’t care that we’re having a pandemic. They're living their lives. Being tall.

Hamblin: That concludes today’s giraffe segment.

Yong: All right. Thanks, guys.

Hamblin: Yeah. Thanks so much.

Wells: Thank you, Ed.