Why Covid-19 case numbers are falling in the US

The official case count for Covid-19 in America is declining. But that’s not a reason to relax just yet.

The United States has suffered one of the worst Covid-19 epidemics in the world. But here’s a bit of good news: Since late July, the number of new coronavirus cases has steadily declined across most of the country.

That’s not to say the US is beating the coronavirus. Reported cases are still higher than they were in the spring (partly, but likely not entirely, the result of more testing). More than 700 people are still dying from Covid-19 on average every day — more daily new Covid-19 deaths than in any other developed country in the world. There are still large epidemics in some states, especially in parts of the Midwest and South.

Still, the decline in America’s Covid-19 cases is real and significant, translating to fewer illnesses and deaths in the next few weeks and, hopefully, months.

So what happened? How did the US turn it around?

The short of it: We can’t say for certain (as with many things related to the coronavirus), but it seems as though the US’s overall reaction to the July resurgence of Covid-19 — in which much of the nation stepped up social distancing and masking — has tamed the spread of the virus.

“I think the decline is due to the combination of [government] measures taken,” Jaime Slaughter-Acey, an epidemiologist at the University of Minnesota, told me. “The big outbreaks also led people to be more mindful about integrating social distancing and masks into their everyday norms.”

Some of that is a result of state actions, as some state governments mandated masks and closed down risky indoor spaces such as bars. Some of it is due to public action; as the coronavirus surged back, many people had the good sense to reconsider whether they were going out too much and if they needed to be more rigorous about their mask-wearing.

The federal government, however, has not earned much credit. In my conversations with experts, some suggested the decline in Covid-19 is happening despite federal inaction. Between President Donald Trump’s magical thinking — his administration denied there was a second wave even as it began — and Congress’s inability to pass another stimulus bill, it’s been largely left to the public, along with local and state governments, to handle the return of the coronavirus.

Now the US faces the risk of yet another wave as fall and winter arrive. Schools are reopening. When the weather gets cold, more people head indoors, where there’s more risk of transmission. Families and friends will gather for the holidays. A flu season is looming. All of these factors increase the risk of a surge in Covid-19.

Some experts also worry that Labor Day celebrations, with families and friends gathered across the country, could mean another wave is already on the way.

In other words: As promising as America’s recent decline in Covid-19 is, that doesn’t mean it’s time to let up. If the past few months have taught the world anything, it’s that continued vigilance against this virus is necessary, at least until we get a vaccine or similar treatment to really vanquish the disease.

“State and local leaders that have been proactive in their attempt to keep the spread of Covid at bay have been successful,” Slaughter-Acey said. “Others have had to learn by playing with fire, unfortunately. And still, there are leaders at both the state and national level who refuse to acknowledge the gravity of the pandemic and lead in a way that protects the health of the public.”

America reacted to the resurgence of Covid-19

After the initial wave of Covid-19 largely hit the Northeast (particularly the New York City area), Louisiana, and Michigan in March, the virus began to spread in the South and West in May and June — really taking off in Arizona, Florida, and Texas before eventually hitting just about the rest of the country.

States reacted as hot spots did in the first round: instituting new measures pushing social distancing, masking, testing, and contact tracing. That’s seemingly led to a drop in Covid-19 cases nationwide, driven largely by lower case counts in California, Florida, and Texas.

One of state governments’ go-to moves was to shut down risky indoor spaces, particularly indoor dining and bars. Arizona, Florida, and Texas all pulled back their reopenings to close down bars, as did California, Colorado, Illinois, Iowa, and Michigan. Some local and state governments also took stricter measures to close down risky places, including movie theaters.

Based on what we now know about the coronavirus, these indoor spaces are a major source of transmission. The virus seems to spread best in closed-off, poorly ventilated areas where people hang out close together for long periods of time (15 minutes or more). Especially in restaurants or bars, people may not be wearing masks — you can’t eat or drink with one on — further increasing the risk of spread, as some research suggests.

On the flip side, this suggests outdoor spaces are relatively safe during this pandemic. The outdoors aren’t a panacea; it’s still a good idea to keep more than 6 feet from others and wear a mask. But they’re better. During the recent surge of Covid-19, that knowledge — which we simply didn’t have early in the pandemic — has given many people an outlet to socialize and get out of their houses without putting themselves at as much risk. That’s made the current circumstances and renewal of some social distancing measures a bit more bearable and sustainable.

“I think the message that being outdoors is less risky may also play a role” in the Covid-19 decline, Tara Smith, an epidemiologist at Kent State University, told me. “When people are gathering, I’ve anecdotally seen a lot of social media posts noting they’re staying outside as much as possible rather than having indoor events.”

At the same time, more states instituted mask mandates. According to the AARP, 34 states and Washington, DC, now require wearing a mask in some form or another. In states that haven’t instituted mask mandates, some local governments have done so.

Based on what we now know about Covid-19, this too will help: As a respiratory virus, the coronavirus seems to spread when people talk, shout, laugh, breathe, sigh, or do anything else that might spew virus-containing droplets out of their mouths and noses. Putting up a physical barrier, whether through a cloth mask, surgical mask, or respirator, to stop those droplets blocks at least some of the virus’s spread.

On top of the government actions, the public continued or stepped up their own social distancing and masking efforts. In Gallup’s surveys, about 73 percent of polled Americans still reported “always” or “very often” practicing social distancing over the previous 24 hours as of August 30. And 92 percent of polled Americans said they wore a mask in the previous seven days when outside their homes, particularly in indoor settings.

Experts cautioned that it’s not really possible, as of now, to definitively say that all these efforts helped, given that researchers will need time to decisively prove what’s going on. “It’s hard to do the kind of analyses needed to know for sure what all the factors are,” Jen Kates, director of global health and HIV policy at the Kaiser Family Foundation, told me.

But there’s good reason to believe they helped. A review of the research in The Lancet concluded that “evidence shows that physical distancing of more than 1 [meter] is highly effective and that face masks are associated with protection, even in non-health-care settings.” Other studies have supported both social distancing and masking measures.

There’s also a bit of common sense to this. As Kates told me, “We saw the opposite earlier in the summer.” When the public and states eased up on social distancing, especially indoors, and didn’t take masking seriously enough, the US saw a surge in Covid-19 cases and deaths. Doing the opposite, unsurprisingly, has helped reduce new cases and deaths.

The federal government has been largely absent

One thing experts have consistently lamented: the federal government.

From the beginning, Trump has not done a good job with the coronavirus outbreak. He’s downplayed the risk — deliberately, as he admitted in recorded interviews with journalist Bob Woodward. He failed to scale up a testing and tracing system like the ones other developed countries, including Germany, New Zealand, and South Korea, used to control their outbreaks, instead punting the issue to the states. He’s given mixed messages on masking, recently mocking Democratic presidential nominee Joe Biden for wearing one. He’s encouraged states to reopen prematurely, calling on residents to “LIBERATE” themselves.

None of this makes any sense, and it defies the advice that experts have consistently given on Covid-19. “There was a failure to realize what an efficiently spreading respiratory virus for which we have no vaccine and no antiviral meant,” Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security, recently told me. “From the very beginning, that minimization … set a tone that reverberated from the highest levels of government to what the average person believes about the virus.”

Trump’s failures were felt during the recent resurgence in coronavirus cases. Although experts had called on the federal government to dramatically scale up nationwide testing capacity in the spring and summer, the Trump administration by and large refused, claiming the federal government was merely a “supplier of last resort.” This left local and state governments, with far fewer resources than the federal government, to scale up testing and tracing on their own.

The result: As coronavirus cases hit new peaks in various states throughout July and August, there were delays as long as weeks in getting test results back. In many respects, this made the tests useless. Testing is supposed to confirm that someone is sick as early as possible, letting both the infected person and public health officials take steps — from isolation to notifying close contacts of the infected and asking them to quarantine — to prevent further spread of the disease. But if people can only confirm they’re infected weeks after infection, and subsequently days or weeks after they’re actually transmitting the virus, that’s too late.

More broadly, the US has continued to struggle to build up testing. Overall testing numbers each day in the US continue to hover around 600,000 to 900,000, increasing little, if at all, since July. Experts recommend that the percent of tests that come back positive — which gauges whether there’s enough testing to meet the scope of an outbreak — should be below 5 percent or even 3 percent. The US’s positive rate is 5.2 percent, and most states are above the 5 percent cutoff, with some as high as 15 percent or 20 percent.

Trump, however, has suggested he doesn’t want more testing. Arguing that testing makes the US look bad because it reveals more cases, Trump said he told his people, “Slow the testing down, please.” Last month, the Centers for Disease Control and Prevention seemed to listen — updating a guidance to say that people without symptoms may not need to get tested even after close contact with people known to have Covid-19, effectively recommending fewer people at risk get tested.

For Trump, the single goal appears to be making the US look like it’s back to normal, as if the pandemic isn’t messing up so many people’s lives, before the November election. But the reality is that the virus is here to stay, at least until we have a vaccine or an effective treatment. The countries that have gotten closer to normal, like Germany and South Korea, have taken the aggressive steps Trump has so far rejected or downplayed.

Meanwhile, other parts of the federal government aren’t doing a good job, either. Though Congress passed a sweeping stimulus package and other measures earlier this year to deal with the initial brunt of Covid-19, it’s failed to renew those measures as many have expired — with the current big proposal caught up in partisan fights over just how large the benefits for people affected by the bad economy should be.

So dealing with the virus, particularly its most recent resurgence, has been left to the public and to state and local governments, even as they face crippling budget shortfalls as a result of the collapsed economy — with little support from the federal government.

The fall and winter could bring new surges of Covid-19

None of this is to say that the US has, by any means, conquered Covid-19.

“I do worry, though, that fatigue is setting in,” Saskia Popescu, an infectious disease epidemiologist, told me. “I see this in Arizona as the state reopens and the percent positivity [for tests] increases, many might feel the outbreak is over in the US or something we can relax on.”

The US continues suffering more Covid-19 deaths each day than any other developed country. As of September 10, the death rate in the US was 2.19 per million people — 50 percent higher than second-place Spain (1.42) and third-place Israel (1.4), and more than triple fourth-place Australia (0.66).

That adds to an already grisly statistic: Although the US has not suffered the most Covid-19 deaths of any wealthy nation, it’s in the bottom 20 percent for total deaths since the pandemic began, and reports about seven times the coronavirus deaths as the median developed country. If America had the same death rate as, for example, Canada, 100,000 more Americans would likely be alive today.

Recent spikes in parts of the Midwest and South — particularly in North Dakota, South Dakota, Iowa, and Alabama — have also shown that the epidemic in the US is by no means over. If a state gets careless, it’s very likely to see a big spike. South Dakota, for example, allowed a mass gathering at the Sturgis Motorcycle Rally, and that appeared to contribute to the state’s recent surge in Covid-19.

William Hanage, an epidemiologist at Harvard, suggested there might be a divide in how well metropolitan areas are doing compared with more suburban and rural places. That could lead to spikes in cases in less densely populated places, Hanage told me: “The Midwest is much more sparsely populated, but when the virus comes to town it can still do damage. It’s just less predictable when it will come to town.”

There are also concerns that recent Labor Day celebrations, in which friends and families gathered, could already have fueled a Covid-19 surge that we’ll see in the next few days or weeks. But they also may not — if these gatherings were largely outdoors, and people respected social distancing and masking recommendations.

The next big threat could come in the fall and winter. Schools are now reopening, already leading to outbreaks in universities and K-12 settings. In colder areas, it will become much harder to gather outside. Families are bound to gather for the holidays, from Thanksgiving to New Year’s Day. Another flu season is coming, which could strain health care systems at a time they might be dealing with a surge in Covid-19.

And some cities and states have started to relax their measures. Even New York, which has been very cautious since its huge outbreak in the spring, will soon reopen indoor dining in New York City. San Francisco, which has been a leader in early action, is also reopening several indoor spaces, including barbershops, churches, and gyms.

“The virus spreads when a large number of people gather indoors,” Ashish Jha, dean of the Brown University School of Public Health, recently told me. “That’s going to happen more in December than it did in July — and July was a pretty awful month.”

Maybe things won’t go so badly. Maybe the safeguards cities and states have in place will keep the virus at bay, even in indoor areas. Maybe the population immunity built up from so many people already getting sick will offer some protection, as long as people continue to practice some social distancing and masking. Maybe the public will keep following social distancing and masking recommendations after seeing two large Covid-19 waves in the US. Maybe continued social distancing will suppress the next flu season (as seemed to happen in the Southern Hemisphere).

Or perhaps things will go badly. That’s the gamble with the coronavirus: As long as we don’t have a way to vanquish it through a vaccine or other treatment, it presents a constant risk. So the ongoing decline in coronavirus cases will spare some people from suffering and save lives, but it doesn’t mean it’s time to declare victory just yet.

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