President Donald Trump recently announced guidelines for reopening the economy, indicating that a portion of the United States could soon return to a state of normalcy. However, the administration's optimistic outlook on the crisis and the future contrasts with the opinions of medical advisers and scientists. The ultimate outcome of the crisis remains uncertain, and experts in public health, medicine, epidemiology, and history have differing opinions on when we can safely leave our homes. How long will it realistically take before a treatment or vaccine is developed? How can we prevent the spread of the virus? Many believe that American innovation can lead to advancements that will help alleviate the challenges. The key to moving forward successfully involves several factors that may be challenging but achievable, such as a cautious reopening strategy, widespread testing, an effective treatment, sufficient resources for healthcare workers, and ultimately a successful vaccine. However, despite these efforts, there are still pessimistic predictions for the coming year. The narrative being presented by Trump in his daily press briefings, that the lockdowns will soon end and life will return to normal, is unrealistic according to most experts. They predict a bleak future of prolonged confinement indoors, with the possibility of vulnerable populations being quarantined for an extended period. There are concerns that a vaccine may not be readily available, that people will grow tired of restrictions and ignore the risks, and that the virus will continue to be a threat for the foreseeable future. Despite some optimism that the virus may subside in the summer and a vaccine may be developed, the general outlook remains grim. "I am becoming more cautious of my inherently hopeful outlook." Many professionals predicted that after the crisis, the country and its economy would rebound rapidly. However, there will inevitably be a difficult period ahead. The outcome of the pandemic will be influenced by future medical advancements and the actions of individual Americans in the meantime. If we diligently take precautions to protect ourselves and our families, more people will survive. If we fail to recognize the true threat of the virus, it will impact us. The number of deaths from COVID-19 in the US may be higher than what is being reported by the White House. The virus has been responsible for the deaths of over 1,800 Americans daily since April 7, possibly even more than what is officially documented. In comparison, heart disease and cancer, which are leading causes of death in the US, typically claim fewer lives daily than COVID-19. The coronavirus curves are leveling off, with a decrease in hospital admissions and COVID-19 patients in intensive care units in New York, the epicenter of the epidemic. While the daily death toll remains high, it is no longer increasing. The epidemiological model used by the White House, created by the University of Washington’s Institute for Health Metrics and Evaluation, initially forecasted 100,000 to 240,000 deaths by midsummer, but now predicts 60,000. View of New York City from Weehawken, New Jersey on April 16, 2020. The New York Times reported that although there is some positive news regarding the epidemic, there are still major concerns. The institute's projection only covers the first wave of the virus until August 4, and without a vaccine, it is expected to continue circulating for years, leading to an increase in the death toll over time. The progress made so far in combating the coronavirus has been due to the country being shut down, but this cannot last forever. The White House's plan to gradually reopen will likely increase the number of deaths, no matter how cautious the approach. The goal is to keep fatalities to a minimum, although long-term projections show a grim outlook. Experts believe that without intervention, the virus could infect up to 65% of Americans and result in the deaths of 1.7 million people. According to a model created by researchers at Imperial College London, the president stated on March 30 that there could be 2.2 million deaths in the US by September in similar circumstances. In comparison, around 420,000 Americans died in World War II. The data from China is not promising, as their epidemic has been temporarily stopped and almost all those infected in the first wave have either died or recovered. China has officially reported approximately 83,000 cases and 4,632 deaths, resulting in a fatality rate of over 5%. The Trump administration has challenged the accuracy of the figures, but has not provided more precise data. Fatality rates are influenced by how overwhelmed hospitals become and the percentage of cases that are tested. A report from the Centre for Evidence-Based Medicine indicated that China's death rate was 17% in early January during the chaos in Wuhan, but dropped to 0.7% by late February. Hospitals in cities like New York were on the verge of chaos. Wuhan and New York officials recently had to revise their death counts upwards after realizing that many individuals had died at home from COVID-19, strokes, heart attacks, or other reasons, or because ambulances did not arrive. During fast-moving epidemics, a large number of victims flood hospitals or pass away without being tested by doctors, while those with mild symptoms or who are asymptomatic are never tested. This creates a distortion in the true fatality rate in both directions. Without knowing the true number of infections, it is impossible to accurately determine the lethality of a virus. The CDC has indicated that as many as 25% of those who test positive for the virus may be asymptomatic carriers, but it will only be possible to confirm this once tens of thousands of antibody tests are conducted in the US. Researchers in Iceland suggested that the number could be twice as high. A health worker in Central Park, New York, checked her personal protective equipment in a mirror on April 16, 2020. The New York Times reported that China is also reevaluating its estimates. A study in February estimated that only 1% of cases in Wuhan were asymptomatic, but new research now suggests that possibly 60% were. Our lack of understanding in certain areas is so significant that it would bring epidemiologists to tears. Dr. Anthony S Fauci, the science adviser to the White House coronavirus task force, has emphasized that all models are subject to change when new data becomes available. Interestingly, the inconsistency in data may reveal a positive outcome: the virus could be evolving to cause milder symptoms. Contrary to what is often portrayed in movies, viruses typically become less deadly over time as asymptomatic strains spread to more individuals. Even though the 1918 Spanish flu virus eventually evolved into the seasonal H1N1 flu, the current virus's level of transmissibility and lethality remains unknown. The presence of refrigerated trucks outside hospitals indicates that this virus is more severe than a typical flu season. The lockdowns will eventually come to an end, but the process will be gradual. The exact percentage of Americans who have been infected is uncertain, with estimates ranging from 3% to 10%, leaving the majority of the population vulnerable. According to epidemiologists, it is not safe for a large number of people to come out of hiding until a vaccine or other protective measure is available. If Americans rush back out, there may be a temporary calm for a few weeks before emergency rooms become busy again. Dr. Peter J Hotez warns against believing in the idea that everyone can stay isolated until a vaccine is developed. Tomas Pueyo, who accurately predicted the national lockdown in his article "Coronavirus: The Hammer and the Dance," suggests that after the lockdown, essential parts of the economy can gradually reopen with limited staff. Each epidemiological model predicts a pattern similar to a dance, where the virus will surge whenever there are too many hosts and another lockdown is imposed. The models show curves of increasing and decreasing deaths that resemble shark teeth. Despite measures such as closing stadiums, churches, theaters, bars, and restaurants, quarantining travelers, and restricting domestic travel, the models still anticipate inevitable surges as high-intensity areas could reinfect low-intensity areas. Experts suggest that stricter restrictions can result in fewer deaths and longer intervals between lockdowns. Many models predict that states will eventually implement widespread temperature checks, rapid testing, and contact tracing, similar to practices in Asia. Even President Trump's "Opening Up America Again" guidelines include three levels of social distancing and advise vulnerable individuals to remain isolated. The plan supports testing, isolation, and contact tracing, although details about funding and implementation timelines are not provided. Despite this, President Trump contradicted his own message by encouraging protests against shutdowns in Michigan, Minnesota, and Virginia via Twitter on Friday. China waited until there were no new cases for 14 days in Wuhan, Nanjing, and other cities before allowing them to reopen. In contrast to China and Italy, the US has been more lenient with restrictions, allowing Americans to travel domestically, drive freely, and socialize in public spaces. Despite some restrictions in place, many people are still arranging play dates for children, hosting backyard BBQs, and meeting others through dating apps. This has contributed to the US seeing up to 30,000 new cases of infection each day. Schaffner noted that it is important for people to understand that playing poker while wearing bandannas is not safe. Despite strict measures being implemented, Asian countries are facing challenges in controlling the virus. China has reported around 100 new infections daily and has closed all movie theatres. Singapore has shut down schools and nonessential workplaces, while South Korea is also facing difficulties. Japan has declared a state of emergency recently. Resolve to Save Lives, an organization led by Dr. Thomas R Frieden, a former CDC director, has released detailed criteria for reopening and closing the economy. These guidelines include a 14-day decline in cases, extensive contact tracing, no infections among healthcare workers, and facilities for mild cases. Frieden emphasized the need to gradually reopen the economy and highlighted the importance of working towards achieving these goals. He also discussed how immunity to the virus could create societal divisions between those who have recovered and those who are still vulnerable. Dr David Nabarro, a special envoy on COVID-19 for the World Health Organisation, has predicted that there will be a frightening divide in society. Those who have antibodies will have the privilege of being able to travel and work, while those without will face discrimination. People who are presumed to have immunity are currently in high demand, being asked to donate blood for antibodies and perform risky medical jobs without fear. The government will soon need to come up with a way to officially certify who is truly immune. Dr Daniel R Lucey, a pandemics expert at Georgetown Law School, suggests that a test for IgG antibodies, which indicate established immunity, would be a logical solution. Numerous companies are currently working on developing these tests. Fauci mentioned that the White House was considering implementing certificates similar to those in Germany, where China uses cellphone QR codes connected to personal information to prevent sharing. The adult-film industry in California introduced a similar concept ten years ago, requiring actors to use a cellphone app to confirm they tested negative for HIV in the last two weeks, with producers able to verify this on a secure website. With Americans in lockdown watching immune individuals resume normal activities, experts believe there could be a strong temptation to intentionally infect themselves to rejoin society. Younger individuals, especially, may weigh the risk of contracting a serious illness against the possibility of facing financial hardship and social isolation. Dr. Michele Barry, who heads the Centre for Innovation in Global Health at Stanford University, shared that her daughter, a Harvard economist, believes that COVID-19 parties are necessary for her age group to build immunity and support the economy. This strategy has been implemented in the past, as seen in Cuba's successful containment of its small AIDS epidemic in the 1980s through mandatory isolation camps for those who tested positive. Despite the harsh measures, residents in these camps were provided with their own accommodations, food, medical care, salaries, entertainment, and artistic opportunities. Dr. Jorge Pérez Ávila, an AIDS specialist in Cuba compared to Fauci, stated that many homeless youths in Cuba became infected through risky behaviors like sex or blood injections in order to gain entry. Several of them died before antiretroviral therapy became available. Similarly, American youths would also be taking a risk if they engage in such behaviors. It is not only the obese and immunocompromised individuals who are at risk, as even slim and healthy young Americans have succumbed to COVID-19. The virus can be controlled, but only with increased resources. According to experts, the next two years will involve periods of progress followed by setbacks. As more individuals with immunity return to work, the economy will gradually improve. However, if there is a sudden surge in infections, new lockdowns may be necessary. To prevent this, widespread testing will be crucial. Dr. Fauci has indicated that the virus will indicate when it is safe to resume normal activities. He is suggesting that by implementing a widespread national testing program, any increase in viral spread can be identified when the percentage of positive results increases. Detecting rising fevers through Kinsa's smart thermometers may provide an early warning sign, according to Schaffner. However, there have been ongoing issues with diagnostic testing, despite promises from the White House. To effectively control the virus, experts argue that all sick individuals, even those with mild symptoms, must be isolated. In this nation, individuals who receive a positive test result are instructed to remain at home but avoid contact with their families. The media has shown various public figures, such as CNN's Chris Cuomo, recovering in isolation in their homes. However, Cuomo's situation highlighted the risks of home isolation when he announced that his wife had also contracted the virus. Dr. Bruce Aylward, who headed the WHO team in China, emphasized the importance of quickly isolating all cases as the most crucial intervention. In China, individuals who tested positive, regardless of the severity of their symptoms, were mandated to promptly go to a hospital set up like an infirmary, which was frequently located in a gymnasium or community center equipped with oxygen tanks and CT scanners. Here, they would recover under the supervision of nurses. This approach minimized the risk to families and provided comfort to patients by allowing them to be with others in similar situations. Nurses also organized dance and exercise sessions to boost morale and assist patients in clearing their lungs and maintaining muscle tone. However, opinions among experts were split on the concept of these specialized wards. Fineberg and Lipsitch have differing views on quarantine processes, with Fineberg advocating for mandatory but "humane" methods, while Lipsitch expressing distrust in the government's ability to forcibly remove individuals from their families. Effectively suppressing a virus requires testing all contacts of known cases, a goal the US is currently falling short of. For example, in China's Sichuan province, each known case had an average of 45 contacts, highlighting the need for more contact tracers. The CDC has around 600 contact tracers, with state and local health departments employing about 1,600, primarily for tracing syphilis and tuberculosis cases until recently. China recruited and provided training for 9,000 individuals in Wuhan. Frieden has projected that the United States will require a minimum of 300,000 trained individuals. The development of a vaccine is not expected to occur quickly. Despite the commencement of limited human trials for three potential candidates (two in the US and one in China), Fauci has emphasized that the process of creating a vaccine will likely take between one to 18 months. Experts in vaccine production have collectively acknowledged that even this timeline is considered optimistic. Dr. Paul Offit, a specialist in vaccines at the Children's Hospital of Philadelphia, pointed out that the current record for vaccine development is four years, specifically for the mumps vaccine. There is a disagreement among researchers on how to expedite the process. Advances in biotechnology, such as using RNA or DNA platforms, have made it feasible to create potential vaccines more rapidly. However, clinical trials are time-consuming due to the inability to accelerate the production of antibodies in the human body. Additionally, past vaccine candidates for coronaviruses like SARS have caused "antibody-dependent enhancement," making recipients more vulnerable to infection rather than less, for reasons that are not entirely clear. In the past, both HIV and dengue vaccines have unexpectedly had similar outcomes. Typically, a new vaccine is initially tested on less than 100 young, healthy volunteers to determine safety and antibody production. If successful, thousands more volunteers, likely front-line workers at high risk, will participate in a Phase 3 trial where they receive either the vaccine or a placebo. To expedite the process, scientists can conduct "challenge trials" by vaccinating a small group of volunteers, waiting for antibody development, and then intentionally infecting them to test the vaccine's effectiveness. Challenge trials are only used for diseases that are completely treatable, such as malaria or typhoid fever. In usual circumstances, it is considered unethical to expose individuals to a disease without a cure, like COVID-19. However, in the current unusual situation, some experts believe that conducting challenge trials on a small number of Americans at high risk may be more ethical than putting millions at risk for an extended period. Lipsitch, who supports challenge trials, argues that fewer people would be harmed in a challenge trial compared to a Phase 3 trial involving thousands of participants. After publishing a paper advocating for challenge trials, Lipsitch received interest from volunteers, although some individuals were uneasy about the idea. Lucey expressed concern about the ethics of challenge trials, but acknowledged the potential benefits. Vaccinologists warn that challenge trials may not recruit enough volunteers to detect rare but dangerous issues like vaccine enhancement. Michael T Osterholm of the University of Minnesota's Centre for Infectious Disease Research and Policy emphasized that challenge trials may not provide definitive data on safety. Virologist Dr. W Ian Lipkin of Columbia University's Mailman School of Public Health proposed testing at least two vaccine candidates in humans before conducting challenge trials in monkeys as an alternative approach. Begin production of the winning vaccine immediately, while also expanding human testing to identify any potential issues. Experts have noted that while testing a vaccine is challenging, manufacturing hundreds of millions of doses presents an even greater challenge. American vaccine plants typically produce only 5 to 10 million doses annually, primarily for the 4 million babies born each year and the 4 million individuals who turn 65. However, in the event of a new vaccine, the US may require 300 million doses, or 600 million if two doses are necessary, along with a corresponding number of syringes. Douglas emphasized the importance of thinking on a larger scale and increasing production in order to meet the demand for flu vaccines. While traditional vaccine plants that use chicken eggs are not ideal for modern vaccines, European countries have their own plants for their citizens and China has a growing vaccine industry that may be able to produce vaccines for the US in the future. Captive customers are required to pay whatever price the seller demands, and there are concerns about the safety and efficacy standards of certain Chinese companies. India and Brazil also possess significant vaccine industries. If the virus spreads quickly through their dense populations, they could reach widespread herd immunity before the US, potentially leading to excess vaccine manufacturing capacity. Another suggestion is for the government to repurpose existing liquor or beer plants with large fermentation vats for vaccine production, proposed by retired medical historian Arthur M Silverstein from Johns Hopkins School of Medicine. He stated that any distillery could potentially be transformed for this purpose. Treatments are expected to be available before vaccines. In the near future, experts were more hopeful about treatments than vaccines. Many believed that convalescent serum may be effective. The fundamental method has been in use for more than a hundred years: Blood is taken from individuals who have recuperated from an illness, then purified to eliminate everything except the antibodies. In order to treat patients, immunoglobulin rich in antibodies is administered through injections. However, a challenge arises as there are not many survivors available from whom blood can be collected. In the past, antibodies were obtained from horses and sheep, but this method was difficult to maintain sterility and sometimes caused allergic reactions due to animal proteins. A more contemporary option is using monoclonal antibodies. Experts believe that these treatment regimens, which were almost successful in defeating the Ebola outbreak in eastern Congo, are the most promising short-term solution. The process involves selecting the most effective antibodies and inserting the genes responsible for producing them into a harmless virus that can multiply in a cell culture. However, like vaccines, the production and purification of monoclonal antibodies is time-consuming. If produced on a large scale, they could potentially not only save lives but also protect healthcare workers. The longevity of antibodies varies depending on multiple factors, but they can last for weeks before breaking down and are unable to eliminate viruses that are already hidden inside cells. The idea of a daily preventive pill is considered a more efficient solution compared to vaccines or antibodies, as pills can be manufactured quickly in factories. However, even if such a pill were developed, production would need to be increased to make it widely available for the 300 million Americans. President Trump frequently mentions hydroxychloroquine and azithromycin in his news conferences, resembling infomercials, but experts, including Fauci, caution against making any decisions until clinical trials are completed. Some experts point to the 1950s when inadequate testing of thalidomide led to thousands of children being born with deformities. Multiple studies on hydroxychloroquine have been stopped due to patients experiencing abnormal heart rhythms from high doses. Barry expressed skepticism about the tolerability of high doses and potential vision issues from accumulation, but suggested exploring its potential as a PrEP-like drug for HIV prevention. Dr. Luciana Borio criticized Trump's suggestion of combining chloroquine with azithromycin as "total nonsense." "I informed my family that if I were to contract COVID-19, I do not want to be given chloroquine. Some doctors believe that chloroquine could potentially protect hospitalized patients with pneumonia from deadly cytokine storms by reducing immune responses. However, this does not mean it can prevent infections, as President Trump has suggested, because it does not have any known antiviral properties. Several antiviral drugs, such as remdesivir, favipiravir, and baloxavir, are currently being tested against the coronavirus, with trials in China expected to release results soon. However, these results may be inconclusive due to a lack of patients to test. Trial end dates in the US have not been determined yet." The concept of 'America First' is being left behind as unprecedented societal changes have occurred. Schools and businesses have closed nationwide, leading to millions filing for unemployment. Taxes and mortgage payments are being postponed, and foreclosures are being prohibited. Refrigerated trucks are being used as mobile morgues in Randall's Island in New York. Stimulus checks, meant to help during the crisis, have started being deposited into checking accounts, essentially turning much of America into a temporary welfare state. Food banks are being established throughout the nation, leading to long lines of people in need. Refrigerated trucks are being utilized as makeshift morgues in Randall's Island, New York as reported by The New York Times on April 15, 2020. The current public health crisis necessitates a level of international collaboration not witnessed in many years. Despite this, Trump is taking steps to cut funding to the World Health Organization, the primary organization capable of coordinating such efforts. Additionally, his actions have strained relations with China, which currently boasts the strongest economy worldwide and could potentially become the main provider of pharmaceuticals and vaccines. China has utilized the pandemic to expand its global influence by providing medical supplies to close to 120 countries, including the US through Project Airbridge overseen by Jared Kushner. Experts believe that in the current world scenario, the "America First" strategy may not be effective. Nicholas Mulder from Cornell University suggests that President Trump should consider collaborating with China instead of insulting them in order to enhance public health efforts. Mulder has compared Kushner's project to "Lend-Lease in reverse," a program through which the US provided military aid to other nations during World War II. Osterholm was more straightforward in his response. He expressed concern that if we offend the Chinese with our words, it could have negative consequences for us in the future. For example, if they develop the first vaccine for COVID-19, they may choose not to sell it to us. Once the pandemic is over, the country's recovery may happen quickly, as seen after previous world wars. However, it will be more difficult to measure the psychological impact of the pandemic. Extended isolation and financial hardships could lead to an increase in domestic violence, depression, and suicide rates. There may also be changes in political views. Initially, the virus primarily affected Democratic cities such as Seattle, New York, and Detroit. However, as it continues to spread across the country, no one will be spared. Even voters in Republican-leaning states who may not currently hold President Trump responsible for the lack of preparedness or limited access to health insurance in America could change their perspective if they witness loved ones succumbing to the virus. In a thought-provoking analysis presented in his subsequent article titled "Coronavirus: Out of Many, One," Pueyo examined Medicare and census data related to age and obesity in states that have resisted implementing shutdowns and counties that voted Republican in the 2016 election. His calculations suggest that these individuals could face a 30% higher risk of dying from the virus. In the aftermath of both wars, Mulder observed that society became more equal as measures such as veterans' and widows' pensions, the GI Bill, VA home loans, stronger unions, and reduced tax benefits for the wealthy were implemented. Experts believe that if a vaccine proves effective in saving lives, Americans may become more trusting of conventional medicine and more open to accepting scientific concepts like climate change. It is possible that the clear blue skies seen over American cities during the lockdown period could become a permanent fixture.