A framework for thinking through what’s next for COVID-19

The article you're reading doesn't claim to predict what's going to happen specifically. Instead, it's meant to explore the broad range of scenarios that could unfold over the coming weeks regarding COVID-19 and the factors that will ultimately shape which of these potential outcomes actually happens. To help break things down, we’ve developed an internal framework that we use at The Prepared when discussing the coronavirus. It divides the current situation into six distinct levels based on the extent of SARS-CoV-2 transmission in a given area. At **Level 0**, there are absolutely no active cases of COVID-19 in a particular region. This is essentially the baseline state. When we move to **Level 1**, there are a few active cases, but they’re all contained. Assuming this containment remains intact, a return to Level 0 should occur fairly quickly. **Level 2** signifies small-scale local transmission. With sufficient effort, it might be possible to trace and group these cases into clusters. **Level 3** represents widespread local transmission that’s challenging to track effectively, even with strong efforts. However, the disease burden remains manageable, keeping hospitals from being overwhelmed. At **Level 4**, the local disease burden becomes so severe that it starts to overwhelm healthcare systems, though it’s still relatively minor compared to the overall population. Finally, at **Level 5**, the disease burden reaches such a scale that it constitutes a significant portion of the local population. These levels aren’t rigidly defined, but they provide a helpful structure for understanding the progression of the pandemic. So far, many parts of the world have reached Level 3, including major Chinese cities, several European countries, and U.S. cities like Seattle and New York. Only a few places—Hubei Province in China, the Lombardy region in Italy, Daegu in South Korea, and Qom in Iran—have advanced to Level 4. Outside of the Diamond Princess cruise ship, we haven’t yet seen a Level 5 outbreak. Stopping the virus requires three main strategies: natural immunity, public health measures, and therapies. Natural immunity occurs when enough people in a population recover and develop resistance, reducing the virus's spread. Public health involves interventions like isolating cases, contact tracing, travel restrictions, quarantines, and hygiene practices. Therapies include vaccines and treatments for the disease itself. In the long run, the pandemic can only truly end when the virus’s reproductive rate (R) drops consistently below 1 worldwide. Achieving this will require a combination of these strategies. Public health measures are crucial, especially early in an outbreak when the number of cases is manageable. As outbreaks grow in size and scope, however, their effectiveness diminishes. For instance, China’s success in containing the virus in Hubei was aided by the relative stability of other regions. Similarly, the global response to China’s initial outbreak was facilitated by its concentration in a single country. Looking ahead, there are three primary possibilities for how the pandemic might unfold: 1. The outbreak is brought under control through public health measures before therapies become widely available. 2. Public health measures prevent the virus from infecting most people until therapies are scaled up sufficiently to end the crisis. 3. The virus spreads widely among the global population before effective therapies reach sufficient scale. It’s important to recognize that progress against the virus isn’t irreversible. China demonstrated that even areas at Level 4 can recover to Level 2 with strict public health interventions. Likewise, areas at Level 3 can move back to Level 2 with sufficient testing and cooperation from the public. Over the next few months, the situation could change dramatically. What seems stable today might shift entirely in just a few short weeks. While it’s likely the pandemic will persist over the course of a couple of years, it’s essential to keep in mind that both the best and worst-case scenarios can unfold anywhere, depending on how well-prepared and responsive individuals and institutions are. In our next piece, we'll delve deeper into three potential futures for the pandemic, examining how these scenarios might play out across different regions.

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