Once again, the coronavirus is ascendant. As infections mount across the country, it is dawning on Americans that the epidemic is now unstoppable and that no corner of the nation will be left untouched.
As of Wednesday, the pathogen had infected at least 4.3 million Americans, killing more than 150,000. Many experts fear the virus could kill 200,000 or even 300,000 by year’s end. Even President Donald Trump has donned a mask, after resisting for months.
Each state, each city has its own crisis driven by its own risk factors: vacation crowds in one, bars reopened too soon in another, a revolt against masks in a third.
“We are in a worse place than we were in March” when the virus coursed through New York, said Dr. Leana Wen, a former Baltimore health commissioner. “Back then we had one epicenter. Now we have lots.”
To assess where the country is heading now, The New York Times interviewed 20 public health experts — not just clinicians and epidemiologists but also historians and sociologists because the spread of the virus is now influenced as much by human behavior as it is by the pathogen itself.
Not only are U.S. cities in the South and West facing deadly outbreaks, but rural areas are being hurt, too. In every region, people of color will continue to suffer disproportionately, experts said.
While there may be no appetite for a national lockdown, local restrictions must be tightened when required, the researchers said. Testing must become more targeted.
In most states, contact tracing is now moot; there are simply too many cases to track. And while progress has been made on vaccines, none is expected to arrive this winter in time to stave off what many fear will be a new wave of deaths.
With so much wealth and medical talent, how could we have done so poorly?
“National hubris and belief in American exceptionalism have served us badly,” said Martha Lincoln, a medical anthropologist and historian at San Francisco State University. “We were not prepared to see the risk of failure.”
What We’ve Learned
Since the coronavirus was first found to be the cause of lethal pneumonias in Wuhan, China, in late 2019, scientists have gained a better understanding of the enemy.
It is extremely transmissible, through not just coughed droplets but also a fine aerosol mist that is expelled when people talk loudly, laugh or sing and that can linger in indoor air. As a result, masks are far more effective than scientists once believed.
Virus carriers with mild or no symptoms can be infectious.
The infection may start in the lungs, but it is very different from influenza, a respiratory virus. In severely ill patients, the coronavirus may attach to receptors inside the veins and arteries and move on to attack the kidneys, the heart, the gut and even the brain, choking off these organs with hundreds of tiny blood clots.
Most of the virus’s victims are elderly, but it has not spared young adults, especially those with obesity, high blood pressure or diabetes.
Thus far, none of the medicines for which hopes were once high have proved to be rapid cures. One antiviral, remdesivir, has been shown to shorten hospital stays, while a common steroid, dexamethasone, has helped save some severely ill patients.
One or even several vaccines may be available by year’s end, which would be a spectacular achievement. But by then the virus may have in its grip virtually every village and city on the globe.
Solutions Must Be Localized
Some experts, like Michael Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy, argue that only a nationwide lockdown can completely contain the virus now. Other researchers think that is politically impossible but emphasize that localities must be free to act quickly and enforce strong measures.
Testing must be focused, not just offered at convenient parking lots, experts said, and it should be most intense in institutions like nursing homes, prisons, factories or other places at risk of superspreading events. Testing must be free in places where people are poor or uninsured.
None of this will be possible unless the nation’s capacity for testing, a continuing disaster, is greatly expanded. At the moment, the United States tests roughly 800,000 people per day, about 38% of the number some experts think is needed.
Above all, researchers said, mask use should be universal indoors and outdoors anywhere people are less than 6 feet apart.
Arguments that masks infringe on personal rights must be countered both by legal orders and by persuasion. “We need more credible messengers endorsing masks,” Wen said — just before the president himself became a messenger. “They could include CEOs or celebrities or religious leaders. Different people are influencers to different demographics.”
Images of Americans disregarding social distancing requirements have become a daily news staple. But the pictures are deceptive: Americans are more accepting of social distancing than the media sometimes portrays, said Beth Redbird, a Northwestern University sociologist who since March has conducted regular surveys of 8,000 adults about the impact of the virus.
“About 70% of Americans report using all forms of it,” she said.
The key predictor, she said in early July, was whether or not the poll respondent trusted Trump. Those who trusted him were less likely to practice social distancing.
Whether or not people support coercive measures like stay-at-home orders or bar closures depended on how scared the respondent was.
“When rising case numbers make people more afraid, they have more taste for liberty-constraining actions,” Redbird said. And no economic recovery will occur, she added, “until people aren’t afraid. If they are, they won’t go out and spend money even if they’re allowed to.”
The Danger Indoors
As of Wednesday, new infections were rising in 33 states and in Puerto Rico and the District of Columbia, according to a database maintained by the Times.
Weeks ago, experts like Dr. Anthony Fauci, director of the National Institute for Allergy and Infectious Diseases, were advising states where the virus was surging to pull back from reopening by closing down bars, forbidding large gatherings and requiring mask usage.
Many of those states are finally taking that advice, but it is not yet clear whether this national change of heart has happened in time to stop the newest wave of deaths from ultimately exceeding the 2,750-a-day peak of mid-April. Now the daily average is 1,106 virus deaths nationwide.
Deaths may surge even higher, experts warned, when cold weather, rain and snow force Americans to meet indoors, eat indoors and crowd into public transit.
Rural areas face another risk. Almost 80% of the country’s counties lack even one infectious disease specialist, according to a study led by Dr. Rochelle Walensky, chief of infectious diseases at Massachusetts General Hospital in Boston.
The experts were divided as to what role influenza will play in the fall. A harsh flu season could flood hospitals with pneumonia patients needing ventilators. But some said the flu season could be mild or almost nonexistent this year.
Normally, the flu virus migrates from the Northern Hemisphere to the Southern Hemisphere in the spring — presumably in air travelers — and then returns in the fall, with new mutations that may make it a poor match for the annual vaccine.
But this year, the national lockdown abruptly ended flu transmission in late April, according to weekly Fluview reports from the Centers for Disease Control and Prevention. International air travel has been sharply curtailed, and there has been almost no flu activity in the whole southern hemisphere this year.
Partially Effective Remedies
Experts familiar with vaccine and drug manufacturing were disappointed that, thus far, only dexamethasone and remdesivir have proved to be effective treatments, and then only partially.
Most felt that monoclonal antibodies — cloned human proteins that can be grown in cell culture — represented the best hope until vaccines arrive. Regeneron, Eli Lilly and other drugmakers are working on candidates.
According to a database compiled by the Times, researchers worldwide are developing more than 165 vaccine candidates, and 27 are in human trials.
The Food and Drug Administration has said a vaccine will pass muster even if it is only 50% effective. Experts said they could accept that, at least initially, because the first vaccine approved could save lives while testing continued on better alternatives.
“A vaccine doesn’t have to work perfectly to be useful,” Walensky said. “Even with measles vaccine, you can sometimes still get measles, but it’s mild, and you aren’t infectious. We don’t know if a vaccine will work in older folks. We don’t know exactly what level of herd immunity we’ll need to stop the epidemic. But anything safe and fairly effective should help.”
Still, haste is risky, experts warned, especially when opponents of vaccines are spreading fear. If a vaccine is rushed to market without thorough safety testing and recipients are hurt by it, all vaccines could be set back for years.
A Focus on People of Color
No matter what state the virus reaches, one risk remains constant. Even in states with few Black and Hispanic residents, they are usually hit hardest, experts said.
People of color are more likely to have jobs that require physical presence and sometimes close contact. They are more likely to rely on public transit and to live in neighborhoods where grocery stores are scarce and crowded.
They are more likely to live in crowded housing and multigenerational homes, making safe home isolation impossible when sickness strikes. They have higher rates of obesity, high blood pressure, diabetes and asthma.
Federal data gathered through May 28 shows that Black and Hispanic Americans were three times as likely to get infected as their white neighbors and twice as likely to die, even if they lived in remote rural counties with few Black or Hispanic residents.
The differences persist even though Black and Hispanic adults drastically altered their behavior. One study found that through the beginning of May, the average Black American practiced more social distancing than the average white American.
The top factor making people adopt self-protective behavior is personally knowing someone who fell ill, said Redbird. By the end of spring, Black and Hispanic Americans were 50% more likely than white Americans to know someone who had been sickened by the virus, her surveys found.
One lesson that will surely be learned is that the country needs to be better prepared for microbial assaults, said Dr. Julie Gerberding, a former director of the CDC. “This is not a once-in-a-century event. It’s a harbinger of things to come.”