A Blog by Jonathan Low

 

Dec 31, 2020

What Year Two Of the Pandemic Will Bring

To paraphrase, it will end not with a bang but a whimper. Pockets of resistance to vaccination will create clusters of infection in some regions or religious/cultural groups that may last for years. 

And the lessons learned may be open to ideological interpretation. JL

Ed Yong reports in The Atlantic:

The pandemic will end not with a declaration, but with a long, protracted exhalation. Even if everything goes according to plan, which is a significant if, the horrors of 2020 will leave a pummeled health-care system short-staffed, and facing new surges of people with long-haul symptoms or mental-health problems. Social gaps that were widened will be further torn apart. Grief will turn into trauma. And a nation that has begun to return to normal will have to decide what to remember.

The influenza pandemic that began in 1918 killed as many as 100 million people over two years. It was one of the deadliest disasters in history, and the one all subsequent pandemics are now compared with.

At the time, The Atlantic did not cover it. In the immediate aftermath, “it really disappeared from the public consciousness,” says Scott Knowles, a disaster historian at Drexel University. “It was swamped by World War I and then the Great Depression. All of that got crushed into one era.” An immense crisis can be lost amid the rush of history, and Knowles wonders if the fracturing of democratic norms or the economic woes that COVID-19 set off might not subsume the current pandemic. “I think we’re in this liminal moment of collectively deciding what we’re going to remember and what we’re going to forget,” says Martha Lincoln, a medical anthropologist at San Francisco State University.

The coronavirus pandemic ignited at the end of 2019 and blazed across 2020. Many countries repeatedly contained it. The United States did not. At least 19 million  Americans have been infected. At least 326,000 have died. The first two surges, in the spring and summer, plateaued but never significantly subsided. The third and worst is still ongoing. In December, an average of 2,379 Americans have died every day of COVID-19—comparable to the 2,403 who died in Pearl Harbor and the 2,977 who died in the 9/11 attacks. The virus now has so much momentum that more infection and death are inevitable as the second full year of the pandemic begins. “There will be a whole lot of pain in the first quarter” of 2021, Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, told me.

But that pain could soon start to recede. Two vaccines have been developed and approved in less time than many experts predicted, and are more effective than they dared hope. Joe Biden, the incoming president, has promised to push for measures that health specialists have championed in vain for months. He has filled his administration and COVID-19 task force with seasoned scientists and medics. His chief of staff, Ron Klain, coordinated America’s response to the Ebola outbreak of 2014. His pick for CDC director, Rochelle Walensky, is a widely respected infectious-disease doctor and skilled communicator. The winter months will still be abyssally dark, but every day promises to bring a little more light.

On the Fourth of July, Ashish Jha wants to host a barbecue at his house in Newton, Massachusetts. By then, the state expects to have rolled out COVID-19 vaccines to anyone who wants one. The process will be bumpy, but Jha is hopeful. He thinks that the SARS-CoV-2 coronavirus will still be spreading within the U.S., but at a simmer rather than this winter’s calamitous boil. He expects to keep all his guests outside, where the risk of transmission is substantially lower. If it starts raining, they could come indoors after putting on masks. “It won’t be normal, but it won’t be like Fourth of July 2020,” says Jha, the dean of the Brown University School of Public Health. “I think that’s when it’ll start to feel like we’re no longer in a pandemic.”

Many of the 30 epidemiologists, physicians, immunologists, sociologists, and historians whom I interviewed for this piece are cautiously optimistic that the U.S. is headed for a better summer. But they emphasized that such a world, though plausible, is not inevitable. Its realization hinges on successfully executing the most complicated vaccination program in U.S. history, on persuading a frayed and fractured nation to continue using masks and avoiding indoor crowds, on countering the growing quagmire of misinformation, and on successfully monitoring and countering changes in the virus itself. “Think about next summer as a marker for when we might be able to breathe again,” said Loyce Pace, the executive director of a nonprofit called the Global Health Council and a member of Biden’s COVID-19 task force. “But there’s almost a year’s worth of work that needs to happen in those six months.”

The pandemic will end not with a declaration, but with a long, protracted exhalation. Even if everything goes according to plan, which is a significant if, the horrors of 2020 will leave lasting legacies. A pummeled health-care system will be reeling, short-staffed, and facing new surges of people with long-haul symptoms or mental-health problems. Social gaps that were widened will be further torn apart. Grief will turn into trauma. And a nation that has begun to return to normal will have to decide whether to remember that normal led to this. “We’re trying to get through this with a vaccine without truly exploring our soul,” said Mike Osterholm, an epidemiologist at the University of Minnesota.

I. The Vaccine Endgame

having vaccines is not the same as achieving vaccinations. First, pharmaceutical companies need to make enough doses. Manufacturing the Pfizer-BioNTech and Moderna vaccines is a delicate process, involving fragile supply chains. Quality control must be uncompromising, and small glitches can cause steady production lines of vaccine to sputter. “Vaccines are fragile biologics; they’re not T-shirts,” said Kelly Moore of Vanderbilt University, who studies immunization policy. More approved vaccines, though, could mean a more resilient supply.

Vaccines must then be distributed and deployed. Moderna’s can be stored in normal freezers, but Pfizer’s requires ultracold storage such as dry ice. Both require two doses. Tracking these will be challenging for a country without comprehensive national or state vaccination records, and with a poor history of measuring vaccine uptake at the local level. Pfizer’s and Moderna’s vials contain five(-ish) and 10 doses, respectively; these must be used within hours of being opened, which poses logistical challenges for rural clinics that serve widely dispersed communities. And while many vaccines come in ready-to-go syringes, these were developed too quickly to add such conveniences; health-care workers must remember how to thaw and prepare each dose. (Think of the vaccines as cars whose airbags and engines were tested thoroughly, but whose dashboards need work.)

All of this must be done in the middle of a pandemic, in part by understaffed and overworked public-health departments. “We are trying to plan for the most complex vaccination program in human history after a year of complete exhaustion, with a chronically underfunded infrastructure and personnel who are still responsible for measles and sexually transmitted diseases and making sure your water is clean,” Moore said. Although Operation Warp Speed spent $18 billion on developing vaccines, the federal government initially offered states less than 2 percent of that—$340 million—to deploy them. The recently approved stimulus bill will add $8 billion for vaccine distribution, but, though welcome, those funds were needed months ago. And there is still no national vaccination strategy, said Saad Omer, a vaccinologist at Yale. The Trump administration has again left things up to the states, which have again concocted a hodgepodge of plans. “We shouldn’t be going into the biggest immunization effort this country has ever undertaken without a solid playbook and without enough resources to back the plays,” Omer said.

If vaccines are successfully distributed, Americans must agree to get them. As of earlier this month, 27 percent said they wouldn’t get a free COVID-19 vaccine, though that proportion had fallen since September. Many Americans are simply watching to see if the first vaccinations occur without issue. But here, the campaign might run into the same problem that vexes all prevention efforts: People don’t notice when they successfully avoid a disease, “but a negative reaction is memorable,” said Emily Brunson, an anthropologist at Texas State University. Because millions of people are getting vaccinated, many will coincidentally have heart attacks, strokes, or other problems soon after their shots. If viral social-media posts or half-baked news alerts link these health problems to the vaccines, while dwelling on every one of the expected side effects in real time, fear might unduly ground the campaign.

Already, conspiracy theorists, QAnon supporters, and far-right groups believe COVID-19 to be a hoax or a nonissue, and this network, alongside traditional anti-vaccine activists, will downplay or disparage the vaccines. Donald Trump flirted with anti-vaccine messages before his presidency, and may do so again “to echo back what his base wants to hear,” said Kate Starbird of the University of Washington, who studies the spread of disinformation during disasters. Conspiracy theories are hard to counter once they take off, but they are also predictable and can be “pre-bunked,” Starbird said. “The first time you hear a piece of misinformation, it forms a lasting memory, and a correction doesn’t always change it,” but a preemptive countermessage could set that first memory correctly.

Americans who worry that Operation Warp Speed cut corners may be reassured by endorsements from trusted figures such as Fauci. Meanwhile, some 42 percent of Republicans currently say they would refuse a vaccine; “if Trump was enthusiastic about the vaccination, he could play a remarkably constructive role” in swaying his supporters, said David Lazer, a political scientist at Northeastern University. (Mike Pence was vaccinated on December 18.)

Many Black Americans, too, are understandably suspicious of the vaccines and the broader medical establishment after regularly receiving discriminatory care, hearing about the Tuskegee syphilis experiment, and seeing family members die of COVID-19. “The health-care system has not proven itself trustworthy,” said Jasmine Marcelin, an infectious-disease specialist at the University of Nebraska Medical Center. Members of wary communities can help vouch for a vaccine: “As a nurse, I’ll be one of the first people in line,” said Monica McLemore, a nursing professor at UC San Francisco, who is Black. But truly engendering trust in historically wronged communities, McLemore said, would mean investing more fully in care, including free masks, testing, and mental health care.

II. The New Patchwork

one certainty about the vaccines is that they will be deployed unevenly. Just as the virus created a patchwork of infection in 2020, the vaccines will create a patchwork of immunity in 2021. Globally, many poor countries will barely be able to start the vaccination process, because richer countries have hoarded doses. Even within the U.S., there will be difficult months when some states are vaccinating all their citizens while others are still working through prioritized groups, such as essential workers and the elderly. Urban areas could speed ahead of rural areas, where people live farther away from any health facility, including commercial pharmacies such as CVS; where clinics have fewer staff members and fewer ultracold freezers; and where local health departments are busy with pandemic responses. “Who’s going to get to those people?” asked Tara Smith, an epidemiologist at Kent State University.

Some scientists have estimated that 50 to 70 percent of the country will need to be vaccinated to achieve herd immunity, but the actual threshold is still unclear, and several researchers suspect it may be much higher. Whatever the actual number, it will also apply at smaller geographical scales. So what if infected people from regions that have not reached the threshold travel to neighboring areas that have? “The technical term is that it becomes a big mess,” said Sam Scarpino of Northeastern University, who studies infectious-disease dynamics.

Herd immunity is frequently misunderstood. It is not a force field. Outbreaks can still begin in communities with herd immunity if someone brings the virus in, but they will die out on their own because every unvaccinated person is surrounded by enough vaccinated people that the virus will struggle to reach new hosts. Or at least that’s how it works in theory. In practice, there are two complications. First, the theory assumes that the vaccines prevent infected people from passing on the virus—and it’s still unclear whether they do. If they don’t at all, the endgame becomes harder, because vaccinated people might unwittingly spread the virus. But this is more of a theoretical concern than a likely one: Vaccines that are 95 percent effective at preventing symptoms would be expected to “reduce the rate of transmission significantly,” said Akiko Iwasaki, an immunologist at Yale.

Second, unvaccinated people will not be randomly strewn around a community. Instead, they’ll form clusters, because vaccines are unevenly distributed, or because vaccine skepticism spreads among friends and families. These clusters will be like cracks in a wall, through which water can seep during a storm. “Those pockets of vulnerability will be the biggest problems,” said Shweta Bansal, a disease ecologist at Georgetown University. They will mean that even when some communities reach the 70 percent threshold, infections could still spread within them. People who waited because of distrust or hesitancy, and people who could not be vaccinated because of lack of access or preexisting medical conditions, will bear the brunt of these continuing outbreaks.

Such outbreaks will grow smaller and be more easily controlled as more people get vaccinated. As the year progresses, health-care workers might have to fight only localized COVID-19 fires instead of the overwhelming nationwide inferno that’s currently ablaze.

The U.S. still needs to calm that inferno, though. In a study that simulated the effects of vaccination, Rochelle Walensky, the future CDC director, and her colleagues concluded that the percentage of infections and deaths avoided through vaccination decreases “dramatically as the severity of the epidemic increases.” Other measures such as masks, better ventilation, rapid diagnostic tests, contact tracing, physical distancing, and restrictions on indoor gatherings will still be necessary during the long rollout, and will buffer that process against disruptions. “As a nation, we’ll recover faster if you give the vaccine less work to do when it’s ready,” Walensky said on Twitter.

Most Americans—across the political spectrum—support measures aimed at curbing COVID-19, including restricting restaurants to carryout, canceling major sporting and entertainment events, and asking people to stay at home and avoid gatherings, according to surveys done by Lazer, the Northeastern political scientist, and his colleagues. Some state leaders have thus far been unwilling to enact such measures, but their attitudes might shift when the Biden administration takes office. “I’ve talked to many governors who, regardless of geography or political party, want to know what they can do to limit the transmission of this virus,” said Osterholm, who is on Biden’s COVID-19 task force. Especially now, with many questions already swirling around the vaccines, clear, consistent, evidence-based advice from that task force could go a long way in countering the chaotic, conflicting counsel that Trump and his associates have offered.

So could more funding. States cannot legally run at a deficit, so some measures require the federal checkbook, including the mass manufacturing of personal protective equipment, the rollout of cheap and ubiquitous diagnostic tests, and aid for businesses and families financially harmed by social restrictions. “I’d love to see policy makers lay out the social contract on the table,” Scarpino said. “Something like: ‘Here’s the plan; we’re asking for a bit more sacrifice, we’re putting a little money in your pocket to make you comfortable, and we’re targeting a normal July Fourth.’ Until today, it’s been: ‘Do all this stuff with no support, and who the hell knows when it’ll be over?’”

Slowly, life will feel safer. Masks will still be common, and public spaces may be less populated. But many of the joys that 2020 stripped away could gradually (if patchily) return—the joys of indoor dining, the thrill of a crowd, the touch of a loved one. “Vaccines will help us to return to normalcy,” Omer said. “It’ll be a new normal, but a very human normal.”

III. The Virus’s Next Move

even as vaccinations wax and the virus wanes, SARS-CoV-2 will persevere. Drugs that block HIV infections have been around for years, but 1.7 million people still contract the virus every year. Polio vaccines were first created in the 1950s, but polio, though tantalizingly close to eradication, still exists. So do most other vaccine-preventable diseases, including measles, tuberculosis, and cervical cancer.

What happens next with SARS-CoV-2 depends on how our immune systems react to the vaccines, and whether the virus evolves in response. Both factors are notoriously hard to predict, because the immune system (as immunologists like to remind people) is very complicated, and evolution (as biologists often note) is cleverer than you.

Immunity lasts a lifetime for some viral diseases, such as chicken pox and measles, but wears off much earlier for others. There are four mild coronaviruses that cause common colds, and the immune system only remembers how to deal with them for less than a year. By contrast, immunity against the deadlier coronaviruses behind MERS and SARS lasts for several years.

SARS-CoV-2 likely falls somewhere in the middle. So far, most infections seem to trigger immune memory that persists for at least six months, although a small number of people have been reinfected. Iwasaki, the Yale immunologist, expects that COVID-19 vaccines will lead to longer and stronger immunity than natural infections, since vaccines lack the tricks that the virus itself uses to evade and delay the immune system. “The immunity may not last a lifetime, and I wouldn’t be surprised if we had to give a booster vaccine in a few years,” Iwasaki said. “But right now that’s not the major concern.”

A bigger worry, perhaps, is what the virus will do as more people get vaccinated. Viruses are always accumulating mutations—changes in their genes. For example, a lineage of SARS-CoV-2 called B.1.1.7 was recently identified in the United Kingdom and has mutations that seem to make it more transmissible. (These variant viruses are concerning but should still be containable if people wear masks, practice social distancing, and implement other measures that have worked thus far—another good reason to double down on those measures as the vaccines are deployed.) Other mutations might allow variants of SARS-CoV-2 to escape from current vaccines and infect people who were once immune. In that scenario, the virus would become like influenza—an ever-changing foe that forces humanity to regularly play catch-up. The pace at which this scenario might unfold depends on at least four factors.

First, there’s the virus’s evolutionary rate: It is commonly said that coronaviruses pick up mutations at a tenth the speed of influenza viruses, but the B.1.1.7 lineage seems to have rapidly acquired 17 mutations—a striking number. Second, there’s the pressure on the virus to evolve counteradaptations: That’s currently low, but will skyrocket as vaccinations increase. Third, there’s the scale of the pandemic: The more people who are infected with the coronavirus, the higher the odds that it will acquire vaccine-evading mutations. Finally, there’s the question about whether the virus can actually evolve around the vaccines. The measles vaccine was developed in the 1960s, and the measles virus, despite its high mutation rate, still hasn’t evolved to escape it. That’s because the same mutations that would let the virus do so also weaken it in important ways, like a burglar who can turn invisible but no longer move. “Not everything can happen through evolution,” said Jesse Bloom, an evolutionary biologist at the Fred Hutchinson Cancer Research Center.

Michael Mina, an epidemiologist and immunologist at Harvard, is worried, especially because many of the leading vaccines in development have the same target. They teach the immune system to recognize the coronavirus’s spike protein—the studs on its surface that it uses to dock on human cells. “We’ve never bottlenecked a virus like this,” he said. “We’ll start globally rolling out vaccines that are essentially identical, at an unprecedented scale and speed, at a time when the virus is very abundant.”

Studies of the milder human coronaviruses show that the spike protein can evolve to evade the immune system within a decade or two. But Bloom thinks that if SARS-CoV-2 manages this feat, it wouldn’t be disastrous. Vaccinated people should still have some residual immunity to the mutated virus. Several researchers are cataloging the kinds of mutations that might be problematic, so watching them emerge should be possible, when and if that happens. And vaccines that use a sliver of the coronavirus’s genetic material—its mRNA—as the Pfizer and Moderna ones do, were developed to be customizable; if the virus mutates, updating the vaccines without starting from scratch should be doable. “I don’t think everything we’ve done will suddenly become useless,” Bloom said. “We have the capability of staying ahead of the virus.”

Still, “we need to prepare for the eventuality of vaccine escape, and we need to do it now,” said Kristian Andersen, an infectious-disease researcher at Scripps Research. “We have no idea how fast it’ll happen, but we can be almost certain it will.”

IV. The Lasting Scars

no matter what SARS-CoV-2 does in the future, the fallout from America’s year-long failure to control it will continue. On the surface, the country will seem to heal. But even as schools begin to operate normally and social life resumes, scars newly reopened will widen, while wounds freshly formed will fester.

Health-care workers, to start with, “are beyond fatigued,” said Lauren Sauer of Johns Hopkins Medicine, who studies hospitals’ surge capacity. “People have been doing this for almost a year without backup.” Each COVID-19 peak has sapped more energy and morale, and afterward, fatigued health-care workers have had to deal with a backlog of postponed surgeries, as well as new patients who have been sitting on their medical problems and come in sicker than usual. In the current surge, as hospitals have bulged with up to 120,000 COVID-19 patients, nurses, doctors, and respiratory therapists have faced the most grueling conditions yet. They’ve spent hours in intensive-care units packed with some of the sickest patients they have ever cared for, many of whom die. They fear infecting themselves or their families. They suffer the moral injury of fighting the virus while others party, travel, and cry hoax.

Vaccines are, literally and figuratively, a shot in the arm. But despite their arrival, “there’s a tangible feeling of hopelessness”—and anger, said Jessi Gold, a psychiatrist at the Washington University in St. Louis School of Medicine. “It didn’t have to be this way.”

The health-care system was already weak before the pandemic. Recent projections suggest that the U.S. entered the year with a fifth of rural hospitals on the cusp of closing, and 154,000 fewer registered nurses than it needed. By mid-November, 22 percent of all hospitals were understaffed. More than 2,900 health-care workers have died of COVID-19 this year. Many of their surviving peers have had enough. Some have gone on strike over unsafe environments, unsustainable pressures to keep working, and insufficient testing or protective gear. Others have quit or retired early. Medical professionals tend to be stoic; “if some are saying ‘I quit’ on Twitter, there’s going to be a wave behind that,” said Vinny Arora, a hospitalist at the University of Chicago. Entire hospitals, especially those that served poor or uninsured communities, have already closed. The depleted workforce will be hard to replenish, because medical training is lengthy, higher education isn’t graduating new nurses fast enough, and physicians from other countries (who disproportionately provide rural health care) have been dissuaded from coming to the U.S. by years of anti-immigration policies. “We’re really in for a rough ride, in terms of being able to deliver high-quality care to much of the U.S.,” Arora said.

As the supply of health care dwindles, demand will soar. The U.S. population is still aging; chronic diseases are still becoming more common. A wave of mental-health disorders is on its way. Between the stresses of the year, the isolation of physical distancing, and the closure of social spaces, rates of depression, anxiety, substance abuse, and eating disorders have spiked. “I have a ton of patients who were stable for 30 years and all of a sudden are really struggling,” Gold said. Their ranks will swell, she predicts. “In a crisis, you can say, ‘It makes sense that I’m anxious, sad, and not sleeping.’ But there’ll be a surge of problems once people finally get a chance to breathe and realize what the toll has been.” And when that happens, many Americans will learn “quite how hard it is to get care,” Gold said. “The mental-health-care system is inherently broken. We simply have never had enough providers.”

The same goes for chronic illness. Well into the vaccination campaign, many of the 19 million Americans who have been infected with SARS-CoV-2 will still be struggling with “long COVID”—rolling waves of ongoing and debilitating symptoms, including extreme fatigue, cognitive problems, and crashes that follow even mild bursts of activity. Some studies have estimated that 24 to 53 percent of infected people have at least one symptom that lasts for at least a month, if not several. Many “long-haulers” will soon be marking the one-year anniversary of their illness. “It’s going to be really hard,” says Hannah Davis, an artist in New York City who has experienced brain fog, memory issues, pain, and problems with her autonomic nervous system since March 25.

Once neglected, long-haulers have forced the world to recognize their existence. In May, many scientists I spoke with had never heard of the phenomenon; this month, the National Institutes of Health held a two-day conference to discuss it. “I don’t think we can ever be forgotten,” Chimére Smith, a middle-school teacher in Baltimore, told me. “The health-care industry can never again say they don’t know what a long-hauler is.” But “nothing is happening fast enough to help the first wave of us,” Davis told me. Some long-haulers have been diagnosed with chronic illnesses such as myalgic encephalomyelitis and dysautonomia but few specialists study or understand these conditions. Those who do will soon be overwhelmed by a tsunami of new patients. “There’s already such a shortage of doctors who know about long-haulers and can do anything to treat them,” Davis said. “I can’t imagine what will happen with hundreds of thousands more people going down this route.”

Medical inattention is just one concern among many. Davis and four other patients turned researchers recently surveyed 3,800 long-haulers who first became sick in the months before June. Of them, 93 percent were still not recovered, and 72 percent were either not working or working reduced hours. Many people in this cohort couldn’t get access to tests or medical care; without documentation of their illness, they were also struggling to access disability benefits. “A lot of people are reaching the end of their financial and emotional limits,” Davis said.

V. The Widened Gaps

after world war ii, women who entered the workforce in Western Europe mostly stayed there to help rebuild their battered nations. To support them, governments provided better child care, longer school hours, and extended maternity leaves. But the U.S., which was less severely affected, did the opposite, encouraging women to relinquish their wartime jobs to returning men and resume their supposed place at home. “That set the stage for the inequalities we have today,” said Jess Calarco, a sociologist at Indiana University, “where women disproportionately do the work a welfare state should be doing.”

When COVID-19 closed schools and child-care centers, American women shouldered the extra burdens of household work, parenting, and remote learning. Without governmental support for affordable child care, many of these burdens became untenable. “In interviews I’ve done, women felt like they were failing as mothers, workers, and teachers,” Calarco said. “Many had to choose between sending their kids to school and maybe getting them sick, or keeping them at home and dropping out of the workforce.” Many women in heterosexual couples picked the latter. In September alone, four times as many women left the workforce as men—865,000 in total. “That will have lifelong effects,” said Loyce Pace, of the Global Health Council. “You can barely have a baby in this country and have a job again, and that’s not even a two- or three-month leave.”

The closure of schools has widened inequalities among children too. “For a lot of people, school is a place where they get food and safety,” said Seema Mohapatra, who studies health equity at Indiana University. Many students with disabilities have struggled without individual attention from trained professionals. Children in 4.4 million households, especially in Black, Latino, and Indigenous communities, lack access to personal computers. Overseeing remote learning is hard enough for parents with flexible, well-paying jobs; those who work hourly, low-wage jobs have been put in an even harder position. These disparities will have generational consequences, because early inequalities can “set kids up for a lifetime of success or catching up,” Mohapatra said.

For some families, educational struggles are compounded by grief. Black, Latino, and Indigenous people are roughly three times more likely to be killed by COVID-19 than white people. People in these communities die not only at higher rates, but at younger ages: While just 10 percent of white Americans who have died of COVID-19 were younger than 65, 28 percent of Black Americans and 45 percent of Indigenous Americans were. The pandemic has wiped out the past 14 years of progress in narrowing the life-expectancy gap between Black and white people. That gap was 3.6 years; it is now more than five.

These inequities stem from centuries of racist policies that segregated people of color into neglected neighborhoods, deprived them of medical care, and concentrated them in low-paying jobs that have made social distancing impossible. And because Black, Latino, and Indigenous people have been more likely to lose their jobs, homes, and access to health care during the pandemic, they will be even more vulnerable to the inevitable epidemics of the future.

Biden has appointed Marcella Nunez-Smith of Yale to lead a federal task force focused on racial inequities during the pandemic. “There’s a strong commitment to equity, and there’s not a single conversation that doesn’t involve talking about how we reduce disparities,” Luciana Borio, who is part of that group and who was formerly on the National Security Council, told me. “That was never a consideration” for the outgoing administration. But Pace, who is Black, worries that the broader societal will to recognize and reduce health inequities will fade as the U.S. begins edging back toward normalcy. “People are accustomed to us dying,” she said. “It’s always been acceptable for us to not do well, to be locked up, to die. It’s a habit, and habits are hard to break.”

VI. The Lessons Learned

in the coming years, the full toll of the pandemic will become clearer, as researchers calculate more accurate estimates of how many lives were affected and lost. A blizzard of investigations by independent commissions will assess how governments and agencies fared against the virus. (Some have already begun.) Helpfully, the coronavirus pandemic has been documented extensively, providing an unparalleled trove of real-time accounts.

But many tragedies are still hidden. Some of the most overworked people, including health-care workers and caregivers, have had little time to record their experiences. Many long-haulers have suffered in silence, lacking the energy to share their stories. Many patients have died in hospital beds, alone. The need for medical privacy has meant that most people have never learned what the virus can truly do to a body. And from America’s gaping political fissure, warring versions of reality have emerged. With conspiracy theories now mainstream, “we can’t analyze disasters anymore without [asking if] we can even achieve a shared description of the events that are happening,” Knowles, the disaster historian, told me. How does a country learn from its mistakes if it cannot even agree on whether it made any?

COVID-19 will neither be the last pandemic nor the worst. Its lessons will dictate how well the U.S. prepares for the next one—and the country should start with its understanding of what preparedness actually means. In 2019, the Global Health Security Index used 85 indicators to assess how ready every country was for a pandemic. The U.S. had the highest score of all 195 nations, a verdict that seems laughable just one year later. Indeed, six months into this pandemic, the index’s scores had almost no correlation with countries’ actual death rates. If anything, it seems to have indexed hubris more than preparedness.

The idea that “America and the West are more advanced than Eastern and African countries is not true, but is seeded in the way global health operates,” said Abraar Karan of Brigham and Women’s Hospital and Harvard Medical School. “But when the tires hit the ground, the car didn’t start.” In retrospect, many Western health experts were too focused on capacities, such as equipment and resources, and not enough on capabilities, “which is how you apply those in times of crisis,” said Sylvie Briand of the World Health Organization. Many rich nations had little experience in deploying their enormous capacities, because “most of them never had outbreaks,” she added. By contrast, East Asian and sub-Saharan countries that regularly stare down epidemics had both an understanding that they weren’t untouchable and a cultural muscle memory of what to do.

Vietnam, the first country to contain SARS in 2003, “immediately understood that a few cases without an emergency-level response will be thousands of cases in a short period,” said Lincoln, the San Francisco State medical anthropologist, who has worked in Vietnam extensively. “Their public-health response was just impeccable and relentless, and the public supports health agencies.” At the time of my writing, Vietnam had recorded just 1,451 cases of COVID-19 all year, fewer than each of the 32 hardest-hit U.S. prisons.

Rwanda also took the pandemic seriously from the start. It instituted a strict lockdown after its first case, in March; mandated masks a month later; offered tests frequently and freely; and provided food and space to people who had to quarantine. Though ranked 117th in preparedness, and with only 1 percent of America’s per capita GDP, Rwanda has recorded just 8,021 cases of COVID-19 and 75 deaths in total. For comparison, the disease has killed more Americans, on average, every hour of December.

Crucially, while U.S. health care is skewed toward treating sick people in hospitals, Rwandan health care is skewed toward preventing sickness in communities. The U.S. devotes just 5 percent of its gargantuan health budget to primary care; Rwanda spends 38 percent. The U.S. was forced to hire and train thousands of contact tracers; Rwanda already had plenty of community health workers who knew their neighbors and had their trust. “Community health workers know where the most vulnerable people are and what they need,” said Sheila Davis, the chief executive of the nonprofit Partners in Health. A living safety net, these workers can intervene early if people need food, medications, or prenatal care. “We [in the U.S.] wait for someone to completely crash and burn before we provide those things,” Davis said. “We are too focused on high-tech and expensive health care. We’re set up to fail in a pandemic like this.”

After the post-9/11 anthrax attacks in 2001, fears of bioterrorism encroached on American attitudes toward naturally emerging diseases. Preparedness was framed with the rhetoric of national security. Health experts developed surveillance systems for disease, simulated epidemics in war games, and focused on fighting outbreaks in other countries. “This came at the expense of investment in public health, equity, and housing—boringly crucial sectors that actually support human wellness,” Lincoln said. “One cannot prevent a pandemic by preparing for a war, but that is exactly what the U.S. has been doing.”

To truly prepare itself against the next pandemic, the U.S. has to reimagine what preparedness looks like. Every epidemic is different, as new pathogens with unique characteristics emerge from different regions. But those pathogens eventually test the same health systems and expose the same historical inequities. Think of epidemics as a million rivers that must all flow through the same lake. The U.S. has been trying to dam the rivers. It has to focus on the lake.

It must reverse the decades-long underfunding of public health. It should invest in policies such as paid sick leave, affordable child care, and reparations that would narrow the old inequities that make some Americans more susceptible than others to new diseases. “Epidemics are always social phenomena with historical roots,” said Mary Bassett, who studies health equity at Harvard. “Viewing them purely as a matter of an individual confronting a virus leaves out all the things that affect that person’s vulnerability. I worry that as vaccines come online, that part of the equation will be forgotten.”

There is a likely future in which America’s immune system learns lessons from COVID-19 but its collective consciousness does not. Indeed, the U.S. has a long history of plastering over social problems with technological fixes. It and other wealthy countries have already monopolized global vaccine supplies, and, despite having the worst outbreaks, are likely to reach the pandemic’s endgame first. They might deduce that magic bullets won the day, forgetting the costs of idly waiting for those solutions and leaving vulnerable people to die.

In The Past Is a Foreign Country, the historian David Lowenthal wrote, “The art of forgetting is a high and delicate enterprise … It can be a process of social catharsis and healing or one that sanitises and eschews the past.” The choice between those options is now before us, as the coronavirus pandemic enters its second full year. As Americans get vaccinated, they must decide whether to remember the people who sacrificed to keep stores open and hospitals afloat, the president who lied to them throughout 2020 and consigned them to disaster, the families still grieving, the long-haulers still suffering, the weaknesses of the old normal, and the costs of reaching the new one. They must decide whether to resist the decay of memory and the elision of history—whether to forget, or to join the many who will never be able to.

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