What Happens After the Worst of the Pandemic Is Behind Us?

What Happens After the Worst of the Pandemic Is Behind Us? 1

No one knows when the pandemic will end. But the worst of it may be over for the United States after this winter. For good reasons — growing vaccine eligibility, boosters and new antiviral treatments — and bad — high levels of prior infections — it’s possible the ongoing Delta surge could be the last major spike in hospitalizations and deaths for the United States.

That does not mean Covid-19 is going away. Cases will likely increase in the winter, when more people are gathered indoors, and persist wherever there are pockets of unvaccinated people who had not been exposed. While there will continue to be spikes and drops — cases are beginning to tick back up — the pandemic in the United States will eventually peter out, possibly in the spring or early summer, its long-term fate subject to viral evolution.

But right now, in the United States over 1,000 people continue to die each day, and over 750,000 American lives have been lost so far — one of the highest Covid death rates in the world.

Americans are sharply divided on how to act. There are highly vaccinated areas with few cases where some people remain unsure if they can let down their guard at all and other areas with low vaccination rates and high community transmission where people are living as if it’s 2019.

The pandemic has proved to be a nearly two-year stress test that the United States flunked, with an already distrustful populace exposed to a level of institutional failure that added fuel to the angry battles over how to respond. Dr. Martin Cetron, a Centers for Disease Control and Prevention veteran of battles against Ebola in Africa, described people’s losing confidence during an epidemic as a “bankruptcy of trust.” Right now, America is bankrupt.

It once seemed that if the United States ever faced a viral pandemic, it would be more than up to the challenge. Just weeks before the first Covid-19 cases were reported in China, the United States was ranked No. 1 out of 195 countries in pandemic preparedness by experts convened by Johns Hopkins University, The Economist and others. After all, the C.D.C. is one of the most respected public health institutions in the world, and the United States is home to many of the world’s leading pharmaceutical companies and academic research institutions.

The fact that the United States fared so poorly, despite all the seeming advantages that dazzled those experts, is a profound sign of how decayed our institutions and capacity have become. To understand how we fell so far short and to navigate a second full Covid winter and future pandemics and challenges requiring collective action, it’s important to review the outbreak’s early days to see why the United States — once considered the global leader in public health — is floundering in mistrust, paranoia and exhaustion.

One of the most dangerous things about Covid-19 is not necessarily what it does to any given person who is infected by the coronavirus but that someone can be contagious and not even know about it for days — if at all. The disease can spread before symptoms start and sometimes even without any ever appearing.

At the start of the pandemic, this meant that the number of people who needed to be tested would be far, far greater than the number of people who were visibly sick after suspecting that they came into contact with the virus. This was the first major test for the Food and Drug Administration and the C.D.C. — develop a test and deploy it at scale — and it was one they resoundingly failed.

Their delay in developing a sufficient number of reliable tests and in systematically collecting surveillance data meant that health responders didn’t have a clear sense of where the virus was spreading as it started to rip across the country.

But even if they didn’t necessarily know where the virus was, there were simple precautions that officials could advise anyone to take, such as wearing masks. This was another critical test the United States failed. The C.D.C. didn’t advise people to wear masks until April 2020, when more than a thousand people a day were dying from Covid and many thousands more were infected.

Yet another failure is America’s approach to rapid at-home tests. Here, they are expensive, the supply is fickle, and the public remains confused about their use. The home tests can’t detect the minute levels of virus that the lab tests can find but do return positives when viral loads are high. That means they can alert people within minutes when they are likely to be most infectious. With frequent and widespread use, they can help dampen spread. While many countries have embraced at-home tests as a way to have a more normal daily life — in Britain you can get a pack of tests free, and other countries sell them in vending machines — the United States only recently started increasing their availability and working to reduce their costs.

For too long, F.D.A. officials authorized only a few tests and required a prescription for them. Experts argued tests that failed to detect all infections would give people a false sense of confidence. It was similar to the argument made by officials who initially said masks would make people ignore other public safety measures: The public wasn’t to be trusted. Instead, regulators denied people crucial, if imperfect, tools rather than educate and empower them.

That distrust of the public could not have enhanced the public’s trust in officials, which was so vital, and so lacking, when the government urged people to get vaccinated. This is true across the political spectrum. When it was reported in September 2020 that some vaccines might be available by early November, it was often Democrats and liberals who expressed great skepticism about the speed and suspected the Trump administration was pressuring regulatory agencies to take shortcuts with safety.

Nonetheless, the vaccines were approved in record time, produced on a significant scale and distributed via a sizable public-private effort that included everything from sprawling National Guard sites to the aisles of pharmacies.

But despite having one of the earliest and most abundant supplies of vaccines, the United States has a vaccination rate that isn’t in the top 50 in the world — lower than many, many other countries that started much later.

Some of the reasons for our relatively low vaccination coverage trace back to the dysfunctions of our medical system. The United States is the only developed nation without universal health coverage, and our medical system continues to disproportionately fail people from minority backgrounds; such shortcomings don’t help develop the necessary trust.

But there is another dynamic. Many Republican politicians and pundits have chosen to pump hostility to vaccines and public health institutions as a platform for their supporters to rally around. Some of their claims are outright false or wildly misleading, but as with such demagogy historically, sometimes they capitalize on existing failures.

All this finds a ready home on online platforms designed to optimize for how much time and effort we spend on them. Even before the pandemic, doctors were begging tech platforms like Facebook and YouTube to take action about the rampant vaccine misinformation on their sites that not only existed but thrived. Leaked internal documents show that Facebook’s own researchers were worried about how rampant vaccine misinformation was on the platform during the pandemic. The public has even less insight into YouTube, but it only recently pledged to ban all vaccine misinformation on its platform — a step taken almost two years into the pandemic. This information environment fuels tribalization and demagogy the way warm water intensifies a hurricane. This, in turn, further degrades the capacity for mending our dysfunctional governance.

Given all the missteps and whiplash, it’s no wonder so many Americans are frustrated and confused — even the ones who have been doing their best to follow official guidelines.

So what now?

In the absence of trust in their leaders and peers, people will likely continue to deal with the virus the way they have been, by keeping themselves bubbled or ignoring it altogether. Even within my social circle, which is fully vaccinated, some people’s dispositions toward the virus remain unchanged from the summer or even before, no matter their personal risk level or changing conditions. Some remain highly cautious, while others have practically tuned out the pandemic.

Such constancy despite changing circumstances is not necessarily a good sign. While certain precautions need to remain, especially when transmission is high, it’s reasonable for fully vaccinated Americans to stop living as if they were in a prevaccine era (but also be ready to adjust if the conditions change). But such flexibility requires deep trust in timely guidance.

Meanwhile, not even a rate of 1,000 deaths a day has been enough to motivate all eligible people in high transmission areas to get vaccinated and stop arguing over simple courtesies like wearing a mask indoors in public places. More should also be done to protect employees who cannot work from home; vaccine mandates have been effective, and measures such as free workplace testing, better ventilation standards and paid sick leave can help.

I’ve made peace with the idea of getting an eventual breakthrough infection myself — my risk for severe outcomes seems low and similar to other things I do in life — but I would hate to pass Covid-19 to someone else. I’ve been using rapid tests, especially before meeting people to spend time with them indoors, despite their outrageous price of around $12 or more a pop. I’ve urged everyone I know who is higher risk to get a booster. My workplace mandates vaccines for everyone working in the office without an exemption, and masks indoors where social distancing is not possible. I wear surgical masks in offices, stores and restaurants nowadays, but if I felt spooked about conditions somewhere, I’d put on my N95.

So Thanksgiving is on, and this year even the youngest at the table will have had a first shot, and the few higher risk people have had a booster. Yes, I’ll be breaking out the rapid tests, and I have an appropriate-size HEPA filter in my house.

But you can see how individualized this all is. It’s based on my working conditions, the tests I can afford, HEPA filters I know how to buy and can pay for and vaccines abundant in the country where I live.

My household may be the exception, not the norm.

When the pandemic is finally over, what will remain is not only 800,000 or more Americans dead but also a country too riven to appreciate our survival and a world where even the more privileged are surrounded by avoidable death and suffering.

In her book “March of Folly,” the historian Barbara Tuchman describes civilizations that collapsed not because of insurmountable challenges but because “wooden-headedness” took over: Those in charge were unable to muster the will and vision to make the necessary course corrections in the face of difficulties.

But that’s not the only possibility.

After the horrors of World Wars I and II and the Great Depression between them, there was rebuilding of democracies, including constructing a public sphere geared toward preventing the rise of fascism, an expanded safety net and great reductions in income inequality. It wasn’t perfect, but it wasn’t what you’d guess would come next, looking at the smoldering ruins of 1945.

Arguably, it’s our successes that have lulled us. Few remember all that or what it was like to fear polio or smallpox. Covid-19 was a reminder that humanity’s upper hand on infectious diseases was an illusion.

Fixing all this requires an interconnected effort that unleashes a virtuous cycle. Rebuilding the public health infrastructure and creating a sane, sensible health care system in which we don’t keep spending more than any other developed nation for poorer results will help restore trust and improve our lives. Fair taxation policies would reduce income inequality and generate resources to execute these measures. We can investigate what went wrong, with an eye to actually fixing it instead of simply finding scapegoats. Regulation and oversight can better align the incentives of social media platforms with that of a healthier public sphere. We’ve done that before with transformative technologies.

There’s been significant underfunding of public health in the United States, along with other parts of our national infrastructure, but the problem is deeper than just lack of resources. Former officials frequently end up working for the very companies they oversaw, often helping them stave off regulation or acting as lobbyists writing laws to benefit their companies.

Many politicians from both parties are unwilling or incapable of reining in this process; it’s reasonable to assume that’s at least partly because they are cozy with powerful interests that help them get elected.

Beyond this bipartisan back-scratching, Republicans, who are particularly averse to regulatory oversight and strong government spending, currently wield power disproportionate to their share of voters. Cushioned from electoral accountability, some Republican politicians have taken an attitude toward the pandemic that borders on nihilism: whatever fuels or entrenches the tribal anger.

So necessary ambitions can likely be blocked by those in power who prioritize their short-term interests. Maybe they will think their wealth will let them live out their lives in compounds, isolated from the deterioration around them.

But they will soon realize that even a first-class ticket on the Titanic is still a ticket on the Titanic.

We need a new public spirit: more people willing to recognize things aren’t going to get better unless we fight for it. It’s not easy, but we have nothing to lose but a lot of wooden-headedness and the next catastrophic failure. If this path could be taken, we already have everything we need — wealth, science, technology, know-how. It might not mean the end of pandemics, but it could mean there’s not another one like this.

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