More than a dozen states have seen record-high Covid-19 infections in the past five days, as the country experiences case counts never seen before anywhere in the world and, once again, surging hospitalizations and deaths.
But public health experts around the country told STAT they were deeply worried that there has not been a correspondingly urgent response from federal, state, and local leaders. As a result, they warned, the country is set on an even more dire course as it moves deeper into the fall and holiday season.
Even as cases spiral, many state leaders — wary of inflaming a worn-out public, dismissive of the pandemic, or philosophically opposed to government intervention — are not implementing the types of measures that succeeded in reining in major outbreaks in the spring and summer. By and large, public leaders — some Democrats but particularly Republicans — are putting the impetus on individuals to take steps to slow transmission instead of spearheading new campaigns to curtail the coronavirus.
“Things are completely out of control in Utah right now, and they’re not really doing anything about it,” Stephen Goldstein, a virologist at the University of Utah, said last week about government officials in his state, which has seen record infections and deaths in the past week and where hospital administrators have warned that clinicians might have to start rationing care because of the crush of patients.
Some governors and other elected officials say the public is tired of burdensome interventions. Leaders also feel burned by the backlash to more intensive measures or believe the virus will spread no matter what, so restrictions that harm the economy and society aren’t worth the costs. The result, experts say, is a dangerous combination of fatigue, fatalism, and forfeiture that will only result in more illnesses, hospitalizations, and deaths. On Election Day, the country once again crossed 1,000 daily Covid-19 deaths, and it has stayed above that mark most days since, according to STAT’s Covid-19 Tracker.
Take last Thursday: Minnesota, Ohio, Illinois, Michigan, and a dozen other states hit new daily case records (some of which have already been broken). Florida and Arizona reported their highest daily infections since August that day as well, just one day after Texas did. The country confirmed 120,000 Covid-19 cases, a figure no other country has hit; it was the second day in a row and ever the country had hit 100,000 detected infections in a day. Subsequent days saw similarly high case counts.
Yet in Iowa on Thursday, Gov. Kim Reynolds, while announcing a media campaign to promote the type of individual behavior that can slow coronavirus transmission, said she wouldn’t institute any other policies in the state, which does not have a mask mandate and which is seeing its hospitals fill up. In Nebraska, amid record infections and hospitalizations, Gov. Pete Ricketts said he planned to wait a few more weeks to see if changes implemented last month — like preventing standing-room crowds in bars and restaurants — could have an effect before enhancing the strategy. And in Utah, Gov. Gary Herbert warned that “we will continue to see dramatic increases until we choose to act differently,” but that any new plans from the state wouldn’t be announced until at least this week. (Late Sunday night, Herbert did announce new rules, including a statewide mask mandate, expanded testing at colleges, halting most school extracurricular activities, and a plea for people to only socialize with people in their households for two weeks.)
Those governors are all Republicans, but it’s not just GOP-led states seeing worrying spikes. On Saturday, the health department in Washington state said that rising cases since September had “erased the progress that we made this summer,” and that the state was “ending the week with yet another broken record” in daily infections. (It can be difficult to compare current infection counts to those on a day in April, say, just because expanded testing means more cases are detected now than earlier during the pandemic.)
Cautious individual behavior — the type that governors and other leaders have been so focused on — is an incredibly powerful tool against the pandemic. If people wear masks, keep their distance from others, wash their hands, and stay home when they’re sick or might have been exposed to the virus, it can have a major effect on overall transmission. Health authorities say they are preaching responsible individual behavior in part because significant transmission is occurring among households and at gatherings of family and friends. This type of messaging is crucial, experts say.
But experts worry that simply relying on people to do the right thing might not be enough. Even people who have done their best to comply are slipping a bit and are doing certain activities — indoor dinner parties with friends, for example — they wouldn’t have done a few months ago. In addition, President Trump and other leaders who have downplayed or dismissed the virus have undermined efforts to motivate people to act responsibly — posing a threat to everyone else.
“Especially with the Trump aspect, you have from the top that this is not a disease to be feared, that masks aren’t effective, that this is a hoax, and of course getting sick himself and seemingly getting over it pretty quickly — I think this has reinforced the idea that this isn’t a virus to be feared, that we have to keep going on with our lives,” said Tara Smith, an infectious disease epidemiologist at Kent State University in Ohio. In Smith’s state, Gov. Mike DeWine received praise for his early handling of the pandemic but has since been hesitant to institute new strategies even as cases rise.
What’s particularly frustrating to public health experts is that time matters when it comes to how effective a given intervention will be at slowing the spread of a virus. With infections growing exponentially, a strategy that can help corral cases one day might only make a dent if instituted later on. Waiting a week to strike can mean the difference between it being sufficient or not, between people staying alive or dying.
Experts also stress that the range of interventions available has been falsely perceived as a binary of “lockdown” or nothing. Rather, they say, it’s more of a spectrum — targeted closures or certain restrictions that prevent crowding can have an impact before the virus gets so out of control and hospitals get so overwhelmed that stay-at-home orders are issued. More than a dozen states don’t have mask mandates (though some cities or counties in those places do). Other measures like widespread testing can also have an impact.
This summer, for example, Texas and Arizona paused certain parts of their reopening plans, reshuttered bars, allowed for mask mandates, and reduced indoor dining capacities, helping rechart the trajectories of their outbreaks. Experts say these layered approaches — with interventions like masks, closing high-risk businesses, and deterring people from gathering each chipping in some amount of benefit — can turn perilous situations around.
“Social distancing policy is not an on/off switch — this is a dial that needs to be calibrated to the temperature,” said Thomas Tsai, a health policy expert at Harvard’s T.H. Chan School of Public Health. “And in a lot of these places, these are hot spots, and we may have to reinstitute more localized or focused physical distancing, such as bans on indoor dining.”
In states where the virus is raging, however, there seems to be little appetite for those measures. One reason is because Congress and the Trump administration have failed to approve new sources of aid to businesses and workers for months, making it all the less likely that governors or mayors would be willing to shut down restaurants, gyms, theaters, and bars.
But experts worry that political leaders could be painting themselves into a corner. Options dwindle as transmission picks up. If no action is taken, the situation will eventually get so bad that their only choice may be to reimpose some type of lockdown in order to stop a deluge of patients from collapsing hospitals.
“It’s thinking about using a sharper or finely tuned instrument, as opposed to a larger, blunter tool,” Tsai said. “But you have to use those sharper instruments in the right window of opportunity.”
No one wants another lockdown. They are incredibly damaging economically, culturally, socially, educationally, and to people’s health. But if there has to be a second round of them in some places, experts say there are smarter ways to institute them, based on the knowledge now of where the virus spreads most prolifically and how to minimize the collateral damage. European countries that have reentered some form of shutdown have exempted schools. Health systems are adapting to encourage people to keep up with cancer screenings instead of canceling appointments en masse.
“The idea is to now, from what we know, create more efficient and evidence-based types of lockdowns,” said Ana Bento, a disease ecologist at Indiana University. “In different cities and in different states, these lockdowns may look very different from each other,” depending on the level of transmission and if a certain type of activity, such as sporting events, is driving the spread in a given region, for example.
There are some local and state officials who are acting now to try to stave off more disruptive measures. Illinois shut down indoor dining once again (some restaurants have in turn sued). In Texas, El Paso County is in the middle of a two-week closure of nonessential businesses (though some businesses and the state have tried to have the order overturned). Oregon has asked people in some counties to “pause” gatherings and businesses to limit capacities.
Some experts have questioned the impact of limited hours for indoor dining, given that it still allows the underlying, risky activity of eating inside; the virus doesn’t care if it’s 8 p.m. or 10 p.m. last call. But others have said such a strategy could have some impact given that it limits the hours people can be around others. Plus, the later people are out (which often corresponds to how much they’re drinking), the sloppier their precautionary behavior gets.
As for more substantive measures, there is no real momentum for leaders at the state and local level to act in many cases.
“Political leaders take action when there’s popular support for something — and it’s led by demands among their constituents or if there is top down pressure or support for these policies,” like the White House trying to rally governors to act, said Zoë McLaren, a health policy expert at the University of Maryland, Baltimore County. “What we’re seeing in the U.S. right now is a lack of pressure on both those fronts.”
People are understandably tired of Covid-19 precautions and in many cases worry that the economic and social damage inflicted by the country’s failure to control the virus will only get worse with more restrictions. And the Trump administration has largely washed its hands of trying to stem the spread of the SARS-CoV-2 virus, which causes Covid-19.
President-elect Biden has proclaimed that tackling Covid-19 will be among his top priorities. But experts fear the place the country will be in when Biden assumes the presidency on Jan. 20. Cases are already surging as dropping temperatures push more people indoors and propel viral transmission, and as people are expected to travel and get together for the holidays.
“This can be hard to do for nine months,” Pritish Tosh, an infectious disease physician and medical director for emergency management at the Mayo Clinic, said about the precautions we’ve all been asked to take. “And now we’re coming up on the holidays, and people coming back from college, and people wanting to have gatherings with their families. These are decisions that people have to make — is it safe to bring an 80-year-old with multiple comorbidities into your home?”
Public health experts say they’re regularly asked when current outbreaks will peak or just how high cases could go. This is not predetermined, they stress. With so many susceptible people out there, the virus will continue to circulate if it’s allowed to. Cases will keep rising unless behavior and policy change.
“This is a virus that just truly does not care about borders, it doesn’t care about elections, it doesn’t care about politics,” said Harvard epidemiologist Michael Mina. “It’s not even alive. A virus is like a little robot that hijacks people’s cells. It doesn’t care about any of this stuff. It will just spread.”