Biden’s Covid Plan Will Define His Presidency

On Day Zero of the presidential administration of Joe Biden, the single priority of the federal government must be Covid-19. Without torquing the numbers of deaths and infections downward, no other policy—economic improvement, immigration reform, even a serious approach to stopping climate change—can happen. And that sentence works in reverse too; dealing with Covid-19 is dealing with all that other stuff.

Like any big machine, the federal government’s public health system takes time and energy to come up to speed. It hasn’t functioned at its peak efficiency during the administration of Donald Trump. So nothing will change at first. And then something will. And then everything will.

Assuming all goes as planned. For the last year, nothing has gone as planned, when there was a plan at all.

So, the new plan: Last week, Biden laid out a new, more aggressive approach, part of a promise to let science lead policy during his term. The US public health system, broken and underfunded, hasn’t been able to cope with the pandemic, leaving vaccines as the best and only hope, for now, of controlling it. But for all the blazing speed of their development and testing, vaccine rollout has been, in Biden’s (and everyone else’s) words, “a dismal failure.” Biden has now set a goal of giving 100 million shots of vaccine in the first 100 days of the administration. (As of January 19, the number in the US was 14.7 million, according to Bloomberg’s tracker.)

That won’t be easy, but it is possible. Biden proposed opening up who’s allowed to get vaccinated—sidestepping the tier system recommended to states by various government panels in an attempt to ensure equity along with speedy shot-giving. The Federal Emergency Management Agency will build 100 mass vaccination centers in places like stadiums and convention centers, and the feds will deploy mobile vaccination clinics as well—run, Biden said, by FEMA and the Centers for Disease Control and Prevention, and staffed by the public health corps, retired medical professionals, even the military.

Of course, to make all that work, the government will need to increase vaccine production and improve distribution. Last week, outgoing Health and Human Services secretary Alexander Azar also proposed releasing doses that had been “held back” to guarantee the second shots required by both the Pfizer and Moderna vaccines, and opening up vaccinations to everyone over 65 years old. That was just before The Washington Post reported that there wasn’t enough vaccine to go around. “Our plan is as clear as it is bold: Get more people vaccinated for free. Create more places for them to get vaccinated. Mobilize more medical teams to get shots into people’s arms. Increase supply and get it out the door as soon as possible,” Biden said on Friday. “This is going to be one of the most challenging efforts ever undertaken by our country, but you have my word, we will manage the hell out of this operation.”

(Biden also said he’d mandate mask-wearing wherever federal policy allowed him to do so, and ask everyone else to mask up. That’s one of the only public health efforts that could have some real effect, but the politicization of mask use has hampered its effectiveness. “Quite frankly, it was shocking to see members of Congress, while the capitol was under siege by a deadly mob of thugs, refuse to wear masks while they were in secure locations,” Biden said. “Republican colleagues refusing to put them on—what the hell’s the matter with them? It’s time to grow up.”)

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It’s Not Just You: Everyone’s Mental Health Is Suffering

This is the first sentence I’ve written this week. I wrote it on a Thursday. Like many people right now, I’m finding work harder to get done, and even basic daily tasks feel heavier than usual. If that sounds familiar, you’re not alone. The pandemic has taken a toll on everyone’s mental health, and there’s data to prove it.

While there’s been ample discussion of the economic fallout from a global pandemic, the toll it takes on our collective mental health is harder to quantify. It’s almost impossible to stay at home for months on end, cancel years worth of events, and disrupt even basic routines like how we shop for groceries without a significant impact on our mental health. And yet, it can feel like the impact of these changes is “just stress,” and treat it as something to power through.

According to data from Mental Health America (MHA), however, more people are facing deteriorating mental health. From January through September of 2020, the number of people who have taken MHA’s anxiety screenings has increased by 93 percent over the entire previous year. The organization’s depression screening has seen a 62 percent increase over 2019’s totals. Before the year was even over, more people were trying to find out if they were suffering from anxiety or depression than ever before.

MHA isn’t the only organization with data pointing to the mental health impact of the pandemic. A survey from the Kaiser Family Foundation in July 2020 found that 53 percent of adults said the pandemic had a negative toll on their mental health. Data collected from the CDC found that 41 percent of adults experienced symptoms of an anxiety or depressive disorder in December 2020, compared to 11 percent in January-July of 2019.

All of which is to say, it’s not just you. Mental health troubles are a natural reaction to an ongoing traumatic event like a pandemic.

Why a Pandemic Spikes Mental Health Problems

The pandemic has disrupted most aspects of our lives, but the added isolation of quarantines, social distancing, and canceled events is one of the biggest tolls on our collective mental health. It’s not just that we miss our friends and family. The social bonds we have form support systems and safety networks. With those gone or reduced, it can lead to an increase in anxiety or depression symptoms.

MHA’s vice president for mental health and systems advocacy, Debbie Plotnick, explained that one of the ways this can manifest—particularly in young people—is self-harm. “In November, 53 percent of those 11 to 17 years old reported—so more than half of them—having frequent thoughts of suicide or self-harm.”

One of the top reasons, not just for self-harm thoughts among young people, but for the mental health problems in people of all ages, is the distance we’ve had to put up between each other. “We’ve been asking [the people who take MHA surveys] what troubles them—and remember, they’re not all young—and they’re telling us it’s loneliness and isolation.”

It might seem like isolation isn’t quite as bad as some of the other stressors that a pandemic can bring—a loss of income, political unrest, and disrupted schedules—but it’s a crucial one. We need other people, and while digital connections like Zoom meetings or Discord parties are great filler, it’s hard to be away from the people we care about for so long.

And then there’s the practical impact. As of September 2020, a quarter of US adults said they’d had trouble paying their bills since the start of the pandemic, according to a Pew Research Center survey. However, that number rises to 46 percent among lower-income households. “For folks who have jobs, they’re very grateful,” explained Plotnick. “For folks who are losing their jobs, this is excruciating.”

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Yes to Masks. No to Parties. 2021 Will Be a Lot Like 2020

In the most positive interpretation of the data, there could still be millions of people left vulnerable to Covid-19 in the US, because their bodies can’t mount an immune response to the shot or because they are too young to receive it. (The Food and Drug Administration’s emergency use authorization permits the Pfizer/BioNTech vaccine to be used in those 16 and older; the youngest age is 18 for the Moderna vaccine.) Do the math, add in the projected rollout of six months or more, and it becomes clear that the protective behaviors we’ve been practicing can’t be stopped anytime soon.

And that informal equation doesn’t even account for the people who would subtract themselves from it—for outright opposition to vaccination, fear of side effects, or past disrespect of minority groups’ health. The most recent poll done by the Henry J. Kaiser Family Foundation shows that 27 percent of American adults remain reluctant to take the vaccine, and that proportion goes up in minority groups and in rural areas. Distrust can be overcome, says Theresa Chapple-McGruder, a maternal and child epidemiologist working in the Washington, DC, area, but the educational efforts needed to reassure people have been neglected thus far.

“What I’ve been hearing from a lot of people is, Wait and see,” she says. “I think they’re happy not to be first in line. I haven’t heard anyone really upset that they haven’t gotten there yet and someone else has—outside of politicians kind of jumping the line.”

The calculations of who will be protected and when—and how long it will be until we all are—were further upended just before Christmas by the news that variants of the coronavirus have emerged in South Africa and the United Kingdom, leading to flight cancellations and port closures to keep the more-transmissible version contained. There have been no indications that the variants can’t be contained by the already-developed vaccines, says Angela Rasmussen, a coronavirus virologist and affiliate at the Georgetown Center for Global Health Science and Security. “But the same way to prevent transmission of the variant, if it is more transmissible, is the same way we prevent transmission of every other variant of Covid,” she says. “It’s taking the same precautions: masking, avoiding crowds, no holiday gatherings, and so on.”

If all of this seems to be adding up to a 2021 that looks like 2020: Yes, that’s what the experts predict. Despite the commitment of everyone who participated in social distancing, much of the world is now worse off than in the spring, when lockdowns and mask-wearing first seemed crucial things to do. And vaccines are arriving so heterogeneously that, for some number of months, people who have gotten the shots will be living or working alongside people who are still at risk. A nurse might be protected when her kids have not been; a senior citizen might get the vaccine but be living in a household with fortysomethings who are considered low priority. Until enough people have been vaccinated to establish herd immunity, the safest thing to do is to behave as though everyone is vulnerable.

This is already not happening, says Saskia Popescu, an infectious disease epidemiologist and infection preventionist in Arizona, one of the worst-hit states in the US. “The second the vaccines came out, I’ve seen a change in behavior, people thinking, Well, it’s over, let’s go back to normal,” she says. “That worries me, because this is going to take a long time.”

But there should come a point at which we cease to be so vulnerable; at which enough people have accepted the vaccine, or have been infected and recovered, that herd immunity is within reach. What will be challenging is that the entire US won’t get to herd immunity at the same moment. The virus peaked in different states at different times, thanks to differences in housing density, age, race, and willingness to practice protective behaviors. Its retreat could resemble its advance.

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30 Years Since the Human Genome Project Began, What’s Next?

In 1987, when researchers first used the word genomics to describe the newly developing discipline of mapping DNA, Eric Green had just finished medical school. A few years later, he found himself working on the front lines of the young field’s marquee moon shot: the Human Genome Project. To lead the nation’s participation in the global effort, Congress established the National Human Genomics Research Institute, or NHGRI, in 1989.

Sequencing the entire human genome began the following year, and it took 13 years to complete. Not long after, in 2009, Green took the helm of the research institute. By then, NHGRI’s mission had evolved to include expanding the field of genomics into medicine. That meant funding and coordinating projects aimed at pinpointing the mutations responsible for genetic disorders, then developing tests to diagnose them and therapies to treat them. And even more broadly, it meant generating evidence that DNA data could effectively improve outcomes, even for people who don’t suffer from rare diseases.

To help chart that course, one of Green’s tasks is to periodically put together a strategic vision for the field. Aimed at celebrating progress, identifying technological gaps, and inspiring scientists to pursue the most impactful areas of research, his team published its latest projection in October. For the first time, Green and his colleagues outlined a set of 10 bold predictions about what might be realized in human genomics by the year 2030. Among them: High schoolers will show off genetic analyses at the science fair, and genomic testing at the doctor’s office will become as routine as basic blood work.

Three decades after that sequencing race began, we’ve perhaps reached the end of the early genomics era, a period of explosive technological growth that led to breakthroughs like the sequencing of the first dog, chicken, and cancer cells and the advent of cheap home DNA tests. The field has matured to the point that genomics is nearly ubiquitous in all of biology—from fighting invasive giant hornets to brewing better-tasting beer. Genomic medicine is no longer theoretical. But it’s also not widespread. Although scientists have mapped the human genome, they do not yet completely understand it. Green spoke to WIRED about what the next decade, and the next era in genomics, may have in store. This interview has been edited for length and clarity.

WIRED: October marked the 30th anniversary of the Human Genome Project. When you look around at where we are today, how does it live up to the expectations you had for the impacts the project would make in medicine?

Eric Green: I was inside the Human Genome Project from day one, and I can’t stress enough how back then we didn’t know what we were doing. We had this big audacious goal of reading out the 3 billion letters of the human instruction book, but we didn’t have the technology to do it. We didn’t have the methods. We didn’t even have a functional internet. There was no playbook. So, as someone who got into this as a young physician, I could sort of imagine that one day genomics might be part of clinical care. But I truly did not think it would happen in my lifetime.

If we go back just 10 years, nobody was really using genomics in health care. We fantasized then about the idea of having a patient in front of us, where we did not know what was wrong with them, and being able to sequence their genome and figure it out. That was a hypothetical in 2011. Now it’s routine. At least for people suspected of having a rare genetic disease.

That’s amazing. But also, it’s still a far cry from some of the hype around what the Human Genome Project was going to accomplish. In his remarks at the White House in 2000, then-NHGRI director Francis Collins said it would likely take 15 or 20 years to see a “complete transformation in therapeutic medicine,” promising personalized treatments for everything from cancer to mental illness. Obviously, that hasn’t exactly come to pass. Why not?

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In a Pandemic, Medical Illustrators Made Science Accessible

Even with all that research, there’s some room for artistic licence. Illustrators follow some conventions about color based on what’s generally true in nature—veins are always blue, for instance, and arteries are always shown as red. But the microscopic structures inside cells are smaller than the wavelengths that create visible light, so they don’t have their own color. As a result, no standard color code for them exists. “The great thing about molecules is they’re too small to have color, so I get to pick anything,” Falconieri says.

Falconieri does her best to be as accurate as possible but, she says, “‘accurate’ is a moving target.” After she finished her illustration of SARS-CoV-2 for Scientific American in mid-May, for example, researchers uncovered more details about the virus. “If I were to do the illustration again, it would reflect new science, like the flexibility of the spike protein’s stem, and the organization of the RNA and protein inside the virus,” she says. “That’s the great thing about medical and scientific illustration: Because science is never done, my job is never done.”

Oftentimes, illustrators will have to decide when to sacrifice accuracy in favor of creating an image that explains a concept more clearly. “If a researcher is talking about this particular place in a protein as a binding site, of course we’re going to be accurate,” says Alan Hoofring, lead medical illustrator at the National Institutes of Health Office of Research Services. But if the illustration is meant to emphasize something other than that specific site, Hoofring might simplify that part of the image, substituting a general shape for the protein and the binding location, rather than trying to replicate them in intricate detail. That’s because other parts of the information design might be more important.

As another example, if an illustrator is trying to show how SARS-CoV-2 binds to a lung cell, enters it, and starts reproducing, it’s important to make sure viewers can follow that process clearly. In this case, top priority goes to making the chronology clear. “Medical illustration is just all about putting arrows in the right spot,” Hoofring jokes.

And how much information gets included in each image depends a lot on who the image is for. For example, an image of DNA that doesn’t show the correct number of base pairs might not be exactly accurate, but it might be enough to get an idea across to a viewer who isn’t an expert in genetics. “It’s a judgement call,” says Joanne Muller, president of the Association of Medical Illustrators. “You don’t want anything to be untruthful. It has to be correct. But you don’t necessarily have to tell them everything about everything, because that’s confusing.”

That’s not the same as making mistakes, and a few common errors are huge pet peeves among illustrators. Sometimes brains are drawn backwards, with the brainstem and frontal lobe facing the wrong way, or knee and elbow joints are depicted bending in the wrong direction. There are the bladders shown as being half full, even though the bladder doesn’t actually hold any air. (It just expands as it collects more urine.) And there’s the industry’s number one complaint: DNA that twists left instead of right. “Backwards DNA always gets me,” says Falconieri.

Those details may seem small, but as more and more scientific topics like Crispr, vaccines, and Covid-19 emerge in pop culture and politics, it’s increasingly important that the public has access to accurate information that they can understand. “It’s a really interesting time to be involved in science illustration, because more complex science is becoming more relevant in everyday life,” says Maya Kostman, who makes illustrations for the Innovative Genomics Institute at the University of California, Berkeley. For example, she says, take the Covid-19 vaccine. People want to understand how it was created, researched, and tested. But just making a report from the Food and Drug Administration public might not be enough to answer peoples’ questions. “How is someone going to interpret that? It’s very hard and it’s becoming more and more important for it to be an understandable concept,” she says.

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The Error of Fighting a Public Health War With Medical Weapons

Here’s the wild part, the most 2020 thing about 2020: That schism—that conflict between public health and private well-being, between personal liberties and communal gain—is as old as pandemics. The germ of the idea was, in fact, the idea of the germ.

In the mid-1800s, physicians and scientists were starting to come around to the long-gestating idea that diseases could be caused by wee, invisible critters that jumped from person to person—a “contagium animatum,” as 16th-century thinkers put it. They didn’t know what viruses or bacteria were, but they knew something was carrying illness.

The contagionists had their opposite number: scientists who in 1948 the researcher Edwin Ackerknecht famously called “anticontagionists.” Oh, they believed that some diseases spread by some agent, person-to-person. Smallpox and syphilis, maybe. Those were contagious. But they weren’t epidemics—yellow fever, cholera, or the plague, things that seemed to spread seasonally, or in specific places, or only among specific kinds of people. Nobody knew how. They didn’t know anything about food- and waterborne pathogens, about differences between viruses and bacteria, about surface-borne “fomites” that transmitted disease in some cases, while exhaled droplets and aerosols might in others. Absent any of that? Well, maybe it was something atmospheric—a cloud of illness, a miasma, maybe even the “filth” of poverty and pre-sanitation cities. (It’s telling that scientists are still fighting over the idea of an airborne contagium animatum, even today.)

But the anticontagionists knew one thing for sure. Those big three epidemics—with typhus thrown in sometimes, too—were the things that had, since the 14th century, caused governments to take population-scale measures to control them. That meant quarantines, travel restrictions, business closures—what today we might call lockdowns. And that made the anticontagionists nuts. They said that lockdowns, then as now, were bad for business; losses incurred as a result outweighed those caused by the epidemic itself. In the midst of the 19th century’s Industrial Revolution, anything that inhibited business was an inhibition of freedom itself. “Quarantines meant, to the rapidly growing class of merchants and industrialists, a source of losses, a limitation to expansion, a weapon of bureaucratic control that it was no longer willing to tolerate,” Ackerknecht wrote. “Contagionism would, through its associations with the old bureaucratic powers, be suspect to all liberals, trying to reduce state interference to a minimum. Anticontagionists were thus not simply scientists, they were reformers, fighting for the freedom of the individual and commerce against the shackles of despotism.”

Also, by saying that disease came from lack of sanitation and poor hygiene, the pro-filth contingent was sometimes quietly and sometimes loudly associating disease with ethnicity and socioeconomic status. It was immunological social Darwinism; if poor and nonwhite people got sick first, or more often, that proved to some “reformers” that those people made bad personal choices (rather than indicating a failure of the systems around them). In that light, identifying filth as the generator of epidemics paved the way for the hygiene movement, showed the moral and physical superiority of unpoor whites, and provided a rationale for “slum clearance” and residential zoning laws. Squint at redlining and you see not just the geography of racism but also a colonial cordon sanitaire.

To be fair, as one historian notes, the (paltry) science of miasmas did suggest that quarantines would actually make epidemic diseases worse, because they amplified the confinement and lousy conditions that spread the disease. And if you read “miasma” as “the conditions that make a disease spread,” well, that’s also the point I’m trying to make, so … yeah. These were good-faith scientific arguments that also happened to be politically motivated economic and philosophical ones, tinged by racism.

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Vaccines Are Here. We Have to Talk About Side Effects

Since Monday, eagerly awaited Covid-19 vaccines have been going into the upper arms of health care workers around the United States, the first slender tranche of millions of doses to come. But the joy that has greeted the shots’ arrival is already being muted by worries. Billions of dollars were spent to achieve the formulas. Prepping the US population to receive them got much less attention.

This may turn out to be a mistake. The documentation provided by Pfizer and Moderna to the Food and Drug Administration notes that both vaccines have side effects—minor ones that fade after roughly two days, but that occurred in substantial percentages of people who received them in the trials—and a few serious reactions have been reported. Descriptions of those side effects are beginning to circulate, via news reports and also social media accounts written by trial participants.

Those descriptions are reaching the public in the absence of any effort to contextualize or counter them. There has not, to this point, been a coordinated national campaign that reassures people the vaccine not only works, but is safe to take and will not cause long-term illness. Planners and health researchers are getting concerned that it is already getting late to start.

“It’s really important, at this juncture when vaccines are about to be distributed, to talk to people about the predictable side effects from the vaccine,” says Eric Toner, a physician and senior scholar with the Johns Hopkins Center for Health Security. “The worst case scenario would be that we don’t tell people this, and they have a reaction, and they either believe that they got Covid from the shot or that there’s something wrong.”

That is a pressing concern, for two reasons. First, fear of side effects turns out to be one of the main reasons why people doubt these vaccines. And second, mistrust opens the door not just to confusion but to weaponized disinformation, and those will prevent people taking a vaccine that they need.

The Henry J. Kaiser Family Foundation’s KFF Covid-19 Vaccine Monitor, a rolling survey of 1,600 people 18 and older that launched this week to provide an ongoing measure of public feeling, reveals that, overall, people are feeling more positive about the shot than they were earlier this year. In November, 71 percent of participants said they are likely to take the vaccine, up from 63 percent in a survey done in September. But the remaining 27 percent said they would probably or definitely never take it, a proportion that rose to 33 percent among Black adults, 33 percent among essential workers, and 29 percent among people working in health care. For those who are hesitant, the leading worry was fear of side effects.

This is a tricky thing to create reassurance about, because the side effects are real. Though the Pfizer vaccine was only granted emergency authorization last weekend, and the Moderna one is not authorized yet, tens of thousands of people received them earlier this year in clinical trials. In news accounts and on social media, participants have described experiencing “a severe hangover,” “fever … fatigue and chills,” “full-on Covid-like symptoms.” One participant told CNBC he shook so hard with chills that he cracked a tooth.

Those accounts match the data submitted by the companies to the FDA’s Vaccines and Related Biological Products Advisory Committee, which reviews safety and efficacy. According to briefing documents, the Pfizer formula caused fatigue in 59.4 percent of trial participants after their second dose, headaches in 51.7 percent, muscle pain in 37.3 percent, joint pain in 21.9 percent, chills in 35.1 percent, and headaches in 15.8 percent. The numbers for the Moderna formula, which were released Tuesday, are similar: fatigue in 68.5 percent of recipients, headache in 63 percent, aches and pains in 59.6 percent, chills in 43.4 percent, and fever in 15.6 percent.

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A Letter to My Pandemic Baby

On March 26, 2020, as hospitals in the US were starting to fill with coronavirus patients and the country was adjusting to the new reality of lockdown, WIRED senior associate editor Zak Jason found out he was expecting his first child. Over the next nine months, he and his wife, Kristen, wrote letters and recorded notes to their unborn daughter, trying to explain the world she’d be born into as it seemed to spin faster than ever.

As World War II may seem to baby boomers and 9/11 to Gen Z, children born during and after 2020 may view memories of the pandemic, the smoke-choked orange skies over Australia and the American West, protests in the streets, an endless election, and a hologram of a deceased father wishing his daughter a happy birthday as a bizarre fairytale. This is one attempt to show it was real: virtual birthing classes, nasal swabs, sonograms over FaceTime, risk assessment for visiting grandparents, trying to lift a phantom blueberry with your vagina during a streamed Kegel lesson, troglodytic apps for daddies, and all. In this week’s episode of the Get WIRED podcast, the parents-to-be share some of their dispatches from a most difficult year to breathe—virions and ash attacking lungs, lies suffocating truth, a knee on a neck—as their daughter, Leona, prepared to take her first breath.

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The First Shots, Grim Milestones, and More Coronavirus News

An FDA advisory panel authorizes the first vaccine, the US hits grim milestones, and cases rise worldwide. Here’s what you should know:

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FDA advisory panel authorizes the US’ first vaccine, and it may soon be on the way

On Thursday night, an independent advisory panel reporting to the FDA gave Pfizer and BioNTech’s Covid-19 vaccine the green light. Hours later, the FDA said it will work to quickly issue the shot an emergency use authorization. Once the EUA is issued, ultracold trucks packed full of vaccines will leave Pfizer’s Kalamazoo plant and head to distribution sites around the US. Vaccines can start being doled out as soon as the CDC officially recommends it, and its Advisory Committee on Immunization Practices has emergency meetings on the books for today and next Monday.

Once it’s here, how will the vaccine make it into the arms of Americans in need? On Thursday, FedEx and UPS executives told a Senate transportation subcommittee that they will provide location tracking and priority flights for vaccine shipments, even during the busiest holiday shipping season on record. Meanwhile, Walmart announced that it is preparing more than 5,000 of its pharmacies to administer the vaccine. Each of us can do our part to prepare too, by encouraging skeptical loved ones to get on board with receiving a shot.

The pandemic hits grim milestones in the US

This week, coronavirus numbers in the US continued to get bleaker. On Thursday, as cases and hospitalization rates rose further, the country hit a grim milestone: The total number of Americans who have died from Covid-19 surpassed the number of US service people who died in combat during World War II. The day before, the US set a new record for the most Covid-19 deaths in a day at 3,054, a total that exceeds the death tolls of 9/11 or Pearl Harbor. CDC director Robert Redfield warned that deaths are likely to exceed those numbers for the next 60 to 90 days.

In response, many states are implementing new restrictions. Virginia imposed a new curfew and expanded its mask mandate, while Maryland and New York City did away with indoor dining. New Mexico has temporarily suspended all nonessential surgeries to alleviate the strain on the state’s hospitals. A plan has also been put in place that would allow doctors to ration supplies and determine who to care for based on their likelihood of survival, should that be necessary. Part of the challenge is that policymakers and public health experts know the sum of all these different interventions reduces spread, but it’s unclear which are the most effective on their own. Without that information, it’s essential that everyone follows all the guidelines we have as best we can.

Other countries double down on interventions as cases rise worldwide

Outside of the US, cases are also on the rise, even in countries where infection rates were once enviably low. Cases and hospitalizations are up in Japan, prompting experts to urge people not to travel for New Year’s, a time when it is customary for many to return to their hometowns. South Korea, whose numbers were once as low as two new cases per day, is struggling to contain a new swell too. Both countries have also deployed military personnel to assist health care workers in the throes of handling the pandemic.

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The Perfect Strategy to Fight Covid-19 Is … Everything?

The pandemic has changed—and it’s worse than ever.

Cases of Covid-19 are spiking in nearly every state. The statistics are grim. With more than 100,000 new cases and 2,000 deaths every day, hospital intensive care units are filling up everywhere. It’s an entire country of New-Yorks-in-April. And yet Covid skepticism—over how to fight the disease, and sometimes even the reality of the disease itself—remains a hallmark of right-wing politics.

Read all of our coronavirus coverage here.

There’s a light at the end of the tunnel—vaccines may well be available to millions of people before the end of the year. That’s a scientific triumph, to be sure, but meanwhile, we’re still in the tunnel. Manufacturing and distribution challenges mean that it’ll take until at least June 2021 to vaccinate everyone, according to the head of logistics for the government’s vaccine-goosing Operation Warp Speed program. Until then, the same public health measures that slow the spread of the virus—curve-flattening “non-pharmaceutical interventions” like mask-wearing and canceling gatherings—remain the only tools in the toolbox.

So policymakers and leaders have a stark choice: Force everyone, again, to abide by effective but potentially onerous public health measures, or let hundreds of thousands of people die. It’s a tougher choice than it sounds. Anti-“lockdown” rhetoric and a year of stress has ground people down emotionally and nuked the economy. Plus, it’s a basic tenet of public health that abstinence enjoinders and shame don’t work. If curve-bending efforts aren’t politically and socially viable, they’ll fail—and hundreds of thousands of people will die. As Mike Ryan, executive director of the World Health Organization Health Emergencies Programme, said at a press conference last Friday: “Those countries currently in the fight of their lives, you have got to stick with this. You’ve got to try and control this transmission, or your health systems will not be able to cope.”

What you’d really like to know here is which specific interventions give the most bang for the buck, the greatest reduction in disease transmission with the lightest possible touch on the social fabric and the economy. Is it … a mask mandate? Closing bars and restaurants? Closing schools? Temperature checks at building entrances? It would be very, very good to know this, because all of those things have benefits, but also costs. But scientists and public health experts don’t have answers. They know these things work in the aggregate, but not how they overlap and synergize, how behaviors change in response to new rules, and how politics and sociology affect adherence.

That’s why nothing seems to make sense today—indoor dining open, places of worship closed; outdoor playgrounds closed, gyms open; outdoor dining areas open then closed; curfews implemented on bars. In many countries, early measures combined with financial support and rigorous testing, tracing, and isolation programs squashed the disease. The US and Europe did some of the first thing and almost none of the others, dooming those places to a bloody oscillation: Cases spike, lockdowns come, economies and mental health crash, places reopen, cases spike, repeat. And now, well, we are where we are.

In the initial months of the pandemic, everybody blew it. “Ideally, you want interventions that have maximal effectiveness with the least social and economic downside,” says Lawrence Gostin, director of the O’Neill Institute for National and Global Health Law at Georgetown University. “That’s the rational way of doing it. But there’s been no rationality around fighting this pandemic, particularly in the United States and Europe.”

Public health experts know, in the broadest terms, what measures will bend the curve, but the science of it is really more of an art. Every country around the world rolled out roughly similar sets of public health interventions to fight Covid-19 in roughly the same order, at roughly the same moments in their encounters with the disease. According to research led by Thomas Hale at the Blavatnik School of Government at Oxford, most countries started communicating to their citizens in February about the potential problems to come, and instituted border controls even before they had confirmed cases. About 25 days later, in mid-March, countries started canceling public events and closing schools, and then closing workplaces five days after that. Four days after that, on average, came stay-at-home orders and public transportation closures—lockdowns.

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