[image: Coronavirus testing at a site in Los Angeles last week. The
pathogen has infected at least 4.3 million Americans, killing almost
Coronavirus testing at a site in Los Angeles last week. The pathogen has
infected at least 4.3 million Americans, killing almost 150,000. Credit...Jenna
Schoenefeld for The New York Times
A Viral Epidemic Splintering Into Deadly Pieces

There’s not just one coronavirus outbreak in the United States. Now there
are many, each requiring its own mix of solutions.
[image: Donald G. McNeil Jr.]

By Donald G. McNeil Jr. <>
July 29, 2020

As of Wednesday, the pathogen had infected at least 4.3 million Americans,
killing more than 150,000. Many experts fear the virus could kill 200,000
even 300,000
by year’s end. Even President Trump has donned a mask, after resisting for
months, and has canceled the Republican National Convention
celebrations in Florida.

Each state, each city has its own crisis driven by its own risk factors:
vacation crowds in one, bars reopened too soon in another, a revolt against
masks in a third.

“We are in a worse place than we were in March,” when the virus coursed
through New York, said Dr. Leana S. Wen
a former Baltimore health commissioner. “Back then we had one epicenter.
Now we have lots.”

To assess where the country is heading now, The New York Times interviewed
20 public health experts — not just clinicians and epidemiologists, but
also historians and sociologists, because the spread of the virus is now
influenced as much by human behavior as it is by the pathogen itself.

Not only are American cities in the South and West facing deadly outbreaks
like those that struck Northeastern cities in the spring, but rural areas
are being hurt, too. In every region, people of color will continue to
suffer disproportionately
experts said.

While there may be no appetite for a national lockdown, local restrictions
must be tightened when required, the researchers said, and governors and
mayors must have identical goals. Testing must become more targeted.

In most states, contact tracing is now moot — there are simply too many
cases to track. And while progress has been made on vaccines
none is expected to arrive this winter in time to stave off what many fear
will be a new wave of deaths.

Overall, the scientists conveyed a pervasive sense of sadness and
exhaustion. Where once there was defiance
and then a growing sense of dread
now there seems to be sorrow and frustration, a feeling that so many
funerals never had to happen and that nothing is going well. The United
States is a wounded giant, while much of Europe, which was hit first,
is recovering
and reopening
— although not to us

“We’re all incredibly depressed and in shock at how out of control the
virus is in the U.S.,” said Dr. Michele Barry
<>, the director of the Center
for Innovation in Global Health at Stanford University.

With so much wealth and medical talent, they asked, how could we have done
so poorly
How did we fare not just worse than autocratic China and isolated New
Zealand, but also worse than tiny, much poorer nations like Vietnam and

“National hubris and belief in American exceptionalism have served us
badly,” said Martha L. Lincoln
<>, a medical
anthropologist and historian at San Francisco State University. “We were
not prepared to see the risk of failure.”
What We’ve Learned
[image: Homemade masks for sale in Dinuba, Calif., earlier this month.]
Homemade masks for sale in Dinuba, Calif., earlier this month. Credit...Ryan
Christopher Jones for The New York Times

Since the coronavirus was first found to be the cause of lethal pneumonias
in Wuhan, China, in late 2019, scientists have gained a better
understanding of the enemy.

It is extremely transmissible, through not just coughed droplets but also a
fine aerosol mist that is expelled when people talk loudly, laugh or sing
<> and
that can linger in indoor air
As a result, masks are far more effective
than scientists once believed.

Virus carriers with mild or no symptoms can be infectious, and there may be
10 times
many people spreading the illness
as have tested positive for it.

The infection may start in the lungs, but it is very different from
influenza, a respiratory virus. In severely ill patients, the coronavirus
may attach to receptors inside the veins and arteries, and move on to
attack the kidneys, the heart, the gut and even the brain, choking off
these organs with hundreds of tiny blood clots.

Most of the virus’s victims are elderly, but it has not spared young adults
especially those with obesity, high blood pressure or diabetes. Adults aged
18 to 49 now account for more hospitalized cases
<> than people aged 50 to
64 or those 65 and older.

Children are usually not harmed
<> by
the virus, although clinicians were dismayed to discover a few who were
struck by a rare but dangerous
Young children
appear to transmit the virus less often than teenagers
which may affect how schools can be opened.

Among adults, a very different picture has emerged. Growing evidence
suggests that perhaps 10 percent of the infected account for 80 percent of
new transmissions
Unpredictable superspreading events in nursing homes, meatpacking plants,
churches, prisons and bars are major drivers of the epidemic.

Thus far, none of the medicines for which hopes were once high — repurposed
malaria drugs, AIDS drugs and antivirals — have proved to be rapid cures.
One antiviral, remdesivir, has been shown to shorten hospital stays
while a common steroid, dexamethasone, has helped save some severely ill

One or even several vaccines may be available by year’s end, which would be
a spectacular achievement. But by then the virus may have in its grip
virtually every village and city on the globe.
Solutions Must Be Localized
[image: A closed outdoor gym in Miami earlier this month. Florida and
California now have reported more coronavirus infections than New York
State, once the epicenter of the epidemic.]
A closed outdoor gym in Miami earlier this month. Florida and California
now have reported more coronavirus infections than New York State, once the
epicenter of the epidemic. Credit...Scott McIntyre for The New York Times

Some experts, like Michael T. Osterholm, the director of the University of
Minnesota’s Center for Infectious Disease Research and Policy, argue that
only a nationwide lockdown can completely contain the virus now. Other
researchers think that is politically impossible, but emphasize that
localities must be free to act quickly and enforce strong measures with
support from their state capitols.

Danielle Allen <>, the
director of Harvard University’s Edmond J. Safra Center for Ethics, which
has issued pandemic response plans
<>, said that finding
less than one case per 100,000 people means a community should continue
testing, contact tracing and isolating cases — with financial support for
those who need it.

Up to 25 cases per 100,000 requires greater restrictions, like closing bars
and limiting gatherings. Above that number, authorities should issue
stay-at-home orders, she said.

Testing must be focused, not just offered at convenient parking lots,
experts said, and it should be most intense in institutions like nursing
homes, prisons, factories or other places at risk of superspreading events.

Testing must be free in places where people are poor or uninsured, such as
public housing projects, Native American reservations and churches and
grocery stores in impoverished neighborhoods.

None of this will be possible unless the nation’s capacity for testing, a
continuing disaster, is greatly expanded. By the end of summer, the
administration hopes to start using “pooling,” in which tests are combined
in batches
to speed up the process.

But the method only works in communities with lower infection rates, where
large numbers of pooled tests turn up relatively few positive results. It
fails where the virus has spread everywhere, because too many batches turn
up positive results that require retesting.

At the moment, the United States tests roughly 800,000 people per day
about 38 percent of the number some experts think is needed.

Above all, researchers said, mask use should be universal indoors —
including airplanes, subway cars and every other enclosed space — and
outdoors anywhere people are less than six feet apart.

Dr. Emily Landon, an infection control specialist at the University of
Chicago Pritzker School of Medicine, said it was “sad that something as
simple as a mask got politicized.”

“It’s not a statement, it’s a piece of clothing,” she added. “You get used
to it the way you got used to wearing pants.”

Arguments that masks infringe on personal rights must be countered both by
legal orders and by persuasion. “We need more credible messengers endorsing
masks,” Dr. Wen said — just before the president himself became a messenger.

“They could include C.E.O.s or celebrities or religious leaders. Different
people are influencers to different demographics.”

Although this feels like a new debate, it is actually an old one. Masks
were common in some Western cities
during the 1918 flu pandemic and mandatory in San Francisco. There was even
a jingle
“Obey the laws, wear the gauze. Protect your jaws from septic paws.”

“A libertarian movement, the Anti-Mask League
emerged,” Dr. Lincoln of San Francisco State said. “There were fistfights
with police officers over it.” Ultimately, city officials “waffled” and
compliance faded.

“I wonder what this issue would be like today,” she mused, “if that hadn’t

Images of Americans disregarding social distancing requirements have become
a daily news staple. But the pictures are deceptive: Americans are more
accepting of social distancing than the media sometimes portrays, said Beth
Redbird, a Northwestern University sociologist
who since March has conducted regular surveys <>
of 8,000 adults about the impact of the virus.

“About 70 percent of Americans report using all forms of it,” she said.
“And when we give them adjective choices, they describe people who won’t
distance as mean, selfish or unintelligent, not as generous, open-minded or

The key predictor, she said in early July, was whether or not the poll
respondent trusted Mr. Trump. Those who trusted him were less likely to
practice social distancing. That was true of Republicans and independents,
“and there’s no such thing as a Democrat who trusts Donald Trump,” she

Whether or not people support coercive measures like stay-at-home orders or
bar closures depended on how scared the respondent was.

“When rising case numbers make people more afraid, they have more taste for
liberty-constraining actions,” Dr. Redbird said. And no economic recovery
will occur, she added, “until people aren’t afraid. If they are, they won’t
go out and spend money even if they’re allowed to.”
The Danger Indoors
[image: Closing a bar in Houston on June 27, after Gov. Greg Abbott ordered
a partial re-closing of Texas.]
Closing a bar in Houston on June 27, after Gov. Greg Abbott ordered a
partial re-closing of Texas. Credit...Erin Trieb for The New York Times

As of Wednesday, new infections were rising in 33 states, and in Puerto
Rico and the District of Columbia, according to a database maintained by
The Times.

Weeks ago, experts like Dr. Anthony S. Fauci, the director of the National
Institute for Allergy and Infectious Diseases, were advising
where the virus was surging to pull back from reopening by closing down
bars, forbidding large gatherings and requiring mask usage.

Many of those states are finally taking that advice, but it is not yet
clear whether this national change of heart has happened in time to stop
the newest wave of deaths from ultimately exceeding the 2,750-a-day peak of
mid-April. Now, the daily average is 1,106 virus deaths nationwide.

Deaths may surge even higher, experts warned, when cold weather, rain and
snow force Americans to meet indoors, eat indoors and crowd into public

Oddly, states that are now hard-hit might become safer, some experts
suggested. In the South and Southwest, summers are so hot that diners seek
air-conditioning indoors, but eating outdoors in December can be pleasant.

Several studies have confirmed transmission in air-conditioned rooms. In
one well-known case cluster
in a restaurant in Guangzhou, China, researchers concluded that
air-conditioners blew around a viral cloud, infecting patrons as far as 10
feet from a sick diner.

Rural areas face another risk. Almost 80 percent of the country’s counties
lack even one infectious disease specialist, according to a study
<> led by Dr. Rochelle
Walensky <>, the
chief of infectious diseases at Massachusetts General Hospital in Boston.

At the moment, the crisis is most acute in Southern and Southwestern
states. But websites that track transmission rates <> show
that hot spots can turn up anywhere. For three weeks, for example, Alaska’s
small outbreak has been one of the country’s fastest-spreading, while
transmission in Texas and Arizona has dramatically slowed.

Deaths now may rise more slowly than they did in spring, because
hospitalized patients are, on average, younger this time. But overwhelmed
hospitals can lead to excess deaths from many causes
all over a community, as ambulances are delayed and people having health
crises avoid hospitals out of fear

The experts were divided as to what role influenza will play in the fall. A
harsh flu season could flood hospitals with pneumonia patients needing
ventilators. But some said the flu season could be mild or almost
nonexistent this year.

Normally, the flu virus migrates from the Northern Hemisphere to the
Southern Hemisphere in the spring — presumably in air travelers — and then
returns in the fall, with new mutations that may make it a poor match for
the annual vaccine.

But this year, the national lockdown abruptly ended flu transmission in
late April, according to weekly Fluview reports
<> from the Centers for Disease
Control and Prevention. International air travel has been sharply
curtailed, and there has been almost no flu activity
in the whole southern hemisphere
this year.

Assuming there is still little air travel to the United States this fall,
there may be little “reseeding” of the flu virus here. But in case that
prediction turns out be wrong, all the researchers advised getting flu
shots anyway.

“There’s no reason to be caught unprepared for two respiratory viruses,”
said Tara C. Smith
<>, an
epidemiologist at Kent State University’s School of Public Health.
Partially Effective Remedies
[image: Blood samples for coronavirus research in a lab in New York City.]
Blood samples for coronavirus research in a lab in New York City.
Friedman for The New York Times

Experts familiar with vaccine and drug manufacturing were disappointed
that, thus far, only dexamethasone and remdesivir have proved to be
effective treatments, and then only partially.

Most felt that monoclonal antibodies — cloned human proteins that can be
grown in cell culture — represented the best hope until vaccines arrive.
Eli Lilly and other drugmakers are working on candidates.

“They’re promising both for treatment and for prophylaxis, and there are
companies with track records and manufacturing platforms,” said Dr. Luciana
Borio <>, a former director of
medical and biodefense preparedness at the National Security Council. “But
manufacturing capacity is limited.”

According to a database compiled by The Times, researchers worldwide are
developing more than 165 vaccine candidates
and 27 are in human trials.

New announcements are pouring in, and the pressure to hurry is intense: The
Trump administration just awarded nearly $2 billion to a Pfizer-led
that promised 100 million doses by December, assuming trials succeed.

Because the virus is still spreading rapidly, most experts said “challenge
trials,” in which a small number of volunteers are vaccinated and then
deliberately infected, would probably not be needed.

Absent a known cure, “challenges” can be ethically fraught, and some
doctors oppose doing them for
virus. “They don’t tell you anything about safety,” Dr. Borio said.

And when a virus is circulating unchecked, a typical placebo-controlled
trial with up to 30,000 participants can be done efficiently, she added.
Moderna and Pfizer have already begun such trials.

The Food and Drug Administration has said a vaccine will pass muster even if
it is only 50 percent effective
Experts said they could accept that, at least initially, because the first
vaccine approved could save lives while testing continued on better

“A vaccine doesn’t have to work perfectly to be useful,” Dr. Walensky said.
“Even with measles vaccine, you can sometimes still get measles — but it’s
mild, and you aren’t infectious.”

“We don’t know if a vaccine will work in older folks. We don’t know exactly
what level of herd immunity we’ll need to stop the epidemic. But anything
safe and fairly effective should help.”

Still, haste is risky, experts warned, especially when opponents of
vaccines are spreading fear
If a vaccine is rushed to market
without thorough safety testing and recipients are hurt by it, all vaccines
could be set back for years.
A Focus on People of Color
[image: Ayub Farah working at a drive-through testing site in Houston
earlier this month.]
Ayub Farah working at a drive-through testing site in Houston earlier this
month. Credit...Callaghan O'Hare for The New York Times

No matter what state the virus reaches, one risk remains constant. Even in
states with few Black and Hispanic residents, they are usually hit hardest
experts said.

People of color are more likely to have jobs that require physical presence
and sometimes close contact, such as construction work, store clerking and
nursing. They are more likely to rely on public transit and to live in
neighborhoods where grocery stores are scarce and crowded.

They are
likely to live in crowded housing and multigenerational homes
some with only one bathroom, making safe home isolation impossible when
sickness strikes. They have higher rates of obesity, high blood pressure,
diabetes and asthma.

Federal data
gathered through May 28 shows that Black and Hispanic Americans were three
times as likely to get infected as their white neighbors, and twice as
likely to die, even if they lived in remote rural counties with few Black
or Hispanic residents.

“By the time that minority patient sets foot in a hospital, he is already
on an unequal footing,” said Elaine Hernandez
a sociologist at Indiana University.

The differences persist even though Black and Hispanic adults drastically
altered their behavior. One study found that through the beginning of May,
the average Black American practiced more social distancing
<> than the
average white American.

Officials in Chicago
and other communities faced another threat: rumors flying about social
media that Black people were somehow immune.

The top factor making people adopt self-protective behavior is personally
knowing someone who fell ill, said Dr. Redbird. By the end of spring, Black
and Hispanic Americans were 50 percent more likely than white Americans to
know someone who had been sickened by the virus, her surveys found.

Dr. Hernandez, whose parents live in Arizona, said their neighbors who had
not been scared in June had since changed their attitudes.

Her father, a physician, had set an example. Early on, he wore a mask with
a silly mustache when he and his wife took walks, and they would decline
friends’ invitations, saying, “No, we’re staying in our bubble.”

Now, she said, their neighbors are wearing masks, “and people are telling
my father, ‘You were right,’” Dr. Hernandez said.
This Is the Beginning
[image: A line for coronavirus testing in Atlanta on July 6.]
A line for coronavirus testing in Atlanta on July 6. Credit...Dustin
Chambers for The New York Times

There was no widespread agreement among experts about what is likely to
happen in the years after the pandemic. Some scientists expected a quick
economic recovery; others thought the damage could persist for years.

Working at home will become more common, some predicted, while crowded,
open-plan offices may be changed. The just-in-time supply chains on which
many businesses depend will need fixing because the processes failed to
deliver adequate protective gear, ventilators and test materials.

A disease-modeling system like that used by the National Weather Service
<> to predict storms is needed, said Caitlin Rivers
<>, an
epidemiologist at the Johns Hopkins Center for Health Security. Right now,
the country has surveillance for seasonal flu but no national map tracking
all disease outbreaks. As Dr. Thomas R. Frieden, a former C.D.C. director,
recently pointed out, states are not even required to track
the same data.

Several experts said they assumed that millions of Americans who have been
left without health insurance or forced to line up at food banks would vote
for politicians favoring universal health care, paid sick leave, greater
income equality and other changes.

But given the country’s deep political divisions, no researcher was certain
what the outcome of the coming election would be.

Dr. Redbird said her polling of Americans showed “little faith in
institutions across the board — we’re not seeing an increase in trust in
science or an appetite for universal health care or workers equity.”

The Trump administration did little to earn trust. More than six months
into the worst health crisis in a century, Mr. Trump only last week urged
Americans to wear masks and canceled the Republican convention in Florida,
the kind of high-risk indoor event that states have been banning since

“It will probably, unfortunately, get worse before it gets better,” Mr.
Trump said at the first of the resurrected coronavirus task force briefings
earlier this month, which included no scientists or health officials. The
briefings were discontinued in April amid his rosy predications that the
epidemic would soon be over.

Mr. Trump has ignored
contradicted <> or disparaged
his scientific advisers, repeatedly saying that the virus simply would go
away, touting unproven drugs like hydroxychloroquine even after they were
shown to be ineffective and sometimes dangerous, and suggesting that
disinfectants or lethal ultraviolet light might be used inside the body.

Millions of Americans have lost their jobs
and their health insurance
and are in danger of losing their homes,
as they find themselves in the path of a lethal disease. The Trump
presidency “is the symptom of the denigration of science and the gutting of
the public contract about what we owe each other as citizens,” said Dr.
Joia S. Mukherjee
<>, the
chief medical officer of Partners in Health in Boston.

One lesson that will surely be learned is that the country needs to be
better prepared for microbial assaults, said Dr. Julie Gerberding, a former
director of the C.D.C.

“This is not a once-in-a-century event. It’s a harbinger of things to come.”
[image: Social-distancing signage at Coney Island in Brooklyn in May.]
Social-distancing signage at Coney Island in Brooklyn in May.
Newman/The New York Times