After more than a year of pandemic, after months of an aggressive vaccination campaign, the United States should finally be better positioned to protect itself against the coronavirus. Nearly all of our long-term-care residents are vaccinated. Tens of millions of other people have been vaccinated, and tens of millions more have some level of immunity from previous infection. With more people protected, a new surge could behave differently, but early signals from the states with rising case numbers suggest that this will not universally be the case.
Just look at Michigan, the leading edge of this new surge. Cases are going up quickly, and hospitalizations are moving in lockstep—just as they have in past surges. This is a bit of a surprise. Given that so many older, more vulnerable people have been vaccinated, one might expect a divergence in the number of cases and hospitalizations. For the immunized, this disease is essentially harmless. Washington State, for example, has reported just 100 cases and as few as eight hospitalizations among its 1.2 million fully vaccinated people. But for the vulnerable and unvaccinated, COVID-19 is as devastating as it has always been.
The United States is entering a new phase of the pandemic. Although we’ve previously described the most devastating periods as “waves” and “surges,” the more proper metaphor now is a tornado: Some communities won’t see the storm, others will be well fortified against disaster, and the most at-risk places will be crushed. The virus has never hit all places equally, but the remarkable protection of the vaccines, combined with the new attributes of the variants, has created a situation where the pandemic will disappear, but only in some places. The pandemic is or will soon be over for a lot of people in well-resourced, heavily vaccinated communities. In places where vaccination rates are low and risk remains high, more people will join the 550,000 who have already died.
Cases are rising sharply in several different cities, but the patterns look different. In Michigan, some smaller, whiter counties have vaccination rates twice as high as in Detroit, where rising cases are concentrated and the vaccination rate among the city’s mostly Black population is still low. According to national survey data, in line with political divergences over masks and social distancing, vaccine hesitancy is now highest among Republicans and white evangelical Christians. In Philadelphia, zip codes that are relatively whiter but have lower educational attainment have experienced the most case growth over the past 30 days. Baltimore’s outbreak is growing too, but the data are messy.
In these places, and in other hot spots around the country, the rise in cases is an acute crisis that public-health officials should battle with all the available tools, as my colleague Zeynep Tufekci noted this week. CDC Director Rochelle Walensky spent her weekly press conference on Monday pleading with the American people, noting “the recurring feeling I have of impending doom.” She asked the country to “work together to prevent a fourth surge,” and compared the pandemic’s path here to the experience of Germany, Italy, and France, where cases have spiked dramatically in the past few weeks.
But the United States might chart its own, very unequal track in the coming weeks. Three distinct factors are now shaping this country’s pandemic experience.
First, the United States did a terrible job preventing transmission of the disease. The country's level of excess death—the margin over the number of deaths expected in a typical year—has been high, signaling that the pandemic's true toll has been even steeper than the officially tabulated COVID-19 deaths. Most other countries did not experience the same levels of consistent transmission. A year of unchecked spread means that our 30 million reported cases are a fraction of the total number of people who have been infected. Most estimates place the number closer to 100 million, and possibly tens of millions more.
So unlike in Germany, for example, which fairly effectively suppressed the virus, tens of millions of people in the U.S. have some level of immunity. While reinfection may be more common with some current or future variants, it has been rare so far. That high level of past infection should now help reduce transmission of the virus via population immunity.
Second, the U.S. is vaccinating people quite efficiently. It has given out the largest absolute number of doses in the world, and trails only a few much smaller countries (Israel, the U.K., and Chile among them) in the percentage of the population that’s been vaccinated. Almost three-quarters of the U.S. population over 65 has received at least one dose of the vaccine, with nearly half now fully inoculated. On a percentage basis, the U.S. has immunized nearly three times the number of people that Germany, Italy, and France have, and in two months, the U.S. will almost certainly have a very large percentage of vaccinated adults.
Third, the virus has had staggeringly unequal effects on the American population. For a person of a given age, the risk for certain racial and ethnic groups is several times that of a white person. Native American, Latino, Pacific Islander, and Black communities have suffered large and deadly outbreaks across the country. Our heterogeneous population and racialized economic hierarchy have exposed many people of color to higher levels of risk at home and at work. The same factors—as well as, perhaps, distrust of the medical establishment—are holding down vaccination rates in poorer places with less access to care. So some communities have both higher risk and fewer fully protected people.
This all makes for an extremely messy and volatile near-term situation. The first two factors mean that some places will see the pandemic’s worst pressures fade. The timing is great for those places, such as California, because they will have a chance to get more and more people vaccinated. But where the virus is already spreading quickly, the danger is still high, and the days are running out to slow transmission via vaccination.
In these places, it’s still unclear if previous disease or new vaccination will shift the pandemic’s darkest pattern. In every previous surge, a rise in deaths has lagged behind a rise in cases by a few weeks. Perhaps this time deaths will not rise to the level that they did in the past. Or low vaccination rates combined with possibly more deadly variants could mean that in some communities, the toll of this surge will match that of the winter’s.
In Michigan, both hospital admissions and cases are moving swiftly toward the height of the winter peak. So far, the fatality numbers have not turned upward. Now we can only wait to see if deaths will follow hospitalizations at the pace of past surges—or if something has changed.