And just like that, the national attitude on COVID is flipping like a light switch. As the United States descends the bumpy back end of the Omicron wave, governors and mayors up and down the coasts are extinguishing indoor mask mandates and pulling back proof-of-vaccination protocols. In many parts of the country, restaurants, bars, gyms, and movie theaters are operating at pre-pandemic capacity, not a face covering to be seen; even grade schools and universities have started to relax testing and isolation rules. These policy pivots mirror a turn in public resolve: Two years into the pandemic, many Americans are ready to declare the crisis chapter of COVID-19 over, and move on to the next.
We can debate ad nauseam whether these rollbacks are premature. What’s far clearer is this: We’ve been at similar junctures before—at the end of the very first surge, again in the pre-Delta downslope. Each time, the virus has come roaring back. It is not done with us. Which means that we cannot be done with it.
What’s up ahead is not COVID’s end, but the start of our control phase, in which we invest in measures to shrink the virus’s burden to a more manageable size. “This is the larger, longer game we’re having to think about,” Jennifer Nuzzo, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health, told me.
To even think of controlling COVID for the long term means knocking up against some of the limits of our knowledge. Our future will depend both on the virus’s continued evolution, impossible to predict right now, and on our response, which will hinge on the strength of our resources and our willingness to deploy them. Every disease that troubles us prompts some sort of reaction; for this one, the nation is still deciding how much to invest. Control, then, can’t mean putting the virus behind us—quite the opposite. It means keeping tabs on it, even when it’s not terribly abundant; it means building and maintaining an arsenal of weapons to fight it; it means having the resources and sociopolitical will to react rapidly when the threat returns. Monitor, then intervene, then monitor, then intervene.
Taking this challenge seriously—trying to properly contain a deadly, fast-moving, shape-shifting virus that has spent the past two years walloping us—could require a revamp of the standard American approach to quelling disease, on a scale the nation’s never managed before. We’ll have to write a brand-new public-health playbook, and figure out a way to execute it.
Control is a simple word that, in the realm of infectious disease, doesn’t come with a sharp definition. It is possible, in some cases, to roughly anchor the concept to epidemiological goals—cutting cases of X disease by Y percentage by Z year, say; organizations such as the World Health Organization have set benchmarks like this for the control of measles, malaria, and tuberculosis. For COVID, too, we may eventually agree upon “milestones to measure where you’re at,” Wafaa El-Sadr, an epidemiologist at Columbia University, told me. But hard numbers are not necessary to define a control program, says David Heymann, an epidemiologist and global-health expert at the London School of Hygiene and Tropical Medicine. What unites diseases that are under control is human effort—a sustained commitment to restrain a pathogen, and hack away at its harms.
Controlled diseases, then, might be better imagined as ones that “do not impact a lot of social functions, and do not drastically exacerbate inequities,” Saad Omer, an epidemiologist and global-health expert at Yale University, told me. Control manages a threat down into something that society can accept day after day after day—practically, less disease, less death, less suffering than might otherwise occur. It is “how we talk about diseases we’re doing something about,” says Ellie Murray, an epidemiologist at Boston University.
With COVID, one of the only things we can be sure about is that control will be difficult. The coronavirus spreads stealthily and speedily, and can hop among many animal species; it shape-shifts frequently, such that our immune systems have trouble keeping track. All of this will make it tougher to suppress. But with the tools we have—among them vaccines, treatments, tests, masks, and air filtration—a less chaotic reality than the one we’re living now also remains within reach. Exactly what degree of control is possible will depend on the precise (and still-evolving) potency of those tools—the durability of shot-induced protection, for instance—and how broadly and equitably we can distribute them. Control’s timeline can also stretch extraordinarily long. After millennia of coexistence with the bacterium that causes tuberculosis, which kills some 1.5 million people a year, humanity is still trying to diminish its staggering global burden.
We also know that COVID control won’t be static. At this point, we can expect disease to wax and wane. But bringing the virus to heel, and keeping it there, will require monitoring it even when it appears scarce. That starts with a commitment to surveillance—tracking where and in whom the virus is circulating, how quickly its levels are rising, and whether a new version poses an additional threat. The granular details that surveillance offers can help policy makers plan a response. Early blips of a variant that’s highly immune evasive, for instance, might demand a different response (consider updating the vaccines) than one that’s primarily pummeling the unvaccinated, elderly, and immunocompromised (boost the vulnerable, and shield them to squelch further spread). “The virus will dictate a lot of the terms,” Omer said.
That doesn’t mean counting every case. But it does mean improving our capacity for testing, and being more systematic about whom and what in the population we’re surveying—and not just in the midst of a surge. Flu can offer us a starter package, at least technologically: The globe is freckled with surveillance sites designed to track where flu viruses are percolating, and what mutations they’re accumulating; in the U.S., an intricate network of hospitals, laboratories, and state and local health departments regularly shuttle samples and symptom data from flu patients to the CDC for analysis. To build capacity for COVID, we’ll need better ways to zero in on infections, Nuzzo, of Johns Hopkins, told me—ones that aren’t biased by who’s seeking out tests or who has access to medical care. “We need a representative sampling scheme to know what we’re looking at, as it’s happening,” she said. The more sensitive these systems are, the faster they’ll be able to signal that a viral comeback is nigh.
Periods of relative calm, too, offer opportunities for institutions to prepare for the next difficult stretch. Medical infrastructure will need some suturing. Should COVID become a winter disease, it will slam us when many other pathogens do. “We need to make sure our health-care systems are able to meet demand,” Crystal Watson, a senior scholar at the Johns Hopkins Center for Health Security, told me. There’s no single or easy solution for this, but we could start with building more flexibility into the systems we use to treat the sick. Staffing shortages could be patched with a supplemental workforce, while hospitals offer retention packages; mental-health resources could ease burnout in overtaxed personnel. Trained teams of community health workers could help bridge gaps in communication, and deliver care to where it’s often been lacking, says Camara Jones, an epidemiologist and an anti-racism researcher at UC San Francisco. At the same time, the federal government could funnel funds into developing and maintaining stocks of high-quality masks, tests, and over-the-counter antiviral pills, with a particular focus on ferrying tools to high-risk settings—long-term-care facilities, prisons, and the like—so that they could be speedily distributed “right when surges start,” Anne Sosin, a rural-health expert at Dartmouth College, told me.
Proper ventilation in public spaces, as my colleague Sarah Zhang has written, could also be key to COVID control. Done well, systematically decontaminating our air can exemplify public-health intervention at its best—one so constant, invisible, and ubiquitous that people can be protected without even knowing it, “the difference between everyone boils their own water versus we have clean water everywhere,” Whitney Robinson, an epidemiologist at the University of North Carolina at Chapel Hill, told me. But society-wide overhauls of infrastructure tend to be slow going. Schools, for instance, have been billed as an especially important target for these upgrades, but the pandemic funds that might drive such changes have plenty of other pressing uses too. And specific indoor-air-quality standards could push lawmakers to update building codes, but these, too, have been sluggish to arrive.
Our country’s immunity will need shoring up as well. In the United States, too many people remain unvaccinated, among them 19 million kids under 5, who are still ineligible for their shots. Demand for boosters has been tepid, and people who are older or immunocompromised don’t always respond to their first dose. The situation abroad is even more dire; many nations still struggle to access the supply to deliver first doses, much less seconds or thirds. And the more susceptible hosts it finds, the more SARS-CoV-2 will split itself into new and dangerous forms. For Jones, the biggest near-term goal is to, as “expeditiously as possible, vaccinate the world,” she told me. Even after the foundations of protection are established, they will need updates, whether because our defenses against infection are dropping, because a surprise variant has arrived on the scene, or both. Going forward, vaccine mandates may have a heightened role to play, as certain businesses, schools, or entire jurisdictions try to buoy uptake, says Jason Schwartz, a vaccine-policy expert at Yale. The policy is controversial, but the United States already has centuries of precedent to guide it, and thanks to flu shots, has long harbored the infrastructure to roll vaccines out en masse, and at a regular clip. If that capacity is partnered with policies that help close equity gaps, population immunity could soar. Ensuring that everyone’s up to date on their shots, Schwartz told me, is how we generate a lasting “baseline of protection.”
Not all COVID interventions can simply come on and stay on. Some tools operate at the individual level, and these are the control-phase wild cards. Their success depends not only on capacity and planning but on public acceptance. Protections won’t work if no one is willing to adopt them.
If control is a moving target, then there’s little question that response must shift in lockstep with the threat. Several experts told me we could reasonably expect a future in which we abide by a tiered system of response, with the stringency of public-health measures titrated to how much virus is around. “The idea is that you can have gradations of every policy, rather than just taking everything on or off,” Abraar Karan, an infectious-disease physician and global-health expert at Stanford University, told me. Such a system might be roughly analogous to how we categorize and respond to hurricanes. Most of the time, life can proceed as usual, our tools on standby, our surveillance systems whirring. But as soon as danger begins to brew, protections may start to kick back into place.
The mechanics of bringing such a system online hinge on three big questions. The first is about thresholds—determining what viral conditions merit what protective responses, and when those measures get rolled out or pulled back. Options abound: new cases per 100,000 people? Test positivity? Hospital capacity? A sharp upswing in viral particles, picked up by wastewater monitoring? First we have to choose one metric, or a combination, then set careful benchmarks to distinguish fine from less fine from way less fine from actually, that’s quite bad. But each option has its flaws. Case counts depend on people showing up for limited available tests and aren’t representative of the larger population; hospitals fill too late to nip a blooming surge in the bud and don’t capture less severe cases; wastewater analysis is fast and reliable, but too coarse to show who’s getting infected and how bad their symptoms are. “No one has pulled out a magic formula for switching measures on and off,” Omer said. And different parts of the country will probably come to different conclusions.
Even if we manage to reach a consensus on cues, there’s not a lot of obvious intuition about the second big question: which precautions should take priority. With COVID, the manual’s still being written, but it could go something like this: Say there’s a surge next winter. An initial upswing in cases might prompt your company holiday party to, once again, require employees to test to attend; your local grocery store to, once again, ask that you mask. Local leaders might set up mask- and test-distribution centers throughout the community so residents can grab and go. These early pivots put the focus on the tools that are, in theory, lower-effort investments that don’t impede much mingling and help keep most businesses afloat. The leading edge of a wave is also an essential time to buttress blanket protections: If older or immunocompromised individuals have skipped boosters, they might be nudged to catch up; if hospitals are running low on personnel, reinforcements might be rallied and deployed. “We don’t waste the lead time we’re given,” Omer said. Should all go well at this stage, the outbreak could quickly be quashed.
But if cases continue to climb, if ICUs begin to fill, if a new variant starts to sidestep the protection that vaccines or previous infections left behind, those are signals to go stricter. New vaccine mandates or booster requirements could kick in. Government or business owners could put in place capacity limits in restaurants and entertainment venues, flip to work-from-home policies, or amend travel protocols, to ensure that the outbreak doesn’t spiral out of control. As a last resort, policy makers could consider shutting entire swaths of society down—closing schools and other essential institutions, Celine Gounder, an infectious-disease specialist and epidemiologist, and a senior fellow at Kaiser Health News, told me. “Things would have to really get bad for that,” she said: “basically, if we get to the point where hospitals are not able to function.”
The trick is balancing public well-being with palatability. Which raises the third, and thorniest, issue: Who gets to make these decisions, and who bears the cost if plans go awry? “That’s what it ultimately comes down to: how much of what we’re doing is mandatory versus motivated by personal risk-based decisions,” Nuzzo told me. Certainly, if deaths are skyrocketing, if health-care systems are near the point of collapse, governments will need to step in. Where experts start to diverge, though, is on questions of who’s in charge at every other stage—whether governments or individual members of the public should conduct the brunt of risk assessment and management.
Mandates are the business of leadership. Their strength is that they “reach more people,” Julia Raifman, a health-policy expert at Boston University, told me. “And they reach them more equitably.” A coordinated response, helmed by leaders with money and a platform, can present a unified front against an incoming threat, and offer people clear-cut guidelines to follow. Denmark, which recently announced that it was lifting nearly all of its COVID restrictions, has embarked on a rather extreme version of this tactic, its government repeatedly removing and reimposing restrictions as circumstances shift. At its best, such a strategy can be especially well aligned with an infectious threat: Collective danger merits collective response.
But totally extracting personal choices from the equation of disease prevention is impossible. Adherence to mandates and long-term investments in protective behaviors are “tied to the levels of trust” we have in one another and in the people who lead us, Tom Bollyky, the director of the global-health program at the Council on Foreign Relations, told me. He and his colleagues have found that in outbreaks past and present, trust in government seems to buoy vaccination rates and the adoption of infection-prevention behaviors—such as hand-washing and physical distancing—thus curbing contagion. In the U.S., with its streak of individualism and eroded confidence in the government, the chances of following the Danish model appear essentially shot. Plus, policies that are constantly switching from on to off run the risk of losing public interest each time they flicker. In the United States, decisions about mandates have also been left up to states, even to local jurisdictions, seeding a patchwork of policies. Many Americans have had to wearily navigate the chaos of living in a masks required neighborhood and working in a masks not required one.
For these reasons and more, several other experts are wary of a mandate-forward approach. Nuzzo’s among them. “We have to be sparing with what we’re asking people to do,” Nuzzo said, both to keep people invested and to preserve their stamina for the next infectious crisis. Schwartz, of Yale, feels similarly. Most mandates are a lever to be pulled “in case of emergency” and, generally speaking, are far too great a sledgehammer to wield at other times.
When it comes to daily-use interventions, such as masks, Watson, of Johns Hopkins, thinks that Americans might feel better if they’re told it’s okay to strike out on their own; such an idea could even be actively empowering, if people feel that they’re able to make informed choices in times of crisis. Heymann, of the London School of Hygiene and Tropical Medicine, says a version of this is now in place in England. “The government shifted risk assessment and risk management to the individual,” he told me. Masks, tests, and vaccines are widely available to residents; people are advised to cover their faces in certain crowded settings, but there’s no outright legal requirement under most circumstances. Should Americans follow suit, Watson imagines they might benefit from a tool to help guide personal, day-to-day choices—something like “a weather forecast for infectious disease,” which might take the form of a computer- or smartphone-accessible feed of data on local viral conditions. The precursors for a system like that are already taking root at the CDC, and with information in hand, she thinks that “people will take their own actions to protect themselves.” In the same way that weather apps issue winter-storm advisories, or flag high local pollen counts, governments could flag that a ton of virus is in the vicinity, and recommend precautions.
Still, Watson and Schwartz admit that a system like this has no precedent—it would be a “large-scale reimagining of how we think about prevention,” Schwartz said. Americans have never had to be so keenly aware of how much of a respiratory virus is bopping around. And not everyone will be eager or able to opt in. Many will simply lack the time or resources to check such a forecast, much less act on the intel, especially if access to masks, air filtration, and tests remains “a premium” in this country, Deshira Wallace, a health-equity researcher at UNC Chapel Hill, told me. And while the weather provides its own feedback—precipitation is visible and audible; temperature can be felt—viruses elude our senses, so their perils are harder to gauge. They’re much more insidious. One person’s ignoring a rainy forecast risks only that they get wet, but an individual’s negligence in responding to infectious disease can sicken both them and someone else.
This is the problem with wrangling viruses: They do not obey the boundaries of bodies, or of cities or states. When they spill between people and communities, they ratchet up everyone’s risk. In the face of collective risk, the better bet will be at least to choose some policy, with the understanding that we’ll have to tweak and finagle it, rather than select door No. 3—total inaction, an opportunity for the virus to run roughshod over us because we simply let it.
Disease control, when it’s done right, is as much a social undertaking as it is a scientific one. Weak social infrastructures can derail containment and push goals out of reach. But just as neglect can augment burdens, investment can diminish them. “Public health travels at the speed of trust,” Dartmouth’s Sosin told me.
Even when state or federal governments falter, trust can still be forged. Springfield, Missouri, vanished its masking requirements in May 2021, and “I don’t think we’ll ever go back,” Cora Scott, the city’s director of public information and civic engagement, told me. But she said she and her team feel that they’re still making inroads on mitigation by recruiting local messengers. For months, they’ve been pouring resources into getting the city’s still-low vaccination rates up—an initiative that’s included sending public-health personnel door-to-door.
Leveraging the strength of communities will be an essential strategy in the months and years to come. For a long time now, American confidence in government has been troublingly low. But people still place immense trust in their own health-care providers, for instance—the individuals who feel close to home. And the tactic has played a role in halting outbreaks before. Bollyky points out that partnerships between local and national leaders, bulwarked by community liaisons, helped turn the tide during the 2014 outbreak of Ebola in Guinea, Liberia, and Sierra Leone. Key to all of this is “paying attention to the specific needs of individual communities,” Andrea Milne, a medical historian at Case Western Reserve University, told me, and tailoring policies to suit them. What works to stamp out misinformation in Guinea won’t necessarily be what gets shots into arms in Springfield. Locals will understand those differences best, and know how to navigate through them.
HIV, too, offers an example of a virus that can be well managed via a community-centered approach, El-Sadr, of Columbia, said. In the past four decades, infections have become more bearable through the development of powerful and readily available antivirals and tests that can be taken at home, through routine surveillance for infections, and through public investment, education, and partnerships with the communities most severely affected by disease. Milne points to the San Francisco Model of AIDS care, which has centered a “multisystem, holistic approach” in beating the city’s epidemic back. Even in its early days, the program focused not just on clinical care but on “getting food to people, and making sure people could afford bus rides to the doctor,” she said. “Community members were doing the educating. People were treated not just as patients, but as agents in this health-care work.” In the years since the model’s debut, new HIV diagnoses in San Francisco have plummeted.
SARS-CoV-2 is an entirely different pathogen, but our current response to it risks rehashing some of the failures of the early HIV response, shifting the burden of suffering to the vulnerable. The task of taming this new threat, El-Sadr told me, can and should bear hallmarks to the successful strategies we’ve leaned on before. There’s even opportunity to riff and expand on the templates that past pandemics have offered: to introduce paid sick leave and food assistance; to speed the development of safer housing options; to meet the needs of people who are chronically ill, immunocompromised, and disabled; to address the inequities that have concentrated suffering in marginalized populations, both domestically and abroad. Pandemics are an opportunity to respond in the present but also prepare for the future. And if SARS-CoV-2 sparks its own revolution, that won’t be the first time a virus has catalyzed lasting change. “When there’s no trust, it’s often because people feel they haven’t been listened to,” El-Sadr said. “In the HIV world, we always say, ‘Nothing about us without us’”—no decisions should be made about the fate of a particular group of people without their involvement. “I think that’s at the core of it.” It’s true that some of the best public-health interventions are ones we don’t notice. But others succeed precisely because they enlist people’s attention and use it.