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"Women in West Virginia smoked during pregnancy more than five times as often as women in the states with the lowest prevalence,"

The researchers also found that prevalence of smoking during pregnancy varied by age and race. The prevalence was highest among women 20 to 24 at 10.7%, followed by women 15 to 19 at 8.5% and 25 to 29 at 8.2%.

The prevalence also was highest among non-Hispanic American Indian or Alaska Native women at 16.7%, followed by non-Hispanic white women at 10.5%, non-Hispanic black women at 6%, Hispanic women at 1.8% and non-Hispanic Asian women at 0.6%.

"We still have a serious issue with infant mortality -- prematurity and infant mortality are clearly linked to cigarette smoking, as is low birth weight -- and when you begin to explain these things to patients, it really does appear to make a difference to them," he said.Brown pointed out that some of the states in the new CDC report with the highest prevalence of smoking during pregnancy also tend to have high rates of infant mortality. A CDC data brief released in January showed that, between 2013 and 2015, West Virginia and Kentucky had infant mortality rates higher than the overall national rate.

what the administration should have been doing in January to prepare us for today.

She cites the delay on tests, without which “cases go undetected and people continue to circulate” as a leading issue along with other missed federal government responses—many of which are still not fully operational

The prescient recommendations from experts across disciplines in the period before COVID-19 reached American shores—about testing, equipment, and distancing—make clear that more than any single factor, it was Trump’s squandering of out lead-time which should have been used to prepare for the pandemic that has exacerbated this crisis.

What follows is an annotated timeline revealing the warning signs the administration received and showing how slow the administration was to act on these recommendations.

The Early Years: Warnings Ignored

2017: Trump administrations officials are briefed on an intelligence document titled “Playbook for Early Response to High-Consequence Emerging Infectious Disease Threats and Biological Incidents.” That’s right. The administration literally had an actual playbook for what to do in the early stages of a pandemic

February 2018: The Washington Post writes “CDC to cut by 80 percent efforts to prevent global disease outbreak.” The meat of the story is “Countries where the CDC is planning to scale back include some of the world’s hot spots for emerging infectious disease, such as China, Pakistan, Haiti, Rwanda and Congo.”

May 2018: At an event marking the 100 year anniversary of the 1918 pandemic, Borio says “pandemic flu” is the “number 1 health security issue” and that the U.S. is not ready to respond.

One day later her boss, Rear Adm. Timothy Ziemer is pushed out of the administration and the global health security team is disbanded

Beth Cameron, former senior director for global health security on the National Security Council adds: “It is unclear in his absence who at the White House would be in charge of a pandemic,” Cameron said, calling it “a situation that should be immediately rectified.” Note: It was not

January 2019: The director of National Intelligence issues the U.S. Intelligence Community’s assessment of threats to national security. Among its findings:

A novel strain of a virulent microbe that is easily transmissible between humans continues to be a major threat, with pathogens such as H5N1 and H7N9 influenza and Middle East Respiratory Syndrome Coronavirus having pandemic potential if they were to acquire efficient human-to-human transmissibility.”

Page 21: “We assess that the United States and the world will remain vulnerable to the next flu pandemic or large scale outbreak of a contagious disease that could lead to massive rates of death and disability, severely affect the world economy, strain international resources, and increase calls on the United States for support.”

September, 2019: The Trump Administration ended the pandemic early warning program, PREDICT, which trained scientists in China and other countries to identify viruses that had the potential to turn into pandemics. According to the Los Angeles Times, “field work ceased when funding ran out in September,” two months before COVID-19 emerged in Wuhan Province, China.

2020: COVID-19 Arrives

anuary 3, 2020: The CDC is first alerted to a public health event in Wuhan, China

January 6, 2020: The CDC issues a travel notice for Wuhan due to the spreading coronavirus

Note: The Trump campaign claims that this marks the beginning of the federal government disease control experts becoming aware of the virus. It was 10 weeks from this point until the week of March 16 when Trump began to change his tone on the threat.

January 10, 2020: Former Trump Homeland Security Advisor Tom Bossert warns that we shouldn’t “jerk around with ego politics” because “we face a global health threat…Coordinate!”

January 18, 2020: After two weeks of attempts, HHS Secretary Alex Azar finally gets the chance to speak to Trump about the virus. The president redirects the conversation to vaping, according to the Washington Post. 

January 21, 2020: Dr. Nancy Messonnier, the director of the National Center for Immunization and Respiratory Disease at the CDC tells reporters, “We do expect additional cases in the United States.”

January 27, 2020: Top White House aides meet with Chief of Staff Mick Mulvaney to encourage greater focus on the threat from the virus. Joe Grogan, head of the White House Domestic Policy Council warns that “dealing with the virus was likely to dominate life in the United States for many months.”

January 28, 2020: Two former Trump administration officials—Gottlieb and Borio—publish an op-ed in the Wall Street Journal imploring the president to “Act Now to Prevent an American Epidemic.” They advocate a 4-point plan to address the coming crisis:

(1) Expand testing to identify and isolate cases. Note: This did not happen for many weeks. The first time more than 2,000 tests were deployed in a single day was not until almost six weeks later, on March 11.

(3) Prepare hospital units for isolation with more gowns and masks. Note: There was no dramatic ramp-up in the production of critical supplies undertaken. As a result, many hospitals quickly experienced shortages of critical PPE materials. Federal agencies waited until Mid-March to begin bulk orders of N95 masks.

January 29, 2020: Trump trade advisor Peter Navarro circulates an internal memo warning that America is “defenseless” in the face of an outbreak which “elevates the risk of the coronavirus evolving into a full-blown pandemic, imperiling the lives of millions of Americans.”

January 30, 2020: Dr. James Hamblin publishes another warning about critical PPE materials in the Atlantic, titled “We Don’t Have Enough Masks.”

January 29, 2020: Republican Senator Tom Cotton reaches out to President Trump in private to encourage him to take the virus seriously.

Late January, 2020:  HHS sends a letter asking to use its transfer authority to shift $136 million of department funds into pools that could be tapped for combating the coronavirus. White House budget hawks argued that appropriating too much money at once when there were only a few U.S. cases would be viewed as alarmist.

Trump’s Chinese travel ban only banned “foreign nationals who had been in China in the last 14 days.” This wording did not—at all—stop people from arriving in America from China. In fact, for much of the crisis, flights from China landed in America almost daily filled with people who had been in China, but did not fit the category as Trump’s “travel ban” defined it.

January 31, 2020: On the same day Trump was enacting his fake travel ban, Foreign Policy reports that face masks and latex gloves are sold out on Amazon and at leading stores in New York City and suggests the surge in masks being sold to other countries needs “refereeing” in the face of the coming crisis.

February 4, 2020: Gottlieb and Borio take to the WSJ again, this time to warn the president that “a pandemic seems inevitable” and call on the administration to dramatically expand testing, expand the number of labs for reviewing tests, and change the rules to allow for tests of people even if they don’t have a clear known risk factor.

Note: Some of these recommendations were eventually implemented—25 days later.

February 5, 2020: HHS Secretary Alex Azar requests $2 billion to “buy respirator masks and other supplies for a depleted federal stockpile of emergency medical equipment.” He is rebuffed by Trump and the White House OMB who eventually send Congress a $500 million request weeks later.

February 4 or 5, 2020: Robert Kadlec, the assistant secretary for preparedness and response, and other intelligence officials brief the Senate Intelligence Committee that the virus poses a “serious” threat and that “Americans would need to take actions that could disrupt their daily lives.”

February 5, 2020: Senator Chris Murphy tweets: Just left the Administration briefing on Coronavirus. Bottom line: they aren't taking this seriously enough. Notably, no request for ANY emergency funding, which is a big mistake. Local health systems need supplies, training, screening staff etc. And they need it now.

February 9, 2020: The Washington Post reports that a group of governors participated in a jarring meeting with Dr. Anthony Fauci and Dr. Robert Redfield that was much more alarmist than what they were hearing from Trump. “The doctors and the scientists, they were telling us then exactly what they are saying now,” Maryland Gov. Larry Hogan (R) said.

the administration lifted CDC restrictions on tests. This is a factually true statement. But it elides that fact that they did so on March 3—two critical weeks after the third Borio/Gottlieb op-ed on the topic, during which time the window for intervention had shrunk to a pinhole.

February 20, 2020: Borio and Gottlieb write in the Wall Street Journal that tests must be ramped up immediately “while we can intervene to stop spread.”

February 23, 2020: Harvard School of Public Health professor issues warning on lack of test capability: “As of today, the US remains extremely limited in#COVID19 testing. Only 3 of ~100 public health labs haveCDC test kits working and CDC is not sharing what went wrong with the kits. How to know if COVID19 is spreading here if we are not looking for it.

February 24, 2020: The Trump administration sends a letter to Congress requesting a small dollar amount—between $1.8 billion and $2.5 billion—to help combat the spread of the coronavirus. This is, of course, a pittance

February 25, 2020: Messonier says she expects “community spread” of the virus in the United States and that “disruption to everyday life might be severe.” Trump is reportedly furious and Messonier’s warnings are curtailed in the ensuing weeks.

Trump mocks Congress in a White House briefing, saying “If Congress wants to give us the money so easy—it wasn’t very easy for the wall, but we got that one done. If they want to give us the money, we’ll take the money.”

February 26, 2020: Congress, recognizing the coming threat, offers to give the administration $6 billion more than Trump asked for in order to prepare for the virus.

February 27, 2020: In a leaked audio recording Sen. Richard Burr, chairman of the Intelligence Committee and author of the Pandemic and All-Hazards Preparedness Act (PAHPA) and the Pandemic and All-Hazards Preparedness and Advancing Innovation Act (reauthorization of PAHPA), was telling people that COVID-19 “is probably more akin to the 1918 pandemic.”

March 4, 2020: HHS says they only have 1 percent of respirator masks needed if the virus became a “full-blown pandemic.”

March 3, 2020: Vice President Pence is asked about legislation encouraging companies to produce more masks. He says the Trump administration is “looking at it.”

March 7, 2020: Fox News host Tucker Carlson, flies to Mar-a-Lago to implore Trump to take the virus seriously in private rather than embarrass him on TV. Even after the private meeting, Trump continued to downplay the crisis

March 9, 2020: Tom Bossert, Trump’s former Homeland Security adviser, publishes an op-ed saying it is “now or never” to act. He advocates for social distancing and school closures to slow the spread of the contagion.

Trump says that developments are “good for the consumer” and compares COVID-19 favorably to the common flu.

March 17, 2020: Facing continued shortages of the PPE equipment needed to prevent healthcare providers from succumbing to the virus, Oregon Senators Jeff Merkeley and Ron Wyden call on Trump to use the Defense Production Act to expand supply of medical equipment

March 18, 2020: Trump signs the executive order to activate the Defense Production Act, but declines to use it

At the White House briefing he is asked about Senator Chuck Schumer’s call to urgently produce medical supplies and ventilators. Trump responds: “Well we’re going to know whether or not it’s urgent.” Note: At this point 118 Americans had died from COVID-19.

March 20, 2020: At an April 2nd White House Press Conference, President Trump’s son-in-law Jared Kushner who was made ad hoc point man for the coronavirus response said that on this date he began working with Rear Admiral John Polowczyk to “build a team” that would handle the logistics and supply chain for providing medical supplies to the states. This suggestion was first made by former Trump Administration officials January 28th

March 22, 2020: Six days after calling for a 15-day period of distancing, Trump tweets that this approach “may be worse than the problem itself.”

March 24, 2020: Trump tells Fox News that he wants the country opened up by Easter Sunday (April 12)

As Trump was speaking to Fox, there were 52,145 confirmed cases in the United States and the doubling time for daily new cases was roughly four days.

our risk sensor is fixed to the anxieties and illusions of the 1900s

We’re arming and empowering the police like it’s 1990, when urban crime had reached historic highs. But violent-crime rates have fallen by more than 50 percent in almost every major American city in the past generation, while police still drape themselves in military gear and kill more than 1,000 people annually.

Too many police are instructed to believe that the 20th-century crime wave never ended.

Between the 1960s and the early 1990s, the violent-crime rate in many U.S. cities rose “to levels seen only in the most violent, war-torn nations of the developing world,”

As American cities became perceived as war zones, police responded by adopting a “warrior” mentality.

Then violent crime plunged by more than 70 percent from 1993 to 2018, according to data maintained by the Department of Justice. Although officers routinely face threats that most white-collar workers never will, cops are safer now than at any point in nearly 50 years.

The U.S. has about the same number of police officers per capita as, say, Australia; but adjusted for population, U.S. law enforcement kills 10 times more people.

The message is clear: Be a warrior, because it’s a war out there.

The warrior mentality encourages an adversarial approach in which officers needlessly escalate encounters.

calls the idealization of the warrior “the most problematic aspect of modern [police] policy.”

the CDC had waited “its entire existence for this moment,” but it was so unprepared to deal with COVID-19 that the group initially in charge of the response, the Division of Viral Diseases, had to cede responsibilities to the Influenza Division, despite the fact that COVID-19 is not caused by any kind of influenza virus

Police aren’t just trained to feel like warriors; many are armed for war

Over time, SWAT itself served as a gateway drug for police militarization, as equipment once reserved for special teams, such as AR-15 rifles, were made available to ordinary officers.

the War on Drugs has been roundly discredited as a trillion-dollar failure that incurs thousands of unnecessary deaths. But it has bequeathed us a world where police bearing semiautomatics are armed with the wrong tools for the actual job

“The world has changed dramatically since the most violent years of the 1990s, but police training trails lived experience,”

the U.S. mental-health crisis has been effectively outsourced to the streets, where police who aren’t trained as social workers or behavioral therapists must perform the ad hoc duties of both.

Rather than respond to the drastically changing nature of American life, our cities and counties use police as a civic Swiss Army knife to solve problems such as homelessness and mental-health emergencies that have little to do with police training.

the failures of American police are not unique, but rather a symptom of a broader breakdown in high-quality governance.

Before it stood for the Centers for Disease Control and Prevention, the CDC was founded as the Communicable Disease Center in the 1940s. Its original mission was to stop an epidemic. The organization’s first 400, Atlanta-based employees were tasked with arresting an outbreak of malaria in the Southeast

Today, the center’s 14,000 employees work “at the speed of science”—that is, slowly and deliberately—to understand an array of health issues, including cancer, obesity, and vaping.

its mission creep has transformed what was once a narrowly focused agency into a kaleidoscopic bureaucracy with no fast-twitch instinct for achieving its founding mission to protect Americans from an epidemic.

The CDC’s recent failures are well known, but worth repeating. It failed to keep track of early COVID-19 cases in part because of a leaden-footed reliance on fax machines and other outdated record-keeping technology. It failed to compile accurate case counts, forcing private actors—such as The Atlantic’s COVID Tracking Project—to fill the void. It failed its most basic coordination functions as an agency

Violent crime plays a minuscule role in the day of a modern officer, who spends most of his or her time driving around, taking ho-hum radio calls, and performing the tertiary duties of traffic patroller and mental-health counselor.

Most important, the CDC failed to manufacture basic testing equipment. Its initial test kits were contaminated and unusable, which allowed the disease to spread undetected throughout the U.S. for weeks.

Compare the situation in the U.S. with the one in East Asia, where several countries have navigated the pandemic far more deftly. China, South Korea, Taiwan, Singapore, and Vietnam all updated their infectious-disease protocols based on what they learned from 21st-century epidemics: SARS in 2003, H1N1 in 2009, and MERS in 2012. These countries quickly understood what artillery would be necessary to take on COVID-19, including masks, tests, tracing, and quarantine spaces. Yet the CDC—armed with an $8 billion budget and a global team of scientists and officials—was somehow unprepared to read from the playbook.

The FDA fumbled just as tragically. In January, Alex Greninger, a virologist at the University of Washington, was prepared to build an in-house coronavirus test

By the time Greninger was ready to set up his lab, the calendar had turned to March. Hundreds of thousands of Americans were sick, and the outbreak was uncontrollable.

the White House cannot be entirely blamed for the ponderous incompetence of what ought to be the greatest public-health system in the world.

Not every American institution is trapped in amber. For a perhaps surprising example of one that has adapted to 21st-century needs, take the Federal Reserve.

Ben Bernanke, the Fed chair during the Great Recession, used his expertise about the 1930s economy to avoid a similar collapse in financial markets in 2008. Today’s Fed chair, Jerome Powell, has gone even further, urging Congress and the Treasury to “think big” and add to our already-historic deficits.

the Federal Reserve has junked old shibboleths about inflation and deficit spending and embraced a policy that might have scandalized mainstream economists in the 1990s. Rejecting the status-quo bias that plagues so many institutions, this 106-year-old is still changing with the world.

what strikes me is that America’s safekeeping institutions have forgotten how to properly see the threats of the 21st century and move quickly to respond to them. Those who deny history may be doomed to repeat it. But those who deny the present are just doomed

The CDC defines people who are fully vaccinated as those who are two weeks past their second dose of the Moderna or Pfizer/BioNTech Covid-19 vaccines or two weeks past a single dose of the Johnson & Johnson vaccine.

"That was a determination made by the CDC. It wasn't driven by or directed by the White House," Psaki said of the CDC guidelines when asked if Biden agreed on not issuing new guidance on travel for people who are fully vaccinated.

Wen, who is also a CNN medical analyst, added that she thinks people who are fully vaccinated should be able to travel "and that's one of those incentives that we can give as a way for restoring freedoms" for those who get vaccinated.

The Biden administration is ramping up vaccination efforts, and as of Wednesday afternoon nearly 93.7 million vaccines had been administered, according to the CDC. About 9.7% of the population is fully vaccinated, the CDC says.

But in terms of how the U.S. has responded, in terms of how the CDC has responded ... are you able to defend the Trump administration's record on this as anything other than a catastrophic failure?Well, I'm actually very proud of the response that CDC has done. I think if I have one criticism that I do believe is significant is the importance of consistency and unity of message.

Last September, you testified before a Senate panel that masks were an effective tool to combat spread. Also, that a vaccine would not be widely available to the general public until summer or fall of this year, 2021. And a few hours later, the president came out, gave a press conference and contradicted you on both points. He said you were confused. Were you confused?No. I stand by my comments that masks are extremely effective and what I was trying to point out — if you had a vaccine, it was 50% effective and you were the half that it didn't work in, your mask is your best shot.

The gold standard for the nation's public health — has been tarnished." How would you respond to that?That's just not true. The men and women at CDC are highly respected across this nation and around the world. Clearly, there's no doubt that the lack of reinforcement and support from some individuals in the administration of the public health message had impact.

So when the president came out and contradicted you and said, "[Redfield is] confused," do you have an obligation then to stand up and say, no, sir?What I did was just repeat the position that I took, I didn't change the position, I just repeated the position as I did for you just now.

When you say the CDC has done everything it could to get the right guidance out there, to get good public messaging out there, why did the CDC stop giving press conferences for critical months in the middle of the pandemic?Yes, you know, I'm very disappointed in that. Again, the reality is --But you're in charge of it. So why, when we went back and looked at the numbers. In January, you did 10 media telebriefings. In February, you did eight, and then it fell off a cliff. There were two in March, zero in April, zero in May. Why?I would say, you know, that ultimately the ability to do those briefings had to be cleared by the secretary of health's office for us to be able to do those. That's the system that's in place under the current relationship between CDC and the secretary of health.

I interviewed you in April of last year, and I asked you what your sense was of where we were in the arc of this. And here's what you said: "We're nearing the peak of the outbreak, the pandemic, in our country right now. ..." What goes through your mind when you hear those words now?Well, as you know, we were looking at that at the time of what we call the first peak, the spring surge, and obviously that was at a time when we still didn't understand to the fullest degree asymptomatic, silent epidemic. What I say right now is, we're about to be in the worst of it.

When will we get to the point where the vaccine is going to be available to the general public — everybody can get one?Well, you know, that would be speculative, but as I said even earlier in my testimony in Congress, I didn't see that day coming until end of the second quarter, beginning third quarter of 2021.

Nearly 10 million Americans are behind on their rent payments, according to the U.S. Census Bureau. In the last two COVID-19 relief bills, Congress has approved more than $50 billion for rental assistance.

But the state and local application portals that the money will flow through are only just now opening up to take applications. So the vast majority of people who need the help won't have gotten it by the end of March when the CDC eviction order expires.

Studies have found that evictions spread COVID-19 and result in more deaths from the disease since people are forced into more crowded living situations and often double up with other families or family members.

Landlord groups have applauded the rental assistance money from Congress, but they are opposed to the CDC extending its order, saying landlords need to have the right to move forward with eviction cases a year into the pandemic.

In the midst of a pandemic surge in Massachusetts last month, UMass Memorial Health Care canceled an event to vaccinate health workers because it had no idea how many doses it would receive. A month later, the hospital system says it learns how many doses it will receive just one to two days before they arrive.

“This is the toilet-paper situation all over again,” said Eric Dickson, the UMass hospital system’s chief executive, referring to the hoarding of vaccine doses. He said federal leaders failed to issue clear guidance on how vaccines would be allocated and when they would arrive. “The federal government blew it.”

The slow pace likely means tens of thousands of lives that could have been saved will be lost

Officials on Operation Warp Speed and on the White House task force have privately faulted the CDC’s handling of the prioritization of vaccines for the slow rollout. Those officials were unhappy that the CDC and its federal advisory body on immunizations planned to prioritize health-care workers over older Americans and urged the CDC to take a looser approach that would have made more Americans initially eligible to receive the vaccine.

The CDC recommended that health-care workers and nursing-home residents receive the first doses of vaccine, followed by people ages 75 and over and front-line essential workers. The CDC responded that health-care workers are a high priority for vaccination because they are exposed to Covid-19 and need to be healthy to take care of patients.

CDC Director Robert Redfield implored Congress in September to provide about $6 billion to the agency to help states prepare for the vaccination campaign. The next month, state officials asked congressional leaders for at least $8 billion for vaccine distribution.

Congress didn’t pass a bill authorizing more funds for the CDC for vaccine administration until late December. Officials in a number of states say they had to use funding approved earlier by Congress for other urgent needs for the pandemic.

CDC and other public-health officials also urged the use of existing systems with  immunization records of which vaccines a person has received, and when. They had to convince Operation Warp Speed leaders that these systems, or registries, were essential for a successful vaccination program, according to CDC and other public-health officials. Warp Speed eventually approved funding for upgrades to the systems in the fall, and military experts helped make them.

“I want to stress that we are deeply concerned that this strain is more transmissible and can accelerate outbreaks in the U.S.

Covid cases and deaths have broken record after record across the country, with a peak number of deaths, 4,400, announced on Tuesday. At least 3,973 new deaths and 238,390 new cases were reported on Thursday, and the nation is nearing a milestone of 400,000 deaths.

The new variant, called B 1.1.7 was first identified in Britain, where it rapidly became the primary source of infections, accounting for as many 60 percent of new cases diagnosed in London and surrounding areas.

In the new report, C.D.C. scientists modeled how quickly the variant might spread in the United States, assuming about 10 percent to 30 percent of people have pre-existing immunity to the virus, and another 1 million people will be vaccinated each week beginning this month.

It’s not yet clear what makes the new variants more contagious. They share at least one mutation, called N501Y, that is thought to be involved. One possibility, researchers said, is that the mutation may increase the amount of virus in the nose but not in the lungs — potentially explaining why it is more contagious, but not more deadly.A higher amount of virus in the nose means anyone infected would expel more virus while talking, singing, coughing or even breathing, said Trevor Bedford, an evolutionary biologist at the Fred Hutchinson Cancer Research Center in Seattle

Federal health officials sounded the alarm Friday about a fast spreading, far more contagious variant of the coronavirus that is projected to become the dominant source of infection in the country by March, potentially fueling another wrenching surge of cases and deaths.

The variant is not known to be more deadly or to cause more severe disease. But the dire warning — hedged by limited data about just how prevalent the variant first identified in Britain has become — landed in a week where the nation’s nascent vaccination campaign was hampered by confusion and limited supplies as demand grew among growing numbers of eligible people

Only 76 cases of the variant have been identified so far in the U.S., but the actual number is believed to be higher and is expected to spiral upward in the next few weeks, officials said.

One in 860 Americans have died of Covid-19 in the last year, according to new figures released by the C.D.C. But the burden of deaths has not fallen equally across racial, ethnic lines and geographic regions, and there is concern that vaccines will not reach the hardest hit communities, where access to health services is limited and distrust is rampant. Editors’ PicksFor Pro Athlete Leading Social Justice Push, a Victory and UncertaintyJames Comey’s View of Justice — and How It Differs From Donald Trump’sHow ‘Orwellian’ Became an All-Purpose InsultAdvertisementContinue reading the main storyImage

But spikes in cases threaten to cripple already overwhelmed hospitals and nursing homes in many parts of the country. Some are at or near capacity. Others have faced troubling rates of infection among their staff, causing shortages and increasing patient loads.

If the variant is about 50 percent more contagious, as suggested by data from Britain, it will become the predominant source of all infections in the United States by March, the model showed. A slow rollout of vaccinations will hasten that fate.

‘Odds are, people are going to get sick this year,’”

In typical years, flu hospitalizes an estimated 140,000 to 710,000 people in the United States alone; some years, RSV can add on some 200,000 more. “Our baseline has never been great,” Yvonne Maldonado, a pediatrician at Stanford, told me. “Tens of thousands of people die every year.”

this time of year, on top of RSV, flu, and COVID, we also have to contend with a maelstrom of other airway viruses—among them, rhinoviruses, parainfluenza viruses, human metapneumovirus, and common-cold coronaviruses.

Illnesses not severe enough to land someone in the hospital could still leave them stuck at home for days or weeks on end, recovering or caring for sick kids—or shuffling back to work

“This is a more serious pathogen that is also more infectious,” Ajay Sethi, an epidemiologist at the University of Wisconsin at Madison, told me. In the past year, COVID-19 has killed some 80,000 Americans—a lighter toll than in the three years prior, but one that still dwarfs that of the worst flu seasons in the past decade.

Globally, the only infectious killer that rivals it in annual-death count is tuberculosis

Rivers also pointed to CDC data that track trends in deaths caused by pneumonia, flu, and COVID-19. Even when SARS-CoV-2 has been at its most muted, Rivers said, more people have been dying—especially during the cooler months—than they were at the pre-pandemic baseline.

This year, for the first time, millions of Americans have access to three lifesaving respiratory-virus vaccines, against flu, COVID, and RSV. Uptake for all three remains sleepy and halting; even the flu shot, the most established, is not performing above its pre-pandemic baseline.

COVID could now surge in the summer, shading into RSV’s autumn rise, before adding to flu’s winter burden, potentially dragging the misery out into spring. “Based on what I know right now, I am considering the season to be longer,” Rivers said.

barring further gargantuan leaps in viral evolution, the disease will continue to slowly mellow out in severity as our collective defenses build; the virus may also pose less of a transmission risk as the period during which people are infectious contracts

even if the dangers of COVID-19 are lilting toward an asymptote, experts still can’t say for sure where that asymptote might be relative to other diseases such as the flu—or how long it might take for the population to get there.

it seems extraordinarily unlikely to ever disappear. For the foreseeable future, “pretty much all years going forward are going to be worse than what we’ve been used to before,”

although a core contingent of Americans might still be more cautious than they were before the pandemic’s start—masking in public, testing before gathering, minding indoor air quality, avoiding others whenever they’re feeling sick—much of the country has readily returned to the pre-COVID mindset.

When I asked Hanage what precautions worthy of a respiratory disease with a death count roughly twice that of flu’s would look like, he rattled off a familiar list: better access to and uptake of vaccines and antivirals, with the vulnerable prioritized; improved surveillance systems to offer  people at high risk a better sense of local-transmission trends; improved access to tests and paid sick leave

Without those changes, excess disease and death will continue, and “we’re saying we’re going to absorb that into our daily lives,” he said.

And that is what is happening.

last year, a CDC survey found that more than 3 percent of American adults were suffering from long COVID—millions of people in the United States alone.

“We get used to things we could probably fix.” The years since COVID arrived set a horrific precedent of death and disease; after that, this season of n+1 sickness might feel like a reprieve. But compare it with a pre-COVID world, and it looks objectively worse. We’re heading toward a new baseline, but it will still have quite a bit in common with the old one: We’re likely to accept it, and all of its horrors, as a matter of course.

As part of its biennial school health profile, the CDC asked all states to survey school health educators on what they teach to students when it comes to sex. Ultimately, 44 states had enough respondents to be included in the data, which also looked at certain large urban school districts and U.S. territories.

The survey listed 16 recommended topics as critical to sexual health, falling under four broad subject areas: HIV prevention, STD prevention, pregnancy prevention and information on sexuality.

The findings offer a glimpse inside thousands of classrooms to reveal that what gets taught about sex — often decided at the district level — varies widely nationwide.

For example, the study found that Kentucky had the lowest rate of the states surveyed for teaching middle schoolers the full range of recommended material, at just under 4 percent. North Carolina had the highest rate for middle schoolers, with over 45 percent.

In high school, the gap is even wider. In New Jersey, 9 out of 10 high school students receive the full list of recommended topics. Arizona was lowest in the survey, with fewer than 1 in 5 students.

Zaza says there's a variety of reasons why sex education is sometimes put on the back burner, including a lack of time or qualified staff, or restrictive policies.

Young people are a high-risk population when it comes to sexual health: Nearly half of high school students say they have had sex, and half of all new sexually transmitted infections occur in people ages 24 and younger.

An administration official told CNN that CDC leadership had not seen the draft document before it was leaked, and there were two concerns when it reached the task force. It was "overly prescriptive" because "guidance in rural Tennessee shouldn't be the same guidance for urban New York City," and the recommendations in the document did not fit the "phases" that had already been outlined by the task force.

The draft document included specific guidance for six categories: child care programs; schools and day camps; communities of faith; employers with vulnerable workers; restaurants and bars; mass transit administrators. For each category, the draft document notes reopening in phases.

"This is a governor-led effort. The President has said that governors make the decisions as to move forward and we encourage them to follow our phased approach," McEnany said.

"The CDC, the White House task force and White House principles were in disagreement on how strongly a public health response should still be in place," said the official.

"In the absence of law, it's regulation, and in the absence of regulation, it's recommendations. They think it's left too much open to be interpreted by the courts if something happens on the job. It doesn't matter if (the Occupational Safety and Health Administration) is playing ball or not," the CDC source said.

The new CDC guidance says fully vaccinated people can:Read MoreVisit other vaccinated people indoors without masks or physical distancingVisit indoors with unvaccinated people from a single household without masks or physical distancing, if the unvaccinated people are at low risk for severe disease.

Skip quarantine and testing if exposed to someone who has Covid-19 but are asymptomatic, but should monitor for symptoms for 14 daysThis means that vaccinated grandparents may finally feel comfortable visiting their unvaccinated grandchildren and giving them a big hug, especially if they're local -- the CDC still says people should avoid travel -- and as long as none of the unvaccinated people in that household are at risk for severe Covid-19.

However, people who are fully vaccinated still need to take precautions in many scenarios. The guidelines say fully vaccinated people must:Wear a mask and keep good physical distance around the unvaccinated who are at increased risk for severe Covid-19, or if the unvaccinated person has a household member who is at higher riskWear masks and physically distance when visiting unvaccinated people who are from multiple households.

If fully vaccinated people live in a non-health care congregate setting, such as a group home or detention facility, they should quarantine for 14 days and get tested if exposed to someone with a suspected or confirmed Covid-19 case.The guidelines say that the risk of infection in social activities like going to the gym or restaurant is lower for the fully vaccinated. However, people should still take precautions, as transmission risk in these settings is higher and increases the more unvaccinated people are involved. So wear that mask on the treadmill, and if dining out, keep it on while waiting for your meal

Walensky said CDC travel guidelines will remain the same for the vaccinated until there is more data about how much or how little vaccinated people can transmit the virus to others. She added that a "larger swath" of the population will also need to be vaccinated before it's really safe. About 90% of the country is still not vaccinated, Walensky said. Travel brings too much exposure to crowds and the spread of variants is also a real concern.

"We are here in no small measure because of the safety protection that many, many Americans have taken with regard to their family, friends and neighbors," Zients said. "We ask people to continue to do that so we can get there, as quickly and as permanently as possible."There are now 30 million people in the United States who are fully vaccinated, but the United States still averaged more than 60,000 cases per day over the last seven days, according to Johns Hopkins University.

"We continue to have high levels of virus around the country, and more readily transmissible variants have now been confirmed in nearly every state, while we work to quickly vaccinate people more and more each day, we have to see this through," Walensky said Monday. "Let's stick together. Please keep wearing a well fitting mask and taking the other public health actions we know work to help stop the spread of this virus."

Within a week of its first confirmed case, South Korea’s disease control agency had summoned 20 private companies to the medical equivalent of a war-planning summit and told them to develop a test for the virus at lightning speed. A week after that, the first diagnostic test was approved and went into battle, identifying infected individuals who could then be quarantined to halt the advance of the disease.

Some 357,896 tests later, the country has more or less won the coronavirus war. On Friday only 91 new cases were reported in a country of more than 50 million.

The US response tells a different story. Two days after the first diagnosis in Washington state, Donald Trump went on air on CNBC and bragged: “We have it totally under control. It’s one person coming from China. It’s going to be just fine.”

Though the decision to allow private and state labs to provide testing has increased the flow of test kits, the US remains starkly behind South Korea, which has conducted more than five times as many tests per capita. That makes predicting where the next hotspot will pop up after New York and New Orleans almost impossible.

Today, 86,012 cases have been confirmed across the US, pushing the nation to the top of the world’s coronavirus league table – above even China.

Most worryingly, the curve of cases continues to rise precipitously, with no sign of the plateau that has spared South Korea.

Jeremy Konyndyk, who led the US government’s response to international disasters at USAid from 2013 to 2017, frames the past six weeks in strikingly similar terms. He told the Guardian: “We are witnessing in the United States one of the greatest failures of basic governance and basic leadership in modern times.”

It was not until 29 February, more than a month after the Journal article and almost six weeks after the first case of coronavirus was confirmed in the country that the Trump administration put that advice into practice. Laboratories and hospitals would finally be allowed to conduct their own Covid-19 tests to speed up the process.

If Trump’s travel ban did nothing else, it staved off to some degree the advent of the virus in the US, buying a little time. Which makes the lack of decisive action all the more curious.

In the absence of sufficient test kits, the US Centers of Disease Control and Prevention (CDC) initially kept a tight rein on testing, creating a bottleneck. “I believe the CDC was caught flat-footed,” was how the governor of New York, Andrew Cuomo, put it on 7 March. “They’re slowing down the state.”The CDC’s botched rollout of testing was the first indication that the Trump administration was faltering as the health emergency gathered pace. Behind the scenes, deep flaws in the way federal agencies had come to operate under Trump were being exposed.

In 2018 the pandemic unit in the national security council – which was tasked to prepare for health emergencies precisely like the current one – was disbanded. “Eliminating the office has contributed to the federal government’s sluggish domestic response,” Beth Cameron, senior director of the office at the time it was broken up, wrote in the Washington Post.

It was hardly a morale-boosting gesture when Trump proposed a 16% cut in CDC funding on 10 February – 11 days after the World Health Organization had declared a public health emergency over Covid-19.

The Food and Drug Administration (FDA), which regulates the diagnostic tests and will control any new treatments for coronavirus, has also shown vulnerabilities. The agency recently indicated that it was looking into the possibility of prescribing the malaria drug chloroquine for coronavirus sufferers, even though there is no evidence it would work and some indication it could have serious side-effects.

As the former senior official put it: “We have the FDA bowing to political pressure and making decisions completely counter to modern science.”

Trump has designated himself a “wartime president”. But if the title bears any validity, his military tactics have been highly unconventional. He has exacerbated the problems encountered by federal agencies by playing musical chairs at the top of the coronavirus force.

The president began by creating on 29 January a special coronavirus taskforce, then gave Vice-President Mike Pence the job, who promptly appointed Deborah Birx “coronavirus response coordinator”, before the federal emergency agency Fema began taking charge of key areas, with Jared Kushner, the president’s son-in-law, creating a shadow team that increasingly appears to be calling the shots.“There’s no point of responsibility,” the former senior official told the Guardian. “It keeps shifting. Nobody owns the problem.”

So it has transpired. In the wake of the testing disaster has come the personal protective equipment (PPE) disaster, the hospital bed disaster, and now the ventilator disaster.Ventilators, literal life preservers, are in dire short supply across the country. When governors begged Trump to unleash the full might of the US government on this critical problem, he gave his answer on 16 March.In a phrase that will stand beside 20 January 2020 as one of the most revelatory moments of the history of coronavirus, he said: “Respirators, ventilators, all of the equipment – try getting it yourselves.”

In the absence of a strong federal response, a patchwork of efforts has sprouted all across the country. State governors are doing their own thing. Cities, even individual hospitals, are coping as best they can.

And on Monday, the US Centers for Disease Control and Prevention brought that moment into clearer focus. The agency came out with its first set of guidance about what fully vaccinated people can now do.

My parents had a significant emotional burden lifted after they were vaccinated, because they are now approximately 95% protected against getting severely ill from Covid-19. But like the rest of the country, they are restless and want to do something with their newly vaccinated status. That is why they called me right after they saw the news report about new recommendations from the CDC to ask me what it all meant. I laid out the good news for them, and the caveats as well.

In a major step, the CDC said people who are fully vaccinated against Covid-19 can safely visit with other fully vaccinated people in private settings without masks, without social distancing and without having to be outdoors.

Additionally, however, the CDC guidance now allows for fully vaccinated people to visit indoors with unvaccinated people from a single household without masks or physical distancing, if the unvaccinated people are at low risk for severe disease. That last part is important.

It's a theme I hear from CNN readers, viewers and listeners all the time: When am I going to be able to see my grandchildren, my elderly father, my sister and her family? Most everybody has somebody they long to hug, to hold close and see in person.

As I kept digging into the guidelines and speaking with members of the Biden administration's Covid-19 task force, it became increasingly clear that a visit was looking possible, but with a few strings attached.

And, perhaps most notably, fully vaccinated people are also still being discouraged from traveling, something that throws a monkey wrench into my fantasy of an imminent family reunion.

"I think the guidelines are in a good middle ground," she said. "We're starting to go back to normal now, but it's not going to be flipping a switch... We will make that journey towards normalcy, or at least a new normal, as more people get vaccinated."

At 10% vaccinations we have this guidance. At 20-30%, we will have new guidance," he said, noting that there's going to be a distinct shift in the messaging of what people can and cannot do -- moving away from more binary messaging to one that describes activities as a range of low, medium and high risk.

Even as Walensky delivered the hopeful new guidance, she also noted the country still stands at a seven-day average of about 59,000 new cases of Covid-19 per day -- a rate that has leveled off somewhat, instead of continuing to steadily decline. And there are close to 2,000 deaths per day. So, she and other experts warn, any easing of restrictions is going to have to be gradual.

So where does that leave my family reunion plan? Unless my parents make the long drive to see us, we are going to hold off on a visit for now. With more than 2 million people getting vaccinated a day, however, another 20% of the country could be vaccinated by the end of the month. And, that will probably lead to a further relaxing of CDC guidelines and maybe allow my parents a plane ride instead, which means a possible visit to celebrate their wedding anniversary this spring!

The document likely signals a more basic change in how public health decisions will be made and disseminated. The timeliness and boldness seem to indicate that the CDC under President Joe Biden, and led by Dr Rochelle Walensky, is ready to leave behind its mumble-mouthed voice and rather resolve difficult issues by deciding, not equivocating.

It also suggests that the data behind the grandma-can-hug-grandchild guidance must be quite strong. The new CDC may be bold and daring, but it will never be improvident or capricious.

Still, a consensus has formed that health care personnel should be first in line to get the vaccine, given their high risk of exposure. Health care workers are defined by ACIP as "paid and unpaid persons serving in health care settings who have the potential for direct or indirect exposure to patients or infectious materials." This population is estimated at 21 million.

To that end, a modeling study presented by CDC epidemiologist Matthew Biggerstaff showed that vaccinating all adults 65 years and older first (after health care workers) might have the greatest effect on reducing the overall number of deaths in the U.S.

There are 64 jurisdictions, including states, territories and some large cities, that have submitted preliminary plans to the CDC for distributing the vaccines. The CDC provided feedback on the plans this week, and expects states to be enrolling providers, setting up data systems to track who's getting vaccines, and working with community leaders, so states are ready to give out vaccines as soon as one is authorized by the FDA.

It's up to the FDA to approve or give emergency authorization to any vaccine. There are currently four candidate vaccines in the final phase of clinical study in the U.S. None of the companies so far has applied for authorization or approval from the FDA.

Last year, a Chinese scientist he worked with published a specific forecast: “It is highly likely that future SARS- or MERS-like coronavirus outbreaks will originate from bats, and there is an increased probability that this will occur in China.”

Humans today are exposed to more deadly new pathogens than ever. They typically come from animals, as global travel, trade and economic development, such as meat production and deforestation, push people, livestock and wildlife closer together

Scientists knew infectious disease outbreaks were becoming more common, with 2010 having more than six times the outbreaks of pathogens from animal origins than in 1980, according to data in a study by Brown University researchers.

Yet plenty was left undone, in areas including funding, early-warning systems, the role of the WHO and coordination with China. A big chunk of U.S. funding went toward protecting Americans against a bioterror attack. Government funding for pandemics has come largely in emergency, one-time packages to stop an ongoing outbreak.

She said a better solution would be to fund public health more like national defense, with much more guaranteed money, year in, year out.

“Will there be another human influenza pandemic?” Dr. Webster asked in a paper presented at an NIH meeting in 1995. “The certainty is that there will be.”

Experts including Dr. Webster were particularly concerned about the potential for spillover in southern China, where large, densely populated cities were expanding rapidly into forests and agricultural lands, bringing people into closer contact with animals. Two of the three influenza pandemics of the 20th century are thought to have originated in China.

Dr. Webster and others warned it could re-emerge or mutate into something more contagious. With U.S. funding, he set up an animal influenza surveillance center in Hong Kong. The WHO, which hadn’t planned for pandemics before, started compiling protocols for a large-scale outbreak, including contingency plans for vaccines.

At a dinner back in the U.S., he remembers one guest saying, “Oh, you really needed to have someone in the U.S. to be impacted to really galvanize the government.”

That “drove home the reality in my own mind of globalization,” said Dr. Fukuda. SARS showed that viruses can crisscross the globe by plane in hours, making a local epidemic much more dangerous.

The WHO’s director-general, Gro Harlem Brundtland, publicly criticized China. The government under new leaders reversed course. It implemented draconian quarantines and sanitized cities, including a reported 80 million people enlisted to clean streets in Guangdong.

By May 2003, the number of new SARS cases was dwindling. It infected around 8,000 people world-wide, killing nearly 10%.

After SARS, China expanded epidemiologist training and increased budgets for new laboratories. It started working more closely in public health with the U.S., the world’s leader. The U.S. CDC opened an office in Beijing to share expertise and make sure coverups never happened again. U.S. CDC officials visiting a new China CDC campus planted a friendship tree.

In Washington in 2005, a powerful player started driving U.S. efforts to become more prepared. President George W. Bush had read author John M. Barry’s “The Great Influenza,” a history of the 1918 flu pandemic

Mr. Bush leaned toward the group of 10 or so officials and said, “I want to see a plan,” according to Dr. Venkayya. “He had been asking questions and not getting answers,” recalled Dr. Venkayya, now president of Takeda Pharmaceutical Co. ’s global vaccine business unit. “He wanted people to see this as a national threat.”

Mr. Bush launched the strategy in November, and Congress approved $6.1 billion in one-time funding.

The CDC began exercises enacting pandemic scenarios and expanded research. The government created the Biomedical Advanced Research and Development Authority to fund companies to develop diagnostics, drugs and vaccines.

A team of researchers also dug into archives of the 1918 pandemic to develop guidelines for mitigating the spread when vaccines aren’t available. The tactics included social distancing, canceling large public gatherings and closing schools—steps adopted this year when Covid-19 struck, though at the time they didn’t include wide-scale lockdowns.

A year after the plan was released, a progress report called for more real-time disease surveillance and preparations for a medical surge to care for large numbers of patients, and stressed strong, coordinated federal planning.

A European vaccine makers’ association said its members had spent around $4 billion on pandemic vaccine research and manufacturing adjustments by 2008.

The $6.1 billion Congress appropriated for Mr. Bush’s pandemic plan was spent mostly to make and stockpile medicines and flu vaccines and to train public-health department staff. The money wasn’t renewed. “The reality is that for any leader it’s really hard to maintain a focus on low-probability high-consequence events, particularly in the health arena,” Dr. Venkayya said.

In the U.S., President Barack Obama’s administration put Mr. Bush’s new plan into action for the first time. By mid-June, swine flu, as it was dubbed, had jumped to 74 countries. The WHO officially labeled it a pandemic, despite some evidence suggesting the sickness was pretty mild in most people.

That put in motion a host of measures, including some “sleeping” contracts with pharmaceutical companies to begin vaccine manufacturing—contracts that countries like the United Kingdom had negotiated ahead of time so they wouldn’t have to scramble during an outbreak.

In August, a panel of scientific advisers to Mr. Obama published a scenario in which as many as 120 million Americans, 40% of the population, could be infected that year, and up to 90,000 people could die.

H1N1 turned out to be much milder. Although it eventually infected more than 60 million Americans, it killed less than 13,000. In Europe, fewer than 5,000 deaths were reported.

The WHO came under fire for labeling the outbreak a pandemic too soon. European lawmakers, health professionals and others suggested the organization may have been pressured by the pharmaceutical industry.

France ordered 94 million doses, but had logged only 1,334 serious cases and 312 deaths as of April 2010. It managed to cancel 50 million doses and sell some to other countries, but it was still stuck with a €365 million tab, or about $520 million at the time, and 25 million extra doses.

The WHO had raised scares for SARS, mad-cow disease, bird flu and now swine flu, and it had been wrong each time, said Paul Flynn, a member of the Council of Europe’s Parliamentary Assembly and a British lawmaker, at a 2010 health committee hearing in Strasbourg.

Ultimately, an investigation by the council’s committee accused the WHO and public-health officials of jumping the gun, wasting money, provoking “unjustified fear” among Europeans and creating risks through vaccines and medications that might not have been sufficiently tested.

“I thought you might have uttered a word of regret or an apology,” Mr. Flynn told Dr. Fukuda, who as a representative of the WHO had been called to testify.

Back in Washington, scientist Dennis Carroll, at the U.S. Agency for International Development, was also convinced that flu wasn’t the only major pandemic threat. In early 2008, Dr. Carroll was intrigued by Dr. Daszak’s newly published research that said viruses from wildlife were a growing threat, and would emerge most frequently where development was bringing people closer to animals.

If most of these viruses spilled over to humans in just a few places, including southern China, USAID could more easily fund an early warning system.

“You didn’t have to look everywhere,” he said he realized. “You could target certain places.” He launched a new USAID effort focused on emerging pandemic threats. One program called Predict had funding of about $20 million a year to identify pathogens in wildlife that have the potential to infect people.

Drs. Daszak, Shi and Wang, supported by funds from Predict, the NIH and China, shifted their focus to Yunnan, a relatively wild and mountainous province that borders Myanmar, Laos and Vietnam.

One key discovery: a coronavirus resembling SARS that lab tests showed could infect human cells. It was the first proof that SARS-like coronaviruses circulating in southern China could hop from bats to people. The scientists warned of their findings in a study published in the journal Nature in 2013.

Evidence grew that showed people in the area were being exposed to coronaviruses. One survey turned up hundreds of villagers who said they recently showed symptoms such as trouble breathing and a fever, suggesting a possible viral infection.

Over the next several years, governments in the U.S. and elsewhere found themselves constantly on the defensive from global viral outbreaks. Time and again, preparedness plans proved insufficient. One, which started sickening people in Saudi Arabia and nearby

On a weekend morning in January 2013, more than a dozen senior Obama administration officials met in a basement family room in the suburban home of a senior National Security Council official. They were brainstorming how to help other countries upgrade their epidemic response capabilities, fueled by bagels and coffee. Emerging disease threats were growing, yet more than 80% of the world’s countries hadn’t met a 2012 International Health Regulations deadline to be able to detect and respond to epidemics.

The session led to the Global Health Security Agenda, launched by the U.S., the WHO and about 30 partners in early 2014, to help nations improve their capabilities within five years.

Money was tight. The U.S. was recovering from the 2008-09 financial crisis, and federal funding to help U.S. states and cities prepare and train for health emergencies was declining. Public-health departments had cut thousands of jobs, and outdated data systems weren’t replaced.

“It was a Hail Mary pass,” said Tom Frieden, who was director of the CDC from 2009 to 2017 and a force behind the creation of the GHSA. “We didn’t have any money.”

At the WHO, Dr. Fukuda was in charge of health security. When the Ebola outbreak was found in March 2014, he and his colleagues were already stretched, after budget cuts and amid other crises.

The United Nations created a special Ebola response mission that assumed the role normally played by the WHO. Mr. Obama sent the U.S. military to Liberia, underscoring the inability of international organizations to fully handle the problem.

It took the WHO until August to raise an international alarm about Ebola. By then, the epidemic was raging. It would become the largest Ebola epidemic in history, with at least 28,600 people infected, and more than 11,300 dead in 10 countries. The largest outbreak before that, in Uganda, had involved 425 cases.

Congress passed a $5.4 billion package in supplemental funds over five years, with about $1 billion going to the GHSA. The flood of money, along with aggressive contact tracing and other steps, helped bring the epidemic to a halt, though it took until mid-2016.

Global health experts and authorities called for changes at the WHO to strengthen epidemic response, and it created an emergencies program. The National Security Council warned that globalization and population growth “will lead to more pandemics,” and called for the U.S. to do more.

r. Carroll of USAID, who had visited West Africa during the crisis, and saw some health workers wrap themselves in garbage bags for protection, started conceiving of a Global Virome Project, to detect and sequence all the unknown viral species in mammals and avian populations on the planet.

Billionaire Bill Gates warned in a TED talk that an infectious disease pandemic posed a greater threat to the world than nuclear war, and urged world leaders to invest more in preparing for one. The Bill & Melinda Gates Foundation helped form a new initiative to finance vaccines for emerging infections, the Coalition for Epidemic Preparedness Innovations.

Congress established a permanent Infectious Diseases Rapid Response Fund for the CDC in fiscal 2019, with $50 million for that year and $85 million in fiscal 2020.

In May 2018, John Bolton, then President Trump’s national security adviser, dismantled an NSC unit that had focused on global health security and biodefense, with staff going to other units. The senior director of the unit left.

It pushed emerging disease threats down one level in the NSC hierarchy, making pandemics compete for attention with issues such as North Korea, said Beth Cameron, a previous senior director of the unit. She is now vice president for global biological policy and programs at the Nuclear Threat Initiative.

Deteriorating relations with China reduced Washington’s activities there just as researchers were becoming more certain of the threat from coronaviruses.

Dr. Carroll had earlier been ordered to suspend his emerging pandemic threats program in China.

Dr. Carroll pitched to USAID his Global Virome Project. USAID wasn’t interested, he said. He left USAID last year. A meeting that Dr. Carroll planned for last August with the Chinese CDC and Chinese Academy of Sciences to form a Chinese National Virome Project was postponed due to a bureaucratic hang-up. Plans to meet are now on hold, due to Covid-19.

The COVID vaccines are, without exaggeration, among the safest and most effective therapies in all of modern medicine. An unvaccinated adult is an astonishing 68 times more likely to die from COVID than a boosted one

Yet widespread vaccine hesitancy in the United States has caused more than 163,000 preventable deaths and counting

Even in absolute numbers, America’s unvaccinated and current-smoker populations seem to match up rather well: Right now, the CDC pegs them at 13 percent and 14 percent of all U.S. adults, respectively, and both groups are likely to be poorer and less educated.

Countries such as Denmark and Sweden have already declared themselves broken up with COVID. They are confidently doing so not because the virus is no longer circulating or because they’ve achieved mythical herd immunity from natural infection; they’ve simply inoculated enough people.

data suggest that most of the unvaccinated hold that status voluntarily at this point

The same arguments apply to tobacco: Smokers are 15 to 30 times more likely to develop lung cancer. Quitting the habit is akin to receiving a staggeringly powerful medicine, one that wipes out most of this excess risk.

If everyone who is eligible were triply vaccinated, our health-care system would be functioning normally again.

With a vaccination timeline that stretches over years, our patience for restrictions, especially on the already vaccinated, will be very limited. But there is middle ground. We haven’t banned tobacco outright—in fact, most states protect smokers from job discrimination—but we have embarked on a permanent, society-wide campaign of disincentivizing its use.

We should neither expect that every stubbornly unvaccinated person will get jabbed before next winter nor despair that none of them will ever change their mind. Let’s accept instead that we may make headway slowly, and with considerable effort

Long-term actions for COVID might include charging the unvaccinated a premium on their health insurance, just as we do for smokers, or distributing frightening health warnings about the perils of remaining uninoculated

And once the political furor dies down, COVID shots will probably be added to the lists of required vaccinations for many more schools and workplaces.

nother aspect of where we’re headed with COVID. Tobacco is lethal enough that we are willing to restrict smokers’ personal freedoms—but only to a degree. As deadly as COVID is, some people won’t get vaccinated, no matter what, and both the vaccinated and unvaccinated will spread disease to others.

anti-COVID actions, much like anti-smoking policies, will be limited not by their effectiveness but by the degree to which they are politically palatable.

Without greater vaccination, living with COVID could mean enduring a yearly death toll that is an order of magnitude higher than the one from flu.

this, too, might come to feel like its own sort of ending. Endemic tobacco use causes hundreds of thousands of casualties, year after year after year, while fierce public-health efforts to reduce its toll continue in the background. Yet tobacco doesn’t really feel like a catastrophe for the average person.

Losing a year or two from average life expectancy only bumps us back to where we were in … 2000.

We still care for smokers when they get sick, of course, and we reduce harm whenever possible. The health-care system makes $225 billion every year for doing so—paid out of all of our tax dollars and insurance premiums

Hospitals have a well-honed talent for transforming any terrible situation into a marketable “center of excellence.”

But we shouldn’t forget the most important reason that the coronavirus isn’t like the flu: We’ve never had vaccines this effective in the midst of prior influenza outbreaks, which means we didn’t have a simple, clear approach to saving quite so many lives. Compassionate conversations, community outreach, insurance surcharges, even mandates—I’ll take them all. Now is not the time to quit.

The president, though, was slow to absorb the scale of the risk and to act accordingly, focusing instead on controlling the message, protecting gains in the economy and batting away warnings from senior officials.

Mr. Trump’s response was colored by his suspicion of and disdain for what he viewed as the “Deep State” — the very people in his government whose expertise and long experience might have guided him more quickly toward steps that would slow the virus, and likely save lives.

The slow start of that plan, on top of the well-documented failures to develop the nation’s testing capacity, left administration officials with almost no insight into how rapidly the virus was spreading. “We were flying the plane with no instruments,” one official said.

But dozens of interviews with current and former officials and a review of emails and other records revealed many previously unreported details and a fuller picture of the roots and extent of his halting response as the deadly virus spread:

The National Security Council office responsible for tracking pandemics received intelligence reports in early January predicting the spread of the virus to the United States, and within weeks was raising options like keeping Americans home from work and shutting down cities the size of Chicago. Mr. Trump would avoid such steps until March.

Despite Mr. Trump’s denial weeks later, he was told at the time about a Jan. 29 memo produced by his trade adviser, Peter Navarro, laying out in striking detail the potential risks of a coronavirus pandemic: as many as half a million deaths and trillions of dollars in economic losses.

The health and human services secretary, Alex M. Azar II, directly warned Mr. Trump of the possibility of a pandemic during a call on Jan. 30, the second warning he delivered to the president about the virus in two weeks. The president, who was on Air Force One while traveling for appearances in the Midwest, responded that Mr. Azar was being alarmist

Mr. Azar publicly announced in February that the government was establishing a “surveillance” system

the task force had gathered for a tabletop exercise — a real-time version of a full-scale war gaming of a flu pandemic the administration had run the previous year. That earlier exercise, also conducted by Mr. Kadlec and called “Crimson Contagion,” predicted 110 million infections, 7.7 million hospitalizations and 586,000 deaths following a hypothetical outbreak that started in China.

By the third week in February, the administration’s top public health experts concluded they should recommend to Mr. Trump a new approach that would include warning the American people of the risks and urging steps like social distancing and staying home from work.

But the White House focused instead on messaging and crucial additional weeks went by before their views were reluctantly accepted by the president — time when the virus spread largely unimpeded.

When Mr. Trump finally agreed in mid-March to recommend social distancing across the country, effectively bringing much of the economy to a halt, he seemed shellshocked and deflated to some of his closest associates. One described him as “subdued” and “baffled” by how the crisis had played out. An economy that he had wagered his re-election on was suddenly in shambles.

He only regained his swagger, the associate said, from conducting his daily White House briefings, at which he often seeks to rewrite the history of the past several months. He declared at one point that he “felt it was a pandemic long before it was called a pandemic,” and insisted at another that he had to be a “cheerleader for the country,” as if that explained why he failed to prepare the public for what was coming.

Mr. Trump’s allies and some administration officials say the criticism has been unfair.

The Chinese government misled other governments, they say. And they insist that the president was either not getting proper information, or the people around him weren’t conveying the urgency of the threat. In some cases, they argue, the specific officials he was hearing from had been discredited in his eyes, but once the right information got to him through other channels, he made the right calls.

“While the media and Democrats refused to seriously acknowledge this virus in January and February, President Trump took bold action to protect Americans and unleash the full power of the federal government to curb the spread of the virus, expand testing capacities and expedite vaccine development even when we had no true idea the level of transmission or asymptomatic spread,” said Judd Deere, a White House spokesman.

Decision-making was also complicated by a long-running dispute inside the administration over how to deal with China

The Containment IllusionBy the last week of February, it was clear to the administration’s public health team that schools and businesses in hot spots would have to close. But in the turbulence of the Trump White House, it took three more weeks to persuade the president that failure to act quickly to control the spread of the virus would have dire consequences.

There were key turning points along the way, opportunities for Mr. Trump to get ahead of the virus rather than just chase it. There were internal debates that presented him with stark choices, and moments when he could have chosen to ask deeper questions and learn more. How he handled them may shape his re-election campaign. They will certainly shape his legacy.

Facing the likelihood of a real pandemic, the group needed to decide when to abandon “containment” — the effort to keep the virus outside the U.S. and to isolate anyone who gets infected — and embrace “mitigation” to thwart the spread of the virus inside the country until a vaccine becomes available.

Among the questions on the agenda, which was reviewed by The New York Times, was when the department’s secretary, Mr. Azar, should recommend that Mr. Trump take textbook mitigation measures “such as school dismissals and cancellations of mass gatherings,” which had been identified as the next appropriate step in a Bush-era pandemic plan.

The group — including Dr. Anthony S. Fauci of the National Institutes of Health; Dr. Robert R. Redfield of the Centers for Disease Control and Prevention, and Mr. Azar, who at that stage was leading the White House Task Force — concluded they would soon need to move toward aggressive social distancing

A 20-year-old Chinese woman had infected five relatives with the virus even though she never displayed any symptoms herself. The implication was grave — apparently healthy people could be unknowingly spreading the virus — and supported the need to move quickly to mitigation.

The following day, Dr. Kadlec and the others decided to present Mr. Trump with a plan titled “Four Steps to Mitigation,” telling the president that they needed to begin preparing Americans for a step rarely taken in United States history.

a presidential blowup and internal turf fights would sidetrack such a move. The focus would shift to messaging and confident predictions of success rather than publicly calling for a shift to mitigation.

These final days of February, perhaps more than any other moment during his tenure in the White House, illustrated Mr. Trump’s inability or unwillingness to absorb warnings coming at him.

He instead reverted to his traditional political playbook in the midst of a public health calamity, squandering vital time as the coronavirus spread silently across the country.

A memo dated Feb. 14, prepared in coordination with the National Security Council and titled “U.S. Government Response to the 2019 Novel Coronavirus,” documented what more drastic measures would look like, including: “significantly limiting public gatherings and cancellation of almost all sporting events, performances, and public and private meetings that cannot be convened by phone. Consider school closures. Widespread ‘stay at home’ directives from public and private organizations with nearly 100% telework for some.”

his friend had a blunt message: You need to be ready. The virus, he warned, which originated in the city of Wuhan, was being transmitted by people who were showing no symptoms — an insight that American health officials had not yet accepted.

On the 18-hour plane ride home, Mr. Trump fumed as he watched the stock market crash after Dr. Messonnier’s comments. Furious, he called Mr. Azar when he landed at around 6 a.m. on Feb. 26, raging that Dr. Messonnier had scared people unnecessarily.

The meeting that evening with Mr. Trump to advocate social distancing was canceled, replaced by a news conference in which the president announced that the White House response would be put under the command of Vice President Mike Pence.

The push to convince Mr. Trump of the need for more assertive action stalled. With Mr. Pence and his staff in charge, the focus was clear: no more alarmist messages. Statements and media appearances by health officials like Dr. Fauci and Dr. Redfield would be coordinated through Mr. Pence’s office

It would be more than three weeks before Mr. Trump would announce serious social distancing efforts, a lost period during which the spread of the virus accelerated rapidly.Over nearly three weeks from Feb. 26 to March 16, the number of confirmed coronavirus cases in the United States grew from 15 to 4,226

The China FactorThe earliest warnings about coronavirus got caught in the crosscurrents of the administration’s internal disputes over China. It was the China hawks who pushed earliest for a travel ban. But their animosity toward China also undercut hopes for a more cooperative approach by the world’s two leading powers to a global crisis.

It was early January, and the call with a Hong Kong epidemiologist left Matthew Pottinger rattled.

Mr. Trump was walking up the steps of Air Force One to head home from India on Feb. 25 when Dr. Nancy Messonnier, the director of the National Center for Immunization and Respiratory Diseases, publicly issued the blunt warning they had all agreed was necessary.

It was one of the earliest warnings to the White House, and it echoed the intelligence reports making their way to the National Security Council

some of the more specialized corners of the intelligence world were producing sophisticated and chilling warnings.

In a report to the director of national intelligence, the State Department’s epidemiologist wrote in early January that the virus was likely to spread across the globe, and warned that the coronavirus could develop into a pandemic

Working independently, a small outpost of the Defense Intelligence Agency, the National Center for Medical Intelligence, came to the same conclusion.

By mid-January there was growing evidence of the virus spreading outside China. Mr. Pottinger began convening daily meetings about the coronavirus

The early alarms sounded by Mr. Pottinger and other China hawks were freighted with ideology — including a push to publicly blame China that critics in the administration say was a distraction

And they ran into opposition from Mr. Trump’s economic advisers, who worried a tough approach toward China could scuttle a trade deal that was a pillar of Mr. Trump’s re-election campaign.

Mr. Pottinger continued to believe the coronavirus problem was far worse than the Chinese were acknowledging. Inside the West Wing, the director of the Domestic Policy Council, Joe Grogan, also tried to sound alarms that the threat from China was growing.

The Consequences of ChaosThe chaotic culture of the Trump White House contributed to the crisis. A lack of planning and a failure to execute, combined with the president’s focus on the news cycle and his preference for following his gut rather than the data cost time, and perhaps lives.

the hawks kept pushing in February to take a critical stance toward China amid the growing crisis. Mr. Pottinger and others — including aides to Secretary of State Mike Pompeo — pressed for government statements to use the term “Wuhan Virus.”Mr. Pompeo tried to hammer the anti-China message at every turn, eventually even urging leaders of the Group of 7 industrialized countries to use “Wuhan virus” in a joint statement.

Others, including aides to Mr. Pence, resisted taking a hard public line, believing that angering Beijing might lead the Chinese government to withhold medical supplies, pharmaceuticals and any scientific research that might ultimately lead to a vaccine.

Mr. Trump took a conciliatory approach through the middle of March, praising the job Mr. Xi was doing.

That changed abruptly, when aides informed Mr. Trump that a Chinese Foreign Ministry spokesman had publicly spun a new conspiracy about the origins of Covid-19: that it was brought to China by U.S. Army personnel who visited the country last October.

On March 16, he wrote on Twitter that “the United States will be powerfully supporting those industries, like Airlines and others, that are particularly affected by the Chinese Virus.”

Mr. Trump’s decision to escalate the war of words undercut any remaining possibility of broad cooperation between the governments to address a global threat

Mr. Pottinger, backed by Mr. O’Brien, became one of the driving forces of a campaign in the final weeks of January to convince Mr. Trump to impose limits on travel from China

he circulated a memo on Jan. 29 urging Mr. Trump to impose the travel limits, arguing that failing to confront the outbreak aggressively could be catastrophic, leading to hundreds of thousands of deaths and trillions of dollars in economic losses.

The uninvited message could not have conflicted more with the president’s approach at the time of playing down the severity of the threat. And when aides raised it with Mr. Trump, he responded that he was unhappy that Mr. Navarro had put his warning in writing.

From the time the virus was first identified as a concern, the administration’s response was plagued by the rivalries and factionalism that routinely swirl around Mr. Trump and, along with the president’s impulsiveness, undercut decision making and policy development.

Even after Mr. Azar first briefed him about the potential seriousness of the virus during a phone call on Jan. 18 while the president was at his Mar-a-Lago resort in Florida, Mr. Trump projected confidence that it would be a passing problem.

“We have it totally under control,” he told an interviewer a few days later while attending the World Economic Forum in Switzerland. “It’s going to be just fine.”

The efforts to sort out policy behind closed doors were contentious and sometimes only loosely organized.

That was the case when the National Security Council convened a meeting on short notice on the afternoon of Jan. 27. The Situation Room was standing room only, packed with top White House advisers, low-level staffers, Mr. Trump’s social media guru, and several cabinet secretaries. There was no checklist about the preparations for a possible pandemic,

Instead, after a 20-minute description by Mr. Azar of his department’s capabilities, the meeting was jolted when Stephen E. Biegun, the newly installed deputy secretary of state, announced plans to issue a “level four” travel warning, strongly discouraging Americans from traveling to China. The room erupted into bickering.

A few days later, on the evening of Jan. 30, Mick Mulvaney, the acting White House chief of staff at the time, and Mr. Azar called Air Force One as the president was making the final decision to go ahead with the restrictions on China travel. Mr. Azar was blunt, warning that the virus could develop into a pandemic and arguing that China should be criticized for failing to be transparent.

Stop panicking, Mr. Trump told him.That sentiment was present throughout February, as the president’s top aides reached for a consistent message but took few concrete steps to prepare for the possibility of a major public health crisis.

As February gave way to March, the president continued to be surrounded by divided factions even as it became clearer that avoiding more aggressive steps was not tenable.

the virus was already multiplying across the country — and hospitals were at risk of buckling under the looming wave of severely ill people, lacking masks and other protective equipment, ventilators and sufficient intensive care beds. The question loomed over the president and his aides after weeks of stalling and inaction: What were they going to do?

Even then, and even by Trump White House standards, the debate over whether to shut down much of the country to slow the spread was especially fierce.

In a tense Oval Office meeting, when Mr. Mnuchin again stressed that the economy would be ravaged, Mr. O’Brien, the national security adviser, who had been worried about the virus for weeks, sounded exasperated as he told Mr. Mnuchin that the economy would be destroyed regardless if officials did nothing.