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Traditionally, a scientist submits her paper to a journal, which sends it to a (surprisingly small) group of peers for (several rounds of usually anonymous) comments; if the paper passes this (typically months-long) peer-review gantlet, it is published (often behind an expensive paywall). Languid and opaque, this system is ill-suited to a fast-moving outbreak. But biomedical scientists can now upload preliminary versions of their papers, or “preprints,” to freely accessible websites, allowing others to immediately dissect and build upon their results. This practice had been slowly gaining popularity before 2020, but proved so vital for sharing information about COVID‑19 that it will likely become a mainstay of modern biomedical research. Preprints accelerate science, and the pandemic accelerated the use of preprints. At the start of the year, one repository, medRxiv (pronounced “med archive”), held about 1,000 preprints. By the end of October, it had more than 12,000.

The U.S. is now catching up. In April, the NIH launched a partnership called ACTIV, in which academic and industry scientists prioritized the most promising drugs and coordinated trial plans across the country. Since August, several such trials have started.

Researchers have begun to uncover how SARS‑CoV‑2 compares with other coronaviruses in wild bats, the likely reservoir; how it infiltrates and co-opts our cells; how the immune system overreacts to it, creating the symptoms of COVID‑19. “We’re learning about this virus faster than we’ve ever learned about any virus in history,” Sabeti said.

Similar triumphs occurred last year—in other countries. In March, taking advantage of the United Kingdom’s nationalized health system, British researchers launched a nationwide study called Recovery, which has since enrolled more than 17,600 COVID‑19 patients across 176 institutions. Recovery offered conclusive answers about dexamethasone and hydroxychloroquine and is set to weigh in on several other treatments. No other study has done more to shape the treatment of COVID‑19.

SARS‑CoV‑2’s genome was decoded and shared by Chinese scientists just 10 days after the first cases were reported. By November, more than 197,000 SARS‑CoV‑2 genomes had been sequenced. About 90 years ago, no one had even seen an individual virus; today, scientists have reconstructed the shape of SARS‑CoV‑2 down to the position of individual atoms

Respiratory viruses, though extremely common, are often neglected. Respiratory syncytial virus, parainfluenza viruses, rhinoviruses, adenoviruses, bocaviruses, a quartet of other human coronaviruses—they mostly cause mild coldlike illnesses, but those can be severe. How often? Why? It’s hard to say, because, influenza aside, such viruses attract little funding or interest.

COVID‑19 has developed a terrifying mystique because it seems to behave in unusual ways. It causes mild symptoms in some but critical illness in others. It is a respiratory virus and yet seems to attack the heart, brain, kidneys, and other organs. It has reinfected a small number of people who had recently recovered. But many other viruses share similar abilities; they just don’t infect millions of people in a matter of months or grab the attention of the entire scientific community

Thanks to COVID‑19, more researchers are looking for these rarer sides of viral infections, and spotting them.

These factors pull researchers toward speed, short-termism, and hype at the expense of rigor—and the pandemic intensified that pull. With an anxious world crying out for information, any new paper could immediately draw international press coverage—and hundreds of citations.

“There’s a perception that they’re just colds and there’s nothing much to learn,” says Emily Martin of the University of Michigan, who has long struggled to get funding to study them. Such reasoning is shortsighted folly. Respiratory viruses are the pathogens most likely to cause pandemics, and those outbreaks could potentially be far worse than COVID‑19’s.

Their movements through the air have been poorly studied, too. “There’s this very entrenched idea,” says Linsey Marr at Virginia Tech, that viruses mostly spread through droplets (short-range globs of snot and spit) rather than aerosols (smaller, dustlike flecks that travel farther). That idea dates back to the 1930s, when scientists were upending outdated notions that disease was caused by “bad air,” or miasma. But the evidence that SARS‑CoV‑2 can spread through aerosols “is now overwhelming,”

Another pandemic is inevitable, but it will find a very different community of scientists than COVID‑19 did. They will immediately work to determine whether the pathogen—most likely another respiratory virus—moves through aerosols, and whether it spreads from infected people before causing symptoms. They might call for masks and better ventilation from the earliest moments, not after months of debate

They will anticipate the possibility of an imminent wave of long-haul symptoms, and hopefully discover ways of preventing them. They might set up research groups to prioritize the most promising drugs and coordinate large clinical trials. They might take vaccine platforms that worked best against COVID‑19, slot in the genetic material of the new pathogen, and have a vaccine ready within months

the single-minded focus on COVID‑19 will also leave a slew of negative legacies. Science is mostly a zero-sum game, and when one topic monopolizes attention and money, others lose out.

Long-term studies that monitored bird migrations or the changing climate will forever have holes in their data because field research had to be canceled.

negligence has left COVID‑19 long-haulers with few answers or options, and they initially endured the same dismissal as the larger ME community. But their sheer numbers have forced a degree of recognition. They started researching, cataloging their own symptoms. They gained audiences with the NIH and the World Health Organization. Patients who are themselves experts in infectious disease or public health published their stories in top journals. “Long COVID” is being taken seriously, and Brea hopes it might drag all post-infection illnesses into the spotlight. ME never experienced a pivot. COVID‑19 might inadvertently create one

Other epistemic trespassers spent their time reinventing the wheel. One new study, published in NEJM, used lasers to show that when people speak, they release aerosols. But as the authors themselves note, the same result—sans lasers—was published in 1946, Marr says. I asked her whether any papers from the 2020 batch had taught her something new. After an uncomfortably long pause, she mentioned just one.

The incentives to trespass are substantial. Academia is a pyramid scheme: Each biomedical professor trains an average of six doctoral students across her career, but only 16 percent of the students get tenure-track positions. Competition is ferocious, and success hinges on getting published

Conservationists who worked to protect monkeys and apes kept their distance for fear of passing COVID‑19 to already endangered species.

Among scientists, as in other fields, women do more child care, domestic work, and teaching than men, and are more often asked for emotional support by their students. These burdens increased as the pandemic took hold, leaving women scientists “less able to commit their time to learning about a new area of study, and less able to start a whole new research project,

published COVID‑19 papers had 19 percent fewer women as first authors compared with papers from the same journals in the previous year. Men led more than 80 percent of national COVID‑19 task forces in 87 countries. Male scientists were quoted four times as frequently as female scientists in American news stories about the pandemic.

American scientists of color also found it harder to pivot than their white peers, because of unique challenges that sapped their time and energy.

Science suffers from the so-called Matthew effect, whereby small successes snowball into ever greater advantages, irrespective of merit. Similarly, early hindrances linger. Young researchers who could not pivot because they were too busy caring or grieving for others might suffer lasting consequences from an unproductive year. COVID‑19 “has really put the clock back in terms of closing the gap for women and underrepresented minorities,”

In 1848, the Prussian government sent a young physician named Rudolf Virchow to investigate a typhus epidemic in Upper Silesia. Virchow didn’t know what caused the devastating disease, but he realized its spread was possible because of malnutrition, hazardous working conditions, crowded housing, poor sanitation, and the inattention of civil servants and aristocrats—problems that require social and political reforms. “Medicine is a social science,” Virchow said, “and politics is nothing but medicine in larger scale.”

entists discovered the microbes responsible for tuberculosis, plague, cholera, dysentery, and syphilis, most fixated on these newly identified nemeses. Societal factors were seen as overly political distractions for researchers who sought to “be as ‘objective’ as possible,” says Elaine Hernandez, a medical sociologist at Indiana University. In the U.S., medicine fractured.

New departments of sociology and cultural anthropology kept their eye on the societal side of health, while the nation’s first schools of public health focused instead on fights between germs and individuals. This rift widened as improvements in hygiene, living standards, nutrition, and sanitation lengthened life spans: The more social conditions improved, the more readily they could be ignored.

The ideological pivot away from social medicine began to reverse in the second half of the 20th century.

Politicians initially described COVID‑19 as a “great equalizer,” but when states began releasing demographic data, it was immediately clear that the disease was disproportionately infecting and killing people of color.

These disparities aren’t biological. They stem from decades of discrimination and segregation that left minority communities in poorer neighborhoods with low-paying jobs, more health problems, and less access to health care—the same kind of problems that Virchow identified more than 170 years ago.

In March, when the U.S. started shutting down, one of the biggest questions on the mind of Whitney Robinson of UNC at Chapel Hill was: Are our kids going to be out of school for two years? While biomedical scientists tend to focus on sickness and recovery, social epidemiologists like her “think about critical periods that can affect the trajectory of your life,” she told me. Disrupting a child’s schooling at the wrong time can affect their entire career, so scientists should have prioritized research to figure out whether and how schools could reopen safely. But most studies on the spread of COVID‑19 in schools were neither large in scope nor well-designed enough to be conclusive. No federal agency funded a large, nationwide study, even though the federal government had months to do so. The NIH received billions for COVID‑19 research, but the National Institute of Child Health and Human Development—one of its 27 constituent institutes and centers—got nothing.

The horrors that Rudolf Virchow saw in Upper Silesia radicalized him, pushing the future “father of modern pathology” to advocate for social reforms. The current pandemic has affected scientists in the same way

COVID‑19 could be the catalyst that fully reunifies the social and biological sides of medicine, bridging disciplines that have been separated for too long.

“To study COVID‑19 is not only to study the disease itself as a biological entity,” says Alondra Nelson, the president of the Social Science Research Council. “What looks like a single problem is actually all things, all at once. So what we’re actually studying is literally everything in society, at every scale, from supply chains to individual relationships.”

Latinos have maintained this type of edge despite generally having lower incomes, less access to health care and a greater prevalence of some chronic health issues, such as diabetes and obesity. Some researchers believe the life expectancy advantage is tied to the fact that many Latino immigrants to the U.S. are younger and healthier than many older Latinos, and have lower rates of smoking.

The researchers used projections of COVID-19 mortality to reach their conclusions, and a follow-up study arrived at similar findings. A CDC analysis showing provisional life expectancy estimates also pointed to a three-year drop in life expectancy for Latinos, and a shrinking gap between Latinos and whites.

Latino subgroups have an array of political and cultural differences. But one cultural norm that cuts across all groups is the primacy of family. Whatever country they’re descended from, it’s not uncommon for Latinos in the U.S. to live in multigenerational households that often include young children, their adult parents and a grandparent or grandparents.When young children and adults – many of whom are essential workers – live with elderly grandparents, “that increases the risk for the older people in the household,” says Dr. Luis Ostrosky, chief of the Division of Infectious Diseases at the McGovern Medical School at UTHealth Houston. “If the younger people in the household contract COVID-19, they may be OK, because younger people have stronger immune systems and tend to be healthier. Older people – who tend to be not as healthy and have chronic diseases – may become severely ill, with increased risk of hospitalization and mortality.”

“Once you put all those together, what you find is you have the disappearing of the Latino paradox,” Saenz says.While older Latinos have continued to have a higher rate of COVID-19 mortality than their white counterparts during each year of the pandemic, the difference in death rates has diminished over time. During the first year of the crisis, Latinos age 65 and older died of COVID-19 at 2.1 times the rate of older whites, Saenz and Garcia’s research shows. In 2021, older Latinos died at 1.6 times the rate of older whites, and into late April of this year, older Hispanics had died at 1.2 times the rate of older whites. Saenz attributes the narrowing difference to COVID-19 death rates among older whites in red states where vaccination rates are lower.

Transportation, language and employment. A study in 2020 from the UCLA Latino Policy & Politics Initiative found Latinos (and Blacks) in Los Angeles County and New York City were roughly twice as likely to die of COVID-19 as non-Hispanic whites as of July 20 of that year, and noted that carpooling or taking public transportation to work may raise the risk of coronavirus exposure. The study also found that 34% and 37% of the populations in Los Angeles County and New York City were foreign-born, respectively, with Latinos making up the largest share of that population in each area. Approximately 13% of the foreign-born do not speak English, according to the report, which poses a challenge to their obtaining important health information.

“A three-year reduction in life expectancy is huge in historical terms. We usually have not seen reductions this large except during times of war or major pandemics,” says Theresa Andrasfay, a postdoctoral scholar at the Leonard Davis School of Gerontology at USC and one of the PNAS study’s researchers. “Of course, it’s really sad to think about the individuals who died of COVID, but it also has broader implications for the family members of those who died.”COVID-19 has not only claimed the lives of many older Latinos, but many younger, working-age Latinos as well, leaving behind children, siblings, parents and grandparents who depended on them, Andrasfay says. She says she and other researchers are working on an update, tracking the effect of COVID-19 on life expectancy in 2021: “We’re finding a similar pattern (to 2020), with Latinos having the largest reduction in life expectancy.”

Though he wasn’t in the best of health, Salvador Macias, 83, enjoyed going to a neighborhood community center for senior activities in Long Beach, a beachside city about 25 miles south of downtown Los Angeles. He lived in a modest, tidy house with his wife, Manuela, and their adult daughter, Julie.Salvador suffered from three chronic health conditions: diabetes, high cholesterol and high blood pressure, says his son, Joe Macias.In August 2020 – four months before health care workers received the first COVID-19 vaccine – the elder Macias became ill with the disease, suffering from fatigue and severe shortness of breath. After several days, Salvador died at home. Manuela, who doesn’t have the chronic health conditions her husband had, also contracted COVID-19. She was hospitalized for a week, but survived.

“My first and biggest wish is that we had known early that Covid-19 was airborne,”

, “Once you’ve realized that, it informs an entirely different strategy for protection.” Masking, ventilation and air cleaning become key, as well as avoiding high-risk encounters with strangers, he says.

Instead of washing our produce and wearing hand-sewn cloth masks, we could have made sure to avoid superspreader events and worn more-effective N95 masks or their equivalent. “We could have made more of an effort to develop and distribute N95s to everyone,” says Dr. Volckens. “We could have had an Operation Warp Speed for masks.”

We didn’t realize how important clear, straight talk would be to maintaining public trust. If we had, we could have explained the biological nature of a virus and warned that Covid-19 would change in unpredictable ways.  

In the face of a pandemic, he says, the public needs an early basic and blunt lesson in virology

“The science is really important, but if you don’t get the trust and communication right, it can only take you so far,”

and mutates, and since we’ve never seen this particular virus before, we will need to take unprecedented actions and we will make mistakes, he says.

Since the public wasn’t prepared, “people weren’t able to pivot when the knowledge changed,”

By the time the vaccines became available, public trust had been eroded by myriad contradictory messages—about the usefulness of masks, the ways in which the virus could be spread, and whether the virus would have an end date.

, the absence of a single, trusted source of clear information meant that many people gave up on trying to stay current or dismissed the different points of advice as partisan and untrustworthy.

We didn’t know how difficult it would be to get the basic data needed to make good public-health and medical decisions. If we’d had the data, we could have more effectively allocated scarce resources

For much of the pandemic, doctors, epidemiologists, and state and local governments had no way to find out in real time how many people were contracting Covid-19, getting hospitalized and dying

Doctors didn’t know what medicines worked. Governors and mayors didn’t have the information they needed to know whether to require masks. School officials lacked the information needed to know whether it was safe to open schools.

people didn’t know whether it was OK to visit elderly relatives or go to a dinner party.

just months before the outbreak of the pandemic, the Council of State and Territorial Epidemiologists released a white paper detailing the urgent need to modernize the nation’s public-health system still reliant on manual data collection methods—paper records, phone calls, spreadsheets and faxes.

While the U.K. and Israel were collecting and disseminating Covid case data promptly, in the U.S. the CDC couldn’t. It didn’t have a centralized health-data collection system like those countries did, but rather relied on voluntary reporting by underfunded state and local public-health systems and hospitals.

doctors and scientists say they had to depend on information from Israel, the U.K. and South Africa to understand the nature of new variants and the effectiveness of treatments and vaccines. They relied heavily on private data collection efforts such as a dashboard at Johns Hopkins University’s Coronavirus Resource Center that tallied cases, deaths and vaccine rates globally.

With good data, Dr. Ranney says, she could have better managed staffing and taken steps to alleviate the strain on doctors and nurses by arranging child care for them.

To solve the data problem, Dr. Ranney says, we need to build a public-health system that can collect and disseminate data and acts like an electrical grid. The power company sees a storm coming and lines up repair crews.

If we’d known how damaging lockdowns would be to mental health, physical health and the economy, we could have taken a more strategic approach to closing businesses and keeping people at home.

t many doctors say they were crucial at the start of the pandemic to give doctors and hospitals a chance to figure out how to accommodate and treat the avalanche of very sick patients.

The measures reduced deaths, according to many studies—but at a steep cost.

The lockdowns didn’t have to be so harmful, some scientists say. They could have been more carefully tailored to protect the most vulnerable, such as those in nursing homes and retirement communities, and to minimize widespread disruption.

Lockdowns could, during Covid-19 surges, close places such as bars and restaurants where the virus is most likely to spread, while allowing other businesses to stay open with safety precautions like masking and ventilation in place.  

If England’s March 23, 2020, lockdown had begun one week earlier, the measure would have nearly halved the estimated 48,600 deaths in the first wave of England’s pandemic

If the lockdown had begun a week later, deaths in the same period would have more than doubled

The key isn’t to have the lockdowns last a long time, but that they are deployed earlier,

It is possible to avoid lockdowns altogether. Taiwan, South Korea and Hong Kong—all countries experienced at handling disease outbreaks such as SARS in 2003 and MERS—avoided lockdowns by widespread masking, tracking the spread of the virus through testing and contact tracing and quarantining infected individuals.

Had we known that even a mild case of Covid-19 could result in long Covid and other serious chronic health problems, we might have calculated our own personal risk differently and taken more care.

Early in the pandemic, public-health officials were clear: The people at increased risk for severe Covid-19 illness were older, immunocompromised, had chronic kidney disease, Type 2 diabetes or serious heart conditions

t had the unfortunate effect of giving a false sense of security to people who weren’t in those high-risk categories. Once case rates dropped, vaccines became available and fear of the virus wore off, many people let their guard down, ditching masks, spending time in crowded indoor places.

it has become clear that even people with mild cases of Covid-19 can develop long-term serious and debilitating diseases. Long Covid, whose symptoms include months of persistent fatigue, shortness of breath, muscle aches and brain fog, hasn’t been the virus’s only nasty surprise

In February 2022, a study found that, for at least a year, people who had Covid-19 had a substantially increased risk of heart disease—even people who were younger and had not been hospitalized

respiratory conditions.

Some scientists now suspect that Covid-19 might be capable of affecting nearly every organ system in the body. It may play a role in the activation of dormant viruses and latent autoimmune conditions people didn’t know they had

 A blood test, he says, would tell people if they are at higher risk of long Covid and whether they should have antivirals on hand to take right away should they contract Covid-19.

If the risks of long Covid had been known, would people have reacted differently, especially given the confusion over masks and lockdowns and variants? Perhaps. At the least, many people might not have assumed they were out of the woods just because they didn’t have any of the risk factors.

A high vaccination rate was especially important in Florida, which trails only Maine in the share of residents 65 and older. By the end of July, Florida had vaccinated about 60 percent of adults, just shy of the national average

Had it reached a vaccination rate of 74 percent — the average for five New England states at the time — it could have prevented more than 16,000 deaths and more than 61,000 hospitalizations that summer, according to a study published in the medical journal The Lancet.

in Florida, unlike the nation as a whole — and states like New York and California that Mr. DeSantis likes to single out — most people who died from Covid died after vaccines became available to all adults, not before.

Mr. DeSantis and his aides have said that his opposition was to mandates, not to the vaccinations themselves. They say the governor only questioned the efficacy of the shots once it became evident that they did not necessarily prevent infection — which prompted him to criticize experts and the federal government.

The governor had early success in following his instincts. In 2020, the state supplied its nearly 4,000 long-term care homes with Covid tests and isolated Covid patients, avoiding New York’s mistake of releasing Covid patients from hospitals to nursing homes where they infected others. Florida’s death rate in the pandemic’s first year, adjusted for age, was lower than all but 10 other states’.

Florida was also one of only four states to require schools to hold in-person classes in the fall of 2020, a move that Mr. DeSantis has said defied the nation’s public health experts

In fact, Dr. Anthony S. Fauci, a federal infectious disease expert on former President Donald J. Trump’s task force, said repeatedly that summer and fall that schools could open safely with the right precautions. Nonetheless, facing strong opposition from teachers’ unions, nearly three-fourths of the nation’s 100 largest school districts offered only remote learning that fall.

At the same time, though, the governor was embracing more extreme views, including those of Dr. Scott W. Atla

Both he and Dr. Bhattacharya argued that people who were not at risk of severe consequences should not face Covid restrictions. If they were infected, they would develop natural immunity, which would eventually build up in the population and cause the virus to fade away, they said.

Many public health experts were alarmed by this strategy, which was articulated in a document known as the Great Barrington Declaration. They said it would be impossible to ring-fence the vulnerable, or even to clearly communicate to the public who they were. Besides older Americans, as many as 41 million younger adults were considered to be at high risk of severe disease if infected because of underlying medical conditions like obesity.

Dr. Atlas, however, argued that the virus was not dangerous to an overwhelming majority of Americans. Both he and Dr. Bhattacharya said the Covid death rate for everyone under 70 was very low. Dr. Atlas claimed that children had “virtually zero” risk of death.

As of this summer, more than 345,000 Americans under 70 have died of the virus, and more than 3.5 million have been hospitalized

The disease has killed nearly 2,300 children and adolescents, and nearly 200,000 have been hospitalized.

Mr. DeSantis gave him a platform at a series of public events in Florida at the end of the summer of 2020. He would go on to echo Dr. Atlas’s views, sometimes in modified form, throughout the pandemic.

Mr. DeSantis subsequently promoted the shots in 27 counties. Florida offered the vaccine to everyone 65 and older, an eligibility system simpler than an early one recommended by the Centers for Disease Control and Prevention, and adopted by many states, that prioritized essential workers and those over 75.

But his enthusiasm for shots waned fast, tracking the growing hostility toward them among the party’s conservative activists. In late February, when Mr. DeSantis hosted a gathering of such activists for the Conservative Political Action Conference in Orlando, he boasted that Florida was an “oasis of freedom” in a nation led by misguided health authorities.

By the time all adults became eligible for the vaccines in April of that year, Mr. DeSantis was rarely promoting them.

“Some are choosing not to take it, which is fine,” he said in March, at a 100-minute public event on Covid in which he did not once urge people to get vaccinated. In dozens of appearances on Fox News in the first half of 2021, he was carefully neutral about shots, except for those over 65.

“Younger people are just simply at very little risk for this,”

A few months later, he told Fox News that he had concluded early on that Covid “was something that was risky for elderly people,” but that it posed minimal risks for people “who were in reasonably good health, who were, say, under 50.”

The data-driven governor also turned away from Covid case data.

In May 2021, Florida closed its 27 state-run testing centers. The next month, on orders from the governor’s office, the Health Department halted daily reports on infections and deaths, switching to weekly reports that drew less attention.

Both polls and political events showed that Republicans were not as excited as Democrats about the shots. At an Alabama political rally that August, Mr. Trump recommended the vaccine — and was booed. When a reporter asked Mr. DeSantis later that year if he had gotten a booster shot, he responded that he had gotten “the normal shot.”

After the highly contagious Delta variant began spreading in Florida that summer, Mr. DeSantis insisted that his approach had worked. Younger adults were driving the surge but “they’re not getting really sick from it or anything,” he said, adding: “They will develop immunity as a result of those infections.”

But they were getting sick. And vaccinations, which Mr. DeSantis suddenly began recommending again in late July, took weeks to confer protection

With hospitalizations rising, he began a campaign to offer monoclonal antibody treatments — a triage response to the pandemic’s frightening resurgence.

The drug cost vastly more than shots and required more medical staff to administer. Within about six weeks, the state had administered more than 90,000 treatments and probably kept 5,000 people out of the hospital, Dr. Rivkees said.

Mr. DeSantis accused the media in early August of “lying” about Covid patients’ flooding hospitals. Two weeks later, Mary C. Mayhew, head of the Florida Hospital Association, said: “There can be no question that many Florida hospitals are stretched to their absolute limits.”

“Our patients are younger and sicker,” Mr. Smith wrote. Of 17 patients on ventilators in intensive care on Aug. 13, 2021, more than half were younger than 55. Only one was vaccinated.

“People say that the decision about vaccination is a personal one and it doesn’t affect anyone else,” Mr. Smith wrote. “Tell that to the kids who lost their mom.”

When shots became available last year for children under 5, Florida did not preorder them because, Mr. DeSantis said, he did not consider them “appropriate.” Florida’s vaccination rates are well below the national average for children under 5. The state also trails in booster shots.

After Dr. Ladapo issued misleading claims about the risks of Covid shots for young men, the heads of the C.D.C. and the Food and Drug Administration sent a scathing four-page rebuttal. Such misinformation “puts people at risk of death or serious illness,” they said.

While the pandemic waned, leaving more than 80,000 Floridians and 1.13 million Americans dead, the governor continued to push policies that kept him at the vanguard of the anti-vaccine and anti-mandate conversation. A new state law, signed by Mr. DeSantis in May, bans government agencies, businesses and schools from requiring Covid testing, vaccination or mask wearing.

“Everything involving Covid — I think there needs to be major, major accountability,” he said in Iowa this month. “Because if there’s not, if you don’t have a reckoning, they are going to do it again.”

To contain such a pathogen, nations must develop a test and use it to identify infected people, isolate them, and trace those they’ve had contact with. That is what South Korea, Singapore, and Hong Kong did to tremendous effect. It is what the United States did not.

That a biomedical powerhouse like the U.S. should so thoroughly fail to create a very simple diagnostic test was, quite literally, unimaginable. “I’m not aware of any simulations that I or others have run where we [considered] a failure of testing,”

The testing fiasco was the original sin of America’s pandemic failure, the single flaw that undermined every other countermeasure. If the country could have accurately tracked the spread of the virus, hospitals could have executed their pandemic plans, girding themselves by allocating treatment rooms, ordering extra supplies, tagging in personnel, or assigning specific facilities to deal with COVID-19 cases.

None of that happened. Instead, a health-care system that already runs close to full capacity, and that was already challenged by a severe flu season, was suddenly faced with a virus that had been left to spread, untracked, through communities around the country.

With little room to surge during a crisis, America’s health-care system operates on the assumption that unaffected states can help beleaguered ones in an emergency.

That ethic works for localized disasters such as hurricanes or wildfires, but not for a pandemic that is now in all 50 states. Cooperation has given way to competition

Partly, that’s because the White House is a ghost town of scientific expertise. A pandemic-preparedness office that was part of the National Security Council was dissolved in 2018. On January 28, Luciana Borio, who was part of that team, urged the government to “act now to prevent an American epidemic,” and specifically to work with the private sector to develop fast, easy diagnostic tests. But with the office shuttered, those warnings were published in The Wall Street Journal, rather than spoken into the president’s ear.

Rudderless, blindsided, lethargic, and uncoordinated, America has mishandled the COVID-19 crisis to a substantially worse degree than what every health expert I’ve spoken with had feared. “Much worse,”

“Beyond any expectations we had,” said Lauren Sauer, who works on disaster preparedness at Johns Hopkins Medicine. “As an American, I’m horrified,” said Seth Berkley, who heads Gavi, the Vaccine Alliance. “The U.S. may end up with the worst outbreak in the industrialized world.”

it will be difficult—but not impossible—for the United States to catch up. To an extent, the near-term future is set because COVID-19 is a slow and long illness. People who were infected several days ago will only start showing symptoms now, even if they isolated themselves in the meantime. Some of those people will enter intensive-care units in early April

A “massive logistics and supply-chain operation [is] now needed across the country,” says Thomas Inglesby of Johns Hopkins Bloomberg School of Public Health. That can’t be managed by small and inexperienced teams scattered throughout the White House. The solution, he says, is to tag in the Defense Logistics Agency—a 26,000-person group that prepares the U.S. military for overseas operations and that has assisted in past public-health crises, including the 2014 Ebola outbreak.

The first and most important is to rapidly produce masks, gloves, and other personal protective equipment

it would also come at a terrible cost: SARS-CoV-2 is more transmissible and fatal than the flu, and it would likely leave behind many millions of corpses and a trail of devastated health systems.

This agency can also coordinate the second pressing need: a massive rollout of COVID-19 tests.

These measures will take time, during which the pandemic will either accelerate beyond the capacity of the health system or slow to containable levels. Its course—and the nation’s fate—now depends on the third need, which is social distancing.

There are now only two groups of Americans. Group A includes everyone involved in the medical response, whether that’s treating patients, running tests, or manufacturing supplies. Group B includes everyone else, and their job is to buy Group A more time. Group B must now “flatten the curve” by physically isolating themselves from other people to cut off chains of transmission.

Given the slow fuse of COVID-19, to forestall the future collapse of the health-care system, these seemingly drastic steps must be taken immediately, before they feel proportionate, and they must continue for several weeks.

Persuading a country to voluntarily stay at home is not easy, and without clear guidelines from the White House, mayors, governors, and business owners have been forced to take their own steps.

when the good of all hinges on the sacrifices of many, clear coordination matters—the fourth urgent need

Pundits and business leaders have used similar rhetoric, arguing that high-risk people, such as the elderly, could be protected while lower-risk people are allowed to go back to work. Such thinking is seductive, but flawed. It overestimates our ability to assess a person’s risk, and to somehow wall off the ‘high-risk’ people from the rest of society. It underestimates how badly the virus can hit ‘low-risk’ groups, and how thoroughly hospitals will be overwhelmed if even just younger demographics are falling sick.

A recent analysis from the University of Pennsylvania estimated that even if social-distancing measures can reduce infection rates by 95 percent, 960,000 Americans will still need intensive care.

There are only about 180,000 ventilators in the U.S. and, more pertinently, only enough respiratory therapists and critical-care staff to safely look after 100,000 ventilated patients. Abandoning social distancing would be foolish. Abandoning it now, when tests and protective equipment are still scarce, would be catastrophic.

If Trump stays the course, if Americans adhere to social distancing, if testing can be rolled out, and if enough masks can be produced, there is a chance that the country can still avert the worst predictions about COVID-19, and at least temporarily bring the pandemic under control. No one knows how long that will take, but it won’t be quick. “It could be anywhere from four to six weeks to up to three months,” Fauci said, “but I don’t have great confidence in that range.”

there are three possible endgames: one that’s very unlikely, one that’s very dangerous, and one that’s very long.

The first is that every nation manages to simultaneously bring the virus to heel, as with the original SARS in 2003. Given how widespread the coronavirus pandemic is, and how badly many countries are faring, the odds of worldwide synchronous control seem vanishingly small.

The second is that the virus does what past flu pandemics have done: It burns through the world and leaves behind enough immune survivors that it eventually struggles to find viable hosts. This “herd immunity” scenario would be quick, and thus tempting

The U.S. has fewer hospital beds per capita than Italy. A study released by a team at Imperial College London concluded that if the pandemic is left unchecked, those beds will all be full by late April. By the end of June, for every available critical-care bed, there will be roughly 15 COVID-19 patients in need of one.  By the end of the summer, the pandemic will have directly killed 2.2 million Americans,

The third scenario is that the world plays a protracted game of whack-a-mole with the virus, stamping out outbreaks here and there until a vaccine can be produced. This is the best option, but also the longest and most complicated.

there are no existing vaccines for coronaviruses—until now, these viruses seemed to cause diseases that were mild or rare—so researchers must start from scratch.

The first steps have been impressively quick. Last Monday, a possible vaccine created by Moderna and the National Institutes of Health went into early clinical testing. That marks a 63-day gap between scientists sequencing the virus’s genes for the first time and doctors injecting a vaccine candidate into a person’s arm. “It’s overwhelmingly the world record,” Fauci said.

The initial trial will simply tell researchers if the vaccine seems safe, and if it can actually mobilize the immune system. Researchers will then need to check that it actually prevents infection from SARS-CoV-2. They’ll need to do animal tests and large-scale trials to ensure that the vaccine doesn’t cause severe side effects. They’ll need to work out what dose is required, how many shots people need, if the vaccine works in elderly people, and if it requires other chemicals to boost its effectiveness.

No matter which strategy is faster, Berkley and others estimate that it will take 12 to 18 months to develop a proven vaccine, and then longer still to make it, ship it, and inject it into people’s arms.

as the status quo returns, so too will the virus. This doesn’t mean that society must be on continuous lockdown until 2022. But “we need to be prepared to do multiple periods of social distancing,” says Stephen Kissler of Harvard.

First: seasonality. Coronaviruses tend to be winter infections that wane or disappear in the summer. That may also be true for SARS-CoV-2, but seasonal variations might not sufficiently slow the virus when it has so many immunologically naive hosts to infect.

Second: duration of immunity. When people are infected by the milder human coronaviruses that cause cold-like symptoms, they remain immune for less than a year. By contrast, the few who were infected by the original SARS virus, which was far more severe, stayed immune for much longer.

scientists will need to develop accurate serological tests, which look for the antibodies that confer immunity. They’ll also need to confirm that such antibodies actually stop people from catching or spreading the virus. If so, immune citizens can return to work, care for the vulnerable, and anchor the economy during bouts of social distancing.

Aspects of America’s identity may need rethinking after COVID-19. Many of the country’s values have seemed to work against it during the pandemic. Its individualism, exceptionalism, and tendency to equate doing whatever you want with an act of resistance meant that when it came time to save lives and stay indoors, some people flocked to bars and clubs.

“We can keep schools and businesses open as much as possible, closing them quickly when suppression fails, then opening them back up again once the infected are identified and isolated. Instead of playing defense, we could play more offense.”

The vaccine may need to be updated as the virus changes, and people may need to get revaccinated on a regular basis, as they currently do for the flu. Models suggest that the virus might simmer around the world, triggering epidemics every few years or so. “But my hope and expectation is that the severity would decline, and there would be less societal upheaval,”

After infections begin ebbing, a secondary pandemic of mental-health problems will follow.

But “there is also the potential for a much better world after we get through this trauma,”

Testing kits can be widely distributed to catch the virus’s return as quickly as possible. There’s no reason that the U.S. should let SARS-CoV-2 catch it unawares again, and thus no reason that social-distancing measures need to be deployed as broadly and heavy-handedly as they now must be.

Pandemics can also catalyze social change. People, businesses, and institutions have been remarkably quick to adopt or call for practices that they might once have dragged their heels on, including working from home, conference-calling to accommodate people with disabilities, proper sick leave, and flexible child-care arrangements.

Perhaps the nation will learn that preparedness isn’t just about masks, vaccines, and tests, but also about fair labor policies and a stable and equal health-care system. Perhaps it will appreciate that health-care workers and public-health specialists compose America’s social immune system, and that this system has been suppressed.

Attitudes to health may also change for the better. The rise of HIV and AIDS “completely changed sexual behavior among young people who were coming into sexual maturity at the height of the epidemic,”

Years of isolationist rhetoric had consequences too.

“People believed the rhetoric that containment would work,” says Wendy Parmet, who studies law and public health at Northeastern University. “We keep them out, and we’ll be okay. When you have a body politic that buys into these ideas of isolationism and ethnonationalism, you’re especially vulnerable when a pandemic hits.”

Pandemics are democratizing experiences. People whose privilege and power would normally shield them from a crisis are facing quarantines, testing positive, and losing loved ones. Senators are falling sick. The consequences of defunding public-health agencies, losing expertise, and stretching hospitals are no longer manifesting as angry opinion pieces, but as faltering lungs.

After COVID-19, attention may shift to public health. Expect to see a spike in funding for virology and vaccinology, a surge in students applying to public-health programs, and more domestic production of medical supplies.

The lessons that America draws from this experience are hard to predict, especially at a time when online algorithms and partisan broadcasters only serve news that aligns with their audience’s preconceptions.

“The transitions after World War II or 9/11 were not about a bunch of new ideas,” he says. “The ideas are out there, but the debates will be more acute over the next few months because of the fluidity of the moment and willingness of the American public to accept big, massive changes.”

One could easily conceive of a world in which most of the nation believes that America defeated COVID-19. Despite his many lapses, Trump’s approval rating has surged. Imagine that he succeeds in diverting blame for the crisis to China, casting it as the villain and America as the resilient hero.

One could also envisage a future in which America learns a different lesson. A communal spirit, ironically born through social distancing, causes people to turn outward, to neighbors both foreign and domestic. The election of November 2020 becomes a repudiation of “America first” politics. The nation pivots, as it did after World War II, from isolationism to international cooperation

The U.S. leads a new global partnership focused on solving challenges like pandemics and climate change.

In 2030, SARS-CoV-3 emerges from nowhere, and is brought to heel within a month.

On the Global Health Security Index, a report card that grades every country on its pandemic preparedness, the United States has a score of 83.5—the world’s highest. Rich, strong, developed, America is supposed to be the readiest of nations. That illusion has been shattered. Despite months of advance warning as the virus spread in other countries, when America was finally tested by COVID-19, it failed.

The Democrats’ message, Schrier said, should be clear and simple: All vaccines are good. And the best thing American can do to protect themselves and their loved ones is to get a shot.

Pelosi spokesman Henry Connelly said the Speaker was simply reflecting concerns in her diverse caucus about whether minority communities were being treated equitably in the aggressive push to vaccinate all Americans.

That disparity has been attributed, in part, to the fact that the earlier Moderna and Pfizer vaccines each require two shots and colder refrigeration, complicating storage and distribution. That’s created additional barriers for getting the vaccine to poorer, historically underserved populations and rural communities.

Black people are nearly three times more likely to be hospitalized with COVID-19 than white people and nearly two times more likely to die from the disease; Hispanics are more than three times more likely to be hospitalized with COVID-19 than whites and 2.3 times more likely to die. 

White people have been vaccinated for COVID-19 at two times the rate of Black people, according to a New York Times analysis. The figures are worse for Hispanics. 

The disagreement among Democrats comes during a pivotal moment in the fight against the coronavirus pandemic as states like Texas and Mississippi end their mask mandates and lift restrictions on businesses, and health experts worry about a surge in cases driven by COVID-19 variants.

Because the new Johnson & Johnson vaccine requires only one shot and regular refrigeration levels, some officials like New Jersey Gov. Phil Murphy (D) have ordered that shipments of that vaccine be prioritized for harder-to-reach Black and brown communities. 

But while Pfizer and Moderna vaccines have an overall efficacy of about 95 percent in preventing moderate to severe disease, that number for the Johnson & Johnson version is just 66 percent — though experts point out the J&J vaccine was being tested after more contagious variants had begun spreading in the U.S., unlike the Pfizer and Moderna versions. 

That's led to some in those minority communities voicing concerns in recent days that they are being given a less-effective vaccine than more affluent, white communities.

Rep. André Carson (D-Ind.), another CBC member, noted that those suspicions have historic roots, pointing to the infamous Tuskegee syphilis study — a deadly federal research project that targeted poor Black people in rural Alabama in 1930s — as evidence of the "painful history" of biomedical mistreatment of African Americans in the United States. 

Despite such reservations, the broad consensus in the caucus appears to favor efforts to maximize vaccinations in the shortest possible time, regardless which shot is available in a given community.

On Wednesday, Kelly is set to join Rep. Joyce BeattyJoyce Birdson BeattyDemocrats spar over COVID-19 vaccine strategy Black Caucus backs Biden's pick to head DOJ Civil Rights Division Sole GOP vote on House police reform bill says he 'accidentally pressed the wrong voting button' MORE (D-Ohio), head of the Black Caucus, in an online forum with medical experts designed to educate minority communities on best vaccine practices. 

Rep. Anthony BrownAnthony Gregory BrownOvernight Defense: Pentagon chief to press for Manchin's support on Colin Kahl | House Dems seek to limit transfer of military-grade gear to police Democrats spar over COVID-19 vaccine strategy 140 lawmakers call for Biden administration to take 'comprehensive' approach to Iran MORE (D-Md.) said officials should monitor the distribution of vaccines to identify “patterns” that might indicate prejudices in the dispensation. But he’s also encouraging all of his constituents to get whatever vaccine is available first, and he highlighted the advantages of the one-dose Johnson & Johnson shot, particularly in hard-to-reach populations like the homeless. 

In an ideal epidemiological scenario, everyone would willingly deploy the full arsenal of COVID precautions, such as masking and forgoing crowded indoor activities, especially during waves. But that kind of all-out response no longer makes sense. “It’s probably not realistic to expect people to take precautions every time, perpetually, or even every winter or fall, unless there is a particularly concerning reason to do that,

when so few people feel that the potential benefit of dodging an infection is worth the inconvenience of precautions, what does it even mean to care about COVID?

people over 50 account for 93 percent of COVID-related deaths in the U.S., even though they represent just 35.7 percent of the population. As long as the death rate remains as high as it is, caring about COVID should mean orienting precautions to protect them.

Barring another Omicron-esque event, we thankfully won’t ever return to a moment where Americans obsess over COVID en masse. But this virus isn’t going away, so we can’t escape having a population that is split between the high-risk minority and the low-risk majority

Right now, Nuzzo told me, the language we use to describe one’s position on COVID is “black-and-white, absolutist—you either care or you don’t.” There is space between those extremes. At least for now, it’s the only way to compromise between the world we have and the world we want.

They worried that a vaccine would initially elude scientists, that weary citizens would abandon restrictions despite the risks, that the virus would be with us from now on.

Most experts believed that once the crisis was over, the nation and its economy would revive quickly. But there would be no escaping a period of intense pain.

Exactly how the pandemic will end depends in part on medical advances still to come. It will also depend on how individual Americans behave in the interim. If we scrupulously protect ourselves and our loved ones, more of us will live. If we underestimate the virus, it will find us.

More Americans may die than the White House admits.

The epidemiological model often cited by the White House, which was produced by the University of Washington’s Institute for Health Metrics and Evaluation, originally predicted 100,000 to 240,000 deaths by midsummer. Now that figure is 60,000.

The institute’s projection runs through Aug. 4, describing only the first wave of this epidemic. Without a vaccine, the virus is expected to circulate for years, and the death tally will rise over time.

Fatality rates depend heavily on how overwhelmed hospitals get and what percentage of cases are tested. China’s estimated death rate was 17 percent in the first week of January, when Wuhan was in chaos, according to a Center for Evidence-Based Medicine report, but only 0.7 percent by late February.

Various experts consulted by the Centers for Disease Control and Prevention in March predicted that the virus eventually could reach 48 percent to 65 percent of all Americans, with a fatality rate just under 1 percent, and would kill up to 1.7 million of them if nothing were done to stop the spread.

A model by researchers at Imperial College London cited by the president on March 30 predicted 2.2 million deaths in the United States by September under the same circumstances.

China has officially reported about 83,000 cases and 4,632 deaths, which is a fatality rate of over 5 percent. The Trump administration has questioned the figures but has not produced more accurate ones.

The tighter the restrictions, experts say, the fewer the deaths and the longer the periods between lockdowns. Most models assume states will eventually do widespread temperature checks, rapid testing and contact tracing, as is routine in Asia.

In this country, hospitals in several cities, including New York, came to the brink of chaos.

Only when tens of thousands of antibody tests are done will we know how many silent carriers there may be in the United States. The C.D.C. has suggested it might be 25 percent of those who test positive. Researchers in Iceland said it might be double that.

China is also revising its own estimates. In February, a major study concluded that only 1 percent of cases in Wuhan were asymptomatic. New research says perhaps 60 percent were.

The virus may also be mutating to cause fewer symptoms. In the movies, viruses become more deadly. In reality, they usually become less so, because asymptomatic strains reach more hosts. Even the 1918 Spanish flu virus eventually faded into the seasonal H1N1 flu.

The lockdowns will end, but haltingly.

it is likely a safe bet that at least 300 million of us are still vulnerable.

Until a vaccine or another protective measure emerges, there is no scenario, epidemiologists agreed, in which it is safe for that many people to suddenly come out of hiding. If Americans pour back out in force, all will appear quiet for perhaps three weeks.

The gains to date were achieved only by shutting down the country, a situation that cannot continue indefinitely. The White House’s “phased” plan for reopening will surely raise the death toll no matter how carefully it is executed.

Every epidemiological model envisions something like the dance

On the models, the curves of rising and falling deaths resemble a row of shark teeth.

Surges are inevitable, the models predict, even when stadiums, churches, theaters, bars and restaurants remain closed, all travelers from abroad are quarantined for 14 days, and domestic travel is tightly restricted to prevent high-intensity areas from reinfecting low-intensity ones.

In his wildly popular March 19 article in Medium, “Coronavirus: The Hammer and the Dance,” Tomas Pueyo correctly predicted the national lockdown, which he called the hammer, and said it would lead to a new phase, which he called the dance, in which essential parts of the economy could reopen, including some schools and some factories with skeleton crews.

Even the “Opening Up America Again” guidelines Mr. Trump issued on Thursday have three levels of social distancing, and recommend that vulnerable Americans stay hidden. The plan endorses testing, isolation and contact tracing — but does not specify how these measures will be paid for, or how long it will take to put them in place.

On Friday, none of that stopped the president from contradicting his own message by sending out tweets encouraging protesters in Michigan, Minnesota and Virginia to fight their states’ shutdowns.

China did not allow Wuhan, Nanjing or other cities to reopen until intensive surveillance found zero new cases for 14 straight days, the virus’s incubation period.

Compared with China or Italy, the United States is still a playground.Americans can take domestic flights, drive where they want, and roam streets and parks. Despite restrictions, everyone seems to know someone discreetly arranging play dates for children, holding backyard barbecues or meeting people on dating apps.

Even with rigorous measures, Asian countries have had trouble keeping the virus under control

But if too many people get infected at once, new lockdowns will become inevitable. To avoid that, widespread testing will be imperative.

Reopening requires declining cases for 14 days, the tracing of 90 percent of contacts, an end to health care worker infections, recuperation places for mild cases and many other hard-to-reach goals.

Immunity will become a societal advantage.

Imagine an America divided into two classes: those who have recovered from infection with the coronavirus and presumably have some immunity to it; and those who are still vulnerable.

“It will be a frightening schism,” Dr. David Nabarro, a World Health Organization special envoy on Covid-19, predicted. “Those with antibodies will be able to travel and work, and the rest will be discriminated against.”

Soon the government will have to invent a way to certify who is truly immune. A test for IgG antibodies, which are produced once immunity is established, would make sense

Dr. Fauci has said the White House was discussing certificates like those proposed in Germany. China uses cellphone QR codes linked to the owner’s personal details so others cannot borrow them.

As Americans stuck in lockdown see their immune neighbors resuming their lives and perhaps even taking the jobs they lost, it is not hard to imagine the enormous temptation to join them through self-infection

My daughter, who is a Harvard economist, keeps telling me her age group needs to have Covid-19 parties to develop immunity and keep the economy going,”

It would be a gamble for American youth, too. The obese and immunocompromised are clearly at risk, but even slim, healthy young Americans have died of Covid-19.

The virus can be kept in check, but only with expanded resources.

Resolve to Save Lives, a public health advocacy group run by Dr. Thomas R. Frieden, the former director of the C.D.C., has published detailed and strict criteria for when the economy can reopen and when it must be closed.

once a national baseline of hundreds of thousands of daily tests is established across the nation, any viral spread can be spotted when the percentage of positive results rises.

To keep the virus in check, several experts insisted, the country also must start isolating all the ill — including mild cases.

“If I was forced to select only one intervention, it would be the rapid isolation of all cases,”

In China, anyone testing positive, no matter how mild their symptoms, was required to immediately enter an infirmary-style hospital — often set up in a gymnasium or community center outfitted with oxygen tanks and CT scanners.

There, they recuperated under the eyes of nurses. That reduced the risk to families, and being with other victims relieved some patients’ fears.

Still, experts were divided on the idea of such wards

Ultimately, suppressing a virus requires testing all the contacts of every known case. But the United States is far short of that goal.

In China’s Sichuan Province, for example, each known case had an average of 45 contacts.

The C.D.C. has about 600 contact tracers and, until recently, state and local health departments employed about 1,600, mostly for tracing syphilis and tuberculosis cases.

China hired and trained 9,000 in Wuhan alone. Dr. Frieden recently estimated that the United States will need at least 300,000.

There will not be a vaccine soon.

any effort to make a vaccine will take at least a year to 18 months.

the record is four years, for the mumps vaccine.

for unclear reasons, some previous vaccine candidates against coronaviruses like SARS have triggered “antibody-dependent enhancement,” which makes recipients more susceptible to infection, rather than less. In the past, vaccines against H.I.V. and dengue have unexpectedly done the same.

A new vaccine is usually first tested in fewer than 100 young, healthy volunteers. If it appears safe and produces antibodies, thousands more volunteers — in this case, probably front-line workers at the highest risk — will get either it or a placebo in what is called a Phase 3 trial.

It is possible to speed up that process with “challenge trials.” Scientists vaccinate small numbers of volunteers, wait until they develop antibodies, and then “challenge” them with a deliberate infection to see if the vaccine protects them.

Normally, it is ethically unthinkable to challenge subjects with a disease with no cure, such as Covid-19.

“Fewer get harmed if you do a challenge trial in a few people than if you do a Phase 3 trial in thousands,” said Dr. Lipsitch, who recently published a paper advocating challenge trials in the Journal of Infectious Diseases. Almost immediately, he said, he heard from volunteers.

The hidden danger of challenge trials, vaccinologists explained, is that they recruit too few volunteers to show whether a vaccine creates enhancement, since it may be a rare but dangerous problem.

if a vaccine is invented, the United States could need 300 million doses — or 600 million if two shots are required. And just as many syringes.

“People have to start thinking big,” Dr. Douglas said. “With that volume, you’ve got to start cranking it out pretty soon.”

Treatments are likely to arrive first.

The modern alternative is monoclonal antibodies. These treatment regimens, which recently came very close to conquering the Ebola epidemic in eastern Congo, are the most likely short-term game changer, experts said.

as with vaccines, growing and purifying monoclonal antibodies takes time. In theory, with enough production, they could be used not just to save lives but to protect front-line workers.

Having a daily preventive pill would be an even better solution, because pills can be synthesized in factories far faster than vaccines or antibodies can be grown and purified.

Goodbye, ‘America First.’

A public health crisis of this magnitude requires international cooperation on a scale not seen in decades. Yet Mr. Trump is moving to defund the W.H.O., the only organization capable of coordinating such a response.

And he spent most of this year antagonizing China, which now has the world’s most powerful functioning economy and may become the dominant supplier of drugs and vaccines. China has used the pandemic to extend its global influence, and says it has sent medical gear and equipment to nearly 120 countries.

This is not a world in which “America First” is a viable strategy, several experts noted.

“If President Trump cares about stepping up the public health efforts here, he should look for avenues to collaborate with China and stop the insults,”

If we alienate the Chinese with our rhetoric, I think it will come back to bite us,” he said.“What if they come up with the first vaccine? They have a choice about who they sell it to. Are we top of the list? Why would we be?”

Once the pandemic has passed, the national recovery may be swift. The economy rebounded after both world wars, Dr. Mulder noted.

In one of the most provocative analyses in his follow-up article, “Coronavirus: Out of Many, One,” Mr. Pueyo analyzed Medicare and census data on age and obesity in states that recently resisted shutdowns and counties that voted Republican in 2016.

He calculated that those voters could be 30 percent more likely to die of the virus.

In the periods after both wars, Dr. Mulder noted, society and incomes became more equal. Funds created for veterans’ and widows’ pensions led to social safety nets, measures like the G.I. Bill and V.A. home loans were adopted, unions grew stronger, and tax benefits for the wealthy withered.

If a vaccine saves lives, many Americans may become less suspicious of conventional medicine and more accepting of science in general — including climate change

Alaska's public health structure was built for complications -- its size and tendency for inclement weather require it. So when it came time to start vaccinating residents, the state didn't have to build a robust public health system from scratch like some others, said Dr. Anne Zink, Alaska's chief medical officer.

A localized approach to vaccination hasn't worked everywhere, but it's worked in Alaska, Zink said. The state distributes vaccines to different regions but doesn't give directives, she said -- it's up to the communities to decide how to administer vaccines based on their needs.

Because so much power has been turned over to different regions of Alaska and the health care providers trusted in those areas, health care workers have been able to "meet people where they're at," Zink said: That means they'll deliver vaccines by boat, dog sled, helicopters and small planes, or go door-to-door in small communities to vaccinate as many community members as possible.

Vaccine eligibility in Alaska is more expansive than it currently is in most other states: Vaccines are available to anyone 55 years or older, people with certain underlying conditions, essential workers, residents of a multigenerational household, anyone who assists a senior in getting vaccinated and anyone who lives in a community where 45% of houses don't have pipes or septic tanks.

In areas where the population is mostly Alaska natives, there's a greater amount of people living in multigenerational housing. That qualifies young people who may live with an at-risk elderly person to get vaccinated, too, said Dr. Bob Onders, administrator of the Alaska Native Medical Center in Anchorage. And since 25% of rural Alaska doesn't have running water or sewage, which can heighten residents' risk for respiratory illness, it didn't make sense to exclude rural residents from the first round of vaccinations, Onders said.

Alaska Natives have borne the brunt of Covid-19 in the state -- the Kaiser Family Foundation's Covid-19 data tracker shows that Alaska Natives make up more than a quarter of Covid-19 cases but 15% of the population, compared to White residents, who made up 38% of cases but 68% of the population.

"Rather than a top-down mechanism, where someone from outside of Alaska or rural Alaska is dictating how things are going, it's much more about giving them supplies," Onders said.

Alaska asked the federal government to be treated "like a territory instead of state," so it would receive a monthly allocation of vaccines versus a weekly or biweekly lot. That made it easier to plan ahead and deliver vaccines "creatively," Zink said.

It can be costly to transport vaccines to some remote reaches of Alaska -- over $15,000 for one trip, in some cases, Zink said. To make vaccinations more cost-efficient, some areas that are less densely populated receive their entire vaccine allotment, which makes it possible to vaccinate entire communities in one go.

"We've been doing redistribution of vaccines for years," said Dr. Anne Zink, Alaska's chief medical officer. "It was pretty easy for us to stand up our existing [public health] structure."

Invest in protecting minority communities. Alaska expanded its eligibility for the first round of vaccines to include Alaska Natives and low-income residents of the state that are more vulnerable to Covid-19. While there's still work to do to alleviate that disproportionate risk, Onders said so far, it's working.

Another way to alleviate that burden is to prioritize zip codes in addition to age and health status, Karmarck said. Vaccinating residents of low-income neighborhoods or areas where the majority of residents are Black, indigenous or people of color could reduce Covid-19's disproportionate impact, though backlash is likely: In Dallas, county officials axed their plan to prioritize residents in "vulnerable zip codes" after the state threatened to reduce its vaccine allocation, the Texas Tribune reported in January.

Enlist trusted members of communities to educate. In communities where residents are hesitant to get the vaccine, particularly among Black and Latino Americans, sharing information about vaccine access is crucial to address Covid-19 racial disparities, Karmarck said.

Customize the approach. States that were lagging in vaccinations are catching up, Karmarck said, as they formalize an approach to vaccination that best fits their state. In Massachusetts, for example, large vaccination sites have opened up at Fenway Park and Gillette Stadium to accommodate more people and storage the vaccines require. It's improved the state's vaccination rates, she said.

What that index didn't take into account — and what has compounded months of governmental failures — is that even before COVID-19 arrived on its shores, the U.S. was an unusually sick country for its level of wealth and development.

High blood pressure, obesity and metabolic disorders are all on the rise in the U.S.

Healthy life expectancy — the number of years people can expect to live without disability — is 65.5 years in the U.S., more than two decades fewer than in Japan.

65,700 Americans died of drug overdoses in 2019, more than double the number in 2010. Those deaths account for more than half of all drug overdose fatalities worldwide and held down life expectancy in the U.S.

Mortality for mothers and children under 5 is 6.5 per 1,000 live births in the U.S., compared to 4.9 for other wealthy countries.

All in all, more than 40% of American adults have a pre-existing health condition that puts them at higher risk of severe COVID-19.

A study published in August found cardiovascular disease can double a patient's risk of dying from COVID-19, while diabetics — who number more than 30 million in the U.S. — are 1.5 times more likely to die.

Context: Lancet Editor-in-Chief Richard Horton has called COVID-19 a "syndemic" — a synergistic epidemic of a new and deadly infectious disease and numerous underlying health problems. The U.S. is squarely in the heart of that syndemic.

Those conditions are particularly prevalent in minority communities with unequal health care access that have disproportionately suffered from COVID-19.

A report from McKinsey earlier this month estimated that poor health costs the U.S. economy about $3.2 trillion a year

For every $1 invested in targeting population health, the U.S. stands to gain almost $4 in economic benefit, and altogether health improvements could add up to a 10% boost to U.S. GDP by 2040.

The bottom line: There is no excuse for the way the U.S. has mishandled COVID-19, but the seeds of this catastrophe were planted well before the novel coronavirus arrived on American shores.

2. How movement spread COVID-19

What's happening: Researchers in Germany studied the effect of entry bans and mandatory quarantines on COVID-19 mortality, and found the earlier such measures were implemented, the greater the effect they had on limiting deaths.

Of note: The study found mandatory quarantines for incoming travelers were more effective than outright entry bans, largely because such bans often exempted citizens and permanent residents, while quarantines usually applied to everyone.

The U.S. lost track of at least 1,600 people flying in from China in just the first few days after the ban went into effect, according to reporting from the AP.

Border controls are of little use if governments don't track and quarantine travelers coming from infected areas.

The bottom line: A virus only moves with its host. One lesson we should learn for future pandemics is that restricting that movement is key to controlling a new pathogen, even though the costs of such controls will only grow in a globalized world.

But he suggested that a statewide mask mandate would not help halt the surge, adding that it is nearly impossible to participate in the Arizona economy without wearing a mask due to various local restrictions.

She said cases were increasing in many states with mandates, adding that communities were free to establish local regulations. 

The U.S. has reported more than 11.5 million cases and more than 250,000 deaths, according to Johns Hopkins University data. The global totals: 56.4 million cases and 1.35 million deaths.

As state officials and lawmakers urged the shutdown of a Tyson Foods pork processing plant in Iowa, managers at the plant reportedly placed bets on how many would end up getting sick.

As COVID-19 cases pile up at a staggering rate, Republicans and Democrats remain in stark disagreement over the threat of the virus and the steps necessary to mitigate its spread.

That has surprised political scientists and public health experts who thought that, if the pandemic worsened, the partisan gap would begin to close

European officials announced a modest gain in the continent's battle against the virus.

Still, an average of 4500 lives are lost to COVID-19 in Europe every day, Kluge said.

He described further lockdowns as a last resort and said that if mask use reached 95%, lockdowns would not be needed.

Almost 100,000 long-term care U.S. residents have died in the coronavirus pandemic, and advocates for the elderly say tens of thousands more are succumbing to neglect by overwhelmed staffs and slow declines from isolation imposed as protection from COVID.

The U.S. has become the first country to have 250,000 people die from COVID-19, nearly 19% of the global total of 1.35 million fatalities.

That means we can begin inoculating health care and other essential workers even before we’re done with the Thanksgiving leftovers,

The vaccine being developed Oxford researchers and U.K.-based AstraZeneca appears to trigger a "robust immune response" in healthy adults, including those aged 56 and older, the university said in a release.

Although the COVID-19 outbreak is looking worse than ever, news from vaccine makers is fueling optimism

The death toll the virus has inflicted among Americans is more than twice as large as the number of U.S. service members who died in World War I.

Colleges are scrambling to prevent a massive spread, with some urging or requiring students to quarantine or receive a negative coronavirus test before traveling home. Without those precautions, college leaders say, students should consider abstaining from their holiday plans and instead opt for a celebration closer to campus.

Boston University's recommendation is that students either stay in Boston for the holiday or go home and not come back. Kenneth Elmore, dean of students, says the school is urging students to think of the greater good. 

As Arizona's COVID-19 trends spike, the state is giving hospitals $25 million to bolster staffing, but Gov. Doug Ducey said Wednesday that he won't impose a statewide mask mandate.

Ducey suggested that a statewide mask mandate would not effectively curb the spread of the virus, and emphasized that about 90% of the state is under a local mask mandate. He also said it is nearly impossible to participate in the Arizona economy without wearing a mask.

More than 90,000 students in the state's largest school district will return to virtual learning starting Nov. 30 through the end of the semester.

The district reported about 13 cases per week when it first opened early childhood education centers. Cases have now surpassed 300 per week.

There are some reasons for this. The U.S. Centers for Disease Control and Prevention, acknowledging the nation's pandemic-related rodent problem, points out restaurants have reduced service, which means fewer food scraps are ending up in the dumpsters on which rats and mice often feed.

Dr. Anthony Fauci is urging Americans to "think twice" about traveling and having indoor gatherings for the holidays.

"As we get into the colder weather, we should really think twice about these kind of dinner parties where you're not sure of whether the people that are in your bubble (are safe)," he said. "Then you're going to start seeing these unanticipated infections related to innocent home gatherings, particularly as we head into the holiday season."

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)