The coronavirus is spreading at dangerous levels across much of the United States, and public health experts are demanding a dramatic reset in the national response, one that recognizes that the crisis is intensifying and that current piecemeal strategies aren’t working.
This is a new phase of the pandemic, one no longer built around local or regional clusters and hot spots. It comes at an unnerving moment in which the economy suffered its worst collapse since the Great Depression, schools are rapidly canceling plans for in-person instruction and Congress has failed to pass a new emergency relief package. President Donald Trump continues to promote fringe science, the daily death toll keeps climbing and the human cost of the virus in America has just passed 150,000 lives.
"Unlike many countries in the world, the United States is not currently on course to get control of this epidemic. It's time to reset," declared a report released last week by Johns Hopkins University.
Another report from the Association of American Medical Colleges offered a similarly blunt message: “If the nation does not change its course — and soon — deaths in the United States could be well into the multiple hundreds of thousands.”
The country is exhausted, but the virus is not. It has shown a consistent pattern: It spreads opportunistically wherever people let down their guard and return to more familiar patterns of mobility and socializing. When communities tighten up, by closing bars or requiring masks in public, transmission drops.
That has happened in some Sun Belt states, including Arizona, Florida and Texas, which are still dealing with a surge of hospitalizations and deaths but are finally turning around the rate of new infections.
There are signs, however, that the virus is spreading freely in much of the country. Experts are focused on upticks in the percentage of positive coronavirus tests in the upper South and Midwest. It is a sign that the virus could soon surge anew in the heartland. Infectious-disease experts also see warning signs in East Coast cities hammered in the spring.
"There are fewer and fewer places where anybody can assume the virus is not there," Gov. Mike DeWine, R, of Ohio said Wednesday. "It's in our most rural counties. It's in our smallest communities. And we just have to assume the monster is everywhere. It's everywhere."
A briefing document released Friday by the Federal Emergency Management Agency counted 453,659 new infections in the past week.
Alaska is in trouble. And Hawaii, Missouri, Montana and Oklahoma. Those are the five states, as of Friday, with the highest percentage increase in the seven-day average of new cases, according to a Washington Post analysis of nationwide health data.
"The dominoes are falling now," said David Rubin, director of the PolicyLab at Children's Hospital of Philadelphia, which has produced a model showing where the virus is likely to spread over the next four weeks.
His team sees ominous trends in big cities, including Baltimore, Chicago, Detroit, Indianapolis, Kansas City, Louisville, Philadelphia, St. Louis and Washington, with Boston and New York not far behind. And Rubin warns that the expected influx of students into college towns at the end of this month will be another epidemiological shock.
"I suspect we're going to see big outbreaks in college towns," he said.
Young people are less likely to have a severe outcome from the coronavirus, but they are adept at propelling the virus through the broader population, including among people at elevated risk. Daily coronavirus-related hospitalizations in the United States went from 36,158 on July 1 to 52,767 on July 31, according to The Post's data. FEMA reports a sharp increase in the number of patients on ventilators.
The crisis has highlighted the deep disparities in health outcomes among racial and ethnic groups, and data from the Centers for Disease Control and Prevention last week showed that Black, Hispanic and Native American coronavirus hospitalization rates are roughly five times that of Whites.
Thirty-seven states and Puerto Rico will probably see rising daily death tolls during the next two weeks compared with the previous two weeks, according to the latest ensemble forecast from the University of Massachusetts that combines more than 30 coronavirus models.
There are glimmers of progress. The FEMA report showed 237 U.S. counties with at least two weeks of steady declines in numbers of new coronavirus cases.
But there are more than 3,100 counties in America.
"This is not a natural disaster that happens to one or two or three communities and then you rebuild," said Beth Cameron, vice president for global biological policy and programs at the Nuclear Threat Initiative and a former White House National Security Council staffer focused on pandemics. "This is a spreading disaster that moves from one place to another, and until it's suppressed and until we ultimately have a safe and effective and distributed vaccine, every community is at risk."
A national strategy, whether advanced by the federal government or by the states working in tandem, will more effectively control viral spread than the current patchwork of state and local policies, according to a study from researchers at the Massachusetts Institute of Technology published Thursday in the Proceedings of the National Academy of Sciences.
The coordination is necessary because one state's policies affect other states. Sometimes, that influence is at a distance, because states that are geographically far apart can have cultural and social ties, as is the case with the "peer states" of New York and Florida, the report found.
"The cost of our uncoordinated national response to covid-19, it's dramatic," said MIT economist Sinan Aral, lead author of the paper.
Some experts argue for a full six-to-eight-week national shutdown, something even more sweeping than what was instituted in the spring. There appears to be no political support for such a move.
Neil Bradley, executive vice president of the U.S. Chamber of Commerce, said fresh federal intervention is necessary in this second wave of closures. Enhanced federal unemployment benefits expired at the end of July, with no agreement on a new stimulus package in sight.
"Congress, on a bipartisan basis, was trying to create a bridge to help individuals and businesses navigate the period of a shutdown," Bradley said. "Absent an extension of that bridge, in light of a second shutdown, that bridge becomes a pier. And then that's a real problem."
With the economy in shambles, hospitals filling up and the public frustrated, anxious and angry, the challenge for national leadership is finding a plausible sea-to-sea strategy that can win widespread support and simultaneously limit sickness and death from the virus.
Many Americans may simply feel discouraged and overtaxed, unable to maintain precautions such as social distancing and mask-wearing. Others remain resistant, for cultural or ideological reasons, to public health guidance and buy into conspiracy theories and pseudoscience.
DeWine is struggling to get Ohio citizens to take seriously the need to wear masks. A sheriff in rural western Ohio told the governor Wednesday that people didn't think the virus was a big problem. DeWine informed the sheriff that the numbers in his county were higher per capita than in Toledo.
"The way I've explained to people, if we want to have Friday night football in the fall, if we want our kids back in school, what we do in the next two weeks will determine if that happens," DeWine said.
The coronavirus has always been several steps ahead of the U.S. government, the scientific community, the news media and the general public. By the time a community notices a surge in patients to hospital emergency rooms, the virus has seeded itself widely.
The virus officially known as SARS-CoV-2 can be transmitted by people who are infectious but not symptomatic. The incubation period is typically about six days, according to the CDC. When symptoms flare, they can be ambiguous. A person may not seek a test right away. Then, the test results may not come back for days, a week, even longer.
That delay makes contact tracing nearly futile. It also means government data on virus transmission is invariably out of date to some degree — it’s a snapshot of what was happening a week or two weeks before. And different jurisdictions use different metrics to track the virus, further fogging the picture.
The top doctors on the White House coronavirus task force, Deborah Birx and Anthony S. Fauci, are newly focused on the early warning signs of a virus outbreak. Last week, they warned that the kind of runaway outbreaks seen in the Sun Belt could potentially happen elsewhere. Among the states of greatest concern: Indiana, Kentucky, Ohio and Tennessee.
Fauci and Birx have pointed to a critical metric: the percentage of positive test results. When that figure starts to tick upward, it is a sign of increasing community spread of the virus.
“That is kind of the predictor that if you don’t do something — namely, do something different — if you’re opening up at a certain pace, slow down, maybe even backtrack a little,” Fauci said in an interview Wednesday.
Without a vaccine, the primary tools for combating the spread of the virus remain the common-sense "non-pharmaceutical interventions," including mask-wearing, hand-washing, staying out of bars and other confined spaces, maintaining social distancing of at least six feet and avoiding crowds, Fauci said.
"Seemingly simple maneuvers have been very effective in preventing or even turning around the kind of surges we've seen," he said.
Thirty-three U.S. states have positivity rates above 5%. The World Health Organization has cited that percentage as a crucial benchmark for governments deciding whether to reopen their economy. Above 5%, stay closed. Below, open with caution.
Of states with positivity rates below 5%, nine have seen those rates rise during the last two weeks.
"You may not fully realize that when you think things are okay, you actually are seeing a subtle, insidious increase that is usually reflected in the percent of your tests that are positive," Fauci said.
Some governors immediately took the White House warnings to heart. On Monday, Kentucky Gov. Andy Beshear, D, said at a news conference that he had met with Birx the previous day and was told he was getting the same warning Texas and Florida received "weeks before the worst of the worst happened."
To prevent that outcome in his state, Beshear said, he was closing bars for two weeks and cutting seating in restaurants.
But as Beshear pleaded that "we all need to be singing from the same sheet of music," discord and confusion prevailed.
Iowa Gov. Kim Reynolds, R, said Thursday she wasn't convinced a mask mandate is effective: "No one knows particularly the best strategy."
Earlier in the week, Tennessee Gov. Bill Lee, R, demurred on masks and bar closures even as he stood next to Birx and spoke to reporters.
"That's not a plan for us now," he said. He added emphatically, "We are not going to close the economy back down."
The virus is spreading throughout his state, and not just in the big cities. Vacationers took the virus home from the honky-tonks of Nashville and blues clubs of Memphis to where they live in more rural areas, said John Graves, a professor at Vanderbilt University studying the pandemic.
“The geographical footprint of the virus has reached all corners of the state at this point,” Graves said.
In Missouri, Gov. Michael Parson, R, was dismissive of New York’s imposition of a quarantine on residents from his state as a sign of a worsening pandemic. “I’m not going to put much stock in what New York says — they’re a disaster,” he said at a news conference Monday.
Missouri has no mask mandate, leaving it to local officials to act — often in the face of hostility and threats. In the town of Branson, angry opponents testified Tuesday that there was no reason for a mask order when deaths in the county have been few and far between.
"It hasn't hit us here yet, that's what I'm scared of," Branson Alderman Bill Skains said before voting with a majority in favor of the mandate. "It is coming, and it's coming like a freight train."
Democratic mayors in Missouri's two biggest cities, Kansas City and St. Louis, said that with so many people needing jobs, they are reluctant to follow Birx's recommendation to close bars.
"The whole-blanket approach to shut everybody down feels a little harsh for the people who are doing it right," said Jacob Long, spokesman for St. Louis Mayor Lyda Krewson. "We're trying to take care of some bad actors first."
Minneapolis Mayor Jacob Frey also got a warning from Birx. On Wednesday, he said all bar drinking must move outside.
"We don't want to be heading in the direction of everybody else," said Kristen Ehresmann, director of the infectious-disease epidemiology division at the Minnesota Department of Health. She acknowledged that some options "are really pretty draconian."
The problem is that less-painful measures have proven insufficient.
"The disease transmission we're seeing is more than what would have been expected if people were following the guidance as it is laid out. It's a reflection of the fact that they're not," she said.
Wisconsin Gov. Tony Evers, D, tried to implement broad statewide measures early in the pandemic, only to have his "Safer at Home" order struck down by the state's Supreme Court.
With cases in his state rising anew, he tried again Thursday, declaring a public health emergency and issuing a statewide mask mandate.
"While our local health departments have been doing a heck of a job responding to this pandemic in our communities, the fact of the matter is, this virus doesn't care about any town, city or county boundary, and we need a statewide approach to get Wisconsin back on track," Evers said.
Ryan Westergaard, Wisconsin's chief medical officer, said he is dismayed by the failures of the national pandemic response.
"I really thought we had a chance to keep this suppressed," Westergaard said. "The model is a good one: testing, tracing, isolation, supportive quarantine. Those things work. We saw this coming. We knew we had to build robust, flexible systems to do this in all of our communities. It feels like a tremendous disappointment that we weren't able to build a system in time that could handle this."
There is one benefit to the way the virus has spread so broadly, he noted: “We no longer have to keep track of people traveling to a hot spot if hot spots are everywhere.”