The U.S. COVID-19 Outbreak Is Worse Than It’s Ever Been. Why Aren’t We Acting Like It?

Nothing about the current COVID-19 explosion should come as a surprise. As the virus spread throughout summer and fall, experts repeatedly warned winter would be worse.

They cautioned that a cold-weather return to indoor socializing, particularly around the holidays, could turn a steady burn into a wildfire. Throw in a lame-duck President, wildly differing approaches by the states and a pervasive sense of quarantine fatigue, and the wildfire could easily become an inferno.

So it has. The U.S. is now locked in a deadly cycle of setting, then shattering, records for new cases and hospitalizations. On Nov. 13, a staggering 177,224 people in the U.S. were diagnosed with COVID-19. As of Nov. 17, more than 70,000 coronavirus patients were hospitalized nationwide. And unlike in earlier waves, which were fairly regionalized, the virus was as of Nov. 17 spreading–and fast–in virtually every part of the U.S., according to Johns Hopkins University data. This coast-to-coast surge is pushing hospitals across the country to the edge of catastrophe, their doctors and nurses exhausted and their intensive-care units running dangerously low on beds. Some cities are already playing out their dystopian worst-case scenarios; in El Paso, Texas, the dead have been shunted to mobile morgues partially staffed by the incarcerated.

But the U.S. public has become terrifyingly good at ignoring those harsh realities. Almost 40% of respondents to a recent Ohio State University survey said they plan to gather with at least 10 people for Thanksgiving, even though in many areas this comes with the likelihood of sharing a table with an infectious person. Many people continue to dine at indoor restaurants and work out in gyms, because many elected officials continue to let them. Almost 980,000 people passed through U.S. airport security checkpoints on Nov. 15, nearly quadrupling the number recorded six months earlier, when COVID-19 was nowhere near as widespread.

That people are behaving this way at the most dangerous moment of the U.S. outbreak speaks volumes about human nature, which in the world of public health can be as dangerous a variable as any pathogen. Rallying cries about flattening the curve have been replaced with a desire to return to normal life at all costs. Solid leadership is in short supply, with the outgoing Trump Administration refusing to concede the election and give President-elect Joe Biden the tools he needs to take over the pandemic response. Good news about promising COVID-19 vaccine candidates seems to be emboldening people in the wrong ways.

As Americans’ reactions to the pandemic become increasingly divorced from the reality of it, public-health officials may be facing their biggest challenge yet: forcing the public to face how bad things still are, and how much worse they may become.

From a public-health perspective, Thanksgiving was always going to be a problem. Maskless indoor gatherings in close quarters are perfect breeding grounds for the virus, and many Thanksgiving celebrations will likely include older adults at high risk of severe COVID-19. After months of separation, it’s natural that people are desperate to see loved ones and reclaim a sense of normality–but things are far from normal.

More than half of U.S. COVID-19 cases have been recorded since August, and the speed at which they are accumulating is ratcheting up: more than 1 million new cases were logged in just the week leading up to Nov. 17. Nonetheless, people appear unwilling to take the kind of drastic measures they did this spring, when lockdowns went into effect in many parts of the country and most people cut out socializing with anyone outside their household. “The fear was there at the beginning. It was national, there was a sense of patriotism–and then it faded,” says Dr. Natasha Kathuria, an emergency-medicine physician based in Austin. “The public is tired.”

With resolve weakening, models in mid-October suggested up to 50 million Americans would travel for Thanksgiving this year, according to AAA’s annual holiday-travel report–not many fewer than the 55 million who did so last year. (AAA did note that it expects the actual number of 2020 travelers to be lower, given the evolving COVID-19 crisis.) With COVID-19 case counts rising, that could be catastrophic. Canada saw a spike in cases after its Thanksgiving holiday in October, and the U.S. may be in for the same fate. As people travel to and from areas where the virus is surging, they risk carrying the infection with them and seeding it to new places.

People may be inclined to travel because of a mistaken perception that the pandemic is better controlled now than it was earlier in the year. In mid-April, about 37% of Americans said they were “very” concerned they or someone they know would catch COVID-19, according to data from the website FiveThirtyEight. As of Nov. 17, that number had dipped to less than 32%, despite the fact that case counts are now higher and more geographically diverse than they were in April. A recent study in the medical journal plos one found that people of all ages were more likely to partake in risky behaviors, like attending gatherings and seeing friends, as the pandemic dragged on.

That’s in part because the Trump Administration has repeatedly promised, without evidence, that the U.S. is turning a corner on the pandemic. But it may also be an unwanted side effect of a rare flurry of good news related to the outbreak.

The U.S. Food and Drug Administration has now authorized multiple drugs for treating COVID-19, including the antiviral remdesivir and the monoclonal antibody bamlanivimab, and hospitals are reporting better survival rates among COVID-19 patients than they were this spring. But Dr. Megan Ranney, an emergency-medicine physician from Brown University, says that could easily change if hospitals become overwhelmed–which many already are, and many more will be as recently diagnosed patients get sicker in the coming weeks.

“Yes, we know more than we did,” Ranney says. “However, many of the gains we have seen have nothing to do with having good treatments–they have more to do with the fact that we’re comfortable with [the virus] and the health system isn’t overwhelmed.” If the virus’s spread isn’t brought under control, that won’t stay true. And though doctors do know more than they did this spring, there are still plenty of outstanding questions about why some previously healthy people get seriously ill and others don’t; why some people develop long-lasting symptoms after infection and others don’t; and how immunity to the virus works.

Vaccines have also been a source of optimism lately. Pharmaceutical companies Pfizer and Moderna each announced in November that their vaccine candidates are at least 90% effective at preventing COVID-19, setting off a flurry of positive headlines. But, as of this writing, neither vaccine has yet been approved or granted emergency-use authorization by the FDA, and even once they are, it will take months for doses to become available to most of the general public.

The promising vaccine news “doesn’t mean that we can go back to our pre-pandemic lifestyles,” says Dr. William Moss, executive director of the International Vaccine Access Center at the Johns Hopkins Bloomberg School of Public Health. “We’re going to have to continue our social distancing and mask wearing for the foreseeable future, until we get really high coverage with a vaccine that’s highly protective and reduces transmission.”

But individual choices around masking and social distancing only go so far. In times of crisis, people turn to their leaders for support and guidance–and on that front, elected officials are failing. The Trump Administration has done little to counter rampant misinformation about the pandemic, and has made numerous incorrect statements about the virus’s origins, spread and deadliness. The COVID-19 situation could be very different “if we had a President and Administration that were not going counter-current to science and facts,” says Dr. Eric Topol, director of the Scripps Research Translational Institute. “From day one, Trump and his team have basically not taken it seriously.”

Now, with Trump serving out the rest of his term as a lame duck who won’t admit he lost, the situation is particularly scary, Topol says. Trump has stopped attending White House coronavirus task-force meetings and has said little about the current coronavirus surge gripping the country.

President-elect Biden and Vice President–elect Kamala Harris have signaled commitment to public-health interventions that could help get the virus under control, like expanded access to testing, mask mandates and a robust vaccine-distribution program. But Biden and Harris can’t do much of substance until they take office, and the Trump Administration is reportedly withholding information about vaccine development and distribution that could help solidify plans for January. And with no official platform from which to communicate with the public, Biden and Harris “are not having nearly the impact that they could,” Topol says. On Nov. 16, Biden said that “more people may die” if the Trump Administration does not coordinate the transition of the vaccine program. (Biden has also pushed for the passage of a coronavirus-relief bill during the lame-duck period, but it looks unlikely one will clear Congress.)

State and local leaders have also been slow to reimplement lockdown measures that could help curb the virus’s spread. Unlike in Europe, where countries including France, Italy and Germany reimplemented restrictions of various levels in response to spiking case counts this fall, many U.S. officials have been hesitant to slap regulations on reopened businesses. Europe is struggling right now too–France, Russia, Spain and the U.K. hold the fourth through seventh spots on the list of the world’s hardest-hit countries–but many of the Continent’s leaders have shut down businesses and public places, and distributed relief money, to contain the virus. Officials across the E.U. have also called upon citizens’ senses of duty and empathy, promoting messages of unity and communal sacrifice.

The same can’t be said of the U.S. Officials in Chicago and Philadelphia have issued new stay-at-home advisories, and states including Washington, California, Oregon and Michigan have closed restaurants for indoor dining. But in many parts of the country–even in areas where schools are once again closing, like New York City–people are still free to drink at bars, eat in restaurants and work out in gyms. “It is incredibly difficult, from a public-health perspective, to defend people eating maskless indoors or going to indoor gyms,” Ranney says. She’d like to see “strategic shutdowns” of businesses in hard-hit areas, ideally with stimulus money to prevent further economic damage. More shocking, Topol says, is that some states, including Florida and Georgia, still don’t require masks in all public places, even as cases go through the roof. North Dakota Governor Doug Burgum, who long resisted a mask mandate, reversed that stance on Nov. 13, but only after his state’s test-positivity rate topped 15% and hospitals nearly exhausted ICU capacity statewide.

For the U.S. to find the same curve-flattening spirit it harnessed this spring, public-health and elected officials must help a tired and skeptical population dig deep and accept that it’s still crucial, and possible, to make changes that will keep the virus from spreading further. Quarantine fatigue is real, and so is misinformation. As of June, 25% of American respondents to a Pew Research Center poll thought there was some truth to the conspiracy theory that powerful people planned the coronavirus pandemic. Others have latched on to the incorrect idea, promoted by Trump and others in his orbit, that COVID-19 is “just the flu.” Some don’t think the pandemic is real at all–some patients have called the coronavirus a hoax until the moment they stop breathing, according to reports from a South Dakota nurse that have attracted widespread news coverage.

“My dream would be that politicians and people who have the trust of each side of the political aisle would come together and at least make a shared statement that COVID is not a political thing and this is real and this is what you need to do” to stop the spread, says Dr. Bradley Benson, a professor at the University of Minnesota Medical School. Letting public-health officials hold daily briefings and push out real-time data would help too, Topol says, since it would give people a reliable, nonpartisan source to turn to each day.

Individual doctors can also have a strong impact, Benson says. Americans typically trust their personal physician, often more than they trust researchers and scientists as a whole. Skeptics may be more likely to listen to their doctor’s advice than to that of politicians and journalists–especially, Benson says, if it’s personalized and contains direct requests about necessary behavior changes, like wearing a mask or canceling Thanksgiving travel. Positive vaccine news could also prove to those struggling with caution fatigue that there’s a light at the end of the tunnel, as long as it’s described as a fresh source of motivation rather than an excuse to abandon other pandemic precautions. “It’s not just, ‘Keep running,'” Benson says. “You’re at mile 18 and you’ve got to get to 26. Let’s double down.”

But Kathuria says it’s difficult to hammer home those lessons for people who don’t want to listen. Social media platforms must do a better job of removing false content, she says, and all media outlets need to cover the pandemic accurately. In the meantime, Kathuria says she tries to stress that the joy of a Thanksgiving or Christmas with family pales in comparison to the pain of losing a loved one. For most people, who will never see the chaos of a packed ICU or the horror of an overflowing morgue, that’s the best way to strike a chord.

“I really wish there was some way for us to show people what the suffering looks like,” Kathuria says. “It doesn’t hit home until it hits home.”

–With reporting by BRIAN BENNETT, MARIAH ESPADA, ALEX FITZPATRICK and JULIA ZORTHIAN