The End of the Public Health Emergency

When I recall the early days of the pandemic, I remember first the quality of the light that March and April, casting soft shadows over a city emerging from winter, then gradually growing harsher and more angled as we moved deeper into the season. From my apartment, I watched the trees outside my window tentatively put forth tiny buds that eventually flowered and turned into leaves. One day that spring, I ventured out for a bi-weekly grocery run and saw a man in a full hazmat suit standing on the sidewalk outside the store, fiddling with his phone as he awaited his turn to go in and shop like the rest of us.

We are now more than three years into Covid, living with a disease that has affected our entire global population in ways both predictable and unanticipated. Covid has upended families and communities, launched new vaccines and medications, and shaped our collective response to suffering. Although much has changed culturally and medically, here in the United States, much more has not changed. The initial Covid shutdowns were abrupt, with businesses open one day and unavailable the next. Each week brought new disruptions and reconfigured routines as we learned the vocabulary of epidemiology and infectious disease. Governments and public health officials muddled through, doing their best to offer recommendations in the midst of constantly shifting information. But each time we were faced with something incomprehensible, like refrigerated morgue trucks outside NYC hospitals, we adjusted just enough for it to become comprehensible. We slowly became numb to the rising death counts, the incredible losses in Black and brown communities, and the ways in which the inequality of American society was being replicated once more.

For a brief moment, the United States more closely resembled a Western European country, with free Covid testing and vaccinations, expanded health insurance, and more generous unemployment benefits. But the last of this assistance ceased in May with the official end of the Covid public health emergency. Rather than making some of these policies permanent and working toward a society that takes better care of its citizens, we have instead decided to return to our old, broken system . We could have continued the expansion of Medicaid, instead of removing health insurance for up to 24 million people. We could have shored up our public health apparatuses to focus on disease prevention and overall wellness, rather than leaving it up to individuals to avoid getting sick. Most of all, we could have internalized the lesson that when we are linked within in a community, one person’s vulnerabilities become everyone’s.

Much has been written about what Covid has taught us about pandemics, and, knowing what we now know, whether we are better prepared to deal with the next one. (We are not.) We have squandered an opportunity to shift our priorities toward the more equitable and the more humane, not just for the sake of public health, but to build a better society. It is a colossal failure of imagination and one that will affect our response to future pandemics, as the incomprehensible will become comprehensible yet again.

The State of the Pandemic

On Sunday in an interview on “60 Minutes,” President Biden said the pandemic is over. In apparently unscripted remarks, he added that we still have a problem with Covid, that much has changed in our society and our communities, that a lot of uncertainty remains. But the pandemic is over.

Many Americans would agree. Pandemic restrictions have all but disappeared across the country. Regulations limiting capacity were the first to go, followed by vaccination requirements and, finally, mask mandates. When New York Governor Kathy Hochul lifted the mask requirement for the NYC transit system a few weeks ago, she was merely formalizing what had already been the de facto policy for a majority of riders for at least several months. Elsewhere, people have decided that they’re done, they’re over it; they might get Covid but probably won’t get seriously ill and are willing to roll the dice on long Covid. In my daily life, the only place where any kind of pandemic restrictions are still enforced is the food coop where I buy my groceries, which requires a mask to shop and proof of vaccination to work a shift.

Nearly three years in, the pandemic may look different from earlier times, but is not over. The US is averaging over 400 deaths a day and we’re recording tens of thousands of new daily infections, surely an undercount as many people are testing at home or not at all. Test positivity rates in NYC have remained steady at 9 or 10% for months. While vaccines excel at staving off serious illness and death, they’ve turned out to be much less effective at preventing infection, particularly with the new variants. Confusing messaging around booster shots—whether they’re necessary, for whom, and when to get them—has led to low levels of uptake, only 33% for the first one. Now we have a bivalent booster that provides increased protection against BA.5, but the messaging around it has been similarly confusing and not well publicized. Meanwhile, slow distribution, in addition to substantial vaccine hesitancy, has left much of the world outside of the US, Canada, and Western Europe unvaccinated. The virus is still disrupting people’s lives and its future remains unpredictable.

At this point, government officials and public health authorities (outside of, perhaps, China, which continues to pursue a zero-Covid strategy despite the massive disruptions to social and economic life) have thrown up their hands and abdicated responsibility for keeping their populations safe. They have relegated decision-making to the individual, leaving it to each of us to decide what level of risk we can tolerate. The problem is that the management of the pandemic, if ever it was a collective endeavor, is now entirely personal. This shifts the majority of risk to vulnerable populations—people with disabilities, the elderly, those with immunosuppressive conditions—leaving them at the mercy of whatever everyone else feels like doing. There’s no sense of the public, or of the greater good.

Biden is right to point out that the pandemic has taken a toll on our national psyche. The void will remain for all that we have lost: loved ones, livelihoods, schooling, shared moments, time. The end of the pandemic may indeed be in sight, as Tedros Adhanom Ghebreyesus of the World Health Organization says. But even as many people move on and resume whatever normal life they can access, the scars of our collective trauma will linger for generations.

A Pandemic Fall

On my run in the park this afternoon, I noticed that the cherry trees have begun to bloom. Their small, pale pink flowers look jarringly out of place against the last of the fall foliage on the loftier elm and linden trees, where yellowed leaves cling tenuously to branches that will soon be bare. In a different year, I would be troubled by such a clear symptom of climate change but also relatively sure that, after a few weeks of cooler weather, the trees would realize it was winter and behave accordingly. This year, however, it feels entirely fitting to see trees senselessly flowering in December, yet another sign of how deeply our customary rhythms, and those of the world around us, have been dislodged.

The summer and fall in NYC were luminous, week after week of mild, temperate days stretching into gentle evenings. We learned to live outdoors, sharing space with one another in ball fields, on stoops and sidewalks; in the park, I saw jazz performances, karaoke parties, cocktail hours, yard sales, and a wedding. Indoor dining resumed, albeit at reduced capacity. My gym reopened. We wore masks, we physically distanced, and the number of new infections remained low. We began to dare to believe that after our dark, horrifying spring, perhaps—perhaps—we had figured out a way to endure.

And then. An autumn chill started to creep into the edges of the afternoons and the daylight grew scarcer—gradually at first, and then all at once. We retreated indoors, cranked up the baseboard heaters, traded t-shirts for wool sweaters. And as public health experts had been warning us for months, the numbers began to tick up. At the beginning of September, NYC was averaging fewer than 300 new cases per day; now, the number is over 2,500. Other areas of the country are faring even worse, with hospitals at capacity and health care workers burned out and demoralized after so many months.

Elsewhere in the world (New Zealand, some Asian countries, parts of Australia), aspects of pre-pandemic life have returned; children are back in school, sporting events have resumed, and restaurants are open for business. In the US today, we logged over 200,000 infections, a new record. The virus is raging through every community and every county. Yet because of the complete abdication of responsibility by this administration, we still have no coordinated response, no consistent public health messaging, no national leadership. There are still places in the country where you can walk into a grocery store without a mask on, a colossal failure not just of sound public health strategy, but of political will. Vaccines are days away from approval, with the first inoculations expected later this month. Things will get better, at least in the US. But before they do, they will get much, much worse. People will continue to get sick, and many will die. And we will continue to confront shattering, unnecessary loss while we spend the next few months as we spent the last few: alone.

Confronting Multiple Pandemics

Sometime in the past week, my neighborhood ceased its 7 p.m. nightly cheers. We began them in March as a way to acknowledge health care workers, taxi drivers, delivery workers, grocery store employees, transit workers, and others whose continued labor allowed the rest of the city to stay home. At the beginning, we came to our windows at twilight and retreated two minutes later into apartments illuminated from within, shutting out the chill of early spring. More recently, our cheers have taken place in the lingering sunlight of evenings lengthening toward the solstice. Over time, our nightly gatherings evolved into a way to keep tabs on one another and express community during confinement. From my window, I kept an eye on the gay couple at the corner of my block, the long-haired woman in her third-floor apartment across the street, and the child who started bringing a tambourine to each evening’s noisemaking.

It has been a long, strange spring. I think we stopped cheering, in part, because things feel so different now from a few months ago. Back then, each day, even each hour, brought new, alarming updates about the virus and its toll on our city. Subway ridership plunged 90% as people stopped going to their offices. We confronted empty grocery shelves, shuttered restaurants and cafes, overburdened ICUs, isolation, devastating loss, and our own fear and uncertainty about when we might start to emerge from the darkness. Now NYC has begun to reopen, however cautiously. I’ve noticed more cars on the roads, more people on the sidewalks, more stores beginning to raise their gates. We’re not returning to a pre-COVID era, but we have moved past the initial shock of the sudden and substantial changes we were compelled to make. Now we seem resigned to an extended pandemic and have adapted our behaviors and our attitudes to account for a prolonged period of social distancing, mask wearing, and ambiguity.

We stopped cheering each night, as well, because events of the past few weeks have altered the political mood. The killing of George Floyd and the ensuing protests against police brutality and racial injustice, in the midst of a pandemic disproportionately affecting Black people, Latinos, and Native Americans, have made unbearably clear the relationship between racism and health. Nationwide, the mortality rate for African Americans from COVID-19 is 2.4 times higher than for whites. We know that Blacks and Latinos are more likely to be “essential workers” whose numerous contacts with others put them at increased risk. They’re more likely to be uninsured or underinsured, and to have underlying conditions such as asthma, diabetes, or hypertension that are linked to worse outcomes.

But poor health is not simply a matter of poverty or economic status. There’s a growing body of scholarship on the social production of illness, premised on the idea that patterns of disease distribution are shaped by power and politics. It’s not just race but racism that affects one’s health. Social epidemiologists, notably Nancy Krieger of the Harvard School of Public Health, have shown that constant exposure to stress raises blood pressure and cortisol levels and hardens one’s arteries, prematurely aging the body. It includes the effects not only of interpersonal hostility and violence, but also of unsafe neighborhoods and other structural conditions that become written corporally.

Racial justice and public health are inextricably linked, and our attempts to address the coronavirus must include measures to mitigate structural racism. Otherwise, the racial disparities in health and health outcomes that the pandemic has exposed will persist, and in our failure to act we will have indicated our acquiescence to it.

Rethinking Risk

The tulips and daffodils have faded, replaced by azaleas and rhododendrons in full bloom. Rows of seedlings fill the stalls at the farmers market—herbs, tomatoes, peppers—and neighbors plant their windows boxes with flowers. The mood in NYC has finally begun to feel more hopeful. A month ago, every interaction with another human felt perilous and potentially lethal. Each day’s headlines brought more grim news about the virus’s toll; it felt as though we were in a tunnel descending into darkness, with no indication of when we might reach the bottom. On our worst days, we lost around 800 New Yorkers, or about one every two minutes. And while the economic fallout will continue for years, the death toll now hovers around 100 per day—still higher than anywhere else in the US, but a drastic improvement from the peak in April.

As summer approaches and we move toward déconfinement, we’re hearing encouraging news that the risks of viral transmission outdoors are probably much lower than previously thought. This makes running and walking outside more possible, less fraught. At the same time, the risks of transmission in an indoor space with people who are talking, shouting or singing seem to be greater than researchers presumed. As we discover more about the coronavirus, the recommendations will change. But according to this new information it appears that sitting in a park, wearing facial coverings and keeping an appropriate distance from others, might be less risky than we thought, while it could be a very long time before audiences once again feel comfortable attending live theater and music performances in enclosed spaces.

As the risks of contracting the coronavirus in various ways continue to be elucidated, I’ll be keeping an eye on how we think about the role of personal responsibility in avoiding COVID-19 and whether—and why—it might shift. For illnesses including HIV/AIDS, lung cancer, heart disease, and obesity and its associated health issues, a strong element of moralism shapes social attitudes toward the afflicted. We have a responsibility to be healthy, the thinking goes, by eating well, exercising regularly, and avoiding unnecessary threats to our well-being. One’s ability to do all of this, of course, depends on resources of time, money, and accessibility that are further shaped by gender, race, and racism.

But as researchers learn more about the transmissibility of SARS-CoV-2, we may find that people who become sick—at least those working outside of health care settings—will be held responsible for their own failure, or perceived failure, to take appropriate precautions. Already we’ve seen Health and Human Services Secretary Alex Azar blame meatpacking workers for their high rates of infection, citing the “home and social” conditions of a largely immigrant workforce. This type of move deflects responsibility from public health authorities and governmental agencies tasked with making recommendations and enforcing regulations to keep us safe, and shifts it instead onto the individual, who is supposed to stay up to date about best practices and scrupulously follow them. Some variables are more straightforward to address. It’s a relatively simple matter, for instance, to protect those around us by wearing a mask in confined spaces. Other issues are more intractable: a family of four sharing a two-bedroom apartment with one bathroom cannot easily isolate someone who’s sick. The link between morality and illness predates our current crisis; it extends back long before AIDS, obesity, or lung cancer. But as the routes of infection for COVID-19 become less random and better understood, the way we think about the infected may shift, as well.

The Coronavirus’s Less Visible Effects on Public Health

If the characteristic soundtrack of this pandemic is the ambulance siren, its distinguishing visual feature is the face mask. Nearly everyone here in NYC wears one, even to run or bike. We’ve been required to since mid-April, and those who fail to comply are given as wide a berth as possible. Surgical masks are ubiquitous, as are cloth masks of varying hues and prints. My own masks are made from a red-flowered fabric that I bought in high school and never used; my mom rescued it from storage, sewed masks with a pattern she found online, and sent several to me. I find I can still recognize acquaintances and people from the neighborhood underneath their masks; what’s more difficult is to know when someone is smiling.

The pandemic’s health repercussions will reverberate throughout our society for decades. There are, of course, the direct effects on those who have been sick and are now considered to have recovered. We’re hearing of lingering weakness and respiratory issues in this population, and the long-term health consequences of SARS-CoV-2 infection will continue to emerge. Those who have lost income and medical coverage will have a harder time accessing care, which could produce or exacerbate chronic health conditions. The death toll persists in its grim trajectory upward; each person we have lost died in isolation, cut off from the comfort of family and loved ones, who in turn remain sequestered in their grief. Many health care workers, as well as any number of those in confinement, will need mental health assistance in the coming months and years.

Across the country, people are foregoing checkups, elective procedures, dental work, and necessary medical care, including cancer treatments, out of a desire to avoid medical settings right now. Parents are postponing vaccinations of their children, which will skew immunization schedules. In March, a number of states, including Texas, Oklahoma, and Tennessee, attempted to ban surgical and some medication abortions, claiming that such procedures were “non-essential” and scarce medical equipment should be reserved for first responders. The restrictions have since been blocked by court order everywhere except Alaska and Arkansas.

There have been other, less publicized measures that could have public health implications. In Georgia, nearly 20,000 teenagers have received their driver’s licenses without a road test, with Wisconsin to follow in temporarily suspending the requirement. The new drivers are supposed to have fulfilled all other conditions for a license, including a certain number of hours of supervised driving. But the road test serves as a kind of final check, a state-sanctioned approval that someone shows a minimal level of competence behind the wheel. The upshot of waiving the requirement for a road test may turn out to be inconsequential in the long run. But it’s one more example of the ways, both large and small, in which the coronavirus is affecting and will continue to affect the nation’s health.

The Pandemic Has No End Date

Today marks the 40th day of confinement in New York City. We spent April indoors, watching the gradual arrival of spring from our apartments, tracking the rainstorms that mirrored our darkened moods. The wail of sirens was ever-present, with phantom echoes invading even our dreams. The tulips bloomed and people donned masks. Each night at 7 p.m., we opened our windows to acknowledge those who continue to leave their homes to work during this pandemic, the clapping now accompanied by banging on pots and pans, cathartic yelling, and the occasional primal scream.

As much as I long for elements of our lives of just a few months ago—the ability to hug a friend, or to run to the grocery store if I’m missing an ingredient for dinner—I find myself increasingly accustomed to confinement. Some days it feels as though this is all we’ve ever known. Routines help, as well as the knowledge that most of the country, if not the world, is in the same boat. Levels of comfort and safety vary. There are those with more space and more ability to stockpile supplies and stay indoors. Some face dangerous domestic situations, while others are incarcerated or lack domiciles entirely. The uneven ways in which the pandemic has affected communities across the country underscores what needs to change as we begin to recover: an intensive focus on public health and disease prevention, particularly in vulnerable populations; a radical expansion of social insurance and the safety net; and drastic changes to the ways in which companies treat and compensate workers. Those of us who grieve for our former lives must remember that, for millions, the old system was cruel and unjust.

The 1918 influenza pandemic that infected 500 million people and killed between 50 and 100 million worldwide occurred in three waves over two years. The second wave, in the fall of 1918, was the deadliest, with more than half of the fatalities occurring over a six- or seven-week period from mid-September to early December. But those who were infected and recovered developed some natural immunity to the virus. People who had been ill during the first wave fared better during the second wave, and so on. At the same time, the virus, a form of H1N1 influenza, appeared to mutate over time to a less severe form. Over one hundred years later, H1N1 strains related to the 1918 virus continue to circulate in the population, but in much milder, less lethal forms.

Whether acquired immunity and beneficial viral mutations will happen with SARS-CoV-2 remains to be seen. We know a fair amount about the origins of this pandemic: in bats in Wuhan, China, sometime in 2019. It’s much less clear how it will end. A handful of states across the US have begun to loosen restrictions and allow some businesses to reopen, insisting either that the coronavirus was never rampant in their area or that cases are declining. But for all the talk of “flattening the curve,” the goal of staying at home and engaging in social distancing was merely to reduce vectors of transmission, to slow down the rate of new infections to prevent overwhelming the health care system if a lot of people got sick at the same time. Once the curve has flattened, as appears to be the case in NYC, it’s not a simple matter of allowing businesses to reopen and operate as they did before the lockdowns. Because this is a new virus, there is no immunity to it. Those who have recovered from COVID-19 may have limited protection against future infections, but it’s not clear yet if this is the case, and if so, how long it will last. And with an estimated 5% of the US population exposed thus far, the numbers we’re talking about are very small, nowhere near the estimated 60-70% we’d need for herd immunity.

It’s likely the virus will become endemic in our population: always present, never eliminated.

Which Future?

At the corner of my street is a cherry tree that bursts into spectacular bloom each spring. Its lowest branches are just taller than the head of an average person, and if you stand underneath and look up, you will find yourself immersed in an unbroken expanse of soft pink blossoms. On windy days, the petals drop to the ground and disperse, blowing against curbs and doorsteps in a lush accumulation of color. N. has dubbed it the “celebritree,” as few passerby can resist stopping for a moment to bask in its ostentatious splendor. This year I’ve had to keep tabs on it from my window as I stay indoors, but it is only a little less glorious from a distance.

In New York City, the peak of this wave of the pandemic seems to be behind us. Each day brings fewer deaths, fewer calls to 911, fewer hospitalizations. But the numbers have stabilized at a very high rate: still nearly 500 deaths per day and over 10,000 confirmed deaths from coronavirus to date, more than in most European countries. We have lost so many—friends, neighbors, beloved members of our communities—and will lose many more before we emerge from this. The ongoing questions are when that will be and what our city and country will look like in the coming months and years.

The uncertainty of what lies ahead weighs on us right now—when we will see our parents again, when we will be able to gather with friends, when we will be able to grocery shop without fear of infecting workers or becoming infected ourselves. But it’s likely that we will never return to where we were just a few months ago. This pandemic is stunning in how quickly it has reshaped everyday life, shuttering restaurants, bars, retail stores, and public transportation in some locales in a matter of days. Many of these businesses won’t reopen, and the ones that do could be required to operate at reduced capacity. We may stop shaking hands with one another and start wearing masks year-round. Concerts, festivals, and sporting events will have to rethink their models for attendance.

We have survived pandemics before; the Black Death and the influenza pandemic of 1918 are the ones most frequently mentioned, comparable in their global scope to what we’re experiencing now. And we’ve been through countless other epidemics and outbreaks of infectious diseases: cholera, yellow fever, smallpox, polio, and, more recently, AIDS, SARS, and Ebola. A number of them have had lasting social impact, ushering in, for instance, changes in sanitation, water purification, and sexual behavior. No one can predict what the world will look like in a year, both the human toll and the consequences for societies around the globe. But returning to some approximation of regular life will not be like flipping a switch; it will proceed erratically and non-linearly, with inevitable setbacks requiring new shutdowns at the same time that researchers work to develop treatments and ultimately, we must hope, a successful vaccine.

The virus is within us, and it likely will be for a long time.