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Tag: coming months

  • Why Are We Still Flu-ifying COVID?

    Why Are We Still Flu-ifying COVID?

    Four years after what was once the “novel coronavirus” was declared a pandemic, COVID remains the most dangerous infectious respiratory illness regularly circulating in the U.S. But a glance at the United States’ most prominent COVID policies can give the impression that the disease is just another seasonal flu. COVID vaccines are now reformulated annually, and recommended in the autumn for everyone over the age of six months, just like flu shots; tests and treatments for the disease are steadily being commercialized, like our armamentarium against flu. And the CDC is reportedly considering more flu-esque isolation guidance for COVID: Stay home ’til you’re feeling better and are, for at least a day, fever-free without meds.

    These changes are a stark departure from the earliest days of the crisis, when public-health experts excoriated public figures—among them, former President Donald Trump—for evoking flu to minimize COVID deaths and dismiss mitigation strategies. COVID might still carry a bigger burden than flu, but COVID policies are getting more flu-ified.

    Read: The flu-ification of COVID policy is almost complete

    In some ways, as the population’s immunity has increased, COVID has become more flu-like, says Roby Bhattacharyya, a microbiologist and an infectious-disease physician at Massachusetts General Hospital. Every winter seems to bring a COVID peak, but the virus is now much less likely to hospitalize or kill us, and somewhat less likely to cause long-term illness. People develop symptoms sooner after infection, and, especially if they’re vaccinated, are less likely to be as sick for as long. COVID patients are no longer overwhelming hospitals; those who do develop severe COVID tend to be those made more vulnerable by age or other health issues.

    Even so, COVID and the flu are nowhere near the same. SARS-CoV-2 still spikes in non-winter seasons and simmers throughout the rest of the year. In 2023, COVID hospitalized more than 900,000 Americans and killed 75,000; the worst flu season of the past decade hospitalized 200,000 fewer people and resulted in 23,000 fewer deaths. A recent CDC survey reported that more than 5 percent of American adults are currently experiencing long COVID, which cannot be fully prevented by vaccination or treatment, and for which there is no cure. Plus, scientists simply understand much less about the coronavirus than flu viruses. Its patterns of spread, its evolution, and the durability of our immunity against it all may continue to change.

    And yet, the CDC and White House continue to fold COVID in with other long-standing seasonal respiratory infections. When the nation’s authorities start to match the precautions taken against COVID with those for flu, RSV, or common colds, it implies “that the risks are the same,” Saskia Popescu, an epidemiologist at the University of Maryland, told me. Some of those decisions are “not completely unreasonable,” says Costi Sifri, the director of hospital epidemiology at UVA Health, especially on a case-by-case basis. But taken together, they show how bent America has been on treating COVID as a run-of-the-mill disease—making it impossible to manage the illness whose devastation has defined the 2020s.

    Each “not completely unreasonable” decision has trade-offs. Piggybacking COVID vaccines onto flu shots, for instance, is convenient: Although COVID-vaccination rates still lag those of flu, they might be even lower if no one could predict when shots might show up. But such convenience may come at the cost of protecting Americans against COVID’s year-round threat. Michael Osterholm, an epidemiologist at the University of Minnesota School of Public Health, told me that a once-a-year vaccine policy is “dead wrong … There is no damn evidence this is a seasonal virus yet.” Safeguards against infection and milder illness start to fade within months, leaving people who dose up in autumn potentially more susceptible to exposures by spring. That said, experts are still torn on the benefits of administering the same vaccine more than once a year—especially to a public that’s largely unwilling to get it. Throughout the pandemic, immunocompromised people have been able to get extra shots. And today, an advisory committee to the CDC voted to recommend that older adults once again get an additional dose of the most recently updated COVID vaccine in the coming months. Neither is a pattern that flu vaccines follow.

    Read: Fall’s vaccine routine didn’t have to be this hard

    Dropping the current COVID-isolation guideline—which has, since the end of 2021, recommended that people cloister for five days—may likewise be dangerous. Many Americans have long abandoned this isolation timeline, but given how new COVID is to both humanity and science, symptoms alone don’t yet seem enough to determine when mingling is safe, Popescu said. (The dangers are even tougher to gauge for infected people who never develop fevers or other symptoms at all.) Researchers don’t currently have a clear picture of how long people can transmit the virus once they get sick, Sifri told me. For most respiratory illnesses, fevers show up relatively early in infection, which is generally when people pose the most transmission risk, says Aubree Gordon, an epidemiologist at the University of Michigan. But although SARS-CoV-2 adheres to this same rough timeline, infected people can shed the virus after their symptoms begin to resolve and are “definitely shedding longer than what you would usually see for flu,” Gordon told me. (Asked about the specifics and precise timing of the update, a CDC spokesperson told me that there were “no updates to COVID guidelines to announce at this time,” and did not respond to questions about how flu precedents had influenced new recommendations.)

    At the very least, Emily Landon, an infectious-disease physician at the University of Chicago, told me, recommendations for all respiratory illnesses should tell freshly de-isolated people to mask for several days when they’re around others indoors; she would support some change to isolation recommendations with this caveat. But if the CDC aligns the policy fully with its flu policy, it might not mention masking at all.

    Read: No one really knows how much COVID is silently spreading … again

    Several experts told me symptom-based isolation might also remove remaining incentives to test for the coronavirus: There’s little point if the guidelines for all respiratory illnesses are essentially the same. To be fair, Americans have already been testing less frequently—in some cases, to avoid COVID-specific requirements to stay away from work or school. And Osterholm and Gordon told me that, at this point in the pandemic, they agree that keeping people at home for five days isn’t sustainable—especially without paid sick leave, and particularly not for health-care workers, who are in short supply during the height of respiratory-virus season.

    But the less people test, the less they’ll be diagnosed—and the less they’ll benefit from antivirals such as Paxlovid, which work best when administered early. Sifri worries that this pattern could yield another parallel to flu, for which many providers hesitate to prescribe Tamiflu, debating its effectiveness. Paxlovid use is already shaky; both antivirals may end up chronically underutilized.

    Flu-ification also threatens to further stigmatize long COVID. Other respiratory infections, including flu, have been documented triggering long-term illness, but potentially at lower rates, and to different degrees than SARS-CoV-2 currently does. Folding this new virus in with the rest could make long COVID seem all the more negligible. What’s more, fewer tests and fewer COVID diagnoses could make it much harder to connect any chronic symptoms to this coronavirus, keeping patients out of long-COVID clinics—or reinforcing a false portrait of the condition’s rarity.

    The U.S. does continue to treat COVID differently from flu in a few ways. Certain COVID products remain more available; some precautions in health-care settings remain stricter. But these differences, too, will likely continue to fade, even as COVID’s burden persists. Tests, vaccines, and treatments are slowly commercializing; as demand for them drops, supply may too. And several experts told me that they wouldn’t be surprised if hospitals, too, soon flu-ify their COVID policies even more, for instance by allowing recently infected employees to return to work once they’re fever-free.

    Early in the pandemic, public-health experts hoped that COVID’s tragedies would prompt a rethinking of all respiratory illnesses. The pandemic showed what mitigations could do: During the first year of the crisis, isolation, masking, distancing, and shutdowns brought flu transmission to a near halt, and may have driven an entire lineage of the virus to extinction—something “that never, in my wildest dreams, did I ever think would be possible,” Landon told me.

    Most of those measures weren’t sustainable. But America’s leaders blew right past a middle ground. The U.S. could have built and maintained systems in which everyone had free access to treatments, tests, and vaccines for a longer list of pathogens; it might have invested in widespread ventilation improvements, or enacted universal sick leave. American homes might have been stocked with tests for a multitude of infectious microbes, and masks to wear when people started to cough. Vaccine requirements in health-care settings and schools might have expanded. Instead, “we seem to be in a more 2019-like place than a future where we’re preventing giving each other colds as much as we could,” Bhattacharyya told me.

    Read: Next winter, what if we test for even more viruses?

    That means a return to a world in which tens of thousands of Americans die each year of flu and RSV, as they did in the 2010s. With COVID here to stay, every winter for the foreseeable future will layer on yet another respiratory virus—and a particularly deadly, disabling, and transmissible one at that. The math is simple: “The risk has overall increased for everyone,” Landon said. That straightforward addition could have inspired us to expand our capacity for preserving health and life. Instead, our tolerance for suffering seems to be the only thing that’s grown.

    Katherine J. Wu

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  • A Wild and Dangerous 2024 Experiment

    A Wild and Dangerous 2024 Experiment

    “We are in this to win it,” No Labels’ chief strategist, Ryan Clancy, told me one morning earlier this month. Clancy and 16 other representatives of the beleaguered centrist group were staring at me through their respective Zoom boxes during a private briefing, electoral maps and polling data at the ready, all in defense of their quest to alter the course of the 2024 presidential campaign.

    He continued: “And that’s a function not only of having a ticket eventually that can accumulate electoral votes—”

    That’s when Nancy Jacobson, the group’s CEO and founder, interjected.

    “But I just want to clarify, this organization is not in it to win it,” Jacobson said, a truly unusual statement for a political operative.

    “This organization is in it to give people a choice.”

    In the coming weeks, No Labels seems poised to intervene in the presidential race with a “unity ticket”—ideally one Republican and one Democrat—meant to appeal to the large number of Americans dissatisfied with the likely major-party nominees, President Joe Biden and former President Donald Trump. Unlike Robert F. Kennedy Jr., Cornel West, Jill Stein, and other independent or third-party contenders, the No Labels candidates will likely be mainstream and, to use No Labels’ preferred language, offer “commonsense” values.

    David A. Graham: The brain-breaking logic of No Labels

    Even if the forthcoming White House bid ends up as nothing but a sideshow, it is still garnering attention: Polls indicate that a No Labels ballot line may well draw more votes away from Biden than Trump. It could be the deciding variable that secures Trump’s return to power.

    Why is No labels doing this? Some of the group’s opponents allege that No Labels is nothing more than a money-raising grift. Others have suggested that No Labels is a shadowy Republican dark-money group, and that the “unity ticket” is a stalking-horse bid to help Trump. Yet another theory is that No Labels is full of idealists who, whether they realize it or not, are playing Russian roulette with American democracy, as one critic recently put it to me. Jacobson and the organization vehemently deny all of the above accusations.

    I’ve spent the past several weeks talking with No Labels’ leaders, staffers, consultants, and opponents, trying to understand the organization’s endgame. I came away confused, and convinced that the people behind No Labels are confused, too. They’ve correctly diagnosed serious problems in the American political system, but their proposed solution could help lead to its undoing.

    Nancy Jacobson, a longtime Democratic fundraiser who is married to the longtime Democratic pollster Mark Penn, founded No Labels 15 years ago. Back then, her goal was to build the voice of the “commonsense majority” and bring compromise to Capitol Hill during what was then seen as an era of division and dysfunction. (It looks bucolic compared with the present day.) The bipartisan Problem Solvers Caucus, an earnest, relatively uncontroversial coalition of Democrats and Republicans, eventually emerged in the House of Representatives as the result of No Labels’ work.

    So many political observers view Jacobson as a Beltway operator that her colleague and friend of 30 years, Holly Page, who sits on No Labels’ board of advisers, came to our interview prepared to dispute that characterization before I even mentioned it. Page informed me that Jacobson is not, in fact “a conventional creature of Washington,” and instead likened her to a Silicon Valley disrupter who’s willing to “try things” and “challenge conventional norms.”

    Disruptive is certainly one way to describe the group’s recent change in focus from congressional gridlock to the White House, where its leaders saw a much bigger problem. Given the timing of this pivot, one might assume this bigger problem they identified was a dictator knocking at the door. Not quite.

    No Labels’ leaders look at the 2024 race and see failure on both sides underscored by a larger failure of choice. They see Trump lumbering toward another Republican nomination as he faces the possibility of conviction(s) and imprisonment. They view Biden as both far too old and having tacked too far to the left, a man who didn’t keep his campaign promises and abandoned his long-held reach-across-the-aisle mentality. No Labels raised $21.2 million in 2022, up from $11.3 million the year before. (The 2023 figures are not yet available to the public.)

    In mid-January, I sat down for a group interview with three of No Labels’ leaders—Clancy, Page, and a co-executive director, Margaret White. Clancy told me that Biden had abused his presidential power in signing an executive order to forgive student-loan payments. He compared this decision to Trump’s executive action to fund the construction of a southern border wall.

    I asked everyone to share whom they’d voted for in the 2020 election. Clancy and Page both said they’d voted for Biden. White demurred: “Oh, I don’t know if I want to answer that question.” I asked again, this time about 2016. Page voted for Hillary Clinton, Clancy for Gary Johnson. “Yeah, I don’t want to—I’m not interested in putting that out there,” White said once more.

    No Labels’ leaders are hardly alone in hating their 2024 options. In late January, a Decision Desk HQ/NewsNation poll showed that 59 percent of voters are “not too enthusiastic” or “not at all enthusiastic” about the prospect of a 2020 rematch. A separate poll in December found roughly the same thing.

    But unlike all the people sitting around complaining about the coming election, No Labels is trying to do something. And sometimes that something is described in grandiose terms. In one email to me, Jacobson shared that her college-age daughter had decided to enlist in the Israeli Defense Forces upon graduation. “I am scared for her as a parent. Terrified,” Jacobson wrote. “But how can I not celebrate her when I myself am risking so much for a cause I believe in?”

    Over the past two years, her group has been working to place its name on ballots around the country. It has succeeded in 16 states so far, and aims to reach 33 in the coming months. In the remaining states, No Labels is leaving the task of getting on the ballot up to its eventual “unity ticket” candidates. Though No Labels would dispute that these candidates would really be “its” candidates in any meaningful sense.

    The group insists that it is merely a 501(c)(4) social-welfare organization and not, as one might assume, a nascent political party. But not everyone at No Labels is on message. At the private briefing this month, one team member shared their screen with a chart boasting that 110,000 people were “No Labels Party Members.” When I asked about that specific word—party—which contradicts the organization’s central argument, Clancy, the chief strategist, said, “To the extent that this is convoluted, we can blame our campaign-finance laws.” A day later, a No Labels representative emailed me a lengthy statement explaining the difference between what a political party does and what No Labels is doing. I can’t say I was able to discern a clear distinction.

    Perhaps oddly for an organization dedicated to political choice, No Labels also insists on keeping secret the selection process for the “unity ticket” candidates. Guessing the eventual ticket has become a sort of parlor game during an otherwise boring primary season. While still not official, Clancy told me it was looking “pretty likely” that No Labels would announce a ticket, though he added that no politician has “an inside track” to the ballot line. Larry Hogan, the former governor of Maryland and a former No Labels co-chair, was believed to be in consideration, but he is instead pursuing a Senate bid. So was Senator Joe Manchin of West Virginia, a centrist Democrat, who this month went so far as to float Senator Mitt Romney as a potential running mate. “Third-party run, everything is on the table,” Manchin told reporters. A day later, he announced that he wouldn’t run for president at all. Dean Phillips, the Minnesota congressman challenging Biden for the Democratic nomination, is already a member of the Problem Solvers Caucus, and recently said he’d consider running on a “unity ticket” if the conditions were right.

    Back in November, the organization’s leaders scuttled plans for an April 2024 in-person convention in Dallas. My request for details about a rumored replacement “virtual convention” went unanswered, perhaps under the logic that they can’t plan a convention if they don’t have candidates. So the conversations are happening quietly.

    More generally, the group is cagey about its internal operations, and won’t even share the names of its donors. (Harlan Crow, the Texas real-estate tycoon who has financially supported conservative Supreme Court Justice Clarence Thomas, is one.)

    Even once the ballot-access work is finished and the candidates are secured, No Labels’ plan seems quixotic. In the United States, it remains nearly impossible for a third-party candidate to win a presidential election. The most successful third-party candidate of the modern era, Ross Perot, whom No Labels often name-drops, received just less than 19 percent of the popular vote in 1992 despite briefly dropping out of the race, but didn’t secure a single electoral vote.

    In an email to me, Jacobson alluded to the idea that “winning” a majority of the vote is not necessarily No Labels’ main goal. “Abraham Lincoln was actually a winner with 39% running on the No Labels of his day—the little-known Republican Party,” Jacobson wrote. “Ross Perot in 1992 before he pulled out was actually polling at 39%, ahead of both Bush and Clinton. Most people don’t realize that you don’t need 50% to win—you only need 35% or slightly above that.”

    Todd S. Purdum: Ross Perot’s lasting legacy

    Back in December, Clancy raised the head-scratching idea of creating a “coalition government.” He noted that if no candidate secured the requisite 270 electoral votes to claim the presidency, certain “unbound electors” could be “traded” among candidates. This sounded a bit like something out of a West Wing episode.

    Around this time, another No Labels co-founder, former Representative Tom Davis, told NBC News that No Labels candidates could potentially “cut a deal” with another party’s ticket and offer electors in exchange for Cabinet positions, or even the vice presidency. A different path, Davis said, was that a contingent election could simply be decided by the House. Such an outcome would almost certainly throw the election to Trump.

    Rick Wilson, one of the founders of the “never Trump” Lincoln Project, is a vocal No Labels critic. He believes the formerly centrist group has evolved into yet another cadre of Trump enablers, and that its ballot-access plan is far from benevolent.

    “While No Labels has every right in the world to try to put somebody on the ballot, we have an equally sacred right under the First Amendment to object to it,” Wilson told me. “I feel like No Labels is doing something dangerous and definitely stupid,” he added. “Probably extremely dangerous. Likely to cause the return of Donald Trump. And in those things, I’m going to speak out.”

    But it’s not just No Labels’ opponents who are questioning the group’s recent actions. Former Senator Evan Bayh, a personal and political ally of Jacobson’s for 25 years, whom she recommended I interview for this story, is fully supporting Biden. “It’s possible to be friendly with someone and disagree with them—or even occasionally strongly disagree,” Bayh told me. He spoke highly of Jacobson’s character and her integrity, but he also told me that several months ago, he expressed concern about her approach. “Look, I know you’re doing what you think is the right thing here,” Bayh said he told his friend. “But the consequences of error could be profound.”

    In that warning, Bayh articulated the most common criticism you tend to hear of No Labels: that its leaders are, to use a tired political metaphor, way out over their skis. As the “unity ticket” unveiling supposedly approaches, more veteran Democrats and Republicans are beginning to take notice, and voice concerns. On February 5, a bipartisan group of 11 former members of Congress sent a letter to three No Labels leaders warning them that a contingent election would be “calamitous.”

    Although it’s stocked with former elected officials and veteran Washington power brokers, No Labels can seem naive about the ugly contours of contemporary American politics. On a Thursday morning last month, the organization held an event at the National Press Club. All the No Labels luminaries were there: former Senator Joe Lieberman, the civil-rights activist Benjamin Chavis, former North Carolina Governor Pat McCrory. I thought the group might finally announce its candidates, and I suspect that many of the roughly two dozen other reporters in attendance assumed the same. No such luck. We were handed a purple folder containing a letter sent to the Department of Justice alleging an “illegal conspiracy to use intimidation, harassment, and fear against representatives of No Labels, its donors, and its potential candidates.”

    Read: Joe Lieberman weighs the Trump risk

    The letter claims that Melissa Moss, a consultant associated with the Lincoln Project, told Page, “You have no idea of the forces aligned against you. You will never be able to work in Democratic politics again.” And: “You are going to get it with both barrels.” (Page told me that this happened last summer over lunch in a public setting; Moss declined to comment for this story.) In a video screened at the press conference, Rick Wilson can be heard saying on a podcast that “they”—No Labels—“need to be burned to the fucking ground.” Jonathan V. Last, the editor of The Bulwark who has contributed to The Atlantic and other outlets, is also heard saying, “Anybody who participates in this No Labels malarkey should have their lives ruined,” and “The people who are affiliated with No Labels should be publicly shamed to society’s utmost ability to do so.”

    As the clip rolled on a flatscreen TV, the No Labels representatives looked out at the assembled reporters, solemn-faced. McCrory, the group’s national co-chair, raised his voice in disbelief when it was his turn to speak from the dais. “I mean, did you see that video? Did you listen to that video?” he asked. “Who do they think they are, Tony Soprano?”

    Though scheduled to last an hour, the event ended after 45 minutes when the Q&A portion was abruptly cut short without apparent reason. The No Labels brass exited the room. Out in the hallway, journalists were told that a follow-up “gaggle” was imminent. But it never happened. Several reporters stood around talking for a bit, then, one by one, dispersed.

    Later, when I spoke with Wilson about his comments in the clip, he said the video screened for reporters had been disingenuously edited.

    “I am not a person who is known for holding back,” Wilson said. “I was shocked, though, when they elided a quote of mine in their press conference, where I said they had to be burned to the effing ground. But then I said the next word. The word they cut off was politically.”

    The full quote does appear in the DOJ letter. But the whole episode seemed, to me, less an example of bad faith and mendacity than a simple loss of focus. Why spend all this time and effort complaining about your opponents’ tactics when you’re supposed to be selling the public on your ability to beat them?

    As of now, the top of the “unity ticket” seems likely to go to a Republican—if it goes to anyone. During last month’s press conference, Lieberman said that the current Republican candidate and former United Nations ambassador Nikki Haley could be a No Labels contender of “the most serious consideration.” Haley’s campaign immediately said she’s not interested. On Sunday, Joe Cunningham, No Labels’ national director, raised the prospect again. Once more, her campaign immediately said no thanks.

    Nevertheless, Haley’s name keeps coming up in conversations.

    At the virtual briefing earlier this month, one No Labels adviser, Charlie Black, a Republican strategist who worked on presidential campaigns for John McCain, Ronald Reagan, and both Bushes, told me he was personally rooting for Haley in the Republican primary and hopes she pulls off “a miracle.” Were this to happen, it’s unlikely that No Labels would launch a ticket. I asked whether it had been more difficult than anticipated to secure candidates for the No Labels ballot line. Black replied that the group had only begun talking to prospective candidates this month—an assertion contradicted by prior reporting.

    Elliot Ackerman: Meet the super SPAC

    No Labels’ recent shift in priority from Congress to the executive branch has caught many by surprise, and some of the group’s supporters are asking questions about the pivot. Last month, two members of the Durst family sued the organization over breach of contract and “unjust enrichment.” Douglas and Jonathan Durst, who are cousins in a real-estate dynasty, allege that No Labels pulled a “bait and switch” with their $145,000 donation in pursuing this third-party presidential project. In an email to me, a lawyer representing the Dursts wrote, “The commitment No Labels made to its donors was that it would not be a third party but, rather, a facilitator of bipartisanship to bridge the political divide. It has now broken that commitment and must be held accountable for it.”

    Clancy, for his part, told me that the Durst lawsuit lacks credibility, and described it as part of a broader effort to make his and his colleagues’ lives “difficult” during the current ballot-access push. “I mean, they might have a leg to stand on if they gave money six months ago with some expectation this is only going to congressional work,” Clancy said. “They gave money six years ago and three years ago, respectively. We didn’t even start this 2024 project until two years ago.”

    Clancy also dismissed criticism of the organization as fundamentally unjust. “Look, I don’t mean to keep pleading the refs, saying our opponents are being unfair,” Clancy told me. “Though they are.”

    “The way that, just repeatedly, the worst motives are ascribed to No Labels, and to Nancy—it’s very frustrating,” Clancy said a bit later. “Nancy and No Labels are very comfortable operating quietly, and just hoping that good stuff gets done.”

    During the private briefing, Andy Bursky, the group’s chair, told me unprompted: “No Labels’ ballot-access infrastructure is not the work of crackpots or crazy dreamers or amateurs. Rather, it’s an effort led and staffed by clear-eyed, sober professionals, animated by a shared concern for our democracy and, in particular, the choices that the two-party duopoly is shoving down the throats of the electorate.” A few minutes later, Jacobson chimed in with a more macro, and more confusing, thought: “No Labels will never, ever be involved in politics.”

    Perhaps they assumed that everyone viewed the 2024 election through No Labels’ lens: that once ballot-access was secured, some patriotic, high-profile politician would be grateful to be tapped for the third-party nomination. So far, that hasn’t happened.

    Read: The long-shot candidate who has the White House worried

    Near the end of my in-person interview with Page, Clancy, and White, I asked them point-blank if they’d lose sleep at night if No Labels ran a candidate and, as a result, Trump won the election. Clancy virtually repeated my words back to me, as if articulating them gave them extra weight.

    “I’d lose sleep if I thought I was part of an effort that was responsible for getting Trump back in the White House,” he said.

    “Me too,” Page added.

    “Yeah, absolutely,” White said.

    In an email, Jacobson told me, “Personally, I would never vote for Trump ever, nor would the leaders or the donors to the group.”

    Her email signature features an animated GIF of Washington Crossing the Delaware with the words BE BRAVE and her group’s logo hovering above the painting’s choppy waters. Jacobson and her allies seem to earnestly feel they are doing just that—being brave—but in the fog of presidential-election war, they may also have lost sight of their enemy.

    John Hendrickson

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  • What Is Nikki Haley Even Talking About?

    What Is Nikki Haley Even Talking About?

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    N

    ikki Haley was standing a few feet in front of me on a warm December night in New Hampshire. She had just finished a town-hall event at a Manchester ski lodge, from which no snow was visible for miles except the manufactured white stuff coating a sad little hill outside.

    Presidential candidates often try to conjure a sense of momentum around their campaign, and Haley’s had been accumulating the key elements: rising poll numbers, crowd sizes, and fundraising sums. Her ascendancy began around Thanksgiving, an unofficial benchmark for when voters supposedly tune in to primary campaigns. Among many of them, the former South Carolina governor and United Nations ambassador had become a source of intrigue: Could she actually win? Or was she merely the latest contender to lead a post–Donald Trump Republican Party that never arrives?

    I was in New Hampshire to gauge the extent of this apparent upsurge. Of all the campaign events in the past year—except Trump’s, which occupy their own category—Haley’s have been the most commanding. She has run the best race against Trump out of a motley bunch of Republicans—far better than former Vice President Mike Pence and South Carolina Senator Tim Scott, both long gone; Vivek Ramaswamy, whose yapping provocations gained him early notoriety but grated fast; and especially Florida Governor Ron DeSantis, who squandered his early status as Trump’s main challenger—and massive amounts of cash—by turning out to be a colossal dud of a candidate. (“Like a wounded bird falling from the sky,” Trump said of DeSantis, an overlooked but fascinatingly poetic assessment.)

    On this night in Manchester, I watched Haley pound out a stump speech about how, among other things, her main achievement as UN ambassador was to take “the kick-me sign off of our backs.” And how “our kids need to know to love America.” And how she was determined to “humanize” the fractious issue of abortion and, rest assured, “the days of demonizing that issue are over.”

    Haley is a gifted political performer, particularly in a certain kind of room. This was one of those, a politely boisterous gathering of a few hundred people, serious and professional, many still dressed for work. She came off as reasonable and solicitous, holding the same authority as she did at the various Trumpless debates she has rated so well in. You can see how Haley could rise to the level she has, the most formidable alternative to Trump or (if you prefer) first among the Republican also-rans.

    Read: Nikki Haley offers an alternate reality

    After completing her set remarks to a standing ovation, Haley took audience questions, greeted a 30-minute lineup of supporters, and satisfied their various selfie and autograph needs, nailing eye contact, small talk, and drive-by rapport. “She understands that kind of customer-service approach,” New Hampshire Governor Chris Sununu raved to me after telling the Manchester crowd that he was endorsing Haley. (“You bet your ass I am!”)

    At the end of the night, Sununu stood to Haley’s left as she faced a clot of television cameras and microphones and shouted questions from reporters. She is good at this too—parrying pointed inquiries with self-assurance, then moving on before anyone can really reflect on what she said, or didn’t say.

    But Haley’s sturdy pronouncements belie a certain wobbliness. Wait, what did she say exactly?

    Nikki Haley supporters at a town hall in Manchester, New Hampshire, in December
    Picture of Governor Chris Sununu who endorsed Nikki Haley
    New Hampshire Governor Chris Sununu, who endorsed Haley at the Manchester event

    Beyond her expertly rendered deliveries, Haley’s actual answers can be mushy or even nonsensical, with strange constructions and frequent malaprops. In Manchester, Haley praised Sununu for having his “pulse to the ground” in his state and boasted that her campaign already had momentum before his endorsement “just gave it a speed bump.” At a November debate, she ordered Ramaswamy to “leave my daughter out of your voice” (as opposed to her daughter’s name out of his mouth). “We have to deal with the cancer that is mental health,” she declares in her town halls when the subject arises (mental health, not cancer).

    Later in the session, a reporter asked Haley about Trump’s then-most-recent flare-up, his statement to Sean Hannity that he would be a dictator “on day one,” long since overshadowed by Trump’s “rot in Hell” Christmas message and his claim that immigrants are “poisoning the blood of our country.” In the moment, the “dictator” comment did feel germane, as did the question to Haley about whether that should perhaps preclude him from leading the world’s most powerful democracy.

    “First of all, that’s for the voters to decide,” Haley declared, “if they want a dictator on day one.”

    Yes, unquestionably. But what about Haley, the candidate we were speaking to—what did she decide?

    “I’m not going to be a dictator on day one,” she assured everyone, not answering.

    “I’ve always spoken in hard truths” is one of Haley’s trademark claims. In reality, the bluntness she discharges is reserved mostly for easy targets: the media, President Joe Biden, and “Kamala” (first name only, per GOP style). When it comes to speaking the hardest Republican truths of all—about Trump—Haley’s words fall feebly (wounded-bird-like), and her voice acquires a slightly halting tone and slower cadence.

    Her preferred pose is one of pronounced exasperation. “Anti-Trumpers don’t think I hate him enough; pro-Trumpers don’t think I love him enough,” Haley said at the press gaggle. She shook her head and flashed a Man, I just can’t win look before escaping into a smoke screen of platitudes (“at the end of the day, I just put my truths out there and let the chips fall where they may”).

    For all her cultivated brashness, Haley, whose campaign declined my requests to interview her, can also convey an impression of being terrified—of saying the wrong thing, of offending too many MAGA or MAGA-adjacent voters, or certainly of Trump himself.

    The most excruciating example of this occurred a few days after Christmas, when a New Hampshire voter asked Haley to explain why the Civil War was fought. She provided a stem-winder of vague conservative assertions (“government doesn’t need to tell you how to live your life”) while omitting the obvious cause: slavery. She appeared to be sensitive to the fact that some Americans might be sick of being reminded about the nation’s shameful, bloody history. Haley, who as governor removed the Confederate flag from the South Carolina statehouse, has said that as president she would not play into the “national self-loathing” that she is always lamenting, “this idea that America is bad, or rotten, or racist.”

    But trying to talk about the Civil War without mentioning slavery is like trying to run for the Republican nomination in 2024 while barely touching the all-encompassing, front-running figure at the center of it all.

    One of Haley’s niftier moves occurs later in her stump speech, when she builds to a seemingly dramatic revelation.

    “I think President Trump was the right president at the right time,” she reassures her audience. It is an imprecise and puzzling statement—what “time” exactly? (Charlottesville? COVID?) But Haley delivers the line with a force that sets a few heads bobbing in the crowd and leads her safely into her next credential. “I had a good working relationship with him when I was in his administration,” she further affirms.

    “But …”

    The words that follow this inevitable but are as fraught as any that a Republican candidate can utter. Say something like “He’s becoming crazier,” as former New Jersey Governor Chris Christie did of Trump last month, and you might win candor points but probably not any Republican primaries.

    David A. Graham: Chris Christie, liberal hero

    Haley’s next line barely deviates a word, speech to speech: “Rightly or wrongly, chaos follows him.” You could construct a tidy diagram to illustrate the perfect passivity she achieves here. Haley assigns no judgment (“rightly or wrongly”) and makes no suggestion that Trump might have ever said or done anything that actually caused this “chaos”—a euphemism for, say, the events of January 6 or whatever else is embedded in those 91 criminal counts. All of this “chaos” somehow comes randomly to rest upon the 45th president.

    “Chaos follows him,” Haley said again at a December 14 town hall in the southern–New Hampshire town of Atkinson. “You know I’m right” was the extent of her elaboration.

    “It just does.”

    Haley’s soft landing at “chaos follows him” comes after a zig-zagging and sometimes turbulent journey with Trump. The odyssey began during the 2016 campaign, when Haley called him “scary” and the embodiment of “everything we teach our kids not to do in kindergarten.” She endorsed Senator Marco Rubio—like Haley, a child of immigrants—by saying she was excited to support a candidate who “was going to go and show my parents that the best decision they ever made was coming to America.”

    Picture of Nikki Haley at the Town Hall held in McIntyre Ski Area in Manchester, NH.
    Haley speaks at the Manchester town hall.

    After Trump won the Republican nomination, Haley said, reluctantly, that she would vote for him. Trump asked her to serve as his ambassador to the United Nations reportedly as a favor to South Carolina’s lieutenant governor, Henry McMaster, a big Trump supporter, who wanted Haley out of the way so he could become governor. The UN job allowed Haley to burnish her foreign-policy résumé, and being in New York kept her removed from the daily discord of Trump’s White House. She served until 2018. “I got out of the administration without a tweet,” she likes to say.

    Following Trump’s 2020 defeat and the January 6 insurrection, Haley sounded eager to bury her former boss and get on with her pursuit of his job. “His actions since Election Day will be judged harshly by history,” she declared in a January 7 speech at a Republican National Committee meeting. Haley said there was no chance Trump would ever run for federal office again. When those predictions proved premature, she reportedly tried to pay a quick make-up visit to Mar-a-Lago but was told by the proprietor not to bother. Less than three weeks after the insurrection, she told the Fox News host Laura Ingraham that everyone should “give the man a break.”

    That April, Haley promised that she would support Trump if he ran for president again in 2024. And if he did, she said, she would not run herself.

    Until … never mind.

    As a candidate, Haley, whom Trump has taken to calling “Birdbrain,” frequently mentions how much better she would fare against Biden than Trump or DeSantis would. She often cites a Wall Street Journal poll from last month that shows her leading Biden by 17 points in a head-to-head matchup (Trump wins by four points). No doubt “electability” is a compelling argument, but this hypothetical Haley blowout is also premised on a dubious assumption—that Trump would be a gracious loser and urge his supporters to vote for their Republican standard-bearer, Ambassador Birdbrain.

    When it comes to Trump’s indictments, Haley can’t bat away questions fast enough. “A lot of these cases have been politicized, we all know that,” she said in Manchester. Haley has promised to support the GOP nominee, whether it’s Trump or someone else. And in Plymouth, New Hampshire, at the end of December, she said that if she were elected president and Trump were convicted, she would likely pardon him “so that we can move on as a country and no longer talk about him.”

    Such flaccid scolding is of course a big part of why Trump is still here. Appeasement has been the Republican business model since 2015. “It’s like what happened last time—nobody wanted to criticize Trump,” Mark Sanford, a former Republican representative from and governor of South Carolina, told me. Sanford, who declined to speak about Haley on the record, lost his 2018 House primary after becoming a strident Trump critic. “They figured he would go away,” Sanford said, referring to Trump’s Republican opponents over the years. “And they sort of waited and waited and waited, and he didn’t go away.”

    Eight years later, Haley seems to be of a similarly passive mindset: put up tepid resistance to Trump, at least early on; stay alive; and hope that someone, or something, comes along to take care of the problem. “Maybe she catches a break from a jury,” Chip Felkel, a longtime Republican strategist in South Carolina told me, referring to the possibility of Trump being convicted in the coming months. Felkel, who is not affiliated with Haley’s campaign, says that he’s no fan of hers but that he’s hugely hostile to Trump, so he’ll support his former governor.

    Chris Christie offers a different specimen of Trump alternative: a former friend and longtime ally of the 45th president whose unambiguous denunciations were the centerpiece of his campaign. Christie has held back little, calling Trump a “coward,” a “fool,” and a “self-centered, self-possessed, self-consumed, angry old man.”

    In other words, Christie has been the rare candidate willing to tell actual hard truths about Trump. He will also not be the Republican nominee: He suspended his campaign last night.

    Will Haley be the nominee? Are her pillowy “attacks” on the front-runner simply the undignified price of Republican viability today? Has this approach at least given her the best shot of any Republican to defeat Trump—an extremely long shot, but a shot nonetheless?

    Her theory of the race is straightforward enough: Beat DeSantis for second in Iowa; be competitive with Trump in New Hampshire, where she’s gained in recent polls but still trails by double digits in most; and then parlay that momentum into defeating Trump in her home state (where the former president also remains well ahead).

    Both Christie and Haley are pragmatic former governors who appeal to independents and college-educated moderates. Polling this past fall showed that a significant portion of his backers in New Hampshire would migrate to Haley if he bowed out of the race before the state’s January 23 primary.

    A week before Christmas, Christie faced growing public pressure, much of it from people backing Haley, to drop out in the name of stopping Trump. The former New Jersey governor had made a sustained and effective case against Trump over several months, but struggled to boost his support into the teens and was strongly considering it.

    But he held off for a few weeks. Christie has been frustrated, even appalled, by Haley’s unwillingness to say how she really feels about Trump, according to sources close to Christie. He has become less and less shy about expressing his dissatisfaction with her in public. He has taunted Haley for not ruling out a role as Trump’s running mate, as he and DeSantis have. “I don’t play for second” has been Haley’s standard answer to the vice-presidential question, an emphatic non-denial. “That’s why she’s not saying strong things against Donald Trump,” Christie said on Face the Nation.

    Jonathan V. Last: Nikki Haley’s endgame

    His reaction to Haley’s slavery misadventure was especially pointed. “She’s unwilling to offend anyone by telling the truth,” he said in Epping, New Hampshire. “It’s worse to be able to be dishonest with people, and that’s what’s happening here.”

    Now that Christie’s out of the primary, Haley will surely get some of his voters, though an endorsement seems unlikely anytime soon. Shortly before Christie announced his exit last night, at a town hall in New Hampshire, a hot mic caught him saying of Haley: “She’s gonna get smoked … She’s not up to this.”

    Christie’s quandary over Haley is one that many Trump-skeptical Republicans identify with. “It’s the Nikki Haley dilemma,” Mike Murphy, a longtime Republican media consultant who has deep loathing for Trump and would love to see him lose, told me. He finds Haley’s cynicism depressing and is disgusted by her willingness to pander to “the latest insipid GOP crowd-pleasing trope,” as he recently wrote on Substack.

    “Still, compared to Trump, she’s Gandhi,” Murphy continued. And he thinks she has a real chance to beat Trump in New Hampshire, where Murphy helped John McCain upset George W. Bush in 2000. “If I lived in New Hampshire, I’d vote for Haley in a heartbeat,” he told me.

    Left photograph showing Nikki Haley signing autographs after the town-hall. Right photograph showing an empty chair after the town-hall ended.
    Left: Haley signs an autograph. Right: Supporters leave after the town hall.

    Haley’s knack for connecting one-on-one with voters does not always extend to political peers. On the contrary, her career has featured an array of disposable alliances, stubborn grudges, and a sense of paranoia about opponents, as my colleague Tim Alberta, then of Politico, documented in a 2021 profile of Haley. “She cut me off,” Sanford told Alberta. “This is systematic with Nikki,” he continued. “She cuts off people who have contributed to her success. It’s almost like there’s some weird psychological thing where she needs to pretend it’s self-made.”

    “I don’t trust, because I’ve never been given a reason to trust,” Haley told Alberta. “Friend,” she added, “is a loose term.” She is fond of saying she wears heels not as a fashion statement but “for ammunition.”

    No doubt Haley comes to this worldview honestly, having grown up as an Indian American in the Deep South of the 1970s and ’80s. She has faced discrimination, racism, sexism, and smears—not subtle ones, either. When she ran for governor, in 2010, a South Carolina political blogger and a lobbyist working for one of Haley’s rivals in the race both claimed to have had affairs with Haley (she denied them), and a Republican state senator called her a “raghead.”

    “Every South Carolina politician here has been through that, all of us,” Katon Dawson, the former chair of the South Carolina GOP and a Haley supporter, told me. “We’re from South Carolina, and it is a bare-knuckled brawl.”

    For Haley to win, Felkel, the South Carolina strategist, said he thinks she will have to channel some of that South Carolina pugilism and “open up a can of whoop-ass” on Trump. “We need to see more stiletto weaponry from her, and less ‘bless your heart,’” Felkel said.

    In recent days, Haley has taken a somewhat more combative tack against Trump, after a pro-Trump super PAC released a campaign ad in New Hampshire that accused her of supporting a gas-tax increase in South Carolina and dubbed her “‘High Tax’ Haley.” (Haley had backed a gas-tax hike coupled with an income-tax cut.) “In his commercials and in his temper tantrums, every single thing that he’s said has been a lie,” she told an audience at a January 2 town hall on the New Hampshire coast.

    “So if he’s gonna lie about me,” Haley went on, “I’m gonna tell you the truth about him.” The line drew the biggest applause of the event. Haley delivered it slowly, clearly, and with authority—like a candidate to be reckoned with, who might just be willing to escalate things.

    But wasn’t Haley supposedly telling “hard truths” all along? Isn’t that kind of her signature thing? “She’s admitting that her retaliation to Trump’s lying about her is that she will stop lying about him,” Jonathan V. Last wrote in The Bulwark. Last dubbed Haley’s line “the most complete exposure to a politician’s subconscious I’ve ever seen.”

    Or maybe this was always Haley’s conscious plan—to gradually parcel out her clever “hard truths” if convenient and when openings arise, and impress the right people and donors while doing so. Perhaps Haley already views this foray as a success. Even if she never seriously threatens Trump, she’s likely to perform respectably in the early states, win a second place or two, outlast DeSantis, and land some breezy swipes at Trump. Then, when his nomination becomes inevitable again, she can safely endorse her old boss (they always had a good working relationship!) and move on to her next campaign, to be Trump’s vice president or to try again in 2028.

    Related Podcast

    Listen to Mark Leibovich discuss Nikki Haley on Radio Atlantic:

    Mark Leibovich

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  • How Bad Are America’s COVID-Vaccination Rates?

    How Bad Are America’s COVID-Vaccination Rates?

    Relatively speaking, 2023 has been the least dramatic year of COVID living to date. It kicked off with the mildest pandemic winter on record, followed by more than seven months of quietude. Before hospitalizations started to climb toward their September mini-spike, the country was in “the longest period we’ve had without a peak during the entire pandemic,” Shaun Truelove, an infectious-disease modeler at Johns Hopkins University, told me. So maybe it’s no surprise that, after a year of feeling normalish, most American adults simply aren’t that worried about getting seriously sick this coming winter.

    They also are not particularly eager to get this year’s COVID shot. According to a recent CDC survey, just 7 percent of adults and 2 percent of kids have received the fall’s updated shot, as of October 14; at least another 25 percent intends to nab a shot for themselves or their children but haven’t yet. And even those lackluster stats could be an overestimate, because they’re drawn from the National Immunization Surveys, which is done by phone and so reflects the answers of people willing to take federal surveyors’ calls. Separate data collected by the CDC, current as of October 24, suggest that only 12 million Americans—less than 4 percent of the population—have gotten the new vaccine, according to Dave Daigle, the associate director for communications at the CDC’s Center for Global Health.

    CDC Director Mandy Cohen still seems optimistic that the country will come close to the uptake rates of last autumn, when 17 percent of Americans received the updated bivalent vaccine. But for that to happen, Americans would have to maintain or exceed their current immunization clip—which Gregory Poland, a vaccine expert at Mayo Clinic, told me he isn’t betting on. (Already, he’s worried about the possible dampening effect of new data suggesting that getting flu and COVID shots simultaneously might slightly elevate the risk of stroke for older people.) As things stand, the United States could be heading into the winter with the fewest people recently vaccinated against COVID-19 since the end of 2020, when most people didn’t yet have the option to sign up at all.

    This winter is highly unlikely to reprise that first one, when most of the population had no immunity, tests and good antivirals were scarce, and hospitals were overrun. It’s more likely to be an encore of this most recent winter, with its relative calm. But that’s not necessarily a comfort. If that winter was a kind of uncontrolled experiment in the damage COVID could do when unchecked, this one could codify that experiment into a too-complacent routine that cements our tolerance for suffering—and leaves us vulnerable to more.

    To be fair, this year’s COVID vaccines have much been harder to get. With the end of the public-health emergency, the private sector is handling most distribution—a transition that’s made for a more uneven, chaotic rollout. In the weeks after the updated shot was cleared for use, many pharmacies were forced to cancel vaccination appointments or turn people away because of inadequate supply. At one point, Jacinda Abdul-Mutakabbir, an infectious-disease pharmacist at UC San Diego, who’s been running COVID and flu vaccination in her local community, was emailing her county’s office three times a week, trying to get vaccine vials. Even when vaccines have been available, many people have been dismayed to find they need to pay out of pocket for the cost. (Most people, regardless of insurance status, are supposed to be able to receive a free COVID-19 vaccine.)

    [Read: Fall’s vaccine routine didn’t have to be this hard]

    The vaccine is now easier to find, in many places; insurance companies, too, seem to be fixing the kinks in compensation. But Abdul-Mutakabbir told me she worries that many of the people who were initially turned away may simply never come back. “You lose that window of opportunity,” she told me. Even people who haven’t gotten their autumn shot may be hesitating to try if they expect access to be difficult, as the emergency physician Jeremy Faust points out in his Inside Medicine newsletter.

    Plus, because the rollout started later this year than in 2022, many people ended up infected before they could get vaccinated and may now be holding off on the shot—or skipping it entirely. And some Americans have simply decided against getting the shot. The CDC reported that 38 percent don’t plan to vaccinate themselves or their children; earlier this fall, more than half of respondents in a Kaiser Family Foundation poll said they probably or definitely wouldn’t be signing up themselves or their kids. More than 40 percent of those polled by KFF remain doubtful, too, that COVID shots are safe—dwarfing the numbers of people worried about flu shots, and even about RSV shots, which are newer than their COVID counterparts.

    The consequences of low COVID-vaccine uptake are hard to parse. This year, like last year, most Americans have been vaccinated, infected, or both, many of them quite recently. COVID’s average severity has, for many months, been at a relatively consistent low. The last catastrophic SARS-CoV-2 variant—one immune-evasive enough to spark a massive wave of sickness, death, and long COVID—arrived two years ago. Barring another feat of viral evolution, perhaps these dynamics have reached something like a stable state, Justin Lessler, an infectious-disease modeler at the University of North Carolina at Chapel Hill, told me. So maybe the most likely scenario is a close repeat of last winter: a rise in hospitalizations and deaths that’s ultimately far more muted than any earlier in the outbreak. And the COVID-19 Scenario Modeling Hub, which Lessler co-leads alongside Truelove and a large cohort of other researchers, projects that “next year will look a lot like this year, whatever this year ends up looking like,” Lessler said.

    But predictability is distinct from peace. COVID has still been producing roughly twice the annual mortality that flu does; roughly 17,000 people are being hospitalized for the disease each week. SARS-CoV-2 infections also still carry a risk, far higher than flu’s, of debilitating some people for years. “And I do think we’re going to experience a winter increase,” Truelove told me. Even if this year’s COVID-vaccine uptake were to climb above 30 percent, models suggest that January hospitalizations could rival numbers from early 2023. Go much lower than that, and several scenarios point to outcomes being worse.

    Based on the limited data available, at least one trend is mildly encouraging: Adults 75 and older, the age demographic most vulnerable to COVID and that stands to benefit most from annual shots, also have the highest vaccine uptake so far, at about 20 percent. At the same time, Katelyn Jetelina, the epidemiologist who writes the popular Your Local Epidemiologist newsletter, points out that CDC data suggest that only 8 percent of nursing-home residents are up to date on their COVID shots. “That is what keeps me up at night,” Jetelina told me. Early National Immunization Surveys data also suggest that uptake is lagging among other groups that might fare less well against COVID—among them, rural populations, Hispanic people, American Indians and Alaskan Natives, the uninsured, and people living below the poverty line.

    Last winter was widely considered to be a bullet dodged, and the reactions to the coming months may be similar: At least it’s no longer that bad. Since the winter of Omicron, the country has been living with lower vaccine uptake while experiencing lower COVID peaks. But those lower peaks shouldn’t undermine the importance of vaccines. Infection-induced immunity, past vaccinations, improvements in treatments, and other factors have combined to make COVID look like a gentler disease. Add more recent vaccination to that mix, and many of those gains would likely be enhanced, keeping immunity levels up without the risks of illness or passing the virus to someone else.

    [Read: The one thing everyone should know about fall COVID vaccines]

    As relatively “okay” as this past year-plus has been, it could have been better. Missed vaccinations still translate into more days spent suffering, more chronic illnesses, more total lives lost—an enormous burden to put on an already stressed health-care system, Jetelina told me. For the flu, more Americans act as if they understand this relationship: This year, as of November 1, nearly 25 percent of American adults, and more than 20 percent of American kids, have gotten their fall flu shot. Most of the experts I spoke with would be surprised to see such rates for COVID vaccines even at the end of this rollout.

    If last winter was a preview of future COVID winters, our behaviors, too, could predict the patterns we’ll follow going forward. We may not be slammed with the next terrible variant this year, or the next, or the next. When one does arrive, though, as chances are it will, the precedent we’re setting now may leave us particularly unprepared. At that point, people may be years out from their most recent COVID shot; whole swaths of babies and toddlers may have yet to receive their first dose. Some of us may still have some immunity from recent infections, sure—but it won’t be the same as dosing up right before respiratory-virus season with protection that’s both reliable and safe. Systems once poised to deliver COVID vaccines en masse may struggle to meet demand. Or maybe the public will be slow to react to the new emergency at all. Our choices now “will be self-reinforcing,” Poland told me. We still won’t be doomed to repeat our first full COVID winter. But we may get closer than anyone cares to endure.

    Katherine J. Wu

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  • America May Be Missing Out on a Better COVID Treatment

    America May Be Missing Out on a Better COVID Treatment

    Japan is home to an untold number of conveniences and delights that American consumers regularly go without: Faster public transit! Better sunscreen! Lychee KitKats! But as we head into sick season, one Japanese invention would be especially welcome on the U.S. market: an antiviral pill that appears to shorten COVID symptoms, might protect against chronic disease, and doesn’t taste like soapy grapefruit.

    Ensitrelvir, a drug made by the Osaka-based pharmaceutical company Shionogi, was conditionally approved in Japan last November. Like Paxlovid, ensitrelvir works by blocking an enzyme that the SARS-CoV-2 virus uses to clone itself inside the human body. But for the millions of Americans who will likely get COVID in the coming months, the new drug is almost certain to be out of reach. In 2021, Pfizer waited just five weeks for Paxlovid to receive its emergency use authorization. But ensitrelvir is still sitting in the approval pipeline, stuck in another round of clinical trials that may run well into 2024.

    Existing data (not all of which have been peer-reviewed) show that people with COVID who promptly take ensitrelvir, marketed as Xocova in Japan, test negative about 36 hours faster than people who take a placebo. Fever, congestion, sore throat, cough, and fatigue disappear about a day earlier too. Even smell and taste loss appear to resolve more quickly. The company also has some tentative evidence suggesting that the drug can help protect patients from developing long COVID.

    These findings were not enough for the FDA, but they are extremely encouraging, says Michael Lin, a bioengineering professor at Stanford University who works on drugs for treating coronavirus infections. Xocova “looked as good or a little bit better than Paxlovid,” he says. For instance, Pfizer’s clinical trials failed to show that Paxlovid clears symptoms any faster than a placebo in people who aren’t at high risk of developing severe COVID. Shionogi’s did just that.

    Reshma Ramachandran, a family physician at Yale, told me that if the early Xocova results hold up in additional trials, she’d be inclined to prescribe it to her vaccinated patients in place of Paxlovid, simply because the evidence supporting its use is more direct. She said she’d be especially keen to give Xocova if the long-COVID finding can be reproduced.

    Read: Rebound COVID is just the start of Paxlovid’s mysteries

    No lab or pharmaceutical company has yet published a study that pits Xocova against Paxlovid head-to-head in treating COVID, so it’s impossible to say with certainty which one is better. You can’t draw conclusions just by comparing Pfizer’s clinical-trial results with Shionogi’s: Their drugs were tested in different populations with different levels of immunity at different points in the pandemic when different variants were circulating. Shionogi also required clinical-trial participants to start taking Xocova within three days of feeling sick, whereas patients in the Paxlovid trials began their treatment up to five days after symptoms started. Daniel Griffin, an infectious-disease specialist at Columbia University, told me that timing is everything when it comes to antivirals: In general, the sooner a patient starts taking a drug, the better it works.

    A Pfizer spokesperson told me that the efficacy and adverse-event rates of Paxlovid and Xocova cannot directly be compared, and emphasized Paxlovid’s power to stave off hospitalization and death. (Xocova’s clinical trials were not able to provide meaningful data on those outcomes, which are now much rarer than they were in 2021.) “Since the beginning of the pandemic, we’ve known it will take multiple treatment options and preventative measures for the world to overcome the challenges of COVID-19,” he said in an email.

    Even if Xocova turns out to be no more effective than Paxlovid, it still has several practical advantages. For one thing, it is literally easier to swallow. Paxlovid must be taken twice a day for five days, and each time you have to gulp down three pills: two containing nirmatrelvir (which actively combats the virus), plus one containing ritonavir (which slows the metabolism of nirmatrelvir, keeping it in your system longer). Xocova is taken just once a day for five days, and after the first three-pill dose, it’s one pill at a time. Paxlovid can also cause dysgeusia, a.k.a. Paxlovid mouth—a sour, metallic, taste that may last for hours after swallowing. Xocova seems to taste just fine.

    Read: Paxlovid mouth is real—and gross

    Experts hope that Xocova will be more widely accessible than Paxlovid, too. Pfizer announced last week that the price of Paxlovid will soon rise from $529 to $1,390 when the drug enters the commercial market. Shionogi hasn’t decided on Xocova’s price in the U.S. market, but there’s reason to think it will be cheaper. In Japan, the only market where both drugs are currently available, a course of Xocova costs 51,851 yen (about $346), and Paxlovid is nearly double the price, at 99,027 yen (about $661). And whereas Japanese health authorities—like those in the U.S.—have recommended Paxlovid for use by patients at high risk of severe COVID, Xocova has been shown to benefit people with infections regardless of their risk status. Finally, whereas Paxlovid’s reach is limited by its many harmful interactions with other drugs, Xocova might pose fewer problems because it doesn’t contain ritonavir, Lin told me. The newer drug’s interaction profile is still being ironed out, but a company spokesperson pointed me to a running list from the University of Liverpool. (According to that source, you should avoid taking Paxlovid and Adderall at the same time—but going on Xocova is fine.)

    Xocova may also sidestep one of patients’ most commonly voiced concerns about Paxlovid: that it will make their COVID go away and then return. One recent observational study of COVID patients found that symptoms rebounded among 19 percent of Paxlovid takers, versus 7 percent of nontakers. By contrast, Shionogi has reported that symptom rebound was vanishingly rare in its clinical trials of Xocova.

    Read: Inside the mind of an anti-Paxxer

    Neither Shionogi nor the FDA would give me an estimate of Xocova’s approval timeline in the U.S., but earlier this year, the company’s CEO estimated that it might get the nod in late 2024. This past spring, the FDA gave the drug “fast track” status, which means Xocova will be eligible for an expedited review process once the company submits its application. (The FDA declined to comment on Xocova’s prospects for approval, citing federal disclosure laws.) Until then, it’s running more clinical trials in the U.S. and abroad. One of them, conducted in partnership with the National Institutes of Health, will evaluate the drug’s performance in hospitalized patients. Another will evaluate its efficacy against long COVID, among other things.

    To some experts, Xocova’s track is not nearly fast enough. David Boulware, an infectious-disease specialist at the University of Minnesota, told me that the FDA appears to be “slow walking” the approval process. Lin, too, would like to see more action. But it’s not clear how, exactly, that would happen. “I think the FDA is doing all that they can,” Ramachandran said; an emergency use authorization for Xocova isn’t a realistic option, given that the COVID public-health emergency has expired. Plus, Griffin said, caution is prudent when dealing with new drugs. “We want to make sure it’s safe. We want to make sure it’s effective,” he told me. “We also don’t want to fall into the trap we fell in with molnupiravir,” an earlier antiviral that looked promising at first, but ultimately offered disappointing benefits to COVID patients (though a surprising utility for cats).

    If the FDA were to approve Xocova tomorrow, demand for Paxlovid likely wouldn’t disappear, experts told me. Lin said the two drugs might compete for users, like Motrin and Aleve. People who are in danger of being hospitalized or dying from COVID could still opt for Paxlovid. “But there’s a much larger group of people who just feel crummy, and they just want to feel better,” Griffin told me. For them, Xocova could make more sense. They just won’t have a choice until the FDA approves it.

    Rachel Gutman-Wei

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  • Birth Control Isn’t the Only Thing That Just Went Over-the-Counter

    Birth Control Isn’t the Only Thing That Just Went Over-the-Counter

    The FDA announced yesterday that it had for the first time approved a daily birth-control pill for over-the-counter sales. That’s a big change; once the product, called Opill, is on the market—which may be as soon as early 2024—Americans will be able to buy daily hormonal birth control without a prescription. That’s historic news, but hidden underneath it is another set of firsts: In the coming months, Americans will also be able to grab an over-the-counter treatment for their heavy periods, cramps, headaches, and even migraines; they’ll have prescription-free access to a drug for endometriosis and polycystic ovary syndrome; and they’ll be able to buy a medication that can mitigate the symptoms of menopause. It’s all in the same, progestin-based pill.

    The FDA’s approval only covers Opill’s use as a form of birth control, but doctors have been prescribing pills that contain progestin for noncontraceptive needs for years. For the most part, the intervention works much better when the pills include both progestin and estrogen. Adding that second hormone to the mix amplifies all of progestin’s beneficial effects, plus helps control hormonal acne. It also leaves more wiggle room in terms of timing: Progestin-only pills—sometimes called a minipill—have a much shorter half-life in the body, so if you don’t take them during the same three-hour window each day, they’re much less reliable at preventing pregnancy, says Anne-Marie Amies Oelschlager, the chief of pediatric and adolescent gynecology at Seattle Children’s. (Some women are prescribed progestin-only pills because they are particularly susceptible to certain risks associated with estrogen.)

    As a result, an over-the-counter progestin-only pill is far from the best way of treating these conditions, experts told me. “While I suppose that it could be used off-label, I would be hesitant to do that if someone was otherwise able to obtain a prescription for a combined oral contraceptive,” Erin Fleurant, a family-planning fellow at Northwestern Medicine, told me. And if progestin by itself really were the right approach, then an IUD, implant, or injection might be a more effective way to deliver the drug.

    From July 1939: The responsibilities of birth control

    Despite the fact that progestin on its own would not usually be a doctor’s first choice—“I generally don’t prescribe it,” Veronica Ades, the vice chair of ob/gyn at Jacobi Medical Center, told me—the drug can have meaningful benefits when taken on its own. Amies Oelschlager told me that she prescribes it to suppress patients’ periods, especially if they’re experiencing pain or heavy bleeding. Even low-dose pills (like Opill) can be helpful for controlling period- and perimenopause-related migraines, as well as mood swings from premenstrual syndrome or premenstrual dysphoric disorder.

    Progestin pills can also be used to treat endometrial hyperplasia, an abnormal thickening of the uterine lining (a.k.a. the endometrium) that can develop into cancer. Same for endometriosis, a condition that may affect up to 11 percent of American women in which endometrial tissue grows outside the uterus. Patients with PCOS produce unusually high levels of male sex hormones and, Ades said, generally have too much estrogen in their body relative to progesterone (the naturally occurring analogue of progestin). Progestin pills can help strike a healthier balance.

    Right now, patients have few options to get relief from any of those symptoms without a doctor’s help. Until Opill hits the market, the best non-prescription way to treat PCOS is with healthy eating and exercise, Amies Oelschlager told me. For heavy periods, the best option patients can buy without a prescription is an NSAID like ibuprofen. “As far as an over-the-counter, daily hormonal medication, this is the first in the United States,” she said.

    Perhaps the best circumstances for off-label use of Opill will be as a stopgap. If someone starts having abnormal bleeding or period pain but can’t get an appointment or travel to a doctor for several weeks, they could buy themselves some progestin-only pills for the interim. Opill could also be a backup plan for patients who are already taking birth-control pills for a non-birth-control purpose but can’t make it to their doctor to renew their prescription, or can’t get their prescription filled at a pharmacy.

    Read: A vaccine for birth control?

    Still, Ades cautioned that even stopgap use might not be wise for endometriosis patients, for whom switching medications could disrupt a delicate balance of hormones and “create a cascade of problems.” Fleurant warned that some of the symptoms that progestin pills could help alleviate may also be associated with very serious conditions that need a different treatment plan. “Say someone was 45 years old and having irregular bleeding and also had a lot of other risk factors for uterine cancer. I wouldn’t want them to pick up this pill and think that that was going to cure everything,” she said. Instead, they should be seen by a health-care provider.

    For most women who need to be on birth control, a single-hormone drug like Opill is not the most reliable option; but starting next year, it could well be the most convenient. That same trade-off, between effectiveness and access, affects other uses of progestin, too.

    Rachel Gutman-Wei

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  • ‘She’s Going to Be Famous for a Long Time’

    ‘She’s Going to Be Famous for a Long Time’

    For many judicial nominees, a Senate confirmation hearing is one of life’s most grueling experiences—an hours-long job interview led by lawmakers who are trying to get them to face-plant on national television.

    Not for Aileen Cannon. When the federal judge who will oversee former President Donald Trump’s criminal trial testified in 2020, the Senate Judiciary Committee didn’t go easy on her so much as they ignored her.

    Cannon, then a 39-year-old prosecutor, appeared on Zoom alongside four other nominees, her face framed by a wall of diplomas on one side and an American flag on the other. Her opening statement lasted all of three minutes and sounded like an Oscar winner’s speech—lots of thank-yous and little else. She didn’t say a word about her legal philosophy or how she would approach the job of a judge. The senators didn’t seem to mind: None of them addressed a question specifically to Cannon for the rest of the hearing. The committee’s chair at the time, Senator Lindsey Graham of South Carolina, skipped the proceeding entirely, as did each of the five most senior Republicans on the panel. The hearing was over after barely an hour. Three months later, while Trump was beginning his effort to overturn his defeat in the presidential election, a bipartisan Senate majority (including a dozen Democrats) voted to confirm Cannon’s nomination as a federal judge in the Southern District of Florida.

    For low-profile nominations like Cannon’s, perfunctory hearings aren’t unusual. But the scrutiny she was spared in the Senate is coming her way now. After just two and a half years as a judge, Cannon will soon preside over a trial with no precedent in American history. The defendant is the former president who appointed her, and her rulings during the investigation that led to Trump’s indictment have already prompted many legal experts to fear that she will tilt the trial in his favor.

    But some of the Democratic lawyers who have appeared in Cannon’s courtroom don’t share those worries. They say that she is a smarter, more deliberate, and more even-handed judge than the early criticism of her would suggest. “I think the government should be very happy that they have Judge Cannon,” says Richard Klugh, a longtime defense attorney in Miami who has dealt with Cannon both as a judge and when she served as a federal prosecutor there. Klugh, a lifelong Democrat, told me that aside from her “narrow” rulings on Trump’s case last summer, he had heard no complaints about Cannon from either prosecutors or defense attorneys. “She’s very confident, very honest … and very thorough,” he told me. “She’s confident enough to go through things independently.”

    Read: Will Trump get a speedy trial?

    That may be, but she’s extremely inexperienced. Since taking her seat on the bench, Cannon has worked mostly out of a courthouse in Fort Pierce, a two-hour drive from Miami and a town that one local lawyer described to me as “a backwater.” She has presided over just four trials as a judge, none of which covered crimes remotely similar to the willful retention of classified documents that the government has accused Trump of committing. (She is set to oversee a far more complex trial involving alleged Medicare fraud in the coming months.)

    Cannon was born in Colombia and is the daughter of Cuban refugees. In her brief statement to the Judiciary Committee, she described how her mother, at the age of 7, “had to flee the repressive Castro regime in search of freedom and security.” Cannon graduated from Duke University, and by the time she earned her law degree from the University of Michigan, she had already joined the conservative Federalist Society. After law school, she embarked on a fairly conventional legal career: She clerked for an appellate judge, spent several years at a large law firm, and then became an assistant U.S. attorney in Miami. In written responses to the Judiciary Committee, Cannon wrote that she considered herself both an “originalist” and a “textualist”—two approaches long identified with conservative judges—but that she would follow all precedents set by the Supreme Court and other appellate rulings.

    Two South Florida lawyers told me that they were struck by Cannon’s overt religiosity, which has seeped into her pronouncements in court. She routinely tells defendants “God bless you” after they enter guilty pleas, said Valentin Rodriguez, a lawyer who has appeared before Cannon. “In my entire 30-year career I’ve never had a judge mention God to a client ever,” Rodriguez told me. “She does that as a matter of course.”

    Although presidents formally nominate all federal judges, they frequently appoint district-court judges at the recommendation of home-state senators. Cannon told the Judiciary Committee that she was first approached about filling a judicial vacancy by the office of Senator Marco Rubio in 2019, nearly a year before Trump sent her nomination to the Senate. Her appointment came at a moment when Trump and then–Senate Majority Leader Mitch McConnell were trying to reshape the federal courts by filling as many open judgeships as possible with young conservatives in their 30s and 40s. Three previous nominations for judgeships in Florida’s Southern District had gone to men in their 40s. “It made sense that Trump would select a woman with good credentials who also happens to be Hispanic,” a South Florida defense lawyer who knows Cannon told me. (The lawyer requested anonymity to speak candidly about a judge in their jurisdiction.)

    At the time of her nomination, Cannon had virtually no public profile outside of the courtroom. On her Senate questionnaire, she said she had never given a speech, served on a panel discussion, or testified before a legislative body. She had never held public office and told the Senate she had never participated in a political campaign, although she and her husband each contributed $100 to Ron DeSantis’s bid for governor in 2018. The only interview Cannon said she had ever given for publication was for a photo feature on TheKnot.com about her wedding. Her relative anonymity has caused headaches for publications that have searched in vain for a public photo of Cannon that hasn’t already been used repeatedly; almost every story features the same Zoom screenshot from her Senate testimony in 2020.

    Like most Republican-appointed judges in Florida’s Southern District, Cannon is known as a tough sentencer. But there have been notable exceptions when she has handed down a shorter prison term than she could have, Rodriguez told me. He mentioned a case in which a 21-year-old defendant, Artavis Spivey, who had been incarcerated on and off since he was 11, pleaded guilty to armed carjacking. He and another defendant committed the crime just 18 days after Spivey had been released from prison. Cannon sentenced Spivey to 15 years, but Rodriguez said she could have added many more years to his term. “She could have thrown the book at him, and I think she saw redeeming qualities in the young man,” Rodriguez said. Spivey had grown up in a troubled home without a father, “kind of given up by his parents,” Rodriguez added. “That experience tended to make me appreciate the fact that she could look beyond just the retribution and vengeance of a sentence and look at the person.”

    Andrew Weissmann: A ruling untethered to the law

    Cannon also handed down a lighter-than-expected sentence to a 34-year-old man, Christopher Wilkins, who threw a chair at and threatened to kill a federal prosecutor after receiving a 17.5-year sentence on gun and witness-tampering charges. Cannon added six and a half years to his prison term, which was less than the sentencing guidelines called for. “I’ve heard stuff about tough sentencing. I can’t report that. I can report fair sentencing,” Wilkins’s lawyer, Jeffrey Garland, a Republican, told me.

    Yet none of the decisions that Cannon has made in her young judicial career have stirred as much controversy as her rulings in the lawsuit that Trump filed after the FBI searched his Mar-a-Lago estate for unreturned classified documents last summer. Cannon initially appointed a special master to review the documents that federal investigators had collected, and barred the government from accessing some of them. The rulings were a gift to Trump at the time and delayed the FBI’s investigation. But in a sharp rebuke of Cannon, the conservative Eleventh Circuit Court of Appeals overruled her decisions and said she should not have even heard the case.

    Some legal experts have cited those rulings and the fact that Trump appointed Cannon as reasons for her to recuse herself or be taken off the case. A few of the Florida defense lawyers I interviewed—who, it should be noted, routinely argue against the government’s position—characterized Cannon’s orders as understandable considering how unprecedented the case was. The defense lawyer who spoke on the condition of anonymity, however, was more critical. “That ruling was totally out of bounds,” the lawyer told me.

    One of the most significant decisions Cannon now faces is whether to attempt to hold the trial in advance of the 2024 presidential election. Should Trump win the White House, he could quash the government’s prosecution of him. South Florida lawyers were dubious that Cannon could try the case before the election, noting the complexities surrounding classified documents that frequently slow down prosecutions at the federal level. Howard Srebnick, a Democratic defense lawyer on the Medicare-fraud case before Cannon, also praised her early performance on the bench. But he said that it still took 18 months for the Medicare case to get to trial even though it does not involve government secrets. “The notion that this case could go quickly? That’s absurd,” Klugh told me.

    Still, Cannon has already issued her first order—one that could indicate she wants to move swiftly. On Thursday, she instructed lawyers who want to take part in the case to get security clearances by next week. That was the first of many decisions Cannon will make that, in ways big and small, will shape the first-ever federal criminal prosecution of a former president. They will change Cannon’s life, creating a reputation for favoritism or fairness where none existed. A young judge whose photograph had never appeared in a newspaper until last year is set to become a household name. As Rodriguez observed with a slightly nervous laugh: “She’s going to be famous for a long time.”

    Russell Berman

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  • Will COVID’s Spring Lull Last?

    Will COVID’s Spring Lull Last?

    By all official counts—at least, the ones still being tallied—the global situation on COVID appears to have essentially flatlined. More than a year has passed since the world last saw daily confirmed deaths tick above 10,000; nearly a year and a half has elapsed since the population was pummeled by a new Greek-lettered variant of concern. The globe’s most recent winters have been the pandemic’s least lethal to date—and the World Health Organization is mulling lifting its COVID emergency declaration sometime later this year, as the final pandemic protections in the United States prepare to disappear. On the heels of the least-terrible winter since the pandemic’s onset, this spring in the U.S. is also going … kind of all right. “I am feeling less worried than I have been in a while,” Shweta Bansal, an infectious-disease modeler at Georgetown University, told me.

    That sense of phew, though, Bansal said, feels tenuous. The coronavirus’s evolution is not yet predictable; its effects are nowhere near benign. This might be the longest stretch of quasi-normalcy that humanity has had since 2020’s start, but experts can’t yet tell whether we’re at the beginning of post-pandemic stability or in the middle of a temporary reprieve. For now, we’re in a holding pattern, a sort of extended coda or denouement. Which means that our lived experience and scientific reality might not match up for a good while yet.

    Read: The next stage of COVID is starting now

    There is, to be fair, reason to suspect that some current trends will stick. The gargantuan waves of seasons past were the rough product of three factors: low population immunity, genetic changes that allowed SARS-CoV-2 to skirt what immunity did exist, and upswings in behaviors that brought people and the virus into frequent contact. Now, though, just about everyone has had some exposure to SARS-CoV-2’s spike protein, whether by infection or injection. And most Americans have long since dispensed with masking and distancing, maintaining their exposure at a consistently high plateau. That leaves the virus’s shape-shifting as the only major wild card, says Emily Martin, an infectious-disease epidemiologist at the University of Michigan. SARS-CoV-2 could, for instance, make another evolutionary leap large enough to re-create the Omicron wave of early 2022—but a long time has passed since the virus managed such a feat. Tentatively, carefully, experts are hopeful that we’re at last in a “period that could be kind of indicative of what the new normal really is,” says Virginia Pitzer, an infectious-disease epidemiologist at Yale.

    Top American officials are already gambling on that guess. At a conference convened in late March by the Massachusetts Medical Society, Ashish Jha, the outgoing coordinator of the White House COVID-19 Response Team, noted that the relative tameness of this past winter was a major deciding factor in the Biden administration’s decision to let the U.S. public-health emergency lapse. The crisis-caliber measures that were essential at the height of the pandemic, Jha said, were no longer “critical at this moment” to keep the nation’s health-care system afloat. Americans could rely instead primarily on shots and antivirals to keep themselves healthy—“If you are up to date on your vaccines and you get treated with Paxlovid, if you get an infection, you just don’t die of this virus,” he said. (That math, of course, doesn’t hold up as well for certain vulnerable groups, including the elderly and the immunocompromised.) The pharmaceuticals-only strategy asks much less of people: Going forward, most Americans will need to dose up on their COVID vaccines only once a year in the fall, a la seasonal flu shots.

    Making sweeping assessments at this particular juncture, though, is tough. Experts expect SARS-CoV-2 cases to take a downturn as winter transitions into spring—as many other respiratory viruses do. And a half-ish year of relative quietude is, well, just a half-ish year of relative quietude—too little data for scientists to definitively declare the virus seasonal, or even necessarily stable in its annual patterns. One of the most telling intervals is yet to come: the Northern Hemisphere’s summer, says Alyssa Bilinski, a health-policy researcher at Brown University. In previous years, waves of cases have erupted pretty consistently during the warmer months, especially in the American South, as people flock indoors to beat the heat.

    SARS-CoV-2 might not end up being recognizably seasonal at all. So far, the virus has circulated more or less year-round, with erratic bumps in the winter and, to a lesser extent, the summer. “There is a consistency there that is very enticing,” Bansal told me. But many of the worst surges we’ve weathered were driven by a lack of immunity, which is less of an issue now. “So I like to be extremely careful about the seasonality argument,” she said. In future years, the virus may break from its summer-winter shuffle. How SARS-CoV-2 will continue to interact with other respiratory viruses, such as RSV and flu, also remains to be seen. After an extended hiatus, driven largely by pandemic mitigations, those pathogens came roaring back this past autumn—making it more difficult, perhaps, for the coronavirus to find unoccupied hosts. Experts can’t yet tell whether future winters will favor the coronavirus or its competitors. Either way, scientists won’t know until they’ve collected several more years of evidence—“I would want at least a handful, like four or five,” Bansal said.

    Amassing those numbers is only getting tougher, though, as data streams dry up, Martin told me. Virus-surveillance systems are being dismantled; soon, hospitals and laboratories will no longer be required to share their COVID data with federal officials. Even independent trackers have sunsetted their regular updates. Especially abysmal are estimates of total infections, now that so many people are using only at-home tests, if they’re testing at all—and metrics such as hospitalization and death don’t fully reflect where and when the virus is moving, and which new variants may be on the rise.

    Shifts in long-term approaches to virus control could also upend this period of calm. As tests, treatments, and vaccines become privatized, as people lose Medicaid coverage, as community-outreach programs fight to stay afloat, the virus will find the country’s vulnerable pockets again. Those issues aren’t just about the coming months: COVID-vaccination rates among children remain worryingly low—a trend that could affect the virus’s transmission patterns for decades. And should the uptake of annual COVID shots continue on its current trajectory—worse, even, than America’s less-than-optimal flu vaccination rates—or dip even further down, rates of severe disease may begin another upward climb. Experts also remain concerned about the ambiguities around long COVID, whose risks remain ill-defined.

    Read: Long COVID is being erased—again

    We could get lucky. Maybe 2023 is the start of a bona fide post-pandemic era; maybe the past few months are genuinely offering a teaser trailer of decades to come. But even if that’s the case, it’s not a full comfort. COVID remains a leading cause of death in the United States, where the virus continues to kill about 200 to 250 people each day, many of them among the population’s most vulnerable and disenfranchised. It’s true that things are better than they were a couple of years ago. But in some ways, that’s a deeply unfair comparison to make. Deaths would have been higher when immunity was low; vaccines, tests, and treatments were scarce; and the virus was far less understood. “I would hope our standard for saying that we’ve succeeded and that we don’t need to do more is not Are we doing better than some of the highest-mortality years in history?” Bilinski told me. Perhaps the better question is why we’re settling for the status quo—a period of possible stability that may be less a relief and more a burden we’ve permanently stuck ourselves with.

    Katherine J. Wu

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  • The COVID Emergency Is Ending. Is Vaccine Outreach Over Too?

    The COVID Emergency Is Ending. Is Vaccine Outreach Over Too?

    Stephen B. Thomas, the director of the Center for Health Equity at the University of Maryland, considers himself an eternal optimist. When he reflects on the devastating pandemic that has been raging for the past three years, he chooses to focus less on what the world has lost and more on what it has gained: potent antiviral drugs, powerful vaccines, and, most important, unprecedented collaborations among clinicians, academics, and community leaders that helped get those lifesaving resources to many of the people who needed them most. But when Thomas, whose efforts during the pandemic helped transform more than 1,000 Black barbershops and salons into COVID-vaccine clinics, looks ahead to the next few months, he worries that momentum will start to fizzle out—or, even worse, that it will go into reverse.

    This week, the Biden administration announced that it would allow the public-health-emergency declaration over COVID-19 to expire in May—a transition that’s expected to put shots, treatments, tests, and other types of care more out of reach of millions of Americans, especially those who are uninsured. The move has been a long time coming, but for community leaders such as Thomas, whose vaccine-outreach project, Shots at the Shop, has depended on emergency funds and White House support, the transition could mean the imperilment of a local infrastructure that he and his colleagues have been building for years. It shouldn’t have been inevitable, he told me, that community vaccination efforts would end up on the chopping block. “A silver lining of the pandemic was the realization that hyperlocal strategies work,” he said. “Now we’re seeing the erosion of that.”

    I called Thomas this week to discuss how the emergency declaration allowed his team to mobilize resources for outreach efforts—and what may happen in the coming months as the nation attempts to pivot back to normalcy.

    Our conversation has been edited for clarity and length.

    Katherine J. Wu: Tell me about the genesis of Shots at the Shop.

    Stephen B. Thomas: We started our work with barbershops and beauty salons in 2014. It’s called HAIR: Health Advocates In-Reach and Research. Our focus was on colorectal-cancer screening. We brought medical professionals—gastroenterologists and others—into the shop, recognizing that Black people in particular were dying from colon cancer at rates that were just unacceptable but were potentially preventable with early diagnosis and appropriate screening.

    Now, if I can talk to you about colonoscopy, I could probably talk to you about anything. In 2019, we held a national health conference for barbers and stylists. They all came from around the country to talk about different areas of health and chronic disease: prostate cancer, breast cancer, others. We brought them all together to talk about how we can address health disparities and get more agency and visibility to this new frontline workforce.

    When the pandemic hit, all the plans that came out of the national conference were on hold. But we continued our efforts in the barbershops. We started a Zoom town hall. And we started seeing misinformation and disinformation about the pandemic being disseminated in our shops, and there were no countermeasures.

    We got picked up on the national media, and then we got the endorsement of the White House. And that’s when we launched Shots at the Shop. We had 1,000 shops signed up in I’d say less than 90 days.

    Wu: Why do you think Shots at the Shop was so successful? What was the network doing differently from other vaccine-outreach efforts that spoke directly to Black and brown communities?

    Thomas: If you came to any of our clinics, it didn’t feel like you were coming into a clinic or a hospital. It felt like you were coming to a family reunion. We had a DJ spinning music. We had catered food. We had a festive environment. Some people showed up hesitant, and some of them left hesitant but fascinated. We didn’t have to change their worldview. But we treated them with dignity and respect. We weren’t telling them they’re stupid and don’t understand science.

    And the model worked. It worked so well that even the health professionals were extremely pleased, because now all they had to do was show up with the vaccine, and the arms were ready for needles.

    Read: The flu-ification of COVID policy is almost complete

    The barbers and stylists saw themselves as doing health-related things anyway. They had always seen themselves as doing more than just cutting hair. No self-respecting Black barber is going to say, “We’ll get you in and out in 10 minutes.” It doesn’t matter how much hair you have: You’re gonna be in there for half a day.

    Wu: How big of a difference do you think your network’s outreach efforts made in narrowing the racial gaps in COVID vaccination?

    Thomas: Attribution is always difficult, and success has many mothers. So I will say this to you: I have no doubt that we made a huge difference. With a disease like COVID, you can’t afford to have any pocket unprotected, and we were vaccinating people who would otherwise have never been vaccinated. We were dealing with people at the “hell no” wall.

    We were also vaccinating people who were homeless. They were treated with dignity and respect. At some of our shops, we did a coat drive and a shoe drive. And we had dentists providing us with oral-health supplies: toothbrush, floss, paste, and other things. It made a huge difference. When you meet people where they are, you’ve got to meet all their needs.

    Wu: How big of a difference did the emergency declaration, and the freeing-up of resources, tools, and funds, make for your team’s outreach efforts?

    Thomas: Even with all the work I’ve been doing in the barber shop since 2014, the pandemic got us our first grant from the state. Money flowed. We had resources to go beyond the typical mechanisms. I was able to secure thousands of KN95 masks and distribute them to shops. Same thing with rapid tests. We even sent them Corsi-Rosenthal boxes, a DIY filtration system to clean up indoor air.

    Without the emergency declaration, we would still be in the desert screaming for help. The emergency declaration made it possible to get resources through nontraditional channels, and we were doing things that the other systems—the hospital system, the local health department—couldn’t do. We extended their reach to populations that have historically been underserved and distrustful.

    Wu: The public-health-emergency declaration hasn’t yet expired. What signs of trouble are you seeing right now?

    Thomas: The bridge between the barbershops and the clinical side has been shut down in almost all places, including here in Maryland. I go to the shop and they say to me, “Dr. T, when are we going to have the boosters here?” Then I call my clinical partners, who deliver the shots. Some won’t even answer my phone calls. And when they do, they say, “Oh, we don’t do pop-ups anymore. We don’t do community-outreach clinics anymore, because the grant money’s gone. The staff we hired during the pandemic, they use the pandemic funding—they’re gone.” But people are here; they want the booster. And my clinical partners say, “Send them down to a pharmacy.” Nobody wants to go to a pharmacy.

    Read: The COVID strategy America hasn’t really tried

    You can’t see me, so you can’t see the smoke still coming out of my ears. But it hurts. We got them to trust. If you abandon the community now, it will simply reinforce the idea that they don’t matter.

    Wu: What is the response to this from the communities you’re talking to?

    Thomas: It’s “I told you so, they didn’t care about us. I told you, they would leave us with all these other underlying conditions.” You know, it shouldn’t take a pandemic to build trust. But if we lose it now, it will be very, very difficult to build back.

    We built a bridge. It worked. Why would you dismantle it? Because that’s exactly what’s happening right now. The very infrastructure we created to close the racial gaps in vaccine acceptance is being dismantled. It’s totally unacceptable.

    Wu: The emergency declaration was always going to end at some point. Did it have to play out like this?

    Thomas: I don’t think so. If you talk to the hospital administrators, they’ll tell you the emergency declaration and the money allowed them to add outreach. And when the money went away, they went back to business as usual. Even though the outreach proved you could actually do a better job. And the misinformation and the disinformation campaign hasn’t stopped. Why would you go back to what doesn’t work?

    Wu: What is your team planning for the short and long term, with limited resources?

    Thomas: As long as Shots at the Shop can connect clinical partners to access vaccines, we will definitely keep that going.

    Nobody wants to go back to normal. So many of our barbers and stylists feel like they’re on their own. I’m doing my best to supply them with KN95 masks and rapid tests. We have kept the conversation going on our every-other-week Zoom town hall. We just launched a podcast. We put out some of our stories in the form of a graphic novel, The Barbershop Storybook. And we’re trying to launch a national association for barbers and stylists, called Barbers and Stylists United for Health.

    The pandemic resulted in a mobilization of innovation, a recognition of the intelligence at the community level, the recognition that you need to culturally tailor your strategy. We need to keep those relationships intact. Because this is not the last time we’re going to see a pandemic even in our lifetime. I’m doing my best to knock on doors to continue to put our proposals out there. Hopefully, people will realize that reaching Black and Hispanic communities is worth sustaining.

    Katherine J. Wu

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  • China’s COVID Wave Is Coming

    China’s COVID Wave Is Coming

    In China, a dam seems on the verge of breaking. Following a wave of protests, the government has begun to relax some of its most stringent zero-COVID protocols, and regional authorities have trimmed back a slew of requirements for mass testing, quarantine, and isolation. The rollbacks are coming as a relief for the many Chinese residents who have been clamoring for change. But they’re also swiftly tilting the nation toward a future that’s felt inevitable for nearly three years: a flood of infections—accompanied, perhaps, by an uncharted morass of disease and death. A rise in new cases has already begun to manifest in urban centers such as Chongqing, Beijing, and Guangzhou. Now experts are waiting to see just how serious China’s outbreak will be, and whether the country can cleanly extricate itself from the epidemic ahead.

    For now, the forecast “is full of ifs and buts and maybes,” says Salim Abdool Karim, an epidemiologist at the Centre for the AIDS Programme of Research in South Africa. Perhaps the worst can be averted if the government does more to vaccinate the vulnerable and prep hospitals for a protracted influx of COVID patients; and if the community at large reinvests in a subset of mitigation measures as cases rise. “There is still the possibility that they may muddle through it without a mass die-off,” says Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations. “But even the most smooth and orderly transition,” he told me, “will not prevent a surge of cases.”

    China represents, in many ways, SARS-CoV-2’s final frontier. With its under-vaccinated residents and sparse infection history, the nation harbors “a more susceptible population than really any other large population I can think of,” says Sarah Cobey, an computational epidemiologist at the University of Chicago. Soon, SARS-CoV-2 will infiltrate that group of hosts so thoroughly that it will be nearly impossible to purge again. “Eventually, just like everyone else on Earth, everyone in China should expect to be infected,” says Michael Worobey, an evolutionary virologist at the University of Arizona.

    Read: How many COVID deaths will Chinese protesters accept?

    Whatever happens, though, China’s coming wave won’t recapitulate the one that swept most of the world in early 2020. Though it’s hard to say which versions of the virus are circulating in the country, a smattering of reports confirm the likeliest scenario: BF.7 and other Omicron subvariants predominate. Several of these versions of the virus seem to be a bit less likely than their predecessors to trigger severe disease. That, combined with the relatively high proportion of residents—roughly 95 percent—who have received at least one dose of a COVID vaccine, might keep many people from falling dangerously ill. The latest figures out of China’s CDC marked some 90 percent of the country’s cases as asymptomatic. “That’s an enormous fraction” compared with what’s been documented elsewhere, says Ben Cowling, an epidemiologist at the University of Hong Kong.

    That percentage, however, is undoubtedly increased by the country’s ultra-rigorous testing practices, which have been catching silent cases that other places might miss. All of Omicron’s iterations also remain capable of triggering severe disease and long COVID. And there are still plenty of worrying omens that climbing cases could reach a horrific peak, sit on a prolonged plateau, or both.

    One of China’s biggest weak spots is its immunity, or lack thereof. Although more than 90 percent of all people in the country have received at least two COVID shots, those over the age of 80 were not prioritized in the country’s initial rollout, and their rate of dual-dose coverage hovers around just 66 percent. An even paltrier fraction of older people have received a third dose, which the World Health Organization recommends for better protection. Chinese officials have vowed to buoy those numbers in the weeks ahead. But vaccination sites have been tougher to access than testing sites, and with few freedoms offered to the immunized, “the incentive structure is not built,” says Xi Chen, a global-health expert at Yale. Some residents are also distrustful of COVID vaccines. Even some health-care workers are wary of delivering the shots, Chen told me, because they’re fearful of liability for side effects.

    Regardless of the progress China makes in plugging the holes in its immunity shield, COVID vaccines won’t prevent all infections. China’s shots, most of which are based on chemically inactivated particles of the 2020 version of SARS-CoV-2, seem to be less effective and less durable than mRNA recipes, especially against Omicron variants. And many of China’s residents received their third doses many months ago. That means even people who are currently counted as “boosted” aren’t as protected as they could be.

    All of this and more could position China to be worse off than other places—among them, Australia, New Zealand, and Singapore—that have navigated out of a zero-COVID state, says Caitlin Rivers, a senior scholar at the Johns Hopkins Center for Health Security. Australia, for instance, didn’t soften its mitigations until it had achieved high levels of vaccine coverage among older adults, Rivers told me. China has also clung to its zero-COVID philosophy far longer than any other nation, leaving itself to contend with variants that are better at spreading than those that came before. Other countries charted their own path out of their restrictions; China is being forced into an unplanned exit.

    What Hong Kong endured earlier this year may hint at what’s ahead. “They had a really, really bad wave,” Kayoko Shioda, an epidemiologist at Emory University, told me—far dwarfing the four that the city had battled previously. Researchers have estimated that nearly half the city’s population—more than 3 million people—ended up catching the virus. More than 9,000 residents died. And Hong Kong was, in some respects, in a better place to ease its restrictions than the mainland is. This past winter and spring, the city’s main adversary was BA.2, a less vaccine-evasive Omicron subvariant than the ones circulating now; officials had Pfizer’s mRNA-based shot on hand, and quickly began offering fourth doses. Hong Kong also has more ICU beds per capita. Map a new Omicron outbreak onto mainland China, and the prognosis is poor: A recent modeling paper estimated that the country could experience up to 1.55 million deaths in the span of just a few months. (Other analyses offer less pessimistic estimates.)

    Lackluster vaccination isn’t China’s only issue. The country has accumulated almost no infection-induced immunity that might otherwise have updated people’s bodies on recent coronavirus strains. The country’s health-care system is also ill-equipped to handle a surge in demand: For every 100,000 Chinese residents, just 3.6 ICU beds exist, concentrated in wealthier cities; in an out-of-control-infection scenario, even a variant with a relatively low severe-disease risk would prove disastrous, Chen told me. Nor does the system have the slack to accommodate a rush of patients. China’s culture of care seeking is such that “even when you have minor illness, you seek help in urban health centers,” Huang told me, and not enough efforts have been made to bolster triage protocols. More health-care workers may become infected; patients may be more likely to slip through the cracks. Next month’s Lunar New Year celebration, too, could spark further spread. And as the weather cools and restrictions relax, other respiratory viruses, such as RSV and flu, could drive epidemics of their own.

    That said, spikes of illness are unlikely to peak across China at the same time, which could offer some relief. The country’s coming surge “could be explosive,” Cobey told me, “or it could be more of a slow burn.” Already, the country is displaying a patchwork of waxing and waning regulations across jurisdictions, as some cities tighten their restrictions to combat the virus while others loosen up. Experts told me that more measures may return as cases ratchet up—and unlike people in many other countries, the Chinese may be more eager to readopt them to quash a ballooning outbreak.

    Read: China’s zero tolerance for Xi’s COVID restrictions

    A major COVID outbreak in China would also have unpredictable effects on the virus. The world’s most populous country includes a large number of immunocompromised people, who can harbor the virus for months—chronic infections that are thought to have produced variants of concern before. The world may be about to witness “a billion or more opportunities for the virus to evolve,” Cowling told me. In the coming months, the coronavirus could also exploit the Chinese’s close interactions with farmed animals, such as raccoon dogs and mink (both of which can be infected by SARS-CoV-2), and become enmeshed in local fauna. “We’ve certainly seen animal reservoirs becoming established in other parts of the world,” Worobey told me. “We should expect the same thing there.”

    Then again, the risk of new variants spinning out of a Chinese outbreak may be a bit less than it seems, Abdool Karim and other experts told me. China has stuck with zero COVID so long that its population has, by and large, never encountered Omicron subvariants; people’s immune systems remain trained almost exclusively on the original version of the coronavirus, raising only defenses that currently circulating strains can easily get around. It’s possible that “there will be less pressure for the virus to evolve to evade immunity further,” says Emma Hodcroft, a molecular epidemiologist at the University of Bern; and any new versions of the virus that do emerge might not fare particularly well outside of China. In other words, the virus could end up trapped in the very country that tried to keep it out the longest. Still, with so many people susceptible, Cobey told me, there are zero guarantees.

    Either way, viral evolution will plod on—and as it does, the rest of the world may struggle to track it in real time, especially as the cadence of Chinese testing ebbs. Cowling worries that China will have trouble monitoring the number of cases in the country, much less which subvariants are causing them. “There’s going to be a challenge in having situational awareness,” he told me. Shioda, too, worries that China will remain tight-lipped about the scale of the outbreak, a pattern that could have serious implications for residents as well.

    Even without a spike in severe disease, a wide-ranging outbreak is likely to put immense strain on China—which may weigh heavily on its economy and residents for years to come. After the SARS outbreak that began in 2002, rates of burnout and post-traumatic stress among health-care workers in affected countries swelled. Chinese citizens have not experienced an epidemic of this scale in recent memory, Chen told me. “A lot of people think it is over, that they can go back to their normal lives.” But once SARS-CoV-2 embeds itself in the country, it won’t be apt to leave. There will not be any going back to normal, not after this.

    Katherine J. Wu

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  • The GOP Can’t Hide From Extremism

    The GOP Can’t Hide From Extremism

    The role of extremist white nationalists in the GOP may be approaching an inflection point.

    The backlash against former President Donald Trump’s meeting with Nick Fuentes, an avowed racist, anti-Semite, and Christian nationalist, has compelled more Republican officeholders than at any point since the Charlottesville riot in 2017 to publicly condemn those extremist views.

    Yet few GOP officials have criticized the former president personally—much less declared that Trump’s meeting with Fuentes and Ye, the rapper (formerly known as Kanye West) who has become a geyser of anti-Semitic bile, renders him unfit to serve as president again.

    Even this distancing from Fuentes (if not Trump) comes as House GOP Leader Kevin McCarthy, the putative next speaker, is poised to restore prominent committee assignments for Representatives Marjorie Taylor Greene and Paul Gosar, two House Republicans who have publicly associated with Fuentes. It also comes as Republican officials, including McCarthy and Governor Ron DeSantis of Florida, are locking arms in support of Elon Musk’s push to allow extremist voices more access to Twitter.

    Although it took days to develop, some believe the widespread Republican criticism of Trump’s meeting could signal a new determination to restore the barriers between mainstream conservatism and far-right Christian and white nationalism that eroded during the Trump era.

    Brian Klass: The Trump apocalypse has not been canceled

    Elizabeth Neumann, a former assistant secretary at the Department of Homeland Security under Trump who focused on domestic extremism, told me she believes the backlash—however belated—combined with the GOP’s disappointing performance in last month’s midterm elections, could mark a turning point. “I think we are going to be playing footsie with fascism and authoritarianism and extremism for a while,” because it helped Trump win the presidency in 2016 and sustain his support thereafter, she said. But, she added, after several years of feeling “very pessimistic” about the prospect of weakening those movements, “this is the first time I’ve felt there might be some light at the end of the tunnel.”

    Yet others remain unconvinced that the GOP is ready to fundamentally break with Trump or ostracize the coalition’s overtly racist, homophobic, and anti-Semitic white supremacists and Christian nationalists. “I think what we are looking at is the entrenchment of extremism, and that’s what is so worrisome,” Jonathan Greenblatt, the CEO of the Anti-Defamation League, told me.

    If anything, extremist groups could gain momentum in the coming months. Musk’s proposed mass amnesty for banned Twitter accounts would provide “a tremendous amount of oxygen to extremists on the radical right” and allow those groups to push back much harder against any Republican elected officials resisting their presence in the party, Michael Edison Hayden of the Southern Poverty Law Center’s Intelligence Project told me. If Musk opens the door to extremist organizing on Twitter, Hayden said, the white-nationalist presence in the GOP coalition will become “potentially irreversible in the short term.”

    Trump famously declared that there were “very fine people on both sides” of the neo-Nazi riot against the removal of confederate monuments in Charlottesville, Virginia, during his first year in office. Asked to denounce the extremist Proud Boys during one 2020 presidential debate, Trump instead told them to “stand back and stand by.” After the January 6 insurrection, in which white-supremacist groups played a central role, the overwhelming majority of House and Senate Republicans voted against impeaching or convicting Trump for spurring the violence. More recently, hardly any Republicans have raised objections to Trump repeatedly floating the possibility of providing mass pardons (and even government apologies) to the insurrectionists if he wins the presidency again in 2024.

    Other officials inside the GOP coalition have pushed through the boundaries Trump has weakened. Gosar and Greene both appeared at Fuentes’s America First Political Action Conference. So did Republican Arizona State Senator Wendy Rogers, who called the audience at one of the events “patriot,” and declared, “We need to build more gallows. If we try some of these high-level criminals, convict them, and use a newly built set of gallows, it’ll make an example of these traitors who have betrayed our country.”

    The Republican-controlled Arizona State Senate censured Rogers this year for threatening her colleagues, but she was nevertheless fulsomely embraced by Kari Lake, the Republican nominee for Arizona governor this year. Other prominent GOP candidates, including Doug Mastriano in Pennsylvania, also associated with white and Christian nationalists or directly echoed themes from those movements this year.

    In a similar vein, in the days before the election, McCarthy made clear that he would restore committee assignments to Greene and Gosar, whom the Democratic majority had stripped of such roles for their association with extremists and embrace of violent imagery. McCarthy also promised Greene and other hardline conservatives that he would authorize an investigation into the government’s prosecution and treatment of the January 6 insurrectionists, many of whom are extremists tied to white and Christian nationalism.

    “After Trump’s rise, these barriers became softer and softer, and they really broke down in the aftermath of January 6 altogether,” Hayden said. “And now you have this kind of opening between the fringe world and the mainstream world in a way that is very difficult to separate.”

    Musk has quickly become a major new factor in further razing those barriers between the far right and the conservative mainstream, restoring the Twitter accounts of figures banned for misinformation, promotion of violence, or intimidation—including Trump and Greene. Hayden said the Southern Poverty Law Center’s research shows that some previously banned white nationalists have already been restored to the site.

    In a torrent of combative posts, Musk wrapped himself in the mantle of “free speech” to justify restoring accounts previously banned for violating the site’s standards. And he’s accused individuals and institutions that argue for drawing a line against extremist rhetoric of threatening the core American value of free expression. In Musk’s formulation, even the most noxious forms of hate speech can be justified as free speech, and any effort to combat divisive rhetoric is an un-American attempt at censorship or intimidation by the “woke” mob. “This is a battle for the future of civilization,” Musk insisted in one tweet. “If free speech is lost even in America, tyranny is all that lies ahead.” That’s quite a minuet: According to Musk’s logic, it’s a form of “tyranny” to oppose his amplification of authoritarian, racist, and neo-Nazi views antithetical to democracy.

    The rush of GOP leaders such as McCarthy, DeSantis, and incoming House Judiciary Chairman Jim Jordan to support Musk as he works to restore more banned accounts shows how hard it will be for the GOP to completely divorce itself from white and Christian nationalism. So does McCarthy’s pledge to restore committee assignments to Greene and Gosar, as well as the reluctance of almost all GOP officials to directly criticize Trump.

    Polling by the Associated Press and the National Opinion Research Center has found that only about one in 11 Republicans express directly favorable views of white-nationalist groups such as the Proud Boys and Oath Keepers (whose leader, Stewart Rhodes, was convicted this week of seditious conspiracy for his role in the January 6 attack).

    But a much larger slice of Republican partisans express views that might be called white-nationalist adjacent. In various polls, preponderant majorities of GOP voters have said that discrimination against white people is now as big a problem as bias against minorities, that Christianity in the U.S. is under assault, and that the growing number of immigrants threatens American values and traditions. About half of Republicans have expressed agreement in other polls with tenets of white nationalism, including the racist “replacement theory” that elites are importing immigrants to undermine the political power of native-born white people, the core Christian-nationalist belief that “God intended America to be a new promised land,” and the assertion that “the traditional American way of life is disappearing so fast that we may have to use force to save it.”

    Only a minuscule percentage of those Republican partisans might contemplate violence or join extremist organizations, Neumann and other experts point out. But the receptivity of so many Republican voters to arguments, even if less virulent, that overlap with those championed by white- and Christian-nationalist organizations may be a crucial reason for party leaders’ reluctance to confront Trump and others, like Greene, who have associated with such groups. Given the extent of such views inside the GOP coalition, Neumann said, Republicans feel no political incentive to reject the far right “other than out of the goodness of their heart and moral clarity. And apparently that wasn’t enough.”

    Neumann, now the chief strategy officer of Moonshot, a company that combats online extremism, worries that organized far-right violence could still erupt if Trump ever faces a trial as a result of the various investigations targeting him. But she sees the possibility that the visibility and influence of the extreme right inside the GOP peaked with this fall’s converging events, especially the party’s disappointing election results. “I really do think this is, like, a 10-, 20-year process,” she told me, but “I have a slight hope that this sticks and that we move past it.”

    David Frum: A ploy, not a principle

    Robert P. Jones, the president and founder of the nonpartisan Public Religion Research Institute and the author of White Too Long, a history of Christian nationalism, is less optimistic. He believes Christian-nationalist beliefs are spreading more widely among Trump’s followers because they believe “they are at a kind of ‘last stand’ moment” for their vision of a white-Christian-dominated America. “The unwillingness of party leaders, time and time again, to denounce Trump for giving these voices support and cover has allowed them to move into the center of the GOP today,” Jones wrote to me in an email. “I would be surprised if we didn’t see increasing numbers of GOP party leaders openly associating with these voices in the future, particularly leading up to the 2024 presidential election.”

    Greenblatt is also less sanguine. The Anti-Defamation League tracked more than 2,700 anti-Semitic incidents in 2021—the highest annual total it has ever recorded and triple the number of incidents it documented as recently as 2015, the last year before Trump emerged as the GOP’s leading man. Furthermore, Greenblatt is unconvinced that the current Republican distancing from Trump will last any longer than it did in earlier episodes, such as Charlottesville. And he worries that Musk is on course to radically increase the volume of racist and anti-Semitic hate speech on Twitter, which was already a problem before Musk bought the company.

    On all of these fronts, Greenblatt sees what he calls “the normalization of extremism” hardening in ways that would have been unimaginable only a few years ago. “Society itself is at risk if we don’t finally move the extremists … out of the mainstream, back to the margins where they belong,” he told me. “I think we don’t realize the peril that we run, the risk that’s upon us, if we don’t get this right.”

    Ronald Brownstein

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  • COVID Antibody Treatments Are in Decline

    COVID Antibody Treatments Are in Decline

    For the first couple of years of the coronavirus pandemic, the crisis was marked by a succession of variants that pummeled us one at a time. The original virus rapidly gave way to D614G, before ceding the stage to Alpha, Delta, Omicron, and then Omicron’s many offshoots. But as our next COVID winter looms, it seems that SARS-CoV-2 may be swapping its lead-antagonist approach for an ensemble cast: Several subvariants are now vying for top billing.

    In the United States, BA.5—dominant since the end of spring—is slowly yielding to a slew of its siblings, among them BA.4.6, BF.7, BQ.1, and BQ.1.1; another subvariant, XBB, threatens to steal the spotlight from overseas. Whether all of these will divvy up infections in the next few months, or whether they’ll be pushed aside by something new, is still anyone’s guess. Either way, the forecast looks a little grim. None of the new variants will completely circumvent the full set of immune defenses that human bodies, schooled by vaccines or past infections, can launch. Yet all of them seem pretty good at dodging a hefty subset of our existing antibodies.

    For anyone who gets infected, such evasions could make the difference between asymptomatic and feeling pretty terrible. And for the subset of people who become sick enough to need clinical care, the consequences could get even worse. Some of our best COVID treatments are made from single antibodies tailored to the virus, which may simply cease to work as SARS-CoV-2 switches up its form. Past variants have already knocked out three such concoctions—REGEN-COV, sotrovimab, and bamlanivimab/etesevimab—from the U.S. arsenal. The only two left are bebtelovimab, a treatment for people who have already been infected, and Evusheld, a crucial supplement to vaccination for those who are moderately or severely immunocompromised; both are still deployed in hospitals countrywide. But should another swarm of variants take over, these two lone antibody therapies could also be obsolete within months, if not weeks. “It seems like the writing is on the wall,” says Erin McCreary, an infectious-disease pharmacist at the University of Pittsburgh Medical Center. “I live constantly low-key worried that I’m not going to have an active therapy for my patients, and I won’t be able to help them.”

    All of this bodes poorly for this winter and beyond. In the near term, millions of immunocompromised people could be left without viable options either to keep SARS-CoV-2 at bay or to temper its blaze once an infection begins to burn. And that loss would set a troubling precedent for seasons to come. The business end of the virus “is now adapting so rapidly that I don’t know how it’s going to be possible for monoclonals to keep up,” says Jeanne Marrazzo, an infectious-disease physician at the University of Alabama at Birmingham. Experts may need to revamp the strategies they use to bring new therapies to market—or find themselves, once again, in a serious bind. “I worry,” Marrazzo told me, “that we’re on a razor’s edge.”

    Whatever happens this winter, doctors will still have some options to treat COVID patients. Experts don’t think the virus will develop widespread resistance to our antiviral drugs—molnupiravir, remdesivir, and Paxlovid—“anytime soon,” Marrazzo said. But the vanishing of effective antibody therapies would still leave a massive hole that other treatments can’t fill. The benefits of molnupiravir seem lackluster at best; remdesivir offers a few more perks but is a hassle to administer, requiring several days of infusions. And although Paxlovid has worked wonders for people in high-risk groups, one of its ingredients can screw with a long list of other drugs. McCreary has seen many patients hospitalized, she told me, because their physicians prescribed Paxlovid without properly adjusting their regular meds. “Plus,” she added, “Paxlovid tastes awful.”

    Read: Paxlovid mouth is real—and gross

    Monoclonal antibodies aren’t perfect. But at their best, they’re astoundingly effective and safe, and often the first thing McCreary reaches for when caring for newly infected people. Some patients are also “just more comfortable with monoclonal antibodies than they are with antivirals,” says Mari Nakamura, an infectious-disease specialist at Boston Children’s Hospital. And Evusheld remains the only COVID treatment that is authorized to guard people before they encounter the virus at all. People who don’t mount much of a response to vaccines can sign up for a pair of injections—one into each gluteal muscle—and expect to have their defenses buoyed for a good six months. “I see it as an extension of vaccines for those who are vulnerable,” says Jonathan Abraham, an immunologist and physician at Harvard Medical School.

    The greatest strength of these treatments, however, also happens to be their most glaring weakness. Monoclonal antibodies work their magic by glomming so tightly onto SARS-CoV-2’s surface that the virus can’t dock onto our cells. Their grip is ultra precise—enough so that it can be nullified by just one viral mutation in exactly the right spot. Those genetic changes have already booted antibody treatments from our lineup. Now the data hint that bebtelovimab might not work against BQ.1 or BQ1.1. The list of subvariants that might be able to resist Evusheld is even longer: BQ.1, BQ.1.1, BA.4.6, BA.2.75.2, BF.7, and XBB.

    Soon health-care providers will have to start making tough calls about when to retire these two antibody treatments—and with few hard rules to guide them. Resistance can be a pretty murky concept: Viral mutations sometimes soften an antibody’s grasp without totally obliterating it. With antibiotics, for example, doctors can respond to some forms of low-level drug resistance just by increasing the dose, McCreary told me. But COVID monoclonal antibodies are still new to the scene. Even when an antibody cocktail has clearly become functionally useless against a given set of variants, there’s no universal standard for deciding when those variants have become so common that the cocktail should be shelved. (When I asked the FDA about this, it declined to comment on specifics.) So the choice is often left up to individual hospitals, Nakamura told me, which can create a bit of a patchwork in how experts are approaching COVID treatment—and put a burden on surveillance efforts to deliver hyperlocal data in real time.

    In Pittsburgh, McCreary’s team has, in prior seasons, pulled monoclonals when they stop working against just 20 to 30 percent of the reported variant milieu. Alpana Waghmare, a physician at the Fred Hutchinson Cancer Center and Seattle Children’s Hospital, told me her threshold may be closer to about 50 percent, though she pointed out that the more the options dwindle, the more willing health-care workers may be to keep using a variant-mismatched antibody. Alfred Kim, a rheumatologist at Washington University in St. Louis, told me he’d need to see resistant variants make up “the majority in a region” before he’d even consider putting an antibody out to pasture. There’s little downside to administering the treatments, he said, and for his patients, the potential cost of withholding them is just too immense.

    Should bebtelovimab and Evusheld be forced from the stage in the coming months, they might, at least, have a few understudies waiting in the wings. Regeneron, the maker of the late REGEN-COV, has two antibody treatments in Phase 1 trials, according to a spokesperson; AstraZeneca, Evusheld’s parent, also has replacements in development, though a spokesperson declined to provide more details on where in the pipeline they sat. Eli Lilly, which manufactures bebtelovimab and the now-gone bamlanivimab/etesevimab, didn’t respond to my questions about whether they were cooking up new recipes for future use. Vir, which makes sotrovimab—still available overseas—is working on “several highly potent” new antibodies “that have shown activity against all COVID-19 variants tested to date including BQ1.1,” according to a spokesperson.

    Clearing drugs for human use remains a plodding process; all of those options could be months away from regular use. “The virus may have moved on” by then, Abraham told me. Already, experts are grappling with whether once-a-year shots will be enough to keep pace with coronavirus evolution; updates on the treatment side may have to come much faster. The problem could get worse as SARS-CoV-2 lineages continue to jockey for control. For the moment, at least, the leading variants are invalidating antibody treatments in relatively similar ways. But if variants diverge further, pharmaceutical companies could have an even tougher time devising broadly effective antibody therapies.

    Some experts are also concerned that the market for monoclonals may be going dry. Antibodies are expensive to produce, and with a turnover rate this high, the industry may not have much incentive to stay involved, McCreary told me. Marrazzo, too, thinks the urgency may have lessened with the advent of oral antivirals, and the rush to return to “normal.” If anything, though, the need for good monoclonal options may be growing in urgency. Treatments such as REGEN-COV and bamlanivimab/etesevimab once had clearance to be used in people right after they were exposed to SARS-CoV-2—a sort of emergency antiviral contraceptive. Now no monoclonals are available for so-called postexposure prophylactic use. Kids, too, could use more treatment options. Children under 12 are eligible for three-day courses of remdesivir, given by IV infusion—but those are a tough ask for many families who don’t have the time or means to make such frequent trips to the hospital, Nakamura told me. “And that’s pretty much it.”

    Yet no one would feel the loss of antibody-based COVID treatments more than the immunocompromised, Waghmare told me. “It’s this horrible nexus,” Marrazzo said: The most vulnerable people will lose their best options first. Many of those who received Evusheld in the spring will soon be due for their second set of injections, scheduled six months after the first. As of right now, “we’re still telling patients to come in,” McCreary told me. But that may not be the advice she gives next month, or the next. Robyn Ruth, of Augusta County, Virginia, is at that decision point now. Her first experience with the treatment, in April, was momentous: “I had my first hug since the beginning of the pandemic,” Ruth told me. “I just remember my knees buckled, because I hadn’t touched another human being in so long.” In the weeks after, Ruth felt safe enough to go to a couple of doctor appointments and visit a few friends, even garden in their company—activities she hadn’t engaged in since the start of 2020. But as variants continue to chip away at Evusheld’s efficacy, Ruth is steeling herself for the possibility that another dose won’t bring the same relief.

    Caregivers and patients alike must now strategize for what could be a very difficult winter stretch. Many immunocompromised people can still benefit from vaccines, even if not as much as others. Marrazzo also cautiously pointed out that if things get bad enough, some providers might go back to convalescent plasma—a treatment with just so-so effectiveness that’s hard to roll out in large quantities, and that doesn’t deliver consistent results—as a desperate stopgap. Other than that, though, it’ll come down to the behavioral measures that many Americans have long since abandoned: isolation, quarantine, masking, distancing.

    Read: It’s gotten awkward to wear a mask

    Nakamura told me she’s been struggling to deliver optimistic advice. “All they can do is try not to get the virus,” she said. She also worries about what might happen should her young patients actually fall ill. “Our hospitals are already overflowing,” she said, amid an early seasonal surge of respiratory viruses, including RSV, and a massive mental-health crisis. McCreary, too, knows many tough conversations are ahead. “There’s nothing worse than one day having something safe and highly effective,” she told me, “and the next day, it’s, ‘Sorry, we don’t have that anymore.’”

    For some, the simultaneous disappearance of bebtelovimab and Evusheld could almost rewind the clock to the pandemic’s start. Sara Anne Willette, a data analyst in Ames, Iowa, has a condition called common variable immunodeficiency that keeps her from making certain types of protective antibodies. She also has a history of anaphylaxis to antivirals, potentially making bebtelovimab her only postinfection treatment option should she fall ill. Willette’s second dose of Evusheld is scheduled for December, but she’s not sure whether, by that point, risking the trip will even be practical. “It feels like we’re back at square one,” she told me. “I get COVID, and it’s ‘go it alone.’”

    Katherine J. Wu

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  • America’s COVID Booster Rates Are a Bad Sign for Winter

    America’s COVID Booster Rates Are a Bad Sign for Winter

    And just like that, with the passing of Labor Day, fall was upon us. Seemingly overnight, six-packs of pumpkin beer materialized on grocery shelves, hordes of city dwellers descended upon apple orchards—and America rolled out new COVID boosters. The timing wasn’t a coincidence. Since the beginning of the pandemic, cases in North America and Europe have risen during the fall and winter, and there was no reason to expect anything different this year. Spreading during colder weather is simply what respiratory diseases like COVID do. The hope for the fall booster rollout was that Americans would take it as an opportunity to supercharge their immunological defenses against the coronavirus in advance of a winter wave that we know is going to come.

    So far, reality isn’t living up to that hope. Since the new booster became available in early September, fewer than 20 million Americans have gotten the shot, according to the CDC—just 8.5 percent of those who are eligible. The White House COVID-19 response coordinator, Ashish Jha, said at a press conference earlier this month that he expects booster uptake to increase in October as the temperatures drop and people start taking winter diseases more seriously. That doesn’t seem to be happening yet. America’s booster campaign is going so badly that by late September, only half of Americans had heard even “some” information about the bivalent boosters, according to a recent survey. The low numbers are especially unfortunate because the remaining 91.5 percent of booster-eligible people have already shown that they’re open to vaccines by getting at least their first two shots—if not already at least one booster.

    Now the bungled booster rollout could soon run headfirst into the winter wave. The virus is not yet surging in the United States—at least as far as we can tell—but as the weather cools down, cases have been on the rise in Western Europe, which has previously foreshadowed what happens in the U.S. At the same time, new Omicron offshoots such as BQ.1 and BQ.1.1 are gaining traction in the U.S., and others, including XBB, are creating problems in Singapore. Boosters are our best chance at protecting ourselves from getting swept up in whatever this virus throws at us next, but too few of us are getting them. What will happen if that doesn’t change?

    The whole reason for new shots is that though the protection conferred by the original vaccines is tremendous, it has waned over time and with new variants. The latest booster, which is called “bivalent” because it targets both the original SARS-CoV-2 virus and BA.5, is meant to kick-start the production of more neutralizing antibodies, which in turn should prevent new infection in the short term, Katelyn Jetelina, a public-health expert who writes the newsletter Your Local Epidemiologist, told me. The other two goals for the vaccine are still being studied: The hope is that it will also broaden protection by teaching the immune system to recognize other aspects of the virus, and that it will make protection longer-lasting.

    In theory, this souped-up booster would make a big difference heading into another wave. In September, a forecast presented by the Advisory Committee on Immunization Practices (ACIP), which advises the CDC, showed that if people get the bivalent booster at the same rate as they do the flu vaccine—optimistic, given that about 50 percent of people have gotten the flu vaccine in recent years—roughly 25 million infections, 1 million hospitalizations, and 100,000 deaths could be averted by the end of March 2023.

    But these numbers shouldn’t be taken as gospel, because protection across the population varies widely and modeling can’t account for all of the nuance that happens in real life. Gaming out exactly what our dreadful booster rates mean going forward is not a simple endeavor “given that the immune landscape is becoming more and more complex,” Jetelina told me. People received their first shots and boosters at different times, if they got them at all. And the same is true of infections over the past year, with the added wrinkle that those who fell sick all didn’t get the same type of Omicron. All of these factors play a role in how much America’s immunological guardrails will hold up in the coming months. “But it’s very clear that a high booster rate would certainly help this winter,” Jetelina said.

    At this point in the pandemic, getting COVID is far less daunting for healthy people than it was a year or two ago (although the prospect of developing long COVID still looms). The biggest concerns are hospitalizations and deaths, which make low booster uptake among vulnerable groups such as the elderly and immunocompromised especially worrying. That said, everyone aged 5 and up who has received their primary vaccine is encouraged to get the new boosters. It bears repeating that vaccination not only protects against severe illness and death but has the secondary effect of preventing transmission, thereby reducing the chances of infecting the vulnerable.

    What will happen next is hard to predict, Michael Osterholm, an epidemiologist at the University of Minnesota, told me, but now is a bad time for booster rates to be this low. Conditions are ripe for COVID’s spread. Protection is waning among the unboosted, immunity-dodging variants are emerging, and Americans just don’t seem to care about COVID anymore, Osterholm explained. The combination of these factors, he said, is “not a pretty picture.” By skipping boosters, people are missing out on the chance to offset these risks, though non-vaccine interventions such as masking and ventilation improvements can help, too.

    That’s not to say that the immunity conferred by the vaccination and the initial boosters is moot. Earlier doses still offer “pretty substantial protection,” Saad Omer, a Yale epidemiologist, told me. Not only are eligible Americans slacking on booster uptake, but lately vaccine uptake among the unvaccinated hasn’t risen much either. Before the new bivalent shots came around, less than half of eligible Americans had gotten a booster. “That means we are, as a population, much more vulnerable going into this fall,” James Lawler, an infectious-diseases expert at the University of Nebraska Medical Center, told me.

    If booster uptake—and vaccine uptake overall—remains low, expecting more illness, particularly among the vulnerable, would be reasonable, William Schaffner, a professor of infectious diseases at Vanderbilt University Medical Center, told me. Hospitalizations will rise more than they would otherwise, and with them the stress on the health-care system, which will also be grappling with the hundreds of thousands of people likely to be hospitalized for flu. While Omicron causes relatively minor symptoms, “it’s quite capable of producing severe disease,” Schaffner said. Since August, it has killed an average of 300 to 400 people each day.

    All of this assumes that we won’t get a completely new variant, of course. So far, the BA.5 subvariant targeted by the bivalent booster is still dominating cases around the world. Newer ones, such as XBB, BQ.1.1, and BQ.1, are steadily gaining traction, but they’re still offshoots of Omicron. “We’re still very hopeful that the booster will be effective,” Jetelina said. But the odds of what she called an “Omicron-like event,” in which a completely new SARS-CoV-2 lineage—one that warrants a new Greek letter—emerges out of left field, are about 20 to 30 percent, she estimated. Even in this case, the bivalent nature of the booster would come in handy, helping protect against a wider crop of potential variants. The effectiveness of our shots against a brand-new variant depends on its mutations, and how much they overlap with those we’ve already seen, so “we’ll see,” Omer said.

    Just as it isn’t too late to get boosted, there’s still time to improve uptake in advance of a wave. If you’re three to six months out from an infection or your last shot, the best thing you can do for your immune system right now is to get another dose, and do it soon. Though there’s no perfect and easy solution that can overcome widespread vaccine fatigue, that doesn’t mean trying isn’t worthwhile. “Right now, we don’t have a lot of people that feel the pandemic is that big of a problem,” and people are more likely to get vaccinated if they feel their health is challenged, Osterholm said.

    There’s also plenty of room to crank the volume on the messaging in general: Not long ago, the initial vaccine campaign involved blasting social media with celebrity endorsers such as Dolly Parton and Olivia Rodrigo. Where is that now? Lots of pharmacies are swimming in vaccines, but making getting boosted even easier and more convenient can go a long way too. “We need to catch them where they come,” said Omer, who thinks boosters should be offered at workplaces, in churches and community centers, and at specialty clinics such as dialysis centers where patients are vulnerable by default.

    After more than two years of covering and living through the pandemic, believe me: I get that people are over it. It’s easy not to care when the risks of COVID seem to be negligible. But while shedding masks is one thing, taking a blasé attitude toward boosters is another. Shots alone can’t solve all of our pandemic problems, but their unrivaled protective effects are fading. Without a re-up, when the winter wave reaches U.S. shores and more people start getting sick, the risks may no longer be so easy to ignore.

    Yasmin Tayag

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  • How Do You Actually Stop the Steal?

    How Do You Actually Stop the Steal?

    Preventing the next attempt to overturn an election is a bit like playing whack-a-mole. Plug one gap in the nation’s rickety, interlocking system for counting votes—say, by ensuring that a power-hungry vice president cannot unilaterally declare his or her ticket the winner—and another pest seems to materialize immediately.

    Congress is confronting this reality as it tries to rewrite a 135-year-old law governing the final, fraught act of certifying the Electoral College results—the very statute that former President Donald Trump used as a pretext to demand that then–Vice President Mike Pence anoint him the victor on January 6, 2021. Last month, a bipartisan group of senators announced, to substantial fanfare, that it had reached an agreement to revise the 1887 Electoral Count Act. But closing off every path to subversion is proving to be a tricky task.

    The legislation is modest in scope; its aims are not. The proposal’s authors believe that its enactment is necessary to guarantee that the violent insurrection that occurred last time around does not become a quadrennial affair. “That happened. It was real. It was not a visit from friends back home,” Democratic Senator Joe Manchin of West Virginia, Congress’s most famous centrist and a co-sponsor of the bill, testified Wednesday at a hearing on the measure. “And we have a duty to ensure that it never happens again.”

    Election-law experts across both parties agree that the Senate proposal, known as the Electoral Count Reform Act, would resolve legal ambiguities that Trump and his allies tried to exploit before the transfer of power. As written, the bill would clarify that the vice president, regardless of party, has only a ministerial role in presiding over Congress’s certification of the Electoral College vote. The proposal would also make it harder for members of Congress to raise objections to a state’s electors; doing so would require support of at least one-fifth of the members in each chamber, rather than just one in both the House and the Senate, as it stands now. Another provision seeks to head off rogue state legislatures by ensuring that they respect the outcome of their popular vote as determined by the laws that were in place at the time of the election.

    Read: Kamala Harris might have to stop the steal

    The proposed changes “set us on a path to reform that represents an extraordinary bipartisan achievement,” Bob Bauer, a longtime Democratic election lawyer who served as White House counsel in the Obama administration, told the Senate Rules Committee. “The proposals before the committee represent a vast improvement over existing law. There can be no question about that—none whatsoever.”

    Actually, there were a few questions. Appearing on the same panel, another Democratic lawyer, Norm Eisen, conceded that the Electoral Count Reform Act marked “a significant step forward” in efforts to thwart another attempt to overturn the presidential election. But he warned that, as written, the proposal “could invite unwelcome manipulation.” Eisen highlighted a pair of provisions that he said could be exploited by governors trying to ignore or outright reject the popular vote in their state.

    One would set a six-day window to challenge the certification of an election by a governor. The goal is to ensure that legal disputes are resolved in time for the Electoral College to meet in December and then for Congress to certify the results in January. But, Eisen pointed out, that time frame could actually play to the advantage of a governor who certified the wrong winner rather than the candidate who clearly won his or her state’s election. “It just doesn’t work,” he told the committee.

    Another provision Eisen flagged would bar states from declaring a “failed election” while allowing them to change or extend their elections because of “extraordinary and catastrophic events.” The point is to give states some flexibility to alter elections for legitimate reasons, as in the case of a terrorist attack or a natural disaster; the attacks of September 11, 2001, for example, occurred on a pivotal election day as New Yorkers prepared to choose their next mayor. (New York City postponed its primary by two weeks.) The bill, however, doesn’t clearly define what constitutes “extraordinary and catastrophic events.” That, too, presents an opportunity for “mischief” by election-denying state officials, Eisen warned. What if a governor alleged, without evidence, rampant voter fraud and deemed that “an extraordinary event” that warranted a re-vote?

    Eisen’s concerns are shared by another prominent Democratic election lawyer, Marc Elias, who successfully fought in court many of the challenges that Trump and other Republicans brought against the 2020 results. Part of their complaint is the bill’s narrow scope: In order to win Republican support for any changes to election law, Democrats had to jettison their much broader dreams of enacting stronger protections for voting rights and minimum federal standards for access to the polls.

    But Eisen and Elias are also highlighting a potential flaw with the new proposal that may be impossible for Congress to fully rectify. For instance, the bill seeks to reduce the chances that the vice president, Congress, or a rogue secretary of state will mess around with or overturn election results. In doing so, however, the legislation grants more authority to governors to certify a state’s electors. What if the sitting governor is corrupt? As Eisen was testifying Wednesday, vote counters in Arizona were determining whether Republicans had nominated one of the nation’s most steadfast election conspiracy theorists, Kari Lake, as the state’s next governor. In Pennsylvania, the GOP has already given its nod to a Trump loyalist, Doug Mastriano, who marched to the Capitol on January 6.

    The bill’s bipartisan support increases its chances of passage, and during the hearing, lawmakers in both parties seemed open to some revisions. “It’s a good start, but like every important bill, the initial version has some areas that need development,” Eisen, who served as a House counsel for the Democrats during Trump’s first impeachment, told me afterward. Some provisions, he said, “do pose risk if they are not fixed.”

    Nine Republicans are already backing the legislation in the Senate, and Minority Leader Mitch McConnell has praised the effort, suggesting that the bill will have enough votes to overcome a filibuster if Democrats fall in line. Each party has reasons to vote for it. Democrats want to prevent Trump and his allies from trying again to overturn a defeat, while Republicans fear a scenario in which Vice President Kamala Harris plays a decisive role when presiding over Congress on January 6, 2025. Senator Shelley Moore Capito of West Virginia, a Republican, said there was “a sense of urgency” to act before the next presidential campaign begins. “My personal feeling is we need to button this up before the end of the year,” she said at the hearing.

    Yet among Democrats, there remains some pause, as senators recognize a need to adopt a compromise while lamenting the new bill’s limitations. “The text didn’t exploit itself,” Senator Alex Padilla, a Democrat of California, said at one point during the hearing, referring to the flaws in the 1887 Electoral Count Act. “People did. The former president did. Senators, members of Congress did.”

    Congress is fond of loopholes—closing them, opening them, preserving them. And even the strongest defenders of the Electoral Count Reform Act acknowledged that the proposal was not entirely free of them. “No law can prevent all mischief,” Derek Muller, a professor at the University of Iowa, told me. The question lawmakers must answer in the coming months is whether this new attempt to fortify America’s elections stops more mischief than it inspires.

    Russell Berman

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