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This fall, unlike the one before it, and the one before that, America looks almost like its old self. Schools and universities are in session; malls, airports, and gyms are bustling with the pre-holiday rush; handwashing is passé, handshakes are back, and strangers are packed together on public transport, nary a mask to be seen. On its surface, the country seems ready to enjoy what some might say is our first post-pandemic winter.
Americans are certainly acting as if the crisis has abated, and so in that way, at least, you could argue that it has. “If you notice, no one’s wearing masks,” President Joe Biden told 60 Minutes in September, after proclaiming the pandemic “over.” Almost no emergency protections against the virus are left standing; we’re dismantling the few that are. At the same time, COVID is undeniably, as Biden says, “a problem.” Each passing day still brings hundreds of deaths and thousands of hospitalizations; untold numbers of people continue to deal with long COVID, as more join them. In several parts of the country, health-care systems are struggling to stay afloat. Local public-health departments, underfunded and understaffed, are hanging by a thread. And a double surge of COVID and flu may finally be brewing.
So we can call this winter “post-pandemic” if we want. But given the policy failures and institutional dysfunctions that have accumulated over the past three years, it won’t be anything like a pre-pandemic winter, either. The more we resist that reality, the worse it will become. If we treat this winter as normal, it will be anything but.
By now, we’ve grown acquainted with the variables that dictate how a season with SARS-CoV-2 will go. In our first COVID winter, the vaccines had only just begun their trickle out into the public, while most Americans hadn’t yet been infected by the virus. In our second COVID winter, the country’s collective immunity was higher, but Omicron sneaked past some of those defenses. On the cusp of our third COVID winter, it may seem that SARS-CoV-2 has few plot twists left to toss us.
But the way in which we respond to COVID could still sprinkle in some chaos. During those first two winters, at least a few virus-mitigating policies and precautions remained in place—nearly all of which have since come down, lowering the hurdles the virus must clear, at a time when America’s health infrastructure is facing new and serious threats.
The nation is still fighting to contain a months-long monkeypox outbreak; polio continues to plague unvaccinated sectors of New York. A riot of respiratory viruses, too, may spread as temperatures cool and people flock indoors. Rates of RSV are rising; flu returned early in the season from a nearly three-year sabbatical to clobber Australia, boding poorly for us in the north. Should flu show up here ahead of schedule, Americans, too, could be pummeled as we were around the start of 2018, “one of the worst seasons in the recent past,” says Srinivasan Venkatramanan, an infectious-disease modeler at the University of Virginia and a member of the COVID-19 Scenario Modeling Hub.
The consequences of this infectious churn are already starting to play out. In Jackson, Mississippi, health workers are watching SARS-CoV-2 and other respiratory viruses tear through children “like nothing we’ve ever seen before,” says Charlotte Hobbs, a pediatric-infectious-disease specialist at the University of Mississippi Medical Center. Flu season has yet to go into full swing, and Hobbs is already experiencing one of the roughest stretches she’s had in her nearly two decades of practicing. Some kids are being slammed with one virus after the other, their sicknesses separated by just a couple of weeks—an especially dangerous prospect for the very youngest among them, few of whom have received COVID shots.
The toll of doctor visits missed during the pandemic has ballooned as well. Left untreated, many people’s chronic conditions have worsened, and some specialists’ schedules remain booked out for months. Add to this the cases of long COVID that pile on with each passing surge of infections, and there are “more sick people than there used to be, period,” says Emily Landon, an infectious-disease physician at the University of Chicago. That’s with COVID case counts at a relative low, amid a massive undercount. Even if a new, antibody-dodging variant doesn’t come banging on the nation’s door, “the models predict an increase in infections,” Venkatramanan told me. (In parts of Europe, hospitalizations are already making a foreboding climb.)
And where the demand for care increases, supply does not always follow suit. Health workers continue to evacuate their posts. Some have taken early retirement, worried that COVID could exacerbate their chronic conditions, or vice versa; others have sought employment with better hours and pay, or left the profession entirely to salvage their mental health. A wave of illness this winter will pare down forces further, especially as the CDC backs off its recommendations for health-care workers to mask. At UAB Hospital, in Birmingham, Alabama, “we’ve struggled to have enough people to work,” says Sarah Nafziger, an emergency physician and the medical director for employee health. “And once we get them here, we have a hard time getting them to stay.”
Clinical-laboratory staff at Deaconess Hospital, in Indiana, who are responsible for testing patient samples, are feeling similar strain, says April Abbott, the institution’s microbiology director. Abbott’s team has spent most of the past month below usual minimum-staffing levels, and has had to cut some duties and services to compensate, even after calling in reinforcements from other, already shorthanded parts of the lab. “We’re already at this threshold of barely making it,” Abbott told me. Symptoms of burnout have surged as well, while health workers continue to clock long hours, sometimes amid verbal abuse, physical attacks, and death threats. Infrastructure is especially fragile in America’s rural regions, which have suffered hospital closures and an especially large exodus of health workers. In Madison County, Montana, where real-estate values have risen, “the average nurse cannot afford a house,” says Margaret Bortko, a nurse practitioner and the region’s health officer and medical director. When help and facilities aren’t available, the outcome is straightforward, says Janice Probst, a rural-health researcher at the University of South Carolina: “You will have more deaths.”
In health departments, too, the workforce is threadbare. As local leaders tackle multiple infectious diseases at once, “it’s becoming a zero-sum game,” says Maria Sundaram, an epidemiologist at the Marshfield Clinic Research Institute. “With limited resources, do they go to monkeypox? To polio? To COVID-19? To influenza? We have to choose.” Mati Hlatshwayo Davis, the director of health in St. Louis, told me that her department has shrunk to a quarter of the size it was five years ago. “I have staff doing the jobs of three to five people,” she said. “We are in absolute crisis.” Staff have left to take positions as Amazon drivers, who “make so much more per hour.” Looking across her state, Hlatshwayo Davis keeps watching health directors “resign, resign, resign.” Despite all that she has poured into her job, or perhaps because of it, “I can’t guarantee I won’t be one of those losses too.”
This winter is unlikely to be an encore of the pandemic’s worst days. Thanks to the growing roster of tools we now have to combat the coronavirus—among them, effective vaccines and antivirals—infected people are less often getting seriously sick; even long COVID seems to be at least a bit scarcer among people who are up-to-date on their shots. But considering how well our shots and treatments work, the plateau of suffering at which we’ve arrived is bizarrely, unacceptably high. More than a year has passed since the daily COVID death toll was around 200; nearly twice that number—roughly three times the daily toll during a moderate flu season—now seems to be a norm.
Part of the problem remains the nation’s failed approach to vaccines, says Avnika Amin, a vaccine epidemiologist at Emory University: The government has repeatedly championed shots as a “be-all and end-all” strategy, while failing to rally sufficient uptake. Boosting is one of the few anti-COVID measures still promoted, yet the U.S. remains among the least-vaccinated high-income countries; interest in every dose that’s followed the primary series has been paltry at best. Even with the allure of the newly reformulated COVID shot, “I’m not really getting a good sense that people are busting down the doors,” says Michael Dulitz, a health worker in Grand Forks, North Dakota. Nor can vaccines hold the line against the virus alone. Even if everyone got every shot they were eligible for, Amin told me, “it wouldn’t make COVID go away.”
The ongoing dry-up of emergency funds has also made the many tools of disease prevention and monitoring more difficult to access. Free at-home tests are no longer being shipped out en masse; asymptomatic testing is becoming less available; and vaccines and treatments are shifting to the private sector, putting them out of reach for many who live in poor regions or who are uninsured and can least afford to fall ill.
It doesn’t help, either, that the country’s level of preparedness lays out as a patchwork. People who vaccinate and mask tend to cluster, Amin told me, which means that not all American experiences of winter will be the same. Less prominent, less privileged parts of the country will quietly bear the brunt of outbreaks. “The biggest worry is the burden becoming unnoticed,” Venkatramanan told me. Without data, policies can’t change; the nation can’t react. “It’s like flying without altitude or speed sensors. You’re looking out the window and trying to guess.”
There’s an alternative winter the country might envision—one unencumbered by the policy backslides the U.S. has made in recent months, and one in which Americans acknowledge that COVID remains not just “a problem” but a crisis worth responding to.
In that version of reality, far more people would be up-to-date on their vaccines. The most vulnerable in society would be the most protected. Ventilation systems would hum in buildings across the country. Workers would have access to ample sick leave. Health-care systems would have excesses of protective gear, and local health departments wouldn’t want for funds. Masks would come out in times of high transmission, especially in schools, pharmacies, government buildings, and essential businesses; free tests, boosters, and treatments would be available to all. No one would be asked to return to work while sick—not just with COVID but with any transmissible disease. SARS-CoV-2 infections would not disappear, but they would remain at more manageable levels; cases of flu and other cold-weather sicknesses that travel through the air would follow suit. Surveillance systems would whir in every state and territory, ready to detect the next threat. Leaders might even set policies that choreograph, rather than simply capitulate to, how Americans behave.
We won’t be getting that winter this year, or likely any year soon. Many policies have already reverted to their 2019 status quo; by other metrics, the nation’s well-being even seems to have regressed. Life expectancy in the U.S. has fallen, especially among Native Americans and Alaskan Natives. Institutions of health are beleaguered; community-outreach efforts have been pruned.
The pandemic has also prompted a deterioration of trust in several mainstays of public health. In many parts of the country, there’s worry that the vaccine hesitancy around COVID has “spread its tentacles into other diseases,” Hobbs told me, keeping parents from bringing their kids in for flu shots and other routine vaccines. Mississippi, once known for its stellar rate of immunizing children, now consistently ranks among those with the fewest young people vaccinated against COVID. “The one thing we do well is vaccinate children,” Hobbs said. That the coronavirus has reversed the trend “has astounded me.” In Montana, sweeping political changes, including legislation that bans employers from requiring vaccines of any kind, have made health-care settings less safe. Fewer than half of Madison County’s residents have received even their primary series of COVID shots, and “now a nurse can turn down the Hepatitis B series,” Bortko told me. Health workers, too, feel more imperiled than before. Since the start of the pandemic, Bortko’s own patients of 30 years, “who trusted me with their lives,” have pivoted to “yelling at us about vaccination concerns and mask mandates and quarantining and their freedoms,” she told me. “We have become public enemy No. 1.”
At the same time, many people with chronic and debilitating conditions are more vulnerable than they were before the pandemic began. The policies that protected them during the pandemic’s height are gone—and yet SARS-CoV-2 is still here, adding to the dangers they face. The losses have been written off, Bortko told me: Cases of long COVID in Madison County have been dismissed as products of “risk factors” that don’t apply to others; deaths, too, have been met with a shrug of “Oh, they were old; they were unhealthy.” If, this winter, COVID sickens or kills more people who are older, more people who are immunocompromised, more people of color, more essential and low-income workers, more people in rural communities, “there will be no press coverage,” Hlatshwayo Davis said. Americans already expect that members of these groups will die.
It’s not too late to change course. The winter’s path has not been set: Many Americans are still signing up for fall flu and COVID shots; we may luck out on the viral evolution front, too, and still be dealing largely with members of the Omicron clan for the next few months. But neither immunity nor a slowdown in variant emergence is a guarantee. What we can count on is the malleability of human behavior—what will help set the trajectory of this winter, and others to come. The U.S. botched the pandemic’s beginning, and its middle. That doesn’t mean we have to bungle its end, whenever that truly, finally arrives.
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Katherine J. Wu
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