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  • A Major Clue to COVID’s Origins Is Just Out of Reach

    A Major Clue to COVID’s Origins Is Just Out of Reach

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    Updated at 2:45 p.m. on March 21, 2023

    Last week, the ongoing debate about COVID-19’s origins acquired a new plot twist. A French evolutionary biologist stumbled across a trove of genetic sequences extracted from swabs collected from surfaces at a wet market in Wuhan, China, shortly after the pandemic began; she and an international team of colleagues downloaded the data in hopes of understanding who—or what—might have ferried the virus into the venue. What they found, as The Atlantic first reported on Thursday, bolsters the case for the pandemic having purely natural roots: The genetic data suggest that live mammals illegally for sale at the Huanan Seafood Wholesale Market—among them, raccoon dogs, a foxlike species known to be susceptible to the virus—may have been carrying the coronavirus at the end of 2019.

    But what might otherwise have been a straightforward story on new evidence has rapidly morphed into a mystery centered on the origins debate’s data gaps. Within a day or so of nabbing the sequences off a database called GISAID, the researchers told me, they reached out to the Chinese scientists who had uploaded the data to share some preliminary results. The next day, public access to the sequences was locked—according to GISAID, at the request of the Chinese researchers, who had previously analyzed the data and drawn distinctly different conclusions about what they contained.

    Read: The strongest evidence yet that an animal started the pandemic

    Yesterday evening, the international team behind the new Huanan-market analysis released a report on its findings—but did not post the underlying data. The write-up confirms that genetic material from raccoon dogs and several other mammals was found in some of the same spots at the wet market, as were bits of SARS-CoV-2’s genome around the time the outbreak began. Some of that animal genetic material, which was collected just days or weeks after the market was shut down, appears to be RNA—a particularly fast-degrading molecule. That strongly suggests that the mammals were present at the market not long before the samples were collected, making them a plausible channel for the virus to travel on its way to us. “I think we’re moving toward more and more evidence that this was an animal spillover at the market,” says Ravindra Gupta, a virologist at the University of Cambridge, who was not involved in the new research. “A year and a half ago, my confidence in the animal origin was 80 percent, something like that. Now it’s 95 percent or above.”

    For now, the report is just that: a report, not yet formally reviewed by other scientists or even submitted for publication to the journal—and that will remain the case as long as this team continues to leave space for the researchers who originally collected the market samples, many of them based at the Chinese Center for Disease Control and Prevention, to prepare a paper of their own. And still missing are the raw sequence files that sparked the reanalysis in the first place—before vanishing from the public eye.

    Every researcher I asked emphasized just how important the release of that evidence is to the origins investigation: Without data, there’s no base-level proof—nothing for the broader scientific community to independently scrutinize to confirm or refute the international team’s results. Absent raw data, “some people will say that this isn’t real,” says Gigi Gronvall, a senior scholar at the Johns Hopkins Center for Health Security, who wasn’t involved in the new analysis. Data that flicker on and off publicly accessible parts of the internet also raise questions about other clues on the pandemic’s origins. Still more evidence might be out there, yet undisclosed.

    Transparency is always an essential facet of research, but all the more so when the stakes are so high. SARS-CoV-2 has already killed nearly 7 million people, at least, and saddled countless people with chronic illness; it will kill and debilitate many more in the decades to come. Every investigation into how it began to spread among humans must be “conducted as openly as possible,” says Sarah Cobey, an infectious-disease modeler at the University of Chicago, who wasn’t involved in the new analysis.

    The team behind the reanalysis still has copies of the genetic sequences its members downloaded earlier this month. But they’ve decided that they won’t be the ones to share them, several of them told me. For one, they don’t have sequences from the complete set of samples that the Chinese team collected in early 2020—just the fraction that they spotted and grabbed off GISAID. Even if they did have all of the data, the researchers contend that it’s not their place to post them publicly. That’s up to the China CDC team that originally collected and generated the data.

    Part of the international team’s reasoning is rooted in academic decorum. There isn’t a set-in-stone guidebook among scientists, but adhering to unofficial rules on etiquette smooths successful collaborations across disciplines and international borders—especially during a global crisis such as this one. Releasing someone else’s data, the product of another team’s hard work, is a faux pas. It risks misattribution of credit, and opens the door to the Chinese researchers’ findings getting scooped before they publish a high-profile paper in a prestigious journal. “It isn’t right to share the original authors’ data without their consent,” says Niema Moshiri, a computational biologist at UC San Diego and one of the authors of the new report. “They produced the data, so it’s their data to share with the world.”

    If the international team released what data it has, it could potentially stoke the fracas in other ways. The World Health Organization has publicly indicated that the data should come from the researchers who collected them first: On Friday, at a press briefing, Tedros Adhanom Ghebreyesus, the WHO’s director-general, admonished the Chinese researchers for keeping their data under wraps for so long, and called on them to release the sequences again. “These data could have and should have been shared three years ago,” he said. And the fact that it wasn’t is “disturbing,” given just how much it might have aided investigations early on, says Gregory Koblentz, a biodefense expert at George Mason University, who wasn’t involved in the new analysis.

    Publishing the current report has already gotten the researchers into trouble with GISAID, the database where they found the genetic sequences. During the pandemic, the database has been a crucial hub for researchers sharing viral genome data; founded to provide open access to avian influenza genomes, it is also where researchers from the China CDC published the first whole-genome sequences of SARS-CoV-2, back in January 2020. A few days after the researchers downloaded the sequences, they told me, several of them were contacted by a GISAID administrator who chastised them about not being sufficiently collaborative with the China CDC team and warned them against publishing a paper using the China CDC data. They were in danger, the email said, of violating the site’s terms of use and would risk getting their database access revoked. Distributing the data to any non-GISAID users—including the broader research community—would also be a breach.

    This morning, hours after the researchers released their report online, many of them found that they could no longer log in to GISAID—they received an error message when they input their username and password. “They may indeed be accusing us of having violated their terms,” Moshiri told me, though he can’t be sure. The ban was instated with absolutely no warning. Moshiri and his colleagues maintain that they did act in good faith and haven’t violated any of the database’s terms—that, contrary to GISAID’s accusations, they reached out multiple times with offers to collaborate with the China CDC, which has “thus far declined,” per the international team’s report.

    GISAID didn’t respond when I reached out about the data’s disappearing act, its emails to the international team, and the group-wide ban. But in a statement released shortly after I contacted the database—one that echoes language in the emails sent to researchers—GISAID doubled down on accusing the international team of violating its terms of use by posting “an analysis report in direct contravention of the terms they agreed to as a condition to accessing the data, and despite having knowledge that the data generators are undergoing peer review assessment of their own publication.”

    Maria Van Kerkhove, the WHO’s COVID-19 technical lead, told me that she’s learned that the China CDC researchers recently provided a fuller data set to GISAID—more complete than the one the international team downloaded earlier this month. “It’s ready to go,” she told me. GISAID just needs permission, she said, from the Chinese researchers to make the sequences publicly available. “I reach out to them every day, asking them for a status update,” she added, but she hasn’t yet heard back on a definitive timeline. In its statement, GISAID also “strongly” suggested “that the complete and updated dataset will be made available as soon as possible,” but gave no timeline. I asked Van Kerkhove if there was a hypothetical deadline for the China CDC team to restore access, at which point the international team might be asked to publicize the data instead. “This hypothetical deadline you’re talking about? We’re way past that,” she said, though she didn’t comment specifically on whether the international team would be asked to step in. “Data has been uploaded. It is available. It just needs to be accessible, immediately.”

    Why, exactly, the sequences were first made public only so recently, and why they have yet to reappear publicly, remain unclear. In a recent statement, the WHO said that access to the data was withdrawn “apparently to allow further data updates by China CDC” to its original analysis on the market samples, which went under review for publication at the journal Nature last week. There’s no clarity, however, on what will happen if the paper is not published at all. When I reached out to three of the Chinese researchers—George Gao, William Liu, and Guizhen Wu—to ask about their intentions for the data, I didn’t receive a response.

    “We want the data to come out more than anybody,” says Saskia Popescu, an infectious-disease epidemiologist at George Mason University and one of the authors on the new analysis. Until then, the international team will be fielding accusations, already flooding in, that it falsified its analyses and overstated its conclusions.

    Researchers around the world have been raising questions about these particular genetic sequences for at least a year. In February 2022, the Chinese researchers and their close collaborators released their analysis of the same market samples probed in the new report, as well as other bits of genetic data that haven’t yet been made public. But their interpretations deviate pretty drastically from the international team’s. The Chinese team contended that any shreds of virus found at the market had most likely been brought in by infected humans. “No animal host of SARS-CoV-2 can be deduced,” the researchers asserted at the time. Although the market had perhaps been an “amplifier” of the outbreak, their analysis read, “more work involving international coordination” would be needed to determine the “real origins of SARS-CoV-2.” When reached by Jon Cohen of Science magazine last week, Gao described the sequences that fleetingly appeared on GISAID as “[n]othing new. It had been known there was illegal animal dealing and this is why the market was immediately shut down.”

    There is, then, a clear divergence between the two reports. Gao’s assessment indicates that finding animal genetic material in the market swabs merely confirms that live mammals were being illegally traded at the venue prior to January 2020. The researchers behind the new report insist that the narrative can now go a step further—they suggest not just that the animals were there, but that the animals, several of which are already known to be vulnerable to SARS-CoV-2, were there, in parts of the market where the virus was also found. That proximity, coupled with the virus’s inability to persist without a viable host, points to the possibility of an existing infection among animals, which could spark several more.

    The Chinese researchers used this same logic of location—multiple types of genetic material pulled out of the same swab—to conclude that humans were carrying around the virus at Huanan. The reanalysis confirms that there probably were infected people at the market at some point before it closed. But they were unlikely to be the virus’s only chauffeurs: Across several samples, the amount of raccoon-dog genetic material dwarfs that of humans. At one stall in particular—located in the sector of the market where the most virus-positive swabs were found—the researchers discovered at least one sample that contained SARS-CoV-2 RNA, and was also overflowing with raccoon-dog genetic material, while containing very little DNA or RNA material matching the human genome. That same stall was photographically documented housing raccoon dogs in 2014. The case is not a slam dunk: No one has yet, for instance, identified a viral sample taken from a live animal that was swabbed at the market in 2019 before the venue was closed. Still, JHU’s Gronvall told me, the situation feels clearer than ever. “All of the science is pointed” in the direction of Huanan being the pandemic’s epicenter, she said.

    To further untangle the significance of the sequences will require—you guessed it—the now-vanished genetic data. Some researchers are still withholding their judgment on the significance of the new analysis, because they haven’t gotten their hands on the genetic sequences themselves. “That’s the whole scientific process,” Van Kerkhove told me: data transparency that allows analyses to be “done and redone.”

    Van Kerkhove and others are also wondering whether more data could yet emerge, given how long this particular set went unshared. “This is an indication to me in recent days that there is more data that exists,” she said. Which means that she and her colleagues haven’t yet gotten the fullest picture of the pandemic’s early days that they could—and that they won’t be able to deliver much of a verdict until more information emerges. The new analysis does bolster the case for market animals acting as a conduit for the virus between bats (SARS-CoV-2’s likeliest original host, based on several studies on this coronavirus and others) and people; it doesn’t, however, “tell us that the other hypotheses didn’t happen. We can’t remove any of them,” Van Kerkhove told me.

    More surveillance for the virus needs to be done in wild-animal populations, she said. Having the data from the market swabs could help with that, perhaps leading back to a population of mammals that might have caught the virus from bats or another intermediary in a particular part of China. At the same time, to further investigate the idea that SARS-CoV-2 first emerged out of a laboratory mishap, officials need to conduct intensive audits and investigations of virology laboratories in Wuhan and elsewhere. Last month, the U.S. Department of Energy ruled that such an accident was the likelier catalyst of the coronavirus outbreak than a natural spillover from wild animals to humans. The ruling echoed earlier judgments from the FBI and a Senate minority report. But it contrasted with the views of four other agencies, plus the National Intelligence Council, and it was made with “low confidence” and based on “new” evidence that has yet to be declassified.

    Read: The lab leak will haunt us forever

    The longer the investigation into the virus’s origins drags on, and the more distant the autumn of 2019 grows in our rearview, “the harder it becomes,” Van Kerkhove told me. Many in the research community were surprised that new information from market samples collected in early 2020 emerged at all, three years later. Settling the squabbles over SARS-CoV-2 will be especially tough because the Huanan market was so swiftly shut down after the outbreak began, and the traded animals at the venue rapidly culled, says Angela Rasmussen, a virologist at the University of Saskatchewan and one of the researchers behind the new analysis. Raccoon dogs, one of the most prominent potential hosts to have emerged from the new analysis, are not even known to have been sampled live at the market. “That evidence is gone now,” if it ever existed, Koblentz, of George Mason University, told me. For months, Chinese officials were even adamant that no mammals were being illegally sold at the region’s wet markets at all.

    So researchers continue to work with what they have: swabs from surfaces that can, at the very least, point to a susceptible animal being in the right place, at the right time, with the virus potentially inside it. “Right now, to the best of my knowledge, this data is the only way that we can actually look,” Rasmussen told me. It may never be enough to fully settle this debate. But right now, the world doesn’t even know the extent of the evidence available—or what could, or should, still emerge.

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    Katherine J. Wu

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  • The Future of Long COVID

    The Future of Long COVID

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    In the early spring of 2020, the condition we now call long COVID didn’t have a name, much less a large community of patient advocates. For the most part, clinicians dismissed its symptoms, and researchers focused on SARS-CoV-2 infections’ short-term effects. Now, as the pandemic approaches the end of its third winter in the Northern Hemisphere, the chronic toll of the coronavirus is much more familiar. Long COVID has been acknowledged by prominent experts, national leaders, and the World Health Organization; the National Institutes of Health has set up a billion-dollar research program to understand how and in whom its symptoms unfurl. Hundreds of long-COVID clinics now freckle the American landscape, offering services in nearly every state; and recent data hint that well-vetted drugs to treat or prevent long COVID may someday be widespread. Long COVID and the people battling it are commanding more respect, says Hannah Davis, a co-founder of the Patient-Led Research Collaborative, who has had long COVID for nearly three years: Finally, many people “seem willing to understand.”

    But for all the ground that’s been gained, the road ahead is arduous. Long COVID still lacks a universal clinical definition and a standard diagnosis protocol; there’s no consensus on its prevalence, or even what symptoms fall under its purview. Although experts now agree that long COVID does not refer to a single illness, but rather is an umbrella term, like cancer, they disagree on the number of subtypes that fall within it and how, exactly, each might manifest. Some risk factors—among them, a COVID hospitalization, female sex, and certain preexisting medical conditions—have been identified, but researchers are still trying to identify others amid fluctuating population immunity and the endless slog of viral variants. And for people who have long COVID now, or might develop it soon, the interventions are still scant. To this day, “when someone asks me, ‘How can I not get long COVID?’ I can still only say, ‘Don’t get COVID,’” says David Putrino, a neuroscientist and physical therapist who leads a long-COVID rehabilitation clinic at Mount Sinai’s Icahn School of Medicine.

    As the world turns its gaze away from the coronavirus pandemic, with country after country declaring the virus “endemic” and allowing crisis-caliber interventions to lapse, long-COVID researchers, patients, and activists worry that even past progress could be undone. The momentum of the past three years now feels bittersweet, they told me, in that it represents what the community might lose. Experts can’t yet say whether the number of long-haulers will continue to increase, or offer a definitive prognosis for those who have been battling the condition for months or years. All that’s clear right now is that, despite America’s current stance on the coronavirus, long COVID is far from being beaten.

    Despite an influx of resources into long-COVID research in recent months, data on the condition’s current reach remain a mess—and scientists still can’t fully quantify its risks.

    Recent evidence from two long-term surveys have hinted that the pool of long-haulers might be shrinking, even as new infection rates remain sky-high: Earlier this month, the United Kingdom’s Office for National Statistics released data showing that 2 million people self-reported lingering symptoms at the very start of 2023, down from 2.3 million in August 2022. The U.S. CDC’s Household Pulse Survey, another study based on self-reporting, also recorded a small drop in long-COVID prevalence in the same time frame, from about 7.5 percent of all American adults to roughly 6. Against the massive number of infections that have continued to slam both countries in the pandemic’s third year and beyond, these surveys might seem to imply that long-haulers are leaving the pool faster than newcomers are arriving.

    Experts cautioned, however, that there are plenty of reasons to treat these patterns carefully—and to not assume that the trends will be sustained. It’s certainly better that these data aren’t showing a sustained, dramatic uptick in long-COVID cases. But that doesn’t mean the situation is improving. Throughout the pandemic, the size of the long-COVID pool has contracted or expanded for only two reasons: a change in the rate at which people enter, or at which they exit. Both figures are likely to be in constant flux, as surges of infections come and go, masking habits change, and vaccine and antiviral uptake fluctuates. Davis pointed out that the slight downward tick in both studies captured just a half-year stretch, so the downward slope could be one small portion of an undulating wave. A few hours spent at the beach while the tide is going out wouldn’t be enough to prove that the ocean is drying up.

    Read: We’re bungling the COVID wind-down

    Recent counts of new long-COVID cases might also be undercounts, as testing slows and people encounter more challenges getting diagnosed. That said, it’s still possible that, on a case-by-case basis, the likelihood of any individual developing long COVID after a SARS-CoV-2 infection may have fallen since the pandemic’s start, says Deepti Gurdasani, a clinical epidemiologist at Queen Mary University of London and the University of New South Wales. Population immunity—especially acquired via vaccination—has, over the past three years, better steeled people’s bodies against the virus, and strong evidence supports the notion that vaccines can moderately reduce the risk of developing long COVID. Treatments and behavioral interventions that have become more commonplace may have chipped away at incidence as well. Antivirals can now help to corral the virus early in infection; ventilation, distancing, and masks—when they’re used—can trim the amount of virus that infiltrates the body. And if overall exposure to the virus can influence the likelihood of developing long COVID, that could help explain why so many debilitating cases arose at the very start of the pandemic, when interventions were few and far between, says Steven Deeks, a physician researcher at UC San Francisco.

    There’s not much comfort to derive from those individual-level stats, though, when considering what’s happening on broader scales. Even if immunity makes the average infected person less likely to fall into the long-COVID pool, so many people have been catching the virus that the inbound rate still feels like a flood. “The level of infection in many countries has gone up substantially since 2021,” Gurdasani told me. The majority of long-COVID cases arise after mild infections, the sort for which our immune defenses fade most rapidly. Now that masking and physical distancing have fallen by the wayside, people may be getting exposed to higher viral doses than they were a year or two ago. In absolute terms, then, the number of people entering the long-COVID pool may not really be decreasing. Even if the pool were getting slightly smaller, its size would still be staggering, an ocean of patients with titanic needs. “Anecdotally, we still have an enormous waitlist to get into our clinic,” Putrino told me.

    Deeks told me that he’s seen another possible reason for optimism: People with newer cases of long COVID might be experiencing less debilitating or faster-improving disease, based on what he’s seen. “The worst cases we’ve seen come from the first wave in 2020,” he said. But Putrino isn’t so sure. “If you put an Omicron long-COVID patient in front of me, versus one from the first wave, I wouldn’t be able to tell you who was who,” he said. The two cases would also be difficult to compare, because they’re separated by so much time. Long COVID’s symptoms can wax, wane, and qualitatively change; a couple of years into the future, some long-haulers who’ve just developed the condition may be in a spot that’s similar to where many veterans with the condition are now.

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

    Experts’ understanding of how often people depart the long-COVID pool is also meager. Some long-haulers have undoubtedly seen improvement—but without clear lines distinguishing short COVID from medium and long COVID, entry and exit into these various groups is easy to over- or underestimate. What few data exist on the likelihood of recovery or remission is inconsistent, and not always rosy: Investigators of RECOVER, a large national study of long COVID, have calculated that about two-thirds of the long-haulers in their cohort do not return to baseline health. Putrino, who has worked with hundreds of long-haulers since the pandemic began, estimates that although most of his patients experience at least some benefit from a few months of rehabilitation, only about one-fifth to one-quarter of them eventually reach the point of feeling about as well as they did before catching the virus, while the majority hit a middling plateau. A small minority of the people he has treated, he told me, never seem to improve at all.

    Letícia Soares, a long-hauler in Brazil who caught the virus near the start of the pandemic, falls into that final category. Once a disease ecologist who studied parasite transmission in birds, she is now mostly housebound, working when she is able as a researcher for the Patient-Led Research Collaborative. Her days revolve around medications and behavioral modifications she uses for her fatigue, sleeplessness, and chronic pain. Soares no longer has the capacity to cook or frequently venture outside. And she has resigned herself to this status quo until the treatment landscape changes drastically. It is not the life she pictured for herself, Soares told me. “Sometimes I think the person I used to be died in April of 2020.”

    Even long-haulers who have noticed an improvement in their symptoms are wary of overconfidence. Some absolutely do experience what could be called recovery—but for others, the term has gotten loaded, almost a jinx. “If the question is, ‘Are you doing the things you were doing in 2019?’ the answer is largely no,” says JD Davids, a chronic-illness advocate based in New York. For some, he told me, “getting better” has been more defined by a resetting of expectations than a return to good health. Relapses are also not uncommon, especially after repeat encounters with the virus. Lisa McCorkell, a long-hauler and a co-founder of the Patient-Led Research Collaborative, has felt her symptoms partly abate since she first fell ill in the spring of 2020. But, she told me, she suspects that her condition is more likely to deteriorate than further improve—partly because of “how easy it is to get reinfected now.”

    Last week, in his State of the Union address, President Joe Biden told the American public that “we have broken COVID’s grip on us.” Highlighting the declines in the rates of COVID deaths, the millions of lives saved, and the importance of remembering the more than 1 million lost, Biden reminded the nation of what was to come: “Soon we’ll end the public-health emergency.”

    When the U.S.’s state of emergency was declared nearly three years ago, as hospitals were overrun and morgues overflowed, the focus was on severe, short-term disease. Perhaps in that sense, the emergency is close to being over, Deeks told me. But long COVID, though slower to command attention, has since become its own emergency, never formally declared; for the millions of Americans who have been affected by the condition, their relationship with the virus does not yet seem to be in a better place.

    Read: Trying to stop long COVID before it even starts

    Even with many more health-care providers clued into long COVID’s ills, the waiting lists for rehabilitation and treatment remain untenable, Hannah Davis told me. “I consider myself someone who gets exceptional care compared to other people,” she said. “And still, I hear from my doctor every nine or 10 months.” Calling a wrap on COVID’s “emergency” phase could worsen that already skewed supply-demand ratio. Changes to the nation’s funding tactics could strip resources—among them, access to telehealth; Medicaid coverage; and affordable antivirals, tests, and vaccines—from vulnerable populations, including people of color, that aren’t getting their needs met even as things stand, McCorkell told me. And as clinicians internalize the message that the coronavirus has largely been addressed, attention to its chronic impacts may dwindle. At least one of the country’s long-COVID clinics has, in recent months, announced plans to close, and Davis worries that more could follow soon.

    Scientists researching long COVID are also expecting new challenges. Reduced access to testing will complicate efforts to figure out how many people are developing the condition, and who’s most at risk. Should researchers turn their scientific focus away from studying causes and cures for long COVID when the emergency declaration lifts, Davids and others worry that there will be ripple effects on the scientific community’s interest in other, neglected chronic illnesses, such as ME/CFS (myalgic encephalomyelitis or chronic fatigue syndrome), a diagnosis that many long-haulers have also received.

    The end of the U.S.’s official crisis mode on COVID could stymie research in other ways as well. At Johns Hopkins University, the infectious-disease epidemiologists Priya Duggal, Shruti Mehta, and Bryan Lau have been running a large study to better understand the conditions and circumstances that lead to long COVID, and how symptoms evolve over time. In the past two years, they have gathered online survey data from thousands of people who both have and haven’t been infected, and who have and haven’t seen their symptoms rapidly resolve. But as of late, they’ve been struggling to recruit enough people who caught the virus and didn’t feel their symptoms linger. “I think that the people who are suffering from long COVID will always do their best to participate,” Duggal told me. That may not be the case for individuals whose experiences with the virus were brief. A lot of them “are completely over it,” Duggal said. “Their life has moved on.”

    Kate Porter, a Massachusetts-based marketing director, told me that she worries about her family’s future, should long COVID fade from the national discourse. She and her teenage daughter both caught the virus in the spring of 2020, and went on to develop chronic symptoms; their experience with the disease isn’t yet over. “Just because the emergency declaration is expiring, that doesn’t mean that suddenly people are magically going to get better and this issue is going to go away,” Porter told me. After months of relative improvement, her daughter is now fighting prolonged bouts of fatigue that are affecting her school life—and Porter isn’t sure how receptive people will be to her explanations, should their illnesses persist for years to come. “Two years from now, how am I going to explain, ‘Well, this is from COVID, five years ago’?” she said.

    A condition that was once mired in skepticism, scorn, and gaslighting, long COVID now has recognition—but empathy for long-haulers could yet experience a backslide. Nisreen Alwan, a public-health researcher at the University of Southampton, in the U.K., and her colleagues have found that many long-haulers still worry about disclosing their condition, fearing that it could jeopardize their employment, social interactions, and more. Long COVID could soon be slated to become just one of many neglected chronic diseases, poorly understood and rarely discussed.

    Davis doesn’t think that marginalization is inevitable. Her reasoning is grim: Other chronic illnesses have been easier to push to the sidelines, she said, on account of their smaller clinical footprint, but the pool of long-haulers is enormous—comprising millions of people in the U.S. alone. “I think it’s going to be impossible to ignore,” she told me. One way or another, the world will have no choice but to look.

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    Katherine J. Wu

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  • A Rare Reprieve From the Permanent Presidential Campaign

    A Rare Reprieve From the Permanent Presidential Campaign

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    Does anyone want to be president?

    Typically, by the time a president delivers the State of the Union address at the start of his third year in office, as Joe Biden will on Tuesday, at least half a dozen rivals are already gunning for his job. When Donald Trump began his annual speech to Congress in 2019, four of the Democrats staring back at him inside the House chamber had already declared their presidential candidacies.

    Not so this year. The only Republican (or Democrat, for that matter) officially trying to oust Biden is the former president he defeated in 2020. Trump announced his third White House run in November and then barely bothered to campaign for the next two months before holding relatively small-scale events in New Hampshire and South Carolina in January. Trump will finally get some company next week, when Nikki Haley, the former South Carolina governor and United Nations ambassador, plans to kick off her campaign in Charleston. More Republicans could soon jump into the presidential pool. But the 2024 campaign has gotten off to a decidedly slow start, and the first weeks of 2023 have brought a rare reprieve from what has become known—with some derision—as the permanent campaign. This pause is not the result of some collective cease-fire; it’s what happens when you have a former president who lost reelection but still inspires fear in his party, along with a Democratic incumbent—the oldest to ever serve—who is not exactly itching to campaign.

    Even New Hampshire—normally one of the first states to welcome would-be presidents—has been subdued. “Other than Trump, I can’t think of a leading person being here for the last couple of months,” Raymond Buckley, the longtime chair of the state’s Democratic Party, told me. He said he’s used the lull to prioritize party building, “instead of constantly focusing on one Republican senator or governor after another.”

    The same is true in Iowa, that other presidential proving ground with a year-round appetite for stump speeches. “It’s pretty quiet on the western front,” David Oman, a Republican strategist and former co-chair of the Iowa state GOP, told me. As my colleague McKay Coppins recently reported, most of the Republicans who want the party to nominate someone other than Trump are, once again, reluctant to actually do anything about it. Trump’s potential GOP rivals have been similarly shy about taking him on; until Haley put out word about her announcement last week, no one in the emerging field—which could include Florida Governor Ron DeSantis, former Vice President Mike Pence, and former Secretary of State Mike Pompeo, among others—was willing to be the first target of the barrage of insults and invective Trump would surely hurl their way.

    Read: Republicans’ 2024 magical thinking

    The momentary quietude has dampened any pressure for Biden to shift back into campaign mode, and he’s in no rush anyway. Tuesday’s State of the Union address will likely yield even more performance reviews than usual, as pundits and viewers alike judge the toll that Biden’s advancing age has taken on his oratory. As for the substance of his speech, White House officials told me Biden will continue the project he began months ago: promoting the accomplishments of his first two years in office, especially his bipartisan infrastructure law and the Democrats’ Inflation Reduction Act that he signed last summer.

    In the absence of a fully formed GOP presidential field, Biden has been content to use the new House Republican majority as a foil—adopting a strategy that Presidents Bill Clinton and Barack Obama employed after Democrats lost power in Congress during their first terms. Biden has vowed to protect programs such as Medicare and Social Security from GOP budget cuts; refused to negotiate over the debt ceiling (although the White House said last week he’d entertain “separate” conversations on deficit reduction); and eagerly highlighted ill-fated GOP proposals to replace the federal income tax with a 30 percent national sales tax.

    Yet with Speaker Kevin McCarthy seated behind the president on the House rostrum for the first time, Biden is expected to stress conciliation over confrontation. “The president will once again amplify his belief that Democrats and Republicans can work together,” a White House official told me, speaking anonymously to preview a speech that hasn’t been finalized, “as they did in the last two years and as he is committed to doing with this new Congress to get big things done on behalf of the American people.”

    Biden allies expect the president to formally announce his reelection bid sometime after the State of the Union, but they note that could still be months away. Such a wait isn’t unusual for incumbents, who don’t need to introduce themselves to the electorate and generally want to be seen as focused on governing. But no president since Ronald Reagan has faced as much uncertainty about whether he would seek a second term. (Then the oldest president, Reagan was eight years younger in 1983 than the 80-year-old Biden is now.) Outgoing Chief of Staff Ron Klain pointedly referenced a reelection bid as he departed the White House last week, telling Biden he looked forward to supporting him “when you run for president in 2024.” But other White House officials routinely affix the qualifier “if he runs” to discussions about a potential campaign, suggesting it remains less than a sure thing.

    Franklin Foer: How Joe Biden wins again

    Aiding Biden is the fact that no Democrats of note (besides Marianne Williamson) have made any moves to challenge him for the nomination, and the president’s allies are operating under the assumption that he will have the field to himself. “I would be shocked at this point if this becomes a competitive primary,” Amanda Loveday, a senior adviser to the pro-Biden super PAC Unite the Country, told me.

    The bigger question is how many Republicans will challenge Biden knowing they’ll have to get through Trump first—and when they’ll see fit to jump in. GOP officials told me they expect Haley’s announcement to prompt others to enter the race soon. But Trump clearly froze the field for a while. All through 2021 and most of 2022, Buckley told me, “rarely a week went by without a major visit” to New Hampshire from a White House aspirant. “It all came to a grinding halt once Trump announced,” he said. Jeff Kaufmann, the Republican Party chair in Iowa, told me that the first months of 2021—the brief period after January 6 when Trump’s political future was in doubt—were busier for GOP hopefuls than this past January, just a year before the caucuses.

    For most of American history, the observation that barely anyone was campaigning more than a year and a half before the election would be entirely unremarkable. Only in this century has a two-year campaign for a four-year term in the White House become the norm. (As recently as 1992, the governor of a small southern state declared his candidacy only 14 months before the election, and he did just fine.)

    For most of the country, this respite from presidential politics is probably welcome, especially for voters who were inundated with nonstop campaign ads leading up to the midterm election. The view is a bit different, however, in Iowa and New Hampshire, where the quadrennial pilgrimage of politicos brings welcome attention and a sizable economic boost. Republicans in both states want to ensure that the GOP does not follow the Democrats in trying to leave them behind. Kaufmann told me he wasn’t worried; Senator Tim Scott would be coming out to Iowa in a few weeks, and others were calling to schedule events, perhaps preparing their launches. By March, he assured me, all would be back to normal. This extended presidential halftime will be over, and America’s never-ending campaign will resume in full.

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    Russell Berman

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  • The FDA’s New ‘Don’t Say Gay’ Policy for Blood Donation

    The FDA’s New ‘Don’t Say Gay’ Policy for Blood Donation

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    For decades now, gay men have been barred from giving blood. In 2015, what had been a lifetime ban was loosened, such that gay men could be donors if they’d abstained from sex for at least a year. This was later shortened to three months. Last week, the FDA put out a new and more inclusive plan: Sexually active gay and bisexual people would be permitted to donate so long as they have not recently engaged in anal sex with new or multiple partners. Assistant Secretary for Health Rachel Levine, the first Senate-confirmed transgender official in the U.S., issued a statement commending the proposal for “advancing equity.” It “treats everyone the same,” she said, “regardless of gender and sexual orientation.”

    As a member of the small but honorable league of gay pathologists, I’m affected by these proposed policy changes more than most Americans. I’m subject to restrictions on giving blood, and I’ve also been responsible for monitoring the complications that can arise from transfusions of infected blood. I am quite concerned about HIV, given that men who have sex with men are at much greater risk of contracting the virus than members of other groups. But it’s not the blood-borne illness that I, as a doctor, fear most. Common bacteria lead to far more transfusion-transmitted infections in the U.S. than any virus does, and most of those produce severe or fatal illness. The risk from viruses is extraordinarily low—there hasn’t been a single reported case of transfusion-associated HIV in the U.S. since 2008—because laboratories now use highly accurate tests to screen all donors and ensure the safety of our blood supply. This testing is so accurate that preventing anyone from donating based on their sexual behavior is no longer logical. Meanwhile, new dictates about anal sex, like older ones explicitly targeting men who have sex with men, still discriminate against the queer community—the FDA is simply struggling to find the most socially acceptable way to pursue a policy that it should have abandoned long ago.

    Strict precautions made more sense 30 years ago, when screening didn’t work nearly as well as it does today. Patients with hemophilia, many of whom rely on blood products to live, were prominent, early victims of our inability to keep HIV out of the blood supply. One patient who’d acquired the virus through a transfusion lamented to The New York Times in 1993 that he had already watched an uncle and a cousin die of AIDS. Those days of “shock and denial,” as the Times described it, are thankfully behind us. But for older patients, memories of the crisis in the ’80s and early ’90s linger, and cause significant anxiety. Even people unaware of this historical context may consider the receipt of someone else’s blood disturbing, threatening, or sinful.

    As a doctor, I’ve found that patients tend to be more hesitant about getting a blood transfusion than they are about taking a pill. I’ve had them ask for a detailed medical history of the donor, or say they’re willing to take blood only from a close relative. (Typically, neither of these requests can be fulfilled for reasons of privacy and practicality.) Yet the same patients may accept—without question—drugs that carry a risk of serious complication that is thousands of times higher than the risk of receiving infected blood. Even when it comes to blood-borne infections, patients seem to worry less about the greatest danger—bacterial contamination—than they do about the transfer of viruses such as HIV and hepatitis C. I can’t fault anyone for being sick and scared, but the risk of contracting HIV from a blood transfusion is not just low—it’s essentially nonexistent.

    Read: Blood plasma, sweat, and tears

    Donors’ feelings matter, too, and the FDA’s policies toward gay and bisexual men who wish to give blood have been unfair for many years. While officials speak in the supposedly objective language of risk and safety, their selective deployment of concern suggests a deeper homophobia. As one scholar put it in The American Journal of Bioethics more than a decade ago, “Discrimination resides not in the risk itself but in the FDA response to the risk.” Many demographic groups are at elevated risk of contracting HIV, yet the agency isn’t continually refining its exclusion criteria for young people or urban dwellers or Black and Hispanic people. Federal policy did prohibit Haitians from donating blood from 1983 to 1991, but activists successfully lobbied for the reversal of this ban with the powerful slogan “The H in HIV stands for human, not Haitian.” Nearly everyone today would find the idea of rejecting blood from one racial group to be morally repugnant. Under its new proposal, which purports to target anal sex instead of homosexuality itself, the FDA effectively persists in rejecting blood from sexual minorities.

    The planned update would certainly be an improvement. It comes out of years of advocacy by LGBTQ-rights organizations, and its details are apparently supported by newly conducted government research. Peter Marks, the director of the Center for Biologics Evaluation and Research at the FDA, cited an unpublished study showing that “a significant fraction” of men who have sex with men would now be able to donate. But the plan is still likely to exclude a large portion of them—even those who wear condoms or regularly test for sexually transmitted infections. An FDA spokesperson told me via email that “additional data are needed to determine what proportion of [men who have sex with men] would be able to donate under the proposed change.”

    Research done in France, Canada, and the U.K., where similar policies have since been adopted over the past two years, demonstrates the risk. A French blood-donation study, for instance, estimated that 70 percent of men who have sex with men had more than one recent partner; and when Canadian researchers surveyed queer communities in Montreal, Toronto, and Vancouver, they found that up to 63 percent would not be eligible to donate because they’d recently had anal sex with new or multiple partners. Just 1 percent of previously eligible donors would have been rejected by similar criteria. The U.K. assumed in its calculations that 35 to 50 percent of men who have sex with men would be ineligible under a policy much like the FDA’s, while only 1.4 percent of previous donors would be newly deferred. If the new rule’s net effect is that gay and bisexual men are turned away from blood centers at many times the rate of heterosexual individuals, what else can you call it but discrimination? The U.S. guidance is supposed to ban a lifestyle choice rather than an identity, but the implication is that too many queer men have chosen wrong. The FDA spokesperson told me, “Anal sex with more than one sexual partner has a significantly greater risk of HIV infection when compared to other sexual exposures, including oral sex or penile-vaginal sex.”

    If the FDA wants to pry into my sex life, it should have a good reason for doing so. The increasing granularity and intimacy of these policies—specifying numbers of partners, kinds of sex—gives the impression that the stakes are very high: If we don’t keep out the most dangerous donors, the blood supply could be ruined. But donor-screening questions are a crude tool for picking needles from a haystack. The only HIV infections that are likely to get missed by modern testing are those contracted within the previous week or two. This suggests that, at most, a couple thousand individuals—gay and straight—across the entire country are at risk of slipping past our testing defenses at any given time. Of course, very few of them will happen to donate blood right then. No voluntary questionnaire can ever totally exclude this possibility, but patients and doctors already accept other life-threatening transfusion risks that occur at much greater rates than HIV transmission ever could. When I would be on call for monitoring transfusion reactions at a single hospital, the phone would ring a few times every night. Yet blood has been given out tens of millions of times across the country since the last known instance of a transfusion resulting in a case of HIV.

    Read: How blood-plasma companies target the poorest Americans

    Early data suggest that the overall risk-benefit calculus of receiving blood isn’t likely to change. When eligibility criteria were first relaxed in the U.S. a few years ago, the already tiny rate of HIV-positive donations remained minuscule. Real-world results from other countries that have recently adopted sexual-orientation-neutral policies will become available in the coming years. But modeling studies already support removing any screening question that explicitly or implicitly targets queer men. A 2022 Canadian analysis suggested that removing all questions about men who have sex with men would not result in a significantly higher risk to patients. “Extra behavioral risk questions may not be necessary,” the researchers concluded. If there must be a restriction in place, then one narrowly tailored to the slim risk window of seven to 10 days before donation should be good enough. (The FDA says that its proposed policy “would be expected to reduce the likelihood of donations by individuals with new or recent HIV infection who may be in the window period.”)

    As a gay man, I realize that, brief periods of crisis during the coronavirus pandemic aside, no one needs my blood. Only 6.8 percent of men in the U.S. identify as gay or bisexual, so our potential benefit to the overall supply is inherently modest. If we went back to being banned completely, patients would not be harmed. But reversing that ban, both in letter and in spirit, would send a vital message: Our government and health-care system view sexual minorities as more than a disease vector. A policy that uses anal sex as a stand-in for men who have sex with men only further stigmatizes this population by impugning one of its main sources of sexual pleasure. There is no question that nonmonogamous queer men have a greater chance of contracting HIV. But a policy that truly treats everyone the same would accept a tiny amount of risk as the price of working with human beings.

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    Benjamin Mazer

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  • The House GOP’s Investigation Conundrum

    The House GOP’s Investigation Conundrum

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    The list of investigative priorities for the House Judiciary Committee that the incoming chairperson, Jim Jordan, sent to the Justice Department earlier this month reads like an assignment sheet for Fox News.

    And that was before Jordan, with incoming House Oversight and Government Reform Committee Chair James Comer, repeatedly insisted the FBI had colluded with “Big Tech” to undermine former president Donald Trump by “suppressing” information about Hunter Biden’s laptop prior to the 2020 election.

    It was also before reports surfaced that Kevin McCarthy, in his bid to secure the votes as speaker, promised far-right members of his caucus that he would authorize investigations into the Justice Department’s treatment of the insurrectionists who rioted in support of Trump on January 6. This was also before McCarthy threatened to launch impeachment proceedings against Department of Homeland Security Secretary Alejandro Mayorkas.

    Two months before taking power, the new House Republican majority has signaled that its investigative agenda will channel the preoccupations of the former president and his die-hard base of supporters. But it has set this course immediately after a midterm election in which voters outside the core conservative states sent an unmistakable signal of their own by repeatedly rejecting Trump-backed candidates in high-profile senate and gubernatorial races. That contrast captures why the GOP’s plans for aggressive investigations of President Joe Biden may present as much political risk for the investigators as it does for the targets.

    Read: The new majority

    House Republicans and their allies are confident that the investigations will weaken Biden in advance of the 2024 presidential election. “This is not just superficial stuff—this is damaging stuff,” former Republican Representative Tom Davis, who chaired the National Republican Congressional Committee, told me.

    But the new majority’s focus on airing echo-chamber conservative obsessions risks further stamping the GOP as the party of Trump precisely as more Republican leaders and donors insist the recent election results demonstrate the need to move beyond him.

    “All these folks are coming out saying, ‘Turn the page; move forward’ … and I think this is really a problem if some of these [House] members are going to continue to look back and embrace Trump at a time when we saw the most Trumpian candidates get their heads handed to them,” former Republican Representative Charlie Dent told me.

    The choices confronting GOP leaders on what—and how—to investigate encapsulates the much larger challenge they will face in managing the House. This month’s midterm election left the GOP with a House majority much smaller than it expected. The results also created a kind of split-personality caucus operating with very different political incentives.

    Most incoming House Republicans represent districts in Trump country: 168 of them hold seats that Trump won by 10 percentage points or more in 2020. Another three dozen represent more marginal Republican-leaning seats that Trump carried by fewer than 10 points two years ago.

    But the GOP majority relies on what will likely be 18 members (when all the final votes are counted) who won districts that voted for Biden in 2020. Eleven of those 18 are in New York and California alone—two states that will likely become considerably more difficult for Republicans in a presidential-election year than during a midterm contest.

    For the Republicans from the hard-core Trump districts, demonstrating a commitment to confronting Biden at every turn is crucial for preempting any possible primary challenges from their right, says the Democratic consultant Meredith Kelly, a former communications director at the Democratic Congressional Campaign Committee. But, as Dent told me, the Republicans precariously holding the Biden seats have the “polar opposite” incentive: “They need to have bipartisan victories and wins.”

    Amid that cross-pressure, many analysts second the prediction of outgoing Democratic Representative David Price of North Carolina, a political scientist who has written several books about Congress, that the new GOP House majority is not likely to pass much legislation. The problem, Price told me, is not only the partisan and ideological fracture in the GOP caucus, but that its members do not have “an agenda that they campaigned on or they are committed to.”

    All members of the GOP caucus might agree on legislation to extend the Trump tax cuts, to promote more domestic energy production, or to increase funding for border security. But resistance from the Republicans in blue and purple districts may frustrate many of the right’s most ambitious legislative goals, such as repealing elements of Biden’s Inflation Reduction Act, passing a national ban on abortion, and forcing cuts to Social Security and Medicare.

    With their legislative opportunities limited, House Republicans may see relentless investigation of Biden and his administration as a path of least resistance that can unite their caucus. And, several observers in both parties told me, all sides in the GOP are likely to support efforts to probe the White House’s policy record. Such targets could include the administration’s handling of border security, the chaotic withdrawal from Afghanistan, and how it is allocating the clean-energy tax credits and loan guarantees that the Inflation Reduction Act established.

    But Republicans have already indicated they are unlikely to stop at such conventional targets.

    Jordan, in his letter to Attorney General Merrick Garland earlier this month, warned of coming investigations into the Justice Department’s treatment of Project Veritas; allegations that the department has targeted conservative parents as “domestic terrorists” for their actions at school-board meetings; and the department’s decision making in the choice to execute a search warrant at Mar-a-Lago.

    At the press conference last week with Jordan, Comer declared that evidence from the GOP’s investigation of Hunter Biden’s business activities, including information obtained from his laptop, “raises troubling questions about whether President Biden is a national-security risk.”

    Jordan, asked at that press conference about the reports that McCarthy has committed to an investigation of the prosecution and treatment of the January 6 rioters, refused to deny it, instead repeating his determination to explore all examples of alleged politicization at the Justice Department. At one point, Jordan, an unwavering defender of Trump through his two impeachments, delivered an impassioned attack on federal law enforcement that reprised a long list of familiar Trump grievances. “When is the FBI going to quit interfering with elections?” Jordan excitedly declared.

    David Frum: Another flop from GOP Productions

    Jordan doesn’t even represent the outer edge of conservative ambition to use House investigations to settle scores for Trump. Earlier this week, Representative Matt Gaetz of Florida tweeted that when Republicans take the majority, they “should take over the @January6thCmte and release every second of footage that will exonerate our Patriots!”

    That might be a bridge too far even for McCarthy. But as he scrambles to overcome conservative resistance to his bid for speaker, he has already shown deference to demands from the Trump-country members who constitute the dominant block in his caucus. One example was the report that he promised Representative Marjorie Taylor Greene that he would allow some investigation into treatment of the January 6 rioters. Another came in his appearance along the Texas border this week. McCarthy went beyond pledging oversight of the Biden administration’s border record to raise the much more incendiary (but also Fox-friendly) notion of impeaching Mayorkas.

    Dent, the former GOP representative, told me that on all these fronts, House Republicans risk pushing oversight to a confrontational peak that may damage its members from marginal seats at least as much as it hurts Biden—particularly if it involves what he described as airing Trump grievances. “These rabbit holes are just fraught with political peril in these more moderate districts,” Dent said.

    Democrats hope that the coming GOP investigations will alienate more voters than they alarm. Several Democratic strategists told me they believe that the focus on so many conservative causes will both spotlight the most extreme Trump-aligned voices in the Republican caucus, such as Jordan and Greene, and strike swing voters as a distraction from their kitchen-table concerns.

    Leslie Dach, a veteran Democratic communications strategist now serving as a senior adviser to the Congressional Integrity Project, a group mobilizing to respond to the investigations, told me the GOP inquiries will inexorably identify the party with the same polarizing style of Trump-like politics that voters just repudiated in states such as Michigan, Pennsylvania, and Arizona. “We saw in this election that voters reject the Trump playbook and MAGA politics, but that is exactly what they will see in these hearings,” he said.

    Congressional investigations always carry the risk of disclosures that could hurt or embarrass Biden and other officials. And whatever they find, investigations also promise to divert significant amounts of the administration’s time and energy. The White House has already staffed up a unit in the counsel’s office dedicated to responding to the inquiries. Cabinet departments are scrambling to do the same.

    Recognizing the potential political risk, several Republican representatives newly elected in Biden districts have already urged their party to move slowly on the probes and instead to prioritize action on economic issues. Their problem is that McCarthy already has given every indication he’s likely to prioritize the demands for maximum confrontation from his caucus’s pro-Trump majority.

    “If past is prologue, Kevin McCarthy will fall much on the side of the ruby-red Republican base and the pro-investigation, pro-culture-war side,” Kelly says. “He’s never proven able to stand up to the fringe.” And that means the new members from Biden-leaning districts who have provided the GOP its narrow majority have reason to sweat almost as much as the Biden administration over the swarm of investigations that House Republicans are poised to unleash.

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    Ronald Brownstein

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  • Will Flu and RSV Always Be This Bad?

    Will Flu and RSV Always Be This Bad?

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    In the Northern Hemisphere, this year’s winter hasn’t yet begun. But Melissa J. Sacco, a pediatric-intensive-care specialist at UVA Health, is already dreading the arrival of the one that could follow.

    For months, the ICU where Sacco works has been overflowing with children amid an early-arriving surge of respiratory infections. Across the country, viruses such as RSV and flu, once brought to near-record lows by pandemic mitigations, have now returned in force, all while COVID-19 continues to churn and the health-care workforce remains threadbare. Most nights since September, Sacco told me, her ICU has been so packed that she’s had to turn kids away “or come up with creative ways to manage patients in emergency rooms or emergency departments,” where her colleagues are already overwhelmed and children more easily slip through the cracks. The team has no choice: There’s nowhere else for critically ill kids to go.

    Similar stories have been pouring in from around the nation for weeks. I recently spoke with a physician in Connecticut who called this “by far the worst spike in illness I’ve seen in 20 years”; another in Maryland told me, “There have been days when there is not an ICU bed to be found anywhere in the mid-Atlantic.” About three-quarters of the country’s pediatric hospital beds are full; to accommodate overflow, some hospitals have set up tents outside their emergency department or contemplated calling in the National Guard. Last week, the Children’s Hospital Association and the American Academy of Pediatrics asked the Biden administration to declare a national emergency. And experts say there’s no end to the crisis in sight. When Sacco imagines a similar wave slamming her team again next fall, “I get that burning tear feeling in the back of my eyes,” she told me. “This is not sustainable.”

    Read: The worst pediatric-care crisis in decades

    The experts I spoke with are mostly optimistic that these cataclysmic infection rates won’t become an autumn norm. But they also don’t yet fully understand the factors that have been driving this year’s surge, making it tough to know with certainty whether we’re due for an encore.

    One way or another, COVID has certainly thrown the typical end-of-year schedule out of whack. Respiratory viruses typically pick up speed in late fall, peak in mid-to-late winter, and then bow out by the spring; they often run in relay, with one microbe surging a bit before another. This year, though, nearly every pathogen arrived early, cresting in overlapping waves. “Everything is happening at once,” says Kathryn Edwards, a pediatrician and vaccinologist at Vanderbilt University. November isn’t yet through, and RSV has already sent infant hospitalizations soaring past pre-pandemic norms. Flu-hospitalization rates are also at their worst in more than a decade; about 30 states, plus D.C. and Puerto Rico, are reporting high or very high levels of the virus weeks before it usually begins its countrywide climb. And the country’s late-summer surge in rhinovirus and enterovirus has yet to fully abate. “We just haven’t had a break,” says Asuncion Mejias, a pediatrician at Nationwide Children’s Hospital.

    Previous pandemics have had similar knock-on effects. The H1N1-flu pandemic of 2009, for example, seems to have pushed back the start of the two RSV seasons that followed; seasonal flu also took a couple of years to settle back into its usual rhythms, Mejias told me. But that wonky timetable wasn’t permanent. If the viral calendar is even a little more regular next year, Mejias said, “that will make our lives easier.”

    This year, flu and RSV have also exploited Americans’ higher-than-average vulnerability. Initial encounters with RSV in particular can be rough, especially in infants, whose airways are still tiny; the sickness tempers with age as the body develops and immunity builds, leaving most children well protected by toddlerhood. But this fall, the pool of undefended kids is larger than usual. Children born just before the pandemic, or during the phases of the crisis when mitigations aplenty were still in place, may be meeting influenza or RSV for the first time. And many of them were born to mothers who had themselves experienced fewer infections and thus passed fewer antibodies to their baby while pregnant or breastfeeding. Some of the consequences may already have unfurled elsewhere in the world: Australia’s most recent flu season hit kids hard and early, and Nicaragua’s wave at the start of 2022 infected children at rates “higher than what we saw during the 2009 pandemic,” says Aubree Gordon, an epidemiologist at the University of Michigan.

    Read: What a ‘tripledemic’ means for your body

    In the U.S., many hospitals are now admitting far more toddlers and older children for respiratory illnesses than they normally do, says Mari Nakamura, a pediatric-infectious-disease specialist at Boston Children’s Hospital. The problem is worsened by the fact that many adults and school-age kids avoided their usual brushes with flu and RSV while those viruses were in exile, making it easier for the pathogens to spread once crowds flocked back together. “I wouldn’t be surprised,” Gordon told me, “if we see 50 to 60 percent of kids get infected with flu this year”—double the estimated typical rate of 20 to 30 percent. Caregivers too are falling sick; when I called Edwards, I could hear her husband and grandson coughing in the background.

    By next year, more people’s bodies should be clued back in to the season’s circulating strains, says Helen Chu, a physician and an epidemiologist at the University of Washington. Experts are also hopeful that the toolkit for fighting RSV will soon be much improved. Right now, there are no vaccines for the virus, and only one preventive drug is available in the U.S.: a tough-to-administer monoclonal antibody that’s available only to high-risk kids. But at least one RSV vaccine and another, less cumbersome antibody therapy (already being used in Europe) are expected to have the FDA’s green light by next fall.

    Even with the addition of better tech, though, falls and winters may be grueling for many years to come. SARS-CoV-2 is here to stay, and it will likely compound the respiratory burden by infecting people on its own or raising the risk of co-infections that can worsen and prolong disease. Even nonoverlapping illnesses might cause issues if they manifest in rapid sequence: Very serious bouts of COVID, for instance, can batter the respiratory tract, making it easier for other microbes to colonize.

    A few experts have begun to wonder if even milder tussles with SARS-CoV-2 might leave people more susceptible to other infections in the short or long term. Given the coronavirus’s widespread effects on the body, “we can’t be cavalier” about that possibility, says Flor Muñoz Rivas, a pediatrician at Baylor College of Medicine. Mejias and Octavio Ramilo, also at Nationwide, recently found that among a small group of infants, those with recent SARS-CoV-2 infections seemed to have a rougher go with a subsequent bout of RSV. The trend needs more study, though; it’s not clear which kids might be at higher risk, and Mejias doubts that the effect would last more than a few months.

    Gordon points out that some people may actually benefit from the opposite scenario: A recent brush with SARS-CoV-2 could bolster the body’s immune defenses against a second respiratory invader for a few days or weeks. This phenomenon, called viral interference, wouldn’t halt an outbreak by itself, but it’s thought to be part of the reason waves of respiratory disease don’t usually spike simultaneously: The presence of one microbe can sometimes crowd others out. Some experts think last year’s record-breaking Omicron spike helped punt a would-be winter flu epidemic to the spring.

    Even if all of these variables were better understood, the vagaries of viral evolution could introduce a plot twist. A new variant of SARS-CoV-2 may yet emerge; a novel strain of flu could cause a pandemic of its own. RSV, for its part, is not thought to be as quick to shape-shift, but the virus’s genetics are not well studied. Mejias and Ramilo’s data suggest that the arrival of a gnarly RSV strain in 2019 may have pushed local hospitalizations past their usual highs.

    Read: Will we get Omicron’d again?

    Behavioral and infrastructural factors could cloud the forecast as well. Health-care workers vacated their posts in droves during the pandemic, and many hospitals’ pediatric-bed capacity has shrunk, leaving supply grossly inadequate to address current demand. COVID-vaccination rates in little kids also remain abysmal, and many pediatricians are worried that anti-vaccine sentiment could stymie the delivery of other routine immunizations, including those against flu. Even temporary delays in vaccination can have an effect: Muñoz Rivas points out that the flu’s early arrival this year, ahead of when many people signed up for their shot, may now be aiding the virus’s spread. The new treatments and vaccines for RSV “could really, really help,” Nakamura told me, but “only if we use them.”

    Next fall comes with few guarantees: The seasonal schedule may not rectify itself; viruses may not give us an evolutionary pass. Our immune system will likely be better-prepared to fend off flu, RSV, rhinovirus, enterovirus, and more—but that may not be enough on its own. What we can control, though, is how we choose to arm ourselves. The past few years proved that the world does know how to drive down rates of respiratory disease. “We had so little contagion during the time we were trying to keep COVID at bay,” Edwards told me. “Is there something to be learned?”

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    Katherine J. Wu

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  • How Election Denial Lost

    How Election Denial Lost

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    Outside the Maricopa County tabulation center last weekend, a few dozen outraged Arizonans paced single file along the sidewalk waving KARI LAKE flags. Through megaphones, some of them denounced imaginary corruption schemes and clamored for a “redo” election. Others chanted the Lord’s Prayer, like the musicians on the Titanic playing hymns to calm the passengers.

    The noteworthy thing about the Maricopa protest, though, wasn’t the scene. It was its singularity. Two years ago, shouts of “Stop the steal!” could be heard across the country in nearly every state. This year, the refrain was largely limited to one block in downtown Phoenix, where at times reporters outnumbered the demonstrators.

    If any state was going to devolve into chaos after a disappointing election for Republicans, it would have been Arizona—ground zero for election denial in 2020, and where this year, primary voters nominated an entire slate of fringe election cranks to all of the state’s major offices. Instead, the midterms delivered a sure blow to the election-denial movement, both there and everywhere else: The most prominent conspiracists, such as the Arizona secretary-of-state candidate Mark Finchem and Pennsylvania’s Doug Mastriano, lost by significant margins; some of these candidates even acknowledged their losses by—surprise!—actually conceding. On Monday night, Lake was declared the loser in her race for Arizona’s governorship, adding a final note to what has seemed like a comprehensive repudiation of the denialists. And where experts and reporters had anticipated widespread election-fraud mayhem, nothing close to it has yet emerged.

    Read: In Arizona, shouts of ‘fraud’ again

    It would be foolish, though, to pronounce “Stop the Steal” dead. The movement may have fizzled without Donald Trump, but if he runs again in 2024, we haven’t seen the last of it. Even if Trump isn’t on the ballot, an entire swath of the Republican Party is now open to the idea that any narrow loss can be blamed on fraud. Trust in elections among rank-and-file GOP voters remains low, and in some respects has gotten worse, according to a recent survey from the Pew Research Center. The damage inflicted in 2020 endures. “He’s broken the seal,” Sarah Longwell, the publisher of The Bulwark, told me. Election denial “is part of our politics now.”

    Things could have been so much worse.

    Ahead of the election, poll workers in Arizona and beyond feared for their safety, and the Lawyers’ Committee for Civil Rights Under Law reported an uptick in calls to its Election Protection hotline. In the Phoenix suburbs, armed men were patrolling ballot drop-off sites. The day before the election, I watched a group of women stake out a ballot box, studying voters through binoculars for signs of cheating. The central counting facility in downtown Phoenix was fenced off with a ring of plastic Jersey barriers, and police patrolled the streets on horseback.

    Election officials in Maricopa County, who appeared very tightly wound, held a press conference to get ahead of any potential claims of election chicanery. A time-consuming vote count does not indicate fraud, they reminded the room full of reporters; ballots are processed and reviewed by bipartisan teams; tabulation machines work.

    Unfortunately, events on Election Day quickly undermined those careful efforts at reassurance. The sun had not yet risen when the first handful of tabulation machines stopped reading ballots. By midday, dozens of machines were malfunctioning at polling sites throughout the county. Voters at those sites were told to feed their ballots into “Door 3,” a regrettably sinister-sounding name for a secure slot that would sort the misread ballots to be counted later. And they would be counted later, as officials reassured voters in a series of follow-up press conferences.

    Read: Trumpism has found its leading lady

    Voters I spoke with were understandably confused and frustrated. And the malfunctioning machines had state GOP leaders immediately taking to Twitter to suggest wrongdoing. “They are incompetent and/or engaging in malfeasance just like in 2020,” GOP Chair Kelli Ward posted. Those complaints spiraled into partisan hysteria as the counting went on. Frustrated MAGA commentators suggested that Maricopa County officials had engaged in outright corruption and “CIVIC TERRORISM.” Finchem accused them of “screwing with the election counts.”

    Still, despite those initial glitches and dark mutterings, Election Day unfolded mostly without threats or funny business. Poll workers weren’t harmed, and voters were, for the most part, not intimidated. Almost everyone on the America First Secretary of State Coalition slate lost last week, including Michigan’s Kristina Karamo, who’d described Democrats as having a “satanic agenda”; Finchem, the mustachioed Oath Keeper of Arizona; and the head of the coalition himself, Nevada’s Jim Marchant.

    Parroting Trump’s election lies got many Republican candidates across the finish line in their primary. Finchem’s repeated election-fraud claims won him a regular spot on Steve Bannon’s War Room podcast. The former president has praised Lake’s commitment to the bit, too, reportedly telling donors that even if asked about the weather, Lake would find a way to bring the conversation back to 2020. But these wild claims proved poisonous to moderates and swing voters—polling suggests that some went to the polls explicitly to vote against deniers. We know this because many Republicans who didn’t traffic in election lies performed well: Brian Kemp beat Stacey Abrams by almost eight points in the Georgia governor’s race. In Florida, Governor Ron DeSantis won reelection by nearly 20 points.

    Fans of democracy can take heart that only 14 out of 94 election deniers won in races for positions that oversee elections, including secretary of state, attorney general, and governor, according to States United Action, a nonpartisan nonprofit that advocates for election integrity. Of those 14, only five candidates were not incumbents. “The movement is still not gaining ground,” Joanna Lydgate, the CEO of States United Action, told me.

    David Frum: Trump lost the midterms. DeSantis won.

    That things didn’t turn out worse is a relief, given the chaos of 2020. But the dynamic of this year’s election was different in a few important ways. Republicans were on the defensive back then: The general election was a national referendum on their president. This year, Trump himself wasn’t on the ballot—whereas, in 2020, he had spent months priming the base to blame polling fraud if he lost. It’s clear now that nobody does Stop the Steal like 45.

    “The thing that gives you power as an election denier is that people believe you, and Trump was able to make people believe him,” Longwell told me. Few other candidates have that power, and none in this midterm election could nationalize the issue as he did in the presidential contest. This time, the GOP had no central character over whom Trump supporters could feel outraged.

    Yet the election-fraud fires that Trump and his allies have fanned for so long will not be easily extinguished. If repeated audits and cold evidence haven’t done enough to deter conspiracists these past two years, then a disappointing midterm cycle won’t dissuade them either.

    Election deniers didn’t win in swing states, but elsewhere they did. Four of them will oversee elections in Indiana, Wyoming, Alabama, and South Dakota. More than 200 Republicans running for Congress and statewide positions who’d questioned the legitimacy of the 2020 election won or retained their office last week, including more than 180 in the House. Other election deniers won at the state level in ultraconservative districts across the country. These ruby-red areas might sink deeper into denial, creating islands where both voters and officials are debilitatingly distrustful of elections.

    Read: ‘Stop the steal’ is a metaphor

    Take Cochise County, Arizona. There, 170 miles southeast of Phoenix, some GOP election officials have been hankering to do a full hand-count audit in the election. Paradoxically, Republican candidates won handily there both this year and in 2020, so no obvious motive for distrusting the results is apparent. But the years-long drumbeat of misinformation from the state GOP chair, Ward, and her allied band of election-fraud kooks have nurtured a deep suspicion of the whole process.

    Republican leaders in Arizona don’t believe in machine tabulation and view hand counts as the purest, most accurate way to tally votes—never mind the extensive evidence that the opposite is true. This year, Cochise County tried to forge ahead with a full hand-count audit, even after a judge ordered local officials not to. Only a timely ruling from the Arizona Supreme Court last week kept them from carrying one out. “What I’ll be doing over the next two years is looking at these counties that have gone really hard to the right,” Jessica Huseman, the editorial director of Votebeat, a nonpartisan election-news outlet, told me. “Because there’s no one to push back.”

    Even in states where election deniers lost, voters have been primed to suspect outcomes they don’t like, glitches they don’t understand, and delays in counting. “If [Lake] doesn’t announce that she’s going to win tonight, we might have to go through like a week or so of shenanigans—the same shenanigans that they pulled in 2020,” Stephen Tenner, a former actor from New York, told me at a lavish GOP Election Night party in Scottsdale. “We’re waiting for it this time; we weren’t ready last time. So we’re going to catch the fraud.”

    Other Republicans I interviewed were less persuaded of the likelihood of fraud, but were comfortable entertaining the idea. “I’d like to go back to same-day voting and paper ballots. There are problems with machines,” a man named William from Phoenix, who declined to give his last name, told me at the party. Would he blame fraud if Republicans lost? I asked. “Well, there were problems with the elections two years ago,” he said, adding that, this time around, Secretary of State Katie Hobbs should have recused herself from official duties during the election. “I would be hesitant to say I thought [this one] was completely honest.”

    Barton Gellman: The impeachment of Joe Biden

    The thing about trust is that it’s painstakingly hard to build and relatively easy to demolish. Election denial is now a chronic wound in America’s body politic, only partially healed, and ready to reopen—red and raw—whenever circumstances permit. Those circumstances may arise sooner rather than later if Trump is on the ballot again in 2024. Even if he isn’t, the former president has already broken the tradition of gracious presidential concessions and peaceful transfers of power. He’s encouraged a populist animus toward institutions that will likely remain a litmus test for future Republican candidates. And more than anything, Trump has created a blueprint for exploiting the messiness and complexity of America’s elections. An audience for this type of exploitation is still out there, if Republicans want to take advantage of it.

    On Monday, after Maricopa County released a decisive batch of ballots that led all major news networks to declare Hobbs the next governor of Arizona, a few members of Team Lake sprang into action to ensure that any ballots with errors were quickly cured. That’s a standard and legitimate procedure in elections, and can be helpful in especially close ones. But other Republicans continued to follow the denialist script. Ward accused Maricopa County of voter suppression. Finchem, the failed secretary-of-state candidate, began to do the impossible calculations. “I should win by 3% and @KariLake should win by 11%,” he tweeted. “If that doesn’t happen you know the real story.”

    Lake’s own account was silent for more than an hour after the networks had called the race. After all of this, would this cycle’s Stop the Steal standard-bearer actually concede? The answer came at 10:30 p.m. eastern, with a simple tweet: “Arizonans know BS when they see it,” Lake wrote.

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    Elaine Godfrey

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  • What’s the One Book That Explains American Politics Today?

    What’s the One Book That Explains American Politics Today?

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    On November 8, as in any election season, voters will be asked to weigh in on issues such as inflation, crime, and gas prices. Battling for their attention are loaded cultural debates over the end of Roe v. Wade and what children should learn in school. But this is no normal midterm cycle: Few American elections in recent memory have been as threatened by the specter of political violence and democratic dissolution as this one. Last week, a man attacked Nancy Pelosi’s husband with a hammer in the couple’s San Francisco home; Donald Trump’s false claim that he was the rightful victor of the 2020 presidential election continues to cast a long shadow over the integrity of the democratic process; hundreds of candidates who deny the legitimacy of Joe Biden’s election will appear on ballots.

    Ahead of the midterms, Atlantic staff and contributors are offering reading suggestions for what feel like unprecedented times. Some of their choices are works of history; others lie more in the realm of theory; some deal with other countries’ systems. But each contains wisdom or insight on a central question: How do we understand the state of American politics today?

    Princeton University Press

    Spin Dictators, by Sergei Guriev and Daniel Treisman

    At first glance, Spin Dictators might not seem relevant to U.S. elections. The book describes new forms of dictatorship based not on fear or terror, but on manipulating media and undermining democratic institutions. To create a mass following, these new dictators set one part of society against another, exacerbating polarization and mutual distrust. Instead of establishing an old-fashioned, top-down cult of personality, they borrow from the entertainment world to build their popularity, relying on their followers to create memes and merchandise celebrating them. Guriev and Treisman’s examples are drawn from places such as Russia, Venezuela, Singapore, and Kazakhstan, but they could be writing about some American politicians too. U.S. voters will find it useful to read this book and then ask themselves whether any of the candidates in their local senatorial or gubernatorial race have explicitly adopted the language and tactics originally created by modern autocrats. — Anne Applebaum

    Read: The bad guys are winning

    The cover of The Age of Reform
    Anchor

    The Age of Reform, by Richard Hofstadter

    History can’t fully explain the present or predict the future, but it can help us understand the patterns of contemporary politics and the likely paths ahead. In 1955, Hofstadter, one of the great American historians of the 20th century, published The Age of Reform—a political and social history of the years 1890 to 1940, the period of populism, progressivism, and the New Deal. Rapid technological change, monopoly power, deep inequality, endemic corruption, mass immigration, nativist demagogues, the transformation of both political parties, repeated efforts at reform, recurring spasms of reaction: Perhaps no other age so resembles our own. Hofstadter is brilliant at analyzing types that feel quite familiar to us today—the crusading urban progressive, the small-town conspiracy theorist. He was a liberal who sympathized with the passion for progress while unsentimentally diagnosing its illiberal ideas and motives. The fevered moralism of that age seems a long way from the paralyzing cynicism of ours. But reading Hofstadter will remind you that reform and reaction not only follow each other, but also often coexist in the same moment; neither ever has the last word. Americans are always dreaming of a better country, and some have actually made it so. — George Packer

    The cover of One Mighty and Irresistible Tide
    W. W. Norton & Co.

    One Mighty and Irresistible Tide, by Jia Lynn Yang

    Our broken immigration system has been a favorite topic of Republicans on the stump during this midterm-election cycle. But many voters are struggling to understand how Congress has failed for decades to fix it, particularly when the fate of Dreamers—people who were brought to the United States illegally as children—has been unresolved for more than 10 years, and there is nothing to prevent a future president from reviving the use of family separation as an enforcement tactic. One Mighty and Irresistible Tide provides some helpful explanations by tracing another fraught period in history. Yang, who heads The New York Times’ national desk, vividly profiles key figures, such as the New York Representative Emanuel Celler, in the 40-year battle to repeal the ethnic quotas signed into law in 1924. Celler’s steady fight finally ended in 1965, during the civil-rights movement. It makes an implicit case that the moment some in Congress today seem to be waiting for—one where a universal consensus can be established, and reforming the system carries no political risk—will never come, and that challenging fearmongering rhetoric about immigrants remains as important as ever. — Caitlin Dickerson

    Read: An American catastrophe

    The cover of Devil's Bargain
    Penguin Press

    Devil’s Bargain, by Joshua Green

    How did extremism move from the outer edge of our discourse to the very center of our politics? In the final days before yet another existential election, I’m revisiting Devil’s Bargain. Green, a former senior editor at The Atlantic, was among the first journalists to recognize the unique threat that Steve Bannon posed to the future of the American experiment. Devil’s Bargain chronicles Bannon’s journey from Goldman Sachs to the inner workings of then-candidate Donald Trump’s head. It also illustrates the many ways in which influential money moves around right-wing circles and shapes our democracy. Some critics have accused Green of overstating Bannon’s influence, but five years after the book’s publication, Bannon is neither gone nor forgotten. Although he ultimately served less than a year in Trump’s White House, he was the eventual recipient of a presidential pardon. Last month, he was sentenced to four months in prison for a different offense—defying a subpoena from the January 6 committee. His old boss, meanwhile, appears to be preparing to retake the White House. — John Hendrickson

    The cover of Public Opinion
    Free Press

    Public Opinion, by Walter Lippmann

    One of the best things you can say about Lippmann’s 1922 classic is also one of the worst things you can say about this moment: Public Opinion, at 100, has never been more relevant. Lippmann’s study of the human mind and the body politic, produced in the aftermath of World War I, analyzes the impact of a new mass-media system—on government, on news, on “the pictures in our heads.” It applies the lessons of psychology, then a nascent field, to electoral politics. It warns of how easily propaganda, that evasive weapon of war, can become banal. The book created a lasting lexicon: Lippmann coined stereotype as a category of thought; he discussed mediums and “pseudo-environments” long before other thinkers would expand the concepts; he observed the totalizing power of narrative decades before postmodernists would simulate that idea. Public Opinion saturates political discourse so completely that its insights, today, might seem obvious. In truth, they are ominous. Democracy is the work of minds made manifest; how will it proceed when “the pictures in our heads” are blurred by lies? — Megan Garber

    Read: The paranoid style in American entertainment

    The cover of Crabgrass Frontier
    Credit

    Crabgrass Frontier, by Kenneth T. Jackson

    Jackson’s 1985 work, Crabgrass Frontier, is beloved by urban historians, and it underscores how novel America’s urban geography really is. Prior to 1815, Jackson writes, the suburbs were exactly that—the outlying area of the city, “in every way inferior to the core.” Over the next two centuries, a reversal of fortunes would make single-family homes in peripheral communities crucial to the American Dream. This change reflected and reinforced a new way of life—one where work, home, and play were cleaved from one another; where privacy and the nuclear family became fundamental; and where races and classes were physically separated. The political ramifications remain, visible in the stark differences in the quality of public services in cities and suburbs. Entrenched low-density homeownership has been a primary driver in the segregation that continues to define American life. Ahead of momentous elections, Crabgrass Frontier is a potent reminder that what’s built in one era shapes the next. We are living in a present constructed by people who could never have imagined our lives. As the nation faces an inflection point—a startling shortage of housing, and a dearth of renewable-energy and mass-transit infrastructure, all in the face of climate emergency—what policy makers build today will determine the fate of our descendants.  — Jerusalem Demsas

    The cover of The Man Who Ran Washington
    Vintage

    The Man Who Ran Washington, by Peter Baker and Susan Glasser

    James Baker is no longer a power player in Washington. The former secretary of state’s  influence peaked during the presidencies of Ronald Reagan and George H. W. Bush, two leaders whom the Trump wing of the Republican Party has all but renounced. Yet the journalists Baker (unrelated) and Glasser show that Baker, despite thinking himself above the fray, is not so out of place in Donald Trump’s GOP after all. Baker, now 92, wants to be remembered as a statesman, not as a campaign operative. But his most durable legacy might be his contributions to a party whose zeal for winning and holding power at nearly any cost has overtaken its commitment to ideology and principle. The authors smartly frame Baker’s story around his late-in-life struggle over whether to vote for Trump, a man he plainly can’t stand personally or politically. But Baker, clinging to the hope that even in his late 80s he might stay relevant in Washington, ultimately chose party loyalty. He appears now as more of a precursor to our fraught political moment than a throwback to a more genteel one. — Russell Berman

    ​​When you buy a book using a link on this page, we receive a commission. Thank you for supporting The Atlantic.

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    Emma Sarappo

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  • It’s Gotten Awkward to Wear a Mask

    It’s Gotten Awkward to Wear a Mask

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    Last week, just a couple of hours into a house-sitting stint in Massachusetts for my cousin and his wife, I received from them a flummoxed text: “Dude,” it read. “We are the only people in masks.” Upon arriving at the airport, and then boarding their flight, they’d been shocked to find themselves virtually alone in wearing masks of any kind. On another trip they’d taken to Hawaii in July, they told me, long after coverings became optional on planes, some 80 percent of people on their flight had been masking up. This time, though? “We are like the odd man out.”

    Being outside of the current norm “does not bother us,” my cousin’s wife said in another text, despite stares from some of the other passengers. But the about-face my cousin and his wife identified does mark a new phase of the pandemic, even if it’s one that has long been playing out in fits and starts. Months after the vanishing of most masking mandates, mask wearing has been relegated to a sharply shrinking sector of society. It has become, once again, a peculiar thing to do.

    “If you notice, no one’s wearing masks,” President Joe Biden declared last month on 60 Minutes. That’s an overstatement, but not by much: According to the COVID States Project, a large-scale national survey on pandemic-mitigation behaviors, the masking rate among Americans bounced between around 50 and 80 percent over the first two years of the pandemic. But since this past winter, it’s been in a slide; the project’s most recent data, collected in September, found that just 29 percent have been wearing masks outside the home. This trend may be long-standing on the population level, but for individuals—and particularly for those who still wear masks, such as my cousin and his wife—it can lead to moments of abrupt self-consciousness. “It feels like it’s something that now needs an explanation,” Fiona Lowenstein, a journalist and COVID long-hauler based in Los Angeles, told me. “It’s like showing up in a weird hat, and you have to explain why you’re wearing it.”

    Now that most Americans can access COVID vaccines and treatments that slash the risk of severe disease and death, plenty of people have made informed decisions to relax on masking—and feel totally at ease with their behavior while paying others’ little mind. Some are no longer masking all the time but will do so if it makes others feel more comfortable; others are still navigating new patterns, trying to stay flexible amid fluctuating risk. Saskia Popescu, an infectious-disease epidemiologist at George Mason University, told me that she’s now more likely to doff her mask while dining or working out indoors, but that she leaves it on when she travels. And when she does decide to cover up, she said, she’s “definitely felt like more of an outlier.”

    For some, like my cousin and his wife, that shift feels slightly jarring. For others, though, it feels more momentous. High-filtration masks are one of the few measures that can reliably tamp down on infection and transmission across populations, and they’re still embraced by many parents of newborns too young for vaccines, by people who are immunocompromised and those who care for them, and by those who want to minimize their risk of developing long COVID, which can’t be staved off by vaccines and treatments alone. Theresa Chapple-McGruder, the public-health director for Oak Park, Illinois, plans to keep her family masking at least until her baby son is old enough to receive his first COVID shots. In the meantime, though, they’ve certainly been feeling the pressure to conform. “People often tell me, ‘It’s okay, you can take your mask off here,’” Chapple-McGruder told me; teachers at the local elementary school have said similar things to her young daughters. Meghan McCoy, a former doctor in New Hampshire who takes immunosuppressive medications for psoriatic arthritis and has ME/CFS, has also been feeling “the pressure to take the mask off,” she told me—at her kid’s Girl Scout troop meetings, during trips to the eye doctor. “You can feel when you’re the only one doing something,” McCoy said. “It’s noticeable.”

    Read: Mask mandates are illogical. So what?

    For Chapple-McGruder, McCoy, and plenty of others, the gradual decline in masking creates new challenges. For one thing, the rarer the practice, the tougher it is for still-masking individuals to minimize their exposures. “One-way masking is a lot less effective,” says Gabriel San Emeterio, a social worker at Hunter College who is living with HIV and ME/CFS. And the less common masking gets, the more conspicuous it becomes. “If most people met me, they wouldn’t know I was immunocompromised,” McCoy told me. “There’s no big sign on our foreheads that says ‘this person doesn’t have a functioning immune system.’” But now, she said, “masks have kind of become that sign.”

    Aparna Nair, a historian and disability scholar at the University of Oklahoma who has epilepsy, told me that she thinks masks are becoming somewhat analogous to wheelchairs, prosthetics, hearing aids, and her own seizure-alert dog, Charlie: visible tools and technologies that invite compassion, but also skepticism, condescension, and invasive questions. During a recent rideshare, she told me, her driver started ranting that her mask was unnecessary and ineffective—just part of a “conspiracy.” His tone was so angry, Nair said, that she began to be afraid. She tried to make him understand her situation: I’ve been chronically ill for three decades; I’d rather not fall sick; better to be safe than sorry. But she said that her driver seemed unswayed and continued to mutter furiously under his breath for the duration of the ride. Situations of that kind—where she has to litigate her right to wear a mask—have been getting more common, Nair told me.

    Masking has been weighed down with symbolic meaning since the start of the pandemic, with some calling it a sign of weakness and others a vehicle for state control. Americans have been violently attacked for wearing masks and also for not wearing them. But for a long time, these tensions were set against the backdrop of majority masking nationwide. Local mask mandates were in place, and most scientific experts wore and championed them in public. With many of those infrastructural supports and signals now gone, masking has rapidly become a minority behavior—and people who are still masking told me that that inversion only makes the tension worse.

    San Emeterio, who wears a vented respirator when they travel, recently experienced a round of heckling from a group of men at an airport, who started to stare, laugh, and point. Oh my god, look at what he’s wearing, San Emeterio recalls the strangers saying. “They clearly meant for me to hear it,” San Emeterio told me. “It didn’t make me feel great.” Alex Mawdsley, the 14-year-old son of an immunocompromised physician in Chicago, is one of just a handful of kids at his middle school who are still masking up. Since the start of the academic year, he’s been getting flak from several of his classmates “at least once a week,” he told me: “They’re like ‘You’re not gonna get COVID from me’ and ‘Why are you still wearing that? You don’t need it anymore.’”

    Alex’s mother, Emily Landon, told me she’s been shaken by the gawks and leers she now receives for masking. Even prior to the pandemic, and before she was diagnosed with rheumatoid arthritis and began taking immunosuppressive drugs, she considered herself something of a hygiene stan; she always took care to step back from the sneezy and sniffy, and to wipe down tray tables on planes. “And it was never a big deal,” she said.

    Read: Put your face in airplane mode

    It hasn’t helped that the donning of masks has been repeatedly linked to chaos and crisis—and their removal, to triumph. Early messaging about vaccines strongly implied that the casting away of masks could be a kind of post-immunization reward. In February, CDC Director Rochelle Walensky described masks as “the scarlet letter of this pandemic.” Two months later, when the administration lifted its requirements for masking on public transportation, passengers on planes ripped off their coverings mid-flight and cheered.

    To reclaim a mask-free version of “normalcy,” then, may seem like reverting to a past that was safer, more peaceful. The past few years “have been mentally and emotionally exhausting,” Linda Tropp, a social psychologist at the University of Massachusetts at Amherst, told me. Discarding masks may feel like jettisoning a bad memory, whereas clinging to them reminds people of an experience they desperately want to leave behind. For some members of the maskless majority, feeling like “the normal ones” again could even serve to legitimize insulting, dismissive, or aggressive behavior toward others, says Markus Kemmelmeier, a social psychologist at the University of Nevada at Reno.

    It’s unclear how the masking discourse might evolve from here. Kemmelmeier told me he’s optimistic that the vitriol will fade as people settle into a new chapter of their coexistence with COVID. Many others, though, aren’t so hopeful, given the way the situation has unfolded thus far. “There’s this feeling of being left behind while everyone else moves on,” Lowenstein, the Los Angeles journalist and long-hauler, told me. Lowenstein and others are now missing out on opportunities, they told me, that others are easily reintegrating back into their lives: social gatherings, doctor’s appointments, trips to visit family they haven’t seen in months or more than a year. “I’d feel like I could go on longer this way,” Lowenstein said, if more of society were in it together.

    Americans’ fraught relationship with masks “didn’t have to be like this,” Tropp told me—perhaps if the country had avoided politicizing the practice early on, perhaps if there had been more emphasis on collective acts of good. Other parts of the world, certainly, have weathered shifting masking norms with less strife. A couple of weeks ago, my mother got in touch with me from one such place: Taiwan, where she grew up. Masking was still quite common in public spaces, she told me in a text message, even where it wasn’t mandated. When I asked her why, she seemed almost surprised: Why not?

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    Katherine J. Wu

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  • Polio Is Exploiting a Very Human Weakness

    Polio Is Exploiting a Very Human Weakness

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    In 1988, the World Health Assembly announced a very ambitious goal: Polio was to be vanquished by the year 2000. It was a reach, sure, but feasible. Although highly infectious, polioviruses affect only people, and don’t hide out in wild animals; with two extraordinarily effective vaccines in regular use, they should be possible to snuff out. Thanks to a global inoculation campaign, infections had, for years, been going down, down, down.

    But 2000 came and went, as did a second deadline, in 2005, and a third, in 2012, and so on. The world will almost certainly miss an upcoming target at the end of 2023 too. In theory, eradication is still in sight: The virus remains endemic in just two countries—Pakistan and Afghanistan—and two of the three types of wild poliovirus that once troubled humanity are gone. And yet, polio cases are creeping up in several countries that had eliminated them, including the United Kingdom, Israel, and the United States. Earlier this year, New York detected America’s first paralytic polio case in nearly a decade; last week, the governor declared a state of emergency over a fast-ballooning outbreak.

    This is the cruel logic of viruses: Give them enough time—leave enough hosts for them to infect—and they will eventually find a way to spread again. “You have to stop transmission everywhere, all at the same time,” says Kimberly Thompson, a health economist and the president of the nonprofit Kid Risk. Which means eradication will demand a near-perfect syncing of vaccine supply, access, equity, political will, public enthusiasm, and more. To beat the virus, population immunity must outlast it.

    Right now, though, the world’s immunological shield is too porous to stop polio’s spread. At the center of the new epidemics are vaccine-derived polioviruses that have begun to paralyze unimmunized people in places where immunity is low—a snag in the eradication campaign that also happens to be tightly linked to one of its most essential tools. Vaccine performance has always depended on both technology and human behavior. But in this case especially, because of the nature of the foe at hand, those twin pillars must line up as precisely as possible or risk a further backslide into a dangerous past.

    In the grand plan for eradication, our two primary polio vaccines were always meant to complement each other. One, an ultra-effective oral formulation, is powerful and long-lasting enough to quash wild-poliovirus transmission—the perfect “workhorse” for a global vaccination campaign, says Adam Lauring, an evolutionary virologist at the University of Michigan. The other, a supersafe injectable, sweeps in after its colleague has halted outbreaks one country at a time, maintaining a high level of immunity in post-elimination nations while the rest of the world catches up.

    For decades, the shot, chaser approach found remarkable success. In the 1980s, wild poliovirus struck an estimated 300,000 to 400,000 people each year; by 2021, the numbers had plummeted to single digits. But recently, as vaccine coverage in various countries has stalled or slipped, the loopholes in this vaccination tactic have begun to show themselves and grow.

    The oral polio vaccine (OPV), delivered as drops in the mouth, is one of the most effective inoculations in the world’s roster. It contains weakened forms of polioviruses that have been altered away from their paralysis-causing forms but still mimic a wild infection so well that they can stop people from spreading wild pathogens for years, even decades. In the weeks after people receive the vaccine, they can also pass the weakened virus to others in the community, helping protect them too. And OPV’s transportability, low price point, and ease of administration make it a “gold standard for outbreak interruption,” says Ananda Bandyopadhyay, the deputy director for the polio team at the Bill & Melinda Gates Foundation. Since its mid-20th-century debut, OPV has helped dozens of countries—including the U.S.—eliminate the virus. Those nations were then able to phase out OPV and switch to inoculating people with the injected vaccine.

    But OPV’s most potent superpower is also its greatest weakness. Given enough time and opportunity to spread and reproduce, the neutered virus within the vaccine can regain the ability to invade the nervous system and cause paralysis in unvaccinated or immunocompromised people (or in very, very rare cases, the vaccine recipient themselves). Just a small handful of genetic modifications—three or fewer—can spark a reversion, and the mutants, which are “better at replicating” than their kin, can take over fast, says Raul Andino, a virologist at UC San Francisco. In recent years, a few thousand cases of vaccine-derived polio have been detected around the world, far outstripping the toll of wild viruses; dozens of countries, the U.S. now among them, are battling such outbreaks, and the numbers seem to be only going up. Vaccine-derived polio is still a true rarity: Billions of oral vaccines have been delivered since the global campaign began. But it underscores “the real problem” with OPV, Lauring told me. “You’re fighting fire with fire.”

    Read: The epidemic that preyed on children

    The injected polio vaccine, or IPV, which contains only chemically inactivated versions of the virus, carries none of that risk. To purge all polio cases, “you have to stop using oral polio vaccine,” Thompson told me, and transition the entire globe to IPV. (Post-eradication, countries would need to keep IPV in their routine immunization schedule for at least 10 years, experts have said.) But the injected vaccine has a different drawback. Although the shot can very effectively stave off paralysis, IPV doesn’t elicit the kind of immunity that stops people from getting infected with polioviruses and then passing them on. In places that rely on injected vaccines, “even immune individuals can participate in transmission,” Thompson told me. Which opens up a vulnerability when too many people have skipped both types of vaccines: Paralyzing polioviruses erupt out of communities where the oral vaccine is still in use—then can spread in undervaccinated areas. It might be tempting to blame OPV for our troubles. But that’s not the main threat, Bandyopadhyay told me. “It’s the lack of adequate vaccination.”

    As things stand, the goal in the endemic countries of Pakistan and Afghanistan remains achieving sufficiently high vaccine coverage, Bandyopadhyay said. But many of the communities in these nations are rural or nomadic, and tough to reach even with convenient drop-in-the-mouth vaccines. Civil and political unrest, misinformation, natural disasters, and most recently, the COVID pandemic have raised additional hurdles. So have intermittent bans on house-to-house vaccination in Afghanistan, says John Vertefeuille, the chief of the polio-eradication branch at the CDC. Cases of wild polio have experienced a recent jump in Pakistan, and have also been imported into the non-endemic countries of Malawi and Mozambique.

    But the toll of those outbreaks—all featuring type 1 polio—currently pales in comparison with those featuring vaccine-derived type 2. The last case of wild type 2 polio was detected in 1999, but that version of the virus has persisted in its modified form in oral polio vaccines. And when it reverts to its dangerous form, it gains particularly infectious oomph, allowing it to spread unchecked wherever immunity is low. Some 30 countries around the world are battling outbreaks of poliovirus whose origin can be traced back to the oral inoculations; vaccine-derived type 2 is what’s been circulating in Jerusalem, London, and New York, where it ultimately paralyzed an unvaccinated young man. The extent to which the virus is churning in other parts of the country isn’t fully known; routine immunization has dropped since the COVID pandemic’s start, and the U.S. hasn’t regularly surveyed its wastewater for the pathogen.

    The success of these vaccine-derived viruses is largely the result of our own hubris—of a failure, experts told me, to sync the world’s efforts. In 2016, 17 years after the last wild type-2 case had been seen, officials decided to pivot to a new version of OPV that would protect against just types 1 and 3, a sort of trial run for the eventual obsolescence of OPV. But the move may have been premature. The switch wasn’t coordinated enough; in too many pockets of the world, type-2 polio, from the three-part oral vaccine, was still moseying about. The result was disastrous. “We opened up an immunity gap,” Thompson told me. Into it, fast-mutating vaccine-derived type-2 viruses spilled, surging onto a global landscape populated with growing numbers of children who lacked protection against it.

    A new oral vaccine, listed for emergency use by the WHO in 2020, could help get the global campaign back on track. The fresh formulation, developed in part by Andino and his colleagues, still relies on the immunity-boosting powers of weakened, replicating polioviruses. But the pathogens within have had their genetic blueprints further tweaked. “We mucked around” with the structure of poliovirus, Andino told me, and figured out a way to make a modified version of type 2 that’s far stabler. It’s much less likely to mutate away from its domesticated, non-paralyzing state, or swap genes with related viruses that could grant the same gifts.

    Technologically, the new oral vaccine, nicknamed nOPV2, seems to be as close to a slam dunk as immunizations can get. “To me, it’s just super cool,” Lauring told me. “You keep all the good things about OPV but mitigate this evolutionary risk.” In the year and a half since the vaccine’s world premiere, some 450 million doses of nOPV2 have found their way into children in 22 countries—and a whopping zero cases of vaccine-derived paralysis have followed.

    But nOPV2 is “not a silver bullet,” Andino said. The vaccine covers just one of the three poliovirus types, which means it can’t yet fully replace the original oral recipe. (Trials for type-1 and -3 versions are ongoing, and even after those recipes are ready for prime time, researchers will have to confirm that the vaccine still works as expected when the three recipes are mixed.) The vaccine’s precise clinical costs are also still a shade unclear. nOPV2 is a safer oral polio vaccine, but it’s still an oral polio vaccine, chock-full of active viral particles. “You can think of it as more attenuated,” Thompson said. “But I don’t think anybody expects that it won’t have any potential to evolve.” And nOPV2’s existence doesn’t change the fact that the world will still have to undergo a total, coordinated switch to IPV before eradication is won.

    As has been the case with COVID vaccines, and so many others, the primary problem isn’t the technology at all—but how humans have deployed it, or failed to. “Vaccine sitting in a vial, no matter how genetically stable and how effective it is, that’s not going to solve the problem of the outbreaks,” Bandyopadhyay said. “It’s really vaccination and getting to that last child in that last community.”

    Read: How the poor get blamed for disease

    If dwindling vaccination trends don’t reverse, even our current vaccination strategies could require a rough reboot. In 2013, health officials in Israel—which had, for years prior, run a successful IPV-only campaign for its children—detected wild type-1 virus, imported from abroad, in the country’s sewage, and decided to roll out another round of oral vaccines to kids under 10. Within a few weeks, nearly 80 percent of the targeted population had gotten a dose. Even “polio-free countries are not polio-risk-free,” Bandyopadhyay told me. The situation in New York is different, in part because type-1 polio causes paralysis more often than type-2 does. But should circumstances grow more dire—should substantial outbreaks start elsewhere in the country, should the nation fail to bring IPV coverage back to properly protective levels—America, too, “may have to consider adding OPV as a supplement,” says Purvi Parikh, an immunologist and a physician at NYU, “especially in rural areas” where emergency injected-vaccine campaigns may be tough. Such an approach would be a pretty extreme move, and a “very big political undertaking,” Thompson said, requiring a pivot back to a vaccine that was phased out of use decades ago. And even then, there’s no guarantee that Americans would take the offered oral drops.

    The CDC, for now, is not eager for such a change. Noting that most people in the U.S. are vaccinated against polio, Katherina Grusich, an agency spokesperson, told me that the CDC has no plans to add OPV or nOPV to the American regimen. “We are a long way from reaching for that,” she said.

    But this week, the U.S. joined the WHO’s list of about 30 nations with circulating vaccine-derived-poliovirus outbreaks. The country could have avoided this unfortunate honor had it kept shot uptake more uniformly high. It’s true, as Grusich pointed out, that more than 90 percent of young American children have received IPV. But they are not distributed evenly, which opens up vulnerabilities for the virus to exploit. Here, the U.S., in a sense, had one job: maintain its polio-free status while the rest of the world joined in. That it did not is an admonition, and a reminder of how unmerciful the virus can be. Polio, a fast mutator, preys on human negligence; the vaccines that guard against it contain both a form of protection and a catch that reinforces how risky treating these tools as a discretionary measure can be.

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    Katherine J. Wu

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  • Should Your Flu and COVID Shots Go in Different Arms?

    Should Your Flu and COVID Shots Go in Different Arms?

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    At a press briefing earlier this month, Ashish Jha, the White House’s COVID czar, laid out some pretty lofty expectations for America’s immunity this fall. “Millions” of Americans, he said, would be flocking to pharmacies for the newest version of the COVID vaccine in September and October, at the same appointment where they’d get their yearly flu shot. “It’s actually a good idea,” he told the press. “I really believe this is why God gave us two arms.”

    That’s how I got immunized last week at my local CVS: COVID shot on the left, flu shot on the right. I spent the next day or so nursing not one but two achy upper arms. Reaching high shelves was hard; putting on deodorant was worse. And it did make me wonder what would have happened if I’d ignored Jha’s teleological advice and gotten both jabs in the same arm. Maybe my annoyance would have been lessened. Or perhaps the same-side shots would have made the soreness in my left arm way worse. When I posed this puzzle to immunologists, vaccinologists, and pharmacists, I got back a lot of hems and haws. For the millions of Americans who will be getting two-shot appointments by fall’s end, they told me, the choice really does come down to personal preference in the absence of clear data: You’ve just gotta pick a side. Or, you know, two.

    On the one hand (sorry), there are the vaccine double-downers. Sallie Permar, a pediatrician at Weill Cornell Medicine, and Stephanie Langel, an immunologist at Duke University, both said they’d probably get both shots in the same shoulder; so would Rishi Goel, an immunologist at the University of Pennsylvania. “Personally, I’d rather have one arm that’s slightly uncomfortable than both,” Goel told me.

    On the other hand, we’ve got Team Divide-and-Conquer. Several experts said they’d follow the White House protocol of splitting shots left and right. Ali Ellebedy, an immunologist at Washington University in St. Louis, told me he’d prefer to have two slightly sore arms to one totally dead one. Jacinda Abdul-Mutakabbir, a pharmacist at Loma Linda University, says she generally recommends that her patients get the vaccines on separate sides “for comfort.” Last year, she opted to get the flu shot and a COVID booster within a few inches of each other, and “I wanted to chop my arm off,” she told me. “Never again.”

    Read: America’s fall booster plan has a fatal paradox

    The deciding logic here should be pretty intuitive, Permar told me. Two shots on one side might be expected to double how sore that arm will get, though the experience of each vaccine recipient will depend on a bevy of factors, including the ingredients in the shots and that person’s infection and vaccination history, as well as their immune-system health. Also, for people like my husband—who’s prone to very heavy vaccine side effects—the choice may not matter at all. He was so knocked out by the fever and chills that came with his COVID-flu-shot combo, he couldn’t have cared less which arms got the shots.

    I dug around for studies examining the consequences of the one-versus-two-arm choice and found only one: a Canadian trial from 2003, which vaccinated a few hundred sixth-graders at two dozen middle schools against group C meningitis and hepatitis B at the same time. Roughly half the kids got both shots in the same arm; the others received one on each side. (Some kids in the latter group requested that their shots be administered by a pair of nurses who could plunge both syringes at the same time.) Among students in the same-arm group, 18 percent ended up with tenderness at the injection site that they rated “moderate or severe.” But those kids fared better than the ones in the two-arm group, 28 percent of whom experienced moderate or severe tenderness in at least one arm, and 8 percent of whom had it in both arms at the same time.

    But those results apply only to that group of kids in that setting, with those two specific vaccines; there’s no telling whether the same trends would be seen with flu shots and COVID shots when given to children or adults. Michela Locci, an immunologist at the University of Pennsylvania, told me she suspects that combining flu and COVID inoculations in the same arm could actually drive extra side effects: “The overall inflammation might be higher,” she said.

    Many pediatricians, who often have to administer four or five shots to a baby at once, are habitual splitters. “If there’s more than one vaccine syringe to give to a baby, generally, two legs are used,” Permar told me. (Kids usually upgrade to arm shots sometime in toddlerhood—it’s all about finding a muscle that’s big enough for the needle to hit its mark.) Doctors also have a nerdy reason to split shots between arms or legs. “If there’s a local reaction to the vaccine,” Permar said, “you can identify which vaccine it was if you separate them by space.” (For the record, I had a more painful reaction in my left arm, where I got the COVID shot. Others I’ve spoken with have reported the same disparity.)

    Read: Families are going rogue with rapid tests

    The CDC advocates for separating vaccination shots by at least one inch of space. Per the agency, if a COVID shot is being given at the same time as a vaccine “that might be more likely to cause a local injection site reaction,” the shots should be dosed into “different limbs, if possible.” Two types of flu shots cleared for use in people 65 years and older—the high-dose vaccine and the adjuvanted one—fall into that category. But the different-limb advice doesn’t seem to apply to other flu shots, including those cleared for use in younger adults and kids.

    However someone ends up taking simultaneous flu and COVID shots, the placement is unlikely to affect how much protection the vaccines provide. There could be an argument for letting “each side focus on its own thing,” says Gabriel Victora, an immunologist at Rockefeller University. “But it probably doesn’t make a whole lot of difference.” Children routinely get combo vaccines, such as DTaP and MMR, each of which combines multiple disease-fighting ingredients in a single syringe. The triple-threat formulas work just as well as injecting their individual parts. The immune system is used to multitasking: It spends all day being bombarded by microbes, so there’s good reason to believe that with vaccines, too, our body will see simultaneous shots “as independent events,” Goel told me.

    Which arm gets picked for which shot, though, will affect where the jab’s contents end up. After a vaccine is injected, its immunity-inducing ingredients meander to the nearest lymph node, such as the ones in the armpits. There, hordes of immune cells fight over the vaccine’s bits, and the fittest and fiercest among them are selected to leave the lymph node and fight. Here, again, doubling up on one arm shouldn’t be an issue, Goel said: The immune-cell boot camps in these lymph nodes have “a good amount of real estate.”

    It might even be a good idea to stick the same limb—and thereby, the same lymph node—every time you get another dose of a particular vaccine. After immune cells in a lymph node spot a particular bit of pathogen, some of them march off into battle, but others may hang around like reserve troops, mulling over what they’ve learned. A couple of recent studies, one of them in mice, hint that repeated delivery of the same ingredients to those veteran learners could give the body a slight edge—though the extent of that advantage “might be marginal,” Victora told me. Still, Langel, of Duke, told me jokingly that because she usually gets all of her vaccines in her “non-writing” arm, the lymph node beneath it could now be especially superpowered—a “nice bonus” for her defenses on the whole.

    That said, no one should stress too much about getting a shot in the “wrong” arm. “It’s not like you’re immune on the left side and not on the right side,” Goel told me. Immune cells travel throughout the body; there is no midline DMZ. Permar even points out that getting the newly formulated COVID vaccine, which includes new ingredients tailored to fight Omicron subvariants, on the opposite side from the previous rounds could help its ingredients reach a fresher slate of cells. “I think you could convince yourself either way,” she told me. Which, honestly, leaves me totally at peace with my choice. Apart from arm achiness, I had no other side effects—and in a way, I preferred the symmetry of the one-on-each-side injections.

    With all that said, it’s worth briefly acknowledging a third option: Splitting the flu and COVID vaccines into separate visits. I was, before my most recent COVID shot, some 10 months out from my previous dose. But it felt awfully early for my flu shot, which might be better timed for peak protection if taken later in the season. Still, the allure of getting it all over with was too tantalizing, especially because I happen to have a lot of travel up ahead. In the grand scheme of things, the bigger, more important choice was opting into the shots at all.

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    Katherine J. Wu

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  • Trump Returns to Rally Team MAGA

    Trump Returns to Rally Team MAGA

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    WILKES-BARRE, Pa.—Donald Trump’s rally on Saturday night was his first major public appearance since the FBI searched his Florida home—and you could tell. A kind of manic, vengeful energy circulated among the throngs of supporters in the blue stadium seats at the Mohegan Sun Arena. Fans wore T-shirts reading YOU RAIDED THE WRONG PRESIDENT and THREAT TO DEMOCRACY, in a reference to President Joe Biden’s speech last week in Philadelphia. The audience of thousands screamed in agreement when Representative Marjorie Taylor Greene, who’s become a regular warm-up act at these rallies, declared that the FBI had “violated our president’s rights.” And later on, the crowd exploded into one resounding, ricocheting jeer when Trump, finally on stage, addressed the matter himself.

    “There can be no more real example of the very clear threats to American freedom than just a few weeks ago,” the former president said, when “we witnessed one of the most shocking abuses of power we have witnessed from any administration in American history!”

    Trump is back at the forefront of American politics, just two months ahead of the midterm elections. This time, the former president is in a strange new position: He’s backed into a corner by legal trouble. And his ever-loyal fans have joined him in a defensive crouch. “We came because of the Mar-a-Lago raid,” Mike Rutherford, a truck driver from East Stroudsburg, told me. He sat near the stage in a folding chair alongside his wife, Pat. “We’re here to support him,” Pat said, nodding. “I can’t believe how brave that man is.”

    Pennsylvania found itself smack-dab in the eye of the midterms hurricane this week. Trump’s rally was intended to give a boost to the flagging campaigns of the gubernatorial candidate and State Senator Doug Mastriano and the Senate candidate Mehmet Oz, both of whom have endorsed Trump’s election lies and received his endorsement in exchange. Just two days ago, Biden spoke 100 miles to the south before an eerily lit Independence Hall, and was more direct in his warnings than he’s been in previous addresses: “Donald Trump and the MAGA Republicans represent an extremism that threatens the very foundations of our Republic.” The Darth Vader optics of his speech may have interfered with its intended effect, but Trump and the candidates he’s endorsed are a threat to democracy because they appear to believe in only two kinds of election outcomes: Either they win or the system is rigged.

    David Frum: The justification for Biden’s speech

    Pennsylvania has become a hub for “Stop the Steal” candidates thanks, in part, to Mastriano, who spoke ahead of Trump on Saturday night. The Republican state senator and former Army colonel was outside the Capitol when rioters broke in on January 6; he helped lead the state efforts to overturn the presidential election in 2020; and he’s been subpoenaed by the January 6 committee for his alleged involvement in organizing an alternate set of Electoral College electors for Trump. (Last week, Mastriano sued the panel to avoid testifying.)

    Both he and Oz offered versions of their stump speeches and declared solidarity with their party leader in his moment of need on Saturday. Other headliners included Greene, the Georgia representative who’d descended the arena steps earlier in the afternoon as “She’s a Beauty” by the Tubes played over the loudspeakers, and the Pennsylvania congressional candidate Jim Bognet, who quipped that America should hire “87,000 more border patrol agents, not IRS agents!”

    When Trump emerged shortly after 7 p.m., backed by the usual Lee Greenwood soundtrack, he meandered through his standard repertoire: the Russia investigation “hoax,” Biden’s failures, the death penalty for drug dealers. He even managed to encourage a mass heckling of the press seated in the back of the stadium on at least five occasions. But it was Trump’s FBI comments that got the crowd most riled up. “The FBI and the Justice Department have become vicious monsters, controlled by radical-left scoundrels, lawyers, and the media, who tell them what to do,” he told them. Audience members whooped, and a few shouted out “Defund the FBI!”

    The Trump’s fans I’d spoken with earlier, standing near the Dippin’ Dots ice-cream stall and in line for Chickie’s & Pete’s chicken cutlets, all had his back. “It’s politically motivated,” Jim Shaw, a barber from New Milford, told me when I asked what he made of the search at Mar-a-Lago. “If Donald Trump wasn’t looking like he was the [leading] Republican candidate for president, I don’t think it would have happened.” Every one of the dozen or so people I talked with offered some defense of the former president: The search was a setup; the evidence was planted; Biden’s DOJ was trampling on Trump’s constitutional rights to keep him from running for office again.

    Read: ‘Stop the Steal’ is a metaphor

    I detected a touch of desperation in many people’s responses—a sense that, if Trump-endorsed candidates don’t win in November, America as they know it will cease to exist. Here in northeast Pennsylvania—just 20 miles down the road from Biden’s hometown—was a gathering of people not just pessimistic about the future of the country under his leadership, but deeply fearful too. “At this point right now, I’m worried about being targeted by the FBI because I’m a Christian, I’m conservative,” Pat Rutherford said. “I know they won’t find anything, but I am going to need a lawyer to prove I am innocent.” The DOJ “is like a militia for the Democrats,” Linda Hess, from Selinsgrove, told me. “I think our First Amendment rights are basically gone as conservatives. I really do.”

    Trump and his loyalists are eager to fan these fears. “Your president called all of you extremists!” Greene told the rally when she was on stage. “Joe Biden has declared that half of this country are enemies of the state!” (The president, in fact, made a clear distinction: “Not every Republican, not even the majority of Republicans, are MAGA Republicans.”) “Save us, Trump!” one woman yelled from the crowd during his speech.

    Fear can be a winning political tactic. It helped candidates like Mastriano sail to victory in the Republican primary. But general elections are different. The president’s party usually fares poorly in the midterms cycle, and just a few weeks ago, the fundamentals would have indicated that Republicans were about to have an excellent November. Recently, though, the numbers have shifted in the Democrats’ favor. Inflation is down, and so are gas prices; new job numbers are high, and unemployment is still low; and Democrats are already seeing signs that their voters are highly motivated by the overturning of Roe v. Wade. In the latest polls, both Mastriano and Oz are trailing their respective Democratic opponents, Josh Shapiro and John Fetterman.

    Still, 10 weeks is a long time in American politics. Republicans could gain back an edge between now and then. Some experts predict that both races will probably end up much closer than they are now. The risks of electing an election denier such as Mastriano are clear: As governor, he’d have the power to appoint the secretary of state, and together, the two officials could muddy the waters after a close election or, allied with the Republican-dominated state legislature, even change election rules to benefit their party.

    That danger extends far beyond the Keystone State. Other “Stop the Steal” candidates are running all over the country. In 2020 battleground states, candidates who’ve endorsed Trump’s lies about election fraud have won nearly two-thirds of GOP nominations for state and federal offices with election-oversight powers, according to a Washington Post analysis.

    Read: The radical fringe that just went mainstream in Arizona

    Whether these specific candidates win or lose, election denial has become the most important litmus test for the MAGA base. “Stop the Steal” is an expression of a deepening distrust in government and institutions—a mantra to remind its adherents that they, not their political opponents, are the rightful inheritors of America. The phrase is a metaphor, the sociologist Theda Skocpol told me last month, “for the country being taken away from the people who think they should rightfully be setting the tone.”

    When their candidates lose, it can be only through trickery. When their leader is investigated for squirreling away cartons of national secrets at his country club, it’s a targeted attack by the “Regime,” to use Florida Republican Governor Ron DeSantis’s word—and capitalization.

    After Mastriano had finished speaking, and before Trump took to the stage, an elderly white man stood up behind me and shouted, “Whose country is this?” The people nearby in the bleachers joined him in response: “It’s our country!” Later, Trump affirmed the sentiment. “No matter how big or powerful these corrupt radicals may be, you must never forget that this nation does not belong to them,” he told his supporters. “This nation belongs to you!” The people in the stadium roared their approval.

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    Elaine Godfrey

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