While the country's attention is fixed on the rollout of the vaccine and the arrival of a new administration, the coronavirus pandemic rages on. In many parts of the U.S., case counts and deaths are still sky-high. And new variants of the virus are worrying scientists and prompting new restrictions around the globe.
Despite widespread COVID-19 fatigue, public health experts say practicing mitigation strategies is as crucial as ever to save lives. But which strategies have proven most effective?
There is still wide variation in what local and state governments are willing and able to enforce. Should masks be mandated or only encouraged? Should indoor dining be limited or halted? Different places have taken widely different approaches, and this patchwork approach has meant outbreaks keep flaring up again and again.
We know what works to slow the spread, says Dr. Ashish Jha, public health policy researcher and dean of Brown University's School of Public Health. That is, find ways to prevent people from gathering unmasked in indoor spaces for extended periods of time.
But that has been easier said than done in a country that has struggled to balance protecting public health with resuming economic activity.
"Some states have done it, other states have not, and we've seen pretty substantial differences in disease spread across states," Jha says.
Public health experts also note that many of the issues that have hampered states' pandemic response are playing a role in the country's complex and slow-moving vaccine distribution process.
And, they say, vaccines are only part of the solution — state and federal leaders can still take other actions to help save lives.
"If we really cared about people, we wouldn't be waiting for a vaccine," says Dr. Camara Jones, an epidemiologist and past president of the American Public Health Association. "If we really cared about people, the government would do everything in its power to keep people safe right now."
Nearly a year into the pandemic, NPR asked public health experts to reflect on what works — and what doesn't — to control outbreaks. Here's what they say is essential for getting through the current public health crisis — and for preparing for the next one.
Act, and act quickly
Experts agree that when it comes to state actions to slow infections, timing is key.
"Every minute, every day counts," says Sen Pei, a research scientist at Columbia University's Mailman School of Public Health.
Pei coauthored a study that looked at social distancing and other contact-reduction measures across the U.S. between mid-March and early May. It found that introducing the same level of restrictions just one week earlier could have prevented more than 600,000 confirmed cases and 32,000 deaths, with a two-week difference growing those numbers even more.
A two- or three-day delay can double the number of cases during the exponential growth phase of an outbreak, Pei explains.
"It's really necessary to bring down the prevalence in the population to actually control the spreading of the coronavirus," he says. "That's why, initially, you need to take decisive and kind of harsh measures."
Choose smart, targeted restrictions
As communities reopen, Pei says, they should be quick to respond to subsequent surges by reimposing limits on businesses and activities. The longer they wait, the higher the cost, he adds.
Policy decisions drive numbers, says Jennifer Nuzzo, an associate professor of epidemiology and senior scholar at the Johns Hopkins Center for Health Security.
"A fundamental rule is if you do nothing, you will see a rise in cases followed by a rise in hospitalizations followed by a rise in deaths," Nuzzo says.
At this stage in the pandemic, communities don't necessarily all need sweeping stay-at-home orders or sector closures, Nuzzo says. Contact tracing can shed light on where cases are coming from and that can help states and localities respond with targeted interventions rather than by locking everything down.
"I don't think that blunt instrument is a good strategy unless you are in truly dire straits," Dr. Paul Carson, a professor of practice of management of infectious diseases at North Dakota State University, told NPR over email. "We look at the various measures as sort of a thermostat that you dial up or dial down as need demands."
For example, states can selectively cancel large indoor gatherings or reduce the number of people allowed inside restaurants and bars, Pei says. And Nuzzo encourages authorities to think not just about opening or closing places but also about how to make them safer, such as through masking and ventilation.
Ideally, Nuzzo says, states would shut things down when facing a serious surge and use that time to develop a targeted strategy for when cases rise again.
"What happens is we just open and shut, and then we kind of do this halfhearted attempt at contact tracing when we open, so of course the case numbers are going to come back," Nuzzo says. "There's nothing magic about these shutdowns. These are pause buttons, but if you hit play and you don't follow it with anything, it's going to have another resurgence."
Amp up federal support to ensure local efforts succeed
Increased federal funding is key to empowering states' pandemic response, says Jha.
"The biggest thing that has hindered almost every state from acting is the economic costs of putting in restrictions," he says. "The way out of this is for Congress to provide some relief to workers and small businesses," he says.
He adds that for many governors, mandating certain public health best practices can be "very politically painful."
Federal relief from the CARES Act made it relatively easier for states to respond aggressively in April and May, Jha explains.
After months of back-and-forth, Congress passed a second COVID-19 relief bill at the end of December, with provisions including $600 relief checks for many individuals, aid to small businesses and money for vaccine distribution.
And President Biden has unveiled a relief proposal asking for $1.9 trillion in spending. His proposals include raising the federal minimum wage as well as providing billions of dollars for child care assistance, federal nutrition programs, rental assistance and funding for state, local and tribal governments.
Dr. Jody Heymann, director of the UCLA Fielding School of Public Health's WORLD Policy Analysis Center, says the U.S. lacks measures that many other United Nations countries have, such as national paid sick leave, adequate unemployment insurance and income for those who lose work during shutdowns.
"With strong and effective federal action ... states can act more rapidly and decisively without the trade-off being such a high toll," Heymann says.
Heymann says she is confident that people would be more likely to follow health recommendations, such as staying home when exposed to the coronavirus, if such protections existed.
Jones, the former American Public Health Association president, says support such as eviction protections and financial assistance to states and localities would all help, as well as signal that leaders are taking the pandemic seriously.
"If the government paid people to stay at home [when they're sick or exposed], if we protected the people who had to be at work, then we would have no huge forest fire of an infection in this country," Jones says.
Coordinate the national response on key issues
While experts say states and localities should tailor their response to the conditions on the ground, they agree that a coordinated response and certain federal measures are needed. Key among those are a federal plan for vaccine distribution and a national approach to mask-wearing.
Heymann says that while local and state mask mandates are better than nothing, she wants to see a national policy on masks, given the amount of travel across borders. Heymann, like many of the experts interviewed for this story, noted with concern that masks have become politicized but expressed optimism that things will improve under the Biden administration.
Two of Biden's first acts as president were signing executive orders mandating masks on federal property and for interstate travel. And his plans for his first 100 days in office include asking all Americans to wear masks for that time.
Nuzzo points to New York City as an example of the fact that without a nationwide approach to COVID-19 precautions, even places that had been doing relatively well can flare up when the virus rages elsewhere.
States have increasingly implemented their own travel requirements and recommendations, which are inconsistent across the country and hard to enforce. Nuzzo says this makes screening and education measures, like telling travelers where they can get tested, all the more important.
"If you could wall off New York City from the rest of the world, and you wouldn't let anybody come in with the virus — like New Zealand has been able to do because it's an island — I think that would have an important impact," she says. "But I just don't think it's practically feasible in the United States."
Be consistent in public health communication
How can states get more people to take public health precautions? The answer, or a large part of it, lies in better communication.
"One of the first tenets of a crisis is being transparent and having consistent messaging, and we failed at that over and over again," says Dr. Megan Ranney, an emergency medicine physician and Brown University associate professor.
She runs through a list of examples, including: conflicting messages that created confusion; messages that eroded trust in public health by downplaying the threat of the virus, playing up nonexistent cures or injecting partisan politics into science; and responses that failed to take into account the structural racism, economic inequality and urban-rural divisions exacerbated by the pandemic.
Even some scientists, she says, initially fell short of "creating coherent messaging that both acknowledged the uncertainty of the moment and that enabled people to do the best they could to keep themselves and their families safe."
Rita Burke, a professor of clinical preventive medicine at the University of Southern California's Keck School of Medicine, says communication around COVID-19 has been especially challenging because the response comes from multiple agencies.
She stresses the need for one coherent message across the board and for being clear with the public about the science guiding the restrictions.
Replace "personal responsibility" with support for behavior change
Measures like in-home gathering limits and social distancing requirements only work if people actually follow them — and laws do not always lead to changed behaviors.
Dr. Patrick Remington, a professor emeritus in the University of Wisconsin-Madison School of Medicine and Public Health, previously worked as an epidemiologist at the Centers for Disease Control and Prevention. He says a career spent studying public health policy has taught him that laws are typically only effective for the people already inclined to follow a given health recommendation, like wearing seat belts in cars or not smoking indoors.
What really drives behavior, he says, is culture.
And for people whose livelihoods, paychecks and homes are on the line, he says, the cost of certain public health measures may understandably be just too high.
Nuzzo says it's not enough just to tell people they can't do something — they need to provide alternatives.
In California, for example, evidence shows a shutdown of bars prompted a rise in house parties. Like a game of whack-a-mole, Nuzzo says, authorities can't get ahead of the virus without giving people the tools to "maintain some level of normalcy in their lives but to do so more safely."
"So much of their strategy is relying on personal responsibility, and I think that's ultimately a flawed strategy because not all of us can comply at the same level even if we wanted to," Nuzzo says. "But let's assume there are some who can, and aren't. How you talk about it, I think, is important for reaching those people."
Ranney says leaders can learn a lesson from how many colleges handled their fall semester.
After seeing outbreaks in the early weeks of the semester, many turned to what she called the "basics of behavior change theory" to motivate their students to do better.
That means setting norms — in this case, reminding them their community expects a certain kind of behavior — and making it easy to do the right thing, such as by making masks readily available. It also means recognizing people's motivations and making sure their basic needs are met, for instance by providing support for testing and isolation.
She says all this requires carrots as well as sticks. And while society at large is not a campus, she believes these principles hold.
Of course people get fatigued, she says: "You have to recognize that people are going to prioritize getting food on their table and keeping a roof over their heads over following some kind of theoretical public health measure." But then you find ways "to remind them when they're not doing the right thing, and kind of nudge them back," she says.
Make public health responses inclusive
The disproportionate harm the pandemic has inflicted on communities of color has become normalized as the months unfold, Jones says. It's vital to make sure public health responses and messaging are inclusive.
"People of color are more likely to get infected because we're more exposed and less protected, and then once infected, we're more likely to die because we're more burdened by chronic diseases ... with less access to health care," Jones says. "All four of those things are deeply rooted in racism."
The challenges that people face, and risk calculations they make, vary widely, Ranney says
"When we forget to pay attention to the fact ... that different people are going to have different needs both in terms of care delivery and in terms of trustworthy messaging, we fail," says Ranney.
Jones adds that the vaccine rollout and messaging should also prioritize vulnerable populations — including communities of color — who are more likely to be exposed where they live and work.
For example, she suggests broadening the category of long-term care residents to include people who are incarcerated and those who live on highly-isolated reservations or in high-prevalence communities.
And, when it comes to actually choosing to get vaccinated, Jones says it's important to recognize the reasons why people might hesitate, like scientific questions or the history of racism in medicine. The goal should be not to try to convince, she says, but to inform people about the efficacy and safety of the vaccines.
Speed the vaccine rollout with more federal coordination and funding
The same challenges that have hampered the country's pandemic response are also playing out in its sluggish vaccine rollout.
"It's the cheesy old leadership maxim of a failure to plan is a plan to fail, and we failed to plan and we're failing to get vaccines in arms," Ranney says. She notes that each state has its own plan, that none are adequately funded and that vaccine prioritization varies even between hospitals.
As a result, she notes, the public is confused about eligibility and may feel that "vaccines are going to the rich and powerful instead of to those who are most at risk."
The need to vaccinate as many people as quickly as possible is all the more pressing, Ranney says, because of the more transmissible coronavirus variant, which was first discovered in the U.K. and has made its way to the U.S.
There is already urgency, she notes, with around 3,000 U.S. deaths a day and extremely high rates of new infections. But this new variant poses an even greater risk to health care systems, schools and the economy.
She says the virus will continue to mutate, and the longer it takes to get the public vaccinated, the greater the risk of another, more lethal mutation emerging.
"The only protection that we have right now are two things: One is physical distancing and mask-wearing, which we are not doing a good job of, and the other is the vaccine," Ranney says.
Ranney says the solution lies in more money to support efforts like hiring and setting up vaccination clinics, as well as a more flexible approach to distribution in which states aren't so worried about vaccinating everyone in the first subgroup before starting to address the second.
President Biden's plan to jump-start the vaccination campaign — including by distributing 100 million doses in his first 100 days — incorporates some of these elements. It also requires a substantial amount of federal funding.
Prepare now for the next public health emergency
A lack of investment in public health limited the country's ability to respond to the pandemic from the very beginning, experts say. It's not too late to boost our efforts in the short term and to start investing in the future so we're never caught as unprepared again.
"You cannot wait until there's a problem to invest in science and public health," says Ranney. "What we saw during this pandemic was everybody scrambling to set up communication, to set up data systems, to set up supply chains, and these things can't be set up effectively overnight."
On the other hand, she says, the U.S. has seen success in areas that receive longer-term funding and commitment, like scientific research.
"We have vaccines in less than a year not because of some miracle of science but because of a decade-plus of research into mRNA," Ranney says. "Science and public health work, but it can't be created out of thin air."
Countries that have developed a strong COVID-19 response all have strong digital infrastructures for monitoring and detecting the early spread of disease in order to implement preventive measures, Ranney says, in contrast to the U.S., where certain places still rely on faxes and paper tracking of test results and contact tracing.
Experts say the country needs to reinvest in public health by increasing budgets and promoting science.
Many public health departments were underfunded and understaffed even before the pandemic hit, leaving them ill-equipped to carry out operations like contact tracing, Nuzzo says. That's why having resources in place is so crucial, she says.
"We don't shut down firehouses just because there hasn't been a fire in a community for a year," Nuzzo says. "And [it's] the same thing for public health."
Ranney notes that a number of public health officials have quit during the pandemic after being the target of vitriol. State and national leaders set local and state health departments up to fail when they don't take scientific evidence seriously, she argues.
The next few months will see a ramping up of public health infrastructure if Biden's COVID-19 relief plans become a reality. Key elements of his administration's strategy include creating more large-scale vaccination sites, hiring 100,000 new community health workers and launching a major public education campaign.
But while the pandemic may be the country's most pressing public health problem, it's not the only one.
"I don't want us to lose sight of the fact that there are other coexisting epidemics in this country that are worsening during COVID-19," Ranney says, pointing to issues like opioid abuse and preventable chronic diseases.
A lot of the infrastructure required to meet the needs of the pandemic — systems set up to help with vaccine rollout and increased funding for public health departments — can be repurposed to deal with these other issues, Ranney points out.
Nuzzo says that once the country is no longer reacting to the pandemic, it should take stock of its experience in order to better prepare for the next inevitable public health emergency.
"This is not going to be the last situation we go through, it may not even be the worst," she says. "We absolutely need to make sure we have the resources to act when and if the next thing happens, and keep them in place."