President Donald Trump’s speech on Thursday — and the events surrounding the Republican National Convention in general — at times came off as a celebration: a series of rhetorical monuments to a president who, based on what he and his supporters said, had triumphantly carried America through one of its best periods.

It’s an image that’s been hard to reconcile with Trump’s actual record. Under Trump, the economy is tanking. The country is in the throes of widespread unrest, as Black Lives Matter protests and related riots continue. The murder rate in large cities has spiked, and the opioid epidemic continues.

And more than 180,000 Americans have so far died from Covid-19.

The contradiction was perfectly captured by this photo posted on Twitter by USA Today reporter Matt Brown, in which protesters pointing out America’s massive Covid-19 death toll stood in front of the Republican convention’s fireworks show:

It’s a moment that encapsulates what amounted to a week of gaslighting on Covid-19 by Trump and the Republican convention — an attempt to make America think that a president who had so clearly failed had in fact won a victory for the US.

Experts, and the data, tell a very different story than what Trump tried to suggest.

For one, Trump’s performance on Covid-19 really has been a disaster. When the coronavirus first reached America, Trump was slow to react, instead suggesting that the virus would suddenly disappear “like a miracle.” Once states began locking down, Trump pushed them to reopen too early and too quickly — to “LIBERATE” themselves from economic calamity. His administration was slow to expand the US’s testing capacity, instead punting the issue to local, state, and private actors. As his administration suggested people wear masks in public, Trump said it was a personal choice, refused to wear a mask himself, and claimed people wear masks to spite him. Instead of offering calm, collected messaging during a crisis, Trump was erratic — at one point musing about people injecting bleach to treat Covid-19.

The result: America stands out as the one developed country, with the possible exception of Spain, that not only failed to prevent a massive coronavirus outbreak when it first arrived in the spring, but has continued to struggle deep into the summer. So while many other developed nations, from Germany to South Korea, see their lives inch back to normal, America continues to see high numbers of Covid-19 cases and deaths.

It’s a uniquely bad position, as this chart of Covid-19 deaths in developed nations shows:

That failure on Covid-19 “begins in many ways, and you could argue it ends in many ways, with the Trump administration,” Ashish Jha, faculty director of the Harvard Global Health Institute, told me. “If George W. Bush had been president, if John McCain had been president, if Mitt Romney had been president, this would have looked very different.”

But in a reelection campaign, Trump wants to do everything he can to mask his failure. So we get a strangely celebratory convention when there isn’t much to celebrate in America.

For more on Trump’s failure on Covid-19, read Vox’s full explainer.

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Earth is now in the middle of a mass extinction, the sixth one in the planet’s history, according to scientists.

And now a new study reports that species are going extinct hundreds or thousands of times faster than the expected rate.

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The researchers also found that one extinction can cause ripple effects throughout an ecosystem, leaving other species vulnerable to the same fate. “Extinction breeds extinctions,” they write in their June 1 paper in the Proceedings of the National Academy of Sciences.

With the accelerating pace of destruction, scientists are racing to understand these fragile bits of life before they’re gone. “This means that the opportunity we have to study and save them will be far greater over the next few decades than ever again,” said Peter Raven, a coauthor of the study and a professor emeritus of botany at Washington University in St. Louis, in an email.

The findings also highlight how life can interact in unexpected ways and how difficult it can be to slow ecological destruction once it starts. “It’s similar to climate change; once it gets rolling, it gets harder and harder to unwind,” said Noah Greenwald, the endangered species director for the Center for Biological Diversity, who was not involved in the study. “We don’t know what the tipping points are, and that’s scary.”

It’s worth pausing to reflect on what “extinction” means: a species completely and forever lost. Each one is an irreparable event, so the idea that they are not only happening more often but also might be sparking additional, related extinctions is startling. And these extinctions have consequences for humanity, from the losses of critical pollinators that fertilize crops to absent predators that would otherwise keep disease-spreading animals in check.

So researchers are now looking closely at which animals are teetering on the edge of existence to see just how dire the situation has become, and to figure out what might be the best way to bring them back.

Hundreds of animals are on the brink of extinction over the next two decades

There is tremendous biodiversity on earth right now. The number of species — birds, trees, ferns, fungi, fish, insects, mammals — is greater than it ever has been in the 4.5 billion-year existence of this planet. But that also means there is a lot to lose.

The new study examined 29,400 species of vertebrates that live on land — mice, hawks, hippos, snakes, and the like. These species from all over the world were cataloged by the International Union for Conservation of Nature.

Out of those examined, 515 species — 1.7 percent of those studied — were found to be on the brink of extinction, meaning fewer than 1,000 individuals were left alive. These species include the vaquita, the Clarion island wren, and the Sumatran rhino. And half of these 515 species have fewer than 250 individuals left. If nothing is done to protect them, most of them will go extinct over the next 20 years.

But these species on the precipice of the abyss are not spread evenly across the world; they’re concentrated in biodiversity hotspots like tropical rainforests. That makes sense because tropical forests have the most variety of species to begin with and they have the highest rate of habitat destruction. “About two-thirds of all species are estimated to occur in the tropics, and we know less about them than those in other parts of the world,” said Raven. “[Y]et more than one-quarter of all tropical forests have been cut in the 27 years since the ratification of the Convention on Biological Diversity.”

Losing one endangered species can endanger many others

The species teetering on the edge of eternal loss often live alongside other endangered species, even if they are present in greater numbers. The species on the brink then serve as loud sirens of the possible bigger threat to other life in their environs. As species within a pond, forest stand, or watershed die off, others soon follow.

In many cases, species interact with others in complicated and often unforeseen ways that aren’t recognized until they are gone. For example, if a plant-eating insect dies off, the plants it eats could run rampant and choke off other vegetation. Meanwhile, the birds that feed on the insect could be without an important food source. Each of these subsequent changes could have myriad other impacts on distant species, and so on and so on. The disruption can continue until the ecosystem is hardly recognizable.

Scientists have observed these kinds of rippling disruptions in ecosystems for decades in places like the Amazon rainforest, watching what happened when species went extinct in a given area or when a habitat fractured into pieces.

As these ecosystems degrade or collapse, humans stand to lose a lot of functions from nature they take for granted, like forests that generate rainfall for aquifers or mangroves that shield coasts from erosion. Many land vertebrates, for instance, are critical for spreading the seeds of trees. Without them, the makeup of a forest could transform.

Even if a less diverse prairie, forest, or desert were to remain, it would be more vulnerable to shocks like fires and severe weather. Diverse ecosystems act as buffers against environmental extremes, and without them, humans will face more risks of phenomena such as heat waves without vegetation to cool the air, or they may suffer more coastal inundation without mangroves to absorb waves.

And as humans build closer to areas that were once wild, they face higher risks of exposure to threats such as animal-borne disease and wildfire. So the economic and health costs of runaway extinctions could be immense.

Humans are the problem, and humans are the solution

The new study is part of a steady stream of grim news for endangered species. In 2019, the United Nations’ Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services (IPBES) released a massive 1,500-page report on global biodiversity. The report concluded that up to 1 million species are at risk of extinction, including 40 percent of all amphibian species, 33 percent of corals, and about 10 percent of insects.

And a unifying theme among the various studies of extinctions is that humans are to blame.

Through destroying habitats, spreading disease, raising livestock, dumping waste, overharvesting, overfishing, and climate change, the 7.5 billion humans on this planet have become their own force, unlike any that exists in nature.

“We are in no sense simply a part of the global ecosystem anymore, living in a broad, wide world,” said Raven. “[W]e are one species, totally dominant, among the millions of others that exist.”

It’s true that species do go extinct naturally, but the rate of extinction now is thousands of times higher than the expected background rate. It can be difficult to tease out whether an organism disappeared as a direct consequence of human activity or because a species it depended on was wiped out by people, but both types of losses stem from humanity. “We can’t easily reverse the trend but can learn as much as we can in the time we have left,” Raven said.

However, the fact that human activity is driving the vast majority of these extinctions means that changing human activity can help pull back vulnerable species from annihilation.

Conservation policies have already proven effective at thwarting some permanent losses, like the Endangered Species Act in the United States. It’s even spurring the recovery of several species, like the bald eagle. And there is still time to rescue other species that are on the brink. But saving what’s left will require concerted action, and time to act is running out.

“You do not want to get into a deep depression. You want to get involved and do the very easy things we can do to prevent us from destroying the planet,” said Stuart Pimm, a professor of conservation at Duke University and president of Saving Nature, an environmental conservation nonprofit. “The important story is there is a lot we can do about it.”

Since humans are causing most of the destruction that is driving extinctions, humans can change their behaviors in ways to protect life. One of the most effective steps people can use to protect endangered species is to protect the environments where they live, shielding them from mining, drilling, development, and pollution.

“We can definitely make a difference. We can slow the pace of extinction,” Greenwald said. “We know how to do that. We can set aside more area for nature.”

Another tactic is building corridors for connecting fragmented ecosystems, creating larger contiguous areas. That can allow the synergy between species to grow and build a more resilient ecosystem that could better withstand the disappearance of a species and restore those in decline.

However, the threats to so many species have been building for years and they can’t be reversed overnight. It will take a sustained global conservation effort to protect the precious few and restore them to the multitudes that once swam, flew, and walked the earth.

The World Health Organization (WHO) on Friday announced changes to its guidelines on who should wear a mask during the Covid-19 pandemic and where they should wear it.

The new guidance recommends that the general public wear cloth masks made from at least three layers of fabric “on public transport, in shops, or in other confined or crowded environments.” It also says people over 60 or with preexisting conditions should wear medical masks in areas where there’s community transmission of the coronavirus and physical distancing is impossible, and that all workers in clinical settings should wear medical masks in areas with widespread transmission.

It’s a major update to the agency’s April 6 recommendations, which said members of the general public “only need to wear a mask if you are taking care of a person with Covid-19” or “if you are coughing or sneezing.” And it’s important advice for countries around the world battling the virus, especially those in South America, the Middle East, and Africa, where the rate of Covid-19 transmission appears to be accelerating.

At a WHO press conference on June 3, Michael Ryan, an infectious disease epidemiologist and the executive director of the WHO’s Health Emergencies Programme, said WHO still believes that masks should primarily be used “for purposes of source control — in other words, for people who may be infectious, reducing the chances that they will infect someone else.”

And on Friday, WHO Director-General Tedros Adhanom Ghebreyesus offered a few words of warning as part of the announcement: “Masks can also create a false sense of security, leading people to neglect measures, such as hand hygiene and physical distancing. I cannot say this clearly enough: Masks alone will not protect you from Covid-19.”

But the changes finally bring the WHO in line with many countries around the world that have made masks mandatory in crowded public spaces, including Cuba, France, Cameroon, Vietnam, Slovakia, and Honduras. While it has not made masks a requirement, the US Centers for Disease Control and Prevention (CDC) has since April 3 suggested “wearing cloth face coverings in public settings where other social distancing measures are difficult to maintain.”

Many health experts have wondered why it’s taken this long for the WHO to update its mask guidelines, given the accumulation of evidence that they may be helpful and have few downsides.

Eric Topol, a research methods expert and director of the Scripps Research Translational Institute, calls WHO’s delay “preposterous.” He adds, “I have great respect for the World Health Organization — but they got the mask story all wrong, and we have lost people because of it.” Lawrence Gostin, director of the O’Neill Institute for National and Global Health Law at Georgetown University, agrees, saying, “Everyone should be wearing a mask.”

Here’s what the research suggests and why experts think WHO has now revised its guidelines.

Why wear a mask?

The WHO didn’t cite any particular research for its dramatic change, noting only that it “developed this guidance through a careful review of all available evidence and extensive consultation with international experts and civil society groups.”

But there have been a number of recent studies that experts point to as the best evidence for mask use in the general public to reduce Covid-19 transmission. And a growing number of doctors, scientists, and public health experts have been calling for universal masking in indoor public spaces and crowded outdoor spaces.

One meta-review published in Lancet waded through 172 studies on Covid-19, SARS, and MERS, from 16 countries and six continents. Its authors determined that masks — as well as physical distancing and eye protection — helped protect against Covid-19.

The studies reviewed evidence both in health care and non-health care settings and then adjusted the data so they could be directly compared. The researchers found that your risk of infection when wearing a mask was 14 percent less than if you weren’t wearing a mask, although N95 masks “might be associated with a larger reduction in risk” than surgical or cloth masks.

Other literature reviews have not been as favorable. Paul Hunter, professor in medicine at the University of East Anglia, coauthored one such preprint review in early April. “In evidence-based medicine, randomized-controlled trials are supposed to trump observational studies,” he says, “And randomized-controlled trials have all been pretty much negative on face masks in the community.” The Lancet piece, he notes, gives more consideration to observational studies with surgical masks.

A few recent observational studies on mask use by the public in this pandemic, however, support general mask usage to prevent the spread of Covid-19. One from Hong Kong concluded, “mass masking in the community is one of the key measures that controls transmission during the outbreak in Hong Kong and China.” Another concluded that if 80 percent of a population were to wear masks, the number of Covid-19 infections would drop by one-twelfth, or about 8.3 percent, based on observations from several Asian countries where mask-wearing is common.

There’s been some debate over the efficacy of homemade cloth masks and surgical masks (especially compared to N95 masks, which have more evidence behind them) for the general public. But one recent article, published in the Annals of Internal Medicine, found that even cloth masks block some viral particles from escaping.

The general consensus is that masks are better at keeping your viral particles from spreading to others than keeping someone else’s from spreading to you. Catherine Clase, the lead author of the Annals of Internal Medicine piece and an associate professor of medicine at McMaster University, says one study she reviewed found even a single layer of cotton tea towel tested against a virus aerosol reduced transmission of the virus by 72 percent. “One thing to remember,” she says, “is that a mask doesn’t need to be perfect” to bring down the average number of people being infected by one sick person. “It just has to reduce the probability of transmission to some degree.”

William Schaffner, an infectious disease specialist at Vanderbilt University Medical Center, notes that previous data on masks and viruses came out of the SARS and MERS epidemics, which involved viruses that weren’t as transmissible. “Masks were thought of then as more personal protection as opposed to community protection,” he said, helping explain why masks weren’t widely regarded as particularly effective.

But with Covid-19, the rate of asymptomatic patients may be as high as 40 percent, requiring a shift in thinking about masks from protecting the wearer to protecting the community. Clase concludes that while cloth masks may not protect you from inhaling someone else’s germs, “the evidence that they reduce contamination [from sick people] of air and surfaces is convincing, and should suffice to inform policy decisions on their use in this pandemic.”

Clase adds, “The pandemic is not going particularly well. So this is probably worth employing now and doing the additional research later.”

Why the WHO may have had trouble reaching consensus on universal masking

The WHO generally does rigorous reviews of evidence, as the whole world’s health rides on their recommendations. This may explain their delay in recommending the general public wear masks.

The agency used to largely base its decisions around expert advice, says Hunter. “They would get together a group, and they would use these experts to drive WHO guidelines.” But in 2007, a Lancet paper criticized the agency for not following evidence-based medicine, which prioritizes randomized controlled trials.

As a result, Hunter says, “WHO went through a major upheaval in its guideline development practices. Now, it has to base its recommendations on systematic reviews,” and its guideline development committees now have methodologists.

“I think [the delay] reflects a general principle often followed by scientists, which is not to change practice until the evidence is strong and definitive,” Trish Greenhalgh, a professor of primary care sciences at the University of Oxford, wrote in an email interview. “Whilst many people (including me) believe that is already the case, some scientists on WHO committees have been waiting for additional evidence to strengthen the case.”

Greenhalgh argued in early April that it was time to apply the precautionary principle to pandemic response and that the public should wear masks “on the grounds that we have little to lose and potentially something to gain.”

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But David Heymann, a professor of infectious disease epidemiology at the London School of Hygiene and Tropical Medicine and a member of WHO’s Strategic and Technical Advisory Group for Infectious Hazards (STAG-IH) advisory board, says the agency “is very cautious to only use evidence when we have it. We don’t make any precautionary measures if we don’t have any contributing evidence.”

STAG-IH was asked to look into the evidence for and against mask use in early May and compiled a report for the WHO that was made public on May 25. The finding “supports mask use by the general public in the community to decrease the risk of infection,” the WHO said in a statement to Vox, noting that in updating their guidance, they took the STAG-IH advice into consideration.

Cliff Lane, the clinical director at the National Institute of Allergy and Infectious Diseases at the National Institutes of Health and another member of STAG-IH, says the WHO is ”very good at trying to get a diverse set of opinions before making recommendations.” But he admits he doesn’t know why the WHO has timed its recommendations for masks the way it has.

He is one of many experts Vox interviewed who said it’s difficult to conduct a randomized, double-blind controlled study of mask use in the general public. Because of ethics and practicality, “much of the epidemiologic data on the impact is inferred,” he says. This magnifies a general problem he sees: “Any guideline you make does an assessment of risk and benefit, and you want to get as much information as you can.” For example, if wearing a mask provides a sense of false security and encourages people to stop social distancing, then consequences may not be worth it. “It’s not a trivial decision,” he says.

Heymann says the WHO’s delay in recommendation comes in part from needing to consider evidence from around the world. “WHO takes longer because there’s a need to obtain consensus from global experts and inform six regional offices.”

Hunter added that nation-states can make decisions based in part on politics or educated guesses. “But WHO cannot take political decisions like that. It has to try to get consensus opinion among scientists, because people look to WHO to make decisions on hard evidence wherever possible.”

As Heymann sees it, “WHO is just the gold standard. Countries many times are ahead of WHO — there’s no need for them to wait for WHO to make recommendations.”

Topol, on the other hand, says the best reason he can think of for the WHO not recommending everyone wear masks is because of the worry over a global shortage of masks, particularly in the US. Perhaps, he says, “They didn’t want to have masks maldistributed, because of the dire need for, and lack of, PPE for health care personnel.”

But, he adds, “That’s not the reason to say you don’t need masks — that’s the reason to say we desperately need to make masks.”

“The world needs the WHO — and it needs it now more than ever”

The WHO has been under a lot of scrutiny since the beginning of the pandemic. And it recently got worse: At the end of May, President Trump announced that the US would pull out of the WHO altogether, potentially withdrawing a significant portion of the agency’s funding.

But the WHO isn’t alone in being slow to suggest mask use. Countries like Venezuela made masks mandatory on March 14, and the Czech Republic made the move on March 18. But the US CDC also originally recommended against masks for the public, only changing its guidance to universal masking on April 3.

Richard Besser, president of the Robert Wood Johnson Foundation and former acting director of the CDC, explains that during an emergency, experts have to look at new information and evaluating decisions. He led the emergency planning and response at the CDC for four years, and says, “When guidance went up, it was always interim. Early on, what you don’t know always exceeds what you do know, and as you learn more, you make changes.”

Sometimes those changes are minor, and sometimes, as in the case of the CDC’s mask guidance, they are significant. “In order for that to make sense to the public, you need to have something that we’re lacking right now: direct communication,” Besser says. “That’s valuable because it engenders trust in settings of crisis, where there are things people should do to protect their health. They’re much more likely to do them if they trust the messenger.”

Unlike the CDC, which has been roundly criticized for its lack of press briefings, the WHO is still holding daily conference calls during the pandemic.

“The WHO, like the CDC, is far from perfect, and is flawed in many ways,” says Gostin, the Georgetown public health law expert. “Having worked with WHO for 30 years, I can say they can be maddeningly bureaucratic and unresponsive. But the world needs the WHO — and it needs it now more than ever.”

Lois Parshley is a freelance investigative journalist and the 2019-2020 Snedden Chair of Journalism at the University of Alaska Fairbanks. Follow her Covid-19 reporting on Twitter @loisparshley.

Decades of research paint a clear picture: The No. 1 environmental health risk in the US is soot. Also known as particulate pollution, it is made up of extremely small particles spewed into the air by power generation, industrial processes, and cars and trucks.

There are “coarse particles,” between 2.5 and 10 micrometers in diameter, and “fine particles,” at 2.5 micrometers and smaller. By way of comparison, the average human hair has a diameter of about 70 micrometers.

Research has consistently found that inhaling these particles is incredibly harmful to human physiology, at high concentrations over short periods or low concentrations over extended periods. Particulate pollution is linked to increased asthma, especially among children, along with lung irritation and inflammation, blood clots, heart attacks, weakened immune systems, and, according to a wave of recent research, long-term cognitive impacts (reduced productivity, inability to concentrate, and dementia).

Research is equally consistent on another point: the harms of particulate pollution are not equitably distributed. They fall most heavily on vulnerable populations like children, the elderly, people with preexisting health conditions, low-income people, and, above all, people of color.

A groundbreaking 2019 study from researchers at the Universities of Minnesota and Washington attempted to quantify both sides of particulate pollution, who produces it and who suffers from it. They found that the consumption producing the pollution was concentrated in majority white communities, while exposure to the pollution was concentrated in minority communities.

“On average, non-Hispanic whites experience a ‘pollution advantage’: They experience ∼17% less air pollution exposure than is caused by their consumption,” the study concluded. “Blacks and Hispanics on average bear a ‘pollution burden’ of 56% and 63% excess exposure, respectively, relative to the exposure caused by their consumption.”

To put it more bluntly: People of color are choking on white people’s pollution.

The current regulatory limits on particulate pollution under the Clean Air Act were set in 2012, based on scientific review concluded in 2010. As subsequent science has revealed, they are inadequate to protect public health. That was the strong and unanimous conclusion of the panel of 19 scientists assembled in 2015 to assess the evidence.

Nonetheless, EPA claims the science is not settled and is refusing to tighten the standards, which will mean, on an ongoing basis, well over 10,000 unnecessary deaths in the US every year.

The purported rationale, of this and all the administration’s deregulatory efforts, is to reduce costs to industry. But the costs of pollution don’t disappear when they are removed from industry’s books. They are simply shifted onto the public ledger, in the form of health care costs and lost work days. Lax pollution standards represent an ongoing transfer of costs from industry to the public.

In the case of particulate pollution, the costs are disproportionately borne by black people — who, in part because of the air pollution in their communities, also suffer disproportionately from Covid-19.

Lax particulate pollution standards are, in short, yet another way of devaluing black bodies and black lives, yet another expression of the structural racism that Trump has so effectively flushed to the surface.

How EPA stacked the deck to ignore the science

Particulate pollution is regulated under the Clean Air Act’s National Ambient Air Quality Standards (NAAQS) program. The Act mandates that scientists periodically review the latest evidence on air pollution and recommend updates to NAAQS standards as necessary, so that the program stays abreast of the latest science.

The EPA’s seven-member Clean Air Scientific Advisory Committee (CASAC) reviews the standards, but because it does not have depth of expertise in all the various subject matters, it typically consults with a panel of outside scientists.

When the latest review of particulate standards began in 2015, such a panel was assembled: the 19-member Particulate Matter Review Panel, made up of experts in epidemiology, physiology, and other relevant disciplines. The review was delayed in getting underway, and Trump’s EPA initially talked about moving the deadline for completion to 2022. But in early 2018, then-EPA Administrator Scott Pruitt abruptly announced that the agency would rush to be done by December 2020, the tail end of Trump’s first term.

Later in 2018, to “streamline” the review process, newly appointed EPA Administrator Andrew Wheeler unceremoniously disbanded the PM Review Panel and left the review in the hands of CASAC — which had, over the previous year, been entirely reconstituted with Trump appointees. It was chaired by an industry consultant; just one of the seven members was a scientist.

The disbanded scientific panel later reconvened and rebranded as the Independent Particulate Matter Review Panel. It went on to issue the same assessments and recommendations it would have offered CASAC.

For fine particles (PM2.5), it recommended reducing the annual average concentration limit from 12 micrograms per cubic meter of air to between 10 and 8, though it noted that “even at the lower end of the range, risk is not reduced to zero.” It recommended reducing the daily exposure limit from 35 to between 30 and 25.

Now, the Independent PM Review Panel has penned an extraordinary piece in The New England Journal of Medicine, excoriating the EPA.

“We unequivocally and unanimously concluded that the current PM2.5 standards do not adequately protect public health,” they write. Ignoring that clear conclusion required serial abuses of the review process, as outlined in this somewhat mind-boggling paragraph:

The dismissal of our review panel is just one of numerous recent ad hoc changes to scientific review of the NAAQS since 2017 that undermine the quality, credibility, and integrity of the review process and its outcome. Other changes include imposing nonscientific criteria for appointing the Clean Air Scientific Advisory Committee members related to geographic diversity and affiliation with governments, replacing the entire membership of the chartered committee over a period of 1 year, banning nongovernmental recipients of EPA scientific research grants from committee membership while allowing membership for persons affiliated with regulated industries, ignoring statutory requirements for the need for a thorough and accurate scientific review of the NAAQS in setting a review schedule, disregarding key elements of the committee-approved Integrated Review Plan, reducing the number of drafts of a document for committee review irrespective of whether substantial revision of scientific content is needed, commingling science and policy issues, and creating an ad hoc “pool” of consultants that fails to address the deficiencies caused by dismissing the Clean Air Scientific Advisory Committee PM Review Panel.

That is … a lot. “It’s not surprising [CASAC] would retain the standards,” Gretchen Goldman, research director for the Union of Concerned Scientists, told the Washington Post, “because they broke the process.”

The chair of CASAC, Tony Cox — who has worked as a consultant for energy and chemical industry trade groups — contends that the particulate science doesn’t hold up. In the end, CASAC ignored the panel’s work and recommended that the standards be kept where they are.

The 60-day comment period on the new rule ends on June 29; there is no sign that the vast number of critical comments and submissions to EPA will change Wheeler’s mind.

Once the rule is put into effect, it will immediately face lawsuits. Given how shoddy the process has been and how clearly the results fly in the face of consensus science, it is unlikely to hold up in court. Like many of the Trump administration’s hastily executed regulatory rollbacks, it will likely end up quietly rejected — in the end, less an enduring victory than a flashy nationalist pageant that merely delays inevitable changes.

If it is rejected, it will go back to EPA for another rulemaking process that will take years. In the meantime, tens of thousands of people, disproportionately people of color, will needlessly get sick and die.

Black people are most likely to suffer the effects of soot

It is well known that the harms of pollution are inequitably distributed. Like so many social harms, they fall hardest on the most vulnerable.

That means people with weak or compromised immune systems, like children, the elderly, or people with preexisting respiratory or circulatory problems. And it also means people who happen to live close to the industrial facilities and highways that produce the pollution, typically low-income communities and communities of color. Black people fall disproportionately into both those categories, with high rates of preexisting conditions and high likelihood of living proximate to pollution sources.

A 2018 study by EPA scientists, published in the American Journal of Public Health, attempted to quantify the disparities in pollution exposure down to the county level. It found that, for PM2.5 pollution, “those in poverty had 1.35 times higher burden than did the overall population, and non-Whites had 1.28 times higher burden. Blacks, specifically, had 1.54 times higher burden than did the overall population.” These results held steady across the country.

This illustrates that the impact of pollution on the black population can not be reduced to geography or economic status. It “should be considered in conjunction with existing health disparities,” the study says. “Access to health care has well-documented disparities by race/ethnicity, and the prevalence of certain diseases is notably higher in non-White populations.” In other words, the pollution burden should be considered in the context of systemic racism.

Another recent study, focused on Texas, found that “the percentage of Black population and median household income are positively associated with excess emissions; percentage of college graduate, population density, median housing value, and percentage of owner-occupied housing unit are negatively associated with excess emissions.”

These studies are consonant with a long history of research — see here, here, here, and here — showing that air pollution reflects and reproduces wider income and racial disparities. The poor suffer; minorities suffer; black people suffer most of all.

Trump’s environmental policies reinforce structural racism

Inequitable distribution of pollution is as old as industrial society. The Clean Air Act was meant, in part, to address that injustice, to secure healthy air for every American. And despite its flaws and failings, it has been, among other things, one of the most effective environmental justice policies in US history. Just as pollution hurts people of color most, reducing it helps them most.

Emission of the six big pollutants — particles, ozone, lead, carbon monoxide, nitrogen dioxide, and sulfur dioxide — declined an average of 73 percent between 1970 and 2017. Fine particle concentrations fell by 43 percent between 2000 and 2019.

The Clean Air Act has accomplished this much because it is not a static law but a living, evolving set of policy tools. It has scientific reviews built in every few years, so that the level of public protection keeps up with the latest evidence. Scholars call this “green drift,” as the landmark environmental laws of the 1970s continue updating, even in the face of some hostile administrations.

Trump’s is the most hostile yet, working overtime to gum up the Clean Air Act and blunt its effectiveness. It goes beyond weakened standards for particulates, mercury, methane, and fuel economy.

There’s the “Transparency in Regulatory Science” (or “secret science”) rule, which would prohibit EPA from considering a broad swathe of the epidemiological research that supports particulate rules. There’s the effort to alter EPA cost-benefit analysis to exclude consideration of “cobenefits.” Many rules reducing other pollutants — mercury and CO2, for example — are justified in part by the fact that they also reduce particulates, which substantially adds to their health benefits. Excluding cobenefits is a way to justify weakening a whole range of other air-quality standards.

EPA is doing as much as it can to dismantle, weaken, or delay Clean Air Act protections before the end of Trump’s first term. The typical framing of these moves is that Trump is doing them on behalf of industry and that they are hurting “the environment,” or, worse, “the planet” (ugh).

There’s another way to frame them: They are expressions of structural racism, America’s long history of exploiting people of color for their labor while rewarding them with deprivation, marginalization, and ill health. Just as black people are often denied police protection while subjected to police violence, they are often denied the wealth and consumption that produce pollution while subjected to the health ravages of inhaling it.

Science-based air quality standards are one way to ease the burdens imposed on black bodies. The Trump administration’s staunch opposition to those standards, its attempts to undermine the bureaucratic machinery that produces them, is just one more expression of its disregard for black lives.

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When states had strict stay-at-home orders and lockdowns in place, many decisions about the risk of getting the coronavirus were simple. People didn’t have to think about whether dining in a restaurant is safe if the restaurant was closed.

Now, that states are opening up — with varying degrees of precautions and adherence in place — individuals will need to weigh some risks on their own.

It isn’t easy; information about what’s safe, and what’s not, can be contradictory and confusing. A state may allow restaurants to reopen and concerts to resume, but should you really go? Is it safer if people are only allowed to dine outside?

The hunger for guidance is clear: On May 6, infectious disease expert Erin Bromage posted a blog post summarizing the evidence of coronavirus transmission risks, and 17 million people have since read it, he says. The CDC didn’t post its own updated guidance for individuals and events venturing out into a post-lockdown world until June 12. Perhaps a bit too late, as new cases and hospitalizations are currently rising in several states.

As Bromage conveys, the scientific understanding of how the virus transmits in public is improving. Contact tracing studies around the world have taken a magnifying glass to the “superspreading” events, where one person ends up infecting dozens of others. These studies shine a light on the key risk factors that create dangerous situations.

From these studies, one thing is clear: The main way people are getting sick with SARS-CoV-2 is from respiratory droplets spreading between people in close quarters. The risk of catching the coronavirus, simply put, “is breathing in everybody’s breath,” says Charles Haas, an environmental engineer at Drexel University. Droplets fly from people’s mouths and noses when they breathe, talk, or sneeze. Other people can breathe them in. That’s the main risk, and that’s why face masks are an essential precaution (they help stop the droplets from spewing far from a person’s mouth or nose).

The Centers for Disease Control and Prevention (CDC) emphasizes the risk of close contact over other modes of transmission. “The virus does not spread easily in other ways,” the CDC writes. It’s still possible that a person can catch it from touching a contaminated surface (more on that below.). But it’s “not thought to be the main way the virus spreads,” the CDC states.

As Bromage put it in his piece, “We know most people get infected in their own home,” from housemates or family members who caught the virus in the community.

So how can we assess the risk of going places outside the home?

The story is a little more complicated than the simple “stay 6 feet away” guidelines. Coronavirus risk is simply not one-dimensional. We need to think about risk in four dimensions: distance to other people, environment, activity, and time spent together.

Let’s walk through them.

A simple suggestion: Imagine people are smoking, or farting really bad, and try to avoid breathing it in

It’s easy to get into the weeds talking about the risk of catching and spreading the coronavirus as people reenter communal spaces in society. We can talk about the number of viral-laden droplets expelled by a single breath (a lot, perhaps 100 or more), by a person talking (10 times more than breathing), about how far a sneeze can propel those droplets (much farther than 6 feet), how long those viral droplets linger in the air (around eight to 14 minutes, at least in a controlled indoor lab setting).

But really, what all this means is that the greatest Covid-19 risk is being around breathing, laughing, coughing, sneezing, talking, people.

It’s still hard to visualize the risk, though, as the respiratory droplets are invisible to our eyes.

Perhaps helpful: Imagine everyone is smoking, as Ed Yong reported in the Atlantic, and you’d like to avoid inhaling as much smoke as possible. In a cramped indoor space, that smoke is going to get dense and heavy fast. If the windows are open, some of that smoke will blow away. If fewer people are in the space, less smoke will accumulate, and it might not waft over to you if you’re standing far enough away. But spend a lot of time in an enclosed space with those people, and the smoke grows denser.

The denser the smoke, the more likely it is to affect you. It’s the same with this virus: The more of it you inhale, the more likely you are to get sick.

An alternative image to thinking about this risk: “With my kids, I just sort of joke around that if you can smell their farts, you need to move farther apart,” Bromage says. So if not smoking, imagine everyone is farting. Keep this in mind and surely you’ll realize outdoor activities are better than indoor ones. “This tells you the gradient of risk,” Bromage says. “The closer you are, the more it’s gonna smell, the more dangerous it is.“

At a barbecue, you can still imagine being close enough to people to smell their farts. So even in outdoor spaces, we need to limit our contacts.

A crowded indoor place, then, with poor ventilation, filled with people talking, shouting, or singing for hours on end will be the riskiest scenario. A sparsely populated indoor space with open windows is less risky (but not completely safe). Running quickly past another jogger outside is on the other end of the spectrum; minimal risk.

There are many scenarios in between. “In general, outdoors is lower risk,” Muge Cevik, a physician and virology expert at the University of St. Andrews, says. But “if you have a gathering or a barbecue outside, and you spent all day together with your friends, your risk is still higher.”

What recent contact tracing studies can teach us about risk

Scientists pointed out a few recent contact tracing studies that nicely illustrate the dimensions of Covid-19 risk.

In China, 8,437 shoppers and employees of a supermarket were tracked in late January after one of the employees was confirmed positive with Covid-19 while working in the store.

The risk for infection was much higher for the workers than for the shoppers. Around 9 percent of the supermarket employees (11 out of 120 employees) got sick as a result. But just 0.02 percent of the shoppers (2 out of 8,224 shoppers) got sick.

What does this show?

The employees are at a much larger risk due to the time they spent working in the store. Both the employees and shoppers were in the same physical space, but their risk was not the same. (The study did not note whether the shoppers and customers were wearing masks in the store.) The employees may have interacted more with their colleagues, but they also had a greater chance of breathing in the virus.

What we should learn from this: If we have to spend time with people indoors, try to make it quick.

Another recent study out of China investigated an outbreak that started at a Buddhist temple event.

Two buses brought people to the function. On one of the buses, there was a person who later tested positive for the coronavirus who had not yet started to feel symptoms. The other bus was free of infected people.

Both buses brought people to the same temple, where they mixed and mingled outdoors*. But who was most at risk of getting sick? Those who rode the bus with the infected person. Twenty-four out of 67 people on that bus got sick. No one on the other bus did. The event was attended by another 172 people who arrived by other transportation. Only seven of these people got sick.

The lesson? The confines of a bus are a much riskier environment for viral spread than a larger outdoor space, like at the temple. The risk at the temple was not zero. But it was much reduced compared to the confines of the bus. And it appears those who were exposed at the temple were in close contact with the infected person.

“When you look at public transport, work spaces, restaurants — places where we’re just trying to fit many people in a small confined space — respiratory viruses like those spaces,” Cevik says. It’s “just common sense.”

There’s no set time that’s safe to be in these places. “Generally, for droplet transmission, we say 15 minutes,” Cevik says. “So if you spend 15 minutes face to face with somebody, you’re close contact [and at high risk], but that doesn’t mean if you spend 14 minutes your risk is zero.” And if you have to choose between a big open indoor space and a smaller one, choose the larger one, where people can spread out.

It’s not just the location or the time spent together: The activity people are engaged in matters, too.

In Washington state, a person with the virus attended a choir practice, and more than half of the other singers subsequently got sick. This was labeled a “superspreading” event, as one infection led to 32 others. Why was this so risky?

“The superspreading event is about the behavior of the person involved,” Cevik says. There are many reasons why a person could become a “superspreader”: Some people shed more of the virus than others, and it appears people shed most of it when they are just starting to feel symptoms.

But what made this event so risky was the convergence of many risk factors: the singing activity (during which the infected person released viral particles into the air), the time spent together (the practice was 2.5 hours), and the interaction between the choir members in an enclosed space (not only did they all practice together, they also split up into smaller groups and shared cookies and tea).

In a new paper published by CDC, researchers in Japan identified 61 clusters (five or more cases stemming from a common event) of Covid-19 cases. The researchers found most commonly the clusters originated in health care facilities. But outside of that they note “many Covid-19 clusters were associated with heavy breathing in close proximity, such as singing at karaoke parties, cheering at clubs, having conversations in bars, and exercising in gymnasiums,” the scientists wrote.

Notably, too, were the ages of the people who instigated spread outside of the health care settings. “Half … were 20–39 years of age,” the report finds. Which is a reminder: younger people can catch the virus, survive, but at the same time spread it to others who may die from it.

What about touching something with infected droplets? Is that still a risk?

According to the CDC, the coronavirus does not often spread from people touching surfaces. That is, if someone with Covid-19 touches a hand railing, does that make that hand railing dangerous for other people to touch? The CDC is now saying that such events are not a huge risk for Covid-19 transmission.

But, there’s a catch: It is still the case that surface transmission is possible. Scientists believe the virus can remain viable on a hard, non-porous surface like plastic or steel for around three days, and a rough surface like cardboard for about a day. You could, conceivably, touch a contaminated surface, and then touch your face, and get sick. (The good news is that even though some virus can remain on a surface for a day or more, the amount of virus on a given surface drops by half after several hours, and then continues dropping.)

Bromage cautions it’s just really hard to study surface transmission. In contact tracing studies, it’s much easier to ask people who they’ve been in contact with than to have them remember every surface they’ve touched.

“I agree with this [CDC] statement,” Cevik says, agreeing that surfaces aren’t the most significant mode of transmission. “But this does not mean it does not happen.” Cevik points me to a contact tracing study that suggests (with a good deal of uncertainty) that some people caught the infection in a mall via the restroom. “Bottom line,” she says, “it’s still important to maintain personal hygiene and wash hands.”

Also consider how scientists recently found live Covid-19 virus in feces. So good bathroom hygiene is still as important as ever.

There are no magic numbers to eliminate risk

It would be great if there were very specific numbers and guidelines we could follow to minimize coronavirus risk to zero.

But there aren’t. While 6 feet away from another person, it’s not like the virus will immediately decide to drop dead. That’s why we need to think of risk in terms of many dimensions: so we can each think critically and not fall back on rules that are too simplified.

“When I first said restaurants were risks, people interpreted that as ‘every restaurant is a risk,’” Bromage says. “Each restaurant has its own unique environment, its own unique challenges that need to be worked out. If you’ve got a large open-seating area, and you can open up the windows and doors … the risk there is much lower than a boutique restaurant with five tables that creates that really intimate atmosphere.”

When we venture out into the world, we need to remember we can reduce risk, but never eliminate it.

“Wearing a mask is not going to completely reduce your risk, hand-washing is not going to completely reduce your risk, and staying a distance away from people in an enclosed space is not going to completely reduce your risk,” Haas, the Drexel professor, says. “But the concurrent use of all those strategies will hopefully reduce your risk down to a lower level. We can never get to zero. There’s no such thing as zero risk.”

And we still need more data, and follow-up on potential exposures. A hair salon in Missouri made headlines when a couple of their hair stylists were reportedly back at work after testing positive for Covid-19. Both hairdressers wore masks, and so did their clients, and a follow-up investigation by their county health department revealed no new infections among the 140 clients they saw.

This data point is a bit anecdotal. “I think they got lucky,” Bromage says. “But it does highlight the importance of masks.” Perhaps more data will reveal that getting a haircut while everyone is wearing a mask is a low-risk activity.

Contact tracing studies have taught us a lot so far. But as of now, most of this work has been done in Asian countries, which may have different expectations around mask-wearing, among other differences.

“Contact tracing, testing, isolating — these are the building blocks to understand where the transmission is occurring,” Cevik says. And the more we learn, the more power we have to stop the spread of this pandemic.

*This piece was updated to clarify the temple event occured outdoors.

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Several states are now seeing a surge in new Covid-19 coronavirus infections and hospitalizations. And the states with more alarming outbreaks — Arizona, North Carolina, South Carolina, Texas, Utah, Arkansas, Florida, and Tennessee — generally saw few cases early in the pandemic.

Many of these states have started to relax the restrictions on movement, businesses, and public gatherings that were meant to control the spread of Covid-19. But with infections rising, there will be more illnesses, deaths, and financial hardships for people who have already suffered immensely from this pandemic.

If cases continue to rise and threaten to overwhelm the health system, officials may be faced with a daunting prospect: another round of shutdowns, requiring businesses that have reopened to close, public gatherings to be banned again, and stay-at-home orders to go back in effect.

Some local officials are already talking about this possibility. The city of Houston, Texas, for instance, is weighing another stay-in-place order. (It may ultimately be prohibited from having stricter rules than the state government.)

Thanks to several studies, including two recent scientific papers in the journal Nature, there’s now more certainty these measures dramatically lower the case count and save lives. However, the shutdowns also drove a massive spike in unemployment and caused huge social strains as people were forced to stay apart.

Asked about the prospect of further lockdowns, Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, told Science Friday last week it depends on how well other public health strategies are deployed.

“Whether those infections turn into a real resurgence of infections and a rebound will depend on how effectively we’re able to identify, isolate, and contact trace,” Fauci said.

Other public health experts are debating the viability of additional lockdowns, noting it may be harder for leaders to muster the political will for them now, and that citizens may be less likely to comply with them.

What’s clear is that it will be difficult to get quick, satisfying results from shutdowns at this stage of the pandemic. And while there are other ways to protect public health that don’t require such sacrifices from the public, they require investment, coherent public messaging, and political will. Unfortunately, it doesn’t appear every state has these elements in place.

The US is in a much different place than it was at the start of the Covid-19 pandemic

The United States is now the epicenter of Covid-19, with 2.16 million confirmed cases and 118,000 deaths as of June 16.

This growth is evident in states like Arizona, now a hot spot for the virus with daily cases climbing rapidly in the last two weeks. Will Humble, former director of the Arizona Department of Health Services, said the shutdowns worked when they were implemented on March 31. Arizonans largely complied with stay-at-home orders. Businesses closed. People maintained social distance.

But there was little transmission at that point. “The first stay-at-home order was done when we just had a couple hundred cases a day,” Humble said. Then on May 15, Arizona Gov. Doug Ducey allowed the order to expire, replacing it with an executive order that suggested guidelines for how people should behave, but no enforcement. It’s likely that this relaxation contributed to the rise in cases.

“We’re blowing the doors off now with 1,500. … We’d be going into a stay-at-home order under very different circumstance than back in April,” Humble said.

A reimposition of shutdown measures at this point, if they were obeyed, would still reduce the number of new infections. But that reduction would be in proportion to a higher baseline. New cases would drop, but it would take much longer to reach the levels seen after the first round of shutdowns.

When starting from a higher number of cases, there is more transmission baked in. For instance, there will likely be more cases of household spread among family members under a stay-at-home order. And when there are a higher number of overall infections, there are likely to be even more undetected infections that may continue to worsen the pandemic.

And as states saw during their first brush with shutdowns, it can take a while for pandemic control policies to show up in the data. “We can expect those lags and timings would operate in a similar way,” said Joshua Salomon, a professor of medicine at the Stanford University School of Medicine who studies disease models and public health interventions. “It takes a few weeks after you change people’s interactions and contacts for that to translate into a reduction in the number of cases.”

Perhaps the biggest unknown for a second shutdown is how well people will adhere to the orders. Already, people in some parts of the country are gathering en masse, flocking to reopened businesses, and flouting guidance to wear masks in public places.

“We are starting to notice a lot of people across South Carolina are not doing the social distancing or not avoiding group gatherings and wearing masks in public the way, especially, that they were earlier on,” Brannon Traxler, the physician consultant for the South Carolina state health department, told ABC News. Public officials are also facing intense political pressure to ease restrictions.

Hannah Druckenmiller, a doctoral student at the University of California Berkeley, co-authored a recent paper looking at the effectiveness of shutdown measures. She and her team found that across the US, such tactics averted 4.8 million more confirmed cases of Covid-19 and up to 60 million infections in total.

But the results also showed that these policies had different effects in different parts of the world because some governments took the policies more seriously than others.

“This is likely a result of the fact that populations have different cultures and governments enforced the policies to varying degrees,” said Druckenmiller, in an email. “One interpretation of this result is that if a second round of lockdowns was less strictly enforced and had lower levels of compliance, these containment measures may not be as effective as they were in March and April.”

With states taking so many different approaches to the pandemic, however, the US is likely to experience a patchwork of different outcomes from further school closures, public gathering bans, and shelter-in-place orders.

There are alternatives to shutdowns, but the US hasn’t invested in them enough

Economic and social shutdowns are effective, but they’re expensive. They weren’t meant to stay in place indefinitely, but were aimed at slowing the spread of the virus to prevent hospitals from being overwhelmed with patients.

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The more targeted strategy for containing Covid-19 is testing, tracing, and isolation. With a robust system of testing, health officials can identify people who are infected and spreading the disease, even before they feel sick. Then they can trace the contacts of the infected to test other people who may have been exposed. And the people who test positive can be directed to isolate themselves. All the while, the general public should maintain social distance and minimize exposure as they take calculated risks in going about their lives.

Such an approach would break the chain of transmission of the virus. It would also only require a handful of people to stay home rather than large swaths of the population. But it demands a lot of infrastructure to deploy tests and trace contacts, and it takes time to set up.

“Shutdowns really had two goals. One was to stop the uncontrolled spread, which they did,” said Salomon. “The other was to try to buy us time to set up the public health infrastructure to do testing and tracing and isolation at scale. And we really failed to make use of that time.”

Another round of closures and stay-at-home orders could still be availed to build up the testing and tracing capacity. The more testing and tracing is available, the less strict shutdowns need to be. And building a system for testing millions of people would still be cheaper than an indefinite pause of the economy.

At this point in the pandemic, public health officials also have a better understanding of the spectrum of risk for the virus. Rather than issuing blanket orders to stay home, more nuanced guidance about what kinds of public spaces are safe and what precautions are necessary could ease the acceptance of pandemic control measures. But that requires careful and nuanced public messaging, and given the mixed messages the public has received on tactics like wearing masks, health officials would have to rebuild trust.

“What we really want to do is get as much benefit as we can from lockdowns in a way that’s more targeted and doesn’t demand as much sacrifice,” Salomon said. He added that policies like paid sick leave and building up work-from-home capabilities would also be important steps to helping people avoid unnecessary exposure to Covid-19.

As for when states can relax, that remains a fraught question. Some of the guidelines from the federal government for reopening have been confusing, and some states have gone ahead and established their own.

More recently, the Centers for Disease Control and Prevention put out a list of best practices to reduce Covid-19 risk as shutdowns relax. Measures include wearing masks and maintaining distance from other people.

However, with cases spiking in several states, it may still be too soon to think about relaxing, and efforts may still be needed for containment. But with the most blunt yet effective public health tool losing strength, it’s more urgent than ever to fight the pandemic without such drastic measures.

Texas broke records for Covid-19 hospitalizations six times last week, including a record 2,504 hospitalizations in a single day on June 10.

South Carolina, North Carolina, Alaska, Florida, Mississippi, and Arkansas have also all broken records of new cases reported in a single day. Alabama saw a 92 percent increase in its seven-day average of new cases, and more than a quarter of Arizona’s total Covid-19 cases have been reported in the last week. Overall, 21 states have seen an increase in their daily average cases.

As these states have loosened lockdowns and people have come back into close contact, the virus is spreading rapidly again, and hospital ICUs are filling up. And public health experts say health care providers and essential workers remain at high risk of infection for the same reason they have since March: there’s a shortage of critical supplies, including personal protective equipment (PPE).

As of April 14, the Centers for Disease Control and Prevention (CDC) estimated that 9,200 medical professionals had been infected in the US; it’s not known how many have died.

An ongoing problem with PPE is that supplies still aren’t being distributed equally around the country and even within hot spots. Better-resourced hospitals have more supplies while other facilities struggle to find enough.

The federal Centers for Medicare and Medicaid say that one in five Florida nursing homes do not have a one-week supply of gowns or the N95 masks needed to care for Covid-19 patients and prevent transmission. According to WCNC Charlotte, North Carolina ran perilously low on gowns and masks in May even before its recent surge in cases, receiving only 99,000 of the 27 million N95 masks it had ordered. An internal report from the Federal Emergency Management Agency (FEMA) suggests “[t]he demand for gowns outpaces current U.S. manufacturing capabilities” and that the government plans to continue to ask medical staff to reuse N95 masks and surgical gowns intended to be disposed of after one use into July.

Val Griffeth is an emergency and critical care physician in Oregon and the co-founder of Get Us PPE, a grassroots organization that finds and donates PPE to health care workers who don’t have enough. (Project N95 is another organization that works with institutions who can afford to buy supplies but are having trouble procuring them.) Griffeth says Get Us PPE has seen a recent uptick in requests, particularly for gowns and gloves.

“I worry there hasn’t been a true fix to the supply-chain issues,” Griffeth says. “Our government has basically said that we’re going to allow the free economy to fix the issues. Unfortunately, it takes time and capital to ramp up production, and because the government has not devoted capital to helping solve the situation, we’re seeing a delay in its resolution.”

Griffeth argues the Defense Production Act (DPA), which Trump has deployed selectively, could be used more broadly to increase production of essential protective gear. The lack of federal leadership and coordination, the lack of a central agency prioritizing distribution based on need, Griffeth says, has led to difficulty procuring supplies, with states and hospitals often bidding against each other and elevating prices.

Now, as cases surge in several states, grassroots efforts are filling the vacuum. Here’s a closer look at a few of the country’s hot spots, and the people organizing to try to help protect their communities.

Why is PPE important?

A May preprint study, conducted by researchers at Massachusetts General Hospital, King’s College London, and Zoe Global Ltd., looked at data from the Covid Symptom Tracker app. It found that front-line health care workers were at nearly 12 times higher risk of testing positive for Covid-19 compared with members of the public, and those workers with inadequate access to PPE had an even higher risk.

“The limited availability of adequate PPE, such as masks, gowns, and gloves, has raised concerns about whether our health care system is able to fully protect our health care workers,” said senior author Andrew Chan, chief of the Clinical and Translational Epidemiology Unit at Mass General, in a statement.

Carri Chan, an associate professor at the Columbia Business School and an expert in hospital operations management, explains that PPE is essential not just to reduce transmission in hospital settings but because studies have shown that in a respiratory disease pandemic, trained health care workers are the bottleneck. If they get sick, patient care suffers. “You can have all the ventilators in the world, and if you don’t have specially trained people to provide care, it doesn’t matter how many machines you have,” she says.

It’s not only hospitals that need more staff and PPE; many other areas of health care do too, including primary care facilities, homes for the disabled, and nursing homes — a fifth of which reported at the end of May that they had less than a week’s supply of critical PPE. Chan notes that other essential workers, including grocery store clerks, delivery workers, and those “who don’t have the luxury to work from home” also need PPE to protect themselves and others.

Because a large portion of the masks, gowns, and gloves the US uses come from China, and because of the overnight global demand, supply chains have been disrupted. “Due to limited access, as hot spots grow, some more underserved communities could be again hit disproportionately,” she says.

This is yet another area where the lack of federal leadership hindered the Covid-19 response. As a New York City resident, Chan compares Elmhurst — a hospital in Queens that saw “apocalyptic conditions” — to better-resourced and well-connected facilities in other parts of the city, saying that “because of the decentralized manner in which PPE procurement occurred, some [hospitals] were much worse off than others.”

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In her hospital, Griffeth is currently given one N95 respirator mask and one face shield per day. She wears the face shield both as eye protection and to decrease droplets contaminating the respirator. N95s are placed in a paper bag between uses while face shields are cleaned with sanitizing wipes between patients. Best practices would involve using a new mask and face shield with each potentially infectious patient. “Both masks and respirators continue to be an issue,” she says, “despite falling out of the nightly news cycle.”

Chan says, so far, there have been few national efforts to ensure PPE is distributed equally. “At Elmhurst, people were dying just waiting to get access to care. There’s a lot of imbalances about the way the system is set up.”

Florida: “Left out to the wolves”

Rebekah Jones, a scientist and former manager of data and surveillance at Florida’s Department of Health, says that, back in January, the CDC told the department it needed to prepare for a widespread pandemic.

Jones was in charge of the state’s public tracking of Covid-19 cases until May 19, when she allegedly refused a superior’s request to alter numbers so that the coronavirus positivity rating would drop below the state’s threshold to reopen. Before she was fired, Jones says she saw requests for PPE rolling in from around the state — requests for shoe covers and hand sanitizer and masks — suggesting many places in Florida still didn’t have the equipment they needed to stay safe. Since mid-May, 24 health care workers in St. Petersburg have been infected, prompting at least one nurse to quit, and firefighters and first responders in Immokalee recently reported they are running out of PPE.

Desiree Ann Wood, a truck driver and founder and president of Real Women In Trucking, says that Florida’s need for PPE extends far beyond hospital doors. She’s been organizing donations of PPE for truck drivers, who have struggled to maintain the country’s supply chains during lockdown.

Wood reports that rest stops truckers normally rely on to go to the bathroom, sleep, and eat have been closed, and many drivers are no longer allowed inside the places they deliver. “You’re like a social pariah,” she says, but “we are part of the logistical supply chain, and no one’s thought that the people restocking shelves are being left out of the equation.” She says with the temporary suspension of regulations limiting long-haul driving hours, “Drivers can drive more for less money, and for less services, and no one ever thought, ‘What about them?’ It doesn’t even occur to you to give them a mask, too.”

Wood started handing out donated masks in early March. “I couldn’t get permission initially. I’d just show up at a truck stop and pass masks out till I was asked to leave.” But though she’s met skepticism — truckers “assume I’m going to hassle them, or I’m a working girl in the parking lot” — the Real Women in Trucking network has now handed out more than 8,000 masks, gloves, and bottles of hand sanitizer.

Thanks in part to a donation by Uber Freight, as well as donated supplies and a cash donation from the freight company DDC FPO, Wood is now handing out PPE in Florida, Kentucky, Mississippi, Iowa, Georgia, and Michigan.

Jones, the former Florida state data scientist, has also developed her own dashboard, which, unlike the state’s, shows the total number of positive cases for everyone tested in Florida regardless of their legal address. “If you live here and are sick here and die here, your information should be included,” she says.

Wood agrees that it doesn’t seem as though the state is considering everyone. “We see this over and over again,” she says. “We’ve really been left out to the wolves.”

Georgia: “We’re not united anymore.”

On June 11, Georgia saw a single-day increase in Covid-19 cases of more than 26 percent. The increase in cases isn’t surprising to Edward Aguilar, Shourya Seth, and Manu Suresh, juniors in high school in a suburb of Atlanta. They’ve been busy after school, building software to get PPE to hospitals that needed it.

“It’s been frustrating seeing cases rise, and the lack of government response,” says Aguilar. “It really does point out the weak points of the whole supply chain,” Seth says. “It’s almost like a confederacy. We’re not united anymore.”

After talking to Seth’s cousin who works at Emory University Hospital, the teens called five maker spaces — collaborative workspaces that often have shared tools — in early March to see if they could find a way to get additional PPE to medical workers. They created a grassroots organization, Paralink, and since April 1 have delivered donated PPE supplies, primarily face shields, to health care providers around the South. “FEMA has delivered 180,000 face shields to Georgia,” says Aguilar. “We’ve delivered 190,000.”

At first, the teens were calling hospitals to make a list of who needed what, but now the group uses Get Us PPE’s database to prioritize shipments. It’s been a crash course in logistics: Paralink now coordinates more than 50 maker spaces to 3D-print face shields, and relies on 150 volunteer drivers to distribute them.

Aguilar recalled one shipment of 3,000 face shields that urgently needed to get to Albany, New York; within a day, they used Facebook groups to find seven volunteers, who each drove the shipment for several hours in a human chain between Georgia and New York.

As they’ve scaled up, the teens have run into some of the same stop-and-go problems as larger corporations. While Georgia was locked down, there was a drop in requests for PPE, so Paralink called some of the volunteers to tell them their help was no longer needed making face shields. “Now we need to call back and say we need more,” Aguilar says. “We’ve had some really tough conversations.”

Paralink’s requests for face shields have recently doubled. “It’s scary to see we’re not able to keep up production — and we know we can move faster than the federal government. What happens when the government has to make these phone calls to massive companies? How do you tell [manufacturers] that after retooling, they have to stop, or then start again? The backlash won’t be in favor of the manufacturers,” says Aguilar.

“People call us and say we’re inspiring — and it’s scary. The focus, as it should be, has been on health care workers, but a lot of [them] are in the same position now and aren’t getting any help,” Aguilar says. “It’s not just people in hospitals. Everyone needs this protection.”

Arizona: “It’s been heartbreaking”

Over the last week, Arizona’s Covid-19 cases surged by 54 percent. Saskia Popescu, a senior infection prevention epidemiologist at the University of Arizona, says she was “surprised and deeply worried when the state opened so prematurely. We’re seeing the fallout of that right now.”

Northern Arizona in particular has been hard-hit, seeing hospitals approach capacity, and the largest care system in the state, Banner Health, warned that the number of patients on ventilators has quadrupled since May 15. The Arizona Department of Health Services told hospitals to “fully activate” their emergency plans.

Because it’s so hot in Arizona — it hit 112 degrees Fahrenheit in Phoenix twice in late May after the stay-at-home order lifted — it’s more difficult to follow recommendations to socialize outside instead of inside. That may help explain why Arizona’s case numbers have been spiking after lockdown was lifted, says Popescu.

But it’s not just increased transmission that’s putting a strain on the state’s PPE supplies. The Arizona Department of Health Services has recently allowed elective surgeries to restart, adding traffic to hospitals and creating what Popescu calls “a perfect storm for rapid case growth, and a very stressed health care system.”

Popescu says that she’s seen a widespread shortage of even basic supplies like disinfecting wipes, as well as disposable stethoscopes and laryngoscope blades — “things people don’t think are big deals, but that show that the supply chain problem is not resolved.”

Watching people become increasingly lax about prevention while knowing that hospitals are increasingly full has “been heartbreaking,” Popescu says.

Lois Parshley is a freelance investigative journalist and the 2019-2020 Snedden Chair of Journalism at the University of Alaska Fairbanks. Follow her Covid-19 reporting on Twitter @loisparshley.

The Centers for Disease Control and Prevention (CDC) on Friday reversed changes to its Covid-19 testing guidelines, once again recommending that people without symptoms get tested for the coronavirus if they have come into close contact with someone known to be infected.

The CDC’s new guidelines now state, “If you have been in close contact, such as within 6 feet of a person with documented SARS-CoV-2 infection for at least 15 minutes and do not have symptoms. You need a test. … Because of the potential for asymptomatic and pre-symptomatic transmission, it is important that contacts of individuals with SARS-CoV-2 infection be quickly identified and tested.” It also calls for such people to self-isolate for 14 days, even if the test comes back negative.

Recent guidelines suggested that people without symptoms who have come into close contact with others known to be infected “do not necessarily need a test.” The new guidance, in effect, returns the CDC to a recommendation for more testing.

Public health experts and officials criticized the previous revisions. They noted that people without symptoms can still spread the coronavirus, and, in fact, people may be at greatest risk of spreading the virus before they develop symptoms. For those without symptoms, the test may be the only way to confirm an infection — and, as a result, get people to isolate to stop further spread of the disease.

The previous changes to not recommend testing, however, appeared to be politically motivated. President Donald Trump, arguing that more tests make the US look bad by exposing more Covid-19 cases, previously said that he told his people to “slow the testing down, please.” Media reports confirmed the White House and Trump’s Department of Health and Human Services forced and oversaw the previous changes to recommend less testing — even as CDC officials objected. That fell into broader efforts by the Trump administration to muzzle and warp the CDC to downplay Covid-19 and Trump’s botched response.

The latest revisions to the guidelines amount to the CDC rebuking Trump and his officials’ politically motivated efforts.

Since the start of September, the number of people getting tested for Covid-19 in the US has stalled out and even fallen. Some experts said that the previous revisions to the CDC guidelines were partly to blame.

Testing is crucial to stopping Covid-19 outbreaks. When paired with contact tracing, tests allow officials to isolate the sick, track down close contacts and get them to isolate as well, and deploy other public health measures as necessary. Aggressive testing and tracing were key to controlling Covid-19 outbreaks in other countries, such as Germany and South Korea.

The US, however, has struggled to build up its testing capacity. In the spring, the country was slow to do so due to a mix of federal screw-ups and bureaucratic hurdles, resulting in a “lost month” for confronting Covid-19. In the months after, testing did increase. But then, when cases started to spike nationwide in the summer, there were more testing shortages as some labs reported delays for results as long as weeks. Starting this month, testing appeared to decline again.

The testing failures are one reason the US, which is now nearing 200,000 confirmed Covid-19 deaths, has struggled so much to contain the virus. While the US hasn’t seen the most coronavirus deaths of wealthy nations, it’s in the bottom 20 percent for deaths since the pandemic began, and reports seven times the deaths as the median developed country. If the US had the same death rate as, say, Canada, 115,000 more Americans would likely be alive today.

The recent drop in testing is particularly concerning now: The fall and winter threaten another wave of rising Covid-19 cases — as people return to school, the holidays bring families and friends close together, the cold pushes people into indoor spaces where the virus is more likely to spread, and a flu season looms.

At least with its new guidance, the CDC is pushing for the kind of testing that could help America get control over future outbreaks and, hopefully, prevent them from becoming dire.

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Back in March, Michigan’s Covid-19 cases exploded — leaping from zero to 3,657 in just two weeks. Detroit’s three big automakers closed factories temporarily, and the state’s largest health care system warned it was reaching capacity.

In the midst of this crisis, Joseph Roche, an associate professor in the physical therapy program at Wayne State University, had an idea.

From his research into muscular dystrophies, Roche understood that inflammation can do significant damage to the body. When he read that in severe Covid-19 cases, runaway inflammation was causing damage to tissues and organ failure, he dove into the data as well as older research on SARS.

Initially, it appeared that the virus might cause immune cells to overproduce molecules called cytokines, causing a severe inflammatory response known as a cytokine storm. But what Roche suspected as he sifted through early case studies was that it wasn’t the immune system’s cytokines causing so much of the damage but an entirely different pathway in the circulatory system knocked off balance by the virus: bradykinin signaling.

He believed that an accumulation of two peptides, des-Arg(9)-bradykinin, abbreviated to DABK, and bradykinin — both part of a system that regulates blood pressure and other functions — were starting a feedback loop of inflammation and tissue injury. By stopping this reaction, he argued in an open letter to the scientific community in April and in a May paper published in the Journal of the Federation of American Societies of Experimental Biology, doctors could prevent some of Covid-19’s worst effects.

Several months later and 500 miles away, a group of researchers unaware of Roche’s work started feeding the world’s second-fastest computer data from about 17,000 genetic samples from 1,300 Covid-19 patients. The team, based at the Oak Ridge National Laboratory in Tennessee, asked the $200 million computer to look for patterns in how Covid-19 was changing genes and impacting different systems in the body.

After almost a week of data crunching, the supercomputer landed on something they found surprising: bradykinins. “I was literally at home on a Sunday afternoon looking at different visualizations, and it just jumped out at me,” Daniel Jacobson, a computational systems biologist at Oak Ridge, says.

He calls these haywire reactions a “bradykinin storm,” and like Roche, believes they may help researchers treat severely ill Covid-19 patients, possibly staving off damage to organ systems or even preventing deaths. Outside researchers agree: Elements of the supercomputer’s analysis have been corroborated since it was published in July, and researchers say it could help lead the way to more effective treatments.

Here’s a deep dive into what has been published on bradykinin signaling since the pandemic began, and what we know about how this compound might be instigating some of the worst Covid-19 damage.

Why bradykinin signaling might be making Covid-19 so much worse

How Covid-19 can prompt an inflammatory cascade gets complicated, but Roche and other experts now think bradykinin might be the key to the vascular changes, lung damage, and even neurological symptoms the disease can cause.

The virus usually enters the body through the airways and lands on cells, where a protein called ACE2 functions as a doorway. As the virus replicates in the body, it finds other cells that have ACE2 receptors, such as those in the lungs, hearts, intestines, kidneys, and brain.

“The virus not only uses ACE2 as an entryway into cells but also tells that cell’s nucleus to start reducing ACE2 expression,” Roche says. This causes an accumulation of an enzyme called DABK, which creates conditions for inflammation.

This is where bradykinin might come in. When the virus binds with ACE2 receptors, DABK piles up, and bradykinin levels increase—causing an inflammatory cascade. “It creates a vicious feedback loop,” Roche says, amplifying inflammatory processes, including producing more cytokines.

Scientists initially thought that Covid-19 caused the immune system to release an overwhelming flood of cytokines — as often happens in response to a viral infection. In fact, promising treatments like remdesivir lower cytokine production. But recent evidence suggests that Covid-19 patients may not have particularly elevated levels of cytokines compared to people critically ill with other respiratory conditions, and other interventions attempting to lower cytokine production failed to reduce mortality — suggesting something else is going on.

That something, says Jacobson, might be a bradykinin storm instead. This hypothesis fits with a surprising number of Covid-19’s bizarre symptoms.

Researchers have observed many vascular symptoms, but previously blamed cytokine storms’ inflammation or direct damage from the virus. But bradykinin can impact how your blood coagulates — possibly explaining the strange clotting problems reported in Covid-19 patients and the high percentage of Covid-19 deaths from heart attacks, strokes, and deep vein thrombosis. As the virus causes bradykinin to accumulate in the cells it has hijacked, it makes your blood vessels permeable, letting your blood leak out. This could also explain the “Covid toes,” that have been linked to blood circulation.

In the lungs, increasing gaps in the cells of blood vessels can spell further damage. Lungs are covered in capillaries, so these gaps start leaking blood and immune cells into the interior surface of the lungs, potentially providing the reason for Covid-19 patients’ respiratory distress.

To make things worse, according to the supercomputer analysis, the virus might also increase the natural production of hyaluronic acid—a biopolymer familiar to skincare aficionados, as it can absorb more than 1,000 times its weight in water. As bradykinin causes blood vessels to leak water into your lungs, it hits the hyaluronic acid in your lungs and forms a hydrogel. “It’s like trying to breathe through Jell-O,” Jacobson says. “At that point, unfortunately no matter how much oxygen you’re pumping through a ventilator, you can’t get a gas exchange through the hydrogel.”

Bradykinin dysregulation may also be behind the thyroid problems some Covid-19 patients are reporting. Previous research has found that, in addition to influencing the circulatory system, bradykinin is an important regulator of thyroid hormones.

Ilaria Muller, an endocrinologist at the Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico in Milan, and colleagues recently found that many patients who were hospitalized had abnormally low levels of thyroid-stimulating hormones, suggesting thyrotoxicosis and at least temporary thyroid damage. She says this damage could come from direct damage from the virus through the thyroid’s ACE2 receptors or from systemic inflammation.

More surprisingly, bradykinin storms also help offer an explanation for some of Covid-19’s neurological symptoms — from headaches to long-term nerve damage — which in one study afflicted 57 percent of Covid-19 patients. High levels of bradykinin in particular can cause the blood-brain barrier to break down, potentially allowing the virus into the brain and causing inflammation and damage.

Finally, as Elemental reports, the theory may even explain why men seem to be more likely to have worse cases of Covid-19. Some aspects of the RAS systems have receptors on the X chromosome, meaning that women have twice the levels of these stop-gap proteins, possibly giving them extra protection against the virus.

The supercomputer model also found different gene expression patterns in the lavage fluid from the lungs of COVID-19 patients. This is rare data, in part because getting that fluid can be dangerous to healthcare professionals, who may get infected while taking the samples, so this procedure is no longer carried out. A clinical trial measuring actual bradykinin levels in samples from Covid-19 patients’ lungs would provide a lot of valuable information but is unlikely to happen because of the transmission risk.

When something like a virus tweaks part of the body’s intertwined systems, you often end up with rippling consequences—in this case, a dire trend toward inflammation, possibly through both bradykinin pathways and cytokine production. Essentially, the bradykinin pathway gets off the track—and then it’s like a runaway train, potentially causing damage in many locations around your body.

What do bradykinin storms mean for possible Covid-19 treatments?

After finding the potential role of bradykinins in severe Covid-19 in March, Roche went looking for a way to halt this inflammatory cascade. “It’s like a set of gear wheels—inflammation, injury, inflammation—and you’re trying to jam up the wheels,” he says. Along with his wife, Renuka Roche, an assistant professor in occupational therapy at Eastern Michigan University, he started to explore potential treatments that were ready to use.

As clinicians trained to pay a lot of attention to recovery through rehabilitation, he says, “We know that health care does not end with just saving a person’s life.” Roche says life quality is important too, meaning any intervention that could minimize damage would be a true advancement in the fight against Covid-19’s ravages.

Treatment targeting bradykinin signaling wouldn’t have to be perfect to improve lung damage and long-term outcomes. “If you’re able to even dampen the cycle by 50 percent, that means that much tissue may be spared,” Roche says.

In the medical literature, the Roches found a medication called icatibant that is both known to be safe and inhibits bradykinin signaling. It was already approved by the FDA, with the added benefit of an expired patent, meaning generic versions could be made much more affordably. They reached out to the Canadian and Indian governments about starting rapid research on icatibant in late March, wrote an open letter to the scientific community in April, and published a paper on their hypothesis in May.

At the same time, Frank van de Veerdonk, an infectious disease specialist at Radboud University Medical Center in the Netherlands, was reaching similar conclusions. He knew that ACE2 is an important part of the RAS, and in April, hypothesized that a dysregulated bradykinin system was causing blood vessels to leak into Covid-19 patients’ lungs.

More recently, “We published data in patients with icatibant targeting bradykinin in Covid-19 as a treatment,” van de Veerdonk wrote Vox in an email. While not a controlled clinical trial, van de Veerdonk published a study where nine hospitalized patients were treated with icatibant and matched to similar Covid-19 patients who were not; the patients who’d received icatibant needed less supplemental oxygen and experienced no adverse effects from the drug.

In the US, Quantum Leap Healthcare Collaborative has started a clinical trial of five potential treatments, including icatibant. (They are still currently enrolling patients.) “The safety of the drug is well understood, and it’s fast-acting,” says Paul Henderson, director of collaboration at Quantum Leap.

In general, he says bradykinin receptors are interesting because they are upstream of most of the inflammatory response, including cytokines. If proven effective, he says, these treatments will probably also be useful for influenza and other diseases that cause acute respiratory distress.

Henderson doesn’t discount cytokines’ inflammatory impact altogether but suggests that interventions targeting cytokines may have been “taking out too little of all the processes going on to have much impact.” Imagine how much easier it is to dam a river at its headwater than closer to its mouth—similarly, interventions further “upstream” in biological pathways could have a larger impact.

In some ways, this work could be as important as finding a vaccine. “Reducing the burden on the health care system and preventing the very sickest from dying is really important,” Henderson says.

But he also cautions that, like with cancer, there is unlikely to be one “magic bullet drug.” Instead, it’s more likely a combination therapy, including anti-inflammatory medications and antivirals, will be necessary. “You’ll likely need different interventions in different stages of infection,” he says. “It is extremely complicated.”

Nevertheless, since Jacobson’s paper came out, his hypotheses have been supported by other research. For example, vitamin D is known to regulate RAS, and vitamin D deficiencies have been associated with severe cases of Covid-19.

This fits with a part of the supercomputer analysis that suggested the virus activates genes that break down more vitamin D. Lo and behold, at the end of August, a clinical trial in Spain on vitamin D found that it significantly reduced the need for ICU treatment in Covid-19 patients.

Similarly, another analysis, run by the World Health Organization, which incorporates seven different clinical trials, found that corticosteroids, which inhibit a protein activated by the bradykinin receptor, reduced the risk of Covid-19 death — fitting the computer model’s prediction neatly.

Bradykinin storms may also have implications for long-haul Covid-19 patients. Jacobson is now collaborating with Covid patient groups to gather data. “We’re looking at the top 100 symptoms and trying to map them to this mechanism,” he says, adding that several of his fellow researchers are long-haulers.

He says one of the next questions they hope to address is whether bradykinin dysfunction continues even after the virus has cleared, if the virus itself is persisting in different organ systems or some combination of both.

When new information raises more questions

The notion of bradykinin storms are appealing because they offer a tantalizingly unified theory that would explain so many of Covid-19’s inscrutable impacts. Joshua Zimmerberg, a biophysical virologist at the Eunice Kennedy Shriver National Institute of Child Health and Human Development at the National Institutes of Health, who was not involved in any of the bradykinin research, says the evidence is now compelling. “When you have independent confirmation, when people come to the same conclusion for different reasons—that’s very good evidence.”

But he warns against raising hopes for immediate treatments. “We all crave simple pathways and simple ideas, but inflammation is really complicated. There are still a lot of inflammatory diseases without good treatments.” Dampening bradykinin production too much, or at the wrong time—for example, early in the infection, when the natural inflammation cycle is needed to fight the virus—might actually be harmful.

Roche says the next steps are for large-scale randomized placebo-controlled clinical trials on potential drugs that inhibit bradykinin. “The hypothesis, [Jacobson’s] gene expression data, [van de Veerdonk’s] small-scale case series—these won’t move the needle,” he says. Data is needed to add drugs to doctors’ arsenal against the pandemic. But he’s gracious about more widespread attention only being directed toward bradykinin now, after he’s spent months trying to raise its profile.

“The pandemic has exposed key weaknesses in health care itself,” he says. “We need to empower ourselves with as much knowledge as we can, so we can serve our patients and protect ourselves.”

Lois Parshley is a freelance investigative journalist. Follow her Covid-19 reporting on Twitter @loisparshley.

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The United States has reached a new terrible milestone in the Covid-19 pandemic. This past week, the country saw, on average, about 79,000 new cases per day — the highest on record in a pandemic full of atrocious records. On Friday, more than 98,000 Americans received a positive test result.

From north to south, east to west, the virus is spreading uncontrolled again. This is not a peak. We’re in the midst of a climb. Next week, we can expect yet another record: leaping from more than 9 million total cases to 10 million cases in a matter of a few days.

The number of people in hospitals across the country is ascending, too, hitting 46,000 on Thursday. And this will likely be followed by rising numbers of deaths in the coming weeks.

Why? Because this is the pattern we’ve seen in every Covid-19 surge during the pandemic. It’s not going to change now. There’s a momentum to this virus.

Cases incubate silently for days in a human body, and it can take several days for a person to be tested, and more to find out the results. Next week’s record number of cases is already festering in the population now, waiting to be uncovered. All the while, the infected can continue spreading this very contagious virus exponentially, especially in places that don’t have mask mandates or restrictions on bars and restaurants being open for indoor dining.

Yet the disconnect between this grim reality and President Donald Trump’s words has never been greater. The president wants the public to believe the recent spikes are something of a mirage, based solely on expanded testing.

“We’re rounding the turn,” Trump told his supports at a rally on Monday. “Our numbers are incredible.”

A rise in Covid-19 cases means we’ll see a spike in hospitalization. Again.

While part of the increase in cases can indeed be explained by more testing, that’s far from the whole story. Look no further than the test-positive rate to understand why. The national rate has climbed more than a percentage point over the past two weeks, reaching 6.3 percent. That average obscures far higher test positive rates in states with some of the worst-controlled outbreaks:

This means a growing number of Americans being tested have the virus — and health officials aren’t keeping up with the rising demand for testing, nor are they keeping on top of outbreaks.

Covid-19 hospitalizations are also rising again, following a sharp drop through August and early September. Over the past month, the number of US patients in hospitals with the disease increased by more than 50 percent, according to the COVID Tracking Project, surpassing 46,000 on October 29.

As Vox’s Dylan Scott reports, this has already forced radical measures across the country: Wisconsin and Texas are building field hospitals; Idaho is planning to transfer patients out of state; Utah is ready to ration care.

“Although we are not yet close to the hospitalization peaks of almost 60,000 that we observed in the spring and summer,” the editors at the Covid Tracking Project observed, “the average number of people hospitalized this week rose to 42,621, a very substantial increase from the lows of about 30,000 that we saw just a month ago.”

If cases keep rising — as they’re expected to with the cold weather and more indoor gathering — this means we’re on track for a new hospitalization record. And, again, that will be followed by a new surge in deaths.

People with the disease are more likely to survive today. But the gains doctors have made treating critically ill patients could rapidly be undone as hospital wards become overwhelmed again.

“Each hospital’s overwhelmed point is different now than it was in April, but there is a point that’s too much for any hospital,” Theodore Iwashyna, a professor of critical care medicine at the University of Michigan who has been treating Covid-19 patients, told Vox. “There are only so many hands. You can only be in so many rooms.”

This was not a surprise, nor was it inevitable

What makes this moment so frustrating is that researchers and health officials have been warning for months that a fall and winter spike in Covid-19 cases was looming.

“There’s a possibility that the assault of the virus on our nation next winter will actually be even more difficult than the one we just went through,” Centers for Disease Control and Prevention Director Robert Redfield told the Washington Post in April. “And when I’ve said this to others, they kind of put their head back, they don’t understand what I mean.”

We were warned, as early as March, that there would be no going back to normal life until community transmission of the virus had been suppressed. We were warned that any successes achieved through business closures and social distancing would have to be replaced by equally effective public health measures if we were to take steps toward returning to life as normal. In many parts of the country, those alternative strategies never came.

Scientists also told us that we’d be living with the pandemic for potentially years without a vaccine. That’s still true.

In May, we were warned that state reopenings were coming too soon, and that case spikes, and later hospitalizations and deaths, would follow. And they did.

Over the summer, we were warned that falling temperatures in the autumn, along with continued lax precautions, might lead to another surge. And here we are.

Yet earlier this month, as it became more apparent that the United States was on track for a major increase in Covid-19 cases, states like Florida were relaxing restrictions, allowing bars and restaurants to reopen for indoor patrons. (A similar pattern emerged this summer as cities and states relaxed restrictions even as cases were rising, fueling a spike in new infections in June.)

The current rise in cases is starting from a much higher baseline, with the added element of increased transmission in winter conditions. As people spend more time indoors in the cold weather, and as lower humidity makes it easier to transmit a respiratory virus, the air is fertile for viral spread. That means the next Covid-19 surge could break more records.

Scientists say it didn’t have to be this way. “Through comparative analysis and applying proportional mortality rates, we estimate that at least 130,000 deaths and perhaps as many as 210,000 could have been avoided with earlier policy interventions and more robust federal coordination and leadership,” researchers at Columbia University reported this month.

Other parts of the world have also done a far better job of containing the spread of the virus. Officials in Taiwan reported this week that the island has gone 200 days without local transmission of Covid-19. South Korea, which confirmed its first Covid-19 case on the same day as the US, managed to keep its per capita infections far lower throughout the pandemic. Even with a recent rise in cases, South Korea’s infection rate remains much lower. The country also reported that its economy is even starting to grow.

These countries maintained much more aggressive restrictions on movement, while investing far more in testing for Covid-19 and tracing contacts of the infected. They also embraced mandatory face masks.

These lessons have been repeatedly emphasized throughout the pandemic, in the US and around the world. But these are lessons the US has still failed to learn. America is still struggling with basic pandemic control measures like social distancing. And now, with the days getting shorter, the country is facing the darkest stretch of the pandemic yet.

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