Where year two of the pandemic will take us: As vaccines roll out, the US will face a choice about what to learn and what to forget

Some highlights:

[U]nvaccinated people will not be randomly strewn around a community. Instead, they’ll form clusters, because vaccines are unevenly distributed, or because vaccine skepticism spreads among friends and families. These clusters will be like cracks in a wall, through which water can seep during a storm. “Those pockets of vulnerability will be the biggest problems,” said Shweta Bansal, a disease ecologist at Georgetown University. They will mean that even when some communities reach the 70 percent threshold, infections could still spread within them. People who waited because of distrust or hesitancy, and people who could not be vaccinated because of lack of access or preexisting medical conditions, will bear the brunt of these continuing outbreaks.

Such outbreaks will grow smaller and be more easily controlled as more people get vaccinated. As the year progresses, health-care workers might have to fight only localized COVID-19 fires instead of the overwhelming nationwide inferno that’s currently ablaze.

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By mid-November, 22 percent of all hospitals were understaffed. More than 2,900 health-care workers have died of COVID-19 this year. Many of their surviving peers have had enough. Some have gone on strike over unsafe environments, unsustainable pressures to keep working, and insufficient testing or protective gear. Others have quit or retired early. Medical professionals tend to be stoic; “if some are saying ‘I quit’ on Twitter, there’s going to be a wave behind that,” said Vinny Arora, a hospitalist at the University of Chicago. Entire hospitals, especially those that served poor or uninsured communities, have already closed. The depleted workforce will be hard to replenish, because medical training is lengthy, higher education isn’t graduating new nurses fast enough, and physicians from other countries (who disproportionately provide rural health care) have been dissuaded from coming to the U.S. by years of anti-immigration policies. “We’re really in for a rough ride, in terms of being able to deliver high-quality care to much of the U.S.,” Arora said.

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Many rich nations had little experience in deploying their enormous capacities, because “most of them never had outbreaks,” she added. By contrast, East Asian and sub-Saharan countries that regularly stare down epidemics had both an understanding that they weren’t untouchable and a cultural muscle memory of what to do.

Vietnam, the first country to contain SARS in 2003, “immediately understood that a few cases without an emergency-level response will be thousands of cases in a short period,” said Lincoln, the San Francisco State medical anthropologist, who has worked in Vietnam extensively. “Their public-health response was just impeccable and relentless, and the public supports health agencies.” At the time of my writing, Vietnam had recorded just 1,451 cases of COVID-19 all year, fewer than each of the 32 hardest-hit U.S. prisons.

Rwanda also took the pandemic seriously from the start. It instituted a strict lockdown after its first case, in March; mandated masks a month later; offered tests frequently and freely; and provided food and space to people who had to quarantine. Though ranked 117th in preparedness, and with only 1 percent of America’s per capita GDP, Rwanda has recorded just 8,021 cases of COVID-19 and 75 deaths in total. For comparison, the disease has killed more Americans, on average, every hour of December.

Crucially, while U.S. health care is skewed toward treating sick people in hospitals, Rwandan health care is skewed toward preventing sickness in communities. The U.S. devotes just 5 percent of its gargantuan health budget to primary care; Rwanda spends 38 percent. The U.S. was forced to hire and train thousands of contact tracers; Rwanda already had plenty of community health workers who knew their neighbors and had their trust. “Community health workers know where the most vulnerable people are and what they need,” said Sheila Davis, the chief executive of the nonprofit Partners in Health. A living safety net, these workers can intervene early if people need food, medications, or prenatal care. “We [in the U.S.] wait for someone to completely crash and burn before we provide those things,” Davis said. “We are too focused on high-tech and expensive health care. We’re set up to fail in a pandemic like this.”