In the early days of May, Umair Shah, director of the public-health department in Harris County, Texas, was feeling hopeful.
It looked as if his county might succeed in controlling the coronavirus outbreak. The number of new cases per day had plummeted to an average of about 50 from a peak of 239 in early April, and it was holding steady. On the charts that Shah studied on his computer each morning, the uptick — a mountain that had been rising into existence for weeks — had given way to a plateau.
The virus wasn’t disappearing. But it wasn’t spreading rapidly anymore, either.
That stalemate was no small feat. For one thing, Harris County stretches across 4,600sq km of the state’s southeastern edge.
The region includes two international airports, four international seaports and the city of Houston.
The first case was confirmed there in early March, around the same time that cases first popped up in New York, and modelers initially worried that the county’s hospitals and morgues would be overrun — just as New York City’s eventually were.
For another thing, the work itself was gruelling. By early May, Shah’s staff had logged 16-hour days, six or seven days a week, for two months.
Contact tracers and outreach workers had made thousands of phonecalls: To persuade people exposed to the virus to report their symptoms, get tested, and self-isolate; and to prevail on businesses, apartment complexes, and nursing homes to hang more handwashing signs and distribute informational pamphlets.
Shah and his team had not been particularly well-armed for any of these fights.
Decades of research shows that a robust national public-health system could save billions of dollars annually by reducing the burden of preventable illnesses and keeping the population healthier overall.
But like most public health departments across the country, Harris County’s was grossly underfunded.
Shah had started out in clinical medicine, but his parents pressed him from early on to “do well, and do good” and to his mind, public health was the best way to fulfil that charge. His department employed just 700 or so people in a broad range of health-promotion efforts, from mosquito control to maternal health and child health.
He recently secured a $15m (€12.75m) budget increase, thanks to some aggressive lobbying and a turn in political fortunes: The Commissioner’s Court, which controlled the health department’s budget, turned Democratic during the previous election for the first time in a generation.
But even that had not been enough. When the county confirmed its first SARS-CoV-2 cases, the department had just 10 epidemiologists on staff.
Shah was amazed at what they had been able to achieve: A monthlong stalemate against the pandemic of the century.
But he also knew that success was fragile, and he wasn’t completely surprised when it began to evaporate in mid-June.
As a result, the state’s reopening had been hasty and poorly coordinated.
And now, a month and a half in, case counts were rising and intensive-care units were bracing for an onslaught.
Texas was not alone.
In other countries, officials locked down entire cities and employed large-scale, high-tech surveillance programs to stop the virus from spreading.
The Centers for Disease Control and Prevention, the nation’s leading public- health department, had stopped holding its own news conferences in early March.
In May, several states — not just Texas — rushed to reopen. And by late June, case counts were surging in at least 20 of them.
Or for flu season or hurricane season, either of which would almost certainly worsen the current crisis.
As the plateau on his computer screen gave way to another mountain, Shah worried that his team was too exhausted and demoralized to continue.
Public-health interventions work best when the forces of politics and culture are aligned behind them — when elected officials provide the necessary resources, and citizens abide by the necessary strictures. Even now, with hospitals filling up, such convergence seemed unlikely. The people of Harris County were tired, too, he guessed.
In the past century, the largest gains in human health and life expectancy have come from public-health interventions, not medical ones.
Clinical medicine — treating individual patients with medication and procedures — has registered enormous gains. But even stacked against those triumphs, public health — the policies and programs that prevent entire communities from getting sick in the first place — is still the clear winner.
“It’s saved the most lives by far, for the least amount of money,” Tom Frieden, a former director of the CDC, told me recently. “But you’d never guess that based on how little we invest in it.”
Between early March, when the first cases of coronavirus were detected in Harris County, and May 1, when Governor Greg Abbott began his phased reopening of the entire state, the Harris County chief executive, Lina Hidalgo, was sued at least five times.
She was sued over a rodeo closure, bar closures and church closures. She was sued over mask edicts.
She was also called a tyrant, a fear-mongerer, and a fool and told her political career would be over. She was trying to follow the science anyway.
Abbott originally left the coronavirus response to local leaders like her, because, he said, the state was too big for a one-size-fits-all plan.
But in late March, he reversed course and issued a statewide order superseding all existing local ones.
Now, in May, he was lifting that state order and loosening restrictions far more aggressively than scientists advised or local officials like Hidalgo were comfortable with.
Abbott’s plan involved opening the economy in phases.
The first phase included restaurants, retail shops, and cinemas, all at 25% capacity, beginning on May 1. On May 18, the second phase would begin.
The governor promised that each phase could be adjusted or possibly delayed if case counts rose in the interim. But critics said that his timeline moved too quickly to measure those upticks.
It would take several days for people to take full advantage of the lifting of restrictions, and at least two weeks beyond that to see the impact on the virus’s spread.
In the meantime, almost none of Abbott’s own criteria for a safe reopening were being met. Testing capacity was still limited, and contact tracing had yet to be sufficiently scaled up.
Officials had no hope of pinpointing potential case surges or of keeping them in check. And if they could not contain the virus once they reopened, the entire shutdown would have been for nothing.
Viruses were invisible — and slow. It took weeks to know if any given decision was the right one, and in the meantime, constituents clamored for officials to do less, not more.
When Hidalgo erected a temporary field hospital in April so that intensive-care units would not be overwhelmed by a surge of coronavirus infections, Republican lawmakers accused her of wasteful overreaction.
And when she made masks mandatory in all public spaces, Lt Gov Daniel Patrick singled her out for rebuke.
Abbott quickly issued yet another executive order, stating unequivocally that mask-wearing was a matter of personal choice. (Abbott never responded to requests for comment for this article.)
His resistance to tough restrictions aligned him with other Republican governors (in Florida and Arizona, for example) and with the president, whom he visited at the White House in early May, as reopening efforts across the country made headlines.
The virus was far from under control in most of those states, but ailing economies were taking precedence over safety concerns.
Abbott accelerated the timeline for reopening the state when a Dallas-based hairstylist was sentenced to a week in jail for opening her salon in defiance of his shutdown, and two Republican state representatives followed her lead by getting their own haircuts.
Abbott initially threatened to prosecute shop owners who violated his edict.
But now, with a working mother in jail and his own party in partial revolt, he reversed course again, softening the penalties for such infractions and announcing that salons and barbershops could reopen on May 8 — 10 days earlier than planned.
The move confused and frustrated other business owners: If salons and barbershops could open, why not tattoo parlours and bars?
By Memorial Day weekend, Texas was almost fully reopened.
And, while Harris County’s case counts had plateaued, case counts in other parts of the state were rising.
Public-health initiatives have always been vulnerable to both public resistance and political interference.
Some of the nation’s first public-health departments emerged as a response to exactly this problem.
From the republic’s earliest days it was clear that certain health threats could not be staved off by individuals acting alone.
Elected officials also knew that when it came to protecting constituents from such threats, the wisest course of action was almost always the least politically popular one.
Businesses had to be closed when plagues sneaked in on merchant ships. People and goods had to be quarantined and certain behaviors, like spitting in public, occasionally outlawed.
Independent health committees were often created during public-health crises and authorized to act as needed so that the worst outcomes could be prevented — ideally without some politician having to lose his next election.
In time, some of those committees morphed into permanent departments.
The Texas Health and Safety Code gives the local public-health authorities power to act in times of crisis to protect the community.
But in May, Abbott suspended those powers, so that leaders like Hidalgo and Shah could not issue any rules that were stricter than those he issued.
By then, just about all businesses were open at some level, and case counts were rising with alarming speed. Shah felt as though he were trapped in the driver’s seat of a car with a stuck accelerator.
“It’s like we’re shouting out the window,trying to tell everyone, ‘Hey, this thing is out of control,’” he told me.
“But we can’t do anything to slow it down.”
It wasn’t just the bars and restaurants and cinemas that worried him; it was the layering of so many other risks. There had been outdoor graduations, Mother’s Day and Father’s Day celebrations and Memorial Day weekend.
There had also been a demonstration with thousands of protesters over of the murder of the Houston native George Floyd.
Each event increased the virus’s opportunity to spread. And each added to the forward momentum.
“Every time we dial forward, the consequences of dialing back become greater,” Shah said. “And so we keep dialing forward. And it builds on itself and creates this collective sense that: ‘Hey, everything is OK. Everything is back to normal. We can go to the gym again.’”
Abbott initially dismissed the uptick in cases, saying that it was a result of more testing — a sign that things were going well — not a cause for alarm.
Then he played down the cases, explaining that the uptick was confined to jails, meatpacking plants and nursing homes and therefore not a concern for the wider population.
When it became clear that young adults were driving the surge, he admonished individual groups to take more personal responsibility for protecting themselves. On June 12, he told reporters that he was concerned but not alarmed.
On June 17, he clarified his mask-ordinance ban, saying that county leaders could order businesses to order customers to cover their faces.
But by then, mask-wearing itself had become a cultural flashpoint, every bit as contentious as business closures and rapid reopenings.
America was a paradox — a beacon of science embedded in a culture increasingly suspicious of scientists — and Harris County reflected that paradox perfectly.
Its cities were filled with medical and scientific riches, including a Nasa space complex, an energy sector rife with engineers and the Texas Medical Center, the biggest health care complex in the world.
The epidemiology team had been expanded to include hundreds of contact tracers and other new hires, but they struggled to stop the virus’s spread, especially as the reopening continued.
There was still not enough testing capacity to meet demand, and the wait time for results was still too long. For contact tracing to work, sources of infection need to be pinpointed as quickly as possible.
“You can’t trace without a case,” as Shah is fond of saying. By mid-June, Hidalgo worried that the virus had outrun their best efforts.
“We’re throwing everything we have at it,” Hidalgo told me.
“And we have no evidence right now that any of our strategies are working.”
The levelling out of cases that Shah and his team managed to achieve — the plateau — was gone.
New case counts were up to 200 a day and, given the testing shortage, the actual number of cases was probably much higher than that.
Many experts agree that lockdowns to stop the coronavirus from spreading could have been safely lifted, in a targeted way, based on careful localized assessments and close monitoring.
Restrictions would be reintroduced as needed — potentially several times in the next few years — until either a vaccine was made available or 70 to 80 percent of the population developed immunity to SARS-CoV-2.
Numerous papers have laid out a range of potential models for creating this system.
The coronavirus pandemic has laid bare gnawing questions at the core of America’s many divisions: Are we willing to trust science and scientists in a crisis? What, exactly, do we want from our government?
And what are we willing to sacrifice for one another? A recent poll by the Kaiser Family Foundation found that a majority of Americans, in both political parties, favour strict social-distancing edicts and other tight measures to control viral spread.
Health departments across the country have seen their budgets shrink by nearly 30% since 2008.
As a result, they have had to cut 56,000 jobs (nearly 23% of the total public-health workforce) and to make do without a roster of operational essentials, including modern laboratory equipment, modern computer systems and routine pandemic preparedness drills.
The CDC budget has remained flat over the same period, relative to inflation, and the White House recently eliminated a directive aimed specifically at pandemic preparedness, a move that was widely noted and denounced as SARS- CoV-2 reached pandemic proportions.
As 2020 wears on, Shah and others are grappling with a new and bitter reality: Because of the economic crisis, which was triggered by the current pandemic, which was worsened by a lack of public-health investment, public-health agencies will probably suffer more budget cuts in the coming years.
In late June, Abbott reversed course again and ordered the state’s bars to close and restaurants to reduce their capacity to 50% (they had been at 75% for several days).
He also issued an executive order requiring all Texans in counties with more than 20 active Covid-19 cases to wear a mask in public.
Scientists worried that it was too little too late, and by early July, the numbers seemed to prove them right. On July 8, the state hit a record 9,952 new coronavirus cases reported in a single day.
The state’s positivity rate — the portion of all tests done that come out positive — also rose to 15.6%, from 7.9% just three weeks earlier.
Hospital beds were filling up, hospital floors reconfigured and surge units readied.
Doctors and nurses, in Harris County and elsewhere, have begun a worrying and familiar census-taking of ventilators and personal protective equipment.
And the same stories that played out in Wuhan and Lombardy and Seattle and New York were beginning anew. And not only in Texas.
People in Texas, Florida, California and New Jersey are bracing for a second wave of outbreaks in the fall, even as the first wave has yet to fully recede.
The root of this catastrophe, doctors, scientists and health historians say, is our failure to fully incorporate public health into our understanding of what it means to be a functioning society.
Until we do that, we will be unable to effectively respond to crises like this one — let alone prevent them.