H5N1

Picard: The COVID-19 mess in the US will only get worse

The Globe and Mail's health columnist André Picard writes: The coronavirus mess in the U.S. will only get worse. Excerpt:

It took two months for the U.S. to record its first 50,000 cases of COVID-19. 

Now, as it gallops toward three million cases, the numbers are increasing at a rate of 50,000 cases a day and, if the current trends continue, it will soon be 100,000 cases daily. 

It’s hard to overstate how bad the situation has become as the novel coronavirus rips across the Sun Belt from Florida to Texas to Arizona to California. Cases are trending up in 43 states. They are trending down in only two, New Jersey and Rhode Island. Even there, things are hardly going well; Rhode Island,, population 1.1 million, has roughly the same number of deaths as Japan, population 127 million. 

It’s not the kind of Fourth of July fireworks anyone hoped for, but as Americans fan out across the country for the weekend, we can fully expect the outbreak to boomerang back to already hard-hit eastern states such as New York, Illinois and Michigan.  

With no end in sight to the COVID-19 carnage, we need to ask ourselves how it is possible for a country with unlimited financial, medical and communications clout to screw up its response so badly?  

Even more importantly: Does the mighty United States of America have the political will to stop this seemingly runaway train?  

There is no country on Earth where the response to the coronavirus has been more politicized. Since day one, U.S. President Donald Trump has followed a well-worn playbook of blaming others, shameless braggadocio, blissful denial, and delusional thinking. 

The President has pointed fingers at everyone from China to the World Health Organization, embraced everything from conspiracy theories to overhyped “cures,” and systematically ignored the advice of epidemiologists and public-health experts in favour of that of sycophants.  

When indoor gatherings were strongly discouraged, Mr. Trump staged a rally in a large arena. He is hosting a Fourth of July fireworks display at Mount Rushmore, where social distancing will be virtually impossible. And – until very recently – he steadfastly refused to wear a mask. 

Despite the raging outbreaks in the U.S. South, the President insists “we’re getting things under control.”

 And his long-term plan? “I think, at some point, that’s going to just disappear, I hope.” 

Apparently, infection control, like gun control, depends on hopes and prayers, not sound public policies. 

Beyond the glaring absence of political leadership, the U.S. is paying a steep price for its impatience.  

The states that are now seeing fearsome increases in COVID-19 cases all have one thing in common: They ended their lockdowns early and broadly.  

They arrogantly ignored the key take-home lesson from Asia and Europe: Lock down swiftly, and re-open slowly. Instead, virtually everything reopened at once: shopping malls, hair salons, movie theatres, casinos, strip clubs, restaurants, and bars. 

It is puzzling that so much effort was put into re-opening bars and so little into reopening schools and keeping workers in the service sector safe.  

But, in America, seemingly everyone was champing at the bit to make money again, pandemic be damned. This has backfired. The premature rush to “back to normal” will have a steep economic price.

Financial crisis at PAHO in the time of COVID-19: A call for action

Via The Lancet: Financial crisis at PAHO in the time of COVID-19: a call for action. The authors are senior staffers with PAHO.

On May 21, 2020, at a special session of the Executive Committee of the Pan American Health Organization (PAHO), WHO Regional Office for the Americas, Carissa Etienne, Regional Director, declared that due to non-payment of Member States' contributions, PAHO stands on the brink of insolvency. 

As of April 30, 2020, most of the non-payment is attributable to the USA (67%); however, late payments are outstanding from Brazil, Venezuela, Mexico, Argentina, Colombia, Chile, and others, to a total of US$164·6 million. This includes an unprecedented $63·8 million (57%) of 2019 assessed contributions. 

This financial crisis could not have occurred at a worse time. The Americas have recorded the greatest COVID-19 morbidity and mortality of any region. As of June 25, 2020, the COVID-19 Information System for the Region of the Americas has recorded 4·6 million cases and 230 400 deaths in 54 countries. The trajectory is worsening.  

Health security in the western hemisphere would be severely threatened without a functioning PAHO. Reserve funds will be exhausted by September, 2020. PAHO faces dire actions, including executing borrowing options and possible implementation of key staff furlough measures. 

PAHO was established in 1902 to promote public health action against infectious disease threats. A core value was Pan-Americanism, expressed in the countries' commitment to work together to improve the health of populations living in the poorest countries. With PAHO's leadership, countries of the Americas eliminated polio in 1991, measles in 2002, rubella in 2002, congenital rubella syndrome in 2009, and neonatal tetanus in 2017. PAHO has played crucial roles in responding to numerous other infectious disease threats, controlling the rising tide of non-communicable disease and strengthening health systems. 

Leadership and coordination at global and regional levels are pivotal to minimising morbidity and mortality during the COVID-19 pandemic. PAHO must work with all member states to ensure a sustained response to the pandemic and equitable access to vaccine, treatment, and supplies. 

As health services have been adversely affected by COVID-19, we must anticipate and respond to epidemic-prone vaccine-preventable disease outbreaks as well as complications arising from disruption in the management of chronic diseases and cancer. 

This is a call to action to countries of the Americas to pay their outstanding contributions and avoid a financial crisis with known and unknown consequences. It is a call for all countries to work together to overcome the challenge of COVID-19 in the spirit of solidarity and protecting the health of all.

Hollowed-out public health system faces more cuts amid COVID-19 pandemic

Many thanks to Lauren Weber for sending this major report by Kaiser Health News and The Associated Press: Hollowed out public health system faces more cuts amid virus. Here's an excerpt and then a comment, but you should just click through and read the whole long, grim story. Don't let it depress you, but do let it enrage you.

The U.S. public health system has been starved for decades and lacks the resources to confront the worst health crisis in a century. 

Marshaled against a virus that has sickened at least 2.6 million in the U.S., killed more than 126,000 people and cost tens of millions of jobs and $3 trillion in federal rescue money, state and local government health workers on the ground are sometimes paid so little, they qualify for public aid.  

They track the coronavirus on paper records shared via fax. Working seven-day weeks for months on end, they fear pay freezes, public backlash and even losing their jobs.  

Since 2010, spending for state public health departments has dropped by 16% per capita and spending for local health departments has fallen by 18%, according to a KHN and Associated Press analysis of government spending on public health. At least 38,000 state and local public health jobs have disappeared since the 2008 recession, leaving a skeletal workforce for what was once viewed as one of the world’s top public health systems. 

An Associated Press-KHN investigation has found a skeletal workforce facing more possible county budget cuts. KHN, also known as Kaiser Health News, and AP interviewed more than 150 public health workers, policymakers and experts, analyzed spending records from hundreds of state and local health departments, and surveyed statehouses. On every level, the investigation found, the system is underfunded and under threat, unable to protect the nation’s health.  

Robert Redfield, the director of the Centers for Disease Control and Prevention, said in an interview in April that his “biggest regret” was “that our nation failed over decades to effectively invest in public health.”  

So when this outbreak arrived — and when, according to public health experts, the federal government bungled its response — hollowed-out state and local health departments were ill-equipped to step into the breach.

Over time, their work had received so little support that they found themselves without direction, disrespected, ignored, even vilified. The desperate struggle against COVID-19 became increasingly politicized and grew more difficult. 

States, cities and counties in dire straits have begun laying off and furloughing their limited staff, and even more devastation looms, as states reopen and cases surge. Historically, even when money pours in following crises such as Zika and H1N1, it disappears after the emergency subsides. Officials fear the same thing is happening now. 

“We don’t say to the fire department, ‘Oh, I’m sorry. There were no fires last year, so we’re going to take 30% of your budget away.’ That would be crazy, right?” said Dr. Gianfranco Pezzino, the health officer in Shawnee County, Kansas. “But we do that with public health, day in and day out.”

This is not just a Republican failure; the Democrats are equally to blame. Both parties, since about 1980, have presided over an enormous project of social engineering: the transfer of wealth from working people and the middle class to the 0.1%.

"Government is the problem" was Reagan's mantra, and as people began to notice that their incomes couldn't quite cover all their bills any more, they were taught to blame government spending for their suddenly heavy taxes. (Never mind that Americans were already among the most lightly taxed citizens of any industrialized country.)

 

So tax cut after tax cut came from Republican and Democratic administrations alike, on all levels of government. Somehow the taxes were always too burdensome, the government spending too wasteful. Universal health care was for those overtaxed "socialist" Europeans and Canadians, and a little grudging support for public health came only to provide symptomatic relief—to provide a Band-Aid, not to prevent the cut in the first place.

 

"We're all in this together" rings hollow in a country that's been taught for 40 years that everyone is personally responsible for his or her success or failure, health or sickness. And now that the consequences of 40 years of wealth transfer are manifest, 126,000 rugged American individualists are dead, 2.6 million have been sickened (so far), and everyone but the 0.1% have been further impoverished. (The 0.1% have been doing just fine, thanks.)

 

It will take more than yet another transfer of power from Republicans to Democrats to roll back COVID-19. It will take a rollback of 40 years of systemic theft from the 99%.

The lessons Canada can take from the US's mishandling of COVID-19

Via CBC News: The lessons Canada can take from the U.S.'s mishandling of COVID-19. Excerpt:

Nearly two months ago, a health-care adviser to two U.S. presidents burst out in frustration when asked whether Americans would see a quick spike in new COVID-19 cases as states reopened. 

Zeke Emanuel, who served in the Obama White House and has informally advised President Donald Trump, expressed exasperation that people kept looking for an immediate effect. 

Launching into a sermon about the mathematical realities of exponential growth rates, Emanuel said the disastrous consequences of reopening too early would only emerge around early summer. 

"Two months, not two weeks," Emanuel said in early May. "That's likely when you'll see the effects of what we're doing today. ... That's when people will recognize, 'Wow, now we've got 1,000 cases today, 3,000 cases tomorrow, 6,000 the next day.'"  

He predicted the country would awaken to the disaster around mid-July.  

It's happening ahead of schedule. 

The U.S. has surpassed 127,000 deaths and case counts are rising rapidly in numerous states, mainly in the south. An alarming surge has forced Texas to pause its reopening plans. Hospitalizations have hit record highs in Arizona and in California. 

Florida has backpedaled on its reopening bullishness. A governor who recently accused the media of fear-mongering over COVID-19 — wagging his finger at reporters over what he characterized as "black helicopter" conspiracy theories — was forced to announce Friday that bars would close again as Florida experienced an astronomical spike in positive tests. 

"This is what happens when you reduce social distancing measures and you have community transmission ongoing and those two things collide and it just spreads," said Jason Kindrachuk, an assistant professor of viral pathogenesis at the University of Manitoba in Winnipeg and Canada Research Chair of emerging viruses. 

Kindrachuk said that Canadians would be well-advised to take lessons from the American response to the pandemic.  "We can take that information and posit here in Canada that as we reduce social distancing, especially in regions that are more population-dense, we're likely going to see a resurgence in cases, because ultimately the virus is still in our communities and it's still able to spread."

COVID-19 and the second Great Depression

Via The Atlantic: The Second Great Depression. Excerpt:

A fiscal cliff for families. Rolling business failures. A budget crisis for state and local governments. Each is bad enough. Each might be a big-enough headwind to tip the economy into recession alone. But the last element is the true alpha and omega of our worst-case scenario: the catastrophe of the American government’s management of the novel-coronavirus pandemic. 

Like many of its peer nations, the United States imposed shelter-in-place and social-distancing measures to curtail the spread of the virus. But it did so late, leading to the unnecessary deaths of tens of thousands of people. And it wasted the time these extreme measures bought, because the government failed to set up a strong test-and-trace regime. Countries including South Korea and New Zealand crushed the coronavirus. The United States merely patted it down. The country is reopening with the disease still spreading and maiming and killing, as several states experience a dramatic surge in caseloads. 

Never getting the pandemic under control means never unleashing the economy. Just look at the casinos in Las Vegas: open, yet half-empty. The botched response means millions of parents will need to continue watching their young children instead of committing to work. It means thousands of offices will remain on work-from-home orders, hurting the commercial operations built to support them. It means Americans will avoid doctors’ offices, bars, and sporting events, staying at home and starving local businesses of revenue. It means localities might end up having to return to extreme social-distancing measures over the summer and fall. And it means fear and mistrust: depressed consumer confidence, ruined faith in government, and concerns about the economy’s ability to recover.  

The Trump administration has repeatedly argued that there is a trade-off between the country’s economic health and its public health. But economists and physicians have repeatedly argued that that is untrue: Ending the pandemic would have been the single best thing the federal government could have done to preserve the country’s wealth, health, and economic functioning. The Trump administration, in its hubris, obstinacy, and incompetence, failed to do it.

COVID-19: Amid threats and political pushback, public health officials are leaving their posts

This is appalling. Via The Washington Post: Amid threats and political pushback, public health officials are leaving their posts. Excerpt:

For Lauri Jones, the trouble began in early May. The director of a small public health department in western Washington State was working with a family under quarantine because of coronavirus exposure. When she heard one family member had been out in the community, Jones decided to check in.  

The routine phone call launched a nightmare.  

“Someone posted on social media that we had violated their civil liberties [and] named me by name,” Jones recalled. “They said, ‘Let’s post her address . . . Let’s start shooting.’ ” 

People from across the country began calling her personal phone with similar threats.  

“We’ve been doing the same thing in public health on a daily basis forever. But we are now the villains,” said Jones, 64, who called the police and set up surveillance cameras at her home. 

Public health workers, already underfunded and understaffed, are confronting waves of protest at their homes and offices in addition to pressure from politicians who favor a faster reopening. Lori Tremmel Freeman, chief executive of the National Association of County and City Health Officials, said more than 20 health officials have been fired, resigned or have retired in recent weeks “due to conditions related to having to enforce and stand up for strong public health tactics during this pandemic.”  

Although shutdown measures are broadly popular, a vocal minority opposes them vociferously. There have been attacks on officials’ race, gender, sexual orientation and appearance. Freeman said some of the criticisms “seem to be harsher for women.”  

Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials, said attacks on health officials have been particularly awful in California, Colorado, Georgia, Ohio and Pennsylvania.  

This month in California, Nichole Quick, Orange County’s chief health officer, stepped down after she faced threats and protests at her home for requiring face coverings in many businesses as cases rose. The mandate, issued May 23, was softened to a recommendation a week later.  

Andrew Noymer, a professor of public health at the University of California at Irvine who is part of a county task force, said it was not the first time Quick had been undermined.  

On March 17, Quick issued a strict lockdown order; a day later it was amended to add exceptions.  

“It was couched as a clarification, but it was a walk back,” Noymer said, because of pressure from business leaders.  

Quick’s departure is part of an exodus of public health officials across the country who have been blamed by both citizens and politicians for the disruptions caused by the coronavirus pandemic.  

“I don’t think I’ve ever seen anybody resign for the kinds of reasons we’ve seen recently,” Plescia said. “We are very concerned that if it continues to get worse it’s going to have major implications for who will be willing to have these jobs.”  

Ohio’s public health director, Amy Acton, shifted to an advisory role after enduring months of anger against the state’s preventive measures, including armed protesters at her home bearing messages including anti-Semitic and sexist slurs. One Republican lawmaker linked Acton, who is Jewish, to Nazi Germany; another called her a dictator.  

Georgia’s public health director said last month that she receives threats daily and now has an armed escort. 

Pennsylvania’s secretary of health, who is transgender, has come under fire for the state’s handling of the pandemic, including from a county official who resigned after saying at a recent meeting that he was “tired of listening to a guy dressed up as a woman.” 

Four public health officials in Colorado have left their jobs recently.  

A day after telling political leaders in Weld County, Colo. that their insistence on a speedy reopening despite a high case rate and widespread transmission was giving him “serious heartburn,” Public Health Director Mark Wallace got a 7:30 p.m. email: He had until 9 a.m., it said, to weigh in on guidelines for reopening businesses — “churches, salons, restaurants, etc.” They would go public an hour later.  

Wallace, who declined to comment for this article, retired soon after. 

Theresa Anselmo, executive director of the Colorado Association of Local Public Health Officials, said 80 percent of members had reported being threatened and more than that were at risk of termination or lost funding.

Uncertain future as COVID-19 infection rate sets global records

Via the South China Morning Post: Uncertain future as Covid-19 infection rate sets global records. Excerpt:

Six months into the Covid-19 pandemic and the good news is a number of countries are easing lockdown measures, allowing a semblance of what was normal life to return. The bad news is global infection numbers are surging. 

The number of newly infected people set records on multiple days in June, according to data from Johns Hopkins University in the US. The World Health Organisation issued a telling statistic of its own, noting that 85,000 cases were reported in the first two months of the outbreak; in the past two months, it was 6 million. The WHO’s grim figures coincided with a new flare-up of the disease in Beijing. 

China, where the coronavirus was first identified at the end of last year, had earlier locked down a region of 60 million people and shut its borders to foreigners to control the disease. Even after those stringent measures, the virus surfaced again in the capital. 

Consequently, epidemiologists and other specialists in disease control are reluctant to make a call on whether global infections are set to peak and then decline, or whether the coming months will see a surge or even a second wave.  

“Over the next six months we could see as many cases as we’ve seen in the first six months, or in extreme circumstances perhaps even more,” said John Mathews, an honorary professor at the University of Melbourne’s School of Population and Global Health. 

“It depends on how responsive people are and how responsive the governments are,” said Mathews, a former deputy chief medical officer to the Australian government. 

Michael Osterholm, director of the Centre for Infectious Disease Research and Policy at the University of Minnesota, was more blunt. 

He said people had to realise they were in the early stages as far as getting anywhere near to the 60 to 70 per cent “herd immunity” level needed to stop the pandemic’s spread. 

“The world needs to wake up and understand that previous pandemics often took years to fully roll through their cycle, so why are we still thinking that this is a four-month experience?” he said.  

Herd immunity refers to the point where roughly two-thirds of the population have been exposed to the virus or been vaccinated, which stalls transmission of the pathogen. However, vaccine timelines remain unclear and antibody tests show that even in hard-hit areas, populations are nowhere close to the herd immunity threshold. 

“Think of all the pain, suffering and economic disruption that has occurred and it’s only up to 5 per cent of the population and we need to get to 60 to 70 per cent,” Osterholm said, pointing to studies that show antibody levels in the single digits. 

Nonetheless, around the world lockdowns and other social distancing measures put in place to try and slow the spread of Covid-19 are being eased. This is sometimes despite new daily infections hovering around 20,000 people, as in the United States, or are on the rise, as in South Africa. 

“Some of these decisions to open up are directly economic, which has knock-on effects on people’s health,” said Hannah Clapham, an assistant professor at National University Singapore’s Saw Swee Hock School of Public Health. 

“But in other places these are more direct choices between the coronavirus health impact and the problems that are coming with the lockdown measures, such as lack of access to food, necessary medications and other health care,” she said. 

Reopening schemes could lead to more infections and needed to be carefully calibrated to work well, she said. “It’s a tough decision for governments.”

WHO Director-General's opening remarks at the media briefing on COVID-19 - 19 June 2020

Via WHO: WHO Director-General's opening remarks at the media briefing on COVID-19 - 19 June 2020. Excerpt:

The pandemic is accelerating. More than 150 thousand new cases of COVID-19 were reported to WHO yesterday – the most in a single day so far. Almost half of those cases were reported from the Americas, with large numbers also being reported from South Asia and the Middle East. 

The world is in a new and dangerous phase. Many people are understandably fed up with being at home. Countries are understandably eager to open up their societies and economies. But the virus is still spreading fast, it’s still deadly, and most people are still susceptible.  

We call on all countries and all people to exercise extreme vigilance. Continue maintaining your distance from others. Stay home if you feel sick. Keep covering your nose and mouth when you cough. Wear a mask when appropriate. Keep cleaning your hands. 

We continue to call on all countries to focus on the basics: find, isolate, test and care for every case. Trace and quarantine every contact. As the pandemic gathers pace, it’s the most vulnerable who will suffer the most. All countries rich and poor have populations who are vulnerable to a higher risk of severe disease and death. 

Tomorrow is World Refugee Day – an important moment to highlight the risks of COVID-19 for some of the world’s most vulnerable people. Refugees are particularly at risk of COVID-19 because they often have limited access to adequate shelter, water, nutrition, sanitation, and health services. Over 80 per cent of the world’s refugees and nearly all the world’s internally displaced people are hosted in low- and middle-income countries. WHO is deeply concerned about the very real and present danger of widespread transmission of COVID-19 in refugee camps.  

Beyond the health threat posed by the virus, COVID-19 is also exposing many refugees to even more severe hardship. A report published today by the International Red Cross and Red Crescent Movement shows that about 70 percent of refugees surveyed in Turkey reported having lost their jobs since the start of the pandemic. 

We have a shared duty to do everything we can to prevent, detect and respond to transmission of COVID-19 among refugee populations. Public health measures that reduce transmission of COVID-19 require strict and sustained implementation. This is difficult to achieve in refugee camps, where the public health situation is weak. 

COVID-19 has widened America's vast racial wealth gap, study finds

Via The Guardian: Coronavirus has widened America's vast racial wealth gap, study finds. Excerpt:

The coronavirus pandemic has proved a bonanza for billionaires and further widened the enormous racial wealth gap in the US, according to a new report released Friday. 

In the 12 weeks between 18 March and 11 June, the combined wealth of all US billionaires increased by more than $637bn to a total of $3.581tn, more than the entire wealth of the US’s 59 million Latinx population combined and equal to three-quarters of all Black wealth, according to an analysis by the Institute for Policy Studies (IPS). 

The report is called: White Supremacy is the Pre-existing Condition: Eight Solutions to Ensure Economic Recovery Reduces the Racial Wealth Divide. 

The top five billionaires – Jeff Bezos, Bill Gates, Mark Zuckerberg, Warren Buffett and Larry Ellison – saw their wealth grow by a total of $101.7bn, or 26% between 18 March and 17 June. They captured 17.4% of the total wealth growth of all 600-plus billionaires in the last three months. The fortunes of Bezos and Zuckerberg together grew by nearly $76bn.  

Over the same period, 44 million Americans lost their jobs and filed for unemployment insurance. The numbers have declined from a one week peak of 6.6 million in April but are still historically high. More than 3 million people have filed for unemployment in the last two weeks alone. Latinx and African American people have been hit hardest by the layoffs.  

The share of households of color with zero or “negative” wealth, meaning their debts exceed the value of their assets, is much higher than the share of white households. According to the report, 37% of black families and 33% of Latino families have zero or negative wealth, compared to just 15.5% of white families. Black Americans have a homeownership rate of just 44%, compared to a white homeownership rate over 70%.  

Darrick Hamilton, one of the report’s authors and the executive director of the Kirwan Institute for the Study of Race and Ethnicity at Ohio State University, said: “Today’s racial wealth divide is an economic archeological marker, the result of the multigenerational history of white supremacy running from the African slave trade, Jim Crow, separate and unequal, predatory lending, and other forms of systematic discrimination in wealth-building opportunities.” 

Even before the pandemic, the racial wealth gap had expanded. Racial wealth inequality increased by more than $40,000 from 1983 to 2016, according to a previous IPS report, Ten Solutions to Bridge the Racial Wealth Divide.  

“In 1983, white median wealth was $110,160, while black wealth was $7,323, and Latino wealth was $4,289. By 2016, white median wealth had increased by $36,000 to $146,984, while Latino median wealth increased by only a couple thousand to $6,591. 

“Black wealth declined by about $4,000, to a mere $3,557,” the report found. 

Hamilton said the racial wealth gap had been worsened by government efforts to address the 2008 financial crisis – bailing out banks and propping up the stock market – and that the federal response to the coronavirus pandemic needed to address systemic issues with racial inequality. 

“Surging billionaire wealth contrasting with a worsening racial wealth divide undercuts the solidarity and unity required to overcome the health and economic challenges of this pandemic,” he wrote.

COVID-19 cases spike across Sun Belt as economy lurches into motion

Via The New York Times: Coronavirus Cases Spike Across Sun Belt as Economy Lurches into Motion. Excerpt from a very discouraging report:

CHICAGO — The warning has echoed ominously for weeks from epidemiologists, small-town mayors and county health officials: Once states begin to reopen, a surge in coronavirus cases will follow. 

That scenario is now playing out in states across the country, particularly in the Sun Belt and the West, as thousands of Americans have been sickened by the virus in new and alarming outbreaks. 

Hospitals in Arizona have been urged to activate emergency plans to cope with a flood of coronavirus patients. On Saturday, Florida saw its largest single-day count of cases since the pandemic began. Oregon has failed to contain the spread of the virus in many places, leading the governor on Thursday to pause what had been a gradual reopening. 

And in Texas, cases are rising swiftly around the largest cities, including Houston, San Antonio and Dallas.  

“I’m very concerned about it,” said Mayor Eric Johnson of Dallas, noting that after months of warnings and isolation, many residents had stopped wearing masks and maintaining social distance out of sheer fatigue. “They’ve been asked for quite some time to not be around people they love, and that they want to spend time with. Wearing a mask is not pleasant. And I think people are tired.” 

For close to a month, much of the United States has looked like a nation open or beginning to open, and increasingly unfettered by restrictions meant to slow the spread of the coronavirus. With many government limits removed and people left to make individual choices about precautions, Americans have gone back to salons and restaurants, crowded into public parks and, in dozens of cities, joined large public demonstrations protesting police misconduct.  

Over all, daily coronavirus cases across the United States are essentially steady, stuck on a plateau. More than two million people have now contracted the virus in this country, according to a New York Times database, and every day, about 21,100 new known cases are reported, not much lower than the numbers from a month ago. About 800 people die from it each day. Those figures have both dropped significantly since peaking in April. 

But as of Saturday, the daily number of new coronavirus cases was climbing in 22 states, shifting course from what had been downward trajectories in many of those places.  

The spikes in cases bring leaders in these states to a new crossroads: Accept the continued rise in infections as an expected cost of reopening economies or consider slowing the lifting of restrictions aimed at stopping the spread or even imposing a new set of limits.  

In Houston on Thursday, the county’s top elected official warned that the community was “on the precipice of a disaster” and urged residents to minimize contact with others. More than 300 new cases have been identified in that county on each recent weekday. 

But at the city’s Galleria mall, there were few signs of concern: People stood in a tightly spaced line for pretzels at an Auntie Anne’s kiosk. At California Nails, two women sat maskless during pedicures. Signs urged social distancing, but in crowded walkways outside stores, shoppers brushed past one another, only inches apart.