After the White House declined to pursue a unified national strategy, governors faced off against lobbyists, health experts and a restless public consumed by misinformation.
The path to beating the coronavirus was clear, but Kelley Vollmar had never felt so helpless.
As the top health official in Missouri's Jefferson County, Vollmar knew a mandate requiring people to wear masks could help save lives. She pressed the governor's office to issue a statewide order, and hospital leaders were making a similar push. Even the White House, at a time when President Donald Trump was sometimes mocking people who wore masks, was privately urging the Republican governor to impose a mandate.
Still, Governor Mike Parson resisted, and in the suburbs of St. Louis, Vollmar found herself under attack. A member of the county health board called her a liar. The sheriff announced that he would not enforce a local mandate. After anti-mask activists posted her address online, Vollmar installed a security system at her home.
"This past year, everything that we've done has been questioned," said Vollmar, whose own mother, 77, died from complications of the coronavirus in December. "It feels like the Lorax from the old Dr. Seuss story: I'm here to save the trees, and nobody is listening."
For nearly the entire pandemic, political polarisation and a rejection of science have stymied the United States' ability to control the coronavirus. That has been clearest and most damaging at the federal level, where Trump claimed that the virus would "disappear," clashed with his top scientists and, in a pivotal failure, abdicated responsibility for a pandemic that required a national effort to defeat it, handing key decisions over to states under the assumption that they would take on the fight and get the country back to business.
But governors and local officials who were left in charge of the crisis squandered the little momentum the country had as they sidelined health experts, ignored warnings from their own advisers and, in some cases, stocked their advisory committees with more business representatives than doctors.
Nearly one year since the first known coronavirus case in the United States was announced north of Seattle on January 21, 2020, the full extent of the nation's failures has come into clear view: The country is hurtling toward 400,000 total deaths, and cases, hospitalisations and deaths have reached record highs, as the nation endures its darkest chapter of the pandemic yet.
The situation has turned dire just as the Trump administration, in its final days, begins to see the fruits of perhaps its biggest coronavirus success, the Operation Warp Speed vaccine programme. But already, a lack of federal coordination in distributing doses has emerged as a troubling roadblock.
The incoming president, Joe Biden, has said he will reassert a federal strategy to bring the virus under control, including a call for everyone to wear masks over the next 100 days and a coordinated plan to widen the delivery of vaccines. "We will manage the hell out of this operation," Biden said on Friday. "Our administration will lead with science and scientists."
The strategy signals a shift from the past year, during which the Trump administration largely delegated responsibility for controlling the virus and reopening the economy to 50 governors, fracturing the nation's response. Interviews with more than 100 health, political and community leaders around the country and a review of emails and other state government records offer a fuller picture of all that went wrong:
• The severity of the current outbreak can be traced to the rush to reopen last spring. Many governors moved quickly, sometimes acting over the objections of their advisers. The reopenings nationally led to a surge of new infections that grew over time: Never again would the country's average drop below 20,000 new cases a day.
• Science was sidelined at every level of government. More than 100 state and local health officials have been fired or have resigned since the beginning of the pandemic. In Florida, leading scientists offered their expertise to the governor's office but were marginalised, while Governor Ron DeSantis turned to Dr. Scott W. Atlas, a Trump adviser, and others whose views were embraced in conservative circles but rejected by scores of scientists.
• While the president publicly downplayed the need for masks, White House officials were privately recommending that certain states with worsening outbreaks require face coverings in public spaces. But records show that at least 26 states ignored recommendations from the White House on masks and other health issues. In South Dakota, Governor Kristi Noem, boasted to political allies about not requiring masks even as her state was in the midst of an outbreak that became one of the worst in the nation.
Governor Jared Polis of Colorado said states had faced difficult choices in balancing the virus — often hearing competing voices on how to do it best — and said Trump had left them without the political support they needed as they urged the public to accept masks and social distancing. "The single biggest thing that would have made a difference was the clarity of message from the person at the top," Polis said in an interview.
The pandemic indeed came with significant challenges, including record unemployment and a dynamic disease that continued to circle the globe. Without a national strategy from the White House, it is unlikely that any state could have fully stopped the pandemic's spread.
But the majority of deaths in the United States have come since the strategies needed to contain it were clear to state leaders, who had a range of options, from mask orders to targeted shutdowns and increased testing. Disparities have emerged between states that took restrictions seriously and those that did not.
America now makes up 4 per cent of the world's population but accounts for about 20 per cent of global deaths. While Australia, Japan and South Korea showed it was possible to keep deaths low, the United States — armed with wealth, scientific prowess and global power — became the world leader: it now has one of the highest concentrations of deaths, with nearly twice as many reported fatalities as any other country.
SPRING
The rush to reopen was 'the opportune moment that was lost'
The country once had a chance to set itself on a path to defeat the virus.
There had been many early missteps. The United States failed to create a vast testing and contact tracing network in January and February, which could have identified the earliest cases and perhaps held back the crisis. Then, cases silently exploded in New York, while Governor Andrew Cuomo and New York City Mayor Bill de Blasio waited crucial days to close schools and businesses.
Thousands of lives might have been saved in the New York metropolitan area alone if measures had been in place even a week earlier, researchers found. Driven by the spring surge, New York and New Jersey to this day have the worst death rates in the nation.
Elsewhere, though, most of the country had an opportunity to get ahead.
By mid-April, most states had resorted to historic stay-at-home orders to avoid the horror seen in the Northeast. At the time, about 30,000 people had died, and the worst of the outbreak was still concentrated in the Northeast.
It was during this period that experts say the country had an opportunity to get a handle on the crisis — had it invested in testing and contact tracing and endured a prolonged, if painful, shutdown until cases had been identified and controlled. At the time, the United States was doing only about one-third of the testing researchers thought was necessary.
But the White House balked at enforcing its own guidelines, and Trump was openly encouraging states to open up. He turned over control to governors on April 16. "You're going to call your own shots," he told them.
Looking back, public health experts trace the bulk of the nation's cases, now reflected in a record death toll, back to this turning point in late April.
"That was the critical time," said Jeffrey Shaman, an infectious-disease expert at Columbia University. "That was the opportune moment that was lost."
In their hurry to get back to business, many governors moved swiftly to reopen and balked at ordering new closures, sometimes ignoring the pleas of local health boards and mayors, according to interviews with health officials and a review of thousands of records obtained under public records law by The New York Times and other groups, such as Accountable. US and the Documenting Covid-19 public record project.
In Colorado, a local health official warned that his state's reopening plan risked upending the gains made during painful shutdowns. In South Carolina, health officials failed to persuade the governor to delay opening indoor dining and the state epidemiologist, Dr. Linda Bell, suggested in emails, first reported by the newspaper, The State, that health officials needed to step forward and provide different messages to the public.
"I will not 'stand next to the governor' anymore without speaking to what the science tells us is the right thing to do," she tapped out on her iPhone one Sunday morning.
In Iowa, the health director in Black Hawk County, Dr. Nafissa Cisse Egbuonye, was stunned in April when she found employees working elbow to elbow at a Tyson meatpacking plant — only some of them in masks.
For weeks, she said, her calls to the governor's office about closing down the plant went nowhere, as infections rose so steeply that the local hospital was overrun. "We didn't know where the resistance was occurring, whether it was Tyson or at the state government level," Egbuonye said. "It was falling on deaf ears."
Governor Kim Reynolds said at the time that it was essential to keep the nation's food supply chain up and running. The plant shut down only after the virus had disabled much of its workforce — more than a thousand employees were infected, many of them immigrants, and at least five workers died.
Perhaps nowhere were the consequences of reopening more clear than in Texas.
With 29 million residents and a conservative identity built upon being friendly for business, Texas was among the states that were later in enacting stay-at-home orders. Within two weeks, protesters were clamouring outside the governor's mansion, waving flags emblazed with the motto "Don't Tread on Me" and demanding to be able to go back to work.
Governor Greg Abbott was quickly pivoting toward reopening. One day after Trump's call handing authority to governors, Abbott announced a "strike force to open Texas." More than half of its members had donated to Abbott's campaigns, including real estate developer Ross Perot Jr. and Drayton McLane Jr., a former owner of the Houston Astros.
In a series of phone calls and meetings over the course of several weeks, the strike force hashed out ideas. The Texas Restaurant Association submitted a plan to reopen restaurants. Each step of the way, the ideas were funnelled through a panel of four medical experts, who were empowered to veto ideas.
But the task before them was clear: how to get Texas' US$1.8 trillion economy up and running again.
By late April, Abbott was considering opening up the economy in phases.
"My advice was to go a bit slower," said one member of the governor's team, Dr. Mark McClellan, a former commissioner of the US Food and Drug Administration. He worried that the state was not allowing time between phases to measure any upticks in infection before progressing through further reopenings, and he feared a surge in new infections.
But on May 1, Texas opened back up, starting with restaurants, stores and movie theatres. By Memorial Day, Texas was effectively up and running.
A spokesman for Abbott pointed to states like California and New York, which kept restrictions in place for longer but have recently seen resurgences of the virus, as evidence that "lockdowns for months after months" do not work. He said Abbott had balanced "saving lives, while preserving livelihoods."
From late May to late July, new infections in Texas soared tenfold, from around 1,000 new cases a day to as many as 10,000.
"It was like a wildfire in brush," said Dr. Jose Vazquez, who served as the health authority in Starr County, Texas, and who contracted the virus himself as the state's Southern border region was hard hit over the summer.
By late June, Abbott called another meeting of his medical advisers. Reversing course, he shut down bars. Days later, he issued a mask order, which was credited with saving lives in the months to come.
Deaths continued to soar into August, and for weeks this summer, Vazquez watched as helicopters swooped into Starr County to pick up patients, taking them to hospitals as far away as Oklahoma and New Mexico.
Few returned alive.
SUMMER
'It was just horrific': Health experts were exhausted, threatened and sidelined
Summer was supposed to bring a reprieve from the horror.
Across the Northeast, deaths were subsiding. The weather was growing warm, a chance to spend more time outdoors, where the virus spreads less easily. Health officials hoped the season would be the bridge they needed to prepare for the fall, when infections were expected to worsen.
Instead, as officials in New Zealand were recording 100 days in a row without a single new infection and countries like Germany were recording only a few new deaths per day, the United States nearly broke its spring coronavirus hospitalisation record.
Around the country, health officials who had been steering their communities through the crisis were increasingly facing harassment, dwindling resources and political battles that left them exhausted. The reaction reflected the tone set by Trump, who demanded loyalty from Republican allies and whose rhetoric on masks and the economy became a rallying cry in many communities. Amid the chaos of the year, dozens of health officials were fired or resigned.
Amber Elliott, the former health director for St. Francois County, Missouri, said she had received calls from people spewing "curse words, and, 'You better watch out,' " and a photograph of her family at her son's baseball game was taken without her knowledge and posted online. She began checking security cameras before leaving her office in the evenings, and she eventually resigned. "It's not worth their safety," she said, citing the risk to her two young children. "You don't wait until it's too late."
In Wisconsin, Dr. Jeanette Kowalik, the health commissioner in Milwaukee, was worn down by a lack of resources. People in her office had been working 20-hour days, struggling to keep up with growing caseloads and dealing with cumbersome technology that reflected a public health system that had been underfunded for years.
"It was just horrific," Kowalik said. "You couldn't keep up."
At one point, Kowalik sent a plea for help to the Centers for Disease Control and Prevention, according to records. It took the CDC six weeks to respond.
In Kansas, Dr. Gianfranco Pezzino, the health officer for Shawnee County, was growing frustrated as commissioners in the county relaxed mask restrictions for the farmers' market and later extended bar hours and allowed youth sports practices, against his advice.
Tired and increasingly frustrated, Pezzino sat down at his desk and drafted his resignation letter.
"You can't put public health professionals in charge of making these difficult decisions and then overrule them based on no data," said Pezzino, who, in a moment characteristic of the pandemic, read the letter aloud during a video meeting last month and then turned off his camera to leave.
At the beginning of the pandemic, the Florida Department of Health convened top experts for an urgent, Saturday morning teleconference with the state surgeon general, Dr. Scott A. Rivkees.
"We had this bang-up meeting," said Dr. Aileen M. Marty, an infectious-disease professor at Florida International University who assumed the meeting would be the first of many.
Instead, it was the only one.
Rivkees was later sidelined, little to be seen after correctly suggesting at a news conference that social distancing and other measures would need to be in place for at least a year. Another group of scientists that met within the Health Department was also phased out.
DeSantis, the governor who owed his 2018 election in large part to Trump's early endorsement, was hewing closely to the White House's messaging, and increasingly surrounded himself with business leaders and advisers of his own choosing.
Of 22 people on the executive committee of the governor's task force to reopen Florida, only one, the president of Tampa General Hospital, came from a health care background. None of the others were doctors.
One person DeSantis did turn to was Atlas, at the time a high-profile adviser to Trump whose views had been described as dangerous by members of the medical establishment. A radiologist whose appearances on Fox News caught the president's eye, Atlas frequently clashed with leading health experts, arguing, for example, that the science of mask wearing was uncertain and that children could not spread the coronavirus.
DeSantis and Atlas appeared together at events across Florida in late August, promoting in-person instruction at schools and colleges, including the return of fall sports.
A spokesperson for DeSantis credited him as an innovator who understood that lockdowns were "ineffective," had come up with a data-driven approach and had remained "singularly focused" on protecting older residents and others most at risk of dying.
In September, DeSantis' office placed a call to Dr. Jay Bhattacharya, a professor at Stanford who had criticised coronavirus lockdowns as harmful. In an interview, Bhattacharya said the call had come more or less out of the blue, and he was pleasantly surprised to learn that the governor seemed to have studied his work.
The governor asked Bhattacharya to appear on a panel, along with Dr. Martin Kulldorff from Harvard, who with Bhattacharya went on to help draft the so-called Great Barrington Declaration, a treatise that calls for better protecting the vulnerable while others in society "resume life as normal," an approach that has been fiercely criticised within the scientific community.
The next day, DeSantis moved forward with a plan to keep Florida open. He allowed restaurants and bars to operate at full capacity, and he prohibited local governments from enforcing mask mandates, curfews and other restrictions.
The country had just exceeded 200,000 deaths, including more than 14,000 in Florida.
It was a devastating toll, but one that would soon worsen.
FALL
The science of masks was well-documented, but governors resisted
By fall, Trump's own coronavirus diagnosis was dominating headlines, and he was still insisting that the country was "rounding the corner" in the pandemic and that the virus would soon "disappear."
But inside the White House, health officials knew more was needed to control the crisis.
In a series of unpublicised weekly memos tailored to each state, the White House's coronavirus task force had been privately pressuring states to do more. The reports recommended that states like Alaska, Georgia and Wyoming embrace face masks. States like Alabama, Louisiana and Mississippi were advised to put more stringent limits on indoor dining.
But those states and others — at least 26 in all — ignored the urgings of the White House, even when new cases were ticking upward.
For Noem, the governor of South Dakota, the laissez-faire approach was a point of pride. More than perhaps any other state, South Dakota had kept its doors open, hosting Trump for an event at Mount Rushmore and committing US$5 million in federal coronavirus relief funds to enticing tourists.
In the fall, Noem travelled the country with the help of a former Trump campaign manager, Corey Lewandowski, eager to showcase that her brand of liberty governance was the right one.
In New Hampshire, she told a group of Republicans that one of her strategies was that she "never talked about the number of cases of Covid-19 that we have."
In Maine, Noem criticised the state's restrictions while claiming that her state's death rate was among the lowest. "Leadership has consequences, and you are all living under some very poor leadership out of your governor's office," Noem told the crowd.
In fact, new cases and deaths were climbing in South Dakota. A rally that drew hundreds of thousands of motorcyclists to Sturgis, South Dakota, over the summer is believed to have contributed, in addition to colder weather that pushed many indoors. Noem also continued to resist a mask order despite urging from the White House.
South Dakota ended the year with one of the highest death rates in the nation — four times Maine's — though it also mounted one the nation's most successful vaccination efforts.
Idaho's governor, Brad Little, also resisted a mask order, but behind the scenes, he appeared to acknowledge that such action was needed. Bryan Elliot, who heads the health board in a heavily hit region in southwest Idaho, said two of Little's advisers had joined a conference call with two board officials to press them to embrace more control measures, including masks.
The request, Elliot said, included a threat. Any such measure was bound to spark a public backlash, and the intention, it seemed, was that Elliot's board would absorb it. If the region did not impose a mask order, the state advisers told Elliot, the governor's office would publicly shame him as being responsible for the case numbers.
"It was not appropriate," Elliot said.
The decision to further delegate responsibility to local officials opened the door, as it had in many states, to politics and misinformation.
A woman invited to testify at one board meeting, Dr. Vicki Wooll, suggested that it was 5G cellphone networks that were putting people's health at risk.
One state over, Dr. Ed Zimmerman, the health officer in Washakie County, Wyoming, saw his community being inflamed by other conspiracy theories on social media, including suggestions that virus fears had been overblown in an effort to harm Trump's reelection campaign.
"It's a complete relegation of science to the back burner," said Zimmerman, who described himself as conservative.
A week after ordering a mask mandate, he was fired.
WINTER
A dark winter brings record deaths
Against the odds, some states have managed to keep the virus under control.
Washington state, which recorded 37 of the nation's first 50 coronavirus deaths, has kept in place a steadily adjusting suite of mitigation measures and now ranks 44th in deaths per capita. If the nation had achieved a rate comparable to Washington's, about 220,000 fewer people would be dead. Vermont has also been among the states with the fewest deaths, thanks in part to a cautious reopening, significant testing and a mask order.
But a year of political division and uncontrolled coronavirus spread has caught up to most of the country.
In recent days, the virus has been accelerating in nearly every state, and deaths were climbing from Arizona to Connecticut. Even New York, which became a national model for virus restrictions and testing after its spring crisis, is seeing a resurgence.
Winter was always the season in which the virus posed the biggest threat, but in many states, residents have also fallen victim to pandemic fatigue, rendering existing controls less effective.
That has been the case in California, which is now experiencing one of the worst outbreaks in the nation.
The nation's most populous state was the first to issue a stay-at-home order last spring, and it managed to keep the virus in check for most of the year. But as winter approached, a restlessness set in.
Local journalists exposed how the Democratic leaders Governor Gavin Newsom and Mayor London Breed of San Francisco — outspoken advocates for virus precautions — had attended birthday parties at the French Laundry restaurant in the Napa Valley, ignoring their own best practices. Disdain for masks and business closures resonated in more conservative parts of Southern California, and health officials pointed to people who had let their guard down at Thanksgiving as a turning point.
Now federal health officials are warning that a much more contagious variant of the virus could become the dominant source of infection by March, threatening to accelerate the country's outbreak.
The arrival of vaccines could slow the spread, but the lack of a unified national strategy has resurfaced again as a fundamental flaw. The federal government has pushed the responsibility for administering vaccines to state and local governments, who are strapped for funding and still dealing with daunting virus caseloads. Some states have struggled to deliver the vaccine swiftly, and rules vary widely from state to state.
Biden, who takes office this week, said he would call on the Federal Emergency Management Agency to establish 100 federally supported vaccination centers around the country and would also push for thousands of community and mobile vaccination sites.
But tight supplies will limit how quickly any such plans can be rolled out, and already there are political divisions over whether to trust the vaccine and what social groups should get it first.
Dr. Marissa J. Levine, the director of the Center for Leadership in Public Health Practice at the University of South Florida, said that a failure of leadership — first from the White House, and later from the states — had polarised the entire response to the pandemic and given the virus an extended life. "The toll points to a colossal failure at every level of government," she said.
The top five worst days for new deaths in the United States have come in January. As the calendar page turned for a new year, the virus was worse than it had ever been.
Written by: Sarah Mervosh, Mike Baker, Patricia Mazzei and Mark Walker
Photographs by: Daniel Brenner, Whitney Curtis, Tamir Kalifa, Erin Trieb, Verónica G. Cárdenas, Christopher Lee, Audra Melton and Anna Moneymaker
© 2021 THE NEW YORK TIMES