Flatten the Curve

March 2020

Donald Trump stood at the podium in the James S. Brady Press Briefing Room on March 16, flanked by an unusually stacked cast of government and health officials. As the president announced the guidelines for “15 Days to Slow the Spread,” standing with him were Vice President Mike Pence, Drs. Anthony Fauci and Deborah Birx, Health and Human Services Secretary Alex Azar, Surgeon General Jerome Adams, and others.¹

It was Trump who began by announcing the guidelines. They included general recommendations for Americans, such as working or attending school from home if possible, avoiding gatherings of more than ten people, avoiding bars, restaurants, and food courts, staying home when sick, and avoiding visits to nursing homes and long-term care facilities. There was additional advice for states experiencing community spread; officials recommended governors close schools in affected and nearby areas, as well as restaurants, gyms, and other social venues.²

The initiative was not a federal declaration of “lockdown,” as it would come to be known, because none of the recommendations offered at first were binding. Rather, they were framed in the language of a social contract. Americans needed to rise to the occasion to coordinate their behavior and save lives. These measures, officials told us, were the best way to do that.¹

Anthony Fauci then explained the rationale for the government’s recommendations. Fauci, whom many now remember as either a saintly proxy for science itself or a self-absorbed tyrant, then served as the director of the National Institute of Allergy and Infectious Diseases (NIAID). He had held that position for decades, guiding the government’s public health responses to HIV, West Nile virus, SARS, MERS, Ebola, and H1N1.^3,4

In a room visibly dominated by its dumbest occupant, Fauci seemed to ooze competence. Gesturing with his hands, he traced a steep imaginary curve in the air for the cameras, contrasting it with a squashed curve that was wider at the tails but shorter at the peak. The problem was framed in terms of mitigating the spread of infections to blunt the shock to the healthcare system. He also noted that reported cases lagged far behind actual transmission.¹

The exponential growth of infections meant that the country had little time to avoid a brutal triage regime. Even the early strain on some hospitals suggested that additional pressure was already unavoidable: many of the people who would be hospitalized in the coming weeks had probably already been infected.^5,6

Thus, the narrow promise of flattening the curve was not necessarily fewer hospitalizations, but fewer hospitalizations at once. Mitigation might also prevent some infections entirely, but at minimum, it would distribute serious cases over time, keeping demand within the healthcare system’s capacity while buying time to expand testing, secure PPE, and develop useful clinical knowledge.⁶

There is an important distinction to make here between mitigation and suppression, because these are not the same goal. Mitigation is what “flatten the curve” properly meant. Mitigation assumes that spread will occur and concerns itself with controlling the rate of infections. Lower the peak, protect high-risk groups, and weather the pandemic with finesse; this was the logic that public health guidance laid out early on. Suppression, by contrast, aims to push viral reproduction below replacement and reverse epidemic growth.⁶

To understand this distinction, let us turn to the basic mathematics of contagion. Suppose a man decides to treat himself to a steaming pot of turkey vulture soup with a side of roadkill possum sashimi. Unfortunately for our protagonist, that possum carried a novel virus. Now he does too. As the virus’s first human host, he is the sole member of Generation 0. Before he either succumbs or, hopefully, recovers, he spreads it to eight other people. Those eight people make up Generation 1 and go on to spread it to eight more each. So, with each infection and each new branch, the number of infections in that generation is represented by 8ⁿ, where n denotes the number of transmission generations after the initial infection. That is exponential growth.

Viral reproduction is quantified as R₀, pronounced “R-naught.” It describes the transmission rate in a population without interventions. R_t, the “effective” reproduction number, describes transmissions under the conditions prevailing at a given time, including any interventions then in place. If R_t is below 1, transmission declines. If R_t is higher than 1, then each infected person will spread the virus to more than one person, on average.⁷ For our hypothetical virus, assuming no measures to suppress the virus, our R₀ and R_t would both be equal to 8.

The wrinkle for observers in March 2020 is that the practical distinction between mitigation and suppression was not especially clear. Mitigation and suppression could rely on many of the same measures, but they applied them toward different thresholds: mitigation sought to slow spread and reduce peak burden, while suppression required keeping R_t below 1 long enough to reverse epidemic growth.

In the first few weeks of the emergency, however, the distinction had little practical relevance for the public. A March report from Imperial College London projected that mitigation alone could still overwhelm hospitals, making rapid transmission reduction the immediate imperative regardless of the longer-term strategy.⁶ Despite some uncertainty about which strategy health officials and governments were pursuing, the meme of the squashed curve became the perfect vehicle through which to instruct the public on how to avoid getting sick and how to avoid getting others sick. 

Flattening the curve was attractive because of its intuitive appeal. It gave every citizen a simple role with a handful of concrete actions: stay home, avoid gatherings, and all the rest. Nearly every recommendation could be distilled to the bedrock principle of increasing the distance between you and the people around you. The universalist message here was particularly conducive to the refrain often heard throughout the pandemic: we’re all in this together. It put agency back in the hands of a frightened population and gave it a shared task that generated immense social solidarity. The bargain here was that we would all need to accept severe disruption now to protect our hospitals and buy time. Shutting down society was an aberration, but a necessary and prosocial one that initially seemed to bring people closer together, at least in spirit.⁸

In announcing 15 Days to Slow the Spread, Fauci called for a “15-day trial,” after which recommendations would be reconsidered. Crucially, there was never a promise that normality would return when those 15 days ended, despite the impression many people, including me, took away at the time. The press conference left the duration contingent on the outbreak, with no endpoint specified.¹

The problem was that 15 days was never going to be enough time to produce an interpretable result. The virus’s incubation period was too long, testing and surveillance were still being built out, and the outcomes that mattered most lagged infections by weeks.⁶ Trump also acknowledged at the press conference that the pandemic could last much longer, saying, “They think August. Could be July. Could be longer than that.”¹

Fauci soon clarified that Trump was referring to the epidemic itself, not the 15-day guidelines, which were still framed as a set of quick emergency measures designed to blunt the virus’s first surge.¹ Yet there remained an unresolved question: what counted as success? What would happen if, after day 15, transmission continued?

Stay Home

March–April 2020

Within days of that stacked-cast press conference, “we recommend” became “you may not.” Though there was no single US lockdown policy, states and cities implemented restrictions quickly and decisively, often mirroring federal advice closely enough to make the regime seem nationally imposed.⁹    

Some states were earlier than others. California was the first to issue a statewide order, with several San Francisco Bay Area localities issuing shelter-in-place orders on March 16, followed by a statewide order from Gov. Gavin Newsom on March 19.^9,10 Executive Order N-33-20 was brief but powerful; residents were directed to remain home except for designated essential work and essential needs such as healthcare and food. Necessary infrastructure like government, utilities, and transportation were to remain operational. Activities deemed non-essential—visiting restaurants, bars, nightclubs, going to gyms or theaters or concerts or events, attending parties, browsing malls; or working in offices that could move online—were all prohibited.¹¹ Unlike the guidelines proffered by the federal government, this order was legally enforceable, with violations classified as misdemeanors punishable by up to a $1,000 fine, six months in jail, or both.¹²

In practice, California’s citizens were not routinely being waterboarded for failing to prove that they were going to Walmart for potatoes rather than throw pillows and scented candles. Few citations were issued, partly because selective enforcement against businesses and the most conspicuous individual offenders was easier and partly because voluntary compliance made enforcement largely unnecessary.¹³

Despite important differences in implementation, the basic outline of early lockdown was remarkably similar across states, and by the first week of April, around 90% of Americans were living under restrictions that closely resembled California’s framework.¹⁴

My home state of Virginia issued regulations in an escalating series, closing K-12 public schools for two weeks on March 13 and restricting public events exceeding 100 people on March 15. On March 17, the governor and state health commissioner formally limited restaurants, gyms, and theaters to ten patrons. A closure order followed on March 23, which banned all gatherings of ten or more and closed schools for the remainder of the 2019-20 school year. It was converted into a statewide stay-at-home order seven days later, making violations a Class 1 misdemeanor.¹⁵ The order, however, largely formalized the new reality rather than imposing it; people had already changed their behavior before the stay-at-home-order. Individuals were avoiding businesses, workplaces, and gathering; schools and employers were closing up independently. Government orders, while they did affect the scale and uniformity of the shutdown, mostly standardized, extended, and enforced those changes.¹⁶

In Virginia and in most places, the allowed activities of daily life were increasingly bifurcated between “essential” and “nonessential.” It is remarkable how seamless the transition online was for so many white-collar, non-essential professionals. Almost overnight, office workers moved their meetings and paper-shuffling to Zoom, which was for some reason immediately promoted to vital societal infrastructure. Others—the grocery store clerks, police officers, healthcare professionals and postal workers—mostly carried on with their jobs and hoped that the mitigation measures would protect them.¹⁷ Physical life had to be held together, and many people did just that. But the social world was still so fully gutted that it created its own strange vacuum. Those absent from the physical world were relegated to experiencing its digital facsimile online.

Leaving home in late March or early April often felt oddly dreamlike. Roads were empty, storefronts and malls were dark, and parking lots were so barren that one would feel a vague sense of unease. I shouldn’t be here was the thought that would pop to mind. Even a perfectly normal activity like grocery shopping acquired an eerie, liminal quality; you were allowed to be there, technically, but you could still feel the faint compunction of a teenager breaking curfew.

Those quiet streets and that frozen public sphere might have brought a kind of physiological calm had they not also announced a burgeoning economic crisis. The financial disruption of spring 2020 was the largest economic contraction Americans had experienced since the Great Depression.¹⁸ By April, unemployment stood at 14.7%, nearly fifty percent higher than the worst month of the Great Recession.¹⁹ Yet this was no ordinary recession; economic activity had been deliberately curtailed in response to a public-health emergency. There was no bubble to burst, no attack on American soil, no financial system tearing at its seams. Instead, individual caution, institutional closures, and government restrictions had combined to idle vast sectors of the economy in the hope of averting a worse catastrophe.^16,18

There was early recognition that many Americans would suffer significant financial hardship in the effort to flatten the curve. That recognition helped lead Congress to pass the Coronavirus Aid, Relief, and Economic Security (CARES) Act, an emergency-relief law meant to keep businesses and families afloat for the immediate future. It funneled $2.2 trillion into loans and grants to businesses, support for hospitals and public health, and $600-per-week supplements to state-administered unemployment payments.^20,21 Most memorably, the law Trump signed on March 27 included $1200 stimulus checks for most eligible adults.²¹ The CARES Act was implemented at unprecedented speed, which likely contributed to the enormous losses from fraud and abuse.²² Even so, it was a signal that the coronavirus’s impact was already expanding beyond the illness caused by the virus and the cabin fever of stay-at-home orders.

About all of this, there was bickering. But the basic social bargain was accepted unusually broadly for public policy in the Trump era. In one March 19-24 survey, Pew found widespread support for school closures and limits on gatherings, although support for business closures was less uniform.⁸ Perhaps this was due to fear, and I tend to think it was; but I also think it was partly due to the understanding that this really was an emergency. Americans broadly accepted the initial bargain, as they should have.

That broad acceptance was easier to sustain while the public remained focused on the immediate emergency. By April, staying home already governed daily life for most people. The public had collectively assumed a guarded stance of endurance, its attention narrowed to the shortest of time horizons. It is thus unsurprising that, in this new social order, few people seemed to consider how long the emergency could remain an emergency.

The Emergency Extends

April–May 2020

Health officials and politicians openly said that they did not know how long the crisis would last; there was no promise that fifteen days would remain fifteen days. That did not stop many people from inferring that the lockdowns and stay-at-home orders would be bounded rather than open-ended. Yet by early April, the miasmatic sense of emergency had failed to dissipate, and the indefinite emergency still made sense to most people, whether or not laws and recommendations reinforced that impression.²³ Indeed, the original fifteen-day pause revealed itself to be a mirage before the period had fully elapsed. On March 29, federal guidance was extended through April 30; this announcement was treated mostly with resignation and acknowledgement that the coronavirus’s spread had failed to be arrested and that an enormous surge was already in motion.²³

The available data showed that the outbreak was still accelerating. The WHO’s March 29 report noted 103,321 confirmed cases in the U.S. and 1,668 deaths; 18,093 of those cases had been reported in the previous 24 hours.²⁵ The White House projected that daily deaths would peak in about two weeks, although the timing remained uncertain. Fauci noted that day that experts believed mitigation efforts might be having an effect, but they were thus far impossible to quantify because cases were still rising.²⁴ Caution, then, remained justified, but we did not know how much the March 16 guidance was changing the pandemic’s trajectory.

New York was the clearest justification for the extension, announcing itself daily as a warning of the kind of damage the virus was capable of inflicting. A hub of international travel and commerce, New York City was likely seeded early, while high population density and very limited testing in March allowed infections to spread unchecked for weeks, producing a wave of serious cases that arrived in hospitals at once.^26,27 In other words, New York was probably going to suffer through late March regardless of any measures taken two weeks prior.^6,27 It illustrated why a two-week trial could not yet answer the question it had been meant to answer. The calendar, then, could not tell Americans when the emergency had succeeded. What could?

The answer to that question was nominally avoiding the kind of hospital overflow occurring in New York, where makeshift beds reflected strained capacity and long hours stretched providers, likely harming outcomes.^27,28 If mitigation could prevent the healthcare system from being overwhelmed, that would be the win.

But that is not an affirmative goal—it is disaster averted. And it is difficult to mobilize a nation around avoiding a thing. Because averting hospital overflow offered no visible finish line, more affirmative goals began appearing in public language. Not only would restrictions delay infections, but those same measures might reduce total infections, protect the vulnerable, and buy time for better treatment and testing.^6,29 The problem was that the same measures could pursue all these objectives, making the intended standard of success unclear.

The benefits themselves were not especially controversial. There was broad agreement that the emergency was justified, COVID was dangerous, and restrictions were probably necessary to buy time. Yet through April, it remained unclear what exactly was being purchased. Because the interventions offered a package of benefits, it was difficult to say which one had to be secured before pre-pandemic life could resume. Would this be when testing and contact tracing were fully mature? When treatments improved and clinical knowledge matured? Or when we had lower baseline transmission? What about a vaccine? Most people were not yet clamoring for a reversal of all the restrictions, but they acknowledged the need to draw a roadmap to reopening.²³

By the end of March, reopening frameworks began to appear. The American Enterprise Institute, a center-right think tank, posted a proposal titled “National Coronavirus Response: A Road Map to Reopening” on March 29. It proposed a four-phase response implicitly modeled on mitigation. The first goal was to slow the spread. States could reopen one by one after they sustained a decline in cases, had adequate hospital capacity, and developed mature testing and contact tracing. Lingering distancing restrictions could be lifted once the population was better protected through a vaccine, better treatments, or effective surveillance. Finally, it advocated for expanding capacity to respond to the next pandemic, focusing more on identifying and isolating cases than on population-wide restrictions. This was an early move toward a conditional yes on reopening: the proposal did not challenge the initial restrictions so much as identify the conditions under which they should end.²⁹

The White House’s “Opening Up America Again” framework became the most visible set of nonbinding guidelines when it was announced on April 16. It introduced “gating criteria,” prerequisites for entering a three-phase reopening that began tentatively, progressed to schools and gatherings, and ended with lifting all restrictions.³⁰ This was a welcome development and a point of credit to federal health officials; it was at least an attempt to move from reflexive emergency restrictions toward discrete, measurable goals that would produce an exit logic.

By the time the White House framework appeared, some of the capacities it demanded had improved. By the third week of April, for example, FEMA had coordinated the delivery of more than 10,000 ventilators and deployed more than 8,600 federal medical station beds.³¹ Emergency hospital capacity had increased, even if many states or individual hospitals were still not prepared to handle a surge without crisis care.^31,33 Testing capacity had expanded, though it still wasn’t sufficient or accessible enough to support widespread reopening under the guidelines of the White House’s April 16 framework.^31,32 Similarly, PPE deliveries had increased, but shortages still forced some hospitals to conserve or reuse equipment.^31,33

Georgia was among the first states to treat improving hospital and testing capacity as grounds for lifting restrictions. On April 20, Gov. Brian Kemp announced the state’s intention to reopen in the coming days. He cited a “flattening” in documented cases, an increase in available hospital beds, and declining emergency room visits for influenza-like illnesses as justification. Gyms, bowling alleys, salons, and similar businesses would be allowed to open April 24. Restaurants, dining rooms, theaters, and private clubs would follow on April 27, and the general shelter-in-place order would remain through April 30.³⁴ Importantly, Kemp himself acknowledged that Georgia was “on track to meet” the federal government’s reopening criteria—not that they had already been met.³⁴ Public data at the time did not show the prescribed 14-day decline in cases.³⁵

Those gains did not eliminate large gaps in Georgia’s readiness claim. The state announced a major testing expansion alongside its reopening decision, but it did not amount to a mature surveillance system already in operation.^34,35 Expansions in testing capacity made raw case counts difficult to interpret.³⁵ Although test positivity rates were potentially more useful, they depended on complete reporting of negative tests, which officials had reason to believe were being undercounted at the time.³⁶ What Georgia officials pointed to were more concrete measures of hospital readiness: staffed-bed availability and the number of people arriving at emergency rooms.³⁴ The community transmission metrics emphasized by federal guidelines had to be inferred from incomplete and delayed testing data.^7,35 At the time, then, Georgia had stronger evidence that it could accommodate sick patients than that infections were declining. But improvement in one reopening criterion could not prove that others had been met.

Trump, who evidently had been assiduously poring over the data in his private study, disagreed with Kemp’s decision to reopen those businesses. On April 24, he tweeted “I (or @VP) never gave Governor Brian Kemp an OK on those few businesses outside of the Guidelines. FAKE NEWS!”³⁷ Kemp seemed not to care all that much, and the disagreement exposed a discrepancy between the apparent authority of the federal guidelines and the discretion governors retained to interpret or disregard them.^30,31 Trump behaved as if federal guidelines were edicts. They identified relevant evidence, but incomplete data still left room to dispute whether their criteria had been met. Reopening was always going to be a political and moral judgment about acceptable risk and competing harms.

The disagreement illustrated a broader limitation of any reopening plan: conditions varied between states and cities, and people assigned different weight to competing harms. No one disputed that COVID caused death and suffering, but science alone could not determine how those harms should be weighed against the harms of continued restrictions. Those unresolved tradeoffs brought the first reopening disputes to the fore.

One such dispute had already erupted in Michigan on April 15, when two conservative groups organized “Operation Gridlock,” an effort to deliberately jam traffic around the state capitol in Lansing. The protest brought grievances related to job loss and perceived government overreach but also contained a fair amount of conspiratorial paranoia: protesters chanting “lock her up” in reference to Gov. Gretchen Whitmer, militia-looking men carrying rifles, and displays of Trump-adjacent iconography.³⁸ Trump himself made it worse by tweeting “LIBERATE MICHIGAN!” on April 17, one day after releasing his administration’s cautious three-phase plan.^30,39 He later clarified that he did not mean that states should remove all restrictions—just that “elements” of them went overboard.³¹ Yet no matter how many qualifications escaped from the orange gremlin’s mouth, the political signal had already been received; opposition to COVID restrictions was becoming a right-wing cause right alongside gun rights and abortion laws and clean coal. This was no longer a dispute, but a patriotic resistance against tyranny.

Irate Michiganders again showed their displeasure at the April 30 ‘American Patriot Rally,’ belting out chants of ‘heil Whitmer,’ while one sign warned, ‘tyrants get the rope.’⁴⁰ Armed protesters this time entered the capitol building and, though no violence occurred, their intent to intimidate lawmakers and the governor was crystal clear.⁴⁰ Uncomfortably, it is difficult to review the record and conclude that these protesters were completely irrational; the state had added several restrictions on April 9, and some were plainly silly, even at the time.⁴¹ The travel ban included travel between two residences you owned. Golf courses were closed and motorboating was banned without a clear rationale as to why they were worse than socially distanced hiking or fishing.^41,42 Most absurdly, gardening supplies, paint, furniture, and several other non-essential sections at big-box stores were cordoned off, making it easy to buy tomatoes but illegal to buy a tomato plant.⁴¹

Even so, the disputes over lockdown measures in April and into May should not be reduced to public health authoritarianism or dismissed as the yammering of Trumpers who could not be bothered to care about COVID. The pandemic was still an acute crisis, but these conflicts may have been an early manifestation of a class divide deeper than any one restriction. The universal language of shared sacrifice was belied by the fact that people could not all endure the emergency from the same economic or occupational position. The burden of “staying home” was not shared equally.¹⁷ For some, restrictions meant going to a Zoom meeting instead of driving into the city. For others, it meant a lost job, a lost semester, or the rupture of a developmental period.

Recognizing those unequal burdens does not vindicate the vacuous dullards milling around Lansing with AR-15s. It does suggest that they may have been reacting to real uncertainty in messages from state and federal governments and public health institutions. The longer restrictions went on, the greater the disruption; the greater the disruption, the greater the obligation to explain a restriction’s current purpose and exit conditions. This is proportionality over time. “COVID is bad, and restrictions will reduce its spread” becomes less and less compelling as an explanation over time, even if it remains true.

 Officials cannot be blamed for changing their opinions and guidance over time, especially in the spring of 2020; action under uncertainty requires revision. But the legitimacy of revision did not relieve officials of the obligation to justify each restriction as conditions changed. A measure can be reasonable in March and remain so in May, but for different reasons. When the justification changed, the public deserved to know why. Increasingly, restrictions were morphing from emergency measures to systems, policies, and durable norms. Once internalized by institutions and enough members of the public, they ceased to be guidelines and became social infrastructure.

The initial bargain of 15 Days to Slow the Spread was not necessarily void—plenty of officials attempted to explain their rules in an ongoing fashion. But it had changed character. An emergency need not be brief, but as summer began, the question was no longer how to endure it. It was how we would know when the measures implemented in its name had served their purpose.

Notes

1. The White House. (2020, March 16). Remarks by President Trump, Vice President Pence, and members of the Coronavirus Task Force in press briefing. https://trumpwhitehouse.archives.gov/briefings-statements/remarks-president-trump-vice-president-pence-members-coronavirus-task-force-press-briefing-3/
2. The White House. (2020, March 16). 15 days to slow the spread. https://trumpwhitehouse.archives.gov/articles/15-days-slow-spread/
3. National Institutes of Health. (2022, August 22). Statement by Anthony S. Fauci, M.D. https://www.nih.gov/news-events/news-releases/statement-anthony-s-fauci-md
4. National Institutes of Health. (2022, November 28). Dr. Fauci reflects on the perpetual challenge of infectious diseases. https://www.nih.gov/news-events/news-releases/dr-fauci-reflects-perpetual-challenge-infectious-diseases
5. Remuzzi, A., & Remuzzi, G. (2020). COVID-19 and Italy: What next? The Lancet, 395(10231), 1225–1228. https://doi.org/10.1016/S0140-6736(20)30627-9
6. Ferguson, N. M., Laydon, D., Nedjati-Gilani, G., Imai, N., Ainslie, K., Baguelin, M., Bhatia, S., Boonyasiri, A., Cucunubá, Z., Cuomo-Dannenburg, G., Dighe, A., Dorigatti, I., Fu, H., Gaythorpe, K., Green, W., Hamlet, A., Hinsley, W., Okell, L. C., van Elsland, S., . . . Ghani, A. C. (2020, March 16). Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand (Report 9). Imperial College London. https://doi.org/10.25561/77482
7. Centers for Disease Control and Prevention. (2026, June 5). Rt: Estimating the direction of disease transmission. https://www.cdc.gov/cfa-modeling-and-forecasting/modeling-handbook/mh-rt.html
8. Pew Research Center. (2020, March 26). Worries about coronavirus surge, as most Americans expect a recession—or worse. https://www.pewresearch.org/politics/2020/03/26/worries-about-coronavirus-surge-as-most-americans-expect-a-recession-or-worse/
9. Moreland, A., Herlihy, C., Tynan, M. A., Sunshine, G., McCord, R. F., Hilton, C., Poovey, J., Werner, A. K., Jones, C. D., Fulmer, E. B., Gundlapalli, A. V., Strosnider, H., Potvien, A., García, M. C., Honeycutt, S., Baldwin, G., CDC Public Health Law Program, & CDC COVID-19 Response Team, Mitigation Policy Analysis Unit. (2020). Timing of state and territorial COVID-19 stay-at-home orders and changes in population movement—United States, March 1–May 31, 2020. Morbidity and Mortality Weekly Report, 69(35), 1198–1203. https://doi.org/10.15585/mmwr.mm6935a2
10. County of San Mateo. (2020, March 16). Seven Bay Area jurisdictions order residents to stay home. https://www.smcgov.org/ceo/news/march-16-2020-seven-bay-area-jurisdictions-order-residents-stay-home
11. Newsom, G. (2020, March 19). Executive Order N-33-20. Office of Governor of California. https://www.gov.ca.gov/wp-content/uploads/2020/03/3.19.20-EO-N-33-20-COVID-19-HEALTH-ORDER-03.19.2020-signed.pdf
12. California Legislative Information. (n.d.). California Government Code § 8665. https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=GOV&sectionNum=8665
13. Luna, T., & Willon, P. (2020, March 31). Should California punish people who refuse to stay home? Newsom prefers social pressure. Los Angeles Times. https://www.latimes.com/california/story/2020-03-31/gavin-newsom-social-pressure-california-coronavirus-shutdown-stay-home-order
14. Norwood, C. (2020, April 3). Most states have issued stay-at-home orders, but enforcement varies widely. PBS NewsHour. https://www.pbs.org/newshour/politics/most-states-have-issued-stay-at-home-orders-but-enforcement-varies-widely
15. National Governors Association. (2020, March 9). Virginia—Coronavirus state actions. https://www.nga.org/updates/virginia/
16. Goolsbee, A., & Syverson, C. (2021). Fear, lockdown, and diversion: Comparing drivers of pandemic economic decline 2020. Journal of Public Economics, 193, 104311. https://doi.org/10.1016/j.jpubeco.2020.104311
17. Pew Research Center. (2020, March 30). Most Americans say coronavirus outbreak has impacted their lives. https://www.pewresearch.org/social-trends/2020/03/30/most-americans-say-coronavirus-outbreak-has-impacted-their-lives/
18. Weinstock, L. R. (2021, May 11). COVID-19 and the U.S. economy (CRS Report No. R46606). Congressional Research Service. https://www.congress.gov/crs_external_products/R/PDF/R46606/R46606.3.pdf
19. U.S. Bureau of Labor Statistics. (2020, May 13). Unemployment rate rises to record high 14.7 percent in April 2020. https://www.bls.gov/opub/ted/2020/unemployment-rate-rises-to-record-high-14-point-7-percent-in-april-2020.htm
20. U.S. Department of the Treasury, Bureau of the Fiscal Service. (2021, May 25). CARES Act [Presentation slides]. https://www.fiscal.treasury.gov/files/dnp/dnp-day-presentation5-25-2021.pdf
21. U.S. Congress. (2020). H.R. 748—CARES Act, 116th Congress (2019–2020). Congress.gov. https://www.congress.gov/bill/116th-congress/house-bill/748
22. U.S. Government Accountability Office. (2023, February 1). Emergency relief funds: Significant improvements are needed to address fraud and improper payments (GAO-23-106556). https://www.gao.gov/products/gao-23-106556
23. KFF. (2020, April 23). Poll: 8 in 10 Americans favor strict shelter-in-place orders to limit coronavirus’ spread, and most say they could continue to obey such orders for another month or longer. https://www.kff.org/global-health-policy/poll-8-in-10-americans-favor-strict-shelter-in-place-orders-to-limit-coronavirus-spread-and-most-say-they-could-continue-to-obey-such-orders-for-another-month-or-longer/
24. The White House. (2020, March 29). Remarks by President Trump, Vice President Pence, and members of the Coronavirus Task Force in press briefing. https://trumpwhitehouse.archives.gov/briefings-statements/remarks-president-trump-vice-president-pence-members-coronavirus-task-force-press-briefing-14/
25. World Health Organization. (2020, March 29). Coronavirus disease 2019 (COVID-19): Situation report—69. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200329-sitrep-69-covid-19.pdf
26. Gonzalez-Reiche, A. S., Hernandez, M. M., Sullivan, M. J., Ciferri, B., Alshammary, H., Obla, A., Fabre, S., Kleiner, G., Polanco, J., Khan, Z., Alburquerque, B., van de Guchte, A., Dutta, J., Francoeur, N., Melo, B. S., Oussenko, I., Deikus, G., Soto, J., Sridhar, S. H., . . . van Bakel, H. (2020). Introductions and early spread of SARS-CoV-2 in the New York City area. Science, 369(6501), 297–301. https://doi.org/10.1126/science.abc1917
27. Thompson, C. N., Baumgartner, J., Pichardo, C., Toro, B., Li, L., Arciuolo, R., Chan, P. Y., Chen, J., Culp, G., Davidson, A., Devinney, K., Dorsinville, A., Eddy, M., English, M., Fireteanu, A. M., Graf, L., Geevarughese, A., Greene, S. K., Guerra, K., . . . Fine, A. (2020). COVID-19 outbreak—New York City, February 29–June 1, 2020. Morbidity and Mortality Weekly Report, 69(46), 1725–1729. https://doi.org/10.15585/mmwr.mm6946a2
28. Peters, A. W., Chawla, K. S., & Turnbull, Z. A. (2020). Transforming ORs into ICUs. The New England Journal of Medicine, 382(19), e52. https://doi.org/10.1056/NEJMc2010853
29. Gottlieb, S., Rivers, C., McClellan, M. B., Silvis, L., & Watson, C. (2020, March 29). National coronavirus response: A road map to reopening. American Enterprise Institute. https://www.aei.org/research-products/report/national-coronavirus-response-a-road-map-to-reopening/
30. The White House. (2020, April 16). Opening Up America Again. https://trumpwhitehouse.archives.gov/openingamerica/
31. The White House. (2020, April 17). Remarks by President Trump, Vice President Pence, and members of the Coronavirus Task Force in press briefing. https://trumpwhitehouse.archives.gov/briefings-statements/remarks-president-trump-vice-president-pence-members-coronavirus-task-force-press-briefing-april-17-2020/
32. Neergaard, L., & Pace, J. (2020, April 14). Fauci: “We’re not there yet” on key steps to reopen economy. Associated Press. https://whyy.org/articles/fauci-were-not-there-yet-on-key-steps-to-reopen-economy/
33. Grimm, C. A. (2020, April). Hospital experiences responding to the COVID-19 pandemic: Results of a national pulse survey, March 23–27, 2020 (OEI-06-20-00300). U.S. Department of Health and Human Services, Office of Inspector General. https://oig.hhs.gov/oei/reports/oei-06-20-00300.pdf
34. Office of Governor Brian P. Kemp. (2020, April 20). Gov. Kemp updates Georgians on COVID-19. https://gov.georgia.gov/press-releases/2020-04-20/gov-kemp-updates-georgians-covid-19
35. Gazaway, W. (2020, April 21). Cases, deaths continue to increase as Georgia prepares to start reopening. WTOC. https://www.wtoc.com/2020/04/21/cases-deaths-continue-increase-georgia-prepares-start-reopening/
36. Office of Governor Brian P. Kemp. (2020, May 12). Gov. Kemp, DPH, DCH, GEMA, Department of Insurance and Georgia Guard give update on COVID-19. https://gov.georgia.gov/press-releases/2020-05-12/gov-kemp-dph-dch-gema-dept-insurance-and-georgia-guard-give-update-covid
37. The American Presidency Project. (2020, April 24). Tweets of April 24, 2020. https://www.presidency.ucsb.edu/documents/tweets-april-24-2020
38. Demas, S. J. (2020, April 15). Whitmer stay-home-order protest turns into Trump celebration with Confederate flags and guns. Michigan Advance. https://michiganadvance.com/2020/04/15/whitmer-stay-home-order-protest-turns-into-trump-celebration-with-confederate-flags-and-guns/
39. The American Presidency Project. (2020, April 17). Tweets of April 17, 2020. https://www.presidency.ucsb.edu/documents/tweets-april-17-2020
40. Nichols, A. L. (2020, April 30). “Tyrants get the rope”: Small anti-Whitmer protest rocks Capitol, reporter hit by gun. Michigan Advance. https://michiganadvance.com/2020/04/30/tyrants-get-the-rope-small-anti-whitmer-protest-rocks-capitol-reporter-hit-by-gun/
41. Office of Governor Gretchen Whitmer. (2020, April 9). Governor Whitmer extends, expands “Stay Home, Stay Safe” executive order to save lives. https://www.michigan.gov/whitmer/news/press-releases/2020/04/09/governor-whitmer-extends-expands-stay-home-stay-safe-executive-order-to-save-lives
42. Office of Governor Gretchen Whitmer. (2020, April 24). Governor Whitmer extends Stay Home, Stay Safe order, directs Michiganders to wear homemade masks in enclosed public spaces. https://www.michigan.gov/whitmer/news/press-releases/2020/04/24/extends-stay-home-stay-safe-order-directs-michiganders-to-wear-homemade-masks

Rumors from Wuhan

December 2019–January 2020

Twenty-first-century Americans are used to scary headlines. Whether it’s nuclear war, sentient AI, climate change, or more lurid examples like murder hornets, Y2K, killer clowns, or a Mayan apocalypse, we are used to being regularly served with the inevitability of our impending doom. As such, the average person can be excused for failing to douse their hair in gasoline and ignite it whenever the AP or Reuters report something new to worry about.

In December 2019, one such story began circulating about an as-yet unknown illness in Wuhan, China. Early reports were aggressively banal compared to the examples above; one such brief referred to an “unidentified pneumonia outbreak” in Hubei province with 27 identified patients and no observed human-to-human transmission.¹

SARS, MERS, H1N1 (“swine”) flu, and Ebola had all been serious, but none had materially affected the daily lives of average Americans despite the media frenzies that surrounded them. And so, as cases increased steadily in an ever-expanding crisis in Wuhan, the world remained unchanged. The question, then, is not why Americans did not see the pandemic coming, but when the evidence crossed the threshold from reasonable indifference to existential salience.

The news cycle droned on. Kobe Bryant’s death, the Harvey Weinstein trial, the U.S. killing of top Iranian general Qassem Soleimani, and the 2020 Democratic presidential primary peppered the headlines with a series of mostly ordinary, if sometimes gripping, news.

Even so, keen observers could notice a steady drip of details as scientists and public health officials worked furiously to get a handle on that novel respiratory illness, which was identified as being caused by a coronavirus on January 7 and initially named “2019-nCoV,” short for “novel coronavirus-2019.”² The outbreak hit a meaningful milestone on January 14 when the World Health Organization (WHO) reported the possibility of human-to-human transmission; reports of cases in other countries, primarily in travelers coming from China, trickled into the news cycle.³

Americans first began seeing glimpses of the coming catastrophe in late January, with the first case of “coronavirus” in the United States on January 21, 2020, in a traveler who had returned to Washington State from Wuhan.⁴ While unsettling, this mostly prompted a sense of vague unease for the duration one spent thinking about it; it conjured memories of Americans returning from Africa with Ebola only a few years prior, and the leading expectation in the public imagination was still that the disease would be unceremoniously contained without too much trouble.

By January 21, that human-to-human transmission was confirmed. Up until that point, a casual observer could understand 2019-nCoV as an isolated cluster of illnesses likely of animal-to-human origin. Human-to-human transmission established that propagation of the virus beyond its initial source was possible, although not yet how efficient it was at achieving that end.

Yet another ominous murmur came from the Chinese government itself mere days later, on January 23. At only 444 recorded cases and 17 deaths, Wuhan authorities took unprecedented measures to suspend public transportation, close airports and train stations, and instruct residents not to leave without reason in an effort to contain the outbreak.⁵ Virtually overnight, eleven million residents of a modern metropolis were effectively shut out from the rest of the world. The scale of this disruption seemed surreal and wildly disproportionate to the raw case count, a fact that itself portended the scale of infection yet to come. Moreover, the restrictions began immediately before Lunar New Year, a significant event that was expected to precipitate large population movement and was also culturally difficult to disrupt.⁵

These measures were not in themselves a reason to panic; they functioned as a nudge that, in context, pointed to the disturbing possibility that the novel coronavirus might become something bigger. Increasingly severe restrictions in China combined with the revelation of human-to-human transmission and the recent history of SARS and MERS (which both had startlingly high mortality rates) elevated the concern from a faraway public health issue to a recurring media bugaboo that earned the attention of mainstream news outlets.⁶

Meanwhile, there was significant debate in the public health establishment about how to respond to the new pathogen. The World Health Organization (WHO) held an emergency committee meeting on January 22–23, though they failed to reach consensus about whether the situation warranted an emergency declaration. Barely a week later, on January 30, the WHO reconvened and this time issued that emergency declaration. Cases had risen sharply, more countries began reporting infections, and human-to-human transmission started appearing outside China. The outbreak was declared a Public Health Emergency of International Concern (PHEIC) that, while not yet calling it a pandemic, indicated to public health officials and experts worldwide that the pathogen likely posed significant risks to countries beyond China and that containing it would likely require significant international cooperation.³

By January 31, the situation had become much more serious: 9,826 confirmed cases, of which 9,720 were in China. 213 people were confirmed to have died of the disease, 106 cases had been reported in 19 countries other than China, and the United States stood at a total of six confirmed cases. At this point, the trajectory was clearly disturbing, but much was still unknown; it was not yet known how readily the virus spread, for example, or its true severity. But to the average American, containment still seemed more likely than a global pandemic.⁷

The Numbers Start Moving

January–February 2020

There is evidence that officials and concerned onlookers were alarmed by the novel coronavirus earlier than many of us remember. By January 31, the Trump administration had been sufficiently convinced of the threat to issue sweeping travel restrictions that took effect at 5 p.m. ET on February 2. These restrictions barred foreign nationals who had been in mainland China at any point in the previous two weeks from entering the U.S., though they did grant exceptions for returning Americans and some others. Americans returning from Hubei province were routed to specific airports and faced quarantine requirements.⁴

The coronavirus had something of a breakout cultural moment with the coverage of several coronavirus-infested cruise ships beginning with Diamond Princess in early February. The ship set off from Japan with some 3,700 passengers in late January, and by the first week of February the ship had become an uncontrolled natural experiment in the spread of coronavirus in a sealed environment. One passenger who disembarked on January 25 in Hong Kong tested positive on February 1; the ship nevertheless continued its itinerary through February 3, at which point it returned to Yokohama, Japan, after six stops in three countries. Initially, passengers did not disembark, though it was apparent the illness was rapidly spreading. By February 5^, passengers were being confined to their cabins to prevent spread. By February 16, 355 cases had been confirmed, the largest known cluster outside of mainland China through most of February. All told, 712 of 3,711 passengers tested positive. 331 of those were asymptomatic.⁸

The Diamond Princess was important because it signaled to the public two alarming facts: coronavirus can spread quickly—and symptoms are not a foolproof way to identify infection. This largely set the stage for the Westerdam debacle. That ship, with some 2,257 passengers and crew aboard, spent roughly two weeks in early February sailing around East Asia trying to secure a port while being denied by Japan, Guam, the Philippines, Taiwan, and Thailand. Though Cambodia eventually allowed the ship to dock, the incident is noteworthy because the ship had no confirmed cases.⁹ Evidently, fear itself was rapidly becoming powerful enough to dictate political decisions with real social and economic consequences.

Judging its temporary designation of the novel coronavirus as “2019-nCoV” inadequate, the WHO renamed the disease “COVID-19,” short for “coronavirus disease 2019.” The virus itself was renamed “SARS-CoV-2” by the International Committee on Taxonomy of Viruses (ICTV), short for “severe acute respiratory syndrome coronavirus-2.”¹⁰ Until then, it had mostly been referred to just as “the coronavirus.”

By the third week of February, the newly christened COVID-19 began popping up all around the globe. South Korea was early to sound the alarm, reporting a major cluster in Daegu associated with the Shincheonji Church.¹¹ Aside from the cruise ships crisscrossing the oceans, this was one of the first major instances of widespread domestic transmission—that is, most of the cases were not in travelers from China. Iran announced its first cases on February 19, the same day it reported its first fatalities; this was, unfortunately, suggestive that the virus had been spreading unchecked there for some time, given the incubation period and course of illness that precedes a fatal bout with the disease.¹¹

Public anxiety steadily rose with each report from the Iranians and the South Koreans. Still, the eruption of cases in northern Italy in the fourth week of February seemed to mark a turning point in American media coverage. It is difficult to say why Italy was so psychologically jarring, but I will venture a guess that it was because it felt closer to home. China was a faraway country that felt alien to most Americans; Iran was a closed-off authoritarian backwater. South Korea was closer, but it could be hand-waved away by its proximity to China, no matter how silly that seems in retrospect. Italy, on the other hand, is European—it’s a vacation destination with a familiar culture, littered with landmarks whose likenesses adorn fridges, classroom walls, and picture books nationwide.

As WHO and European Centre for Disease Prevention and Control (ECDC) officials descended upon Lombardy and Veneto on February 24, the mood was mostly a drip-drip ratchet of increasing worry rather than panic.¹¹ The outbreaks still had not been designated a pandemic, even as officials increasingly concluded that the disease had moved past the point where it was best explained by travel from China.

A foreboding cloud descended upon Wall Street the week of February 24–28 as a global stock market selloff began; it would rapidly become the worst week for the markets since the housing bubble burst in 2008. More than five trillion dollars evaporated worldwide—all before most major restrictions were implemented, before the death toll began climbing in earnest, and before anyone knew how long a ride we were in for.¹²

The selloff intensified after February 25, when Nancy Messonnier, then the director of the National Center for Immunization and Respiratory Diseases at the CDC, issued the strongest warning from an American official yet. Her admonition was curt and firm: prepare for disruption. This was the first time many Americans were given a preview of what the next couple of years would look like: school and workplace closures, cancelled large gatherings, and other measures that could severely disrupt everyday life.¹³ It also marked a stark turning point with respect to the rhetoric U.S. officials were using to communicate about the virus.

The next day, the first recognized case of community transmission was reported in a California patient with no relevant travel history and no known contact with an infected person. Importantly, this was only the first known community spread, almost certainly not the first. Barely seventy-two hours passed, and by February 29, additional likely cases of community spread were identified in Oregon, Washington, and elsewhere in California. Concurrently, a man in Washington State that day became the first reported U.S. death from COVID-19 (though later analyses would reveal the actual first death occurred much earlier).¹⁴

The month had begun with 9,826 confirmed cases; it ended with 85,403. It began with cases reported in 20 countries; it ended at 54.^7,15 It would not stop there.

Rupture

March 2020

The beginning of March had a faintly airy, uncertain, unreal quality to it. COVID-19 was clearly a problem, and it appeared to be an increasingly local one, but very few in the public had yet come to appreciate its magnitude. We knew something was happening, but not how big or how important that thing was. The period leading up to the rupture of March’s second week felt as though the pandemic was slowly inching closer to everyday life. It was there in January, but it’s only in Hubei. It was there in early February, but it’s only in East Asia…well, now Europe too… It was in the United States, yes, but only on the West Coast. Surely it won’t make it all the way to me.

On March 1, New York State confirmed its first case, foreshadowing the early disastrous spread in the state.¹⁶ Around the same time, Americans got their version of the Westerdam and Diamond Princess; yes, we had our very own death-cruise spectacle. The Grand Princess had recently completed a cruise to Mexico, returning to San Francisco; on March 4, health authorities in California learned that some of the passengers from the previous voyage had developed COVID-19, including one man who had died. The implication here was that the disease was probably still circulating on board, because most of the crew and some passengers had remained.⁸ The ship was ordered to return to the United States but was initially not allowed to dock. The hulking white lump remained afloat conspicuously outside San Francisco, encircled by news helicopters and gawked at by a nation feeling both fascination and horror.

The Grand Princess drama unfolded over the course of several days. As the ship was held offshore, the California National Guard delivered tests for the virus, which, unsurprisingly, yielded several positives—21 of the first 45 tested had it.⁸ Meanwhile, a national debate percolated over what to do with the passengers. Contemporaneous reports said that Donald Trump’s advisors favored bringing them to the mainland for quarantine, but Trump disagreed. “They would like to have the people come off,” he said on March 6. “I’d rather have the people stay, but I’d go with them. I told them to make the final decision. I would rather—because I like the numbers being where they are. I don’t need to have the numbers double because of one ship.”¹⁷ Trump’s admission was startlingly blunt, though perhaps less so for him than it would be for another politician.

On March 9, the Grand Princess was finally allowed to dock in Oakland. Over the ensuing five days, passengers and some crew disembarked in staggered batches, each one greeted by a small army of health officials clad in respirators, face shields, and hooded white Tyvek coveralls. The episode finally ended with foreign passengers repatriated, Americans transferred into quarantine arrangements on military bases, and nine deaths from COVID-19 complications.¹⁸

Meanwhile, case numbers continued growing. On March 7, worldwide confirmed case counts surpassed 100,000, with the true number certainly much higher.³ The WHO finally declared COVID-19 a pandemic on March 11, noting 118,000 cases and more than 4,000 deaths across 114 countries. Cases outside China had, in the preceding two weeks, increased by more than an order of magnitude.¹⁹

That evening, the President delivered an Oval Office address whose content was so diligently, suspiciously obedient to his teleprompter that many of us were alarmed by the sheer lack of compulsive allusions to rat-bag Democrats, Crooked Hillary, or the Rigged Mueller Investigation. Even as he announced travel restrictions from Europe, blamed the Chinese, and labeled COVID-19 a “foreign virus,” Trump’s delivery was uncharacteristically restrained, almost somber, and he showed the visible discomfort of someone both aware that something was badly wrong and catastrophically unprepared—personally, as well as professionally—to handle it.²⁰

Underpinning Trump’s unease were the beginnings of real disruptions to American social institutions. The same day, the NBA suspended its season after Jazz-Thunder player Rudy Gobert tested positive.²¹ Tom Hanks, one of the most broadly recognizable and reassuringly familiar celebrities one could name, announced he had it too.²² New York postponed its St. Patrick’s Day Parade—the first time it had not been held since the eighteenth century.²³ Television shows began announcing tapings with no audience.²⁴ Universities crossed a threshold—many, including my future alma mater, William & Mary, cancelled all in-person instruction and moved classes online.²⁵

The next several days brought a rapid succession of state and local closures affecting schools, businesses, tourism, and social events. Between around March 12 and March 16, scores of seemingly disconnected institutions all seemed to reach a similar conclusion at the same time: shut down or prepare to be shut down.¹³ It was as if every hour, another pillar of American life collapsed, the beams buckling in sequence that inched, then crawled, then lunged at the throat of normalcy.

On March 13, the federal government formally declared a national emergency, finally signaling that COVID-19 was a real crisis unlikely to be contained and would require massive mobilization of attention and resources across local, state, and federal levels.²⁶ By the time this emergency was declared, it was plainly obvious that it was justified; the whiplash came more from the Trump administration’s instincts to, over the preceding weeks, minimize its significance and wish it away into the category of routine public health annoyance.

The panic-buying that followed the recognition that reality itself had, in some sense, fractured read like a script I’ve often seen in the South, particularly when there is an approaching snowstorm. The event is so novel and so terrifying that, in addition to typical foodstuffs like milk, bread, eggs, and canned foods, shoppers start to fixate on specific items in a way that leads to a runaway sense of scarcity. The most memorable items from this cycle were typical flu-season infection control essentials like sanitizer, disinfectants, soap, paper towels, face masks, disposable gloves, and bleach. Slightly more bizarre was the obsession with toilet paper, which plenty of Americans evidently assumed would be necessary to stock by the ton if they were going to survive a prolonged viral siege.²⁷ With masks, gloves, and disinfectants specifically, officials began worrying that hospitals and the healthcare professionals who staff them would be faced with shortages of personal protective equipment.²⁸

By March 16, the White House announced its “15 Days to Slow the Spread,” which did not initiate the national response to the virus as much as it gave rhythm to the rolling, out-of-phase waves of local closures and social retreat. Though the implications of the message had not yet been absorbed completely, the federal government was beginning to tell the public that normal behavior was now itself dangerous. Gatherings should be avoided, travel skipped, and work and school reorganized or shuttered.²⁹ The virus had thus completed its journey from obscure foreign concern to looming threat to the single governing fact of American life. What remained to be seen was whether the fear that so quickly reordered American life was proportionate to the danger Americans could reasonably have understood at the time.

What Was Reasonable to Fear?

As of March 2020

The initial response to COVID-19 has rightly come under immense criticism in the years thereafter. At the same time, there are limits to a fully retrospective account of policy decisions made under uncertainty. With that in mind, I ask the reader to set aside everything we have learned since mid-March of 2020 and ask what a sensible person and a competent government could have reasonably feared at the time.

The picture of the disease at that time was clear in some ways and yet more opaque than we might have hoped. We knew that the virus transmitted efficiently enough between humans to escape containment in China and establish runaway chains of infections in several countries.¹⁵ We knew that cases were increasing exponentially and that the virus could be carried by healthy people or the soon-to-be sick, and thus that cases were likely to be severely undercounted.⁸ We also knew from the outbreak in Italy that a modern Western healthcare system could come under severe pressure sufficient to threaten functional collapse.³⁰ This last point was crucial—there was no vaccine, no proven treatment, and no population immunity to blunt the tsunami that could jeopardize our healthcare system.³¹

Yet much remained obscure. The true prevalence of the virus was unknown, though assumed to be much higher than the confirmed case count. This was especially a problem in the beginning when tests were in short supply, but it continued to be relevant because mild and asymptomatic infections had already been documented.^32,33 Someone with a minor “cold” might not think of COVID at all, and someone asymptomatic might unknowingly spread the virus to others, all the while unaware of the bioreactor humming in their respiratory system.

Because of this, the actual fatality rate of the virus was not known, or knowable, at the time beyond the observation that it seemed to kill far more people who came down with it than ordinary seasonal viruses—the overwhelmed healthcare systems in northern Italy provided ample evidence for that.³⁰ What we did know was a rough estimate of the case fatality rate (CFR), which needs to be distinguished from the infection fatality rate. The case fatality rate is the proportion of documented cases that result in death. The CFR was estimated at between 2% and 3%.³⁴ That figure could not be directly compared with influenza’s estimated IFR because the true number of COVID-19 infections was still unknown. Health officials had only an observed CFR to work with, and its value was terrifying.

The attack rate of the virus was similarly unknown. “Attack rate” refers to the proportion of the population that becomes infected with a pathogen during an outbreak.³⁵ The projected proportion of the population that might become infected would become a central justification for the mitigation measures that were implemented, and for good reason. In recent years, the American healthcare system has often been perilously close to surge capacity without an additional infectious disease on the loose. Immediately pre-COVID, around two-thirds of hospital beds were occupied at any given time; by 2023–24, that number was about three-quarters.³⁶ Moreover, just because a bed exists does not mean it can be properly staffed. It does not mean there is a nurse to check vitals, a doctor to prescribe treatments, or a ventilator to keep a sick patient breathing.

The decision environment for health officials, politicians, and members of the public was thus asymmetric. Once COVID became a bona fide emergency, every incentive favored severe mitigation measures, because failing to slow the disease could trigger a cascading health disaster: patients would arrive too quickly and in numbers too great to treat properly, many would receive worse care, and many more would die—not to mention the routine care that would be displaced.³⁷ Routine and preventive care would also be displaced: hypertension would go undetected, time-sensitive cancers would have more time to spread, strokes heart attacks, and other emergencies would compete for beds, staff, drugs, and attention.

The immediate goal, then, was not to stop infections but rather to slow them—to “flatten the curve” and protect the healthcare system from being stretched past its breaking point.³⁷ Related goals were to buy time for the public health machinery to increase testing and surveillance, allow doctors to develop the first shreds of clinical intuition about how to treat the virus, and protect healthcare workers from unsafe conditions. The impulse to consider temporary disruption to daily life a worthwhile tradeoff was, then, eminently defensible. This is not to say that every restriction deserves to be validated, even from a contemporaneous perspective. Objectives, endpoints, and proportionality matter. It is only to say that from the perspective of America circa March 2020, severe caution with respect to COVID-19 was justified in exchange for the expected benefit of time and preserved healthcare capacity. How that bargain was implemented is another matter entirely.

Notes

1. CIDRAP. (2019, December 31). Chinese officials probe unidentified pneumonia outbreak in Wuhan. University of Minnesota. https://www.cidrap.umn.edu/covid-19/news-scan-dec-31-2019
2. World Health Organization. (n.d.). Coronavirus disease (COVID-19). Retrieved August 23, 2026, from https://www.who.int/europe/health-topics/coronavirus/taking-stock-of-the-health-related-sdg-during-covid-19
3. World Health Organization. (2020, June 29). Listings of WHO’s response to COVID-19. https://www.who.int/news/item/29-06-2020-covidtimeline
4. Patel, A., Jernigan, D. B., & 2019-nCoV CDC Response Team. (2020). Initial public health response and interim clinical guidance for the 2019 novel coronavirus outbreak—United States, December 31, 2019–February 4, 2020. Morbidity and Mortality Weekly Report, 69(5), 140–146. https://doi.org/10.15585/mmwr.mm6905e1
5. Xinhua. (2020, January 23). China’s Wuhan suspends public transportation, outward flights, trains. https://www.xinhuanet.com/english/2020-01/23/c_138727567.htm
6. Petrosillo, N., Viceconte, G., Ergonul, O., Ippolito, G., & Petersen, E. (2020). COVID-19, SARS and MERS: Are they closely related? Clinical Microbiology and Infection, 26(6), 729–734. https://doi.org/10.1016/j.cmi.2020.03.026
7. World Health Organization. (2020, January 31). Novel coronavirus (2019-nCoV): Situation report—11. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200131-sitrep-11-ncov.pdf
8. Moriarty, L. F., Plucinski, M. M., Marston, B. J., Kurbatova, E. V., Knust, B., Murray, E. L., Pesik, N., Rose, D., Fitter, D., Kobayashi, M., Toda, M., Cantey, P. T., Scheuer, T., Halsey, E. S., Cohen, N. J., Stockman, L., Wadford, D. A., Medley, A. M., Green, G., . . . Friedman, C. R. (2020). Public health responses to COVID-19 outbreaks on cruise ships—Worldwide, February–March 2020. Morbidity and Mortality Weekly Report, 69(12), 347–352. https://doi.org/10.15585/mmwr.mm6912e3
9. Law, V. (2020, February 14). Nightmare holiday: Virus runs cruise passengers’ plans aground. Al Jazeera. https://www.aljazeera.com/news/2020/2/14/nightmare-holiday-virus-runs-cruise-passengers-plans-aground
10. Kretchmer, H. (2020, April 22). Key milestones in the spread of the coronavirus pandemic. World Economic Forum. https://www.weforum.org/stories/health-and-healthcare-systems/coronavirus-spread-covid19-pandemic-timeline-milestones/
11. World Health Organization. (2020, February 25). Coronavirus disease 2019 (COVID-19): Situation report—36. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200225-sitrep-36-covid-19.pdf
12. Jones, M. (2020, February 28). Coronavirus crash wipes $5 trillion off world stocks. Reuters. https://www.reuters.com/article/global-markets/global-markets-coronavirus-crash-wipes-5-trillion-off-world-stocks-idUSL5N2AS3T4/
13. Centers for Disease Control and Prevention. (n.d.). CDC Museum COVID-19 timeline. Retrieved September 4, 2026, from https://www.cdc.gov/museum/timeline/covid19.html
14. Jorden, M. A., Rudman, S. L., Villarino, E., Hoferka, S., Patel, M. T., Bemis, K., Simmons, C. R., Jespersen, M., Johnson, J. I., Mytty, E., Arends, K. D., Henderson, J. J., Mathes, R. W., Weng, C. X., Duchin, J., Lenahan, J., Close, N., Bedford, T., Boeckh, M., . . . Starita, L. M. (2020). Evidence for limited early spread of COVID-19 within the United States, January–February 2020. Morbidity and Mortality Weekly Report, 69(22), 680–684. https://doi.org/10.15585/mmwr.mm6922e1
15. World Health Organization. (2020, February 29). Coronavirus disease 2019 (COVID-19): Situation report—40. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200229-sitrep-40-covid-19.pdf
16. Office of Governor Andrew M. Cuomo. (2020, March 1). Governor Cuomo issues statement regarding novel coronavirus in New York. https://www.governor.ny.gov/news/governor-cuomo-issues-statement-regarding-novel-coronavirus-new-york
17. The White House. (2020, March 7). Remarks by President Trump after tour of the Centers for Disease Control and Prevention | Atlanta, GA. https://trumpwhitehouse.archives.gov/briefings-statements/remarks-president-trump-tour-centers-disease-control-prevention-atlanta-ga/
18. Ng, R. A. C., Fonseca-Ford, M., Friedman, C. R., Tardivel, K., White, S., Murphy, R., Petersen, L. R., Attfield, K., Bower, W. A., Murray, E. L., Jain, S., Marlow, M., Wheeler, W., Stockman, L. J., Mead, P., Pesik, N. T., Rose, D., Weidle, P. J., Readhead, A., . . . Novak, R. T. (2025). Public health response to COVID-19 among travelers disembarked from the Grand Princess cruise ship, March 2020. Public Health Reports, 140(4), 316–324. https://doi.org/10.1177/00333549251321762
19. World Health Organization. (2020, March 11). WHO Director-General’s opening remarks at the media briefing on COVID-19—11 March 2020. https://www.who.int/news-room/speeches/item/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19—11-march-2020
20. The White House. (2020, March 11). Remarks by President Trump in address to the nation. https://trumpwhitehouse.archives.gov/briefings-statements/remarks-president-trump-address-nation/
21. National Basketball Association. (2020, March 12). NBA to suspend season following Wednesday’s games. https://www.nba.com/news/nba-suspend-season-following-wednesdays-games
22. Whitcomb, D. (2020, March 12). Tom Hanks, wife Rita Wilson test positive for coronavirus in Australia. Reuters. https://www.reuters.com/article/world/tom-hanks-wife-rita-wilson-test-positive-for-coronavirus-in-australia-idUSKBN20Z07T/
23. Reuters. (2020, March 12). New York City’s St. Patrick’s Day parade canceled on coronavirus concern. https://www.reuters.com/article/world/new-york-citys-st-patricks-day-parade-canceled-on-coronavirus-concern-idUSKBN20Z0DA/
24. Elber, L. (2020, March 11). Virus prompts late shows to drop audiences, “Survivor” delay. AP News. https://apnews.com/article/2073ff69c2cf0002b6dcf8fe8583001c
25. William & Mary. (2020, March 13). W&M provides details on interim actions around COVID-19. https://www.wm.edu/news/stories/2020/wm-takes-interim-actions-on-instruction,-travel,-events-to-prevent-covid-19.php
26. The White House. (2020, March 13). Proclamation on declaring a national emergency concerning the novel coronavirus disease (COVID-19) outbreak. https://trumpwhitehouse.archives.gov/presidential-actions/proclamation-declaring-national-emergency-concerning-novel-coronavirus-disease-covid-19-outbreak/
27. Reuters. (2020, March 17). Shoppers rush to stock up as coronavirus spreads. https://www.reuters.com/news/picture/idUSRTS35ZLY/
28. World Health Organization. (2020, March 3). Shortage of personal protective equipment endangering health workers worldwide. https://www.who.int/news/item/03-03-2020-shortage-of-personal-protective-equipment-endangering-health-workers-worldwide
29. The White House. (2020, March 16). 15 days to slow the spread. https://trumpwhitehouse.archives.gov/articles/15-days-slow-spread/
30. Remuzzi, A., & Remuzzi, G. (2020). COVID-19 and Italy: What next? The Lancet, 395(10231), 1225–1228. https://doi.org/10.1016/S0140-6736(20)30627-9
31. World Health Organization. (2020, February 28). Report of the WHO-China Joint Mission on coronavirus disease 2019 (COVID-19). https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf
32. Mizumoto, K., Kagaya, K., Zarebski, A., & Chowell, G. (2020). Estimating the asymptomatic proportion of coronavirus disease 2019 (COVID-19) cases on board the Diamond Princess cruise ship, Yokohama, Japan, 2020. Eurosurveillance, 25(10), 2000180. https://doi.org/10.2807/1560-7917.ES.2020.25.10.2000180
33. Sharfstein, J. M., Becker, S. J., & Mello, M. M. (2020). Diagnostic testing for the novel coronavirus. JAMA, 323(15), 1437–1438. https://doi.org/10.1001/jama.2020.3864
34. Wu, Z., & McGoogan, J. M. (2020). Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72,314 cases from the Chinese Center for Disease Control and Prevention. JAMA, 323(13), 1239–1242. https://doi.org/10.1001/jama.2020.2648
35. Centers for Disease Control and Prevention. (2012). Principles of epidemiology in public health practice: Lesson 3, Section 1—Frequency measures. https://archive.cdc.gov/www_cdc_gov/csels/dsepd/ss1978/lesson3/section1.html
36. Leuchter, R. K., Delarmente, B. A., Vangala, S., Tsugawa, Y., & Sarkisian, C. A. (2025). Health care staffing shortages and potential national hospital bed shortage. JAMA Network Open, 8(2), e2460645. https://doi.org/10.1001/jamanetworkopen.2024.60645
37. Ferguson, N. M., Laydon, D., Nedjati-Gilani, G., Imai, N., Ainslie, K., Baguelin, M., Bhatia, S., Boonyasiri, A., Cucunubá, Z., Cuomo-Dannenburg, G., Dighe, A., Dorigatti, I., Fu, H., Gaythorpe, K., Green, W., Hamlet, A., Hinsley, W., Okell, L. C., van Elsland, S., . . . Ghani, A. C. (2020, March 16). Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand (Report 9). Imperial College London. https://doi.org/10.25561/77482