The graph, by itself, tells much of the story. We are still in the first wave of COVID-19, but the US is seeing a second hump to that wave. We are having the highest number of new cases right now, five months into this pandemic. A few months ago we hoped that by July we would start to see the tail end of this first wave, while we anxiously await a possible second wave in the fall, but instead we are seeing a surge. What is happening?

It’s always challenging to clearly see what is going when we are still in the middle of this pandemic, and our information is always a couple of weeks behind reality. But infectious disease experts and epidemiologists are seeing some patterns and are all expressing the same concerns. First, part of what we are seeing is just the natural course of this pandemic. In the US it largely started in urban centers with airports. NY had multiple introductions of the virus from Europe, for example. For this reason they were hit early and hard, while rural America was largely unscathed.

But the wave has moved through those urban centers into the rest of the US. Part of the problem is that, if you look at pooled US data it looked in May and into June that the death toll was declining and new cases were also declining. This created the false impression that, as a country, we were seeing the end of the first wave and we could start opening up. Plus there were legitimate concerns about the effect on the economy of prolonged shutdown, and understandably people were getting lockdown fatigue. But the total US numbers did not tell the full story. In April, as total US numbers started to go down, if you just removed New York from the data the rest of the 49 states were still going up. New York City, which was hit very early, was distorting the data. In May and June all you had to do was remove NY, CT, NJ, and MA from the data, and the other 46 states were increasing. But the illusion that the first wave was winding down had its effect.

Many states started to open up. Some did it well, slowly and with precautions, and other did it not well, too fast and too loose. Unfortunately the very states that had not yet seen the peak of their wave were often the rural states that also opened up too early and too quickly. The worst now are Arizona, Florida, South Carolina, Louisiana, Georgia, and Texas. The result is a surge even worse than the first surge in March and April.

There is also a political angle to this, because rural states tend to be more conservative. Why does this matter? Largely because mask wearing has been made into a political issue, rather than just a scientific and public health issue. Republicans are less likely to wear masks, and there is a significant movement pushing back against mandated mask wearing based on arguments of personal liberty. Further, the evidence is pretty clear now that face masks work. Those who oppose face masks, ostensibly on grounds of personal liberty, sometimes also falsely claim that they don’t work or cause problems of their own. The face mask wars are now political.

We can see the cultural divergence manifest in the social events that are also happening during this second surge. One is the Black Lives Matter (BLM) protests. These often involve large numbers of people gathering together in large numbers and marching and protesting. On can support BLM and the importance of the protests, but still worry about the timing and its impact on the pandemic. I certainly hope that protesters remember we are still in the middle of this pandemic, and plan their protests accordingly. The good news is that there is no discernable bump in cases that can be tied to BLM protests. This may be partly due to location, in urban centers that were already passed their peak, but also because the protests were largely outside and many protesters wore masks. Being outside is a huge advantage, because wind dissipates any droplets with virus quickly. Looking at the pictures and videos of BLM protests, I see a lot of masks. I would like to see a little more social distancing as well, however.

Contrast this to the other events happening – 2020 is an election year and campaign rallies are starting to ramp up. So far these are all Trump rallies, as Biden has not yet held any, and likely won’t. The Tulsa rally, in contrast to the BLM protests, was indoors, and looking at the pictures and video there is scant mask wearing. Wearing a mask was not required, Trump famously does not wear a mask, and the result was predictable. It’s now a little over two weeks after the Tulsa rally and we are starting to see a surge in cases in Tulsa. Local health experts think there is a connection, and that they can “connect the dots” from the rally to the current surge.

My point here is not to take political sides but to state the facts and point out the obvious – but which needs to be emphasized. What all these things have in common is that people are anxious to get about living their lives. We need to open up the economy and get back to work. We need to get on with our election. And we need to exercise our rights to protest and seek justice. These are all important. But – we need to do these things in the middle of a deadly pandemic. Over 130,000 Americans have died from the virus (and likely more), and we will almost definitely get to 200k before this first wave is over, and there likely will be more than one wave. Many people have survived, but their health was adversely affected by the severe infection. And many people have died because of fear of the virus and the use of medical resources by the pandemic.

Right now we are failing. America is having the most new cases per capita. We took our eyes off the ball, and rather than crushing the curve, the curve is crushing us. What should we do?

There is no mystery here. The experts know what to do, and states that are following their advice are doing well. Mask wearing needs to be universal. Continue good hygiene with physical distancing, no touching, and frequent hand washing. And states need to carefully tie opening up with data – testing and contact tracing. We need to think carefully about how to open schools in September. That will also be critical.

It seems reasonable to point to a lack of leadership at the Federal level here. States with good leadership are taking up the slack and doing well, but those with the double whammy of no federal leadership and poor state leadership are doing horribly. It’s frustrating because we can do this – we just need to do it.