Politicians need clearer plans for rolling back (and reinstating) covid measures.

This story has been updated.

The United States is starting to contemplate the end of the pandemic — but getting there may be the toughest challenge yet.

With polls suggesting many Americans are growing weary of public health precautions, several Democratic governors this week said they would roll back mask requirements for indoor public places and schools. And on Tuesday, President Joe Biden’s chief medical adviser, Anthony Fauci, said that the U.S. is exiting its “full-blown” pandemic phase.

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But moving from emergency mode to coexistence with covid will require more than blunt-force optimism. Although the number of new cases nationwide has fallen sharply from the peak of the omicron surge, they still match last winter’s peak. Each day more than 2,000 Americans are dying of covid, and many hospitals are still slammed. That’s too high a burden to accept as normal, many public health experts argue.

They expect the virus will inevitably rear its head in the coming months. Navigating a path to a level of disease the country can live with will require health officials to convince politicians and the public to reinstate protections at key points — balancing the very real and reasonable desire for normal life with the risks covid still poses. In this third year of the pandemic, walking that line has never been harder.

“Two things can be true: The public can be tired of the pandemic and also still recognize we need measures to control it,” said Anne Sosin, a public health policy researcher at Dartmouth College. “That’s why we need data-driven policies that we can turn on and off when it’s most important.”

The U.S. has faltered before at moments like this. Last May, when the Centers for Disease Control and Prevention abruptly dropped its recommendation that vaccinated people wear masks, dozens of states followed suit without clear plans for how to reinstate measures if case counts spiked. By early July, the highly contagious delta variant was ravaging the country.

The CDC’s sudden switch on masking “laid the groundwork for what we’ve seen during the delta and omicron surges,” said Sosin. “Most states entered those surges with little to no mitigation measures in place, and they’ve struggled to reinstate them.” As a result, the covid death rate in the U.S. is higher than in other wealthy nations.

The emerging rift between the Biden administration and blue-state governors, who have been among the most cautious to date, could make navigating the end of the pandemic harder than it needs to be. The CDC and White House have so far not changed masking guidance, which still advises masks indoors where transmission is high — virtually the entire country — and masking in all K-12 schools. With no guidance around how to ease off restrictions, state officials are taking action using sharply varying criteria.

The lack of federal leadership is a major problem, said Julia Raifman, a public health policy researcher at Boston University who tracks state covid policy. “When the federal government recommends policies, we see states respond quickly … we need a long-term plan,” she said — one that balances the desire to push ahead with the fact that there are still many groups vulnerable to covid.

In regions with low cases and high vaccination rates, like parts of the Northeast, lifting some restrictions now may be the right move. “The improving situation is clearly the foundation of these decisions,” said Jonathan Levy, an environmental health researcher at Boston University. “But if policies are being articulated based on dates rather than conditions on the ground, then it becomes very hard to explain to people precisely why the change is happening now or what would cause more restrictions to be required.”

Recent history shows that conditions can change fast. Last November, Hopkinton High School in Massachusetts relaxed its mask mandate, in part because at least 95 percent of the student body was vaccinated. Still, school infections spiked in December, leading to a reinstatement of the mandate. In England, Prime Minister Boris Johnson advised schools to lift their mask mandates in mid-January as omicron infections ebbed, only to have many schools reverse that policy a week later as cases spiked.

Better policies for the next phase of the pandemic would involve clearer criteria for both ramping up and ramping down public health protections, Levy said. That should be coupled with an explicit acknowledgment by government and health leaders that best practices can change as we learn more about the virus or new variants emerge.

Some states and regions are already taking this approach.

In Nevada, masking requirements had been explicitly tied to county transmission levels that are updated weekly. But on Thursday afternoon, the governor abruptly lifted that mandate, despite high levels of transmission across the entire state. Boston plans to lift the requirement to show proof of vaccination for indoor dining when the city’s test positivity rate dips below 5 percent, fewer than 95 percent of ICU beds are occupied and hospitalizations fall below 200 per day. “People can quibble about whether those are the right metrics, but it is at least a clearly stated rationale,” Levy said.

Whatever the metrics or rationale, any plan should be designed to protect the most vulnerable — including people with compromised immune systems and those at elevated risk of covid because of their race, age or job. So far, leaders have not articulated how to do that.

“Not everyone is equally burdened by the pandemic, and low-income populations, immunocompromised people and others are at greater risk,” Levy said. “Making decisions based on the healthiest and most advantaged is not going to protect those who are most vulnerable.”

Low-income workers have been hit especially hard by the pandemic, and mask mandates provide a degree of extra protection for those who work indoors, said Lakshmi Ganapathi, a pediatric infectious diseases physician at Harvard University Medical School. That’s especially true for places like restaurants, grocery stores and other workplaces where close proximity to others can’t be avoided.

Relaxing mask mandates will make these workplaces less safe, she said, disproportionately impacting an already disproportionately impacted group. “The agenda does not seem to be being driven by the realities of [these] communities,” she said.

Unvaccinated kids represent another vulnerable group. While children tend to have less severe illness, hospitalizations have peaked during the omicron surge, with more than 800 kids being admitted each day. Children 5 and older are currently eligible to be vaccinated against the virus, but the uptake among the youngest in that group is still low. The FDA is considering whether to approve covid shots for children as young as 6 months in the coming weeks.

“The fact is that at least three-fourths of kids from 5 to 11 aren’t fully vaccinated,” said Odis Johnson Jr., a social policy researcher and executive director of the Johns Hopkins Center for Safe and Healthy Schools. There are downsides to mask mandates in schools, “but it’s clear to me that lifting a mask mandate now would have far more consequences than keeping one,” he said, citing absences due to infection and the potential for spread outside the classroom. He’d like to see the lifting of mask mandates in schools tied to vaccination rates.

Such measures could reassure parents who’ve been more cautious, perhaps because of their communities’ experience of the pandemic. “My son goes to a majority minority school in Boston where 90 percent of kids are Black or Latino and rely on free school lunch; in the past two years, no one has demanded that we get rid of masks,” Ganapathi said. “It’s the converse, people are worried about relaxing these measures prematurely because we are the communities who have been disproportionately impacted.”

The midterm elections later this year loom large over state and federal leaders crafting covid plans. Voters will judge them in part on how normal life seems come November. Such leaders would do well to remember that “it’s the virus, not mitigation strategies being employed to control it, that continues to disrupt our health systems, schools and economy,” said Sosin.

Simply waiving restrictions away, without clear plans to prepare for the next surge, will not bring normalcy back, she said: “I think that economic and political considerations are prevailing over public health ones, and we will be poorly served by the premature rush to normalcy.”

Jonathan Lambert

Beware the premature rush to normalcy