Many of us dread being alone. We find isolation uncomfortable or downright scary. If you want to know just how eager we are to avoid it, consider a scientific study that offered people a choice between giving themselves electric shocks or being alone with their thoughts for 15 minutes. Believe it or not, many chose the electric shocks.

But here’s the good news: Being alone is a skill. And, just like any other skill, you can get better at it with practice. I want to suggest that honing this skill now can help you get through this pandemic winter. Instead of dreading being alone, you can lean into it.

Whether you’re skipping holidays with your family in an effort to contain the current coronavirus surge, or quarantined in your room because you have Covid-19, you’ve probably felt at least a momentary surge of panic at the idea of being physically cut off from your loved ones for days or weeks or months.

That’s a reasonable feeling: Social distancing is brutal. Full stop. Human beings have evolved over thousands of years to take comfort in one another’s presence, so when we’re isolated, it hurts us on a physiological level.

At the same time, we can probably recognize that some of our fear about being alone is not unique to the current pandemic. It’s a fear that has lurked in us for years, as we’ve forgotten — or perhaps never really learned — how to sit with ourselves, including with our uncomfortable thoughts and emotions.

“I think most of us are afraid to be alone with ourselves because getting to know ourselves is a very fearsome process,” Jack Fong, a sociologist who researches solitude at California State Polytechnic University, Pomona, told me. To keep this fear at bay, lots of us have a podcast or TV show constantly playing in the background, or a rotation of friends we call one after another.

Many factors have conspired to make us bad at solitude. They’re mostly not our fault. As Jenny Odell lays out in her book How to Do Nothing, we live in a culture where sociability and constant connectivity are rewarded, and where choosing to be by yourself marks you out as a loser, crazy, possibly immoral.

And when we do find ourselves alone, we’re increasingly at the mercy of an attention economy that bombards us with ever-present, ever-pleasant distractions. With external stimulation always just a click away, it’s never been so easy to avoid our inner worlds. Why would you sit with a feeling like boredom or sadness if you can distract yourself from it by texting a friend, or bingeing a Netflix show, or launching a Zoom call?

And indeed, these technologies are the salves everyone seems to be proposing for pandemic-induced loneliness. Don’t get me wrong: They can be genuinely useful. Like I said, loneliness hurts us physically as well as mentally. I live alone, so to stay sane, I’ve engaged in my fair share of Zoom dance parties.

Nevertheless, these fixes feel unsatisfying because they’re all about how to avoid being alone instead of just, well, being alone. And that avoidance stands to make us even more scared of our solitude. Decades of psychology research have taught us that trying to escape a distressing emotion is a bad long-term strategy; it teaches our brain that we can’t handle that emotion, and our distress actually grows more intense.

So how can we use this opportunity not to escape solitude but to lean into it? We can learn from people who figured out how to do this long before the coronavirus came knocking.

What we can learn from survivors of solitary confinement

For starters, we need to distinguish between voluntary solitude and enforced solitude. Plenty of people who’ve experimented with the former — hermits and monks, philosophers and artists — have worthwhile lessons to teach us about being alone. But it’s people in the latter category whose experience is most instructive for us now.

Consider what Keith LaMar, who’s been in solitary confinement in a supermax prison for 27 years, recently told Mother Jones. I want to be clear that I think solitary confinement is a form of torture that should be abolished, and it makes our self-enforced, tech-enabled isolation look like a walk in the park. There is simply no comparing the two.

Yet LaMar — as well as Jason Rezaian, a journalist who survived solitary confinement in an Iranian prison — have discussed their experiences in the context of the wide-scale quarantining going on now, in an effort to help us through this period. So let’s consider LaMar’s insights:

Being in solitary confinement is really just being thrown upon yourself: You’re running around, just like people do in your regular life, and now all of a sudden you’re confronted with yourself, and find that in a lot of cases you haven’t really put anything into yourself to occupy yourself. Everything is outward directed. That’s what happened to me 27 years ago, and what happens to a lot of guys who are initially thrown into this situation — it’s like being thrown into the ocean. You have to learn how to swim. You have to learn how to deal with yourself.

I’ve been lucky in a lot of ways. My cell has a bookshelf with three shelves, and there’s a table to sit and write. I have a lot of music, books to read. Not to distract myself from myself, but to take me deeper into myself. I paint, I work out, I do yoga, I meditate.

I’ve watched quite a few people fall apart, lose their minds. But I went in another direction. So 27 years later I’m still sound in mind and body and spirit. I attribute that to just reading and cultivating myself. That’s the thing, when you’re thrown upon yourself, you realize you are more equipped than you realized. A lot of the system keeps us from realizing our own power. It’s a good opportunity for people to tap into that. … Hopefully young people being forced to stay home outside of the mainstream curriculum are able to get a glimpse of themselves and start pulling on that thread.

There’s a lot of wisdom in this perspective. In fact, it echoes many of the key observations scholars have made over the years about solitude.

First, there’s the idea that to succeed at solitude, you have to accept that you’re being “thrown upon yourself” — to confront your reality rather than opting for distraction. Then you have to “put something into yourself” — to make solitude a generative practice that takes you deeper into who you are and develops you further.

Matthew Bowker, a Medaille College researcher who studies solitude, says something very similar in The Handbook of Solitude. He notes that being adept at being alone “implies the capacity to generate meaningful and valuable experiences in the internal world, for if one wishes to be when alone and not merely to wither or starve, one must be able to generate and possess some of the vital stuff of being.”

In other words, you’ve got to quit seeing solitude as an experiment in subtraction, and start seeing it as an experiment in addition. What you’re adding is your self — a true self, because at last it’s you who’s building it, not anyone else. You’re no longer looking to other people for their attention or approval.

The psychologist D.W. Winnicott often drew a distinction between the “authentic self” and the “false self.” Without realizing it, he said, we look to other people to scaffold our sense of who we are. It’s they who perform the construction of our identity. When we’re alone — when their judgments and preferences are no longer there to shape our self-concept — it tends to break down. That can be terrifying. But it can also be a gift. Because when the false self falls away, it leaves space for you to build a more authentic self.

What we can learn from people who pretend to live on Mars

Another key ingredient to successful solitude, psychologists have found, is having a clear sense of purpose.

Steve Cole, a researcher at the University of California Los Angeles, studies interventions designed to help people cope with loneliness. He’s found that the ones that work tend to focus not on decreasing loneliness but on increasing people’s sense of purpose. Recalling one pilot program that paired isolated older people with elementary school kids whom they’re asked to tutor and look out for, Cole told Vox, “Secretly, this is an intervention for the older people.”

Philosophers have also noted the fortifying effects of a clear sense of purpose. “Nietzsche said if you find purpose in your suffering, you can tolerate all the pain that comes with it,” Fong, the sociologist, told me. “It’s when people don’t see a purpose in their suffering that they freak out.”

In 2003, Kate Greene moved into a geodesic dome on top of a Hawaiian volcano, where she spent four months pretending to be an astronaut on Mars. NASA funded the experiment because it needs to know how human beings deal with isolation, so that real missions won’t go kaput just because someone gets lonely. In a recent essay, Greene confesses that she had a hard time living in the dome. Separated from her loved ones and troubled by confusing information from mission support, it was hard to remember her sense of purpose. But when she did, it made all the difference, she writes:

Remembering that we were doing something that might be good for the future of human exploration and maybe even humanity kept me grounded when I wanted to be flying and let me fly when I felt heavy and stuck. To be part of something historic, to do something potentially grand for others — it was remarkable how focusing on that was often enough.

Billy Barr, who’s been living alone in an abandoned mining shack high up in the Rocky Mountains for almost 50 years, has very similar advice. He says we should all keep track of something.

In his case, it’s the environment. How high is the snow today? What animals appeared this month? For decades, he’s been keeping track of the answers to these questions, and his records have actually had a serious influence on climate change science.

Now, he suggests that people in isolation get through the coronavirus pandemic by participating in a citizen science project such as CoCoRaHS, which tracks rainfall.

“I would definitely recommend people doing that,” he told WAMU. “You get a little rain gauge, put it outside and you’re part of a network where there’s thousands of other people doing the same thing as you, the same time of the day as you’re doing it.”

He and Greene both also emphasize the importance of routines — the little daily rituals that anchor us in time and give shape to a day.

The rewards — and risks — of solitude

Isolation has many virtues. But, harnessed incorrectly, it can also harbor danger.

First, the virtues. A long line of nature writers — from William Wordsworth and Henry David Thoreau to Annie Dillard and Mary Oliver — have described how solitude allows them to reconnect with nature, and through nature, a deep bliss. Many artists insist that isolation is necessary for creative work. “I paint with my back to the world,” said the painter Agnes Martin, because “the best things in life happen to you when you’re alone.”

Most world religions, even if they’re ambivalent about solitude as a long-term path, acknowledge that it’s useful for fostering spiritual insight. The Hebrew Bible says Moses spent 40 days alone on Mount Sinai before receiving the Torah. In the Roman Empire, Symeon the Stylite lived on top of a 60-foot pillar — for 37 years! Hinduism and Buddhism both have rich traditions of solitary forest dwellers. And Christianity has countless recluses; my favorite is Julian of Norwich, who at age 30 asked to be permanently shut into a cell so she could have visions of God and write about them.

The Trappist monk Thomas Merton and the psychologist Carl Jung both pointed out that dissociating from society allows us to perceive and call out its illusions. “I am a solitary,” Jung wrote, “because I know things and must hint at things which other people do not know, and usually do not even want to know.”

Nietzsche, in Thus Spoke Zarathustra, suggested that solitude can heal us from an overstimulating culture (“Flee, my friend, into your solitude! I see you dazed by the noise of men”) and reconnect us to ourselves (“go into isolation … seek the way to yourself”).

But isolation also comes with its fair share of danger. The problem is that, as Nietzche’s Zarathustra puts it, “whatever one brings into solitude grows in it, even the inner beast.” That can mean anxiety, or melancholy, or some other kind of distress. For this reason, the philosopher said “solitude is ill-advised” for many people.

“Nietzche was prescient enough to know that solitude is a dangerous project,” Fong told me. “If you are not ready for it, the cave you enter can be a very scary place. For those who have unresolved issues that may not have been attended to by a mental health expert, this may not be a good place to go.”

That’s why psychologists typically recommend gradual exposure. If being alone is scary to you, ideally you want to seek it out in small doses first, and then — once you’ve proven to your brain that it can in fact tolerate the distress — slowly increase the dose. If you’re in the midst of a full-blown panic attack, that’s not a good time to practice honing a new skill; you may need to first soothe the distress a bit. Engaging the senses to bring yourself back into your body is one commonly recommended way to do that (it’s no coincidence that everyone on social media is now baking sourdough bread and planting fragrant herbs).

Unfortunately, a pandemic doesn’t allow us to take the stepladder of solitude as gradually as we might like. It’s not ideal, but even under these circumstances, we can build up to the skill of being alone.

How to practice “distress tolerance skills” for being alone: A practical guide

The best step-by-step guide I’ve read for this purpose comes from the Centre for Clinical Interventions, supported by the Australian government’s department of health. Psychologists there have published a comprehensive guide to developing “distress tolerance skills.” It’s free, it’s online, and it uses an evidence-based approach rooted in cognitive-behavioral therapy and mindfulness-based therapy. It’s worth checking out the whole guide, but I’ll give a capsule summary of the process it recommends.

First, accept the distress you’re feeling. Instead of engaging in your usual escape methods for avoiding uncomfortable emotions (whether it’s bingeing TV, numbing out with alcohol, or whatever), commit to doing the opposite: Stay with the emotion.

Second, watch the emotion. Noting how it’s manifesting in your clenched muscles or using imagery to describe it (“this feeling is not me, it’s just like a cloud floating past in the sky”) may help you detach from it a bit. Keep observing it until it naturally subsides.

Third, turn your attention back to a task you want to do in the present moment. It can be a simple inward task like focusing on your breath, or an outward task like volunteering to help people in need during the pandemic.

Expect that the distressing feelings will come back. But know, too, that by actually facing them rather than running away from them, you’re teaching yourself that you’re strong enough to handle them.

If this is sounding a bit familiar, that’s because it echoes the strategies laid out by the experienced solitaries we met above, like the survivor of solitary confinement and the woman on the ersatz Mars mission. Accepting your isolation, letting it take you deeper into yourself, remembering your purpose — these are tried-and-true strategies for successful solitude. You will find the same strategies echoed in other sources, from contemporary Western psychologists and mindfulness teachers to ancient Buddhist texts.

And perhaps there’s some comfort in that. As alone as you might feel right now, remember that many human beings have experienced isolation before you, and they’ve left you their best tips for how to make the most of it. In a sense, you’re in community with them right now.

You’re also in community with the friends and family you have access to through your phone, Zoom, and so on. We should absolutely keep using these distance-collapsing technologies.

But there’s a difference between using them from a place of desperation, where we’re scrambling to generate a constant stream of chatter to distract us from our aloneness, and using them from a place of mindfulness, where we’ve already faced the distress of being alone and experienced it naturally subside. When we do the latter, psychologists say, that Zoom dance party becomes a reward for approaching rather than avoiding our solitude.

Reporting for this article was supported by Public Theologies of Technology and Presence, a journalism and research initiative based at the Institute of Buddhist Studies and funded by the Henry Luce Foundation.

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Fourteen thousand years ago, a star called Vela died. Its core collapsed first and then, in a violent burst, propelled the shattered star’s body out into space. Vela’s death bled into the interstellar medium, blasting cosmic radiation out in every direction.

For 800 years, the guts of this star traveled from its location in the Milky Way galaxy toward Earth. It took several years for the cosmic rays to permeate our atmosphere and settle to the ground, where they were absorbed into trees, ocean coral, and lakes around the planet.

Hundreds of years after that, in Tasmania, a dead tree was discovered, turned by time into a log and buried under sediment. Scientists studied the radioisotopes of the tree’s rings and found a surge of radiation 14,000 years old.

However distant and however ancient, seemingly random occurrences such as the death of Vela — a perfectly average star — and the shudder it caused on this average rocky planet are evidence of our inextricable link to everything in the cosmos, including the passage of time.

Scientists study tree rings for evidence of solar storms and supernovas in order to better understand the cycles of stars and how their lives and their deaths impact us.

We’ve used tree rings to measure these links since we learned how to study radioisotopes in the middle of the 20th century; we do the same with rocks and layers of ice deep below Antarctica. Humans have always wanted to know what’s happened in the past in order to help us understand our present. We have always longed to understand time.

But time itself has felt different this year, our relationship with it altered significantly by the pandemic. Whatever comfort we once derived from considering the past is gone. Now it’s a stark reminder of all that we had, all that we took for granted, and what we must still reckon with — that our future is not likely to look like what we’re used to.

Meanwhile, our hours and days dissolve together into some nebulous glob of experience. While time may run on a larger scale around us, we still live in our own intimate worlds. That dislocation in time has become a part of our running discourse, inspiring memes and jokes about not knowing what day it is. They drive home the fact that we’re all truly experiencing the same phenomenon — a sort of time melt.

As our usual markers of time vanish, the days feel as though they’ve been whipped through a blender. We are animals living in a social world, and as such, we’ve created strict routines for our lives. We wake up, take the kids to school, commute to work, take lunch breaks, go to the gym, have dinners out. Now, though, any activities we once might have participated in outside the home have been abruptly removed, and we’ve lost the sense of time these seemingly mundane markers once provided.

Lunch is whenever. Dinner is whenever. There is no more gym or meals with friends or travel plans. Our days are now simply that: days.

Since the pandemic began, we’ve been faced with a paradox: So much has changed around us, politically, environmentally, within our own lives. At the same time, so many of us are at home, living what often feels like cloned days. This is especially challenging for humans because our brains are hardwired to do one main thing: survive. And while many of us are staying home as a means of surviving, our ingrained nature counts survival as action, prediction, and planning.

Dean Buonomano is a neuroscientist and researcher at UCLA who studies how our brains relate to time. “Time is incredibly important because, in many ways, the brain’s most important functions are to predict the future,” he explains. “Because the degree to which an animal predicts where there’s going to be food or where there is going to be a predator or where there’s going to be water or where it’s going to find a mate determines the success of that animal. The brain is a prediction device.”

Covid-19, and its resulting effect on our lives, has stifled this instinct. Even thinking about the future conjures only a strange, fuzzy block because we know neither when this will end nor how different our world will look when it does.

What we are doing is waiting.

To understand how our experience of time has recently changed, we need first to understand what time really is (which, as you might have guessed, does not have a simple answer). At the most basic level, it is the fourth dimension — a coordinate, a way for us to know where we are.

“When someone says, ‘The movie starts at 7 pm,’ nobody is seized by anxiety, like, ‘Oh, my god, what does that mean? How am I supposed to interpret this weird, abstract way of looking at the world?’ Everyone knows what it means,” says Sean Carroll, a theoretical astrophysicist at Caltech. This is what is called “clock time,” and it helps us organize our lives.

Our brains tell time as well, like how we instinctively know when it’s day or night. This is what is called a circadian clock or rhythm — it’s how our bodies intuitively know to power down and get sleepy after the sun has set, and why sunlight or bright lights (hello, cellphones) alert our brains to wake up. Humans aren’t the only living beings that tell time this way. Nearly all animals need to know when it’s day versus night, so, for example, those that hunt after dark instinctively know to sleep during the day. It’s why light pollution is such an issue, not just for us humans but also for animals that rely on darkness to initiate mating, foraging, or sleep.

Plants also have a circadian clock — they know not to photosynthesize at night, because what good would that do? Many bacteria also keep to this rhythm because UV light from the sun is incredibly harmful to DNA. Time appears at such a basic cellular level that, like the blood coursing through us, it can be easy not to notice it as such.

But knowing this information won’t help you meet your friend at the movies, and it won’t explain why this year has turned our brains into washing machines on the spin cycle. If we can understand a little more about how the universe is moving forward, we might feel a bit better about our collective existential despair. Maybe we can even forgive ourselves for forgetting what day it is.

We measure time in relation to the star we orbit. We know that it takes 365 days for us to complete one lap around the sun and that it takes 24 hours for our planet to complete one spin around its axis. For thousands of years, we’ve used sundials to measure how the sun’s light changes in the sky throughout the day — in fact, the shadowed semicircle this measurement makes on the ground is why our clocks are round. We joke that time is a flat circle, thanks in part to True Detective. Only that’s not true. Time is a forward arrow.

It’s called time’s arrow. We know that time moves forward for a few reasons, the most obvious of which are that we can remember the past and not the future, and that we don’t get younger, we grow older. But the universe runs forward because of a process called entropy. Entropy at its heart is the measure of the quality physicists refer to as disorder. And disorder is just another way to think of change.

Entropy appears all around us, all day long, in ways so fundamental that even the infrared heat your body is giving off right now is a form of entropy. But to really understand time’s arrow, let’s make a very weird and inefficient cup of tea. When you take an ice cube out of your freezer, it is in an ordered state — a low-entropy state — because the molecules are cold and unmoving. As the ice cube melts, however, it enters a higher-entropy state. The molecules are free-flowing and less ordered, and if you choose to boil the melted ice cube (we are making tea, remember), the boiling water will create steam. A very high-entropy state for the water, steam sends molecules flying all over the place, onto your walls and ceiling and under the crack beneath your door.

You’d never be able to find them all and put them back into an ice cube; you cannot go back in time. There is now more disorder in your kitchen. But just for fun, let’s increase the entropy even more: If you steep that tea and pour in a dash of milk, you’d have just raised the entropy, because you’ve taken something hot and added something cold, mixing something together that cannot be unmixed. That’s time’s arrow.

The very young universe, too, began in a more ordered, low-entropy state, and as it expands, as the extreme heat from the Big Bang cools off and as things mix together, the overall entropy increases. This might seem like a bad thing, but it’s not. This state of change is required for all life, and without it, the universe would reach a state of equilibrium and, ultimately, its own end — a “heat death” that culminates in everything reaching the same temperature and being enveloped by black holes. When things stop changing, time’s arrow stops moving forward.

When Vela exploded 14,000 years ago, the Paleolithic paintings of France’s Chauvet Cave had been sitting hidden, frozen in a moment in time, for nearly 15,000 years before that. Not long after Vela’s death, the woolly mammoth went extinct, along with the cave bear and cave lion. Their bones for thousands of years were enveloped by a changing climate, melting glaciers and sediment, burying their skeletons and leaving evidence of their existence alongside the marks in red and black paint lining the walls deep inside Chauvet. One hundred million years earlier, dinosaurs occupied this land, at the same time that Saturn’s rings were forming.

In this way, time feels truncated, the past cut up into slices, more so because we still live on an ancient Earth, the bones of dinosaurs likely under our feet. Our ability to connect these markers in time has created entire fields of study: archeology, astronomy, geology, biology. Science and history, when intertwined, help us see what we would otherwise never have access to.

Knowing these stories helps us understand that the universe is constantly exhaling and inhaling new energy, in new stars and in the death of old ones. This cycle has been happening for billions of years. But as new stars are forged from an abundance of hydrogen lingering from the Big Bang, those stars convert the hydrogen to other elements. Eventually there won’t be enough hydrogen left in the universe to birth new stars, and the creation cycle will cease.

The same cyclical disorder is happening here on Earth. Species appear, they live, they go extinct, and we study them believing we are exempt from their fate.

We are a future-facing species. Even our memories are designed to help us predict the future. We have storage of past experiences that are, on a biological level, designed to inform our decisions. If you once touched a hot stove and burned yourself, you know not to do it again.

This goes against how we understand our memory. We think of it as something that belongs solely to the past, or perhaps the present. But our memories, above all, are not about the past; they are for our future. Our brains know to do anything we can to stay alive, while also planning out the next steps. Of all the things Covid-19 has taken from us, this might, abstractly, be one of the biggest sources of anguish: We’ve lost not only the present, but our sense of the future as well.

This time spent largely inside messes with our internal clocks, which is why March felt like it was a year long and how it is also suddenly December but it was only just April and somehow today is Wednesday and also seems like Monday, but who even knows. “For people during Covid, time can feel like it’s going slowly on a day-to-day level, but quickly on a week-to-week or month-to-month,” says Buonomano. This is what’s called retrospective time.

Retrospective time, he explains, is “not so much about time, but about memory, about items in memory. So if you had a month in which you didn’t have that many new experiences — you certainly didn’t go to a new country, you probably didn’t get out to meet new people, you probably didn’t take up a hobby, and you weren’t meeting people for work — you’re likely not to have anchors or lay down many long-term memories. So retrospectively, that creates the subjective experience of time flowing quickly.”

It is when our individual days don’t align with our internal clocks and the world’s external events that this odd confusion reigns.

“At some point,” Buonomano says, “Homo sapiens developed this ability to not just simply predict the future but to mentally time-travel to the future, which allowed us to do something totally radical: create the future.”

This is hyperbole, but instead of trying to predict where we might find plants and food, humans began planting seeds knowing that it was not for instant gratification but for long-term survival. Our nature is to create the future. It is one of our most inherent skills and desires, and in this moment, it has been snatched from us all.

Luckily, the pandemic’s erasure of any sense of past, present, and future won’t have any long-term effects on our brains, Buonomano says (though the PTSD and long-term emotional challenges we may suffer from being in isolation remain another cosmic unknown). “I think the lesson here is really how adaptive our species is. And that’s what the brain evolved to do, is to be adaptive. Humans are notoriously resilient.”

Before modern humans had the ability to count past 10, age did not exist. We didn’t keep track of how old people were; those numbers, that concept of time, did not exist yet. While humans have always observed the movement of planets in the sky and the changing seasons to help understand the passing of time, for the majority of human history our modes of relating to it were different. In the late 18th century, people began making timelines. They started to map the scale of the Roman Empire and measure the spread of disease.

It wasn’t until the 19th century, with the invention of the steam engine, that our relationship to time began to shift. Suddenly, time became incredibly important, as train operators needed to ensure that it was the same time in London as in Glasgow so that departure and arrival schedules were accurate. People started carrying pocket watches and were newly acutely aware of how the minutes passed in the day.

No matter how far back we look in human history, there has always been room for us to forge new relationships with this most valuable, most mysterious, and most fundamental thing. Just as it has always been and will always be, time is a paradox. We move through time wishing to grasp onto our most valuable moments — the first kiss, the new love, a special meal, a new city. Whatever those moments are that we cherish, the more they seem to slip through our fingers like sand. Yet as we exist within those seconds, so acutely aware of our grounding in the present, the future will beckon as though in echo, prodding us, leaving us wondering, will we get to keep this? Will this love stay? Will I get to come back to this place? And we will think, “I must do what I can to make it so.”

There is no flat circle of time except that which we humans have made. Real time is a tree’s rings, a labyrinth; it’s in stellar remnants, in letters, in books, in red and black paint etched on cave walls. It is love, in beginnings, in your tea, in chaos. It is endings — it is everything, just as we are everything.

As we approach another significant marker of time — the new year — we are faced with a real challenge. How do we contend with our nature, which fundamentally longs to predict the future and to protect and plan for it, while we face an indeterminate bleeding-together of days?

Maybe it can be of some comfort to us all to know that the nagging undercurrent of bewilderment, fear, sadness, and anxiety are there for more than the obvious reasons and are truly part of a natural collective experience. We are in a profound moment of being human. As time is changing — devolving, even — we know at least that it is still taking us forward.

Shannon Stirone is a writer in the Bay Area. Her work on science, culture, and technology can be found in the New York Times, the Washington Post, Wired, Longreads, and elsewhere.

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Winter and the holidays can be hard even in typical years: short days, cold winds, and family stress, to name a few. But the ongoing US Covid-19 surge, with more than 200,000 new virus cases reported every day since December 7 (about double what they were a month before), is putting the hallmark activities that help sustain us — holiday gatherings, meals with friends, volunteering, or a visit to see Santa — in more dire limbo.

Despite being more than nine months into the pandemic, figuring out whether and how to approach a previously routine event is still complicated. And the calculus seems to change with new case rates and evolving guidelines — and with our own fluctuating pandemic burnout.

Experts are still parsing the data on what role Thanksgiving played in the increase in Covid-19 cases and deaths. But the hard fact remains that, with case rates so high, “all activities are going to have some risk of being impinged upon by the virus,” says Amesh Adalja, a physician and faculty member of the Johns Hopkins University Bloomberg School of Public Health’s department of environmental health and engineering.

And doing things with people you know — but aren’t living with — can heighten that risk. Just because you love them, a family member or old acquaintance doesn’t have any lower risk of carrying or catching the virus than a stranger does. And it will likely make you less careful than if you were interacting with a stranger.

So this winter is going to be different, but it doesn’t have to be all bad unless we are determined to think of it that way. “Usually people find the holidays stressful, so this could potentially be the year with less stress — just see what it feels like not to go to or host all those parties,” Krysia Lindan, an epidemiologist at the University of California San Francisco, notes in an email to Vox. She calls it a year for “some experimentation.” For example, she had a picnic on the beach for Thanksgiving this year. Other experts suggest trying different activities, like a distanced hike instead of gathering around a meal or at a party.

A big part of the challenge is that Covid-19 spreads before people start showing symptoms. So anybody can show up feeling the picture of health only to unwittingly spread the virus to those they come into close contact with.

We talked with epidemiologists and other health experts about the safest — and riskiest — ways to see others, keep kids busy, help out, and travel this winter during the pandemic. (Note: Activities are ranked relatively within each category, so a “moderate” risk in one category does not carry the same relative risk as “moderate” in another category.) Here is what they said.

As a result of the pandemic, millions of people in the US are struggling to put enough food on the table for themselves and their families. More people need help this winter than perhaps at any other time in the past 80-plus years. So there has been no better time to find ways to help others.

Helping out not only benefits others, it also has a knock-on positive effect for you. For example, thinking about and helping others is a really important way to combat anxiety and stress and a feeling of helplessness — all of which are currently pervasive.

“It’s always good to volunteer, and doing so might lighten the sadness of not being able to see family and friends as in years past,” Lindan writes.

Other experts agree: “I do think people are hungry for ways to help each other right now,” says Jodie Guest, vice-chair of the department of epidemiology at Emory University’s Rollins School of Public Health.

Safest: Give money

Charitable organizations can often stretch donated money further than donated goods. So financial contributions are especially helpful, in addition to being Covid-19 transmission-free. Established charity-rating sites, such as GuideStar or Charity Navigator, can tell you how much of your contribution will go directly to the cause.

Next safest: No-contact help

The next safest way to help out this season is through contact-free volunteering or donations. This could be a formal, organized effort, like contributing food to a local pantry, or it could be personal efforts, like arranging grocery or meal deliveries for higher-risk community members.

Guest notes that these kinds of efforts can also safely be turned into a shared experience of sorts — such as organizing a coat or blanket drive with friends, family, or neighbors. (She suggests quarantining the donated goods for three days before you touch them.)

Moderate: Helping out in person with a few others

There are many organizations that rely heavily on behind-the-scenes volunteers. Food pantries or clothing and household goods distribution centers might offer opportunities to donate time and help in a slightly safer environment than, say, serving meals. Before you go, find out how many other people you will be working with, if they require masks, and how long you will be expected to work (shorter shifts are better for limiting exposure).

You shouldn’t have to look far for opportunities to contribute this way in your area, says Guest: Since the start of the pandemic, “the need for volunteers has only gotten bigger.”

Riskier: Volunteering in person with larger numbers of people

If you want to do more personal work, first check in with places where you might want to volunteer and ask if they are accepting in-person help and what precautions they are taking. For instance, if you want to serve meals, ask how many people they allow in at any time, if people are required to have masks, how often the organization cleans the area, and whether you will be the only one touching serving utensils, Guest notes.

“You should continue to use the same precautions as always when in a group setting — masks, even face shields, hand-washing, and distancing to the extent possible,” Lindan writes.

Riskiest: Volunteering in congregate living settings

The highest-risk ways to give back this year are those where you volunteer in person in a place where lots of people live, whether that’s a homeless shelter or an assisted living facility. Each carries different risks in terms of acquiring the virus or passing it along. But, as Guest notes, most of these places are being quite careful in terms of their protocol around any outside people (and whether they allow them at all). Even so, it’s still good to check on their practices first. You can also ask if there are other ways your time or money could be even more valuable to them than serving in person.

Whether you usually celebrate Christmas, Festivus, New Year’s, or a birthday this time of year, it’s likely that plans for a get-together will need to be adapted — if not scuttled altogether.

For one, having people from different households together is risky. Before the pandemic, more than 85 percent of Americans planned to attend a gathering with extended family or friends for the holidays. And the average holiday meal included about 11 people.

Now, in many states, that exceeds the limit allowed for private gatherings. (The maximum is 10 or fewer — sometimes as few as five — in many places, including Connecticut, Delaware, Idaho, Illinois, Kentucky, Massachusetts, Mississippi, Nevada, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Texas, Virginia, Washington, and Washington, DC. And in some states — including California, Colorado, Illinois, Minnesota, Rhode Island, Vermont, and Washington, gatherings cannot include people from other households at all.)

Even if your state allows gatherings (decisions that are often made based on a variety of reasons including transmission rates and also political and economic interests), there are good reasons to reconsider get-togethers.

In many places, for example, “you shouldn’t do anything with people you aren’t actively living with [because] there’s so much virus spreading out in the community,” says Lisa Gralinski, an epidemiologist at the University of North Carolina Gillings School of Global Public Health. For example, an area with more than 5 percent of tests coming back positive indicates that there is undocumented community spread. Just two states as of mid-December have test positivity rates below that. Even in those places, she says, “I would encourage people to be incredibly cautious.”

As Lindan notes, it is especially important to “avoid multi-generational gatherings that include older adults and those with pre-disposing health conditions.”

Expected family time might need to be skipped this year. “This may be the year not to invite your young adult children to come home or, conversely, to visit your parents or grandparents,” Lindan writes.

The final Covid-19 caution to remind others of is that this particular virus frequently spreads just before someone develops symptoms (as well as from people who never develop symptoms at all). So feeling fine provides little to no measure of safety.

With these things in mind, here are considerations for different formats of gatherings this season.

Safest: Virtual

It’s hard to pass the dessert when you’re celebrating on Zoom. But it’s also impossible to pass Covid-19.

Althoff said that although she loves visiting her “ginormous” family in Iowa, she won’t be seeing them in person this year. Instead, she is planning to partake in video toasts and virtual game nights with family and friends.

Other ideas include having everyone make the same food or drink to enjoy during the call or playing a game of charades — or even enlisting kids to provide entertainment.

Next safest: Small, short, outdoors, distanced, and masked — hold the food and drink

For some, seeing others in person is not something they are willing to hold off on until there is widespread vaccination. So the safest way to do this is by keeping gatherings small, brief, outdoors, distanced, and continuously masked — which means no food and drink.

“Outside is where we want to be if we want to be together,” Guest says. She also recommends keeping it under a total of 10 people — with only one or (if your area permits it) two other households — and keeping everyone separated by household pod.

One caution this time of year is to be mindful of outdoor heaters. They can help extend the outdoor season, but if too many people are crowded around them, that could increase the risk of disease spread. As Guest notes, she bought two heaters for her porch: one for her household and the other, spaced far away, for one couple they see regularly, outdoors.

Moderate risk: Outdoor meal

If eating and/or drinking are non-negotiable, “Consider having tables spaced around outside and people within bubbles or family units seated together,” Lindan writes.

Guest adds that everyone should be masked when they’re not eating or drinking. People should also be mindful of alcohol consumption, she says, as it reduces inhibitions, making people less likely to stick with safety protocols and more likely to revert to pre-pandemic socializing behaviors.

Riskier: Indoors, distanced, and masked — or testing and quarantining

If you decide having people together indoors is the only option, there are several things you can do to decrease the risk of turning your event into a Covid-19 outbreak. Most of the usual advice applies: Ensure people keep their masks on at all times and remain physically distant. Keeping households in different areas “is not perfect,” says Gralinski, “but it’s better than completely intermingling and being right next to each other.”

Keep the event short, and limit the number of people attending. And increase air circulation by opening windows, turning on fans, and cranking on the central AC or heat, Althoff said.

But be forewarned that although a gathering might be set up with the best of plans — distanced seats, open windows, masks — indoor risk is higher than outdoor risk, says Adalja. “Especially if it’s a social gathering with friends or family that [people] feel comfortable around.”

If strict distancing seems like it will be challenging, one option is to have everyone test and quarantine beforehand. It’s not a perfect strategy, but it can decrease risks a bit. Here’s how:

• Test: Have everyone get a Covid-19 test before the gathering — and if anyone is traveling, they should test before they make the trip.
• Quarantine after testing and before seeing others: This means households should avoid contact with others, including not going to the grocery store, work, or school in person. “Once you test, you need to quarantine as much as possible,” Guest says, so that you don’t then contract the virus in the interim. The CDC is recommending that people traveling should quarantine for at least a week upon arrival — as well as testing again three to five days after traveling.

Now, if everyone is negative, the gathering could proceed with slightly less worry about spreading Covid-19.

Adalja recommends doing some research on testing first. Many places are facing delays returning results, and the American Clinical Laboratory Association has warned of increased stress on testing capacity and shortages of testing equipment ahead of the holidays.

Also, as Adalja points out, “Test results are not ironclad — just look at the White House,” where top-level officials are tested regularly but there have still been numerous outbreaks. And tests are only a snapshot of one point in time and can even return negative results if someone is early on in their infection.

If someone is unable to effectively quarantine upon arrival (say, a young adult who comes home to their parents’ house and cannot remain entirely separate from other household members), the next best option is to at least get everyone tested and attempt as much of a quarantine as possible while awaiting results, says Lindan.

Riskiest: Indoors with few or no precautions

A standard, sit-down indoor meal with anyone outside of your household presents a substantially increased risk of transmitting the virus. Other things that further increase the risk include a large number of people, multiple households, a lengthy gathering, physical closeness — whether that’s people packed into a kitchen cooking together or around a table — limited mask-wearing, and shouting (it was an election year, after all) or singing (hold the holiday songs).

“I would just avoid large gatherings indoors at all costs,” Lindan says. “I know it’s really hard.”

Traveling during the holidays is usually a little hellish: crowded planes, overheated trains, and gridlocked automobiles. But this year, the specter of Covid-19 makes it that much more daunting.

“Given the rise in cases throughout many parts of the US, the best advice is to avoid travel at this time,” Lindan writes. The CDC has, in fact, asked people to avoid travel.

Travel right now can also get pretty complicated pretty quickly, and not just because you need to pack extra masks and hand sanitizer.

Some 24 states and the District of Columbia have travel advisories or orders — carrying fines of up to $10,000 for violating them — for some or all people to test, quarantine, and/or submit official paperwork if they will be visiting the state for more than 24 hours (i.e., not just traveling through). So that usual week-long visit to see family in California, New York, or Chicago, for example, isn’t going to be as feasible. (Specific guidance is also available through the CDC’s travel planner.) “It might be a logistical nightmare to make sure you’re in compliance,” Adalja said in a November press briefing.

In addition to state or city guidelines for travel, many employers, schools, and day cares are issuing rules about travel, so Althoff advised reviewing those as well. “Be ready to accept abrupt changes to your travel plans.”

If you must travel this winter, there are ways to reduce your risk of catching or spreading the virus. Much of it depends on how you travel.

Safer: Self-contained car trip with your household

In this case, while you’re in the car, you’re just with your pod. But the key is to make it household members only. Expanding the roster to other people vastly increases the risk of this mode of travel, especially since, “If you’re taking a road trip with a bunch of your friends, you’re more likely to be unmasked, and you’re less likely to distance,” Adalja says.

Things to consider along the way: where you’ll eat, where you’ll sleep, and where you’ll make pit stops.

Short pit stops to use a public bathroom should be okay, says Guest — wear your mask and wash and/or sanitize your hands. Some travelers are choosing to bring their own open-air facilities on car trips these days.

“The safest is going to be being self-contained as much as possible,” Gralinski says. For sleeping, that might mean renting a dwelling that you have entirely to yourself to stay in “and bringing as many supplies as you possibly can.” The idea is to minimize contact with others, which includes limiting trips to a local grocery store. For additional food, curbside pickup and drive-through are safest.

What about hotels? A November study in Nature, based on cellphone data of 98 million people in large cities, found that this spring, hotels and motels were fairly large drivers of Covid-19 spread — just below restaurants, gyms, and cafes. (Their data, though, is from March 1 to May 2, a period during which mask mandates and other Covid-19-prevention protocols were just starting.)

Adalja says these days hotels are taking many more precautions and should be fairly safe so long as you’re careful. “It’s not the hotel itself, it’s what you do in the hotel,” he says. So wear a face covering, wash your hands, and avoid other people (for example, skip the elevator, restaurant, bar, and lobby common areas).

For her part, Gralinski said she still avoids hotels. For a fall vacation she and her husband took, they rented a camper to travel in. “We had our own bedroom, our own bathroom, got curbside takeout; we were pretty self-sufficient,” she says. They would park in the driveways of friends’ houses and see them safely from a distance outdoors. Even though it was cold, it worked. “We got to see friends, and it was amazing.”

Moderate risk: Airplane

We still don’t have definitive data on the safety of air travel right now. Many of the studies that looked at airplane risk — which did show cases of transmission — were carried out before masks were required.

Increasing the safety is the fact that masks are now mandated, and planes have very high rates of air circulation — replacing the full air of the cabin with clean air about 20 to 30 times per hour, thus hopefully removing more virus from the air. “The data does show that airline travel is fairly safe right now if people are wearing face coverings,” Adalja says.

But there are other downsides to flying, and they mostly have to do with other people. Namely, you’re in close proximity to a lot of them — even with middle seats empty, as they remain on some, but not all, airlines — and you’re largely at the mercy of their choices. Do they keep their mask on for the entire flight or have it off for long stretches?

Another thing to be mindful of in air travel is that it involves a lot more than just sitting on a plane. ”It’s the whole experience,” Althoff says, including airport shuttles, lines, lots of high-touch surfaces, and people mingling from all over the country, including areas with very high rates of transmission. If you’re going to be in an airport, she advises to “practice your statement about how you will remind a stranger to maintain a distance.”

Also, be prepared to remind people about masks. In airports and even in airplanes, “insouciant mask-wearing — by having them dangle from earlobes or positioned under the nose — still seems to happen,” Lindan says. “Don’t be afraid to ask people to put on their masks when in the airport.”

How can you lower your risk if you do decide to fly? Wear not only a good mask but also eye protection, such as sunglasses, safety glasses, goggles, or a face shield (with a mask), says Guest. Also, you can check to see if a flight will serve snacks or beverages. This used to be a perk, but these things now up the odds of virus transmission as people remove their masks to eat or drink, so if possible you might want to avoid a flight with food and drink services. “If you need to eat or drink something on a plane, do so when other people are not eating,” Lindan writes. “Keep your mask on, and only lift it up to insert food or drink into your mouth.”

Slightly riskier: Train

There has been even less research on train travel than on plane travel. A study from passenger trains in China relatively early in the pandemic — mid-December 2019 through early March 2020 — found Covid-19 spread fairly easily to nearby passengers on these trips, especially if people were in close proximity for more than three hours. Based on these findings, which were published over the summer, the authors suggested physical distancing, mask-wearing, and improved air filtration would lower the rate of spread on trains.

These are all steps Amtrak has instituted, along with enhanced cleaning and other measures. Trains also have the advantage of generally having fewer passengers per square foot than planes, and you might be more able to get away from someone who is not following the rules or appears ill. (Amtrak also offers private rooms on some trains.)

However, experts we spoke with suggested it might still be slightly riskier than air travel. This is in part because distance train trips are more likely to be longer than a typical domestic flight, increasing your exposure time to others. Train cars also don’t quite have the same rate of air replacement as an airplane cabin — Amtrak is promising clean air exchange 12 to 15 times an hour.

Like airports, there are also train stations to contend with — and there might be even less enforcement of rules, as they are typically more open to the public (rather than the majority of airport space being behind TSA checkpoint screening).

Riskiest: Long-haul bus

We also don’t have a lot of solid scientific information about the risk of Covid-19 transmission on long-haul buses. But early research suggests this mode of travel could be riskier than planes or trains, especially when people aren’t taking proper precautions. One case study showed how a single sick passenger on a bus in China infected 23 of 67 others on a drive that was less than an hour. Of note, though, is that in this superspreading event, which occurred in January 2020, none of the passengers were wearing masks, and the bus was recirculating air.

Bus companies in the US have updated safety protocols to help reduce spread of the virus. Greyhound, for example, requires face masks, has upped cleaning and sanitizing of its buses, replaces the bus air about 12 times per hour, and is “encouraging” passengers to physically distance.

Epidemiologists, however, are still warier of bus travel over other modes of transport right now. “It might be harder on a longer ride to keep your mask on, and it’s probably not as enforced as it is on an airplane,” Adalja says.

Outside, outside, and mostly outside is what experts say as a general rule for kid activities this winter. To that end, if you live in a colder climate, it’s an important year to make sure you have warm outdoor gear that fits your kids well.

That said, there are some caveats to this guidance. Not all outdoor activities are created equal, and there could be some indoor ones that, if done responsibly, could carry slightly less risk. It’s also important to remember that “the virus survives longer in the winter due to the lower temperature and lower humidity, resulting in increased risk of transmission in winter compared to summer,” Dean Blumberg, chief of pediatric infectious disease at the UC Davis Children’s Hospital, writes in an email to Vox.

Safest: Activity with only household members

The activities that carry the lowest risk of Covid-19 for kids are the same as adults: avoiding exposure to anyone outside the household, whether it’s indoors or out.

This could mean there’s more screen time this winter — including those video calls with family and friends. Or time offline doing crafts (particularly to give to people you cannot see in person) or house projects, such as cleaning out old toys and clothing to donate. Or bundling up for outdoor activities away from other households, such as exploring quiet parks, hiking, biking, or sledding.

Moderate: Quiet indoor activity with masks and distancing

What about all of those museums and movie theaters that were key — especially during long school breaks — in the Before Times? “If you’re going to a kids museum where you’re restricting the number of people, and everybody’s wearing a mask and hand-washing, and they have good air filtration, that’s probably okay,” Lindan says.

Adalja agrees. Even though a museum is indoors, “if they’re distanced and wearing masks, that becomes an obstacle that’s harder for the virus to overcome.”

That said, some experts caution that other indoor activities — even though they might seem to have similar precautions — carry higher risk, especially if local case numbers are high. “If there is increased transmission in your community, then an indoor activity like a movie theater is risky,” noted Blumberg. “There may be compromising of social distancing in common areas, such as corridors and bathrooms, and people may not be masking at all times as they sip their soda or snack.”

Riskier: Busy outdoor activity with intermittent distancing and masking

According to the experts we spoke with, a busy playground might bring higher risk of Covid-19 transmission than a quiet indoor activity in which all of the best protocols are being followed.

For example, “playgrounds — those are not ever going to be without risk,” Adalja says. Not all kids are diligent about wearing their masks, surfaces are very high-touch, and it’s essentially impossible to keep children physically distanced. “That’s a risk where you have to make an individual risk calculation,” he says.

Also, outdoor sports in which kids come into contact with one another increase the risk of transmission, as could crowded outdoor events or activities, especially those where people do not always have their masks on (such as for eating or drinking).

Riskiest: Close activities indoors with others

Families are all having to make the best decisions for themselves. And keeping kids isolated from others, especially on school breaks or when schools are remote, is not always feasible.

Adalja suggests some things families can do to lower the risk in these situations. Continue to avoid any crowded indoor spaces where you will come into contact with other households. Instead, work with another family or two (if permitted in your locality) to establish a small, closed group of children for in-person visits, ensuring everyone is comfortable with each household’s risks and behavior, and insist on hand-washing.

“The whole thing is about weighing risks and benefits,” he says. “Children playing is crucial for psychosocial development. It is a balancing act.” But high levels of community transmission can tip those scales and make in-person activities with friends too risky for many. And any time group visits can be outdoors, that will help lower the risk.

We have an opportunity, through our actions, to make a real impact on the spread of the pandemic — not just among our own circles but in the broader community. This has important implications for health justice and equity because when the virus spreads, it is more likely to hit and cause greater harm to essential workers, their families, and people of color.

“Our epidemic is only going to recede if people take the appropriate precautions,” Lindan writes to Vox. “The problem is that we just do not want to do what we have to do.”

So this winter will take some acceptance, perseverance, and perspective.

How are epidemiologists putting this difficult season into perspective for themselves? For one, by “acknowledging that this is hard and that the holidays of 2020 are going to look much different,” Guest says. “We need to be cautious and protect each other now so that when we do get together [in the future] everyone we care about is there. It’s important to keep that in mind so that these sacrifices now feel like they’re worth it.”

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Lindan agrees. “It’s really difficult over the holidays. We want to see our family and friends, and it’s a really difficult task not to after living this way for so long. But it’s a small price to pay for the long-term benefit.”

And as Althoff reminds us, “We will be telling stories from these holidays for generations to come.” It’s largely in our control to make them the right ones.

Katherine Harmon Courage is a freelance science journalist and author of Cultured and and Octopus! Find her on Twitter at @KHCourage.

“I am seeing tons of hair loss,” Mona Gohara says.

Patients come to Gohara, a dermatologist and professor at the Yale School of Medicine, for all kinds of reasons from skin cancer screenings to cosmetic procedures. But this year more than ever, they’re worried about their hair.

It’s not a coincidence. Stress — like, say, that brought on by living through a deadly pandemic — is known to cause hair loss. Ordinarily, “90 percent of the hairs on our head are in the growing cycle; 10 percent are in the shedding cycle,” Gohara explained. “But when we’re subject to some type of physiologic or emotional stress, that cycle shifts to where the shed outweighs the grow.” The result: “people notice a massive, massive shed.”

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And those stray hairs are part of a bigger trend. At this point, millions of Americans have spent nine months living through a public health nightmare and an unprecedented economic crisis at the same time. They have also had to cope with all this while avoiding gatherings, limiting physical contact, and, when possible, staying inside their homes. Put together, the isolation and anxiety of life in 2020 have brought with them numerous side effects. For one, they might be doing weird things to our bodies.

If you’ve noticed your menstrual cycle is more irregular this year, for example, you’re not alone: More patients are reporting irregular periods since the pandemic began, Mary Jane Minkin, an OB-GYN who teaches at the Yale School of Medicine, told Vox. The likely culprit, as with hair loss, is the anxiety of living in such a difficult and uncertain time. “When stressors come into play,” Minkin said, “we end up with screwy periods.”

If you’ve spotted more gray hairs on Zoom calls, there may be a pandemic-related explanation for that too. And according to some, life in lockdown may even be changing people’s body odor.

Those are just some of the smaller effects. Some experts are also concerned because isolation has documented effects on health, increasing the risk of cardiovascular disease and even death. “Humans are considered a social species,” Julianne Holt-Lunstad, a professor of psychology and neuroscience at Brigham Young University who studies the impact of social relationships on health, told Vox. “When we lack proximity to others, and particularly trusted others, this creates a heightened state of alert or stress” — which, over time, can have harmful effects on our bodies.

To be clear, none of this is an argument for getting rid of pandemic-related restrictions — after all, the effects of Covid-19 on the body can be far more severe than the effects of isolation.

But the rise of pandemic periods, weird smells, and other bodily indignities are a reminder that Americans are going through something right now that most of us have never experienced before. And that takes its toll in a lot of ways — some of them stranger than others.

2020 is messing with people’s periods

Let’s talk about periods first. Trend pieces about menstrual changes — either irregularity or worsened symptoms like cramps — began popping up in the spring. “A couple of weeks into the stay-at-home order in Washington State, where I live, I woke up in the middle of the night with the worst cramps I’ve ever had,” Colleen Stinchcombe wrote at Self in May.

And while it’s likely too soon for any published research on the impact of the pandemic on menstruation, Minkin isn’t the only one to see increased reports of irregularity among her patients. “It’s common for us to see patients with changes in their menstrual cycle, but anecdotally, it seems like it’s been happening more over the last six months,” Beth Schwartz, an OB-GYN at Thomas Jefferson University Hospital in Philadelphia, told the Washington Post in August.

These changes aren’t necessarily surprising, Minkin told Vox. “Most people think that the ovaries and the uterus regulate periods,” she said. But actually, “the boss is sitting in our brain.”

Specifically, it’s the hypothalamus and the pituitary gland that control the ovaries, regulating their hormone production, which in turn regulates the menstrual cycle. “It’s our nice, regular hormonal activity from the hypothalamus and the pituitary which stimulate the ovaries to do their thing appropriately and get us nice, regular periods,” Minkin said.

And when we’re under stress, that can disrupt the functioning of the hypothalamus and pituitary, leading to irregularity. Researchers have noticed a similar effect among young people who go away to college — and often experience irregular periods as they adjust to a new environment and a new set of worries and pressures.

The good news, Minkin said, is having an irregular period generally isn’t dangerous. When her patients report irregularity, she’ll typically test their thyroid function and levels of certain hormones to rule out conditions like polycystic ovary syndrome, but as long as everything’s normal, no treatment is needed. If the irregularity is especially bothersome, people can take hormonal contraception to regulate their periods, Minkin said. “Once we get through things and people’s lives get back toward normal, most folks are probably going to regulate themselves just fine.”

The pandemic could also be changing people’s body odor

But irregular periods aren’t the only strange symptom people are reporting after months of reduced contact with others. Another is body odor — some say they’ve started to smell worse, or just different, since the pandemic began.

“I am a man who prides himself on smelling fresh and fancy free at all times,” Joseph Lamour wrote at Mic in July. But during the pandemic summer, he became “so limburger-esque that my own odor woke me up in the middle of the night.”

As with periods, there’s not yet published research on changes in body odor during the pandemic. But anecdotal reports of the issue have gotten back to Julie Horvath, head of the Genomics and Microbiology Research Lab at the North Carolina Museum of Natural Sciences and a professor at North Carolina Central University. An expert in primate genetics who expanded into studying microbes and odor (“I never thought I would be the armpit researcher,” she says), Horvath explains that a big factor in the way we smell is our skin microbiome, or the mix of bacteria, fungi, and viruses that live on our skin.

“When you’re in your home, you’re now coming into contact more with maybe your pets and your family, who you didn’t see as many hours a day,” she told Vox. This means we’re exchanging microbes with a different group of people (and animals) than usual, which could affect our smell. Spending more time indoors can also affect the microbiome, as can wearing different types of clothes — synthetic fabrics can host different kinds of microbes than cotton, for example. And a lot of people have changed their style (if you can call it that anymore) during the pandemic. “When I talk to people, maybe they’re wearing a nice shirt, but now they have jeans or sweatpants on,” Horvath said.

Stress can also affect the microbiome, Horvath said. A specific set of glands, the apocrine glands, release sweat when you’re nervous. That sweat contains different compounds from sweat that comes from the ecrine glands, which get to work when you’re too hot. And if your apocrine glands — found in the armpit and a few other places on the body — are highly active, then they are providing a “different food source to some of those microbes there, and maybe you’re promoting the growth of some that smell different than what they would’ve before,” Horvath said.

But the microbiome doesn’t just affect the way we smell. Beneficial bacteria on our skin create a “protective barrier,” Horvath explained. “If you have these good, beneficial microorganisms that are on your skin, eating oil or sweat and living there happily, they’re taking up residence,” she said. Then, if something lands on your skin that can make you sick — a staph bacterium, for example — “then it can’t take hold very quickly, because your beneficial organisms are going to outcompete it for resources.”

Washing your hands with soap and water just washes away the lop layer of microbes, potentially allowing some of the good ones to stick around. But hand sanitizer kills the microorganisms on your skin, the good along with the bad, Horvath said. Thus, using too much hand sanitizer during the pandemic could leave us more vulnerable to staph, acne, or other infections down the road.

Airborne spread of the coronavirus in close contact is the main danger in the pandemic, but we still need to wash our hands, too. Horvath recommends using soap and water when possible to help maintain a healthy microbiome. Beyond that, habits like eating a healthy diet could be good for your microbial balance, though they may or may not help you smell better. Spending time outside if you can is also a good idea, Horvath said. “Certain organisms that are outside in the soil are actually beneficial for your overall body.”

Stress is affecting our hair and skin

Beyond weird smells and irregular periods, the isolation of this year has brought with it other physical changes for many. In addition to hair loss, a proliferation of gray hair is a common complaint — one that can also likely be pinned on stress, as Deanna Pai reports at Medium. While the mechanism by which stress causes graying isn’t fully understood, one recent study in mice found that stress led to the death of stem cells that produce melanocytes, the cells in hair follicles that produce pigment.

Gray hair isn’t reversible (except with dye), Pai points out, but managing stress — as much as anyone can during a pandemic — can help slow the process.

Stress could also be making our skin look worse, Gohara, the dermatologist, said. It causes an increase in the hormone cortisol, which “wreaks cosmetic havoc on your skin” and can lead to anything from dryness to puffy eyes, she explained. “Everything just looks worse with a surge in cortisol.”

An increase in stress can also lead to more acne, something also exacerbated by the friction of wearing a mask (hence the 2020 neologism “maskne,” or breakouts on the lower part of the face linked to mask-wearing). Luckily, unlike gray hair, much of this is reversible — you can combat maskne by washing masks in the same gentle cleanser you use for your face, Gohara said, and using a product with salicylic acid or benzoyl peroxide. For hair loss, meanwhile, she sometimes prescribes supplements, but also reassures patients that when it comes to shedding, “eventually the cycle is going to re-equilibrate itself and your hair will be back on track.”

Loneliness could cause more severe physical effects

While things like hair loss are typically harmless, if annoying, the way we live in 2020 could be causing more serious issues too.

Researchers have long known that isolation — the condition of having little or no contact with other people — and loneliness — the subjective feeling of being alone, regardless of how much contact with people one has — can be harmful, Holt-Lunstad, the psychologist, said. For example, in one 2015 analysis, she and her coauthors found that isolation was associated with a 29 percent increased likelihood of mortality, while loneliness was associated with a 26 percent increase.

There are a couple of ways that loneliness can potentially hurt our health. For one, friends and loved ones can influence us to take better care of ourselves — “having someone who encourages you to get to bed,” or eat fruits and vegetables, or quit smoking, is good for our health, Holt-Lunstad said.

But many studies actually control for lifestyle factors like smoking and diet, and still find that loneliness and isolation have a negative effect. One reason, some researchers believe, is that “our brains have adapted to expect proximity to others, and particularly trusted others,” Holt-Lunstad said. When they aren’t around, the brain signals other parts of the body to go into a heightened state of alert. That can lead to changes in heart rate and blood pressure that could increase our risk of cardiovascular disease. But it could also lead to systemic inflammation in the body, which in turn has been linked to a host of mental and physical problems, Holt-Lunstad said, from Alzheimer’s disease to, troublingly, increased susceptibility to viruses.

These impacts are especially concerning because some early research has found high rates of loneliness and isolation during the pandemic. In an August survey, for example, two-thirds of adults reported social isolation, and more than 7 in 10 said the pandemic had made it harder to connect with friends.

Luckily, there are ways to reduce isolation, even during a time of social distancing. In a study this summer sponsored by the neighborhood-focused social network Nextdoor, Holt-Lunstad and her colleagues found that performing small acts of kindness for neighbors, such as bringing them groceries or checking in on them over the phone, was associated with a significant drop in loneliness — 1 in 10 participants felt lonely at the beginning of the study, while just 1 in 20 felt the same at the end.

But it can’t all be on individuals to fix their isolation during this very lonely time. Instead, Holt-Lunstad has advocated for policymakers to pay more attention to people’s social needs throughout the pandemic and recovery, including increased funding to help students and older people, who may be especially vulnerable to loneliness right now. And while funding for anything remains a fraught subject in Congress, Holt-Lunstad writes at Health Affairs that decisions “should be based on scientific evidence of benefits and drawbacks to our well-being, not solely on economic costs and convenience.”

Some of the smaller effects of pandemic living may dissipate naturally when this time in our lives is over. When it comes to issues like irregular periods, for example, the biggest takeaway is “don’t panic,” Minkin says. “We will get back to normal.”

But for other, larger problems, like isolation and its serious effects on the body, the pandemic could be a wake-up call. “My hope is now that we have all experienced, in some degree or another, this feeling of isolation and loneliness, that there may be greater awareness and less stigma,” Holt-Lunstad said.

There are around 1,000 mountain gorillas left in the wild, and about 460 of them live in Bwindi Impenetrable National Park in Uganda. In the park’s very dense, high-altitude forest (hence the name “impenetrable”), veterinarian Gladys Kalema-Zikusoka is working to keep them alive through the Covid-19 pandemic.

No gorilla has come down with Covid-19, but Kalema-Zikusoka fears what might happen if one did. Gorillas live in tight-knit groups, so a respiratory infection could easily spread among them. Infected gorillas could get sick and die, or possibly suffer long-term consequences from the disease.

Kalema-Zikusoka founded the nonprofit Conservation Through Public Health, where she works with the local community, and the park, to keep the gorillas healthy, and create a tourism economy that’s sustainable for both the gorillas and the people who live near them.

“This virus is a threat to the gorillas,” she said on a recent Zoom call from Entebbe, Uganda, where she lives. “Before, we never used to have to wear a mask when you visit the gorillas, but now you have to.” Also new: Visitors must stay 32 feet (10 meters) away from the animals, up from 23 feet (7 meters) before the pandemic. Visitors now also get their temperatures checked upon arrival.

Kalema-Zikusoka told me about other precautions in place to protect the animals — what she’d do if one got sick, and how to quarantine these 300-plus-pound animals should they be exposed. She also described the intense and competing challenges conservation groups like hers face to keep the animals safe these days: When tourism dropped due to the pandemic, poaching increased. But when tourism resumed this fall, the threat of spreading disease to the gorillas increased.

“Tourism is a good thing, but it has to be done in a responsible way so that it doesn’t end up wiping out the very species,” she says. “It’s a very delicate balance.”

This conversation has been edited for length and clarity.

A gorilla can’t social distance

Brian Resnick

The gorillas in Bwindi — do they often come close to humans?

Gladys Kalema-Zikusoka

Yes. There’s about 459 gorillas in the park, and about 200 are habituated for tourism and research.

Brian Resnick

What does habituated mean? They will let people approach them?

Gladys Kalema-Zikusoka

Habituated generally means … you can get as close as 5, 7 meters to them. It means they won’t run away when they see a human being.

Brian Resnick

Do the gorillas come in close enough contact with people that you have to worry about respiratory diseases like Covid-19?

Gladys Kalema-Zikusoka

Yes, we definitely do worry about it.

There have always been strict guidelines [for humans to stay 23 feet away from them]. But some of the gorillas, which are so used to people, can get even closer. So actually, that’s why we thought that during the pandemic we really needed to reduce their proximity to people.

Before, we never used to have to wear a mask when you visit the gorillas, but now you have to wear a mask when you visit the gorillas.

And I think it’s going to continue to be emphasized even after the pandemic, whenever it ends. I think we’re going to continue with all these regulations.

Brian Resnick

I imagine you can’t put a mask on a gorilla or have them protect themselves.

Gladys Kalema-Zikusoka

Absolutely not. You can’t. And the problem with them is that they don’t know how to social distance. They are in a harem with a lead silverback and many females and babies and a few other adult males. And they’re always grooming each other, they’re always moving together as a group. So if one of them gets Covid-19, it’s very easy for the rest of them to get it because they don’t know how to social distance.

So the best we can do is teach people to social distance from them. And also at the same time, hand hygiene has really been reinforced, and use of hand sanitizer.

Many human diseases can infect gorillas
Brian Resnick

Is this a constant problem: diseases passing between people and these gorillas?

Gladys Kalema-Zikusoka

Yes. Disease becomes an issue once you habituate [gorillas] for tourism and research, because you get close enough to make them sick. Either when gorillas are visited inside the park [or] when gorillas go out of the park to people’s gardens, they can pick up diseases.

In 1996, actually, one of the first outbreaks that I had to handle was when the gorillas walked outside the park to eat people’s banana plants and they found dirty clothing and scarecrows and got scabies. It caused death in an infant.

So, yeah, we’re worried about those kinds of diseases. Influenza viruses are also a very big worry for us, other diseases that cause the common cold, and other viral respiratory diseases.

Brian Resnick

Is it generally the case that any virus that can infect a human can infect a gorilla?

Gladys Kalema-Zikusoka

Yes, all of them, because we share 98.4 percent genetic material and can easily make each other sick.

Let’s say a gorilla gets Covid-19. What happens next?
Brian Resnick

Do you worry if one gorilla gets sick, it could kill them? Do we know how Covid-19 would present itself in a gorilla?

Gladys Kalema-Zikusoka

The same way that it has varied effects in people — some people don’t show symptoms, some people it’s mild symptoms, others it’s very severe. We feel that the same thing could happen with the gorillas. We’ve known that when gorillas get diseases like scabies, it’s very severe in the gorillas, more severe than it would be in a human being.

People, gorillas, chimps, and other old-world primates like some of the monkeys and baboons, we share the same protein receptor that the SARS-CoV-2 virus attaches to. Which probably means that the way that it can make us sick is the way that it can make them sick.

Brian Resnick

Are you prepared to treat the gorillas? Is there a plan?

Gladys Kalema-Zikusoka

We definitely would. If the gorillas were to get it, there’s a contingency plan that has been developed with other conservation partners. It’s been led by the International Gorilla Conservation Programme.

If Covid-19 gets into one gorilla, that gorilla group has to be quarantined — it’s not allowed to mix with any other gorilla group. Once they start to mix, then we have a complete disaster on our hands, complete disaster. So the first thing is to cordon off that group.

Brian Resnick

How do you quarantine gorillas?

Gladys Kalema-Zikusoka

So the park rangers have to be with them 24 hours basically to make sure they don’t mix with other groups. At least they have to be with them from the beginning of the day to the end of the day because at night they don’t move around. They just stay in their nests.

Brian Resnick

If one gets sick, would you use some of the therapies that have been developed for humans, or …

Gladys Kalema-Zikusoka

They’ll be treated with the same things that are being used to treat people.

But it’s much more difficult to treat a wild animal than it is to treat a human being. You can’t provide the same level of intensive treatment to a wild gorilla as you would a human being who you can put in a hospital ward, put on a ventilator for days and days. Because there’s just over 1,000 mountain gorillas remaining in the world … we wouldn’t want Covid-19 to be the reason why they’re being wiped out.

Brian Resnick

When you said you can’t put them on a ventilator for days: Why not?

Gladys Kalema-Zikusoka

Because the gorillas are living in the wild and as much as possible we don’t want to disrupt them, bring them into a captive setting, put them though all of this and then release them back to the wild, because they could even return with more diseases that can affect the others. So it’s a very delicate balance. It’s very, very rare that we take in a gorilla, treat it in a hospital setting, and then release them out. As much as possible, we do all the treatments in the field.

Brian Resnick

How do you treat them in the field?

Gladys Kalema-Zikusoka

You have to dart them with the drug because the mountain gorillas are not … they only eat the food that they’re supposed to eat in the forest. They’re not fed. We don’t feed the mountain gorillas. They’re completely free-ranging, they’re completely wild.

Why resuming gorilla tourism is worth the risk
Brian Resnick

Is resuming tourism worth the risk of potentially bringing Covid-19 into the park?

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Gladys Kalema-Zikusoka

Yes. We think that is worth the risk, for sure. The local communities of Bwindi have become so reliant on gorilla tourism to survive — which is good and bad. It’s good in that they feel that the gorillas are their survival. The future of the gorillas is tied in with their future. So they really protect [them].

When tourism went down and there was no tourists coming in, everybody was struggling. The local economy suffered and poaching went up. In other parts of Africa, people actually eat gorillas as a delicacy.

So if you don’t have tourism, it’s very hard to protect the gorillas because grant money is not necessarily enough, especially now. The only gorilla subspecies whose population is increasing is the one where tourism is happening.

Do the gorillas notice anything unusual going on?
Brian Resnick

Do you think the gorillas know something different is happening? Have they noticed people wearing masks or noticed the greater distance between them and people?

Gladys Kalema-Zikusoka

I guess they were used to being visited often by people every day. Different people come and spend an hour with them and go away. And so one thing I think they’re finding a bit strange is that they can’t get close to people like they used to. So we’re kind of de-habituating them.

But one thing that we’ve been happy about is that more gorillas are being born. More gorillas are being born this year than other years. And we don’t know whether it’s to do with a lack of tourism or just coincidental. Research has to be done on that.

Could a gorilla be vaccinated?
Brian Resnick

As we see the vaccines for humans get approved by various governments, could you potentially vaccinate these gorillas, or is that not something that would happen?

Gladys Kalema-Zikusoka

Vaccination of gorillas cannot be ruled out, but to vaccinate gorillas we have to make sure that it’s really, really, really safe for humans. I think it’s going to take a while to see how humans react to the vaccine. And we need to see how much they are actually protected as a result of the vaccine.

Yeah, we need more data to know whether it’s safe on the gorillas.

Brian Resnick

Would you say this pandemic is an existential threat to gorillas?

Gladys Kalema-Zikusoka

This virus is a threat to the gorillas. It definitely is a threat to gorillas, chimpanzees, orangutans — the three non-human great apes. Just this morning I was having a chat with people working with orangutans and we were talking about some of the things that I’m talking about with you: how do we protect these great apes during a pandemic like Covid-19, the people looking after them, the people who come to visit them.

It’s also a big threat to other wildlife. It came from wildlife, it can easily go back to wildlife, and that’s something that we’re all very concerned about.

The room didn’t spin like they say it does. My life didn’t flash before my eyes. I had no difficulty understanding the verdict: It was incurable.

They could offer no prognosis. They had some general ideas about how they might treat me; it was considered “manageable” in its normal form, but in my case, there was no telling what would or wouldn’t work. They told me that if they could find an effective treatment, I should expect to be on it “for life.”

The week of the 2016 election, my foot had gone numb — paralyzed, actually. I’d first arrived at the neurologist’s office unable to wiggle my toes, and now I was leaving with a singularly rare cancer diagnosis, a blood cancer that had jumped its track and hadn’t shown up as it was supposed to. Even though my blood, lymph, and bone marrow were all clear, a blood cancer had somehow emerged in my cerebrospinal fluid and lodged itself along my spinal cord, forming hundreds of microlesions. The oncologist (who specialized in rare lymphomas) responded, “Get out!” when the neurologist shared the results of my spinal tap. They were looking forward to meeting me. There isn’t much that’s good about being a unique cancer case, but at least the specialists are excited to see you.

It wasn’t until the drive home, as my husband, David, and I tried to figure out how and what to tell the children, that the terror overcame me. How could I prepare my middle schoolers for what we might face? There was no reassurance I could offer. Any expectation that the next day would be better or even vaguely resemble the days before had disappeared entirely.

We told them the naked truth. The doctors couldn’t say what might happen next because they had never seen this before. The outcome was uncertain, so hope and fear were both reasonable. Anything could happen: anything bad, anything good, or anything in between.

That night, unable to sleep, a strange, intrusive thought scrolled through my head: “The future has been amputated.” There would be weeks of hospitalizations, infusions, nausea, and fatigue before I could summon the presence of mind to interrogate that thought. On my first wobbly walk around the park near my home, I spotted a cute two-bedroom house on a side street.

“Maybe,” I wondered, “we could downsize to a cute little house like that once the kids are off to college … ?”

I stopped myself short. That would be seven years away. My survival relied on the efficacy of a chemotherapy, fresh out of trials, designed to treat cancers of the blood. My medical team wasn’t sure if it would work at all.

I might not live to see my eldest graduate. Who knew if I would survive even the year?

I sat down on a bench, dizzy. People hurried past me, some rushing home from work, some squeezing in a run before dinner, others racing toward schools to fetch their kids. Everywhere they were headed, it seemed, was a lot more important than where they happened to be right now.

For decades, my life had been as organized as theirs. I was always ambitious, my calendar overflowing: a private psychotherapy practice, parenting, writing, martial arts, caring for elderly family members, volunteering as a community organizer. Friends and colleagues marveled at how I got so much done. Now it was clear I had been running on overdrive for years, racing toward some magical day in the future when I’d have accomplished enough and might allow myself to rest.

It was as if cancer had flung me into a parallel universe where I would never again spend, waste, or experience time as others did, or as I had before. Sitting on that bench watching the early winter sunset, I realized that I never had the ability to shape my future. I’d been chasing an illusion. The causal chain I’d been constructing was wiped away in a single stroke. The only real time was now: the sun setting, the park bench, the crisp, cold air filling my lungs.

I thought of the many future-focused conversations I had daily: psychotherapy clients dreaming of one day finding the right partner, or the right job, or hoping to eventually leave the wrong ones. Neighbors planning their vacations. Other parents fantasizing about their children’s college and career trajectories. Every weekday conversation filled with yearning for the next weekend. The systems that surround us intensify our future fantasies, like an unattainable carrot at the end of a proverbial stick, driving us all to press ourselves harder and faster toward some end that never quite comes in the way we imagine.

Ambition has a necessary function: It may offer hope in times of desolation, or motivate us out of states of suffering and depletion. Yet aspirations have their shadows. Striving can imply that the present moment is inadequate. It seems as though ambition has been elevated into a distorted religion. But our relentless cultural habit of structured goal-setting and futurizing are nonsensical once we gaze into the abyss. Existentialist philosophy and therapies, Buddhist notions of impermanence, and the Christian practice of memento mori (remember your death) all assert that the process of accepting the inescapability of death can help us to live a more meaningful life.

The amputation of my felt-sense of unfolding time was violent and sudden. It began with a visceral realization of how I spent my now-limited time. If lost time could not be recouped, did I really want to spend much (or any) of it at a professional association meeting, or organizing fundraisers, or trapped on long phone conversations with a needy acquaintance?

Over the next three years of treatment, I extricated myself from activities and relationships that either didn’t serve or took precious time away from core priorities: being present for my family, supporting my clients, giving what I could to my community, and — always — respecting my limitations. I no longer worried about reaching arbitrary goals, building “momentum,” or even growing a business. I sat with the person in front of me for the time they were in front of me. Each moment, pleasant or unpleasant, had become an end in itself, rather than a means to an end.

My small family downsized our home and our lives, and we adjusted expectations in order to reduce financial pressures. I abandoned long-term writing projects and wrote only when I felt I had something to say. I gave up the belts and stages of martial arts practice and instead took long walks. My book list shifted to shorter collected readings that would offer up new ideas along the way, free of the demand to reach every last page. Eventually, I had no more attachments or plans beyond a general weekly schedule, no more fantasies of a great come-and-get-it day. The tasks were simple: to fully live the one day I’d been given; to be who I meant to be in each moment, to the best of my abilities.

At first, this shift in my orientation to time was alienating and lonely as everyone around me continued to think ahead. Later, I realized I didn’t miss that. A large bite had been taken out of my sense of linear, causal, chronological time — the Greek notion of chronos. But what I’d found in its place was kairos: this particular, critical moment. The appointed time. The time of action.

My unpredictable cancer unpredictably became undetectable after 30 hard months of treatment. I have been off chemotherapy for a year and a half. It is possible that I have 10, even 20, years of time and health left. Or maybe this unpredictable cancer will reemerge when I least expect it. Maybe next week I’ll learn that I have a lesion on my optic nerve. No one knows, because there is no knowing.

A smaller, lighter sense of future has crept back into my life, terrifying in its own way. I can now permit myself to fantasize a year ahead, or sometimes two. I’ve noticed gentle new goals sneaking in: to spend a little more time teaching and a little less time counseling. I’ve applied to a seminary program, aware that I may not make it to enrollment or live to finish the program. But I do know this will be a pleasurable, meaningful project — one that I can make practical use of each new day. I can picture our home emptier as the kids move into the world. But my sense of meaning and identity aren’t dependent on any of these imaginings. I’ll be the best mother, partner, therapist, and friend that I can be, today. I will take long hikes and watch the hawks circle overhead. I will rest when I am tired. And when my time comes, it will have been enough.

Martha M. Crawford is a psychotherapist, coach and supervisor in private practice since 1998 in NYC and now in Santa Fe and the author of the blog What a Shrink Thinks.

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As of mid-December, hospitals on average had just 22 percent of their intensive care unit (ICU) beds available across the country, and many were completely full. As the Covid-19 surge continues to intensify, lack of ICU beds can have dire consequences, including not being able to properly care for the sickest patients, potentially rationing lifesaving care.

But even these bed capacity numbers don’t tell the whole story.

Adding extra critical-care beds in other departments or buildings takes precious time, resources, and space. But adding trained staff is much more difficult, especially deep into a pandemic.

When trained staff are in short supply, it’s even harder for hospitals to best meet the needs of critical-care patients. These patients include people very sick with Covid-19, but also many who need to be in the ICU for other reasons, such as those who have had a heart attack or stroke, are recovering from major surgery, or are sick with the flu, among others.

Only about a dozen states had more than 30 percent ICU capacity left on December 15, and coronavirus case numbers have only accelerated since then. And the reality on the ground in many areas is much worse, as reporting by the New York Times has shown.

From the Times’s data, gathered from the US Department of Health and Human Services, of about 100 hospitals in the Los Angeles area, more than 65 reported ICU occupancy at 90 percent or higher. Cedars-Sinai Medical Center had an occupancy at 112 percent of its capacity.

In Dallas, the fourth-largest metropolitan area in the country, of the 47 hospitals with more than 20 Covid-19 patients, 80 percent of them had zero or just one ICU bed left. The most open beds any hospital had was five.

In the Minneapolis-St. Paul area, half of the hospitals with more than 20 Covid-19 patients were at more than 95 percent ICU bed capacity.

In Oklahoma, which has the third-highest per capita new case rate in the country, of the hospitals with more than 20 Covid-19 cases, the majority were at more than 90 percent ICU bed occupancy.

Nancy Nagle, a pulmonologist and critical-care physician at Integris health system in Oklahoma City, which reported full ICU occupancy in the most recent data to the HHS, says they have turned regular patient rooms into ICU rooms to try to handle the rush of severely ill people. Even so, she said, “occasionally Covid-19 patients must remain in the emergency department for several hours waiting for a bed to become available.”

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And there is little sign of relief in many places around the country, with an average of more than 200,000 new Covid-19 cases reported daily since early December.

“Patients keep coming, and we have to take care of them regardless of our staffing levels,” Gisella Thomas, a respiratory therapist at Desert Regional Medical Center in Palm Springs, California, wrote to Vox in an email. “I worry that there is only so long staff can hold up before breaking, which ultimately, in itself, could limit capacity” further.

Covid-19 can be a long, unpredictable, complicated illness

The sickest Covid-19 patients can linger in the ICU for weeks — or longer. And although we have learned a lot since the spring about how to better treat severely ill Covid-19 patients, the disease itself is still challenging to address, and we don’t have a cure for it. Which means the 2 percent of people who get Covid-19 and end up needing critical care are often in ICUs until either they are able to recover — which often includes invasive intubation treatment — or die.

One of the reasons ICUs have been filling up is that once a patient with Covid-19 gets that sick, they are not likely to stabilize very quickly. A September study found that an average ICU stay for a Covid-19 patient was about a week — almost double the typical stay of 3.8 days for other ICU patients. Other anecdotal reports show that many patients can be in the ICU for weeks or even months. And pinning down this number is crucial for projecting how many beds might be available in the future if cases continue to climb.

As an October study pointed out, if an average length of stay in the ICU is 10 days, that means that every day there is only a 10 percent chance of a new bed opening up. So when admissions exceed that rate, ICUs are likely to get overwhelmed.

This is something those working with critically ill coronavirus patients have to contend with every day. “Covid-19 patients unfortunately stay in the ICU for a long time,” Nagle said. “The course of the disease is very slow, and this contributes to the shortage of available beds.”

And while Covid patients are there, meeting their needs can be extremely labor-intensive. “Covid-19 patients can be incredibly ill, with multiple machines to watch and adjust, multiple medications to give, and lab results to draw and results to watch,” Nagle said. And although we now have a better understanding of possible treatments for seriously ill patients, “patients still respond in varying ways, and their progress and possible outcome is always unpredictable.” This is another reason hospitals don’t always have a good projection for how many ICU beds they might have in the coming weeks or days.

Caring for Covid-19 patients also requires many more steps and precautions than when ICU staff work with other patients, further jamming units. All staff entering an ICU Covid-19 room must don full gowns and PPE each time, which is resource-intensive. “This also creates real difficulties if someone crashes because it slows down our response,” Thomas said. “The need to more thoroughly clean all equipment also creates delays and makes normal staffing levels inadequate for the pandemic.”

In the meantime, doctors, nurses, and other health care workers are struggling to provide the best care they can while being asked to handle more and more patients. “Critically ill patients are very complex,” said Orlando Garner, a pulmonary critical-care physician at Baylor College of Medicine. “There are a lot of moving parts at the same time that require the same amount of priority.” But, he said, “when you are stretched out beyond capacity, you can’t deliver the same quality care unless you create more skilled health care workers, and as we have found out, these are a scarce resource.”

Staff are even scarcer than ICU beds

Although hospitals can often somewhat expand the number of beds and amount of supplies, staff are in much shorter supply. “The most precious resource in any hospital are the human beings who are knowledgable and capable of caring for patients,” Sarah Delgado, an acute care nurse practitioner and clinical practice specialist with the American Association of Critical-Care Nurses, wrote to Vox in an email. “It is the limiting factor.” Without enough of these people to care for all of those who are very sick, “patient outcomes are likely to suffer,” she said.

And it is not just ICU physicians and nurses who are in short supply. “Critical care is more of a team sport,” Garner said. “This means physician-delivered care and interventions, but also careful medication selection dosage with pharmacists, skilled nursing care, respiratory therapists, midlevel providers, nutritionists, early mobilization with physical therapists.” To that list, Nagle also adds all of the other hospital staff needed to perform other essential tasks in ICUs, including bathing patients, changing linens, and other functions.

To accommodate surges of very ill Covid-19 patients, many hospitals have had to rework their staffing structure. At Christiana Hospital in Delaware, critical-care nurse Lauren Esposito and her colleagues typically work with critical cardiac patients. But this year, her unit has served as overflow for critical Covid-19 cases. “At first it was a little uneasy,” she wrote for the American Association of Critical-Care Nurses.

Their hospital implemented a tiered staffing strategy in which cardiac nurses would work under trained ICU nurses. “During the shift, if a patient was crashing, we were able to flex and have the ICU nurse go to that patient to provide care,” she wrote. They were also able to provide quick training to nursing staff, for example, on working with intubated patients. Still, the overflow duties were straining, and they weren’t made easier given the intensive isolation these patients are in to stop the spread of infection. “I remember the first time I walked into a patient’s room, it really hits you that you are the primary caregiver and no one else can come in.”

Also, staff now often have to attend to more patients at a time. In California, where last week an average of more than 44,600 people each day tested positive for the coronavirus, Gov. Gavin Newsom dropped the state’s nurse-to-patient ratio from 1:2 to 1:3 in an effort to meet the surging numbers of Covid-19 hospitalizations.

In Oklahoma, Nagle notes that although the ICU nurses she works with usually take care of one to two patients during a shift, “with the shortage of critical-care nurses, each nurse may have three, and under very extreme conditions, even four patients to care for.”

This increase in patients each nurse is seeing — especially in a complex illness like Covid-19 — is a major adjustment. “Nurses are at the patient’s side every hour of every day, administering lifesaving medications, collaborating with other health care team members, translating information to families, and providing end-of-life presence when those families cannot visit due to strict isolation requirements,” Delgado said. “This work cannot be done when the number of patients exceeds staffing capacity.”

And staff themselves often fall ill with the virus. According to a November report, as many as a quarter of Covid-19 infections in some states are among health care workers.

“It could have been me”

Garner, whose whole family got sick with Covid-19 earlier this year, including his 4-month-old daughter, says getting the illness himself gave him a new perspective on the patients now flooding into local Texas ICUs.

“It could have been me, my wife, or one of my kids on that ICU bed,” he said. “It’s easy to rationalize the amount of sick patients by thinking, ‘oh, well they weren’t distancing,’ or, ‘they weren’t wearing masks,’ but the fact is that nobody deserves to catch this virus and get sick from it, not even the people who doubt it. As the spike continues to grow, compassion is the only thing that can keep us from becoming jaded and burned out.”

The flip side of that is remembering compassion for the health care workers caring for these patients, especially as the holidays approach. Not only will many of these workers continue long shifts through the holidays, they will do so knowing that many people are disregarding public health warnings to avoid gatherings.

“We need the public to do its part,” Delgado said. “Stop nonessential travel, adhere strictly to mask-wearing and social distancing guidelines, and limit gatherings with those outside your household,” Delgado said.

Katherine Harmon Courage is a freelance science journalist and author of Cultured and and Octopus! Find her on Twitter at @KHCourage.

It’s the year 2020, and scientists are still discovering new species of life on Earth. No one knows exactly how many types of life are yet undescribed in the scientific literature; estimates range from around 86 percent to as high as 99.99 percent. And even though we’re living through an age of great biodiversity loss, the scope and breadth of life on planet Earth is still revealing itself to scientists around the world.

This year, researchers at the California Academy of Sciences have described 213 new species in scientific journals: “101 ants, 22 crickets, 15 fishes, 11 geckos, 11 sea slugs, 11 flowering plants, eight beetles, eight fossil echinoderms, seven spiders, five snakes, two skinks, two aphids, two eels, one moss, one frog, one fossil amphibian, one seahorse, one fossil scallop, one sea biscuit [a.k.a. sand dollar], one fossil crinoid (or sea lily), and one coral,” the academy lists in a press release.

These species weren’t necessarily first spotted this year. Instead, they were officially described in the scientific literature as unique species, some after decades of research.

Terry Gosliner, a curator of invertebrate zoology at the California Academy of Sciences, added one species of sea slug he first saw on a dive in the Philippines 23 years ago. As a sea slug expert, he knows immediately when he’s spotted one he hasn’t seen before. “It’s like if you walk into a room, and you know, almost immediately, if there’s a person in there who you haven’t met before,” he says.

But on that first encounter decades ago, Gosliner didn’t collect a specimen that would allow for DNA analysis, which is crucial for understanding if a presumed new species is actually new to science. Plus, this particular sea slug was nocturnal. “You just happen to have a chance encounter with it on a night dive,” he says. He found a second specimen in 2010. By then, “it was like encountering an old friend that you hadn’t seen forever,” he says.

It’s taken even more time to determine that this creature — now named Hoplodoris rosans — is a truly new entry in the scientific books of life. “The easiest part is finding them,” Gosliner says of discovering new species. The hard part is the scientific work that comes next.

After finding a species, “it’s a very lengthy process after that,” he says to describe a new species. Scientists need to study the DNA, the internal anatomy and external anatomy, “so that you can make comparisons about how that species differs from all the other species that are known.” Then those discoveries have to be written up and submitted to a peer-reviewed journal.

Gosliner and his colleagues also got to name the new species. They call it Hoplodoris rosans for a few reasons. Hoplodoris is the genus of the sea slug. But its species name, rosans, is named after the rose. They chose that because, for one, there are reddish-pink spots on the underside of the body. And two: “It has in its reproductive system this very large spine that holds mates when mating that was shaped like a rose thorn,” Gosliner says.

Along with Hoplodoris rosans, researchers at the California Academy of Sciences have described this year:

A pygmy seahorse about the size of a grape, called Hippocampus nalu.

A gecko residing in the city of Guwahati, India, called Cyrtodactylus urbanus.

The first species of pipefish known to live among red algae, called Stigmatopora harastii.

A newly described flowering plant in Brazil in the Microlicia genus, Microlicia capitata.

And a new sea biscuit (sand dollar) in the Philippines, Clypeaster brigitteae.

Why scientists need to keep documenting life on Earth. And how you can, too.

It’s been a tough year full of sickness and death with the Covid-19 pandemic. It’s hopeful knowing how much there is yet to be discovered about our world. And it’s important work, too.

Between 2010 and 2020, 467 species have been declared extinct (though they might have actually gone extinct in decades prior), according to the global authority on species conservation status, the International Union for Conservation of Nature, or IUCN. Others have been brought to the brink, and still more are seeing serious declines in their population numbers.

In all, the UN’s Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services estimates as many as 1 million species are now at risk of extinction if we don’t act to save them; that number includes 40 percent of all amphibian species, 33 percent of corals, and around 10 percent of insects.

A species can be discovered nearly anywhere: In 2012, a new species of ant was discovered in New York City, of all places. If you’re interested in species sleuthing, Gosliner recommends using the iNaturalist app to document critters and plants you see out in the world.

There, a community of citizen scientists can help determine if what you’ve scouted is truly new. And you don’t need to find something new, per se, to contribute to science. “Just yesterday,” he told me on December 18, “on iNaturalist there was a species of nudibranch [sea slug] that was found in the tide pools just south of San Francisco, that nobody had seen for many, many years. And so that was a really exciting thing to have documented.”

To protect more species, scientists need to know they exist in the first place.

“Describing new species is really documenting biodiversity on the planet,” Gosliner says. “There’s so many areas that we may lose species before we even know that they existed. If you never knew it existed, [and] then it disappeared — that’s kind of a tragedy from my standpoint. There’s the element of the excitement of discovering something new. But also, there’s the urgency that we really need this information to be able to protect biodiversity on the planet.”

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It’s year-end-list season. Usually, the Vox science team has some fun and compiles a year-end list of bad ideas in health and science that ought to die with the end of the year. In the past, we’ve targeted homeopathic medicine, declared it was time to end the relevance of the fatally flawed Stanford Prison Experiment, and dispelled myths about climate change. This year, though, we have only one target for intellectual demolition.

With the end of 2020, let’s leave behind the idea of using herd immunity acquired through natural infections as a means of combating the Covid-19 pandemic. That’s a lot of words to describe a simple, terrible idea: that we could end the pandemic sooner if more people — particularly young, less at-risk people — get infected with the coronavirus and develop immunity as a result.

As a response to a pandemic, the idea is unprecedented. “Never in the history of public health has herd immunity been used as a strategy for responding to an outbreak, let alone a pandemic,” World Health Organization Director-General Tedros Adhanom Ghebreyesus said in October. “It is scientifically and ethically problematic.”

And yet it held sway — at the White House, in particular.

Former White House adviser Scott Atlas (who is a neuroradiologist, not an epidemiologist) was particularly vocal about pursuing more infections. “When younger, healthier people get infected, that’s a good thing,” Atlas said in a July interview with the San Diego news station KUSI-TV. “The goal is not to eliminate all cases. That’s not rational, it’s not necessary if we just protect the people who are going to have serious complications.”

Let’s be clear: It’s not a “good thing” when young people get sick. For one, some of these young people may die, more may get severely ill, and a not-yet-understood proportion of them could suffer long-term consequences. The more people infected, the more chances for rare, horrible things to happen, like a 4-month-old developing brain swelling after testing positive for Covid-19. For that reason, among others, attempting to keep infections to only young or lower-risk people is a foolhardy game to play.

Why building up herd immunity through natural infections is a bad idea

There’s an almost-understandable case for why some people would push for a herd immunity strategy. We are isolated from those we care about, businesses are hurting, education has suffered, and so has our mental health. What if we could just get back to some parts of normal life and contain the risks to those who are least likely to get hurt?

This thinking has proved reckless. Sweden, a country that pursued a more permissive strategy when it came to social distancing, has a much higher death rate than fellow Scandinavian countries.

And look at what happened in Manaus, Brazil: The city of around 2 million people experienced one of the most severe, unchecked Covid-19 outbreaks in the world. Researchers now estimate that between 44 and 66 percent of the city’s population was infected with the virus, which means it’s possible herd immunity has been achieved there (another estimate pegged the infection rate at 76 percent). But during its epidemic period, there were four times as many deaths as normal in Manaus for that point in the year.

More typically, the term “herd immunity” is referred to in the context of vaccination campaigns against contagious viruses such as measles. The concept helps public health officials think through the math of how many people in a population need to be vaccinated to prevent outbreaks. It’s not meant to be applied to control a pandemic through natural infection. Here are five reasons why:

1. Even if we could limit exposure to the people least likely to die of Covid-19, this group still can suffer immense consequences from the infection — such as hospitalization, long-term symptoms, organ damage, missed work, high medical bills, and yes, death.
2. Herd immunity is a very high bar to reach from natural infections. There’s no single, perfect estimate of what percentage of the US population has already been infected by the virus. But by all accounts, it’s nowhere near the figure needed for herd immunity to kick in. The CDC now estimates that there have been 91 million SARS-CoV-2 infections in the US — around 27 percent of the population (though this may be an overestimate). It would take around 60 percent of the population to achieve herd immunity. That’s a rough guess; it could be higher. So we’re about halfway there. Who wants to double the destruction already caused by this virus? In the US, more than 330,000 people have died. (Plus, herd immunity doesn’t work on a nationwide basis but a community-by-community basis. In other words, some communities are still much more vulnerable than others.)
3. Scientists don’t know how long naturally acquired immunity to the virus lasts, or how common reinfections might be. If immunity wanes and the reinfection rate is high, it will be all the more difficult to build up herd immunity.
4. By letting the pandemic rage, we risk overshooting the herd immunity threshold. Once you hit the herd immunity threshold, it doesn’t mean the pandemic is over. “All it means is that, on average, each infection causes less than one ongoing infection,” Harvard epidemiologist Bill Hanage told me. “That’s of limited use if you’ve already got a million people infected.” If each infection causes an average of 0.8 new infections, the epidemic will slow. But 0.8 isn’t zero. If a million people are infected at the time herd immunity is reached, per Hanage’s example, those already-infected people may infect 800,000 more.
5. A herd immunity strategy is likely to harm some groups more than others. There are multiple reasons someone could experience a severe case of Covid-19. It’s not just age — conditions such as diabetes and hypertension also exacerbate risk. So do societal factors including poverty, working conditions, and incarceration.

In the US, severe Covid-19 deaths have disproportionately impacted minorities and less advantaged populations. Encouraging herd immunity through coronavirus infection risks further isolating these already marginalized communities from society, since they may not feel safe in a more relaxed environment. Or, even worse, we risk sacrificing their health in the name of reaching a level of population immunity sufficient to control the virus.

Soon, herd immunity will be a good thing — because of vaccines

Thankfully, we now have a means of building up herd immunity without the risks conferred by infections: vaccines. Unlike the immunity conferred by an actual viral infection, immunity obtained via vaccine doesn’t come with the cost of sickness and death. Vaccines are safe. And while they won’t turn the pandemic around overnight, they will help end it.

We still have to do some difficult waiting. Vaccine rollouts will be slow. Throughout 2020, “herd immunity” was used as a stand-in for “let the pandemic spread.” There was also persistent and erroneous wishful thinking by some who said herd immunity had already been reached, or could be reached sooner than scientists say, or without incurring horrible losses. Yes, the economic restrictions of the pandemic were, and still are, painful. But it’s also true the government could have done more to help.

Soon, herd immunity will become a good-news phrase as we build toward it collectively — and safely — through vaccines. As the vaccines get distributed, herd immunity will develop in a controlled, ethical manner. The pandemic will wane.

And as it does, let’s not forget: The calls to build up herd immunity through infections were a terrible idea. Let’s not repeat them in the future.

Correction: An earlier version of this article misstated the Covid-19 death rate in Sweden compared to other European countries.

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Two highly effective Covid-19 vaccines are now being administered across the United States, and more are in the pipeline. Almost 2 million people have already received the first of two doses of these vaccines, and officials are aiming to immunize one-third of the US population by the end of March 2021.

It’s a stunning accomplishment for a disease that was barely known to the world a year ago, and it means that an end to the crisis is in sight. Yet the US remains in the worst throes of the pandemic to date, with hospitalizations and deaths continuing to break records.

Vaccines are critical in drawing down the pandemic as we know it, but it won’t be a simple return to the world before Covid-19. It will likely be a process that lasts several months, and precautions like social distancing and wearing masks will still be needed until there is widespread immunity to the virus.

“It’s a bit of a glide path in my mind toward a new normal, and a new normal that will continue to get better and better,” said Ashish Jha, dean of the School of Public Health at Brown University. “Ultimately, the mental model that I’m going for is ‘When are people going about their day and not thinking about Covid?’”

Exactly when and how this will happen hinges on several key variables relating to vaccines that scientists and health officials are still trying to sort out.

The vaccines being administered right now — the Moderna vaccine and the Pfizer/BioNTech vaccine — have only received emergency use authorizations, not full approval, from the Food and Drug Administration. Regulators have determined that the benefits of the vaccine outweigh the risks for most adults at high risk of exposure, but there are still some unanswered questions, such as how long protection lasts and how well these vaccines block transmission of the virus between people.

And beyond the vaccines themselves, how quickly and how readily people accept them can change the course of the pandemic.

How well a Covid-19 vaccine contains the pandemic depends on the answers to several key questions

The clinical trials for Covid-19 vaccines are still ongoing, and more clarity will emerge in the coming months. But for now, these remain some of the most important unknowns.

How well do vaccines prevent the spread of SARS-CoV-2?

Both the Moderna vaccine and the Pfizer/BioNTech vaccine reported efficacies of roughly 95 percent against Covid-19 disease, meaning they protected the vast majority of recipients from getting sick enough to have disease symptoms, like loss of smell, fever, and cough.

However, Covid-19 is caused by a virus, SARS-CoV-2, that some people can carry and transmit without having any symptoms at all — whether or not they eventually end up feeling ill.

Finding the people who are carrying the virus (and preventing them from infecting others) is therefore critical to control the spread of the virus, but has proven to be a persistent obstacle during the pandemic. Currently, the main way to identify the infected is by proactively testing for the virus and, ideally, tracing who else they encountered. It’s a tedious, time-consuming process.

This is also true in vaccine clinical trials. Phase 3 trials mainly look at how well vaccines prevent disease in the real world, something that’s readily apparent when comparing the number of disease events in the vaccine group to the placebo group. It only takes 150 events or so to yield results on how well the vaccine prevents disease.

But to gauge efficacy against preventing infections, including low-grade infections that don’t generate symptoms, researchers will have to test the tens of thousands of participants in their phase 3 trial. It’s likely that a Covid-19 vaccine would reduce transmission, but it’s not clear yet by how much.

“What we know is that we’ve been seeing studies focusing specifically on efficacy with regards to severity of disease, meaning ameliorating the severity of the disease itself, but there’s still no studies that really are going to help us understand how we can certainly interrupt transmission,” said Maria Elena Bottazzi, a co-director of the Texas Children’s Hospital Center for Vaccine Development.

The companies conducting trials do plan to test their participants to see if there were any hidden infections, but it may be a while before they report their results.

That said, Moderna presented some early data showing that its vaccine does begin to reduce infections between its doses, which are spaced 28 days apart.

“There were approximately 2/3 fewer swabs that were positive in the vaccine group as compared to the placebo group at the pre-dose 2 timepoint, suggesting that some asymptomatic infections start to be prevented after the first dose,” according to Moderna’s report to the FDA. However, these results are preliminary and will require follow-up testing to see if this effect lasts longer than a few weeks.

The more that a vaccine can reduce the virus’s transmission, the more quickly a population can move toward herd immunity, the point where the virus can no longer spread easily between people. Scientists estimate that herd immunity threshold is when roughly between 60 percent and 90 percent of a population is immune to this virus, whether through a vaccine or from natural exposure. (A recent study in the New England Journal of Medicine showed that health workers in the United Kingdom exposed to SARS-CoV-2 produced protective antibodies against the virus and were protected against reinfection for at least six months.)

But vaccines might not protect every single person who gets a shot from getting infected, just like they don’t provide a 100 percent guarantee against getting sick. That means even the vaccinated will still have to wear face masks and keep their distance from others to prevent virus transmission until immunity is widespread.

How long do vaccines protect against Covid-19?

The Moderna and Pfizer/BioNTech trials have shown that their vaccines start to provide protection against Covid-19 illness quickly — and that protection starts building up right after the first dose.

Whether that protection fades after a few months or a few years is unclear. And researchers can only find out by waiting and observing. That means monitoring the thousands of participants of clinical trials, as well as recipients of the vaccines in the general population, for years. Pfizer and BioNTech, as well as Moderna, have committed to actively monitoring the participants in their clinical trials for at least two years. They are also keeping an eye on people who are receiving their vaccines.

But hints on the durability of vaccine protection could arrive sooner. Looking at vaccine recipients six months or one year after they receive their injections, researchers should be able to see how many were infected with SARS-CoV-2 — and when — to get an early estimate of how quickly protection weakens.

“That would give us potentially some information for what future years will look like,” said Meagan Fitzpatrick, an assistant professor at the center for vaccine development and global health at the University of Maryland School of Medicine. “You will definitely get some signal, but you don’t know really for sure in a way that’s backed up by data until that amount of time passes from when the first people got their first doses.”

Longer protection would buy time for the health sector as vaccines roll out since they wouldn’t have to worry about reinfections or revaccinating people. Evidence from past coronavirus outbreaks like SARS and MERS showed that among survivors, protection for those diseases lasted for several years. But SARS-CoV-2 is a new virus, and much remains uncertain.

There’s also a chance that SARS-CoV-2 could mutate in a way that would escape the protection offered by a vaccine. However, scientists say that’s unlikely in the near term because Covid-19 vaccines target several different parts of the virus and the odds of simultaneous mutations in all of those regions are low.

But more study is needed to yield more definite answers, and the best way to reduce the likelihood of major mutations in SARS-CoV-2 is to limit its spread.

How quickly can we get the vaccine to everyone?

The United States is now in the midst of its largest vaccination campaign in history, an endeavor that’s anywhere from three to four times as big as vaccinating against seasonal flu, according to Moncef Slaoui, the scientific lead for the Department of Health and Human Services’ Operation Warp Speed vaccine program.

It’s a delicate and critical process. “How soon can we really start driving our Covid numbers low really definitely depends on rollout,” Fitzpatrick said. “A vaccine is only as good as the doses that actually get into people.”

However, the debut of Covid-19 vaccines has already hit several bumps. Some states have reported that their initial allotments of the Pfizer/BioNTech vaccine were cut, while the manufacturer reported that many doses have gone unclaimed.

Part of the challenge is technical constraints of the vaccines themselves. Both the Moderna and the Pfizer/BioNTech vaccines require maintaining cold temperatures from factories to transportation to clinics. The Pfizer/BioNTech vaccine in particular demands ultra-cold storage at temperatures of minus 70 degrees Celsius (minus 94 degrees Fahrenheit).

Another complicating factor is simply sorting out who should get the vaccines and when. Enough doses are not immediately available for everyone, so health officials have to make delicate decisions about who to prioritize.

The vaccines available so far have to be administered as two doses spaced several weeks apart, so everyone will have to come back for a second shot. Doses have to be set aside for follow-ups and if people don’t get their second dose, they may have protection that’s less robust or less durable than expected. In a large enough population, that could erode the power of a vaccine to contain the virus.

At the same time, health officials will have to overcome vaccine hesitancy. Getting a high uptake of vaccines is critical in drawing down pandemic restrictions. And the more holdouts there are, the longer it will take. The good news is that reluctance to getting a vaccine seems to have diminished in the United States. A recent poll by the Kaiser Family Foundation found that 71 percent of Americans said they would likely get a Covid-19 vaccine, up from 63 percent in September.

A vaccine is not just about protecting individuals, but protecting a population as a whole. With enough people immunized, even people who haven’t received the vaccine — including those who can’t get vaccinated for health reasons — will experience a much lower risk of infection.

“If you really, really, really want to interrupt and really get rid of this pandemic, you really need high levels of [vaccine] coverage and very high levels of efficacy,” Bottazzi said.

And over the coming months, more Covid-19 vaccines will likely gain approval. That will help ease some of the supply constraints, but will add to the complexity of administering them. Each vaccine has its own storage requirements, dosing schedule, and may be best suited for different demographics.

Taken together, there’s a lot that can go wrong with distributing vaccines. But getting these steps right would mean a much faster route out of the Covid-19 crisis.

How well will the US control the spread of the virus?

In addition to vaccinating millions of people, controlling the spread of SARS-CoV-2 is critical. Efforts to contain the virus will allow the vaccine to have a much greater impact. Vaccines could be targeted to hot spots, for instance, rather than having to push back against a national onslaught.

As mentioned earlier, curtailing the virus’s transmission also reduces the likelihood of a mutation that could render a vaccine less effective. (But if virus variants discovered in the UK that appear more transmissive spread widely in the US, that could complicate efforts of curbing spread, even if the vaccine is just as effective against these variants.)

If all goes fairly well with the logistics of vaccine distribution, it will take weeks to months for it to actually start reducing hospitalizations and fatalities from Covid-19.

A vaccine is meant to prevent illness, so it will do little for people who are already ill with Covid-19. And the SARS-CoV-2 virus can incubate in a person for up to two weeks before the individual starts to show symptoms, and it can take longer after that for them to seek treatment.

As such, there will be a lag in seeing the impacts of a vaccine across the population. But slowing the spread of the virus would make vaccines a more powerful tool to end the pandemic, and results would start to manifest much sooner. Vaccination is also going to be working in tandem with immunity people have built up from surviving infection. Almost 20 million people in the US have been infected to date. “Around 30 percent population immunity, things start slowing a little bit, especially in the places that have been hit hard,” Jha said.

Conversely, if Covid-19 continues to rage out of control, it will be much harder for a vaccine to make a difference in morbidity and mortality, and it will take even longer to see results.

We still need testing, masking, distancing, and treatments

While scientists and health experts have been elated at the speed at which Covid-19 vaccines have been developed, they’ve also been adamant that vaccines on their own are not enough to control the Covid-19 pandemic.

The existing measures for slowing Covid-19 remain just as important as they’ve ever been, if not more so, given that hospitalizations and daily deaths are continuing to mount. Tactics like wearing face masks, rigorous hand-washing, and avoiding large gatherings and close contact with others will still be needed in the coming months, even among people who have been immunized.

Treatments for Covid-19 are also critical since they are the most immediate way to reduce fatalities. Approaches like monoclonal antibodies will be needed to help people survive the illness.

Widespread testing for Covid-19 will also continue to be crucial to identify potential spreaders and to allow people in key jobs to continue working.

It’s a sliding scale between these variables. For example, better testing and tracing could allow people more freedom even if they are not immune. Or effective treatments can drastically reduce fatality rates, reducing the burden of the disease.

However, pressure on all fronts — vaccines, treatment, testing, social distancing — is what will end the crisis the soonest. “The vaccine works at a population level a lot faster if we’re introducing it into a context into which we are throwing all of our other methods to interrupt the virus,” Fitzpatrick said.

While millions of people are growing weary of all the drastic restrictions imposed by the pandemic and the efforts to contain it, keeping them up in the coming months will help ensure that the US finds the quickest and least painful way out of routines bound by Covid-19.

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