In December 2018, I visited a large dyeing facility inside the Shaoxing Industrial Zone, south of the coastal city of Hangzhou, China. Twenty minutes out from the manufacturing hub, I began to smell it: the rotten-egg stench of dye effluent.

The Zone, as it’s known, is 100 square kilometers, nearly double the size of Manhattan. More than 50 textile printing and dyeing companies stand in huge rows, facing out over the Cao’e River where it flows into Hangzhou Bay. Trucks stream north on the highway from the Zone carrying miles of dyed and printed fabrics, en route to becoming billions of dollars’ worth of shirts, dresses, shorts, and leggings.

I was there to research a book I was writing about clothing and textiles, and the Zone, in terms of its sheer scale, was unlike anything I had ever seen in the US. Yet it’s a landscape that a mammoth American consumer market — and the steady, supersize patronage of US clothing brands and retailers — has been critical in shaping.

The US has gobbled up far more Chinese garments and textiles than any other nation every year since 2006. Between 2002 and 2020, China was by far the largest source of garment imports into the US. In 2020, Vietnam outstripped China as the biggest exporter of garments to the US market, but that fact obscures the reality that the cloth used to make those Vietnamese garments is frequently Chinese-made, and is often sewn in Chinese-owned factories.

Because of the deep reliance on this single source to meet insatiable clothing appetites, clothing companies — and consumers — now have a particularly big moral dilemma on their hands.

US officials and human rights organizations say the cotton fields and factories in the Xinjiang region of China are using forced labor, mainly that of the Uyghurs and ethnic Kazakhs imprisoned in the vast internment camp system that the Chinese government has built in the region in recent years.

In January, the Trump administration banned cotton from Xinjiang because of its connection to the alleged human rights violations, roiling a fashion industry heavily reliant on Chinese textiles. Reports of the detention camps began circulating in 2019, but by 2020, reports had surfaced that major international brands’ supply chains were marred by forced labor. Soon, those brands were rushing to make public statements condemning China’s actions in Xinjiang, eagerly professing a zero-tolerance policy on forced labor. Some, like Adidas, pledged to cut Xinjiang-made materials from supply chains; others, such as Patagonia and the millennial “it” brand Reformation, have said they will stop using Chinese cotton altogether. The problem, however, had been building for some time.

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Though Beijing has vociferously denied using forced labor, calling it “totally a lie fabricated by some organizations and personnel in the United States and the West,” US senators met in committee in March to hash out possible solutions to the problem and its presence in the supply chains of US companies.

One of the witnesses giving expert testimony that afternoon, Julia K. Hughes, president of the United States Fashion Industry Association, suggested that it was important to focus on “the real actions that will get to the perpetrators of the crime, which is not the US companies that are good corporate citizens.”

But just who is responsible is, by any account, a difficult question to untangle. China is both the world’s largest producer of cotton yarn and its largest yarn importer, buying up cotton thread from India, Pakistan, and Vietnam to supplement its domestic thread. This yarn is knit, woven, and dyed to make textiles that will become summer dresses for Zara, T-shirts for Gap, and socks, hats, and jeans for the Japanese retailer Muji, even the cotton tote bags that have proliferated in recent years as a replacement for plastic. China is also one of the world’s biggest producers of raw cotton. And nowhere in China produces more cotton than Xinjiang.

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An autonomous region located in the country’s far northwest corner, bordering Kazakhstan, Kyrgyzstan, and Mongolia, Xinjiang has been under Chinese control since the People’s Republic of China was founded in 1949. Uyghurs — the majority of whom follow the Hanafi school of Islamic jurisprudence, one of four schools of thought within Sunni Islam — are by far the largest ethnic group in Xinjiang, although the region is also home to many Uzbeks, Kyrgyz, Tajiks, Kazakhs, and Hui (Chinese Muslims). Their culture is distinct from that of Han Chinese — the majority ethnic group in China — in many ways: Their food is largely halal, based on mutton, wheat noodles, nan, and savory pastries.

Uyghur farmers in Xinjiang were formidable farmers, making virtuosic use of rain-fed agriculture to grow food. But a new agricultural regime would turn the land to another crop: cotton.

Xinjiang has long been strategically central to China’s Belt and Road Initiative, a massive infrastructure project intended to link China globally via railroads, shipping lanes, and gas pipelines. The initiative’s central arteries crisscross the province, which happens to also hold huge reserves of natural gas. As the Chinese government has moved to assert tighter control over the region, cotton has operated as both an end and a means. In the 1990s, it was used as a way to encourage Han migration into the region. Today, it feeds the Chinese textile industry.

Beijing’s effort to move cotton and cloth production west to Xinjiang unfolded in several phases. The Eighth Five-Year Plan (1991-1995) highlighted the region’s huge potential for cotton, and the subsequent plan specified that Xinjiang be turned into a national cotton-producing base. Meanwhile, planners also transferred textile production west, from its traditional base on the east coast. Central planners felt that China’s textile industry could become more competitively priced by being closer to the cotton fields and employing a cheaper rural workforce.

Twenty years later, Xinjiang has a cheaper workforce than planners in the ’90s could have dreamed, and the reason is disturbing. From softer, coercive policies — like giving cotton quotas to Uyghur farmers that they had to meet, even if it wasn’t profitable — Beijing has turned to a policy of forcefully interning Uyghurs in massive, heavily guarded camps, subjecting them to what it has described as “reeducation” but is believed to include sterilization and forced labor. They are actions that, when taken together, constitute what the US State Department has termed a genocide. They are actions that have also been a boon to industry.

The Chinese government dramatically scaled up its repressive policies against Xinjiang’s Uyghurs in late 2016, when Communist Party Secretary Chen Quanguo, a hardliner who has escalated invasive, tech-driven policing and monitoring tactics in China, assumed leadership of Xinjiang. Massive internment camps, which Beijing terms “vocational education centers” — though satellite imagery has revealed that these camps are encircled with barbed wire fencing and surveilled from watchtowers — have since been erected.

The policy of “reeducating” Uyghurs has dovetailed with a desire to keep garment production in China after labor costs there grew uncompetitive with those in places like Vietnam or Bangladesh. By 2018, evidence began to emerge of a major pipeline between detention centers and factories producing garments for US brands when the Associated Press tracked shipments from a factory inside a Xinjiang internment camp to Badger Sportswear in Statesville, North Carolina. Badger quickly moved to source its sportswear elsewhere.

But garments stitched by imprisoned Uyghurs were quietly entering the American wardrobe through myriad avenues — much of it, it would soon be revealed, made from cotton harvested by enslaved people. In January 2021, a shipment of men’s cotton shirts from Uniqlo was blocked from entering the Port of Los Angeles by US Customs agents who believed the goods were produced in part using forced labor in Xinjiang. In July, France’s antiterrorism prosecutor’s office opened an investigation into four brands that it has alleged profited from human rights crimes in Xinjiang: Zara, Uniqlo, Skechers, and SMCP (owner of Sandro and Maje). Even after the situation in Xinjiang had become unmistakable, it was clear that the effort to remove cotton harvested by forced labor from the market was squarely at odds with the imperative to produce ever-cheaper clothing.

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Journalists face extreme restrictions in their attempts to enter Xinjiang, but I had procured a tourist visa for my December 2018 research trip to China and, following my time on the nation’s east coast, I had planned to head to Xinjiang in the guise of a sightseer, to gather whatever I could that way. My research focus was, at that time, on the ecological costs of cotton.

I had enrolled in a formal “Silk Road” tour as a way to avoid imperiling Uyghur interview subjects, who can be arrested for something as minor as speaking to an American. Days before I was scheduled to fly out, I got an email from the tour company with the subject line “URGENT.” “I regret to inform you that we have to cancel your tour,” the email said. “It is something beyond our control.”

Months passed before I again heard from the American employee of the Uyghur-owned tour company who had informed me of the cancellation. She was back in the US, she said, and wanted to explain what had happened now that she had access to a secure email account. Days before my tour, the family that ran the company had been rounded up and “sent to their home village” — a euphemistic way to say that they were sent to an internment camp.

At the time, the detention of Uyghurs by the Chinese government was just beginning to be widely reported. I felt sick. I had assumed that I was being kept out because the ruling Chinese Communist Party was becoming more careful about concealing its actions in Xinjiang and didn’t want to risk even the occasional nosy tourist. This, however, was more direct, more brutal, more blunt.

Since that first inkling that something was awry in the region, Xinjiang has emerged as the center of an international crisis. In March 2020, Sen. Bob Menendez (D-NJ) called on the Commerce Department to take steps to prevent goods produced by forced labor in Xinjiang from entering the US market. Even as the international outcry grew, Beijing worked to keep the region cloaked in secrecy. Journalists looking to document what is occurring in Xinjiang are forced to rely on satellite photos, sift through government budget reports, and collect footage of closed doors and high fences. In the startling glimpses that have emerged, cotton was front and center.

In July 2020, more than 190 organizations — interfaith groups, labor unions, Uyghurs’ rights groups, environmental organizations, anti-slavery organizations — spanning 36 countries issued a call to action, seeking formal commitments from clothing brands to completely disengage from any connection to Uyghur forced labor, either through sourcing, business relationships, or labor transfers, which serve to pipe Uyghurs from internment camps in Xinjiang to factories in other regions of China. In December 2020, German anthropologist Adrian Zenz released an intelligence briefing directly linking the cotton harvest with forced labor.

When I learned about how cotton was being harvested in Xinjiang, I thought about the tour guide who had been scheduled to drive me around, talking about the silk of China’s past. I wondered if he had become one of the prisoners laboring in the fields, picking the cotton of China’s present.

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Corporations didn’t end up sourcing garments from Xinjiang internment camps by accident.

Apparel is a footloose industry, and forced labor is rampant. Brands actively seek out countries that don’t enforce their labor laws, said Scott Nova, executive director of the Worker Rights Consortium, “then put enormous price pressure on suppliers, guaranteeing that they’ll violate labor laws.” The companies’ public statements reveal a desire to project certainty: “Nike does not source products from the [Xinjiang Uyghur autonomous region] and we have confirmed with our contract suppliers that they are not using textiles or spun yarn from the region,” reads an undated statement from Nike that also acknowledges that its supply chains are opaque, even to the company itself. “Nike does not directly source cotton, or other raw materials,” the statement continues, but “traceability at the raw materials level is an area of ongoing focus.” The company concluded by saying that it was working with suppliers and others to better “map material sources.”

Slave cotton is far from new. The use of forced labor by an authoritarian communist regime to grow cotton can — and ought to — inspire the ire of the democratic West. But “free market” cotton has generally entailed very little freedom for most of those involved in its production. There is no global cotton trade outside of brutal colonial or neocolonial relations of power. Cheap cotton has been morally compromised for several hundred years.

The history of European imperialism, industrialization, and cotton are so intertwined as to be nearly identical. Cotton textiles were among the main products for which Britain colonized India. This cotton fabric was in turn the main currency used to purchase enslaved people from Africa, who were forced to grow commodity crops in the New World. After the invention of the cotton gin, cotton became the plantation’s crop par excellence in the United States. In the post-Civil War South, cotton continued to be made by unfree labor, as systematic efforts deprived formerly enslaved people of both land and alternative means of subsistence, all to force them into cotton sharecropping arrangements. Whatever could not be accomplished by this means was accomplished by Black Codes that allowed local authorities to arrest freed people for minor infractions and commit them to involuntary labor.

Large Southern landowners, cotton traders, and merchants — the same actors who had benefited from the antebellum order — were so successful in their efforts to reestablish cotton growing in the American South by forcing formerly enslaved people and landless white tenants to grow cotton via a punishing system of perpetual debt, that their strategy, known as sharecropping, became a model the world over. Today, small cotton farmers in India, for example, face crushing debt.

Private companies may direct flows of garments, but they travel along routes drawn by imperial legacies and colonial armies. In the cotton field, the division between the state and the corporation often fades away entirely. The Xinjiang Production and Construction Corps, the Chinese state-owned entity that administers Xinjiang and directs the cultivation of most of its cotton, is both a corporation and an army.

As for the garment trade itself, that too has relied on the movements of big state actors, and not just a handful of errant entrepreneurs. The globalization of the US garment industry came about as the result of the US State Department’s Cold War policy. After World War II, the Allied powers under Gen. Douglas MacArthur occupied Japan and moved to re-industrialize it as swiftly as possible so it wouldn’t “fall” to communism. MacArthur’s first economic priority was the Japanese textile industry, which had been nearly wiped out by the war. Factories were rebuilt and modernized. The State Department even subsidized the shipment of raw American cotton to Japan.

To absorb the product of these new mills, the United States then opened up its hitherto heavily protected garment market, and Japanese cloth and clothing flowed in. The US textile and garment industries were made a sacrificial lamb, and over the next half-century, garment workers’ rights eroded, and Americans got used to spending less and less on clothing made by workers whose pay became worse and worse.

The pipeline of low-cost Asian-made clothing had been long established by the time China opened its economy and revved up as a garment producer. Workers’ rights had never been on the minds of the architects of these policies, and remained an afterthought.

In March 2021, US Secretary of State Antony Blinken met with his Chinese counterpart, Director Yang Jiechi, for a conversation that quickly devolved into a war of words. Yang made a thinly veiled allusion to the history of slavery in the US and suggested that with a record like that, the US had no right to lecture China. “It’s important that we manage our respective affairs well instead of deflecting the blame on somebody else in this world,” he told Blinken. (This line of attack is frequently taken by Chinese troll armies, networks likened to Russian troll farms mobilized online to attack anyone posting concerns about the Uyghurs.)

Wang’s throwdown was cynical and self-serving. But it highlighted the irony of the US position. The US had emerged as a global leader in the fight against China’s oppression of the Uyghurs: It is the first government to call it a genocide, the first to ban imports of Xinjiang cotton — steps that Canada, the UK, Australia, and the EU also appear to be on their way to taking. In taking a hard stand, however, on China’s actions as a genocidal power using slave labor to harvest cotton for a voracious global market, the United States was looking at itself in the not-so-distant past.

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Self-reflection (or lack of it) aside, there are enormous complexities involved in trying to force the global tentacles of Western multinationals out of a forced labor industry.

According to Nova of the Worker Rights Consortium, an estimated 1.5 billion garments made with Xinjiang cotton streamed into the US market each year before the ban took hold, and there are significant obstacles to knowing how much the ban has reduced that number. “Most consumers do not want to wear clothing made with forced labor,” Nova told me. “That’s a given. And if they knew that a particular product was made with forced labor, very few people would buy it. Of course, that’s where transparency comes in.”

Rights groups have expressed frustration recently that, although the US has placed restrictions on Xinjiang cotton, it is nearly impossible to see how they are being enforced. US Customs and Border Protection, the federal agency responsible, discloses the total number and dollar value of shipments detained quarterly, but that’s it. There are some exceptions — as when the news broke about blocked Uniqlo goods — but most such detentions never reach the press. The public has no way of knowing how many of them involve Xinjiang cotton, let alone which brands are implicated.

Ana Hinojosa, the agency’s executive director for trade remedy law enforcement, acknowledges that in the reporting, Xinjiang cotton detentions and others “are all lumped in together, mainly because it would be very difficult for us to continually update these moving numbers.”

The federal agency “is not required to make that any of that public,” confirms Esmeralda López, legal and policy director of the International Labor Rights Forum, but, she adds, “we think that it’s necessary to ensure effective enforcement.”

It matters, said Nova, because corporations are “waiting to see whether there’s going to be aggressive enforcement before they decide whether to really exit the region.”

Garment supply chains are incredibly complex. So far, Eileen Fisher, ASOS, Marks and Spencer Group, OVS, Reformation, WE Fashion, and others have all publicly committed to follow the steps laid out in the call to action put forward by the Coalition to End Forced Labour in the Uyghur Region. These steps demand that companies engage in intensive research into their own supply chains. Without this kind of work, watchdog groups say, it’s nearly impossible to suss out Xinjiang cotton from the rest.

Cotton picked in Xinjiang may be mixed with cotton from other regions as it is spun into yarn. That yarn may be knit or woven into fabric far from Xinjiang, cut and sewn into a garment still farther afield — likely in Vietnam or Bangladesh. Brands like to point out this complexity to disavow knowledge of what occurs in their supply chains.

But rights groups argue that companies do have choices. “I don’t think that we need to accept those limits,” said Allison Gill, forced labor program director/senior cotton campaign coordinator at Global Labor Justice — International Labor Rights Forum. “A company can tell us that a product was produced in a facility that also processes sesame and nuts. They can tell us all kinds of things if they want to.” According to Gill, “Xinjiang is the central case that we will use for years to show what an absolute failure voluntary standards have been [in] the auditing approach to supply chain. I mean, all of these companies that were operating there, they were all audited, they all passed their audits.”

In Xinjiang, there are known unknowns. “If you have clear due diligence policies, and if you’re saying, ‘We don’t use forced labor goods,’ and you can’t have factory auditors go in and actually check factories,” said Peter Irwin, senior program officer for advocacy and communications at the Uyghur Human Rights Project, “then you need to leave.”

The Coalition to End Forced Labour in the Uyghur Region is calling on brands to make public commitments to disengage from the region, but many brands have said they’d rather exit quietly because they fear losing Chinese market share if they pull out of Xinjiang openly. They’re afraid the Chinese government and nationalist consumers there will interpret any criticism of its conduct in Xinjiang as an open threat and retaliate.

That’s not an unrealistic fear. Days after Sweden joined in the coordinated sanctions on senior officials involved in human rights violations in Xinjiang, the Chinese Communist Youth League launched an online attack on the Swedish retailer H&M, zeroing in on a year-old statement on H&M’s website expressing concern over human rights violations in the Uyghur region. The next day, H&M vanished from the Chinese internet. Major e-commerce platforms including Alibaba’s Taobao dropped its goods, and one ride-hailing app, Didi Chuxing, did not recognize its stores as locations. The party newspaper also leveled criticisms at Burberry, Adidas, Nike, New Balance, and Zara for past statements on Xinjiang, some from as long ago as two years. Celebrities including pop singer Wang Yibo announced they were breaking endorsement contracts.

“Normally in our work, it’s easier to get the brands to say they’re doing the right thing than it is to get them to do it. That has flipped to a degree on this issue,” said Nova. “If their position is that their level of access to China’s consumer market is more important to them than not being directly complicit in the worst human rights crimes that are taking place in the world today, their consumers have a right to know that.”

Then there are those, he argues, that have simply done nothing. “We’ve seen nothing whatsoever from Target, nothing whatsoever from Walmart. Nothing except rhetoric from Amazon, among many others,” Nova says. (Neither Target nor Walmart replied to Vox’s requests for comment; Amazon issued a statement that read, in part, “Amazon expects all products sold in the Amazon Stores to be manufactured and produced in accordance with our Supply Chain Standards. Whenever we find or receive proof of forced labor, we take action and remove the violating product and may suspend privileges to sell.”)

One promising new tool in supply chain transparency is technology developed by a company called Oritain, which can analyze a cotton fiber and determine its point of origin. Cotton from different locations bears different molecular blueprints: Distance from the sea will affect its sulfur content, for instance, while altitude will impact its hydrogen. However, Grant Cochrane, Oritain’s CEO, cautioned, “We’re not a standalone service. We work with other systems: really solid traceability systems.”

Even if the US cotton ban is made airtight, to work optimally, “It’s very important that a cotton ban … be a global effort,” said Johnson Yeung, urgent appeal coordinator and campaigner at the Clean Clothes Campaign. Yeung points to Muji, the Japanese retailer, which has said it has stopped sending Xinjiang cotton products to the US but will continue to sell them in countries without the ban. In Hong Kong, where Yeung is based, Muji actively advertises the presence of Xinjiang cotton in its products — a practice it jettisoned in Western markets after an uproar in the human rights community — attempting to brand “Xinjiang” as an upscale, luxury marker.

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In the meantime, for Uyghurs in the diaspora, an act as simple as clothes shopping has become fraught. Zumretay Arkin is the program and advocacy manager at the World Uyghur Congress, part of the coalition asking brands to leave the Uyghur region. “I’m not an angel,” said Arkin. “I used to shop fast fashion.” Now, though, when Arkin sees cotton clothes in stores, “I just freeze there, thinking, ‘Maybe one of my relatives made this piece.’”

Arkin’s grandmother was a retired seamstress who used to sew clothing for Arkin using colorful printed cloth, sometimes cutting up her old dresses and veils to use as materials. Arkin brought these handmade garments along as a treasured memory when she immigrated to Canada at age 10. When Arkin’s grandmother passed away in 2017, Arkin could not go back for the funeral. The risk of detention was too great. Today, long dresses like the ones Arkin’s grandmother both wore and repurposed for Arkin’s wardrobe have been criminalized in Xinjiang. Uyghur women are stopped on the street to have long dresses shortened with scissors on the spot.

Rushan Abbas, founder and executive director of the nonprofit Campaign for Uyghurs, also finds it fraught to shop for clothes these days. In retaliation for Abbas’s activist work in the US, she alleges, authorities in Xinjiang detained her sister, a retired medical doctor, in September 2018. (Radio Free Asia has confirmed her detention.) “I’m afraid of going out and buying some of the things in the store now. Because I don’t know where my sister is,” or whether she is being forced to make products, Abbas said. Although China’s government has framed its labor transfers with the dystopian euphemism of “job training” programs, Abbas notes that “Uyghurs being held and sent to those factories to work, they are professors, writers, doctors, successful business people, elites — they’re professionals in the different fields.”

Abbas lives with her husband, who is also Uyghur, in Herndon, Virginia. His parents, both over 70, have been missing since 2017. So have four siblings and their spouses, along with 14 nieces and nephews. The Abbas family is far from exceptional in this, she said. “Me and my husband are the example of every single Uyghur in the diaspora.”

The United States’ link to the Uyghur internment camps isn’t just a matter of parallel histories.

US corporations have played a central role in creating the situation in Xinjiang today, and consumers have been their unwitting accomplices. “When you pour money into a region where there’s rampant forced labor, you’re both supporting and profiting from forced labor,” said Nova.

“Forced labor is a spectrum,” Gill said. “People in forced labor very often have agency, they are often making very hard choices. But genocide — genocide is different.”

“We hear a lot of different arguments for basically ignoring these atrocities, one being, well, the US needs to clean up their own act first,” said Julie Millsap, director of public affairs and advocacy at the Campaign for Uyghurs. “It’s not that simple. This is also our issue. We don’t get to say that while we’re improving things … in the States that we’re going to outsource human rights abuses.”

Sofi Thanhauser is the author of Worn: A People’s History of Clothing, forthcoming from Pantheon Books on January 25, 2022. She teaches in the writing department at Pratt Institute.

By removing all troops from Afghanistan shortly before the 9/11 attacks’ 20th anniversary, President Joe Biden sent a none-too-subtle message: He wanted America, and the world, to see that he was turning the page — that the war on terror era was well and truly over. In a speech last week justifying his decision, he stated the rationale explicitly: “It’s about ending an era of major military operations to remake other countries.”

It’s easy to be skeptical of Biden’s seriousness. US forces remain engaged in counterterrorism operations across the globe. After an ISIS suicide bombing at Kabul airport during the withdrawal killed an estimated 170 people, including 13 American service members, the US launched drone strikes against ISIS targets in Afghanistan — killing at least 10 Afghan civilians. And some of the attacks on Biden’s policy from the Washington foreign policy establishment suggest its appetite for war is hardly sated.

Yet the Afghan withdrawal shows a significant break with the post-9/11 order — at least among liberals.

September 7 was Brazil’s Independence Day, and Brazilian President Jair Bolsonaro used the occasion to continue his assault on the country’s democratic institutions.

Bolsonaro had called on his hardcore supporters to rally, as he battles Congress and the judiciary over their refusal to go along with his attempts to rewrite electoral rules ahead of the 2022 election and over probes into him and his allies that could imperil them criminally.

He addressed crowds in Brasilia and São Paulo, using the platform to attack and threaten the supreme court. “Either the leader of this branch of power gets this minister under control, or this branch will suffer what none of us want,” Bolsonaro said. He said he would not follow the decisions of certain justices, including one who will be in charge of the electoral tribunal during the 2022 elections.

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Though an estimated 100,000 Bolsonaro backers gathered in the capital, Brasilia, as well as in São Paulo, according to Brazilian media outlets, the marches did not erupt in mass violence and chaos. Ahead of September 7, some feared a repeat of something like the January 6 insurrection in the United States.

That didn’t happen, despite worries that pro-Bolsonaro demonstrators might try to storm the Supreme Court. Though police and protesters clashed, attempts to push past police barriers largely failed.

But the threat to Brazil’s institutions has not lapsed, not from Bolsonaro nor from those who unquestionably back him.

That danger comes from Bolsonaro’s political weakness. A large swath of the public is angry over his mishandling of the Covid-19 pandemic, which has killed more than 580,000 people, one of the worst death rates in the world. That, along with Brazil’s still-sluggish economy and the myriad scandals following Bolsonaro, has tanked his popularity; his approval rating has hit an all-time low of around 23 percent. Right now he’s losing — badly — in most recent presidential polls, with some suggesting the incumbent might even fail to advance to a runoff.

Bolsonaro is seeing his political, and maybe personal, downfall in real time. Faced with these crises of his own making, he is creating another one against Brazil’s democracy, in a desperate attempt to hold power and protect himself.

“We cannot accept a voting system that does not offer any security in the elections,” Bolsonaro said in São Paulo on Tuesday, according to Reuters. “I can’t participate in a farce like the one sponsored by the head of the electoral court.”

Bolsonaro’s rhetoric isn’t new — from him or, you know, other people. But just because the playbook isn’t original does not make it less of a menace.

“They are fine with going with these democratic processes, provided that they are the winners,” Paulo Barrozo, an associate law professor at Boston College, said of leaders in the mold of Bolsonaro and former US President Donald Trump. “The moment that there is any indication that they’re not going to win, then they are no longer committed to electoral democracy.”

“The playbook is the same, the motivation is the same,” Barrozo continued. “And it remains to be seen how much traction [Bolsonaro] is going to get in the larger Brazil society.”

The September 7 marches were a culmination of Bolsonaro’s attempts to discredit democracy

Bolsonaro’s campaign to discredit Brazilian democracy began way, way before September 7. He decried possible voter fraud even after his first victory in 2018, and his efforts have intensified once in the presidency and as his electoral prospects have worsened.

For months, Bolsonaro has been trying to sow doubt in the electoral system and frame the institutions defending those norms as corrupt actors out to get him. It may sound familiar.

He has repeatedly attacked Brazil’s electronic voting system — a kind of mirror image of Trump’s attacks on vote-by-mail and the like during the 2020 election. He is insisting that Brazilian voters must use paper ballots in the 2022 election, otherwise the results can’t be trusted. (Brazil’s electronic voting system was created to reduce fraud and corruption and to manage the logistics of a complex voting system, and has been in use since the country’s 2002 election.) “I’ll hand over the presidential sash to whoever wins the election cleanly,” the far-right Bolsonaro said in July. “Not with fraud.”

Bolsonaro pushed Congress to change the rules, and on the day Congress debated the voting proposal, he presided over a military parade in Brasilia. Still, Congress declined to pass a law requiring paper ballots; Bolsonaro attacked some of those lawmakers as having been “blackmailed.”

Bolsonaro has also directed his ire toward the judiciary, both the supreme court and what’s known as the Superior Electoral Court, which oversees and administers the country’s elections.

Some current and former supreme court justices have directly criticized Bolsonaro’s anti-democratic rhetoric and defended the integrity of Brazil’s elections. Ultimately the Supreme Court opened an investigation into Bolsonaro’s efforts to spread voting misinformation and threatening Brazil’s democracy.

The supreme court has also opened a bunch of other investigations into Bolsonaro, along with those in his inner circle, including an ally arrested for allegedly spreading fake news. Bolsonaro is under investigation for posting a sealed document from an electoral investigation on social media, in an attempt to prove voter fraud. He’s under investigation for his mishandling of the Covid-19 pandemic, including a possible vaccine kickback scheme. He and his sons are also implicated in other corruption schemes, with potential criminal consequences.

All of these pressures are looking harder and harder for Bolsonaro to shake, and it’s happening against the shadow of Covid-19 and high unemployment and inflation. “The political scenario is worsening for him, so he’s trying to figure out some way to hold on to power to protect himself,” Sean T. Mitchell, an associate professor of anthropology at Rutgers University, told me last month.

The September 7 marches fit with Bolsonaro’s attempts to hold power. The question now is whether the demonstrations were enough to embolden him to launch even more aggressive attacks on the country’s institutions.

Brazil’s September 7 rallies were not January 6. But they are still ominous for Brazilian democracy.

In Brasilia and in São Paulo, Bolsonaro’s supporters draped themselves in the Brazilian flag, or wore its green and yellow colors.

It wasn’t record turnout, but it also wasn’t a total flop. Bolsonaro’s loyalist base showed up, and they are motivated. (There were also some anti-Bolsonaro counterprotests in cities Tuesday, though opposition leaders largely urged their supporters to gather on September 12 instead to avoid potential clashes.) The marches also showed that they are buying into Bolsonaro’s attacks on Brazil’s democracy. They carried pro-Bolsonaro signs, a number in English. Some blasted the Supreme Court. Some called for a military takeover.

It was a show of President Bolsonaro’s die-hard supporters, which was the goal. Bolsonaro is losing popular support, and the calls for his impeachment have intensified. But so far, the public outrage hasn’t fully translated into political consequences; Bolsonaro still has allies in Congress, whom he’s managed to keep by making deals, not out of any ideological loyalty (Bolsonaro actually doesn’t have a political party right now). But Bolsonaro doesn’t want those ties fracturing.

“He’s trying to give a demonstration that will somehow overwhelm his 20 percent approval numbers, show that he has support where it’s really needed — he can bring people out to the streets,” said Amy Erica Smith, an associate professor of political science at Iowa State University. “He’s trying to rally support to himself by showing that he already has support.”

The September 7 marches were also a test for how far Bolsonaro and his backers might take their threats against democracy, and how law enforcement might respond.

Bolsonaro escalated his rhetoric against the supreme court and other institutions — walking up to the coup line, perhaps, but not quite crossing it. There was his threat that if the judiciary continued to act as it had been, it “will suffer what none of us want.” He also declared that he would no longer follow rulings made by one of the supreme court justices, Alexandre de Moraes, who initiated some of the investigations against him.

“I want to tell those who want to make me unelectable in Brazil: Only God removes me from there,” Bolsonaro said in São Paulo, according to the Associated Press.

“There are three options for me: be jailed, killed or victorious. I’m letting the scoundrels know: I’ll never be imprisoned!”

Bolsonaro’s supporters spoke in all-or-nothing language. “Even if we need to pick up arms and die for Brazil then we’ll do that,” Luis Bonne, a 50-year-old civil servant and rally attendee, told the Guardian.

And though the fears that September 7 might become a preemptive “stop the steal” didn’t materialize, experts said the danger hasn’t passed. Instead, it seems clear from Bolsonaro’s language that there is no scenario where he will let the election play out and not challenge the results, or willingly leave.

Where the military stands on this adds to the precariousness of the situation. Bolsonaro does have support among lower ranks and military police, and elected leaders feared that many would turn out for the September 7 marches.

But whether high-ranking generals would go along with a Bolsonaro power grab or break with him is not at all clear. Experts said it’s unlikely he has enough of their support to launch a full-scale coup, but unlikely is not exactly a comfort when it comes to a military takeover. “Nobody can say this with 100 percent certainty among many observers who are watching this,” Smith told me last month. “And the fact that people can’t say this with 100 percent certainty is a source of power for [Bolsonaro].”

Brazil’s institutions have, so far, reacted to Bolsonaro, in some cases quite strongly. “There are very good signs of that working,” Barrozo said. “But again, it’s too close to a fatal accident that it could derail things.”

September 7 showed that Bolsonaro is testing Brazil’s democratic institutions. The question is how far those institutions can push back on him — and how much of his onslaught they can withstand.

Covid-19 is upending our lives and forcing us to make complex decisions with little information and conflicting guidance from authorities. Summer, typically the season of staying up late and popsicles in the park, offers no escape. Many of us are already turning to the fall, and the fate of schools.

What will we do with our kids? Can we really send them back to school? If we keep them at home, will they forget how to read? If we send them to school, what might be the consequence? We are living a nightmare, but this is where we are. The choices are high-stakes and plagued by uncertainty. Even thinking about them makes me sweat.

I am the father of three girls ages 16, 13, and 10, and like every parent in America, I am worried about the fall.

I’m also an infectious disease doctor and epidemiologist, and have spent the past four months drinking from the fire hose of Covid-19 science, designing infection control policies for my hospital, and caring for patients on the front line. I serve on the reopening committee for my synagogue and for my school district. I consult for businesses as they reopen.

I have a first-row seat to the coronavirus pandemic, both as a parent and as a professional. In both of those roles, I hear the same questions, repeated with mounting urgency: “Are our kids going to be safe?” “Are our teachers going to be safe?” “Will kids bring Covid-19 home to our family?” “Will opening schools lead to a second wave and lockdown?” “What are the risks of not reopening?”

I have spent time reviewing the data and seeking answers to the challenging questions we face. Having the knowledge to make your own assessment, however, need not be a position of professional privilege. With this short primer, I hope you can add your voice to the debate and advocate for yourself, your family, and your community. The good news is, we can hope to send kids back to school in the fall, but there is a lot of work to do.

Are our kids going to be safe?

If any of us is ever going to send our kids to school again, we need a clear answer. Fortunately, I think we have one, at least for the children. Children are less likely than adults to be infected with Covid-19. There are multiple ways to study this question, and all the approaches arrive at this same conclusion.

First, when we look at public health reporting, children under the age of 18 make up only 2 percent of cases in the US, even though they represent 22 percent of the total population. Similar studies in Chicago and Massachusetts found that children make up fewer Covid-19 cases than expected, as have studies in Italy, South Korea, and Iceland. For me, that is a lot of similar results for this to be a fluke. When one study in one location produces a finding, it is notable. When five studies from five different settings find the same thing, it is compelling.

One reason case counts may be lower among kids than would be expected is that we did close our schools in March. Maybe we protected our kids by keeping them out of harm’s way. But if we send them back to school this fall, will they still enjoy protected status from the coronavirus?

One way to study this question is to estimate the “attack rate” of the disease — that is, the proportion of people exposed who become infected. Multiple studies from China investigated the attack rate among people living in a house with someone who is infected. They found that only about 4 to 5 percent of kids developed an active infection. In comparison, about 17 to 20 percent of adults became infected after exposure.

To be fair, data in the US is more concerning. In New York state, 57 percent of people living with a Covid-infected person developed an infection. It is hard to take reassurance from that fact. But even with such a high attack rate, children were still less likely to develop an infection and there was a gradient over ages, a sort of “dose effect” for age.

Finally, even in the worst-case scenario, in which a child does contract Covid-19, the outcomes of the disease are less severe in younger people than among older adults. In one analysis of more than 550 confirmed cases among children under age 18 in China, Italy, and Spain, only nine people (1.6 percent) had severe or critical disease. In another study, approximately 5 percent (one out of 20) developed symptoms that required hospitalization, but only 0.6 percent required intensive care. In comparison, a recent Centers for Disease Control and Prevention report indicates that among those ages 60 to 69 who have the coronavirus, 22 percent require hospitalization and 4 percent require intensive care.

Are teachers going to be safe?

There is far less data specifically on teachers and staff than on kids. One study in France is reassuring. In that investigation of 541 students and 46 teachers, there were no documented transmission events from students to teachers. However, while many of us immediately think of the risk to teachers from exposure in the classroom, we may not consider the additional risk that teachers face in break rooms and staff meetings.

Working in the hospital, I have personally seen that staff have a difficult time maintaining personal protection at all times. Doctors and nurses tend to let down their guard when they are away from patients and during breaks. Masks come down, people eat snacks in potentially unsafe spaces, and social distancing lessens.

The same will likely be true in schools. The potential risk to teachers, therefore, goes beyond the classroom. Staff risk in schools likely looks similar to the risk of any adult working in a crowded indoor environment during the pandemic. School opening plans must consider teacher safety in addition to the well-being of students.

Will my kids bring Covid-19 home to our family?

For most parents, the next question after the safety of their kids will be their own safety and that of loved ones in the house. Even if the kids are all right, could they bring the coronavirus home?

Here, again, the data appears reassuring. One large review of over 700 scientific publications found that children accounted for only a small fraction of Covid-19 cases, and that they were rarely the first case in a cluster of infections in a household. For example, in China, only 5 percent of household clusters were found to have a child as the index case. Similarly, in Switzerland and Holland, children accounted for only 8 percent of household transmission clusters.

Unfortunately, the US numbers make me a little less certain. In a Chicago study of 15 households with available data, 73 percent of infected children contracted the virus from an adult. However, that means that 27 percent of infections were child-to-child, which is substantially more than 5 to 8 percent.

Still, the Chicago study only examined 15 households, and adult-to-child transmission remained far more common than child-to-child or child-to-adult.

Will someone in America contract Covid-19 from their sick child? Yes. Should I structure my life around such a rare occurrence? I do not think so.

Will opening schools lead to a second wave and more lockdowns?

We have reached the most challenging question to answer and one that is a holy grail for Covid-19 epidemiologists. I want to give you the plain answer here — we do not know.

An objective summary of the evidence in hand suggests that schools will play little role in sustaining the pandemic. A recent review of 210 transmission clusters around the world found that only eight of them (3.8 percent) involved school transmission. Case studies of outbreak investigations in Ireland, France, and Australia demonstrate almost zero cases of in-school transmission.

Modeling studies demonstrate no clear role of in-school transmission in explaining current Covid-19 epidemiology. All of this data tells us that despite our gut instincts and parental anxiety, schools will likely be okay this fall.

But the story does not end there. First, there are examples of in-school outbreaks that did force a second shutdown. Israel is an example.

Israel reopened schools with limited class sizes in early May and lifted class size restrictions on May 17. By June 3, they had to reclose after a major outbreak. The largest outbreak was 116 students and 14 teachers at one school. Per NPR, one child tested positive without symptoms and the school decided to quarantine the grade. Next, a child in a different grade tested positive and they closed the school.

At that time, they discovered that they already had more than 100 cases. It is not certain that all of those children were infected in the school, but the story is concerning and it raises the bar on monitoring our schools.

The data that’s available is mixed. If a person (or school district) wants to tell you that schools play little role in transmission, then ask them how their district is different from Israel’s. Why can an outbreak happen in that setting but not yours? Perhaps there is a reason, but until someone can give you a good one, be skeptical.

What are the risks of not reopening?

A discussion of school closures that focuses only on Covid-19 and not at all on education is incomplete. There are real risks to keeping our children at home. In fact, the risks of staying home are in many ways clearer than the risks of returning to school.

One study using statistical models projects major losses in math performance if we continue with remote learning until 2021. Perhaps more compelling than statistics, however, is some simple common sense.

On any given day, it is hard to point to the loss of learning from home. At the same time, we all agree that education is essential. If we keep our kids home for another school year, they will have missed 12 percent of their total education. I cannot identify the specific losses from that much absence, but I am confident there is a cost to missing that much school. For perspective, missing 12 percent of school time is the same as missing 22 days of school in a single year.

Further, the losses will not be equal. The “Covid-19 slide” will likely be greatest among the socially vulnerable, such as children with learning disabilities and those whose situation at home is not conducive to homeschooling.

We must also acknowledge that the losses will hit people of color much harder than those who are white. Further, school officials account for approximately 20 percent of formal reports of child abuse and domestic violence. Without school-based counselors and social workers, these concerns may not be investigated.

All of these harms weighed on the American Academy of Pediatrics’ guidance that school reopening plans start with the goal of having students be physically present in schools.

What should we do?

A great mentor of mine, Milton Weinstein at Harvard, is generally credited as being the person who introduced the field of medicine to the concept of rigorous decision-science. The central question to all decision-science is: “What should we do, given that we have imperfect information?”

Milt is fond of the expression “a decision has to be made.” His wisdom has never been more pertinent than it is today. We have to make a decision. There is no choice to do nothing, because either way — go to school or learn remotely — we are making a decision.

Unfortunately for all of us, we are making a decision with significant uncertainty about all the risks involved. Fortunately, this is not the first time that people have been forced to make decisions with uncertainty. There are approaches to making uncertain decisions in a way that maximizes the chances of a good outcome and minimizes the harm if the outcome is poor.

You’ve likely heard of one of them: hedging your bets. When multibillion-dollar investment funds make a choice to invest, they recognize that they could be wrong. They do not make all-in versus out decisions. Instead, they hedge their bets. They may think that the newest beach toy is destined for greatness, but just in case of a rainy summer, they also invest in umbrellas.

When I look across all the data, I see an uncertain decision. First, I propose that the balance of data we have now suggests that we need to try to open schools in the fall. The risks of reopening are uncertain; the harm of staying home is clear.

If your school district cites the data above to you that “schools are safe,” ask your school board: What is the plan beyond reopening? What if we are wrong? How will your district know that things are going well (or not well)? Don’t let the conversation stop at “data suggests that schools are safe.” Don’t let the plan stop with “symptomatic people should call their doctor.”

If we are going to open safely in the fall, we must have the capacity to know — quickly — when an outbreak occurs. Israel is an important cautionary tale. When Israel closed down its schools again, it had only identified two school-based cases, yet in the end it discovered that more than 100 students had been infected.

To do this well, and to do it safely, we must have school-based Covid-19 symptom screening, testing, contact tracing, and isolation. “School-based testing” does not mean that the test themselves must occur in school buildings. “School-based testing” means that students and teachers can easily access a test by contacting the school, and that the results of those tests are sent directly to the school district in real time.

That seems straightforward, but it is not. The community does not yet have adequate testing, contact tracing, or isolation. Schools currently have nothing.

It requires building new capacity in schools for testing and contact tracing. It requires a budget. It requires a formal plan. Ideally, that budget should come from the federal government and be directed to states and ultimately school districts, as part of a national Covid-19 testing strategy. Realistically, given the lack of any such national plan, the funds need to come from individual states.

Building such infrastructure comes at a cost and many districts are already facing budget shortfalls. Districts that rely only on their existing testing infrastructure will not have the real-time information they need to make good decisions. Imagine a child has a fever and cough in October and is told by the school to call the doctor for a Covid-19 test. Results are typically returned in two days to the doctor’s office. After another day (or two), the data might make it to the school district. So it will take at least four to five days for the district to have any information.

We need testing within the school system to shorten the delay at every step of the process and reduce the turnaround time for the test to only a day. With that kind of time resolution, we can increase awareness of the situation at our schools, along with the ability to react appropriately. Without it, we are flying blind and gambling with the health of our children, teachers, and community.

Ultimately, when I look at the decision about school as both a father and a scientist, I see a difficult decision that must be made despite uncertainty. The risks of opening are uncertain, but the benefits are clear. We need to try to reopen.

We have been wrong before about Covid-19. In March, the epidemiology world was quite confident that transmission could not occur before a person develops symptoms. Three months later, there is consensus that asymptomatic people were likely one of the main drivers of the pandemic. In March, the CDC and the US surgeon general told the public that masks play no role in controlling the spread of the disease. Now we see masks as a central component of our reopening strategies.

We could be wrong about schools, but we cannot afford to wait to find out for certain. We need school-based Covid-19 symptom screening, testing, contact tracing, and isolation. Opening without a plan to test is irresponsible and a gamble with our children’s health.

Benjamin P. Linas is an associate professor of epidemiology and an infectious disease physician at Boston University School of Medicine. Find him on Twitter @BenjaminLinas.

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Covid-19 testing in the US improved dramatically over the first half of 2020, but things now appear to be breaking down once more as coronavirus cases rise and outstrip capacity — to the point that the mayor of a major American city can’t get testing quickly enough to potentially avoid spreading the virus.

“We FINALLY received our test results taken 8 days before,” Atlanta Mayor Keisha Lance Bottoms tweeted on July 8. “One person in my house was positive then. By the time we tested again, 1 week later, 3 of us had COVID. If we had known sooner, we would have immediately quarantined. Perhaps the National Guard can help with testing too.”

Anecdotally, I’ve heard of similar delays across the country — people waiting days or even weeks for their Covid-19 test results after standing in lines for hours to get tested. Labs have warned about problems: Quest Diagnostics, one of the biggest lab companies in the US, said wait times for test results are now averaging between four and six days for most people.

“Basically, two things are happening,” Ashish Jha, faculty director of the Harvard Global Health Institute (HGHI), told me. “One is the outbreaks are getting much bigger, so the amount of testing we need to get our arms around the outbreak is going up. And second, what we did [before] was some tweaking on capacity issues to get ourselves up to 500,000 to 600,000 tests a day, but didn’t fundamentally address the supply chain problems.”

He added, “This was supposed to be the job of the White House. … But they just never have prioritized really building up a robust testing infrastructure for the country.”

The problems have become more localized than in previous months. New York and Connecticut’s testing capacity seems to be holding up pretty well, largely because their Covid-19 outbreaks seem to be under control for now. States where epidemics are raging, such as Arizona, Florida, and Texas, are where testing problems seem to be spiraling.

As Bottoms’s story conveys, this is a big problem for getting the coronavirus outbreak under control: Testing is crucial for controlling disease outbreaks because they let officials and individuals see when further action, such as isolation and contact tracing, is necessary. But if testing is slow or insufficient, it can’t show people they’re infected and need to take action until it’s likely too late. That’s especially true with Covid-19 because people can have the virus and spread it without showing any symptoms.

“This is the same story we heard in the earlier days of the outbreak,” Jennifer Kates, vice president and director of the Global Health and HIV Policy Program at the Kaiser Family Foundation, told me. “But it’s much worse because everyone felt like the US was a little caught off guard at the beginning. … What we’re learning now is that none of the things that should’ve happened in the interim [during lockdowns] happened.”

So as America faces a surge of new coronavirus cases, the testing delays threaten to make the pandemic even worse.

America improved its testing capacity — to a point

America made huge improvements in Covid-19 testing capacity over the past few months, largely due to local, state, and private action as President Donald Trump’s administration delegated the issue downward and said the federal government would act merely as a “supplier of last resort.”

Nonetheless, the improvements were substantive and real. The US went from testing hundreds of people a day (at most) in late February and early March to consistently hitting 500,000 to 700,000 tests a day in June and now July.

The benchmark of 500,000 tests per day was particularly important, as it was the minimum experts had long called for in order to get the pandemic in the US under control.

But as the country neared that benchmark, attention to testing seemed to plummet. The Trump administration, which had already delegated testing down to lower levels of government and private actors, especially appeared to lose interest: The country’s “testing czar,” Brett Giroir, stood down and went back to his regular job at the Department of Health and Human Services. Trump falsely claimed in May that “America leads the world in testing”; at his Tulsa rally in June, he said he told his people to “slow the testing down” because the rising case count made him look bad. (He later asserted that his statement at the rally was not a joke, despite White House officials insisting it was.)

As all this happened, many of the underlying problems with testing capacity remained.

For one, there’s still a lot of variation between states. While most states, as of July 8, had 150 new tests per 100,000 people per day — the equivalent to 500,000 daily tests nationwide — 18 states still didn’t.

The state-by-state situation looks worse through another metric: the test positive rate, or the percentage of tests that come back positive. If a place tests widely enough, allowing it to catch even the people who show few symptoms but could still spread the virus, it should have a low positive rate — typically below 5 percent, though some experts now argue for less than 3 percent. A high positive rate indicates only people with obvious symptoms are getting tested, so there’s not quite enough testing to measure the scope of an outbreak.

As of July 8, most states in the US had a positive rate above 5 percent, suggesting their testing capacity isn’t keeping up with the scale of their outbreaks.

The consequence is delays in testing results as the demand for tests outmatches the supply. So people can’t get their test results quickly enough to act on a positive report, preventing tests from achieving the exact goal they’re supposed to accomplish.

Testing was always supposed to scale with larger outbreaks

The diversion between many states hitting 150 daily tests per 100,000 people and still having positive rates that are too high exposes another problem: The call for 500,000 tests a day nationwide was supposed to be only the minimum. Experts always warned that if the Covid-19 outbreak got much worse, there would likely need to be even more testing to keep up with the rise in new potential patients and cases.

“There’s the testing capacity you need to get to the place of opening up, then there’s the testing capacity you need to be open,” the Kaiser Family Foundation’s Kates said. “Once economies start to open again, people start moving and returning to the public sphere, and there are outbreaks. If there’s not enough testing, and testing hasn’t been built along with contact tracing, you’re going to have this explosion that we’re seeing, and the testing is not going to catch up with it.”

Jha, from the HGHI — which was one of the more vocal advocates for the threshold of 500,000 tests — said he worries something got lost in his communications to journalists and government officials.

At the same time, Jha and the other experts I spoke to were always clear, at least to me, that the 500,000 benchmark was a minimum. In fact, even before the current testing problems, Jha and the HGHI said the number was likely too low to keep up with the US epidemic and called instead for a minimum of 1 million daily tests.

“We were the ones who generated the 500,000-a-day number. We did it based on a particular size of the outbreak,” Jha said. “Clearly, things have gotten much worse since then.” He added, “We’re learning. We’re trying to figure out how to control the virus and where the country should go. And obviously in that we’re going to be updating data as it goes along.”

With the positive rate, it’s a similar story. Thomas Tsai, a health policy expert at Harvard, said the real goal for the positive rate is 0 percent — when the coronavirus is vanquished. So it’s important for states not to get complacent just because they’re now below an “acceptable” maximum of 3 percent or 5 percent. “The tests are a mean to an end,” Tsai said. The metrics “are just signposts along the way to give you directions.”

But as Covid-19 cases dropped and plateaued for the greater part of May and early June, much of the public and officials may have become complacent with the testing situation. They set their attention to other issues, such as the rise of new Black Lives Matter protests. Trump and the rest of the White House stopped focusing on the topic, halting daily press briefings about Covid-19, perhaps as officials realized that the president’s botched response to the crisis had made him look much worse. Meanwhile, there was a push, from Trump in particular, for states to reopen as quickly as possible to boost the economy.

Now it’s clear that problems with Covid-19 testing remain.

Earlier on, the hurdles with testing were linked to supply chain problems: not enough swabs to collect samples, vials to store them, or reagents and kits to run the tests. Over time, those problems were fixed or worked around.

The issue, experts say, is that these kinds of problems were always bound to come back as testing demand increased. Fixing a bottleneck for kits may let the country get to 500,000 tests a day, but that bottleneck can easily come back if, for instance, the nation needs 1 million per day and there are only enough kits for 700,000.

Jha pointed to basic economic concerns as a key problem. “If we decided to tomorrow, do we have the technological capacity to be able to get many millions of tests a day? Absolutely,” he said. But labs aren’t sure that making the massive investment for way more tests is financially sustainable, he explained, especially as Covid-19 outbreaks ebb and flow — and, as a result, occasionally deplete demand for those tests, as well as the number of people who need them.

Ideally, the federal government would be in charge of handling these problems. It’s the one entity that can go to labs across the country, see what the holdups are, then work along the global supply chain to see what can be done to address the issues. It has the funding ability to ensure labs and suppliers remain whole. And it can prioritize limited resources to specific cities, counties, or states that need them most, instead of leaving these supplies to a free-for-all.

This is, in fact, what the federal government does with other issues — such as when it ensures that a manufacturer has all the parts needed for an order of guns, tanks, or jets.

“The military has visibility into the entire supply chain, and the military oversees the entire supply chain,” Jha said. “It may be working with private companies, but the [Department of Defense] doesn’t leave this all up to chance.”

The Trump administration, however, has described the federal government as a “supplier of last resort.” That’s very different from the kind of proactive approach the feds take on other issues to get ahead of supply constraints.

So the problem is left to private actors as well as local and state governments, which often face legal, financial, and practical constraints that hinder their ability to move quickly. And the problem persists, even as Covid-19 cases continue to rise.

Testing always mattered and still matters

It’s been said a countless number of times in recent months, but it’s still true: Testing is key to stopping the Covid-19 pandemic.

When paired with contact tracing, testing lets officials track the scale of an outbreak, isolate the sick, quarantine those with whom the sick came in contact, and deploy community-wide efforts as necessary. Aggressive testing and tracing are how other countries, such as South Korea and Germany, got their outbreaks under control, letting them partly reopen their economies.

This testing problem is solvable in the US. “New York at its peak had people dying in the hallways of hospitals. Test positive rates were routinely above 20 percent,” Tsai said. “Look at it now, with a test positive rate of about 1 percent. In Massachusetts, our positive rate is about 2 percent now. These states show that concerted efforts … can not just mitigate the pandemic, not just flatten the curve, but also contain and suppress the pandemic.”

This only works, however, if officials can move quickly on a test, preferably within 24 to 36 hours. In the time it takes to confirm whether someone either has Covid-19 or came into contact with someone who has it, the person is more likely to continue their typical routine, potentially infecting others in the public or even within their own homes. In this context, every day and hour matters to get people to stop the spread of the coronavirus.

Testing and tracing can’t solve the pandemic all on their own. They have to be paired with precautions such as wearing masks and keeping 6 feet apart in public. In extreme cases, lockdowns can still be warranted if an outbreak is so out of control that a stay-at-home order becomes the only way to reel things back.

Lockdowns, however, were also supposed to buy the nation time to build up its testing system. As Natalie Dean, a biostatistics professor at the University of Florida, previously told me, “The whole point of this social distancing is to buy us time to build up capacity to do the types of public health interventions we know work. If we’re not using this time to scale up testing to the level that we need it to be … we don’t have an exit strategy. And then when we lift things, we’re no better equipped than we were before.”

It’s now clear that the US didn’t take full advantage of the time it bought with lockdowns. While testing did dramatically improve compared to the early days of the pandemic, it’s still not at a point where America can handle the higher demand brought on by another surge in coronavirus cases.

“It’s pathetic. This is not how a first-world country functions,” Jha said. “That people should not expect to access a test to an infectious disease many, many months into a pandemic — I find myself amazed that this is where we are as a country.”

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In late March, when Covid-19 was first surging, Jake Suett, a doctor of anesthesiology and intensive care medicine with the National Health Service in Norfolk, England, had seen plenty of patients with the disease — and intubated a few of them.

Then one day, he started to feel unwell, tired, with a sore throat. He pushed through it, continuing to work for five days until he developed a dry cough and fever. “Eventually, I got to the point where I was gasping for air literally doing nothing, lying on my bed.”

At the hospital, his chest X-rays and oxygen levels were normal — except he was gasping for air. After he was sent home, he continued to experience trouble breathing and developed severe cardiac-type chest pain.

Because of a shortage of Covid-19 tests, Suett wasn’t immediately tested; when he was able to get a test, 24 days after he got sick, it came back negative. PCR tests, which are most commonly used, can only detect acute infections, and because of testing shortages, not everyone has been able to get a test when they need one.

It’s now been 14 weeks since Suett’s presumed infection and he still has symptoms, including trouble concentrating, known as brain fog. (One recent study in Spain found that a majority of 841 hospitalized Covid-19 patients had neurological symptoms, including headaches and seizures.) “I don’t know what my future holds anymore,” Suett says.

Some doctors have dismissed some of his ongoing symptoms. One doctor suggested his intense breathing difficulties might be related to anxiety. “I found that really surprising,” Suett says. “As a doctor, I wanted to tell people, ‘Maybe we’re missing something here.’” He’s concerned not just for himself, but that many Covid-19 survivors with long-term symptoms aren’t being acknowledged or treated.

Suett says that even if the proportion of people who don’t eventually fully recover is small, there’s still a significant population who will need long-term care — and they’re having trouble getting it. “It’s a huge, unreported problem, and it’s crazy no one is shouting this from rooftops.”

In the US, a number of specialized centers are popping up at hospitals to help treat — and study — ongoing Covid-19 symptoms. The most successful draw on existing post-ICU protocols and a wide range of experts, from pulmonologists to psychiatrists. Yet even as care improves, patients are also running into familiar challenges in finding treatment: accessing and being able to pay for it.

What’s causing these long-term symptoms?

Scientists are still learning about the many ways the virus that causes Covid-19 impacts the body — both during initial infection and as symptoms persist.

One of the researchers studying them is Michael Peluso, a clinical fellow in infectious diseases at the University of California San Francisco, who is currently enrolling Covid-19 patients in San Francisco in a two-year study to study the disease’s long-term effects. The goal is to better understand what symptoms people are developing, how long they last, and eventually, the mechanisms that cause them. This could help scientists answer questions like how antibodies and immune cells called T-cells respond to the virus, and how different individuals might have different immune responses, leading to longer or shorter recovery times.

At the beginning of the Covid-19 pandemic, “the assumption was that people would get better, and then it was over,” Peluso says. “But we know from lots of other viral infections that there is almost always a subset of people who experience longer-term consequences.” He explains these can be due to damage to the body during the initial illness, the result of lingering viral infection, or because of complex immunological responses that occur after the initial disease.

“People sick enough to be hospitalized are likely to experience prolonged recovery, but with Covid-19, we’re seeing tremendous variability,” he says. It’s not necessarily just the sickest patients who experience long-term symptoms, but often people who weren’t even initially hospitalized.

That’s why long-term studies of large numbers of Covid-19 patients are so important, Peluso says. Once researchers can find what might be causing long-term symptoms, they can start targeting treatments to help people feel better. “I hope that a few months from now, we’ll have a sense if there is a biological target for managing some of these long-term symptoms.”

Lekshmi Santhosh, a physician lead and founder of the new post-Covid OPTIMAL Clinic at UCSF, says many of her patients are reporting the same kinds of problems. “The majority of patients have either persistent shortness of breath and/or fatigue for weeks to months,” she says.

Additionally, Timothy Henrich, a virologist and viral immunologist at UCSF who is also a principal investigator in the study, says that getting better at managing the initial illness may also help. “More effective acute treatments may also help reduce severity and duration of post-infectious symptoms.”

In the meantime, doctors can already help patients by treating some of their lingering symptoms. But the first step, Peluso explains, is not dismissing them. “It is important that patients know — and that doctors send the message — that they can help manage these symptoms, even if they are incompletely understood,” he says. “It sounds like many people may not be being told that.”

Long-term symptoms, long-term consequences

Even though we have a lot to learn about the specific damage Covid-19 can cause, doctors already know quite a bit about recovery from other viruses: namely, how complex and challenging a task long-term recovery from any serious infection can be for many patients.

Generally, it’s common for patients who have been hospitalized, intubated, or ventilated — as is common with severe Covid-19 — to have a long recovery. Being bed-bound can cause muscle weakness, known as deconditioning, which can result in prolonged shortness of breath. After a severe illness, many people also experience anxiety, depression, and PTSD.

A stay in the ICU not uncommonly leads to delirium, a serious mental disorder sometimes resulting in confused thinking, hallucinations, and reduced awareness of surroundings. But Covid-19 has created a “delirium factory,” says Santhosh at UCSF. This is because the illness has meant long hospital stays, interactions only with staff in full PPE, and the absence of family or other visitors.

Theodore Iwashyna, an ICU physician-scientist at the University of Michigan and VA Ann Arbor, is involved with the CAIRO Network, a group of 40 post-intensive care clinics on four continents. In general, after patients are discharged from ICUs, he says, “about half of people have some substantial new disability, and half will never get back to work. Maybe a third of people will have some degree of cognitive impairment. And a third have emotional problems.” And it’s common for them to have difficulty getting care for their ongoing symptoms after being discharged.

In working with Covid-19 patients, says Santhosh, she tells patients, “We believe you … and we are going to work on the mind and body together.”

Yet it’s currently impossible to predict who will have long-lasting symptoms from Covid-19. “People who are older and frailer with more comorbidities are more likely to have longer physical recovery. However, I’ve seen a lot of young people be really, really sick,” Santhosh says. “They will have a long tail of recovery too.”

Who can access care?

At the new OPTIMAL Clinic at UCSF, doctors are seeing patients who were hospitalized for Covid-19 at the UCSF health system, as well as taking referrals of other patients with persistent pulmonary symptoms. For ongoing cough and chest tightness, the clinic is providing inhalers, as well as pulmonary rehabilitation, including gradual aerobic exercise with oxygen monitoring. They’re also connecting patients with mental health resources.

“Normalizing those symptoms, as well as plugging people into mental health care, is really critical,” says Santhosh, who is also the physician lead and founder of the clinic. “I want people to know this is real. It’s not ‘in their heads.’”

Neeta Thakur, a pulmonary specialist at Zuckerberg San Francisco General Hospital and Trauma Center who has been providing care for Covid-19 patients in the ICU, just opened a similar outpatient clinic for post-Covid care. Thakur has also arranged a multidisciplinary approach, including occupational and physical therapy, as well as expedited referrals to neurology colleagues for rehabilitation for the muscles and nerves that can often be compressed when patients are prone for long periods in the ICU. But she’s most concerned by the cognitive impairments she’s seeing, especially as she’s dealing with a lot of younger patients.

These California centers join new post-Covid-19 clinics in major cities across the country, including Mount Sinai in New York and National Jewish Health Hospital in Denver. As more and more hospitals begin to focus on post-Covid care, Iwashyna suggests patients try to seek treatment where they were hospitalized, if possible, because of the difficulty in transferring sufficient medical records.

Santosh recommends that patients with persistent symptoms call their closest hospital, or nearest academic medical center’s pulmonary division, and ask if they can participate in any clinical trials. Many of the new clinics are enrolling patients in studies to try to better understand the long-term consequences of the disease. Fortunately, treatment associated with research is often free, and sometimes also offers financial incentives to participants.

But otherwise, one of the biggest challenges in post-Covid-19 treatment is — like so much of American health care — being able to pay for it.

Outside of clinical trials, cost can be a barrier to treatment. It can be tricky to get insurance to cover long-term care, Iwashyna notes. After being discharged from an ICU, he says, “Recovery depends on [patients’] social support, and how broke they are afterward.” Many struggle to cover the costs of treatment. “Our patient population is all underinsured,” says Thakur, noting that her hospital works with patients to try to help cover costs.

Lasting health impacts can also affect a person’s ability to go back to work. In Iwashyna’s experience, many patients quickly run through their guaranteed 12 weeks of leave under the Family Medical and Leave Act, which isn’t required to be paid. Eve Leckie, a 39-year-old ICU nurse in New Hampshire, came down with Covid-19 on March 15. Since then, Leckie has experienced symptom relapses and still can’t even get a drink of water without help.

“I’m typing this to you from my bed, because I’m too short of breath today to get out,” they say. “This could disable me for the rest of my life, and I have no idea how much that would cost, or at what point I will lose my insurance, since it’s dependent on my employment, and I’m incapable of working.” Leckie was the sole wage earner for their five children, and was facing eviction when their partner “essentially rescued us,” allowing them to move in.

These long-term burdens are not being felt equally. At Thakur’s hospital in San Francisco, “The population [admitted] here is younger and Latinx, a disparity which reflects who gets exposed,” she says. She worries that during the pandemic, “social and structural determinants of health will just widen disparities across the board.” People of color have been disproportionately affected by the virus, in part because they are less likely to be able to work from home.

Black people are also more likely to be hospitalized if they get Covid-19, both because of higher rates of preexisting conditions — which are the result of structural inequality — and because of lack of access to health care.

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“If you are more likely to be exposed because of your job, and likely to seek care later because of fear of cost, or needing to work, you’re more likely to have severe disease,” Thakur says. “As a result, you’re more likely to have long-term consequences. Depending on what that looks like, your ability to work and economic opportunities will be hindered. It’s a very striking example of how social determinants of health can really impact someone over their lifetime.”

If policies don’t support people with persistent symptoms in getting the care they need, ongoing Covid-19 challenges will deepen what’s already a clear crisis of inequality.

Iwashyna explains that a lot of extended treatment for Covid-19 patients is “going to be about interactions with health care systems that are not well-designed. The correctable problems often involve helping people navigate a horribly fragmented health care system.

“We can fix that, but we’re not going to fix that tomorrow. These patients need help now.”

Lois Parshley is a freelance investigative journalist and the 2019-2020 Snedden Chair of Journalism at the University of Alaska Fairbanks. Follow her Covid-19 reporting on Twitter @loisparshley.