As the U.S. wades deeper into a brutal fall surge of the coronavirus, Americans are living under a growing list of restrictions aimed at curbing the exponential rise of COVID-19.
They come in all shapes and sizes.
California has resorted to a curfew. Other states — including Oregon and Washington — have moved to partial lockdowns, shuttering sectors of the economy and limiting social gatherings. Quite a few states are trying to find a middle ground that staves off the economic pain of closing businesses altogether and ordering people to stay home.
But given the unrelenting advance of the virus, can these varied approaches make a difference? Or is it delaying the inevitable return to the sweeping lockdowns of the springtime?
"It's really hard to slow it down once it gets going like this," says Don Milton, professor at the University of Maryland School of Public Health. "That's when these awful draconian measures come into play."
The Trump administration has reiterated that any kind of national lockdown is off the table.
A top adviser to President-elect Joe Biden has even pushed back on using the term "lockdown" to describe what many states did during the spring and has indicated that would be too heavy-handed a response.
Yet the U.S. faces continued growth in cases — with more than 1 million in the last week alone and an all-time high of over 85,000 hospitalizations. For the dark weeks ahead, the scattershot approach to the pandemic — where each state or region is left to sort out the trade-offs — will likely define the U.S. public health response.
"We're going to see a sputtering of shutdowns in the same way that we saw only haphazard shutdowns in March, April and May," says Dr. Michael Mina, a professor at the Harvard T. H. Chan School of Public Health, who has advocated for a nationwide rapid testing program.
"My concern is this is going to lead to the worst of all options, where we're going to have massive economic destruction and the virus is barely going to be dented at a national level."
Lockdowns work — but at a price
To see a place that's returned to strict lockdown, look to New Mexico.
Calling it a "matter of life and death," Gov. Michelle Lujan Grisham ordered residents to shelter-in-place on Nov. 16 and closed all "nonessential" businesses for two weeks. (This does not include big-box retailers.)
Broad lockdowns do work as a measure of last resort, says Ana Bento, an assistant professor at the School of Public Health at Indiana University Bloomington.
It's the simplest, most blunt tool to break the chain of transmission, which reduces the probability of people getting infected and lightens the load on the health care system.
"That's the whole purpose of it," Bento says.
Much has changed since the spring, but evidence shows those lockdowns were quite effective.
For example, Delaware's stay-at-home order dramatically changed the course of the state's outbreak after being implemented in mid-April. That policy decision, along with a mask mandate and contact tracing, led to an 88% reduction in COVID-19 hospitalizations and a 100% drop in mortality from late April to June, according to a recent analysis from the Centers for Disease Control and Prevention.
Another study found that, in many places, shelter-in-place orders and closing restaurants, bars and entertainment venues did substantially slow the spread of the virus.
"The lockdown as a strategy, if implemented absolutely correctly, in an ideal utopian world, would be very effective," says Bhramar Mukherjee, professor of biostatistics and epidemiology at the University of Michigan School of Public Health.
But aggressive lockdowns crush the economy and are tremendously difficult to sustain without a well-coordinated national strategy and a strong safety net.
"What we learned from April is that blanketed, blind lockdowns cannot be withstood for a long period of time," Bento says. "People get fatigued, and they get desensitized about the risks."
A major shortcoming of the U.S. spring approach was not only the patchwork of different policies, but also that restrictions were relaxed too quickly in many places. And many states did not have enough testing and contact tracing in place to stomp out outbreaks that led to wider community spread, according to a recent modeling study.
Ultimately, the decision to shut down parts of the economy is political and hinges on how much disease and death states are willing to tolerate. Parts of the Midwest and West have reached staggering per-capita rates of infection yet have not gone into lockdowns or substantially curtailed businesses. Some governors have vowed not to go there.
What else works? A surgical approach based on local data
In many states, there is hope that dialing up targeted restrictions can avert broad shutdowns, and in some places that may be feasible.
The targeted approach is not easy to pull off, either.
Ideally, the restrictions are coordinated, based on local data gleaned from contact tracing that show when and where most people are getting infected in that region, Bento says.
"The goal is to do it surgically with the least economic and social pain," says Gregg Gonsalves, an assistant professor in the Department of Epidemiology of Microbial Diseases at the Yale School of Public Health.
Gonsalves says there is no "boilerplate" list of restrictions to avert a full lockdown, but there are obvious places to start, such as businesses that lead to people crowding inside together for long periods of time.
He says states that have scaled up testing and kept the virus in check are in a better position to quell the rising case numbers, but in other parts of the country, these more circumscribed strategies can falter.
"For places in the Midwest and the Upper Plains, where the virus is sort of everywhere, it's going to be very hard to use testing to target our interventions," Gonsalves says.
Lacking local data, communities can learn from research and the experience of their neighbors. Here's what research and experts say about the effectiveness of common restrictions and mandates:
Mask mandates: There's unanimous support for these among researchers. It's clear that such mandates curb the growth of the virus, and even some governors, such as Iowa's and North Dakota's, who spent much of the pandemic refusing to issue them, have relented as their hospitals near crisis. More than a dozen states still don't have universal face mask mandates.
Curfews: Experts have mixed views on these. In states such as New York and Massachusetts, late-night curfews are aimed at the most high-risk settings, including restaurants and bars. Much of California is now under a curfew between 10 p.m. and 5 a.m. State health officials said that move will cut down on nighttime social activities when people let their guard down and may spread the virus.
Ohio's curfew baffled some public health experts: "I haven't met a single public health official who thinks these types of curfews/10pm shutdowns will be particularly helpful," tweeted Tara C. Smith, a professor of epidemiology at Kent State University, in reaction to Ohio's action.
This kind of curfew may help bring down cases in the short term, Indiana University's Bento says, but it would need to be in place long term to decrease transmission significantly.
Limits on gatherings: Research shows superspreading events play an outsize role in the transmission of the coronavirus, including weddings, funerals, choir practices and other similar communal events. Some states, especially those that have resisted closing businesses, have enacted measures limiting the size of such gatherings or banning them outright.
And some have left in exceptions that appear to contradict their other policies. Indiana has exempted religious services from its rule on crowd limits, even though multiple outbreaks have been linked to places of worship.
Closing (or limiting capacity) at restaurants and bars: This appears to be the "single, most effective social distancing order," according to preliminary research from Harvard and Google.
Another study found that reopening full-service restaurants was "particularly risky," along with fitness centers and places of worship. Using cellphone location data from the Chicago area, the researchers showed that capping maximum occupancy at 20% in these most high risk settings could cut down new predicted infections by 80%.
But some experts say limiting the number of people is probably not enough when they are indoors, where the risk of catching the virus goes up substantially.
"We should certainly shut down restaurants and bars first before anything else," the University of Maryland's Milton says, "not just cutting back, but shutting them down."
Closing down K-12 schools: This is a particularly contentious measure. Recent research suggests that schools are not leading to large outbreaks as initially feared and may be able to stay open safely, but there are still substantial risks if there is rampant community spread. After keeping schools open for a fraction of students, New York City has again halted in-person learning because the city has surpassed a COVID-19 positivity rate of 3% — a threshold agreed upon by the teachers union when schools restarted.
Perils of the scattershot approach
For all these restrictions, Bento says, there could be a "race to contact" when the policies are relaxed and people are eager to start interacting again.
"While these work short term, if they aren't implemented for a long enough time to truly decrease transmission, once they are relaxed there will be a rebound of cases," she says.
With the virus spreading at record speed, it's still far from clear that even data-driven, tailored approaches will work, given the enormous reach of the virus and the coming holiday travel season.
Ultimately it's like there's a fire raging, but you're only able to douse the spot fires and wait for help.
"We are putting out fires as they happen," Bento says. "This is not a long-term solution."
She and other experts say what's really needed is widely accessible rapid testing, a robust system of contact tracing and eventually the vaccine.
There is progress on some of these fronts, but the pandemic is moving at a breathtaking pace, and the health care system is already starting to buckle under the growing number of patients.
Some public health experts say the U.S. may not be able to afford to wait for those interventions to be ramped up.
"I do think a shelter-in-place order is probably what we really need right now," Columbia University epidemiologist Jeffrey Shaman says.
NPR's Nurith Aizenman contributed to this report.
This story was published as part of a partnership with Kaiser Health News.