The next phase of the U.S. pandemic? Pockets of localized outbreaks.

People in Fairbanks, Alaska’s second-largest city, have embraced a return to normalcy. Alaska made national headlines in March as the first state to make vaccines available to any adult, and as the snow melted into a long-awaited spring, restaurants were packed, church pews were full, and schools reopened for in-person classes.

Yet signs of trouble became apparent before the trees had even budded. Demand for vaccinations swiftly plateaued; in early April, clinics could no longer fill their appointments. In the last two weeks of April, COVID-19 cases in the Fairbanks North Star Borough rose by 253 percent, and test positivity rates doubled to more than 10 percent. Fairbanks Memorial Hospital, which serves the entire Alaskan Interior, was soon wrestling with its largest spike of the pandemic.

No single outbreak or super-spreader event drove Fairbank’s surge, says Angelique Ramirez, a physician and the chief medical officer of the main health care system in Fairbanks. Rather, this spike is the inevitable result of reopening with low vaccination rates. As such, it’s a grim preview of what could be the next phase of the pandemic in the United States.

Ramirez describes the surge as “sobering.” The hospital hit its capacity in early May, and for three days, administrators had to consider whether they could care for every patient before admittance, sending cases as far away as Anchorage and Seattle. As the only hospital in the area, she was worried what might happen if her family got in a car accident, or needed even non-COVID medical care. “That’s just a serious point,” she says. “And we got there so quickly.”

The vaccines have proven highly effective at preventing severe disease and reducing transmission, and so far, the mRNA vaccines have proven effective against known variants. “But despite the Biden administration’s success in expanding vaccine campaigns, only 39 percent of the U.S.  is fully vaccinated—leaving many Americans still vulnerable.”

Resurgent epidemics

Fairbanks is not alone in seeing a disturbing number of cases. In many states, including Washington, Colorado, Michigan, and Maine, among the unvaccinated, transmission is still at winter-surge levels.

Public health experts warn that even as continuing vaccinations reduce the daily number of cases nationally, ongoing—and sometimes epidemic-scale—regional outbreaks will continue. A recent Centers for Disease Control and Prevention report suggests that by September 2021, “some states could reach levels of disease similar to those observed in late 2020.” The national average wouldn’t see resurgences in that size, because vaccinations will protect some communities.

Justin Lessler, a co-author of the report and an associate professor at the Johns Hopkins Bloomberg School of Public Health explains that every model has to make certain core assumptions, like the impact of interventions like masking. The report combined data from six different models, to improve accuracy and integrate different modeling decisions. It forecast a continuum of scenarios, from optimistic to pessimistic, with a lot of variability in potential outcomes—driven, in part, by how quickly people are vaccinated. Although, Lessler warns, “we can’t forecast human behavior.” Lessler says that in scenarios where there is a low vaccination rate and a lack of control measures—like in Fairbanks and much of rural America—“you start seeing resurgence epidemics in late summer and fall.”

Lessler adds that the recent CDC announcement that fully vaccinated people don’t need to wear masks in public places has led to “relaxing measures much more quickly, which could lead to significant resurgences.” The concern is that because there’s no easy way to verify who has been jabbed, unvaccinated people may choose not to wear masks, increasing risk for themselves and others. In fact, market-research firm Cardify looked at surveys and consumer spending and found that people who don’t plan to get the vaccine were more likely to go out to restaurants, salons, and other venues than those who have been vaccinated. Yet some states, like Texas, have gone as far as preemptively banning vaccine verifications. Theresa Chapple-McGruder, an epidemiologist, scoffs at the idea of an honor system for masking. “We don’t say get a driver’s license, but you don’t have to carry it.”

Masks are also coming off at the same time as more infectious variants are rising. The variant named B.1.1.7, which is about 50 percent more contagious than the original strain, is now responsible for the majority of U.S. cases. So far, there have been very few breakthrough cases, where people who have been vaccinated still get infected: about one in 10,000. But the risk of breakthrough infections increases when transmission is high in the community. That’s one reason many have criticized the communication of the new mask guidelines. The problem is in the policy that has been made as a result, which focuses on individual decisions, rather than on protecting vulnerable populations as a matter of policy. Public health, Chapple-McGruder says, is not just large-scale individual medical care. “When we’re hearing advice geared toward individuals, we’re missing the boat,” she says. “We need system-level approaches to ensure the public is healthy.”

Compounding disparities in rural areas

Future outbreaks will likely be centered around those left vulnerable by low vaccination rates. “Right now, we’re at the level that we were in June of last year. We considered it horrific then, and now, we’re all opening up,” says Alan Morgan, chief executive officer of the National Rural Health Association (NRHA), who studies county-level data daily.

For some, vaccine hesitancy is the root of the problem. NRHA recently conducted a survey of almost 200 hospitals and found that even though healthcare workers have had access to shots for months, a third of rural hospitals reported that less than half of their employees had been vaccinated. Morgan notes that may cause a workforce problem if these employees get sick, making these communities less able to respond to surges. A recent Kaiser Family Foundation survey found that three in 10 Republicans, essential workers, and younger adults say they will definitely not get vaccinated. Rural residents also say they are less likely to wear a mask.

“There’s a real risk of a slow burn in rural places which the country ignores,” Morgan says. “The fact of the matter is I’m worried about rural America being a reservoir for COVID.”

These are often areas with already fragile health-care systems. Rural populations tend to be older, as well as health-compromised, whether from jobs with greater occupational hazards, or from difficulties accessing preventative care, explains Tom Mueller, assistant professor of sociology at Utah State University. “It’s hard to get rural healthcare, and it’s likely only gotten worse during the pandemic,” he says.

But he adds, “It’s important to remember rural America is not a monolith—it’s not just conservative white people.” There are also significant Black, Latino, and Native American rural communities, for whom, Mueller suspects, it’s more about access than hesitancy. Another Kaiser Family Foundation survey supports these suspicions; they found that less than half of Black adults say their rural communities have enough vaccine supply, compared to 59 percent of white rural adults.

Cities have similar equity issues, says Julia Raifman, who conducts research on health and social policies as an assistant professor at Boston University. “It’s not really a surprise that there are large racial and ethnic disparities in vaccinations,” she says. “That’s a logical result of our prioritization policies.” She points to structural barriers, like the ability to take time off work to recover from side effects, or transportation to get to vaccine appointments. Even being five miles from a clinic, as the Biden administration says 90 percent of Americans now are, is a hurdle if you don’t have access to a car. “I not only expect there will be outbreaks, but that the people most affected will continue to be Black, Latinx, and Native American,” Raifman says.

As the pandemic shifts into a new phase, Chapple-McGruder is concerned about children, who she says are now seeing a disproportionate burden of disease as adults get vaccinated; Texas and Iowa have nevertheless banned masks in schools. Morgan predicts that workplace exposures will continue to be significant. Last summer, he was able to anticipate surges in communities that have summer resort destinations, major truck stops, or processing plants—”communities where people travel in, congregate, and travel out again.” It’s a dynamic he expects will repeat this summer. Raifman adds the new CDC guidelines will exacerbate these disparities by removing indoor masking before many essential workers have a chance to be vaccinated.

For Ramirez, the new recommendations are also making it harder to do her job. Despite Fairbank’s surge, doctors and nurses at Fairbanks Memorial Hospital have been frustrated by patients refusing to wear masks within the hospital, which follows CDC guidelines for healthcare facilities that all individuals should be masked, regardless of vaccination status. She says the hospital has also had patients and family members who didn’t believe their doctors’ diagnoses. “When people tell you to your face they don’t believe what you’re saying—that really hits the core of the relationship between caregivers and patients.” And when patients don’t get better, it adds to the staff’s trauma. “It’s really hard when people die of preventable illnesses, and even harder when it’s a young person,” she says. “This didn’t have to happen—that pulls at people.”

The situation in Fairbanks is improving now; Ramirez says that as a low-density area, it doesn’t take much to reduce transmission, highlighting the importance of behavior. But looking ahead, Ramirez says she’s afraid COVID-19 is going to be an endemic disease in Alaska. “I think we lost our chance,” she says, referring to Alaska’s plateauing vaccination rates. “Which really brings home that until we have a significant number of people vaccinated, or people wear masks, we are at risk.”