SAN FRANCISCO – Nearly a year into a life-altering pandemic, many Americans are fed up with wearing masks, desperate for a return to normalcy and numb to the relentless stream of grim numbers, such as the 500,000 COVID-19 deaths the USA is about to surpass.

Health care workers don’t want to hear any of that.

They have been working endless hours amid constant death and suffering, forsaking time off and exposing themselves to the disease, leaving them exhausted and with no real indication of when the pandemic will relent.

“There’s definitely some tangible fatigue on the health care workers’ side, being sick of COVID and sick of people disregarding public health guidance, getting sick and expecting us to defer another vacation or put off something else,” said Eric Cioe-Peña, an emergency room physician running a COVID-19 field hospital in Staten Island, New York. “I’ve been telling people who thank me for this, ‘Just tell yourself and everyone you know to wear a mask when you’re out in public places. Don’t clap, don’t give me baked goods. I don’t need any of that. I need you to wear a mask and not get COVID.’”

The toil has taken a toll. The Centers for Disease Control and Prevention has recorded nearly 409,000 coronavirus cases and 1,438 deaths among health care personnel nationwide, but the agency acknowledges its data is incomplete. A report in late December by Kaiser Health News and The Guardian said the number of fatalities was closer to 3,000.

The arrival of vaccines in mid-December has removed some of the worry for medical workers, who were at the front of the line for inoculations.

Michael Daignault, an emergency room physician at Providence St. Joseph Medical Center in Burbank, California, recalls the joy and relief among his co-workers when they got vaccinated. Several posted online photos of themselves getting the shot, which he said may have helped convince some people that the vaccine is safe.

But Daignault also remembers the exasperation he felt watching his fellow Los Angeles County residents ignore health advice as infections piled up and turned the area into the center of the COVID-19 calamity over the winter.

“Last year was super frustrating for me because I worked most of the major holidays – July 4, Memorial Day, Labor Day, Thanksgiving – with the exception of Christmas,” Daignault said. “Listening to the radio driving to work, they’re saying, ‘Please don’t congregate over the holidays, or we’re going to contribute to the spread.’ And it seemed like Los Angelenos celebrated every holiday last year.”

LA, by far the most populous county in the nation, has recorded 1.18 million coronavirus cases and almost 20,000 deaths, more than double the totals for any other county. That has raised concerns about the long-term mental health effects on medical workers there and in other highly affected areas.

Burnout, leaves of absence among medical workers

Julita Mir, an infectious disease physician and the chief medical officer at Community Care Cooperative in Boston, said she and her colleagues draw strength from their commitment to serving the community at a clinic with a large percentage of low-income patients.

She has seen a significant number of nurses, medical assistants and physicians take leaves of absence to care for family members who got sick or for children who couldn’t attend school in person. Amid the COVID-19 burnout she has noticed, Mir wonders what life will be like afterward, and when we’ll get there.

“Thinking about new variants that may be so different that maybe the vaccine I got a month ago is not going to work in six months, it makes me want to cry,” she said. “We have to hope that at least it provides some protection.”

Even as the USA becomes the first country to reach half-a-million COVID deaths – the actual figure was 497,823 as of Sunday morning EST – there are signs the pandemic may be abating, from the decreasing number of cases, hospitalizations and fatalities to the improved vaccine rollout and production. 

Amid this hopeful scenario, the emergence of coronavirus variants scrambles the picture of what the near future may look like.

Will most students be able to return to schools in the coming weeks, or will a proliferation of infections fueled by variants keep them learning remotely? The CDC reported more than 1,500 COVID-19 cases caused by variants, the majority of them by the one that originated in the United Kingdom.

When will vaccines be readily available to all Americans? The answer has been a moving target, shifting from as early as April to late July, the timeline mentioned by President Joe Biden.

The CDC projects the highly transmissible variant first identified in the U.K. could become the dominant U.S. strain by the end of March. Variants first found in South Africa and Brazil, both believed to be somewhat more resistant to vaccines, have also been detected in this country, along with domestic variants.

Some public health experts worry the variants could prompt a spring surge that may negate many of the gains made since the nation endured a post-holiday spike that peaked with a one-week average of nearly 250,000 new infections per day in early January. That figure is now around 67,000, still considerably higher than the averages in the 40,000 range during parts of August and September.

Closing in on the one-year anniversary of the coronavirus outbreak being declared a pandemic – March 11, 2020 – it’s still not clear when the United States, which has reported more than twice as many cases and deaths as any other country, will have a hold on the health crisis.

“The curveball is the variants, but I don’t think it’s a big enough curveball that we can’t hit the pitch,” said Dr. Robert Wachter, who chairs the Department of Medicine at the University of California-San Francisco. “They’re coming, they’re growing, but the good news is the main one we’re seeing and are worried about is the British one, and the vaccines work essentially as well as they do for the old virus. So it’s just a matter of whether we can get enough people vaccinated quickly enough to stay somewhat ahead of the variants.”

Reasons for optimism amid the reality   

After a slow and troubled start to vaccination programs, the United States has picked up the pace and inoculated almost 43 million people, 18 million of them with both of the required shots. At the distribution rate of 13.5 million doses a week, Biden’s promise of 100 million shots in his first 100 days in office looks easily achievable and, in fact, may be too conservative. Critics said that won’t be enough to stay ahead of the variants and that 2 million-3 million shots a day should be the goal.

Public health specialists draw optimism from the likelihood a new Johnson & Johnson vaccine will be authorized soon, providing a valuable tool that requires only one shot and normal refrigeration, major benefits when trying to reach distant communities. Another vaccine from the Maryland firm Novavax may be next in the pipeline, and the discovery that the Pfizer vaccine is 85% effective weeks after the first dose could increase the supply as well.

Daignault said vaccines other than those produced by Pfizer and Moderna “were not given their day in the sun by the media because of decreased effectiveness against the variants. But what they missed was that all the vaccines reduced serious illness and death from all the variants.”

Wachter’s also bullish on the findings, still preliminary, from studies that indicate those who have been infected need only one shot of the vaccines to get complete protection. That could free up millions of the scarce doses.

Though the reported number of Americans who have contracted the coronavirus is upward of 28 million, some researchers said the actual amount is four times that many, about 110 million, largely because so many cases are asymptomatic and lots of infected people never got tested.

People who have had COVID-19 are presumed to have a high level of immunity, based on the small number of known reinfections. Between the 110 million who might have contracted the virus and the 43 million with at least some protection from the vaccines, “you have enough non-susceptible people to create enough down pressure that the variants may not take off in the way that we fear,” Wachter said.

Regardless, CDC Director Rochelle Walensky and other members of the Biden administration emphasize the need for vigilance and adherence to well-known practices such as wearing masks and maintaining social distance.

Ken Thorpe, a professor of health policy at Emory University in Atlanta, said the importance of a consistent message from the federal government in times of crisis can’t be overstated.

“That’s seemingly simple, but it’s a dramatic departure from last year. You now have a clear message,” Thorpe said. “The Biden administration has said this is real, the problem’s going to get worse before it gets better. Just making sure people understand this is not to be underplayed, it’s not a hoax, the numbers are real, but we can do things with social distancing and masks to mitigate the transmission.”

Reaching out to underserved communities

At the state and local levels, experts see danger signs in some governments lifting restrictions and mask mandates. The influential model of the University of Washington’s Institute for Health Metrics and Evaluation projects 589,000 deaths by June 1, a gloomy reminder of the damage COVID-19 continues to inflict.

That forecast takes into account the impact of vaccines, which will need to reach distant and reluctant populations for the USA to achieve the approximately 80% protection required for herd immunity.

Cioe-Peña and Mir, both of whom speak Spanish and tend to diverse patient populations, say the best way to connect with hesitant communities is through their trusted leaders, such as pastors, teachers and doctors from local clinics. Conducting vaccine education sessions in the native language of immigrants would also help.

“You can’t just throw up a vaccination center in a poor area and say, ‘Come in, we’ll do it,’” Cioe-Peña said. “You really have to engage the leaders, explain the process, facilitate registration. Without doing that, you’re not going to engage them as well.’’

Mir said most of her patients don’t own a computer or lack the skills to make a vaccination appointment online, so they’re liable to be left behind without outreach. Some are distrustful of vaccines, including an 85-year-old Puerto Rican man who suggested she find someone older to be the first in line at her clinic. She explained in Spanish why he should get the shot, and he agreed.

Mir learned of some aversions she wasn’t aware of while giving a talk to the staff members of a nursing home that employs a high number of immigrants.

“I got questions like, ‘Does the vaccine have any pork or any animal products? My religion doesn’t let me eat or take anything that’s animal-related, so I’m not going to take the vaccine,’” Mir said. “These are things I had not come across. They don’t trust their government, and they think this government is hiding something.”

Those are some of the challenges the United States faces as it conducts the largest vaccination campaign in its history, hoping to arrest the march toward 600,000 COVID-19 deaths. It’s too late to avoid getting to 500,000, more than twice as many as reported in Brazil, a distant second on the somber list.

Daignault called the 500,000 milestone “heartbreaking,” thinking back to his grandfather’s participation in the D-Day invasion during World War II, a conflict that claimed the lives of about 405,000 U.S. service members.

“I have a bunch of pictures of him on my wall,” Daignault said, “and when I go into work every day, I look at those pictures and feel like, ‘This is my D-Day. This is our generation’s D-Day here. This is our fight.’”

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