PITCH: Six years ago, an epidemiologist put her baby in a carrier, sat down at her dining room table, and started typing because she couldn't believe how little trustworthy information existed about Covid-19. Now she's asking: what have we learned — and what are we still refusing to do differently? This piece contains the surprising finding that trust, not healthcare infrastructure or population density, predicted which countries survived the pandemic best.
Six Years of Real Progress and Real Stubbornness
Katelyn Jetelina reflects on six years since the start of her newsletter, Your Local Epidemiologist. A lot has changed — and continues to change.
Covid-19 is no longer the third leading cause of death. It now carries roughly the same severity as the flu. While flu is nothing to dismiss, this virus not being a top killer represents genuine relief. Peaks are getting smaller with each successive wave, a pattern reflected in almost every metric including hospitalizations.
This isn't surprising: as collective immunity builds, the virus has a harder time breaking through. SARS-CoV-2 continues to evolve along the same narrow path toward less dangerous forms — similar to how the coronaviruses causing the common cold emerged over time. We're clearly not there yet, but the trajectory is meaningful.
Hospitalization rates show two waves each year: one in winter, one in summer. But over the past two years, the summer wave has been larger than the winter wave. We don't know why.
Unfortunately, vaccination rates continue to fall. Roughly 3.5 million fewer older Americans were vaccinated this year compared to last year. That means 3.5 million people in the highest-risk group are now less protected from a largely preventable disease.
The Unknowns That Should Keep Us Humble
There's still a lot we don't know. It strikes how much remains unknown about this virus six years in.
Long Covid — physical symptoms persisting weeks or months after infection — is still poorly understood, with millions of people living with fatigue, cognitive impairment, and cardiovascular effects that medicine is only slowly grappling with. We know risk has decreased alongside the decline in severe acute disease, but we still lack reliable data on the extent of that decline, and we still have no effective treatments.
Vaccine dosing for older adults is another gap. Current guidance recommends two updated vaccine doses per year for older adults: one in the fall and one in the spring. But robust data on whether two annual doses offer better protection than one is still extremely limited.
We also still don't have a clear, honest accounting of which interventions worked during the biggest health emergency this country has faced in more than 100 years — what works best to slow the spread of Covid-19. This is mind-boggling given all we sacrificed as a society, let alone how ill-prepared we are for next time.
The Real Crisis Is Trust
When researchers compared countries that fared well during Covid-19 to those that didn't, they looked at healthcare infrastructure, population density, universal healthcare, age distribution, how many vaccines they got, and a ton of other factors. But the strongest predictors weren't any of these.
It was trust: trust in government, trust in institutions, trust in each other. Countries where people broadly believed their neighbors and leaders were acting in good faith did measurably better.
The United States ranked among the lowest among high-income countries. Six years later, it's getting worse. Federal leadership has promised to restore trust. But the latest data show record-low levels of trust in government overall, and specifically in health agencies; trust is eroding further day by day.
Lack of transparency, full-on destruction of systems and capabilities, partisan attacks, lack of accountability, performative acts without real change, and a failure to listen to the public are all contributing to it.
Public health isn't providing an alternative path forward either. Many institutions and leaders are stuck in defense mode, circling the wagons to preserve the status quo, or paralyzed, afraid to take even one step forward. Wishing we could return to 2019 is not a plan.
Public health systems saved many people, but they also failed many. Some appetite for change is emerging here and there, giving hope that things might improve — but not at the pace that meets the urgency of the moment. The health of Americans and biosecurity depend on it.
"The strongest predictors of Covid-19 infections wasn't healthcare infrastructure, population density, or universal healthcare — it was trust."
Bottom Line
Jetelina's strongest argument is the undeniable data: trust in institutions predicted pandemic outcomes better than any traditional measure of public health capacity. Her biggest vulnerability is practical — we still lack evidence on basic vaccine dosing questions for older adults, and no one has clearly catalogued which interventions actually worked. The reader should watch for this: even as Covid's severity diminishes, the crisis of institutional trust may pose a bigger threat to future preparedness than any viral variant.