The COVID-19 pandemic is coming to a disastrous boiling point in the United States, with one of the nation’s top public health officials predicting a high death toll as the pandemic surges nationwide over the winter months.

“The reality is, December, January, and February are going to be rough times,” said Robert Redfield, MD, director of the Centers for Disease Control and Prevention (CDC). “I actually believe they are going to be the most difficult time in the public health history of this nation, largely because of the stress it is going to put on our healthcare system.”

Redfield, whose tenure at the agency ends in January 2021 with the change of administrations, spoke Dec. 2, 2020, to the U.S. Chamber of Commerce.1

“We really have a very extensive pandemic now throughout the nation,” he said. “In the month of November, unfortunately, we had over 1 million cases reported each week 4 million cases were reported. Our hospitalization rates are going up. Whereas in the spring we were talking about 20,000 to 30,000 people in the hospital, now we are over 90,000 people in the hospital.

“One of the most concerning things about the impact of the pandemic right now is to recognize that 90% of our hospitals in this nation are actually in what we call one of the hot zones, in the red zones,” Redfield said.

Underscoring a message that has fallen on too many deaf ears, Redfield emphasized that there now is scientific proof that masking prevents SARS-CoV-2 transmission. In a CDC study in Kansas, counties that adopted a mask mandate saw COVID-19 cases fall, while the disease continued to spread in counties that opted out and did not wear masks.2

“The time for debating whether masks work or not is over,” he said. “We have scientific evidence.”

When comparing counties that opted in, “they had about a 6% decrease in new cases per 100,000. Other counties [that] opted out of the mandate had over 100% increase in cases,” Redfield said. “Couple that with social distancing, handwashing, being smart about crowds, doing things more outside than inside these are critical mitigation steps. They have an enormous impact.”

The mask issue was politicized early, going from a common-sense public health measure to a badge of partisanship.

“I am disappointed in one thing as CDC director, and that was that the inconsistency of the American public embracing the message,” Redfield said. “Mask wearing is not a political discussion. This is a powerful public health tool.”

Without such measures, even if the vaccines begin to roll out to certain groups, the United States may see another 150,000 to 200,000 COVID-19 deaths by February 2021 bringing the overall toll to 450,000 in the United States during the pandemic, he said.

“Mitigation works we are not defenseless,” he says. “The challenge with the virus is, it is not going to work if [only] half of us do what we need to do. It is not even going to work probably if three-quarters of us do what we need to do.”

Home gatherings are driving some of the upsurge now, particularly since many infected people under age 40 years will have no symptoms.

“[They] don’t recognize it until, unfortunately, the virus gets transmitted and somebody that is vulnerable, older, ends up developing symptomatic illness, and they end up in the hospital.”

As one “example of hope,” Redfield said many colleges have been able to reopen after taking mitigation measures, using widespread screening to identify asymptomatic cases and quarantine them. This “silent” aspect of the pandemic had the CDC back on its heels during the early days of the pandemic.

“One of the big challenges that hit us with this COVID-19 pandemic was we had modeled it like severe acute respiratory syndrome (SARS) or influenza. SARS and influenza make you sick. So, it is not that complicated for you to have a case identification program that says, let’s look at people who are sick and [determine] if they have COVID-19 and then isolate, contact trace, and control the pandemic.”

But COVID-19 was not like those other respiratory infections. It could spread in the absence of cases, particularly from younger people. “Therefore, we had to say, wait a minute how do we then define the silent epidemic? How do we define asymptomatic transmission?” Redfield said. “We would argue going back to the college campuses. They figured out by doing regular weekly screenings of students, they are able to identify the asymptomatic infections and pull them out of the transmission cycle, isolate them, contact trace around them, and isolate those individuals, and control the output. There has to be a strategic use of testing.”

Lessons Learned

No doubt there will be a series of after-action reports and postmortem analyses, but Redfield’s immediate verdict is that the nation was “severely unprepared” for the pandemic.

“We have to call it like it is,” he says. “I wasn’t prepared to understand how little investment had been made in the capabilities of public health. And that is [for] the premier public health institution in our nation. We really have not invested where we need to be in day-to-day data analytics. We haven’t invested in what I call laboratory resilience, to make sure our public health capacity has multiple platforms. There is a huge lack of investment, which I hope this pandemic will change.”

The costs of the pandemic, including the economic implications, have been estimated in the range of $8 trillion to $20 trillion.

“It would seem wise for us to invest $100 billion across the nation,” Redfield said. “Remember, most of our CDC funding actually goes to the local, state, territorial, tribal health departments. In most of the states, we are the dominant funder of the public health infrastructure of those state or local communities. It is time for this nation to have the public health system that we not only need, but we deserve.”

Another “painful lesson” is how critical it is to have agreement and harmony in messaging.

“When you really want to get everybody on board, you have to have clear, unified, reinforced messaging,” he said. “The fact that we were still arguing in the summer about whether or not masks work was a problem.”

The closures of businesses and schools and the shutting down of many healthcare procedures went too far and should be rethought for the next pandemic, he said.

“What did we learn that works?” Redfield said. “What did we learn that didn’t work? So, the next time this happens and there will be a next time this nation will be much more prepared.”


  1. C-SPAN. CDC Director Dr. Redfield on the surge in COVID-19 numbers. Dec. 2, 2020.!
  2. Van Dyke ME, Rogers TM, Pevzner E, et al. Trends in county-Level COVID-19 incidence in counties with and without a mask mandate — Kansas, June 1-August 23, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1777-1781.