But this? This is like nothing else.

As the Memorial Day weekend ushered in the summer season, the 75 lifeguards, beach ambassadors and cashiers working for Bongiovanni all wear face masks. Hand sanitizer stations are set up at every entrance on the mile-long beach. A freshly painted yellow line divides the boardwalk with white arrows directing patrons to stay in their lanes. Hundreds of benches have been rounded up, wrapped in yellow crime tape and corralled in a pen to discourage stopping and sitting. And every 50 feet, signs remind visitors about social distancing, a phrase that meant nothing to anyone three months ago and is now as common as the novel coronavirus it is meant to contain.

The opening of New Jersey’s beaches and boardwalks is among the state’s first hopeful steps toward some kind of normal after a spring that was anything but. People want to be outside. Business needs to come back. But the worry hanging in the air at the shore won’t be blown away by a brisk ocean breeze. Bongiovanni and his staff are keeping a hawk eye on the crowds – monitoring spacing, mask-wearing and the numbers.

“The overcrowding thing. We really don’t want to be in that situation,” he said Friday, standing on the boardwalk wearing his red Asbury Park windbreaker, shorts, sunglasses and still looking as fit as most 18-year-old lifeguards. “We’re not just going to allow a free-for-all. When we see it’s getting saturated, we’ll stop selling beach passes. Our focus is going to be on being safe.”

Up and down the Jersey Shore, that’s the mantra as the pandemic summer begins: Safety first, safety first.

New Jersey doesn’t need any more death. A brutal stretch since March has claimed the lives of 11,081 residents as of Saturday. As the U.S. death toll closes in on 100,000, New Jersey accounts for more than 11 percent of the nation’s fatalities. Only New York has paid a higher price.

But what does safety first look like when the enemy approaches unseen and unheard, like a dark spirit in the night claiming hundreds of lives a day? For months the answer has been to wash your hands and avoid each other. No touching, no hugging, no getting too close. That’s a tough ask at the beach, where the whole point is to be together in a sea of people, to be carefree and forget about all the things you spend the rest of your time worrying about.

New Jersey Gov. Phil Murphy, a Democrat, on Friday increased the size of allowed gatherings from 10 to 25 people. That includes on the beaches, and the six-foot social distancing and mask recommendations remain in place. It’s not how anyone wants to spend the summer, but Murphy knows that a resurgence of covid-19 cases could be devastating. In coordination with local governments, the state will closely monitor developments along the shore and be in position to act.

Murphy said he can’t guarantee that the virus won’t resurge, but the state is readying itself by stockpiling ventilators, personal protective equipment, hospital bed capacity and medicine just in case.

“I hope we don’t have to go through hell again, but boy we better be prepared if we do,” Murphy said in an interview Friday, adding that adhering to the rules will help avoid a recurrence, but only if everyone cooperates. “I think this is going to be very tricky. I don’t think there’s any way of saying it otherwise. As we all begin to dip our toes back in the water . . . we’ve got to be really careful and responsible.”

For beach towns, there is no alternative to the strict guidelines if they want to salvage even a sliver of a normal summer.

Vigilance is the only remedy, said Asbury Park Mayor John Moor, who slung hot dogs on the boardwalk as a teenager, saw dozens of bands at the magnificent Convention Hall and has marveled at the city’s rebirth following a long downturn in the last few decades of the 20th century. The city, which was incorporated in 1897 and has a year-round population of about 16,000 residents, estimates it had 450,000 people visit its beaches last year and approximately 2.5 million visitors in total.

This summer won’t be like last year’s. Asbury Park is limiting sales of season beach passes and will shut down daily beach pass sales if social distancing guidelines are threatened. Hotel bookings and short-term rentals won’t be allowed until June, and then only with limited capacity. Arcades and bowling alleys remain shut down as do the bustling bars and popular live music spots such as the Stone Pony and Wonder Bar. Even as Moor helps the city navigate the season ahead and put safety protocols in place, uncertainty is the only sure thing. He’d rather deal with an enemy he could see.

“Give me a blizzard. Give me a hurricane. Give me 10 of those. This thing is an unknown and that’s what’s scaring everyone,” Moor said Friday as he walked the boardwalk under a clear blue sky. “I wouldn’t wish this upon anybody.”

Along with dozens of other Jersey Shore towns – Long Branch, Spring Lake, Belmar, Ventnor, Ocean City, Sea Isle, Wildwood – summer business is the economic driver. And that summer beach tourism is an engine for New Jersey’s broader economy. Of the state’s $45 billion in tourism revenue last year, nearly half came from the state’s four dominant coastal counties – Monmouth, Ocean, Atlantic and Cape May – according to Joe Simonetta, spokesman for the New Jersey Tourism Industry Association. The shore’s tourism economy employs about 235,000 people.

Projections for this summer are already way down.

“We’re optimistic that we’re open, but we know with the restrictions and following the guidelines around hotel and restaurant capacity that we don’t expect to realize those numbers,” Simonetta said. “I don’t think we’ll ever get near 100 percent. Most of the tourism industry is resolved to the fact it’s going to be at least half that, if not worse.”

It has been two months since Sean Holmes and his wife Valerie Hegarty have had a guest at the boutique hotel they’ve owned since 2005 in Ocean Grove, a quiet seaside town of Victorian homes and hotels adjacent to Asbury Park. The 16-room Majestic Hotel is typically booked solid through the summer, but almost all of the calls the couple have received lately have been cancellations.

“People want the fresh air and to be on the beach. Any time the sun shows its face there’s a lot of traffic coming into town,” Holmes, a native of Galway, Ireland, said with a lyrical Irish accent that camouflaged the concern he feels about the coming season.

“Our livelihood depends on getting open,” Holmes said. “The biggest challenge for most in this business is that we have to make money this time of year to get us through the rest of the year. We’ll be lucky if we get 50 percent for the summer.”

Businesses everywhere at the shore are making similar calculations. At Eddie Confetti’s ice cream stand on the Asbury boardwalk, patrons can order from a vast array of homemade flavors – from banana chunk and cannoli to peanut butter caramel cookie dough and cinnamon bun. But this year they might have to wait a little more than usual.

Owner Eddie Catalano, who started the business 16 years ago, is limiting the number of workers inside the stand. Typically he would have five or six teenagers scooping and selling ice cream on each shift, but he’s keeping it to two or three to start the summer to meet distancing guidelines and ensure that his workers are safe.

“God forbid, I wouldn’t want to be the root cause of something happening,” Catalano said. “That’s my biggest concern, way above the financial.”

Typically, Catalano has 300 tubs of ice cream ready at the start of the season, but this year he has just 100. If he’s forced to close back down, he doesn’t want to get stuck with extra product.

“On the business end, I’m welcoming opening up to get the revenue. But I can also see people getting way too comfortable way too quick, and there’s a risk of that,” he said. “This is all a trial. But what if the trial fails?”

What if? That question hangs around every corner at the shore. The only hope, most people feel, is that everyone does their best to keep things as safe as possible. The messages are everywhere. On the highway heading to shore points, an LED display targets younger beachgoers: “Going down the shore, bro? Practice social distancing.” Most are paying heed for now, but some dismiss the warnings and say the state is overreaching.

Andrew Amonte, 22, was not wearing a mask Friday afternoon as he sat on a boardwalk railing watching visitors stroll by. The Asbury Park resident said he thinks orders to wear a mask violate his civil rights and believes the state should reopen entirely and without the limitations now in place.

“Covid is not as lethal as people are making it out to be,” Amonte said. “They need to reopen everything. Things need to reopen because more people are going to die from homelessness if the economy stays shut down.”

Amonte said he was planning to move to Tampa, Florida, to “get out of a Democratic state and to be part of a Republican freedom state.”

A block away, Natasha Campbell, 30, pushed her smiling 7-month-old son Nicolas in a stroller on the boardwalk. A doctor at nearby Jersey Shore University Medical Center, Campbell has been treating patients with covid-19 for the past two months in the hospital’s intensive care unit. Many of those patients have died.

“You can’t take it all to heart or you would lose your mind, but it’s terrible and some really hit close to home,” Campbell said. “When you have a 30-year-old die and the parents have to come to the hospital, that’s really terrible.”

Taking Nicolas for strolls on the boardwalk has been a welcome escape for Campbell and her husband, who also is a doctor at the hospital. But as Memorial Day and summer approach, Campbell said she is concerned about what’s next.

“They’ve really made an effort to separate people, and that’s great. But I am worried,” she said. “The cases are on the downtrend now, but I’m worried about this summer and opening up.”

No one person has done as much for Asbury Park’s image and identity as Bruce Springsteen, who grew up in nearby Freehold and whose freewheeling debut album in 1973, “Greetings from Asbury Park,” burned this little shore town into the imagination of generations of fans around the world. Many of the songs on that and subsequent albums captured the roughshod romance of the boardwalk and beach life with a bursting-at-the-seams exuberance that can feel starkly at odds with these constrained coronavirus times. It’s difficult to imagine any good boardwalk song coming forth from this socially distanced, masked-up summer.

In his song “Asbury Park, Fourth of July (Sandy),” Springsteen delivers a line about a local fortune teller, singing: “Did you hear the cops finally busted Madame Marie for tellin’ fortunes better than they do.”

The song made Madam Marie famous, and her blue-and-white fortune telling stand, Madam Marie’s Temple of Knowledge, still sits on the boardwalk. Marie Castello died in 2008, but her granddaughter, Dainzie Marie Castello, 52, sees customers all summer long, including many Springsteen fans who’ve traveled here from all over the world. Legend has it that her grandmother told a teen Springsteen that he would be a star long before his meteoric rise.

Castello has done readings via FaceTime and Zoom for the past two months. Now back on the boardwalk where she started telling fortunes when she was 9 years old, she’s wearing a mask and medical gloves and is having a plexiglass shield installed so she can tell fortunes and read palms safely.

These days, everyone is asking Castello about the future.

“You know what I tell them? I tell them this summer is not going to be great, but it’s not going to be as bad as everybody thinks,” Castello said. “And by next summer, we’re going to be back to a new normal. But I don’t think we’re ever going to be the same again for a long time.”

Her grandmother was right about Springsteen. Maybe she’ll be right too.

Quebec, which borders New York and three other states, is the Canadian province hit hardest by the coronavirus. Home to roughly 22% of the country’s population, it has suffered more than 60% of its deaths.

It’s also the province now moving most aggressively to reopen.

Epidemiologists are unsure cases in the French-speaking province have peaked. But retail businesses outside Montreal opened this month. So did elementary schools – a step that provinces with zero cases have not attempted. Construction and manufacturing resumed. Some businesses in Montreal reopen next week. Dentists resume work next month.

The approach – Quebec’s top doctor described it as a “weighted risk” – is being closely watched. Critics have called for more data before pushing ahead.

“My big concern is that we are starting a bit early,” said Benoît Mâsse, a professor of public health at the University of Montreal. “I think we should wait a bit.”

Prime Minister Justin Trudeau, who represents a constituency in Montreal, said he was “worried” for Quebecers.

“I understand how much people do want to go outside,” he said this month. “But we need to do it in ways that we are sure are going to keep people safe.”

Quebec confirmed its first case in February, a month after Ontario and British Columbia. But it was the first to declare a public health emergency, and mobility data from Google showed residents were largely complying with orders to stay home and maintain social distance.

Nonetheless, the province has reported roughly 46,000 of the country’s 84,000 cases, and 3,900 of its 6,400 deaths.

Analysts offer several explanations for the outbreak’s severity.

Quebec’s public school students took spring break during the first week of March, earlier than other provinces. Families decamped for Europe, Mexico and the United States, where the virus was on the march.

At the time, public health officials in Canada said the threat posed by the virus was “low.” By the time federal officials advised against nonessential travel and sealed Canada’s borders, most Quebecers had already returned to work or school.

“If you’re the virus, you cannot have chosen a better time to allow people to travel,” Mâsse said.

In mid-March, officials in Montreal were so concerned by what they said was inadequate screening by border agents that they deployed their own public health workers to airports to screen travelers.

The coronavirus quickly gained a foothold in the province’s ill-prepared and long-neglected long-term care homes. Caregivers, often lacking protective gear, worked at multiple facilities, increasing the opportunity for spread.

At one point, Quebec Premier François Legault said the health-care system was missing some 11,000 workers who were stricken with the virus or afraid to work. Hospital staff have filled in, and the federal government agreed to send more than 1,000 military troops to overwhelmed care homes. Some of them are now sick, too.

The results have been calamitous. At the Résidence Herron in Dorval, 31 residents were found dead after some staff abandoned the facility. Some survivors had not been fed or changed in days. At the Sainte-Dorothée in Laval, at least 87 residents have died.

Legault said he took “full responsibility” for the nursing home crisis, which is responsible for roughly 70 percent of Quebec’s covid-19 deaths. Deaths in long-term care homes account for 81 percent of Canada’s deaths from the coronavirus, with the vast majority occurring in Quebec and neighboring Ontario. He acknowledged facilities were “poorly equipped” for a pandemic.

There are also hot spots outside long-term care homes, though analysts said they might be related. In Montreal-Nord, the borough with the most coronavirus cases in the city, infected health-care workers make up 25% of cases. The median income of the densely populated borough is roughly $16,800, according to the 2016 census.

Some workers live in crowded quarters with multiple generations of a family, making isolation difficult and potentially hastening the virus’s spread through the community.

“It’s not like you can say, ‘Most of the cases are happening in long-term care homes or in hospitals, so we don’t need to worry about what’s happening in the community,’ ” said Ashleigh Tuite, an epidemiologist at the University of Toronto. “People move back and forth and interact.”

Montreal, with a metropolitan population of 4 million some 40 miles from the U.S. border, is the epicenter of Canada’s outbreak, with more than one-quarter of the country’s cases. Matthew Oughton, an infectious diseases specialist at the city’s Jewish General Hospital, said the virus’s “unfortunate predilection for the vulnerable people in our social fabric” has played a role. The city has some of Canada’s poorest neighborhoods.

Legault said conditions there remain “worrisome.”

When Quebec announced its reopening plan in April, Horacio Arruda, the province’s top doctor, said new cases were inevitable but the goal was to keep the number manageable. He said he hoped “not too many people will die,” and that he would change course if necessary.

“We know that it’s a risk. We cannot eliminate the virus,” he said. “It is circulating. The question is, how do we do it? How do we balance things out?”

The province has altered its pandemic response before. Initially, Legault pushed the concept of “herd immunity” as he discussed plans to reopen schools, before backtracking. He twice delayed the reopening of schools in Montreal before canceling the rest of the school year last week.

The decision came after the province’s public health institute released projections indicating deaths could skyrocket to 150 per day in the greater Montreal area by July if all restrictions were lifted.

“It’s hard to keep the entire province shut because of the hot spot in Montreal,” Tuite said. “The challenge is that Montreal is highly connected to the rest of the province, and so there’s a bit of a balancing act there.”

In recent days, new cases and hospitalizations in Quebec have plateaued, but analysts say it’s too soon to tell whether they’ve peaked.

Critics say more testing and contact tracing is needed before reopening the economy. The province has not been able to administer the 14,000 tests per day that officials promised, and some are concerned that areas that haven’t experienced outbreaks don’t have the resources to identify and deal with them.

“I wish the government would err on the side of caution,” said Kate Zinszer, an epidemiologist at the University of Montreal. “My big worry is our capacity to respond as things degenerate.”

Mona Nemer, Canada’s chief science adviser, told Radio-Canada this month that she had asked Quebec “several times” for its plan for widespread testing, but had not seen one.

Arruda said he was not accountable to “this lady,” but to his bosses and the people of Quebec. He then criticized the “gérants d’estrades” – a phrase that translates loosely as “back-seat drivers.”

Mâsse noted the tension between Ottawa and Quebec.

“When the federal government comes in and tells us what we should do, it doesn’t go too well,” he said. “But at some point, we had to call the army to help us, so you cannot have it both ways.”

He added: “I had the same question [as Nemer].”

Critical parts of the lungs of patients infected by the novel coronavirus also suffered many microscopic blood clots and appeared to respond to the attack by growing tiny new blood vessels, the researchers reported.

The observations in a small number of autopsied lungs buttress reports from physicians treating covid-19 patients. Doctors have described widespread damage to blood vessels and the presence of blood clots that would not be expected in a respiratory disease.

“What’s different about covid-19 is the lungs don’t get stiff or injured or destroyed before there’s hypoxia,” the medical term for oxygen deprivation, said Steven Mentzer, a professor of surgery at Harvard Medical School and part of the team that wrote the report. “For whatever reason, there is a vascular phase” in addition to damage more commonly associated with viral diseases such as the flu, he said.

The research team compared seven lungs of patients who died of covid-19, the disease caused by the coronavirus, with lung tissue from seven patients who died of pneumonia caused by the flu. They also examined 10 lungs donated for transplant but not used. The lungs, acquired in Europe, were matched by age and gender.

They did not look at blood vessels in organs such as the kidneys and heart, where other researchers have described finding attacks from the virus and unexpected blood clots.

In larger blood vessels of the lungs, the number of blood clots was similar among covid-19 and flu patients, the researchers wrote. But in covid-19 patients, they found nine times as many micro-clots in the tiny capillaries of the small air sacs that allow oxygen to pass into the blood stream and carbon dioxide to move out. The virus may have damaged the walls of those capillaries and blocked the movement of those gases, the researchers wrote.

They also found inflamed and damaged cells in the lining of blood vessels in the covid-19 patients.

Most surprising was evidence that the lungs of people attacked by the SARS-CoV-2 virus grew new blood vessels.

“The lungs from patients with covid-19 had significant new vessel growth,” a discovery the researchers described as “unexpected.” In an interview, Mentzer speculated that may have been an attempt by the lungs to pass more oxygen to hypoxic tissue.

“That may be one of the things that gets people better,” he said.

The researchers looked for genetic and other differences that might help predict who is most susceptible to severe illness from the virus but did not find any in their tiny sample. So far in the pandemic, covid-19 has hit certain groups, including older people, African Americans and people with underlying diseases such as diabetes, the hardest.

“Patients who do fairly well have a purely respiratory disease, and the patients who have trouble have a vascular component as well,” Mentzer said. But efforts to determine or explain who will fall into each group have not panned out, he said.

While smoking has been declining globally, in Indonesia it’s still common — and growing — and public health experts argue it’s no coincidence that many of the 18,000-plus coronavirus patients in the vast island nation have died. The fatality rate in the country is about 6.6%.

“Many of the fatalities from this coronavirus disease were contributed by the poor health of the patients’ lungs, which were mostly because they are smokers,” said Pandu Riono, an epidemiologist at the University of Indonesia. “The fact that Indonesia has such a high tobacco consumption is not helping us in this fight.”

Nearly two-thirds of Indonesian males 15 and older smoke, and with its large population, the country has been one of the tobacco industry’s last big growth markets. Now, as the coronavirus death toll mounts, Indonesia illustrates the dangers of a permissive public health approach to smoking — and a reliance on tobacco industry tax revenue — amid the outbreak of a virus that turns especially deadly when it reaches the lungs.

The U.S. Food and Drug Administration said in April that smoking makes people more susceptible to coronavirus, and the World Health Organization has said that the effects of coronavirus hit smokers harder. “A review of studies by public health experts convened by WHO on 29 April 2020 found that smokers are more likely to develop severe disease with COVID-19, compared to non-smokers,” it said in a statement.

The link isn’t entirely straightforward. In Greece, the only country where smoking is more prevalent than Indonesia, the coronavirus outbreak has been relatively mild, with fewer than 3,000 cases, though nearly 6% of patients have died. In Germany, where smoking is also prevalent, the rate of coronavirus fatality is a relatively low 4.5%, suggesting the difference a robust health care system can make. French scientists are looking at whether nicotine — or, in medical applications, nicotine substitutes — might offer some protection against the virus.

In Indonesia, smoking is only one of several factors that contribute to poor health, pulmonary and otherwise. Air quality in the capital city of Jakarta is poor. Not everyone has access to quality medical care. And the covid-19 fatality rate is, as of now, really just an educated guess: only a small number of Indonesians have been tested for the virus, out of a total population of more than 270 million.

Still, the government has made scant efforts to discourage tobacco use, and a pack of cigarettes can be bought for as little as $1. In January, the government raised the excise tax on cigarettes, and four months later agreed to delay tax collection from the tobacco companies as part of an economic stimulus package.

About 8% of the government’s total tax revenue, projected at about 173.2 trillion rupiah ($11.6 billion) this year prior to the pandemic, comes from cigarettes and tobacco. Syarif Hidayat, a Finance Ministry director, said in a statement that “the continuation of this industry is needed” to prevent more economic disruption and job loss.

After dozens of workers became infected with covid-19 and two died, Philip Morris International PT Hanjaya Mandala Sampoerna closed two of its factories temporarily. Analysts estimate the subsidiary’s earnings will drop by about 8.9% this year, the most since 2003.

HM Sampoerna declined to comment.

Revenue growth for the company’s main rival, PT Gudang Garam, is expected to slow to 2.1% this year according to average analysts estimates compiled by Bloomberg. That would be the weakest pace since the company went public in 1990.

In any event, the government’s tax relief for the tobacco companies may backfire in the long term, said Abdillah Ahsan, a researcher and lecturer at the University of Indonesia. Smoking remains a leading cause of death from other maladies, including lung cancer, heart disease and stroke.

“In the end the people will be able to keep buying the cigarettes,” said Ahsan, “and their lungs are prone to be compromised.”

“I do have some other contours that are a hot damn mess all over my mask, but this seems to stay in place pretty well,” she says, and slides the loops of a plain black face mask – the little black dress of pandemic protection – behind her ears. “You can see the contour and blush, and everything is in an area where the mask does not sit.”

Her brow pencil is working overtime. Lipstick is an afterthought.

The coronavirus has changed the face of the country, literally. Most Americans now wear masks when they’re out and about. In many areas, workers and shoppers and public-transportation passengers are not allowed not to wear one. The bemasking of America has changed the landscape of human expression at a time when people are looking to one another anxiously for signs of fellowship, hope and danger.

Basnight understands this better than most. When she’s not making makeup videos, she works as a discharge assistant at a hospital in Temple, Texas – a job that, pre-coronavirus, did not require her to wear a mask. Now she must wear one all day long.

“It is really difficult when you’re at work, trying to interact with patients, because they can’t see your face,” says Basnight. And because the patients too are wearing masks, she can’t read their expressions, either. “You don’t know if they’re smiling in there. You don’t know if they’re scowling at you. And I felt myself sort of being a little more expressive with my eyes if I wanted somebody to know that I was smiling at them.”

Three months into a global pandemic, and on top of everything else we’re dealing with, we have to get used to a whole new face. Same nose, eyes, lips and brows – but with this giant cloth thing covering half of it. The lockdowns are ending in some states, and social distancing may not last forever. But masks, it seems, will be with us indefinitely: fogging our glasses, smudging our lipstick, changing how we see one another and allow ourselves to be seen.

– – –

When considering the information that masks now conceal, it’s helpful to know that we’re actually pretty bad at reading faces. We think people who have feminine features are more trustworthy, for example, or that people with lower eyebrows are more dominant. Computers are better than people at distinguishing whether someone is smiling in frustration versus delight, or faking pain versus experiencing it.

When people wear a mask, “You’re left really only with the eyes. And that can make it difficult for people to make these snap judgments that they like to make, even if they’re wrong,” says Leslie Zebrowitz, a psychology professor at Brandeis University who studies facial perception. “We feel more comfortable when we feel that we’re able to assess what someone is like.”

In the mask era, those haphazard assessments continue – as do the prejudices they can reveal. Two black men recently said they were kicked out of a Walmart for wearing protective masks, highlighting the challenges facing Americans who, because of racial profiling, might be perceived as threatening with a mask on – a terrible irony, because a mask is supposed to make the wearer less of a danger to others.

Entrepreneurs have emerged to meet the demand for masks that communicate whatcovered mouths and muffled voices cannot. At Mask For It, one of the online mask companies that have sprung up like weeds in the last month, the top-sellingdesign is a simple smile. There are friendly masks with big, toothy grins, or red lipstick puckers. There are less-friendly masks with snarls and zombie mouths. There are masks that simply say “Go Away.”

The face is a blank canvas, and not just for tongue-in-cheek expressions superimposed on our actual tongues and cheeks. Custom Ink is working with companies that are making masks part of the corporate uniform.

“In the fall, you could see it evolving to the point where law firms want like, super high-end masks embroidered with their logos for their attorneys to wear,” said Marc Katz, Custom Ink and Mask For It CEO. Or when – if? – big conferences come back, branded masks could be a popular swag-bag giveaway. People at conferences will need masks, and besides, “It’s a keepsake,” said Katz.

Faces would become billboards, with logos front and center – way easier to interpret than the expressions underneath.

– – –

But forget about other people for a minute. How well will we recognize ourselves?

Taylor Welden’s mask has competition. He is a champion on the competitive beard circuit, and boasts a long, red mane of facial hair.

“When I’m wearing a mask, I have a really big mustache, so it kind of like, pushes down in front of my mouth,” says Welden.

Where the mask makes contact with Welden’s hair, “You get this kind of beard divot thing going on,” he explains. He has resorted to using his girlfriend’s hair straightener to fix it. Some of his fellow beard aficionados who work as first responders have shaved. “We joke: ‘Another one has fallen,’ ” he says.

There’s no getting around the tension between mask and beard. Welden is a unique case, and that may put him at an advantage, because his championship beard simply cannot be contained: “In a sense, I get to keep my identity more than most people” when wearing a mask, he says. “I mean, there’s probably a solid foot beneath the mask.” Those who rely on subtler features to stand out in public might be at a loss.

“If they’re wearing sunglasses and a hat,” says Welden, “they are totally anonymous.”

For those who wear eyeglasses, a loss of identity might be less of a concern than comfort.

“The way glasses fit onto the face is incredibly nuanced, and wearing masks will make that even more complex,” said Dave Gilboa, co-founder and co-CEO of the glasses brand Warby Parker, via email. “We’ll probably start to see more interest in frames that sit higher on the nose bridge to accommodate mask placement, or frames with nose pads that allow for a more adjustable fit.” The brand is considering producing anti-fogging spray, to solve a common complaint of masked-up glasses wearers.

Masks dominate; everything else becomes an accessory, including the visible parts of the face. Makeup brands will probably gravitate toward bolder eye looks, such as the one Basnight favors. But looking good in the Mask Era doesn’t just mean emphasizing the uncovered features; it also means covering for the blemishes masks leave behind.

“We’re seeing a lot of demand for skin care,” says Nick Stenson, senior vice president of salon services and trend at Ulta Beauty, the makeup store. Mask wear has created a new skin ailment – “maskne,” acne where the mask makes contact with the face – and consumers are using their time at home to tend to their complexions.

After all, the masks do come off eventually. And so lipstick endures, if only for the benefit of family members, Zoom colleagues and Instagram followers.

“People still want to look good,” said Stenson, “and they still want to feel like there’s a sense of normal in their life.”

– – –

The basic design of medical masks hasn’t changed much in more than a century.Photos from the pandemic of 1918-1920 show people wearing a similar design to the ones that such brands as Old Navy, J. Crew, and Citizens of Humanity are selling now: Rounded or pleated fabric, with ties behind the head or loops behind the ears. As we look to a masked future, it seems poised for rapid evolution.

“As a historian of medicine, I don’t think I’ve ever seen anything like this – this move to have everyone wearing masks, creating masks and really having a chance to really sort of play with that,” says Alexandra Lord, chair of the division of medicine and science at the National Museum of American History,who is collecting face masks for future scholarship.

Both high-end and mass-market brands are treating the mask as a new category of accessory, and rethinking the materials and shape of facial protection. First they were clinical, then folksy and homemade. Now they’re slick, professional and geared toward every possible interest. There are more than 600 designs from the retailer LookHuman, informed by trend-tracking software: meme masks, Dungeons and Dragons masks, “Tiger King” masks. Elsewhere, you’ll find wedding masks, clear masks, and, paradoxically, MAGA masks. There are masks that would be too risque for the office, if the office were open.

Vasilios Christofilakos, assistant professor of accessories design at the Fashion Institute of Technology, thinks a molded shape will surpass the flat, cloth mask – N95, but make it fashion. “They’re going to be like women’s brassieres,” says Christofilakos.

The surgical face mask – the three-ply, aqua-colored ones found in hospitals – may become less acceptable as streetwear. In some medical offices, they might even be replaced with more lively designs.

“Hospitals are going to stick with the no-frills ones,” predicts Peter Stefanides, an orthopedic surgeon in New York. “In private practice, the dermatologists, the plastic surgeons, they may want to get a more fashionable one.”

Soon enough, the masks will go high-tech: Kristian Hammond, an engineering professor at Northwestern University who specializes in artificial intelligence, believes mask design will incorporate technology to inform contact tracing, or to notify people with a gentle beep when someone gets too close. And facial recognition technology will adapt, perhaps allowing you use your iPhone’s face unlock feature while wearing a mask. One Israeli inventor has already developed a mechanical mask with a mouth that opens and closes, allowing people to wear a mask while eating in restaurants. It makes the wearer look like a dystopian Muppet.

The Mask Era has inspired creativity, but is shaped by deprivation. It has united people in the feeling of being muzzled; we have rallied to make that experience slightly less depressing. But it has introduced at least one experience that everyone looks forward to: the feeling of stepping into your sanctuary after a shift at work or a trip to the grocery store and freeing yourself, at long last, from the mask.

“That feeling of ripping off your bra, or taking off your heels – it’s the same type of feeling,” says Basnight, the hospital worker who does makeup tutorials on YouTube. “It’s just a relief to have it off of your face.”

The company reported that in eight patients who had been followed for a month and a half, the vaccine at low and medium doses triggered blood levels of virus-fighting antibodies that were similar or greater than those found in patients who had recovered. The antibody-rich blood plasma donated by patients who have recovered is separately being tested to determine whether it is an effective therapy for covid-19.

The vaccine showed no worrisome safety signals, aside from redness at the injection site for one patient and some “systemic” symptoms in three patients given the highest dose, the company said.

The interim data Moderna announced come from a clinical trial aimed at showing the safety of its experimental vaccine and helping the company select the correct dose. The company has not yet picked the dose or announced the size or length of the large trial that it will start in July, which will be the key one that regulators consider to decide whether the vaccine is safe and effective.

“We are very, very happy because first the vaccine was generally safe,” Stephane Bancel, chief executive of Moderna said in an interview. “The piece that was really exciting and was the big question, of course, was can you find antibodies in people in enough quantities” to prevent disease.

Moderna also reported that the vaccine protected mice who were vaccinated and then exposed to the virus, preventing it from multiplying in their lungs. The animal and human data being released by the company have not yet been published.

Moderna’s vaccine uses a genetic material called messenger RNA that codes for the distinctive spike protein that studs the outside of the novel coronavirus. The vaccine delivers the messenger RNA to cells, which then follows the genetic instructions to create the virus protein – allowing the body to learn to recognize and neutralize the pathogen.

Moderna’s announcement comes days after one of its board members, Moncef Slaoui, stepped down from the board to become chief scientist for Operation Warp Speed, a White House initiative to speed up vaccine development. Slaoui still owns stock options in Moderna, and made an apparent reference to the early data in a Rose Garden news conference on Friday afternoon.

The 12-year-old from Covington, Louisiana, padded out of her room in her PJs shortly after 7 a.m., ate a half-bowl of Rice Krispies, and got on a Zoom call with her sixth-grade social studies class. She had been feeling unwell all weekend with twisting abdominal pains, vomiting and a fever of 101.5, but she seemed to be on the mend.

The weird thing, she recalled, was that her lips looked bluish in the mirror and she was super tired. In fact, she kept falling asleep unexpectedly. On the couch. In front of her computer. In the bath.

“I thought I was feeling a bit better,” she said, “but I couldn’t keep my eyes open.”

With all the news swirling around them about the pandemic, her parents, Sean and Jennifer Daly, had been monitoring their daughter’s illness closely. She had been healthy and did not have a cough, shortness of breath or other typical symptoms of covid-19, so Jennifer, a radiologist, initially suspected appendicitis, some kind of stomach bug, or perhaps the flu.

That afternoon, they took Juliet to the emergency department, where doctors noticed an unusual constellation of symptoms pointing to a different problem. Her heart rate was extraordinarily low, jumping around in the 40s when it should have been between 70 to 120 beats per minute. And when they squeezed her nails, they turned white and stayed white when they should have gone back to pink.

Juliet was in a kind of toxic shock, and her heart had become so inflamed it was barely beating.

It was still relatively early in the outbreak, April 6, and the hospital hadn’t seen other children in this condition. But the doctors knew enough about the pathogen’s effects on adults that they immediately suspected the coronavirus.

– – –

Cases like Juliet’s, a puzzling inflammatory syndrome in children believed linked to covid-19, had been popping up in different parts of the world for months, but it wasn’t until recently that health authorities began tracking the phenomenon.

The number of infected children, while still small, is estimated to be a few hundred – larger than anyone anticipated for a disease thought to inflict little, if any, harm on children. Doctors in Britain and Italy had issued alerts in April, and the American Heart Association warned last week that some pediatric patients “are becoming very ill extremely quickly,” urging providers to evaluate them right away.

On Thursday night, the Centers for Disease Control and Prevention issued an advisory and gave the unusual condition a name – multisystem inflammatory syndrome in children, or MIS-C.

More than 100 children are believed to have it in New York state, with about half in New York City, where three have died. In recent days, medical centers in 14 other states have reported similar cases. Scientists still believe most children and young people experience only mild illness or none at all if they become infected with the coronavirus. But they’re concerned about the critical nature of the inflammatory syndrome cases, which seem to be appearing in children weeks after a wave of infections in their communities.

“We’ve been seeing kids steadily for two months,” said Roberta DeBiasi, infectious disease specialist at Children’s National Hospital in the District. “But this presentation is clearly different. It’s not that we just didn’t notice this before. It’s a new presentation. And the fact that it’s happening two months after the initial circulation of the virus gives weight to the idea that it’s an immune-mediated phenomena.”

Jennifer Owensby, a pediatric intensivist at Rutgers’s Robert Wood Johnson University Hospital in New Brunswick, New Jersey, said the first group of children she saw with covid-19 appeared to have classic respiratory symptoms, such as shortness of breath. Now, she said, “The vast majority are coming in with symptoms of cardiac failure, which is extremely rare in pediatrics, especially in normal, healthy kids – which is why this is so alarming.”

Writing in the Lancet medical journal this week, Italian doctors reported on a cluster of 10 children struck with the inflammatory condition in the coronavirus epicenter of Bergamo. The cases appear to have characteristics of an illness first identified in Japan known as Kawasaki disease, which causes inflammation in blood vessels and includes a persistent fever. But these children were older than is typical with Kawasaki, which usually strikes those younger than 5, and they had more serious heart issues.

Just like Juliet, who is among the first known children in the United States to develop multisystem inflammatory syndrome.

– – –

Sean Daly was at the hospital with “Jules,” as he sometimes called her, while Jennifer was on the phone from work.

A transportation planning consultant with no medical background, Sean remembers feeling confused as doctors told him they were giving his daughter an epinephrine drip to help her heart, and were sending her to a larger hospital with more expertise and equipment. They said they would put her on a ventilator to stabilize her for the helicopter trip to Ochsner Medical Center, about 50 miles away in New Orleans.

Sean, unaware of the gravity of his daughter’s condition, thought ridiculous thoughts about the absurdity of his shorts and flip-flops amid the alien-looking hospital workers in head-to-toe protective equipment. And he thought about how, just a few minutes earlier, his daughter had been well enough to walk across the parking lot and into the ER. He heard an announcement about something called a “code blue” and wondered why more and more people kept rushing into her room.

When the attending doctor finally popped out, Sean recalled, she was shaking. She said Juliet had gone into cardiac arrest, and it took them nearly two minutes of CPR, or cardiopulmonary resuscitation, to revive her.

“It didn’t process all that well with me,” he said. “She was telling me Juliet was ‘back,’ and I was like, ‘That’s good. I didn’t know she had gone anywhere.’ Thankfully I was not in the room. I don’t think I would have handled that.”

Jennifer was hysterical.

“It was horrific. It was beyond anything. It was shocking how quickly it happened,” she recalled.

– – –

When Jennifer arrived at Ochsner, she didn’t understand how she could have possibly beaten her daughter there. She had driven for about an hour in a semicircle around Lake Pontchartrain while Juliet had been airlifted.

“I was crying and freaking out,” she recalled. By the time she was able to grab a nurse, she feared the worst. “I just need to know one thing now,” she demanded. “Is she alive?”

Juliet’s helicopter had been delayed because she had coded a second time and, again, doctors restarted her heart. But by the time they wheeled her into the pediatric intensive care unit in the new hospital, some of her other organs had begun failing, too, probably because the heart was unable to pump the oxygen-filled blood they needed.

Juliet’s liver and kidneys were in shock. There was blood in her lungs. Her pancreas was inflamed.

Heartbeats are controlled by electrical impulses that travel down the right and left branches of the heart at the same speed. Somewhere in Juliet’s heart, a block was causing the system to go haywire.

A team of pediatric cardiology specialists gave Jennifer a name for her daughter’s condition: acute fulminant myocarditis – a sudden onset of heart failure, shock or life-threatening arrhythmias.

The doctors began medications, requisitioned a heart bypass machine in case it was needed, and prepared Jennifer for the possibility that Juliet might need a transplant.

“They were not sure she was going to make it the first night,” Jennifer said. “It was a total nightmare.”

Meanwhile, Juliet’s nasal swabs came back positive for the coronavirus and adenovirus, one cause of the common cold. The results were bewildering because none of the other family members – Sean, Jennifer or Juliet’s brothers, ages 5 and 16 – had been the least bit sick. But if her condition was post-viral, occurring weeks after infection – as scientists increasingly suspect in such cases – there were any number of ways she could have been exposed, since school had still been in session and stay-at-home orders had not yet been issued.

Since none of Juliet’s family had symptoms and test kits were in short supply in the area, doctors opted not to test them.

After confirming the coronavirus diagnosis, doctors gave Juliet an immunoglobulin product used successfully on Kawasaki patients. They ruled out using hydroxychloroquine, the anti-malarial touted by President Donald Trump, because they were worried about cardiac side effects given her already fragile heart condition.

As Jennifer sat in the room with full protective equipment, including a face shield, mask and gown, she held her daughter’s hand. Only one parent was allowed, so Sean stayed at home with the boys.

Unable to sleep, Jennifer started a group text chat so she could keep family and friends updated. She played Juliet’s favorite song – Maroon 5′s “Moves Like Jagger” – vowed to be as optimistic as possible and prayed.

– – –

That first night was torture. Juliet’s heart was starting and stopping, beating too fast and then too slow, as doctors adjusted the medications. But within 24 hours, almost miraculously, she seemed to be stabilizing. The numbers on her labs for her kidneys and liver were moving in the right direction, and the echocardiogram of her heart had improved.

While Jennifer joked with her husband about Juliet being a heavy sleeper, there were instances when her daughter woke up and seemed to understand her completely.

“We love you,” Jennifer would say. “You’re going to get better.”

She talked about an Easter egg hunt she would have in the yard with her brother, Dominic.

Juliet was able to give a thumbs up and squeeze her hand.

“I’m optimistic she is neurologically intact,” Jennifer texted to Sean. Her tone was clinical, but it had been one of her worst fears as a mother.

By Thursday, doctors were confident enough in Juliet’s progress that they took her off the ventilator, letting Juliet breathe on her own. She was still on a lot of medications and confused and upset about all the tubes coming out of her body.

Jennifer remembers reassuring her she was safe in the hospital, but that she was still very sick and weak.

Juliet’s reaction wasn’t what she expected: “No Mommy, I’m not weak. I’m strong!”

“The first day of regaining consciousness, I was freaking out. I wanted to go home badly,” Juliet recalled. She said she was terrified of how everyone kept stepping on all her cords, which were tangled and plugged in outside because the nurses wanted to limit how many times they came into her room. The Band-Aid on her neck was “way too sticky for humankind.” And she could taste the saline they were giving her via IV, and it was bad.

Then on April 15, almost as suddenly as she had been admitted nine days before, doctors told Juliet she was well enough to go home.

– – –

Juliet has no memories of when her heart stopped twice, and her parents are grateful for that.

She was discharged on four medications – two for the heart, a blood thinner and one for her pancreas – but bounced back physically in no time. She was able to return to her school’s online classes, in which she’s continuing her streak of As, and has no trouble riding her bike around the neighborhood.

Doctors monitoring her closely say the drugs are temporary and that they are hopeful she’ll make a full recovery. On Friday, she returned to Ochsner for the first time since her hospitalization for a one-month follow-up appointment. Jake Kleinmahon, the pediatric cardiologist who is treating her, said he was thrilled when the echocardiogram of her heart looked “completely normal.” Like other children with myocarditis, she is restricted from competitive sports for six months (Juliet’s parents say that’s not a problem as she doesn’t really like to sweat) but is otherwise free to engage in activities.

“I do not expect her to have any long-term complications or limitations, even though she came in so severely ill,” Kleinmahon said. “She is quite a fighter and such a brave young girl.”

The only odd change, Juliet said, is that she came out of the hospital with a monster craving for bacon, which she didn’t love before. And she no longer wanted doughnuts, which had been among her favorite foods. Such changes in taste are not uncommon after ICU stays, doctors say.

The emotional part of her recovery has been more challenging. Juliet thinks about other kids who might become sick with the same syndrome. She says she would advise them “not to freak out too much because freaking out makes things worse. Because that’s what I did, and that didn’t help at all.”

She worries more about her family and friends, their future and hers, and the strange world of viruses she knew nothing about before.

“I feel like I’m a bit self-conscious about my body because I don’t know what’s going to happen next,” she said. “I’m worried about how there’s a lot of other stuff you can get.”

The pushback came after comments by Sanofi Chief Executive Paul Hudson.

“The U.S. government has the right to the largest preorder because it’s invested in taking the risk,” Hudson told Bloomberg News in a story published Wednesday. The United States, Hudson said, expanded its investment in the company’s vaccine research in February and thus expects that “if we’ve helped you manufacture the doses at risk, we expect to get the doses first.”

Those comments did not sit well in Paris.

“For us, it would be unacceptable if there were privileged access from this or that country under a pretext that would be a monetary pretext,” France’s state secretary for economy and finance, Agnès Pannier-Runacher, told France’s Sud Radio on Thursday.

Olivier Véran, France’s health minister, said he was shocked when he saw Hudson’s interview.

“When I read that, I took my phone – it was late, it would have been something like 11 at night – and I called the CEO of Sanofi France for an explanation,” Véran said, speaking Thursday to France’s BFM TV.

A covid-19 vaccine “should be a global public good,” Prime Minister Edouard Philippe tweeted. “Equal access for everyone to the vaccine is not negotiable.”

A spokesman for the Elysee Palace, the seat of the French presidency, said that President Emmanuel Macron was struck by Hudson’s comments in the same way as his ministers were, and that Hudson would meet Macron at the Elysee next week, although a date for that meeting had not yet been set.

The Elysee said it was “concentrating its efforts on a coordinated multilateral response so that a vaccine is available to all and at the same time, because it knows no borders.”

Early in the coronavirus outbreak, France came under heavy criticism for its reluctance to share protective medical equipment with its European neighbors. It subsequently has taken a more communal approach. And Macron, along with German Chancellor Angela Merkel, has been an especially vocal proponent of a global initiative to develop a successful covid-19 vaccine that would not favor any particular country.

“We need to make sure it is rendered accessible to all of those around the world,” he said in April.

Macron and Merkel, along with the World Health Organization, spearheaded a roughly $8.2 billion vaccine fundraising drive that culminated in a virtual summit this month, during which world leaders and prominent philanthropists pledged to fund vaccine research, testing kits and mass-produced drugs that could effectively fight the coronavirus.

The United States did not participate in the conference. It has instead partnered directly with pharmaceutical companies, contributing half a billion dollars to Johnson & Johnson’s vaccine effort and hundreds of millions of dollars to Sanofi and to Moderna, a biotech company in Massachusetts teaming with a Swiss company for vaccine manufacturing.

More than 100 covid-19 vaccine research efforts are in progress around the world, in laboratories in the United States, Britain, Germany, France and elsewhere. The question of national preference in these trials has been present from the beginning.

Heralding an Oxford University trial last month, for instance, British Health Secretary Matt Hancock said citizens of Britain should have preference if the trials proved successful. But Prime Minister Boris Johnson has talked about the importance of a globally available vaccine.

“The race to discover the vaccine to defeat this virus is not a competition between countries but the most urgent shared endeavor of our lifetimes,” Johnson said at the virtual vaccine summit.

The agency that approves medicine for the European Union said Thursday that in an optimistic scenario, a vaccine could be approved by early 2021.

Sanofi has two coronavirus candidate vaccines in pre-clinical evaluation.

The research behind the first, investigating a preclinical SARS (severa acute respiratory syndrome) candidate vaccine, was conducted in conjunction with British pharmaceutical conglomerate GlaxoSmithKline and supported by the Biomedical Advanced Research and Development Authority, part of the U.S. Department of Health and Human Services.

Sanofi said it expects to launch human trials for that vaccine in the second half of 2020.

The firm’s second candidate vaccine is being developed with Translate Bio, a Lexington, Massachusetts-based therapeutics company.

Hudson’s comments and additional messaging from Sanofi may be part of an effort to prod European governments to invest more in vaccine research. As Hudson told Bloomberg, his aim was partially to “to try to create a debate in Europe to say, ‘Don’t let Europe be left behind.’ ”

But by Thursday morning, the company appeared to be backpedaling somewhat.

Olivier Bogillot, head of Sanofi’s French division, told France’s BFMTV network that the vaccine would be available to Europeans at the same time as Americans if the European Union were as “efficient” a partner.

“If we discover a vaccine, it will be accessible to everyone – the Americans and the Europeans will have it at the same time,” Bogillot said. “The words of Paul Hudson were misunderstood; he was just calling on the European Union to be more efficient.

“For me, the debate is closed,” he said. “The vaccine, if discovered, will be made available to French patients.”

“GSK and Sanofi both believe that global access to COVID-19 vaccines is a priority,” the company said in a statement. “And we are committed to making any vaccine developed through the collaboration available and affordable through mechanisms that offer fair access to people around the globe, including the U.S.

“It is critical that governments support this goal and collaborate to help industry to make fair allocation decisions,” the company said.

The Baltimore plant is the second of four planned locations around the world where Johnson & Johnson plans to pump out vaccine on a massive scale, months before testing the first dose in a human being. The manufacturing head start is one part of a worldwide scramble to protect the human population from the virus that is not expected to vanish on its own.

If SARS-CoV-2 establishes itself as a stubborn, endemic virus akin to influenza, medical experts say there almost certainly will not be enough vaccine for at least several years, even with the unprecedented effort to manufacture billions of doses. About 70 percent of the world’s population – or 5.6 billion people – will likely need to be inoculated to begin to establish herd immunity and slow its spread, scientists say.

Yet the nationalistic priorities of individual nations could thwart the strategic imperative to tamp down hotspots wherever they are on the planet – including poor countries that can’t afford the vaccine. The United States in particular could be left in the cold if vaccines developed here as part of a go-it-alone approach turn out to be less effective than those produced in China or Europe.

The scenario public health experts fear most is a worldwide fight in which manufacturers sell only to the highest bidders, rich countries try to buy up the supplies, and nations where manufacturers are located hoard vaccines for their own citizens.

“The model of countries thinking only of themselves is not going to work. Even if you’re living somewhere that’s somehow perfectly without any infections. Your best efforts to fight the virus are going to fail unless you shut off all your borders and trade,” said Seth Berkley, CEO of Gavi, a public-private partnership that helps provide vaccines to developing countries. “This is a global problem that requires a global solution.”

International health advocates want to avoid a repeat of 2009, when wealthy countries – including the United States, which was led by the internationalist-leaning Barack Obama – were at the head of the line for H1N1 swine flu vaccine, leaving underdeveloped countries with little supply until after the pandemic subsided.

Such an approach will be sorely tested by President Donald Trump and other world leaders with nationalistic impulses and their own anxious populations who want to reduce the deadly threat and bring their economies back to life.

In the United States, the federal government agency in charge of emergency vaccine development indicated it is prioritizing domestic concerns – an “America First” mentality that has shaped much of the Trump administration’s pandemic response.

“Right now, we’re focused on the whole-of-America approach required to expedite the availability of vaccines,” said Gary Disbrow, acting director of the Biomedical Advanced Research and Development Authority (BARDA), in an emailed response to written questions from The Washington Post.

BARDA – which is tasked with protecting Americans from biological threats – is channeling nearly half a billion dollars in emergency funds to Johnson & Johnson to develop a vaccine. It also is providing hundreds of millions of dollars in financial support for vaccine efforts by Sanofi, the large French drug company, and Moderna, a biotech company in Massachusetts teaming with a Swiss company for vaccine manufacturing.

“By working with multiple companies, we have more ‘shots on goal’ to increase the chances that the U.S. will have one or more vaccines available as quickly as possible,” Disbrow said.

The global grab for protective equipment and ventilators that left poorer countries empty-handed suggests the competition over vaccines could be at least as fierce. Dozens of companies large and small are rushing to develop vaccines using different technologies and approaches. Avalere Health, a pharmaceutical consulting company, is tracking at least 120 separate vaccine projects sponsored by governments, universities, nonprofit institutes and private companies.

Large-scale manufacturing capacity will be required to produce viable products out of those experiments and clinical trials. Some vaccines may require two doses, putting greater pressure on manufacturing capacity. Some top officials in the Trump administration are raising attention to the issue. Francis Collins, the director of the National Institutes of Health, and Anthony Fauci, director of the National Institute for Allergy and Infectious Diseases, both physicians, were co-authors of an article published in the journal Science on Monday that urged international coordination.

“Cost, distribution system, cold-chain requirements, and delivery of widespread coverage are all potential constriction points in the eventual delivery of vaccines to individuals and communities,” they wrote. “All of these issues require global cooperation among organizations involved in health care delivery and economics.”

Recognizing the financial and logistical bottlenecks for smaller biotech firms, Bill Gates, the philanthropist and Microsoft founder, announced in April on The Daily Show with Trevor Noah that the Bill and Melinda Gates Foundation would make billions of dollars available to help seven undisclosed companies build out manufacturing capacity.

The race for a vaccine is full of risks because no one knows which projects will succeed. That forces companies to scale up to produce millions of doses of vaccine that might end up being worthless. There is another risk.

The United States might not be well-positioned if the best vaccines end up coming from other countries or international collaborations – such as a development and manufacturing cooperative that world leaders pledged billions toward this month at an online event the Trump administration skipped. A Trump administration official, not speaking for attribution this month under White House rules for speaking to reporters, said the United States supports such efforts despite skipping the pledge event.

“We need to lay the groundwork for global vaccine sharing now, before we know who is the winner. It’s basically negotiated – there’s not a global framework or protocol, there’s not a preexisting framework about how to do this,” said Jeremy Konyndyk, a senior policy fellow at the Center for Global Development, who worked on the U.S. government’s response to international disasters in the Obama administration. “What we don’t want is a situation of haves and have-nots, based on either who gets vaccine to work or who has the production capacity or who has the wealth.”

Much of the international outrage during the H1N1 swine flu pandemic 11 years ago centered on supply contracts western governments secured with vaccine manufacturers. The United States, under former President Barack Obama, had contracts in 2009 that entitled it to 600 million doses, The Washington Post reported at the time, a huge share of potential global supply.

Stronger frameworks for international planning have since been established for influenza vaccines. But those frameworks do not automatically apply to the coronavirus. David Fidler, adjunct senior fellow for cybersecurity and global health at the Council on Foreign Relations and a visiting professor at the Washington University School of Law in St. Louis, said the much larger threat of the coronavirus could make it more difficult for countries to act together – especially in the United States, which has experienced the highest covid-19 caseload and death toll in the world.

“Access to vaccine, as a safety valve to release that political and economic pressure, is going to be astronomical for anyone who is in the White House. That pressure is not going to dissipate if (presumptive Democratic nominee) Joe Biden wins in November,” he said.

Large drug companies may enter into vaccine contracts again as they face pressure to recoup their investments, Fidler added.

“For pharmaceutical companies that make vaccines, your best customer for return on investment are high-income countries,” Fidler said. “If you’re going to get a return on investment, somebody has to buy it.”

According to data from the Centers for Disease Control and Prevention, more than 80 million Americans were inoculated in the 2009 swine flu pandemic – an amount that roughly equals the total number of doses that were received in 77 different countries under a distribution plan organized by the World Health Organization.

“Rich countries monopolized the vaccine, poor countries were left behind. They got the vaccine later, and they got less of it,” Gavin Yamey, director of the Center for Policy Impact in Global Health at Duke University said in a university podcast. Allowing a repeat scenario in the battle against the coronavirus would be a devastating mistake, he said.

“Unless we make this vaccine globally available,” he said, “we are not going to be able to end the pandemic because . . . an outbreak anywhere is an outbreak everywhere.”

BARDA has not yet signed contracts with Johnson & Johnson or other companies for delivery of specific numbers of doses, a step Disbrow said would be “premature at this point.”

Johnson & Johnson “has indicated that approximately 300 million doses of vaccine would be available in the U.S. each year,” he said, which is enough to vaccinate 90 percent of the U.S. population of 330 million people. That number of doses matches up with the projected annual capacity at the Baltimore plant, which is operated by a publicly traded corporation called Emergent BioSolutions and receives funding as one of four federal Centers for Innovation in Advanced Development and Manufacturing.

Asked about Disbrow’s assertion, a top executive at Johnson & Johnson did not commit to specific volumes or timing of delivery of vaccine in the United States, citing the need to evaluate global priorities to stop the pandemic.

The company wants to produce 1 billion doses by the end of 2021, making the first doses available as early as this winter. Where vaccine will be most needed is not known, although health care workers will be a high priority, Paul Stoffels, Johnson & Johnson’s executive vice president and chief scientific officer, said in an interview.

Stoffels said Johnson & Johnson is committed to satisfying demand wherever it is most needed. The company also is not interested in making a profit on the coronavirus vaccine, he said.

“It’s very difficult to determine at the moment where the epidemic is then going to be,” Stoffels said in an interview. “We think honestly . . . that the priority should go to the people who need it most – first, that are probably the health care workers and people at high risk, and maybe wherever they are in the world.

“On the one hand, we work very much with the U.S.,” he added, “but on the other hand we also do our best to make sure we can serve the world.”

Johnson & Johnson says its vaccine technology is particularly well suited to underdeveloped regions because vials of doses can be shipped at relatively warm temperatures in the last stage of delivery. In addition to Baltimore, it will be producing a vaccine at its own plant in the Netherlands and is looking for at least two other locations in Asia and Europe, according to the company. It also is contracting with glass-vial manufacturers to buy 5-dose vials to ease shortages of packaging, Stoffels said.

Pfizer, which is testing multiple vaccine candidates, has identified factories in the United States and Belgium and is securing its supply chain, with the goal of having 10 to 20 million doses available by fall and hundreds of millions of doses next year, the company said.

“We’re thinking completely outside of what is, quote-unquote, normal. We come up with unique approaches, we’re getting into contract negotiations with suppliers, and we haven’t seen a single clinical data point,” said Kathrin Jansen, head of Vaccine Research and Development for Pfizer. “It’s unheard of.”

Pfizer’s vaccine contains genetic material encapsulated in a fat droplet made of four different lipids. Before it even knew which vaccine would move forward, Pfizer had to secure enough of each of those lipids. Pfizer managers need enzymes to make the genetic material, called RNA, so they had to find suppliers and secure enough supply for their anticipated demand.

Layered on top of the logistical supply chain is scientific uncertainty. Pfizer’s planning scenario is built on a “worst-case prediction” that the vaccine it ends up making will be the one that requires the highest dose. If the company succeeds with a different version – one that makes copies of itself once inside cells and thus is effective at about a tenth of the dose – Pfizer could be thinking about billions of doses as opposed to hundreds of millions.

“All those are wild cards, and the whole planning right now needs a certain amount of flexibility,” Jansen said. “We don’t want to have too little capacity, we don’t want to have too much capacity, we don’t know how much we need. It’s a very interesting dance going on right now to get it right, and none of us has ever done this.”

Jansen said that the global community will have to figure out how to distribute vaccine equitably through the world, through organizations like the WHO She did not say where Pfizer’s vaccines would go.

“I think by the time we will face the issue, I’m very confident there will be plans in place, to make sure that there’s an equitable roll out,” Jansen said.

Moderna has a factory in a suburb south of Boston capable of producing 100 million doses in a year. This month, the company announced a 10-year partnership with Lonza, a Swiss contract development and manufacturing firm that will help it scale up production, with the goal of beginning manufacturing in July. The partnership could expand manufacturing capabilities to 1 billion doses a year.

Stephane Bancel, chief executive of Moderna, said he hopes governments will place large orders with companies like his before the products are formally approved – so that they can spend the next 12 to 18 months making as much vaccine as they can, to be ready for the surge in demand if and when they get the regulatory okay.

“If we start stockpiling now,” he said, “all the products we make between now and launch are available the day of launch.”

Harvard researchers found that women who consumed the most fiber overall were 8% less likely to develop breast cancer than those who consumed the least, according to a report in the journal Cancer, based on analysis of data involving more than 8.5 million women. They found that the risk reduction applied to women of all ages, both pre- and postmenopausal, although studies that focused solely on premenopausal women revealed a greater effect, with risk 18% lower for women who consumed the most fiber, compared with those who consumed the least.

The researchers noted that the risk-reduction benefit was similar for all fiber-containing foods that had been tracked, including cereals, fruits, vegetables and legumes such as beans and peas. Health experts tend to believe that the beneficial effects of dietary fiber on breast cancer risk relate to the ability of fiber to help control blood sugar and decrease estrogen levels.

Current dietary guidelines call for the average adult woman to consume about 25 grams of fiber a day to achieve the most benefit (38 grams a day for men), although people often fall short of that goal – a situation described as America’s “fiber gap.” People adding dietary fiber to their daily menu are advised to do so gradually and to drink plenty of water, to avoid the gas, bloating and cramping that can develop as the digestive system adjusts to the change.