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Afghanistan’s Health Care System Is Collapsing Under Stress

KABUL, Afghanistan — Amena, 7 months old, lay silently in her hospital crib amid the mewling of desperately ill infants in the malnutrition ward.

Her mother, Balqisa, had brought the child to Indira Gandhi Children’s Hospital in Kabul, Afghanistan’s capital, the night before. “Her body was so hot,” she said, stroking her daughter’s emaciated leg.

The baby had a high fever, convulsions and sepsis, said Dr. Mohammad Iqbal Sadiq, a pediatrician, glancing at her chart.

“Her chances are not good,” the doctor said. “We got her too late.”

At the Indira Gandhi hospital, and in faltering hospitals across Afghanistan, famished children arrive by car and taxi and ambulance every day and night. Acute malnutrition is just one of a cascade of maladies that threaten to topple the country’s fragile health system.

acute poverty, with 4.7 million Afghans likely to suffer severe malnutrition this year, according to the United Nations. Last month, the organization made its biggest appeal ever for a single country, asking international donors to give more than $5 billion to fend off a humanitarian disaster.

doubled since August, with 40 children dying in December on their way to receive medical care.

Jonas Gahr Store, the prime minister of Norway, whose country hosted meetings between Taliban representatives and Afghan civil society groups last week, spoke to the Security Council about the urgency to expedite aid.

“We need new agreements and commitments in place to be able to assist and help an extremely vulnerable civil population, and most vulnerable among them, the children who face hunger and suffering,” he said.

Before the U.S.-backed Afghan government disintegrated in August as the Taliban overran the country, the health system relied on international aid to survive. But much of that funding has been frozen to comply with sanctions imposed on the Taliban.

As a result, the International Rescue Committee recently predicted that 90 percent of Afghanistan’s health clinics were likely to shut down in the coming months. The World Health Organization has said that outbreaks of diarrhea, measles, dengue fever, malaria and Covid-19 threaten to overwhelm overburdened hospitals.

including $308 million in relief authorized by the United States, they have not been enough to cover 1,200 health facilities and 11,000 health workers.

Though the drastic decline in war-related casualties has relieved the burden of such patients on many hospitals, the suspension of operations by private facilities and the ability to safely travel Afghanistan’s roads has left other hospitals overrun with people.

On a recent morning, the corridors of Indira Gandhi hospital were crammed with beds as patients’ family members squatted on floors amid parcels of food bought at the local bazaar.

Patients’ meals consist of an egg, two apples, a milk packet, rice and juice, so many families supplement them with outside food. Some buy medicine at local pharmacies because the hospital can provide only about 70 percent of required medication, Dr. Sadiq said.

has now claimed more than 900,000 lives across the country, and the Covid death rates remain alarmingly high. The number of new infections, however, has fallen by more than half since mid-January, and hospitalizations are also declining.

Few Afghans wear masks — even at the Ministry of Public Health in Kabul. There, officials clustered in groups on a recent weekday, greeting visitors with hugs and kisses, and ignoring faded signs saying masks were required throughout the building.

At the Afghan-Japan Communicable Disease Hospital in Kabul, the only remaining Covid-19 facility in the capital, few staff members or patients complied with worn stickers on the floors that proclaimed: “Let’s Beat Coronavirus — Please keep at least 2 meters from people around you.”

“When I try to talk to people about Covid-19, they say we have no food, no water, no electricity — why should we care about this virus?” said Dr. Tariq Ahmad Akbari, the hospital’s medical director.

Dr. Akbari suspected that the Omicron variant had entered the country, but the hospital lacked the medical equipment to test for variants. He and his staff had not been paid for five months, he said, and the hospital was critically low on oxygen supplies and health care workers.

Seven of the hospital’s eight female doctors fled after the Taliban takeover in August, part of a hollowing out that reduced the staff from 350 to 190 the past five months. Four of the five staff microbiologists quit. And only five of the country’s 34 Covid-19 centers were still operating, Dr. Akbari said.

Several staff members lived in the hospital in Kabul because, without salaries, they cannot afford rent, he said.

The hospital was recently buoyed by a two-month stopgap grant of $800,000 from an affiliate of Johns Hopkins Hospital, Dr. Akbari said. And Afghanistan’s relative isolation following the Taliban takeover had likely helped contain the spread of Covid-19, he said.

Up to 20 patients died per day during the previous wave, but just one or two a day now. And the hospital tests about 150 patients a day now, down from 600 to 700 daily tests during the second wave, Dr. Akbari said.

He speculated that Afghans are so overwhelmed by other survival issues that they are less likely to seek treatment for Covid-19.

Before the Taliban takeover, the Ministry of Public Health published detailed daily charts showing the number of coronavirus cases, hospitalizations and deaths — and the positivity rate for testing. But now the poorly funded ministry struggles to keep tabs on the pandemic.

Of the more than 856,000 tests conducted since the first wave of Covid-19 in early 2020 — of an estimated population of nearly 40 million — roughly 163,000 were positive, a health ministry spokesman said. More than 7,400 Covid-19 deaths had been confirmed since 2020, he said.

But because testing is extremely limited and the cause of death is not recorded in many instances, particularly in rural areas of Afghanistan, no one knows the pandemic’s true scale.

Dr. Akbari shook his head in frustration as he described how little was known about the virus in Afghanistan.

Looking defeated, he said, “If we have a surge like we had during the second and third wave, we would not be equipped to handle it.”

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Bosses Have a New Headache: How Long Should Sick Workers Isolate?

Barbara Sibley’s four New York restaurants had already weathered the city’s initial Covid-19 wave, the prevaccine surge last winter and this summer’s Delta spike when last weekend it finally happened: Fearing an outbreak and struggling with staffing after one of her workers got sick with Covid, she temporarily shut down one of her locations.

That was only the start of Ms. Sibley’s worries. She also had to weigh how long the employee, who was fully vaccinated, should isolate before returning to the job. And the messaging from public health experts was not clear-cut.

In the early days of the pandemic the Centers for Disease Control and Prevention recommended that most people who tested positive for the coronavirus isolate for 14 days. It later reduced its recommended isolation period to 10 days. But these policies were based on data from unvaccinated individuals and were implemented before the widespread availability of rapid tests. An increasing number of health and policy professionals now suggest that vaccinated people can end their isolation after five to seven days, so long as they are not symptomatic and they test negative.

On Thursday, the C.D.C. reduced, in some circumstances, the number of days it recommends that health care workers who test positive for the coronavirus isolate themselves, but it did not address other businesses.

said on Friday that fully vaccinated critical workers could return to work five days after testing positive, so long as they have no symptoms or their symptoms are resolving and they have had no fever for 72 hours. Those workers will also have to wear a mask, she said.

Omicron has intensified staffing shortages across industries, and the spike in cases has disrupted travel during the holidays, stranding thousands of customers and underscoring the economic toll of employees needing to isolate. Already, some economists are warning about the potential impact that shutdowns can have on consumer spending.

Delta Air Lines asked the C.D.C. on Tuesday to cut isolation time to five days for fully vaccinated people, warning that the current 10-day period may “significantly impact” operations. It was followed by JetBlue and Airlines for America, a trade group that represents eight airlines.

eliminated weekly testing for vaccinated players who are asymptomatic, with its chief medical officer saying the pandemic had reached a stage in which it’s unnecessary for vaccinated players to sit out if they feel healthy.

canceled performances through Christmas. CityMD, the privately owned urgent care clinic, temporarily shut 19 sites in New York and New Jersey because of staffing shortages. At least a dozen New York restaurants have temporarily closed in response to positive tests.

“I think lots of companies are looking at a lot of disruption in the next month and trying to put in policies right now, because they know their employees are going to get infected in very high numbers,” said Dr. Jha.

The United States might take direction from policy shifts abroad. Britain said on Wednesday that it was reducing to seven from 10 the days that people must isolate after showing Covid-19 symptoms.

After the British government lifted nearly all its pandemic restrictions in July, hundreds of thousands of workers were pinged by the National Health Service’s track-and-trace app and told to isolate because they had been exposed to the coronavirus. Businesses complained of being short-staffed, and economists said the “pingdemic” may have slowed economic growth in July.

In the United States, new tools to help manage through the pandemic are on the way.

The Food and Drug Administration this week authorized two pills to treat Covid, from Pfizer and Merck. Those treatments have been shown to stave off severe disease and have potential to reduce transmission of the virus, though supply of both pills, especially Pfizer’s, will be limited in the next few months.

President Biden said on Tuesday that he planned to invoke the Defense Production Act to buy and give away 500 million rapid antigen tests, a crucial tool in detecting transmissibility, though those tests will not be available for weeks or longer.

If a combination of the antiviral pills and rapid tests is able to get individuals back to work faster, “that’s a big economic point,” said Dr. Eric Topol, a professor of molecular medicine at Scripps Research.

Molly Moon Neitzel, who owns an ice cream business in Seattle with just over 100 employees, said she had kept guidelines for isolation conservative.

“I’m on the side of protecting people over getting them back to work right now,” she said, adding that if it were summer and her business were busier, she might consider a shorter isolation period. “It’s the slowest time of the year for an ice cream company, so that is in my favor.”

Some public health experts worry that if the C.D.C. shortens its guidelines on isolating, employers could pressure workers to get back before they’re fully recovered.

“What I don’t want to see happen is for this to be used as an excuse to force people to come back while they are unwell,” Dr. Ranney of Brown said.

And even with clearer guidelines, putting policies in place can be tricky. While some experts suggest different isolation rules for vaccinated and unvaccinated employees, some companies do not yet have a system for tracking which of their workers have gotten a vaccine. The question of whether the C.D.C. will change its definition of fully vaccinated to include booster shots adds another layer of complexity.

It’s not just sick employees who may have to stay home: Companies are also grappling with whether vaccinated workers should quarantine after exposure to someone with Covid-19, which C.D.C. guidelines do not require.

“It becomes a challenge for employers to choose between providing a safer environment and keeping staff intact, or going with the C.D.C. guidance,” said Karen Burke, an adviser at the Society for Human Resource Management.

But almost two years into the pandemic, that’s the position that employers continue to find themselves in, amid an ever-flowing cascade of new data, guidelines and considerations.

“Every moment, you’re making life or death decisions,” Ms. Sibley said. “That’s not what we signed up for.”

Rebecca Robbins contributed reporting.

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Biden’s Covid Vaccine Mandate Reinstated for Large Businesses

But Judge Joan L. Larsen, a Trump appointee, dissented, arguing — as had the Fifth Circuit panel before her — that the agency had exceeded its legal authority.

“The mandate is aimed directly at protecting the unvaccinated from their own choices,” Judge Larsen wrote. “Vaccines are freely available, and unvaccinated people may choose to protect themselves at any time. And because the secretary likely lacks congressional authority to force them to protect themselves, the remaining stay factors cannot tip the balance.”

All of the judges on the Fifth Circuit panel that had blocked the rule were conservative Republican appointees.

Challengers to the decision could appeal directly to the Supreme Court, which is controlled by a conservative bloc of six Republican appointees. (The Supreme Court this month refused to block New York’s requirement that health care workers be vaccinated against the coronavirus even when they cite religious objections.)

Challengers could also appeal to the full U.S. Court of Appeals for the Sixth Circuit. Of its 16 sitting judges, five were appointed by Democrats and 11 were appointed by Republicans. (However, one of the Republican appointees, Judge Helene N. White, was originally a nominee of a Democratic president, Bill Clinton, before being renominated by a Republican one, George W. Bush, as part of a political deal.)

Conditions on the ground are rapidly changing, with new cases surging, apparently because of the more-infectious Omicron variant. The Justice Department last month warned that keeping the mandate from coming into effect “would likely cost dozens or even hundreds of lives per day, in addition to large numbers of hospitalizations, other serious health effects and tremendous costs.”

The OSHA rule, alongside a separate requirement for federal contractors, has helped drive a number of large companies to announce a form of vaccine mandate, including Procter & Gamble, IBM and American Airlines. Others, like Tyson Foods and Google, introduced mandates on their own, in the face of the rising risk of the Delta variant.

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Omicron Wave Heads for U.K., but It’s Not Clear How Bad It’ll Be

LONDON — With cases of the Omicron variant doubling every three days and the government doing an about-face on restrictions it had long resisted, Britain is bracing for a new coronavirus surge, unsure if it will be a relatively minor event or a return to the dark days of earlier pandemic waves.

So far, the number of Omicron cases — 817 confirmed by Thursday, though officials say the real figure is likely much higher — is small compared with the daily average of 48,000 new coronavirus cases overall. But the government’s Health Security Agency warned that if the recent growth rate continues, “we expect to see at least 50 percent of Covid-19 cases to be caused by the Omicron variant in the next two to four weeks.”

Early evidence in Britain backs up tentative findings elsewhere, notably in South Africa, where the heavily mutated new variant is already widespread: It appears to be the most contagious form of the virus yet, a previous case of Covid-19 provides little immunity to it, and vaccines seem less effective against it. But it also seems to cause less severe illness than earlier variants.

Britain’s experience with Omicron may be a harbinger of what others can expect. Until now, it has been looser about social restrictions than many other nations in Western Europe, and Britain ordinarily has extensive travel to and from South Africa, so it could be the first wealthy country to be hit hard by Omicron. It also has one of the world’s most robust systems for sequencing viral genomes, so it can identify and track new variants earlier and more thoroughly than other countries.

opposed stricter controls that have been adopted around Europe, which was suffering through its biggest coronavirus wave so far before Omicron appeared.

Times analysis shows how infrastructure issues and the public’s level of willingness to get vaccinated may pose larger obstacles than supply.

“It’s not going to take long before it becomes obvious in other places, but it’s clearer earlier here,” Dr. Barrett said. “I think other countries should basically assume the same thing is happening.”

The genomic surveillance could also give Britain a head start in determining how severe Omicron cases are, though there will be a lag because it takes days or weeks for a person who gets infected to become seriously ill.

“It is increasingly evident that Omicron is highly infectious and there is emerging laboratory and early clinical evidence to suggest that both vaccine-acquired and naturally acquired immunity against infection is reduced for this variant,” Susan Hopkins, the chief medical adviser to the Health Security Agency, said in a statement.

Experts fear what that could mean for Britain’s already struggling National Health Service.

“A lot of staff have left or are burnt out,” Dr. English said, after months of dealing with the strains of the pandemic. “Now we’ve going to have another big hit — very likely — from Omicron. I am really, really sympathetic toward my poor colleagues working in clinical practice at the moment.”

said in a statement that the country had been having “increasingly high incidences of Covid-19 for some time,” adding that “health care workers are rightly worried about the impact the Omicron variant could have” on the health system’s ability to function if caseloads rise fast.

Some hospitals have already canceled elective care again, a strategy seen at the start of the pandemic to free up resources for treating coronavirus patients. Patients are already experiencing hourslong waits for ambulances as a result of the existing pressures on the system, Dr. Nagpaul added.

“While the number of Covid hospitalizations today is much lower than last winter, we must not risk complacency by ignoring the rapid doubling of Omicron cases every two to three days,” he said.

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Can Olaf Scholz, Germany’s New Chancellor, Revive the Left in Europe?

BERLIN — Last December, as he was plotting what most considered to be a hopeless bid to become Germany’s next chancellor, Olaf Scholz interrupted his campaign preparations for a video call with an American philosopher.

Mr. Scholz, a Social Democrat, wanted to talk to the philosopher, Prof. Michael J. Sandel of Harvard, about why center-left parties like his had been losing working-class voters to populists, and the two men spent an hour discussing a seemingly simple theme that would become the centerpiece of the Scholz campaign: “Respect.”

On Wednesday, Mr. Scholz will be sworn in as Germany’s ninth postwar chancellor — and the first Social Democrat in 16 years — succeeding Angela Merkel and heading a three-party coalition government. Defying polls and pundits, he led his 158-year-old party from the precipice of irrelevance to an unlikely victory — and now wants to show that the center-left can again become a political force in Europe.

Mr. Scholz won for many reasons, not least because he persuaded voters that he was the closest thing to Ms. Merkel, but his message of respect resonated, too. For the first time since 2005, the Social Democrats became the strongest party among the working class. Just over 800,000 voters who had abandoned the party for the far left and far right returned in the last election.

President Biden’s political agenda in the United States.

For the center-left in Europe, Mr. Scholz’s victory comes at a critical moment. Over the past decade, many of the parties that once dominated European politics have become almost obsolete, seemingly bereft of ideas and largely abandoned by their working-class base.

The political energy has been on the right, especially the populist far right, with many American conservatives flocking to countries like Hungary to study the “illiberal democracy” of Viktor Orban, that nation’s far-right prime minister.

the lone defender of liberal democracy in an age of global strongmen, whether President Vladimir V. Putin of Russia or President Donald J. Trump. Yet Germany was not immune to populist fury, and the Alternative for Germany, or AfD, won seats in Parliament and became a political force in the country’s east.

“The biggest concern in politics for me is that our liberal democracies are coming increasingly under pressure,” Mr. Scholz says about himself on the Social Democrats’ website. “We have to solve the problems so that the cheap slogans of the populists don’t catch.”

a Trump victory. Then he spent months analyzing why the Democrats lost and reading a raft of books by authors from working-class backgrounds in the United States, France and Germany.

“He studied very carefully what happened in the United States,” said Cem Özdemir, a prominent member of the Greens who is a minister in Mr. Scholz’s incoming government. “He studied the losses of the Democrats in the U.S. Why didn’t Hillary win?”

When Mr. Scholz’s own party collapsed in the 2017 election, losing for the fourth time in a row, he wrote an unsparing paper concluding that one reason the Social Democrats had lost their core voters was that they had failed to offer them “recognition.”

cut benefits and undertook a painful overhaul of the labor market from 2003 to 2005 in a bid to bring down a jobless toll that had surpassed five million. Mr. Scholz, then the party’s general secretary, became the public face of the changes.

Unemployment did gradually fall, but the program also helped create a sprawling low-wage sector and prompted many working-class voters to defect from the Social Democrats.

Professor Sandel argues that it was around this time that center-left parties, including the Democrats of President Bill Clinton, embraced the market triumphalism of the right, became more closely identified with the values and interests of the well-educated and began losing touch with working-class voters.

Mr. Scholz, once a fiery young socialist who joined his party as a teenager, defended workers as a labor lawyer in the 1970s before gradually mellowing into a post-ideological centrist. Today he is considered to be to the right of much of the party’s base, not unlike Mr. Biden, with whom he is sometimes compared, even though, like Mr. Biden, he has demonstrated some liberal reflexes.

a three-party government with the progressive Greens and the libertarian Free Democrats. Their governing treaty calls for raising the minimum wage to 12 euros, or about $13.50, an hour, from €9.60 today — an instant pay rise for about 10 million people. Mr. Scholz has also promised to build 400,000 homes a year, 100,000 more than was previously planned, and to guarantee stable pension levels.

More abstract, but equally important, is his promise of another “industrial revolution” that will aim to make Germany a manufacturing power for the carbon-neutral age and provide the economic bedrock for the welfare state of the future.

“We need to tell people two things,” Mr. Scholz said during the campaign. “First, that we need respect, we need good pay and proper recognition for work. And second, we have to ensure that there are good jobs in the future.”

the Socialist mayor of Paris, Anne Hidalgo, who recently announced her own long-shot presidential bid, has evoked the “respect” theme.

But slogans go only so far. The Social Democrats came in first in the splintered September vote in Germany but mustered only 26 percent of the total, a far cry from the 40 percent they recorded at the start of Mr. Schröder’s first term. Mr. Kühnert, the party’s general secretary, said that Mr. Scholz’s challenge was to show that the Social Democratic model is the right approach for the country and beyond.

“We hope that our election victory in Germany will send a signal for the revival of social democracy internationally,” Mr. Kühnert said. “We’re looking above all to the rest of Europe, because we need to strengthen the E.U. in the next years if we want to have anything to say in the world in coming years.”

Christopher F. Schuetze contributed reporting.

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Vaccine Hesitancy Hurts Covid Fight in Poorer Countries

JOHANNESBURG — The detection of the Omicron variant in southern Africa signals the next stage of the battle against Covid-19: getting many more people inoculated in poorer nations where vaccines have been scarcest in order to deter new mutations from developing.

But while world leaders sometimes talk about this as if it were largely a matter of delivering doses overseas, the experience of South Africa, at least, hints at a far more complex set of challenges.

Like many poor countries, South Africa was made to wait months for vaccines as wealthier countries monopolized them. Many countries still do not have anywhere near enough vaccines to inoculate their populations.

The problems have not ended as shots began arriving in greater numbers.

Neglected and underfunded public health infrastructure has slowed their delivery, especially to rural areas, where storage and staffing problems are common.

turned away shipments of doses from Pfizer-BioNTech and Johnson & Johnson, worried that their stockpile of 16 million shots might spoil amid insufficient demand.

Dr. Saad Omer, a Yale University epidemiologist, and they have had a deeper effect.

have said. In several countries, fewer than half say they intend to get vaccinated.

sometimes-violent resistance in rural communities. Vaccine hesitancy rates there approach 50 percent among those who have not completed high school. In some parts of the country, more than a third of doses spoil amid the low demand.

Still, many are eager to be vaccinated. When doses first became widely available in South Africa earlier this year, a third of the country’s adults swiftly got inoculated, a pattern that is repeating elsewhere.

allegations of corruption amid last year’s lockdown, have heightened public unease.

“There’s a lack of confidence in the public health system’s ability to provide vaccines,” said Chris Vick, the founder of Covid Comms, a South African nonprofit group.

The group has been holding vaccine information sessions, but overcoming skepticism is not easy. After a session in the Pretoria township of Atteridgeville, one 20-year-old who attended said she had not been persuaded.

briefly pause delivery of the Johnson & Johnson vaccine, leading South Africa to delay its rollout to health care workers. Both countries decided to resume the shots after concluding that they were safe.

The South African government held regular briefings, but these were on television and in English, when radio remains the most powerful medium and most South Africans do not speak English as their mother tongue.

a recent study found. That is in part because of mistrust of the Black-led government, but also because American Covid conspiracists have found wide reach among white South Africans on social media, according to Mr. Vick of Covid Comms.

Covid pill from Merck for high-risk adults, the first in a new class of antiviral drugs that could work against a wide range of variants, including Omicron. The pill could be authorized within days, and available by year’s end.

The first modern, worldwide campaign, begun in 1959 against smallpox, provoked deep skepticism in parts of Africa and Asia, where it was seen as a continuation of colonial-era medical abuses. Some W.H.O. officials used physical force to vaccinate people, deepening distrust. The campaign took 28 years.

The effort to eradicate polio, which finally ramped up in poor countries in the 1980s and is still ongoing, has run into similar resistance. A study in the science journal Nature found that vaccine avoidance was highest among poor or marginalized groups, who believed that the health authorities, and especially Western governments, would never voluntarily help them.

In Nigeria in the early 2000s, amid a spike in religious tensions, unfounded rumors circulated that foreign health workers were using polio vaccines as cover to sterilize the country’s Muslim population. Boycotts and local bans led to a polio resurgence, with cases spreading to 15 other countries, as far as Southeast Asia.

survey by the Africa Center for Disease Control found that 43 percent of those polled believe Africans are used as guinea pigs in vaccine trials — a legacy of Western drug companies’ doing exactly this in the 1990s.

Even within their own borders, Western governments are struggling to overcome vaccine resistance. So it is hard to imagine them doing better in faraway societies where they lack local understanding.

Any appearance of Western powers forcing unwanted vaccines into African or Asian arms risks deepening the backlash.

“If the objective is to keep the U.S. and the rest of the world safe, it should be pretty obvious that the success of the domestic program depends on what happens internationally,” Dr. Omer said.

Declan Walsh contributed reporting from Nairobi.

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World Omicron Fight Hindered by Fragmented Response

ROME — In a wrenchingly familiar cycle of tracking first cases, pointing fingers and banning travel, nations worldwide reacted Monday to the Omicron variant of the coronavirus in the piecemeal fashion that has defined — and hobbled — the pandemic response all along.

As here-we-go-again fear and resignation gripped much of the world, the World Health Organization warned that the risk posed by the heavily mutated variant was “very high.” But operating once again in a vacuum of evidence, governments chose approaches that differed between continents, between neighboring countries, and even between cities within those countries.

Little is known about Omicron beyond its large number of mutations; it will be weeks, at least, before scientists can say with confidence whether it is more contagious — early evidence suggests it is — whether it causes more serious illness, and how it responds to vaccines.

In China, which had been increasingly alone in sealing itself off as it sought to eradicate the virus, a newspaper controlled by the Communist Party gloated about democracies that are now following suit as Japan, Australia and other countries gave up flirting with a return to normalcy and slammed their borders shut to the world. The West, it said, had hoarded vaccines at the expense of poorer regions, and was now paying a price for its selfishness.

announced that government employees, health care workers and staff and students at most schools must be vaccinated by Jan. 22.

tied to a single soccer team — and Scotland reported six, while the numbers in South Africa continued to soar.

Experts warned that the variant will reach every part of the world, if it hasn’t already.

The leaders of the world’s top powers insisted that they understood this, but their assurances also had a strong whiff of geopolitics.

President Xi Jinping of China offered one billion doses of Covid vaccine to Africa, on top of nearly 200 million that Beijing has already shipped to the continent, during an address to a conference in Senegal by video link.

The Global Times, a Chinese tabloid controlled by the Communist Party, boasted of China’s success in thwarting virus transmission, and said the West was now paying the price for its selfish policies. “Western countries control most of the resources needed to fight the Covid-19 pandemic,” it wrote. “But they have failed to curb the spread of the virus and have exposed more and more developing countries to the virus.”

told France Inter radio on Monday that variants would continue to emerge unless richer countries shared more vaccines. “We need a much more systemic approach,” she said.

“zero Covid” strategy.

China has steadfastly kept a high wall against visitors from the rest of the world. Foreign residents and visa holders are allowed in only under limited circumstances, leading to concerns by some within the business world that Covid restrictions were leaving the country increasingly isolated.

Visitors must submit to two-week quarantines upon arrival and face potential limits on their movement after that. Movements are tracked via monitoring smartphone apps, which display color codes that can signal whether a person has traveled from or through an area with recent infections, triggering instructions to remain in one place.

In other parts of Asia, people are less focused on eradicating the virus than just surviving it.

“This news is terrifying,” said Gurinder Singh, 57, in New Delhi, who worried about his shop going under. “If this virus spreads in India, the government will shut the country again, and we will be forced to beg.”

Reporting was contributed by Declan Walsh from Nairobi, Patrick Kingsley from Jerusalem, Carlos Tejada from Seoul, Sameer Yasir from Srinagar, India, Lynsey Chutel from South Africa, Aurelien Breeden from Paris, Elian Peltier and Monika Pronczuk from Brussels, Megan Specia from London, Christopher F. Schuetze from Berlin, Emma Bubola from Rome and Nick Cumming-Bruce from Geneva.

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Singapore Struggles to Reopen After Vaccinations

The country’s experience has become a sobering case study for other nations pursuing reopening strategies without first having had to deal with large outbreaks in the pandemic. For the Singapore residents who believed the city-state would reopen once the vaccination rate reached a certain level, there was a feeling of whiplash and nagging questions about what it would take to reopen if vaccines were not enough.

“In a way, we are a victim of our own success, because we’ve achieved as close to zero Covid as we can get and a very, very low death rate,” said Dr. Paul Tambyah, an infectious diseases specialist at National University Hospital. “So we want to keep the position at the top of the class, and it’s very hard to do.”

vaccinated people are already gathering at concerts, festivals and other large events. But unlike Singapore, both of those places had to manage substantial outbreaks early in the pandemic.

Lawrence Wong, Singapore’s finance minister and a chair of the country’s Covid-19 task force, said the lesson for “Covid-naive societies” like Singapore, New Zealand and Australia is to be ready for large waves of infections, “regardless of the vaccine coverage.”

up against the Delta variant, Mr. Wong said.

“In Singapore, we think that you cannot just rely on vaccines alone during this intermediate phase,” he said. “And that’s why we do not plan an approach where we reopen in a big bang manner, and just declare freedom.”

highest since 2012, a trend that some mental health experts have attributed to the pandemic. People have called on the government to consider the mental health concerns caused by the restrictions.

“It’s just economically, sociologically, emotionally and mentally unsustainable,” said Devadas Krishnadas, chief executive at Future-Moves Group, a consultancy in Singapore. Mr. Krishnadas said the decision to reintroduce restrictions after reaching such a high vaccination rate made the country a global outlier.

granted full approval to Pfizer-BioNTech’s coronavirus vaccine for people 16 and up, paving the way for mandates in both the public and private sectors. Such mandates are legally allowed and have been upheld in court challenges.

  • College and universities. More than 400 colleges and universities are requiring students to be vaccinated against Covid-19. Almost all are in states that voted for President Biden.
  • Schools. California became the first state to issue a vaccine mandate for all educators and to announce plans to add the Covid-19 vaccine as a requirement to attend school, which could start as early as next fall. Los Angeles already has a vaccine mandate for public school students 12 and older that begins Nov. 21. New York City’s mandate for teachers and staff, which went into effect Oct. 4 after delays due to legal challenges, appears to have prompted thousands of last-minute shots.
  • Hospitals and medical centers. Many hospitals and major health systems are requiring employees to get vaccinated. Mandates for health care workers in California and New York State appear to have compelled thousands of holdouts to receive shots.
  • Indoor activities. New York City requires workers and customers to show proof of at least one dose of the Covid-19 for indoor dining, gyms, entertainment and performances. Starting Nov. 4, Los Angeles will require most people to provide proof of full vaccination to enter a range of indoor businesses, including restaurants, gyms, museums, movie theaters and salons, in one of the nation’s strictest vaccine rules.
  • At the federal level. On Sept. 9, President Biden announced a vaccine mandate for the vast majority of federal workers. This mandate will apply to employees of the executive branch, including the White House and all federal agencies and members of the armed services.
  • In the private sector. Mr. Biden has mandated that all companies with more than 100 workers require vaccination or weekly testing, helping propel new corporate vaccination policies. Some companies, like United Airlines and Tyson Foods, had mandates in place before Mr. Biden’s announcement.
  • “I think a lot of times we are so focused on wanting to get good results that we just have tunnel vision,” she said.

    Ms. Ng lives across from a testing center. Almost daily, she watched a constant stream of people go in for tests, a strategy that many public health experts say is a waste of resources in such a highly vaccinated country.

    “Freedom Day — as our ministers have said — is not the Singapore style,” said Jeremy Lim, an associate professor at the National University of Singapore and an expert on health policy, referring to England’s reopening in the summer. But moving too cautiously over the potential disadvantages of restrictions is a “bad public health” strategy, he said.

    The government should not wait for perfect conditions to reopen, “because the world will never be perfect. It’s so frustrating that the politicians are almost like waiting for better circumstances,” Dr. Lim said.

    Sarah Chan, a deputy director at Singapore’s Agency for Science, Technology and Research, said she had a fleeting taste of what normal life was like when she arrived in Italy last month to visit her husband’s family.

    No masks were required outdoors, vaccinated people could gather in groups, and Dr. Chan and her son could bop their heads to music in restaurants. In Singapore, music inside restaurants has been banned based on the notion that it could encourage the spread of the virus.

    Dr. Chan said she was so moved by her time in Italy that she cried.

    “It’s almost normal. You forget what that’s like,” she said. “I really miss that.”

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