When Covid Came for Provincetown

It is July 10, 2021, a Saturday, and Sean Holihan is on a short flight down the East Coast of the United States. The nonprofit strategist and his partner are coming home from Provincetown, Massachusetts, where they spent the week with friends they hadn’t seen since the pandemic began . Everyone was vaccinated, and the state had dropped its mask mandate, so the holiday felt gloriously normal.

The group rented cottages and hung out together, sharing brunch and cocktails, hitting the beach in the afternoon and dinner and shows at night. Provincetown was its old delirious self: 60,000 visitors turned a mile-long portion of Commercial Street, the main thoroughfare, into an impromptu parade, and crammed into nightclubs so crowded that you had to slide skin to skin to get outside for some air. Holihan is exhausted, but happy.

On the same day, in New York City, a data scientist named Michael Donnelly is making plans with friends who are driving back from Provincetown. He and his husband try to go every summer, but this year things booked up crazy fast. They’re all planning to meet up tonight when everyone arrives.

Donnelly maintains a Covid analysis site as a hobby and has been the nerd node for his friends when they need information. He’s looking forward to taking the night off. Commercial Street, the main drag in Provincetown.

On Cape Cod, Theresa Covell has just gotten back from her first vacation since the pandemic began. Covell is an assistant public health nurse for Barnstable County, the jurisdiction that stretches all along the arm of the Cape, from the shoulder joint at the Bourne Canal to the wrist curve that shelters Provincetown from the ocean. She and her colleagues have spent 2021 grinding—tracking cases, running vaccine clinics, trying to manage the emergency in a place that is low on revenue when the tourists are gone and short of housing and services once they arrive.

When she left for her time off, the Covid curve was bending down. In all of June, Provincetown didn’t see a single positive case. But recently a local health organization has reported a surge among vaccinated people.

That’s new , Covell thinks. Holihan logs on to the airplane Wi-Fi, and he feels his phone vibrate. It’s a friend who checked out early this morning from their rental, complaining of a summer cold.

He has gotten home and taken a Covid test . The text shows the bright double lines of a positive result. Holihan’s first reaction is disbelief: The authorities had said they were safe.

His second is dread. I’m on a plane , he thinks. Am I going to give this to other people? Donnelly’s phone lights up.

His carload of friends just got word that someone they know tested positive, and they’ve pulled off the highway in Connecticut in search of rapid tests. They are all vaccinated, but three of the five soon test positive. Their plans to meet are off.

By the end of the day, another 12 people who were in Provincetown tell Donnelly they’ve contracted Covid. This isn’t supposed to happen , he thinks. It feels like the floor is falling out from under him.

If you even remember the Provincetown outbreak a year ago—which, in Pandemic Time, probably feels like a century—this may be what you know about it: The shots had been available for seven months. The Centers for Disease Control and Prevention had said that vaccinated Americans could take their masks off. There was a delicious anticipatory buzz of life returning to normal, and then the ice-bucket shock of discovering hot vax summer was over before it started.

The Delta variant caused breakthrough infections and illness even in vaccinated people, and the Provincetown outbreak was the proof. Maybe you remember the disappointment of mask recommendations coming back, or the whiff of homophobia that floated through some of the coverage, or the sense that a summer capital for artists and queer people had been made responsible for the Delta variant rather than being its accidental host. (“How do we stop the press portraying us as a leper colony?” a local business owner asked on the town manager’s Facebook page.

) Whatever you remember, the actual story is this. The partyers in Provincetown didn’t spread the virus; they, and their allies, controlled it. On the fly, they created a model for how a community can organize against a disease threat.

Even a year later, it is worth looking back at what they did—not just because Covid has not left us but also because other pandemics will come. Much of the US response to Covid has been fractured, hostile, or self-sabotaging. Provincetown was “a huge success story,” says William Hanage, codirector of Harvard’s Center for Communicable Disease Dynamics, who helped analyze the outbreak.

“It should have been a message: We can avoid large outbreaks, if we want to. ” When Sean Holihan heard about the first breakthrough infections from Provincetown, his initial reaction was disbelief. Holihan and his partner reached their home in Washington, DC, and found some rapid tests tucked under their doormat—a gift from the friend who had texted his positive result.

They both took them right away. Holihan’s test popped positive immediately. They masked up and maneuvered awkwardly around their apartment, trying to figure out where they could separately eat and sleep.

The next morning, feverish and sweating, Holihan walked to a pop-up clinic for a PCR test, then went home to isolate. The next day, Monday, he emailed his office—he is the state legislative director for a gun-violence-prevention organization—to say he wouldn’t be in. He was already feeling better, but when his test result arrived, it was positive.

Of course. “At that point I started texting everyone I’d come in contact with over the week,” he says. Realizing how many people visit Provincetown from across the country, he posted about being infected on Twitter and Instagram too.

DMs flowed back, from people who thought they’d picked up some summer crud as they traveled. “They thought they were fine,” he says. “Then they tested themselves, and it turned out they also had Covid.

” Rumors about people testing positive were zipping through group chats: most of this house, everyone in that cottage, the Pennsylvania group, the California group, that couple from DC. One of the people Holihan texted was Donnelly. This might seem odd, because Donnelly isn’t an epidemiologist.

He is a policy geek who has done macroeconomic forecasting at the Federal Reserve Board and data analysis at Spotify and Facebook. But since early 2020, Donnelly had also been applying his skills to forecasting what Covid might do in the US, a way of making sense for himself of the data flowing from other countries and explaining to others why they ought to be more worried than they were. “Essentially, I wanted to convince my friends it was bad,” he says.

Donnelly’s analyses, which he initially published on Medium, had been solid. He had foreseen that federal action would be needed two days before President Donald Trump declared a national emergency . He had warned that New York City would have to shut down six days before Governor Andrew Cuomo announced that the whole state would be put “on pause.

” That prediction led to a consulting gig with New York state (forecasting possible case counts, bed needs, and ventilator orders) and then to founding a site called CovidOutlook. info , a home for reports and predictions that he spun up with Michael LeVasseur, an epidemiologist at Drexel University. So by the time the Delta variant began creeping through Provincetown, Donnelly was an informal but thoroughly informed expert in what Covid was doing in the US.

“I had been tracking variants over the previous six months and, broadly, thought concerns about them were overblown,” he says. When his friends started testing positive, he was surprised, and nettled. He didn’t like being wrong.

Early in the pandemic, Michael Donnelly became an expert in Covid data and a nerd node for his friends. Rumors about people testing positive were zipping through group chats: most of this house, everyone in that cottage; the Pennsylvania group, the California group, that couple from DC; 10 people positive, or 15, or 25. Text by text, Donnelly began verifying the stories, asking people about the symptoms they had and the tests they had taken, when they were vaccinated and which shot they got, and all the details of their visits to Provincetown—where they stayed, who they hung out with, which bars and restaurants and shows they went to.

He started collecting information on Saturday afternoon, and by Monday he had more than 50 names in a spreadsheet. “It’s the most accelerated response I’ve ever seen in public health. And Michael pretty much started that outbreak investigation himself.

” The list represented a shocking number of breakthrough infections for a young, healthy, affluent population, a group that should have been at the lowest risk. Donnelly felt an itch to do a study, but LeVasseur persuaded him to turn the project over to a bigger institution than their team of two. Donnelly got in touch with Demetre Daskalakis, the former head of the infectious disease programs in New York City’s health department, who was now at the CDC.

On Monday night, Donnelly texted, offering the spreadsheet. Daskalakis asked for it immediately. Within 24 hours, Daskalakis set up calls between Donnelly, the CDC, and the Massachusetts health department.

By the end of the week, the agencies had created a task force, set up a phone number and an email for people to self-report, reached out to other states that visitors had gone home to, and gotten mobile testing units rolling toward Provincetown. “It’s the most accelerated response I’ve ever seen in public health,” Daskalakis says. “And Michael pretty much started that outbreak investigation himself.

” Donnelly’s refrigerator has pictures from his time in Provincetown. This ought to be obvious, but to make it clear: Everyone Donnelly interviewed, those who visited Provincetown and came away with a Covid infection, is gay. That was why they were in that place in one of its biggest tourist weeks of the year.

But people don’t go to Provincetown just to party—they go for community. “Even if you live in LGBT-friendly neighborhoods, you’re still a minority,” says Rob Anderson, a former journalist who moved to the town a decade ago and owns a Commercial Street restaurant called The Canteen with his partner. “Even in New York, you can be walking down the street and get called a fag.

When you come to Provincetown, you just get to be yourself. You feel normal, for the first time in your life. ” The physical setting helps with that.

Provincetown is remote—it lies at the dead end of miles of two-lane highway—and pretty in an unthreatening way, made up of low, shingled buildings surrounded by tidal marshes and soft ocean light. But its social norms help too. It is a place that takes openness to sex and gender expression as a basic social contract.

That openness might show up as a guy wearing heels and fairy wings to the corner store, or a mom bringing her kids cross-country to the beach because every child there will have queer parents—or the town collectively accepting that tens of thousands of smooching, shouting people will flood the streets and clubs for the themed holidays that segment the summer: Memorial Day for young lesbians, July Fourth for gym guys, Bear Week right afterward for big, hairy men, special weeks for Black queer men and women, a raucous costumed Carnival to close out the summer. Despite the partying, there’s a shadow of trauma present in Provincetown, an acknowledgment of the long grief of the HIV pandemic—which was identified in the US 40 years, minus a few weeks, before Delta came to town. Provincetown has been a queer community for so long that AIDS is not past history there, even though it has been survivable for more than 20 years and preventable for just about 10.

Before good treatments were available, some men who were infected fled there to escape stigma; across from the towering Pilgrim Monument, there’s a memorial to the lost, a massive slab of quartzite carved to resemble the surface of the ocean. In a way, Provincetown’s sex-positive culture owes its existence to the health-focused practices imposed by HIV: not just staying alert to the risk of infection and practicing safe sex, but also getting tested regularly and disclosing your status when it changes. “We’ve had to develop social norms and expectations to share our risks and exposures,” says Donnelly, who is 37, born after the first, worst years of HIV.

“I don’t want to be Pollyannaish about it: This is still work. We’re not perfect at it. ” Thus many Provincetown visitors and residents were primed, the way a vaccination primes the body to fight a later infection, to recognize that Delta was spreading among them and to be very public about it.

People who realized they’d been exposed in the July Fourth week went further than simply admitting to Donnelly that they tested positive. They began doing contact tracing on themselves and looked for professionals to give the information to. One of them was Daskalakis.

“I got emails, and the emails went, ‘Hi, my name is X. On Monday I was here, on Tuesday I was here, on Thursday I had dinner with this person,’” he recalls. “It was amazing.

Other CDC folks will tell you: It was unlike any other group they’ve dealt with in terms of getting information. ” The men identifying themselves were fully aware that there might be a cost to doing so. Some of the residents remember, and just about everyone has heard, about the ways in which HIV-positive men were blamed for their own illnesses.

Speaking up about Covid meant risking that again—both from the wider world (right-wing media were vicious) and within the gay community. Holihan’s tweet about his positive result didn’t only draw encouraging DMs. “I had old friends reach out and say I had been irresponsible, almost like a little bit of slut-shaming,” he recalls.

“First it was the gay and bisexual population, then it was the seasonal workers, then it became residents and schoolkids. It just continued to grow. ” Theresa Covell returned from her days off to find her boss, Deirdre Arvidson, and her colleague Maurice Melchiono—the entirety of the Barnstable County public-health nursing team—turning back to the tasks they’d been doing for a year: Receiving reports of positive cases from the state.

Identifying infected people and calling and counseling them. Making sure those people were isolating and finding out whether they had a workplace to be notified or kids who needed care. Getting them help if they needed pulse oximeters, grocery deliveries, a separate place to sleep.

Calling again, to make sure they were managing. Calling again after that, to make sure they had recovered. Calling and calling and calling, from lists that had new names added every day.

Covell and her coworkers were stunned by the spread. They knew that some bars and clubs in town were checking visitors’ vaccination cards, and that most locals had gotten the shots. But this new wave of Covid didn’t seem to care.

“First it was the gay and bisexual population, and then it was the seasonal workers, and then it became residents and then schoolkids, and it just continued to grow,” Melchiono says. The spiraling case count made clear how much individual behavior and local conditions mattered to the transmission of the virus. A tropical storm had churned up the coast that holiday week, and the weather had been cold and rainy enough to drive people indoors instead of enticing them onto beaches and balconies.

And though federal guidance said vaccinated people were safe indoors and face-to-face, that didn’t account for the unique context of Provincetown—especially its thousands of seasonal workers, some unvaccinated or undervaccinated, bunking in campgrounds and crowded temporary housing. The town government reacted by recommending masks on July 19 and mandating them on July 25, but the outbreak tore through the workforce. Last summer, 60,000 visitors descended on Commercial Street for the week of July Fourth.

Covell’s team had only enough resources and jurisdiction to investigate within Barnstable County. For tracking the people who’d left the Cape, there was a bigger, better-funded effort—the Community Tracing Collaborative, a 4,000-person corps created by the state health department and the global nonprofit Partners in Health. Its size suggested the scope of the job.

Covid isn’t a disease that’s amenable to traditional contact tracing. It doesn’t transmit only one-to-one, the way Ebola, monkeypox, leprosy, and HIV do, but one-to-many as well. Boston itself had been host to one of the largest such events, a super-spreader biotech conference in February 2020 that over months caused more than 330,000 cases worldwide.

There would have been no point in trying to understand which person at that conference infected which other attendee. But if officials had been able to warn all the attendees to isolate, they might have prevented later generations of infection. That was what the Community Tracing Collaborative undertook for Provincetown.

It was a practice of pattern recognition, using data analysis tools to map the relationships between people and the places they had gone and the other people who might have been present at the same time. It required a bending of the normal rules of disease investigations, which strictly define what constitutes a case and what qualifies as exposure—and it asked investigators to look at both where the risks had been and where they might go next. This simultaneous tracing of people and gatherings was a newer approach in the US—the method was copied from Covid strategies in Japan—and it wasn’t easy.

If you diagram the transmission of a disease that goes person-to-person, it looks like a family tree. In Provincetown, it looked like an overgrown forest. “There were so many overlapping interactions, across three different streets, in upwards of 20 different locations—so it was very difficult to pinpoint where someone was actually exposed,” says Perri Kasen, a management consultant who joined the Community Tracing Collaborative in 2020 and became one of the three lead investigators for the Provincetown outbreak.

Among the hundreds of cases detected in the outbreak in the first half of July, contact tracers could identify only six people for whom it was reasonably certain that one had infected the other. But, as Kasen says, “you don’t necessarily need confirmatory evidence to act. ” On July 27, the CDC did act.

In a bombshell media briefing, director Rochelle Walensky announced gloomily that vaccinated people should go back to wearing masks indoors, especially in schools and around the vulnerable. New data, she said, had shown that when vaccinated people developed breakthrough infections from the Delta variant, they carried the same amount of virus as infected people who had never been vaccinated, and could pass the virus to others. “It is not a welcomed piece of news,” she said.

“This new data weighs heavily on me. ” Three days later, the agency released the data in its weekly journal. It was an analysis of an outbreak in “a town in Barnstable County” during “multiple summer events and large public gatherings.

” That day, there were 105,120 new Covid cases reported in the United States—six times as many as on July 1. As the warm months went on and America mourned the loss of hot vax summer, Bronwyn MacInnis tried to figure out exactly how the outbreak happened. She is in charge of pathogen genomic surveillance at the Broad Institute, a private research facility shared between MIT and Harvard.

For more than a year, her team had been sequencing the viruses collected in Covid tests, helping the state understand its local epidemic. Like everyone else, she had started to relax as cases declined. Fewer samples came in; the vaccines seemed to be doing their job.

And like everyone else, she had been shocked to hear about the Provincetown cluster. She got the call while she was riding her bike through Harvard Square. She remembers thinking: Maybe I’d better pull over.

She and her team zeroed in on the tiny mutations that occur when SARS-CoV-2 reproduces, both within a single person and also as it passes from one person to another. “Asking humans where they’ve been and who they have been in contact with can be really complicated,” MacInnis says. “But the viruses can tell you that information in black and white.

” Whenever the researchers encountered a gap in the genomic narrative, they used data from state epidemiologists and contact tracers to fill it in. Piece by piece, they built their model. By October they could define the outbreak’s full size: 1,098 people infected in the Provincetown area in July.

Based on subtle genetic differences, they determined that varieties of the Delta variant were introduced to the town more than 40 times that month. Five of those introductions led to small clusters of cases, and one was responsible for most of the outbreak—83 percent. (This could have been one person or a family or other small group.

) Next, MacInnis’ team compared the signatures of the Provincetown strains with genomes from across the country. Though people infected in the outbreak had come from at least 20 other states and Washington, DC, those genetic signatures were almost nowhere to be found. The outbreak did not amplify across the US.

Instead, it fizzled. Eight people got sick enough to be hospitalized. No one died.

By the middle of September, the Provincetown strains accounted for no more than 0. 1 percent of cases nationwide. Bronwyn MacInnis (bottom row, right) and her team at the Broad Institute.

“It was almost a moment of tears to see how limited the transmission appeared to be,” MacInnis said. “If we hadn’t had the sequences of those viruses, I have no doubt that the public narrative about this outbreak would have been very different. ” The lightning group chats, the visitors offering up their data, the frantic phone-calling by the Barnstable County nursing team, the data massaging that Kasen and the contact tracers did—it had all helped.

Even though Delta swamped the country anyway. No occurrence of a disease is fortunate. Still, it was an extraordinary piece of pandemic luck that the first US explosion of Delta took place in a community so willing to offer up its lives for examination by strangers.

It was a second piece of luck that those stories were told in a state that had the infrastructure to receive them, alongside a research institute equipped and eager to trace what the virus did next. None of that, though, was foreordained. Another reality could have played out just as easily: The Provincetown visitors arrive home, notice what they think are summer colds, and don’t test themselves.

They tell no one. The authorities are slow to notice the outbreak. The contact tracing and genomic analyses take longer to spin up, and people spend weeks or months under the false impression that they’re fully protected.

In this reality, more people would have gotten sick. Almost certainly, some would have died. Those people were saved, whoever they were, because the men who visited Provincetown took on the burden of going public, and the nurses and contact tracers and scientists transformed their information into reasons to act.

In a pandemic marked mostly by how much people have arrayed themselves against each other, they chose to act for others. In the never-ending battle between plagues and people, they chose—as anyone can—not to be on the side of the plague. This article appears in the July/August 2022 issue.

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