Back in the blissfully naive days of early 2020, when you heard about the emerging pandemic and the coming lockdowns, you might have thought to yourself: I really don’t want to get Covid-19, so I’ll just be extremely careful for a while and wait till the virus goes away — then I’ll go back to normal!
The public health messaging seemed to support this wait-it-out strategy. People were told to stay home as much as possible, “flatten the curve” so as not to overwhelm our local hospitals, and hang tight until the vaccines arrived.
Now, the vaccines have arrived (for those of us fortunate enough to be in a rich country, at least). But the reality is bleaker than we’d hoped. “Covid is not going away,” said Krutika Kuppalli, an infectious disease expert at the Medical University of South Carolina. “It’s going to be endemic.” That means the virus will keep circulating in parts of the global population for years, but it’ll come down to relatively manageable levels, so it becomes more like the flu than a world-stopping disease.
It’s important to note that for an infectious disease to be classed in the endemic phase, the rate of infections has to more or less stabilize across years (though occasional increases, say, in the winter, are expected).
The delta variant, however, has been causing infections to surge in a massive way. And most of the global population doesn’t yet have immunity, whether through vaccination or infection, so susceptibility is still high.
“We have to remember that we are still in a pandemic with this virus,” said Jen Kates, director of global health and HIV policy at the Kaiser Family Foundation. “We’re not yet at a point where we’re living with endemic Covid. When we get to that point some of this will be much easier, but we’re not there. We’re not totally on a clear path here.”
This is partly why many people are confused as to how they should be thinking about the virus these days. America is past the early phase of the pandemic — and the messaging of the early phase has not set us up well to deal with the current phase. But we’re also not yet in the endemic phase, so we can’t quite act as if Covid-19 is an everyday virus, like a bad cold or flu.
The truth is we’re in a radically different place than we were in the first half of 2020. We need new mental models to make sense of the pandemic as it exists right now, because early-pandemic thinking is steering us in the wrong direction in at least four ways. Let’s break them down.
Hospitalizations and deaths — not infections — may now be the numbers to watch
In early 2020, everyone was talking about R0 — the number that indicates how many other people one sick person will infect on average, in a group that doesn’t already have immunity. For the original version of the virus, experts estimated the R0 at 2-3. In other words, each infected person was expected to lead to two or three more cases.
Case counts became the primary metric the public used to think about the severity of the pandemic. Public health experts gave us a clear goal: The mission was to prevent a huge spike in cases — to flatten the curve. Many of us developed a behavioral habit of checking the local case count online every day. We also developed a cognitive habit: thinking of all infections as dangerous infections.
That made sense at the time, because in our unvaccinated state, there was a non-trivial risk of infection leading to hospitalization or death. But for vaccinated people, it’s really worth differentiating between asymptomatic or mild cases on the one hand, and severe illness leading to hospitalization or death on the other. The vaccines available in the US are highly effective at preventing the latter, including where delta is involved.
In a vaccinated or even half-vaccinated society, case counts are no longer the primary metric we should be laser-focused on, according to Amesh Adalja, senior scholar at the Johns Hopkins Center for Health Security.
“If you continue to follow cases with an endemic respiratory virus, there is no off-ramp, because it’s not going anywhere. We’re always going to have some baseline level,” Adalja told me. “In general, the idea of cases having the same consequences as they did before the vaccine, that’s really not something you can think about in a country where at least 40 percent of the population is fully vaccinated. There, what we’ve seen is a decoupling of cases and hospitalizations.”
This isn’t to say that case counts are totally irrelevant. First, cases can turn into long Covid in a minority of people; the disability sometimes associated with that condition isn’t discussed as often as hospitalizations and deaths, but it matters.
Second, delta is much more transmissible than the original version of the virus, with an R0 now estimated at between 6 and 7, so it can spread all too easily in areas with low vaccination rates. “Certainly R0 is important when you’re looking at largely unvaccinated populations — a state like Missouri or some counties in Mississippi,” Adalja acknowledged.
But by and large, he said, “We have to move away from focusing solely on cases and really look at hospital stress. It’s not just, ‘Did hospitalizations go up?’ It’s: ‘What are hospitalizations as a percentage of capacity in the ICU? Are hospitals reporting stress scenarios?’ That’s what’s important.”
In 2020, we didn’t have vaccines to prevent cases or make them less severe, and transmission was high enough that the pandemic was expanding. “The only way to alter that was to find interventions to bring the R0 down below 1,” Kates said. “Everything was focused on that. That’s why we had lockdowns, social distancing, masking. All those activities were designed to buy time for the health care system and to buy time for countries to figure out if we can find vaccines.”
Now that we have such highly effective vaccines, our new mission is clear, but distinct from last year’s. “The goal is to vaccinate as many people as possible,” Kates said. “Why is that the goal? Because that single thing will drive deaths and hospitalizations very low.”
Instead of trying to eliminate risk, aim to reduce it
When it comes to HIV and various sexually transmitted diseases, many public health experts have come to embrace an approach called harm reduction. They’ve realized that pushing an abstinence-only approach (avoiding all activities that involve any risk) doesn’t work; people need to have pleasure in their lives, so the best thing to do is explain how to make an activity safer — how to reduce harm — rather than just expecting people to avoid it altogether.
“I think what happened in the early pandemic is that many public health experts ... went back to an abstinence-only approach,” Adalja told me. “That approach basically told people: don’t do anything, none of it is safe, there is no acceptable level of risk. It didn’t allow people to think about graded risk — outdoors versus indoors, masked versus not masked. It also stunted the ability of the average person to be able to make risk calculations.”
To be fair, this “abstinence” approach was an understandable reaction at the beginning of the pandemic, when we were seeing hospitals go into crisis in places like New York City and we still knew relatively little about the novel coronavirus. That kind of crisis encourages short-term thinking: Use a blunt tool now, like telling people to mask everywhere and stay at home whenever possible, to get things under control, and sort out the pros and cons later.
But as the months passed, some experts expressed concerns that the cons of an abstinence-only approach were serious. “What are the negative consequences in terms of decreased childhood vaccinations or psychiatric illnesses or substance abuse or [decreased] cancer screenings? You couldn’t even say that. If you said that, you were actually considered like a Covid denier,” Adalja told me. “I’ve been advocating harm reduction from the very beginning, and I was criticized, ostracized, yelled at …. It was considered completely heretical.”
Some experts kept pushing for harm reduction, and their views became accepted to some degree. But the zero-tolerance approach to risk we inherited from the pandemic’s early days has been, for some, very hard to shake. Again, this mindset is entirely understandable given the trauma we’ve all been through. Yet it’s clear that we’ll likely always have some level of Covid-19 circulating, and we have to learn to accept some risk.
Are kids less vulnerable or more vulnerable than adults?
Although early 2020 was a scary time, one comforting message we kept getting was: The kids are all right. Children, we were told, are far less likely to get seriously ill from Covid-19. The main danger is to older and immunocompromised adults.
It’s still true that kids are at relatively low risk of getting seriously ill. But two things have changed.
First, adults are eligible to be vaccinated, while children under 12 — who number around 50 million in the US — are not. So while we adults got used to thinking of ourselves as more vulnerable than kids last year, those who are vaccinated are now the ones who’ve got a protective coat of armor kids lack.
Second, the delta surge is landing more kids in the hospital than at any previous point in the pandemic. As the Atlantic’s Katherine J. Wu reports, “Across the country, pediatric cases of COVID-19 are skyrocketing alongside cases among unimmunized adults; child hospitalizations have now reached an all-time pandemic high. In the last week of July, nearly 72,000 new coronavirus cases were reported in kids.”
All this makes it very difficult for parents to reason through what they should and shouldn’t let their kids do. And it’s no wonder they’re confused. Although the experts agree on many things — it’s a bad idea to send a child to school without a mask, for example — their approaches diverge in some ways.
“When you look at other respiratory viruses that we deal with in children — influenza and RSV [respiratory syncytial virus] — they exact a bigger morbidity and mortality toll than Covid does,” Adalja told me.
“So I often say, ‘Would you do this for the flu? Would you do this for RSV?’ Many people have incorporated flu and RSV into their daily lives and how they think about their children. And I think that’s what you have to think about,” he added. (The exception, he said, is if you have a child who’s immunocompromised or has asthma or other medical conditions; then more caution is merited.)
Kates said she’s not yet ready to consider Covid-19 in the same light as the flu because we’re still seeing a big increase in cases — it’s not yet endemic. Some of this is subjective, she explained: We consider a virus endemic when we as a society are okay with accepting the level of impact it has, but people will differ as to what constitutes an acceptable level.
For her part, “because there’s still so much spread, I think that’s a risky proposition at this point,” she said. “Kids can spread this virus. So part of what we’re also trying to do — because they cannot get vaccinated yet — is reduce their risk of exposure, not just for them, but for everybody else.” Roughly half the US is still not fully vaccinated.
This doesn’t mean parents should keep their kids home all the time; as mentioned above, the zero-risk approach will have to give way to harm reduction. Kates is still planning to send her child, who’s too young to be vaccinated, to school. She’s relying on mitigation strategies like masks and ventilation, noting that “schools have figured out a lot of things” in the last year.
In general, she added, the best thing parents can do is be fully vaccinated themselves and encourage other people to get fully vaccinated. She also recommends that fully vaccinated parents wear a mask indoors in public places even if their city or state does not require it, so as to lower the risk that they could get infected and bring that infection home.
“Until we are able to get beyond where we are right now with delta, that is another layer of protection that you can put between yourself and this virus, and therefore protect your child,” she said.
The pandemic was always global. Why are so many health strategies still local?
Our focus for most of 2020 was on stamping out the virus in our own cities, our own countries. We used masks and social distancing to avoid overwhelming our local hospital systems. We tried to support and protect our neighbors, whether through mutual aid groups or more informal means.
Toward the end of 2020, Americans began to hear that scary mutations originally detected in the UK and South Africa were showing up in the US. The appearance of variants should have driven home the fact that the pandemic always was, and remains, global: When a problem pops up in one country, it’s in all nations’ interest to take notice and help.
And yet, when vaccines became available in the US, America soon accumulated a staggering surplus of doses — and hoarded them. This May, as the virus ravaged populations from India to Brazil, several experts told me the US was clearly engaged in “vaccine nationalism,” where every nation just looks out for itself, prioritizing its citizens without regard to what happens to the citizens of other countries, especially lower-income countries that can’t afford to buy doses. (The Biden administration did eventually donate more than 110 million doses and send other supplies abroad, though many experts still say it should do more.)
But it’s now become blatantly obvious that caring only for our local community or our country is counterproductive: The more we allow the virus to spread unchecked in other parts of the world, the more chances we give it to mutate into dangerous variants like delta.
To the Medical University of South Carolina’s Kuppalli, that’s a strong argument for working toward global vaccine equity rather than rushing for booster shots in countries with high vaccine availability, like the US. “Let’s give everybody their first shot before we’re giving people their third shot. If we’re going to get this pandemic under control, we need to get the global rates of infection down,” she said. Otherwise, “we’re going to continue to get variants. Unfortunately, we live in a very individualistic society where people have a really hard time understanding that.”
This phase of the pandemic requires a shift away from the individualist or nationalist mindset. Everyone needs to conceive of the fight against Covid-19 as a truly global fight — because it is.