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America needs to decide how much Covid-19 risk it will tolerate

A realistic Covid-19 endgame requires accepting some risk. The question is how much.

Illustration of single cases of viral contamination in a huge crowd of healthy people. 
America still doesn’t have a clear goal on handling the Covid-19 pandemic.
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More than a year and a half into the Covid-19 pandemic, America still doesn’t agree on what it’s trying to accomplish.

Is the goal to completely eradicate Covid-19? Is it to prevent hospitals from getting overwhelmed? Is it hitting a certain vaccine threshold that mitigates the worst Covid-19 outcomes but doesn’t prevent all infections? Or is it something else entirely?

At the root of this confusion is a big question the US, including policymakers, experts, and the general public, has never been able to answer: How many Covid-19 deaths are too many?

The lack of a clear end goal has hindered America’s anti-pandemic efforts from the start. At first, the goal of restrictions was to “flatten the curve”: to keep the number of cases low enough that hospitals could treat those that did arise. But that consensus crumbled against the reality of the coronavirus — leaving the country with patchwork restrictions and no clear idea of what it meant to “beat” Covid-19, let alone a strategy to achieve a victory.

The vaccines were supposed to be a way out. But between breakthrough infections, the risks of long Covid, and new variants, it’s becoming clear the vaccines didn’t get rid of the need to answer the underlying question of what the Covid-19 endgame is.

America is now stuck between those two extremes: The country wants to reduce the risk of Covid-19, but it also wants to limit the remnants of social distancing and other Covid-related restrictions on day-to-day life.

“We’re not trying to go for zero Covid,” Ashish Jha, dean of the Brown University School of Public Health, told me. “The question becomes: When do, in most communities, people feel comfortable going about their daily business and not worrying, excessively, about doing things that are important and meaningful to them?”

Will Americans accept the deaths of tens of thousands of people, as they do with the flu, if it means life returning to normal? Can the public tolerate an even higher death toll — akin to the drug overdose crisis, which killed an estimated 94,000 people in 2020 — if that’s what it takes to truly end social distancing and other precautions?

Does it make a difference if the vast majority of deaths are among those who are willingly unvaccinated, who, in effect, accepted a greater risk from the coronavirus? Are further reductions in deaths worth postponing a return to “normal” — or changing what “normal” means — if continued precautions are mild, like prolonged masking or widespread testing?

There are no easy answers here. Even among the experts I’ve spoken to over the past few weeks, there’s wide disagreement on how much risk is tolerable, when milder precautions like masking are warranted, and at what point harsher measures, like lockdowns and school closures, are needed. There’s not even agreement on what the endgame is; some say that, from a policy standpoint, the goal should be to keep caseloads manageable for hospitals, while others call for doing much more to drive down Covid-19.

One big problem identified by experts: “I don’t think we’re having those conversations enough,” Saskia Popescu, an infectious disease epidemiologist at George Mason University, told me. Instead of the public and officials openly discussing how much risk is acceptable, the public dialogue often feels like two extremes — the very risk-averse and those downplaying any risk of the coronavirus whatsoever — talking past each other.

But the path to an endgame should begin with a frank discussion about just how much risk is tolerable as the coronavirus goes from pandemic to endemic.

We’re looking for a balancing act, not a total end to Covid-19

If there is one point of agreement among most experts, it’s that Covid-19 is here to stay. “Until very recently, I was hopeful that there was a possibility of getting to a point where we had no more Covid,” Eleanor Murray, an epidemiologist at Boston University, told me. Now she believes that “it is infeasible, in the short term, to aim for an eradication goal.”

Particularly with the rise of the delta variant, a consensus has formed that the coronavirus likely can’t be eliminated. Like the flu, a rapidly shapeshifting coronavirus will continue to stick around in some version for years to come, with new variants leading to new spikes in infections. Especially as it becomes unlikely that 100 percent of the population will get vaccinated, and as it becomes clear that the vaccines provide great but not perfect protection, the virus is probably always going to be with us in some form, both in America and abroad.

That doesn’t mean the US has to accept hundreds of thousands of deaths annually in the coming years. While the vaccines have struggled at least somewhat in preventing any kind of infection (including asymptomatic infection), they have held up in preventing severe illness, hospitalization, and death — reducing the risk of each by roughly 90 percent, compared to no vaccine. Research has also found stricter restrictions reduce Covid-19 spread and death, and that masks work.

But it’s also become clear most Americans aren’t willing to tolerate drastic deviations from the pre-pandemic normal — lockdowns, staying at home, and broadly avoiding interactions with other people — for long. While social distancing staved off the virus in the pre-vaccine pandemic days, it also wrought economic, educational, and social devastation around the world. It’s the intervention that, above all, most people want to avoid going forward.

“That’s the goal, in my mind: to eliminate or reduce social distancing,” Jha said.

What policymakers can aim for is not a total end to Covid-19 but a balancing act. On one side of that scale is containing Covid-19 with restrictions and precautions. On the other is resuming normal, pre-pandemic life. Vaccines have changed the balance by giving us the ability to contain Covid-19’s worst outcomes — hospitalization and death — with less weight on the side of restrictions. But vaccines alone can’t drive hospitalizations and deaths to zero if all the weight on the restriction side is removed.

That suggests a choice: Either Americans accept some level of Covid-19 risk, including hospitalization and death, or they accept some level of restrictions and precautions in the long term.

Depending on how that choice is made, the US could be looking at very different futures. Americans could decide some milder precautions, like masking, are fine. Or they could conclude that even masking is too much to ask, even if that means a greater death toll. It hinges on how much weight on the restrictions side remains acceptable for the bulk of the population — how high the threshold is for embracing continued deviations from what day-to-day life was like before.

Regardless, experts say the balance, as the coronavirus becomes endemic, will require accepting some level of Covid-19 risk — both to individuals and to society. America already does that with the flu: In some years, a flu season kills as many as 60,000 people in the US, most of whom are elderly and/or people with preexisting health conditions, but also some kids and previously healthy individuals. As a cause of death, the flu can surpass gun violence or car crashes, but it’s a tolerated cost to continuing life as normal.

“You want to get Covid to a place where it’s more comparable in terms of disease burden and in terms of economic impact to the flu,” Céline Gounder, an epidemiologist at New York University, told me.

With about half the country vaccinated, the Covid-19 death rate is still much higher than that of the flu — the more than 120,000 deaths over the past six months is still more than double the number of people even the worst flu seasons have recently killed. But as more people get vaccinated and others develop natural immunity after an infection, the death rate will likely come down.

A glimpse of what this could look like in the future came from a study in Provincetown, Massachusetts. The study was at first widely reported as evidence that the virus can still spread among the vaccinated because the outbreak happened in a highly vaccinated population, and three-fourths of those who were infected had gotten their shots.

But experts now argue for another interpretation of the study: It’s what a post-pandemic world could look like. Yes, the coronavirus still circulated among vaccinated people. But in an outbreak that eventually infected more than 1,000, only seven hospitalizations and zero deaths have been recorded. If this was 2020, given overall hospitalization and death rates, the outbreak would have likely produced around 100 hospitalizations and 10 deaths.

“We should cheer,” Amesh Adalja, senior scholar at the Johns Hopkins Center for Health Security, told me. “The Provincetown outbreak, contrary to what the press reported, was evidence not of the vaccines’ failure but of their smashing success.”

That doesn’t mean the vaccine is perfect. A 90 percent reduction in death, relative to the unvaccinated, is not 100 percent. But it is a much lower risk. If this holds up despite future variants and potentially waning vaccine efficacy, it’s great news.

But that isn’t how the Provincetown study has been widely interpreted, especially after the Centers for Disease Control and Prevention cited it to reinstitute masking recommendations for the vaccinated in public indoor spaces in areas with substantial or high caseloads.

And the national Covid-19 disease burden may never resemble Provincetown’s anyway, since the city resides in the second most vaccinated state. In that context, Americans may have to come to accept even higher levels of sickness and death if the goal is to return to normal and vaccination rates don’t go up quickly enough.

That leaves the country with a blunt question: How many deaths are Americans willing to tolerate?

We don’t yet know how much Covid-19 risk we’ll accept

The problem is there’s no agreement, including among experts, on Covid-19 risk. Some have accepted merely reducing the coronavirus’s strain on hospitals as the major policy goal. There’s next to no confidence that anything like “Covid zero” can be achieved now, but other experts still prefer harsher restrictions if it means preventing more deaths. And many people fall in between.

It’s this debate, between “flatten the curve” and “Covid zero,” that’s long divided the US’s Covid-19 response. Red states hewed at least for a while to “flatten the curve,” moving to lift Covid-related restrictions and reopen their economies as soon as hospitals stabilized. Blue states never truly pushed for “Covid zero,” but they were generally much less willing to tolerate high levels of cases and deaths — and, as a result, shut down more quickly in response to even hints of major surges. (Although there were some outliers on both sides.)

Even with the vaccines, this division, among both policymakers and the public they serve, has kept America in limbo.

Part of the divide is on a philosophical question about the role of government. But it’s about individuals’ decisions, too: Are they willing to forgo social activities, government mandate or not, to reduce deaths? Are they willing to keep wearing masks? Submit to continued testing in all sorts of settings?

Are 30,000 to 40,000 deaths a year too many? That’s generally what the country sees with gun violence and car crashes — and American policymakers, at least, haven’t been driven to major actions on these fronts.

Are as many as 60,000 deaths a year too many? That’s what Americans have tolerated for the flu.

Are 90,000 deaths a year too many? That’s the death toll of the ongoing drug overdose crisis — and while policymakers have taken some steps to combat that, experts argue the actions so far have fallen short, and the issue doesn’t draw that much national attention.

Is the current death toll — of more than 1,500 a day, or equivalent to more than 500,000 deaths a year — too much? Many people would say, of course, it is. But in the middle of a delta variant surge, Americans may be revealing their preferences as restaurant reservations are now around the pre-pandemic normal — a sign the country is moving on. “The loudest voices on social media and in public are way more cautious than the average American,” Jha said.

Part of the calculus may be influenced by who is getting infected and dying. Once everyone (including children) is eligible for the vaccines, is a high death toll among those who remain unvaccinated simply part of the risk they decided to take by not getting the shot?

This is not something most experts I spoke to are comfortable saying, but it’s a sentiment I’ve repeatedly heard from vaccinated people and even some who are unvaccinated — a very dire version of “actions have consequences.”

Another consideration is whether some Covid-related precautions become permanent. Social distancing in any of its forms doesn’t seem like a candidate. But what about masking in indoor spaces? More frequent testing? Vastly improving indoor ventilation? Doing more things outdoors? Depending on whether Americans embrace these other interventions, the level of Covid-19 risk people have to tolerate may end up being lower — but what “normal” looks like would also be redefined to some degree.

Other countries are talking about these trade-offs more explicitly. Australian leaders, for example, have said that they will shift from a long-heralded “Covid zero” strategy once vaccination rates hit certain thresholds — even though this means continued cases and deaths, particularly among the unvaccinated. In the US, the end goal has never been so clear.

Experts argue that these kinds of questions need to be out in the open, so Americans and their leaders can openly discuss them and decide on a plan forward.

Those conversations “were important to have in the beginning,” Murray said. “But they’re even more important now, as we move into this control phase rather than a phase where elimination or eradication [of Covid-19] seems possible.”

The country may just continue muddling along. Vaccination rates and natural immunity will slowly increase. Deaths and hospitalizations will similarly decline. Eventually, the virus will hit a level that most Americans find tolerable (if that hasn’t happened already). Politicians and the media will talk less about the coronavirus. And, perhaps before we know it, the pandemic will be a thing of the past in the US.

That’s what was happening in June — before the delta surge. But over the past 18 months, we’ve seen that, with no agreement on the endgame, it’s often impossible to say if the end is really near.

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