The whole world has been participating in a giant “what to do when a pandemic comes” experiment. We’re all each other’s control groups, confounding variables be damned. We’ve learned that a sufficiently authoritarian government can, for a while, sustain a Zero COVID strategy, but that the social and economic costs are high.
China has had very few COVID deaths relative to its population — at least as reported — but has damaged its economy—and the world’s—substantially, triggering a global reassessment of the wisdom of having so many supply chains linked to China. We’ve learned from India that a large, densely-quartered population with insufficient access to vaccines, antivirals, masks and simple distance can suffer terrible losses—India’s official COVID death toll of half-a-million is thought by the World Health Organization to be undercounted by about three million.
We’ve learned from Japan and South Korea that there is a sweet spot where aggressive public health measures combined with leading-edge medical measures can substantially contain the virus while preserving a significant share of economic and social life. We’ve learned from some African countries that the disease does not always kill as much as expected, even when defenses are minimal, and we don’t know why. What have we learned from the USA?
Many Americans, it turns out, are not that fond of public health measures, and choose, de facto, to let medicine save them if it can. Loosely defined, medicine treats individuals who have health problems, while public health attempts to protect populations from having health problems. The dividing line is permeable—vaccines, for example, are most beneficial when deployed through both the medical and public health channels. The bias toward medical solutions over public health solutions is not an exclusively American problem, just a particularly American one, and one that’s a good fit for our bias towards individualism over social solidarity. We have not been pushed off our position even by a million deaths in two years, so we’re not likely to change now. Why?
Two reasons come to mind:
- The preventive measures promoted by public health agencies cost something—in time, money, perceived risk—without providing a guaranteed benefit to each person paying the cost. The biggest “win” is to skip the costs of prevention and then dodge the disease, ending up with “free good health.” To answer Clint Eastwood’s question, a lot of people DO feel lucky.
- Public health delivers a much less intense emotional experience—you agree to change your behavior in the hope that there will be an increased chance of a good outcome and a decreased chance of a bad outcome. You still might get either outcome, or maybe you’ll contribute to a good outcome for your family and friends, but still draw the short straw yourself. You’ll have to rely on after-the-fact data to know if your behavior may have made any difference. Compare this experience to having medicine intervene to save your life when you know it’s at acute risk. In the medical case, you feel strong emotions—fear, relief, gratitude—and you feel them right away. As individuals, we are properly amazed that hearts and bones can be repaired, cancers removed, symptoms suppressed, and a vast suite of modern medical practices can keep individuals alive longer and in better health. Public health has a less vivid, though arguably much larger, impact on each of us: clean air and water, safe food, safer highways, and so forth.
Public health is most in the news when it is not perfect: when lead is found in drinking water, or E. coli in ground beef, or brain damage in athletes, or rising obesity in children. Public health is often most visible when it works to change the behaviors of individuals, rather than institutions: campaigns in favor of seat belts and motorcycle helmets, for example, and against smoking and drunk driving. Each of these has done a lot of good, but the beneficiaries don’t feel them in the visceral way that they feel successful medical interventions. When public health opposes popular behaviors—unfettered gun ownership, consumption of soft drinks in big gulps, emissions of carcinogens by two-stroke engines—it typically provokes an angry response, which can cause elected officials to quake in their political boots and leave their public health officers to take the heat.
What does this mean for the nature of our COVID experience going forward? It means, I think, that we’ll tolerate a higher-than-necessary toll of death, serious illness, work impairment, and Long COVID, in return for being freed from most COVID mandates and even norms. Public policy at all levels seems to have quickly become, “It’s time for each of us to take whatever measures we deem necessary to protect our individual health and the health of those close to us.” There will continue to be people who follow all the best practices—vaccines, boosters, masks, etc—and are rewarded by better outcomes, but there won’t be a larger benefit of a whole society also taking reasonable precautions.
COVID brought the dichotomy between medicine and public health to a head in America. Public health practitioners proposed and implemented social distancing, mask wearing, hand washing, test/trace/quarantine requirements, travel restrictions, and other “we can do this right now to save lives” NPIs—Non-Pharmaceutical Interventions. Some worked better than others and the initial kitchen sink approach took time to refine, but taken together these measures have probably saved hundreds of thousands of lives in the US. Nevertheless, they are not fun to do, they have significant costs, and they were quickly polarized for political effect. The benefits are hard to quantify and can only be seen in hindsight. The attacks on public health created such a toxic environment for public health officials that many left the field in fear for their personal safety.
Meanwhile, medical practitioners were struggling heroically in overwhelmed hospitals, many at great personal risk, to save who they could and reduce suffering for the rest. A handful of drugs and other treatments provided bits of help, but only now are effective oral antivirals coming into common use.
The creation of effective vaccines in less than a year was an extraordinarily beneficial development, and united medicine and public health behind a common solution. The record speed for vaccine development prior to COVID was over four years. Imagine life today if there were still no vaccines. The Commonwealth Fund did exactly that and has calculated that vaccines have saved over a million lives in the US and prevented over 10 million hospitalizations. The rollout was imperfect, but still scaled up massively, and the vaccines quickly became, by far, the leading go-to response promoted by both public health and medical experts.
At which point, some people—at least 30% at first, and probably still 20% of the adult population—embraced strong opposition to vaccination, which inspired hesitancy in another 20% or so of the population, which is only slowly melting away. Some people assumed that since public health experts had recommended masking and social distancing and were now recommending vaccination, they should oppose vaccination because they’d hated masking and social distancing.
The state of play today is that the virus remains uncontrolled globally, while rich countries have built up a significant degree of immune resistance to the variants which have circulated so far and are probably poised to pay a lower price in lives lost going forward, thanks to vaccines and waves of vaccine-moderated infection. There is no certainty that a future variant will not evade the effectiveness of immunity gained to date, and as long as much of the world remains vulnerable, the virus has rich opportunities to keep shuffling the deck and adding new cards.
Have you heard about BA.2.12 and BA.2.12.1 yet? They’ve elbowed past BA.2 in New York, even as BA.2 has elbowed past BA.1 (Original Recipe Omicron) in the rest of the country. How about XE? It’s a recombinant hybrid of BA.1 and BA.2 (sometimes formed when one person catches both at once), and seems to be spreading in the UK, where it is apparently more transmissible than BA.2. There are other BA.1/BA.2 recombinants, BA.3 and BA.4 have turned up in South Africa, and as long as the virus is so prevalent globally, we’ll continue to see new variants and re-combinations of variants.
Back in the US, the great collapse in confirmed cases and deaths from the winter Omicron surge (we’ve lost about 200,000 to COVID so far in 2022) has led to a great surge of relief, and a great reduction in case reporting, social distancing, and masking. The case reporting collapse has come about because a higher proportion of cases now are mild or asymptomatic and never intersect with the healthcare system, plus fewer testing sites are open, testing is no longer free in many places, and people who use home tests (a good thing!) frequently don’t report the results.
IHME at UW estimates that confirmed cases reported in the US now only account for about 7% of all cases. This is Donald Trump’s dream come true: if you don’t test for it, people don’t know there’s a pandemic. We have not yet paid a known price for this higher-but-invisible level of cases, because hospitalization and death rates have continued to fall, though they have recently bottomed out at a higher level than in previous post-surge troughs. Moreover, evidence of Long COVID from these cases will only emerge over time. Our current high level of community immunity—a combination of people with vaccine-based immunity and people with “I had COVID” immunity—means that an actual case rate that would have been devastating two years ago is accounting for a mere 4,000 deaths/week in the US, half the average rate of 2020, 2021, and early 2022.
We’ve learned, however, that immunity to infection fades, even though immunity to hospitalization and death seems to last longer. We’ve also learned that boosters seem to recharge immunity to infection to a high level, but that it fades quickly—over a period of just 4 months or so. The same may be true of “natural” immunity. Accordingly, our current high level of post-Omicron immunity—90% or more of Americans have probably had some degree of exposure, either by vaccine or virus—is now quietly ebbing, though the rate is hard to determine, given the rapid spread of BA.2 and the vastly reduced flow of testing data.
Political leaders at every level have largely bowed to the reality that a majority of American voters have either chosen to maximize personal daily freedom of action over collective maximum health, or have chosen not to fight for the more communal path, even if they would prefer it. A balanced dependency on both medicine and public health would be better (look at Japan, for example), but that ship has sailed, so the nature of our endemicity will be determined primarily by what our system of medicine can do for us. What can we expect?
First, we appear to have accepted that COVID may well be a major cause of death indefinitely. To borrow and twist the subtitle of Dr. Strangelove, we’ve learned to stop worrying and love the virus. America’s annual death toll from all causes was a little less than 3 million before COVID. Total deaths in 2021 topped 3.4 million. Total COVID deaths in 2020 and 2021 were close to total deaths from the top two killers, cardiovascular diseases and cancer. After this winter’s Omicron surge, once the COVID death rate dropped through 10,000/week, people began agitating hard to end social distancing and mask mandates.
I used to think that America might be able to get used to 100,000 deaths/year from COVID. Now I think we would tolerate a much higher number, as long as it was a predictable number, and as long as, frankly, it mostly drew from at-risk groups, and didn’t strike randomly across the population at large. Our current rate of over 500 deaths/day amounts to about 200,000 deaths/year. Of course we’ve already had 200,000 deaths this year, so, if we stay in the trough and there are no more surges, 2022 could end with well over 300,000 COVID deaths.
Who will die? Deaths will be concentrated among the older elders, unvaccinated/uninfected people, and people with compromised immune systems. Unless of course there’s a new variant which can skirt our current immunity, in which case the death rate will be higher again and the demographics broader. There’s a kind of 80/20 rule operating here: 20% of the population will probably sustain 80% of the serious cases and deaths, while 80% “get back to normal.”
Watching the effects this week of U.S. District Court Judge Kathryn Kimball Mizelle’s ruling that the CDC did not have the authority to enforce a national masks-on-transportation mandate is instructive. Within hours, some airlines and public transit authorities announced that masks were optional, and TSA announced mandate enforcement in airports, etc. was terminated immediately.
The Biden administration said the Department of Justice would study the ruling and determine whether to appeal. Clearly they see political risks in appealing a decision which is, to be blunt, a hot mess, because it would put them in the position of “fighting for mask mandates” between now and the midterms. Meanwhile, this ruling comes just as cases have turned back upward, even as reporting rates have fallen. Confirmed new cases are up 2.5-fold in King County over the past month.
Americans appear to believe that we have enough immunity now to protect us from the kind of terrifying major COVID surges that swept across the country five times between March of 2020 and April of 2022. We’re ready to let the vulnerable 20% take all the extra precautions they can without imposing restraints on the 80%. We’ve decided to cut funding to anti-COVID activities outside the US, despite our vulnerability.
Fundamentally, we’re making a bet that, between vaccinations, antivirals, and first-world protocols, our medical system can save us, and we don’t have to put up with the annoyances and costs of public health much anymore. There are scenarios in which this bet works out. Maybe no big bad new variants this year, maybe Moderna’s new bivalent vaccine will indeed roll out this fall and be widely accepted, maybe strong antivirals will be readily available everywhere. Maybe we’ll have a pan-Coronavirus vaccine in a few years that lasts for years.
What seems to be off the table, however, is a future in which we follow the Japanese/South Korean model, and combine high vaccination rates with selective, data-supported NPIs, resulting in a much lower death rate. 500/day now feels like practically nothing, but it’s not—we could be at 10% of that. We’re making an explicit choice to sacrifice 4-500 people/day to keep the mandates away, and to accept whatever degree of Long COVID emerges from our high case rate. 80% are on the bus, 20% are under the bus. It’s just who we are.