A month ago, it felt like we could see the future. Boosters were rolling out. School-age kids were getting their second shots in time to see grandparents over winter break. Life in the United States was sliding toward something that looked like it might be normal—not pre-pandemic normal, of course, but maybe a post-pandemic glimpse.
And then came the Omicron variant, squashing hopes for the holidays as completely as Delta chilled hot vax summer in July. Weeks later, we’re still not sure exactly what it portends. It’s vastly more transmissible. It may or may not be more virulent. It is tearing through countries and spreading through friend groups and sending universities back online for the spring semester.
This is not the year-end we wanted, but it’s the year-end we’ve got. Inside it, like a gift basket accidentally left under the tree too long, lurks a rancid truth: The vaccines, which looked like the salvation of 2021, worked but weren’t enough to rescue us. If we’re going to save 2022, we’ll also have to embrace masking, testing, and maybe staying home sometimes, what epidemiologists broadly call nonpharmaceutical interventions, or NPIs.
Acknowledging that complexity will let us practice for the day Covid settles into a circulating, endemic virus. That day hasn’t arrived yet; enough people remain vulnerable that we have to prepare for variants and surges. But at some point, we’ll achieve a balance that represents how much work we’re willing to do to control Covid, and how much illness and death we’ll tolerate to stay there.
“The key question—which the world hasn’t had to deal with at this scale in living memory—is how do we move on, rationally and emotionally, from a state of acute [emergency] to a state of transition to endemicity?” says Jeremy Farrar, an infectious disease physician who is director of the global health philanthropy the Wellcome Trust. “That transition period is going to be very bumpy, and will look very, very different around the world.”
To start, let’s be clear about what endemicity is, and isn’t. Endemicity doesn’t mean that there will be no more infections, let alone illnesses and deaths. It also doesn’t mean that future infections will cause milder illness than they do now. Simply put, it indicates that immunity and infections will have reached a steady state. Not enough people will be immune to deny the virus a host. Not enough people will be vulnerable to spark widespread outbreaks.
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Colds are endemic—and since some types of colds are caused by other coronaviruses, there’s been speculation this coronavirus might eventually moderate too. (The coronavirus OC43, introduced to humans in the late 1800s, took a century to do that.) But flu is also endemic, and in the years before we all started masking, it killed anywhere from 20,000 to 50,000 Americans each year. Endemicity, in other words, isn’t a promise of safety. Instead, as epidemiologist Ellie Murray has argued, it’s a guarantee of having to be on guard all the time.
Endemicity may always have been the best we could hope for. We can’t eradicate SARS-CoV-2, the virus behind Covid, because it has other hiding places in the world: not only the bat species that it likely leapt from, but more than a dozen other animal species in which it has found safe harbor. Only two diseases have ever been eradicated: smallpox and rinderpest. (Not polio, yet, despite decades of trying.) The successful efforts relied on each of those diseases having only a single host, humans for smallpox and cattle for rinderpest. As long as another host for Covid exists, there is no hope of being safe from it forever. As Jonathan Yewdell, a physician and immunologist at the National Institute of Allergy and Infectious Diseases, bluntly wrote last spring: “Covid-19 herd immunity is a pipe dream.”
To be clear, this isn’t because the vaccines are failures. They do the things they were designed to do—protect against serious illness, hospitalization, and death—and taken as a three-dose series, they reduce the duration of infection. But almost 40 million people remain unvaccinated in the US; globally, only 58 percent of the world’s population has been able to receive even a single shot. Collectively, those billions offer the virus incalculable opportunities to endlessly test its evolutionary strategies for survival. (Granted, viruses don’t actually strategize in any conscious way. But after two years of this, it’s difficult not to anthropomorphize.)
As the pandemic has ground on, we’ve told ourselves different stories about why we do all the things we do to reduce transmission: to protect the elderly and immunocompromised, to prevent hospitals from being crushed, to keep kids safe before child-sized vaccines were tested. We might now have to confront the reality that we need to keep doing all these things just to live in a world that continues to have Covid in it, because vaccination by itself has not made the virus go away. This forces us to learn yet another story about the virus: that while we may individually be protected from the worst outcomes, a transmissible new variant creates a fresh societal risk.
Researchers argue that we are late in explaining to people what endemicity actually represents. “We should have been trying, from a very early stage, to teach people how to do risk calculation and harm reduction,” says Amesh Adalja, a physician and senior scholar at the Johns Hopkins University Center for Health Security. “We still should be trying, because people have gone back to their lives. They have difficulty understanding that no activity is going to have zero Covid risk—even though we’ve got great tools, and more of them coming in the new year, that are going to allow us to make Covid a much more manageable illness.”
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Those tools include the monoclonal antibody infusions that could reduce the impact of infection with the Delta variant but look much less effective against Omicron, and the oral antivirals, Merck’s molnupiravir and Pfizer’s Paxlovid, which seem to be maintaining their power against the variant. Those drugs sharply reduce the seriousness of Covid symptoms, provided they are taken early enough. The need to start them early is a reminder of the nonpharmaceutical intervention that’s likely to be most important in 2022: Covid tests, especially the antigen-based rapid tests that you can use at home if you think you’ve been exposed. The White House made them a crucial part of the Covid fight just before Christmas with the announcement the government will ship 500 million free test kits in January. But for now they are in short supply in much of the US.
“We’re not going to vaccinate our way out of this, but the vaccines will work better if we give them a fighting chance,” says A. David Paltiel, a health policy expert and professor at the Yale School of Public Health who has written modeling studies on deploying rapid tests. “Flooding the market with these tests and making them accessible—not at $25 for two but at 20 cents for one—and making rapid testing a part of one's routine, if not daily at least semiweekly, doesn't seem at all unreasonable.”
It’s a weird irony that the US, so well supplied with vaccines that you can get shots without an appointment, is short of rapid tests, when they’re a routine part of the Covid response in Germany and the government distributes them for free in the United Kingdom. It’s an expression of this government’s priorities, maybe, a preference for the shiny big gesture, not the daily incremental grind. But endemicity will be a daily grind, whenever we get there: a painstaking repetition of frequent testing, sometimes masking, and never quite being free of the need to think about the virus, like an annoying neighbor whom you wish would move away.
The bad neighbor is likely to be around for a while, though. Learning to live with the long presence of Covid will require acknowledging that breakthrough infections may happen to us all at some point, even though a full course of vaccination plus rapid use of antivirals will mute their severity. “I think breakthrough infections are inevitable,” Adalja says. “I think that's something that the federal government has not wanted to say, but with an endemic respiratory virus, no one is going to leave the planet without Covid, just like no one leaves the planet without being infected with any of the other coronaviruses. The goal is to get it when you're vaccinated, so it's mild.”
This brings us to a difficult problem: the number of people who haven’t had the shot. In much of sub-Saharan Africa, vaccination rates are in single digits. As activists have argued from the start, the fate of the pandemic is governed by the vulnerability of the least protected. As complex as endemicity is going to be, we won’t even reach it without fresh attention to vaccinating the rest of the world.
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“Recommitting to NPIs is important,” says Angela Rasmussen, a virologist at the Vaccine and Infectious Disease Organization-International Vaccine Centre in Saskatchewan, Canada. “But at the same time we really need to commit to getting more vaccine supplies out to the world, and on top of that actually investing in vaccination campaigns. It's not just a matter of getting vaccine supplies to these places; we need to invest in logistical support, distribution, to make sure that those vaccine supplies can actually effectively be delivered at population scale.”
If that can be managed—emphasis on if, since we haven’t done well thus far—it sets up the question of what happens next time: the next substantial variant, the next bad flu season, the next time a previously unknown virus emerges from the animal world. In November, the World Health Organization convened member states to start drafting a legally binding whole-world treaty that would govern responses to future pandemics. It could empower on-the-ground investigations as well as ensure delivery of supplies and data. But it’s a tricky effort, because not every nation is on board. (The Biden administration, among others, wants to avoid enforceable commitments.)
“The big question for me is, will we see substantially increased resources for preparedness?” asks Thomas Frieden, a physician and president and CEO of the nonprofit Resolve to Save Lives, and former director of the US Centers for Disease Control and Prevention. “This is the now-or-never moment for that to happen. What’s in the balance in 2022 is whether the world can break the cycle of panic and neglect.”
If we resolve to do this better in the next round, we nevertheless are left with how we play out this one. “If we keep going as we are doing, it will be protracted and painful and prolonged,” Farrar says. “We need to commit to making sure everybody in the world has access to their two doses of vaccines by the end of March 2022. A level playing field isn't just sort of a nice thing to do. It's the only way to reduce the chance of other new variants coming.”
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