It’s over


According to historians, pandemics typically have two types of endings: the medical, which occurs when the incidence and death rates plummet, and the social, when the epidemic of fear about the disease wanes.

“When people ask, ‘When will this end?,’ they are asking about the social ending,” said Dr. Jeremy Greene, a historian of medicine at Johns Hopkins.

In other words, an end can occur not because a disease has been vanquished but because people grow tired of panic mode and learn to live with a disease. Allan Brandt, a Harvard historian, said something similar was happening with Covid-19: “As we have seen in the debate about opening the economy, many questions about the so-called end are determined not by medical and public health data but by sociopolitical processes.”

Endings “are very, very messy,” said Dora Vargha, a historian at the University of Exeter. “Looking back, we have a weak narrative. For whom does the epidemic end, and who gets to say?”

By the “social” standard for the ending of a pandemic, Covid is over, even if, by the “medical” standard, it shouldn’t be. (I promised I would stop writing about Covid, but I figure the end of a pandemic is as good a reason as any to crank out one last post.)

Let’s start with a summary of evidence, acknowledging that, as we are still in the early days of Omicron, this evidence is uncertain and might be revised somewhat later. Covid cases in the U.S. have reached their highest levels yet. For Delta and other variants, vaccines were effective against infection and transmission. For Omicron, they are not. The efficacy with a booster shot is 50-70% at best; that with 2 doses alone is significantly less (given that most people got their second dose months ago). Prior infection, without an augmenting vaccine dose, offers even less protection. So, Omicron is burning through a largely immunologically naïve population: it has far more targets than does Delta. Furthermore, its “intrinsic” transmissibility appears to be just as high, if not even higher. In the U.K., when Omicron was still new, it was doubling every 2 to 3 days (which, according to the math of exponential growth, leads to an insane rise in cases in the matter of only weeks).

At the same time, evidence suggests that Omicron is much less likely to cause severe disease than Delta. This effect arises from the combination of at least two factors. First, even though vaccines and prior infection provide little protection against infection from Omicron, they appear to still provide substantial protection against severe outcomes, including death. Second, Omicron may be intrinsically less virulent than Delta, perhaps because it is less effective at burrowing into our lungs and inducing pneumonia. The result is a large “decoupling” between the rise in cases and the rise in hospitalizations, and deaths, with attenuation occurring at each stage. Each case is less likely to cause a hospitalization, and each hospitalization is less likely to require intubation and to ultimately cause death.

Our strategy for containing Covid centers on vaccines. In New York City, most indoor activities (gyms, indoor dining, etc.) require being “fully vaccinated” (2 doses). Many employers have required proof of vaccination: either to go to the office, or simply to remain employed. The Biden administration has issued vaccine mandates (with a weekly testing opt-out) for federal workers and contractors, healthcare workers, and large employers, although some of these have been blocked, at least partially, by the Lochner-era lunatics infesting our judiciary.

Omicron has rendered this strategy largely pointless. There is no reason to believe that limiting indoor dining or deadlifting to 2-dose vaccinated individuals will slow the spread of Omicron. In fact, anecdotal evidence I’ve heard indicates that these locations (particularly dining) are the sites of Covid spread, and one of the reasons why New York has seen a nearly vertical trend in Covid cases over the last few weeks. Of course, an auxiliary purpose of the mandates is to increase the cost of non-compliance — to make being unvaccinated so miserable that people feel compelled to get jabbed. This still seems to be a worthwhile objective, although I wonder how many of the remaining holdouts are even reachable at this point (absent strong coercion).

Another strategy for containing Covid, largely abandoned at this point (at least in the U.S.), is to encourage or require changes in individual behavior. These include wearing masks, wearing high-quality masks, social distancing, banning certain high-risk activities, and lockdowns. Some of these measures, like mask-wearing, require individuals to give up very little (even if, to right-wingers, these seem like a large imposition on their individual freedoms). Others, like banning activities outright, entail large costs, both to individual happiness and to the economy. The latter seems to be essentially a nonstarter at this point (and I’m not endorsing or criticizing the idea, simply noting that it does not seem to be under serious consideration), and even the former would be tough to enforce, as my current stay in a purple state is reminding me. I think a large part of the problem is that Omicron is simply so infectious that usual public health measures seem impotent. Last winter, prior to vaccines, we struggled to contain the “Alpha” variant even in ostensibly “responsible” places like New York. What hope do we have with a more infectious variant and less public desire to suffer, even if only slightly? Omicron strikes me as the perfect excuse to simply give up. If the wave is too high, why bother piling up the sandbags? Let it wash over us so we can finally be done with it. (The horrifying thing to contemplate is what would have happened if Omicron had been as deadly as Delta. I tend to think, sadly, that our collective response would have been largely the same, even if many individuals would be treating it with far more circumspection.)

Let’s assume, then, that we will continue to do what we have been doing: i.e., largely nothing. What then? As mentioned above, there are two aspects: medical and societal, although of course these are not truly distinct.

A few factors will govern the medical outcome. First, does infection with Omicron provide good immunity against Delta (the “cross-immunity” question)? Second, what is the true virulence of these various variants against people who have never had Covid before or been vaccinated? And how many of these people are left? Third, will we have other variants that can cause serious damage? And, finally, what are the effects (like “long Covid”) of being infected? Is it like a cold or a flu, where we succumb to the illness temporarily but rejoin our usual lives a week or two afterwards as if nothing had happened? We know that more than a thousand people per day are dying of this disease. Is that because they are the pockets of unvaccinated people who have been, metaphorically speaking, dodging bullets this entire time? If so, perhaps the death rate will shrink, over a timescale on the order of years, as these pockets shrivel. Under the most optimistic scenario (which is by no means guaranteed), lots of people catch Omicron; there are few or no long-term ill effects, at least for the vaccinated; Omicron provides substantial protection against Delta and other variants; post-infection treatments (like Paxlovid) continue to developed; and, in the long-run, this disease is never fully eradicated but also never causes a high level of damage.

In the meantime, though, a lot of bad things are transpiring and, in the short term, will continue to do so. Workers who maintain and run our societal infrastructure — hospitals, subways, airplanes, and so on — will fall ill, and this infrastructure will creak even more than it has been. The immunocompromised will have to abandon normal public life to avoid getting sick. Parents will have to scramble to find childcare when their child’s school reports an outbreak. Demand for Covid tests will outstrip supply, and many people who would have otherwise gotten tests will end up unwittingly infecting others. Some small, but still scary, number of young children will get hospitalized. Hospitalization, even if not severe, will crowd out other important medical procedures, and many people who might not have died in “normal” times will, sadly, die in these strange times. And that’s just the US-centric outlook, setting aside the possibly horrifying impact of Omicron on the (mostly unvaccinated) Third World.

(As an aside, the fact that an at-home rapid test costs at least $20 here bothers me immensely, and perhaps even irrationally. These tests cost pennies to make! Those saying that the FDA is at fault are not incorrect, but this seems like another area in which competition doesn’t really make sense. Do we truly need dozens of different Covid test companies, each manufacturing a slightly different test, to compete against each other to drive down the price? What if we had one or two (good) tests and the government made enough to satisfy everyone? Not to mention that the government could also run testing sites instead of having everyone wait several hours at a CityMD.)

Whether all of this constitutes a “crisis” returns us to the other aspect: the societal one. For better or worse, society can persist in the same way that it has been persisting for the last few weeks. Privileged people will take more Ubers and fewer trains, and grumble about their flight home being cancelled. Less privileged people will suffer and some will die, unjustly. (As Pat Blanchfield writes, “Services must be provided, even if that means serving ourselves up, too.”) People who are scared and have not accepted this “new normal” will be unable to participate in life’s quotidian pleasures. But, some of the short-term snafus will unsnarl: the provision of tests, the straining of hospitals, the inconsistent and occasionally nonsensical public health guidance. The economy will hum along. Stocks will continue their inexorable march upward. (The only real crises we have in America are those that affect the rich, which is perhaps the best indication that Covid is indeed over.) We will gradually forget, whether because our memory attenuates or, more likely, because we want to, how it was before, and our politics will gradually foreclose any possibility of it being otherwise.


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