In March 2020, just weeks after the pandemic had been declared and the world cast into crisis, Dr. Anthony Fauci, the nation’s top infectious disease expert, went on CNN to prepare Americans for what he thought was the worst-case scenario. With about just 125,000 confirmed cases in the country at that point, he warned that Covid-19 could eventually kill between 100,000 and 200,000 Americans, far exceeding the flu’s annual death toll even in its most severe years.
Some projections had pegged the number of possible Covid deaths much higher, at one million or more. But Fauci, among others in his field, believed such figures would be “almost certainly off the chart” — “not impossible, but very, very unlikely.”
Two years later, the very, very unlikely has come to pass. With the United States having crossed the harrowing threshold of one million Covid deaths, I’d like to use this week’s newsletter as an opportunity to take stock of the state of the pandemic, how to lessen the burden it continues to place on public health and what preparations ought to be made for what it could still hold in store.
Where things stand
Over a year ago, The Atlantic’s Alexis Madrigal posed a deceptively simple question: When, exactly, could the pandemic’s “emergency phase” be considered over? One answer he and public health experts came up with was “the flu test”: When the number of daily Covid deaths in the United States falls to 100, or about the same number of Americans who died of the flu every day, on average, before the pandemic.
By the flu standard, the emergency phase of the pandemic is still far from over in the United States:
Over the past few weeks, cases and hospitalizations have been increasing, and deaths, while much lower than at the height of the Omicron surge several months ago, are currently hovering around 300 per day.
There has also been a recent uptick in cases in other parts of the world, though the global daily death rate is now more in line with upper estimates of the flu’s.
And then there’s long Covid: As The Times’s Jonathan Wolfe recently explained, studies estimate that 10 percent to 30 percent of people infected with the coronavirus may develop long-lasting symptoms, including cognitive dysfunction, loss or distortion of smell and taste, exhaustion and shortness of breath. Vaccines appear to provide protection against long Covid, but just how much remains uncertain.
What’s more, Americans’ mental health continues to suffer. In a recent survey of over 18,000 Americans, four in 10 respondents said they knew at least one person who had died of Covid. One in seven said they’d lost a family member. The survey also found that 27 percent of adults reported levels of depression that would usually prompt a referral for further evaluation. Especially striking, half the respondents between the ages of 18 and 24 reported depressive symptoms.
“In general,” the survey notes, “these numbers have decreased since their peak in December 2020, but otherwise, they are remarkably stable over time and still markedly elevated compared to estimates among adults prior to Covid-19, which indicated about 8 percent of adults had moderate or greater depressive symptoms.”
Where will the virus go from here?
Six months after the Omicron variant was detected in South Africa, an array of subvariants — BA.2 and BA2.12.1 in the United States, and BA.4 and BA.5 in South Africa — are driving fresh waves of cases. As The Times’s Apoorva Mandavilli explains, Omicron and its subvariants have evolved to partly sidestep immunity, increasing the risk of getting Covid more than once. Reinfection may become the norm even for people who have received several vaccine doses, though most will not become sick enough to need medical care.
“If we manage it the way that we manage it now, then most people will get infected with it at least a couple of times a year,” Kristian Andersen, a virologist at the Scripps Research Institute in San Diego, told her. “I would be very surprised if that’s not how it’s going to play out.”
But it’s not all bad news. Because of the increasing prevalence of vaccine- and infection-induced immunity, along with the advent of new treatments, case rates and death rates are no longer as tightly correlated as they once were. The rate of severe illness may also be lower than official numbers imply, since many Covid infections are most likely going undercounted because of at-home rapid tests. And for vaccinated people, an Omicron infection may trigger an immune response that confers protection against a broad range of variants, two new studies suggest.
After Omicron? As Ewen Callaway writes in Nature, previous variants of concern — including Alpha, Delta and the initial incarnation of Omicron — all emerged independently from distant branches of the coronavirus’s genetic tree. But Omicron seems to be following a different pattern, evolving new subvariants that partly evade immunity with relatively minor genetic changes.
If that pattern continues, the coronavirus’s trajectory “could come to resemble that of other respiratory infections, such as influenza,” Callaway writes. “In this scenario, immune-evading mutations in circulating variants, such as Omicron, could combine with dips in population-wide immunity to become the key drivers of periodic waves of infection.”
Some scientists, though, say the prospect of a different variant — a more competitive descendant of Delta, say — shouldn’t be discounted. And regardless of the variant or subvariant in question, if the virus is able to keep evolving to reinfect people, it’s “not going to simply be this wintertime once-a-year thing,” Jeffrey Shaman, an epidemiologist at Columbia, told The Times. “And it’s not going to be a mild nuisance in terms of the amount of morbidity and mortality it causes.”
How should governments and the public respond?
In the short term, with cases on the rise, protecting the vulnerable has become an even more urgent concern. As my colleague Sarah Wildman writes, returning to “normal” still isn’t possible for millions of Americans with compromised immune systems and those who live with them. That population includes Wildman and her 13-year-old daughter, who received a liver transplant as part of her cancer treatment in March 2020.
“If we don’t want to push, at minimum, seven million Americans and their family members to consider avoiding flights and theaters and schools and trains,” she argues, Americans will need to create a new normal, “one that recognizes that everyone deserves the chance to participate in daily life.”
In practice, that could mean artistic organizations setting aside certain dates for mask-required performances, even if more general mask mandates fall; offices providing masked-only spaces, on-site testing and flexible work arrangements; and restaurants continuing to enforce vaccine mandates. It’s a vision not of broad-based restriction, she writes, but of solidarity and “offering inclusivity in perpetuity.”
In the medium term, the question of whether — and how — to improve vaccines and treatments will be hotly debated. Both Moderna and Pfizer are working on Omicron-specific boosters that could be deployed in the fall. Given the potentially broader immunity elicited by Omicron infection in vaccinated individuals, some scientists think that’s a good idea.
But others have misgivings because of how fast the coronavirus is changing. “I think that we have to take a step back right now and ask ourselves what can we accomplish with our mRNA vaccines and be prepared for the possibility of a brand-new variant,” Michael Osterholm, a University of Minnesota epidemiologist, told CNN. “Will we set ourselves back if we adopt an Omicron-specific vaccine, only for a different new variant to emerge?”
Another option, proposed by the Yale immunologist Akiko Iwasaki in The Times, is developing a vaccine that can be administered through a nasal spray rather than a muscular injection. By stimulating higher levels of immunity in the airways, where the coronavirus enters the body, intranasal vaccines could confer stronger protection against infections, which, even if mild, can still cause long Covid: A new large study of long Covid patients found that 76 percent were not hospitalized for their initial infection.
“Combining this approach with efforts underway to develop a single vaccine for a broader range of coronaviruses” — an idea long championed by Eric Topol of Scripps Research, among others — “could potentially offer people protection against future variants, too,” Iwasaki writes.
For all the advancements that have been made in Covid care, there is still no established treatment for long Covid, as Katherine J. Wu points out in The Atlantic. “America’s neglectful posture on long Covid is choreographed into just about every aspect of what’s left of the country’s pandemic response,” she writes. Correcting that posture, she argues, would require far more investment in researching therapies.
And in the long term, national and international commissions will be needed to determine how the world erred in responding to this pandemic and how to respond to future ones, the Times columnist Zeynep Tufekci argued in March. “If we can do that, to save lives and ease suffering in the future, it will not make up for all the loss and hardship we have endured in the last two years,” she wrote. “But we can at least say we did our best to learn from it, and let that be the one positive legacy of all this.”
The New York Times