#CovidIsNotOver

Covid will likely never be over. So how should we respond?

On Twitter, there is a much-used hashtag that is, unlike many such hashtags, indisputably true. It is #CovidIsNotOver.

Confirmed cases, hospitalizations, deaths: By whatever metric you prefer, Covid is very much a going concern. A new sub-variant even has experts worried another wave may be building. Some may have decided they are “done with Covid,” as Bari Weiss memorably put it, but Covid clearly isn’t done with us.

But Weiss did express something real. People no longer feel the threat the way they once did — one of the key reasons being a psychological mechanism I wrote about here — and a great many are no longer willing to put up with the masks and mandatory vaccinations and the countless small intrusions intended to slow the spread and ease the strain on healthcare systems. Democratic governments are responding to these sentiments, and restrictions are melting away like snow in the spring sun. In many places, it’s all gone.

But not Covid. It’s still here.

This incongruence upsets many people. We don’t put away winter coats when we grow tired of wearing them, they reason. We put them away when we no longer need them. From this came #CovidIsNotOver.

In that earlier piece, I tried to show that the declining feeling of threat from Covid is not a good barometer of the risk and shouldn’t be guiding our responses. “I’m done with Covid” is an understandable sentiment. But it is juvenile reasoning.

That said, people on the other side of the divide really should attend to their own blind spot. It’s right there in that hashtag.

It’s true that Covid is not over. But it’s highly likely that Covid will never be over.

History books and Wikipedia and news stories all say the great influenza pandemic of 1918 ended in 1919, or, in some other tellings, 1920 or 1921. And many of the #CovidIsNotOver folks seem to assume that there will be something similar with Covid, some moment at which we can smile and say, now Covid is over. But the influenza pandemic of 1918 was not over in any but a narrowly technical sense in 1919 or 1920 or 1921. Or any year following.

The influenza virus that killed an estimated 50 million people worldwide — at a time when the world population was a fraction of what it is now — didn’t vanish. It evolved into new variants that were considerably less deadly, particularly to the healthy young people who were among those most threatened by the original virus. But these new variants were still highly contagious and lethal and waves of the virus washed over the world in 1922, 1923, and 1924. And it kept coming. These waves happened with such regularity that we took to calling this “seasonal flu.” Particularly in the 1920s and 1930s, it killed people at alarming rates. Over the decades since the pandemic of 1918 ended, the toll it inflicted was immense.

So when were people able to say the influenza pandemic of 1918 was really, truly, finally over? Never. It could even be a hashtag today: #InfluenzaIsNotOver.

Most scientists expect Covid to follow a similar path. Four who study viral evolution published this in The New York Times yesterday:

Taking all this together, we expect SARS-CoV-2 will continue to cause new epidemics, but they will increasingly be driven by the ability to skirt around the immune system. In this sense, the future may look something like the seasonal flu, where new variants cause waves of cases each year. If this happens, which we expect it will, vaccines may need to be updated regularly similar to the flu vaccines unless we develop broader variant-proof vaccines.

And of course, how much all this matters for public health depends on how sick the virus makes us. That is the hardest prediction to make, because evolution selects for viruses that spread well, and whether that makes disease severity go up or down is mostly a matter of luck. But we do know that immunity reduces disease severity even when it doesn’t fully block infections and spread, and immunity gained from vaccination and prior infections has helped blunt the impact of the Omicron wave in many countries. Updated or improved vaccines and other measures that slow transmission remain our best strategies for handling an uncertain evolutionary future.

If we wait for the end of transmission, hospitalization, and death before we turn off the air raid sirens — which seems to be what many using the hashtag have in mind — we probably never will. In theory, at least. As a practical matter, perpetual alarm isn’t going to happen. People can’t live like that. The cost is too great in social and economic terms. And even if it were not, our psychology simply won’t permit it. So if we wait for an end that never comes, we will gradually, thoughtlessly, drift back to the status quo ante. Which is what happened in the 1920s. And what is happening now.

Paradoxically, then, insisting that the crisis continues so restrictions should, too, is likely to result in the opposite of the intended outcome — a collective shrug and ongoing Covid deaths treated as nothing more than the background noise of modern life.

There is a better way: Acknowledge that Covid likely isn’t going to vanish any time in the foreseeable future and we will live with it, as we do the seasonal flu. There’s no way around that. But that doesn’t have to mean simply sweeping away all safeguards and letting the chips, and bodies, fall where they may. We can instead carefully collect the evidence and ask ourselves, based on our understanding of the effect of various preventive measures, at what level of transmission, hospitalization, and death are particular measures in particular circumstances justified?

This is not a matter of getting some numbers and plugging them into a formula. In part, that’s because the evidence will always be at least somewhat ambiguous and evolving. But it’s much more challenging than that because it necessarily involves values. Who bears the costs of action and inaction? Is that fair? These are questions that involve difficult tradeoffs and they cannot be settled by epidemiologists, virologists, or any other type of scientist. They are political questions. For those of us lucky enough to live in democracies, that means they are questions for elected representatives. And that means, ultimately, they are questions for us.

We do this with all risks, it’s important to note. Traffic deaths. Air pollution. Carcinogens like alcohol. Climate change. And, yes, seasonal flu. Anything that puts people at risk engages these questions. The quality of our answers can and does vary enormously. Many of our policies are the product of nothing but psychology and inertia; fewer are much more considered and calibrated. But whether we answer foolishly or wisely, we will answer. There’s no avoiding it.

All we can decide is whether we will drift along and provide answers by default, or whether we will see the challenge clearly, think about it carefully, and answer thoughtfully.