Experts have long predicted that the pandemic will end with a whimper, not a bang. That is, COVID-19 won’t so much disappear as fade into the background, becoming like the many other common pathogens that sicken people, but also can be controlled with vaccines and drugs.
“This can become a livable pathogen where it’s there, it circulates, you’re going to hear on the evening news about outbreaks in a dorm or a movie theater, but people go about their normal lives,” former U.S. Food and Drug Administration (FDA) Commissioner Dr. Scott Gottlieb predicted in an April 2020 interview with TIME. For a while, it felt like the U.S. was closing in on that point. Highly effective vaccines arrived and made their way into millions of arms. The U.S. Centers for Disease Control and Prevention (CDC) relaxed its guidance on wearing face masks. By mid-June, the U.S. was recording an average of about 11,500 new cases each day, with deaths and hospitalizations falling commensurately. Many bars and restaurants opened to full capacity, schools and offices made plans to reopen their doors and travel was rebounding. People were, by and large, returning to normal life.
And then the highly transmissible Delta variant hit, threatening to unravel everything. The U.S. is now clocking around 100,000 new infections per day. Thanks to those highly effective vaccines, fewer people are dying or ending up in the hospital than they did at similar points during previous waves—but with only about half the country fully vaccinated, millions of people in the U.S. remain as vulnerable as ever. The situation has grown bad enough that the CDC on July 27 advised vaccinated people in areas of the country where the virus is spiking to resume wearing masks in public indoor settings, and many schools and offices are walking back just-finalized reopening plans.
Is this really what it feels like to live with COVID-19?
There is only one human virus that the World Health Organization officially considers eradicated: the one that causes smallpox. Wiping out an infectious illness is incredibly difficult. It’s far more common for a pathogen to instead become endemic—that is, part of life in a particular place. Endemic viruses circulate consistently, and not without some disease and death, but they don’t bring society to a screeching halt.
That’s the fate many experts see for SARS-CoV-2, the virus that causes COVID-19. “There’s no plausible way I can imagine us getting to zero COVID-19, and I think it’s a distraction” to aim for that unlikely goal, says Dr. Sandro Galea, an epidemiologist and dean of the Boston University School of Public Health. A more realistic endpoint, he says, is for widespread immunity to make it so most people who get COVID-19 suffer no more than they would from a severe cold.
In that reality, lots of infections wouldn’t necessarily mean mass deaths and hospitalizations. The flu, for example, infects anywhere from 9 to 45 million people in the U.S. each year, according to CDC estimates, but lands far fewer in the hospital (between 140,000 and 810,000) and kills fewer still (between 12,000 and 61,000).
Thanks to vaccines, Galea says, the U.S. isn’t so far from a similar situation with COVID-19. While death and hospitalization rates are dangerously high in states with low vaccine coverage, like Florida and Louisiana, the national picture is changing. About 125,000 people in the U.S. were diagnosed with COVID-19 on August 6 and less than 600 people died from it that day. On the same day last summer, there were about 60,000 new cases diagnosed and more than 1,200 new deaths.
No vaccine is perfect, and that includes the ones authorized for COVID-19. As was always expected, some immunized people are experiencing “breakthrough infections,” which can (but rarely do) lead to serious illness. CDC analysis also suggests vaccinated people who get infected with the Delta variant are capable of infecting others—perhaps even as capable as unvaccinated people—which was a major motivator for the CDC once again recommending indoor masking in many areas.
But that doesn’t mean the vaccines aren’t doing their jobs. They were, after all, designed to protect against severe disease and death, not infections. On that front, they’re still doing exceptionally well. Just 0.01% of fully vaccinated people in the U.S. have reported a breakthrough infection that led to severe disease, according to recent CDC data. And during a recent, high-profile outbreak on Cape Cod, almost three-quarters of the 469 Massachusetts residents who got infected were vaccinated, but just four of them landed in the hospital.
Vaccines are a huge piece of learning to live with COVID-19, but the availability of effective treatments play an important role too. When the pandemic began last year, doctors were learning as they went. In March 2020, a staggering 25% of people hospitalized for COVID-19 in one New York City health system died from it, according to one study. By August 2020, that number had fallen to under 8%, in large part because doctors knew what they were dealing with and had more research on effective drugs and therapies. Now, multiple treatments have received FDA authorization, helping to make the disease more manageable, and even more are in development.
Nevertheless, an obvious problem remains: about half the U.S. population still hasn’t been vaccinated. That leaves millions of lives at stake, and allows the virus to keep tearing through regions, like the South and Midwest, where vaccine coverage is low. Right now, the rough equivalent of an entire stadium full of Ohio State football fans is diagnosed with COVID-19 every day in the U.S. That’s not sustainable, says Dr. Vineet Arora, dean for medical education at the University of Chicago Pritzker School of Medicine. She finds the conversation about endemic COVID-19 both premature and concerning, because she fears some people take it as license to give up. There are still “tools in our toolbox” that we need to use before waving the white flag, Arora says.
For example, vaccines haven’t yet been authorized for kids younger than 12, leaving millions of children vulnerable and potentially able to serve as tiny viral vectors. (Authorization for younger children may come this year, potentially as soon as autumn.) The three vaccines available in the U.S. right now have also only received emergency-use authorization rather than full FDA approval, a higher standard that involves a longer review process. If and when the FDA grants that full approval, Arora says it could both boost confidence in the shots and make schools and workplaces feel more comfortable about requiring them.
And though vaccine hesitancy has been discussed ad nauseam, the truth is that many of the roughly 30% of U.S. adults who remain unvaccinated are not “anti-vaxxers.” Surveys consistently show that roughly 15% of U.S. adults say they will not get the vaccine under any circumstances. But that leaves another 15% or so in the gray area. Some still want to “wait and see” what happens to people who have already been vaccinated. A small percentage have allergies or other medical conditions that prevent them from getting vaccinated. Others may struggle to access vaccines because they’ve been overlooked by the health care system, can’t take time off from work or child care or haven’t gotten trustworthy answers to their questions, Arora says. Reaching those people can take lots of time and individual attention, but she says it can and must be done with targeted, culturally sensitive community outreach.
If the U.S. accepts COVID-19 as an unchangeable fact of life before taking those steps, “We’re giving up on our children, as well as people who already are living with structural inequities,” Arora says—not to mention the burned-out health care workers who will have to keep treating a never-ending queue of coronavirus patients.
Further, letting our guards down early could open the door to new variants even worse than the Delta strain. The longer a virus spreads in a community, the more chances it has to mutate—potentially to the point that currently available vaccines no longer offer strong protection. We’re not there yet, but variants may already be challenging the natural antibodies hard-won by people who previously survived COVID-19 infections, says Katherine Xue, a postdoctoral fellow at Stanford University who studies viral evolution and the microbiome.
Consider the seasonal flu. “The flu virus changes constantly, year to year,” Xue says. “It’s that change that allows it to evade the buildup of immunity that we acquire through our own previous infections”—hence why flu shots are given annually. Similarly, as COVID-19 mutates, it will also likely get better at outsmarting the body’s defenses. The immune system doesn’t forget completely—as with other viruses, you’d likely experience subsequently milder illness with each exposure—but “the more different the virus is, the more pressure it may place on those immune defenses,” Xue says.
That underscores the importance of vaccinating as many people, as fast as possible, to cut off the virus’ ability to mutate. Doing so at a global scale is even more important, since many countries have vaccinated less than 20% of their populations. “As long as we have very large numbers of unvaccinated people around the globe, that still gives the virus many opportunities to transmit, and transmission gives it opportunities to evolve,” Xue says.
In Arora’s mind, that’s another argument for staying vigilant about COVID-19 prevention. “As long as the virus is evolving, we have to evolve with it,” she says. That means being willing to resume certain safety precautions—like wearing masks in public indoor spaces, as the CDC again recommends—when conditions call for it.
The work isn’t over, but Boston University’s Galea says he’s optimistic all the same. He believes vaccination rates will continue to inch upward as more people trust in the shots’ benefits, and as community leaders and health workers find ways to traverse the “last mile” and bring vaccines to the people who need them. He seems to be right, particularly as people see the impact of the Delta variant close to home: On average, more than 400,000 people are now getting their first dose each day, nearly double the daily average a month ago.
There’s also the bittersweet reality that people who get infected with the virus develop some immunity to it (though less than they would get from vaccination), meaning population-level susceptibility goes down each day, Galea says.
As long as COVID-19 continues to circulate and mutate globally, there will be periodic spikes in infections. But—assuming SARS-CoV-2 behaves like other, similar viruses—these spikes should grow progressively milder, since a larger and larger chunk of the population will have immunity, either through vaccination or prior infection, each time it flares up. Eventually, it could become a disease that primarily affects young children, since everyone else would have had a brush with it before, says Jennie Lavine, a computational biologist who models infectious diseases at Atlanta’s Emory University.
“If everyone 50 years from now is getting a first [COVID-19] infection between the ages of 0 and 5, that would actually be lower disease burden than flu,” Lavine notes, because kids, at least so far, have been less likely than adults to die from or develop serious cases of COVID-19.
Of course, there are always exceptions to rules. Future variants could hit kids harder than initial strains, as already seems to be happening to some degree with Delta. Elderly adults and the immunocompromised will likely remain more vulnerable to COVID-19 than the general population, meaning health officials will have to find ways to keep them safe and healthy. And, as with other viruses, there will likely continue to be people who develop long-lasting and sometimes debilitating symptoms after even mild cases of COVID-19—a serious problem that demands more research and better treatments.
None of those exceptions should be discounted. But in terms of learning to live with COVID-19 at a population level, turning it into a disease that kills and hospitalizes far fewer people than it infects is perhaps more important than getting case counts down to zero. “We’re more concerned, really, with how mild or severe it will be when it is at its steady state,” Lavine says.
Reaching that steady state isn’t like turning a page on a calendar. “There’s never going to be a ‘mission accomplished’ banner. There’s not going to be a moment when we switch from pandemic to endemic,” Xue says. “It’s going to be a very gradated move back toward normal life.”
That might mean mitigation tools, like masks and limits on large-capacity events, are periodically recommended during disease flare-ups. It may mean booster shots will be required at some point, to keep pace with the ever-changing virus. And, yes, it will likely mean dealing with some (hopefully small) amount of death and disease as more of the population builds up immunity.
But, as Xue wrote in a recent piece for the New Yorker, humanity has done this before. Influenza strains that routinely circulate today caused pandemics in the past. Some scientists even believe coronavirus OC43, which now causes little more than the common cold, seeded a pandemic in the 1800s. The point is not to minimize the suffering that occurred during those pandemics, but to recognize that the world eventually came out on the other side—and that the same is possible for SARS-CoV-2.
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