As the pandemic has evolved and most Americans have sought vaccines for protection, and as those who chose to forgo vaccination became infected (often more than once), the risk that COVID-19 poses for most Americans has declined. It’s estimated that more than 90% of Americans have some level of immunity to COVID-19 through vaccination or prior infection.
Along with this wall of immunity, approaches adopted when we had few tools to prevent spread are no longer providing benefits that always justify their costs of social disruption, diminished classroom experiences, and economic drag.
But we’ve been slow to adapt our strategies to the evolving notions of risk. The CDC is soon expected to update its policies, moving away from national recommendations and instead tying to measures of local prevalence its guidance for the protective steps people should take. This community-by-community standard may not be enough. We’ve turned restrictions on but haven’t turned them off as conditions changed. In many cases, it’s because we’re still relying on the same metrics that we used at the start of the pandemic. These concepts for measuring risk have remained mostly fixed since that time, even as people acquired protections from the virus.
At the outset of the pandemic, we had a shared sense of the threat and a shared willingness to sacrifice a lot to deal with it. As the pandemic has evolved, and its burdens accumulated, that social compact has frayed. Now we need to shift from measures adopted collectively, to tactics taken individually by people who are judging their own individual risk against their degree of caution. This means we must accept more regional and local variation in measures adopted at the state level. The government’s role will be to make sure people have the tools they need to make those choices.
Steps that were critical in 2020 to reduce death and health care strain when we were overwhelmed are no longer justifiable. But what anchors that change? Even when actions were adjusted based on risk, in many cases it came too slow. Without deliberate guideposts, it’s hard to gauge why one posture should give way to another, and how to make these decisions.
We’ll never go back to many of the tragic steps we had to take in the spring of 2020 when we were overwhelmed by the first wave of the virus. Take the 45 days to slow the spread put in place by President Donald Trump to try and mitigate that devastating first wave. Reflecting on those extreme measures, it’s hard today to remember how bad it was back then because we haven’t anchored the debate in a consistent measure of danger and recovery.
The New York City healthcare system had all but collapsed. We used hospital ships and triage tents pitched in Central Park to try and manage a devastating cascade of disease and death. The White House rightly judged that if other American cities fell, the nation would be overwhelmed. At the time, one White House official told me that in such a circumstance, the federal government would be tapped out, and wouldn’t be able to give another city the “New York treatment.” It was a reference to the extraordinary support that New York received. The comment stuck with me.
Remember that the CDC had failed to field a diagnostic test that could tell us where COVID-19 was spreading, and where it hadn’t yet arrived, so we couldn’t target our steps to the cities where the virus was already epidemic. We didn’t know where COVID-19 was, or where it wasn’t. We badly misjudged the scope of the seeding that was underway in cities like New York and Seattle. People were still arguing that COVID-19 was no worse than the flu, with a case fatality rate of 0.1 percent. By July 2020, when that first wave had subsided, 0.25 percent of the entire population of New York City had died from COVID-19, but only one-fifth of the City’s residents had been infected.
The risk from COVID-19’s continued march was a catastrophic prospect. Our tools to limit its spread didn’t exist. And our vulnerability seemed unbounded. We had no immunity. We had no effective medicines. We didn’t know how to properly care for the patients admitted to our ICUs. We had to slow the spread and buy ourselves some time to get our response in place. At the epidemic’s peak during the winter of 2020, more than 6,000 people in the U.S. were dying each week in nursing homes alone.
That was 2020.
Now in 2022, we need to leave those 2020 notions of risk behind. What was judged to be “moderate” prevalence this time last year, when we were largely unvaccinated, may be the new “low” when our vulnerability has declined. Especially as we confront a more transmissible but less severe strain like Omicron.
Since then, more Americans have acquired immunity through vaccination and successive waves of infection. By some estimates, almost 70% of Americans have been infected at least once. About 87% of adults have had at least one dose of vaccine. We have a growing reserve of therapies that can treat the sick and substantially reduce the risk of hospitalization or death. The U.S. will soon be producing almost a half-billion “at-home” COVID tests each month. We’ve also seen dramatic advances in our care of the sick.
Yet a lot of the other constructs have stayed in place, even as the Omicron wave has started to subside. Until very recently, many children were still wearing masks in schools, with no agreed-upon standard for when that will end. When Omicron peaked, some schools reverted to remote learning. Offices are closed in many big cities. Some states and businesses are still mandating vaccines, trying to coerce a shrinking pool of vaccine holdouts at the cost of increasing acrimony, even as many of the unvaccinated have probably been infected, some more than once.
Confidence in public health has eroded because we’ve been too slow to adapt the steps we take to changing notions of risk. Some people are adopting their own measures to reduce their risk and voluntarily choosing to avoid congregate settings, wear masks, and take other precautions. Many people are excessively vulnerable to COVID-19 because of age or health conditions, and those who remain worried should have access to tools and support to keep safe. There’s understandable apprehension among parents torn between fears of the virus and the steps to keep kids safe, especially toddlers. But for those who feel more confident about the declining risks, we can only ask so much of the public for so long. There is an amassed effect from the disruptions. People are exhausted. Livelihoods and people’s mental health have been hurt by the diminished lives we’ve had to compromise around. Many children haven’t known a normal school day for two years. The constant disruptions take a cumulative toll. We never agreed that the costs can outweigh the benefits. The problem is we have no way of measuring these trade-offs, and no framework for deciding when to turn things on and, equally important, turn them off.
Take the debate over pandemic and endemic. There’s no clear nomenclature for what it will mean when the virus becomes a persistent but manageable risk that doesn’t dominate our lives. Public-health leaders have different definitions of what it means when the pandemic gives way to an endemic state, where COVID-19 is part of the predictable repertoire of circulating pathogens. The simplest way to define that transition is when constant waves of excessive infection no longer plague the country, and COVID-19 settles into a more predictable pattern that follows the seasons. Some, including me, think that 2022 will be the year that we make this transition. Others still rate as high the risk that another unexpected variant emerges and wrecks that forecast.
Regardless, it will remain an ongoing and persistent risk and will require us to be more vigilant around respiratory diseases, especially in the wintertime when these pathogens are most prone to circulate. We’ll need to protect settings where vulnerable people congregate and create incentives for people to stay current with vaccines. We’ll need to improve air quality and filtration in indoor settings. We’ll need to ensure widespread access to testing and create new cultural norms around staying home from work or school when you don’t feel well. We should distribute home diagnostic tests widely so consumers have a small stockpile on hand at all times. Masks could be used on a voluntary basis and become a tool for certain settings and for brief periods, to deal with epidemic peaks. We also must continue to innovate, investing in therapeutics that can treat the sick and provide for their wide distribution.
But so long as we remain mired in a 2020 doctrine for measuring prevalence and how it correlates with risk, we’re going to be unable to adapt public-health measures to the virus’s ebb and flow, or find a common touchstone for managing risk in our lives.
COVID-19 will remain a fearsome virus for the foreseeable future, but one that we must learn how to live with. Federal health officials have steered us through one of the hardest periods in our country’s modern history, and helped preserve life, even as we lost more than 900,000 of our fellow citizens.
We’ve gradually found a way to coexist with this virus. Now we need a glide path to what normal becomes and a new math to guide how we adapt to COVID-19 even if we never fully defeat it.
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