The Path Forward: An Interview with Myself

Interviewer: Nice to see you. You haven’t said anything in a while.

Me: I’m burned out.

Interviewer: Join the club. But we’re out of this pandemic hellhole soon, right?

Me: I have no crystal ball. But we’ve been watching respiratory virus pandemics for more than a hundred years. There have been at least five – 1889, 1918, 1957, 1968, 2009 – and each one behaves like the month of March: in like a lion, out like a lamb. The virus rips around the world for a couple years, killing millions, and then settles into a steady endemic state of seasonal outbreaks. 

Interviewer: Why? The virus evolves to be milder?

Me: Possibly, but it’s more of a buildup of human immunity as more people get infected or vaccinated. 

Interviewer: Like Islamic terrorism. Terrorists didn’t lay low after 9/11, we just strengthened our defenses.

Me: Sure. 

Interviewer: There’s this idea that viruses evolve to become milder over time because that helps them transmit better.

Me: Part truth, part myth. Respiratory viruses kill you when they dive deep into the lower respiratory tract and flood the lungs. But they transmit more efficiently from the upper respiratory tract. There are somewhat different cellular receptors for viruses to bind in the upper versus lower tracts, so there’s a degree of tradeoff.

Interviewer: So that’s why Omicron transmits better but isn’t quite as deadly. It shifted its receptor binding more towards the upper airway. 

Me: Exactly. But it’s worth pointing out that Omicron deaths have already exceeded Delta deaths. The rate of mortality may be lower, but when the denominator of infected people is so high, that’s still a surge of deaths. It’s misleading to call Omicron “mild.” 

Interviewer: But plenty of governments have cited Omicron’s lower death rate as justification for lifting restrictions.

Me: Right, that’s why hospitals are overflowing, ambulances are lining up outside hospitals, medical staff are cracking and quitting, and medical systems are being hollowed out. You think the grocery aisle looks bare. 

Interviewer: Really? It’s that bad.

Me: It’s a vicious cycle. As more healthcare workers quit, the remaining staff get overburdened and more likely to fold too. Some proactive states like Maryland have called in the National Guard to help with hospital staff shortages. But many hospital workers who once felt like heroes now feel abandoned and betrayed.

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Interviewer: America is cracking.

Me: People are cracking because there is no light at the end of the tunnel and the goal posts keep moving. Everyone was told to get vaccinated and life would go back to normal. It feels like a bait and switch. 

Interviewer: So when does this magical shift occur where SARS-CoV-2 becomes a normal seasonal virus we treat like influenza? Are we there yet?

Me: I need to be honest here. When we do cross the COVID-19 finish line there will be nothing satisfying like breaking the tape. No confetti. No war armistice and parades in the street, with hero scientists kissed by beautiful girls. It’ll more like when you don’t know if your partner finished but you’re tired and go to sleep anyway and will eventually find out in the morning.

Interviewer: Ha! You mean the end of Omicron wave could be the end of the pandemic. Or not. It’s anyone’s guess.

Me: Yes, and we’ll be fools if we try to have some Fourth of July celebration in February when Omicrons settles down and we prematurely declare a return to normalcy. We already read that book last summer.

Interviewer: So we just keep going in this interminable void? This is torture. How many people have to get naturally infected or vaccinated before we reach herd immunity?

Me: Let’s be real, there will never be herd immunity. Herd immunity is the gold standard where the virus gets wiped out entirely, like what happened to measles and polio in the 1990s in America. We’re not even going to get close for a many reasons: low vaccine uptake, waning immunity over time, pathogen evolution. Three strikes.

Interviewer: You’re killing me.

Me: This is not doomsday. Humans have been coexisting with deadly pathogens since the dawn of civilization. Realistically, we accept a certain level of death by pathogen as the cost of cities, transport ,and modern economies. We made peace with the equilibrium 10,000 years ago, the same way we’ve made peace with a certain number of automobile fatalities so we can cruise around comfortably in cars. Trying to prevent every death will strangle society.

Interviewer: “Strangled” is how many Americans feel right now. How do we decide what the acceptable number of deaths is.

Me: Remember in April 2020 when it was all about “bending the curve?” We had an explicit goal to keep hospitalizations and deaths low enough so our medical system didn’t collapse.

Interviewer: You don’t hear about bending the curve anymore. 

Me: Go figure. Two years later, we still have the same goal of not decimating the medical system.

Interviewer: Two years later we’ve lost the spirit of cooperation. It’s every man for himself. 

Me: Vaccine holdouts crushed any spirit of cooperation. 

Interviewer: Right, if you died from COVID-19 in 2020 you were a victim. Now you’re just an idiot.

Me: But we’ve forgotten the hospital workers who have to tend to those sick people. The same nurses we desperately need as Baby Boomers age. Our medical system was broken going into COVID-19; god knows what shipwreck we’ll have coming out.

Interviewer: So what should our strategy be right now?

Me: Flattening the curve has been the strategy from day 1. When a wave hits, everyone mobilizes into a new wartime mindset and makes small sacrifices. I was supposed to go on vacation in mid-January as Omicron was surging. I could (a) stick to my travel plans, enjoy my vacation triple-boosted and with low risk to myself; or (b) delay my travel plans by 3-6 weeks to a time when Omicron is not spreading like wildfire. You have a choice. You can throw gasoline on the fire, or you can be the kid that didn’t immediately grab for the marshmallow. We all knew Omicron was coming, we saw the havoc it wrecked in South Africa, we just lost our will.

Interviewer: Bad timing before the holidays.

Me: Yes. But Omicron is starting to go down and there will be a better time to travel soon.

Interviewer: When it’s safer.

Me: It’s not just about personal safety. It’s about not being a vector.

Interviewer: So why exactly is Omicron going down right now? 

Me: Million dollar question. We obviously haven’t reached herd immunity, but we met some immunity threshold that just tips the scales for the virus. And you can see different states reach that Omicron peak at different times based on when the wave started.

Interviewer: By now aren’t all Americans either vaccinated or have been infected? Shouldn’t it be getting much harder for the virus to transmit in America? 

Me: In theory, yes. But immunity wanes. So if you were infected in 2020 your antibodies may have dipped to levels that won’t provide much protection in 2022, particularly to a strain like Omicron that has so many spike protein mutations and looks so different to the immune system. 

Interviewer: But isn’t it good to have a sharp Omicron peak, meet that immunity threshold sooner rather than later, so the Omicron wave is one short big spike and we can go back to our lives sooner. Let’s rip the bandaid fast.

Me: That’s a nice theory, but during a pandemic healthcare workers are like firefighters. It’s better to have a manageable situation even if it lasts a little longer than a dangerous situation spiraling out of control.

Interviewer: How are we going to figure out when the pandemic peters out if we can’t even figure out why the Omicron wave ends?

Me: We need to be square with people. Yes, we will at some point reach an equilibrium with SARS-CoV-2. SARS-CoV-2 is here to stay, but the pandemic will end.

Interviewer: What does that even mean? Is there some arbitrary number of deaths that make something pandemic versus endemic?

Me: No. And I understand the confusion. What defines endemic versus pandemic is seasonality. Influenza is now endemic because it only causes winter epidemics. The virus doesn’t have enough traction to rip through America during summer, even if travelers from the Southern hemisphere bring it in. Seasonal flu needs environmental conditions like temperature and humidity to be just right. A pandemic virus has no rules and can tear through any place, any time, regardless of season. Eventually SARS-CoV-2 will settle into regular predictable cycles, like a menstrual period.

Interviewer: And there will be fewer total deaths each year?

Me: Likely. A virus that isn’t fit enough to transmit during summer also won’t be quite so transmissible during winter.

Interviewer: I think I’m getting it. So we won’t know until this spring and summer if the pandemic is really over.

Me: At least. More importantly, we need to watch what happens in other countries. We can’t keep taking arbitrary victory laps in America while the virus is still ripping through the rest of the world. The pandemic will not end in America before it ends everywhere else. We have this silly notion that because America manages to keep out other plagues in developing countries (parasites, malaria, Ebola, drought, widespread starvation, diarrhea, etc.) with clean water and technology, America is also fortressed against COVID-19. Respiratory viruses play by different rules. That’s why we still have flu, RSV, seasonal colds, and a ton of other viruses, even if we vaccinate a lot more. Flu is no worse most years in Tanzania than in America. Respiratory viruses are the great equalizers.

Interviewer: So not vaccinating the world as fast as possible really was a miss.

Me: Undoubtedly.

Interviewer: So realistically, how do we live with this virus?

Me: When Omicron peters out, we should relax some restrictions. If you ask people to enter a wartime mindset during the Omicron wave, you need to press the release valve when it’s over. 

Interviewer: That’s what people hate, the whiplash. We’re creatures of habit, we hate having the rules constantly changing.

Me: I hear that. Personally, I’d rather the rules follow the science, just as I modulate my driving speed based on the weather conditions. But I get that we are creatures of habit. My toddler can adapt to wearing masks all day at school, but probably would be less compliant if the mask rules changed every couple weeks. 

Interviewer: We can see weather with our own eyes and judge for ourselves. COVID-19 is different. When you commented earlier that our spirit of cooperation was eroded by vaccine holdouts, you could add that people lost faith in government. No one follows a leader spinning you in circles. 

Me: There’s a communication breakdown here. These natural cyclical waves of new variants are signatures of pandemics. All past pandemics experienced atypical waves that strayed from standard seasonal disease patterns, the proverbial snowstorms in June. The patterns seem topsy-turvy, but these pulses are totally expected.

Interviewer: But amazing mRNA vaccines weren’t available for past pandemics. Aren’t they a game changer?

Me: Americans love magic bullets. Ask anyone who’s written a diet book. Science is more complicated than that.

Interviewer: But American leadership seemed to drink the vaccine kool-aid too.

Me: They sure did. 

Interviewer: You care to comment on that?

Me: Not really. But it’s not surprising. America loves winners, ask any Yankees or Dallas Cowboy fan (okay, I’m a child of the 1990s). A vaccine that prevents illness is a bonafide winner. We’ll throw resources at that, and rightly so. But a test that tells you if you’re sick or not, that sometimes gives the wrong result, which usually comes too late anyway, and you’re probably not going to contact trace anyway, is not a proven winner anyone wants to touch. Unsurprisingly, when HHS was asked to write a national strategy testing strategy, they passed. Maybe they thought it unnecessary since vaccines were saving the day. Maybe it was wishful thinking. Maybe bureaucrats hate getting barbecued when programs hit snags for reasons outside their control. But it’s a vicious cycle. If you don’t invest in testing, the tests won’t perform so well, so they’ll be less interest in using testing.

Interviewer: This pandemic is chock full of vicious cycles.

Me: Data collection and surveillance are equally messy and convoluted, sapping the will to even try. Bureaucracy can be a bear, even for people trying really hard to get things done. Especially for people trying to get things done.

Interviewer: You care to comment on that?

Me: Pass.

Interviewer: This has been great. Is there any last thing you want to tell people?

Me: Final plea: be civil. Our minds are all wavering under duress. Cut people slack. The pandemic will end, maybe sooner than later, but that’s not when everything goes back to normal, just when the healing begins.

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