The Perfect Enemy | Opinion | Endemic Covid-19 Looks Pretty Brutal
August 11, 2022

Opinion | Endemic Covid-19 Looks Pretty Brutal

Opinion | Endemic Covid-19 Looks Pretty Brutal  The New York Times

Read Time:25 Minute

It may surprise you to learn, given the mood of the country — and indeed the world — about the pandemic that probably half of all Covid infections have happened this calendar year — and it’s only July. By December, the figure could be 80 percent or more. The gap between cases and severe outcomes is bigger than it has ever been, with the fraction of infections one-tenth that of the pandemic’s early stages. But simply in terms of infection, this year towers over each of the previous two.

Between the discovery of the Delta variant and its takeover of America more than six months passed; with each of the new Omicron variants, we’ve barely had six weeks. Many of the once-authoritative guides to the pandemic, perhaps acknowledging their declining authority among the public, have withdrawn a bit. The Centers for Disease Control and Prevention changed the standards of its local-guidance maps, raising the threshold for concern much higher, though with the rapid spread of the BA.5 variant, most of the country is now meeting it anyway. Mitigation policies, which had been mostly calibrated to local and national spread for two years, have disappeared as a pandemic signpost too.

In late April and early May, when nearly as many New Yorkers got sick as had during the initial Omicron surge that peaked in January — perhaps 1.5 million in the spring surge, compared with 1.8 million in the earlier wave, according to a pair of CUNY preprints using the same methodology — hardly anyone noticed. Hospitalizations ticked up, followed by deaths, but not nearly as rapidly or as worryingly as just a few months before. The same has happened, more recently, in San Francisco, where according to wastewater data there were recently more Covid infections than there were at the peak of the initial Omicron wave in January.

Nationally, the BA.5 wave does not appear to have crested yet, but so far deaths, while rising, are doing so relatively slowly. Pull far enough back in looking at the graphs and it’s hard to even see the increase. Hospitalizations have doubled roughly since May but are still only a quarter as high as they were at the peak of the initial Omicron wave and well below any of the pandemic’s previous peaks. I.C.U. admissions have barely budged.

How can you characterize this dynamic, or make sense of it? Wave after wave of infection passing through, but almost in the background; hospitalizations and deaths bumping up and down, but mostly within a relatively narrow range, and much lower, relative to caseloads, than we remember even from the first Omicron wave, let alone Delta before that and the waves of 2020 still earlier.

One word for it is “endemic,” says Trevor Bedford, a computational virologist at the Fred Hutchinson Cancer Center in Seattle and among the most careful and dependable soothsayers of the past two years.

Bedford is reluctant to dwell on semantic debates about what constitutes a “pandemic phase” rather than an “endemic phase” for Covid-19, for instance. But if we insist that the country is still in a pandemic phase, he says, we’re not going to be able to downshift from that anytime soon, since conditions aren’t likely to look very different for years — and the country’s accumulating immunological protection, if imperfect, is still a categorical break from those earlier phases in which we first calibrated our fears. “If we’re saying that we’re still in a pandemic right now, it’s still going to be a pandemic in year seven — we’ll still be in a pandemic then,” Bedford says. “So I think it’s better to acknowledge that we’re at 98 percent of the population having immunity of some form — certainly over 95 percent. There’s not much more that could change in that regard.”

There are technical reasons other epidemiologists would dispute the term “endemic.” With respiratory diseases, it can refer to diseases where the average sick person infects fewer than one new person, and each of this year’s variants are more infectious than that. And while many use “endemic” to imply viral stability, there remains the possibility of a “surprise” in viral evolution, of course; no one I spoke to for this article was comfortable ruling it out.

But in a vernacular sense, the term fits: A large majority of the country has gotten infected with the coronavirus, probably most of us with a strain of Omicron, and 67 percent of us are vaccinated as well (though only 32 percent boosted). And for all the variant-after-variant turbulence of the past few months, from another perspective, the Covid experience in America has been for months in something like a steady state.

It is natural to look at those charts and feel some relief, appreciating how much immune protection the country has accumulated over time, particularly against severe disease and hospitalization. But the footprint of that steady state is also disconcertingly heavy. More than 300 Americans have been dying nearly every day for months; the number is today above 400, and growing.

Right now, Bedford says, around 5 percent of the country is getting infected with the coronavirus each month and he expects that pattern to largely continue. What would that imply death-wise, I ask? As a ballpark estimate, he says, going forward we can expect that every year, around 50 percent of Americans will be infected and more than 100,000 will die.

This year has been considerably worse than that, largely because it includes the initial arrival of Omicron — which, though often described as “mild,” killed more than 100,000 Americans in the first six weeks of the year. And so although the country’s current trajectory is following an annualized pace of 100,000 deaths, more than 200,000 Americans have died already this year, which implies over 250,000 deaths by the end of 2022.

Michael Mina, an epidemiologist who left Harvard to become the chief scientist at the online medical portal eMed in 2021 after spending most of the pandemic as the country’s leading rapid-testing evangelist, believes it could get worse. With a combination of seasonality and waning immunity among older people, he said, there’s potential for a fall wave of perhaps 1,000 a day. That would bring the number of American deaths, this year, to potentially 300,000 or more.

That toll, 10 times that of recent flu seasons, is smaller, to be sure, than those of the first two years of the pandemic, when just over 400,000 Americans died during both President Donald Trump’s last year in office and in President Biden’s first. But it isn’t that much smaller. Nationally, the infection fatality rate is a fraction of what it once was, but the disease is spreading much more prolifically now and has been all year, which means all told the disease is still generating a quite devastating death toll — particularly among the elderly, who have been accumulating immunity more slowly than the rest of the population and shedding it more quickly.

After a recent stumble in which Ashish Jha, the White House coronavirus response coordinator, called the daily number of deaths “low,” the administration has taken to calling the current level “unacceptable.” But there’s little reason to expect that level will fall much, at least not significantly. “You do feel caught in this loop,” says Natalie Dean at Emory, a biostatistician specializing in the epidemiology of infectious disease. “We all probably feel similarly. It’s like — another wave.” If anything, she says, “it does seem like things are picking up now,” with BA.5. “That steady state doesn’t put us in a great place.”

If Bedford is correct — and that steady state means 100,000 annual Covid deaths going forward, for at least the next several years — the two facts may be a bit hard to square in your mind. (Especially if you remember both the initial state of emergency the pandemic called into being and the more recent hope that it could at some point “be over.”) A hundred thousand deaths is more than the annual toll of any other infectious disease and would make Covid-19 a top-10 cause of death in the country — a major and novel cause of widespread death clouding the American horizon with another dark layer of morbidity we had never known before. It’s a few multiples of a typical flu season and more than die each year from diabetes, pneumonia or kidney disease. It is what this newspaper once called, in an immortal front-page banner, “an incalculable loss.”






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How Covid-19 might fit into the leading

causes of death

Some of the most common causes of death in the United States, sized by number of deaths per year, shown during the pandemic and projected into the future.

2020-22

Projected

Annualized

deaths

Heart disease

Heart disease and cancer each cause around 600,000 to 700,000 deaths per year.

Cancer

Pandemic

Around 360,000 people have died of Covid-19 per year since the coronavirus began spreading in the U.S.

Endemic

Respiratory disease deaths were unusually low during the pandemic.

If current death rates continue, Covid-19 would kill an estimated 100,000 people annually.

About 50,000 deaths a year

Flu and pneumonia

How Covid-19 might fit into the leading causes of death

Some of the most common causes of death in the United States, sized by number of deaths per year, shown during the pandemic and projected into the future.

2020-22

Projected

Annualized deaths

Heart disease

Heart disease and cancer each cause around 600,000 to 700,000 deaths per year in the United States.

Cancer

Pandemic

Around 360,000 people have died of Covid-19 per year since the coronavirus began spreading in the United States.

Respiratory disease deaths were unusually low during the pandemic.

Endemic

If current death rates continue, Covid-19 would kill an estimated 100,000 people annually.

Around 50,000 deaths per year

Flu and pneumonia

How Covid-19 might fit into the leading

causes of death

Some of the most common causes of death in the United States, sized by number of deaths per year, shown during the pandemic and projected into the future.

2020-22

Projected

Heart disease and cancer each cause around 600,000-700,000 deaths per year.

Annualized

deaths

Heart disease

Pandemic

Around 360,000 people have died of Covid-19 per year since the corona-

virus began spreading.

Cancer

Resp. disease deaths were unusually low.

Endemic

If current death rates continue, Covid-19 would kill an estimated 100,000 people annually.

About 50,000 deaths a year

Flu and pneumonia


Source: Mortality data for 2018 through June 2022 from CDC WONDER, provisional from 2021 onward. Future mortality estimated based on 2018 and 2019 data. Note: Respiratory disease deaths were low during the pandemic due in part to lower circulation of respiratory viruses, and because some people with lung problems who could have died from respiratory disease died from Covid-19 infections instead. Graphic by Sara Chodosh

How do you calculate a loss 10 times as high? How can you reckon with that level of dying, each year, going forward? According to Céline Gounder, an infectious disease epidemiologist and a senior fellow at the Kaiser Family Foundation, that figure is actually the low end — the ballpark, she says, runs from 100,000 to 250,000. That’s not her estimate of this year’s toll but of the annual continuing mortality burden rolling forward indefinitely into the future. “And the question I have is, how much death are we OK with?” she asks. “Have we decided this is OK? And if so, why?”

For most of the pandemic, it has been hard to see the trajectory of the disease other than through the lens of partisanship and policy. Questions like Gounder’s often suggest particular sets of interventions others have opposed or deemed unrealistic. Those living relatively normal lives have been labeled Covid minimizers; those calling for continued precautions are described as hysterical alarmists.

And yet, if you could look past the culture-war contestation, each of the first two years of the pandemic had, for all their brutality and human suffering, an intuitive narrative form. In 2020, the story was, below the death and panic, one of state capacity and behavioral response — which governments and communities mobilized most quickly and most effectively to intervene to “flatten the curve” and, in some cases, temporarily eradicate the disease domestically. You could plausibly have blamed local leadership and lack of community vigilance for the level of infection and dying around you, even if those narratives often overstated national differences in pandemic outcomes. If you were satisfied with the response — as those in, say, Taiwan and New Zealand tended to be — you probably felt some civic pride about those outcomes. You might have felt you had done your part, or found yourself in that prosocial spirit, leaning out your window to applaud the emergency medical workers for doing theirs. On the other end of the spectrum, you might have found yourself yelling on social media about people spending Thanksgiving with their families, even with a negative test result in hand.

Then came the vaccine year, 2021, in which the spread of the disease and its relative severity were explained primarily by, first, the distribution of shots and then by the eagerness of certain populations to be vaccinated. You might have regarded the relative level of sickness and death around you as a grotesque, ungenerous vaccination morality play — even if, say, the phenomenon of “Red Covid” was never that much larger than the vaccination gaps defined by income, education and race. Liberals often discounted deaths among the unvaccinated, and when people used the phrase “vaxxed and done,” they were expressing a desire for “normalcy” but also a widespread epistemological view of the virus: All that mattered was how many people had gotten their shots (or how many of the elderly had gotten their shots and, later, how recently).

The experience of the pandemic’s third year has been much muddier, narratively, almost everywhere in the world.

It began with the first wave of Omicron, so distinct from previous variants it amounted almost to a slate-washing of prior immunity against infection and precipitated the brief resurgence of some throwback mitigation measures. What followed was equally disorienting: a rapid series of Omicron sub-variants, each arriving so soon after the last that the waves seemed less to crash than to simply be displaced by infections from a new lineage. Presumably, there will be more to come.

The variants themselves, each with its own immune-evasive properties and spread dynamics, could overwhelm the lay epidemiologists we’ve all become. But it hasn’t been much clearer even to those monitoring it most closely. The severity of recent waves has varied enormously from country to country — with some of the worst outcomes in places like Portugal, where heroic vaccination campaigns had appeared to bring the pandemic to a functional local conclusion. In others — like Denmark, where the earlier BA.2 surge was its largest of the pandemic — there’s been basically no surge in hospitalizations at all.

Some of this, it’s believed, is a result of which countries got which initial strain of Omicron. But even that is probably a simplification. As a British mathematician, Oliver Johnson, has pointed out, given the range of vaccine dosing (zero to four shots) and exposures (there are those few who remain uninfected and those who’ve had one or more infections from the wide variety of variants) and the significant underlying age skew of the disease (with the elderly more vulnerable to severe outcomes and waning protection) — modeling pandemic spread accurately might require accounting for at least 30 distinct categories of people. “It’s definitely harder,” Dean says.

But there is an illuminating effect here, too — a somewhat ironic one. In the pandemic’s third year, the epidemiological picture is complicated enough and the pandemic politics enough in retreat that it feels possible to just tell the story of the disease itself — treating Covid-19 less as a litmus test of one kind or another than a continuing tragedy.

There are still conversations about policy and behavior, of course. Los Angeles has announced it’s on the verge of reinstituting an indoor mask mandate, though only ten percent of patients hospitalized with Covid there are being hospitalized for Covid-19, and its I.C.U.’s are functioning smoothly. Experts talk about normalizing testing as a routine part of life and accelerating the rollout of variant-specific boosters, establishing permanent new occupational and safety standards and making large-scale investments in indoor air quality, along with encouraging people to wear high-quality masks in high-risk indoor settings.

But where once we saw morality plays, in many cases justifiably, we may now more clearly see the underlying landscape of the disease as a once-in-a-generation, or perhaps once-in-a-century, pandemic event, against which many nations of the world were able to marshal first human resources and then the incredible power of pharmaceutical innovation — though not quite well enough to overcome our social and political dysfunctions or to deliver a truly miraculous and permanent pandemic exit.

Even the vaccination categories used to distinguish risk have become muddier. In part because the most vulnerable are also the most well vaccinated, the outcomes for the two groups are not nearly as distinct as they once were. In April, for the first time, there were more deaths among the vaccinated than among the unvaccinated, according to the C.D.C.’s representative 30-jurisdiction sample. In May, 54 percent of Americans dying of Covid had completed at least their primary vaccination schedule.

This is not a black mark on vaccine efficacy, since the U.S. population — and especially the vulnerable population — is well vaccinated enough to distort these calculations. Though vaccines have proved considerably less effective at stopping transmission, vaccination remains a miraculously powerful tool against severe illness. (Protection against those outcomes does wane, but from a very strong baseline.) But it probably no longer makes sense to think about the population in two neat buckets or to attribute the spread of the disease primarily to easy-to-understand vaccine dynamics. The immunological makeup of the country is just much more complicated now, in part because just about everyone has been infected.

At some point, we looked ahead to that future, hoping we wouldn’t reach it, but telling ourselves that if we did, at least it would bring a herd-immunity endgame. Here we are instead.

Where is that, exactly? Mina calls it a “long, bumpy off-ramp,” defined by the imperfect but predictable and reliable accumulation of additional immune protection.

“We are not seeing the same levels of death,” he says. “We’re just not. And that’s really important because this is reflecting not just the fact that we have treatments but a combination of immunity from infections and vaccines.”

Before the pandemic, Mina’s research was focused on the development of immunity in babies and children, and his mental model for our collective experience here is the same. “I’ve always said that we have to grow out of this pandemic,” he said. “We have to literally just build up enough immunity for us to get out of the pandemic as a human species.” Right now, he said, we are the equivalent of 2- or 3-year-olds immunologically speaking — having passed through “the real risk zone,” we are now for the first time able to navigate a world of viruses and bacteria without the same acute medical risks as before. “We know that 3-year-olds still go to the hospital a lot, but we know that given the same infections, 3-year-olds do a lot better than 1-year-olds. And that’s because of immunity.”

The novel coronavirus is no longer novel to us, in other words. Our immunity to Covid-19 is growing up. “That’s where we are as humans,” Mina says.

For many of us, he says, the process will continue. The immunological gains aren’t necessarily huge anymore, given how many times most of us have been exposed — and will be, going forward. “Those who get through it will probably actually have then seen the virus, maybe 10 or 15 times over the next five years,” he says. But each exposure, vaccination or boost does add to the tool kit and makes the risks of future infections less scary — one reason a recent small-scale social-media panic about possible heightened risk from second infections is so misplaced. “Eventually, it will settle out, and then our immune histories will really protect us more and more and more each year,” Mina says.

Of course, there are those who cannot build that additional immunity so well, primarily older people. Thanks to what’s called immunosenescence, the older you are the harder time you have forming new protections against new diseases, and the easier it is for you to lose those protections over time. So if the rest of the world is now building a higher and higher immunity wall, with each additional booster or infection adding some amount of protection — and future variant-specific boosters or pan-coronavirus vaccines potentially adding even more — the vulnerable old are building their own walls a bit more slowly and fitfully.

Covid-19 has always been a disease of the elderly, defined almost more by its age skew of mortality than by any of its other characteristics, with risk doubling roughly every eight years and octogenarians hundreds of times more at risk of death than young adults. But in a time of widespread vaccination and almost universal infection, that gap may well expand.

Mina compares the building of immunity to the learning of a language. “It’s a fact of the biology of immunity that it’s really hard to build a brand-new memory and keep it if you’re old,” he says. “And so I do think that for quite a while our elderly population is going to keep having really big problems because they just can’t retain these new memories.” People exposed today, who will become 80 years old in 25 years or so, won’t have the same problem, Mina says, because they will have built their immune memory at a younger age.

None of this should surprise us, Mina says. “I’ve always said, this is very much a textbook respiratory virus,” he said. “It’s new, which is why it’s mutating a lot. And we’re watching it mutate, which is why it’s scary.” But it’s really just “a baby virus,” he says. “It’s mutating because it’s growing up and learning how to live in us.”

About that. The rate of mutation — and of viral evolution — is the biggest unknown variable giving shape to the next few years. Future Omicron variants will probably follow the pattern of the previous ones: increased transmissibility, presumably through new avenues of immune evasion at the level of infection, without drastic changes in inherent severity. But more significant right turns are possible, too, and it is hard to model those chances.

“We knew from relatively early on that we would expect about two mutations a month,” said Francois Balloux, a computational biologist at the University College of London. “That means that we would have expected, after two and a half years, roughly 70 mutations. And actually that’s where we are.”

What’s been more surprising, he says, was how significantly some of those mutations changed the course of the disease — with Delta first, and then, most strikingly, with Omicron, which he said marked such a break in the pandemic trajectory that “I’m tempted to think about it in terms of two successive pandemics.”

“What that means for the future, it’s really difficult to say,” he continued. “We can have a radical new shift, like we saw with Omicron — something completely, radically different jumping into a population. And then we’re back at square one.”

But this is not necessarily the future path he thinks is most likely. He worries more about a more virulent Delta strain and hopes for a stable circulation of Omicron sublineages, which, he says, could land us by next spring in a relatively relaxed place, virus-wise — the impact of the coronavirus retreated even from where it is now. “But that’s by far the most optimistic scenario,” he says.

In the meantime, there is BA.2.75 to contend with. This newest variant is not what Dean calls “something coming out of left field,” since it remains part of the Omicron family. And while the early spread in India looked quite concerning, Bedford says, it appears already to be growing less so — more in line with the recent arc of BA.5 in the United States than the initial, overwhelming Omicron wave.

As for the possibility of a more left-field, Omicron-like phase shift? “I’ve been trying to think about that, trying to be humble,” Bedford says. He points out that for two and a half years of evolution, there’s been one Omicron-like event. “And so you can ballpark that as happening every year or two,” he says. “Maybe every decade. Or it could have been a black swan event, and it will never happen again.” He pauses. “That seems doubtful.”

David Wallace-Wells (@dwallacewells), a writer for Opinion and a columnist for The New York Times Magazine, is the author of “The Uninhabitable Earth.”

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