We Need To Get Real About How the Pandemic Will End

Even more transmissible new variants means that more people will get infected or vaccinated, and that's how it will all end

I have a new piece out in the New York Times, trying to wrap my mind around what increasingly looks like a catastrophic possibility for the rest of the pandemic.

If world leaders don’t act now, the end of the Covid pandemic may come with a horrible form of herd immunity, as more transmissible variants that are taking hold around the world kill millions.

There’s troubling new evidence that the B.1.617.2 variant, first identified in India, could be far more transmissible than even the B.1.1.7 variant, first identified in Britain, which contributed to some of the deadliest surges around the world.

In countries with widespread vaccination, like the United States and Britain, we can expect that Covid cases, hospitalizations and deaths will continue to decline or stay low, especially because lab tests and real world experience show that vaccines appear to defend recipients well against the severe effects of both variants.

For much of the rest of the world, though, this even more transmissible new variant could be catastrophic.

If you look at a chart of deaths from AIDS, one of the greatest moral stains from our history jumps out. More people died of AIDS after we got the triple combination drug in 1995 that turned HIV into a chronic condition for those who had access to it—but almost all the deaths happened outside the few wealthy countries that could afford it. Not until the mid-2000s, following much loss and activism, campaigns and pressure, did things finally change and drug access expand.

It should be unthinkable to repeat such a scenario, but here we are. 

The latest news from the United Kingdom, which has better genomic surveillance than almost any other country and thus can allow us to disentangle causes of outbreaks better, is not good. The B.1.617.2 variant, first identified in India, looks to be substantially more transmissible compared with even B.1.1.7, which was bad enough. The data is preliminary, and I really hope that the final estimate ends up as low as possible. But coupled with what we are observing in India and in Nepal, where it is rampant, I fear that the variant is a genuine threat.

In practical terms, to put it bluntly, it means that the odds that the pandemic will end because enough people have immunity via getting infected rather than being vaccinated just went way up. 

We seem to be holding onto the comforting fiction that we will eventually get around to vaccinating people in countries that have so far either had success keeping out the pandemic completely, or have had small outbreaks before, while they just keep up mitigating a little longer. I do not believe that the story we tell ourselves is realistic.

First, these countries can only hold the virus at bay for so long. Even quarantining all people arriving, and greatly limiting who comes in can only work for so long. See what’s happening in Taiwan: it takes only one slip-up plus a few amplifying events for a country to see its case load quickly rise. 

Second, if a variant is more transmissible, all our “non-pharmaceutical” interventions will be much less able to hold them at the same level. Something even more transmissible than B.1.1.7 may be very, very hard to stop outside of vaccination (or, yes, immunity through mass infection).

Three, some places have already been keeping out the virus for more than a year—that success can’t last forever.

Four, those countries which lack both widespread prior immunity from previous outbreaks (like us!) and widespread vaccination (also like us!) are sitting ducks. Something like this variant can burn through such populations like a firestorm.

Essentially, we are back to the logical conclusion of the essay by Dylan H. Morris which explained that, for pathogens, novelty is severity.

For perhaps billions of people around the world, the question is whether they will be introduced to this virus via exposure and infection or get vaccinated against it. And with every increase in transmissibility, the timeline for affirmatively making that choice gets shorter.

Increased transmissibility is an exponential threat. If a virus that could previously infect three people on average can now infect four, it looks like a small increase. Yet if you start with just two infected people in both scenarios, just 10 iterations later, the former will have caused about 40,000 cases while the latter will be more than 524,000, a nearly 13-fold difference.

When vaccines arrived, I volunteered at a local clinic. It was one of the most moving experiences of my life, to see thousands of elated elderly people stream in. Some were in tears with relief and joy. The clinic is still operating but few are showing up any longer. Our emergency isn’t fully over — there may be local epidemics and outbreaks among the unvaccinated or uninfected, But despite all the misunderstandings around the concept, one does not need to get around to a magical and binary herd immunity threshold to see great benefits, even to the unvaccinated.

Nor do we need the highest efficacy against symptomatic breakthrough (the number we focus on too much because that’s the number we have from trials, a topic readers of this newsletter are familiar with) to do the job: as far as I can tell from vast amounts of trial and real life evidence, every single vaccine out there does a very very good job against preventing severe disease and death. 

Frankly, I think the United States and United Kingdom, and most of Europe, will mostly be fine. That’s true even with all the hesitancy around vaccines, especially since the most vulnerable group — the elderly — are highly vaccinated. (Right now, about 85% of seniors in the United States have had at least one dose, and that number is bolstered by some amount of the older population that has been infected in the past year). 

And yet, as we can see in India, Nepal and elsewhere, this is far from the case in the rest of the world. I think we overly focused just on waiving patents (long story: I think it was partly muscle-memory from the HIV/AIDS crisis, when that would have been a fine solution) as a solution to getting the rest of the world vaccinated. That is not sufficient for this pandemic. Vaccine production is hard, and merely waiving the patents is like the “thoughts and prayers” politicians express after tragedies, after which they do little or nothing and the tragedy continues unabated.

Officials from all nations that produce vaccines need to gather for an emergency meeting immediately to decide how to commandeer whatever excess capacity they have to produce more, through whatever means necessary. Because of the threat of increased transmissibility, and since the evidence at hand indicates that all of the vaccines, even the Chinese and Russian versions, appear to be highly effective against severe disease or worse, the focus should be on manufacturing and distributing the highest number of doses possible as fast as possible.

If the choice is between no vaccine and any vaccine, the precedence should go to whatever can be manufactured fastest, regardless of patents, nation of origin, or countries prioritizing their allies or wannabe allies.

But here we are. It is increasingly likely that most of the deaths from this pandemic will happen even after we got the vaccines, and even after we either did or could have had enough vaccines to prevent severe outcomes among the most vulnerable around the world.