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On Nov. 15, 2020, in the United States, as the most devastating wave yet of coronavirus infections was beginning to crash over the country, about 1,148 Americans were dying of Covid every day. A year later, that number is 1,129.
To call the statistic sobering would be an understatement. And yet many parts of the country are not in the same place, epidemiologically speaking, as they were last year. In New York City, where I live, and where 87 percent of adults have received at least one vaccine dose, restaurants and bars and theaters fill with people every night. Cases have ticked up once again in recent weeks, but hospitalization and deaths continue to decline — for now, at least.
At this uncertain juncture, how close is the United States to something we could call a new normal, and how should Americans think about managing the transition? Here’s what people are saying.
‘We need a goal’
At the beginning of the pandemic, the overarching public health imperative Americans were given was to “flatten the curve” of infection: Reducing the number of active Covid cases at any given time, the logic went, would relieve pressure on the health care system and save it from collapsing.
But The Atlantic’s Sarah Zhang argues that case numbers are a less and less useful metric for guiding our pandemic thinking. “With vaccines available, not every case of Covid-19 is created equal,” she writes. “Breakthrough cases are largely mild; 10,000 of them will cause only a fraction of the hospitalizations and deaths of 10,000 Covid cases in the unvaccinated. The more highly vaccinated a community is, the less tethered case numbers are to the reality of the virus’s impact.”
A plausible alternative goal, she suggests, is to focus directly on minimizing hospitalizations. And to do that, it will be crucial to increase vaccinations among older Americans, who are far more vulnerable to severe Covid than children and young adults.
In some parts of the United States, Zhang notes, the percentage of adults over 65 who are fully vaccinated is languishing in the 80s. That may sound like a lot, but “you don’t need a lot of infections in the unvaccinated over 65 to give you a problem,” Bill Hanage, an epidemiologist at Harvard, told her.
‘SARS-CoV-2 could be with us forever’
One way or the other — through vaccination or infection — experts say the coronavirus will eventually become endemic: Outbreaks will be rarer and smaller, and hospitalizations and deaths will decline.
How long it will take to get there, though, remains an open question. In the United States, “it’s certainly possible” some regions will be assigned endemic status in 2022, Joshua Petrie, an epidemiologist at the University of Michigan School of Public Health, told Vox.
But even then, as Katherine Eban wrote last month for The Times, the coronavirus is unlikely to disappear. “No one is trying to eradicate Covid from the planet,” Dr. Dara Kass, an associate professor of emergency medicine at the Columbia University Medical Center, told her. “If that was a goal, that’s not the goal right now.” Instead, she said, “we’re trying to remove it from being a guiding force in our lives.”
For some Americans, it already has been. As my colleague David Leonhardt wrote recently, the risk of Covid in some highly vaccinated communities is low enough that many vaccinated people feel comfortable living relatively unencumbered. In Seattle, the daily Covid hospitalization rate for vaccinated people has been slightly above one in one million. By comparison, the flu hospitalization rate in a typical year in the United States is more than twice as high.
“My feeling now is that we’re nearing a steady state where things might get a little better or worse, for the next few years. It’s not great, but it is what it is,” Dr. Robert Wachter, chair of the department of medicine at the University of California at San Francisco, told The Washington Post. “To me, particularly once I got my booster, it prompts me to accept a bit more risk, mainly because if I’m not comfortable doing it now, I’m basically saying that I won’t do it for several years, and maybe forever.”
Wachter, who is 64, told Leonhardt that he may still wear a mask in supermarkets and on airplanes for the rest of his life; he sees no cost to wearing one in those settings, and Covid is not the only respiratory virus masks may protect against. But he has also begun eating in indoor restaurants again and playing poker, unmasked, with vaccinated friends.
But others may have a lower risk tolerance, and for good reason. The journalist David Wallace-Wells has argued that most people are still “hugely underestimating” how much more severe Covid becomes with age, a skew that persists even after vaccination. “As long as the disease continues to circulate, even the vaccinated elderly will continue to be vulnerable to some extent,” he wrote.
The same is true for some immunocompromised people, who make up about 3 percent of the population. Consider the case of Andrew Linder, a kidney transplant recipient who has to take immunosuppressants to keep his body from rejecting the organ. After two doses of the Pfizer vaccine and later an additional dose and a booster, “I had no antibodies whatsoever,” Linder told CNN. “I almost feel just as unsafe or if not potentially a little bit more unsafe now than at the beginning of the pandemic.”
People will make different decisions about the level of Covid precautions they take, and many of those differences will be reasonable. But for higher-risk groups, how their community handles its transition to endemicity — whether it can push vaccination rates up and case rates down, namely, and what restrictions it chooses to keep in place — may end up mattering far more than personal behavioral choices.
[“Booster shots alone won’t protect immunocompromised people from Covid-19”]
“This is the point at which we then have to start looking at ourselves and asking the hard question: Exactly how hard do we want to work to help how many people?” Hanage told The Atlantic.
What will another pandemic winter bring?
Some experts say that at least one more wave of infection, hospitalization and death may stand between the United States and endemicity. As Eric Topol, a professor of molecular medicine at Scripps Research, points out in The Guardian, cases are once again surging across Europe, and only countries with very high vaccination rates such as Spain and Portugal — which have fully vaccinated 80 and 88 percent of their total populations — have resisted the trend.
The United States, by contrast, has fully vaccinated only 59 percent of its total population. “Now is the time for the U.S. to heed the European signal for the first time, to pull out all the stops,” Topol writes. “We can acknowledge and accept endemicity — that a low level of Covid will remain in the background, but that is not >75,000 new cases a day. Instead of succumbing to yet another major rise in cases and their sequelae, this is a chance for America to finally rise to the occasion, showing an ability to lead and execute.”
An appropriate response, in Topol’s view, would include promoting not just primary vaccination but also boosters for a wider segment of the population to compensate for waning immunity.
He’s not alone: In a recent interview with The Times, Dr. Anthony Fauci, America’s top infectious disease official, said that Israeli data had led him to believe that everyone in the United States will eventually need a booster to be fully immunized against the coronavirus.
“Boosting is going to be an absolutely essential component of our response. Not a bonus, not a luxury, but an absolute essential part of the program,” he said. “If we continue to get as many people vaccinated who are not yet vaccinated at all, and aggressively boost the people who have been vaccinated, I think you’re going to see a different pattern than what we saw with the other surges over the past multiple months.”
Do you have a point of view we missed? Email us at [email protected]. Please note your name, age and location in your response, which may be included in the next newsletter.
READ MORE
“Covid will be with us for the next several years, says U.C.S.F. Medicine chair” [WBUR]
“Why even fully vaccinated older people are at high risk for severe Covid-19” [National Geographic]
“Far fewer Californians getting Covid-19 booster shots than expected, bringing new alarms” [The Los Angeles Times]
“Should We Wear Masks for Cold and Flu Season?” [The New York Times]
“How Bad Could California’s Winter Coronavirus Surge Get?” [The New York Times]
