Two years ago to the day, and roughly two months after the novel coronavirus pandemic arrived in Iowa in 2020, I published a post titled Coping With the Reality of COVID-19. One year ago to the day, and roughly two months after the national vaccine rollout, I published a follow-up post titled Coping With the Persistence of COVID-19. In this post, as we enter the third year of the COVID-19 pandemic, I want to take stock of the progress we have made in fighting the disease, and explain why you should remain vigilant even if your immediate personal risk of hospitalization and death now seems relatively remote.
Whether you have been paying rapt or scant attention to news about the COVID-19 pandemic, you probably have a general sense that the immediate threat from the disease has eased over the past year, which is correct. At the same time, you may also have a sense that the COVID-19 pandemic is effectively over, which is not correct. For example, only this past Friday — four days ago — the CDC raised the COVID-19 Community Level Status to ‘High’ for Johnson County, Iowa, where I live. And that’s despite the end of the spring term at the University of Iowa, and the rapid outflow of 30,000 academically integrated and socially active students from that same county.
Although many people in the United States — perhaps even the great majority — are now going about their daily business as if COVID-19 is no longer a threat, the virus itself is going about its daily business of replicating and infecting human beings. Whether from psychological fatigue or intellectual ignorance, the mental conviction that COVID-19 is no longer a current or future threat is no defense against a mindless virus which lives only to propagate itself through transmission from host to host. It may feel better to stop worrying about COVID-19, and it may feel better to ‘get back to normal’ — by, apparently, wantonly spending money into the teeth of a pandemic-driven spike in inflation — but the virus doesn’t care how you feel.
Absent some future medical miracle it is true that COVID-19 is now endemic to human beings and multiple other species — meaning we will likely never be rid of it — but that doesn’t mean any diminishment of the threat will be permanent. Indeed, for every infectious wave over the past two years there has been a consequent trough during which laypersons, media personalities and auto-discrediting experts claimed the pandemic was over, and they were all wrong. (Modern medicine has been fighting polio for generations, but polio has not been eradicated from the planet. The only reason there has not been a case of polio in the United States since the early 1970’s is because of an aggressive and enforced vaccination campaign — not because the disease became weaker, or because freedom-loving Americans decided to stop worrying about polio and get back to normal.)
That most of America’s elected officials are now also acting as if the pandemic is over not only presents as a messaging problem — as the director of the National Institute of Allergy and Infectious Diseases discovered at the end of April — but as an ongoing healthcare problem. The fact that COVID-19 has evolved through multiple mutations over the past two years also introduces uncertainty into the risk equation, but the good news is you don’t have to be a virologist or epidemiologist to make good decisions about your own health, or about the health of people for whom you are responsible. You may have to endure teasing, taunting or trolling from imbeciles, but as we will see there are compelling reasons to err on the side of caution.
While both the pandemic and the disease itself have evolved, and will continue to evolve, future mutations may be countered by additional vaccinations, perhaps on a customized annual or semi-annual basis, much like the seasonal flu. Unfortunately, there are also disincentives to developing such vaccines, including the fact that the virus is mutating so fast that any new vaccine will be susceptible to the same immune escape that the current vaccines are demonstrating. Even if a new vaccine was extremely effective, however, we also already know that the number of people who would avail themselves is relatively small. As an individual you would be safer with up-to-date vaccinations, but based on current attitudes in the United States there may not be enough societal benefit for the scale of the outlay.
To the extent that COVID-19 still poses a pandemic-level threat, the greatest change over the past two years has unquestionably been the ready availability of vaccinations and boosters, which have drastically decreased hospitalizations and deaths. That far too many Americans have failed to maximize their level of vaccine protection is a persistent problem, and underscores the reality that we have maximized our feeble national capacity for suppressing the virus. Meaning from here on out it’s up to you as an individual to make effective choices which decrease the likelihood of infection, while simultaneously navigating a culture which is actively hostile to your well-being.
Dying Our Way to Success
Even as the journalism industry races to generate, propogate and exacerbate fear about monkeypox, it is important to remember that people are still dying from COVID-19. As recently as two weeks ago, in mid-May, the seven-day moving average in the United States was about 300 deaths per day, or 2,100 deaths per week — and those numbers reflect a recent increase in fatalities. So while it’s true that hospitalizations and deaths are down significantly from pandemic highs, the fact that we see that as good news is primarily a reflection of how bad things were over the past two years. Even today, at the zenith of our national ability to embrace vaccinations, Americans are not only still dying from COVID-19 at a rate of more than 100,000 per year, but because of widespread abandonment of masking — whether mandated or voluntary — that rate will almost certainly increase over the remainder of 2022. (If you want to obsess about monkeypox, by all means go ahead. If you’re worried about monkeypox while you’re pretending the COVID-19 pandemic is a thing of the past, then you’re precisely the kind of person who will facilitate transmission of monkeypox around the world and into your own body.)
While the elected and appointed national and state officials who have overseen the response to COVID-19 would obviously prefer not to talk about it, there is another and much darker reason that fewer people are being hospitalized or killed by COVID-19 today, and that is simply that many if not most of the people who would be at greatest risk are already dead from the disease. As of this writing more than one million Americans have perished from COVID-19, or approximately 1 in every 335 citizens. Because many of those people were also the most susceptible to the disease, however, and because they can’t die again, the virus is inherently less likely to kill those who remain.
One of the most important lessons we have learned about COVID-19 over the past two years is that the older you are the more at-risk you are, yet even now most people do not understand how significant that single indicator actually is. Of the million-plus fatalities associated with COVID-19 in the United States, people over sixty-five account for slightly more than eighty percent of that total. So while 1 in every 335 Americans has died from the disease, for those age fifty or older that ratio is closer to “1 in 125“. (Unlike the political discrepancy between vaccination rates and deaths in the U.S., which is still growing, this is also one of the few areas where partisans are in agreement. Whether you are a Democrat or Republican you are probably underestimating the share of 65+ deaths by a factor of two.)
When the pandemic hit America in 2020, COVID-19 found a trove of vulnerable elderly to prey on — abetted by corporate and governmental bureaucrats who failed to take obvious and necessary preventative measures at group homes and care facilities — thus allowing the disease to spread like wildfire among that at-risk population. Today, with roughly eight hundred thousand of America’s elderly now dead, and vaccinations available for the rest, there will probably not be another huge wave of fatalities in that age group, but that doesn’t mean survivors among the elderly are safe. In fact, everything we know so far about vaccine effectiveness suggests that as people age their risk from COVID-19 will increase, making vaccinations and mitigation more important for any given individual over time. (Spoiler: everyone gets old, including those who shun social distancing, masks and vaccines.)
In a relatively short amount of time COVID-19 not only exacted a terrible toll, but that staggering loss of human life at home and around the world has been minimized by officials who do not want to be held responsible for failing to do everything possible to suppress the virus until vaccines were available. In reality, a significant portion of what we now see as success in fighting the virus reflects the reality that there aren’t that many people left who are easy for COVID-19 to kill. (And the fact that most of the people in that group were older — as opposed to very young — is also reminder that ageism is as toxic as any other form of discrimination.) If you and yours have not been traumatized by the pandemic I hope you will be thankful for that, because there are a million American families in pain, and many of them are suffering in silence.
Two Years and Counting
Even if you pay close attention to news about COVID-19, chances are that you have either internalized one or more misconceptions about the disease, have fallen behind on some of the latest developments, or both. As was also true at the beginning of the pandemic, there are still two big reasons why it is hard to keep up with the most recent developments. First, although the United States has implemented a robust vaccination campaign, the disease is evolving at what seems to be an ever-increasing rate, rendering information out of date in months if not weeks. For example, when I began compiling links for this post a month ago or so the U.S. was establishing a new low for hospitalizations and deaths, but now we’re on the way back up in both metrics. (And it’s not just the U.S. Only a few weeks ago, in mid-May, British Airways cancelled all flights from UK airports due to COVID-related staff shortages.)
As for the mutation rate of the virus, not only does it seem to be accelerating, but each new strain seems to be more transmissible than the last. That means even as the overall severity of the illness has decreased due to vaccinations, naturally acquired resistance, improvements in medical care, and changes in the virus itself, the number of people who are currently being infected is not only increasing, but that in turn drives increases in the absolute number of hospitalizations and deaths, though the rate of both remains relatively low. Even at that, however, the rate of deaths from the initial Omicron wave may have been higher than the Delta wave, because there is new evidence that the most recent Omicron mutations had and have an increased ability to escape prior immunization, whether acquired naturally or through vaccination. And of course that once again puts the elderly at increased risk even if they have been fully vaccinated and boosted. (Making matters worse, roughly one third of the elderly in the United States have still not received their first booster shot despite being at objectively greater risk.)
The second problem with keeping abreast of information about COVID-19 is that there is a lot we still don’t know about the current impact of the virus, let alone future risks. For example, during the past two-plus years you may have read comparisons to the varicella-zoster virus that causes chickenpox, which can trigger a related disease called shingles decades later. More recently a long-suspected relationship between the common Epstein-Barr virus and later onset of Multiple Sclerosis has been backed up by two studies, underscoring the possibility that COVID-19 could exact a similar but as-yet-unknown toll among those infected — which already comprises the majority of Americans.
Then again we may not have to wait decades to find that COVID-19 is wreaking medical havoc in unexpected ways. While the worldwide incidence of childhood hepatitis remains exceedingly low, there has recently been a significant increase in the number of cases, raising the possibility that COVID-19 may be a contributing factor. (A recent UK HSA report and thread on that investigation here.)
While the immediate risk of severe illness, hospitalization and death from COVID-19 have all decreased, and markedly so if you have had at least one booster, on at least three fronts the long-term risks remain unknown — and one of those uncertainties hinges on willful mass ignorance in the aftermath of a million American deaths. First, as just discussed, there is the risk of long-term medical complications arising from COVID-19 infection. Second, there is the risk of mutations which not only lead to more transmissible variants, but more virulent variants, unleashing yet another massive wave of deaths as public and private resources lag in response. Third, at the very moment when we do seem to have made important gains against the virus, the infrastructure for tracking cases is being dismantled by officials and politicians who do not want to be held responsible for future outbreaks — meaning, preposterously, that we are once again flying blind.
In fact, did you know that right now there are probably more active cases of COVID-19 in the United States than at any time other than the initial Omicron wave? While likely true, incredibly we can’t actually say for sure because most people have stopped testing — and much of the testing that is being reported involves antigen tests which are notoriously unreliable, as opposed to PCR tests, which are the medical standard. Still, this news shouldn’t comes as a surprise given that official healthcare policy in most of the United States is to tolerate if not encourage as much viral transmission as possible, while leaving it to at-risk individuals to protect themselves. (A working definition of the American way.)
* Twitter thread on the “evolutionary trajectory of SARS-CoV-2”
* A note on the presence and potential threat of recombinant variants.
Evolving Infection Concerns
Whether you are vaccinated or not, you have probably correctly assessed that your current risk of severe illness, hospitalization or death is as low as it has been since the pandemic began. Whether you have had COVID-19 or not, you have probably also correctly assessed that everyone will be infected at some point. From those two correct assessments you may have further concluded that you might as well get back to socializing with friends and family, including going out to public venues teeming with anonymous humanity. Standing as impediments to your newfound freedom, however, are two uncertainties which render your analysis suspect if not failed.
First, nowhere in your calculus have you accounted for what is called ‘long COVID‘. Initially dismissed by the greater medical community, yet now clearly accepted as a constellation of symptoms and outright disabilities which can last for months or even years, long COVID is one big reason that COVID-19 is not just like the flu. Contracting COVID-19 means playing healthcare roulette not only with the immediate effects of the infection, but also with your long-term health, and nothing that has happened over the past two years has diminished that lingering threat. You can pretend things have changed, you can deny you are at risk, or you can gamble that you will be one of the lucky ones, but none of that will keep you from getting long COVID.
Amid the uncertainties that still surround COVID-19 as a disease, one thing that has become clear over the past two-plus years is that the risk of developing long COVID does not correlate with severity of illness. Whether you end up in the hospital or dead as a result of infection is related to the severity of your illness, but the risk of long COVID is not — meaning unless you have truly given yourself over to fatalism you should be taking that risk into account going forward. In truth, even people who have had asymptomatic illness can, weeks or months later, find themselves besieged by symptoms indicative of long COVID. (While there is still no clear definition of long COVID because the symptoms are so variable, and the likelihood of developing long COVID after infection is currently all over the medical map, a one-in-ten chance seems to be a plausible assessment.)
The second error you may be making in assessing your risk going forward, is that you are probably assuming once you have been infected and recovered that you are no longer at risk of recurrent infection. In point of fact — and this was my major concern at the beginning of the pandemic — COVID-19 seems to be acting not so much like a particularly deadly flu, but like a lethal version of the common cold. Just as you can catch a cold more than once in a given year, there is rapidly growing evidence that you can be infected with COVID-19 over and over again — meaning not only more chances of developing severe illness, but more chances of developing long COVID even if the illnesses themselves are mild.
As to whether repeated exposure increases or decreases the risk of severe illness and/or long COVID, there doesn’t seem to be a firm answer, but it’s obviously a concern. Does the human body build up more and more resistance after each infection, or does each case of COVID-19 carry a consistent chance of severe illness or long COVID? At the very least, in the face of uncertainty it would seem warranted to err on the side of caution, yet clearly that is not what most people in the United States are doing right now.
* Anecdotal experience with the personal, psychological and physiological impact of long COVID here, here and here — and many more testimonials available via online search.
Long COVID and Vaccination
On the specific and important question of whether vaccination cuts the risk of long COVID, note the rapid evolution of research on that question over just the past two months — meaning after most Americans decided the pandemic was no longer a threat to their personal health:
If you are fully vaccinated you have significant protection against serious illness or death compared to those who are not vaccinated, but your risk of developing long COVID with any breakthrough infection is essentially the same as it was before vaccinations were available. Factor in the increased transmissibility of the latest variants, and again you may be more likely to contract COVID-19 today than at any point during the pandemic — and vaccinations only marginally decrease your risk of long COVID. If you want to decrease that risk you must decrease your personal risk of infection.
Evolving Treatment Concerns
Unquestionably, the rapid creation, production and distribution of vaccines which were particularly effective against earlier variants counts as a miracle of modern medicine. That we are now embarking on a future largely predicated on the success of America’s vaccination program, however, ignores the fact that we have also had medical setbacks which would have seemed alarming only a year ago. For example, in the first half of 2021 — as the vaccination campaign was getting underway — there were numerous approvals for new monoclonal antibody treatments. Less than a year later, however, against Omicron that same medical treatment failed to produce positive results, and the FDA consequently pulled its emergency authorizations.
As to the vaccination rollout, while the fancy new double-dose mRNA vaccines from Pfizer and Moderna received the lion’s share of the press coverage, Johnson & Johnson received approval for a single-shot vaccine based on traditional virus-vector technology. Whether due to convenience, a fear of needles, or the fact that it used time-tested technology, many people opted for the J&J vaccine. Almost immediately however, concerns were raised about potential blood clots after injection, but those concerns were subsequently lifted. After more study, however, the FDA recently put significant limitations on who may receive the J&J vaccine because of those same blood clot concerns. Meaning in just over a year, one of the three main vaccines used in the initial rollout is no longer available to the average patient.
A few months back you may have also heard about a major governmental push to get Paxlovid — a new antiviral medicine developed by Pfizer in late 2021, which is taken in pill form over five days — out to the public as a treatment against active infection. Now, however, there are concerns that some people are having rebound infections after completing the prescribed course. The obvious concern is that failure to kill off COVID-19 in any host could lead to variants which are resistant to Paxlovid, much as some bacteria have become resistant to antibiotics over time. Although the questions is still under study, there does seems to be some evidence that the course of treatment may need to be extended.
While many if not most Americans are pretending that the pandemic is over — whether out of ignorance, exhaustion or delusion — the experts who know better continue to revise their plans of attack. I don’t have any idea what the pandemic will look like a year from now, but I am confident the pace of change in both the disease and in medicine means the viral battlefield will look significantly different than it does now. Fortunately, your only job is to figure out how to be happy and healthy a year from now, and I don’t think you will regret doing what you can to avoid long COVID or recurrent infections — and that’s true whether or not you have been vaccinated and boosted.
The More Things Change
Because of the ongoing threat of long COVID, the omnipresent risk of increasingly virulent variants, and the proven immune escape of recent variants — which are also significantly more transmissible than the dominant variants in 2020 and 2021 — it makes objective sense to continue to avoid COVID-19 as much as possible. Ironically, however, because of the widespread availability of vaccines, and the consequent relaxation of mitigation measures, it is now much easier to contract COVID-19 than it has been at any point in the past. In fact, if you are obligated to have regular contact with the general public you are almost assured of contracting COVID-19 if you have not already been infected, and repeated infections over the remainder of the calendar year cannot be ruled out.
The good news, if you do want to minimize your chance of contracting the virus, is that after two years you have a wealth of personal experience to draw on in pursuit of that objective. Even better, the best lines of defense have not changed since the pandemic began. The most effective way to avoid any communicable disease is to avoid congregating with others, and that is never going to change. While social distancing obviously has its drawbacks, and may not be possible for everyone, it should be your first line of defense if you are concerned about your risk of infection.
Unfortunately, if you are older or immunocompromised your fellow citizens have decided they can’t take the indignities of social distancing any more, so you’re effectively on your own. In the current context of low deterrence and high transmissibility that means being particularly militant about social distancing in situations where you don’t know the infection status of others, and you should not apologize for that. Again, the pandemic is not over and people are still dying from the disease — and at an increased rate when compared to the pandemic lows a few months ago. If you are at increased risk because of age or health issues, you should absolutely do whatever you need to do to protect yourself from this potentially lethal threat.
To Mask or Not to Mask
Even if you made it your life’s work to avoid news about the COVID-19 pandemic over the past two years, you probably know that nothing inspired more vitriol than the question of masking, and particularly mask mandates. Initially masks were opposed by a significant and vocal segment of the U.S. public on the grounds that they were ineffective. When that proved scandalously wrong mask mandates were opposed on the grounds that they denied individual liberties. More recently, mask mandates have been opposed on the grounds that they damage school children, who were also least likely to be susceptible to severe illness, and were thus said to be unnecessarily disadvantaged. More recently, as infections, hospitalizations and deaths declined, mask mandates were abandoned at the administrative and governmental level, thus opening the door not only to the initial massive Omicron wave, but also to fueling Omicron’s rapid mutation into increasingly transmissible variants.
While it would obviously be fun to highlight the number of people who disgraced themselves with their prognosticating and pontificating about COVID-19 — from mentally defective newspaper columnists to mentally defective television commentators to mentally defective social media celebrities to mentally defective federal judges — here at Ditchwalk we prefer to take the high road. (Although it does need to be said that — like most of the celebrity journalists at the New York Times — David Leonhardt is straight-up trash.) The question before us is not whether mask mandates and pandemic policy should be treated as a loyalty oath, but how you, the individual, can keep yourself safe in a country which manifestly does not care whether you live or die. And on that point it is important to point out that it isn’t just one political party or social demographic that has turned its back on the most vulnerable among us, but pretty much the entire country across the board.
Personally I think that’s more than a little ironic, because if COVID-19 was transmitted sexually instead of from respiration, half or more of the Americans who riotously opposed mask mandates would be insisting on a form of social distancing called abstinence, while the other half would be imploring everyone to use a type of mask called a condom. Instead, because COVID-19 is spread by social contact — meaning pretty much everyone has to to adjust their behavior to suppress transmission, and thus also the rate of mutation — the majority of the country, which is not at particularly significant risk of severe illness, has simply decided it’s too much damn effort to wear a simple face covering to protect others. Still, even if no one else is wearing a mask you can still decrease your risk of infection by wearing one yourself, which is why masking should remain your second line of defense if you are trying to avoid infection.
Fortunately, unlike the early days of the pandemic you will not be competing with healthcare workers for the best masks — which are technically called respirators. Look for N95’s, or KN95’s (which may be more available and are usually more affordable), but do not purchase any masks with a valve. It is also important not to slip into binary thinking about masks as pointless or perfect, but to view them as one tool in your arsenal of avoidance. If masking is not allowed or not possible for part of your day, you should still consider masking when doing elective activities in congregate settings, such as worshiping or grocery shopping. (Along with buying high-quality masks, you should also focus on fit to make sure you are using your masks effectively.)
* From late February: CDC to significantly ease pandemic mask guidelines Friday
To Boost Twice or Not Boost Twice
If there is one question that has no easy answer for the majority of people reading this post, this is it. If you have had two vaccinations and one booster, considerable evidence suggests that a second booster will only provide minimal additional protection, with the following exceptions. If you are elderly or immunocompromised, a second booster is recommended because of the combination of your native vulnerability and waning vaccine immunity. Unfortunately, the most recent variants also show a higher propensity for immune escape, so even those who are most at risk may only experience a marginal gain in protection.
And…as if to underscore how quickly things are changing, as I was finalizing this post for publication the federal guidance for second boosters was updated: C.D.C. Urges Adults 50 and Older to Get Second Booster Shot.
* CDC Explainer: COVID-19 Vaccine Boosters
Pandemic Year Three
In America we are very good at turning the cultural page. Unfortunately, that is often just an excuse for avoiding accountability and forgetting the wounded and dead, so we can gloat about what we’re buying, what we’re eating, what we’re saying or what we’re thinking. (Along with remembering the dead, please also give thanks to the healthcare workers across the country who are ethically and professionallyobligated to treat patients in the real world, while everyone else enthusiastically spreads a disease that has already killed one million Americans.)
The reality of the COVID-19 pandemic in year three is not only that there are many things we still don’t know, but some of the things we do know mean we should be making different choices both collectively and individually. Unfortunately, for the time being the great majority of Americans are not going to get any smarter than they are now, so it’s really up to you to defend yourself from COVID-19 as you see fit. And yes, if you are elderly or immunocompromised your fellow citizens are making it almost impossible for you to keep yourself safe, but I don’t see any way to fix that. (At least not until another lethal wave comes along and wipes out another 250,000 Americans.)
— Mark Barrett