Planning For The COVID Endgame
We live in a world with endemic COVID and need to be preparing ourselves for what that means
Very early on in this crisis, I wondered what the worst-case scenario for COVID was and I came to the conclusion that it would be if COVID became endemic, a new member of the family of diseases that endlessly circulate through the human population.
It seems increasingly likely that is the scenario we have. To be fair, when I said that, we had no idea if there would be an effective vaccine and, lucky for us, there is. Even so, the “endgame” was always a question of what things will look like when we get back to pre-COVID behaviors.
I’ve been pointing to Trevor Bedford for as long as I’ve been doing this newsletter and his recent thread is a good place to start for thinking about how we reconstruct our patterns of behavior in the wake of the COVID disaster.
Read the whole thread, but I’ll cut to the chase on it: COVID is endemic. Everyone will eventually develop some level of immunity either through catching COVID or through getting the vaccine, but COVID is so contagious and breakthrough cases are so common that it will never stop circulating. We cannot vaccinate our way out of this. Vaccines are decent protection, but we will probably end up with some yearly vaccination similar to the flu shot.
Prof Bedford expects that, with a rolling pattern of waning immunities from natural immunity and vaccination, COVID will cause 40,000 - 100,000 deaths per year with some seasonal variations. These numbers would make it about twice as dangerous as the flu.
This sucks.
But this is the most likely scenario, so we should take some time to process how awful it is and then move forward with living with the world that exists instead of the one we wish we lived in.
My Ideal Post-COVID World
In this world of chaos, restrictions, and mandates, my greatest concern is the preservation of human dignity. When I say the word “dignity”, I have a clear vision in my head of what that means, but I’m not sure it’s a very shared definition so I’ll articulate it here.
My vision of dignity is essentially the right to enjoy life on your own terms and to make the most of who we are and the time we have. Dignity means we get to set the priorities of our own lives and act on those priorities. It’s basically “the pursuit of happiness” along with the liberty to pursue it.
Denying people the ability to set their own priorities is perhaps excusable for a short time in an emergency, but that is a wretched way to run a society and an awful way to live. If we’re going to have a policy that infringes on people’s abilities to live their lives with dignity, we need to have a very good reason and we should always be agitating for a return to normalcy.
One person who has deeply impressed me in this pandemic is Dr Monica Gandhi, the Director of the UCSF Center for AIDS Research. When she was told to shut down her ward in response to the COVID threat, she wrote to her staff:
Recognizing that people living with HIV may have special needs and that over one-third of our patients are marginally housed, we will not be restricting in-person care for anyone at Ward 86 who is homeless and for patients the provider deems as needing in-person care.
Dr. Gandhi talks a lot about recognizing that many of the COVID restrictions come with a real human cost and that it’s inappropriate to dismiss those costs.
My ideal world would be simply to return to normal, but I recognize that there are a lot of people for whom things will never be the same. Some people may decide that wearing masks during a regional COVID surge is their new normal. I want to recognize their dignity in making that decision as much as they recognize mine in not doing so.
We need to make sure that everyone is free to enjoy the big parts of life. We need to set priorities for graduations, weddings, funerals, worship services, schools, and hospital visitation. These represent a social glue that helps us hold together as communities, families, and individuals. Being able to meet together regularly and to gather in a group at the pivot points of our lives isn’t a luxury to be allowed but an essential right to be tenaciously preserved.
The practice of mandatory quarantines needs to be done away with. I personally think that the practice of voluntary quarantine is not particularly helpful. My proposal would be that we stop quarantine altogether and replace it with a strong social expectation that, if you’re symptomatic (coughing, sneezing, running a fever) you simply stay home until you’re feeling better.
This particularly needs to happen for children in a school setting. Quarantining children due to their proximity to another child and not based on their own symptoms is an enormously disruptive practice. We cannot allow this to become our standard operating procedure. It has to stop. Maybe not right this minute, it takes time to convince and encourage people and helping people feel comfortable and safe is also a pro-dignity practice. But we should be pro-actively aiming that direction and making real plans to do away with proximity-based quarantines.
Ultimately the various mandates need to end because the point of a mandate is to force everyone into making the same decision regardless of their own risk assessment or priorities. A mandate says explicitly “I have more power than you do and my decision making is better than yours so you have to do what I say”. Mandates are paternalistic and anti-dignity.
This goes for both mask mandates and vaccine mandates.
This is not a blanket statement saying “never any mandate for anyone in any circumstance”. They may be necessary in certain circumstances, but the benefits must be clear and balanced. Risks must be weighed. Given the risks to the elderly and the immunocompromised, I think vaccine mandates are appropriate for long term care workers. I’m mostly in the same camp for hospital staff except that I also think we need to weigh the risks of staff quitting. If implementing a vaccine mandate policy in a hospital is going mean that we are short-staffed, that’s another risk we need to take into account and it should be balanced with respect and intelligence. Maybe we come down on the side of “yes, it is worth it” and that would be fine but it would be nice to see people recognizing that this is a balancing act.
But I would be very much against a vaccine mandate for people visiting family members in the hospital. Visiting the sick is not a privilege that we should casually revoke, it is an essential ministry. My heart breaks every time I read about someone going into the hospital and having to live their final 2-3 weeks of life without being able to see their family and friends. That is a deep disregard of essential human dignity and I think it’s a scandal that we’ve allowed it to go on.
COVID is endemic which means that the goal of eradicating it is not achievable. We need to begin the process of leaning away from policies that were designed to stop COVID and lean toward policies that treat it like another disease that we have to fight against while we travel along this winding road of life.
Looney Tunes: Hare Do
This starts out as a standard “Elmer Fudd chases Bugs” and turns into a short filled with jokes about about the theater-going experience. The overall slapstick is great but some of the jokes get lost as we’ve lost most of the theater experience from the 40’s. Yes, it’s funny to watch Elmer get crushed to cadence of the William Tell Overture as people rush over him during intermission, but I suspect it was a funnier joke when it was closer to the viewer’s lived experience. I had to look up the joke about the two pennies taped to the vending machine carrot (apparently it was common practice to tape exact change to vending machine cigarette packs).
I would, however, love to see the movie whose poster Bugs sprinted past. “Hopalong Shapiro" sounds like a rollicking good time.
> My heart breaks every time I read about someone going into the hospital and having to live their final 2-3 weeks of life without being able to see their family and friends. That is a deep disregard of essential human dignity and I think it’s a scandal that we’ve allowed it to go on.
It's more than a scandal, it's absolutely criminal and all people involved in implementing it should be punished harshly. It needs to be done so it is clear that we cannot and will not accept it ever again in the future.
You do a great job analyzing the numbers. I would like to see you analyze the death rate as a % of total cases by month and if possible compare it to a typical influenza season. USA Today reports "Today's numbers: The U.S. has reported more than 45 million COVID-19 cases and 726,000 deaths, according to data from Johns Hopkins University." Unless I am missing something is a death rate of less than 2%. The monthly death rate in the early stages had to be staggering, so that would imply that the death rate now is really low.
What am I missing?