How does a pandemic end? 

click to enlarge A face mask on the ground.

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A face mask on the ground.

Politicians and pundits often like to compare the COVID-19 pandemic to a war. Nothing in most of our lifetimes has had the society-changing impact of the COVID-19 pandemic — and this kind of feels like the way that our parents say their parents described the Great Depression or World War II.

But World War II ended in a singular moment. Treaties were signed and people rushed into the streets in jubilation. The COVID-19 pandemic, which has plagued our lives for the last 14 months, won't end in a singular moment. There'll be no major "pandemic peace treaty," no all-out party. Perhaps, at best, there'll be a bunch of little ones. And that forces us to ask: How will this end?

The virus isn't going to disappear.

Our vaccines are incredibly safe and effective. For those who are vaccinated, they are a ticket back to "normal" life. Indeed, though rushed and poorly messaged, the CDC's guidance allowing vaccinated people to go unmasked both indoors and outdoors is based in strong science. Evidence has demonstrated that the risk of serious infection in the real world is astoundingly low, and that the viral load in the nasopharynx of vaccinated people is lower — likely explaining the reduced risk of transmission.

Yet, some people aren't getting vaccinated. And worse, the distribution of vaccinations isn't even. If, for example, unvaccinated people were evenly distributed in the population, the probability that they would be exposed to the virus if 70% of eligible people were vaccinated would be quite low. After all, 70% of the people around them would be vaccinated and therefore far less likely to pass the virus on. That's how herd — or community — immunity works. The problem though is that just like the virus itself, the behavioral scourge of vaccine rejection spreads from person to person in localized communities. So those who are unvaccinated are more likely to live among others who are unvaccinated, increasing their collective probability of infecting each other.

The likely scenario is that while communities with high vaccine uptake will get to a point where outbreaks are small, self-delimited, and rare — other communities that remain poorly vaccinated will continue to experience larger, more common, and more deadly outbreaks. And the virus will remain a looming concern in the U.S.

The other issue is viral evolution. New seasonal variants will likely spread among us every fall and winter akin to seasonal flu, which kills tens of thousands of Americans every year. Some COVID seasons will be milder, some far deadlier. And just like the flu, we'll likely need annual boosters against it.

Some things change.

But the virus isn't the pandemic's only ingredient — just the foundational one. For people who never got sick, COVID-19 still changed their lives. There is, of course, no singular pandemic experience. For millions of low-income "essential" workers, the pandemic meant fearing every day that you might be infected at work, or worse, bring the virus home with you to infect someone you love. For millions of healthcare workers, the pandemic meant watching your patients die without their loved ones as you struggled to manage the overflow. For others privileged enough to work from home, the pandemic meant endless days of Zoom calls while your kids tried to learn across from you at the dinner table.

As I wrote previously, work from home is going to be a much more common feature of American life. Small businesses, major corporations, and even some government agencies have found that their workers are surprisingly productive from home — and have reconsidered plans to come "back" to work in the office. And workers themselves have found they like using their own bathroom and eating out of their own fridge at lunch.

Indeed, as many workplaces begin to plan to come back to the offices, workers are pushing back. After Apple CEO Tim Cook sent a note to Apple employees requiring them to be back in the office on Mondays, Tuesdays, and Thursdays beginning in September, Apple employees circulated a letter in response:

"We ask for your support in enabling those who want to work remotely / in location-flexible ways to continue to do so, letting everyone figure out which work setup works best for them, their team, and their role — be it in one of our offices, from home, or a hybrid solution. We are living proof that there is no one-size-fits-all policy for people. For Inclusion and Diversity to work, we have to recognize how different we all are, and with those differences, come different needs and different ways to thrive. We feel that Apple has both the responsibility to recognize these differences, as well as the capability to fully embrace them. Officially enabling individual management chains and individual teams to make decisions that work best for their teams roles, individuals, and needs — and having that be the official stated policy rather than the rare individual exceptions — would alleviate the concerns and reservations many of us currently have."

Other companies, like Dropbox, have preempted this demand simply by offering work from home options permanently.

Beyond employee preference, companies attempting to go back to a brick-and-mortar office space will face the question of risk tolerance. As we well know, some eschewed any sort of pandemic protection — be it a mask or a vaccine — from the jump. Others, despite being fully vaccinated, remain hesitant to share enclosed space. How to navigate lower risk tolerances remains a serious challenge. Part of making workplaces safe may mean mandating vaccines, which has prompted serious pushback in the courts of law and public opinion by anti-vaxxer activists who want to use the pandemic as another line of attack. Navigating these challenges is, in part, what is pushing more and more employers to offer alternative working arrangements. Needless to say, some alterations to working conditions because of the pandemic are likely here to stay.

Other things stay the same (again).

Some pandemic experiences were universal. For children, the pandemic has been a catastrophe. Not only has learning lagged, but children have been robbed of valuable socialization and milestones. Indeed, the consequences have been far worse for poorer students, disproportionately children of color, for whom access to quality WiFi and reliable computers are limited. All indications suggest that kids will be back to school in the fall as vaccinations among teachers and students press on.

Access to other people and the venues in which we enjoyed their company was limited if available at all. Restaurants, concert venues, theme parks, theaters — even stores and shopping malls — had limited access.

But that's changing. Prompted by the CDC's new guidelines for vaccinated people, many of these venues have rushed to reopen, and Americans are slowly but surely taking advantage. Flight traffic is increasing. Last week, LAX, one of the country's busiest airports, logged a 2021 record. And businesses can't hire people fast enough to accommodate their needs.

Though worries about COVID-19 exposure — particularly for children who cannot yet be vaccinated — persist. Yet as cases continue to fall, and vaccines are approved for younger and younger children, these, too, will subside.

The doomsday scenario.

But there remains a possibility that experiences of the pandemic we haven't had since last fall come crashing back. Cases climb, hospitals fill up, and thousands more Americans die. And that's a resistant strain.

We've now identified several variants of the virus that are more transmissible, and some more deadly, than the original garden-variety ("wild type") virus we experienced through most of 2020. Thankfully none of them have fully evaded our vaccine-mediated immunity. Yet.

Every single unvaccinated person presents an evolutionary opportunity for the virus. And even as the U.S. and other high-income countries approach a virus-stifling level of vaccination, the rest of the world continues to lag. Some countries have yet to get their first vaccines. New variants with frightening capabilities continue to emerge in these countries. Indeed, last week a new variant with aspects of the Alpha variant and the Delta variant emerged in Vietnam. So even as vaccine manufacturers roll out boosters to protect against the growing plethora of new variants, a doomsday scenario, where a more transmissible, lethal variant evolves, becomes more likely.

And so, we can't take for granted that this is a truly global pandemic. And until the rest of the world receives what they need to "end" this pandemic, we won't see our end either.

This article was originally published on June 10 in The Incision. It is republished here with permission.

Dr. Abdul El-Sayed is a physician, epidemiologist, public health expert, and progressive activist who served as Detroit's health director and ran for governor in 2018. He is the author of Healing Politics: A Doctor's Journey Into the Heart of Our Political Epidemic and Medicare for All: A Citizen's Guide, as well as the newsletter The Incision. Get more at incision.substack.com.

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