COVID Predictions — From An Expert

I have a friend from medical school who is a pediatrician with a prior background in biosecurity and pandemic response, which is to say, I would call him an expert in this field and I think his thoughts are incredibly valuable.

I’m going to start regularly sharing some of those thoughts with you here, with his permission.

“A few people have asked me what the future holds and when we’ll be able to go back to normal. The trouble with predictions is that pandemics involve two parts — the pathogen, which behaves mostly predictably, and humans and their governments, which mostly don’t.

I believe we have two possible outcomes within the US: endemicity (which is not a good outcome), and full elimination of the virus (which is doable but will be very difficult).

As a number of virologists and epidemiologists have discussed, endemicity means an infection has achieved an equilibrium within a population. As immunity wanes, or as immune people die and non-immune people are born, the pendulum swings. The virus re-surges, then simmers down. But endemicity doesn’t imply a low circulating level of infection among the population, just that it’s at a fairly consistent level. Even though smallpox, measles, and yellow fever were endemic in their day, they were major public health problems that diminished quality of life. Endemicity may take a long time to achieve, and the path there will be littered with dead bodies, from COVID deaths and from other deaths due to overwhelmed hospital systems Unless our vaccines are stellar (so far they’re not, against Omicron) and immunity is lasting (doubtful), the prevalence of COVID in an state of endemicity would be high. Lots of COVID would be going around.

I don’t like the idea of endemic COVID for lots of reasons. One is that COVID can cause life-long disability. I like being able to work and taste food. Did you know COVID can cause erectile dysfunction? More people should know that. That might motivate people to wear a mask.

Historically, societies have figured out that eliminating pathogens works better than living with them. The US was the main funder of global smallpox eradication worldwide. If I remember correctly, the US spent less on eradicating smallpox than was spent each year controlling it.

I also highly doubt that in a state of COVID endemicity we could go back to “normal” (riding the bus without wearing masks, without risking getting COVID). The more infections there are, the more risk of new variants emerging. This has already happened a bunch in just 2 years.

So let’s turn to elimination. First, elimination has become much, much harder now with Omicron, which is extremely transmissible, up there with measles. Using a metric called R0 (pronounced “R-naught” - the number of people each sick person goes on to infect, in a population with no immunity) you can calculate what percentage of the population has to be immune to hit so-called “herd immunity.” The R0 for Omicron is crazy high. By my figuring, that leads us to an estimation of about 93% of people need to have immunity to reach herd immunity. And that assumes that 93% of the population has complete immunity (i.e. vaccines work 100%, previously infected people can’t get reinfected).

Unless patients with Omicron have durable complete or near-complete immunity from COVID (which seems doubtful), then without a population-wide vaccine mandate and an extremely effective vaccine, we won’t achieve a happy steady state. The virus will just keep circulating.

So that leaves one other possible approach — set up an area where the virus will be eliminated, erect borders around that area, and set up a quarantine system. This has been done in some countries (Taiwan, New Zealand) and in some provinces (Western Australia, Hong Kong).

But without either a population-wide vaccine mandate, or an airtight quarantine system, I think we will remain stuck indefinitely.

This is where my ability to predict things break down. Until a substantial portion of the population figures this out, or cares, or until political leaders figure this out and care, we’re stuck. How long will that take? Will it ever happen? I don’t know.

The other thing to keep in mind is that for the Lower 48, you’re stuck with the policy choices of whoever you are fenced in with. States will either need uniform policies, or they will need to fence themselves off from other states or other regions (Hawaii did this).

My best prediction is that some country or region will develop a COVID-free bubble and will charge for outsiders to enter and live there. And those who can afford it will have it great. And those who can’t will be on the outside.

If you were able to get immigration status to New Zealand or Western Australia, and find a job there, even if it paid less, would you turn it down? I’m not sure I would.

I’ve heard the term ‘unprecedented’ batted around a number of times. That this pandemic is unprecedented. I disagree. Pandemics have dominated most of recent modern human history. Just not during our lifetimes.

The good news is that COVID can still be defeated. We have faced worse public health and societal challenges than this and have been able to muster public resolve, and appeal to people’s better angels, and overcome them.

The frustrating thing is that we have always been able to defeat it, and we haven’t. The toughest thing about practicing medicine, for me, is the preventable deaths. I know people will die. I just hate it when people die unnecessarily early.

And a pandemic is a medical problem on a population scale, with population-wide policy solutions instead of medical solutions. Over 100 years ago, Rudolf Virchow, the father of modern pathology and social medicine, said “Medicine is a social science and politics is nothing else but medicine on a large scale. Medicine as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution; the politician, the practical anthropologist, must find the means for their actual solution.”

This means that with this pandemic, all of us are medical practitioners. You, me, everyone. We all are getting a taste of the practice of medicine, of the despair when a patient dies who didn’t need to.

But medicine is an intensely rewarding field because it deals with people’s lives and the stuff of substance. So now that we all are medical practitioners, I hope we all get to experience the wonderful part of the job — the triumph and celebration when we defeat sickness. Welcome aboard.”

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Taylor Nichols

Taylor Nichols

Humanist. Emergency Medicine Physician. Health policy enthusiast. Views are my own. (He/Him)