If you were in Hanover this past summer, you’d be forgiven for thinking that the pandemic was over. Masks came off, social interaction returned and Dartmouth dissolved its COVID-19 Task Force — all actions that seemed to emphasize the lack of a need to plan so intensely around the virus.
Yet at the same time, it now seems more unlikely than ever that we will see a day when the pandemic will finally end. And that’s because there probably won’t ever be an end, at least not totally: SARS-CoV-2 will likely never disappear, public health experts are increasingly convinced. Thus, to “end” this pandemic, we need to redefine our goals — at Dartmouth, across the country and across the world. COVID-19 is not headed the way of smallpox or polio – i.e., completely eradicated or eradicated in most parts of the world thanks to vaccinations. Therefore, in the long term, we should refocus our efforts away from preventing all levels of transmission and instead focus on decreasing severe illness and learning to manage the virus like we do other endemic diseases such as the flu.
To clarify, we shouldn’t abandon many of our current restrictions — COVID-19 is still an order of magnitude more harmful than seasonal influenza. Though more muted in the Northeast, the summer Delta wave overwhelmed regions with lower vaccination rates — a number of Texas hospitals have practically no available beds, for example. Several other states recently experienced their highest rates of hospitalizations and deaths at any point during the pandemic. The daily death rate nationwide has exceeded 2,000 and the total number of deaths from COVID-19 is approaching 700,000 over a year and a half; in comparison, the flu kills 20,000 to 40,000 people in a typical year. Turning the coronavirus into a manageable illness is the goal, but is certainly not the current reality.
Most of Dartmouth’s current, relatively moderate restrictions actually make sense given the threat of the Delta variant, but nonetheless, these restrictions should be tied to more definitive goals around reducing the pandemic’s severity. Masking indoors is hardly a tremendous burden, and, given that children under 12 are unvaccinated and high-risk groups are just now beginning to get boosters, routine testing also makes sense. Vaccine immunity has already waned over time among the elderly, raising the possibility that vaccinated older people will have to face more severe infections.
But imagine this pandemic some time down the line, after still more individuals are vaccinated and boosters are available for groups in need. COVID-19 would still circulate in the population but be less deadly — preventing the virus from threatening to overwhelm the healthcare system and causing massive numbers of severe cases. In this scenario, a positive COVID-19 test should not be a cause for total isolation and contact tracing of all close contacts — just like how if you had the flu, you should probably stay home, but would not be forced into strict quarantine. After we hit a certain goal representing minimized disease severity and deaths — e.g., after a certain percentage of those under 12 are vaccinated and boosters have reached a certain percentage of vulnerable groups like the elderly — we must begin to tolerate some level of community spread. It’s unfortunate that we would find ourselves having to surrender to the disease we tried to totally prevent for so long. But as the context changes, so too must our mindset around COVID-19.
These past two months have been heartbreaking as we’ve watched the virus surge again — but even in COVID’s re-emergence, there is hope for how it can be managed as an endemic disease. We know that the Delta variant can “break through” in vaccinated individuals, even though some vaccines were nearly 100% effective against previous strains. But we also know that rates of death and severe illness have dropped significantly amongst the vaccinated; according to Centers for Disease Control and Prevention estimates, a fully vaccinated individual is 11 times less likely to die from COVID-19 than someone who is unvaccinated. The variants won’t stop with Delta — natural selection drives viruses to spread as efficiently as possible, and newer strains could be even more effective at breaking through prior vaccines. But, if we keep vaccinating the population against variants and reinforcing population immunity, the virus could remain less deadly. Think about what happened to the 1918 influenza — at first killing more people than all of the deaths in World War I, it now circulates as multiple new strains every winter season but is managed with yearly flu shots.
If endemic COVID-19 is our goal, every level of power needs to make that message crystal clear. Dartmouth implemented the new mask restrictions as the “best and most effective” way to reduce transmission and achieve the “earliest possible return to normalcy.” But what does a return to normalcy mean? If we’re being honest, the new normal will include some acceptable level of community transmission of COVID-19. This idea goes far beyond Dartmouth — the Biden administration has repeatedly published plans discussing its goals to “end the pandemic,” seemingly implying a near-total end to transmission. Clearer goals — such as a sustained, substantial reduction in deaths across the country — should define the end of pandemic conditions, not the eradication of the virus itself.
If we can set a clear goal, we have a fairly straightforward pathway from where we are now to a less deadly, endemic COVID-19: increased vaccination uptake, the development of vaccinations for new strains, boosters, the discovery of easier treatments for the infected (comparable to the Tamiflu treatment we have for influenza) and more. We are already making progress — last Thursday, the CDC’s vaccine advisory committee voted to recommend booster shots for those 65 and older, hopefully providing further protection to the group most at risk. Careful, measured social restrictions targeted to protect health systems from being overwhelmed should also be part of the picture. But these initiatives must all be part of a strategic, defined plan to reduce the severity of COVID-19 and prepare to manage the virus long-term.
Endemic COVID-19 is not a perfect outcome. Managing something “like the flu” is ultimately choosing to live with rather unfortunate consequences, including tens of thousands of viral deaths per year. But making our goal total elimination is a hopeless endeavor that will leave us with no clear exit out of this nearly two-year period of uncertainty and suffering. For now, we need to keep testing, masking in areas of high transmission and promoting vaccination because we’re still not where we need to be. The virus is here to stay, but its most devastating consequences need not be.
