What Happens when The Pandemic is Over?

I honestly can’t believe I even wrote that title, because truthfully the optimism that is required to put together that sequence of words in that order is something I could not have conceived of even a few months ago. The pandemic is not over- it’s not close to over actually- in many parts of the world and for certain groups, and SARS-CoV-2’s transition to endemicity is all but certain, but we are seeing it transform into a manageable public health problem in some nations rather than the catastrophe it has been to date that has wrought historic devastation not seen in over a century. That is an extraordinary victory and I am ecstatic thinking about it. On a personal note, watching the rollout of safe, effective vaccines that harness state-of-the art science to save lives and vanquish a novel pathogen has validated everything I believed in before the pandemic, and I am profoundly grateful for that.

The scale of this recent calamity is hard for me to fathom. I’ve lost loved ones to COVID-19, and that grief is bounded only by the sliver of gratitude I can pull from knowing I didn’t lose more. Millions have died. Millions more still will as they wait for the salvation of vaccines. Millions more will survive with disabilities and have to make significant adjustments to how they live their lives, as we work tirelessly to pursue therapeutic leads. Thinking about how much has been stolen from people by this virus shatters me, but it’s not the thought that I agonize most over lately.

There’s a pervasive element to the conversation about how viruses evolve- that they gravitate towards a state of lower virulence, lower pathogenicity, because it enhances their ability to spread. That’s the pressure that evolution imposes on them. It’s a cheery thought, but there are problems with the idea. It’s certainly true that a virus that causes death too quickly to be passed to another host is likely to die out (so to speak), but consider for instance, Ebola: some strains have fatality ratios as high as 90%. It’s been known to humankind since the 1970s- but we haven’t exactly observed an appreciable loss to virulence there (though I grant you there may be aspects to Ebola’s genetics which make its case fairly unique). And then I think about SARS-CoV-2: a virus that spreads largely from overdispersion and presymptomatic/asymptomatic transmission, and with which severe disease, though often unpredictable, is a rarity as a function of cases in COVID-19, and death even more so. It is hard for the selection pressure of increased transmissibility to antagonize virulence if the virus has an easy enough time spreading regardless of how virulent it actually is. In fact, as the pandemic has gone on we have seen variants that manage to be both more virulent and more transmissible. Maybe, one day, SARS-CoV-2 will indeed evolve to be a common cold virus that is more of an economic nuisance at the public health scale from the loss of productivity than the horrific pestilence it currently is- but how many people must be victimized in the process of that for that to happen?

COVID-19 was sufficient to bring the world to its knees despite a relatively low case-fatality ratio, and take so much irreplaceable from us in the process in spite of valiant mitigation measures. But we are living in an age of pandemics. Between climate change and industrialization, and a litany of other factors I am doubtlessly failing to consider, our environment is ripe for zoonotic spillovers like those that gave us SARS-CoV-1, MERS-CoV, influenza, Nipah, Hendra, hantavirus, Zika, Ebola, and most probably SARS-CoV-2. I will never trivialize COVID-19. It is the worst public health disaster I have ever lived through and the worst one I hope to experience in my lifetime. Hearing some people refer to it as a training exercise for the so-called “big one” nauseates me. But in a universe of counterfactuals, all I can think is: will the next one, and be very sure, there will be a next one -it’s a question of “when” and “which one(s),” not “if”- be worse?

We -the international community of stakeholders- have a choice here. We can choose not to be passive spectators to our own demise. We can allow for paid sick leave as a workplace right. We can choose to make the investments in basic science now for the critical research that enables pandemic preparedness. We can choose to have plans. We can maintain stockpiles of PPE for pandemic situations. We can establish interdisciplinary centers that benefit from disparate expertise of many professionals to create novel strategies. We can establish an observatory to identify pandemic threats in nature before they emerge in humans. We can work towards gene drives that prevent the encounters that cause vector-borne diseases. We can establish rapid regulatory pathways that permit for even faster access of a vaccine to the public without sacrificing safety evaluation. We can work to combat the systematic disparities in healthcare that unfairly place some groups at disproportionate syndemic vulnerability. We can put aside the petty squabbles of international conflict (and yes, next to the threat of a pandemic they are petty squabbles- pathogens have no concern for what side of a border you lie on) to establish diplomacy and solidarity so that we may all work for our collective betterment, as we did during the Cold War with polio and as we did with the eradication of smallpox. We may even consider adopting face masks as a fixture of our culture. There is so much good that we can do, and I think right now there is an opportunity to capitalize on the political will for us to do it.

What worries me far more is that in addition to an age of pandemics, we have entered an age of post-truth and infodemics. My friend, Dr. David Gorski, recently pointed out an irony to me: in vaccinology it is said that vaccines are victims of their own success. What is meant by this is that the privilege in refusing vaccination is manifest only through the lack of saliency that the vaccine-preventable disease holds in public consciousness. Parents see little wrong with refusing MMR and DTaP vaccines today because they’ve never known anyone who’s died of subacute sclerosing panencephalitis. They have never seen anyone be rendered sterile by mumps orchitis. They have never seen the congenital anomalies resulting from rubella. They haven’t seen children strangled by diphtheria, nor the tortured contortions of opisthotonos, nor the paroxysmal coughing fits of an infant with pertussis. In accordance with this line of thinking, people working in the space of vaccine confidence such as myself held to a quixotic delusion: watching a pandemic unfold in real time would crush the worldview that was so dismissive of the transcendental protection conferred by vaccines. In some anecdotal encounters, I have indeed observed this. People have come to me and said they didn’t understand why their views about vaccines were misguided until they saw how a single infectious disease ravaged this planet. That was heartening. But overall that’s not what’s happened. Vaccine uptake in the US has stalled- though access may be more substantial as an issue than hesitancy. Epistemic trespassing has become a norm of conduct. Some dismiss COVID-19 as being little more than a cold. Some cling steadfastly to claims of treatments whose efficacy is unvalidated, and in some cases both refuted and demonstrated to be harmful. As identities are built around conspiracy theories and communities are established, people grow more insular and unreachable, and they are well-organized and capable of significant harm. I feel particularly compelled to point to the case of Dr. Elisabeth Bik, a champion of scientific integrity who has worked throughout the pandemic and long before it to ensure the quality of our scientific knowledge compendia, and, for it, is currently facing harassment and legal threats for explaining the flaws in a study of the pandemic nostrum hydroxychloroquine. Public health professionals are resigning as their lives are being threatened and they are met with antipathy from the people they work tirelessly to protect, and laws are being introduced to weaken their authority. Memes such as this need to be viewed as no less deadly than the infectious threats I hope we all resolve to work towards preventing. These are not anthropological curiosities about a strange sect of society- this is a true danger to humankind, and these ideas are growing mainstream and suffusing into a political identity wherein any public health measure risks alienating all who fall within the former’s scope. The inaccessibility of education, of quality sources of information, and to true expertise writes a dark epitaph on humanity’s tombstone as generations are robbed of chances to cultivate their critical thinking and preclude their fall down a rabbit hole from whence the chance of return is charitably considered slim. Here, I will be frank as I’ve been throughout this post: I do not know what to do. I have tried to treat the spread of such harmful ideas as its own contagion and worked to debunk and prebunk for susceptible (in the sense of the SIR model) individuals with efforts such as this blog, in the hopes that they will function as trusted messengers within their own microcosms and epistemic bubbles to spread the truth that banishes absurdity, and through collaboration with those much more seasoned and knowledgeable than me, for whom I am eternally grateful. But it’s very clearly not enough. The schism separating our society into facts and alternative facts tears a chasm scarring our world that places far too many on the latter side for us to claim the triumph of reason, and that is truly heartbreaking.

I recognize that in spite of our most fervid, best efforts, even if we do all I have listed here and more (and certainly, this listing is not intended as comprehensive), we may still fail to contain the next pandemic. Indeed, forestalling the inevitable is a sisyphean task even for a well-organized and concerted group effort. But dying tomorrow is preferable to dying today, and buying time for more permanent solutions means minimizing losses so that more may prosper, so that we may keep our grip on “normal,” and live the lives we most desperately want, that our souls need.

Here is my singular earnest entreaty: regardless of who you are, learn from this pandemic. Use its vicious, remorseless tutelage to work to establish safeguards against future cataclysms and spur upstream actions that obstruct the toppling dominoes of disaster, if only to honor the memory of those forfeit to COVID-19’s clutches, so that something this never happens again. Do not allow yourself to forget these last few years. Do not take for granted the normalcy that has been hard fought and won back, because it can evaporate at any moment. Treasure it and continue to fight to keep it. There are no do-overs, and I refuse to accept something like this a second time- and so should you.

We must be better. We lack the luxury of choosing our status quo because it is tantamount to signing the warrant on our extinction.