Where Do We Go Now With COVID?

Clearly we are moving in the direction of normalcy -- in the direction of treating COVID like just another disease.  I don't think we are there yet, although maybe we might get there when the omicron wave dies down.  A lot of it will depend on whether the omicron wave is the last, or whether there will be future waves, a thing no one can know right now.  But assuming we do return to normalcy soon, it does not logically follow that we should have done nothing from day one, nor does it mean that we should refuse to take the sort of precautions against COVID that we would take against any other disease.  

Further thoughts:

When can we return to normalcy and treat COVID like any other disease?

Given continued reports of overloaded hospitals, I would say that it is still too early to drop all precautions and go back to everyday life.  So when will it be time?  I would say, when the healthcare system stops being overloaded.  And, given talk of pervasive but mild spread of Omicron with huge numbers of people sick but manageable numbers in the hospital, or with schools closing or becoming dysfunctional due to the large numbers of people out sick, I would say when there are not disruptive levels of absenteeism.  There are COVID pills out that are nearly 90% effective in preventing hospitalization, but in short supply.  Maybe if we are able to produce enough to actually reduce hospital admissions by that much, we can move on and return to normalcy.  And maybe normalcy will be a part-time condition, interrupted by occasional waves.

What will normalcy look like?

Well, here is the problem.  To a lot of people returning to normalcy means returning to exactly the way things were before the pandemic, including no vaccines and no need for testing and treatment.  But the same people who reject any sort of change, including taking vaccines, often seem to be willing to make changes in their lives, such as taking prophylactic Ivermectin, nebulizing hydrogen peroxide, or even drinking your own urine. So why do all that but refuse a shot?  So my "plan," such as it is, for dealing with COVID makes the unrealistic assumption that we have a reasonable population, though not a perfect one, something like the population of an Asian or Nordic country.  

What is a reasonable but not perfect population?

So what do I mean by a reasonable but not perfect population?  Roughly speaking, I mean a population that takes COVID seriously but gets pandemic fatigue, a population that is willing to take actions to fight the pandemic, but not unlimited actions, a population whose vigilance declines over time, a population that is best able to sustain actions that are not too burdensome and are most easily incorporated into a routine.  A reasonable but not perfect population would get the vaccine. It would be disappointed and somewhat resentful at finding out protection was short-lived, but would not reject the vaccine altogether.  It would get boosters, but go to less and less trouble to be boosted the more often it was required.  A reasonable but not perfect population would be able to tolerate (say) a two-month lockdown but not willing to return to lockdown under any but the most extreme circumstances.  It would get increasingly neglectful of distancing or hand washing or surface cleaning or home testing over time but not denounce any of them as intolerable tyranny.  It could probably sustain masks for a long time (masks aren't much work; Asian countries do it), but would be more likely to wear them in a public or commercial context than among friends, relatives, or coworkers.  In short, a reasonable but not perfect population would have normal human weakness but would not follow conspiracy theorists.  It would be willing to test after exposure, but limited in its tolerance for quarantine in the absence of either symptoms or a positive test.*

So what would a return to normalcy look like for a reasonable but not perfect population?

A reasonable but not perfect population would be willing to take the sort of precautions against COVID that they would against any other disease.  A reasonable but not perfect population would get vaccinated and get its boosters.  It might be necessary to take boosters into the schools or the workplace or every pharmacy or whatever to make it easy enough to get boosted. A reasonable but not perfect population would self-test if they had symptoms.  A reasonable but not perfect population would stay home if the test was positive (or maybe even it was negative; you really should stay home if you have a contagious disease).  This probably means a reasonable but not perfect population would have reasonable but not perfect employers and a reasonable but not perfect government that would arrange for paid sick leave for people with contagious disease, including paid sick leave to stay home with sick children.  Our reasonable but not perfect employers and government would also give people time off to get vaccinated and deal with after-effects, but would strongly encourage people in the same school/workplace/household to get vaccinated at different times to avoid everyone from being out sick at the same time.  Finally, a reasonable but not perfect population would seek early treatment if they had the disease. Incidentally, Paxlovid, the so-called COVID pill requires the patient to take three pills twice a day for five days.  A reasonable but not perfect person might get careless, so a little telemedicine, i.e., calls from the prescriber to make sure they were keeping up to date, might be in order.  Ditto for Remdesivir, which requires three IV infusions on three successive days.

What can would a reasonable but not perfect population do until then?

To all appearances, the omicron wave will subside well before there are enough therapeutics to keep the hospitalization rate low enough to allow a return to normalcy.  What would a reasonable but not perfect population do until then?  Once the omicron wave subsides, I think we can drop most restrictions and go to something only a little more restrictive than normalcy:

• Get vaxed.
• Get boosted.  (Make boosters as accessible as possible by coming into schools, work places, etc)
• Self test if you have symptoms (This would require our hypothetical reasonable but not perfect population to have a reasonable but not perfect regulatory regimen that does not make self-testing prohibitively expensive or difficult to find.  Other countries have done it).
• Stay home if it is positive. (Same comment on paid sick leave)
• Seek treatment if you are high risk

To this I would add the latest in culture wars -- asymptomatic testing.  Everyone should keep a stash of five or so home tests for use.  If you test positive, inform your contacts.  Your contacts should self-test each day for five days (or whatever is called for).  They don't have to isolate so long as it is negative.  If it is positive, they should quarantine, notify their contacts, and seek treatment if they are high risk.  I would also recommend that schools, work places, and other institutions keep a stash of tests.  If a student, employee, etc. has symptoms, they should test and isolate if positive.  Their contacts should be tested, quarantined if positive, but allowed to show up if negative, subject to daily testing for the next five days (or whatever is called for).  Schools in Los Angeles found this to be just as effective in stopping the spread as quarantining everyone, with mush lower rates of absenteeism.

However, asymptomatic testing is somewhat intrusive and does lead to higher rates of absenteeism than not testing.  The usual suspects are therefore arguing that asymptomatic testing is just a "soft lockdown" and that asymptomatic spread does not happen.  Of course the goal here is not to allow the disease to spread unchecked, which would lead to even higher absenteeism.  And whether or not asymptomatic spread is possible, presymptomatic spread is definitely real. In fact, people are often at their most contagious in the day or two before symptoms.  If true asymptomatic spread does not happen, maybe we can shorten the quarantine period to two or three days to determine who is truly asymptomatic and who is merely pre-symptomatic.  Or develop a good enough mask to allow asymptomatic or pre-symptomatic people to stay at work.**  Or maybe with enough vaccines and tests we will reach the point where the great majority of cases are asymptomatic and we truly can ignore them.

Finally, a reasonable but not perfect population with a reasonable but not perfect government would take advantage of the lull to stockpile tests and N-95 masks, explain the importance of N-95 versus cloth and improve ventilation, with priority to restaurants, bars and gyms because people could not mask there.  Maybe these precautions would be unnecessary, but they certainly are not burdensome.

What would a reasonable but not perfect population do during a wave?

If another wave were to hit a reasonable but not perfect population, they would wear high quality masks and use the ventilation systems they had installed in the interim. There is some reason to believe that if everyone wears a high quality mask, it will make a significant difference.  Maybe even enough, combined with good ventilation, that we truly can treat risk tolerance as a matter of individual choice, and that a person who likes frequenting no-mask venues like restaurants, bars, and gyms poses no danger to others.  Except that there is still the matter of overloading the healthcare system. And besides, restaurant, bar and gym owners presumably don't want to be seen as risky venues and centers of disease.  So what can you do?

Well, there has been a lot of talk and some action about requiring a vaccine card to attend a no-mask venue, which seems reasonable.  Maybe a reasonable but not perfect population could tolerate adding a negative test as a requirement.  (Rapid antigen test should be sufficient, though I can see some room for dispute how to handle it).  Large events (conferences, concerts, travel, etc.) should probably also require a negative test during a wave.  And, given that a reasonable but not perfect population will probably not be willing to wear masks in family and social gatherings, we should encourage everyone to test for such occasions.  A perfect population, with sufficient tests, would test routinely (say, twice a week) during a wave.  But that is probably too much to ask of real world people, except maybe for a very short time.

Why bother, if everyone is going to get it sooner or later?

Aside from not overloading the healthcare system, I can see at least two reasons.  One is that we don't know everyone is going to be infected sooner or later.  If masking, ventilation, and testing deprive the virus of victims, then it will die down and even die out. But even if the virus comes roaring back once people stop masking and testing, there are reasons to think later is better than sooner.  For one, we may get more treatments in the future that will end the risk of overloading the healthcare system.  For another, we may come up with an omicron specific booster so that infection won't be inevitable (even if it requires more boosters down the line).  Or even an Army super-vax that will not give out with every new variant (though who knows if it will require boosters).  In short, as with many things, it is worth kicking the can down to road to see if we can come up with a better long-term solution in the meantime.

That's all fine and good for a reasonable population.  But how to you talk sense into the actual, real-world US population?

Ummm --

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*I will get personal here.  I am a fine well-educated liberal willing to get boosted, wear masks, work from home, test in case of symptoms, etc.  But when I found out I was infected, I called my contacts and only urged them to get tested.  There was no way I was going to ask them to quarantine for 14 days!

**That would no doubt be popular with economic royalists, who would see it as a great way to keep symptomatic employees at work too.

Understanding Why COVID Vaccines Disappointed

 

Clearly COVID vaccines have been a disappointment.  When we first heard the announcement that there were vaccines that were 90% effective, we could hope the pandemic would finally be over and we could go back to normal.  It was actually fairly predictable that there would be new variants that would be vaccine resistant.  That is a routine occurrence with corona viruses and is the reason to get annual flu shots.  But the vaccine companies said if a new variant came about, they could simply plug in the new protein spike.

Well, it hasn't turned out that way.  It turns out that the protection from COVID vaccines wanes quickly and that new variants spread faster than companies can modify the vaccine and get it out.  What went wrong?

Possibly because normally the full test phase takes five years, but COVID vaccines were approved in less than one.  Moderna developed its vaccine within two days of receiving the virus sequence.  The delay was in testing.  By giving emergency use and cutting short the testing, we allowed a vaccine that we had limited knowledge about over the long run.  

This is not a criticism. On the contrary, given that the choices were approving a vaccine before we fully understood it and allowing the pandemic to continue without a vaccine, early approval was clearly the better choice.  But there were tradeoffs at work, and one such tradeoff was that we authorized the vaccine before working out the sort of bugs that would have been worked out with a longer trial period.

If trials had continued for five years, the vaccine manufacturers would have realized that immunity starts waning fast after 5-6 months and requires a booster.  They would, no doubt, have learned how long booster-driven immunity lasts and how often later boosters are required.  And when the announcement came out that drug manufacturers had a vaccine that was effective, but required six-month boosters, everyone would have known about its limitations in advance and not felt angry or betrayed when the vaccine turned out to have a limited duration.

Of course, we would also have had to face delta, omicron, and who knows what else without the benefit of a vaccine.

2021 Was a Bad Year, but Better Than 2020

Remember 2020

Let there be no doubt.  2021 has been a bad year.  But even at its worst, it has still been an improvement from 2020.

Consider a rough recap of the headlines from 2020.  Impeachment.  COVID.  Lockdowns. Panic buying.  Empty shelves.  No toilet paper. Anti-lockdown protests. Black Lives Matter.  Mass riots.  Devastating forest fires, with many people refusing to leave their homes for fear of Antifa.  So many hurricanes we ran out of names. Election.  Trump refuses to accept results.  COVID again, and the prospect of a long, dark winter.

And now a rough recap of 2021.  January 6 insurrection.  Inauguration. Vaccines.  A seeming return to normalcy.  Breakthrough infections. Delta variant.  Disastrous withdrawal from Afghanistan. High crime.  Inflation.  Supply chain problems.  Virginia election.  Omicron variant sweeping away all anti-COVID measures, and the prospect of a long, dark winter.

More 2020

Obviously it ain't great. The vaccine we had hoped would restore our pre-pandemic life turns out to offer only a short-lived protection against infection, with a longer protection against hospitalization and death, but even that (I suspect) will wear out. It turns out we need regular boosters, and that this virus produces regular mutations. At the same time, treatments have improved, and a highly effective treatment (and perhaps a more robust vaccine) are coming down the pike.  The economy has made a comeback, but consumption has outrun production, causing inflation, declining real wages, and shortages. Widespread shortages of staples have given way to spot shortages of various products that can be gotten around.  There has not been a return to widespread riots and civic disturbances, but crime rights are alarming.  Natural disasters have been bad, but not as bad as last year.  And so forth.

Or let me offer the comparison in table format:

	2020	2021
COVID	Rampant spread, inadequate testing, no vaccine or effective treatment	Vaccine, frequent breakthrough infections, omicron variant, beginnings of effective treatment
Economy	Lockdowns, widespread unemployment and business failure	Rapid recovery, consumption outpacing production, 6% inflation
Shortages	Widespread shortages of staples	Sporadic shortages of various products
Civil disturbances	Widespread riots	High crime
Natural disasters	Devastating fire season, so many hurricanes we ran out of names	Bad fire and hurricane seasons

So, yes, things are bad.  But it is still an improvement over 2020.

Do Right Wingers Have Anything Positive to Contribute to the COVID Debate?

 So, I am strongly critical of Joe Biden putting all his eggs in the vaccine basket, for not focusing on testing, ventilation, vaccinating the rest of the world, etc. But that is altogether different from saying that I think right wingers have any sort of standing to criticize him.*

Right wingers were dead set against lockdowns, and in the clear light of hindsight, they had a point. Lockdowns are not only extremely economically burdensome, they also have a high social cost that we have not yet recovered form. Lockdowns were necessary in places like New York where the initial outbreak was very bad, but perhaps they could have been avoided without too much cost in other places. In the clear light of hindsight, our side should have looked passed locking down to stop the spread and immediately prioritized stopping the spread without shutting everything down.

But the right-wing viewpoint overall has been opposition to any attempt to stop the spread, either on the grounds that everyone was going to be infected sooner or later, so let's get it over with, or on the grounds that any government action to stop the spread was tyrannical, and that the absence of government action was infinitely more important that the absence of pandemic.  Also present in the equation is the conviction that since zero COVID is not a realistic goal, there should also be zero mitigation.

So it, granted that vaccines alone are not stopping COVID, is there any approach that right wingers would support?

Masks

Masks, by contrast, have a much lower social cost that shutdowns.  Granted, they are somewhat hot and uncomfortable, but, for the most part, masks are indefinitely sustainable.  Asian countries such as Japan have been able to carry on in a mostly normal fashion while wearing masks.  In the early days of the pandemic, even Fox News personalities endorsed masks, largely because Anthony Faucci and oppsed them.  But when Faucci and the CDC changed their minds, why didn't Fox hosts just gloat that they were right and the experts were wrong and accept their victory?  The answer appears to have been, first of all, that it would remove masks as a culture are issue and, second, admitting that there could be a serious problem during a Trump presidency. So ever since CDC officials endorsed masks, masks have been intolerable tyranny.

Again, there are some legitimate objections to masks.  One is that cloth masks are of limited effectiveness.  That can be overcome by promoting surgical masks and (especially with the Omicron variant on the loose), N-95 masks.  The other is the complaint that if we always have to wear masks, what is the point of getting vaccinated.  So I will agree, there should be metrics as to when masks are and are not seen as necessary.

The biggest burden of masks, however, is to restaurants, bars, and gyms.  Clearly it is not feasible to wear a mask while eating or drinking, and masks seriously inhibit strenuous exercise.  So is there a feasible way to stop the spread of COVID in restaurants, bars and gyms without unduly burdening them and, if so, would right wingers agree to it?

Vaccine passports

The most obvious way to keep restaurants, bars and gyms to stay open without being major sources of spreading COVID is to require customers to present proof of vaccination.  Republicans all over the country have been fighting that tooth and claw as tyranny and demanding that the unvaccinated not be treated as second class citizens.  And, it should be added, there have been enough breakthrough infections, to say nothing of Delta and Omicron variants, to make clear that vaccine passports alone will not keep restaurants, bars and gyms from being sources of spreading COVID.

Testing

Then there is testing. Certainly if we had cheap and abundant rapid tests kits we would have a very useful tool in fighting the pandemic. Schools have found they can reduce absenteeism with no increase in contagion by testing students who may have been exposed and allowing them to stay in class so long as they test negative.  The same technique could be used in work places as well. People are being encouraged to test before social gatherings. If rapid tests were cheap and abundant, restaurants, bars, and gyms could avoid being spreaders by testing customers.  Ideally, people could even be encouraged to routinely self-test to see if they were infected.

In at least one sense, Biden has done us a favor here.  By clearly mishandling testing, he has taken the partisanship out of the issue. Now we can all denounce him for not getting enough tests out. Nonetheless, I don't recall any great rightwing clamor for more testing until the failing became so obvious as to make the outcry universal.  

And suppose we did have an abundance of cheap, rapid tests.  Can anyone doubt what the result would have been?  Does anyone believe that people who see masks, vaccine mandates, and vaccine passports as intolerable tyranny would submit to routine testing?  And certainly if the goal is to have no changes whatever in one's routine as a result of the pandemic, any suggestion of regular self-testing would be intolerable.

Ventilation

Once again, this has been a major part of fighting COVID in Japan. And improved ventilation would have the advantage of not making most people have to do anything at all.  I do recall one Twitter comment that this at last would be something that would not be controversial.  Color me unconvinced.

Why would anyone oppose improving ventilation?  Mostly because of the cost to business and the burden of regulation. Republicans generally oppose health and safety regulations as intolerable burdens to business.  Furthermore, large chains would be better able to afford the upgrades and mom and pop operations.  Of course, the cheapest and simplest way to improve ventilation is simply to open a window. But that can be quite uncomfortable depending on the season, and can let in flies and mosquitos.  And presumably there would be down time while the systems were installed.

Speaking for me, I would favor a major government investment in helping restaurants, bars, and gyms upgrade their ventilation. But let there be no illusions that even this would escape the culture war.

Treatment

The one thing right wingers are absolutely in favor of when it comes to COVID is finding an effective treatment. And effective treatment is certainly good, so far as it goes.  Still, it would be good to keep in mind the old adage that an ounce of prevention is worth a pound of cure. Speaking for me, I would be in favor of a COVID fighting approach that is about 80% prevention -- whether in the form of vaccines, testing, ventilation, or masks when necessary -- and about 20% treatment when prevention fails.  But then again, I am no expert.  Maybe prevention will just be so full of holes that something closer to 50-50 would be more realistic.  But the right wing view appears to be that any attempt at prevention is intolerable tyranny, and that our approach should be zero percent prevention and 100% cure.

Right wingers are currently in the process of gloating because all attempts at mitigation against Omicron have failed, thereby proving we should never have attempted mitigation in the first place, and should have focused entirely on cure.  And right wingers can correctly point to many mis-steps in the search for prevention.  But there have been plenty of others in the search for a cure.  I am thinking if a recent tweet by ant-vaxer Jesse Kelly:

I’m not anti-vaccine. I might have gotten one. I wanted to wait and see how it worked. But then you shut down all other treatments. And then you insisted people shouldn’t be allowed to work without one. Now you insist boosters are needed. I’ve seen all I need to see.

If I’m standing in a room with ten doors and you tell me to ignore nine of them and only take one, I’m gonna be a little suspicious. If you then start threatening me if I don’t take that one, well now I’m never walking through it.

It is unclear what the other "doors" he is talking about refer to. Certainly people on his side of the aisle have decisively rejected the mask door.  And, for the reasons cited above, just about any other prevention door.  So is he referring entirely to treatments?  Well, yes, plenty of treatments have been investigated and proven not to be effective.  Hydroxchloroquin, for instance, or Ivermectin.  Donald Trump's infamous speculations about using bleach can be dismissed as a brain fart, something so obviously dangerous that there was no need to worry about anyone actually doing it.  Rather more alarming was an attempt by Ben Carson and Mike Lindell to promote oleandrin, and extract from the oleander plant, and highly poisonous.  This struck me as more dangerous because most people would probably not know that oleandrin was poisonous and just might try it. Fortunately it never got anywhere.

And contrary to what Kelly says, there are other treatments now, most notably monoclonal antibodies.  To the extent Ron DeSantis has done anything constructive in this pandemic, it has been in making monoclonal antibodies acceptable to right wingers.  Except it turns out there are also problems with putting all your eggs in the monoclonal antibody basket. Monoclonal antibodies are of limited effectiveness against the omicron variant. Other treatments are coming down the pike, but they, too, are rolling out slowly.  But if putting all your eggs in the vaccine basket has proven ineffective, putting all your eggs in the cure basket has its failings as well.

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* I will give credit to my Republican employer.  He is a big supporter of tests and said that if Donald Trump had been President, he would have move to expand testing once vaccines failed.  Color me skeptical. Donald Trump has never been able to admit to making a mistake, and if he relied on vaccines, he would have a very hard time admitting failure.  On the other hand, I do believe that if Donald Trump had been President and the vaccines had failed, there would be a loud an vociferous chorus on the left for more testing.