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.
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