A pretty interesting thread which captures a number of issues in our response to Covid-19, mostly to do with confused communication about what to expect from a new virus.
I don't think leaders here have wrapped their heads around the impact of Delta in the US. This is a new era: A) A bad phase of the pandemic for unvaccinated adults and B) The beginning of the endemic reality for vaccinated people. Policy responses require a new paradigm. 1/n
— Will Hoenig (@WilliamBHoenig) July 17, 2021
Click through for the thread.
Much to disagree with but he is dealing with an important set of issues frequently glossed over by the media, government and health experts.
Barring exceptional circumstances, most novel viruses start with a higher rate of mortality and decline. Similarly, they often start at a lower infection rate and increase. Which makes sense from an evolutionary sense. Too lethal and it will quickly destroy its host environment and itself along with it. Too low an infection rate and it will die out. There is a sweet spot of low to moderate lethality and medium to high infection rates. Also, it needs to evolve variants in order to sustain itself from exhausting hosts who have already developed immunity to earlier versions of the virus.
All this was communicated, at least in some forums, at the beginning of Covid-19. But pretty cursorily. I am only aware of the pattern from history reading. Multiple books on the Black Death, Justinian Plague, the Spanish Flu. (Over fifty years of reading, no particular monomania about plagues).
There are also some pretty standard phases for viruses which take hold. First and early recognition; tracking phase; healthcare infrastructure overload; treatment development; vaccine development; endemic status.
There are plenty of outbreaks which do not take global hold for a variety of reasons - Ebola, SARS, MERS, etc. They burn through a region or population and then are contained and suppressed.
Vaccine development is always an iffy proposition. Sometimes it is so complex a process that there is never a vaccine (see HIV, MERS, SARS) and all you can do is contain it and provide mitigating treatments, not a cure.
In this instance, it has been a remarkable achievement to develop an effective set of vaccines so quickly and with so few side-effects (touch wood).
As a consequence, we have already passed through the recognition phase, and to some degree the tracking phase (the early testing efficacy and infrastructure for tracking were so pitiful that by the time we got to the point of technically being able to effectively test and track, we were miles behind the virus.)
We have also gotten through the infrastructure overload phase. While much discussed, other than in a very small handful of jurisdictions, the infrastructure was never, against expectations, faced with overload.
And given the crash course on vaccine development, we never spent much time on treatments. We learned from a bunch of early policy mistakes such as "don't put everyone on a ventilator" and "don't put the infected in with the elderly." But we never really focused on any sort of systemic and comprehensive treatment protocol.
The media's obsession with denying anything Trump speculated about as a treatment was a contributor to this public blindness. Despite both the policy disinterest, the academic antagonism, and the media aversion, we actually do have quite a wide variety of treatments that seem effective at materially reducing both the severity of the disease and the lethality if administered to the right people at the right time.
But this is still a pretty unwritten chapter. The research is scattered here and beyond with many false criticisms. At some point someone will pull it all together and we will have some quite useful lessons learned on how to treat Covid-19 symptoms. Which is important because given how quickly Covid-19 spread around the world and how firmly it has been lodged in most populations, at this point it will soon be an endemic condition.
It is wonderfully miraculous that we did get to a vaccine (several in fact) and we did get it deployed with great rapidity. Some 95% of the most vulnerable population (above 65) have been vaccinated in the US.
The early research seems to bode well that the vaccines are effective and likely to provide sustained resistance over time. Not, perhaps, as good as actual infection and recovery, but good enough.
In this whole process, though, we have allowed charlatans and grifters to confuse the public and have been veering into totalitarian approaches. Controlling speech to shutdown disapproved opinions, theories and research. Forcing identity cards (vaccine passports) for control of everyone. Insisting on universal vaccination regardless or personal risk-benefit decisions. Aiming for zero Covid cases which has never been a viable goal since probably the end of the first quarter of 2020. Focusing on case numbers instead of excess deaths.
As Hoenig points out, we are far past the point where non-pharmaceutical interventions are a viable strategy for controlling Covid-19.
Too much panic in the thread and, to my mind, exaggeration of the dangers. But I do think he is right about a couple of things. Covid-19 will be with us for a while. We are treating many countries which have had low rates of infection as success stories at controlling Covid-19 when in fact they have either been lucky or only temporarily postponed it taking hold.
There will be more country outbreaks. There will be further waves even in countries where Covid-19 is already well-established (plague outbreaks continued intermittently with less and less impact for three centuries after the Black Death.)
We have, with the vaccines, built a fire break on Covid-19. We have bought time for everyone to build natural immunity (through exposure) or induced immunity (through vaccines). We will not, can not, eliminate Covid-19. It will run its course, becoming endemic in the population, lose some or most of its lethality, and perhaps become more easily spreadable. Covid-19 Delta variant seems to be following this course though there are a lot of contradictory studies.
The implication of all this is that we should not be wasting time and effort on vaccinating children (risk-benefit ratio is markedly more uncertain than for older adults). Mortality rates are essentially zero for children with Covid-19 and natural immunity is usually superior to induced immunity.
We probably will never get to 100% vaccination rates among the 20-55 year cohorts, again, because of the risk-reward assessments of individuals. For the 55+ the vaccination rate percentages will rise for each age cohort but will likely still be below herd immunity thresholds for those below 65. Partly for religious reasons, partly for distrust of government and perceived biased "experts" and partly for a welter of other reasons.
If we get sustained 95% vaccination in the 65+ cohorts and 100% among the co-morbid population, which is quite large in the US, and let natural infections run their course in the younger age cohorts, especially the under 30 age groups and enhance out portfolio of effective treatments, we probably will be ready for the future.
In the next five years, after all this Moon shot hysteria, we will still have disappointing years with unpredicted waves and rashes of infections. However, the death rate will continue to decline and it will become more and more concentrated among those with co-morbidities and yet electing not to be vaccinated. Regrettable as that might be, it will not shock the conscience of the nation or justify the more totalitarian strictures that some are mooting about.
Hoenig's central message is correct - no one in a leadership position has really led this discussion or painted this picture. Too many institutions, political and health, have too significantly benefited from Covid-19 to let go of the manufactured hysteria and focus on the blocking and tackling of routine treatment. They are addicted to coercion and forcing people into vaccination as if vaccination were a silver bullet that will rid the world of Covid-19.
It will not. Covid-19 (or a variant) will be with us a generation from now, mostly unremarked because most citizens will have natural immunity (from childhood and early adult bouts). Those who need can be vaccinated. Perhaps we will have improved some of our worst comorbidity exacerbaters (obesity, diabetes, etc.). In other words, there will now be a stronger motive for living healthily. Certainly we will have improved and standardized our treatments so that infection will be less uncomfortable, of less duration, and less severity.
Were our government and medical industry health experts rational, evidence-based practitioners, this is the story they would be painting now for the public. In the space of six months we have achieved 60% vaccination rate and near universal vaccination among the most exposed. Only 15% of the population seem firmly set against vaccination. A sizeable 20% are vaccine-hesitant but for reasons the government is unlikely to be able to readily address (trust is built, not switched on and off.)
Certainly we should continue to craft communication campaigns about the importance of vaccination, particularly for the infirm and ill, but we should also be educating the public as to what the new normal will look like, invest in better treatments, and in better, cheaper, and more accurate diagnostic tests.
Instead, we seem to be on a one trick pony ride - vaccinate, vaccinate, vaccinate.
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