This pandemic isn’t something that just ends. We need a different way of understanding the journey before we can envision a way out.
I’m regularly surprised at how often I hear, from educated and intelligent people, phrases of undue optimism. They range from “once we have a vaccine” and “as soon as we have herd immunity” to “back to normal” but they all boil down to the same idea: At some point, not far off, it will all be over.
I’m here to rain on that parade. Our exit from this pandemic is not like a doorway we pass through, or a sell-by date on your milk. It isn’t something that happens suddenly and irrevocably.
Instead, it’s a long, hard slog through several coming waves of uncertainty. And the sooner we start grappling with that reality, the better. Let’s go through five essential considerations that convey the stark reality bit by bit. I predict you will, by the end, be as cautiously pessimistic as I am. In a nutshell:
- Essential consideration #1: vaccine availability
- Essential consideration #2: vaccine production and distribution
- Essential consideration #3: vaccine skepticism
- Essential consideration #4: durability of immunity
- Essential consideration #5: reservoirs of the virus
Let’s consider each of these in some detail before closing with a simple to-do item.
Essential consideration #1: vaccine availability
You know this one, right? You’ve heard all about it. Yeah yeah, Trump is crazy when he says a vaccine will be out by the November election, but then…it can’t be far behind, can it?
Yes, it can. Frankly, it could be a while.
Consider the real task here: We need a vaccine that passes out of Phase 3 trials with flying colors, meaning that it meets standards of safety and efficacy. We have already seen an example of troubling results for a once-promising vaccine, as AstraZeneca put its Phase 3 trial on hold. There will surely be other hiccups for other vaccines along the way, including true dead ends for some efforts.
Even when there aren’t dead ends, there can be delays. Phase 3 trials take time, and the analysis of their data takes even longer. This is not a quick process, and it can’t – and according to the leading companies, won’t – be accelerated unduly. Indeed, the companies with leading vaccine candidates have stated bluntly they won’t be rushed to ship a vaccine before it’s ready.
Still, you might feel fine about the vaccine candidates out there, and goodness knows, there are many, including nine (!) in phase 3 trials. So for the moment, let’s assume we get one or more safe, efficacious vaccines on fairly short order.
Essential consideration #2: vaccine production and distribution
Once a vaccine is established to be safe and effective, we need to make a ton of it. Specifically, in the United States, reaching the 70% vaccination threshold – that epidemiologists generally consider the standard for herd immunity that represents broad protection and arrests additional transmission – will require roughly 230 million doses.
To its credit, officials in the Trump administration have made “at risk” outlays to boost private companies’ manufacturing capabilities, a program whose credibility is likely not enhanced by its Hollywood-style name, Operation Warp Speed. The program has made $10 billion in agreements with vaccine teams from Moderna, Pfizer and its partner BioNTech, a team of Sanofi and GSK, the aforementioned AstraZeneca effort, and a company called Novavax (yet to produce any products, but now the proud owner of a $2 billion promise from us, the taxpayers). In several cases, the deals are for 100 million doses, a good start toward what we would need.
If it seems the feds are throwing money at the problem, they are – and thank goodness. As Anthony Fauci has said, “All we can lose is money.” Frankly, that’s the right approach, as the Warp Speed investment is pocket change compared to the economic disruption it could alleviate.
But that all sounds rosier than it should.
First and foremost, consider production and distribution at this scale. In recent years (2018-2019 and 2019-2020), the U.S. has deployed around 160-170 million flu shots. That feels within striking distance of what we’ll need for SARS-CoV-2. Yet we have built up our flu distribution apparatus, along with the messages and human skills to support it, over many years. In this case, we’ll be building something new, and trying to do it quickly.
At best, we’ll be able to piggy-back on an existing private medical establishment and public health apparatus, with clinics and pharmacies. We will have to hope that the necessary supplies and expertise are available when we need them; you may find that concern a bit paranoid, but our health care workers are exhausted, as we’ve seen in reporting from Texas and Florida and Arizona and, frankly, all around the world. If that isn’t enough to worry you, we could clearly easily have another surge of cases in areas most in need of vaccine distribution.
Unfortunately, many people will also feel a greater urgency for this new vaccine than they do for the vaccine for seasonal influenza, a shot people get in a steady trickle from late summer through January or even February. That urgency will be uncomfortable, probably far more uncomfortable than the rationing of testing that characterized hard-hit areas throughout spring. Not getting a test is annoying; not getting a vaccine in a timely manner will be unnerving or, for at-risk populations, terrifying.
And to state the obvious: not all of the doses arrive on Day 1. Deciding who gets it first will be necessary, but also necessarily controversial and even polarizing. (As a momentary aside, I ask you to further imagine what distribution of the early doses will look like if administered by the Trump Whitehouse.)
And finally, it’s worth mentioning that the U.S. is only 4% of the world’s population, and vaccinating 230 million people will require a wide range of equipment that will be in high demand and potentially short supply globally, such as syringes. While we’re on the topic of the rest of the world, let’s also consider how little drug, vaccine, and medical supply manufacturing actually happens in the United States anymore. If this challenge were unique to the U.S., perhaps we could suck up the world’s supplies. But we’ll need all of this stuff at the same time everyone else does.
Still, global manufacturing and our health care logistics could well rise to this challenge, so let’s assume for the moment that production and distribution pull it off when the time comes.
Essential consideration #3: vaccine skepticism
The foregoing section is a litany of potential small and medium-sized problems with getting safe and effective vaccines into the requisite number of bodies. But what about the emerging issue of the brains, attached to those bodies, that want nothing to do with a SARS-CoV-2 vaccine?
Vaccine-led herd immunity requires a critical mass to bring transmission down, and also to depress the severity of the disease among those who get it. (As with the flu vaccine, which not only prevents some infection but also renders many cases more mild than they would otherwise be, a coronavirus vaccine could provide protection of both kinds.)
Recent reports are that perhaps one in three American adults would not trust a coronavirus vaccine, either because the vaccine search has been politicized or because they don’t trust vaccines at all. If that number is even close, it will be especially difficult for our efforts to be effective in the population as a whole.
Perhaps you’re thinking, “Sure, the anti-vax crowd talks a good game right now, but they’ll reconsider when it’s available for free at the local Walgreens Pharmacy.” Yet vaccine “hesitancy” – including for vaccines with well-documented and extensively researched track records of safety and efficacy, such as the MMR vaccine – is on the rise, or at least it was pre-pandemic. It can’t be discounted as a further challenge to fully arresting the spread of SARS-CoV-2.
Yet we might pull it off: after getting a few good vaccines produced and distributed, maybe people will, en masse, get their shots.
Essential consideration #4: durability of immunity
Now consider the science of the virus and of the disease it causes, specifically what it means to have tools to resist the disease. You can acquire those tools of resistance by getting a disease in a way that it leaves you with antibodies, or by getting vaccinated. Often these two cases (vastly simplified here) are treated as equal. Before considering how they aren’t, let’s talk about their variations.
For many viruses, you have, upon vanquishing them, antibodies that provide immediate protection against reinfection, and sometimes permanent protection. Good news: The early research appears to show some of these signs of resistance in patients who have recovered from COVID-19.
Bad news: We have no idea how long this protection will last with SARS-CoV-2. Unfortunately, there is some reason for pessimism. The current pandemic is the result of one coronavirus in a family of coronaviruses; if you’re reading this, you probably know that four of them – wow, four! that’s always surprising to me – cause versions of the common cold. And one of the reasons that cold is so common is that our resistance to these coronaviruses is short-lived, or not durable.
Now don’t act surprised. If you get a flu shot, you get it every year, or at least you don’t expect it to provide protection for long. Not everything is as good as that smallpox vaccine, or what we provide for measles, which is near-100% protection for decades. A plausible scenario: we could well be looking at SARS-CoV-2 shots on at some regular interval – perhaps annually like for the flu, or once per decade like for the combined vaccine for diphtheria, tetanus, and whooping cough.
To be fully transparent, I have no idea what durability will look like for a simple reason: science has no idea, at least not yet. My point here is simply that we can’t reasonably expect permanent or even long-lasting immunity with any certainty. But for now, let’s assume immunity will last a while – say, longer than for the common-cold coronaviruses or for the flu.
Essential consideration #5: reservoirs of the virus
Our final consideration: the cat is out of the bag, virally speaking. There is now so much virus out there that we simply can’t test, trace, and treat our way to eradication.
It was not inevitably so. In 2003, the traits of SARS-CoV-2’s cousin and predecessor SARS – lower infectiousness and a dramatically higher fatality rate – led it to surface more quickly and then come under quicker control of the public health apparatuses in the countries where it first appeared. The original SARS now exists only in the laboratory, or at least not in human populations. It isn’t just “out there” like common colds and influenza strains and Zika and malaria and dengue. And, now, like SARS-CoV-2. The implications of a reservoir of the virus in human populations is profound.
A compelling cautionary tale is Vietnam: with just a few hundred cases, a notable achievement in a population of over 95 million, the country began to re-open in July. Bars and beaches filled again, and like clockwork, cases surged. The numbers are small (the country still has a total of fewer than 1,100 confirmed cases from the entire pandemic), but that should spook us even more. Even with such low prevalence, the virus lies in wait, lurking for the moment in which community transmission can resume.
With Vietnam in mind, now consider India. Home to nearly 18% of humanity, its case count has soared toward five million, and with ever-rising daily confirmed cases, it will almost certainly pass the U.S. to top the list worldwide before the end of 2020. That fact alone is grim. The India story, however, has some additional wrinkles we don’t find elsewhere. The country is vast, and its population is largely rural and poor; its healthcare resources will bend, if not break, under the strain of a widespread outbreak. India is also one of the world’s largest source of migrant workers, typically with a few million of its nationals in Southeast Asia, the Middle East, and elsewhere at any given time. Travel restrictions will no doubt cut off most of that flow, but “most” might not be good enough.
If you bristled at my characterization of India’s uniqueness, perhaps you’re thinking of Latin America, another home to weak states, rising case counts, and regular migration habits. It already may be the case that the virus has spread much more in Mexico than we truly know, and Venezuela’s political chaos is probably exacerbating the outbreak there. It is not comforting that Chile, one of the most advanced Latin American economies and the one with the most capable administrative state, has among the highest per-capita case rates in the region; despite its affluent upper elite, a vulnerable underclass is something Chile has in common with its neighbors.
All of this is a long way of saying that the virus will be “out there” until we assail it with the kind of global focus we have brought to eliminating smallpox (the first such success) and polio (where victory has been close but elusive). That future effort will require us to consider the entire world as a the playing field; until we starting narrowing it, country by country, the reservoirs of virus will continue as looming threats to any local or regional suppression of the disease.
Final thoughts on the long slog ahead
Now of course, I could be wrong. We may, after all, pull out a World War II-level effort here, producing vaccines and getting them distributed, and then dropping our skepticism to participate fully as a society in the effort. And they may after all provide durable herd immunity, extinguishing the virus with ruthless efficiency in one place after another. Maybe the way out is a smooth and speedy path.
But with all of the potential hurdles I described, I’m settling in for the long haul and taking the stance I mentioned at the start: I’m cautiously pessimistic. By contrast, you may be expecting the happy outcome of every issue I’ve raised here. It’s possible.
If you do, we’re on the same page in a qualitative sense: I too believe we’ll wrangle this viral beast to the ground, increasingly with masks and distancing, and also with treatments, and surely with vaccines at some point – and maybe by exploiting some as-yet-undiscovered genomic weaknesses in the virus itself. (Achieving a tentative normalcy will also hinge on new testing strategies, a topic I’ve covered elsewhere.) It won’t be pretty, and it won’t be quick, but we’ll do it. But I’m not expecting everything, or even most things, to break our way.
Whichever stance fits your disposition, consider the wisdom of the so-called Stockdale Paradox. When asked which prisoners did not make it out of Vietnam, decorated U.S. Navy admiral James Stockdale replied, “Oh, that’s easy, the optimists.” He continued:
“They were the ones who said, ‘We’re going to be out by Christmas.’ And Christmas would come, and Christmas would go. Then they’d say, ‘We’re going to be out by Easter.’ And Easter would come, and Easter would go. And then Thanksgiving, and then it would be Christmas again. And they died of a broken heart. This is a very important lesson. You must never confuse faith that you will prevail in the end—which you can never afford to lose—with the discipline to confront the most brutal facts of your current reality, whatever they might be.
So I hope you’ll heed my advice as you discuss the present and the future, and as you do your own thinking – and as you inevitably shape the views of those around you. Definitely don’t give any false impressions about the mountain we must climb. Don’t tell people we’ll be out be Thanksgiving or Christmas. And please please don’t say, “When it’s over…”
Joshua Skov is a faculty member in the Lundquist College of Business at the University of Oregon.