On Friday, pharmaceutical company Merck announced that they were taking their antiviral drug molnupiravir to the Food and Drug Administration (FDA), hoping for a quick Emergency Use Authorization (EUA) after trials suggested the treatment could cut COVID-19 hospitalizations in half. The drug is just one of several antiviral treatments being studied as a means of improving outcomes for those who are infected with the SARS-CoV-2 virus, including both the unvaccinated and breakthrough cases.
While the best protection against COVID-19 remains vaccination, these antivirals offer a considerable advantage over existing treatments, such as monoclonal antibodies from Regeneron and others, because they are administered as simple pills. That makes them easy to store, easy to transport, and capable of being administered by patients at home. Assuming they prove to be equally effective in the real world, and don’t bring with them a host of serious side effects, that’s pretty much the trifecta when it comes to what medical experts want in a disease treatment. Several of the antivirals being studied are also generic, so hopefully they’ll also be available at a reasonable cost. Molnupiravir is not generic, despite being under development for two decades; early indications are that a full course of treatment could exceed $700. That’s still far cheaper than antibody treatments, but not cheap enough for the drug to be a solution that can address the need in poor nations where vaccine availability is a real concern.
Of course, a treatment is only valuable if people will take it, and the same Trump-supporting cohort that has demonized vaccination could just as easily turn against these treatments. However, the early take on right-wing social media is that the antivirals are “more or less just ivermectin” and that this is just Big Pharma boxing up the wisdom of the people who “did their own research.” They’re wrong, of course: There is absolutely no connection between the anti-parasitic drug trending on the right as an ersatz COVID-19 treatment and the genuinely promising antivirals. But if believing it’s all the same gets Trump followers to take the pill then … fine?
No matter what the belief, what molnupiravir and similar drugs mean for the present is a possible relief to overcrowded hospitals and medical workers hanging on by the last millimeter of their ragged fingernails. What these drugs mean for the future depends on what kind of future we get. More and more people seem to be accepting the idea the future will include COVID-19.
Those people don’t understand what that means.
Endemic disease is most disease. The common cold is common because its really just a collection of symptoms caused by dozens, if not hundreds, of different viruses, all of which circulate freely in the population. The reason that colds, the flu, and COVID-19 have symptoms that are often extremely similar is because all that itchy-eyed, achy-limbed, mucus-slinging isn’t directly caused by the virus—those symptoms caused by the body’s attempt to ward off the virus. Though there are very definitely a group of influenza viruses that cause what the CDC logs as “seasonal flu” each year, for most people, what distinguishes between a cold and a flu is simply severity. Get away with a couple of weeks of scratchy throat and sniffles? That’s a cold. Spend two weeks in bed trying to remember when life wasn’t made up of endless misery? That’s the flu.
Anyone who dismisses a mild case of COVID-19 as being “no worse than the flu” has forgotten exactly how awful, painful, enervating, and just genuinely icky the average case of flu really is. They also seem to have forgotten that the flu has a case fatality rate of about 0.1%—or that about 39,000 people in the United States have died from the flu each year over the last decade. And that’s with a flu vaccine that’s regularly administered to about half the adult population each year.
Now the expectation seems to be that COVID-19 will settle down and become just another of the endemic diseases. In fact, multiple sources are openly welcoming this development. Take The Wall Street Journal, which on Friday published an article stating “COVID-19 will soon become endemic—and the sooner the better.” They went on to say that “A disease becomes endemic when it is manageable—defined, for instance, as not causing an undue burden on hospitals or other healthcare resources—but is unlikely to be eliminated because of the pathogen’s inherent properties.”
That’s a nice definition. But it’s wrong. The “when it is manageable” is not part of the definition of endemic disease. A disease becomes endemic when it is essentially always present in a region or population, its manageability be damned.
The article from The Wall Street Journal suggests that nations like Australia, China, and New Zealand—countries that have embraced a policy of eliminating COVID-19 completely—are being “unrealistic.” The right answer, according to The WSJ, is to hustle COVID-19 into the endemic phase, and learn to live with it.
This, and this is a carefully considered response, is not just a formula for millions of deaths, but an absolute ticket to the end of the line for America, and likely for what we currently think of as modern society. We simply cannot live with endemic COVID-19.
Does We cannot live with endemic COVID-19 make it more visible? How about We cannot live with endemic COVID-19?
Hang on, let me say that again: We. Cannot. Live. With. Endemic. COVID-19. I can be louder. And I will be.
To understand the way that everyone from The Wall Street Journal to USA Today seems to be imagining how this will go, think of a nice little line that runs from the left, where someone is dabbing away a sniffle, while to the right, a pair of gravediggers are flinging some dirt. Everything we think of as an endemic disease (yes, even the common cold) can fall anywhere on this line, but in general the cold clusters around the left, the flu spreads out across the middle, and COVID-19 leans harder to the right.
Expectations of the “epidemic COVID-19” crowd seem to be that each year people will line up for their COVID-19 shot when they get their flu shot, that things will go back to a pre-pandemic “normal,” and that “Oh, George is home with the COVID-19” will just join everyday watercooler chatter alongside “Poor Cecelia is out with the flu.” A flurry of “get well soon!” emails, a week or two of moaning in bed, and George and Cecelia will both drag their achy asses back to the office and clear their crowded inboxes.
But that is not at all how allowing epidemic COVID-19 to become endemic COVID would work.
Here’s how it would actually play out:
Forget having any kind of regular schedule
Seasonal influenza has a basic reproduction number (R0) of around 1.4. That means that, on average, one person with flu spreads the disease to just over one other person. Because of this, it takes very little to break the chain of transmission in flu. When more people are outdoors, when conditions are less favorable to the short-term survival of the flu virus outside the body, the flu dies down. Only under the most favorable conditions, with everyone crammed together indoors, and the primary recreational activity is a choice between Netflix and Hulu, does the rate of transmission drive the flu to spread widely.
COVID-19 has a R0 that is over five. Maybe as high as 10. Estimates of the delta variant have been across the board, but the point is that, going forward, the delta variant represents the floor for COVID-19. Any new variant that comes along to supplant delta will do so because it is more transmissible than what we face now.
What does COVID-19 season look like? It looks like Gov. Kristi Noem blaming South Dakota’s spike on people being inside for the winter, and it looks like Gov. Ron DeSantis blaming Florida’s latest surge on the heat. We’ve had COVID-19 spikes in every season, because the transmission rate of COVID-19 is so high that it takes extraordinary precautions—masks, social distancing, improved ventilation, and vaccination—to put the genie back in the bottle and drive the effective R0 below 1.
And because COVID-19 is so highly contagious, it’s not going to be just one person home with the disease. The first thing we’d have to live with if we accept endemic COVID-19 is the idea that not just individual cases, but dense local outbreaks, could happen at any time. What would that look like? Check the recent CDC report on schools that opened in areas where masks are optional.
It would look like a world where businesses and schools frequently have to close for days or weeks because too many people were simply too ill to carry on. On a purely economic basis, the CDC estimates that outages due to the flu cost American business over $10 billion a year; COVID-19’s impact would be many times that amount, and far more disruptive.
Prepare for healthcare that’s much more costly
If there’s one thing that the COVID-19 pandemic has demonstrated effectively, it’s that all healthcare concerns are local. Sure, New Mexico might rescue a Texan or two when that state’s overtaxed healthcare system collapses, but for the most part, people live—and don’t live—with the healthcare systems near their home.
Endemic COVID-19 doesn’t mean it boils at a low level everywhere, filling a predictable 10% of hospital beds and generating lots of opportunities to send bedside balloons that could be appreciated by patients in between visits from comfort dogs. Endemic COVID-19 would behave exactly the same as epidemic COVID-19: in surges, waves, or spikes—pick your descriptor. Every single locality in the nation would be subject to a possible overrun of the local healthcare system at any time.
The scenes that have appeared so many times over the last year—tents being erected in parking lots, exhausted nurses wandering hallways choked with patients—would recur again and again, unless the healthcare system is expanded to deal with a world where not only is median hospital bed and ICU occupancy considerably higher, but both are subject to a maximum rate that far exceeds capacity.
An empty seat at every table
What happens when the healthcare system fails to accommodate the latest surge/spike/wave is clear enough: The case fatality rate rises. In the worst-hit localities, case fatality rate has at times approached the rate of those needing ICU-level treatment, leading to death rates of 13% or higher in some communities over the short term.
That is, of course, the most extreme outcome. But on a more regular basis, COVID-19 is still very much not the flu. Where seasonal flu has a fatality rate of around 0.1%, the overall value for COVID-19 in the United States to date is 1.6%. Worldwide the rate is a bit better, around 1.3%.
Of course, in the latest wave, where some percentage of patients have been vaccinated, monoclonal antibodies are more available, patients have trended younger, and the understanding of how to treat people infected with COVID-19 has improved, the case fatality rate has been considerable better—around 0.9%. Looking forward to endemic COVID-19, the assumption is that this rate will continue to improve. If antivirals can cut that rate in half, maybe that rate falls below 0.5%. Some nations, like Germany, are at that level already, thanks to extensive testing, early care, and a low level of disease coupled with a high level of ICU care availability.
If the level of COVID-19 fatalities could be dropped to just 0.5%, then the rate of deaths would be “just” 160,000 people a year, based on the rate of cases over the last 18 months. That would make the average COVID-19 year almost three times worse than the worst flu season of the last decade. It would also put COVID-19 in a continual tie with accidents (not just auto accidents, but every form of accident) for the third biggest cause of death in the nation.
On both a personal and economic level, that increase in the rate of deaths would be a gut-punch to the nation. It’s the kind of situation that requires an emotional sea change; one that increases the chances that anyone you know—any associate, any friend, any member of the family—could vanish at any time. That’s already true, of course. But this would be an almost 6% increase in the total number of deaths each year. Every single year.
Even then, that number ignores the COVID-19-sized elephant in the room: that R0 number. Those opening their arms to endemic COVID-19 are forgetting what might be the most important factors of this whole discussion: Social distancing measures have been wildly effective. Masks work. Limitations on social gatherings work. Required testing and checks for vaccination work.
Drop all that for “normal,” and what will come won’t be “like the pandemic, but manageable.” It will be “like the pandemic, and quite a bit worse.”
Flu, with its basic reproductive number of 1.4 and an average rate of 51% vaccination each year, generates an average of around 35 million cases each year. In the 2017-2018 season, when the formulation of the vaccine did a poor job of predicting that season’s dominant variant, there were an estimated 50 million cases of flu, resulting in around one million hospitalizations and 90,000 deaths. That year was also the first year TFG and his crew of sycophants were in charge, but it’s not clear how much this factored into the worst season in over a decade.
Now scale all that up for a disease with a minimum R0 of 5, and hospitalization and fatality rates 10 times that of flu. If the U.S. treats endemic COVID-19 like it does the flu, a “bad COVID-19 year” could easily see another 200,000 or 300,000 deaths. Maybe more.
Death is only the tip of the iceberg
From the start of the pandemic, there have been those (like TFG) who shrugged off the threat with some variation of the phrase “why be worried when XX.X%” of people don’t die?” For XX.X%, substitute any number between 99% and 99.9999%, depending on how unrealistic and dismissive the person making the statement was being at the time.
It’s a foolish formulation, one that blithely dismisses the deaths of Americans of every race, age, and in every locality. However, that’s not the most foolish part of the statement.
While diseases like the flu can definitely generate “complications,” lasting damage for survivors is very rare, while lasting damage from COVID-19 is anything but.
This study by Oxford scientists shows that over a third of those who have tested positive for COVID-19 have symptoms months later. Some of these patients were asymptomatic at the time they tested positive for COVID-19, and still developed serious, long-lasting issues weeks later.
The warnings about so-called “long COVID” have been coming for months, including this one from Dr. Anthony Fauci, which warns that COVID-19 patients are turning up with “heart damage, neurological issues that include stroke, and lung damage.”
While a loss of sense of smell or taste has been so common that they’ve become diagnostic of the disease, more data shows that COVID-19 can damage all five senses. That includes numbness in the hands and feet, loss of hearing, and damaged vision. These symptoms are not rare: Around 8% of COVID-19 patients have experienced some level of hearing loss, while vision defects have affected 10%.
Here’s a report from this week, in which researchers confirm that “COVID-19 can infect insulin-producing cells in the pancreas and change their function, potentially explaining why some previously healthy people develop diabetes after catching the virus.” In other words, the SARS-CoV-2 virus can generate a “transdifferentiation,” altering cells that normally generate insulin, so that instead they crank out other hormones.
Going back to our watercooler, when Cecelia comes back to the office after two weeks of flu, she may be wiped out from body aches and dehydration. But she doesn’t come back with hearing loss, brain fog, and a fresh case of diabetes. Thus the cost of COVID-19 can’t be compared to that of the flu, because in addition to the greater number of deaths, COVID-19 causes enormously more long-term illness than any current endemic disease.
Difficult is not impossible
Living with endemic COVID-19 means living in a nation where businesses and schools are subject to extended and erratic closings, where healthcare systems can be overrun at a moment’s notice, where hundreds of thousands more die, and where millions of Americans are hit with long-term damage that can render them unable to work or dependent on long-term care. And again, that’s not a short-term situation, that’s what endemic COVID-19 would look like every year.
Those willing to buy into this endemic vision call the idea of eradicating COVID-19, or pushing it down to the level of a rarely appearing disease, “unreasonable.” The Wall Street Journal in particular goes out of its way to pretend that this is impossible, citing smallpox as the only disease ever eradicated and listing the reasons why it was so much easier to defeat than COVID-19. But there is an enormous gulf between dealing with COVID-19 as an endemic disease that is just accepted into the cycle of everyday life, and causing SARS-CoV-2 to become extinct in the wild.
That gulf holds everything from polio to COVID-19’s close relatives, SARS and MERS. None of those viruses has been completely eliminated, but they’ve been rendered so rare that they are no longer a functional threat to anyone, anywhere.
Reaching that goal for COVID-19 means hitting a vaccination rate in excess of 90%. It involves using new antiviral treatments to not just combat hospitalizations, but to reduce transmission in the homes of those exposed. It involves continuing to use masks and social distancing to break the chain of transmission in areas where COVID-19 is still present in the community.
Those advocating for endemic COVID-19 can say that eliminating it is “unreasonable” all they want, but living with it is impossible. Eradicating COVID-19 may be difficult, but it doesn’t come with a massive body count or millions left with diabetes, blindness, or other afflictions.
Whatever the price of defeating COVID-19 may be—economically, socially, politically—it must be paid. Because the alternative is a stark threat to our nation.
