On Tuesday, Dr. Anthony Fauci held a “fireside chat” with the Center for Strategic and International Studies.” While some of the 30 minute talk was devoted to the attacks on Dr. Fauci being initiated by Republicans like Rand Paul, who have turned stirring up hatred toward the long time public servant into a fundraising opportunity, the major focus of the discussion was on what comes next in the COVID-19 pandemic.
As might be expected, most of the questions directed toward Dr. Fauci were about the COVID-19 pandemic. As almost might be expected, especially considering the venue, most also came weighted with a thick layer of calls to “get back to normal” and “end the emergency,” with more than a little pressure from the questioners that the best way to do this was just by ignoring the pandemic and the mounting cases clogging hospitals across the nation.
In response, Fauci emphasized how ending the pandemic has been a moving target, as the nation has confronted multiple ways (especially delta and now omicron) that saw rising rates of infection. And when it comes to what happens next, Fauci had a very blunt answer when it comes to the omicron variant:
Dr. Fauci: “Omicron, with its extraordinary, unprecedented degree of efficiency of transmissibility, will, ultimately, find just about everybody.”
The biggest key at this point is to be vaccinated. The second key is don’t get sick right now.
In questioning, Fauci was also pushed with the suggestion that COVID-19 will inevitably get weaker and that more infections will simply make that happen faster.
CSIS: “Some very respected figures, Robert Walker, Monica Gandhi, Chris Murray, Jeremy Farrar, who are arguing that accumulating immunity acquired through mass infection and mass vaccination puts elective evolutionary pressure on the virus to be faster, pierce immunity, and perhaps become less virulent.”
The problem with this question is that it conflates two wholly different ideas. Over the course of the pandemic, the effective rate of transmission—expressed most often, and very imperfectly, by using the basic rate of reproduction value usually written as R0—has jumped from somewhere around 2.4 for the original virus, to something like 5 for delta, to numbers as high as 10 for omicron. But these numbers don’t represent some kind of raw level of ability to infect an individual. It’s more complex than that.
The original SARS-CoV-2 virus was highly contagious. Not only did it have a reproduction rate roughly twice that of seasonal flu, the novel coronavirus was just that—novel. As an emerging virus, no one on the planet had existing immunity (no matter what your right-wing uncle claims). Other variants, including the highly infectious delta, emerged onto a planet where some percentage of the human population was already much more difficult to infect due to both vaccination and previous infection. Delta overcame this with, as the internet is fond of saying, One Simple Trick. In this case, a change in delta caused the rate of virus reproduction in the respiratory system to generate over 1,000 times as many viral particles as previous variants.
Omicron doesn’t share that trick. It’s not very good at infecting lung tissue. But it is extremely good at reproducing in the upper respiratory system. In fact, it seems to be capable of producing hundreds of times as many particles in that part of the respiratory system. That’s why delta patients are more likely to have a cough, while omicron patients more likely to have a runny nose.
But wait! Omicron also has Another Cool Trick that’s driving it to record levels of cases: omicron just don’t give a @#!$ about past infections with other variants.
For any virus that hangs around long enough, evasion becomes a more and more important factor in determining rate of infection. That’s because a new variant emerging at this point is doing so in a world where a larger and larger percentage of the human population is carrying antibodies from vaccination or past infection. If that variant has fantastic properties that would allow it to spread at hyper-speed, but lacks evasion, its potential pool of hosts is limited.
So, getting back to the question that CSIS asked Dr. Fauci, the answer is yes, yes, and no. Over time, evolutionary pressure on emerging variants will select for viruses that can “pierce immunity” and one way viruses deal with this is to spread from host to host more quickly, before the original host can mount a vigorous defense to clear the virus from the body. But no, any connection between these and the ultimate severity of the disease is little more than coincidental. Some viruses have, in fact, become less severe within a generation of their initial widespread introduction. Many more have not.
The next time someone points at the 1918 flu as an example of a disease that miraculously “became mild” within two years of ravaging the world, it’s worth remembering that there was also a 1917 flu which had a much lower death toll. Does this mean widespread diseases that have been around for decades can also get much worse? (The answer is “yes,” and “it’s a lot more complicated than that,” and also “flu is a special case.”)
Here’s what flu deaths look like over the past decade. If there’s a pattern here, it’s certainly not one that suggests respiratory viruses must get milder over time.
But when it comes to what happens now, without expecting the miracle intervention of a kinder, gentler evolution, here’s what Dr. Fauci actually said.
Dr. Fauci: “On October the 13th at a press conference at the White House, I showed a slide on one of my scientific briefs that showed the different phases. You go from pandemic to deceleration to control to elimination to eradication.”
Fauci quickly takes eradication—the kind of complete removal from the world that has been done with smallpox—off the table. When it comes to elimination, he considers that possible, but “aspirational” because when it comes to disease like polio or measles that have been effectively eliminated, “we got almost everybody vaccinated.”
So if elimination seems forever out of reach because of Republicans driving a large number of Americans to reject a safe and effective vaccine, what are the options?
Dr. Fauci: “So what’s the box that we’re all looking at now? That box is control, namely, getting the level of infection that causes severe disease low enough that we can incorporate this infection ... I believe we are possibly approaching that.”
But before CSIS can jump on this as a excuse to say “there you go, everybody get your omicron, goodnight, folks!” Fauci makes it clear that current conditions — close to 1 million infections a day, 150,000 COVID-19 patients in the hospital, and over 1,200 dying each day, is not at all a situation where we can say “let’s live with it.”
However, Fauci does believe we may be near a point of transition, one that can get us to that point of control when the number of omicron patients, hopefully, declines. At that point, between the level of vaccination and infection in the population, the rate of disease may actually slow to the point where anyone who does get sick and get prompt medical attention. That includes new treatments like take-at-home pill Paxlovid, which could greatly reduce the strain on the healthcare system.
CSIS then asked Dr. Fauci about “a new national strategy” once the immediate crisis of omicron is past. Dr. Fauci agreed that a new strategy is needed, and in fact hinted that a new strategy exists, but can’t yet be implemented because of the high case counts from omicron.
Dr. Fauci: “The ultimate strategy is what a lot of people are talking about. I mean, a lot of people, even people with diverse and sometimes conflicting viewpoints on things. We cannot let this virus dominate our lives much longer; we’ve got to get into a situation where we get enough people protected, either from vaccination or boosters, and whether that’s going to be a regular boost or the next boost will be the one that keeps us going with a big duration.”
That transition to the time when COVID-19 is not the dominant factor in so many lives is out there. It’s not going to come without effort. It’s certainly not going to come through getting so many people infected now that it leads to overwhelming health care workers.
Get vaccinated. Get boosted. Wear a mask. Stay safe. Be there when we make it around the corner.
That way, when omicron finally gets you, on some distant day, know that your vaccination will protect you, your doctor has treatments to prescribe to make your odds even better, and your local hospital has open beds if things get bad.