First word

THE world’s coronavirus disease 2019 (Covid-19) nightmare increasingly shows the qualities of science fiction and a suspense thriller: sci-fi because the drama challenges the best scientists and technologists in the world and impacts the future; and a suspense thriller also, because there are many twists and turns in the narrative, and mankind is on tenterhooks anxiously trying to decipher the likely outcome of the epic struggle between man and disease.

The latest developments in the pandemic may be the most heart-stopping of all. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes the dreaded Covid-19 has developed several variants that appear to be a driving key part of the recent surge in Covid cases.

As the virus is changing, the disease that it causes appears to be also changing.

Rising on the horizon, say the scientists, is the visage of Covid-21. This is the new adversary that humanity must now prepare to engage and defeat.

This is the compelling message of a provocative article in the March 27 issue of The Atlantic by Dr. James Hamblin entitled, “Covid-19 is different now.”

Hamblin is a doctor of medicine, a lecturer at the Yale School of Public Health, and a frequent contributor to the Atlantic.

It has been my practice since the start of the pandemic to collect, study and then concisely summarize in my column important articles, studies and documents on the pandemic.

I want to do this today with Hamblin’s article. I believe he has put the finger on a critical phase in the struggle against the pandemic. He seems to apprehend how the nightmare will be resolved.

Unrecognizably different

(Abstract of the Atlantic article, “Covid-19 is different now” by Hamblin):

“The pandemic today is almost unrecognizably different. In the United States, an acute, terrifying catastrophe has given way to the monotony of lowered expectations. There are no makeshift morgues in the streets. Businesses are opening despite a thousand American deaths a day…The pervasive sense is that we can’t wait forever for the pandemic to end.

When, exactly, will we reach a point that could be considered a finish line? It’s the natural question, but I think it’s a counterproductive one. Not only because, as Anthony Fauci told me recently, the most honest answer is ‘We just don’t know.’ The inability to give a definitive answer is contributing to misperception of risk, conflating better with good enough. It’s also true that much of what defined the Covid-19 crisis at its worst is no longer an issue. Many health-care workers are vaccinated, and the need to ‘flatten the curve’ is in the past. Tests are widely available, and there are better treatments for the disease. Death rates are falling quickly.

The SARS-CoV-2 pandemic may drag on for years, but the nightmare of last year — of an entirely new viral illness, emerging in a specific sociopolitical context — is behind us. Instead we’re facing a new set of challenges, and they are not easily comparable to what has come before. It’s worth considering a new way of thinking about the period of the pandemic now ahead of us — one that leads us neither to complacency nor to paralyzing despair. In many ways Covid-19 is already over. What lies ahead is Covid-21.

Diseases are not static things. Pathogens change, hosts change, and environments change. In the case of Covid, all three are now different than they were in 2020. What began as one coronavirus has infected well over 100 million people and evolved into new forms that appear to transmit more readily and infect us in subtly different ways. Our immune systems have changed as well, as a result of fending off infections. And, of course, our lifestyles have changed, as have social standards, medical systems, and public-health programs.

Covid-21 is coming

Covid-21 is the product of all these changes in aggregate. It’s the disease as it will be experienced in the months and years to come: with new variants of the virus, new public policies and health behaviors, various degrees of immune memory, and — most important — a cavalcade of new vaccines…

The vaccination effort is sure to change the nature of Covid in unexpected ways. The habitat for the virus is changing: It may still stick in the nasal passages of an immunized person, but it shouldn’t continue on its way into the lungs, much less the toes. The key question is just how long this protection will last, especially against a rapidly mutating virus. Clinical trials have shown the vaccines to be fantastic at preventing serious illness so far, but haven’t yet been able to observe how protection might dissipate over long periods.

Because SARS-CoV-2 hasn’t been infecting humans for much longer than a year, it’s impossible to say exactly how immune responses will play out. The common-cold coronaviruses can reinfect the same person after a year or two. Early research on Covid vaccination shows that people develop high levels of antibodies, but that these begin to decline about a month after the first dose. The CDC’s (Centers for Disease and Prevention) official position on how long immunity lasts after vaccination is ‘We don’t know.’

Antibodies are not the whole story, though. Monica Gandhi, an infectious-disease specialist at UC San Francisco, believes that we’ll be well protected by other immune mechanisms, even after antibody levels drop…

Reassuring evidence has already emerged indicating that these cells can form durable memories of SARS-CoV-2. Recently, a group of researchers biopsied the lymph nodes of vaccinated individuals and found “remarkably” strong B-cell development…

Another promising sign comes from those who contracted the original SARS coronavirus in 2003. The T-cells of people who were infected at the time reliably recognized the spike protein from the virus in lab experiments 17 years later. Gandhi believes that this memory, while not always as protective as having high levels of neutralizing antibodies in your blood, will likely be sufficient to prevent severe disease. ‘Do I think that we’ll have lifelong immunity from severe infection?’ she said. ‘I am very heartened that we will.’

If that’s the case, then Covid-21 will eventually be a milder, less deadly version of the illness that we started with last year. ‘The worst-case scenario is we render it a cold,’ Gandhi said.

‘The best-case is we reach herd immunity and the virus goes almost entirely away.’

Only temporary immunity

But others expect a much worse worst-case scenario, in which immunity to severe disease is only temporary. The biologist and former Harvard professor William Haseltine warns against the rosy view: ‘It seems to me clear that the T-cell theory isn’t going to hold up,’ he told me. Although our memory cells could continue to recognize the virus, that won’t necessarily be enough to give us meaningful protection. The disease might end up being milder the second time around, or after vaccination, but he worries that, as the virus mutates, it also could get worse. As for herd immunity, Haseltine called that a ‘fantasy.’

‘The best we’ll get is seasonal herd immunity. We have 60 years of experience with coronaviruses, and they come back every year.’

Even the bad version of Covid-21 would be far different from the depths of Covid-19, though. Millions of cases of severe disease would be prevented with vaccines, but boosters would have to be given out at regular intervals…

Changing reality of the disease

Between Gandhi’s vision and Haseltine’s is another, quite disturbing, one. Imagine that the vaccines work well, but not indefinitely. The virus continues to spread and mutate. Covid can still have severe, even life-threatening, effects. Vaccination brings rates of serious disease and death down substantially, but not close to zero. And we come to think of this as pretty much okay.

In other words, imagine a world in which the disease persists, and is accepted, as something that is far less deadly than it was last year — more like a bad flu than a common cold. As with influenza, the world might lose hundreds of thousands of people to this illness each year. And yet we would come to see its toll as being within the bounds of acceptable loss…

We are at an inflection point that will change the reality of this disease. The most insidious future is one in which we fail to change our moral benchmarks, and end up measuring the danger of Covid-21 by the standards of 2020. If wealthy countries with early access to vaccines abandon continued, global coronavirus-vaccination efforts as their cases fall or when the disease becomes milder for them, a still-severe disease could haunt the world indefinitely — and lead to rebounds everywhere.

Avoiding this myopia is the central challenge of Covid-21. It extends to the systemic problems highlighted by this pandemic. Much of the damage the virus has wrought has come indirectly, by exacerbating food and housing insecurity, for example, or restricting access to medical care. The Biden administration has elevated science and begun to focus on comprehensive approaches to prevention.

If we beat Covid-21, the numbering could end there.”

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