Written Before Variants or Vaccines: From Killer to Common Cold
A year after my book From Killer to Common Cold was published—well, what has changed? Did I get it right… or?
Composed before variants and vaccines, what would I change if I could, yet again, suffer through the process of writing a book? Which predictions stand the test of time, and, more importantly, what should have been cut?
As a brief reminder, the thesis of the book is that we cannot eradicate covid. After we pass through the Transitional Phase, this killer becomes a common cold.
While seemingly not a revolutionary statement, the idea that covid will never disappear from this world changes everything. It is nearly inexplicable 18 months into the pandemic that the unstated goal of public health is to rid the world of covid… to never have even a single case of asymptomatic non-transmissible infection.
Public health is failing us because they have the wrong goal!
I know with certainty that Yes, You will get covid. And several times before it is just a common cold! Right now: you will either get the vaccine or you will get the virus. Likely both; several times. And in the future, just like the other 4 endemic common cold coronaviruses, covid will circulate year round at low-levels. We cannot eradicate it!
Let’s look at some specific writings from my book. Is From Killer to Common Cold: Herd Protection and the Transitional Phase of Covid-19 still relevant at the one-year anniversary?
From the Back Cover
Let’s start on the back cover (ignore the horrid selfie).
“After the epidemics are over, new cases do not go away. With or without a vaccine, we must learn how to live with Covid-19 in the world…how can we help Covid-19 reach its destiny—to become the common cold?”
The most radical change in the world since the book was published is, of course, the advent of vaccines. While we knew vaccines were coming, few had any idea just how awesomely effective they would be. The quality vaccines (largely due to mRNA and adenovirus vector technology) are a game changer.
We will get to vaccines, but let’s start with the other game changer since writing my book: variants. While Alpha didn’t change much, it is very clear even now that Delta changed everything.
“We are destined to interact with this virus forever.”
Variants and Evolution of the Virus and Host
It is likely that at some point the virus should evolve to better suit its goal (to make more of itself). Unpredictably, covid went months before changing and then all of a sudden demonstrated incredible biodiversity in form of the variants. Most variants didn’t amount to much… and then Delta emerged and outcompeted every single other variant in a matter of weeks.
Is Delta the final game changer in the covid saga? Don’t count on it. In the future, maybe in the spring, a new virus will emerge that is better adapted to widespread partial immunity that will be seen in the population.
“On one side, there is a virus that evolves and modifies the rules of the game while in progress. On the other side, we humans strive to understand the rules, anticipating what changes (both for us and for the virus) are inevitably in store.”
Delta, in my opinion, is the nail in the coffin. It is convincing evidence that covid will adapt to humans and co-evolve to be benign.
Currently, the best adapted form (in an era of no to mostly immunized populations) is clearly Delta. Delta shot through the world like a cannon, consuming those without any prior immunity (from vaccine or prior infection) and causing breakthrough infection and death and disease in those who didn’t respond to vaccination.
Further, as predicted, immunity is not complete. There are some people who don’t respond adequately to prior infection or vaccination (these people are getting a “third shot” currently), and the vaccine wanes with time (these folks will start getting a booster shot soon). This phenomena is clearly predicted in the book, based upon non-permanent immunity derived from the common cold coronaviruses.
And what about the changes in people? Who would have predicted the riots about masking in schools and the bipartisan barrages, let alone social media? Not me.
While it is clear that we are just over and done with covid, covid is not done with us!
Covid Will be Less Lethal in the Future
“Even though we cannot eradicate Covid-19, it will be less lethal in the future. This is predictable either through evolution of the virus itself or through changes in its hosts. Humans, our immune systems, or out cultures will change the face of this killer disease so that it resembles the common cold.”
Clearly after just the first round of vaccination, the virus is less lethal already. While Delta seems to be unchanged (from a severity standpoint), therefore the change is due to disease modifying immunity (you are less sick because you have been exposed to the spike protein in the past). Once we have some immunity to the virus, future infection (which is inevitable) has less consequence.
It is likely we will see different strains of SARS-CoV-2, but less likely that these will entirely evade the immune systems. At the very minimum, there should be some cross reactivity or partial immunity to the drifted strain. Instead of drifting to evade he immune system, the problem with coronavirus is that immunity to it is not long lasting. In 6-24 months, despite having a perfectly adequate initial immune response, you might get the same virus again as your immunity wanes.
As to the changes in our cultures, at the time the book was written I was hopeful that humans had some effective mitigation measures up their sleeves… limiting interaction with people, masking, closing down the type of business where the virus was spreading. Clearly, in the US at least, no mitigation or suppression measures have been successful. And containment was impossible from the start.
That’s right, nothing has prevented this virus from having its way with us. While some people claim that this State or region did better during this particular wave, when taken in toto, States that did everything (CA for example), have fared no better than states that have done nothing. And in many ways (economically, and socially for our poor kids who had to stay home from school), most interventions actually cause more harm than good!
Even mask mandates do more harm than good.
Yes, masks work, but not the masks being recommended by the CDC! What the CDC suggests is mask theater, a Masquerade if you will, and does nothing but cause dissent. If the CDC would talk only about the quality of masking… well, then we might give people some protection. More below. And this is not controversial by the way to those who actually understand the science of aerosols.
On to the next non-controversial topic: why herd immunity is a waste of time.
Why Do Folks Continue to Waste Time with Discussion of Herd Immunity?
Herd Immunity has been a major distraction and a terrific waste of time! If the virus is not eradicable, then herd immunity is impossible! The media is to blame for this fascination as are pseudo-scientists who don’t understand viral dynamics (this, unfortunately, includes most epidemiologists and infectious disease doctors, as well).
I disliked even the mention of the term herd immunity so much that I use “herd protection” which in many circumstances may be a synonym. Herd protection takes into account other things beside immunity from vaccination: mitigation measures, prior immunity, heterogeneous mixing, and immunity from natural infection. All these combine not to eradicate covid, but to stop the current wave.
That’s right, the point of herd protection is to stop a wave, and that wave can start again via a new variant , Or, the same variant can come back with changes in protection (decrease in mitigations, change in mixing, etc).
In the past few weeks we finally have people (life Fauci and Osterholm) saying “forget about herd immunity—we will never get there.” Why didn’t they say this when the virus first spread through the world and we knew eradication is impossible? There are three criteria by which we can attempt eradication. It has never met any of the three. Zero. Since the beginning.
What we have learned, perhaps, is that mitigation measures don’t work. Tell me one State that has prevented surges of the virus through their mitigation measures. The virus will have its way despite what we humans do. Why do we fail to learn this lesson?
Failure (yet again!) to Imagine the Future
First, vaccination was supposed to be the savior. Do you remember re-opening and un-masking?
And now, just because there are unvaccinated getting sick and breakthrough cases, we are supposed to go back to the ineffective mitigations of the past? They didn’t work before, but we think they will work now?
To start this discussion, let’s break those down individually: unvaccinated getting sick and break through cases.
First off: breakthrough cases. Is it really important that you have viral RNA in your nose? That’s just what a PCR is: it detects molecular remnants ON your nasal mucosa (not even from inside of you). Why do these “cases” matter? Please stop counting asymptomatic PCR positive folks who are not contagious as cases! This is not a case let alone a breakthrough case. This dead virus on your nasal mucosa is irrelevant.
Next, there are some who will never get vaccinated and thus they will get infected. Why should we care if they get infected now or later?
Yes, we should do our best to make vaccination free and accessible, and try to discuss the true risks and benefits, but at some point, we must value personal choice. If you chose not to get the vaccine, you will get the virus. I’m ok with that and you are too since you chose not to get the vaccine.
Listen: The vaccine is widely available and safe, effective, and easy for most to access. Get the third shot in the vulnerable people, get boosters going, but don’t limit society because some people are getting sick and dying from covid. People who are not interested in getting vaccinated will get the virus today, and if they don’t get it today it will certainly be tomorrow. And then 3-4 (or more!) times after that.
And, unfortunately, common cold viruses do kill elderly and immunosuppressed people during normal circumstances. That’s what it means to be elderly or immunosuppressed—things that don’t bother a “healthy” person can get you. This will happen now and during the transitional phase, regardless of what humans do to mitigate the damage.
Let’s move on.
CDC Is Not the Center for Common Sense
People: remember the CDC stands for “disease control and prevention.” It is not the center for common sense, nor the center for balancing the economy and preventing disease. It doesn’t care about you, it doesn’t care about the economy, it will try to control and prevent disease almost regardless of the cost.
Don’t let the overly-conservative CDC make recommendations that go against common sense. They will do that all day long. Except, of course, when it comes to using N-95s (more on that below).
Anyway, remember these parting words: “Herd protection is the goal. It may be that the herd protection threshold is as low as 10-20%. That is, after 10-20% of people in a region are infected, the epidemic wave may be over for now.”
For now. Since you cannot eradicate it, it will be back. People will get vaccinated or they will get the virus. Don’t stop either from happening. The more cases, the more vaccine, the less frequent and lethal the waves. The CDC needs to understand the destiny of the virus and help it become more benign.
After all, eradication is impossible.
Eradication Is Impossible
My favorite chapters are about how covid does not meet any of the three criteria that make it a candidate for consideration of eradication, and how coronavirus OC43 jumped from cows to humans in the past.
Eradication is impossible… and one of the current common cold coronaviruses used to be epidemic in humans. What does that mean?
I have yet to see such straight forward thinking in the popular press: 1) where will covid be 5-10 years in the future 2) it is not eradicable based upon criteria laid out by science 3) if it is not to be eradicated, then it must still be here in the future 4) I wonder what form it will be in the future 5) oh, look, here are 4 other human coronaviruses that started out as epidemics in the past and now (for the most part) circulate harmlessly with humans 6) it seems pretty likely since this has happened 4 times before, that covid will have the same fate.
And by the way, I do discuss earlier why SARS and MERS are different and never had the chance to become an endemic virus.
These chapters stand up well a year after being written. While you occasionally see a bit in the popular press that describes covid becoming endemic, that public health still focuses on eradication leads to their policy failures. And there have been many…
Vaccination in From Killer to Common Cold
As for vaccination, odds are high that we will have vaccinations to provide immunity for most who choose to be vaccinated. It is unlikely, however, we will develop a vaccine that provides complete and long lasting immunity. None of the other human coronaviruses provoke permanent immunity, even after natural infection. Immunity is temporary, and just like common cold coronaviruses, re-infection is expected after a period of time.
So there you have it.
I had no idea the number of people who would choose not to get vaccinated, though I called breakthrough infections based upon what we know from other coronavirus infections.
This was eminently predictable a year ago. Get the vaccine or get the virus. Rinse and repeat.
My best guess is that you will need to get the vaccine (or the virus) 3-4 times before you are able to control infection upon future repeated exposure. Yearly vaccination (as for influenza) is not indicated due to waning immunity, or we will need to worry about tachyphylaxis.
But that is more than most will be interested in knowing at this point. Everyone wants to know about the transitional phase.
The Transitional Phase of Covid-19
The transitional phase of covid is a novel and important concept, so much so that I coined the term and included it in my title.
If there are epidemic waves now but the virus will be endemic in the future, there must be a time of transition from one phase to the other. Has the media or CDC picked up on this concept yet?
Are we in the transitional phase yet?
We are still seeing large, epidemic-like surges in different regions.
Once the surges stop threatening our (albeit usually at risk during this time of summer) hospital capacity, we will still have smallish outbreaks for several years until the virus truly become endemic.
I still suggest the transitional phase will take 2-5 more years. Unfortunately, the clock has not started ticking on the transitional phase yet as Delta is contagious enough that it increased the herd protection threshold. Covid changed the rules in mid game.
For you personally, once you have had your second or third covid vaccine (or had the virus a second time), you might be in your personal transition phase. But even in countries with extremely high vaccination rates, we still see surges of hospitalizations. Delta is contagious enough that it won’t be long now (before everyone has been infected at least once).
We know children must go to school, sports must be played, and businesses must reopen. The world will go on. And yet, so will the virus. During the Transitional Phase, we will learn how to navigate the uncertainties after reaching herd protection threshold, keeping the risk of death from the virus in mind. I predict it will be 2-5 years before the Transitional Phase ends and Covid-19 is merely a cause of the common cold. I don’t believe that we can have a full account for Covid-19 until that point, when everyone will have had the virus or been vaccinated several times, and those at highest risk will have died. We will not know whose plan “worked” and who did “good or bad” until we are past the Transitional Phase. Case counts and mortality rates only matter over longer periods of time, so for now, we need to keep looking at the data while always keeping in mind that new cases will occur.
By far and away, this chapter stands out as the most predicative of the world in which we currently live. If you read one part of my book, read the chapter on the Transitional Phase.
Conversely, my greatest disappointment with my book is the final chapter: how to live with covid 19 in the world.
How Can We Live with Covid in the World?
Perhaps it was destined to be the case that my chapter on living with covid should disappoint.
It is pretty easy (for me anyway… the CDC, politicians, and news media are all still clueless) to see what the future has in store. Predicting viral behavior has proven much easier than predicting human response!
But now that I read the chapter again, I’m disappointed because I had no clue just how effective the vaccine would be. The best guess at the time is that vaccines would be disease modifying (reduce severity of illness). However, these incredible vaccines mostly prevent all severe disease and death in most, AND they decrease infection and transmission. Who thought it possible we would have such effective and safe vaccines?
This fact makes the final chapter much less relevant. As I’m apt to say recently: the choice now is simple. Do you want the virus or do you want the vaccine? And after you have the vaccine once or twice, or you’ve had a natural infection once or twice, again, the choice is simple: do you want the virus or do you want the vaccine?
There is not a rock big enough to hide behind such that you won’t get the vaccine or the virus 3-4 or even more times…
So, how do we live with covid in the world? Get vaccinated (as many times as reccomended, within reason). Or don’t. Either way, you will continue to be exposed to the virus during the transitional phase and beyond. Will exposure cause limited local replication in your nasal epithelial cells (which is, by the way, outside of your body and thus really difficult for your immune system to prevent), or will your waning immunity allow further replication and symptoms?
Get vaccinated or hope you get less sick every time you are infected by the virus.
What is clear: you will get the virus. You cannot choose not to! Unless you wear an N-95 mask all of the time.
Masking: Following Bias or Evidence?
I want to end this with a discussion of masking:
“Once there is an adequate supply of N-95 masks, expect to see these instead of bandanas as the facial covering of choice. Masks will remain an important accoutrement for the next several years. As a health care worker, I expect I will be wearing an N-95 mask for much of the rest of my clinical days.”
Let me just be clear: it blows my mind that the CDC has not actually suggested quality masking. I am not anti-masking, again, but let’s just be intellectually honest. If you are going to bother to do something–why not do something that has a chance of working? Simple masks simply don’t work. If they didn’t work effectively against the wild type covid virus, what makes us think they would be effective against the must more contagious Delta variant?
And we are not even wearing N-95s at work in the hospital. Why not? They clearly work better and are necessary for adequate personal protection. CDC, why have you failed to protect healthcare workers?
Is the reason: N-95s are too uncomfortable to wear in a low-risk situation? Well, if that’s the case, then a regular mask is so ineffective that it is, too, to uncomfortable to wear in a low-risk situation. With the non-quality masks that the CDC recommends there is no benefit. Since there is no benefit, the risk/benefit ratio is all risk.
This is the reason why masking doesn’t work in schools. If you are with a cohort of kids for 6 hours a day, will a mask that adds minutes of protection (as opposed to the hours of protection from an N-95) going to make any difference? Especially when we know the effectiveness (vs efficacy) of masking in kids is low because fiddling, wearing below the nose, taking them off to eat, etc.
Parents, if you want to protect your kids at school: have them wear a KN-95 and make sure they don’t remove them the entire time while at school. And remember, ventilation, open windows, distancing and air filtration all play a role as well.
With or without a vaccine or effective treatment, we cannot eradicate this virus. It may evolve to be more benign, but more likely than that our own immune system will provide partial protection after repeat infection, either naturally or though vaccination. SARS-CoV-2 does not meet the criteria to be considered for eradication, thus, humans must learn to live with Covid-19.
Personally, I have had my third covid shot. I’m ready to face a world without restrictions and mitigations (since they don’t work anyway) and without low-quality masks (since they don’t work either). I’m quitting medicine before they mandate N-95s.
If you have been vaccinated as well, then live your life on your terms. Protect those you care about, especially those who still will get sick and perhaps die despite the second or third dose of vaccine. We have another 2-5 years before the killer becomes the common cold.