How Soon Will COVID Be “Normal”?

10 January 2022 13:12:34

By Benjamin Wallace-Wells

On Thursday, six medical experts close to the White House published three op-eds in the Journal of the American Medical Association, arguing that the time had come for a new approach to the pandemic—one that sets aside the campaign for eradication in favor of living with the disease. covid-19, one op-ed argued, should no longer even be tracked on its own but monitored together with other respiratory viruses, such as the flu—the sort of thing that might be done by epidemiologists rather than by all of us refreshing graphs on the Times’ Web site day and night. The argument was particularly notable because the six experts had all been advisers to President Joe Biden’s covid-19 transition team. “A ‘new normal with COVID’ in January 2022 is not living without COVID-19,” Ezekiel Emanuel, of the University of Pennsylvania, Celine Gounder, of N.Y.U., and Michael Osterholm, of the University of Minnesota, wrote. But they believed that the long era of emergency—the one defined by a wartime feeling and frequent briefings from Anthony Fauci—should draw to a close.

That same morning, I spent half an hour interviewing Fauci by Zoom, to try to understand how the Administration saw the current state of the pandemic. Lately, he had been dropping some hints that his view might not be too different from that of the JAMA experts: on ABC last Sunday, he’d said that it might make sense at some point to focus not on covid cases but on hospitalizations, a change that would organize policy around the medical effort to identify and treat the very sick rather than a social campaign to stop the spread of the disease. I asked him what time line he had in mind. “It’s not necessarily something that we’re going to do—or even seriously consider doing—tomorrow,” Fauci said. But eventually the Omicron wave would come to an end, and the sheer contagiousness of the past two waves, combined with the vaccination campaign, would leave a broad protective “immunological memory,” as Fauci put it, throughout the population. “Then you start to think about what being infected means regarding closing down indoor events, impact on the economy, impact on travel, impact on schools.” At that point, he said, if there are very few hospitalizations compared with the number of cases, “the impact on society should be measured not on how many people are blowing their nose but on how many people are really getting sick.”

During this pandemic, Fauci has often been tasked with explaining things that are in tension with one another. Right now, the tension is temporal, between a present in which the number of deaths remains intolerably high—on average, about fourteen hundred per day—and a likely, but not certain, near future in which the emergency has retreated, even if the disease remains. “Let me give you a confounding issue, which I find really interesting,” Fauci said. The first country known to have gone through an Omicron wave is South Africa, which experienced a sharp peak in cases followed by a quick decline—a heartening scenario, if applicable to the U.S. But South Africa, Fauci went on, had very few cases of the Delta variant at the time. “So when we were looking at South Africa, we were looking at a pure Omicron situation. In the United States, we still have a lot of people in the hospital who are Delta people. So right now it’s a little muddy.”

This week, Fauci said, he was watching the situation in London, which he thought might provide a better model for the American experience of the variant. In late December, London hospital admissions were increasing by as much as fifteen per cent a day, but that rate has since dropped dramatically. “Sometimes you have a sawtooth—it goes up and then it looks like it comes down, but then it goes back up again. So, if London does that, that’s what I’m really keeping my eye on,” he said. If the peak in London turned out to be real, I asked, how would he feel about the American wave? “Absolutely more optimistic,” Fauci said.

Fauci, in other words, sounded far more hesitant than the JAMA experts to declare a “new normal.” There were, he said, “too many unknowns.” We don’t know the number of people in the country with no experience of the virus—who haven’t been vaccinated or infected. We also don’t know what level of protection an Omicron infection might provide against the next variant. “Because we will undoubtedly get a next variant,” he said. He spoke for a little while about the differing severity of various kinds of respiratory infections and the challenge of predicting how further covid variants would fit in. “I mean, for people who are not responsible for policy, it’s very easy to make a prediction,” he said. “Because if you are right you’re a hero, and if you’re wrong nobody cares.”

In November, as news of the Omicron variant broke, the White House moved into something like a war-room phase. A daily deputies meeting was established at 8 a.m., in which “our white coats,” as one Administration official described Fauci and the other leading medical advisers, analyzed the newest data on the disease. Five interagency “work streams” were established, two of them devoted to mapping the evolution of the disease and the other three to organizing the provision of needed supplies: one for vaccines, another for therapeutics, the last for tests. Despite the urgency of the planning, when I spoke to White House officials before Christmas, they sounded fairly optimistic about it; one suggested that an “operational” phase of the fight against the new variant was under way. Natalie Quillian, the White House’s deputy coördinator of covid response, mentioned that many Americans could see new local masking requirements. I asked whether they might also expect the sorts of lockdowns that had accompanied mask mandates during the pandemic’s earlier phases. “We’re pretty confident that we don’t need to reënact lockdowns,” she said. “We have tools now that we didn’t have at the beginning of the pandemic.”

Much of the White House’s energy—and some controversy—has focussed on supplying those tools. Dawn O’Connell, the Assistant Secretary for Preparedness and Response at the Department of Health and Human Services, told me that the initial question the government had to answer was whether the existing vaccines and therapeutics would hold up against the new variant. Fortunately, she went on, scientists found that they mostly did. The first studies, even before samples of the variant could be examined in a lab, were conducted on a synthetic virus, and they gave the scientists an early indication that the vaccines and boosters were likely to work, a finding that was borne out by the eventual laboratory research. In those early days, O’Connell said, her team was also talking with pharmaceutical manufacturers about how long it would take to craft a new vaccine if one were needed, and to test what she called the “medicine cabinet”—the set of therapeutics, most essentially monoclonal antibodies, that the government was buying. The news there wasn’t so good. Two of the three monoclonal antibodies proved ineffective against Omicron, leaving just one, manufactured by GlaxoSmithKline.

But the novel feature of the Omicron variant is its extreme transmissibility, which puts special pressure on the availability of rapid tests. As Fauci put it to me, you would like to see enough tests out there that a vaccinated, boosted person, who was going to visit a vulnerable relative—perhaps a newborn baby, or a pregnant woman, or a mother-in-law undergoing chemotherapy—could say, “ ‘You know, I’m going to get a test before I go in there, just in case.’ ”

O’Connell emphasized to me that the investments the Administration has funnelled into making this happen, spending three billion dollars “to ramp up test manufacturing capacity, which quadrupled the number of tests that were available from late summer to December,” and more than a quarter of a billion dollars on what she called “test consumables—making sure we have the pipette tips, the resin that goes into the pipette tips, all of the components that go into making the pipette tips.” For all their scale, these efforts have come late. Early in December, after the Administration announced a plan to reimburse Americans through their private insurance for the cost of rapid tests, NPR’s Mara Liasson asked the White House press secretary, Jen Psaki, whether it might not be simpler to provide them directly. “What are we supposed to do—send them to every American?” Psaki replied. That would have helped. The wave in New York City may already be at its peak, yet the Biden Administration’s order of five hundred million tests is still at the request-for-proposal stage. (Fauci told me that he expected supply to match demand “probably in the next two and a half weeks.”) “I wish I had thought about ordering a half a billion [tests] two months ago,” Biden said in December, after the purchase plan was announced. Maybe even more so now. “We have the tools to protect people from severe illness due to Omicron if people choose to use the tools,” Biden said on Tuesday. But at the same time there were headlines emphasizing the testing shortage, which suggested that the President’s claim was not yet fully true.

During this in-between phase, much has been made of the signalling in Fauci’s statements. When, just before Christmas, he floated the idea that isolation procedures might get shorter in some cases, it was met with general confusion. In the media environment of an earlier generation, that sort of sotto-voce remark was a good way to float a trial balloon to insiders. But now everyone sees the trial balloon at once. Schools would soon be back from break, cases were spiking, the policy was changing; what were the testing and isolation protocols supposed to be? On January 4th, Psaki was asked about the confusion. She said that it was inevitable. “That’s what happens when you lead with the data and the science,” she said. There was some spin in this. But probably some truth, too.

William Hanage, an epidemiologist at Harvard, told me, “The Biden Administration’s intentions are usually quite good, but its messaging is often contradictory: you know, ‘Use rapid tests, except rapid tests are not the gold standard.’ ” Sometimes it’s the message itself that is problematic, Hanage added. “One very clear example of a place where I think things went wrong was when Tony Fauci started talking about how it [the Omicron variant] looks like it’s ‘mild.’ In the first place, that’s premature. In the second place, it’s important to note that even a mild illness that affects people more quickly still has the capacity to do serious damage to health systems.”

What the Administration has been doing in its fight against Omicron tells, in some important ways, a clearer story. The former F.D.A. commissioner Scott Gottlieb told me, “There’s clearly a wholesale movement away from population-wide mitigation measures in the population as a whole—nobody’s talking about closing businesses; nobody’s proactively closing schools—and trying to empower individuals to act to mitigate their risk and to mitigate societal risk collectively. And I think that’s appropriate, given where we are in the pandemic.”

The trouble, Gottlieb went on, was that the Administration had backed into this new policy regime, which left individuals and institutions a little fuzzy about what they ought to do: “The public-health authorities need to talk about this in a plain way and say right up front, ‘We are not going to be implementing population-wide measures anymore. We’re now relying on you to take more individual actions to make you and your family and your community safe. Here are things you can do.’ But people don’t know that this is the new paradigm.”

I asked Gottlieb why he thought the Administration had not more clearly declared the pivot that was so plain to him. He said that he didn’t know, but he thought it might have something to do with not wanting to be seen as declaring success prematurely: “Maybe they don’t want to say we’re going away from all these measures because they want to leave the optionality to go backwards.”