Thinking about Covid and normalcy.
By David Leonhardt ~ photo above: Dr. Robert M. Wachter. Credit…Stephen Lam/San Francisco Chronicle
Among the Covid experts I regularly talk with, Dr. Robert Wachter is one of the more cautious. He worries about “long Covid,” and he believes that many people should receive booster shots. He says that he may wear a mask in supermarkets and on airplanes for the rest of his life.
Yet Wachter — the chair of the medicine department at the University of California, San Francisco — also worries about the downsides of organizing our lives around Covid. In recent weeks, he has begun to think about when most of life’s rhythms should start returning to normal. Increasingly, he believes the answer is: Now.
This belief stems from the fact that the virus is unlikely to go away, ever. Like most viruses, it will probably keep circulating, with cases rising sometimes and falling other times. But we have the tools — vaccines, along with an emerging group of treatments — to turn it into a manageable virus, similar to the seasonal flu.
Given this reality, Wachter, who’s 64, has decided to resume more of his old activities and accept the additional risk that comes with them, much as we accept the risk of crashes when riding in vehicles.
He has begun eating in indoor restaurants again and playing poker, unmasked, with vaccinated friends. He has taken airplanes to visit relatives. He hosted a medical conference in downtown San Francisco with a few hundred masked and vaccinated attendees.
“I’m still going to be thoughtful and careful,” Wachter told The San Francisco Chronicle. But “if I’m not going to do it now, I’m probably saying that I’m not going to do it for the next couple of years, and I might be saying I’m not doing it forever.”
The hospitalization statistics in highly vaccinated communities help explain Wachter’s attitude. In Seattle (which publishes detailed data), the daily Covid hospitalization rate for vaccinated people has been slightly above one in one million. By comparison, the flu hospitalization rate in a typical year in the U.S. is more than twice as high. For most vaccinated people in a place like Seattle or San Francisco, Covid already resembles just another virus.
The risks are also low for unvaccinated children because Covid tends to be mild for them. (Plus, any child 5 or older can now be vaccinated.) For young children, Covid looks like a normal flu, if not a mild one:
As for long Covid, it is real but rare. It’s also not unique. The flu and other viruses also cause mysterious, lasting problems for a small share of people, studies show.
The bottom line is that Covid now presents the sort of risk to most vaccinated people that we unthinkingly accept in other parts of life. And there is not going to be a day when we wake up to headlines proclaiming that Covid is defeated. In many ways, the future of the virus has arrived.
All of which raises the question of which precautions should end — now or soon — and which should become permanent.
Should offices remain mostly empty? Should schools require children and teachers to wear masks? Should classrooms go remote again when they identify a new Covid case? (In Boston, a K-8 school closed for 10 days starting Wednesday because of an outbreak.) For how long should individuals organize their own lives around a fear of Covid?
Most of these questions are tricky, and a few factors can guide the decision-making, epidemiologists say.
1. Local spread
The lower the rate of Covid spread in a community, the less risk to everyone. The C.D.C. defines a low rate of transmission as, among other things, fewer than 10 new weekly cases per 100,000 people. Most of the country is well above that threshold, but parts of the San Francisco, Atlanta, Dallas, Houston, Los Angeles, Miami, New York and Washington areas are below it. (You can look up your county here.)
Nevada has taken an approach that experts like Julia Raifman of Boston University have praised: The state will remove mask mandates after cases have fallen below a certain level. Joseph Allen of Harvard, criticizing the different approach in many other places, has said, “We’re sleepwalking into policy because we’re not setting goals.”
One complication: Nationally, new cases have risen modestly in recent weeks, though they are still far below the levels of late summer. If new cases accelerate as the weather gets colder and more activity moves indoors, it may call for caution.
2. Illness, not cases
Still, with vaccines widely available and treatments increasingly so, caseloads are not as important a metric as they once were. They “are becoming less and less useful,” as The Atlantic’s Sarah Zhang has written. More telling measures are hospitalizations and deaths.
The treatments for people who contract Covid are especially important here. Pfizer’s pill regimen, which seems especially effective, reduces the risk of hospitalization by more than 80 percent. These treatments are another step toward turning Covid into a normal virus rather than one that dominates life.
Different people face different levels of Covid risk. For most vaccinated people and children, the risks are extremely low. But for some immunocompromised people — like those who have received organ transplants — the risks are higher. The same is true among people in their 80s and 90s.
Greater precautions make sense for vulnerable people. They will also particularly benefit if rapid Covid testing ever becomes widely available in the U.S., allowing them to socialize more confidently.
There is a flip side to this point: The aggregate statistics on Covid deaths and hospitalizations exaggerate the risk to most Americans, because a disproportionate share of severe illness occurs among people with specific medical vulnerabilities.
4. Cost vs. benefit
Wachter told me that he might always wear a mask while grocery shopping or flying on a plane because the costs of having a covered face and a muzzled voice in those settings are virtually zero. He isn’t usually trying to have a conversation with somebody. And a mask can help protect him from all sorts of respiratory viruses.