Roadmap: Thirteen Strategies to Help us Live with COVID

Before the advent of COVID, there was plenty of guidance available about how to respond to a new respiratory pathogen with pandemic potential. Measure included sentinel testing, international transparency and rapid scientific communication, extreme efforts to cordon off and control the initial outbreak, rapid development and deployment of tests, travel restrictions, tracing and quarantining, social distancing (escalating to lock-downs as needed), mask-wearing, hand-washing, urgent development of vaccines, treatments, and medical protocols, better ventilation, clear and honest public communication by political leaders and experts, genome sequencing, economic relief, expansion of healthcare and public health capacity, measurements of efficacy of different responses, a global vaccination strategy… the list is familiar.

What we’ve learned over the past 26 months is that humanity isn’t a precision drill team capable of executing in accordance with such guidance; not even close. Even so, measures taken did save lives. There have been brilliant achievements, such as the rapid development and deployment of effective vaccines, and crushing setbacks, such as China’s early secretiveness, US polarization, and the sluggish effort to vaccinate people outside the rich world.

If we were to write a guidebook today for what to do and we proceed through pandemic year three, it would have to start where we are, rather than where we hoped to have been. We should assume that the patterns of behavior over the past two years will evolve incrementally into the future, not flip onto a different track. We can include stretch goals, but the best solution is going to be one that works with who we are and where we are now.

So where are we? Between vaccinations and infections, 90-95% of the US population has some degree of immune awareness of the SARS CoV-2 virus, but the US today is a nation of polarized individualists. Despite vaccines and boosters being free, we still have many people who have not accepted them, which makes those people likely sources of greater risk for everyone else. 

Our governments at every level and many businesses are clearly not going to fight for maximum protective behavior if it means annoying voters or customers by trying to persuade them to constrain their personal behavior in the present for possible common good in the future. Our pharmaceutical companies have powerful financial incentives to keep selling Vaccine 1.0 as long as possible, because it is now very profitable. Such profitability is an anomaly: vaccines are not usually a great business for such companies.

Accordingly, work on a pan-coronavirus vaccine is proceeding in academic, government and start-up labs at a small-budget pace. The rich world has provided a fair amount of vaccine for poorer nations, but we have not attacked the challenge of rapid global vaccination with nearly the intensity we should have. The vaccine is still well-positioned to mutate into variants which might overwhelm our current defenses, and our efforts to even test for variant prevalence are in decline. Long COVID is an ill-defined specter hovering over our future.

A realistic COVID control strategy starts by assuming that some Americans will be readily responsive to calls for boosters, masking, and distancing, but many will not. Accordingly, resources of government and other institutions devoted to COVID control should be allocated in ways that do not depend on rapidly achieving high levels of public compliance. A good goal might be to reduce deaths and Long COVID cases to 10% of present levels. That would mean, say, 30,000 deaths/year in the US, and 2 million active Long COVID cases at any one time. Here are the most important initiatives in a strategy that assumes minimal constraints on individual behavior:

1. Execute “permanent” vaccination/booster campaigns. Vaccine protection against infection fades over time. People age into higher-risk groups. Gaining immunity by natural infection courts death and Long COVID. Our total vaccination and booster rate is still too low. For these reasons, ongoing vaccination campaigns are very worthwhile because they can dampen the impact of each surge, save lives, lower the transmission rate, reduce strain on the healthcare system, reduce economic damage, and prevent Long COVID cases. However, vaccination campaigns are like filling a leaky bucket. If you stop pouring water in, your bucket will drain. Over time, it should be possible to reduce the number of undecideds, if not the number of hardcore antivaxxers, but with current vaccine technology vaccine protection against infection will continue to fade. Vaccination should not be a fits-and-starts operation, it needs to be institutionalized and continuous.
2. Develop polyvalent mRNA vaccines. A polyvalent vaccine presents the immune system with more than one antigen target to learn about. Flu vaccines, for example are quadrivalent: they present four antigens each season. Moderna is testing a bivalent vaccine for possible use this fall, and there’s additional federal testing of other bivalent combinations. Polyvalent vaccines might reduce the risk of getting caught protecting against the “wrong” variant during a surge, and perhaps extend the duration of protection from each shot.
3. Develop a durable pan-coronavirus vaccine. Scientists are pursuing several approaches to vaccines which might, at minimum, protect against a broader range of COVID variants, and even, perhaps, protect against a broad array of coronaviruses. Coronaviruses currently cause 4 versions of the common cold plus SARS, MERS, and COVID. They also cause many illnesses in bats, pangolins, and other species. Vaccines which prompt the immune system to develop a fundamentally broader approach have the potential to also provide long-lived protection. Research in this direction predates COVID—it has been a holy grail among HIV and Influenza researchers for some time. The federal government has two agencies funding R&D in this area, with funds going to startups, academic researchers, and the US Army. For business reasons, the current vaccine leaders would rather not spend their profits developing a vaccine which would kill their current business, so it’s left to upstart businesses, academics, and government labs. The federal government should shovel money into this effort as fast as it can be absorbed. If they can finally crack this nut, the benefits would extend far beyond COVID.
4. Develop multiple antiviral treatments, and an effective system for distribution and timely use. Antiviral drugs are the backbone of HIV control, but to work they need to be delivered in cocktails of at least three, because the virus can evolve around any one of them. Right now there’s one very good antiviral on the market, Pfizer’s Paxlovid. Once distribution problems are solved, it will provide a valuable treatment (when taken early) to limit the severity of COVID cases. There are others with emergency use authorization that have some value but don’t appear to be as effective as paxlovid—remdesivir and molnupiravir. If paxlovid is used alone and used extensively, the virus could evolve around it in a year or two. Hence the need for more cocktail ingredients. In a country with a limited appetite for prevention, remediation is a necessary priority.
5. Maintain high availability of masks for those who need them. Millions of Americans cannot be well-protected from COVID by vaccines: people with diabetes and other co-morbidities, cancer survivors, people with other immune compromises, people too young for immunization, people so old that their immune systems just don’t rise to the challenge anymore, and people whose work is likely to expose them to repeated viral loads. For them, high-quality masks remain vital and should be very readily available. A much larger segment of the population will need masks during surges and should never have a hard time getting them.
6. Improve quality of indoor air. COVID spreads, we now know well, via super-spreader events, where one infected person can increase the viral load in the air of an enclosed space by enough to infect many others in that space. A recent computation of the transmissibility of Omicron estimated that an infectious person can breathe out enough virus in one minute to infect 5,000 people if evenly distributed among them. Of course distribution is never even close to perfectly efficient, but most transmissions are thought to occur in closed spaces, where a single infectious person can, over time, fill the air with enough virus to infect many others present. Active measures to suppress viral loads in indoor air can provide major benefits in disease control. Improvement can be provided by ventilation (replacing the air more rapidly), filtration (removing infectious particles from the air), and sanitation (killing the virus in the air and on surfaces). These methods are often combined, and the best solution varies from building to building. Upgrading indoor air will require addressing building codes and retrofitting issues, and will take time, but can pay off not only in COVID suppression, but with other health benefits, including greater resistance to future respiratory pandemics, less brain fog from elevated CO₂ levels, and reduced exposure to allergens, particulates, etc.
7. Improve treatment for Long COVID at large scale. The most recent estimate I’ve seen for Long COVID in the US is 23 million current cases, or about 7% of the total population. This is enough to contribute to the labor shortage as well as being a source of misery and despair. This number probably does not yet fully account for cases derived from the Omicron surge. It’s unclear whether the rate of Long COVID cases will decline as our immune systems get smarter—it’s hoped for but cannot yet be determined. Even mild cases of COVID have been associated with serious cardiovascular, pulmonary, and neurological consequences, and right now the health care system (let alone the health insurance industry) is not responding well. Better treatment would also mean better data and greater likelihood of developing even better responses. It would also make it easier to add Long COVID risks to the pro-vaccination message.
8. Vaccinate the rest of the world. WHO finds that the efforts to vaccinate the non-rich world are not going well: there are logistical challenges, cultural objections, supply limitations, and communications issues. The rich world should make it a high priority to systematically respond to these challenges and get the global vaccination rate way up from today’s low levels. This is very much in our personal and national interest, in that it’s the only way to lower the risk of new killer variants arriving on our shores.
9. Establish sustained surveillance testing. The University of Washington’s IHME estimates that reported confirmed COVID cases now represent only 7% of actual cases, and this is consistent with a report from the CDC that 58% of all Americans have COVID antibodies in their bloodstream, meaning they’ve had the disease relatively recently. The confirmed case numbers during Omicron, though high, weren’t THAT high. Thanks to vaccines, many of these infections have been mild or asymptomatic, but it’s incredibly important to keep track of what the virus is doing. We need genome sequencing, wastewater testing, testing for everybody in contact with the healthcare system, etc, and it needs to be steady, not hit-or-miss.
10. Improve real-time communication of risk levels.  Asking people to take personal responsibility for their own COVID risks requires that they have ready access to the information needed to make informed decisions. At the moment, the quality of available data is getting worse, not better. Local jurisdictions need to make a major effort to make very up-to-date data available in very granular form about what the virus is doing.
11. Provide much better pandemic education and communication. COVID isn’t going away, it’s settling in, and it won’t be the last pandemic, as humans continue to force greater contact with once-remote species. Official communications during the first two years of COVID left much to be desired. The Trump administration terrorized the experts, driving many out of the government, and the Biden administration tolerated poor communications from the battered front-line agencies. State and local agencies coped with politicized state elected officials. The public deserves better information presented clearly about pandemics in general, COVID in particular, vaccines, antivirals and other treatments, best practices with masks and other non-pharmaceutical interventions, and Long COVID. We need a new covenant between our experts and the general public, which will not be easy to achieve.
12. Upgrade public health capacity. Public health tends to be neglected except when its being berated. It gets too little respect from the medical establishment and is an easy target for political demagogues. But when a COVID comes calling, public health is our first line of defense. It needs to be funded during the lulls and needs to attract talented people. Governments and universities should pump up their support.
13. Tackle healthcare inadequacies and inequities. This is hardly a new issue, but the US has paid a high price during COVID for the fact that a significant share of our population is estranged from out healthcare providers. Many healthcare workers were absolute heroes during the surges, but the system itself performed badly. We need to have universal access and much better reserve capacity to respond when a pandemic hits.

What these goals have in common is that they are largely preventative measures. That means making commitments and spending money in order to maybe solve a future problem. This is the hardest kind of commitment to earn public support for. If COVID doesn’t prove the point, the climate crisis surely does. Childhood development experts talk about how children do (or don’t) develop an ability to defer gratification: resist eating one cookie now in order to get two cookies later. Our modern culture dotes on instant gratification: get the benefit instantly, pay later. An offer which says, “Pay now so that there might (or might not) be a benefit later which might (or might not) accrue to you, which you might (or might not) even realize was received” is a tough sell into a culture of “you deserve a break today.” If we can’t bend the gratification expectation curve back a bit towards doing the right thing now to make the future better, we’ll keep paying the price: the road to global roasting will be paved with pandemics.