It’s September 2022, nearly three years after a mysterious virus began sweeping through China. In the United States, kids of all ages, newly vaccinated against Covid-19, are back in school, and their parents are back to work. But in pockets of the country, especially where vaccine hesitancy lingers, Covid still surges, shutting down schools and workplaces when too many people call in sick. Around the world, the vaccine rollout has been painfully slow, particularly in poorer countries as the richer ones hoard their vaccine patents. This inequality allows the virus to move largely unchecked across the globe, mutating until the vaccines become less effective and everyone needs boosters, as we anxiously monitor new variants. Meanwhile, countless people still battle debilitating symptoms of long Covid every day, even among those who had mild or asymptomatic cases. Covid-19 remains a serious threat, rather than a painful memory.
This is a likely scenario if we continue down our current path. But in this choose-your-own-Covid adventure, there is always time to change course. Now, exactly one year after the World Health Organization declared this emergency a pandemic, SARS-CoV-2 is likely endemic, at least for the next few years. But how long it remains, and how severely it affects our lives, is up to us.
“I feel a little bit like I’m giving you financial advice,” Dr. Carlos del Rio, professor of medicine at Emory University School of Medicine, told me when I called him to get his predictions on what Covid-19 could look like in a year or two. “You say, will I be able to retire? And I say, well, if you save all this money.… However, if you spend all your money and you party, you may not be there.”
It’s very difficult to know where the world is headed in the next few years, since every country—and state, and county, and city—has a different plan. It’s clear we need to learn from our more damaging mistakes in the first year of the pandemic: invest in genomic surveillance to identify new and mutating viruses, update vaccines as variants of concern emerge, provide health care and social support for those who get sick, answer questions people have about the vaccines, and understand that even when a virus is raging far from our shores, it will still reach us. The U.S. in particular didn’t prioritize that in the first year. “How well we learn the lessons is still in our hands, and we have to make an effort. It doesn’t just happen by itself,” Dr. Marc Lipsitch, professor of epidemiology at Harvard T.H. Chan School of Public Health, told me.
This summer, the U.S. will see a new normal: Slowly, cautiously, Americans will begin reuniting with vaccinated friends and loved ones. But about one-quarter of the U.S. population—children—will remain unvaccinated for the next few months at least, and so will those with compromised immune systems and those who refuse the vaccine for ideological reasons.
Vaccination has never been the only answer to ending the pandemic—it is only one tool. The others—avoiding large gatherings, wearing masks, and taking precautions anytime cases start to go back up—need to be used in the coming months, as well. And the U.S. needs to take action to help other countries quell the pandemic.
None of us will be safe from the virus until all of us are. “That will be hard for people to see,” Lipsitch said. “In the same way that we didn’t become aware of the original outbreak until it was really not only on our shores but widespread on our shores—I think people will have a hard time seeing ongoing transmission in the rest of the world as a problem, because we’re an insular country.” But if the virus isn’t fought everywhere, it will keep evolving. “The wildcard is the rise of variants,” Lipsitch said.
Investing in genomic surveillance, and taking quick action on new and mutating viruses, is an important step the U.S. and countries around the world should take, particularly since there’s nothing stopping a new swine or bird flu from emerging as the world reopens. “Building an infrastructure to do genomic surveillance in the United States is a several-year project,” Lipsitch said. “Building the preparedness to make diagnostics against the next pandemic is a several-year project. So if we get busy and put the money into this, then we can do it. And if we lose interest, then we won’t.”
We also need to continue monitoring vaccines to see how long their protection lasts and how they stand up to variants that emerge. We need to do that while sharing technology and rapidly increasing production of vaccines around the world, Lipsitch said. While drugmakers are entering into some sharing agreements and production is increasing, progress has been relatively slow.
“The vaccinated world is not going to stop and wait for the rest of the world to catch up, they’re going to be moving forward,” Dr. Claire Standley, assistant research professor at Georgetown University’s Center for Global Health Science and Security, told me. It’s completely unrealistic to expect other, often poorer countries to impose lockdowns for years on end until they receive vaccines, while the rest of the world gets even further ahead, she said. “Why should they be punished for not having access to the vaccine?”
These global inequities are the biggest unknown for gauging how the next few years will play out. “Latin America is one of the most affected regions in the world, and they’re our neighbors,” del Rio said. Cases are still skyrocketing in Brazil, for instance. “The U.S. needs to be very concerned about ensuring that we help Latin America get vaccines, because it’s not good to have a ticking bomb in your backyard,” he said.
While distributing vaccines globally is both a moral and a practical imperative, there’s also a strategic case for it: China and Russia have already begun using vaccines as diplomatic tools—a “geopolitical power play,” del Rio said. “Vaccines are going be really important in that power play, and it’s going to be China, Russia, and the U.S. primarily playing that game.”
One crucial weakness SARS-CoV-2 revealed about our society is the importance of social safety nets for our collective well-being. Many of the people at greatest risk of getting and dying from the virus couldn’t afford to stay home and weren’t able to distance or, when they fell ill, to isolate completely. They were frequently worried about the costs of seeking tests and medical attention, even if they had insurance.
“Universal health coverage and access to affordable, high-quality care is absolutely a prerequisite for global health security,” Standley said. “You still need to have the protections in place to allow individuals who test positive, even if they’re vaccinated, to isolate or to protect others. I’m worried that as vaccinations roll out, all that talk about supported self-isolation or paid sick leave is going to disappear.” But offering paid sick leave, covering the costs of testing and medical care, and setting up quarantine hotels are just a few of the options that have proven to help contain pandemics, whether Covid-19 or future diseases. “I think letting people say ‘you’re on your own’ is not good,” del Rio agreed.
Rethinking American individualism in the face of global pandemics also means rethinking state-by-state planning. “Public health in our country is run at the state level, and I think one thing we’ve learned is you cannot fight a pandemic with state plans,” del Rio said. “Imagine if we fought a war that way. Each state sends its own army, everybody recruits their own soldiers, everybody buys their own ammunition, and everybody decides when to send their soldiers. It’s really hard to fight a war like that. ‘Well, Texas today is not sending soldiers so, you know, everybody else figure out what you need to do.’” It’s unlikely to happen, he said, but he would like to see Congress pass emergency pandemic powers in order to activate a federal response for crises like these.
It’s possible, over the next few months and years, that the virus will become like a mild cold or the flu, a minor childhood illness. The horrifyingly fatal 1918 flu, for instance, still circulates among us. Once a virus becomes endemic—especially when it can switch between animals and people—this is often the best we can hope for. But Covid-19 could continue claiming lives for the foreseeable future, especially among those without access to vaccines.
Our eagerness to move on and put this tragedy behind us is understandable, but quickly papering over the panic of the past year means forgetting the lessons we have learned—in particular, about the steep costs of individualism and inequality. “One thing we’ve learned with this virus is that we need to be humble and we need to be nimble,” del Rio said. “There’s no purpose in saying, Texas-style, ‘This is over, we’re done, everything is open, and the epidemic is officially over.’ Because viruses don’t listen to those kinds of political declarations.”
Of all the routes we could take over the next few years, del Rio said, “my favorite path is that we talk about this in past tense. We talk about ‘do you remember the pandemic?’” In that world, we’ve vaccinated the country, helped vaccinate the world, then sat down to figure out how to keep this from ever happening again. There are infinite paths branching ahead of us—some better, some worse. It’s never too late to choose a new destination. But the longer we wait, the harder it will be.