August 13, 2021

Is the worst of Covid-19 yet to come? 7 leading experts weigh in.

Daily Briefing

    A majority of Americans—nearly 54 percent—believe the worst of the Covid-19 pandemic is still ahead of us, according to a new Harris poll of more than 2,000 respondents released earlier this week. But is the epidemic truly heading into unprecedented territory, or is this pessimism misguided?

    Advisory Board's Andrew Mohama asked leading experts the same question that Harris asked of its poll respondents: "Do you believe the worst of Covid-19 is behind or ahead of us?"

    Below are their responses:

    Georges C. Benjamin

    Internal medicine physician; executive director, American Public Health Association; former appointee to President Obama's National Infrastructure Advisory Council

    I think we're at a place in this pandemic where we must reframe our thinking about it. In terms of starting with a new very infectious disease for which we only had non-pharmacological measures to contain it, the worst is behind us. We now have therapeutics, better medical management knowledge, and of course, a highly effective vaccine. We also understand the virus much better than we did at the beginning which allows us to better project its behavior in general.

    Having said that, it remains a deceptive foe. The virus has also mutated to a more infectious form and possibly more lethal. The reframing is in the stage the pandemic is in and what its future is for us.

    This disease is most likely endemic in the U.S.; its presence will severely impact unvaccinated populations and will persist at some low level even in vaccinated populations. We should expect that once it runs through the current low-level vaccinated communities with these large outbreaks, we will have episodic outbreaks throughout the year. It is unclear if this will have a seasonal pattern or not. There will be a population of people that will require boosters to include those with immune suppression (probably those on high dose steroids, chronic kidney disease, some cancer patients, and immunologic diseases, etc.). Boosters for the rest of us will depend on new variants that may develop over the years.

    People want a cure. But we don’t have one yet. The Covid-19 vaccine is the closest thing we have to it, but it is not 100% and people like certainty. We need to get people to understand that we will be living with this disease for some time. Yes, it has significantly impacted and changed the way we work, play, and pray. It also has impacted how we engage with other people. But we need to remind people we have been through this before in 1918 with the great Influenza pandemic. Life will go on, but it does require some vigilance for us to hasten our return to some degree of normality. Right now, vaccination is the solution for that.

    We do need to prepare people for new variants since most of the world is not vaccinated and will not be so any time soon. That means the risk for new more infectious, more lethal variants is high. We need to strengthen our public health systems to rapidly identify this shift (as well as any new health threat) and our ability to respond to them. Believe it or not, this could have been worse.

    Asaf Bitton

    Primary care physician, Brigham and Women's Hospital; executive director, Ariadne Labs; health policy professor, Harvard Medical School; senior advisor, CMS Innovation Center

    When we’re thinking about whether the worst of Covid-19 is ahead or behind us, I think it’s first important to ask a question of who “us” actually refers to. If the question is around those states who have high vaccination rates, or those individuals who are already vaccinated, it is still likely that the pandemic’s worst effects may be behind us unless a variant emerges that more completely evades the vaccines’ protective effects. But for states and communities with low vaccination rates, and for any unvaccinated individual, the resurgence of delta suggests a difficult near- and medium-term experience.

    Covid-19 should teach everyone to be extremely humble about their predictions. This is still a new virus with often confusing and confounding ways of spreading, surging, mutating, and recurring. We know from other coronaviruses that they often morph into patterns of cyclical endemic spread. Sometimes this is seasonal and other times it is not. It’s important to not assume that SARS-CoV-2 will act like other coronaviruses given its heightened transmission across the globe and lethality. Most likely it will be with us for a while—eradicating it seems highly unlikely at this point. 

    The evolutionary spread of Covid-19 into new variants also makes prediction difficult. Almost certainly we will see new and possibly more transmissible or even lethal variants emerge. The greatest risk given the information we have now is for populations, especially those around the globe, that are unvaccinated and that have lower access and capacity to engage with essential health services. These communities bear the highest risk. 

    While a super-mutant Covid-19 strain that evades protection from our current arsenal of vaccines is possible, so far, the vaccines are doing their primary jobs of generally and substantially preventing severe disease, hospitalizations, and death. That makes efforts to vaccinate under-vaccinated communities and individuals in the US and abroad all the more urgent. The longer we have highly transmissible Covid-19 spreading through delta and future variants across our country and across the globe, the higher the chance there will be for the emergence of a more transmissible and or lethal strain.

    So in the end, while it’s hard to say with any degree of certainty whether the worst days are behind or ahead of us as a whole, so far we know that for vaccinated individuals and communities that apply evidence-based mitigation protocols and follow them, resurgent spikes in hospitalizations and deaths that were seen last winter or are being seen in some parts of the country now are less likely. For those communities with high numbers of unvaccinated individuals (and for any unvaccinated individual themselves), the worst may still be ahead as the delta variant is more transmissible by a large amount than previous variants of Covid-19. 

    Delivering vaccines to these communities where hesitancy is high, and access may be low, is critical. Vaccines move at the speed of trust. Trust is built and maintained by key community leaders and healthcare professionals who have long-term relationships with their communities. Doing the hard, time-consuming process to bolster vaccine confidence needs to be a top priority. As does delivering vaccines broadly and rapidly to countries outside the United States. In the meantime, we have to get vaccinated, mask while indoors, move as many gatherings as possible outdoors, use rapid home testing, and stay resilient. 

    Christopher Kerns

    VP, Executive Insights, Advisory Board

    While it's true that U.S. hospitals—particularly in regions with low vaccination rates—are again feeling the surge of Covid-19 volumes, death rates are still well below their winter 2020-21 highs. That's largely because the most vulnerable populations have reasonably high vaccination rates relative to the overall population. So in terms of overall U.S. mortality, it does indeed look like the worst is behind us. But the highly transmissible delta variant can still cause tremendous disruption and continued suffering. And unless vaccination rates jump dramatically, the potential for yet another highly contagious variant to develop persists. It does seem as though the reality of the delta variant's alarming transmissibility is spurring increased inoculation rates, so I'm cautiously optimistic that we will eventually see hospitalization rates fall as vaccination rates rise and delta works its way through the population.

    But the public perception of the impact of the delta variant is telling, because it reflects a dangerous and all-too-common misunderstanding of the purpose of vaccines. All of the epidemiological evidence suggests that eradication of Covid-19 is nearly impossible, even with a vaccination rate of 100%. As the virus becomes endemic, vaccinations and prior exposures should make it far less lethal. But as long as significant portions of the public view every Covid case as either a policy failure, or worse, false evidence that vaccines are ineffective, widespread viral transmission will be understandably seen as proof that progress is faltering. 

    Two realities will need to be accepted before we can reasonably expect to see both a reduction in case rates and hospitalizations, and an increase in public confidence:

    (1) Covid-19 isn't going away and we as a society will have to learn to accept some level of it for the foreseeable future; and (2) vaccines may not fully prevent contracting the virus, but they sure as hell increase your chances of surviving it with the fewest long-term consequences. Those realities appear to be settling in, albeit very painfully. 

    Amesh A. Adalja

    Infectious disease physician; senior scholar, Johns Hopkins Center for Health Security; assistant professor, Johns Hopkins Bloomberg School of Public Health

    From the beginning it was apparent to many in the field that this virus was going to be something that became established in a human population and was unable to be eradicated or eliminated. It was going to be a new infectious disease threat that would become something that we dealt with you’re in and you’re out like other respiratory viruses. The goal has always been to tame it, to remove its ability to cause serious disease, hospitalization, and death at the rate that occurred in the past through the use of vaccines especially in high-risk populations. There will always be a baseline level of cases, hospitalizations, and deaths from Covid-19.

    There are many people who did not realize or come to grips with the fact that Covid-19 was not something that could magically be put back into bats. That may underlie why people have dire feelings about the future, because they may have had unrealistic expectations from the start.

    I am optimistic about Covid-19 because we have tremendous vaccines that remove the ability of the virus to cause what matters: serious disease, hospitalization, and death.

    In many parts of the United States the vaccine has decoupled cases from hospitalizations and deaths. Covid-19 is now more of a regional risk than it is a systemic risk in the United States.

    Vineet Arora

    Academic hospitalist; dean for medical education, The University of Chicago Pritzker School of Medicine

    When our expectations are let down, our brains have a hard time thinking of that reality as a win.  After all, the baseline people are starting with in their mind is a maskless summer of relaxation and normalcy if you were vaccinated.  We now know the delta variant changed those rules and another variant could do so again.  Knowing there are those that will never get vaccinated coupled with the misinformation spreading in both public and private circles is demoralizing because the “end” is not the eradication we envisioned. 

    As someone who thinks a lot about burnout, I am struck by the four phases of compassion fatigue and how they directly correspond to public sentiment during the four surges here: the zealot or idealistic phase where we are energized and want to help, the irritability phase where we are annoyed, the withdrawal phase where we are tired of this, and the last phase -the zombie phase when we lose hope and that hope turns into anger.  The chorus of zombies who have lost empathy for those not in their boat is getting louder.  This is a dangerous place for society to be, and even more devastating for our health workforce. 

    My personal hope these days comes from young people, especially those new to our field, who bring both idealism and an eye for innovation.  They are the keys to helping us restore empathy and enable a better future.

    Ryan Armbruster

    Senior fellow and director of healthcare executive studies, University of Minnesota School of Public Health

    It’s difficult to see a significant loss of optimism in our journey through this pandemic, particularly as so many of us have made it this far on the optimism (whether true or manufactured) of our families, friends and colleagues.  As one looks forward, the belief in whether the worst of Covid-19 is ahead or behind us is likely influenced by the balance of weight placed on their own experience or that of a community or population.

    For an individual balanced more toward how it will impact their own life, it is feasible for them to believe that vaccination helped avert the worst-case scenario and therefore hold an optimistic perspective.  However, it is only recently that these same individuals have realized that vaccination may not eliminate some of the other hindrances of covid-19, such as the need to wear a mask. This realization is likely contributing to a shift in those individuals becoming more pessimistic about our future.

    For an individual who gauges the impact of Covid-19 from a community perspective, there are even more reasons to be pessimistic about the future.  Low vaccination rates, Covid-19 variants, and political battles over public health measures make it difficult to imagine things moving in the right direction.  With no significant signals of progress in these areas, a large amount of our population will continue to be pessimistic into the foreseeable future.  I find myself mostly in this category for the time being.

    The combination of these two groups leaning more pessimistic toward our future would explain why the majority of people feel the worst is yet to come, whether for individuals or communities.

    The “worst to come” for many people might reflect the realization that Covid-19 may continue to have an ongoing effect on our daily lives, even if in minimal ways. 

    Pamela Divack

    Consultant, Life Sciences and Health Care Ecosystem, Advisory Board

    I spend a lot of time leading research on medical evidence generation. So, after tracking the Covid-19 virus, emerging and authorized vaccines, and variants over the last 18 months, my trust in the current evidence makes me cautiously optimistic that the worst of pandemic is behind us. 

    Last spring, we had little to no evidence about the virus. Scientists, regulators, and the general public scrambled to generate evidence about Covid-19’s spread and prevention, while racing to keep up with rising caseloads, hospitalizations, and deaths. Today, we have significantly more knowledge about how to protect ourselves and our society, plus strong evidence that supports the efficacy of vaccines as a public health measure. Notably, evidence shows that the authorized vaccines are working as expected; most patients today that are hospitalized with Covid-19 are not vaccinated. 

    However, I understand why the majority of the public thinks the future is so dire. In the last few weeks, there has been a lot of confusing data, messaging, and disempowering findings. It’s understandable that news about the more transmissible Delta variant, reimposed masking guidance, the emergence of new variants like Lambda, and publicized reports of breakthrough infections, are creating public fear. Yet to me, the changing guidance and expanding knowledge base actually makes me more confident that the worst is behind us.

    Every day, we’re learning more and more about the virus, it’s evolution, and how to protect against it. Researchers are actively collecting real-world data that will further advance our understanding of the vaccine’s efficacy against Delta, and we’re getting better at tracking variants as they emerge. As our evidence base expands, so will our knowledge of whether we will need (and who will need) boosters, third doses, or entirely modified vaccines–and when. New treatments are still in development, and evidence may prove them to be effective. And new evidence about Delta’s transmissibility, plus masking guidance, proves that we must remain vigilant. 

    I don’t think that the public is slowly learning that Covid-19 will never truly go away; rather, I think that the public is learning that guidance and prevention measures must change over time as our knowledge expands. It’s inevitable that in the future, more variants will emerge; hopefully our vaccines still protect about those variants, but our future will be in how we use evidence to guide public decision-making. 

    I’m encouraged by increasing vaccination rates, mask mandates, and prevention measures; I encourage the public to be too. However, I urge the public–whether confused, frustrated, or skeptical–to reach out to their local scientists, doctors, or health care leaders. It’s undeniable that we’re in the next wave of the pandemic, where hospitalizations, deaths, and cases are quickly rising.  But the more we spread the knowledge and evidence that emerges, and communicate it in a transparent and clear way, the more we can hope to inflect the course of the pandemic in real-time.  

    (Williams, The Hill, 8/4;  Owens, Axios, 8/4)

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