I vividly recall when we were told that the pandemic would end in May 2020 thanks to the country’s dramatic and brutal lockdown. Then, when the first wave appeared soon after the lockdown relaxed, that universal masking would help beat the pandemic. Then, when this first wave mysteriously petered out despite low levels of masking, we were told this was because a very high proportion of people had experienced asymptomatic infections. This implied that the virus had swept across the land, and most people were not even aware that they had been infected. We had miraculously attained that fabled goal of “herd immunity”. By Diwali 2020, we thought the nightmare was behind us and bars, wedding venues and holiday destinations began heaving with people, celebrating that the virus had been beaten and that we were well on our way back to normal.
Only we were not.
Like that childhood monster that leaps out of the closet just when we have let our guard down, it was back with a vengeance. By the time of the devastating second wave, though, the game had changed: We had the vaccine. Now we were told that not only would we protect ourselves with the vaccine, but we would also help our populations get to herd immunity because, once vaccinated, a person was very much less likely to get infected and to transmit the infection to others. Vaccinating a sufficiently large chunk of our people would win the war. No one is quite sure exactly how many people we need to vaccinate, though whatever the target is, we are still a long way from it.
But will we beat the pandemic even then?
Several bits of emerging data suggest that we won’t. It seems that vaccination, while certainly effective in protecting us from falling ill and dying (a very important benefit, of course), seems to have two potential limitations. First, it does not eliminate our chance of being infected; on the contrary, it appears that if a vaccinated person is infected with the delta variant, now the dominant variant in most countries, they have similar viral loads as people who are not vaccinated. Furthermore, the hopes that vaccination may reduce the chances of passing it on to others because the vaccinated are less likely to become ill are being tempered by the discovery that the delta variant starts spreading even in the absence of symptoms. And so, vaccination will not stop transmission no matter how many we vaccinate. This implies the continuing threat of further mutations. One can only pray that the coming mutations are more benign than its parent.
To compound this, the second limitation is that it now appears that vaccine-induced immunity wanes with time and new variants. This may well be the reason why Israel, once lauded for achieving very high levels of vaccination coverage, is now experiencing another wave. In response to the findings of declining protection, countries with cash are gearing up to start booster doses less than a year after completing vaccination. The necessity of booster doses, except in the immunocompromised, is yet to be determined but it’s likely that they will prolong protection. In short, the current regime of vaccination offers neither “herd immunity” nor long-term protection.
So now, what next? This is surely the elephant in the room for governments, scientists and communities, for it is slowly dawning that, as some pundits had predicted at the very start of the pandemic, we will never eliminate this virus, unless we discover a vaccine which is highly effective in blocking its entry into the body. Another possible game-changer might be a highly effective antiviral medication. But history makes me somewhat pessimistic given the failure of decades of efforts to conjure similar magical potions for any other coronavirus infection.
The dilemma is how to shape policy in the light of these facts. On the one hand, we risk being trapped in a seemingly never-ending cycle of lockdowns, uncertainty, vaccination drives, restrictions on travel and in-person interactions, the evisceration of occupations that require in-person interactions, the loss of learning for children shut out of schools, wearing masks in indoor spaces and so on. Given the rising levels of fatigue, anger and despair with this dispensation, not to mention the shattering of the most vulnerable livelihoods, I cannot countenance such a future. On the other hand, we would have to contend with waves of the epidemic sweeping across the population at regular intervals, sickening and killing many in its wake. Assuming we enter the era of booster doses, the feasibility, acceptability and value of vaccinating a billion people each year is questionable. But there is a glimmer of good news that the risk of dying of Covid-19 is falling, not only due to vaccination but also more effective medical care for the very ill.
Maybe the way forward lies in a middle path. Thus, one may prioritise public resources for vaccinating only the vulnerable, such as the elderly and those with co-morbidities, and all frontline workers. This is the situation we have with influenza, a close cousin of Covid-19; we live with the virus with no restrictions to travel, work or mingling, annually vaccinate those who are vulnerable, and accept that some of us will fall ill and a small fraction will die. Mortality can be further reduced by investment in infectious disease surveillance, community-based supportive care and peripheral hospital critical care.
What seems increasingly likely is that we will need to learn to live with the virus because it is becoming endemic, which simply means it will always be amongst us. This is the time for a national conversation, with public health experts joining up with social scientists, political leaders, businesses and representatives of civil society, to figure out how we, as one people, can soldier forward with solidarity for all sections of our diverse population. Then, we might find the right path towards fully reopening our society while ensuring that the goal is not to eliminate the infection but to reduce sickness and mortality to as low as one possibly can.
This column first appeared in the print edition on September 7, 2021 under the title ‘The virus among is’.
Patel is The Pershing Square Professor of Global Health at Harvard Medical School, and a member of the Lancet Citizen’s Commission on Re-imagining India’s Health System