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An Uncertain New Phase of the Pandemic, in Which Cases Surge But Deaths Do Not

So many things have gone wrong in the American response to the pandemic, but two important things have gone right: scientists have developed a vaccine, and older Americans have got it. Seventy-six per cent of Americans between the ages of fifty and sixty-four have received at least one dose, according to the Mayo Clinic’s vaccination tracker. Between the ages of sixty-five and seventy-four, it’s ninety-one per cent, and among those over the age of seventy-five it’s eighty-seven. (Slightly smaller numbers have received a full, two-dose vaccination.) Blue states have been a little more compliant, and the red states a bit less, but the regional differences among older Americans haven’t been so big. Even in deep-red South Carolina, ninety-three per cent of senior citizens have received at least one dose. In Nebraska, ninety-five per cent have, and the numbers in Idaho and Florida are ninety per cent and ninety-eight per cent, respectively. There was no mass campaign to combat disinformation among the aged, no detectable conversion of anti-vaxxer senior citizens to pro-science liberals. “They have the same worries about the vaccine, but when they did the risk-benefit it was just so clear to them that the risks were so severe,” Mollyann Brodie, who runs public-opinion surveys on the pandemic for the Kaiser Family Foundation, told me. There is a dark irony in this. For months, conservative television hosts have fulminated to a largely older audience about the madness of the vaccine campaign: Tucker Carlson has scrunched up his face and said the word “Fauci” with Old Testament menace; a renegade ex-Times reporter named Alex Berenson has rattled off statistics in a rhythm that sounds designed to perplex. Through it all, this older audience has tuned in loyally, from armchairs in Idaho and South Carolina, while already fully vaccinated—their cells displaying the telltale protein piece, antibodies formed and ready. They have taken the campaigns on television neither literally nor seriously; they have understood that it is for show.

The broadly effective vaccination of older Americans and the embarrassingly ineffective vaccination of everyone else, just as the highly contagious Delta variant has won out in the microbe wars, has given the pandemic its current uncertainty: cases are rising sharply, but deaths are not. One reason for this strange situation is how heavily the coronavirus’s risk of death is concentrated among older people––most of whom are now vaccinated. At the outset of the pandemic, the Dartmouth economist Andrew Levin had calculated the mortality risk from COVID-19 by age (he originally used data from South Korea, Iceland, Sweden, and New Zealand , because it was the first available), creating tables that the Centers for Disease Control and Prevention still uses. Over the phone, just back from a congressional hearing, he read me the numbers: at the age of thirty, one in five thousand infected and unvaccinated Americans might be expected to die; at forty, one in fifteen hundred; at seventy; one in forty; at eighty, nearly one in ten, close to five hundred times the mortality risk of a thirty-year-old. Vaccinating the elderly was the essential prophylaxis—it kept the vulnerable safe and gave everyone else a little more freedom. Levin did a calculation for me and estimated that, even though just half of Americans over all have been fully vaccinated, those vaccines (concentrated among the most vulnerable) have cut the infection-fatality rate by about seventy-five per cent. William Hanage, an epidemiologist at Harvard, told me, “The relationship between cases and outcomes—be they hospitalizations or deaths—has been altered. It is no longer the same.”

This is what made everyone pretty sanguine at the beginning of the summer. As the Delta variant has spread, the relationship between the virus and the most severe illnesses is different from what it has been in the past. Since mid-June, the seven-day average of new cases in the United States has grown by five hundred and fifty per cent, from about fourteen thousand to about seventy-seven thousand. But the number of deaths is almost exactly the same. In mid-June, the national seven-day rolling average of daily deaths was about three hundred and fifty. On Friday, it was three hundred and one. (That level, according to the Kaiser Family Foundation, means that COVID is now just the seventh-leading cause of death—far below heart disease and cancer and also below accidents, strokes, respiratory disease, and Alzheimer’s, and just above diabetes.) The experience of the U.K., where the Delta variant has already peaked, was similar. Michael Osterholm, an epidemiologist at the University of Minnesota who served on the Biden-Harris Transition COVID-19 Advisory Board, reviewed with me data from this summer’s U.K. surge, sorted by age group, and compared it with those from that country’s previous surge. The case numbers were about the same, he pointed out. But the deaths? “Way down, way down, way down.”

Now there is news that brings to the fore the problem presented by a surging number of cases in which people get the virus but do not die from it. On Thursday, the Washington Post published a leaked slide deck from the C.D.C. that summarized what its scientists had discovered about the new variant: Delta is much more contagious than prior strains have been, and leads to more serious illness. Most strikingly, the C.D.C. slides referred to data from a recent outbreak in Barnstable County, Massachusetts, in which vaccinated people who had acquired breakthrough infections had viral loads just as high as the unvaccinated. This outbreak was an outlier in some respects (men made up eighty-five per cent of the cases, and six per cent of the individuals were identified as H.I.V.-positive, and the C.D.C. appended several other caveats) but its publication helped to intensify a public debate over whether vaccinated people might be able to spread the virus more easily than had been previously thought. The slide deck did not contain any new information about deaths—against which vaccines are still, the data show, broadly protective—but it did sharpen the image of the present moment, in which the unvaccinated are at heightened risk of serious illness and even the vaccinated are no longer so sure that they’re entirely safe. “I think given the properties of Delta, it’s not going out on a limb to say pretty soon, people are either going to have been vaccinated or infected,” Hanage, of Harvard, told me.

The pressures that come with rising cases are already being felt in certain low-vaccination parts of the country: Missouri, Florida, the Gulf Coast. In Louisiana, where about thirty-six per cent of the population is fully vaccinated, new cases have increased tenfold since the beginning of June. The number of kids being treated for COVID-19 at Children’s Hospital New Orleans—the lone dedicated pediatric facility between Houston and Atlanta—rose from four on Monday to sixteen on Wednesday to twenty by Thursday morning. With the hospital near capacity, Mark Kline, its physician-in-chief, told me that children with serious illnesses across the South will likely have to be directed to community hospitals without a lot of experience treating severe illnesses in kids. I asked him for a colloquial description of the situation at Children’s. “We’re full to the gills,” Kline said. “We’re going to be in a world of hurt.”

In addition to this kind of systemic strain, the rise in cases also necessitates different calculations around personal risk. If vaccinated adults can still pass on the disease, that means they will likely begin to behave differently around their unvaccinated children and around elderly parents, for whom a rare breakthrough infection could be devastating. As the number of infected Americans swells, so will the number of those at risk for what is called long COVID—the pattern of neurological, respiratory, and other symptoms that seem to linger in some patients after the virus has run its course. One large recent study based on records from the United Kingdom’s National Health Service suggested that, among middle-aged people who’d had COVID, 4.8 per cent had symptoms debilitating enough to affect their daily lives for twelve consecutive weeks. Ellen Thompson, of King’s College London, one of the study’s lead authors, emphasized to me the significance of long COVID: “The impact of that on work, education, and parenthood—it’s a big deal.”

COVID after the vaccines, and after the Delta variant, is in some ways a different disease than the prior versions. Or, at least, it has different characteristics. Even people who carefully studied their own risks early in the pandemic, and decided what they were and weren’t comfortable doing, now have to recalibrate for different risks, the dimensions of which are not yet fully known. It doesn’t just feel different; it is different. Osterholm, of the University of Minnesota, said, “There has been so much focus this week on the transmissions, which is important. But that shouldn’t be confused with the incredible impact these vaccines are having, even in a surge situation. Cases may be going up, but you can’t dismiss the dramatic changes in the number of deaths.” Osterholm pointed out that, if the American pattern follows what happened in the U.K., then we will be through the peak of the Delta surge in three to five weeks—roughly, by Labor Day. By then, we should know for sure whether the altered relationship between cases and deaths has held. At that time, maybe, we’ll be able to breathe a little easier again.

Not every element of this pandemic has turned on human decisions. Still, it is interesting how much the very particular pattern of COVID-19 vaccination in the U.S. has predicted the current situation. We were attentive to the risk to the vulnerable, and so many fewer people are dying; we were lax about protecting the healthy. As a result, a disease that might have been better confined now threatens to become endemic. In this respect, “we had the greatest medical gift, and we threw it out the window,” Markel, of the University of Michigan, said. But it might make sense to think of vaccine resistance as characterized not by the red-blue political divide so much as by a depressing level of self-interest. The story of COVID in the U.S. goes something like this: first, in 2020, more than three hundred thousand people died. Then vaccines became available. Those whose age made them highly vulnerable mostly did get the vaccine. A large portion of those who were not so vulnerable (for whom the benefit of getting the vaccine would mainly have been to protect other people) did not. Caveats are plenty, but for now it seems that the effect of this self-interest is the pandemic we see now: suffering abounds, but not—at least, not in the same way as before—death.


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