I know I don't usually write you midweek. But it feels like emotions are running untenably hot. I think we're at an inflection point in the pandemic, ostensibly spurred by the new vaccine mandates, paired with exhaustion and frustration and anger, and much preventable suffering.
Some 1,600 Americans are dying every day of a disease that—in most cases—could have been avoided with a free shot. People are declining not simply donuts but cash payments to get this shot, putting themselves and everyone around them (and everyone around those people, and on and on) at continued risk.
And this isn't just typical human behavior; the U.S. is failing uniquely. Despite a huge global head start—outbidding poorer countries and hoarding hundreds of millions of doses—American vaccination levels have now fallen to the middle of the pack, behind Cambodia, Uruguay, Mongolia (where, incidentally, our old friends beavers are testing positive for SARS-CoV-2), and most other wealthy countries in the world. Only 54 percent of Americans are fully vaccinated.
Without a clear vision of an end goal, it's tempting to give in to apathy and resentment, even rage or despair. I know at times I have. In recent weeks, readers have been asking even more wearily than usual about when this ends.
Does the pandemic just go on forever? If 80 million Americans aren't going to get vaccinated, what are we even doing here? I postponed my wedding for this? (It was actually for the best. We ended up parting ways because of his showering habits. And then I met Mark, the actual love of my life. Oh, Mark. But still.)
So I thought it might be helpful to step back and look at where we are, and where it's still possible to go. To look at the two potential pandemic paths ahead of us. I'm picturing it like two roads are diverging, if you will, and we could still choose either.
One is straightforward. We have a map and all necessary resources. The other is meandering and recursive. It's like the one we've been on. The birds are clearly screeching at you to turn back, and there are trolls, and we keep stopping to engage with their bizarre riddles, and they keep turning more of us to stone. Some of us get so tired or hopeless that we start to think the riddles are medical advice. The trolls allude to horse paste, and people eat it. You know the road.
The complicated thing is that, given the nature of infectious disease, whichever road we choose, everyone's on it together.
The textbook ways that infectious disease outbreaks play out fall into three categories: (1) eradication, (2) elimination, or (3) control.
These were described in 1997, when the World Health Organization convened a panel of experts in Atlanta to prioritize—among the myriad preventable contagions—where the most good could be done. These are broad categories (and, like most categories, they're actually describing parts of a spectrum). But the terminology remains in use, and throughout the pandemic it's been helpful to me to think of things in terms of these three basic conceptual roads.
This would mean absolutely zero COVID cases anywhere. We've only ever eradicated one virus, smallpox. For centuries, it caused a horrific, sometimes disfiguring disease. Now it’s totally gone. The campaign to beat the virus involved widespread mandatory inoculation (including a mandate from the notorious tyrant George Washington. He wrote: "Necessity not only authorizes but seems to require the measure, for should the disorder infect the Army . . . we should have more to dread from it, than from the Sword of the Enemy.") In other words, freedom isn't free.
Eradication of SARS-CoV-2 isn't currently on the menu, for a lot of reasons, including the basic nature of the virus and disease it causes, and the handful of changes that have happened in the world since 1777 (e.g. even amid this pandemic, people are recreationally darting all over the globe in "flying horseless carriages" and seeding variants faster than they can be identified), and the rather precipitous decline of the global-health coalition that united to fully eradicate smallpox in the mid twentieth century.
So, this leaves us with the other two fates: elimination and control.
This term belongs in quotes. (Not "scare" quotes, but "this word isn't being used in a way that accords with any standard definition" quotes.) In this case, "elimination" actually means something more like ... make it so there's not too much around here. More like vanquish.
"Elimination" is where the U.S. stands with regard to diseases like polio and measles. They still exist, and viral spread persists in under-vaccinated areas of the world. But the diseases have been effectively eliminated from the long list of daily concerns for most humans. Accordingly, interventions to contain outbreaks can be limited and targeted. People don't need to plan their lives around these viruses—even though, as with COVID, our vaccines are less-than-100-percent perfect. Thanks to widespread uptake, in places where 90-plus percent of people are vaccinated, there's so little measles around that it can be considered "eliminated." People don't have to waste time and energy debating things like how to open schools or whether elective surgeries need to be canceled to make room for all the measles cases.
Some experts think elimination is still theoretically on the table for COVID-19, Fauci said last week. At least, as a worthy goal. The possibility also depends on things like how the virus evolves, and how durable immunity proves to be over the years. But on our current course, we're leaning pretty hard into option three.
Control means, essentially, a forever war. The disease persists indefinitely, and though it's rarely at the front of our minds, we're endlessly devoting resources to keep the rates of disease and death "at an acceptable level."
Obviously that's an extremely subjective term, acceptable. No one wants to put it into words. But common examples are things like malaria, which infects hundreds of millions of people, or influenza, which kills hundreds of thousands of people every year, especially among vulnerable populations. Some people are vigilant about doing their part to prevent unnecessary spread—things like hand washing, and getting a flu shot. Vaccines are only required in a few circumstances, and only about half the population chooses to get one. The imperfection of the vaccines is regularly on display (since the virus circulates so widely and mutates so readily that we can't even predict its course well enough to make durable, reliable vaccines), and this imperfection adds to people's reluctance to get vaccinated, and the cycle continues.
Even if it seems we're inevitably headed toward option III with COVID-19, there is still a big difference between a world where the virus occasionally flares up—and people are asked to wear masks and make sure their vaccines are current, and they simply do, and the outbreak is quickly squelched—and a world where each instance is an interminable nightmare of arguments and political grandstanding and deworming agents.
As of now, the goal seem to be to push toward the former path. And we all have some role to play in that. Much depends on how we navigate the escalating culture war. We can either allow ourselves to get sucked into it indefinitely—repeating the same mistakes that have plagued the U.S. throughout this pandemic—or find a way to break the cycle.
There was a time when it was reasonable to hope that vaccine mandates would be unnecessary. It was fine to be That Guy on the Zoom happy hour who said, "I'm all for vaccination, but I don't think it should be required." That's effectively what the Biden administration had been saying until last week. The president waited months to impose these mandates, which many experts thought were warranted earlier.
In an ideal world, mandates aren't needed. No one wants to have to deal with enforcing mandates, or carrying around documentation to do basic things, or missing your train because your phone died and the app was on it. Mandates cost money to enforce, require effort, et cetera. It would've been simpler if people had just gotten vaccinated. But they didn't. We're dealing now in reality, not hypotheticals. The time to argue that vaccination will work without mandates has passed.
And it doesn't need to be complicated. Everyone wants freedom. Living indefinitely in a world where COVID-19 is consistently flaring up, and you wonder if you have it every time you start to feel sick, and school districts are seasonally debating how many pediatric deaths constitute "an acceptable level" is not freedom. There is a long historical precedent for mandates, which are demonstrably legal, widely supported, and can be extremely effective. Even though mandates involve short-term costs and annoyances, they serve to prevent far greater long-term costs (financially and physically).
At the same time, the effectiveness of mandates still depends largely on how they're received, implemented, and enforced. One of the clearest lessons of the pandemic has been that its arc has as much to do with public opinion as with science. Another is that no single intervention is a magic wand. Even mandates. If you think of rules around issues like drunk driving or teenage smoking, regulations will change some behavior, but solving the problem also involves changing hearts and minds. Mandates work best when people understand that they're in their interest, but fail if they seem pointlessly punitive or antagonistic, such that defiance itself becomes appealing.
That sense of antagonism is exactly what the breathless minority is constantly attempting to stoke. By turning basic public-health measures into escalating culture wars, they stretch the road ahead further. The question of just how far it stretches depends on how we react.
On Thursday, the ambient mix of exhaustion and anger and indignation came through in President Biden's pandemic address. “We’ve been patient," he admonished, "but our patience is wearing thin." Biden explained to unvaccinated Americans that vaccination "is not about freedom or personal choice. It's about protecting yourself and those around you.”
If unvaccinated people haven't already been persuaded by that reasoning, it's unclear why they would when it's said a thousandth time, more sternly. The intended audience of lines like that was pretty clearly not unvaccinated people, but the majority of Americans who are vaccinated and whose patience with Biden is wearing thin. His approval ratings have fallen as COVID cases haven't, and the tough-on-crime, law-and-order rhetoric tends to serve politicians well during crises. People want bold, decisive, authoritative leadership.
It also carries risk when the people you actually need to reach are the ones protesting because they want the opposite.
This is where the long-term goals matter, and can be undermined by short-term incentives. If we were driving toward eradication of this virus, it might be strategic to take the George Washington approach. Essentially: Listen, I don't care if you hate me now, it's for your own good, you'll thank me later. But since SARS-CoV-2 will be around indefinitely, and will require efforts to keep in control—e.g. a likely need for booster shots, and things like masking and distancing during future surges—success also depends on actual understanding and buy-in over a long term.
And this is the real, highest-stakes challenge: not allowing COVID to become a chronic wedge issue. Throughout the pandemic, a vocal minority of attention-seeking opportunists have managed to divide us around even the most simply necessary measures. News media are given to amplifying these voices, and buying into a both-sides controversy. Now, each time an expert or leader admonishes unvaccinated people, it serves as yet more fodder for the voices on the other shoulder of unvaccinated Americans (the one telling them to ignore the global scientific consensus and "do your own research").
We saw it clearly last week. Like a spinal reflex, just as Biden announced the new mandates, pundits and opportunists reached under their desks and pressed the Socialism alarm, rallying red-blooded Americans to rise up against this attack on freedom and liberty as yet another example of the condescending elites telling you what to do. A firebrand Senate candidate from Ohio is campaigning on the notion that vaccine requirements are “tyranny.” The term has since been used by governors and sheriffs and many others.
Blustery as that may sound, this is yet another instance of the fundamental false dichotomy that has set the U.S. back so many times. People are told to believe they have to choose between taking a basic collective action to address a problem that almost everyone agrees is indeed a problem *or* having freedom. When you put it like that, it sounds like a valid debate. Many choose the latter. And then, after taking sides, some slide further, objecting even to purely voluntary measures to address the problem, or denying that the problem is even a problem. (See: climate change, gun violence, health-care costs, etc.) Others will continue to say that these are indeed serious problems, but they just don't think we should have rules or policies or mandates to address the problems. Even as the problems persist and persist and persist.
And that's how we end up doing little or nothing about solvable problems that almost everyone previously wanted to solve.
The pandemic continues to remind us that beating it isn't fundamentally about masks or expensive hospitals or vaccines themselves. You can have all these, sometimes in obscene abundance, as the U.S. does, and still fail without social cohesion. Every society has profiteers and contrarians and opportunists who spread disinformation. The U.S. is not alone in that. But we've proven especially vulnerable. Every time someone tries to seed a wedge issue, for attention or personal gain, it's like a school cafeteria yelling "fight! fight! fight!" We know fighting is bad, but we run to watch, and progress halts.
That's why it feels like this is such a precarious moment.
The calls to fight are loud. After 18 months, some people who've been thoughtful, considerate, and conscientious are throwing up their hands and deciding to engage. It may feel justified, even cathartic to see unvaccinated people chastised, mocked, or deprived of health care. The question isn't whether that's right; it's whether it's helpful, or just perpetuating the nightmare. If our objective is to end the pandemic and save lives, the challenge is not to lose sight of the longer-term goal.
Social cohesion doesn't mean everyone needs to get along, or that everyone's opinion on how viruses spread is equally valid. It doesn't mean "both sides are equally to blame." It doesn't mean smiling and nodding when someone who works in a nursing home says that vaccines are 5G, and then swallows a cough as they wheel your mother away. As of last month, about a third of people who work in nursing homes were still unvaccinated. Social cohesion doesn't mean that statistic doesn't sadden or enrage you, and make you feel the urgency of doing something about it.
Social cohesion just means that the something you do is undertaken in the spirit of solving the problem, or at least improving the situation. Which requires remembering that we're all in the same boat. That can be extremely challenging. Most of us have been rowing that boat for more than a year now. Others aren't rowing. A handful are deliberately rowing backwards, trying to get others to do the same. It might feel appropriate to chide or mock or fight them. But ultimately, you need them to row. And keep rowing.
Until this week, I didn't see a problem with the phrase "a pandemic of the unvaccinated." It's an objectively accurate way of framing things: The vast majority of serious COVID cases are among unvaccinated people. Vaccinated people are still at risk of breakthrough cases, yes, but those would be vanishingly uncommon if everyone simply got vaccinated. Now I've started hearing it in a new light. The phrase not only describes who's suffering, but also names them as the cause. In the middle of a crisis, the question isn't whether that sentiment is accurate or just; but whether it's useful. The fact that only half of U.S. adults are vaccinated is not everyone's fault. But it's everyone's problem. It's still everyone's pandemic.
Take care, sorry this got long,
P.S. I'll write again on Friday, at much less length. Please do keep in touch about how it's going and what's on your mind.