The Cold War Against Covid Has Begun

The Covid-19 pandemic is fading, and it sure feels as if life is returning to normal. But we have been warned: Covid-19 is unlikely to disappear.

To figure out what to expect next and how to deal with it, Bloomberg Opinion columnist Michael R. Strain spoke with Dr. Scott Gottlieb, his colleague at the American Enterprise Institute. Gottlieb, a Pfizer board member, investor and former head of the U.S. Food and Drug Administration, is author of “Uncontrolled Spread: Why Covid-19 Crushed Us and How We Can Defeat the Next Pandemic.” This is the first of two excerpts from their conversation.

Michael R. Strain: The public discussion seems to be very focused on this summer — on the virus receding, states rescinding virus-related restrictions, localities and businesses dropping mask mandates, and on things returning to normal. But we're not necessarily out of the woods yet.

Scott Gottlieb: I think we can declare a near-term victory. I don't think this is a mission accomplished moment because this is an infectious disease. It's likely to become endemic, which means it's going to be pervasive. It's going to continue to circulate, and it's going to become a seasonal virus. Typically, coronaviruses are viruses that circulate in late winter. This is going to go from a pandemic phase to more of a seasonal phase, where this is likely to come back every winter.

Right now, we’re seeing infection levels declining. Even still, we might not get below 10,000 or 15,000 cases per day. But what we need to recognize is that the overall vulnerability of the population has declined substantially because many of the most vulnerable Americans now have protective immunity as a result of vaccination or previous infection.

So even if we have 10,000 infections per day now, that's a lot different from 10,000 infections one year ago. It represents a much different circumstance. We're going to have far fewer hospitalizations and deaths as a consequence of the infections that we're experiencing now, because more of the infections are happening in people who are unvaccinated, who tend to be younger, healthier people who aren't going to be at the same risk from Covid.

Strain: If Covid-19 settles into a seasonal pattern, what is your outlook for the fall and winter of 2021?

Gottlieb: The fall is still going to be relatively quiescent. People will be going back to work, kids will be going back to school, so we're going to be building up some risk. But you're not going to see infection levels start to increase until you get into the winter.

I think it's more likely that December and January will be the months when we start to see coronavirus levels pick up. Even so, I think it’s unlikely that we have a dense national outbreak again or a dense national epidemic. What we're likely to see is regionalized outbreaks in which certain cities and states have high virus levels.

Strain: Say a little more about the risk of a Covid-19 surge this coming winter. Given access to vaccines, do you have a sense of what will happen to the fatality rate?

Gottlieb: Well, I think that the case fatality rate is probably approaching more like a flu at this point. It's certainly less than 0.4%, it might be as low as 0.2%, and it is probably heading toward 0.1%.

Strain: What's the fatality rate for the flu?

Gottlieb: Many public health experts say it’s around 0.1%, but it's probably less than that because there's a lot of asymptomatic flu infection that doesn't get documented. But typically, the refrain is that in a bad flu season, the case fatality rate will be about 0.1%.

The case fatality rate for coronavirus, at least in the early stages, was above 1%. As we improved treatment, it was probably cut in half. By the fall, the case fatality rate was 0.5%. Now, it's substantially less than that because more of the people who are getting infected aren't as vulnerable.

Strain: How do you see efforts to vaccinate more of the public playing out?

Gottlieb: I think we'll hit the goal of vaccinating 70% of adults. If we miss it, well, we'll miss it by a little bit.

There'll be a lull, and vaccination will decline, and then we'll start to pick up more vaccinations as we get into the fall as people return to work. We’ll probably get to a point where around 70% of the public is vaccinated, once you include adults and kids. That's a pretty high level of vaccination.

Then you have to figure that there are also going to be a lot of people who are unvaccinated who have had the infection. About a third of the public has had coronavirus infection so they have some naturally acquired immunity. Given that, it’s reasonable to forecast that around 80% of the public will have some form of protective immunity.

We're also probably going to be vaccinating for coronavirus alongside delivering flu vaccines. As people go and get their flu vaccine, a lot of people are going to be offered a coronavirus vaccine.

Strain: Are you worried about a new variant?

Gottlieb: I think the wild card here is whether we get a new variant that spreads differently, that pierces prior immunity for which the vaccines are less effective. If you get a new variant that becomes prevalent, that is able to re-infect people more easily, that changes the equation. That's the big unknown.

The best way to guard against the introduction of that kind of a variant is to have a lot of people vaccinated. We do have a lot of people vaccinated right now, but we are probably not at a sufficient level that a new variant couldn’t gain a foothold if it is able to pierce the immunity provided by vaccines and previous infections. In which case, it could start to spread.

Strain: How worried are you about a variant coming to the U.S. from a part of the world like India or Africa that is lagging behind the U.S. and Europe in administering the vaccine?

Gottlieb: There's certainly a risk of variants coming from other countries, but some make the mistake of thinking that variants have to be imported. We're getting what's called convergent evolution, which means variants are happening everywhere at the same time. The virus is mutating everywhere, and it's not as if a new mutation is going to occur in India and is eventually going to get imported into the United States. The same mutation that's occurring in India is occurring in the United States. It's happening here, it's not being imported here.

If those mutations get into the right environment where there are some initial super spreading events or they're in an environment where vaccination rates are lower, you could get an outbreak of a new variant here.

We think that there's only a finite number of ways that this virus is going to mutate itself. It's shown us a lot of what it's going to do. It's reached a new fitness level, and probably the rate of mutation is going to slow.

Now, they're probably happening at a faster rate, and they're more prevalent in other parts of the world where there's more virus right now. The propensity to have mutations occur spontaneously is proportional to the amount of infection that you have.

In the second part, Strain and Gottlieb will discuss the policy responses to potential Covid-19 outbreaks this winter and steps that can be taken to mitigate the damage from future pandemics.

This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.

Michael R. Strain is a Bloomberg Opinion columnist. He is director of economic policy studies and Arthur F. Burns Scholar in Political Economy at the American Enterprise Institute. He is the author of “The American Dream Is Not Dead: (But Populism Could Kill It).”

©2021 Bloomberg L.P.

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