Toward a new normal

In May, America was celebrating progress. COVID-19 hospitalization and mortality numbers that spiked in January had plummeted and seemed to be flat. The availability of the Pfizer and Moderna vaccines seemed to have led to turning the corner on the pandemic. The prevailing assumption was that we were on a trajectory back to “normal.”

Fast forward two months and the Delta variant has upended that assumption, stirring anxiety, confusion, anger and concern. Masks are back indoors and in schools for the coming year. After the summer of 2020 was hampered by restrictions, questions again are swirling around the safety of summer camps and travel. COVID-19 cases — and hospitalizations — are up. What’s happening and how should we think about?

Delta, a SARS-CoV-2 mutation that originally was identified in India, appears to be significantly more infectious than previous variants that have spread across the world. Even Israel, with a vaccination rate approaching 60% of the population (one of the highest in the world), has seen an uptick in COVID-19 cases as the Delta variant spreads. Although the primary concern has been the risk for unvaccinated people (including children under the age of 12 for whom vaccine use has not been cleared), Delta also has highlighted the prevalence of “breakthrough” infections, in which people who previously had COVID or are fully vaccinated are nonetheless getting infected.

The short-term impact of the Delta variant is not good news — but also not terrible. Although Delta is leading to more COVID-19 infections, the early picture suggests that it is not driving up mortality rates, at least for vaccinated people (now over 60% of Californians) or for unvaccinated children. 

Although the Delta variant is leading to more COVID-19 infections, the early picture suggests that it is not driving up mortality rates, at least for vaccinated people (now over 60% of Californians) or for unvaccinated children.

While California hospitals are seeing an increase in hospitalization rates, it does not appear that we are likely to see hospitals overwhelmed — given the numbers of vaccinated people. The early data show that the Pfizer-BioNTech mRNA vaccine continues to be 80% to 90% effective against the Delta variant. As a result, in the vast majority of “breakthrough” cases, vaccinated people are testing positive but either are asymptomatic or only mildly symptomatic. Consequently, for the vaccinated, the Delta variant warrants precautions, but not panic. The overwhelming majority of hospitalizations are of unvaccinated people, which should motivate ambivalent and reluctant vaccine holdouts to get vaccinated.

The bigger takeaway, though, is the long-term significance of the Delta variant. In 2020, we heard a lot about the goal of “herd immunity,” where so many people have antibodies, whether by vaccination or previous infection, that there are too few vulnerable hosts for a virus to spread. Increasingly, however, the consensus — articulated by Christopher Murray, the director of the Institute for Health Metrics and Evaluation at the University of Washington — is that low vaccination rates worldwide, coupled with COVID-19’s frequent mutation, mean that herd immunity is likely to be unattainable. 

A more realistic way to think of the Delta variant (like the U.K. variant that predominated in April and May) is as just the latest of an ongoing stream of COVID-19 strains that will be with us for the foreseeable future, much like the flu. As with the flu, people at greater risk will get an annual vaccine updated from time to time to address the evolution of the viral strain. The Delta variant may predominate for the next several months, but eventually it will peter out … until the next variant spreads.

Although vaccination is the best way to reduce the availability of hosts for the virus, the reality is that we are still years away from global vaccination. Much of the developing world still lacks access to vaccines, meaning new variants will continue to develop. Although many are rightfully frustrated with those around us who have ready access to vaccines and could be vaccinated but are refusing (the “willfully unvaccinated”), even without them, we will continue to see new strains and “breakthrough” re-infections from the rest of the world for years to come. 

 Although vaccination is the best way to reduce the availability of hosts for the virus, the reality is that we are still years away from global vaccination.

The challenge ahead is the many public and private decisions about other public health measures. Many people are questioning whether business closures or travel restrictions are worth the economic costs of harming and potentially closing down more businesses. Increasingly, the consensus appears to be that these steps are not likely to alter the trajectory of the surge, and carry collateral costs that are too high to justify. Meanwhile, vaccinated people similarly are questioning why they should be burdened with returning to mask-wearing, when the real risk is to the willfully unvaccinated. 

We can take some comfort in the growing chorus of pro-vaccination messaging coming from former anti-vaxxers who learned the price of their poor decision-making after being hospitalized with COVID. The numbers of hardcore anti-vaxxers is likely to keep shrinking with new variants and with more employers and universities ultimately likely to mandate vaccination. 

Personally, I suspect that support for “vaccine passports” will continue to grow as a requirement for entry to stadiums, concerts and private venues. The future is likely to be one in which the willfully unvaccinated will continue to have the right not to be vaccinated, but may face limits in their access to employment or recreational opportunities based on the right of everyone to avoid unnecessary exposure to risk. 

Welcome to the “new normal.”

Harry Nelson is the founder and managing partner of Nelson Hardiman, a healthcare specialty law firm in Los Angeles. He also is the author of “The United States of Opioids: Liberating a Nation in Pain” and “From Obamacare to Trumpcare: Why You Should Care.”