When everything collapsed: Regent Street in central London at the height of the pandemic last year. Photo: Jeff Gilbert / Alamy Stock Photo

The long shadow of Covid-19

As the pandemic becomes endemic, where do we go next?
October 29, 2021

Last winter, at the height of the second lockdown, a friend of mine was cycling to the office through a deserted London. Passing alongside the canal by Regent’s Park, he glimpsed a pack of hyenas running along the opposite bank. In the moment it took him to realise they were still inside their enclosure in the zoo, the post-apocalyptic vision elicited the thought: is this it then? Is this when everything collapses?

It was an understandable thought while our screens were filled with images of overflowing intensive-care wards, mass graves in New York City, and millenarian hordes screaming conspiracies. By contrast, as cafés and cinemas now re-open and vaccines convey some sense of security, many of us enjoying those privileges in affluent countries seem keen to put it behind us and tell ourselves that life goes on. 

But the idea that we can just draw a line under the pandemic and return to our old lives is deluded. As autumn set in this year across the UK, despite the early progress on vaccination, Covid deaths were running at an average of around 100 a day. Just think of all the regulation, enforcement, public education and investment deemed necessary for keeping us safe on the roads, where only five lives are lost on the average day. The global death toll, meanwhile, is officially tallied at around 4.5m to 4.8m, but more comprehensive estimates put it as much as three times higher, and it is rising. How could that possibly be put out of mind, other than through an act of massive collective denial?

Sadly, the virus is here to stay, probably as an endemic pathogen, although we don’t know how it will manifest in future. In the best-case scenario the threat could subside; in the worst, we could be fighting outbreaks and losing many lives for years to come. Any immediate sense in the UK that the “end is in sight” is slipping as the NHS looks ahead to winter, when its capacity is almost routinely tested to crisis point. A very substantial proportion of intensive care beds is already given over to Covid patients and there is building international evidence that vaccine immunity begins to tail off within around six months. 

Although it feels like piling on the misery to say it, more pandemics—whether it’s a lethal flu strain, Ebola, a Sars-like respiratory disease, or something quite new—are likely in our crowded, densely interconnected world. As communities expand into new wildlife habitats and encounter the massive reservoirs of infectious animal viruses there that, like the Covid virus Sars-CoV-2, have the potential to leap into humans, such spillover seems inevitable.

So, as we look forward, what should we expect—for our health and daily lives? And how is this crisis eventually going to be understood? Much remains uncertain, but one sure thing is that if the pandemic doesn’t cause a fundamental rethink on how we got here and how we can avoid a ruinous rerun, that would be a profound and dangerous failure.

The hope that vaccines would bring about the end of Covid-19 was always naive. They have made it more manageable (in countries with ready access to them), but they can only ever be a part of the solution. For one thing, they are inevitably imperfect: they can’t provide complete protection or entirely suppress transmission.

Worse, there is a Darwinian race at work. The virus has already evolved variants that can partly evade vaccines and compromise their ability to slow the spread. And widespread infection in an incompletely-vaccinated population—which is where we are—creates precisely the naturally selective pressure that could encourage still more vaccine-resistant variants.

Community-level protection relies on good vaccine take-up, but that is compromised by cultural factors, including politicisation. The vaccination take-up among Republican voters in the US is 25 per cent lower than among Democrats, and rates of hospitalisation and death are accordingly higher in “red” states. Trust in vaccines is lower in the UK among ethnic minorities; in the US, there is a similar gap, a reflection of a longstanding wariness of the medical establishment that is closely connected to historical abuses.

Especially with the relaxing of many restrictions on international travel, the relevant reservoir of infection and mutation is not national, but global. Most of the world’s population still has little or no access to vaccines. Only 2 per cent of Nigeria’s population has had two shots, for example, and the international Covax scheme for delivering doses to low-income countries is way behind target.

“Controlling a worldwide pandemic by only immunising certain countries is an inherently flawed project,” says Herbert “Skip” Virgin, chief scientific officer of San Francisco-based immunology company Vir Biotechnology.

Eradicating Sars-CoV-2, meanwhile, looks unlikely. That has only ever been achieved for one virus that infects humans—smallpox—and it took decades of dedicated effort, as well as the kind of co-operation and sharing of knowledge and techniques that is nowadays stymied by the guarding of intellectual property by drug companies.

A recent analysis published in Nature by Virgin, his Vir colleagues and other experts, suggests that this coronavirus will remain endemic globally, persisting at low levels in the same way that many other viruses do, including various strains of flu and other coronaviruses that cause common colds. It’s hard to say how problematic this will be. “No one really knows what’s going to happen,” says Virgin—but he adds that “we don’t see any convincing evidence that we’ll become immune and the virus will go away.”

A lot depends on what the virus itself does. The popular and reassuring notion that pathogenic viruses inevitably become milder over time has no strong foundation. “You should not be comforted by that concept,” says Virgin. “So far, it’s not been the case that more spread leads to less virulence. There’s no particular reason why it should.” Becoming less likely to kill the host might make sense for a very deadly virus like the Mers coronavirus (which was fatal in about a third of cases) as there comes a point where deaths and immobilisations will materially inhibit the virus’s spread. But there’s no reason why it should for the less lethal Sars-CoV-2. Indeed, several studies suggest that the now-dominant Delta variant causes more serious illness than the earlier variants.

And when it comes to transmissibility, adds Virgin’s Vir colleague Amalio Telenti, this disease has definitely been getting worse. People infected with the original variant typically infected two other people (the famed R value), he says, but with new variants like Delta it’s more like four to six. That is exactly what we’d expect from evolution: mutations that spread more effectively will crowd out the rest.

Beyond this basic direction, it’s hard to make many predictions about future variants based on other viruses. Every virus has an intrinsic mutation rate, which depends on the frequency of errors when its genome is replicated. On this score Sars-CoV-2 mutates less—and so should be expected to evolve more slowly—than flu viruses. But the effective total rate of mutation also depends on sheer numbers: the more people infected, the bigger the pool of potential variants.

Some other coronaviruses that cause serious respiratory disease, such as those responsible for Mers and Sars, are nastier but don’t transmit asymptomatically as Sars-CoV-2 does: infected people fell ill quickly, and so didn’t keep mingling before they knew they carried the virus, reducing the spread and the caseload.

To lower the chance of this virus evolving in a problematic direction, we need to keep infections low globally—which, since permanent lockdowns are not an option, ultimately depends on attaining widespread immunity either via vaccination or the slow and sometimes deadly march of natural infection. Only then might Sars-CoV-2 settle down into a milder form that can be readily contained with regular vaccination programmes.

One worrying scenario is that Sars-CoV-2, having originated in bats, might move back from humans to other animals and take on new forms there. We know that it can infect cats, dogs, hamsters and non-human primates. “This is a virus that is widely capable of infecting other species,” says Virgin. “It can evolve in them and then jump back into people”—potentially as a nastier variant. That’s how the swine flu virus that caused alarm in 2009 appeared: it was a descendant of the human H1N1 virus that caused the 1918-1919 pandemic.

“The idea that pathogenic viruses inevitably become milder over time has no strong foundation”

Such dangers make it imperative to monitor viral evolution globally: in particular to analyse the viral genomes in positive Covid tests to spot new variants. That has been done very effectively in the UK but for most of the world it’s not happening at all. The worldwide situation is that “the virus is not being effectively sampled in 90 per cent of humans [infected by it],” says Virgin. “It would be extremely unwise not to put substantial resources into this globally.”

The really disturbing scenario is one where, despite the vaccines, we fail to gain control of the pandemic any time soon. In this picture, high global levels of infection persist—with the associated risk of accelerated evolution of the virus—and outbreaks of severe disease keep flaring up in different times and places. This is not the most likely outcome, the Vir team say, but it can’t be ruled out.

In the face of such dangers, regular vaccine shots or boosters (of the kind now being rolled out in the UK) might be needed for the foreseeable future, tailored to the variants found to be most prevalent at the time, just as they are for flu. But as with measles, mumps and rubella, unvaccinated communities that either lack access to or resist vaccines will both create a persistent direct hazard and keep the virus endemic.

The ideal solution—something never yet achieved with varied and fast-changing flu viruses—would be to make a “pan-coronavirus vaccine” that could prime our immune system to recognise the features that all such viruses share. “If you could do that, you’d likely cover all the variants,” says Virgin. “To me, that’s one of the great hopes for dealing with this thing long term.” Vir is currently working on that challenge with GlaxoSmithKline, as are other teams elsewhere.

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As a virus that began in bats, it’s possible Covid-19 could pass back to other species and then mutate, before returning to haunt us—as happened with swine flu. © Oramstock / Alamy Stock Photo

Thankfully, vaccines are not the only answer for taming Covid-19. After all, the real risk is not infection per se but serious illness. The search is on for anti-viral agents that can stop the virus from infecting cells or replicating within them, lessening the severity of illness. Proteins called monoclonal antibodies that recognise and bind to the virus have been shown to be effective, including in people at high risk. One such drug has recently been approved for use by the UK’s regulator. And a drug called molnupiravir, developed by Merck to treat flu, has shown great promise in reducing severe symptoms and hospitalisations, and can be taken as an oral pill with no serious side-effects evident so far.

Even so, containing local outbreaks of an endemic disease will (or, at least, should) continue to merit constant vigilance. Routine testing might become permanent in some situations—such as air travel—and will need to kick in whenever the rate of infection in a population rises over a critical threshold. One relatively cheap surveillance strategy is sewage testing: monitoring levels and sequencing genomes of the virus in municipal wastewater to gauge rates of infection and to detect or track new variants.

Mitigation measures might need to become standard, including simple but effective interventions that reduce infection and transmission: mask-wearing, good ventilation, some degree of social distancing. Vaccine passports and temporary restrictions on large public gatherings could be required to manage outbreaks. Despite politicised and performative opposition, not least from Cabinet ministers who pointedly refuse to wear masks, there is still considerable public support for such measures.

“I think many people will be more willing to wear face coverings than in the past,” says Martin McKee of the London School of Hygiene and Tropical Medicine. “If this happens, we could see significant reductions in not just Covid but also other respiratory infections.” (While some people ask why we make such a fuss about Covid when we are willing to accept several thousand deaths each year from flu, McKee turns that question on its head, and notes that seeing  as “other countries, particularly the Nordic ones, seem to avoid [that] seasonal toll… maybe we shouldn’t accept [that] either”).

Those rise-and-fall graphs of infection rates, hospitalisations and deaths give only a partial picture of the emerging medical challenge. Many who survive Covid develop longer term problems and even seemingly-permanent disabilities. The symptoms of long Covid, including shortness of breath, fatigue and muscular weakness, are expected to afflict at least 10 per cent of infected people; one recent study showed that 37 per cent—more than one in every three—have a symptom lasting over three months. People, some of them young, have experienced organ failure, with consequences including brain damage and cognitive impairment, strokes and diabetes. Although it is possible that the vaccines might give some protection against long Covid, it’s still not clear.

Politicians have now recognised that all the pandemic disruptions and delays in surgical procedures and screening programmes for unrelated health conditions will have lasting consequences: the NHS was recently awarded extra cash for the next couple of years to help with the “Covid backlogs.” But there is nothing like enough discussion of the persistent healthcare burden associated with lasting disabilities and impairments directly produced by the pandemic. All this is before we get to the effects on mental health, not least for the exhausted and traumatised healthcare workers that the rest of us will continue to rely on.

Such consequences are and will be experienced unequally: Office for National Statistics calculations point to an age-standardised death rate from Covid-19 that is a little more than twice as high in England’s most deprived than most affluent neighbourhoods. Unequal vaccine access means that poorer places will suffer the burden of the pandemic for longer. The educational gap has widened too, as pupils at harder-pressed schools were denied the resources to achieve the continuity in learning at home that private schools in particular were quick to apply. Then there is the economic fallout. Many small businesses have vanished: we have lost many clubs, cafés, restaurants, high street shops and theatres for good. Only those who are both privileged and lucky can hope to escape a significant fallout from the pandemic in their own communities and lives for at least the next few years.

In contemplating the future with Covid, we should be wary of giving too much agency to the virus and not enough to ourselves. If we don’t distribute the vaccines fairly, or take swift and effective actions to reduce infections, we are choosing to encourage new variants and increase the global health burden. If leaders fail to control misinformation or to invest in public health infrastructure, while hailing the return of an unsustainable normality, they are sowing the seeds of more problems down the line.

We have choices about our individual behaviour too. “I think we’ll divide into two broad camps,” says Trish Greenhalgh, professor of primary care health sciences at Oxford: “the ones who will ‘get back to normal,’ travelling on public transport, attending mass events… and not really worrying much about getting infected, and the ones whose lives will remain profoundly changed.” What will each group make of the other? Will we end up with each part of the population denouncing the other for being either compliant and frightened or selfish and irresponsible?

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Class apart—coronavirus has exposed and deepened many existing inequalities in the social fabric, not least in education. Anthony Devlin/Getty Images

Such fractures are ripe for political exploitation—and can distract from real accountability. Thus far at least, many obvious blunders of policy and judgment have not been punished by public opinion in the way one might have expected. Those leaders “espousing populist arguments have been associated with the catastrophic mismanagement of the pandemic,” writes McKee with his colleague May van Schalkwyk and others in one recent paper—but they have not been held to account for it. While Donald Trump’s woeful pandemic response—ignorant, indifferent, sometimes surreal—may have helped tip the balance against his re-election in November 2020, the total number of votes he won was nonetheless larger than that of any other candidate in American history, except Joe Biden.

In the UK too, stark failures—such as, to take only the most egregious example, sending children back to school for a single day to spread the virus last January—never stopped Boris Johnson riding high in the polls. He has enjoyed a vaccine dividend, although it remains to be seen whether that will fade as it becomes clear to everyone that inoculation has not turned out to be the pandemic-ending panacea he had assumed.

It would be nice to imagine we will eventually emerge with improved accountability, management and transparency. But there were ominous signs in the damning Commons Select Committees report, published in October, that some blame is going to be unfairly shunted onto the scientific advisers. Perhaps the sheer enormity of the matter somehow prevents politicians—for whom mistakes that cost a dozen lives would once have been career-ending—from suffering for errors that cost many thousands. Such outcomes somehow feel more like natural disasters than policy disasters.

But if democratic systems won’t discipline leaders for deadly missteps, what will? In times of uncertainty and fear, people are vulnerable to simplistic certainties and the illusions of “strong” leadership: another recent study by McKee and colleagues spotted a correlation between deaths in Italian cities during the 1918-1919 pandemic and votes for Mussolini in 1924. More often, as political scientist David Runciman has argued, democracies have a habit of pulling through crises without truly learning from them. (Think of the way “neoliberalism” has limped on since the 2008 financial crash.)

“Right now we just crave escape from the horrors. The arts are in a stage of ABC—Anything But Covid”

So are injunctions to “build back better” after Covid—to restructure the economy, working and travel practices and healthcare systems—merely wishful thinking? Perhaps not. Several world leaders, including the premiers of France, Germany and, to be fair, Britain too, have joined the director-general of the World Health Organisation in calling for an “international pandemic treaty” to “strengthen… capacities and resilience to future pandemics.” With some obvious exceptions, such as Brazil’s Jair Bolsonaro and India’s Narendra Modi, McKee attests that political leaders (and also, interestingly, finance ministers) “now understand the dangers they face if they do not create more resilient societies.”

Far from the grand diplomacy, the pandemic has also revealed a reservoir of public compassion. As writer and activist Rebecca Solnit has described, “at large in disaster are two populations: a great majority that tends toward altruism and mutual aid and a minority whose callousness and self-interest often become a second disaster.” Democracies are often manipulated by that minority. But they remain a minority, and for every act of selfishness or political folly, there have been many examples of generosity, courage and public-spirited ingenuity. And right now, as McKee, van Schalkwyk and colleagues say, “considerable power resides in this wave of hope.”

Hopes of harnessing that wave for lasting change will turn more than anything on how we eventually come to understand what we have just lived (or are still living) through. Many scientists want to use the experience as a call to arms for internationalism and the funding of basic research. But many leaders have reason to prefer to tell the story as a terrible natural tragedy that they could do little to avoid. We are already seeing this “naturalising” of the pandemic as a background source of illness and death, rather like cancer: scarcely a political affair at all.

“We have not,” explains McKee, “reached a consensus about what should have been done differently.” In part, he says, this reflects competing ideologies: individualism versus collectivism. But our differing personal choices, for example about masks, may also reflect different coping strategies for what has been—and might continue to be—a traumatic experience. Some want to move on, forget or even deny; others to commemorate and learn.

In the end, a shared understanding of Covid-19 could be settled by the human stories that make it vivid—if, that is, they get a hearing. The military trauma that preceded the 1918-1919 pandemic was seared in the collective memory by the art it inspired, from Wilfred Owen’s poems and the memoirs of Siegfried Sassoon and Robert Graves to dramas like Chariots of Fire, War Horse and 1917. The even deadlier flu outbreak has never been commemorated to anything like the same degree.

The artistic response to the Covid-19 pandemic has so far been similarly muted. That could be because through lockdowns the arts were themselves too busy fighting for their life. David Hare, whose play Beat the Devil in the late summer of 2020 was one of the first dramatic depictions of the experience of (pre-vaccine) Covid, feels that the processing of wider narratives will take more time. “We’ve only just begun the story,” he says. “I think it is almost impossible to write at this point.”

Perhaps right now we just crave escape from the horrors. The arts are in a stage of ABC (“Anything But Covid”), Hare thinks: “there is at the moment a very strong determination to look away.”

But insofar as the pandemic has revealed pre-existing tears in the social fabric, not least inequality and poverty, there might be an uncomfortable reckoning yet to come. “Everything that was about to happen is happening much faster,” Hare says. Compared to the health impacts, “the social and economic reverberations will be far more profound, and I don’t think they’ve quite begun yet.”

The virus isn’t yet through with changing everything. And much as we may wish it gone, if in five years’ time Covid-19 is merely a dark memory and life really has returned to normal, we will have wasted the crisis.