Explaining COVID in 11 Minutes with Dr. Eric Larson

Imagine yourself in California at a clearing in a large forest. And it’s on fire. There are three groups of people standing before you. A large group is screaming and running around pointing at the fire. They’re yelling that we need to do something, anything we can to stop the fire. 

Meanwhile, there is another group (not as large) with their backs to the fire. They are mocking and ridiculing the group running around panicking. They tell them to calm down and to stop ordering people around. They insist there isn’t anything wrong at all.

Of course, the largest group of people are standing between these groups and looking behind those panicking at an intact forest and behind the ones who don’t notice the giant flames licking at the backs of the those ridiculing the screamers. These people aren’t sure what to do but in the interest of safety feel that getting away from the flames is probably the right decision. They tend to stand with the group that’s worried.

Obviously, this analogy describes our current situation with COVID in America. Most are not in one of the extreme camps. But we either identify with one or are left standing unsure of what to do or think.

What needs to be done, and what I did with my friend Dr. David Graham in April of 2020, is to try and be reflective and better understand what it is that we are dealing with. What are the biological, historical, and medical facts or suppositions that we can make to understand this pandemic?

If we return to our analogy of the forest fire, it would be best if we could somehow hop up in a hot air balloon and look down at the situation to assess what would be the best individual actions and true scope of the problem. History and biology could be used to understand the nature of fires, how they spread, what do you do to stop them, and what they are likely to do in their course.

Contrary to popular opinion, we have some rough ideas about what happens in pandemics and where we will end up. And THAT is the critical fact that we have to accept - those in all camps and in between. Because if we get THAT wrong, then we get everything else wrong.

The critical question we must ask is what is the endpoint for this pandemic? What is the biological consequence for SARS-CoV-2 (the virus that causes COVID-19) and its effect on humans. We have to agree on the ultimate end point in order to get our policies and strategies right for surviving the pandemic.

What became obvious to us in April of last year was that this virus, despite some government efforts at the time, would become endemic. It would join the other four coronaviruses that currently cause the common cold as a virus that will circulate forever throughout the human population. 

It will not get eradicated. It will infect everyone probably multiple times throughout your life. This is the biological history of endemic coronaviruses. It really is the way all these common respiratory viruses operate. Rhinovirus, adenovirus, parainfluenza virus - they infect your upper respiratory tract (nose, sinus, mouth) and cause a cold because although you don’t have enough antibodies to prevent infection (because they’ve waned over time or it’s a new variant that looks different enough to evade your antibody response) you have memory T and B cells that mount a quick response after infection to prevent a systemic or lower respiratory infection (pneumonia).

We know you get this immunity as a child and anyone who has kids knows small children are always sick with runny noses as they are constantly exposed to these different cold viruses which builds up their long term immunity to them when exposed later in life.

The mRNA vaccines are a medical miracle and trick your body into generating an immune response. It’s not magical (except the technology) and an elegant way to get your body to do the work so when it sees the real virus in the wild, it will seek it out and destroy it. But respiratory viruses often infect us before we can mount a complete immune response so you get sick and can transmit the virus. This isn’t a failure - your body has done what it needs to do - and so has the virus which just wants to reproduce and move to the next host.

We live in an equilibrium with these viruses, we develop immunity when we’re young so if we are exposed when we’re older we can prevent really bad outcomes. But we get sick and the virus continues to circulate in the world’s population with different viruses coming and going. It’s a sort of dance.

So what does this all have to do with our wild fire? Well, we know this thing will burn until there isn’t any fuel. And fuel is considered people without immunity to the virus. There are only two ways to get immunity - a vaccine or infection. Until the virus has burnt all the fuel, it will continue to burn - there is nothing we can do to stop it. We might slow it down, we might find ways of treating the fuel on fire (although most treatments for viruses are not very good), but ultimately, everyone is going to get it.

What does history tell us about coronaviruses? Well, until SARS-CoV-2, we had four endemic coronaviruses that cause colds. The youngest is OC43 which researchers believe jumped from cows to humans in the late1800s. This was at the same time as the “Russian Flu” worked its way around the world so perhaps that flu was actually a coronavirus. If so, OC43 caused a lot more problems to humans back then who were older and naive to the virus according to the news reports from all over the world.

But by now, we have all had multiple infections with OC43 and its variants from when we were kids to today where we usually feel terrible for a few days or maybe a week. Over time, the virus does ‘mutate’ towards becoming more benign and infectious but that usually takes a long time. Anyway, it serves as a useful road map for what might happen to us in our biological dance with this new unwelcome visitor. 

We also know, that immunity to these respiratory viruses wanes over time. Either with natural infections or vaccines. The only way you can develop better immunity is through booster shots or infections. But what we really care about - ending up in the hospital - is focused almost entirely on the non-immune.

This is a nasty bug, it affects the obese and elderly the most and it isn’t going anywhere. It has definitely killed hundreds of thousands of Americans. So this gets us to the important policy considerations - if we know that it is endemic (which was obvious over a year ago) then how should we approach our public health?

Obviously, the only point to slowing the spread at this time is if you could get those without any immunity (no infection and no vaccine) vaccinated to minimize the number of people clogging our hospitals. But you can’t get to any vaccination rate that will stop the spread of the virus. There is no herd immunity threshold - no number of vaccinated and immune to perfectly prevent its spread. Besides the fact that our ability to slow the spread is questionable anyway, it just doesn’t make a difference in the end.

We are all going to get this virus. Somewhere, there’s a date with you and you and you and me with this virus. Whether you’ve been vaccinated or not you will almost assuredly get infected. If you have some immunity through a vaccine or previous natural infection, you are much less likely to get very sick. So mandating vaccines - if we agreed that it was wise and just - wouldn’t matter much to those who are vaccinated. It may slow the spread and delay the next time they’re exposed but they will still get it when their immunity wanes. And again and again.

If your mitigation measures worked, all you would do right now is extend the time it takes for everyone to get immunity unless you believe you can convince those who won’t get immunized to get the vaccine. Even so, that only really benefits those who have chosen to not protect themselves while inconveniencing everyone else and taking away a lot of rights and simple joys of life. 

It’s easy to see how we got here. Mission creep is not just something that happens with the military - it happens in public policy too. By believing that we could prevent people from getting infected, we have embarked on a strategy that is unwindable and with no clear end point. There is a preponderance of evidence that people can get reinfected multiple times with COVID and after vaccination. Both through research and observational data we know that infections with SARS-CoV-2 will continue to happen forever whether you are vaccinated or not, whether you have had it before and recovered, and no matter where in the world you are living.

Fundamentally, we have been chasing a zero-COVID strategy in almost every aspect of our society. Obviously, vaccines are a great idea for those who are at risk. I like to point out to how getting chicken pox (Varicella) as an adult is a completely different experience for an adult than it is a child. Adults can die from chicken pox whereas kids almost never do. Also, an infection of varicella puts you at risk of getting shingles later in life which can cause pain and a host of other problems. This is one reason why we vaccinate children for chicken pox.

But clearly, vaccination (since we know it won’t stop transmission in its tracks no matter how high the rate is) is a strategy to keep people out of the hospital and free up hospital resources for other things like heart attacks, strokes, cancer, etc. Masks, lockdowns, testing and quarantining and any other mitigation efforts are Zero-COVID policies which are of dubious efficacy and ultimately, make no difference since we will all get infected eventually. 

The most sensible reason to resist vaccine mandates, masking rules, and various lockdown measures in the US at this point is because they are attempting to stop what cannot be stopped. Even 60% of the deer in Michigan have had COVID and serve as a reservoir for the virus along with mice. SARS-CoV-2 is not going anywhere so acting like you can keep it out is akin to wrapping yourself with a towel when you go swimming to stay dry.

Perhaps you could argue that you are waiting until there is a childhood vaccine but that might take months or years until you get large enough numbers of kids’ parents to get their kids vaccinated. What target are you looking at? It is exceedingly rare for kids to get really sick with this virus. Do these measures justify affecting their socialization and education and all the other aspects of life we take for granted? Is it worth having every child see other people as disease vectors rather than unique individuals to whom they can get to know, collaborate, play, love, and innovate?

Some might argue that the infirm or immunocompromised (like those with solid organ transplants) are at risk and we should encourage vaccination to protect them. Again, the vaccinated can still spread the virus and the only thing vaccination does is frees up hospital resources (which is important). However, once people have had an infection once or maybe twice, they are much less likely to clog the hospitals. Either way, all you’re doing is maybe buying some time with these extreme measures but not significantly altering the course of the pandemic in any significant way.

The effect of all these mitigation measures falls hardest on our youth. They are the ones who need socialization the most. They are the ones who need interactions for learning the most. I’d argue that right now our greatest generation is our youth, (gen Z and gen alpha) as they have given up the unique experiences of high school sports, graduation, dances, gatherings, the arts - in order to protect the elderly in our society. They have given up so much and we must recognize that and always ask ourselves how much more do we need them to sacrifice to slow the spread of an inevitable disease. 

We have become so locked in to thinking that we need a zero-COVID strategy to slow the spread that we have forgotten that that was only supposed to last as long as it took to protect those who wanted protection. We’ve gotten there and now it’s time to allow those who want to isolate go do it and let everyone else go about their lives.