Each day we inch toward the end of COVID-19. The end is not when cases go to zero, but rather when we accept what has been true all along. Because of multiple animal reservoirs, because vaccinated people can still experience breakthrough infections, and because billions of people globally have yet to be vaccinated, the truth is clear: SARS-CoV-2 is an endemic virus.
Over the next decade, give or take a few years, every single person on earth has a date with this virus. We will all be exposed, and the virus might replicate in some of our respiratory mucosa. A few of us might get very sick, while many of us may only get mild illness or not get sick at all from our encounter. I prefer to meet the virus on the best terms: after two doses of the COVID-19 vaccine (as I have gotten).
When we truly come to accept that avoiding the virus for decades is impossible, many things change. Our policy goals change, and the restrictions we place on society change.
If you are an adult and have neither been vaccinated nor have natural immunity, you should seek out vaccination. If you are in a location with limited vaccine availability — and you are older or vulnerable — you might want to shield yourself, as best you can, while you wait for a vaccine. Kids who aren’t yet eligible for vaccines — and people in close contact with young kids or other unvaccinated people — may also choose to take precautions.
If instead you are among the majority of U.S. adults who have been vaccinated or have natural immunity to the virus, your choice is clear: you can continue to follow strict personal precautions (avoid weddings, skip parties, etc.) and delay your encounter with the virus, or you can loosen up those precautions and speed up the time to encountering it. What you can’t do is avoid it forever.
Some folks who are vulnerable may wish to get a booster prior to changing their behavior, but we have yet to see clinical outcomes improve from boosting in the general population, and it is possible that with more time, the booster will also wane and you might need a series of them. Despite all this, you may still eventually encounter the virus.
Healthy people, particularly young people who have been vaccinated (such as college students), might realistically not be able to do anything more to optimize their chances of remaining well when they encounter the virus. They can skip parties, avoid dating, and give up indoor restaurants, but practically this may just delay COVID-19 from age 22 to 30. The price paid for this delay will be the inconvenience of those precautions, and the events they did not experience along the way.
Thinking about meeting SARS-CoV-2 as a matter of when, and under what circumstances, rather than if, changes one’s policy choices. First, it stresses the importance of vaccination. It doesn’t matter if vaccines are not perfect or if you can still get sick — because they greatly reduce the chance of hospitalization and death, they are worth pursuing.
Second, it makes one question our policy choices. For example, many universities are currently testing asymptomatic college students weekly. When cases rise, these schools have banned private gatherings and implemented masking indoors and out. These policies might either have no proven benefits (outdoor masking) or somewhat slow the spread of the virus (banning gatherings), but what is the big picture goal? Every one of these students will eventually be exposed to the virus, particularly as parties get pushed inside in the winter and during big spring break gatherings. If the local healthcare system is not experiencing a rise in hospitalizations (which they’re not in many of these cities), then these policies deprive college students of experiences that mean something and at best shift the date they encounter the virus. Since most students are young and healthy, the risk the virus poses to them and the odds they’re going to encounter it are unlikely to be significantly changed.
Beyond only colleges, heavily vaccinated cities such as San Francisco continue to implement restrictions, such as indoor mask mandates for the vaccinated. Again, at some point in the next decade, the virus will likely meet all the people in San Francisco. If they wear surgical masks for the next 6, 12, or 18 months, eventually they will fatigue, and the virus will be there when they do. The odds of getting very sick won’t change for most people, so what is the goal of delaying the encounter if local hospitals aren’t stressed?
Acceptance means reminding ourselves that the things we have put on hold — dinners, parties, lectures, meetings, museums, restaurants, travel, weddings, and so on — can’t be put on hold forever. And avoiding all these activities in pursuit of health means giving up living in order to stay alive.
Acceptance is coming — that’s the true end of the pandemic. COVID-19 won’t vanish as some may have believed early on. Instead, some pockets of the U.S. will continue to have caseload increases, some hospitals may get overloaded and local measures may be necessary, but the virus is not going away and the burden is on us to come to terms with that. Each of us has to decide how much life we are willing to trade to delay our time to meet the virus.
Vinay Prasad, MD, MPH, is a hematologist-oncologist and associate professor of medicine at the University of California San Francisco, and author of Malignant: How Bad Policy and Bad Evidence Harm People With Cancer.
Last Updated September 22, 2021