The Pernicious Folly of Pursuing Zero Covid

I often return from my hospital rounds as an infectious disease consultant having seen zero COVID-19 patients. Over the past few months, this has become a common occurrence—not only when I round as an infectious disease consultant but also when I am working in the emergency department or the intensive care unit. This is an almost inconceivable change from the situation of 18 months ago, when hospitals were barraged by so many patients that there were real concerns as to whether the healthcare system would survive. After an estimated five and a half million deaths and massive disruptions to our way of life, COVID’s current inability to threaten hospital capacity is a hard-fought victory.

This seems like a fitting moment to reflect on the nature of society and of infectious disease and the obligations we have to one another in light of these facts.

COVID-19 has been transformed into an increasingly manageable risk for both the healthcare system and for individuals. It has become much easier for individuals to calculate the risks associated with COVID, thanks to the widespread availability of vaccines, boosters, monoclonal antibodies, antivirals and home testing kits. Infectious diseases always impact some people more severely than others, but for the vast majority of people the virus has been successfully tamed and the personal risks they face from it are on a par with those from other respiratory viruses, such as influenza (something that was not the case earlier in the pandemic). Given that Covid is a respiratory virus that spreads efficiently and is part of an ineradicable, ubiquitous, common-cold-causing viral family, this is the best outcome we could have hoped for. This almost incredible progress is reflected in updated CDC guidance that is very close to the guidance offered for other respiratory viruses that we deal with day in and day out as well as in President Biden’s off-the-cuff remark that the pandemic is over. The new guidelines and the President’s sentiments reflect the realization that we are no longer in the throes of an emergency.

Yet Yale epidemiologist Gregg Gonsalves has described these changes as “grotesque” and an example of “social Darwinism,” while journalist Tara Haella has tweeted that “Just because you did fine doesn’t mean everyone else does” and the Atlantic’s Ed Yong writes that as “many Americans reveled in their restored freedoms, many immunocompromised felt theirs shrinking.”

And putting the burden on the vulnerable? It's grotesque. Sure, the elderly, immunocomprised and others should just fend for themselves. That's called social Darwinism. It's suggesting only "the strong" survive and is ableist in the most profound way. 8/

— Gregg Gonsalves (@gregggonsalves) August 13, 2022

I am living & enjoying it. For me, good health is literally a vital part of living, and good health can be severely impaired by even one COVID infection. Just because you did fine doesn’t mean everyone else does. The statistics speak for themselves & our family has risk factors.

— Tara Haelle (@tarahaelle) August 16, 2022

What explains this difference in outlook?

The objections to the new CDC guidance reflect the new, egalitarian medical ethics that some want to impose on us. We are told that, despite the undeniable achievements of science and medicine, COVID is not universally manageable and, until no one remains vulnerable to it, the pandemic can never be declared over. Certain health-policy advocates demand a world where no one gets seriously ill, dies or suffers long-term harm because of COVID. They paint vivid pictures of the consequences of catching Covid for the most vulnerable among us, and they urge the rest of us to continue to make sacrifices to shelter the vulnerable from this fate. In doing so, they are forgetting that there have always been and will always be medically vulnerable people among us—people for whom even an ordinary common cold could mean a dire prognosis. And doctors have always counselled them, and those who deal with them directly, to take special precautions, rather than expecting the rest of the world to make extravagant adjustments to their circumstances. This prescription for society is not only unrealistic but disregards the achievements of those who were responsible for developing the tools we all rely upon, while unjustly scorning those of us who seek to resume our social and professional lives, pursue our values and flourish.

And, importantly, the situation with Covid is not going to get much better than it is now (at least in countries well provisioned with vaccines and therapeutics). There will always be a baseline number of hospitalizations and deaths. Calls to work towards Covid Zero are delusional. They treat the pandemic not as an emergency from which we’re emerging, but as an occasion to rewrite the ethics around infectious disease (and health more generally) in normal life, under the pretext of protecting the vulnerable and the immunocompromised.

This position is what I call the collective duty viewpoint. It is held by many in my field and many of the policies that characterized the early-to-mid pandemic response (thankfully mostly revised in the new CDC guidance) were driven by it. These sentiments reveal a desire for equal outcomes (irrespective of individual risk factors for severe disease) that will never be achieved, as well as a disdain for those who are unlikely to experience severe disease.

Of course, we’d all like to live in a world where everyone was healthy, communicable diseases were rare and effective treatments were readily available. Even the healthiest would be better off in a world where others weren’t in such danger from disease, for these diseases can affect our relatives, co-workers, trading partners, etc. and all our lives are made worse when the people we deal with are stricken by illness.

We prefer healthy societies because the more each one of us thrives, the better off we all are. People are values to each other. We should therefore celebrate improvements to population-based outcomes, such as deaths from HIV or vaccination rates. Societies in which population health metrics are optimized tend to be the best societies to live in.

However, the health of the population should not be seen as more important than the health of the individuals that comprise the population. The population is not some super-organism or mystical entity that transcends the lives and interests of individuals. Individuals make up populations and population health is, therefore, a direct consequence of individual health (which can be impacted by the way society is structured).

Collective or population-level outcomes should not be privileged over individual outcomes—the two should be integrated and we should recognize each individual’s need to pursue his or her own happiness. This is the crux of my disagreement with the collective duty advocates. In essence, they hold society or the population as the standard of value and consider each of us to be mere fragments of it and not self-sustaining individuals with our own value.

When controlling contagious infectious diseases such as COVID, population-level factors are important in advising individuals as to which actions are relatively safe and which are relatively dangerous. For example, the case count, the wastewater prevalence, hospital capacity, the activity and the individual’s risk factors for severe disease all help a doctor help a patient decide what level of risk is acceptable to him or her. In this situation, the doctor uses population metrics to advise an individual patient, rather than privileging one over the other. This applies equally whether the pathogen spreads from person to person, from mosquito or tick to person or is an environmental risk.

When a disease is transmissible between people, it is crucial to recognize that one person’s actions can place another, unknowingly, at unwarranted risk. During the COVID pandemic, this risk was especially acute during the pre-vaccine, pre-treatment era, when we had no ability to forestall what might be a serious or fatal illness for some and the population was not yet acclimatized to the new risks that came with social interaction.

When human civilization transitioned from a nomadic hunter-gatherer lifestyle to one characterized by settlements and agriculture, this entailed accepting certain risks along with the myriad benefits. As people began to live close to each other (and to their animals) for longer periods of time, certain infectious diseases became an unavoidable, everyday part of life. The Age of Agriculture is also the Age of Pestilence.

The aftershocks of the trade-off that our ancestors made, and we continue to make, are still felt today.

When an individual decides to live in society among other humans, there will always be a risk of respiratory (and other) pathogen transmission. We implicitly agree to assume that risk when we voluntarily interact with each other and when we choose to live in cities, towns or villages. While those who are overtly contagious are advised to refrain from social contact, many respiratory viruses have mild or unapparent symptoms, making it impossible to know who may be contagious at any given time.

While no one who knows themselves to be contagious should significantly expose others—even to a mild cold—without their consent (or should offer to wear a mask, social distance, etc.) many of us have gone to work or school with a mild cold. Implied consent applies in most such cases as mild infections are an assumed risk of social interaction. However, certain respiratory infections (e.g., tuberculosis) are so severe that people do not implicitly consent to expose themselves to them. In the early days of COVID, before medical countermeasures were widely available, SARS-CoV2 was clearly one such infection.

Moreover, because we are all linked as patients of the same capacity-limited healthcare systems, temporary, clear, and metric-directed guidance on modifications to social interactions that focused on bending the case curve until hospital capacity was addressed was justified. In the US and UK, where the government controls hospital capacity, government officials had to make some of these decisions.

However, vaccines, antivirals, monoclonal antibodies and rapid home tests, coupled with high levels of population immunity against severe disease, have now made COVID a less severe risk. For the vast majority of people (especially vaccinated people), COVID has become more manageable, which in medical terms is defined as an illness that requires only outpatient treatments such as Paxlovid or simple rest and supportive care. As COVID becomes increasingly an infection for which people are rarely hospitalized, it loses its ability to threaten hospital capacity. This is the only form of victory we can expect over what is destined to be an ineradicable, efficiently spreading respiratory virus.

Despite all these advances, some people will still develop severe disease. The existence of this group is often cited as a reason to delay “normalizing” COVID. But how long this delay is to continue and based on which metric, no one knows.

Many of my patients are immunocompromised, and my mother is on an immunosuppressant drug for rheumatoid arthritis, so the needs and vulnerabilities of this population are never far from my mind. But these vulnerabilities are not unique to COVID. Any respiratory virus, from RSV to influenza, can be dangerous to this segment of the population. I have personally counselled such patients pre-COVID to be wary around anyone with even a mild cold, to consider wearing masks (one-way masking works), and to be extra cautious during respiratory virus season. COVID hasn’t changed this standing recommendation.

In the future, I think it is likely that other respiratory viral diseases will take a proportionately higher toll on the immunocompromised than COVID because, unlike COVID, there are no vaccines and very limited treatments for these conditions. While COVID will circulate more widely and cause more hospitalizations and deaths in the near term, we also have more effective and abundant medical countermeasures for COVID than for any other respiratory virus, including home tests, which do not yet exist for any other similar virus.

The key to protecting the immunocompromised from COVID in the years to come will be a plentiful supply of antivirals such as Paxlovid and monoclonal antibodies such as the prophylactic Evusheld as well as ubiquitous access to home tests. These tools are finally becoming increasingly available—indeed, Paxlovid and Evusheld are being underutilized as I write. Additionally, new and improved vaccines and monoclonal antibodies are being developed.

Infectious diseases will never impact people equally. Nature is neither fair nor unfair; it simply is. Some people, through no fault of their own, possess or have acquired attributes that place them at higher risk for severe disease. For example, a person with diabetes is at much higher risk for severe disease from COVID than someone with HIV. This is a biological fact inherent in the world.

Infectious diseases have never been equal opportunity offenders. Bemoaning this fact does not change it; nor should we hold everyone to the strictest standard of risk regardless of whether it is applicable to their individual medical condition or risk tolerance. It is wrong—obscenely wrong—to deny the living the opportunity to live their lives to the full.

We cannot evade certain differences between us: some of us are obese, some of us are immunocompromised, some of us are elderly, some of us have asthma, and some of us have none of these characteristics. Those with certain conditions may have to navigate a world in which COVID circulates more cautiously, just as those with severe food allergies must navigate a world in which allergens abound differently from those who are not allergic. Hopefully, medical science will develop better treatments to minimize the risk to all populations, but there will always be a risk differential.

It is also true that co-morbid conditions will become more common as scientists develop an increasing number of tools that turn deadly diseases into chronic, liveable conditions (type I diabetes was once a death sentence). Indeed, the number of people who are immunocompromised following solid organ and stem cell transplants is testament to our resilience—medicine has conquered formerly fatal conditions. For much of our species’ past, humans rarely lived long enough for the age-related factors that augmented the severity of the pandemic to be a concern.

We cannot place ourselves behind some artificial veil of ignorance, as if we could not know what our individual risks from COVID might be and myopically choose a society that is laser-focused on what is best for the most vulnerable, while ignoring many other relevant factors. For most people, COVID is on a par with many other respiratory viruses to which we have grown acclimatized. If we had always structured our society in such a way as to protect the most vulnerable at the expense of everyone else’s flourishing, humans would still be in caves. An egalitarianism that refuses to recognize risk differentials, carried to its logical end, spells the end of all human progress and ingenuity, including the ingenuity that led to the vaccines and antivirals that will increase our resiliency to the next pandemic.

Moving forward, each of us will develop our own risk tolerance for COVID and other emerging infectious diseases. I advocate an individual or personal responsibility viewpoint. Individual risk tolerances are not one-size-fits-all—nor should they be—as each of us has a unique life, with a unique hierarchy of values. It is important to respect each other’s risk tolerance. For example, if a place you wish to frequent requires a mask, test or vaccination, it is the owner’s right to make that a condition of entry. Similarly, if a person with whom who wish to associate does not feel comfortable with you unmasked, you must wear a mask if you choose to interact with them.

Many of the collectivists fantasize about a COVID- or infectious-disease-free Garden of Eden world, as part of a world in which any unequal distributions of fortune and misfortune must be remedied. COVID has provided the perfect opportunity for them to advocate this position.

But it must be opposed.

When it comes to COVID and future communicable disease threats, what we need is a fully informed approach that permits each of us to pursue our long-term rational self-interest, respect the individual rights of others and calculate our own risk, in accordance with our own unique level of risk tolerance.