— This article by Abdul El-Sayed originally appeared in the newsletter The Incision. It has been edited for style. Subscribe to The Incision here: incision.substack.com
Throughout the pandemic, Europe has been a harbinger of what’s coming next on this side of the pond. And across Europe, COVID cases are climbing. In the U.K., the current weekly average looks like it did last Christmas, during the country’s worst surge. The Netherlands is experiencing a pandemic record high in cases right now.
Last week in the U.S., after months of declines, cases started to climb. It’s only natural to be concerned when cases of a pandemic disease start to go up. After the massive holiday surge last year, it’s not surprising that the news of increasing cases as we prepare for Thanksgiving would set off alarm bells. But there’s another way that Europe’s experience should be instructive: COVID deaths are substantially lower than they have been in the past.
As our anti-COVID armament changes, looking simply at mounting case rates is giving us an increasingly distorted picture of the state of the pandemic. We’ve now reached a place where we need a better way to measure it.
Take the U.K., for example. Despite the same number of cases as it experienced last Christmas, the U.K. is experiencing only 27 percent as much mortality. In the Netherlands, even with record-setting case rates, mortality is only a quarter as high as it was during the next highest case surge over the holidays last year.
Across the country, Americans are making choices — personal choices about how they’ll spend Thanksgiving and the holidays and policy choices about schools and workplaces. These choices should accurately reflect the real risk of COVID, rather than a distorted risk clouded by how we’ve been conditioned to think about COVID from a time when we didn’t have vaccines.
The main reason, of course, is vaccines. Though we tend to think of vaccines as reducing case transmission, vaccines were always intended to reduce symptomatic illness. And they do — which is why the mortality rate is so low across Europe. There’s also a lot more testing now. We’re no longer in the Bad Old Days of 2020 when we simply couldn’t catch up with the glut in COVID tests. Today, testing is done quickly, simply, and cheaply. In the U.K., they offer every single person two rapid tests per week. Increased testing means that more of the asymptomatic cases we might have missed in the past are counted alongside symptomatic ones.
There’s yet more reason for hope on the horizon. Two new oral antiviral pills have shown promise, reducing COVID hospitalization by up to 91 percent. The federal government has already secured 1.4 million courses of Merck’s molnupiravir, currently under review by the Food and Drug Administration. All of this suggests that a case of COVID in 2021 is not the same as a case in 2020. Indeed, despite rising cases, we’re making progress on the pandemic.
And yet there’s a risk of being held hostage to the anxieties of the past. Across the country, Americans are making choices — personal choices about how they’ll spend Thanksgiving and the holidays and policy choices about schools and workplaces. These choices should accurately reflect the real risk of COVID, rather than a distorted risk clouded by how we’ve been conditioned to think about COVID from a time when we didn’t have vaccines. A constant focus on the number of COVID cases may be, in this respect, misguided. And I think it’s time for us to take the next step in how we track, and therefore talk about, COVID.
Rather than daily case rates, I propose tracking three alternative metrics: Daily COVID hospitalizations rates overall, average daily hospitalization rates in counties with greater than 70 percent vaccinations and average daily hospitalization rates in counties with less than 70 percent vaccinations.
Why these metrics? Well, for starters, they’re self-evident and easy to understand. They also reflect the risk of serious symptomatic illness, a far more important indicator of risk of the experience of disease compared to infections, which can include asymptomatic or mild illness. Third, they map to the unfortunate bifurcation in attention to the pandemic that has emerged.
The risk of COVID is far more serious in unvaccinated people in less vaccinated communities, who largely account for the most serious cases of COVID right now. But these aren’t the folks who pay the closest attention to the pandemic.
The risk of COVID is far more serious in unvaccinated people in less vaccinated communities, who largely account for the most serious cases of COVID right now. But these aren’t the folks who pay the closest attention to the pandemic. Rather, paradoxically, most of the attention comes from vaccinated people in more vaccinated communities who interpret the global averages driven upward by the former as a reflection of their risk. Fourth and finally, the disparity in COVID hospitalizations between more and less vaccinated communities serves as an implicit reminder about the risks of staying unvaccinated.
Make no mistake, COVID is not over. There remains real risk of symptomatic illness, hospitalization and death, particularly in unvaccinated communities. Any COVID death is one too many. Even among the vaccinated, the risk of long COVID remains. And yet that risk is low. In a recent study of 1,497 vaccinated healthcare workers — whose risk of COVID exposure is far higher than the average person — of the 39 people who had breakthrough infection, just seven had symptoms lasting more than six weeks.
That’s less than half a percent. Further, in haste to move beyond the pandemic, we cannot forget the risk to the most vulnerable, such as the immunocompromised, for whom even after vaccination the risk of symptomatic illness remains high. The most important answer here is more vaccination… which is why vaccine requirements continue to be the single most important tool in the armament against COVID, even as the state of our fight against it changes.
We are moving into a new phase of the COVID era. As I’ve discussed, the transition from pandemic to endemic is neither obvious nor easy to ascertain. It happens gradually. But it is happening. It comes down to risk tolerance. And like it or not, we take risks every single day. The choice to get into a car is a risk given that automobile accidents are a leading cause of death. Yet, we’ve developed technologies to protect us. Cars are required to have airbags. Seatbelts are mandatory.
Though some choose not to wear them (and bear the risk of getting ticketed in addition to the health risks), the requirement has sharply reduced the rate of death on the road. It’s a helpful metaphor for the pandemic. Seatbelts and airbags make the risk of automobile travel tolerable for most people, just as vaccines, medication and masks should for COVID. If we could just get more people to wear seatbelts… and get vaccinated.
— Dr. Abdul El-Sayed is a physician, epidemiologist, educator, author and a former Michigan gubernatorial candidate
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