Covid cleared the decks

For the first couple of years of the pandemic, other respiratory viruses seemed to be on hiatus. (Rhinoviruses, which cause the common cold, were an exception.) Social distancing measures, sharp declines in international travel, and potentially some interplay between SARS-2 and the other viruses are thought to explain their
absence.

There was no flu season to speak of in the winter of 2020-2021. Last year, flu activity picked up some, and respiratory syncytial virus, or RSV, returned, but in August and September, not over the winter as was the virus’ wont in pre-Covid times. This year, flu and RSV were back with a vengeance, though unseasonably early. With a new kid on the block, it seems like everything’s a bit out of whack.

And the genetic diversity of flu viruses appears to have declined. In fact, one strain of influenza B viruses, Yamagata, hasn’t been seen since March 2020. Some flu experts think it was snuffed out; others say it’s too soon to be sure. Still, the possibility astonishes Cecile Viboud, a senior research scientist in the division of international epidemiology and population studies of the National Institute of Health’s Fogarty International Center. “The thought that we might have eradicated one part of flu — it’s just unbelievable,” she said.

The health care worker roller coaster

Christine Grady has been surprised by the way society has treated health care providers during the pandemic. (She didn’t mention people who work in public health, but everything Grady said also applies to them.)

Very early on, people treated health workers like pariahs, because they feared catching the new disease from them, said Grady, who is chief of the department of bioethics at the NIH’s Clinical Center. Then for a time, health workers were heroes, during the bang-your-pots period. Later, as pandemic fatigue and denialism set in, health workers were again targeted, sometimes with threats of violence. Grady knows well of what she speaks. She is married to Fauci, the NIAID director and President Biden’s scientific adviser, who has had to have a security detail for some time.

Grady warned that “many HCPs are experiencing burnout and mental health challenges and leaving their jobs in large numbers, and fewer students are choosing health professional-related education. Currently, the strain on the capacity of hospitals and clinics caring for large numbers of patients with Covid, influenza, RSV, and other disorders is exacerbated by HCP shortages.”

“I worry what it portends for the future of healthcare,” she wrote in an email.

Unsettled science, scientific hubris, and the attack on science

One of the big surprises for Messonnier is how many scientific questions remain unanswered at this point. We still don’t know the correlates of protection — effectively what a protected immune system looks like — or which of the
transmission-reduction techniques works best. There’s not a clearly accepted definition of long Covid. Her full list is longer.

“I’m not sure that people are asking the right questions in a parsimonious way that you can get solutions,” she said.

Bieniasz was surprised at how much scientific hubris was on display. Despite the fact that the coronavirology field was tiny before the pandemic and there were many gaps in our understanding of this family of viruses, some scientists made confident statements about them — statements that turned out at times to be wrong.

“I’ve been sort of repeatedly surprised by how often I see statements in the press attributable to scientists that have an unwarranted level of confidence associated with them,” he said, suggesting this has contributed to a decline in trust in science and in public health experts over the course of the pandemic.

Bieniasz thinks scientists should have started most statements with “I don’t know, but my best guess is …”

WHO’s Van Kerkhove was stunned by the way the field of science came under attack during the pandemic.

“I was absolutely shocked by the attack, the fundamental attack on science itself, which was in many respects political,” she said. “It surprised me how much this impacted every aspect of our work, how time consuming that was.”

So much for pulling together in a crisis
It turns out that a crisis can further polarize highly polarized nations.

“I think I naively would have predicted that it would have brought everyone together, because in the early days you felt that sense of ‘we’re all in it together,’” said Messonnier. Instead, the country cleaved into the people who were concerned about Covid and keen to reduce its spread and the people who thought the cure — school closures and the like — was substantially worse than the disease.

The fights were vicious, deepening existing divides.
“We had seen fierce arguments in the past about the nature of responses and tensions between business and public health. All of that’s structural. It’s part of the problem. But the extent to which it became associated with political identities was surprising and disappointing,” Hatchett said.

Farrar, the new WHO chief scientist, agreed. “The politicization of public health has surprised me — that wearing a mask became a political statement.”

The politicization and polarization of public health measures has hurt vaccine uptake, said Rupali Limaye, director of behavioral and implementation science at the International Vaccine Access Center at Johns Hopkins University. “It is clear that polarization has led to more extreme beliefs and has hampered our ability to speak with those that may have differing views,” she said. “My hope is that we can dial down the politicization through building back trust in health institutions, as we will need to navigate this for disease control in the future.”

The endless, tractionless fighting
Aerosol or droplet? Lab-leak or natural spillover event? There have been several long-running and nasty scientific disputes during the pandemic. And yet we’ve made little progress in fixing the underlying issues that the participants are fighting about, said Samuel Scarpino, director of AI and life sciences at Northeastern University. (He spent much of the pandemic as vice president for pathogen surveillance at the Rockefeller Foundation.)

Team airborne won the vitriolic debate about how the SARS-2 viruses spread, but little has been done to make the improvements in indoor air quality that would cut the risk of virus transmission, Scarpino said.

Likewise, regardless of whether the SARS-2 leaked from a lab or jumped to humans from animals in Wuhan’s wet markets, the world needs to be better prepared for lab accidents and natural spillovers. “The biggest surprise of all this is that we don’t seem to be coming to terms with either one of those two conclusions,” he said.

How long the damn thing has lasted
Pandemics are rare occurrences; fewer than a handful have happened in the age of modern virology, when laboratories could provide detailed knowledge of what was causing the illness and how that pathogen was evolving.

The pandemics that have been recorded have mainly been caused by flu. And in the recorded flu pandemics, there was generally a wave or two — sometimes, in some places three — and then humans and the new virus reached a detente. The new flu virus settled into causing seasonal flu activity, not pandemic flu.

A lot of people STAT spoke to thought that was the way this pandemic would play out. They didn’t anticipate that we’d be where we are now, with waves of transmission still occurring at various points in the year, rather than during the winter, as is the way of most respiratory pathogens.

“I never would have imagined that three years later we would still be dealing with this in the way that it’s ever-present in our conversations and in our society,” said Messonnier, the former CDC official.

Peacock, who studied flu before the Covid pandemic hit, was also surprised by how long the pandemic has dragged on. “From the flu perspective, within a year, or maybe a year and a half, every previous pandemic has generally hit a seasonal pattern. And although those two or three years afterwards might be the worst years for a while, it does hit a pattern, and it does start to look like seasonal flu at that point. Whereas this has just been weird.”

Farrar likewise did not expect transmission of Covid to be high this far into our experience with the SARS-2 virus. “I would not have guessed way back then, when there was natural immunity plus vaccination that we would still, three years on, have such high community transmission, and that’s really worrying to me.”

With this much transmission, there’s a “non-zero risk” of a new variant, he said. “I don’t think this virus has completed its evolutionary track yet.”

The measures governments and individuals took to slow the spread of Covid dragged out the duration of the pandemic, Viboud said. “We would have been in a much worse place if we hadn’t done it. But I mean in the end it has sort of prolonged [it]. You just keep having susceptibles.”

The ripple effects
Hatchett, for all his studying of previous pandemics, wasn’t anticipating the geopolitical impacts of this one. He likens it to a meteor strike.

In addition to the crushing waves of illness, the lives lost, the swamping of hospitals, and the disruption to routine health care, he points to the economic disruption of the past couple of years, the onset of inflation, the spike in energy prices, and the upheaval in supply chains as all being of a piece.

“I wouldn’t say the pandemic caused the war in Ukraine, but I think the pandemic created circumstances in which Putin, an opportunist, saw an opportunity,” he said, noting the war has contributed to global food shortages. “So you’ve got years of reverberating political impacts from this pandemic event and the initial response to it.”

Farrar added that the supply chain problems throughout the pandemic are making governments rethink some facets of globalization and international trade, particularly the offshoring of manufacturing and the reliance, in many cases, on sourcing critical supplies from a single country.

The panic-neglect cycle persists
Over the past couple of decades, the world has gone through a number of big disease scares. SARS-1. The H1N1 flu pandemic. MERS. Zika. Ebola. With each, the world raced to respond.

And each time, as the panic eased, neglect kicked in. Rather than recognizing these events as warnings that longer-term investments and structural changes were needed to safeguard the globe against the next one, the world moved on. As it appears to be doing now.

“We’ve seen in other epidemics this happening,” said Berkley, the Gavi CEO. “But you kind of thought with this one, it was so global, it was so big that I would not have expected it to have happened so quickly.”

Anna Durbin, director of the Center for Immunization Research at the Johns Hopkins Bloomberg School of Public Health, is also startled at how quickly people seem to have pushed past Covid.

“I get a sense people have forgotten how many people died, how we couldn’t visit with family and friends,” she said. “This is very similar to HIV after HAART,” — highly active antiretroviral therapy, the HIV drugs that have turned the infection from a death sentence to a chronic condition — “but it happened much more quickly.”

“Maybe this is resiliency, maybe a coping mechanism, I am not sure,” Durbin said. “But I hope the lessons learned are not also forgotten.”