The Pandemics to Come

John Wolfson: There’s been a lot of talk lately that COVID is on the path to becoming endemic. That essentially we will never actually eradicate it.

Philip Landrigan: As the various waves of the virus come along, as the different variants have emerged— the Delta, the Omicron—each new iteration is more contagious than the one that came before it. But even as we’re seeing the disease continue to spread, we’re seeing the severity of the impact of the disease diminishing. We’re not seeing as many hospitalizations. We’re not seeing as many deaths as we were earlier. And I think this sequence, from pandemic to recurrent mid-grade epidemic to something that’s more of a smoldering fire, is really what an endemic disease is. But we’re not going to be rid of this thing for a long time. New variants will emerge from time to time I’m sure in the future, as they have already. And I think that, looking to the future, you’re going to see the coronavirus infection become like influenza. It may or may not show seasonality. I’m not clear about that yet, but we’ll see recurrent waves of infection of greater or lesser severity. And we may, in some years, have to take particular precautions like masking and social distancing, or it may be we have new medicines and very quickly just pop a pill in the first few days after having been exposed to a person, the way a lot of people do these days after they get a tick bite, and that just puts it out. So bottom line, it’s not going to go away but I don’t anticipate any major, massive global pandemics of COVID-19 in the future.

John Wolfson: It was to everyone’s great relief, of course, that our existing COVID vaccines proved to be so successful at minimizing the health risks associated with the Omicron variant. How have these vaccines, which were developed with such incredible speed, proved to be so effective?

Nadia Abuelezam: The scientific community luckily had already been working on some variant of the COVID vaccine and that allowed us to jump right in and develop and distribute a vaccine very quickly. The scientific community was on top of its game and managed to get a vaccine out extremely quickly, and not just any vaccine, but a vaccine that’s extremely effective. That is one of our largest triumphs to date. The part of the vaccine conversation that we may need a little more work on is our global distribution efforts. We’ve been doing quite a bit of work to get all of our citizens here in the United States vaccinated. There’s still quite a bit of work to be done, especially among marginalized populations, but there’s also a lot that needs to be done globally to ensure equity and vaccine distribution. And to also ensure that the poorest members of our societies have access to this vaccine because we know that individuals who are marginalized, whether that’s socioeconomically or in any other way, are at highest risk of COVID infection and may be least likely to get vaccinated.

John Wolfson: The Omicron variant is said to have more mutations than any previous variant that we’ve seen. That sounds frightening. How concerned should we be about the number of mutations in the variants to come?

Welkin Johnson: The Omicron variant is interesting because even very early on when it was first reported, there were already indications that it probably was causing a milder disease. The only reason I think this one got more attention than other variants of concern was because it has two or three times as many mutations in it as any other variant. And that’s not really a reason to get concerned. We hear “mutation” and we think that automatically means something bad. But there’s no logical extension that says a mutation has to cause worse disease. And in fact, I think a lot of virologists are expecting milder variants of COVID-19—and perhaps Omicron is it. This could be the sign of the virus now stabilizing and getting into equilibrium with the human host.

John Wolfson: Many of us have tended to think of the pandemic as a once-in-a-lifetime event. It’s certainly been the deadliest one we’ve seen in a century, but it turns out that these kinds of public health crises aren’t actually all that rare. In just the past twenty years or so we’ve had a couple of prior coronavirus outbreaks, and also the swine flu and Ebola epidemics. In any given year, according to a couple of recently published papers I’ve seen, there’s a 2 percent to 3 percent chance of a global pandemic striking. Researchers say there’s as much as a 50 percent chance that we’ll see something like this again in the next twenty-five years. And that’s just if things stay as they are—which, unfortunately, seems unlikely. A growing body of evidence suggests that the probability of outbreaks is actually going to increase in years ahead. Yet here we are still struggling in our current pandemic to convince people that vaccines are safe and that masking is effective. As we plan for the possibility of future pandemics, how can we more effectively get people to buy in to these lifesaving preventive measures?

Katherine Gregory: What the SARS-CoV-2 pandemic has shown us is that we will almost certainly interact with novel pathogens again in the future. And we will have other pandemics, perhaps not at the same scale, but we absolutely will need to take some of our lessons learned from this pandemic. And one of the major lessons learned is that we have a good, maybe a great acute-care infrastructure here in the U.S. for when people get sick. But I think what this has shown us is that we really lack the public health infrastructure to manage large-scale infectious disease. The second thing I think that we have learned, and these have been some bitter lessons, is that there is a gap in overall health literacy and health knowledge in the general population. And so again, when I think about how we educate our care providers, we do a very good job of educating them in how to take care of people in acute situations and maybe even in chronic situations—but not necessarily from the perspective of overall public health, of understanding health literacy and what the science means. The vaccine that the scientific community was able to develop is breathtaking, and yet there was such distrust about it, and there remains distrust, because I don’t think we’ve provided a foundation in health literacy for so many people.

Nadia Abuelezam: I think this is also reflective of the way that the U.S. health care system has been set up. It’s been set up to deal with existing health issues. It has not been set up to be a preventative measure. To prevent disease, to prevent illness. And I think that that’s where a lot of the misunderstanding comes when we think about the general public. Do we accept new potential drugs that could treat coronavirus-related disease? Yes, because people accept treatment as a reasonable way forward. But it’s the prevention piece that always has been controversial. And I think it stems from the way that the health care system has been developed. It’s financially beneficial to treat as opposed to prevent, right? So we have to think about it from that perspective, too: This is the way that we’ve institutionalized medicine and treatment in this country, but we have not institutionalized prevention. And I think that that has been to our detriment during this epidemic.

Philip Landrigan: So how has that played out? Well, what has happened in this country since I would say the late 1960s, early 1970s, is that we have very, very substantially disinvested in public health at every level. We’ve done well on biomedical research. We’ve built beautiful hospitals to treat sick people. But we have cut the budget of the Centers for Disease Control at the federal level. We’ve cut the budget of state and county health departments across the country. The more than 3,000 county health departments that are the bedrock of the American public health system have seen their staffing dropped by 50 percent to 75 percent in the past four years. So that when COVID- 19 burst out of China in 2020, we were dreadfully unprepared within the public health system. It’s a problem, of course, but it’s also an opportunity if we can persuade the leadership of this country—national, state, and local levels—that public health is a key component of the national infrastructure, just the way bridges and highways and airports and broadband are part of the infrastructure. And this is a great opportunity to rebuild this critical component of our country. One of the phrases that’s been used a lot in describing this COVID-19 pandemic is that it’s brought out into the open various problems in American society. It’s brought racism into the open, it’s brought economic inequality into the open. And it’s certainly brought into the open the great need to reinvest in public health, to rebuild the public health system.

John Wolfson: Perhaps in concert with that effort, what is the potential for the science behind the coronavirus vaccines to protect us from future pandemics?

Welkin Johnson: People don’t often mention this, but HIV-1 was a major zoonosis—a disease that jumps from animals to humans—that spread worldwide. And almost all the technology that was applied to this current virus came from people who were working on HIV-1 for the past twenty years. The antiviral drugs that for HIV-1 took ten to fifteen years before they were really fit to be used now can be deployed probably against any other retrovirus that would invade into humans. And the drugs that are coming out for the coronaviruses—because of the way they work, because they attack conserved parts of the coronavirus biology—they very likely can be weapons that we can deploy against future coronaviruses. And then the mRNA vaccine platform, it’s just amazing. I mean, the way vaccines were developed in the early 20th century was just, it was voodoo, right? It was pure empirical. Try this, try that. It would be interesting to read the history of the yellow fever vaccine or something. Whereas this is a very rigorously controlled and they can deploy this so fast that we’ll be more prepared for the next pandemic, at least the next viral pandemic.

John Wolfson: The pharmaceutical companies have been rightly praised for the speed with which they were able to produce those vaccines. But have we done enough to make sure that the vaccines are widely available in the developing world? There’s a moral case for doing so, of course, for making sure that the most marginalized communities and the least privileged among us are kept as safe as the most privileged. But doesn’t our own self-interest argue for making sure that these vaccines are getting to the developing world?

Philip Landrigan: Oh, absolutely. There is indeed a moral case for vaccinating the world and making the vaccines available worldwide at either zero cost or the very lowest possible cost. But there’s also huge self-interest. Look at how small the world is today, how Omicron went from South Africa to the U.K. to various big airports in the United States in less than a week. I mean, the 1918 flu a century ago took many months to travel around the world. This thing is traveling at 500 miles an hour—the speed of a commercial airliner. We’re all interconnected and it’s not just air travel. It’s all the goods that move between countries. The migration of thousands of people every day and every week. When something like this comes, it’s a global emergency. And the only rational way to protect ourselves is to help everybody else. There’s no way we can put some kind of a virus-type wall around our borders. That’s just not possible.

Katherine Gregory: I really agree. I think that there is no health without global health, and maybe this is a silver lining is this pandemic: that this virus has just shown us just how connected we are as a people. And if that doesn’t create the imperative for us in more-resourced places to care about the access to health and vaccines, I don’t know what does. So we can talk about South Africa and Johannesburg, but I think we also have to think a little closer to home. There are still people in our neighborhoods in Boston who have not had vaccine uptake and they’re currently very, very sick. We started this part of our conversation about the triumph of the pharma companies and the speed of vaccination. In retrospect, I think that while they were working in that lane, we could have been doing more education in the community, so that when those vaccines came, we would’ve readied the environment for the vaccine and for the vaccine uptake, certainly here, and then across the globe so that there wouldn’t have been this hesitancy. Maybe that’s one of our most important lessons learned—the need for greater knowledge of how connected we are, and how important it is to have this global public health infrastructure in place.

John Wolfson: So what should we make of the apparent jump in positivity rates and breakthrough cases? Does it make it harder to argue that people should get vaccinated?

Welkin Johnson: I think there’s a shifting perspective now on what vaccines actually do. We’ve talked for so many decades about vaccines as the bulletproof vest: They protect you from infection. But if you look back at the 20th century, the golden era of vaccination—yellow fever, polio, measles, smallpox—what we know for a fact is that those vaccines prevented disease, death, and spread of the virus. What we don’t actually know for a fact is that those vaccines prevented breakthrough infections. We didn’t have the technology then to do the very high-throughput, rapid screening of healthy individuals to see if the virus was still there. And that’s caused some issues this time around because everybody’s expecting the vaccine to be perfect. And the shift in thinking that hopefully is coming now is to stop thinking about positivity rates and start thinking more about hospitalization rates. And that’s not just this vaccine. I think it’s true of any vaccine. We’ll probably retrospectively figure out that would’ve been true of a lot of the very successful vaccines that came before this.

Katherine Gregory: And so, here we come back to this need for a better understanding of science and health literacy. The trials for these vaccines looked at, If we give vaccines to these populations of people, will they experience death or hospitalization? That’s what the trials were set up to assess [rather than whether they protected people from getting infected at all]. But explaining that to a lay population that doesn’t have that fundamental understanding is complicated.

Welkin Johnson: I agree. We hope a vaccine does two things. First, protect you from getting infected in the first place. Second, if you get infected, stop the virus from burrowing deeper into your body and causing disease and possibly death. And for decades, we have overemphasized the first and underemphasized the second. Protection is a hopeful benefit, but it’s a very, very high bar. Whereas preventing the virus from spreading and causing disease once you’re infected is what the immune system really does.

Philip Landrigan: I think the way to communicate this complex reality to people is to say to folks that the vaccine gives you somewhere around 95 percent to 98 percent protection against serious illness and death. But it gives a much lower rate of protection against mild, usually mild, upper-respiratory illness. People just need to know that. And once you’re able to communicate that effectively to people, then that lays the groundwork for telling them that it’s still important to be prudent, even if they’re vaccinated or even if they’re surrounded by vaccinated people. And considering this circumstance, to possibly wear a mask or possibly not take that six-hour flight or not go to that rock concert.

Welkin Johnson: On our campus, I would hazard to guess that we’ve been more impacted by flu during the fall semester than we have by COVID. But the SARS-CoV- 2 positivity numbers are what get published, and that’s what we’re obsessed with. But actually I think there’s been significantly more flu, so significantly more missed classes and loss of work due to flu. But the perception is being skewed by the COVID positivity rates.

John Wolfson: How has the pandemic shaped the priorities and aspirations of our students here at BC?

Philip Landrigan: Altruism has been part of the DNA of Boston College students for a long time. The students that Boston College selects and the students that select Boston College tend as a group to be people that want to make a difference in the world. What I’ve seen happen in the past two years since COVID arrived is that this altruism has been channeled. The number of students who want to do careers in medicine, in nursing, in public health, and the other caring professions has gone up. There’s a push coming up from the grassroots in our society to do something about public health. Now we have to harness that energy and turn it into political reality. It’s a great opportunity if we can seize it.

Welkin Johnson: The careers of the people participating in this conversation are now very attractive. Younger people are more aware of them now. And I think we’re probably even starting to see more interest in them. Graduate school applications very frequently now mention the pandemic in one form or another.

Nadia Abuelezam: Another thing that I’ve observed is folks are starting to realize how interconnected a lot of struggles are. Just because you want to pursue medicine or just because you want to be a biologist or a chemist doesn’t mean that you can’t influence societal issues like racism or climate change. These are all interconnected issues. And so I think students are starting to make the connection that, just because I’m going to be a nurse or just because I’m going to be a doctor doesn’t mean that I can’t influence these other parts of not only society but my life, too. And to be honest, I think that that’s a realization I’ve come to myself, with my work. It’s not just about studying the way that a virus is spread. It’s about recognizing the way that virus is spread within a particular context of racism or inequality. And by doing that, you can have influence on that context. And for me, that’s been really an important discovery. And I think that students are also discovering that. And I think to some extent, the public is also discovering that as well.

Philip Landrigan: I wouldn’t be surprised if one outcome that we see here—in fact, it’s already beginning to happen—is that more people with backgrounds in nursing, medicine, social work, and allied health professions run for public office. Because people are beginning to realize that if we’re going to prepare our society for the next pandemic, there need to be some people at the table who speak the language of public health and epidemiology.

John Wolfson: How has the pandemic affected you on a personal level?

Katherine Gregory: I’m the newest here to Boston College, and I was previously at a large academic medical center in Boston. And I have to be frank and say that I don’t know that I processed it all. It was a very intense clinical environment where we were very literally reading papers from Wuhan overnight and writing hospital policy the next day… that might change twelve hours later. I think the only way to describe it is maybe eight to ten years of work in two years.

Phil Landrigan: Yes, I think we’ve all had to learn how to say, and say publicly, that we don’t know—that we’re waiting for more information: We may know more in a couple of weeks, but right now we don’t know and this is what you have to do in the face of uncertainty.

Welkin Johnson: When something like this challenges humanity, you do feel grateful that you work in a place like Boston College that gives you an opportunity to do something. You don’t want there to be pandemics, but you’re grateful that when something happens, you’re in a position to actually get involved.

Nadia Abuelezam: So I have a pandemic baby—born during the pandemic—and my pandemic baby has not met a lot of people. And we spend a lot of time indoors on our own. And it’s really brought to the forefront for me the importance of human connection, the importance of being able to form that connection even in difficult times and difficult circumstances. The pandemic has really brought to the forefront the interconnectedness of health and well-being with every other aspect of life. And it takes living through something like this to bring that to the top of one’s mind. At Boston College, we believe in men and women for others, and that lines up perfectly with a lot of our COVID mitigation efforts. When we wear our masks and when we socially distance and when we get vaccinated, we’re not just doing that to benefit ourselves but we’re doing that to benefit others around us. And I think it’s a part of not only our personal missions but also our institutional mission.