LIMA, Peru — The doctor watched the patients stream into his intensive care unit with a sense of dread.
For weeks, César Salomé, a physician in Lima’s Hospital Mongrut, had followed the chilling reports. A new coronavirus variant, spawned in the Amazon rainforest, had stormed Brazil and driven its health system to the brink of collapse. Now his patients, too, were arriving far sicker, their lungs saturated with disease, and dying within days. Even the young and healthy didn’t appear protected.
The new variant, he realized, was here.
“We used to have more time,” Salomé said. “Now, we have patients who come in and in a few days they’ve lost the use of their lungs.”
The P.1 variant, which packs a suite of mutations that makes it more transmissible and potentially more dangerous, is no longer just Brazil’s problem. It’s South America’s problem — and the world’s.
In recent weeks, it has been carried across rivers and over borders, evading restrictive measures meant to curb its advance to help fuel a coronavirus surge across the continent. There is mounting anxiety in parts of South America that P.1 could quickly become the dominant variant, transporting Brazil’s humanitarian disaster — patients languishing without care, a skyrocketing death toll — into their countries.
“It’s spreading,” said Julio Castro, a Venezuelan infectious-disease expert. “It’s impossible to stop.”
In Lima, scientists have detected the variant in 40 percent of coronavirus cases. In Uruguay, it’s been found in 30 percent. In Paraguay, officials say half of cases at the border with Brazil are P.1. Other South American countries — Colombia, Argentina, Venezuela, Chile — have discovered it in their territories. Limitations in genomic sequencing have made it difficult to know the variant’s true breadth, but it has been identified in more than two dozen countries, from Japan to the United States.
Hospital systems across South America are being pushed to their limits. Uruguay, one of South America’s wealthiest nations and a success story early in the pandemic, is barreling toward a medical system failure. Health officials say Peru is on the precipice, with only 84 intensive care beds left at the end of March. The intensive care system in Paraguay, roiled by protests last month over medical shortcomings, has run out of hospital beds.
“Paraguay has little chance of stopping the spread of the P.1 variant,” said Elena Candia Florentín, president of the Paraguayan Society of Infectious Diseases.
“With the medical system collapsed, medications and supplies chronically depleted, early detection deficient, contact tracing nonexistent, waiting patients begging for treatment on social media, insufficient vaccinations for health workers, and uncertainty over when general and vulnerable populations will be vaccinated, the outlook in Paraguay is dark,” she said.
How P.1 spread across the region is a distinctly South American story. Nearly every country on the continent shares a land border with Brazil. People converge on border towns, where crossing into another country can be as simple as crossing the street. Limited surveillance and border security have made the region a paradise for smugglers. But they have also made it nearly impossible to control the variant’s spread.
“We share 1,000 kilometers of dry border with Brazil, the biggest factory of variants in the world and the epicenter of the crisis,” said Gonzalo Moratorio, a Uruguayan molecular virologist tracking the variant’s growth. “And now it’s not just one country.”
The Brazilian city of Tabatinga, deep in the Amazon rainforest, where officials suspect the virus crossed into Colombia and Peru, is emblematic of the struggle to contain the variant. The city of 70,000 was swept by P.1 earlier this year. Many in the area have family ties in several countries and are accustomed to crossing borders with ease — canoeing across the Amazon River to Peru or walking into Colombia.
“People ended up bringing the virus from one side to the other,” said Sinesio Tikuna Trovão, an Indigenous leader. “The crossing was free, with both sides living right on top of one another.”
Now that the variant has infiltrated numerous countries, stopping its spread will be difficult. Most South American countries, with the exception of Brazil, adopted stringent containment measures last year. But they have been undone by poverty, apathy, distrust and exhaustion. With national economies battered and poverty rising sharply, public health experts fear more restrictions will be difficult to maintain. In Brazil, despite record death numbers, many states are lifting restrictions. (SOUND FAMILIAR)
That has left inoculation as the only way out. But coronavirus vaccines are South America’s white whale: often discussed, but rarely seen. The continent hasn’t distributed its own vaccine or negotiated a regional agreement with pharmaceutical companies. It’s one of the world’s hardest-hit regions but has administered only 6 percent of the world’s vaccine doses, according to the site Our World in Data. (The outlier is Chile, which is vaccinating residents more quickly than anywhere in the Americas — but still suffering a surge in cases.)
“We should not only blame the policy response,” said Luis Felipe López-Calva, the United Nations Development Program’s regional director for Latin America and the Caribbean. “We have to understand the vaccine market.”
“And there is a failure in the market,” he said.
The vaccine has become so scarce, López-Calva said, that officials are imposing restrictions on information. It’s nearly impossible to know how much governments are paying for doses. Some regional blocs, such as the African Union and the European Union, have negotiated joint contracts. But in South America, it has been every country for itself — diminishing the bargaining power for each one.
“This has been harmful for these countries, and for the whole world to stop the virus,” López-Calva said. “Because it’s never been more clear that no one is protected until everyone is protected.”
Paulo Buss, a prominent Brazilian scientist, said it didn’t have to be like this. He was Brazil’s health representative to the Union of South American Nations, which negotiated several regional deals with pharmaceutical companies before the coronavirus pandemic. But that union came apart amid political differences just before the arrival of the virus.
“It was the worst possible moment,” Buss said. “We’ve lost capacity and our negotiation attempts have been fragmented. Multi-lateralism was weakened.”
Vaccine scarcity has led to line-jumping scandals all over South America, but particularly in Peru. Hundreds of politically connected people, including cabinet ministers and former president Martín Vizcarra, snagged vaccine doses early. Now people are calling for criminal charges.
As officials bicker and the vaccination campaign is delayed, the variant continues to spread. P.1 accounts for 70 percent of cases in some parts of the Lima region, according to officials. Last week, the country logged the highest daily case count since August — more than 11,000. On Saturday, the country recorded 294 deaths, the most in a day since the start of the pandemic.
Peruvians have been stunned by how quickly the surge overwhelmed the health-care system. Public health analysts and government officials had believed Peru was prepared for a second wave. But it wasn’t ready for the variant.
“We did not expect such a strong second wave,” said Percy Mayta-Tristan, director of research at the Scientific University of the South in Lima. “The first wave was so extensive. The presence of the Brazilian variant helps explain why.”
It seems pretty clear the path the United States is on. Within a few months, everyone who wants to be vaccinated against the coronavirus will be, save for those below the minimum age for which vaccines are available. For everyone else, the pandemic Wild West will continue, with the country hopefully somewhere near the level of immunity that will keep the virus from spreading wildly but with large parts of the population — again, including kids — susceptible to infection.
That really gets at one of the two outstanding questions: How many Americans won’t get the vaccine? If the figure is fairly low, the ability of the virus to spread will be far lower. If it’s high, we have a problem. And that’s the other outstanding question: How big of a problem will the virus be, moving forward?
We know that even as vaccines are being rolled out, cases are slowly climbing. While the number of new infections recorded each day is well off the highs seen in the winter, we’re still averaging more cases on a daily basis than we saw even a month into the third wave that began in September. A lot of people are still getting sick, and, even with most elderly Americans now protected with vaccine, a lot more people will probably die.
Data released by Gallup this week shows that both of the questions posed above share a common component. It is, as you probably suspected, those who are least willing to get vaccinated who are also least likely to take steps to contain the virus.
Gallup asked Americans about their vaccination status, finding that about a fifth had been fully vaccinated and an additional 13 percent partially vaccinated. More than a quarter of respondents, though, said they didn’t plan to get vaccinated. It was those in that latter group who were least likely to say that they were completely or mostly isolating in an effort to prevent the virus spreading.
It was also those skeptics who were least likely to say that, in the past seven days, they had avoided crowds, group gatherings or travel. If you’re not inclined to get vaccinated, it is at least consistent that you would be similarly disinclined to take other steps aimed at limiting the spread of the virus.
Gallup didn’t break out those groups by party, but it’s clear that few of them are Democrats. Data from YouGov, compiled on behalf of Yahoo News, shows that Democrats (and those who voted for Joe Biden in particular) are more likely to say that they have already received a vaccine dose.
Among those who hadn’t yet received a dose, Democrats were far more likely to indicate that they planned to do so as soon as possible. Among Republicans, half of those who haven’t been vaccinated say that they don’t have any plans to do so at all.
One reason is that Republicans are simply less worried about the virus. More than half say that they’re not very worried about it or not worried at all. Among those who voted for Donald Trump, the figure is over two-thirds. By contrast, more than three-quarters of Democrats say that they are at least somewhat worried about the virus.
In the YouGov polling, 60 percent of Republicans say that the worst of the pandemic is behind us. They’re also much more likely to say that restrictions aimed at preventing the spread of the virus — mask mandates, limits on indoor dining — should be lifted immediately.
As we mentioned Thursday, there are two ways to achieve herd immunity. One is fast and safe: widespread vaccinations. The other — people contracting the virus — is slow and dangerous. The path the United States is on will take us to a place where much of the country has opted for the first option and the rest, the latter.
So the question again becomes: How many people will die, both over the short term and the long term, as a result of those choices?
As both vaccinations and acquired immunity spread, life will likely settle into a new normal that will resemble pre-COVID-19 days— with some major twists.
The big picture: While hospitalizations and deaths are tamped down, the novel coronavirus should recede as a mortal threat to the world. But a lingering pool of unvaccinated people — and the virus’ own ability to mutate — will ensure SARS-CoV-2 keeps circulating at some level, meaning some precautions will be kept in place for years.
Driving the news: On Tuesday, Johnson & Johnson CEO Alex Gorsky told CNBC that people might well need a new coronavirus vaccine annually in the years ahead, much as they do now for the flu.
- Gorsky’s comments were one of the clearest signals that even as the number of vaccinated people rises, the mutability of SARS-CoV-2 means the virus will almost certainly be with us in some form for years to come.
Be smart: That sounds like bad news — and indeed, it’s much less ideal than a world in which vaccination or infection conferred close to lifelong immunity and SARS-CoV-2 could be definitively conquered like smallpox.
- With more contagious variants spreading rapidly, “the next 12 weeks are likely to be the darkest days of the pandemic,” says Michael Osterholm, the director of the University of Minnesota’s Center for Infectious Disease Research and Policy.
- But the apparent effectiveness of the vaccines in preventing hospitalizations and death from COVID-19 — even in the face of new variants — points the way toward a milder future for the pandemic, albeit one that may be experienced very differently around the world.
Details: From studying what happened after new viruses emerged in the past, scientists predict SARS-CoV-2 will eventually become endemic, most likely in a seasonal pattern similar to the kind of coronaviruses that cause the common cold.
- That’s nothing to sneeze at — literally, it will make us sneeze — but as immunity levels accumulate throughout the population, our experience of the virus will attenuate, and we’ll be highly unlikely to experience the severe death tolls and overloaded hospitals that marked much of the past year.
Yes, but: The existence of a stubborn pool of Americans who say they won’t get vaccinated — as well as the fact that it may take far longer for children, whom the vaccines have yet to be tested on, to get coverage — will give the virus longer legs than it would otherwise have.
- “This will be with us forever,” says Osterholm. “That’s not even a debate at this point.”
What’s next: This means we can expect the K-shaped recovery that has marked the pandemic to continue, says Ben Pring, who leads Cognizant’s Center for the Future of Work.
- With the virus likely to remain a threat, even if a diminished one, “those who are more stuck in the analog world are really going to continue to struggle,” he says.
- Health security will also become a more ingrained part of daily life and work, which means temperature checks, masks, frequent COVID-19 testing and even vaccine passports for travel are here to stay.
The catch: That’s not all bad — the measures put in place to slow COVID-19 have stomped the flu and other seasonal respiratory viruses, and if we can hold onto some of those benefits in the future, we can save tens of thousands of lives and billions of dollars.
- If the inequalities seen in the early phase of the vaccine rollout persist, COVID-19 could become a disease of the poor and disadvantaged, argues Mark Sendak, the co-founder and scientific adviser for Greenlight Ready, a COVID-19 resilience system that grew out of Duke Health.
- Sendak points to the example of HIV, a disease that is entirely controllable with drugs but continues to exert a disproportionate toll on Black Americans, who take pre-exposure prophylactic medicine at much lower rates.
“If we go back to ‘normal,’ then we have failed.”
— Mark Sendak
What to watch: Whether the vaccine rollout can be adapted to reach hard to find and hard to persuade populations.
- The Biden administration announced yesterday that it will start delivering vaccines directly to community health centers next week in an effort to promote more equity in the vaccine distribution process.
- As the administration rolls out new COVID-19 plans, it needs to “invest in the community health care personnel” who can ensure that no one is left behind, says Sendak.
The bottom line: While SARS-CoV-2 has proven it can adapt to a changing environment, so can we. But we have to do so in a way that is fairer than our experience of the pandemic has been so far.
In the seven states hit hardest by the pandemic, more than 1 in every 500 residents have died from the coronavirus.
Why it matters: The staggering death toll speaks to America’s failure to control the virus.
Details: In New Jersey, which has the highest death rate in the nation, 1 out of every 406 residents has died from the virus. In neighboring New York, 1 out of every 437 people has died.
- In Mississippi, 1 out of every 477 people has died. And in South Dakota, which was slammed in the fall, 1 of every 489 people has died.
States in the middle of the pack have seen a death rate of around 1 in 800 dead.
- California, which has generally suffered severe regional outbreaks that don’t span the entire state, has a death rate of 1 in 899.
- Vermont had the lowest death rate, at 1 of every 3,436 residents.
The bottom line: Americans will keep dying as vaccinations ramp up, and more transmissible variants of the coronavirus could cause the outbreak to get worse before it gets better.
- Experts also say it’s time to start preparing for the next pandemic — which could be deadlier.
A family member in her 70s called with the great news that she received her first dose of the COVID vaccine this week. She mentioned that she was hoping to plan a vacation in the spring with a friend who had also been vaccinated, but her doctor told her it would still be safest to hold off booking travel for now: “I was surprised she wasn’t more positive about it. It’s the one thing I’ve been looking forward to for months, if I was lucky enough to get the shot.”
It’s not easy to find concrete expert guidance for what it is safe (or safer?) to do after receiving the COVID vaccine. Of course, patients need to wait a minimum of two weeks after receiving their second shot of the Pfizer or Moderna vaccines to develop full immunity.
But then what? Yes, we all need to continue to wear masks in public, since vaccines haven’t been proven to reduce or eliminate COVID transmission—and new viral variants up the risk of transmission. But should vaccinated individuals feel comfortable flying on a plane? Visiting family? Dining indoors? Finally going to the dentist?
It struck us that the tone of much of the available guidance speaks to public health implications, rather than individual decision-making. Take this tweet from CDC director Dr. Rochelle Walensky. A person over 65 asked her if she could drive to visit her grandchildren, whom she hasn’t seen for a year, two months after receiving her second shot. Walensky replied, “Even if you’ve been vaccinated, we still recommend against traveling until we have more data to suggest vaccination limits the spread of COVID-19.”
From a public health perspective, this may be correct, but for an individual, it falls flat. This senior has followed all the rules—if the vaccine doesn’t enable her to safely see her grandchild, what will? It’s easy to see how the expert guidance could be interpreted as “nothing will change, even after you’ve been vaccinated.”
Debates about masking showed us that in our individualistic society, public health messaging about slowing transmission and protecting others sadly failed to make many mask up.
The same goes for vaccines: most Americans are motivated to get their vaccine so that they personally don’t die, and so they can resume a more normal life, not by the altruistic desire to slow the spread of COVID in the community and achieve “herd immunity”.
In addition to focusing on continued risk, educating Americans on how the vaccinated can make smart decisions will motivate as many people as possible to get their shots.
Early data on vaccine distribution by race and ethnicity show a mismatch between those population groups receiving the vaccine, and those that have been hardest hit by the pandemic. As the graphic above shows, Black and Hispanic Americans have thus far been vaccinated at considerably lower rates in many states compared to their share of population as a whole—and these disparities are likely to worsen as states shift focus to senior populations for priority access, moving away from prioritizing essential workers, who tend to be more racially diverse.
The White population skews older, which stands to widen disparities in the near-term. Another compounding issue: vaccine hesitancy.
A recent Morning Consult poll found that, despite an overall increase in overall vaccine willingness, Black Americans remain the most hesitant, with only 48 percent willing to get the vaccine.
Meanwhile, Black and Hispanic Americans continue to be disproportionately impacted by COVID, with hospitalization and death rates nearly three to four times greater than those of White Americans.
Hesitancy will become an increasingly urgent problem as larger swathes of the population become eligible for vaccination, especially given that communities of color tend to be younger, as shown above.
The national COVID indicators all continued to move in the right direction this week, with new cases down 16 percent, hospitalizations down 26 percent, and deaths (while still alarmingly high at more than 3,000 per day) down 6 percent from the week prior.
More good news: both nationally and globally, the number of people vaccinated against COVID now exceeds the total number of people infected with the virus, at least according to official statistics—the actual number of coronavirus infections is likely several times higher.
On the vaccine front, Johnson & Johnson filed with the Food and Drug Administration (FDA) for an Emergency Use Authorization for its single-dose COVID vaccine, which could become the third vaccine approved for use in the US following government review later this month. The J&J vaccine is reportedly 85 percent effective at preventing severe COVID disease, although it is less effective at preventing infection than the Pfizer and Moderna shots.
Elsewhere, TheLancet reported interim Phase III results for Russia’s Sputnik V vaccine trials, showing it to be 91 percent effective at preventing infection, and a new study found the Oxford-AstraZeneca vaccine to be 75 percent effective against the more-contagious UK virus variant.
Amid the positive vaccine news, the Biden administration moved to accelerate the vaccination campaign, invoking the Defense Production Act to boost production and initiating shipments directly to retail pharmacies. With the House and Senate starting the budget reconciliation process that could eventually lead to as much as $1.9T in stimulus funding, including billions more for vaccines and testing, it feels as though the tide may be finally turning in the battle against coronavirus.
While the key indicators are still worrisome—we’re only back to Thanksgiving-week levels of new cases—and emerging variants are cause for concern, it’s worth celebrating a week that brought more good news than bad.
Best to follow Dr. Fauci’s advice for this Super Bowl weekend, however: “Just lay low and cool it.”
Over the weekend I realized that my son Henry, born in June 2019, has lived more than half of his life in the pandemic era. He’s too young to be cognizant of it, of course, but my wife and I are acutely conscious of the experiences his older brother had already enjoyed by the time he was Henry’s age, things that are impractical or impossible in the moment.
He’s not alone in that, of course. Most Americans are experiencing some ongoing deprivations because of the pandemic. (Most of those for whom the pandemic is not imposing unusual restrictions are, ironically, probably contributing to the pandemic’s extent and duration.) Just about everyone in the United States is eagerly scanning the horizon for signs of normalcy — as we have been for months, occasionally spotting oases that too often turn out to be mirages.
So when will we return to some semblance of normal? It’s hard to say with certainty. The best tool we have to reach that point, though, is the broad deployment of the vaccines approved for emergency use by the government. But even the existence of those vaccines can’t completely answer the question.
For example, the rate at which the vaccines are deployed makes a massive difference. A pace of 2 million shots per day as opposed to 1 million seems like a subtle distinction but, obviously, means achieving immunity for recipients twice as fast.
What level of immunity is necessary is a question of its own. Do we need 70 percent of the country to have been immunized? Or, as infectious-disease expert Anthony S. Fauci has recently said, is the figure closer to 80 or 85 percent?
When doing this calculation, do you include the 26 million Americans who have already had coronavirus infections? What about young people? The vaccine trials included only those age 16 and over. Those younger have constituted about a 10th of the total infections. And what vaccine are we talking about? The Pfizer and Moderna iterations require two shots; the vaccine from Johnson & Johnson requires only one.
All of these factors affect how we can figure out when the country might hit the herd-immunity mark. If we assume that young people will be included among those needed to be vaccinated — a complicated question on its own — the calculator below will allow you to figure out when immunity might be achieved at various immunization rates.
At this rate, the country would reach 70 percent herd immunity through vaccinations by Nov. 10
How we calculate this:
There are about 330 million Americans, meaning that we need 231 million to be resistant to the virus to hit 70 percent immunity. We can take out the 5.8 million Americans who’ve already been vaccinated. That leaves 211.3 million people to be vaccinated.
From there the math is straightforward: doing two-shot vaccinations at a rate of 1.5 million shots per day means it will take 282 days to complete the job.
Bear in mind that sliding the little bar to determine how quickly shots are administered is far easier than actually scaling up the infrastructure to do so. President Biden’s original target for daily vaccinations was 1 million; he recently increased it to 1.5 million. At that rate, we’re still months from resolution. But because administering the vaccine is more complicated and requires more tracking than vaccinations such as that for the seasonal flu, it’s necessarily trickier to scale up.
At this point, the more urgent concern is the efficacy of the vaccine against any variants of the virus that might emerge. Manufacturers have already noted that the vaccine works less well against a virus variant first identified in South Africa, though the vaccines are still broadly effective, particularly at protecting the recipient from severe illness or death after infection.
Well, that and the fact that a fifth of Americans said in a recent Kaiser Family Foundation poll that they won’t get the vaccine or would do so only if it was required. Happily, more Americans are now saying they’re eager to get a vaccine.
The faster we get people immunized, the better we protect against the emergence of new mutations that prove less able to be controlled by the vaccines. The faster we get shots in arms, as the phrasing has it, the faster we get back to normal.
Which would be nice for all of us, including my 1-year-old.