Omicron Is Our Past Pandemic Mistakes on Fast-Forward
With Omicron, everything is sped up. The new variant is spreading fast and far. At a time when Delta was already sprinting around the country, Omicron not only caught up but overtook it, jumping from an estimated 13 to 73 percent of U.S. cases in a single week. We have less time to make decisions and less room to course-correct when they are wrong. Whereas we had months to prepare for Delta in the U.S., we’ve had only weeks for Omicron. Every mistake gets amplified; every consequence hits us sooner. We should have learned after living through multiple waves and multiple variants of COVID, but we haven’t, at least not enough. We keep making the same pandemic mistakes over and over again.
This is not March 2020. We have masks. We have better treatments. Our immune systems are much more prepared to fight off the virus, thanks to vaccines. But as a society, we are still not prepared. Here are the six traps that we keep falling into, each consequence made all the more acute because of Omicron’s speed.
We rush to dismiss it as “mild.”
In February 2020, when the then-novel coronavirus still seemed far away, a reassuring statistic emerged: 82 percent of cases were mild—milder than SARS, certainly milder than Ebola. This notion would haunt our response: What’s the big deal? Worry about the flu! Since then, we’ve learned what mild in “most” people can mean when the virus spreads to infect hundreds of millions: 5.4 million dead around the world, with 800,000 in just the U.S.
This coronavirus has caused far more damage than viruses that are deadlier to individuals, because it’s more transmissible. A milder but more transmissible virus can spread so aggressively that it ultimately causes more hospitalizations and deaths. Mild initial infections can also lead to persistent, debilitating symptoms, as people with long COVID have learned. The notion of a mostly mild disease became entrenched so rapidly that the experience of many long-haulers was dismissed. We’ve seen how such early concepts can lead us astray, and still the idea of Omicron as an intrinsically mild variant has already taken hold.
We don’t know yet if Omicron is less virulent than Delta. We do know it’s far more transmissible in highly immune places. That’s enough for worry. We can expect Omicron cases to be milder in vaccinated people than unvaccinated. And because the variant is able to infect many vaccinated people that Delta cannot, the proportion of infected people who need to be hospitalized will look lower than Delta’s. What’s less clear is if Omicron is intrinsically any less virulent in unvaccinated people. Some early data from South Africa and the U.K. suggest that it might be, but confounding factors like previous immunity are hard to disentangle. In any case, Omicron does not appear so mild that we can dismiss the hospitalization burden of a huge wave.
That burden will depend largely on how many unvaccinated and undervaccinated people Omicron reaches. The U.S. simply has too many people who are entirely unvaccinated (27 percent) and people over 65—the age group most vulnerable to COVID—who are unboosted (44 percent). In a country of 330 million, that’s tens of millions of people. Omicron will find them. Because this variant is so fast, the window for vaccinating or boosting people in time is smaller. And although vaccines remain very good at protecting against hospitalization, we make a mistake when …
We treat vaccines as all-or-nothing shields against infection.
When the COVID-19 vaccines first started rolling out this time last year, they were billed as near-perfect shots that could block not only severe disease, but almost all infections—absolute wonders that would bring the pandemic to a screeching halt. The stakes some prominent experts laid out seemed to be: Get vaccinated, or get infected.
The summer of Delta made it clear that the options were not binary. Vaccinated people were getting infected. Their antibody levels were dropping (as they always do after vaccination), and the new variant was super transmissible and slightly immune-dodging. Infections among the vaccinated very, very rarely turned severe, and the vaccines had never been designed to stave off all infections. But every positive test among the immunized was still labeled a breakthrough, and carried a whiff of failure.
Our COVID shots were never going to stop infections forever—that’s not really what any vaccines do, especially when they’re fighting swiftly shape-shifting respiratory viruses. Think of disease as a tug-of-war on a field with death and asymptomatic infection at opposite ends, and symptomatic disease and transmission in between. The vaccines are pulling in one direction, the virus in the other. A jacked vaccine can force the virus to yield ground: People who would have been seriously ill might get only an irksome cold; people who would have been laid up for a week might now feel nothing at all. When the virus shifts and gains strength, it will first make gains in the zone of infection. But it would have to pull really hard to completely usurp the stretch of field that denotes severe sickness, the vaccines’ most durable stronghold.
With the highly mutated Omicron, the coronavirus has once again yanked on the line. This should prompt a heave from us in response: an additional dose of vaccine. But no number of boosts can be expected to make bodies totally impermeable to infection. That means the vaccinated, who can still carry and pass on the virus, cannot exempt themselves from the pandemic, despite what the White House has implied. None of our tools, in fact, is sufficient on its own for this situation, which makes it extra dicey when …
We still try to use testing as a one-stop solution.
For tests to fulfill their very essential role in the pandemic toolkit, they need to be accessible, reliable, and fast. Nearly two years into the pandemic, that’s still not an option for most people in the United States.
PCR-based tests, while great at detecting the virus early on in infection, take a long time to run and deliver results. Laboratory personnel remain overstretched and underfunded, and the supply shortages they battled early on never truly disappeared. Rapid at-home tests, although more abundant now, still frequently go out of stock; when people can find them, they’re still paying exorbitant prices. The Biden administration has pledged to make more free tests available, and reimburse some of the ones people nab off shelves. But those benefits won’t kick in until after the new year, leapfrogging the holidays. And only people with private insurance will qualify for reimbursements, which are not always easy to finagle. If anything, the gross inequities in American testing are only poised to grow.
Even at their best, test results offer only a snapshot in time—they just tell you if they detected the virus at the moment you swabbed your nose. And yet, days-old negatives are still being used as passports to travel and party. That left plenty of time for Delta to sneak through; with the speedy, antibody-dodging Omicron, the gaps feel even wider. It’s a particular worry now because Omicron seems to rocket up to transmissible levels on a faster timeline than its predecessors—possibly within the first couple of days after people are infected. That leaves a dangerously tight window in which to detect the virus before it has a chance to spread. Test results were never a great proxy for infectiousness; now people will need to be even more careful when acting on results. Already there have been reports of people spreading Omicron at parties, despite receiving negative test results shortly before the events.
Omicron cases are growing so quickly that they’re already stressing the United States’ frayed testing infrastructure. In many parts of the country, PCR testing sites are choked with hours-long lines and won’t deliver answers in time for holiday gatherings; a negative result from a rapid antigen test, although speedier, might not hold from morning to afternoon. (Some experts are also starting to worry that certain rapid tests might not detect Omicron as well as they did its predecessors, though some others, like the very-popular BinaxNOW, will probably be just fine; the FDA, which has already identified some PCR tests that are flummoxed by the variant, is investigating.) Our testing problem is only going to get worse, even as …
We pretend the virus won’t be everywhere soon.
By now, this story should sound familiar: A new virus causes an outbreak in a country far away. Then cases skyrocket in Europe, then in major U.S. cities—and then in the rest of the country. Travel bans are enacted too late and, in any case, are incredibly porous, banning travel by foreigners but not Americans (as if the virus cared about passports). This is what happened with the original virus and China, and this is what has happened again now with Omicron and southern Africa.
Then and now, the experience of other places should have been a warning about how fast this virus can spread. How Omicron cases will translate into hospitalizations will be harder to discern from trends abroad. Whereas everyone started from the same baseline of zero COVID immunity in early 2020, now every country—and even every state in the U.S.—has a unique mix of immunity from different vaccines, different levels of uptake, different booster schemes, or different numbers of previous infections. Americans’ current mix of immunity is not very good at heading off Omicron infections—hence the rapid rise in cases everywhere—but it should be more durable against hospitalizations.
We’ll have to keep all of this in mind as we try to divine Omicron’s future in the U.S. from hospitalizations in South Africa and Europe. Could we see differences simply because a country used AstraZeneca’s vaccine, which is slightly less effective than the mRNA ones? Or boosted more of its elderly population? Or had a large previous wave of the Beta variant, which never took hold elsewhere? And some communities remain especially vulnerable to the virus for the same reasons they were in March 2020. Just like at the beginning of the pandemic …
We fail to prioritize the most vulnerable groups.
As Omicron tears through the U.S., it will likely repeat the inequities of the past two years. Elderly people, whose immune systems are naturally weaker, are especially reliant on the extra protection of a booster. But on top of the 44 percent who haven’t had their boosters yet, 12 percent of Americans 65 and over aren’t even “fully vaccinated” under the soon-to-be-updated definition. Boosters might not even be enough, which is why the most vulnerable elderly people—those packed into nursing homes—must be surrounded by a shield of immunity. But Joe Biden’s vaccine mandate for nursing-home staff has faced legal opposition, and almost a quarter of such workers still aren’t vaccinated, let alone boosted. Even if they all got their first shots today, Omicron is spreading faster than their immune defenses could conceivably accrue. Without other defenses, including better ventilation, masking for both staff and visitors, and rapid testing (but … see above), nursing homes will become grim hot spots, as they were in the early pandemic and the first Delta surge.
Working-class Americans are vulnerable too. In the pandemic’s first year, they were five times as likely to die of COVID-19 as college-educated people. Working-age people of color were hit even harder: 89 percent fewer would have lost their lives if they’d had the same COVID death rates as white college graduates. These galling disparities will likely recur, because the U.S. has done little to address their root causes.
The White House has stressed that “we know how to protect people and we have the tools to do it,” but although America might have said tools, many Americans do not. Airborne viruses are simply more likely to infect people who live in crowded homes, or have jobs that don’t allow them to work remotely. Making vaccines “available at convenient locations and for no cost,” as the White House said it has done, doesn’t account for the time it takes to book and attend an appointment or recover from side effects, and the 53 million Americans—44 percent of the workforce—who are paid low wages, at an hourly median of $10, can ill-afford to take that time off. Nor can they afford to wait in long testing lines or to blow through rapid tests at $25 a pair. Making said tests reimbursable is little help to those who can’t pay out of pocket, or to the millions who lack health insurance altogether.
Once infected, low-income people are also less likely to have places in which to isolate, or paid sick leave that would let them miss work. To make it feasible for vulnerable people to protect those around them, New York City is providing several free services for people with COVID, including hotel rooms, meal deliveries, and medical check-ins. But neither the Trump nor Biden administration pushed such social solutions, focusing instead on biomedical countermeasures such as therapeutics and vaccines that, to reiterate, cannot exempt people from the pandemic’s collective problem.
Unsurprisingly, people with low incomes, food insecurity, eviction risk, and jobs in grocery stores and agricultural settings are overrepresented among the unvaccinated. The vaccine inequities of the summer will become the booster inequities of the winter, as the most privileged Americans once again have the easiest access to life-saving shots, while the more vulnerable ones are left to keep the economy running. Ultimately, the weight of all these failures will come to rest on the hospital system and the people who work in it, because, even now …
We let health-care workers bear the pandemic’s brunt.
Health-care workers have been described as the pandemic’s front line, but the metaphor is inexact. Hospitals are really the rear guard, tasked with healing people who were failed by means of prevention. And America’s continuing laxity around prevention has repeatedly forced its health-care workers to take the brunt of each pandemic surge. Delta was already on its second go at sending hospitalizations climbing. Omicron, with its extreme transmissibility, could accelerate that rise.
If so, many of the trends from the early pandemic will likely recur at rapid speed. Omicron’s global spread could cause shortages of vital equipment. Hospitals will struggle to recruit enough staff, and rural hospitals especially so. (Biden’s plan to send 1,000 military personnel to hospitals might help, but most of them won’t be deployed until January.) Nonessential surgeries will be deferred, and many patients will come in sicker after the surge is over, creating crushing catch-up workloads for already tired health-care workers.
Many Americans have mistakenly assumed that the health-care system recovers in the lulls between surges. In truth, that system has continually eroded. Droves of nurses, doctors, respiratory therapists, lab technicians, and other health-care workers have quit, leaving even more work for those left behind. COVID patients are struggling to get care, but so are patients of all kinds. In this specific way, the U.S. is in a worse state than in March 2020. As the doctors Megan Ranney and Joseph Sakran wrote, “We are on the verge of a collapse that will leave us unable to provide even a basic standard of care.” Being overwhelmed is no longer an acute condition that American hospitals might conceivably experience, but a chronic state into which it is now locked.
Omicron is dangerous not just in itself, but also because it adds to the damage done by all the previous variants—and at speed. And the U.S. has consistently underestimated the cumulative toll of the pandemic, lowering its guard at the first hint of calm instead of using those moments to prepare for the future. That is why it keeps making the same mistakes. American immune systems are holding on to their memories for dear life, but American minds seem bent on forgetting the past years’ lessons.
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