Welcome to Plugging the Gap (my email newsletter about Covid-19 and its economics). In case you don’t know me, I’m an economist and professor at the University of Toronto. I have written lots of books including, most recently, on Covid-19. You can follow me on Twitter (@joshgans) or subscribe to this email newsletter here. (I am also part of the CDL Rapid Screening Consortium. The views expressed here are my own and should not be taken as representing organisations I work for.)
Many other newsletter writers sum up the end of the year by highlighting their most popular posts. I looked through mine and the more depressing they were, the more popular they were. So it just didn’t seem right to highlight them again not when I can just write a new depressing post. So strap in and consider yourself forewarned. This is going to be a rollercoaster.
I want to start by noting a seachange in pandemic management. The broad philosophy in most places has been a centralised ones — rules regarding social distancing, mask-wearing, PPE, and vaccines — have usually come from above. They still do. Quebec this week returned to its harsh lockdown complete with 10pm curfew to annoy essential workers travelling home at night.
But Ontario, for example, has shifted gears. Faced with an inability to conduct PCR tests, it now no longer offers them to the general public. They have shifted from the ‘gold standard’ to determine if you have PCR to the ‘gold is expensive’ strategy of being used if you think knowing whether someone has Covid will help in their treatment. Instead, they advocate using rapid antigen tests (RATs) to clear symptomatic, vaccinated people from isolation (a negative RAT on days 6 and 7 since symptoms began). That is all self-administered with no reporting requirements.
In other words, Ontario, like many public health approaches, is now moving from centralised management to asking people to manage their own risk. That’s a big change in philosophy. It is the kind of thing you do for an endemic disease rather than a pandemic one. There are some solid reasons to think it could be the right approach but there are equally solid reasons to be concerned. I can’t evaluate it except to lament that we really haven’t given people the tools to self-manage in the way we would like — including notably a shortage of rapid tests. Anyhow keep that in mind as I move on.
Plague Inc
When I set out to write a book about Covid back in March 2020, my first thought was the very popular (at least up until then) mobile game called Plague Inc. Here is what I wrote:
Everything is awful. The virus is awful. The immediate choices are awful. The future may be even more awful.
We should have been more prepared. For almost a decade, one of the most popular apps was Plague Inc. (120 million downloads and counting). It showed us how diseases broke out and did their damage. When the COVID-19 outbreak hit, the app surged back to number one in China and was promptly banned in the country.
In Plague Inc., you play the virus and your goal is to wipe out humanity. To the extent they have a goal, that isn’t the goal of most viruses. Instead, it might be survival of its genetic structure, which would end should it wipe out its hosts. But never mind; from humanity’s perspective, we would want to tool up on the tactics for viruses that would lead to extinction.
COVID-19 is not that species-ending virus. But it does have some of the characteristics you would employ in Plague Inc. if you wanted to destroy us all. An inexperienced player normally goes for a highly infectious and deadly disease. But that is not the best course of action. First, because the virus is deadly, human scientists start working extra hard to stop the plague. Second, if you kill people too quickly, you actually slow down the rate of infection. Instead, what you want to do is find a way of infecting many people preferably without any symptoms that would get the infection noticed. Then you want to ramp up the disease after each infected person has spread it around so that you overwhelm health centers before the world shuts down travel.
If the key to winning Plague Inc. is to move in stealth so as not to provoke an effective human response, then COVID-19 fits that bill. People become infectious, many with zero or just mild symptoms, but then there is a deadly movement into pneumonia and other serious problems, which takes some weeks of hospitalization to treat. There is an information problem that prevents a targeted response. If we had known who was infected, we could have kept them from others and monitored their health for signs of problems. But COVID-19, being carried by people free of symptoms, kept that information hidden.
By obscuring its prevalence, COVID-19 gets high marks for being able to spread quickly through the population. While this is not necessarily enough to win Plague Inc., COVID-19 was able to crash the world economy to levels not seen since the Great Depression and make people afraid to come out again. In that respect, it was the pandemic that games, TED talks, books, and medical reports were trying to warn us about for years. And it was a real game that likely would last for some time.
In many respects, that was just the half of it. And that last sentence, in retrospect, is quite misleading.
First of all, Classic Covid, while very effective in a Plague Inc sense, was nothing compared with Omicron. Omicron is possibly more infectious than any airborne respiratory illness was or was conceived of being. It is a Black Swan event for epidemiology and virology. But at the same time, it hits the Plague Inc sweet spot as it is not causing immediate health issues for the vast majority of infected people because they are vaccinated and vaccines appear to be working. That means no one is really resisting its spread. In other words, if the first task in Plague Inc is to get everyone infected, Omicron is near perfect — even better than HIV in that regard. Moreover, there is enough of it so that even when public health finally appears to be getting religion on testing, it is overwhelming that system that was wholly unprepared for all of this.
Second, the whole last two years have not been the pandemic we were scared into worrying about. It certainly isn’t of the Station 11 variety that quickly wipes out 99.99% of the population. (A great HBO show, by the way, which you should watch). And it isn’t of the Contagion variety where it was deadly in a SARS or MERS like way and caused people to hunker down to avoid a quick and gruesome death. That last movie was designed to alert us to pandemic dangers. Most people have not suffered ill health or even known people who have. The fatalities have been relatively low. Life has been mostly boring rather than fearful. In many respects, our last two years have been just plain weird. How would you sit down with your grandkids to tell them what it was like during the pandemic? What it was, was quiet.
In that regard, both Classic Covid and now Omicron have found a strategy for infecting us that is more powerful than just epidemiological properties. They have made the pandemic response ambiguous. Sure, Contagion hit upon that a little with bogus treatments but no one wanted to get infected. Here, the pandemic maximised the conflict between individual choice and social responsibility. That conflict is what made it tough to respond to Covid because, after a very short while, there was no broad consensus of how to do that. There wasn’t even a broad consensus that Covid was bad. In that respect, the new Netflix movie Don’t Look Up does a nice job at showing how such discord makes it impossible to manage catastrophic risk. In a Plague Inc sense, sowing discord is the way the virus wins so we shouldn’t have been surprised that was the virus that broke through and won.
It has won. Omicron is going to be everywhere. That is a viral victory quickly on a global scale that has been achieved by no other. The issue is, now what?
The Complacency Symptom
Some will say, not “now what” but “so what”? So what if the virus has won? Maybe it won’t be harmful so should we care. Maybe, it is a gift that is akin to a virally spread vaccine program for the world? Maybe, it is the thing that ends the bad stuff about the pandemic and we can go to normal even if there is a coronavirus occasionally giving us the sniffles?
And therein lies the problem. If the virus were a sentient player who was interested in just existing in large quantities, then we have reached an accord and everyone can move on. But that isn’t what the virus is. This is not a negotiated peace that the virus can commit to. This is because the virus can mutate. This is also because our own immunity — vaccine provided or otherwise — can wane.
Here’s the scenario I worry about. (It is in fact the same scenario I forecast in April 2021 in my most popular post). Omicron roars through the population without serious health issues and by February is mostly clearing. Then begins a period where it appears to all accounts that the pandemic is over. Life returns to normal. But Omicron never really goes away. It circulates at relatively low levels as viruses can do following outbreaks. But it is at high enough levels to still be working.
Omicron mutates. Not in the spike protein necessarily but in other parts that allow it to more effectively invade the body quickly. In that scenario, we get several times the rate of serious Covid with a virus that is as infectious as Omicron. When our immunity wanes, the virus picks up. In one situation, it is the same Omicron in which case we are fine. In another, it is slightly more infectious but much more virulent in which case the pandemic is back with us, health consequences and all in Fall of 2022 and Winter of 2023. Thanks to complacency, we are wholly unprepared. Thanks to complacency, it takes much longer to get a public health coordinated response. Thanks to complacency, people don’t have better tools to manage their own risk.
This is the way for a virus to play Plague Inc with its stated goal of harming everyone; as opposed to the evolutionary imperative of viruses. The virus needs to get everywhere and then become dangerous quickly. HIV leading to AIDS had this quality. HIV spread, lay low and then turned into the 100% lethal disease.
I have talked with epidemiologists about this possibility. Far from ruling it out, the probabilities they give me — and they are all very subjective — are much higher than the 3% threshold that was my trigger to write this post.
Priming for Insanity
My point here is not to be overly pessimistic. On the balance of probabilities, it seems that we will be just fine after Omicron and can move officially to the endemic phase of this mess.
Instead, my point here is that Omicron seems primed to maximise our own insanity in dealing with its own associated and continual catastrophic risk. If history, especially recent history, tells us anything, it is that that strategy works. I’d bet on insanity happening any day.
But I write this post just in case there is someone, somewhere who may be able to work out how to hedge against that insanity and put us in a better place should the scenario I am worried about actually take place. In terms of preparation, that means that while, for the moment, it may make sense for people to manage their own risk as if we are on the verge of endemicity, someone has to be taking centralised preparatory actions in case the pandemic, as much as it might seem to be, is not actually over.