Welcome back, Shit Givers.

My apologies for not sending you a regular newsletter on Friday. I decided mid-week to replace it with a COVID update, and it grew to what's below. I wanted to fully explore what's going on and that just takes (a hell of a lot of) time. I hope this helps clarify things for you.

If this helps you feel more grounded in what's happening, please forward it along.

Reminder: You can read the entire piece on the website, or you can 🎧 listen to it on the podcast (working on recording today for publish tomorrow).

🕛 Reading Time: 35 minutes

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Here's my COVID update:

TLDR: Not great, Bob. But there's so much more we can do.

Longer version:

Soup to nuts, I’m more concerned about COVID today than I’ve been at any point in the past year. I don’t think it’ll be a horror show soon, not like it was before, but we haven’t (yet!) put ourselves in a position to get ahead of a virus whose entire job is to find ways around our defenses, and now it’s doing just that.

My usual caveats:

• I’m not a virologist
• I’m not an MD
• I’m not an epidemiologist
• I’m not a sociologist
• I’m not a policy maker
• I’m not a journalist
• I’m not a cat

I am: A former liberal arts major with a popular and critically acclaimed newsletter and a podcast, and I’ve spent the past few years trying to learn about the world’s most complex problems from a broad array of incredibly smart, capable, and thoughtful folks to understand where we are, why we’re here, where we might be going, and what the hell you and I can do about it all.

Also: I’d love to be wrong here. I am wrong all of the time. I will be the first to celebrate being wrong on this, too. I will rise from the ashes and dance on my own grave, should my wife and children splurge for one (not guaranteed).

Some background:

In January 2020, I mentioned the “flu-like” disease thought to have originated at a Wuhan market in our weekly newsletter.

In early March 2020, I wrote about the facts on the ground, as far as I could tell, and made educated guesses about others, that masks might not work because the virus droplets might be too big (woof), but also that, all things considered, you should stay home immediately, that the market would crash, that your office and kids school would soon be closed for months, at least, and that the baseball season and Olympics would be canceled.

Last November, I wrote about variant “B.1.1.7” (OG Omicron), and how “it could ravage this country and make 2020 seem like child’s play.”

And all along, I’ve covered the broader shifts of COVID every week in this newsletter, standing on the shoulders of some of the most incredible journalism we've ever seen.

To be clear, this piece isn’t about the moral crimes of the past two years: Millions dead across the globe, an official tally of a million dead in the US, even if it’s at least twice that, a tally we’ve normalized either way, or the complete failure to mourn those lost, etc.

This piece isn’t about the frontline workers who did the jobs the rest of us don’t want to do, the Black and Hispanic people who were sacrificed, or the elderly who have made up the bulk of COVID deaths thus far.

Those people are gone and we can’t get them back, so they can’t catch or spread this fucking virus any more.

But we can.

And here are the facts on the ground:

Because of a huge, overlapping variety of societal and institutional failures, our bodies and health system, however immunized, are under assault from an increasingly wide variety of subvariants of our own making.

We have chosen not to vaccinate the world, and at home, we have almost completely let our guard down, relying on a population whose existing vaccines are becoming less potent every day and who are reluctant to get any additional new ones, no matter how capable.

Institutionally, we are increasingly doing drastically less to not only quell current variants, but to prevent new ones, to research, support, and treat those with Long COVID, to alleviate a hospital system that is, through compound interest, overwhelmed and understaffed, and, most vitally, to communicate how this could get bad all over again, and quickly. And that’s all before the November elections.

Today I want to elaborate on these factors, and help you understand where I think we are, where we might be going, and why, and what we can do about it. While historically our “numbers” remain low (and that’s great!), there’s a very good chance the variants keep evolving to feature better immunity evasiveness, leaving our current vaccines markedly more ineffective and our population exposed again.

Again, a caveat: I might be very, very wrong, and I hope I am. But I don’t think I am.

Background

It’s easy to forget after everything we’ve been through, but here’s a vast over-simplification of how we got here: with a novel virus and an N of everyone on the single habitable planet in the galaxy.

Our only defense: stay home.

Almost two and a half years later, there’s billions of unique physiological circumstances among us, factoring in a growing medley of vaccines, time since last vaccination, individualized antibody and T-cell responses, a huge miscellany of variants and exposures, pre-existing conditions, etc.

Besides that little taste of continually increased medical and sociological complexity, here are the major factors driving the next stage of this pandemic:

• Mitigation
• Global vaccine equity
• Childhood vaccinations
• Boosters
• Variants
• Evasiveness
• Repeat infections
• Long COVID
• Leadership
• Oh, and racism, burn-out/insistence on moving on/denial, inflation, climate change (you’re welcome), and yet another American election with seemingly existential stakes.

It’s important to understand that for each of these factors, we’ve chosen the path of least resistance, prioritized the short-term over the long-term, and emphasized the individual over the communal.

It’s safe to say this is not how you do public health.

My on-going metaphor is that the virus was a pop quiz on all of the societal choices we made in the few hundred years prior to December 2019.

Despite the heroic, last-minute efforts of many, we mostly failed because of who we are, and what we built.

The choices we’ve made in just the past two years will, perhaps irrevocably, define the rest of our lives.

Right now

Hospitalizations are up 134% from all-time lows in the United States in the last month, and rising even in states and cities with the most testing and most vaccines.

Still historically low, by a long shot. But rising, and we don’t have the full picture, starting with cases.

Consider the home test conundrum:

I’ve written ad nauseam these past few months about the benefits and the drawbacks of home tests: long, long overdue, these plentiful and (sometimes) free home tests are private, easy to use and understand: one line is good, two lines is bad.

But home tests that come back positive don’t count towards official totals, so the case numbers you’re seeing for your town or state are probably in reality 10x what you’re seeing on your little dashboard.

10x.

Coming back to hospitalizations: they’re rising, but probably a little more accurate (more on that below), and it’s all relative. Per The Washington Post, “The roughly 23,000 patients with covid in hospitals over the last week still represent near the lowest hospitalization levels of the entire pandemic.”

This continues to be fantastic news. Fantastic news, because we mismanaged this thing so much that 23,000 weekly hospitalizations is among the best news we’ve had.

But will it stay that way? Let’s start with your face –

Mitigation

– and masks.

As Oliver Pybus tweeted this week, “R0 depends on both the intrinsic transmissibility of a pathogen and on the properties of the population it finds itself in. A change in either can alter transmission behaviour.”

On both fronts, we find ourselves simultaneously in entirely new territory, and back to square one. For a million reasons – immunizations, politics, and fatigue equal among them – we are currently, aside from vaccines, utilizing fewer COVID mitigation strategies than since March 2020. Just a quarter of US workers are covered by vaccine mandates in the workplace, and test and mask mandates are either patchwork or nearly gone, despite more people in offices this week than since we all fled them two years ago.

In schools, a few mask mandates have returned with rising cases, but there is just one state (Hawaii) among the 50 that requires them, while five states have banned mandates altogether, with six more states waiting on court approval.

Masks are no longer required on US public transportation or airlines, nor for flights to most of the European Union.

It’s over (mitigation, not the pandemic).

As cases dropped after Omicron to the lowest levels in years, we dropped our first line of defense.

And I get it. Whether or not you or I actually did stop masking, we have all dreamt of going back to the before times, hoping we could just get back to those times, wanting to put our masks in a drawer for good this time, only to unexpectedly find them years later, and remembering: Fuck me, remember all that?

Instead, we have ignored that the before times are what brought us here, that we were tested, and failed, that we are changed, even if we refuse to change, that there is no going back.

We made masks about liberty for all and the most vulnerable among us – the ones who couldn’t drop their masks, or get shots – continue to pay the price. So no more masks for most folks. Better hope those vaccines are up to date.

Vaccine equity

16 months after groundbreaking vaccines became unexpectedly, unbelievably available, over 34% of the world’s population, or 2.7 billion people, haven’t received a single dose, and that includes over 84% of people in low-income countries.

Now, the global vaccination machine is a complicated one, something I learned early in my very informal public health education.

As the recently late Paul Farmer said, “Those whose lives are rarely touched by structural violence are uniquely prone to recommend resignation as a response to it. In settings in which all of us are at risk, as is sometimes true of contagion shared through the air we breathe, we must also contemplate containment nihilism—the attitude that preventing contagion simply isn’t worth it.”

You see, the machine can’t run at all if you don’t charge up the battery (no gas tank metaphors here, friends), and, despite knowing full well how a virus works, the Global North has decided those people – other people – just don’t matter.

It’s true, and despite several on the record and many off the record conversations, no one’s been able to convince me otherwise. The receipts are in. COVAX has failed, because its would-be sugar daddy GAVI is broke, and that’s because countries like the United States simply refused to fund these organizations to the level required to even put a dent in this thing, much less slow it down.

In countries historically swamped with malaria, childhood malnutrition, TB, HIV, and occasionally ebola, misinformation and distrust run rampant, and so conversely, vaccination rates are underwhelming despite the myriad, decades-long and herculean efforts of local health workers.

Sure, President Biden last week convened the 2nd “Global Covid Summit”, and world leaders promised $3.1 billion in new funding, but that’s at least $15 billion short of what was expected.

Biden (who last week had to strip global COVID funding out of a Ukraine war bill because it wouldn’t pass with it) said, of the pandemic, “We have to prevent complacency. This summit is an opportunity to renew our efforts to keep our foot on the gas when it comes to getting this pandemic under control and preventing future health crises.”

Narrator: He gave them 20% of what they asked for.

Sure, yes, the US licensed 11 COVID-related technologies to the UN, but Esteban Burrone, head of policy at the Medicines Patent Pool, a U.N.-backed public health group that promotes access to vaccines and therapies, explained to Politico how these aren’t desperately needed products, to be used today, but simply technologies:

“It’s hard to tell when a specific product will become available,” he said, noting there is no promise the technologies and candidates will eventually become useful products. “A lot of them look extremely promising.”

Ellen t’Hoen, who founded the nonprofit Medicines Patent Pool, agreed the technology licenses are helpful, but also said “You can’t have sustainable vaccine manufacturing capacity if you’re only allowed to produce something when the world is on fire.”

The world is on fire, and we’ve denied a few billion people water cans, despite knowing full well how fire spreads.

So sure, yes, Africa’s got its first COVID vaccine factory, but it hasn’t received a single order, because after two years of COVID and everything else they deal with on a day-to-day basis, fatigue has set in; there’s too much else to do. It just might be too late.

We can talk all day about funding, or manufacturing, or distribution, or distrust, or misinformation – but effectiveness comes down to reliability, and there’s none of it, and we don’t have time to waste.

I don’t want to be melodramatic here, but the circumstances haven’t changed: every single unvaccinated person who is infected by the virus could be asymptomatic, or get sick, need to be hospitalized in a place that’s not able to take them on, or die. We saw this in New York in 2020 and Los Angeles in 2021, and we continue to see it across low-income countries today.

In every scenario where you or someone in Ghana contracts this virus, you or they will most likely pass it to more people, and maybe, just maybe be ground zero for a new variant.

We knew this, so we developed and distributed almost 12 billion vaccine doses in just two years. We built immunity where once we had none. But not everywhere, or equally, or fast enough.

We have steadfastly and increasingly refused to get ahead of the game. If you, a reader in the West, do not think this negligence affects you, I’d encourage you to look around.

If you haven't already, go to the web version to read the whole thing, because Gmail's going to clip it soon.

Vaccines

Depending on your data source, the red, white, and blue is ranked somewhere in the 54th-57th range in the world for life expectancy, at 78-ish years.

Cue The Newsroom theme song.

Would you like to know how that ranking plummets even further? By being 68th in the world for percentage of population that has received a 2-shot vaccination course. And unlike Africa, our relatively shit vaccination rates are by choice. Millions of shots remain unused as our immunity – and interest – continues to drop.

Further, and despite a wealth of evidence for, well, boosting immunity, just a third of eligible Americans have gotten a booster shot.

COVID has done its goddamn best to wipe out everyone over 65 and yet only 2/3 of those folks have gotten a booster.

Despite a nationwide firestorm over the definition of “pro-life”, despite a notable and tragic increase of hospitalized and dead kids since Omicron kicked off and then peaked just a few months ago, children under 5 remain tragically on the precipice of being approved for their first vaccines, and only one-third of eligible kids ages 5-11 have gotten two shots.

Part of our vaccine failures are down to messaging, and boy have we fucking blew it on messaging. We blew it so bad, one new estimate claims 319,000 goddamn American lives could have been saved if we were all vaccinated.

Instead, we normalized those deaths, and at least a million more.

Instead, a third of Americans think the pandemic is “over”, and for good reason. We have told them it’s over; we dropped nearly all restrictions everywhere; we closed nearly all the mass vaccination sites; and we certainly haven’t hired the best marketers anywhere to mount a nationwide “Uncle Sam Wants You To Open The Windows” marketing campaign for ventilation.

Don’t you find it confusing when public health officials tell you you can take your mask off on planes now, but hey also you need another shot, pronto? We’ve bungled boosters so so much, changing our tune on who should get them no less than four thousand times.

Look. When you tell people who can get them or that will respond to them that they’re “fully vaccinated” after two incredible shots, well, they’re going to believe you, and finally move on with their lives. And many can, because they don’t have underlying conditions, they can WFH, they have paid sick leave and time off, they can afford childcare – they can afford to get sick in America.

But we have for some reason the complete inability to operate in the gray area (see: abstinence), to help people understand that science – and viruses, and how we respond to them – is a process. If we have to keep moving the goalposts, and it sure as shit seems like that’s the deal, we’re better off (for example) using still-imperfect but more relative and flexible language like “up to date.”

But here’s the other problem. Lots of people who could did the right thing and got vaccinated in 2020 and 2021, and then a tidal wave of folks got some early version of Omicron, and now there’s another brewing surge, despite all the vaccines, and so it’s kind of understandable when 19% of those polled said doubts about the vaccines’ effectiveness were holding them back from getting boosters.

They did the thing, they feel fine, they can afford to get sick, or simply don’t care.

In some ways, our COVID response reminds me of Sandy Hook (note: this was published before Uvalde. The point is only stronger). I know. But hear me out. If a class full of kindergarteners getting mowed down by semiautomatic weapons doesn’t lead directly to gun control, it’s probably not happening. Nine and a half years later, this country is armed to the fucking teeth.

Similarly, if a pandemic that locks every person on planet Earth inside their home (if they have one), that shuts down economies and societies for months on end, that kills millions, including a huge chunk of frontline hourly workers in the US, doesn’t lead directly to universal sick leave, paid time off, parental leave, etc – I’m just not sure it’s going to happen.

So, because #America, millions of already-marginalized Americans remain unable to take off work or get childcare for a third time for a third shot – even though they’re statistically 2-4x more likely to get the virus, get sick, and die – much less for the chance they’ll feel shitty side effects (requiring more help and/or time off and lost wages) in the days after.

All of this, keep in mind, as shots have been available for free. Where once the lines stretched down the block, we now, quite literally, can’t give these things away.

Maybe this surge dies down quickly, and hospitals don’t get as slammed as they did during Omicron, because we have a lot of people have some immunity, but that’s not how this ends. It’s literally not how it works.

How the hell do you think it’ll go once the variants keep evolving, and the government actually runs out of funding and shots cost money later?

If you’re wondering, “Wait what? Is that going to happen?” Yes, it is, and soon, and then for the rest of your life, probably.

Variants

Because Omicron was so transmissible, and so very many people remain unvaccinated around the world, a potpourri of “variants of concern” are competing day in and day out to become the next Delta, the next Omicron, the next household name.

The current title-belt holder in America, the BA.2.12.1 subvariant, is 30-50% more transmissible than already wildly-transmissible BA 2.

While none seem to be more severe than past variants, newer variants are growing more differentiated. The European Centre for Disease Prevention and Control said, “Preliminary studies suggest a significant change in antigenic properties of BA.4 and BA.5 compared to BA.1 and BA.2, especially compared to BA.1.”

What happens when variants and subvariants fall too far from the proverbial tree?

Well, as Andrew Joseph wrote this week in STAT, “They…look distinct enough from past forms of the virus that they can evade people’s immunity and trigger infections.”

And that’s what we’re seeing. When OG Omicron blew through all of your friends in January, we assumed we’d get a break after. And we did! Cases, hospitalizations, and deaths dropped to all-time lows. Holy hell did that feel good.

But the break is over, in a real way. In Science, Gretchen Vogel wrote: “Initial studies…suggest BA.4 and BA.5 can elude the immunity of patients who were infected with the BA.1 strain, which in South Africa caused a much larger wave than BA.2.”

When the United States (and so many other places) got relatively in the clear and de-emphasized cases, we not only gave up our ability to create a map of the territory, ignored how symptomatic cases affect family life and work life, and further left the immunocompromised out to dry, we considerably depleted our ability to sequence for the virus and new variants, to better grasp just what the hell is going on out there.

In turn, we may have a drastically poorer understanding of the COVID landscape than we did even last year. Which is really saying something, because hey, you might remember testing was never our strong suit.

Increasing re-infections

If a population were depending on immunity from shots and previous infections, but then a subvariant or three came along that evaded the body’s immune response, what does that mean?

First, it means you can get it again, or for the first time, even if you’ve had three shots.

Second, it means we don’t have a damn clue what percentage of the population is vulnerable again (again with the complexity), just when we’ve dropped nearly all mitigation efforts. Some states are tracking reinfections, but the CDC itself doesn’t even seem to be.

Now, you may say say “So COVID is becoming endemic, and like the flu, or even a cold! I’ve only gotten the flu once or twice ever, and I get colds a few times a year, it’s annoying, and sometimes it even sucks, but, this is do-able, right?”

Maybe for you, Todd, but not for a lot of folks. Not unless we do more.

Just because this coronavirus is starting to reinfect people like its other coronavirus brethren, doesn’t mean the long-term implications are the same. For example, you don’t get Long COLD.

More broadly, consider the economic implications of just another cold, as Tyler Cowen pointed out this week, “One 2003 estimate suggested that the common cold costs us $40 billion a year.”

Even if just a small percentage (say, 5% of the infected) get Long COVID, is $40 billion a baseline cost we’re just willing to assume?

If the answer is “yes”, then wow, but also – $40 billion is just table stakes, because this isn’t a cold we’re talking about, and we’re increasingly doing little to prevent this scenario from coming to life.

Vaccinations, Alpha, Delta, and Omicron may have provided a majority of the population with some (hugely varied) level of immunity, and that can hold off a lot of (but not all) severe outcomes, but keep in mind: all of those things happened when we were still wearing masks, and when most of our vaccines were most potent (#Killer T-cells 4 life).

Infection-wise, for the virus, increasingly evasive and finding not even a cloth mask in sight, replicating in America is now akin to eating at an all-you-can-eat buffet. We, on the other hand, are deeply engaged in a highly-technical process called “fucking around, and finding out.”

Long COVID

Let’s talk about the in-between place.

It’s estimated at least 24 million Americans already have some version of Long COVID, just the first cohort in perhaps the most voluminous disabling event in almost a hundred years.

But there are still so many unanswered questions, like “What the hell is Long COVID? How do we test for it? Do vaccines prevent it? How do we treat it?” and, as I wrote last week, “What percentage of positive cases get Long COVID?”

Is it 10%? 30%? Who the hell knows?

When we stop counting cases and we stop sequencing cases, we get further away from answering the latter, and thus, being able to understand (if at all) who may be more likely to get it, and what support structures we need to build to support an enormous and entirely new underlying condition.

Minimal but heroic research may be honing in on the “who gets it” question, but because #science, additional research just opens the door for more questions.

Taking another step back, we have to ask: How exceptional will America, host to a disproportionate number of cases and inversely, vaccines, be with regard to Long COVID?

Yes, war in Ukraine has (rightfully) distracted us, and yet we have to be able to walk and chew gum at the same time, to operate society and our economy but also work to reduce infections and hospitalizations, and yet.

We are so intent on moving on from COVID, we’re just refusing to do the work to understand what tens of millions of people will seemingly be dealing with for the rest of their lives – as infections and re-infections continue to pile up from those subvariants we’re tracking less well than before.

So, again, who gets Long COVID?

Early, pre-print research claims a higher viral load may be an indicator of vulnerability to Long COVID symptoms.

But another analysis shows that over a few months in 2021, 75% of Long COVID patients weren’t actually hospitalized when they tested positive, only later, when breathing problems, coughing, crushing fatigue, and hypertension, among other symptoms, drove them to check in.

From The New York Times:

“While two-thirds of the patients had pre-existing health conditions in their medical records, nearly a third did not, a much larger percentage than Dr. Paddy Ssentongo, an assistant professor of infectious disease epidemiology at Penn State, said he would have expected. “These are people who have been healthy and they’re like, ‘Guys, something is not right with me,’” he said.

[And further], the study…did not include people covered by government health programs like Medicaid or Medicare (though it did include people in private Medicare Advantage plans).

“That’s probably a drop in the ocean compared to what the real number is,” Dr. Claire Steves, a clinical academic and physician at King’s College London, who was not involved in the new research said.”

If there’s one thing that’s clear to me it’s we should be talking about and reacting to two obviously related, but different public health crises: Sars-COV-2/COVID, and Long COVID.

But we’re not. Like climate, we just have to talk about this more. We have to. When we talk about it, when it becomes the social norm, people in power have to take responsibility.

And right now, there’s none.

We’re minimizing the personal, societal, and economic implications of COVID, much less Long COVID; we’re committing epistemic injustice, a hallmark of American health care; we’re asking too much of a healthcare system that’s completely burnt out; we’re failing to provide a safety net to the millions of service workers who can’t just stay home; we’re linking safety to hospitalizations with pretty green maps; we’re telling people they need a booster to protect ourselves and each other but not giving them the time off to get one; we’re telling them they need that booster, now, but that they don’t need masks, ever, no take backs.

The government can’t even get people to sign up for the NIH’s Long COVID research project, RECOVER, a project that should have a huge marketing spend behind it. Our fractured-ass health system is terrible at these studies, unlike the UK, who, while imperfect, used a centralized 40k person study to produce real, useful results with dexamethasone and to shoot down hydroxychloroquine for good.

Clinicians and regular people don’t know how to gauge safety outside what they see and feel on the day to day and that’s partly because we simply aren’t doing the work to find out how safe they are on the macro.

The only treatment that might work? Maybe? Paxlovid.

Paxlovid

My Twitter has been increasingly filled with very-online-people getting infected or re-infected and then swearing on the benefits of a 5 day course of Pfizer’s miracle oral drug, Paxlovid.

But how well does it work? Does it actually prevent deaths? Fun story: we’re not actually sure, because it was tested on unvaccinated people who’d never previously contracted the virus.

Why is that bad? Because it’s the year of our lord two-thousand and twenty two and 76% of US adults have got at least one shot, and/or some quickly growing percentage has been infected more than once, and maybe more than once, with more than one variant.

And now some (seemingly small, but ¯\_(ツ)_/¯ percentage of people who take the drug are testing positive all over again after finishing the prescribed course.

Despite all of this, prescriptions for Paxlovid rose over 300% from April to May after a spring filled with patients demanding it and doctors who had no idea it even existed, and if they did, if they were allowed to prescribe it.

I fucking hope it’s really getting people back on their feet, back to work, and saving lives. Even if it works a little bit, that’s a win. But it needs to be wildly more accessible, and we need to know more about when it works.

And then, there’s this: government-funded stockpiles will run out in the fall, just before the same government is predicting 100 million new cases.

But what about in all of those low-income countries that are struggling to vaccinate their citizens? Of the 30 million courses of Paxlovid that Pfizer is likely to produce in the first half of this year, 28.4 million have already been claimed by wealthy countries.

Pfizer has licensed a generic version to be produced and distributed in those countries, but it won’t be free, and won’t be available until 2023. And we. still. don’t. know. if. it. works. on. vaccinated. people.

We have so much to learn, but we’re unwilling to ask the questions.

New vaccines

One of the things we did learn in the past two years is that we can finally (thank you, Dr. Kariko) make mRNA vaccines, and that they’re fucking awesome.

But since we didn’t get them to enough people, and quickly, we need updated ones, like yesterday, and probably annually for a very long time.

First up: Moderna’s trialing a “bivalent” booster that protects better against more than one variant (like the annual flu shot does). But is it already stale?

I don’t know! I told you I’m not a goddamn virologist or even a microbiologist, despite appearances. All I know is the new booster’s designed to target not only the original variant (like current boosters), but also Beta.

Remember Beta? Probably not! I can’t remember breakfast. Beta was a year and a half ago, and barely even registered in the US.

Fuck, well, what else? Well, another shot under development will target Omicron, and all this sounds great until you remember – we’re fighting the last war all over again. There have been 3 dominant variants since February. February was like a week ago. What will we see this summer? This fall?

I’m so glad we vaccinated and protected so many people, but we can’t live in a snapshot of time and call it a day.

We need to be doing everything we can to run ahead of this thing. We have to go all out on research, trials, production, distributing, and, yes, marketing. We need to stop this thing at the source. Your nose.

Nasal vaccines

In 2020, when people first asked me when we’d have a vaccine for COVID, I said “I have no idea, I write a newsletter from my sweatpants.” But then I called a bunch of really smart folks and I triangulated their responses and it seemed like the most common was, “Eighteen months, if we’re lucky.”

But thanks to decades of work from folks like Dr. Kariko, just twelve fucking months later we all quietly sobbed as we watched a live-stream of those 18 wheelers packed with frozen shots rolling away and towards a government-funded mass vaccination site near you.

We can do it again, right? Not the way we’re going.

There’s no Operation Warp Speed anymore, which is fucking dumb, because there’s eight different nasal vaccines in clinical development, and three in phase 3 trials, and – while we got super lucky and nothing in trials is guaranteed, they fail literally all of the time – we should be throwing everything we have at finding out if they’re for real, or even safe.

You are almost certainly going to get COVID (or whatever else my kids have) by inhaling it through your nose or mouth, and a nasal vaccine could kickstart something called “mucosal immunity”, which can stop viruses before they even get started.

The problem? We’re not 100% sure how mucosal immunity works, or if a nasal shot could affect the brain – just a short jaunt away – somehow.

The good news? The entire world depends on us finding out, kind of like round one with the original shots. The bad news? This time, nobody wants to pay for it, despite the fact that, as I’ve explained here in just a few hundred thousand words, this thing is spiraling out of control again. And all of this is not only a failure of leadership, but a willful abdication of it.

Leadership

Many years from now, after Civil War II (the war) and Avatar VI (the movie), we may look back at this as a shared time of suffering and struggle, but today, we are increasingly less together.

All of this time and suffering, the deaths, the 2020 election, January 6th, the lab leak theory, the Snyder Cut, the increasing polarization and lack of trust, and a huge variety of new lived experiences means we share very little commonality.

There are a million public health officials I have come to know and admire in the past two years but I think it’s safe to say many of them were unprepared to talk about a pandemic in real-time, much less guide an angry, fractured country through one.

Look, ever since we started washing our hands and stopped pooping where we eat, infectious disease has taken a back seat to the huge variety of chronic illnesses the American lifestyle causes. We’ve spent a gajillion dollars on heart disease and cancer and elections (and erections, for that matter), and not a whole lot on air filtration and local health clinics and school nurses.

And yet it’s also important to understand that COVID is not the first time our healthcare system has failed to operate like a well-oiled machine. It is in fact a fractured, backwards, expensive, fax-machine dependent, just-in-time, paper-based, profit and procedure-focused clusterfuck, increasingly the target of ransomware, often staffed by selfless heroes, over-regulated in some places and not nearly enough in others.

Like arguing for, say, degrowth, saying the government simply failed to vaccinate every person in the country as if Joe Biden could have one-clicked 330 million vaccinated Americans into his Amazon cart reveals a profound lack of understanding how the entire system – from the federal to local governments, for-profit hospitals, insurers, pharmacy chains, and primary care – simply doesn’t work together on a regular basis.

This post is so long because the problem is so complicated, because our systems – from Senate confirmations to the CVS mobile app – suck.

Through all of this, the lack of coherent, useful guidance from the top has crippled our collective effectiveness.

Are they not telling everyone to get boosters because the government won’t be able to pay for them soon (they won’t)? Or because the boosters aren’t as effective because they’re increasingly outdated (they are)? Or because everyone’s mad at each other? Or is it because they don’t want to start shit when election season is right around the corner?

Oh, right. The fucking election

Here’s where shit truly hits the fan.

Depending on when I actually finish this (maybe never!), the US midterm elections are something like 168 days away. At stake, just the House, the Senate, maybe even the Presidency (if the GOP gets both House and Senate), 36 governorships, and a million essential state and local races.

If you think the government isn’t functional now, just wait until we get closer and everyone is completely distracted, even more so than they are now by war in Europe, by fossil fuel profiteering, China being shut down again, a bear market, by Elon Musk fleeing to Brazil after offering an employee a horse in exchange for sex, by BeReal, by Starbucks and Amazon and Apple union busting, by–holy shit, did you see who’s leaving SNL after this season?

The midterm elections will consume us, though not as much as a presidential election, unfortunately, but there’s enough on the line politically that absolutely no one’s going out on a limb for anything that isn’t flag-related.

Where we are today – a million officially dead and probably a million more uncounted, tack on another half a million or so with cancer or heart disease who died because of COVID, not of it, tens of millions more with Long COVID, almost ten million immunocompromised still in hiding, and supply chains the world over in the shitter – is the result of the final year of a corrupt GOP administration who, yes, ran Operation Warp Speed, which worked incredibly well, and the first year of a timid (at best) Democratic administration and majority, under which, yes, 75% percentage of the country was vaccinated – and then we basically stopped, because of war and inflation and Joe Manchin and Let’s Go Brandon.

What makes you think a more fractured federal government would be more focused on getting the COVID job done domestically, much less abroad?

Let's think through this:

What makes you think they’d do a Warp Speed for pan-coronavirus vaccines and nasal spray vaccines?

What if hospitals are overwhelmed again on November 8th? They probably won’t be! But we’re doing increasingly less to guarantee that.

It's hard to think of a Congress that could possibly rise to the occasion less than the current one, but do you honestly think a GOP House and Senate that spends all their time trying to impeach and remove Biden would make time to fully fund COVAX? Or fund Biden’s $81.7 billion budget request for pandemic preparedness?

Them? The 203 Republicans who voted last week against a bill to punish price gouging by fossil fuel companies?

The 192 Republicans who voted last week against a $28 million emergency fund to address the critical, horrifying baby formula shortage, two weeks after their Supreme Court said you have to have your baby, whether or not they’re healthy, you were raped, or you can’t afford to feed them?

Or do you mean the “357 sitting Republican legislators in battleground states have used the power of their office to discredit or try to overturn the 2020 presidential election”?

Those guys?

They don’t even have power yet. We’re just talking about practice.

I want you to leave this interactive long-form experience with the understanding that 1) I need an editor and 2) We are semi-protected, and that helps, and it shows, but arguably already more vulnerable than we’ve been in over a year, that it could get worse before it gets better, that we cannot depend on leadership of any party to turn it around, much less to work together, but also that there’s much we can do.

It’s precisely when we stop talking about what we can do that we give up any chance for a better future.

State and local governments are the way. Many states are lost to the bullshit, but it’s drastically more affordable for us to fight (and you to donate, or run) at the state and local level, and the impacts are felt more intimately.

We can elect people who will leave open the opportunity for future mask mandates.

We can elect people who will actually use the money the federal government has provided for ventilation improvements, who will require ventilation and air cleaning, and who will encourage masks.

Who will double-down on wastewater, building a 21st century Weather Channel but for infectious disease, who will front mass vaccination sites again, who will recruit, train, and hire more nurses and doctors, and nurses and doctors of color.

Who will require paid time off and paid sick leave, who will train local health administrations and clinicians in pandemic preparedness, who will reduce air pollution, who will fight diabetes and other underlying health conditions, to improve lives on the daily and make COVID less deadly.

And who will throw everything they have at climate change, understanding that a hotter world means everyone’s chasing cooler temps, which means animals with animal viruses living closer to humans who can now receive those viruses.

Cities and states may not be able to vaccinate the world, produce nasal vaccines, or even the next Paxlovid, but they can sure as shit build the safety net we’ve never had, so this and the inevitable next pandemic aren’t quite so bad.

We’re semi-protected, but the virus is evolving faster every month, and we’re simply not keeping up with it, because – and please make this your take away – we’ve decided not to.

I wrote this so I could work out my own understanding of the current landscape, and, extrapolating on a rapidly changing set of factors, imagine how the next few months and years might go.

I don’t want to be a pessimist, but I also don’t want to be caught off guard if and when things get worse again. So much has changed, and there’s no going back, but because we never decided to do what we had to, the future may feel very similar to the past, and I don’t think we’re ready to do it all again.

You can order eight more tests from the feds here. TLDR: I recommend you do it.

– Quinn

Again, a request: if this helps you feel more grounded in what's happening, please forward it along to friends/family/Joe Biden.

Thanks for reading, and thanks for giving a shit. Stay safe out there.

-- Quinn