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  • The Return of Measles

    The Return of Measles

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    Measles seems poised to make a comeback in America. Two adults and two children staying at a migrant shelter in Chicago have gotten sick with the disease. A sick kid in Sacramento, California, may have exposed hundreds of people to the virus at the hospital. Three other people were diagnosed in Michigan, along with seven from the same elementary school in Florida. As of Thursday, 17 states have reported cases to the CDC since the start of the year. (For comparison, that total was 19, plus the District of Columbia, for all of 2023, and just 6 for 2022.) “We’ve got this pile of firewood,” Matthew Ferrari, the director of the Center for Infectious Disease Dynamics at Penn State, told me, “and the more outbreaks that keep happening, the more matches we’re throwing at it.”

    Who’s holding the matchbook? There’s an easy answer to who’s at fault. One of the nation’s political parties, and not the other, turned against vaccines to some extent during the pandemic, leading to voter disparities in death rates. One party, and not the other, has a presumptive presidential candidate who threatens to punish any school that infringes on parental rights by requiring immunizations. And one party, but not the other, appointed a vaccine-skeptical surgeon general in Florida who recently sidestepped standard public-health advice in the middle of an outbreak. The message from Republicans, as The Washington Post’s Alexandra Petri joked in a recent column, can sound like this: “We want measles in the schools and books out of them!”

    But the politics of vaccination, however grotesque it may be in 2024, obscures what’s really going on. It’s true that vaccine attitudes have become more polarized. Conservative parents in particular may be opting out of school vaccine requirements in higher numbers than they were before. In the blood-red state of Idaho, for example, more than 12 percent of kindergartners received exemptions from the rules for the 2022–23 school year, a staggering rate of refusal that is up by half from where it was just a few years ago. Politicized recalcitrance is unfortunate, to say the least, and it can be deadly. Even so, America’s political divides are simply not the cause of any recent measles outbreak. The virus has returned amid a swirl of global health inequities. Any foothold that it finds in the U.S. will be where hyperlocal social norms, not culture-war debates, are causing gaps in vaccine access and acceptance. The more this fact is overlooked, the more we’re all at risk.

    Consider where the latest measles cases have been sprouting up: By and large, the recent outbreaks have been a blue-state phenomenon. (Idaho has so far been untouched; the same is true for Utah, with the nation’s third-highest school-vaccine-exemption rate.) Zoom into the county level, and you’ll find that the pattern is repeated: Measles isn’t picking on Republican communities; if anything, it seems to be avoiding them. The recent outbreak in Florida unfolded not in a conservative area such as Sarasota, where vaccination coverage has been lagging, but rather in Biden-friendly Broward County, at a school where 97 percent of the students have received at least one MMR shot. Similarly, the recent cases in Michigan turned up not in any of the state’s MAGA-voting, vaccine-forgoing areas but among the diverse and relatively left-wing populations in and around Ann Arbor and Detroit.

    Stepping back to look at the country as a whole, one can’t even find a strong connection—or, really, any consistent link at all—between U.S. measles outbreaks, year to year, and U.S. children’s vaccination rates. Sure, the past three years for which we have student-immunization data might seem to show a pattern: Starting in the fall of 2020, the average rate of MMR coverage for incoming kindergarteners did drop, if only by a little bit, from 93.9 to 93.1 percent; at the same time, the annual number of reported measles cases went up almost tenfold, from 13 to 121. But stretch that window back one more year, and the relationship appears to be reversed. In 2019, America was doing great in terms of measles vaccination—across the country, 95.2 percent of kindergartners were getting immunized, according to the CDC—and yet, in spite of this fantastic progress, measles cases were exploding. More than 1,200 Americans got sick with the disease that year, as measles took its greatest toll in a generation.

    It’s not that our high measles-vaccination coverage didn’t matter then or that our slightly lower coverage doesn’t matter now. Vaccination rates should be higher; this is always true. In the face of such a contagious disease, 95 percent would be good; 99 percent much better. When fewer people are protected, more people can get sick. In Matthew Ferrari’s terms, a dropping immunization rate means the piles of firewood are getting bigger. If and when the flames do ignite, they could end up reaching farther, and burning longer, than they would have just a year or two ago. In the midst of any outbreak large enough, where thousands are affected, children will die.

    Read: The good news about vaccine hesitancy

    Despite America’s fevered national conversation about vaccines, however, rates of uptake simply haven’t changed that much. Even with the recent divot in our national vaccine rates, the country remains in broad agreement on the value of immunity: 93 percent of America’s kindergartners are getting measles shots, a rate that has barely budged for decades. The sheer resilience of this norm should not be downplayed or ignored or, even worse, reimagined as a state of grace from which we’ve fallen. Our protection remains strong. In Florida, the surgeon general’s lackadaisical response to the crisis at the Broward County elementary school did not produce a single extra case of the disease, in spite of grim predictions to the contrary, almost certainly thanks to how many kids are already vaccinated.

    At the same time, however, measles has been thriving overseas. Its reemergence in America is not a function of the nation’s political divides, but of the disease’s global prevalence. Europe had almost 60,000 cases last year, up from about 900 in 2022. The World Health Organization reports that the number of reported cases around the world surged to 306,000, after having dropped to a record low of 123,000 in 2021. As the pandemic has made apparent, our world is connected via pathogens: Large outbreaks in other countries, where vaccination coverage may be low, have a tendency to seed tiny outbreaks in the U.S., where coverage has been pretty high, but narrow and persistent cracks in our defenses still remain. (In 2022, more than half of the world’s unvaccinated infants were concentrated in just 10 countries; some of these are measles hotspots at this moment.) This also helps explain why so many Americans got measles in 2019. That was a catastrophic year for measles around the world, with 873,000 reported cases in total, the most since 1994. We had pretty good protection then, but the virus was everywhere—and so, the virus was here.

    Read: Florida’s experiment with measles

    In high-income countries such as the U.S., Ferrari told me, “clustering of risk” tends to be the source of measles outbreaks more than minor changes in vaccine coverage overall. Even in 2019, when more than 95 percent of American kindergarteners were getting immunized, we still had pockets of exposure where protection happened to be weakest. By far the biggest outbreak from that year occurred among Hasidic Jewish populations in New York State. Measles was imported via Israel from the hot spot of Ukraine, and took off within a group whose vaccination rates were much, much lower than their neighbors’. In the end, more than 1,100 people were infected during that outbreak, which began in October 2018 and lasted for nearly a year. “A national vaccination rate has one kind of meaning, but all outbreaks are local outbreaks,” Noel Brewer, a professor at the University of North Carolina at Chapel Hill and a member of the federal Advisory Committee on Immunization Practices, told me. “They happen on a specific street in a specific group of houses, where a group of people live and interact with each other. And those rates of vaccination in that specific place can drop well below the rate of coverage that will forestall an outbreak.”

    We’ve seen this time and time again over the past decade. When bigger outbreaks do occur in the U.S., they tend to happen in tight-knit communities, where immunization norms are radically out of sync with those of the rest of American society, politics aside. In 2014, when an outbreak of nearly 400 cases took hold in Ohio, almost entirely within the Amish community, the local vaccination rate was estimated to be about 14 percent. (The statewide number for young children at that time was more than 95 percent.) In 2011 and 2017, measles broke out among the large Somali American community in Minnesota, where anti-vaccine messaging has been intense, and where immunization rates for 2-year-olds dropped from 92 percent 20 years ago to 35 percent in 2021. An outbreak from the end of 2022, affecting 85 people in and around Columbus, Ohio, may well be linked to the nation’s second-biggest community of Somalis.

    Care must be taken in how these outbreaks are discussed. In Minnesota, for example, state health officials have avoided calling out the Somali community, for fear of stigmatizing. But another sort of trouble may arise when Americans overlook exactly who’s at risk, and exactly why. Experts broadly agree that the most effective way to deal with local outbreaks is with local interventions. Brewer pointed out that during the 2019 outbreak in New York, for example, nurses who belonged to local Jewish congregations took on the role of vaccine advocates. In Minnesota, the Department of Health has brought on more Somali staff, who coordinate with local Somali radio and TV stations to share its message. Yet these efforts can be obscured by news coverage of the crisis that points to a growing anti-science movement and parents giving up on vaccination all across the land. When measles spread among New York’s orthodox Jews, The New York Times reported on “an anti-vaccine fervor on the left that is increasingly worrying health authorities.” When the virus hit Columbus, NBC News noted that it was “happening as resistance to school vaccination requirements is spreading across the country.”

    Two different public-health responses can be undertaken in concert, the experts told me: You treat the problem at its source, and you also take the chance to highlight broader trends. A spate of measles cases in one community becomes an opportunity for pushing vaccination everywhere. “That’s always an important thing for us to do,” Ferrari said. Even so, the impulse to nationalize the problem will have its own, infelicitous effects. First, it’s meaningfully misleading. By catastrophizing subtle shifts in vaccination rates, we frighten many parents for no reason. By insisting that every tiny outbreak is a product of our national politics, we distract attention from the smaller measures that can and should be taken—well ahead of any upsurge of disease—to address hyperlocal vaccination crises. And by exaggerating the scale of our divisions—by asserting that we’ve seen a dangerous shift on a massive scale, or an anti-vaccine takeover of the Republican Party—we may end up worsening the very problem that worries us the most.

    We are a highly vaccinated nation, our politics notwithstanding. Telling people otherwise only fosters more division; it feeds the feeling that taking or refusing measles shots is an important mode of self-expression. It further polarizes health behavior, which can only widen the cracks in our defenses. “We have become quite militant and moralistic about vaccination,” Brewer told me, “and we probably would do well to be less absolute.” Measles outbreaks overseas are growing; measles outbreaks here will follow. Their specific causes ought not be ignored.

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    Daniel Engber

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  • Why Are We Still Flu-ifying COVID?

    Why Are We Still Flu-ifying COVID?

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    Four years after what was once the “novel coronavirus” was declared a pandemic, COVID remains the most dangerous infectious respiratory illness regularly circulating in the U.S. But a glance at the United States’ most prominent COVID policies can give the impression that the disease is just another seasonal flu. COVID vaccines are now reformulated annually, and recommended in the autumn for everyone over the age of six months, just like flu shots; tests and treatments for the disease are steadily being commercialized, like our armamentarium against flu. And the CDC is reportedly considering more flu-esque isolation guidance for COVID: Stay home ’til you’re feeling better and are, for at least a day, fever-free without meds.

    These changes are a stark departure from the earliest days of the crisis, when public-health experts excoriated public figures—among them, former President Donald Trump—for evoking flu to minimize COVID deaths and dismiss mitigation strategies. COVID might still carry a bigger burden than flu, but COVID policies are getting more flu-ified.

    Read: The flu-ification of COVID policy is almost complete

    In some ways, as the population’s immunity has increased, COVID has become more flu-like, says Roby Bhattacharyya, a microbiologist and an infectious-disease physician at Massachusetts General Hospital. Every winter seems to bring a COVID peak, but the virus is now much less likely to hospitalize or kill us, and somewhat less likely to cause long-term illness. People develop symptoms sooner after infection, and, especially if they’re vaccinated, are less likely to be as sick for as long. COVID patients are no longer overwhelming hospitals; those who do develop severe COVID tend to be those made more vulnerable by age or other health issues.

    Even so, COVID and the flu are nowhere near the same. SARS-CoV-2 still spikes in non-winter seasons and simmers throughout the rest of the year. In 2023, COVID hospitalized more than 900,000 Americans and killed 75,000; the worst flu season of the past decade hospitalized 200,000 fewer people and resulted in 23,000 fewer deaths. A recent CDC survey reported that more than 5 percent of American adults are currently experiencing long COVID, which cannot be fully prevented by vaccination or treatment, and for which there is no cure. Plus, scientists simply understand much less about the coronavirus than flu viruses. Its patterns of spread, its evolution, and the durability of our immunity against it all may continue to change.

    And yet, the CDC and White House continue to fold COVID in with other long-standing seasonal respiratory infections. When the nation’s authorities start to match the precautions taken against COVID with those for flu, RSV, or common colds, it implies “that the risks are the same,” Saskia Popescu, an epidemiologist at the University of Maryland, told me. Some of those decisions are “not completely unreasonable,” says Costi Sifri, the director of hospital epidemiology at UVA Health, especially on a case-by-case basis. But taken together, they show how bent America has been on treating COVID as a run-of-the-mill disease—making it impossible to manage the illness whose devastation has defined the 2020s.

    Each “not completely unreasonable” decision has trade-offs. Piggybacking COVID vaccines onto flu shots, for instance, is convenient: Although COVID-vaccination rates still lag those of flu, they might be even lower if no one could predict when shots might show up. But such convenience may come at the cost of protecting Americans against COVID’s year-round threat. Michael Osterholm, an epidemiologist at the University of Minnesota School of Public Health, told me that a once-a-year vaccine policy is “dead wrong … There is no damn evidence this is a seasonal virus yet.” Safeguards against infection and milder illness start to fade within months, leaving people who dose up in autumn potentially more susceptible to exposures by spring. That said, experts are still torn on the benefits of administering the same vaccine more than once a year—especially to a public that’s largely unwilling to get it. Throughout the pandemic, immunocompromised people have been able to get extra shots. And today, an advisory committee to the CDC voted to recommend that older adults once again get an additional dose of the most recently updated COVID vaccine in the coming months. Neither is a pattern that flu vaccines follow.

    Read: Fall’s vaccine routine didn’t have to be this hard

    Dropping the current COVID-isolation guideline—which has, since the end of 2021, recommended that people cloister for five days—may likewise be dangerous. Many Americans have long abandoned this isolation timeline, but given how new COVID is to both humanity and science, symptoms alone don’t yet seem enough to determine when mingling is safe, Popescu said. (The dangers are even tougher to gauge for infected people who never develop fevers or other symptoms at all.) Researchers don’t currently have a clear picture of how long people can transmit the virus once they get sick, Sifri told me. For most respiratory illnesses, fevers show up relatively early in infection, which is generally when people pose the most transmission risk, says Aubree Gordon, an epidemiologist at the University of Michigan. But although SARS-CoV-2 adheres to this same rough timeline, infected people can shed the virus after their symptoms begin to resolve and are “definitely shedding longer than what you would usually see for flu,” Gordon told me. (Asked about the specifics and precise timing of the update, a CDC spokesperson told me that there were “no updates to COVID guidelines to announce at this time,” and did not respond to questions about how flu precedents had influenced new recommendations.)

    At the very least, Emily Landon, an infectious-disease physician at the University of Chicago, told me, recommendations for all respiratory illnesses should tell freshly de-isolated people to mask for several days when they’re around others indoors; she would support some change to isolation recommendations with this caveat. But if the CDC aligns the policy fully with its flu policy, it might not mention masking at all.

    Read: No one really knows how much COVID is silently spreading … again

    Several experts told me symptom-based isolation might also remove remaining incentives to test for the coronavirus: There’s little point if the guidelines for all respiratory illnesses are essentially the same. To be fair, Americans have already been testing less frequently—in some cases, to avoid COVID-specific requirements to stay away from work or school. And Osterholm and Gordon told me that, at this point in the pandemic, they agree that keeping people at home for five days isn’t sustainable—especially without paid sick leave, and particularly not for health-care workers, who are in short supply during the height of respiratory-virus season.

    But the less people test, the less they’ll be diagnosed—and the less they’ll benefit from antivirals such as Paxlovid, which work best when administered early. Sifri worries that this pattern could yield another parallel to flu, for which many providers hesitate to prescribe Tamiflu, debating its effectiveness. Paxlovid use is already shaky; both antivirals may end up chronically underutilized.

    Flu-ification also threatens to further stigmatize long COVID. Other respiratory infections, including flu, have been documented triggering long-term illness, but potentially at lower rates, and to different degrees than SARS-CoV-2 currently does. Folding this new virus in with the rest could make long COVID seem all the more negligible. What’s more, fewer tests and fewer COVID diagnoses could make it much harder to connect any chronic symptoms to this coronavirus, keeping patients out of long-COVID clinics—or reinforcing a false portrait of the condition’s rarity.

    The U.S. does continue to treat COVID differently from flu in a few ways. Certain COVID products remain more available; some precautions in health-care settings remain stricter. But these differences, too, will likely continue to fade, even as COVID’s burden persists. Tests, vaccines, and treatments are slowly commercializing; as demand for them drops, supply may too. And several experts told me that they wouldn’t be surprised if hospitals, too, soon flu-ify their COVID policies even more, for instance by allowing recently infected employees to return to work once they’re fever-free.

    Early in the pandemic, public-health experts hoped that COVID’s tragedies would prompt a rethinking of all respiratory illnesses. The pandemic showed what mitigations could do: During the first year of the crisis, isolation, masking, distancing, and shutdowns brought flu transmission to a near halt, and may have driven an entire lineage of the virus to extinction—something “that never, in my wildest dreams, did I ever think would be possible,” Landon told me.

    Most of those measures weren’t sustainable. But America’s leaders blew right past a middle ground. The U.S. could have built and maintained systems in which everyone had free access to treatments, tests, and vaccines for a longer list of pathogens; it might have invested in widespread ventilation improvements, or enacted universal sick leave. American homes might have been stocked with tests for a multitude of infectious microbes, and masks to wear when people started to cough. Vaccine requirements in health-care settings and schools might have expanded. Instead, “we seem to be in a more 2019-like place than a future where we’re preventing giving each other colds as much as we could,” Bhattacharyya told me.

    Read: Next winter, what if we test for even more viruses?

    That means a return to a world in which tens of thousands of Americans die each year of flu and RSV, as they did in the 2010s. With COVID here to stay, every winter for the foreseeable future will layer on yet another respiratory virus—and a particularly deadly, disabling, and transmissible one at that. The math is simple: “The risk has overall increased for everyone,” Landon said. That straightforward addition could have inspired us to expand our capacity for preserving health and life. Instead, our tolerance for suffering seems to be the only thing that’s grown.

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    Katherine J. Wu

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  • Ozempic Can Turn Into No-zempic

    Ozempic Can Turn Into No-zempic

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    No medication in the history of modern weight loss has inspired as much awe as the latest class of obesity drugs. Wegovy and Zepbound are so effective that they are often likened to “magic” and “miracles.” Indeed, the weekly injections, which belong to a broader class known as GLP-1s, can lead to weight loss of 20 percent or more, fueling hype about a future in which many more millions of Americans take them. Major food companies including Nestlé and Conagra are considering tailoring their products to suit GLP-1 users. Underlying all this excitement is a huge assumption: They work for everyone.

    But for a lot of people, they just don’t. Anita, who lives in Arizona, told me she “took it for granted” that she would lose weight on a GLP-1 drug because “the people around me who were on it were just dropping weight like mad.” Instead, she didn’t shed any pounds. Likewise, Kathryn, from Florida, hasn’t lost any weight since starting the medication in October. “I was really hoping this was something that would be a game changer for me, but it feels like it was just a lot of wasted money,” she told me. (I’m identifying both Anita and Kathryn by their first name only to allow them to speak openly about their health issues.)

    Some people can’t tolerate the side effects of the drugs and have to stop taking them. Others simply don’t respond. For some, the strength of the dose, or length of the treatment, does not seem to make a difference. Appetites might remain robust; the “food chatter” in the brain may stay noisy. Together, both groups of less successful GLP-1 users account for a not-insignificant share of patients on these drugs—potentially up to a third. “We don’t really know why it happens, [but] we know it does happen,” Louis Aronne, an obesity-medicine specialist at Weill Cornell Medical College, told me. Despite the promise of a so-called Ozempic revolution, lots of “No-zempics” have been left behind.

    Of the two biggest reasons some people don’t lose weight on GLP-1 drugs—side effects and nonresponse—the former is much more straightforward. The GLP-1 drugs Wegovy and Zepbound (which contain the active ingredients semaglutide and tirzepatide, respectively), are known for causing potentially gnarly gastrointestinal symptoms, such as nausea and vomiting, although most people’s reactions are mild and temporary. Yet some have it far worse. Severe, albeit uncommon, side effects include pancreatitis, severe gastrointestinal distress, low blood sugar, and even hair loss, which “can push people off” the drugs, Steven Heymsfield, a professor who studies obesity at Louisiana State University, told me. In one of the biggest studies of semaglutide, encompassing more than 17,000 people over about five years, nearly 17 percent of patients discontinued the medication because of side effects.

    Far more mysterious are the people who tolerate the drugs but respond weakly to them—or sometimes not at all. Researchers have known this might happen since these drugs were in early clinical trials. About 14 percent of people who took semaglutide for obesity saw minimal impacts of less than 5 percent weight loss in one study, as did 9 to 15 percent of people who took tirzepatide in a similar one. In her own experience working with patients, “somewhere between a quarter and a third” are nonresponders, Fatima Cody Stanford, an obesity-medicine specialist at Harvard, told me, adding that it can take up to three months to determine whether the drug is working or not. That the same medication at the same dosage can lead to dramatic weight loss in one person and hardly any in another “remains confounding,” Aronne told me.

    The broad explanation is that it has something to do with genetics. The drugs work by masquerading as the appetite-suppressing hormone GLP-1 and binding to its receptor, like a key fitting into a lock. Although the lock’s overall shape is generally consistent from person to person, its nooks and crannies can vary because of genetic differences. “For some people, that key just won’t fit right,” Eduardo Grunvald, an obesity-medicine doctor at UC San Diego Health, told me. In other cases, genes may limit the effects of these drugs after they bind to GLP-1 receptors. One possibility is that people metabolize the drugs differently: Some patients may break them down too quickly for them to take effect; others may process them too slowly, potentially building up such high levels of the medications that they become toxic, Heymsfield said.

    For No-zempic patients, perhaps the most consequential impact of individual variation is on the propensity for obesity itself. “We are all very different from a genetic standpoint, in terms of our risk of weight gain,” Grunvald said. Numerous factors can drive obesity, including diet, environment, stress, and—most pertinent to GLP-1 drugs—altered brain function.

    GLP-1 drugs target a pathway that regulates appetite and insulin levels. Some cases of obesity can be caused by a disruption in that particular mechanism, in which case GLP-1s can indeed be wondrous. But “not everyone has dysfunction in this particular pathway,” Stanford said. When that is the case, the drugs won’t be very effective. A different pathway, for example, controls the absorption of fat from food; another increases energy expenditure. In these people, GLP-1s might tamp down appetite to a degree, maybe leading to some weight loss, but a different drug may be required to treat obesity at its root. “It is not all about food intake,” Stanford said.

    That’s not to say that No-zempics are out of options. They might have better success switching from one GLP-1 to the other, or even stacking them, Heymsfield said. Some patients who don’t respond to GLP-1s at all can get better results with older drugs that work on different obesity pathways, Aronne said. One, called Qysmia, a combination of the decades-old drugs phentermine and topiramate, can lead to an average weight loss of 14 percent body weight at its highest dose. If medications don’t work, bariatric surgery remains a powerful option, one that may even be growing in popularity. Last year, the number of bariatric surgeries performed in the U.S. grew despite the boom in GLP-1 usage, a trend that some expect to continue, because so many people don’t tolerate the drugs.

    The intense hype around the game-changing nature of GLP-1s makes it easy to forget that they are, in fact, just drugs. “Every drug that’s ever been made” works in some people and not in others, Heymsfield said; there’s no reason to think GLP-1s would be any different. Remembering that they are in an early stage of development has a sobering effect. Eventually, obesity drugs may leave fewer people behind. The category is expanding rapidly: By one count, more than 90 new drug candidates are in development.

    They are evolving to attack obesity from multiple fronts, which, at least in theory, widens their net of potential users. In an early study on an experimental candidate named retatrutide—called a triple agonist because it acts on GLP-1 as well as two other targets involved in obesity, GIP and glucagon receptors—100 percent of people on the highest dose lost 5 percent or more of their body weight. New candidates are also expected to have fewer side effects. They have to, Heymsfield said, because the competition is so steep that any new drug has to be “as good with less side effects, or better.”

    But no matter how good these drugs get, it’s unrealistic to think that they’ll become a one-size-fits-all treatment for everyone with obesity. The disease is simply too complex, with too many drivers, for a single type of medication to treat it. More than 200 different drugs exist for treating high blood pressure alone; in comparison, Aronne said, regulating weight is “far more complicated.” The future, rife with options, holds promise that No-zempics may find a way forward. Yet considering all the unknowns about obesity and what causes it, that may not be enough to guarantee that they will see the results they want.

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    Yasmin Tayag

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  • How Much Less to Worry About Long COVID Now

    How Much Less to Worry About Long COVID Now

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    Compared with the worst days of the pandemic—when vaccines and antivirals were nonexistent or scarce, when more than 10,000 people around the world were dying each day, when long COVID largely went unacknowledged even as countless people fell chronically ill—the prognosis for the average infection with this coronavirus has clearly improved.

    In the past four years, the likelihood of severe COVID has massively dropped. Even now, as the United States barrels through what may be its second-largest wave of SARS-CoV-2 infections, rates of death remain near their all-time low. And although tens of thousands of Americans are still being hospitalized with COVID each week, emergency rooms and intensive-care units are no longer routinely being forced into crisis mode. Long COVID, too, appears to be a less common outcome of new infections than it once was.

    Read: The future of long COVID

    But where the drop in severe-COVID incidence is clear and prominent, the drop in long-COVID cases is neither as certain nor as significant. Plenty of new cases of the chronic condition are still appearing with each passing wave—even as millions of people who developed it in years past continue to suffer its long-term effects.

    In a way, the shrinking of severe disease has made long COVID’s dangers more stark: Nowadays, “long COVID to me still feels like the biggest risk for most people,” Matt Durstenfeld, a cardiologist at UC San Francisco, told me—in part because it does not spare the young and healthy as readily as severe disease does. Acute disease, by definition, eventually comes to a close; as a chronic condition, long COVID means debilitation that, for many people, may never fully end. And that lingering burden, more than any other, may come to define what living with this virus long term will cost.

    Most of the experts I spoke with for this story do think that the average SARS-CoV-2 infection is less likely to unfurl into long COVID than it once was. Several studies and data sets support this idea; physicians running clinics told me that, anecdotally, they’re seeing that pattern play out among their patient rosters too. The number of referrals coming into Alexandra Yonts’s long-COVID clinic at Children’s National, in Washington, D.C., for instance, has been steadily dropping in the past year, and the waitlist to be seen has shortened. The situation is similar, other experts told me, among adult patients at Yale and UCSF. Lisa Sanders, an internal-medicine physician who runs a clinic at Yale, told me that more recent cases of long COVID appear to be less debilitating than ones that manifested in 2020. “People who got the earliest versions definitely got whacked the worst,” she said.

    That’s reflective of how our relationship to COVID has changed overall. In the same way that immunity can guard a body against COVID’s most severe, acute forms, it may also protect against certain kinds of long COVID. (Most experts consider long COVID to be an umbrella term for many related but separate syndromes.) Once wised up to a virus, our defenses become strong and fast-acting, more able to keep infection from spreading and lingering, as it might in some long-COVID cases. Courses of illness also tend to end more quickly, with less viral buildup, giving the immune system less time or reason to launch a campaign of friendly fire on other tissues, another potential trigger of chronic disease.

    In line with that logic, a glut of studies has shown that vaccination—especially recent and repeated vaccination—can reduce a person’s chances of developing long COVID. “There is near universal agreement on that,” Ziyad Al-Aly, an epidemiologist and a clinician at Washington University in St. Louis, told me. Some experts think that antiviral use may be making a dent as well, by decreasing the proportion of COVID cases that progress to severe disease, a risk factor for certain types of long COVID. Others have pointed to the possibility that more recent variants of the virus—some of them maybe less likely to penetrate deeply into the lungs or affect certain especially susceptible organs—may be less apt to trigger chronic illness too.

    But consensus on any of these points is lacking—especially on just how much, if at all, these interventions help. Experts are divided even on the effect of vaccines, which have the most evidence to back their protective punch: Some studies find that they trim risk by 15 percent, others up to about 70 percent. Paxlovid, too, has become a point of contention: While some analyses have shown that taking the antiviral early in infection helps prevent long COVID, others have found no effect at all. Any implication that we’ve tamed long COVID exaggerates how positive the overall picture is. Hannah Davis, one of the leaders of the Patient-Led Research Collaborative, who developed long COVID during the pandemic’s first months, told me that she’s seen how the most optimistic studies get the most attention from the media and the public. With a topic as unwieldy and challenging to understand as this, Davis said, “we still see overreactions to good news, and underreactions to bad news.”

    That findings are all over the place on long COVID isn’t a shock. The condition still lacks a universal definition or a standard method of diagnosis; when recruiting patients into their studies, research groups can rely on distinct sets of criteria, inevitably yielding disparate and seemingly contradictory sets of results. With vaccines, for instance, the more wide-ranging the set of potential long-COVID symptoms a study looks at, the less effective shots may appear—simply because “vaccines don’t work on everything,” Al-Aly told me.

    Studying long COVID has also gotten tougher. The less attention there is on COVID, “the less likely people are to associate long-term symptoms with it,” Priya Duggal, an infectious-disease epidemiologist at Johns Hopkins University, told me. Fewer people are testing for the virus. And some physicians still “don’t believe in long COVID—that’s what I hear a lot,” Sanders told me. The fact that fewer new long-COVID cases are appearing before researchers and clinicians could be in part driven by fewer diagnoses being made. Al-Aly worries that the situation could deteriorate further: Although long-COVID research is still chugging along, “momentum has stalled.” Others share his concern. Continued public disinterest, Duggal told me, could dissuade journals from publishing high-profile papers on the subject—or deter politicians from setting aside funds for future research.

    Even if new cases of long COVID are less likely nowadays, the incidence rates haven’t dropped to zero. And rates of recovery are slow, low, and still murky. At this point, “people are entering this category at a greater rate than people are exiting this category,” Michael Peluso, a long-COVID researcher at UCSF, told me. The CDC’s Household Pulse Survey, for instance, shows that the proportion of American adults reporting that they’re currently dealing with long COVID has held steady—about 5 to 6 percent—for more than a year (though the numbers have dropped since 2021). Long COVID remains one of the most debilitating chronic conditions in today’s world—and full recovery remains uncommon, especially, it seems, for those who have been dealing with the disease for the longest.

    Exact numbers on recovery are tricky to come by, for the same reasons that it’s difficult to pin down how effective preventives are. Some studies report rates far more optimistic than others. David Putrino, a physical therapist who runs a long-COVID clinic at Mount Sinai Health System, where he and his colleagues have seen more than 3,000 long-haulers since the pandemic’s start, told me his best estimates err on the side of the prognosis being poor. About 20 percent of Putrino’s patients fully recover within the first few months, he told me. Beyond that, though, he routinely encounters people who experience only partial symptom relief—as well as a cohort that, “no matter what we think to try,” Putrino told me, “we can’t even seem to stop them from deteriorating.” Reports of higher recovery rates, Putrino and other experts said, might be conflating improvement with a return to baseline, or mistakenly assuming that people who stop responding to follow-ups are better, rather than just done participating.

    Read: Long COVID is being erased—again

    Davis also worries that recovery rates could drop. Some researchers and clinicians have noticed that today’s new long-COVID patients are more likely than earlier patients to come in with certain neurological symptoms—among them, brain fog and dizziness—that have been linked to slower recovery trajectories, Lekshmi Santhosh, a pulmonary specialist at UCSF, told me.

    In any case, recovery rates are still modest enough that long-COVID clinics across the country—even ones that have noted a dip in demand—remain very full. Currently, Putrino’s clinic has a waitlist of three to six months. The same is true for clinical trials investigating potential treatments. One, run by Peluso, that is investigating monoclonal-antibody therapy has a waitlist that is “hundreds of people deep,” Peluso told me: “We do not have the problem of not being able to find people who want to participate.”

    Any decrease in long-COVID incidence may not last, either. Viral evolution could always produce a new variant or subvariant with higher risks of chronic issues. The protective effects of vaccination may also be quite temporary, and the fewer people who keep up to date with their shots, the more porous immunity’s safety net may become. In this way, kids—though seemingly less likely to develop long COVID overall—may remain worryingly vulnerable, Yonts told me, because they’re born entirely susceptible, and immunization rates in the youngest age groups remain extremely low. And yet, little kids who get long COVID may need to live with it the longest. Some of Yonts’s patients have barely started grade school and have already been sick for three-plus years—half of their lives so far, or more.

    Long COVID can also manifest after repeat infections of SARS-CoV-2—and although several experts told me they think that each subsequent exposure poses less incremental risk, any additional exposure is worrisome. People all over the world are being exposed, over and over again, as the pathogen spreads with blistering speed, more or less year-round, in populations that have mostly dropped mitigations and are mostly behind on annual shots (where they’re available). Additional infections can worsen the symptoms of people living with long COVID, or yank them out of remission. Long COVID’s inequities may also widen as marginalized populations, less likely to receive vaccines or antivirals and more likely to be exposed to the virus, continue to develop the condition at higher rates.

    There’s no question that COVID-19 has changed. The disease is more familiar; the threat of severe disease, although certainly not vanished, is quantitatively less now. But dismissing the dangers of the virus would be a mistake. Even if rates of new long-COVID cases continue to drop for some time, Yonts pointed out, they will likely stabilize somewhere. These risks will continue to haunt us and incur costs that will keep adding up. Long COVID may not kill as directly as severe, acute COVID has. But people’s lives still depend on avoiding it, Putrino told me—“at least, their life as they know it right now.”

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    Katherine J. Wu

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  • The Real Reason You Should Get an E-bike

    The Real Reason You Should Get an E-bike

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    Today’s happiness and personal-finance gurus have no shortage of advice for living a good life. Meditate daily. Sleep for eight hours a night. Don’t forget to save for retirement. They’re not wrong, but few of these experts will tell you one of the best ways to improve your life: Ditch your car.

    A year ago, my wife and I sold one of our cars and replaced it with an e-bike. As someone who writes about climate change, I knew that I was doing something good for the planet. I knew that passenger vehicles are responsible for much of our greenhouse-gas emissions—16 percent in the U.S., to be exact—and that the pollution spewing from gas-powered cars doesn’t just heat up the planet; it could increase the risk of premature death. I also knew that electric cars were an imperfect fix: Though they’re responsible for less carbon pollution than gas cars, even when powered by today’s dirty electric grid, their supply chain is carbon intensive, and many of the materials needed to produce their batteries are, in some cases, mined via a process that brutally exploits workers and harms ecosystems and sacred Indigenous lands. An e-bike’s comparatively tiny battery means less electricity, fewer emissions, fewer resources. They are clearly better for the planet than cars of any kind.

    Read: America is missing out on the biggest EV boom of all

    I knew all of this. But I also viewed getting rid of my car as a sacrifice—something for the militant and reckless, something that Greenpeace volunteers did to make the world better. I live in Colorado; e-biking would mean freezing in the winter and sweating in the summer. It was the right thing to do, I thought, but it was not going to be fun.

    I was very wrong. The first thing I noticed was the savings. Between car payments, insurance, maintenance, and gas, a car-centered lifestyle is expensive. According to AAA, after fuel, maintenance, insurance, taxes, and the like, owning and driving a new car in America costs $10,728 a year. My e-bike, by comparison, cost $2,000 off the rack and has near-negligible recurring charges. After factoring in maintenance and a few bucks a month in electricity costs, I estimate that we’ll save about $50,000 over the next five years by ditching our car.

    The actual experience of riding to work each day over the past year has been equally surprising. Before selling our car, I worried most about riding in the cold winter months. But I quickly learned that, as the saying goes, there is no bad weather, only bad gear. I wear gloves, warm socks, a balaclava, and a ski jacket when I ride, and am almost never too cold.

    Sara Hastings-Simon is a professor at the University of Calgary, where she studies low-carbon transportation systems. She’s also a native Californian who now bikes to work in a city where temperatures tend to hover around freezing from December through March. She told me that with the right equipment, she’s able to do it on all but the snowiest days—days when she wouldn’t want to be in a car, either. “Those days are honestly a mess even on the roads,” she said.

    And though I, like many would-be cyclists, was worried about arriving at the office sweaty in hotter months, the e-bike solved my problem. Even when it was 90 degrees outside, I didn’t break a sweat, thanks to my bike’s pedal-assist mode. If I’m honest, sometimes I didn’t even pedal; I just used the throttle, sat back, and enjoyed my ride.

    Indeed, a big part of the appeal here is in the e part of the bike: “E-bikes aren’t just a traditional bike with a motor. They are an entirely new technology,” Hastings-Simon told me. Riding them is a radically different experience from riding a normal bike, at least when it comes to the hard parts of cycling. “It’s so much easier to take a bike over a bridge or in a hilly neighborhood,” Laura Fox, the former general manager of New York City’s bike-share program, told me. “I’ve had countless people come up to me and say, ‘I never thought that I could bike to work before, and now that I have an option where you don’t have to show up sweaty, it’s possible.’” (When New York introduced e-bikes to its fleet, ridership tripled, she told me, from 500,000 to 1.5 million people.)

    Read: How to get fewer people to commute in cars

    But biking to work wasn’t just not unpleasant—it was downright enjoyable. It made me feel happier and healthier; I arrived to work a little more buoyant for having spent the morning in fresh air rather than traffic. Study after study shows that people with longer car commutes are more likely to experience poor health outcomes and lower personal well-being—and that cyclists are the happiest commuters. One day, shortly after selling our car, I hopped on my bike after a stressful day at work and rode home down a street edged with changing fall leaves. I felt more connected to the physical environment around me than I had when I’d traveled the same route surrounded by metal and glass. I breathed in the air, my muscles relaxed, and I grinned like a giddy schoolchild.

    “E-bikes are like a miracle drug,” David Zipper, a transportation expert and Visiting Fellow at Harvard Kennedy School, told me. “They provide so much upside, not just for the riders, but for the people who are living around them too.”

    Of course, e-bikes aren’t going to replace every car on every trip. In a country where sprawling suburbs and strip malls, not protected bike lanes, are the norm, it’s unrealistic to expect e-bikes to replace cars in the way that the Model T replaced horses. But we don’t need everyone to ride an e-bike to work to make a big dent in our carbon-pollution problem. A recent study found that if 5 percent of commuters were to switch to e-bikes as their mode of transportation, emissions would fall by 4 percent. As an individual, you don’t even need to sell your car to reduce your carbon footprint significantly. In 2021, half of all trips in the United States were less than three miles, according to the Bureau of Transportation Statistics. Making those short trips on an e-bike instead of in a car would likely save people money, cut their emissions, and improve their health and happiness.

    E-bikes are such a no-brainer for individuals, and for the collective, that state and local governments are now subsidizing them. In May, I asked Will Toor, the executive director of the Colorado Energy Office, to explain the state’s rationale for a newly passed incentive that offers residents $450 to get an e-bike. He dutifully ticked through the environmental benefits and potential cost savings for low-income people. Then he surprised me: The legislation, he added, was also about “putting more joy into the world.”

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    Michael Thomas

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  • The Pregnancy Risk That Doctors Won’t Mention

    The Pregnancy Risk That Doctors Won’t Mention

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    The nonexhaustive list of things women are told to avoid while pregnant includes cat litter, alfalfa sprouts, deli meat, runny egg yolks, pet hamsters, sushi, herbal teas, gardening, brie cheeses, aspirin, meat with even a hint of pink, hot tubs. The chance that any of these will harm the baby is small, but why risk it?

    Yet few doctors in the U.S. tell pregnant women about the risk of catching a ubiquitous virus called cytomegalovirus, or CMV. The name might be obscure, but CMV is the leading infectious cause of birth defects in America—far ahead of toxoplasmosis from cat litter or microbes from hamsters. Bafflingly, the majority of babies infected in the womb are unaffected, but an estimated 400 born with CMV die every year. Thousands more end up with hearing and vision loss, epilepsy, developmental delays, or microcephaly, in which the head and brain are unusually small. Exactly why the virus so dramatically affects some babies but not others is unknown. There is no cure and no vaccine.

    Amanda Devereaux’s younger child, Pippa, was born with CMV, which caused damage to her brain. Pippa is prone to seizures. She could not walk until she was 2 and a half, and she is nonverbal at age 7. “I was just flabbergasted that no one told me about CMV,” says Devereaux, who is now the program director for the National CMV Foundation, which raises awareness of the virus. The nonprofit was founded by parents of children with congenital CMV. “Every single one of them says, ‘Why didn’t I hear about this?’” Devereaux told me.

    One reason that doctors have hesitated to spread the word is that the most obvious way to avoid this virus is to avoid infected toddlers. Symptoms from CMV are usually mild to nonexistent in healthy adults and children. Toddlers, who frequently pick up CMV at day care, can continue shedding the virus in their bodily fluids for months and even years while totally healthy. “I’ve encountered a classroom of 2-year-olds where every single child was shedding CMV,” Robert Pass, a retired pediatrician and longtime CMV researcher at the University of Alabama, told me when we spoke in 2021. (He recently died, at age 81.)

    This creates a common scenario for congenital CMV: A toddler in day care brings CMV home and infects Mom, who is pregnant with a younger sibling. One recent study found that congenital CMV is nearly twice as common in second-born children than in firstborns. Devereaux’s toddler son was in day care when she was pregnant. “I was sharing food with him because he would not finish his breakfast,” she told me. She had no idea that his half-eaten muffin could end up harming her unborn daughter. In hindsight, she says, “I wish I had spent less time worrying about not eating deli meat and more time focused on, Hey I’ve got this toddler at day care. I’m at risk for CMV.”

    CMV is such a tricky virus because few things about it are absolute. A mother cannot avoid her toddler categorically. Most pregnant women infected with CMV do not pass it to their babies. Most infected babies end up just fine. Doctors warn patients against many risks in pregnancy—see the list above—but in this case thousands of parents every year are blindsided by a very common virus. No one has a perfect answer for how to stop it.

    Day cares have been known as hot spots for CMV since at least the 1980s, when Pass, in Alabama, and other researchers in Virginia first began tracking congenital cases back to child-care centers. The virus is rampant in day cares for the same reason that other viruses are rampant in day cares: Young children are born with no immunity, and they aren’t very diligent about avoiding one another’s saliva, urine, snot, and tears, all of which harbor CMV. Of mothers with infected toddlers in day care, a third who have never had the virus catch it within a year. And getting CMV for the first time while pregnant is the riskiest scenario; these so-called primary infections are most likely to result in serious complications for the fetus. But recent research has found that reinfections and reactivations of the virus can lead to congenital CMV too. (CMV remains inside the body forever after the first infection, much like chickenpox, which is caused by a related virus.)

    So eliminating the risk of congenital CMV entirely is impossible. But some CMV experts advocate giving women a short list of actions to reduce their risk during the nine months of pregnancy: Avoid sharing food or utensils with toddlers in day care; kiss them on the top of the head instead of on the mouth; wash your hands frequently, especially after diaper changes; and clean surfaces that come in contact with saliva or urine. A study in Italy found that pregnant women who were taught these measures cut their risk of catching CMV by sixfold. A study in France found that it lowered risk too.

    In the U.S., patients are unlikely to hear this advice from their obstetricians, though. The American College of Obstetricians and Gynecologists doesn’t recommend telling patients about ways to reduce CMV risk. According to ACOG, the evidence that behavioral changes can make a difference—from just a handful of studies—is not strong enough, and the organization sees downsides to the approach. Advice such as not kissing babies and toddlers could harm “a mother’s ability to bond with her children,” and these hygiene recommendations could “falsely reassure patients” about their risk of CMV, Christopher Zahn, ACOG’s interim CEO, said in a statement to The Atlantic.

    The CMV community disagrees. “I think they’re being a bit paternalistic,” says Gail Demmler-Harrison, a pediatric-infectious-diseases doctor at Texas Children’s Hospital. A group of international CMV experts, including Demmler-Harrison, endorsed patient education in a set of consensus recommendations in 2017. Devereaux, with the CMV Foundation, frames it as a matter of choice. It shouldn’t be “somebody else is saying, ‘You can’t handle this information; I’m not going to share that with you,” she told me. Without knowing about CMV, women can’t decide what kind of risk they’re comfortable with or what kind of hygiene changes are too burdensome. “It’s your choice whether you make them or not,” she says. “Having that choice is important.”

    More data on how well these behavioral changes work might be coming soon: Karen Fowler, an epidemiologist at the University of Alabama at Birmingham, is enrolling hundreds of pregnant women in a clinical trial. Only 8 percent of participants had heard of CMV before joining the study, she says. Patients get a short information session about CMV and then 12 weeks of text-message reminders. Importantly, she says, “we’re keeping our message very simple”: Reduce saliva sharing: no eating leftover food, no sharing utensils, and no cleaning a pacifier in your mouth. This simple rule cuts off the most probable routes of transmission. Sure, CMV is also shed in urine, tears, and other bodily fluids—but mothers aren’t routinely putting any of those in their mouth.

    Prevention of CMV ends up the focus of so much attention because once a fetus is infected, the treatment options are not particularly good. The best antiviral against CMV is not considered safe to use during pregnancy, and another antiviral, although safer, is not that potent. After infected babies are born, antiviral therapy can help preserve hearing in those with other moderate to severe symptoms from CMV, but it can’t reverse damage in the brain. And it’s unclear how much antivirals help those with only mild symptoms. When does benefit outweigh risk? “There’s a big gray area,” says Laura Gibson, a pediatric-infectious-diseases doctor at the University of Massachusetts Chan Medical School. For these reasons, policies of whether to screen all newborns vary state to state, even hospital to hospital. Knowledge can be power—but with a virus as confusing as CMV, knowledge of an infection doesn’t always point to an obvious best choice.

    In an ideal world, all of this could be made obsolete with a CMV vaccine. But such a vaccine has proved elusive despite a lot of interest. In the U.S., the Institute of Medicine deemed a CMV vaccine the highest priority around the turn of the millennium, and about two dozen vaccine candidates have been or are being studied. All of the completed clinical trials, though, have failed. “The immunity may look robust in the first month or year, but then it wanes,” Demmler-Harrison says. And even vaccines that elicit some immune response are not necessarily able to elicit one strong enough to protect against CMV infection entirely.

    CMV is such a challenging virus to vaccinate against because it knows our immune system’s tricks. “It’s evolved with humans for millions of years,” Gibson says. “It knows how to get around and live with our immune system.” Our immune system is never able to eliminate the virus, which emerges occasionally from our cells to replicate and try to find another host. And so a vaccine that completely protects against CMV would need to prompt our immune system to do something it cannot naturally do. It would need to be better than our immune system. “As time goes on, I think fewer and fewer people are thinking that might work,” Gibson says. But a vaccine doesn’t have to protect against all infections to be useful. Because first infections are the riskiest for fetuses, being vaccinated could still reduce risk of congenital CMV.

    Whom to vaccinate is another complicated question to answer for CMV. We could vaccinate all toddlers, as we do against rubella, which is also most dangerous when passed from mother to fetus. This has the potential advantage of promoting widespread immunity that tamps down circulation of CMV, period. But the virus doesn’t actually harm toddlers much, and immunity could wane by the time they grow up to childbearing age. Or we could vaccinate teenagers, as we do against meningococcal disease, but teens are more likely to miss vaccines and again, immunity could wane too soon. So what about all pregnant women? By the time someone shows up at the doctor pregnant, it’s probably too late to protect during CMV’s highest risk period, in the first trimester. A better understanding of CMV immunity and spread could help scientists decide on the best strategy. Gibson is conducting a study (funded by Moderna, which is testing a CMV-vaccine candidate) on how the virus spreads and what kinds of immune responses are correlated with shedding.

    Until a vaccine is developed—should it happen at all—the only way to prevent CMV infection is the very old-tech method of avoiding bodily fluids. It’s imperfect. Its exact effectiveness is hard to quantify. Some people might not find it worthwhile, given the small absolute risk of CMV in any single pregnancy. There are, after all, already so many things to worry about when expecting a baby. Yet another one? Or, you might think of it, what’s one more?

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    Sarah Zhang

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  • The Election You Shouldn’t Look Away From

    The Election You Shouldn’t Look Away From

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    The most important election of 2023 may also offer crucial insights into the most important election of 2024.

    Next Tuesday’s vote for an open seat on the Wisconsin Supreme Court has been justifiably described as the most consequential election in the nation this year, because it will determine whether liberals or conservatives control a majority of the body. The election’s outcome will likely decide whether abortion in the state is completely banned and whether the severely gerrymandered state legislative maps that have locked in overwhelming Republican majorities since 2011 are allowed to remain in place.

    But the contest between the liberal Milwaukee County Circuit Court judge Janet Protasiewicz and the conservative former state-supreme-court justice Dan Kelly has also become a revealing test of the electoral strength of the most powerful wedge issues that each party is likely to stress in next year’s presidential race.

    Protasiewicz and her allies have centered her campaign on portraying Kelly as a threat to legal abortion and an accomplice in Donald Trump’s schemes to undermine democracy—the same issues that helped Democrats perform unexpectedly well in last November’s elections. Kelly and his allies have centered his campaign on presenting Protasiewicz as soft on crime, the same accusation that Republicans stressed in many of their winning campaigns last year.

    With the choice framed so starkly, in a state that has been so evenly balanced between the parties, Tuesday’s result will measure which of those arguments remains more potent, particularly among the suburban voters who loom as the critical swing bloc in 2024’s presidential contest.

    If Kelly wins, after being significantly outspent on television, it would underscore how much risk Democrats face from rising public anxiety about crime. But a Protasiewicz win, which most political observers in Wisconsin expect, would suggest that support for legalized abortion has accelerated the recoil from the Trump-era GOP that is already evident among college-educated suburban voters. And such a shift could restore a narrow but decisive advantage for Democrats in a state at the absolute tipping point of presidential elections.

    “The margins are still very narrow, and of course the economy and other issues will come into play next year, but if it simply becomes a test between abortion and crime, I would say yes, [abortion] is more powerful by a slight, slight margin,” says Paul Maslin, a Democratic pollster who has worked in Wisconsin for decades.

    Read: How working-class white voters became the GOP’s foundation

    Like the state itself, the Wisconsin Supreme Court is closely divided. Conservatives now hold a 4–3 majority (though Brian Hagedorn, one of the four conservative justices, has voted with the liberals on some key cases, particularly four rulings denying Trump’s effort to overturn the state’s 2020 election results). The retirement of a conservative justice has provided Democrats this opportunity to secure a 4–3 liberal majority.

    Though Tuesday’s election is technically nonpartisan, the race has become a brawl between the two parties. The state GOP is mounting an extensive get-out-the-vote campaign for Kelly, who was appointed to the state supreme court by Republican then-Governor Scott Walker to fill an unexpired term in 2016 before losing his bid for a full term in 2020. State Democrats, meanwhile, have raised and transferred millions of dollars into the campaign for Protasiewicz, who served as an assistant county district attorney before winning election as a county-circuit-court judge . The tension between the race’s openly partisan character and traditional notions of judicial neutrality and nonpartisanship has itself become a central point of contention in the campaign.

    Protasiewicz has pushed the envelope for a judicial candidate by offering voters explicit declarations of her views. She has unequivocally affirmed her support for legal abortion, described the gerrymandered state legislative maps as “rigged,” and declared that the signature legislation Walker passed to eviscerate the power of the state’s public-sector unions is unconstitutional. But in the next breath she insists that those views—which she calls her “values”—will not affect her decisions on the bench.

    The juxtaposition of those two assertions can be head-spinning. At a forum this week on the University of Wisconsin at Milwaukee campus, Protasiewicz declared, “I’ve been very clear with everybody that I think women should have a right to choose. Obviously, I can’t comment about what I would do on any case. That robe goes on; my personal opinions go out the door.”

    After her appearance, I asked Protasiewicz why her “values” should matter to voters if they are irrelevant once she dons her judicial robe. “I truly believe that people have an absolute right to know what a candidate’s personal thoughts and personal values are,” she answered. Even if, I asked, they are irrelevant to your decisions? “I put them aside,” she said.

    Kelly and other Republicans have argued that Protasiewicz’s candid expression of her “values” renders her too partisan for a judicial position. (At the Milwaukee forum, the conservative state-supreme-court justice Rebecca Bradley, appearing for Kelly, maintained that Protasiewicz would be forced to recuse herself from cases involving abortion, redistricting, and other issues because she has expressed such clear positions on them—a view that other legal experts reject.) But Kelly is, to say the least, an imperfect messenger for the argument that anyone else is too biased. He has been far more involved than Protasiewicz in direct partisan activities: Kelly has served as a paid legal adviser to the state’s leading anti-abortion group as well as to the state Republican Party.

    Andrew Hitt, the former state GOP chairman, testified to the congressional committee investigating the January 6 insurrection that he had “pretty extensive conversations” with Kelly and another lawyer about the fake-electors scheme that Trump supporters developed after the 2020 election in order to overturn President Joe Biden’s victory in Wisconsin. Kelly says his involvement was limited to a single 30-minute conversation in which he explained he was not “in the loop” on the plans. But at the sole debate between the candidates earlier this month, Protasiewicz described Kelly as “a true threat to our democracy.”

    In the past, local observers say, Wisconsin Supreme Court elections have more narrowly centered on debates about crime and criminal justice (even though the court isn’t directly involved in handing down sentences). “Law-and-order candidates have traditionally done very well,” Mark Jefferson, the executive director of the state Republican Party, told me.

    Read: The four quadrants of American politics

    Kelly is running in that tradition. Ads from his campaign’s final days are focused almost exclusively on lashing Protasiewicz over rulings she made to sentence a rapist and other violent offenders to limited or no jail time. So many sheriffs are appearing in Kelly ads that it’s reasonable to wonder who is still patrolling the state’s highways this week.

    Protasiewicz has responded with ads defending her record on crime, and also jabbing Kelly over his work as a criminal-defense attorney. But mostly her advertising has insisted that Kelly would uphold the 1849 state abortion ban that snapped back into effect when the U.S. Supreme Court last year overturned Roe v. Wade. (Both sides agree that the state supreme court will eventually need to decide whether to sustain or strike down that law, which prohibits abortions in almost all cases, and is now being challenged in a lower state court.) Protasiewicz and the groups supporting her are heavily stressing abortion in their ads and have aired nearly four times as many ads across all subjects as Kelly and his backers, according to AdImpact, a group that tracks ad purchases. (That disparity exists largely because Democrats have raised enough money to allow her to buy the ads directly through her campaign, which receives lower rates, while Kelly’s relying mostly on outside groups that must pay higher rates.)

    That huge tactical advantage for her is one reason some observers are cautious about drawing too many conclusions from next week’s outcome. Conversely, Trump’s indictment yesterday might inspire enough Republican turnout to lift Kelly, especially because far fewer people vote in these off-year contests than on a typical November Election Day.

    Yet a Protasiewicz win could put an exclamation point on a subtle but discernible shift in the state’s political direction.

    Though close elections are usually the rule in Wisconsin, early in this century it often leaned Democratic. The state was part of what I termed the “blue wall”: the 18 states that voted for Democratic presidential candidates in all six elections from 1992 through 2012. (Democrats actually started their Wisconsin presidential winning streak in 1988.) Democrats also controlled both U.S. Senate seats throughout most of that same period, and the governorship for two terms after 2002.

    But the tide began to shift around 2010, with the election of Republican Governor Walker and a GOP sweep of the state legislature. In 2016, two years after Walker won reelection, Trump dislodged Wisconsin from the blue wall, carrying it by 22,748 votes. Like Trump’s 2016 victories in Pennsylvania and Michigan, which had also been part of the “blue wall,” the former president’s Wisconsin breakthrough symbolized his success at forging a winning coalition that revolved around massive margins among non-college-educated and non-urban white voters.

    Charles Franklin, the director of the Marquette Law School poll in the state, says Wisconsin today remains divided almost evenly between the parties: 45 percent of voters identify as Republicans, 44 percent as Democrats, and the rest are unaffiliated. Yet since Trump’s initial victory, Democrats have won most of the state’s key contests. The Democrat Tony Evers beat Walker for governor by about 30,000 votes in 2018 and won reelection by triple that amount last year. In 2018, Democratic Senator Tammy Baldwin won a landslide reelection. Democrats also won big in state-supreme-court elections in 2018 and 2020. Biden carried the state by about 21,000 votes in 2020. The major Republican victories over this period have been narrow ones: Hagedorn’s 6,000-vote 2019 win for the state supreme court and the roughly 27,000-vote win last November by GOP Senator Ron Johnson over the Democrat Mandela Barnes.

    Those results suggest that Democrats have come out slightly ahead from the demographic and geographic re-sorting of the electorate that Trump accelerated here. As in states across the country, Republicans have grown stronger in heavily blue-collar and white rural areas, primarily across Wisconsin’s northern and western counties where Democrats once competed effectively. But Democrats have been boosted by offsetting gains in the state’s most populous cities and towns, many of them relatively more racially diverse or better educated. (About 90 percent of Wisconsin voters are white.)

    Craig Gilbert, a fellow with Marquette University Law School’s Lubar Center for Public Policy Research and Civic Education, calculated that from the 2018–22 governor races, Evers improved his performance in all 30 communities that cast the most votes except for Kenosha (where he was hurt by a backlash against the 2020 riots over the police shooting of a Black man in the city). The places where Republicans are winning “simply aren’t growing,” while Democrats are generally improving in the places that are adding population, Devin Remiker, the executive director of the Wisconsin Democratic Party, told me. “It’s getting harder and harder for them to keep up with that trend.”

    Democrats have benefited from improved showings mostly in two areas. One is the so-called WOW suburban counties (Waukesha, Ozaukee, and Washington) around Milwaukee. Though the GOP still comfortably wins all three, Democrats have noticeably narrowed its margins. As Gilbert calculated, in Waukesha, which he described as “the most important Republican county in Wisconsin,” 21 communities have shifted at least 20 points toward the Democrats in gubernatorial races since 2014.

    Even more significant has been the explosive Democratic gains in Dane County, the highly educated hub for biotech, insurance, and government jobs centered on the city of Madison, home to both the flagship campus of the University of Wisconsin and the state capital. The Democratic share of the vote in Dane County has increased from about 70 percent for Hillary Clinton in 2016 to 75 percent for Biden in 2020 to 79 percent for Evers in 2022; Dane actually provided Evers a larger net vote margin than Milwaukee County did, something that would have been almost unimaginable even a decade ago. Franklin says Dane has become a triple threat for Democrats: “It is growing fast, the turnout keeps rising, and the lopsided partisan margins keep growing.”

    The flip side of the Democrats’ improving performance in Dane and the Milwaukee suburbs is rising concern in the party about lackluster turnout among Black voters, especially in Milwaukee. Some local leaders fear that a political competition between the parties focusing more on social issues such as abortion simply doesn’t engage enough lower-income Black voters, who are focused more on material needs such as jobs and health care. “If people feel like their issues are not going to be reflected, they are going to sit out,” Angela Lang, the executive director of the group Black Leaders Organizing for Communities, told me.

    Lagging Milwaukee turnout next week would be another signal that Democrats, as in 2020, continue to face challenges not only with non-college-educated whites, but also with blue-collar voters of color. But if abortion rights, in effect, trump crime and allow Protasiewicz to extend the Democrats’ gains in white-collar suburbs, that could signal trouble for anti-abortion Republican presidential candidates in 2024—not only in Wisconsin but in the suburbs of any swing state. The Democrats’ rural and inner-city troubles in Wisconsin, which still might allow Kelly to eke out an upset win, testify to the fragility of a modern Democratic coalition bonded less by economic interests than by cultural values. But a Protasiewicz win, in a state that Republicans probably must recapture to regain the White House in 2024, would demonstrate again that there’s formidable power in that new coalition too.

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    Ronald Brownstein

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  • Is the Worst of Winter Over for COVID?

    Is the Worst of Winter Over for COVID?

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    For months, the winter forecast in the United States seemed to be nothing but viral storm clouds. A gale of RSV swept in at the start of autumn, sickening infants and children in droves and flooding ICUs. After a multiyear hiatus, flu, too, returned in force, before many Americans received their annual shot. And a new set of fast-spreading SARS-CoV-2 subvariants had begun its creep around the world. Experts braced for impact: “My biggest concern was hospital capacity,” says Katelyn Jetelina, who writes the popular public-health-focused Substack Your Local Epidemiologist. “If flu, RSV, and COVID were all surging at the same time—given how burned out, how understaffed our hospital systems are right now—how would that pan out?”

    But the season’s worst-case scenario—what some called a “tripledemic,” bad enough to make health-care systems crumble—has not yet come to pass. Unlike last year, and the year before, a hurricane of COVID hospitalizations and deaths did not slam the country during the first month of winter; flu and RSV now appear to be in sustained retreat. Even pediatric hospitals, fresh off what many described as their most harrowing respiratory season in memory, finally have some respite, says Mary Beth Miotto, a pediatrician and the president of the Massachusetts chapter of the American Academy of Pediatrics. After a horrific stint, “we are, right now, doing okay.” With two months to go until spring, there is plenty of time for another crisis to emerge: Certain types of influenza, in particular, can be prone to delivering late-season second peaks. “We need to be careful and recognize we’re still in the middle,” Jetelina told me. But so far, this winter “has not been as bad as I expected it to be.”

    No matter what’s ahead, this respiratory season certainly won’t go down in history as a good one. Children across the country have fallen sick in overwhelming numbers, many of them with multiple respiratory viruses at once, amid a nationwide shortage of pediatric meds. SARS-CoV-2 remains a top cause of mortality, with its daily death count still in the hundreds, and long COVID continues to be difficult to prevent or treat. And enthusiasm for new vaccines and virus-blocking mitigations seems to be at an all-time low. Any sense of relief people might be feeling at this juncture must be tempered by what’s in the rearview: three years of an ongoing pandemic that has left more than 1 million people dead in the U.S. alone, and countless others sick, many chronically so. The winter may be going better than it could have. But that shouldn’t hold us back from tackling what’s ahead this season, and in others yet to come.

    Not all of this past autumn’s gloomy predictions were off base. RSV and flu each rushed in on the early side of the season and led to a steep rise in cases. But both viruses made rather hasty exits: RSV hit an apparent apex in mid-November, and flu bent into its own decline the following month. The staggered peaks “helped us quite a bit, in terms of hospitals being stressed,” says Sam Scarpino, the director of AI and life sciences at the Institute for Experiential AI at Northeastern University. In recent days, coronavirus cases and hospitalizations have been tilting downward, too—and severe-disease rates seem to be holding at a relative low. Just under 5 percent of hospital beds are currently occupied by COVID patients, compared with more than four times that fraction this time last year. And weekly COVID deaths are down by almost 75 percent from January 2022. (Death, though, has always been a lagging indicator, and the mortality numbers could still shift upward soon.) Despite some dire predictions to the contrary, the fast-spreading XBB.1.5 subvariant didn’t spark “some giant Omicron-type wave and crush everything,” says Justin Lessler, an infectious-disease modeler at the University of North Carolina at Chapel Hill. “In that sense, I feel good.”

    Read: How worried should we be about XBB.1.5?

    No one can say for sure why we dodged winter’s deadliest bullets, but the population-level immunity that Americans have built up over the past three years clearly played a major role. “That’s a testament to how vaccination has made the disease less dangerous for most people,” says Cedric Dark, an emergency physician at Baylor College of Medicine. Widespread immunization, combined with the fact that most Americans have now been infected, and many of them reinfected, has caused severe-disease rates to plunge, and the virus to move less quickly than it otherwise would have. Antiviral drugs, too, have been slashing hospitalization rates, at least for the meager fraction of recently infected people who use them. The gargantuan asterisk of long COVID still applies to new infections, but the short-term effects of the disease are now more on par with those of other respiratory illnesses, reducing the number of resources that health-care workers must marshal for each case.

    The virus, too, was more merciful than it could have been. XBB.1.5, despite its high transmissibility and penchant for dodging antibodies, doesn’t so far seem more capable of causing severe disease. And the fall’s bivalent shots, though not a perfect match for the newcomer, still improve the body’s response to viruses in the Omicron clan. Competition among respiratory viruses may have also helped soften COVID’s recent blows. In the days and weeks after one infection, bodies can become more resilient to another—a phenomenon known as viral interference that can reduce the risk of simultaneous or back-to-back infections. On population scales, interference can push down surges’ peaks, or at the very least, separate them, potentially keeping hospitals from being hit by a medley of microbes all at once. It’s hard to say for sure: “Many things go into when an epidemic wave happens—human behavior, temperature, humidity, the biology of the virus, the biology of the host,” says Ellen Foxman, an immunologist at Yale. That said, “I do think viral interference probably does play a role that has not been appreciated.”

    None of the experts I spoke with was ready to issue a blanket phew. Overlapping waves of respiratory illness have already led to nonstop sickness, especially among children, draining resources at every point in the pediatric caregiving chain. Kids were kept out of school, and parents stayed home from work; after a glut of COVID-related closures in New Mexico, schools and day cares running low on teachers had to call in the National Guard. Inundated with illnesses, pediatric emergency rooms overflowed; adult-care units had to be repurposed for children, and some hospitals pitched tents on their front lawns to accommodate overflow. Local stopgaps weren’t always enough: At one point, a colleague of Miotto’s in Boston told her that the closest available pediatric ICU bed was in Washington, D.C.

    Read: The worst pediatric-care crisis in decades

    By any metric, for the pediatric community, “it’s been a horrible season, the worst,” says Yvonne Maldonado, a pediatrician at Stanford. “The hospitals were bursting, bursting at the seams.” The flow of fevers has ebbed somewhat in recent weeks, but remains more flood than trickle. “It’s not over: We still don’t have amoxicillin in general, and we still struggle to get fever medication for people,” Miotto said. A parent recently told her that they’d gone to almost 10 pharmacies to try to fill an antibiotic prescription for their child. And pediatric providers across the country are steeling themselves for what the coming weeks could bring. “I think we could still see another surge,” says Joelle Simpson, the division chief of emergency medicine at Children’s National Hospital. “In prior years, February has been one of the worst months.”

    The season’s ongoing woes have been compounded by preexisting health-care shortages. Amid a dearth of funds, some hospitals have reduced their number of pediatric beds; a mass exodus of workers has also limited the resources that can be doled out, even as SARS-CoV-2 testing and isolation protocols continue to stretch the admission and discharge timeline. “Hospitals are in a weaker position than they were before the pandemic,” says Joseph Kanter, Louisiana’s state health officer and medical director. “If that’s the environment in which we are experiencing this year’s respiratory-virus season, it makes everything feel more acute.” Those issues are not limited to pediatrics: Now that COVID is a regular part of the disease roster, workloads have increased for a contingent of beleaguered clinicians that, across the board, seems likely to continue to shrink. In many hospitals, patients are getting stuck in emergency departments for several hours, even multiple days—sometimes never making it to a bed before being sent home. “It seems like hospitals everywhere are full,” Dark told me, not just because of COVID, but because of everything. “The vast majority of the work I do, and that I bet you what most of my colleagues are doing, is taking place in waiting rooms.”

    The U.S. has come a long way in the past three years. But still, “the cumulative toll of these winter surges has been higher than it needs to be,” says Julia Raifman, a health-policy researcher at Boston University. Had more people gone into winter up to date on their COVID vaccines, the virus’s mortality rate could have been driven down further; had more antiviral drugs and other protections been prioritized for the elderly and immunocompromised, fewer people might have been imperiled at all. If relief is percolating across the country right now, that says more about a shift in standards than anything else. “Our threshold for what ‘bad’ looks like has just gotten so out of whack,” Simpson told me. This winter could have been as grim as recent ones, Scarpino told me, with body-filled freezer trucks in parking lots and hospitals on the brink of collapse. But an improvement from those horrific lows isn’t much to brag about. And this winter—three years into combatting a coronavirus for which we have shots, drugs, masks, and more—has been nowhere close to the best one imaginable.

    The concern now, experts told me, is that the U.S. might accept a winter like this one as simply good enough. Regular vaccine uptake could dwindle even further; another wild-card SARS-CoV-2 variant could ignite another conflagration of cases. If that did happen, some researchers worry that we’d be slow to notice: Genomic surveillance is down, and many tests are being taken, unreported, at home. And with so many different immune histories now scattered across the globe, it’s getting tougher for modelers like Lessler to predict where and how quickly new variants might take over.

    The country does have a few factors working in its favor. By next winter, at least one RSV vaccine will almost certainly be available to protect the population’s youngest, eldest, or both. mRNA-based flu vaccines, which are expected to be far faster to develop than currently available shots, are also in the works, and will likely make it easier to match doses to circulating strains. And if, as Foxman hopes, SARS-CoV-2 eventually settles into a more predictable, seasonal pattern, infections will be less of a concern for most of the year and season-specific immunizations could be easier to design.

    Read: Should everyone be masking again?

    But no vaccine will do much unless enough people are willing and able to take it—and the public-health infrastructure that’s led many outreach efforts remains underfunded and understaffed. Kanter worries that the nation may not be terribly willing to invest. “We’ve fallen into this complacency trap where we just accept a given amount of mortality every year as unavoidable,” he told me. It doesn’t have to be that way, as the past few years have shown: Treatments, vaccines, clean indoor air, and other measures can lower a respiratory virus’s toll.

    By the middle of spring, the U.S. will be in a position to let the public-health-emergency declaration on COVID lapse—a decision that could roll back protections for the uninsured, and ratchet up price points on shots and antivirals. This winter’s retrospective is likely to influence that decision, Scarpino told me. But relief can breed complacency, and complacency further slows a sluggish public-health response. The fate of next winter—and of every winter after that—will depend on whether the U.S. decides to view this season as a success, or to recognize it as a shaky template for well-being that can and should be improved.

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    Katherine J. Wu

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  • American Religion Is Not Dead Yet

    American Religion Is Not Dead Yet

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    Take a drive down Main Street of just about any major city in the country, and—with the housing market ground to a halt—you might pass more churches for sale than homes. This phenomenon isn’t likely to change anytime soon; according to the author of a 2021 report on the future of religion in America, 30 percent of congregations are not likely to survive the next 20 years. Add in declining attendance and dwindling affiliation rates, and you’d be forgiven for concluding that American religion is heading toward extinction.

    But the old metrics of success—attendance and affiliation, or, more colloquially, “butts, budgets, and buildings”—may no longer capture the state of American religion. Although participation in traditional religious settings (churches, synagogues, mosques, schools, etc.) is in decline, signs of life are popping up elsewhere: in conversations with chaplains, in communities started online that end up forming in-person bonds as well, in social-justice groups rooted in shared faith.

    For centuries, houses of worship have been the center of their communities, where people met their friends and partners, where they raised their kids, where they found solace, where they broke bread, where they organized around important issues.

    Shadi Hamid: America without God

    As Robert D. Putnam and David E. Campbell demonstrated in their 2010 book, American Grace: How Religion Divides and Unites Us, most Americans no longer orient their lives around houses of worship. And that loss is about more than just missing out on prayer services. It means that when people move to a new city, they have to work much harder to find new friends than previous generations did. When someone falls ill, they might not have a cadre of their fellow faithful to offer home-cooked meals and prayers for healing. This reorientation away from houses of worship is one of the factors that has led to the decline of a sense of community, the rise of social isolation, and the corresponding negative effects on public health, especially for older adults.

    Religion has historically done four main “jobs.” First, it provides a framework for meaning-making, whether helping our ancient ancestors explain why it rained when it rained, or helping us today make sense of why bad things happen to good people. Second, religion offers rituals that enable us to mark time, process loss, and celebrate joys—from births to coming of age to family formation to death. Third, it creates and supports communities, allowing each of us to find a place of belonging. And finally, fueled by each of the first three, religion inspires us to take prophetic action—to partake in building a world that is more just, more kind, and more loving. Through the pursuit of these four jobs, religious folks might also experience a sense of wonder, discover some new truth about themselves or the world, or even have an encounter with the divine.

    So rather than asking how many people went to church last Sunday morning, we should ask, “Where are Americans finding meaning in their lives? How are they marking the passing of sacred time? Where are they building pockets of vibrant communities? And what are they doing to answer the prophetic call, however it is that they hear it?”

    There have never been more ways to answer these questions, even if fewer and fewer people are stepping into a sanctuary. People are meaning-making in one-on-one sessions with spiritual directors and chaplains. One in four Americans—across racial and religious (and nonreligious) backgrounds—has met with a chaplain in their lifetime, according to a recent survey that Gallup conducted for the Chaplaincy Innovation Lab, of which one of us, Wendy, is a founder. Most find their time with chaplains valuable.

    People are preparing for the end of life with the Shomer Collective, a group that helps people as they prepare for and navigate the end of life, offering wisdom from the Jewish tradition. Death doulas now work with people from a variety of backgrounds, giving hand massages, preparing food, and doing much more for dying people and their loved ones.

    These spiritual offerings are not just for individuals. People are gathering in communities in new ways to celebrate Shabbat rituals with OneTable, and mourning the loss of their loved ones with the Dinner Party. They’re joining small groups through the New Wine Collective, a movement helping people build spiritual communities, and the Nearness, a platform for nurturing your spiritual life while discovering community online. And they’re pursuing faith-driven justice work with organizations such as the Faith Matters Network and Living Redemption.

    From the April 2017 issue: Breaking faith

    Many theological schools aren’t yet training their students to reimagine how to serve people outside traditional religious contexts. Most are still preparing clergy to serve in congregations, a job with diminishing prospects these days. However, a growing number of groups, many of them led by seminary graduates, support spiritual leaders who are fostering new kinds of spirituality in their flocks.

    The Glean Network, of which Elan is the founding director, has incubated more than 100 faith-rooted ventures over the past seven years through its partnership with Columbia Business School. Some of these programs focus on meaning-making, many on building communities, others on creative rituals, and still others on answering a prophetic call. The Chaplaincy Innovation Lab brings chaplains traditionally siloed in the settings where they work—health care, the military, higher education, prisons—into a broader learning community. More than 4,000 chaplains belong to the Lab’s private Facebook group—what we believe to be the largest virtual gathering of chaplains in the world—sharing advice, insights, and improvisational rituals from around the globe. These networks and a growing number of others equip spiritual leaders from a broad range of faith traditions to do their best work, and challenge theological schools to make their education more responsive, expansive, accessible, and practical.

    This swell of spiritual creativity comes at a time when Americans seem to need it most. We are more lonely, more divided, less hopeful, and less trusting than in previous decades. And while there is much to celebrate as these new offerings take shape, their growth comes alongside an unprecedented decline in religious affiliation, which does entail losing some things that are unlikely to be replaced by these creative efforts.

    We are witnessing a tectonic shift in the landscape of American religious life. Putnam was right when he declared a decade ago that religious disaffiliation has “the potential for completely transforming American society.” But he also predicted that it “has the potential for just eliminating religion,” and we beg to differ. Before we conclude that this transformation is solely about decline, let’s make sure we’re looking in all the right places.

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    Wendy Cadge

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  • Will We Get Omicron’d Again?

    Will We Get Omicron’d Again?

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    In COVID terms, the middle of last autumn looked a lot like this one. After a rough summer, SARS-CoV-2 infections were down; hospitalizations and deaths were in a relative trough. Kids and workers were back in schools and offices, and another round of COVID shots was rolling out. Things weren’t great … but they weren’t the most terrible they’d ever been. There were vaccines; there were tests; there were drugs. The worst winter development the virus might produce, some experts thought, might involve the spawning of some nasty Delta offshoot.

    Then, one year ago this week, Omicron appeared. The first documented infection with the variant was identified from a specimen collected in South Africa on November 9, 2021; by December 1, public-health officials had detected cases in countries all around the globe, including the United States. Twenty days later, Omicron had unseated Delta as America’s dominant SARS-CoV-2 morph. The new, highly mutated variant could infect just about anyone it encountered—even if they’d already caught a previous version of the virus or gotten several shots of a vaccine. At the beginning of December, and nearly two years into the pandemic, researchers estimated that roughly one-third of Americans had contracted SARS-CoV-2. By the middle of February this year, that proportion had nearly doubled.

    Omicron’s arrival and rapid spread around the world was, and remains, this crisis’s largest inflection point to date. The variant upended scientists’ expectations about SARS-CoV-2’s evolution; it turned having COVID into a horrific norm. Now, as the U.S. approaches its Omicronniversary, conditions may seem ripe for an encore. Some experts worry that the emergence of another Greek-letter variant is overdue. “I’m at a loss as to why we haven’t seen Pi yet,” says Salim Abdool Karim, an epidemiologist at the Centre for the AIDS Programme of Research in South Africa. “I think there’s a chance we still will.”

    A repeat of last winter seems pretty unlikely, experts told me. But with a virus this unpredictable, there’s no guarantee that we won’t see disaster unspool again.

    Read: The worst pediatric care crisis in decades

    A lot has changed since last year. For one thing, population immunity to SARS-CoV-2 is higher. Far more people have received additional doses of vaccine, many of them quite recently, with an updated formula that’s better tailored to the variants du jour. Plus, at this point, nearly every American has been infected at least once—and most of them with at least some subvariant of Omicron, says Shaun Truelove, an epidemiologist and a modeler at Johns Hopkins University. These multiple layers of protection make it more challenging for the average SARS-CoV-2 spin-off to severely sicken people. They also raise transmission obstacles for the coronavirus in whatever form it takes.

    Omicron does seem to have ushered in “a different phase of the pandemic,” says Verity Hill, an evolutionary virologist at Yale. The variants that took over different parts of the world in 2021 rose in a rapid succession of monarchies: Alpha, Beta, Gamma, Delta. But in the U.S. and elsewhere, 2022 has so far been an oligarchy of Omicron offshoots. Perhaps the members of the Omicron lineage are already so good at moving among hosts that the virus hasn’t needed a major upgrade since.

    If that’s the case, SARS-CoV-2 may end up a victim of its own success. The Omicron subvariants BQ.1 and BQ1.1 appear capable of spreading up to twice as fast as BA.5, according to laboratory data. But their takeover in the U.S. has been slow and halting, perhaps because they’re slogging through a morass of immunity to the Omicron family. That alone makes it less likely that any single Omicron subvariant will re-create the sudden surge of late 2021 anytime soon. In South Africa and the United Kingdom, for instance, different iterations of Omicron seem to have triggered just modest bumps in sickness in recent months. (That said, those countries—with their distinct demographics and vaccination and infection histories—aren’t a perfect bellwether for the U.S.)

    For an Omicron 2021 redux to happen, SARS-CoV-2 might need to undergo a substantial genetic makeover—which Abdool Karim thinks would be very difficult for the virus to manage. In theory, there are only so many ways that SARS-CoV-2 can scramble its appearance while retaining its ability to latch onto our cells; by now, its options should be somewhat slimmed. And the longer the Omicron line of succession persists, the tougher it may be to upend. “It’s just getting harder to compete,” Hill told me.

    But the world has gotten overconfident before. Even if SARS-CoV-2 doesn’t produce a brand-new version of itself, low uptake of the bivalent vaccine could allow our defenses to wither, driving a surge all the same, Truelove told me. Our transmission-dampening behaviors too are slacker than they’ve been since the pandemic’s start. This time last year, 50 to 60 percent of Americans were regularly wearing masks. The latest figures, many of them several months old, are closer to 30 percent. “The more opportunities you give the virus to get into somebody,” Hill said, “the more chances you give it to get the group of mutations that could help it take off.” Immunocompromised people who remain chronically infected with older variants, such as Alpha or Delta, could also become the sites of new viral offshoots. (That may be how the world got Omicron to begin with.)

    Going on probability alone, “it seems more likely that we’ll keep going with these subvariants of Omicron rather than dealing with something wholly brand-new,” says Maia Majumder, an epidemiologist at Boston Children’s Hospital. But Lauren Ancel Meyers, an infectious-disease modeler at the University of Texas at Austin, warns that plenty of uncertainty remains. “What we don’t have is a really data-driven model right now that tells us if, when, where, and what kind of variants will be emerging in the coming months and years,” she told me. Our window into the future is only getting foggier too as fewer people submit their test results—or take any test at all—and surveillance systems continue to go offline.

    It wouldn’t take another Omicron-type event to hurl us into disarray. Maybe none of the Omicron subvariants currently jockeying for control will surge ahead of the pack. But several of them might yet drive regional epidemics, Majumder told me, depending on the local nitty-gritty of who’s susceptible to what. And as winter looms, some of the biggest holes in our COVID shield remain unpatched. People who are immunocompromised are losing their last monoclonal-antibody treatments, and although powerful drugs exist to slash the risk of severe disease and death, useful preventives and treatments for long COVID remain sparse.

    Read: The end of Evusheld

    Our nation’s capacity to handle new COVID cases is also low, Majumder said. Already, hospitals around the country are being inundated with other respiratory viruses—RSV, flu, rhinovirus, enterovirus—all while COVID is still kicking in the background. “If flu has taken over hospital beds,” says Srini Venkatramanan, an infectious-disease modeler at the University of Virginia, even a low-key wave will “feel like it’s having a much bigger impact.”

    As the country approaches its second holiday season with Omicron on deck, this version of the virus may “feel familiar,” Majumder pointed out. “I think people perceive the current circumstances to be safer than they were last year,” she said—and certainly, some of them are. But the fact that Omicron has lingered is not entirely a comfort. It is also, in its way, a reminder of how bad things once were, and how bad they could still get.

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    Katherine J. Wu

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