Covid is Over Because Covid Will Never Be Over

...which means it's really way past time for us to confront our hospital disaster.

It’s a huge cliche to open a covid article with a picture of covid, but I have denied myself this easy way out for over 18 months. This is my annual indulgence.

Take a look at your life, right now. Ask yourself: what measures are you taking to deal with covid? What measures is your state taking? How about the kids at your local public school? What are the rules in local stores? Have you been to a movie since the pandemic started? If a loved one is hospitalized, even dying, would you be allowed to visit? If you live in an old-person’s home, do you ever see your grandkids?

You should take stock now, because this is it. Whatever you’re doing right now, you should assume that’s how it’s going to be for the rest of your life. If you’re wearing a mask this December, you will never have a reason to take that mask off—not next year, not in ten years, not in fifty. If your school-aged kids are eating lunch socially distanced outdoors in winter coats today, then you can expect their school-aged kids will do the same in 2051—because we no longer have any power to change the basic facts.¹

Here are those facts:

Covid is Forever

The covid pandemic will not “end,” ever. It will become a seasonal, endemic² disease that kills some large number of people (mostly old, some young) every year. Like flu, but worse.

There is absolutely nothing you or anyone else can do about this fundamental fact. No human power can end the pandemic.

Indeed, we now know (for reasons I’ll discuss below) that we never had the power to end the pandemic. Once it arrived in the United States through our wide-open borders, the general contours of the outbreak were written in stone. It’s nobody’s fault. This. Was. Inevitable.

If you’re not convinced, here is a proof-by-contradiction. Curtis Yarvin, who (like me) has a deep personal fear of plague, sincerely argues that, no, actually we could have stopped covid if we wanted to, and still could. All we would have to do is:

Phase I: Two Weeks to Crush the Curve

1. Impose and enforce a mandatory, nationwide hard lockdown, in which no one in the country leaves their homes (except the military, which delivers supplies while avoiding infections within its own ranks).

2. All 337 million men, women, and children living in the United States, citizen or not, must take a home covid test every day, verifying their negative test with an app on their smartphones. (The 15% of Americans without smartphones presumably have some alternative method.)

3. Anyone who tests positive is sent to a quarantine hotel, where they are isolated and treated for the disease. This is not optional. Staff at the hotel wears N95 respirators and are themselves quarantined.

4. Anyone who doesn’t submit a daily test result receives a visit from the military, which ensures that a test is carried out—at the point of a gun, if necessary.³

5. Phase One lasts two weeks… except in any areas where it the above four steps are not followed perfectly, in which case it continues until they are followed perfectly. Thus, in practice, this phase lasts two hundred thirty-five years.⁴

Phase II: Constant Vigilance

1. Any other nation on Earth that fails to positively prove that it is following these same guidelines, and succeeding, is quarantined. Any traveler from any of those nations is quarantined for two weeks upon arrival, with no contact with any residents. (This, naturally, requires completely effective border controls and fencing.)

2. All large public spaces (e.g. concert halls, schools, airports) are outfitted with technology that detects the airborne covid virus automatically. Any building where covid is detected is immediately locked down and all inhabitants are tested.

3. Any future outbreaks of covid result in swift contact tracing and mandatory quarantine.

4. If a large-scale outbreak occurs, return to hard lockdown.

5. Phase Two lasts until the Earth is destroyed by solar expansion five billion years from now.

This plan is the baseline of what you would have to do to “end the pandemic.”⁵ Yarvin and I agree about that. Any efforts to “end the pandemic” that fall short of this are not public health, but mere public health theater.

So if a government official exhorts you to get a booster shot so “we can end the pandemic,” but isn’t calling for police to hold vaccine resisters down while vaccination squads forcibly inject them, she’s doing theatre, not health. If a colleague at work⁶ says he’s, “wearing a mask so we get to a day when we don’t have to wear masks anymore,” yet he sometimes leaves his house to buy groceries, then he either doesn’t know or doesn’t care that his actions belie his words. If you want to end the pandemic… if you want to “get back to normal” in pre-pandemic terms… then you’re doing something like Yarvin’s plan. Period.

And, hey good news is, Yarvin’s plan eradicates covid in the United States in a matter of weeks.

The bad news is, Yarvin’s plan is politically and logistically impossible, it wouldn’t work even if it were possible, and, I’m sorry to say, it wouldn’t be worth it if it did.

Yarvin presents our failure to carry out his plan as a simple failure of state capacity. Locking everyone down for a few weeks is politically and logistically impossible, he contends, because we in the West are weak; we have placed public opinion, public accountability, and public rights ahead of the public good.⁷ Meanwhile, Xi Jinping and the Chinese Communist Party are unconstrained by the public or human “rights” and thus can do as they see fit. They can enact this approach to covid—and they have! China’s plan pretty closely resembles Yarvin’s. No other society in history—not Caesar’s Rome, not Stalin’s Russia—could have accomplished it, but China has pulled it off.⁸

As far as it goes, Yarvin’s right. China can do this and we can’t. It is politically and logistically possible to run the Yarvin Plan in a 21st-century techno-dictatorship, but not in a liberal society.

Is that a strike against liberal society?

Nah, not this time. China’s approach hasn’t restored normalcy. Substantial swaths of China still routinely plunge into lockdown as covid continues to circulate—slowly⁹ but surely. They do not have zero covid. They will never have zero covid. The dream of a two-week lockdown followed by permanent more-or-less freedom was perhaps a worthy hope in the face of OG covid. In the face of the more-transmissible Delta variant, it became a fantasy. And here comes Omicron, the most transmissible variant of all. China can slow it; they can’t stop it.

Because it cannot exterminate covid, China will eventually suffer covid casualties similar to ours, even if they maintain these protocols forever.¹⁰

Even if it had worked, and Chinese policy had saved millions of lives outright, would it have been worth it?

Nah. I’m going to insert a non-factual value judgment here: China’s system of government is bad. Sure, the West is a total clown show. But the CCP’s unchecked power inevitably corrupts it, because power is radioactive and rots your soul. Then the corrupt government uses their power for enormous evils that are not only cruel, but profoundly counterproductive. Sorry, Moldbug: all human governments are nests of perverts, clowns, thieves, and rascals; the only total-surveillance techno-dictatorship I wanna live in is not of this world. If the only way to save the millions of Americans who will die of covid is to change to a system of government that sees tens of millions of Americans dying in abortuaries, political prisons, or concentration camps, that’s not a worthwhile tradeoff. You don’t have to be Patrick Henry to see that.

But, I remind you: China’s approach didn’t work. It will never work. China has slowed covid, but, since it has failed to eradicate covid, all it has done is delayed the inevitable deaths that will eventually occur. So there’s no actual tradeoff here. Xi Jinping, like Joe Biden and Boris Johnson, is engaged in public health theatre, not public health; he only performs the play a little differently because his audience is different.

Actually eradicating covid is impossible. It’s going to keep spreading, everywhere, forever.

Covid is Dangerous

…and, as it spreads, it’s going to kill people. I calculated your odds for you last week. I’ve since added obesity stats. Even if it doesn’t kill you, there are lots of ways covid can leave you permanently worse off. I got the flu—the real flu—only once, in Winter 2013, and it was the worst thing that ever happened to my body. I finally understood, deep down in my bones, how people could just die of a lame little viral infection. I’ve gotten the flu shot every year since.

Covid isn’t the worst disease ever, but it’s still about ten to fifteen times more dangerous than influenza. Influenza was already a top-20 cause of death in the United States, and has been for many years. So permanent super-flu is not great news!

Surely There’s Something We Can Do To End It!

Nope. Not one thing.

I’ll go through some of the things people sometimes think can end the pandemic. This section goes on for a while, but, as soon as you’re convinced the pandemic is forever, you can skip ahead to the next section (“Why It Matters”).

• Herd Immunity: Won’t we all eventually get infected, develop natural immunity, and then covid will die off because there’s no one left to infect?

No.

It’s not just that covid has become so transmissible. Every time it becomes more transmissible, its herd immunity threshold rises. It started with OG covid at (we believed) around 60-70%. Delta’s was 80-90%. Omicron’s appears to reach herd immunity only after 90%+ of the population has immunity.

High thresholds make herd immunity a slow process with a large body count… but, in the end, you do get there. Several other diseases spread like covid does: chicken pox, measles, polio. Eventually, pretty much everyone caught all three diseases, and either died or developed long-term immunity. Herd immunity developed—even for hyper-infectious diseases like measles. The only people without herd immunity were children, who were naturally born without the antibodies—and so all these diseases became known as “childhood illnesses.”

No, the real problem is that covid evolves much faster than measles or chickenpox. When’s the last time you heard about a “variant of concern” for mumps? Instead, covid evolves at roughly the same pace as influenza and the common cold,¹¹ which spit out several new variants every year. Those variants almost always have the ability to partially evade prior immunity, so someone who caught the flu in 2019 might be able to catch it again in 2020 and probably can by 2022. Every time we start to get anywhere close to herd immunity for flu, flu just evolves again and gets back to killin’.

Covid’s doing that.

• Vaccine-induced immunity: Can’t vaccines help us get to the herd immunity threshold quickly, faster than covid can evolve away from them?

Good luck with that. You have roughly a six-month window to detect the next dominant variant, update the vaccine for that variant, release the update, inject >90% of the world population with it, and hope covid’s response is to die instead of evolving a little ahead of schedule.

If we had the power to do that, don’t you think we would have done it to influenza decades ago?

Notice that I haven’t even touched on the difficulty posed by people who refuse to get vaccinated, because active vaccine resistance no longer matters from an end-the-pandemic standpoint. Unvaccinated adults are (in my opinion) acting unwisely, even recklessly, but they are not prolonging the pandemic or otherwise causing harm to you (with one exception, which I’ll get to later).

There was a time in Spring 2021 when we thought vaccine resisters were prolonging the pandemic, because we thought the virus evolved slowly and that the herd immunity threshold was around 60-70%. Vaccine resisters were keeping the United States from getting to that point. That’s the rational basis for popular hostility to vaccine resisters.¹²

But, unbeknownst to us, Delta had already evolved by Spring 2021. Indeed, it had evolved before vaccines were even available to the public in the United States—and it evolved in India, a relatively poor nation of a billion souls, far from the vaccine headquarters of the world. Once Delta evolved (with its herd immunity threshold over 80% and modest vaccine evasion), it was game over; we lack the industrial capacity to defeat that, even if we had perfect public cooperation, everywhere in the world.¹³ It just took us six months to find out we’d lost.

Oh, and, just in case you had any lingering suspicions that some future vaccination program might end the pandemic anyway: while it’s clear that vaccines stop a lot of serious illness, they seem to be decreasingly good at stopping actual transmission. A vaccine that doesn’t stop the disease from spreading is not going to be able to end the pandemic. You end a pandemic by stopping the disease from spreading.

• Vaccine-induced local immunity: Okay, maybe we can’t end the pandemic worldwide. But we can at least end the pandemic in our neighborhoods, right? It’s like the measles: it exists somewhere in the world, but can’t get a foothold in my world, because we are all vaccinated. Like… if everyone in my town is vaccinated, nobody can spread it—so, when somebody does pass it on, it must be the fault of the unvaccinated, right?

Alas, this isn’t true. We see too many outbreaks in areas with extremely high vaccination rates. Just one example, and then I’ll move on: Ireland has fully vaccinated more than 90% of its population over the age of 12. They just closed nightclubs, halved capacity at sporting events, re-imposed “household mixing” caps, and are considering lockdown; that’s all before Omicron starts hitting hard in coming weeks. Given high transmissibility, growing vaccine evasion, and rapid evolution, there appears to be no attainable threshold at which breakthrough cases alone can’t fuel a sizable epidemic all by themselves—at least, not without Yarvin-style military lockdowns.

• Masks: But masks reduce transmission, right?

Alright, yeah, optimistically, the ill-fitting piece of cloth looped vaguely over your face-parts is significantly reducing the amount of covid you are taking in or (potentially) emitting. The evidence on this kind of mask is not great and never has been; many studies touted in support of “mask mandates,” like the well-regarded Bangladesh RCT, actually support surgical masks, not the cloth face coverings Americans now call “masks.”

Even when successful, effect sizes are not large (see the Bangladesh RCT). That suggests widespread use of effective masks can take some of the sharp edge off a wave, but can’t prevent it.

Meanwhile, you’re dealing with a domestic and global population that is exhausted, divided, and paranoid. Even if masks could, in theory, get things back to normal, there is no realistic possibility of sufficiently widespread compliance in most Western communities. I tepidly supported a mandate 18 months ago, but it was not visibly effective.

That doesn’t mean masks can’t provide individual protection. They can, especially if you wear a good mask! Right now, I’m just talking about whether masks can end the pandemic or “get us to a day when we don’t have to mask up anymore.” They can’t. If you’re masking today, you’ll be masking in 2149 when we discover the Charon mass relay.

• Lockdowns: If everyone just stays home, they can’t spread the virus, and then the virus will die out!

I already wrote a lot about lockdowns. Scott Alexander has as well. As we saw in the Yarvin Plan, if you are going to make a serious run at ending the pandemic, you’re going to impose some very harsh lockdowns.

We are not doing serious things. We in the West are closing bars, cutting capacities at concerts, and, rarely. ordering everyone to stay home… except for “essential workers,” which turns out to be the ~30% of the population most likely to catch ‘rona and the least likely to have the personal support net and/or health insurance needed to deal with it.

As I explained in my article, such lockdowns not only can’t end the pandemic; they don’t even seem to have slowed it very much, despite the high costs. In 2021, lockdowns and gathering restrictions are a good example of public health theatre at the expense of public health.

• Antivirals: When we get good antiviral treatments for covid, won’t the pandemic end because we’ll be able to cure people?

You don’t end a pandemic by treating the symptoms. The virus keeps spreading, forever.

That being said, effective antivirals like paxlovid and molnupiravir look promising. Bear in mind I said that about HCQ and ivermectin as well, and ended up disappointed. But both paxlovid and molnu have shown much more promise than earlier candidate treatments, so I’m feeling very good about these.

As such, antivirals are my main hope for, not ending the pandemic, but reducing the risk enough that the people in our society who are anxious about covid will finally feel able to relax. In many ways, that comes to the same thing. I don’t see how that can happen in 2022; we can expect roughly 1 billion worldwide cases of covid next year, and perhaps 50-100 million more in the United States, but, worldwide we will probably have only around 150 million total courses of antivirals available, between paxlovid and molnu. Production will grow, but not right away.

At the start of this post, I predicted that, in some areas, kids will still be masked and socially distancing in schools in 2050. There are three main forces that give me hope that might not come to pass. The first is viral evolution. The second is antivirals. The third is political embarrassment and exhaustion, which could drive social and policy change even without a change in the virus or the death toll—and this, I think, is most likely.

But even in those three hopeful scenarios, the pandemic is here to stay. Covid is forever. I wish that were not true. I wish the sacrifices we made had done more good. I go back and re-read some of my early (relatively optimistic) covid posts and it makes me sad… but, alas, facts don’t care about my feelings.

Why It Matters

The permanence of the pandemic is an important fact. We cannot set realistic goals until we stop setting impossible ones. We also cannot start assigning credit and blame to the right people until we understand what our goals and methods actually are.

Public Health™¹⁴ is not going to help you figure this stuff out, which is why I wrote ten thousand words about the covid endgame and, presumably, part of why you’re reading them. Public Health™ has known for some time that covid is not going away, that their recommended maskings and boosters and lockdowns will never end, but Public Health™, as far as I can tell, is either

(a) completely okay with that or

(b) simply incapable of resisting internal pressure and groupthink to start talking seriously about the endgame.

It’s hard to tell, given the degree of duplicity and stupidity in Public Health™ messaging. Also, their apparent complicity in (accidentally) creating the pandemic, and their certain complicity in its early spread. But, from what I’ve read, I think it’s more (a) than (b). The average voice in Public Health™ now thinks that our real mistake was not masking and social distancing before the pandemic, because lots of people died of flu—and, as anyone engaged with Public Health Twitter knows, they are quite happy to label anyone who disagrees with their (quite radical!) non-scientific value judgments as anti-science, anti-vaxx, and anti-grandmas.¹⁵

On that note: please stop shaming people for making different value judgments.

Also, please stop shaming people just for catching covid-19. Stop thinking it’s their fault, or your fault, or Biden’s fault, or Trump’s fault, or anyone’s fault when someone’s test comes back positive.¹⁶ I have had several conversations with people who recently caught covid, but made sure to mention that they were double-vaxxed in every conversation they had about it, every email they sent—as if they had to be absolved of the sin of catching a highly contagious virus! Widespread infection is, and always was, inevitable.

Even if someone was irresponsible, that irresponsibility did not prolong the pandemic! It did not harm others! Such a person deserves your pity, not your contempt! I absolve you all!

Indeed, in general, please stop thinking that someone else’s vaccination is going to reduce the risk to your family in some meaningful way, and (therefore) someone refusing to vaccinate is harming you. It’s not true.

(Unless you are a health care worker. I’m getting there!)

The Omicron Non-Emergency

The coming months seem likely to be a challenge. There’s a lot we don’t know about Omicron, but we know that it’s coming. Maybe it’s less lethal, maybe a lot less lethal, we just don’t know.

Right now, our best guess is that Omicron is going to hit pretty hard. And, better yet, it’s going to hit right in the middle of flu season and the first-ever Delta Winter. The oracular Zvi thinks Omicron is going to overwhelm our hospital capacity, and, unlike those unreliable computer models, Zvi has a good track record of predicting, week-to-week, where the pandemic is heading next. There are going to be a lot of cases. Even if Omicron does turn out to be less lethal, so many cases will still (likely) mean a lot of deaths.

Yikes!

…and that’s normal now. That’s what I’m trying to drive home here: this never ends. Omicron is not “okay.” But it is also not an exception. It is not an emergency. It is the next stage in what will likely become a stable annual cycle. We are not waiting on a vaccine, like we were last year. Gandalf is not coming over the hills with the Rohirrim at the dawn of the third day. We should expect every winter to look something like this for the rest of our lives.

How Do You Want To Live?

Since covid is going to be like this forever, it’s time to ask yourself: how do you want to live?

Covid is dangerous.

If you are young, your odds of dying of it (detailed here) are small, but not trivial. There are additional risks as well. These risks justify prudent preventative measures, akin to wearing a seatbelt or installing a smoke alarm. A small investment of time, effort, money, and comfort is worthwhile if it significantly reduces a small risk.

If you are old, your odds of dying of covid are not small; they are moderate, in some cases high. On the other hand, if you’re old, your odds of dying of everything is moderate. Old people die of falling over in the parlor all the time, and old people are about a hundred times more likely to die of influenza than young people.¹⁷ Old people are also about a hundred times more likely to die of covid than young people. So, even if you’re old, it’s not entirely clear to me that your relative risk of dying from covid is higher than it is for young people, and I’m not sure how much more heavily you should defend yourself against it.

My advice:

1. If you are an adult, get vaccinated. Then, get boosted. Then, get your annual covid shot, just like the annual flu shot, for the rest of your life. (Flu shots have always been a good idea, but the covid shot has a vastly better cost/benefit ratio that makes it head-and-shoulders more valuable than the flu shot.)

2. If you are willing and don’t find it heinously uncomfortable, wear a mask. Don’t wear a public health theatre mask. Get a real mask that will actually keep out the virus: go buy an N95 or a KF94 or whatever the highest-quality publicly-available mask is where you live. Wear this in public spaces for the rest of your life. (If you find masks uncomfortable, then this probably isn’t a modest investment of time, effort, money, and comfort, and you shouldn’t do this one.)

3. If practical and affordable, improve the ventilation in your home. It’s a big help! If you live in an old-person’s home, consider how well-ventilated your building is, and, if practical and affordable, move to a better-ventilated one.

Then… live your life. Don’t harbor anger at other people who make different choices in this regard. They aren’t harming you. They are not prolonging the pandemic. The pandemic will never end, and you cannot escape exposure, so the only people who will bear the consequences of their imprudence is they themselves.

(There is one—fairly large—exception to this, and we’re almost there.)

All other regulations, especially legal regulations (capacity limits, mask mandates), only make sense if they are intended to be permanent features of our society going forward. They should be sold to the public on that basis, and the public should make its decision—through elections, in the case of laws; and through patronage, in the case of stores.¹⁸ Selling covid regulations as mere “emergency” measures is no longer intellectually honest. Maybe the grandmas at St. Frideswyde’s Home for the Aged (who have survived two years without hugging their grandkids) will be fine with a policy of never being allowed to hug their grandkids ever again. But let’s tell them that’s the policy, then see what they decide. Right now, we’re lying to ‘em.

And then, finally, life can get back to the new normal. I expect actors will come out and mingle with audiences after a theatrical performance again—although maybe they’ll be masked. I expect Sesame Street will keep encouraging vaccines, but with slightly less preachy writing. I expect schools will start advertising their disease-resistant ventilation systems as enthusiastically as they advertise their worthless technology investments.

And, of course, I expect everyone to die by the age of 44 because our hospital collapsed and there are no doctors anymore.

The Hospital Crisis

A few sections ago, I mentioned that the oracular Zvi thinks Omicron is going to overwhelm our hospital system. Zvi is usually right, but this is provably wrong. Omicron can’t overwhelm our hospital system.

It’s already overwhelmed. It’s past overwhelmed. It’s on fire.

If you live in Minnesota, and maybe even if you don’t, you’re aware of the full-page letter our hospital execs printed in the Pioneer Press the other day, entitled, “We’re heartbroken. We’re overwhelmed.”:

Now, maybe your first thought is, “Bah, more propaganda from Public Health™!” And fair enough! The thought crossed my mind as well.

But there has been a slow, steady rumble from the hospitals for many months. I wrote about this… *checks the timestamp*… geeze, last fall, even before the big winter wave Minnesota experienced in December 2020-February 2021. And not a single person I know in the hospital- or hospital-adjacent world has told me in the months since that any of it has gotten better. In fact, they say, to a man, that it’s only gotten worse.

Link

They tell me the same thing this chart is telling me: that, in the middle of a pretty massive overall employment boom and a global pandemic, health care employment has somehow gone down—and, the more the pandemic affects day-to-day work, the more employment has gone down… just when the need for more workers has gone way up.

Obviously, you can’t talk to my friends. But you can read the articles they’re sharing! Stories like “The Mass Exodus of America’s Health Care Workers”, “No One Is Listening To Us”, and "Pandemic Burnout Is Getting In The Way.”

Never believe what you read just because it’s in the papers (remember Gell-Mann Amnesia), but, this time, I believe what I read in the papers because it’s what I’m hearing from my few connections to the world of medicine. Here’s one of my friends, commenting directly on a recent article here at De Civ:

[L]et me offer a single perspective from my own trench right now. It's a tiny 25 bed rural critical access hospital. Normal times and even for much of covid era they have had maybe 14 inpatients with 1-2 being ICU level. They have maybe a couple of deaths a month for inpatients. Maybe one person a month brought in for coroner's autopsy who died at home.

The new normal now is a completely full hospital, all four vents in use with no way to get others from anywhere else, all bipaps etc are in use also. Half of the ER is now plastic cordoned off for a covid ICU (the ER nurses call it Camp Covid) that is also full with patients waiting on beds in the hallway for someone to die or actually get transferred out - not likely, unless they hit the jackpot and call a receiving facility right when they've had someone die there, there's no where to transfer any sick patients in the entire states of MI, WI, or MN right now.... They were trying Chicago for someone recently but the family told them to stop trying and they just accepted this would be goodbye up here. There are now multiple deaths a week and every few days there are a couple deaths in a day. That's a *lot* for this area and tiny hospital. The coroner is here a lot for people who are brought in found dead at home (we do postmortem covid PCR), she's covering two counties (other coroner quit) and she has to drive all over the place every day now, a full time job in itself. This isn't what she signed up for by campaigning to be elected coroner a few years ago. This isn't what any of the staff up here signed up for, and not what any of them want. They don't want to be the hollow eyed and fried people I now see every day, while I'm knowing that my contract ends next week and I get to leave, with a huge sigh of relief, while they have their whole lives here... These patients are their local friends, neighbors, shop owners, mechanics - they know them, all of them, and yet our staff are so burned out that they no longer even know who died on the floor today, they can't care that much anymore. It's no longer shocking to lose patients. Staff were already hard to find, now qualified staff is basically impossible to hire here as they really are limited to local/regional people, people don't relocate for jobs in rural community hospitals (there are a smattering of us travelers, but they can't find any more of us now either). A bunch of people here have quit just in the last two weeks, burned out, and it didn't have anything to do with the vaccine mandate. We did lose a few people to that too, and as much as I sympathize with the mandate it really REALLY has harmed us and the patients in this area to lose even those couple of skilled staff over it...

People who don't need to die are dying. Not just of covid, not just the unvaccinated, but people simply dying of things that we should be able to care for, and that we could still care for until about a month ago. The standard of care, the quality of care, *is not there*. God forbid you get sick or in a car wreck in these days.

This is just my experience in this one corner of the country over these past 3 months. But even if covid drops off drastically and we get over it in the community, the effects of losing so many staff and the drain on resources for long term care of these extant covid patients is going to be with this community long into the spring, best case scenario. And I am confident that this impact will be across the country, with excess death rates due to many causes being markedly higher than pre-covid, pre-delta.

I noted this morning a letter to the editor in today's NYT, from an ER doctor also in Michigan and every single sentence he wrote resonated. He understands. The second epidemic is worse than the first - it is the onslaught of non-covid people we could have, should have, saved, but for the first pandemic. Now we can't. It's draining and despair inducing. We signed up to help save lives. Instead we have this. How long do we keep at this? How long can we?

Anyway. I'm kind of raw and rambling right now, I'm sitting in the hospital parking lot writing this on my phone after another exhausting shift. This is my life for another week, then as a traveler I get the privilege to choose to not take another contract for a month or so. I will have some time to rest, off the front lines, and then hopefully be ready to face another contract. For most people they don't get this kind of option, it's either keep going or quit. My daily prayers will be with these people up here in the UP I am leaving behind in the trench. Please, please, pray for them too.

(Please do pray for them, if you are a praying person.)

I don’t even have to hear about the strain anymore. I’m starting to see it for myself.

A case I’m intimately familiar with: 68-year-old female with a tumor on the vocal cord. Biopsy takes longer than you might expect—the hospital is busy—but eventually results come back: malignant throat cancer. Only shot is to remove it, post-haste. Goes in for scheduled surgery, which goes well. During recovery, while breathing through a tracheotomy tube, there’s a complication; patient has a breathing emergency and nearly dies at the hospital. Nevertheless, patient recovers. Patient is sent home just two days later, still unable to speak, still breathing through a tube, with a stern warning to patient’s spouse to closely monitor the trach tube for further breathing problems. On the third night home, patient suffers an episode at 2 AM, stops breathing, wakes spouse before losing consciousness. Although an ambulance is called immediately, patient has yet to regain consciousness, and is not considered likely to do so, ever again. (Your prayers for this patient would also be very much appreciated.)

In ordinary time, do you think this patient would have been sent home, breathing through a tube that has already proved risky to the patient? I certainly don’t. The hospital will never admit it—can’t, legally, I think—but I think they sent the patient home early because they needed the bed. That particular hospital is being crushed by covid patients, just like every other hospital. They probably really did need the bed. And when you need a bed, but all the beds are full… you triage. The people who definitely need the hospital bed get it. The people who only might need the bed get sent on their way, with fingers crossed. Covid is killing people who don’t even have covid. “The standard of care is not there.”

The hospital system is not on the brink. The health care system has been showing worrying signs of burnout for years; it was on the brink in 2018. The pandemic pushed it over the brink. It’s now halfway down the waterfall.

And, because the pandemic will never end, this will never, ever get better.

Who Can Judge You

As I’ve said, for the most part, your choices are your own. What you do in this pandemic affects only you, perhaps those closest to you—because the pandemic is going to rage on and expose everyone regardless. No one else is in a position to judge you for those personal choices, except maybe your priest. You aren’t hurting anyone when you choose to refuse vaccination.

…except for nurses, doctors, and everyone else who will have to treat you, if and when you catch a serious case of the ‘rona and have to go the hospital. Your case will take up one of their beds, taxing their capacity just a little bit further beyond what they can actually handle, making their lives just a little bit more unbearable in what has become an unendurably dark time for many of them.

They can’t be mad at you for leaving your house and living a normal life again. Covid is normal now, and we have to learn how to live a normal life with it. But, if there was something you could have done with only a small investment of time, money, and effort, something that would have reduced your odds of hospitalization—not eliminated it, just modestly reduced it!—and you refused to do that thing… well, then, your choice ended up hurting all those medical pros, and they have every right to be angry with you.

(Also, anyone in the hospital who gets kicked out too early because you needed their bed, especially if then they suffer complications. They get to be mad, too. Also, their families.)

Someday, that won’t be the case. Hospitals must, eventually, staff up to the point where they can handle the new, heightened baseline. At that point, the occasional patient taking up a spare bed because of a mistaken decision won’t be putting the whole system under strain.

But, right now, that’s exactly what we do when we refuse to take prudent precautions against covid. So get vaccinated—if not for yourself, then for the sake of my nurse-friends.

If everyone gets a vaccine,¹⁹ that should reduce the covid-related hospitalization load by roughly 72%. That would be a pretty big help. Your nurses would be very grateful. The quality of care in hospitals would improve for everyone.

Even then, though… our hospitals didn’t have a lot of slack to begin with. Hospitals have always been busy in winter, thanks to flu season. Consider: if we had simply added a second flu to the annual winter playlist, that would have doubled the pressure our hospitals already feel in winter times, requiring a permanent capacity increase. Instead, we’re adding covid, which is like adding ten to fifteen flus all at once. That means our sustainable hospital capacity, which may have been just enough in 2019, is far short of what it needs to be today and for the remainder of the 21st century. That’s true even if everyone gets vaccinated.

Forget the Pandemic; Fix the Hospitals

This seems obvious to me, but nobody on my experts list is talking about this, and I don’t understand why.

I am not a health care sector expert. I haven’t been inside a hospital since 2018. I am not foolish enough to offer specific prescriptions. But it seems to me, from my reading and listening, that there are two key problems:

• There are not enough personnel, leading to decreased morale.

• Morale is critically low, leading to fewer personnel.

(I don’t hear much about equipment shortfalls, like actual beds or ventilators. Masks, sometimes. But mostly what I’m hearing is that we are asking hospital labor to do too much.)

Like I said, I can’t speak in particulars about the medical sector. I suggest going and asking the front-line medical pros (and those who recently burned out) what they need. And then—this is important—give it to them.

But I offer a few generalities that seem safe:

The Long Run

The medical sector has seemed overstretched and understaffed for quite a while. That’s odd, since medicine is a sector where there’s extremely high demand and enormous amounts of money sloshing through the pipes. Economics 101 tells us that you should only see labor shortages in sectors like that if there’s a short-term shock. Over the long-term, people should meet the demand in order to make a lot of money. Yet it seemed like that wasn’t happening in health care.

When you have a labor shortage in a sector that seems like it should be thriving, Economics 101 readily offers two explanations that can cause the free market to malfunction: monopoly and regulation. Both of these forces can suppress wages below the natural “market-clearing” price, causing fewer people to enter the field than are necessary, and, ultimately, creating a labor shortage. Both problems appear to be rampant in the health care system, in enough ways to fill a book. (Or two!)

Briefly, it seems that health care systems have become increasingly consolidated in the hands of just a few firms (often private equity firms), which then turn a profit by “cutting the fat” and trimming short-term costs to a minimum—at a cost to short-term service and long-term resilience. This often makes economic sense: private equity only needs to wring the cash out of a firm before discarding its empty corpse. It is genuinely baffling to me why the key enabler of private equity, the Leveraged Buyout (LBO), which encourages this exact thing, has not been outlawed. But I digress.

The “fat-trimming” usually means a depleted, overstretched labor force survives as best it can until it either burns out naturally, or it gets kicked over the edge by an economic shock that any business that bothered to invest in its own future would have weathered just fine. Then you end up with CVS employees weeping their way through the day until they quit and then suddenly you can’t get covid tests processed anymore, and nobody on the outside quite understands why.

Meanwhile, highly consolidated firms naturally create more internal policies and impose more record-keeping in order to ensure all the hospitals in their system are running to a similar standard. This is a form of (private) regulation. Combined with an already-toxic brew of government regulations on everything that happens in hospitals, plus government-influenced price floors and ceilings defined through its Medicare/caid payment schedules, the omnipresent free-rider problem where uninsured people with no money get hospital care on the hospital’s dime, and the hellaciously opaque relationship between medical providers, insurers, and actual prices… and what you get is lots of price distortions. You also get a lot of physicians complaining that they joined medicine to help people, and now they instead spend the majority of their time filling out paperwork and government-mandated electronic health record coding.

I don’t know how to fix this. But they’re long-term problems that need solving. Perhaps one could fix it all through some comprehensive, bipartisan health care reform bill that sails through Congress because of the urgency of the… okay, okay, stop laughing, sorry I mentioned it. In theory, though, it should be possible for a determined, well-informed Congressional committee to work with the FTC and other executive agencies to solve some of these problems in piecemeal, consensus bills. This is actually possible, and it happens; the key is that you keep anyone outside of Congress from ever hearing about it, politicizing the issue, and starting a political food fight. Like the Ocean Shipping Reform Act of 2021, but for hospitals.

Oh, you’ve never heard of OSRA21?

Exactly.

The bigger problem is, you can’t solve “hospital monopolization” or “medical sector overregulation” in less than two years, and we can’t exactly wait until 2024 while our hospitals burn down. Even when we do solve those problems, we won’t be able to train a new generation of doctors and nurses in a week. We need stopgaps to keep things running until then.

The Short Run

The lowest-hanging fruit is obvious: if we’re low on medical professionals, pay them more. This is exactly what Economics 101 calls for, and, mark my words, it does wonders for morale.

Then keep them: announce retention bonuses for all employees today, and then, for any of them who are still working in August 2022, pay them. Offer even larger retention bonuses for those still working in August 2024.

We may not be able to train up a new supply of doctors and nurses overnight, but how about we bring some back from the bench? Pull the retirees out of retirement, get the burnouts back from burnout city. How? Well, I know I’m starting to sound like a broken record here, but maybe pay them. Right now, we need them more than they need us. That means they get to set the price of their labor, and we should probably pay it.

Add staff until hospital pros are working human hours and aren’t “hollow-eyed and fried” from the sheer weight of the burdens they carry.

I realize that money alone may not be enough to solve the labor shortage (although, if doesn’t get you most of the way there, you aren’t paying them enough). We are in a period of widespread labor shortfalls and rapid wage growth, placing hospitals in a singularly unenviable position as they look for new recruits. Other improvements are possible, and should be encouraged where possible.

For example, it is my (very limited) understanding that a lot of covid patient monitoring and care is relatively straightforward. Would it be possible to turn a high-school graduate into a specialized “covid nurse” in, say, a two-week training course, freeing up other nurses to care for other patients? How about a member of the U.S. military? Obviously I’d rather have an R.N. caring for me, too… but we’re fresh out of R.N.’s, that’s the whole point, and I’d rather have some gangly 18-year-old who just learned CPR watching me than nobody at all. I don’t know whether this can be done,²⁰ but, if it can, maybe now’s the time?

Meanwhile, how many immigration rules stand in the way of our acquiring a corps of experienced doctors and nurses from other countries? Surely there are some medical professionals waiting in the very, very long line for a U.S. green card. Maybe now’s a good time to let them skip to the front of the line?

And, y’know, other stuff, too. Listen to nurses. NPR tells me that simple, inexpensive things like buying a working copy machine can work wonders—although be careful not to forget that you also need to pay them.

I’m out of my depth, so I’ll stop. Yet you can see, I’m sure, that, even though the pandemic will never end and needed hospital capacity will never fall back to the pre-pandemic baseline, there are things we can actually do to help medical professionals.

So maybe we should do those things, instead of… y’know, everything else we’re doing? *gestures vaguely at Twitter*

The government must be smart here. If it just gives a trillion dollars to hospitals, it will all disappear into the medical-administration complex. I naively suggest a stimulus check, akin to what we did last year for all Americans, but targeted solely at front-line health-care workers. Let the government pay each of them an extra, say, $20,000/year (payable monthly while working in the industry) for the next two years, while Congress and the industry adapt to the new normal. I could be doing my math wrong, but I think that would “only” cost a couple hundred billion dollars—much less than Build Back Better or the Tax Cuts and Jobs Act.

Of course, there are lots of details to work out. But these details can be worked out. The only alternatives appear to be our current plan—public health theatre until the hospitals all collapse—or the Yarvin Plan. By comparison, “Reinforce the hospitals,” seems pretty easy, doesn’t it?

Covid is never leaving the hospitals, just as it is never leaving the rest of us. Once we internalize that fact, we can finally start making healthy long-term decisions and investments, both in the hospitals and in other parts of our lives. Covid is never going away—which means, in every important sense, covid is already over.

Now it’s time to decide what our post-covid society looks like.

1. I will now cover my butt a bit.

We no longer have the power to change the basic facts. However, the virus still has some power to change the facts. The virus could evolve to be much less lethal, for example. It is possible, even, that Omicron is a first step in that process. I am optimistic about this!

Nonetheless, so far, even the most optimistic projections I’ve seen say that Omicron is still one-third as deadly as Delta. (For comparison, the nation’s most lethal pre-covid infectious disease—influenza—is only one-tenth to one-fifteenth as lethal as Delta. So, even if we’re lucky, Omicron will still be two to five times deadlier than the flu.)

So we probably need more evolutions to change the fundamental facts of the pandemic. That’s not something we can count on happening soon—or ever. Which is why I think it’s time to assume that, whatever safety measures you’re taking now, that’s what you’ll be doing for the rest of your life. Maybe covid evolves to be no-worse-than-flu in a decade instead of a generation, maybe antiviral miracle drugs make it a non-issue in five instead of ten, and then you can come back and taunt me for being too pessimistic.

2. My biology-inclined friends are emphatic on this: covid will become endemic, but it is not currently endemic. It grinds their gears to hear people (like me, on Facebook, last week, whoops) calling covid “endemic,” today, because a disease can’t be said to be endemic until it has both arrived at a normal “background” level of cases and we humans have ascertained what that level is. We don’t yet have a clear idea what covid’s “background” number is going to be, and we’re unlikely to find out in the next few months. We just know it’s going to be around forever.

3. Even assuming perfect cooperation, you will notice this step requires a true and correct registry of all persons living in the United States. Yarvin also notices this. In an odd but quite possibly deliberate inversion of George Orwell’s “if there is hope, it lies with the proles,” Yarvin observes that the problem with the lumpenproletariat is that the state can’t “see” them well enough to control them, and he proposes correcting this oversight at once. Reader, I merely report, I do not judge.

4. Roughly.

5. I would add, and Yarvin would certainly agree, that you would also mandate vaccination during the hard lockdown. Anyone who does not receive a vaccine by the end of the lockdown is seized and forcibly injected (and remains in lockdown until fully vaccinated). Again, I do not judge, I merely report what would you would have to do to end the pandemic by human effort.

6. With apologies to a work friend of mine, who said this to another colleague right after a Zoom meeting today, where I overheard him and immediately thought, “Oh, you’re going in the blog post, my friend.”

7. Yarvin calls it the salus populi; Catholic integralists call it the common good, but the point is that, in this school of thought, human flourishing trumps human rights. More on this here.

8. The magic ingredient is smartphones. Stalin could totally have done it if he’d had smartphones.

9. At least, we think covid is spreading slowly in China. That’s what the stats say. But we should interpret all official Chinese statistics about coronavirus as minimums, not maximums. The Chinese Communist Party has a proven record of deceiving the world about covid. Indeed, its deceit about the severity of the outbreak in Wuhan arguably allowed the disease to breach containment in the first place. And it continues to deceive and stonewall about the most likely origin of covid-19: an accidental leak from the Wuhan Institute of Virology. Calling it the “Chinese coronavirus” is politically charged but much, much fairer than calling the 1918 pandemic the “Spanish flu.”

10. I guess if they slowed it down enough they could simply outlive covid’s epidemic cycle. Keynes said, “In the long run, we’re all dead,” and, if the Chinese policy allows a bunch of 85-year-olds to catch covid in 2024 instead of 2021… hey, a lot of those 85-year-olds will die off in the meantime anyway, of other causes! I suppose that we could count that as a qualified win for the Chinese containment policy.

11. I know, the common cold is actually like a dozen different bugs all evolving at different paces, don’t @ me, I was just illustrating.

12. Of course, in the United States, anti-vaccine-resister sentiment was also driven by a stereotype of vaccine resisters as red-state rural Trump-lovers. Many blue-state urban #resistance types loathe such people already, and were delighted to have a new excuse to be outraged at their social inferiors. And many vaccine resisters became vaccine resisters largely out of resentment of these critics, who generally belong to a higher social class. (I know some of you doubt this, but I know some vaccine resisters for whom this is true.) American class warfare is constant and unceasing, it’s just invisible because it isn’t actually about income.

For what it’s worth, almost all of this hatred was misdirected.

Blue-staters failed to recognize how badly the actual vacccine resisters in the United States failed to fit their stereotype. A large portion of U.S. vaccine resisters are urban people of color and cautious, disengaged people across the political spectrum. Their skepticism is not some weird artifact of American exceptionalism or whatever; vaccine resistance is the position of a surprisingly stable minority throughout most of the world. Some people mistakenly thought Omicron emerged in South Africa because “vaccine equity” hadn’t sent enough vaccines to the “global South.” But, no, actually, South Africa had plenty of vaccines, so many they were sending vaccines back. What South Africa ran out of was people willing to take the vaccine.

Meanwhile, red-state vaccine resisters who became the face of their movement failed to recognize how many of their own red-state, Trump-voting peers wanted them to get vaccinated, too—many Trump voters even supported mandatory vaccination. Guys, you not only don’t represent the “silent majority” (the majority of Americans are fully vaccinated); you don’t even represent the majority in your own communities.

13. To be clear, we emphatically do not have anything resembling perfect public cooperation in most places in the world. If you think the U.S. anti-vaxxers are a tough nut to crack, just wait ‘til you meet the Cameroon anti-vaxxers!

14. Think of Public Health™ not as the academic field of public health alone (which seems to be no more corrupt than the rest of academia) but as a complex, like the Military-Industrial Complex. Lots of good public health science happens, but ideologically-aligned journalists and (to a lesser extent) politicians play a big role in deciding which parts of the field become recognized components of Public Health™. So do several large non-profit organizations and international agencies. Thus, Public Health™ is not just the academic field; it’s the scientific and policy consensus that results from interactions between that academic field and Power, inevitably corrupting both.

15. Internal thought process:

“I’d better cite this claim by linking to an example of a prominent member of Public Health™ shaming someone for having a different value judgment.”

“Oh, but that’s going to take forever! You know you spend more time looking up citations for your blogletter’s claims than you do writing the actual blogletter! That’s why the Daily Dobbs Updates are so fun — you skip the cites!”

“Yeah, but having the cites is what makes the blogletter valuable. It ties you to the mast of the truth and keeps you from going beyond what you can show evidence for.”

“But it’s soooo time-consuming and this blogletter is soooo late and I have soooo much Christmas shopping to do! It can take twenty minutes to find good evidence of even the most trivial claims!”

“Deal with it. The readers are paying you now. You owe ‘em.”

I then started looking for my cite. Decided to open Dr. Angela Rasmussen’s Twitter, since she is both a very prominent voice in Public Health™—she was on my own experts list before The Treason—and because she has a track record of abusing her scientific platform to make value judgments—e.g. why she was removed from my experts list after The Treason.

Reader, I swear, this was the very first tweet on her timeline at the time. The cite took 30 seconds. *chef’s kiss*

16. It’s Xi Jinping’s fault. First, for (likely) funding the creation of the virus, second for (likely) allowing it to escape from the lab where it was (likely) created, and third and most damnably for lying to China and to the world about it until it was too late to contain. Blame Xi and his enablers. They really should have named Omicron after him.

We’re all trying to point fingers at each other for causing or prolonging the pandemic through insufficient vaccination or destructive mask theatre or for bungling the tests back in February 2020. I think we do this because we would much rather hate each other than some obscure foreign outfit like the CCP. Yet, the clear reality is that, once covid reached our shores and penetrated our flimsy quarantines, none of us were responsible. The game was over by mid-February 2020, before most of us realized we were playing. After that, there was literally nothing literally any of us could do at literally any time to prevent more or less this scenario from playing out on more or less the same time table. So stop hating each other!

17. Source: the CDC influenza disease burden stats for 2014-15 (a fairly average year), the population estimates from my covid odds post, and some admittedly back-of-the-envelope math since the age brackets didn’t match up exactly.

18. In leaving private regulations in the hands of the free market, there’s a real risk that we are going to end up permanently enshrining one of the ugliest features of the pandemic: mask privilege. Upper-class workers are technically bound by mask mandates but have many workarounds: working from home, exploiting the food loophole, or just ignoring the rules. Lower-class workers are actually bound by mask mandates, and lack the privilege to ignore it. Which leads to a lot of pictures like those from the 2021 Met Gala: wealthy unmasked guests catered to by masked peons. Many such cases. But I’m not convinced having the government step in and mandate against mandates is a better solution, especially not in the health care sector.

19. …which, realistically, isn’t going to happen. Even the MMR vaccine, mandated by practically every school system in the Union, only has about 92% uptake. You now know whether you, personally, are allowed to be angry about this, or whether you must resign yourself to sadness.

20. Even if it’s possible, I imagine the nurse’s union might not be happy about the idea of a second tier of lower-paid psuedo-nurses in the hospitals, even temporarily. This could be an example of monopolization from the other direction.