# The way out

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Many people would like to believe that the CV19 pandemic is over. Unfortunately viruses do not listen to what people want to believe: the CV19 pandemic is not over, and there is a significant possibility it may never be over. The way out is not to pretend that it is.

## CV19 is not over

Unless CV19 can be globally eliminated it will not be over: new cases will leak into countries however hard they try to prevent it. Eliminating CV19 globally requires achieving herd immunity through vaccination or infections everywhere.

We are not particularly close to that. It’s tempting to do a lot of calculations at this point to show this but those calculations are fiddly and I always get them wrong. Instead consider the UK: currently (3rd December 2021) about 75% of the population have had at least one dose and there is a current effort to roll out third, ‘booster’, doses. Yet, even before the omicron variant, CV19 was nowhere near gone in the UK. And the UK is doing reasonably well at vaccinations. Boris Johnson’s lies notwithstanding it is nowhere near the top of the table, but it is well above the global average: globally about 55% of people have had at least one dose.

Unfortunately, by hoarding both vaccines and the rights to manufacture them, the rich countries are actively hurting the effort to globally eliminate CV19. So they are undermining the efforts they are making to protect their own populations. It is, apparently, too hard for politicians to understand that the virus cares much less about some lines drawn on a map than they do.

Worse than this, until CV19 is eliminated, it will still continue to evolve new variants, which will spread if they are fit. If we assume that CV19 won’t be eliminated soon, what’s likely to happen, in rich countries like the UK, as new variants appear?

The remainder of this essay concentrates on the UK as far as human responses go: that is obviously parochial, but the UK is where I live and I am most familiar with what the responses are there1.

## What might the virus do?

There are two important choices, which are orthogonal to each other: will a much-less-deadly variant become dominant? and will a variant which escapes the current vaccines become dominant? Neither of these cases excludes anything happening in the future: for instance a mild variant which does not escape vaccines could become dominant this year, only for a serious variant which does escape the vaccines to become dominant in a few years if such a variant has a selective advantage. As long as the virus exists it will be endlessly trying new variants.

Two independent choices gives a total of four scenarios.

### A mild variant: ‘flu’

Two scenarios involve a mild variant which may, or may not, escape the current vaccines: these are the ‘flu’ scenarios. Such a variant might become seasonal in the way flu is (CV19 may well already be seasonal of course: we just haven’t lived through enough seasons yet). If the current vaccines don’t work for this variant the results will not be too severe, and new vaccines will be developed. If vaccines, new or existing, confer long-term immunity, then things would become relatively normal. It’s likely that they don’t, however, so we would probably require regular courses of vaccinations, which may be new vaccines as the virus evolves: this is still pretty close to normal life.

Well, we could live with that, the way we live with flu. Except that we don’t always live with flu: Spanish flu2 killed between 17 and 50 million people, and perhaps as many as 100 million (by comparison, The Economist thinks that CV19 has probably killed about 17 million people so far from a larger population). Again, as long as CV19 exists it will be developing new variants and there is nothing I can see to stop one arising which is like that.

But, perhaps, this is at least no worse than flu is now, except perhaps that more people will need to be vaccinated more often.

### No vaccine escape

A third scenario is that CV19 stays roughly as deadly as it is now, but the vaccines we have keep working against it, probably with regular courses required. People continue to die in significant numbers, with those numbers depending to a great extent on the precautions people are willing to accept. This may seem much like the flu case except that a lot more people die. It might be only that: there are unfortunately much nastier possibilities discussed below.

### Vaccine escape

The final scenario is that a variant arises which is significantly deadly and for which the current vaccines are not effective. This is year zero: new vaccines will need to be developed, and a new urgent vaccination programme will be required. Until the vaccination programme is well under way there will either need to be very significant restrictions on social contact if very high death tolls are to be avoided. Unfortunately very high death tolls during the vaccine development and the early stages of the vaccination programme are, again, far from the worst things that could happen.

### Other scenarios

There are other possibilities. A variant might arise which is much more deadly, for instance. It’s easy to argue that very deadly viruses are selected against: a virus which kills too many of its hosts will tend not to thrive in competition with less lethal one. But in real life things are not that simple: the black death killed between 75 and 200 million people in 7 years, killing between 30% and 60% of the population of Europe, and perhaps 25% of the world’s population. Yersinia pestis was, perhaps, not competing with less deadly versions of itself, wasn’t so subject to mutation as a virus would be and there were other factors, but still: very bad things can happen.

A very nasty possibility is that a variant will arise against which no vaccines work very well. Before the current vaccines were developed some people were suggesting this (search for ‘there has never been a successful vaccine against a coronavirus’: I am not going to link to any of the results because some of them are awful people who do not deserve anyone’s attention). It seems to me that this is absurdly unlikely, but I’m not an expert.

No doubt there are many other scenarios I have not thought about.

### An endless war

Once again: until the CV19 virus is globally eliminated it will continue to evolve new variants. None of the above scenarios excludes any of the others: CV19 will explore as much of the space of options as it can. Until it is eliminated the pandemic will not be over: if it is never eliminated the pandemic will never be over.

## What might the humans do?

The virus is only one of the players in this game: the other is us. What happens depends on our response as much as what the virus does.

### Normality

If the virus is eliminated then normal pre-pandemic life resumes. In either of the ‘flu’ scenarios something quite like normal life resumes. In the flu scenarios normal life only resumes so long as the virus doesn’t evolve some much nastier variant. So, rationally, in these scenarios, work should still continue to eliminate the virus globally as fast as possible. I think it’s safe to say that won’t happen, so the normality in these scenarios is almost certainly impermanent.

### Stability

If there is a deadly variant which does not escape the vaccines then it’s possible to imagine a stable scenario where some combination of restrictions on social contact, regular vaccinations, masks, and just accepting that a fair number more people die each year than before CV19 will keep things under control. That’s a nice dream, anyway.

### Instability

A variant which escapes the vaccines results in instability: it is essentially a whole new pandemic and rapid lockdowns will be needed while new vaccines are developed to avoid very high death tolls or even worse outcomes. The instability can be minimised by careful management but the chances of that seem low.

Unfortunately I think that, even for variants that do not escape current vaccines, stability is unlikely. Instead there will be some more-or-less chaotic cycle of too-much relaxation followed by panics as death rates rise. None of this is helped by politicians who, in the UK at least, do not care very much if many people die, are not competent to understand what is required for stability, and neither understand nor care about the consequences of serious instability.

## What is really happening?

We’re still in the early stages of the pandemic, but what has actually happened?

### The virus

I don’t know. Since I started writing the omicron variant has appeared: this has a very high number of mutations, 62, compared to the original virus, of which 32 affect the spike protein which vaccines target (delta had 8 or 9). Currently (5th December 2021) it’s not known how infectious it is or how severe the illness it causes is compared to the previous, delta, variant. More seriously it’s not known how well vaccines work for it, but with a very large number of mutations on the spike protein people are clearly pretty worried.

So the omicron variant might be a ‘flu’ variant, a vaccine escape variant, both, neither, or something else. It might also not be very interesting at all. But there will be more variants in an effectively endless succession3: sooner or later something interesting will arise. Given selective pressure on the virus it will probably be sooner: if omicron is not it we are not off the hook.

### The humans

What are the humans doing? In particular what is the UK government doing? As a populist government what it does is to offer simple, appealing, wrong answers to complex, unappealing problems. It gives the answers that people would like it to give, without ever trying to explain why those answers are wrong or what the consequences of believing them will be. The johnsonites are very far from democratic, quite the opposite in fact, but in this case we can treat them as avatars of what people would like to be told is true.

Well, until a few days ago the answer was that they were saying that the pandemic was over and that normal life could resume. Now there is incoherent messaging: scientific and medical advisers are advising caution in the face of omicron, while Boris Johnson is publicly ignoring them. Johnson, clearly, is too stupid to understand the consequences of what he is doing and would not care about them if he did. He also has demonstrated, publicly and repeatedly, that he believes rules do not apply to him, thus ensuring that no-one else obeys them either. More competent (perhaps merely less incompetent) members of the government are giving more cautious messages, but there is simply no coherent strategy and the government is very obviously no longer ‘following the science’ nor even pretending to do so.

This is a recipe for instability: if omicron is serious then Johnson’s strategy, if it can be called such, will maximise its impact early in the new year. Johnson shows no sign of having learnt anything at all from his earlier mistakes: if anything he’s learnt that he can, in fact, get away with murder. If lessons are not learnt from this cycle the best we can hope for is a continuing chaotic cycle of restrictions followed by relaxation, for years.

The worst is that Johnson continues to maintain that it is all over, while people die around him in huge numbers. This is stability, of a kind, but not one anyone should wish for. Sadly many people do seem to wish for it, and to be happy with enormous numbers of deaths so that they don’t have to experience the momentary inconvenience of wearing a mask or otherwise behaving safely.

## Collapse

That is, in fact, not the worst outcome. Because we live in a society built on complex systems which took a long time to assemble and which, if they are stressed to the point of collapse, can not then be reassembled quickly, if at all.

In 2008 the global financial system came close to collapse. Many people said at the time, and probably still do say, that the banks should just have been allowed to fail. Those people were fools. Banks are close to the archetypal complex system which, if it collapses, can not quickly be repaired if it can be repaired at all. If the banking system had been allowed to fail in 2008 then essentially money would have ceased to exist: ATMs would have stopped working, salaries would have stopped being paid, everything involving money would have stopped. And once that had happened it would have taken years to restart. Pretty quickly people would have started getting hungry, there would have been riots and far worse. And this would have gone on for years. Huge numbers would have died. The 2008 financial crisis was a nasty experience, but it was vastly less nasty than what was narrowly avoided.

There is another such complex system: the health service. The NHS is one of the great achievements of post-war Britain: I think the greatest in fact. If the NHS is pushed too hard it, too, will collapse, and if it collapses, bad things will happen. And CV19 is pushing the NHS very hard indeed. Already many people are dying of things which would have been treated if not for CV19, and people who are not dying are sitting in lengthening backlogs which will take years or decades to clear. And this is only the start of what could happen. People who are working in ICUs will eventually become burnt out: they’ll end up shell-shocked and unable to work. And so the number of staff in ICUs will decline just as the requirement for them increases. That’s a death spiral: more and more people will get burnt out as their workload increases because their colleagues have already become burnt out. These people will themselves then need care, which is already very limited. Without care they may never return to work. And it takes quite a long time to train someone to work in an ICU: it is not an easy job. And, having witnessed what happens to people who work in ICUs, who is going to apply to be trained?

So the likely end result of a series of chaotic cycles of relaxation and panic is that the NHS will collapse in due course. And the likely end result of simply accepting large ongoing death rates, of Johnson’s stability through suffering, is that the NHS will collapse rather soon.

And if the NHS collapses it can’t be put back together quickly. Perhaps it can’t be put back together at all. And very large numbers of people will then die.

Avoiding collapse of the NHS is critical, but the UK government shows no sign of being competent to do so, or in fact of caring if the NHS collapses.

## The way out

The way out is to eliminate the virus, globally. Until we can do that the best we can hope for is that it becomes like flu and that no nastier variant arises. I can’t see any reason why a nastier variant should not arise from a flu-like variant: nastier variants of flu arise, after all. So a flu-like stage, though very desirable short of elimination, is probably only temporary: something nastier will come back.

Managing the presumed nastier variants is hard. Inevitably there will be cycles of restriction and relaxation. Those cycles will have inevitable economic impact. That is not something that can be wished away.

The UK government, as with populists everywhere, has been hugely incompetent at managing the first few cycles, and shows no sign of becoming more competent. Johnson is stupid, uncaring and believes rules do not apply to him: while he controls the UK government there is little hope. Johnson, perhaps, believes that he can declare the pandemic over and it will be over. But the virus does not care what he thinks.

Almost certainly, absent a competent government, the UK will therefore experience a series of chaotic cycles of relaxation and restriction culminating in the probable collapse of the NHS and all that implies.

A competent government would understand that until the virus is eliminated the old world is simply gone: the world has now changed. Working from home is here for good, with all that implies for cities. Masks are here for good. A competent government would work to educate its people about this. And it would understand that since elimination will take years at least some of these changes must be regarded as permanent: in five years or a decade no-one will want to go back to spending three hours a day on a packed train or in a traffic jam.

The world has changed, and it has changed irrevocably, one way or another. The way out is to accept that there is no way back.

1. Disclaimer: I’m not an expert and I’m not even pretending to be one on the internet. I’m just trying to understand things as best I can, then writing the down so I can see how wrong I was, later.

2. Which, of course, was not Spanish.

3. SARS-CoV–2 has a genome about 30,000 bases long: there are $$4^{30000}$$ such genomes. Only a tiny proportion of those will encode anything interesting and only a tiny proportion of those will encode anything very like SARS-CoV–2, but that is still a lot of variants.