For much of the past year, Americans have guided their behavior using a kind of cognitive triangulation. First, we’ve judged the risks of a coronavirus infection; second, we’ve assessed our willingness to accept those risks; and third, we’ve mulled the value, or perhaps the necessity, of our proposed activities. You may be willing to risk an encounter with the virus to do your job, or to attend your daughter’s graduation, but a trip to the dentist? Maybe not.
The last two variables are largely matters of disposition, values, and circumstance. No epidemiological model can transform you from a wallflower into a risktaker, or tell you whether something is “worth it.” It’s the first variable—the dangers of infection—that science is best positioned to illuminate. And yet those risks sometimes seem to change by the month, if not the week. Immunity ebbs, variants emerge, and the virus surges and fades. Right now, with the rise of the Omicron variant, the pandemic is shifting. Although the risk calculus remains largely unchanged for some people, others—especially those whom doctors describe as “vulnerable” to COVID-19—may be entering a newly dangerous phase of the pandemic.
Who is vulnerable? How concerned should they be? And for how long will they need to remain on high alert?
Vulnerability is at the center of how doctors think. When we describe our patients to one another, we use “one-liners”—succinct, sentence-long summaries of who patients are and why they are seeking care. One-liners center on age and preëxisting conditions. The goal is the division of patients into categories of risk—that is, risk stratification. A healthy thirty-five-old man coming in with chest pain? We think of a muscle strain, not a heart attack. A sixty-five-year-old woman with two recent cardiac stents? Now a heart attack leaps to the fore. There can be surprises: the young man might have an unappreciated family history of early cardiac disease, and the older woman might just have finished a half-marathon. Still, the odds are the odds.
Omicron is thought to be at least twice as transmissible as Delta, which itself is twice as contagious as the original; it may be more than three times as effective at reinfecting those who’ve already contracted the coronavirus. But it doesn’t transform our risk stratification. Those who were most vulnerable to Alpha or Delta are still the people who are most susceptible to the new variant. There will be exceptions—a young vaccinated person who ends up in the I.C.U., or an elderly smoker with nothing but a stuffy nose—but, for the most part, the established logic of COVID risk still serves as a reliable guide.
There’s one category of vulnerability from which it’s possible to escape. A recent analysis examined COVID hospitalizations between June and September—the post-Delta, pre-Omicron period. It found that eighty-five per cent of hospitalized people were unvaccinated. How will Omicron change this picture? It’s too early to say for certain, but, as the new variant starts to displace Delta, a rule of thumb is emerging: to maintain a similar level of protection, you need one more dose than you did before. If two doses of an mRNA vaccine were enough to prevent a Delta infection, then three are needed for Omicron; if you’ve received two shots and you get a breakthrough Omicron infection, you’ll be reasonably protected against severe disease, but you’ll be safer if you’ve received three. Some organizations—the N.F.L., the Metropolitan Opera, a growing number of colleges—are starting to require booster shots. Others are sure to follow. Over all, however, many Americans are insufficiently immunized. Nationwide, only six in ten people have got two shots, and three in ten have received a booster.
People with chronic medical problems make up a second vulnerable group. In general, the chance of having a bad coronavirus infection increases with the number and severity of medical conditions from which you suffer. One study of hospitalized COVID patients found that ninety-five per cent of them had at least one underlying medical condition; some sixty per cent of U.S. adults have a chronic health problem. Still, not all problems are equally concerning. The Centers for Disease Control and Prevention has identified more than a dozen conditions that place individuals at higher risk for severe COVID. People with illnesses affecting the respiratory or immune system—emphysema, heart problems, cancers, and certain autoimmune diseases that necessitate immunosuppressant drugs—will remain vulnerable, even after immunization.
Finally, it’s impossible to talk about COVID risk without focussing on the role of age. Older people make up the third category of vulnerability. The risks start climbing earlier in life than we’d like. The COVID mortality rate for Americans over the age of sixty-five is more than eighty times higher than for those in their late teens and twenties, and over-sixty-fives have accounted for more than three-quarters of COVID deaths in the U.S. The coronavirus has now claimed the lives of at least one in every hundred older Americans. The risk is greatest for those living in nursing homes and long-term-care facilities; during the pandemic’s first year, they constituted less than one per cent of the U.S. population but thirty-five per cent of COVID deaths. That’s not to say that younger people should ignore COVID—in September, it was the leading cause of death among middle-aged Americans—but the risks of infection are, and will remain, highest for those in their sixties, seventies, and beyond. All of this was true before Omicron, and remains true now.
Recently, I spoke with Louise Aronson, a geriatrician at the University of California, San Francisco, who’s been counselling older patients on how to navigate the evolving risks of the pandemic. She, too, walks people through a process of risk triangulation. The first fact to confront, of course, is that Aronson’s patients are vulnerable because of their age. But they differ substantially in their tolerance for risk: “The variability in how people are responding is sort of astonishing,” Aronson told me. “There were those people who got their vaccines and went back to the gym and started travelling and going to movies.” Others are more cautious by nature, and evaluate risks in a fine-grained way: before going to a party, they might find out not just how many people will be there but how many households those guests belong to.
To these variables, she adds an assessment of how important social interaction is to each person. She asks her patients how the pandemic has been for them. “Some people are well-adjusted. I’ve had a bunch say, ‘Wow, I was always a really social person—I think I might actually be an introvert.’ ” Alternatively, Aronson tries to gauge if patients are “suffering and miserable.” “We’ve seen a lot of accelerated cognitive and physical decline in certain people,” she said. In these cases, “part of harm reduction might be that you actually do need to see other human beings. So now let’s think about what you can do to minimize your risk.”
Good risk calculations are often local. People with similar medical circumstances face vastly different risks depending on where they live; it’s important to review the infection and immunization rates in one’s particular community. Aronson suggests that people think demographically, too. “Will there be smaller kids?” she asked. “You know, Gen Z is over it. . . . So do you really want to be with Gen Z?” If so, one might ask if it’s possible to have separate indoor and outdoor spaces. “Could you have places where the more vulnerable go, and the more risky don’t?” she asked. “It’s not disrespect. It’s that we want everybody to be included. It’s a form of inclusion.” Aronson counsels patients on nonconfrontational ways to voice safety concerns. “Just say, ‘I’m so appreciative that you’re throwing this event, I’m so excited to go . . . and, as you know, I’m this age and I have a couple other vulnerabilities.’ ” She went on, “I tell them to blame me—‘My doctor said I should ask you’—because then they’re off the hook.” The same set of strategies would work for people with underlying health conditions.
And yet it’s possible that such conscientious risk assessments are being rendered irrelevant by the sheer contagiousness of Omicron. Last month, around a hundred and twenty fully vaccinated people went to a holiday party in Norway. They said that they’d tested negative before the event, but at least eighty of them emerged with COVID-19. Outbreaks like this will become commonplace as Omicron spreads across the globe. (The variant is just weeks away from becoming the dominant strain in the U.S.)
Vaccinated people, moreover, may come to present a greater threat to vulnerable individuals than they did just a few months ago. Immunized individuals are still less likely to contract the virus—if you don’t get it, you can’t spread it—and, even if they get infected, their immune systems lower the levels of virus circulating in their bodies. But Omicron likely weakens both defenses. Compared to Delta, it is much better at evading vaccine-generated antibodies, and it replicates much faster inside our airways, allowing us to spread it before our immune systems step in. Vaccinated people were more likely to transmit Delta than prior variants, so there’s reason to believe they’re even likelier to transmit Omicron.
All of this is cold comfort for people who are both vaccinated and vulnerable. Vaccine effectiveness is usually reported in the aggregate—for people of all ages, backgrounds, and levels of medical vulnerability—and yet, at the end of the day, a lot depends on your one-liner.
The extent to which Omicron cases will result in mass death—as happened last winter, when nearly a quarter million Americans lost their lives to COVID-19—is not yet clear. In South Africa, where Omicron first started to spread, COVID deaths have not risen in tandem with cases. It’s too early to draw definitive conclusions—deaths can lag infections by a period of weeks, and no country has enough experience with the new variant to feel reassured. But there is some evidence that Omicron may deliver a less punishing illness to those it infects. Moreover, reinfections and breakthrough cases tend to be less severe than infections in people with no immunity. It’s possible that Omicron could be bringing us closer to the long-awaited “decoupling” of coronavirus cases and deaths.
Still, barring new evidence, when it comes to taking risks during the Omicron surge, the right answer for vulnerable people might be to just wait. This sounds easy, but for many people it isn’t. “What happens if you worked your whole life and you saved your whole life, and the pandemic has stolen the couple of years where you were actually healthy enough to travel?” Aronson asked me. “That’s also a form of grief and loss.”
Risk and vulnerability are puzzles we grapple with even in ordinary life. At the beginning of Virginia Woolf’s “Mrs. Dalloway,” Clarissa, the novel’s fiftysomething protagonist, walks the bustling streets of London, gathering provisions for a dinner party. She pauses for a moment in the crowd, her mind wandering to a long-ago suitor and the unrealized dreams of her youth. She considers her own age and the ways in which her life might have gone wrong, and still might. “She felt very young; at the same time unspeakably aged,” Woolf writes. “She always had the feeling that it was very, very dangerous to live even one day.”
Aging involves confronting an ever-expanding set of risks; it means accepting that one’s days are growing more dangerous. A strain, a pain, a virus that in youth might have passed without notice—each new malady becomes saturated with a sense of foreboding. There is no escaping the bodily tax of time. And yet, in another sense, the dangers of aging rise and fall more generally. With the advent of cardiac stents, heart attacks became a little less deadly, and so aging became a little less dangerous. With advances in chemotherapy, some cancers are no longer lethal. Bit by bit, growing old has become safer.
During the pandemic—especially with the arrival of Omicron—the dangers of age have skyrocketed. But that won’t last forever. Being older will eventually return to being ordinarily risky; COVID will be one of many diseases to worry about as we age. Booster shots, COVID pills, rapid tests, better masks, and upgraded ventilation systems could shift the balance. Meanwhile, the COVID risk for vulnerable Americans—and the rest of us—changes dramatically with the level of community spread. A period like the current one, during which the U.S. is tallying, on average, a hundred and thirty-three thousand new coronavirus cases a day, is far more threatening for a vulnerable person than one in which the country records a tenth as many daily cases, as it did at points this past summer. Because immunity isn’t binary but a matter of degree—and because each encounter with the virus or a vaccine makes our immunity broader and more robust—each wave brings us closer to a situation in which the coronavirus is endemic: a familiar, low-level threat to which we’ve all been exposed, along the lines of the flu, rather than an acute, novel emergency. Our one-liners are what they are; our risks will never go to zero. But those risks will ease with time and, eventually, stop dominating our lives.
We’re not there yet. For now, the risk is high. And the infectiousness of the coronavirus means that it’s not just your one-liner that matters. Many of us can use vaccines and boosters to protect ourselves against Omicron. But not everyone has that option. We live in a society with people who can’t escape vulnerability. We owe it to them to reduce their risk. For one more winter, we must make it safer to live each day.
