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“We’re not done with this,” warns Stanford epidemiologist Steven Goodman about the Covid-19 pandemic. I believe my big brother.
In March 2020, as the Covid-19 pandemic was spreading and lockdowns were being imposed, I asked Steven to join me on the Vermont Conversation to share publicly what he was telling me privately about this novel virus. While President Trump assured us that the coronavirus would “miraculously go away” with the arrival of warm weather, Steven warned that what was coming would be “an impending catastrophe.” He explained the cold calculus of exponential growth and accurately predicted the calamity that soon unfolded.
Steven Goodman, M.D., MHS, Ph.D., is an associate dean at Stanford Medical School, where he is also a professor of epidemiology and population health and of medicine.
Today, a fourth wave of Covid-19 is sweeping the country, driven by the highly transmissible Delta variant. While vaccinated Americans are cautiously savoring a return to normalcy, a “pandemic of the unvaccinated” is raging, as nearly all new deaths are among the unvaccinated. Yet Republican leaders and right-wing media are churning out vaccine disinformation, resulting in vaccination rates of under 35 percent in some states. This large reservoir of unvaccinated people will inevitably become everyone’s problem.
“We’re all connected,” Steven says on The Vermont Conversation. “As large portions of major states go unvaccinated, they will become the factory for infections even among vaccinated people. We’re not immune … to the effects of other states and other people who’ve chosen not to be vaccinated.” Unvaccinated communities “turn into virtual waterfalls of mutations and spread of the virus. We’re going to see far less virus in the highly vaccinated populations than if they weren’t vaccinated … but at the same time we’ll see far higher rates in those areas than if there weren’t states that were producing this waterfall of cases.”
Covid-19 remains a major threat around the country and the world, Steven insists. “This is still very much a pandemic — the phrase ‘post-pandemic’ should be banned. [Covid-19] is raging like an intense forest fire across this globe. There are whole countries and whole continents that are absolutely unprepared for the devastation that is about to be wrought.”
Below is a partial transcript, edited for length and clarity.
David Goodman: Let’s start by talking about the major concern right now, which is the spread of the Delta variant. What is the Delta variant? How does it pose a special threat?
Steven Goodman: The Delta variant is a version of the virus that first emerged around December in India and spread very quickly to the UK. Its hallmark is extremely rapid spread from person to person — about 50% faster than the previous variants. Compared to the original virus, which was infecting roughly 2 to 2.5 people on average under normal circumstances, now the Delta variant can infect up to 3.5 to 4 people. With exponential rise, that is a huge difference. So it jumps from one person to the next way more quickly and easily.
The second thing that’s a bit of concern is that there is evidence that it’s making people sicker — that is, once you get Covid, you’re more likely to land in the hospital. So the Delta variant, which now makes up over 80% of new cases in the United States, is far and away the fastest contributor to the rising cases.
David Goodman: Variants are going to be the main problem we face going forward. What are variants? And how do they work?
Steven Goodman: A variant is actually a physical change in the structure of the virus. What antibodies and the immune system look for and respond to are those structural parts of the virus that they can attach to. Every time the virus multiplies — and the virus is multiplying millions of times inside an infected person — it can make a tiny mistake in its genetic code. Some of these mistakes result in an actual change in the virus structure: It substitutes one amino acid for another, and it changes the shape of the virus particles. The spike that you’ve seen in the pictures of the coronavirus — it looks like a crown with little spikes emerging — the shape of those spikes changes just a little bit.
Every time a person with one of these tiny mutations interacts with another person, if the mutation is such that it’s more likely to evade the immune system or make that person sick, that one stays in circulation because that person is more likely to send it to the next person. If it’s not a good mutation, it doesn’t go any further. It’s a massive example of survival of the fittest, of Darwinian selection — that is, the best of these millions of potential mutations are the ones most likely to jump from one person to another and spread the fastest.
David Goodman: Every time we hear about a variant, we all have this collective shudder waiting to hear if the vaccine that we got will protect against it. Do you expect one of these variants will evade the protection that we have from our vaccines?
Steven Goodman: That is the huge question. There’s nothing about the immunizations that guarantee that we couldn’t eventually find a mutation that evades the vaccines. In communities where there are a lot of people who are vaccinated, the only viruses that will “escape” are the ones that are resistant to the vaccines. Groups of unvaccinated people who commingle with the vaccinated will be the engines of multiplication that might create the kind of a variant that can infect an immunized person more easily. That said, the vaccine immunity so far has shown a lot of durability and done a pretty good job at targeting those areas in the virus that might be important for virus multiplication — i.e., they can’t mutate too much without making the virus harmless.
David Goodman: Let’s talk about breakthrough cases. Is it a cause for concern to hear that vaccinated people are testing positive?
Steven Goodman: I would say not really, but we have to keep an eye on this, because they are clues that maybe the new mutations are breaking through more easily. We knew right from the beginning that even the very best vaccines were only 95% protective against symptomatic infection. So right off the bat, we know that roughly 5 out of 100 of people who would have gotten the disease before are still going to get it. But the real thing we’re worried about is infections serious enough to put you in the hospital or kill you. What seems to be very good news is that the number of immunized people who end up getting infected, going to the hospital and dying are very, very small — roughly 1 in 200,000.
Of course, if you hadn’t been vaccinated, your chances of being infected and dying is hundreds of times higher. So the risk of death [from Covid] after vaccination is very tiny and much smaller than many of the risks we live with daily.
David Goodman: You recently did a study of long Covid. Explain what it is and what you and your colleagues found.
Steven Goodman: We looked at all the studies of how long the symptoms of Covid last after the initial syndrome, which of course can make you extremely weak, might produce low blood oxygen, make you desperately short of breath and put you in the hospital. Long Covid is the phenomenon of symptoms either appearing anew or lingering for more than a month after the resolution of acute Covid.
What we found was very concerning. We found about 75% of initially hospitalized folks had persistent symptoms either one or two months after the acute disease, and the numbers at six months weren’t changed much. That’s the minimum duration; we don’t know if or when they will ever disappear. Some portion of the symptoms could have just been a function of prolonged lockdown, like lethargy or depression. But a variety of more Covid-specific symptoms were among them: In particular, shortness of breath and brain fog was reported in about a quarter of people, along with fatigue and sleeping difficulties.
Covid attacks virtually every organ in the body and it requires multi-system care. This is going to be the war after the war, if we ever win the battle with acute Covid. Just like PTSD after the various wars, once the soldiers come home, the war is not over. Given at least 34 million infections in the U.S. so far, if 1 in 10, or even 1 in 20 of people who’ve had Covid have these prolonged symptoms, that’s a serious public health issue that hasn’t been discussed enough.
David Goodman: Let’s widen the lens here to what is going on around the country. It appears that the country is dividing around Covid into Healthy America and Permanent Pandemic America. The Northeast and the West Coast have high vaccination rates and low infection rates. But in much of the South — for example, Arkansas, where just one-third of people are vaccinated, but also Louisiana, Mississippi and Alabama — all have vaccination rates under 40 percent.
These states are now the epicenter of the spread of the Delta variant. And I should also point out that this map nearly exactly mirrors political preferences, as all but 1 of the 14 states with the highest number of new cases are led by Republican governors, and most of those states were won by Trump in the 2020 election.
What does this mean going forward if this scenario continues, with states on the coasts having largely suppressed the virus, while the pandemic is raging in states in the center of the country?
Steven Goodman: We are all connected. What’s going to happen as large portions of major states go unvaccinated and the infection rages is that they will continue to be the factory for cases that then spread across the country, even to immunized people. Those of us who are vaccinated are not immune to the effects of cases from other states. People who’ve chosen not to be vaccinated will turn into virtual waterfalls of cases and mutations and further spread the virus. We’re going to see far less virus in the highly vaccinated populations than we would if they weren’t vaccinated, but we will see far higher rates in highly vaccinated areas than if there weren’t other states that were producing this waterfall of cases.
David Goodman: Let’s broaden the lens further and talk about the global situation with Covid. Large parts of the world remain unvaccinated. What about this global picture concerns you?
Steven Goodman: I’m worried that large portions of the world are unvaccinated or poorly vaccinated, because they’re going to suffer and they are suffering. They are suffering from a humanitarian and public health tragedy just as bad or likely much worse than we did just a few months ago. India has been hit particularly hard, where in many cities they were running out of oxygen.
This is still very much a pandemic. The phrase “post-pandemic” should be banned. Pandemic means it is spread around the world. This is absolutely raging, like an intense forest fire across the globe. There are whole countries and whole continents that are completely unprepared for the devastation that is going to be wrought. The bigger problem is the lack of access to vaccination in most of these countries due to either socioeconomic or political reasons. This poses a tremendous threat to those countries. And we’re connected to them. There’s no country that should be seen as potentially ignorable by the United States. It’s a global catastrophe that’s still very intense.
David Goodman: What do you want to say to vaccine skeptics?
Steven Goodman: At this point, I don’t know what to say to vaccine skeptics, and they likely wouldn’t listen to me anyway. Good information is out there, and the choice to vaccinate or not vaccinate, because it has become so politicized, seems to be almost an issue of personal identity. They are exercising a strange, twisted version of individual choice. There’s almost nothing one can say or facts you can present that will convince some people. That said, there is a small slice of people who are susceptible to community efforts and the voices of trusted individuals. And we’re trying very, very hard to get through to them. If leaders and media on the political right — most of whom are vaccinated — would change their anti-vax messaging, they might be listened to by some hardcore vaccine resisters.
David Goodman: As people are now returning to work and school, many are wondering: to mask or not to mask indoors? What’s your take on the need to mask, especially in states with high vaccination rates?
Steven Goodman: People who are immunized don’t have to be mortally afraid of Covid infections at an individual level, because even if you get infected, the probability that you’ll get very sick or die are very small. If you’re not immunized or if you are at higher risk of serious Covid and you’re in an indoor high-risk setting where there are lots of people, then you absolutely should be thinking of masking, and those businesses themselves might want to impose masking requirements. For the general public health recommendations, I would say you just have to pay attention to what the public health officials are saying and know that they’re saying it for a reason.
David Goodman: What have we learned from this pandemic?
Steven Goodman: Sadly, it’s a combination of what we have learned and what we haven’t. First, we’ve learned that politicizing health and health messaging can kill. Second, we’ve learned that the public health infrastructure is a critical part of both the economic protection of the United States as well as the physical protection of its citizens. The flip side is that it’s not clear what sort of investment we’re making in those public health systems to ensure they’re strong enough to meet the future challenges of Covid, no less the next pandemic.
Let’s be clear what infrastructure means. It means an information system so that the health department can know how many people are in the hospital from Covid. In public health departments, it is the ability to do contact tracing or virtually any critical public health functions, which is still far below the needs of the population. This is not just for Covid, but for all the health threats that we normally face. We have cobbled together a system for Covid with Scotch tape and wires. What is absolutely clear is if we don’t make significant investments, we will suffer the same fate in the next pandemic that we did in this one.
