Vaccines to combat COVID-19 are on the cusp of turning the tide of the global pandemic. But experts say not to expect total victory.
While things may never again get as bad as they have been the last year, experts expect that in time, COVID-19 will become a chronic, but manageable, threat. Societies need to plan for how to cope with inevitable resurgences, they say.
"We're not going to see cases plummet to zero. That's magical thinking," said epidemiologist Michael Mina of Harvard University T.H. Chan School of Public Health. "Which is why I really think it's important for us to take a step back as a society and just ask the question, what do cases mean? How are they going to impact us?"
Here to stay
There are several reasons why the coronavirus behind COVID-19 is not likely to disappear anytime soon.
First, rates of vaccine hesitancy are declining but still high. In a recent U.S. survey, about a third of people said they probably or definitely would not get vaccinated.
"Even among people who should be welcoming the vaccine — front-line workers, health care workers — you are seeing a lack of willingness to take the vaccine," said Allyala Nandakumar, director of the Institute for Global Health and Development at Brandeis University. "That is, to me, the single biggest problem that we are facing."
A recent poll found 18% of U.S. health care workers were not planning to get vaccinated, and another 12% were undecided.
Meanwhile, vaccine access is extremely unequal around the world. Many countries may not get any vaccines at all this year. That leaves vast areas where the coronavirus can continue to spread and mutate.
"The longer transmission happens around the world, new variants are going to develop," said Geoffrey Joyce, director of health policy at the University of Southern California (USC) Leonard D. Schaeffer Center for Health Policy & Economics.
Variants have already arisen that undermine the effectiveness of the vaccines. It is not yet clear what impact they will have in vaccinated populations.
"We're not out of the woods at all," Joyce said.
Plus, scientists do not know how long immunity lasts from vaccines or from infection. The virus could resurface in several months even in people who have been vaccinated.
"It does seem likely that there will be flare-ups or some kind of resurgence," said Duke University health policy expert Hemi Tewarson.
The next round
If so, what happens then? Another lockdown?
Most experts say no.
"I just don't think we have... the appetite to continue to shut down the economy," Nandakumar said. "We have to find a smart way to live with the virus."
Some limited version of the restrictions currently in place may make a comeback in a flare-up, but most of life will go on, said health economist Kate Baicker, dean of the University of Chicago Harris School of Public Policy.
"We may limit large gatherings. We may focus on outdoor activities. People may need to modify how they interact with each other, but the new normal is something that we can really live pretty comfortably and happily with," she said.
Some places are considering whether vaccinated people can forego the restrictions. In Israel, vaccinated people get a "green pass" that gives them permission to go to indoor bars, gyms, concerts and other places where unvaccinated people are barred.
Others are considering it. Some employers may consider requiring employees to get vaccinated in order to come back to the office or work with the public.
The idea is controversial, however.
On the one hand, offering special privileges to the vaccinated gives hesitant people an incentive.
But it is not yet clear whether vaccinated people can still get asymptomatic infections and spread the virus, even if they do not get sick themselves. Some early studies suggest that the vaccines cut transmission, as well, but the case is not closed.
There are also civil liberties issues.
While getting vaccinated is still optional, "is it really optional if you're then banned from doing things if you don't opt in?" Baicker said.
It also means people have to share sensitive medical information. And while vaccines have been authorized for emergency use, they have not been fully approved, which involves a higher level of scrutiny.
"I think these are important questions about privacy of medical information and who should mandate what... I don't think that policymakers or the public have worked through yet," Baicker said.
The trade-off between public health and personal liberty may be a tough sell in the United States, with its live-free-or-die streak, USC's Joyce said.
"But if you look at what we do at schools," he added, "almost every state in the country has some immunization rules for school. Your kids can't come unless they get particular vaccines... because we think the societal benefit is worth it. So, I don't see why this is a different argument."
Protect the vulnerable and move on
On the other hand, experts say, maybe restrictions will not be necessary once enough of the most vulnerable people are vaccinated.
So far, more than half of the deaths from COVID-19 have been among people 75 years or older. This group has been the top priority for vaccination, and should remain so, Joyce said.
When the vast majority of the elderly and vulnerable are protected, "then you don't have overcrowded hospitals. You don't have death rates that are frightening. And then it's a manageable virus," he said.
Younger people still get sick and die of COVID-19, but at much lower rates, Joyce noted.
"It's not something you want to get, but it doesn't require massive shutdowns," he said.
Public health officials hope to get cheap, widely accessible testing up and running to keep an eye on where the virus is spreading and what variants there are.
"When you start seeing an emergence of cases, you go in with an extra vaccine effort. You go in with extra testing, and you try to contain it, as opposed to trying to lock everything down," Tewarson at Duke University said.
Hopefully, the number of people getting sick will soon drop to the level where public health departments can handle them like any other outbreak.
"We can actually do contact tracing that we couldn't do when the epidemic was just too rampant," Joyce said. "When you have smaller numbers, you can isolate this person — Got it. Here's a cluster. Let's lock down this particular group — as opposed to shutting down schools" and everything else.