“When can I visit my immunocompromised daughter?”
“Is it too risky to host an indoor birthday dinner for my 70-year-old husband?”
My inbox overflows with sensible—yet unanswerable—questions.
For the past 18 months, my patients have craved straightforward answers: a simple “Yes—it’s perfectly safe” or “Go for it. Have fun!” or even a “No, you absolutely cannot” to quiet the endless loops of risk calculations. But medicine is not about certainty. It never has been.
The two things that patients want—reassurance that they won’t get COVID-19 and permission to engage in life—I cannot deliver, and I never will be able to. SARS-CoV-2 is here to stay. The virus will be woven into our everyday existence much like RSV, influenza, and other common coronaviruses are. The question isn’t whether we’ll be exposed to the novel coronavirus; it’s when.
And although many of us will inevitably get COVID-19, for the majority of vaccinated people, it won’t be so bad. The vaccines weren’t designed to wholly prevent COVID-19; they transformed it into a manageable illness like the flu.
That means that, from a decision-making perspective, we’re starting to reach the acceptance phase of the pandemic: a time when we must recalibrate our individual risk gauges, which have been completely thrown out of whack. The approach I’m embracing with patients boils down to a secular version of the serenity prayer. We need “the serenity to accept the things [we] cannot change, courage to change the things [we] can, and the wisdom to know the difference.”
This begins with a broader reckoning with risk. It ends, I hope, with clarity on what we actually can do as a society to protect life—and a commitment to do it.
Human beings have always coexisted with threats to our health: violence, vehicular crashes, communicable diseases. And many of us have meandered through our perilous existence without thinking much about it. Sure, people may drive more cautiously at nighttime, use condoms with a new partner, and avoid walking through dark alleys alone. But before the pandemic, we didn’t lock down our lives to eliminate all risk. Schools didn’t close during flu season. Doctors didn’t preach abstinence for all in the face of herpes and HIV. We had accepted the inherent riskiness of being human, and we took reasonable precautions where possible.
But for many of us, the pandemic blew apart our complacency—at least when it came to the risk of contracting COVID. People rejiggered their lives with a singular goal in mind: Don’t get infected with the novel coronavirus.
Of course no one wants to get COVID. The Delta variant continues to take lives and cause lasting harm for many. But abstinence from living isn’t sustainable, nor is it healthy. In trying to contain COVID-19, we unleashed other health risks. The collateral damage from pandemic restrictions is manifest in alarming increases in obesity rates among adults and kids (obesity itself being a comorbidity that increases the risk of poor COVID outcomes), and spikes in suicide attempts, drug overdoses, and rates of anxiety-, depression-, and stress-related symptoms.
For the first few months, draconian control measures seemed reasonable. Hemming in life seemed like a fair short-term trade-off in order to “flatten the curve.” But the curve didn’t flatten; only our sense of agency did. The arrival of vaccines in December 2020 opened the door for a new risk calculus. And now, almost 19 months into the pandemic, we’re faced with another new balancing act. Vaccination can mostly protect us from severe disease, but the risk of COVID can never be fully eradicated. As we head toward endemicity, we can think about what we have to accept, what we can change, and how we tell the difference between the two.
So what do we have to accept? We have to accept that there is no inoculum for uncertainty—that no human contact is risk-free, that no vaccine is perfect, that we can never guarantee safety in life.
The harder question is determining what is in our power to change. I remind patients that once they’ve been vaccinated, they’ve already taken the most important—albeit imperfect—step toward protecting themselves and others from COVID.
We then talk through the worst-case scenario for a vaccinated person: a breakthrough infection. I explain that the risk is no longer rare but is still quite low—about 1 in 5,000, according to a recent large study out of Washington State.
I explain that, for most people, a breakthrough infection is experienced as a cold or mild flu. Per CDC data published in late September, the chance of a vaccinated person needing hospital care from a breakthrough infection is 0.008 percent, and the chance of death is only 0.002 percent. Many people don’t want to get COVID at all, even a mild case, for fear of long-lasting consequences. However, the risk of long COVID seems to be greatly attenuated by vaccination. Vaccinated and immune people need to recognize the diminishing medical justification for perpetually avoiding COVID.
Next, I remind patients of the proven mitigation measures we do have—such as rapid antigen testing and ventilation—that will help limit the spread of the coronavirus in perpetuity. And last, I arm patients with practical tools to manage their underlying health. Meeting basic biological needs—sleep, regular exercise, healthy eating, and appropriately managing stress—can help restore patients’ sense of agency and control.
Acceptance can also be the birthplace of change. COVID’s permanence does not mean simply reverting to life as it was pre-pandemic. After all, the pandemic has laid bare our countless personal and public-health vulnerabilities—and offered opportunities to do better. We could do more to improve road safety. We could make it easier for caregivers to keep sick kids home from school—and for sick employees to stay home from work—by ensuring paid sick leave. We could invest in Americans’ health by increasing funding for and access to mental-health services. We can make people healthier and safer without surrendering to a permanent pandemic lifestyle.
To be clear: Reopening society once the coronavirus is deemed endemic does not mean jettisoning public-health measures that obviously benefited our most vulnerable populations. Rather, we can all participate in sensible infection-control measures—such as hand-washing and staying home when sick—to reduce the spread of all airborne viruses that pose more danger to high-risk people.
Acceptance is not about agreeing with or surrendering to suffering. It is not about reckless abandonment of caution or carelessness toward others. It means letting go of the false promise of “COVID zero,” taking an honest assessment of our personal risk tolerance, and ceding control where control isn’t possible. It’s about getting vaccinated against COVID and the flu before attending a wedding in person—instead of watching the nuptials on Zoom.
Acceptance doesn’t prescribe the same set of behaviors for all. My immunosuppressed octogenarian patient, for example, may decide to mask indoors indefinitely rather than risk getting any respiratory virus again. Parents of children under the age of 12 might continue to avoid indoor social events until a COVID vaccine is available for this age group.
But when we accept that an encounter with the coronavirus is at some point inevitable—knowing that with vaccination we’ve shielded ourselves from severe outcomes and reduced the likelihood of transmission to other people—we’ll have an opportunity to regain some of the contours of regular life.
Public-health experts will be responsible for deciding where the off-ramps are for restrictions such as mask mandates in public places. When we get to a point where COVID doesn’t strain hospital systems and cause an undue burden of death or suffering to society, mask mandates will lift and normal life will start to resume. But we, as individuals, are responsible for dusting off our pre-pandemic instincts and imagining living again.
Doctoring isn’t about walling off patients from certain exposures. It is about acknowledging our messy world and arming patients with tools to safely inhabit it. Right now, it’s about helping patients redefine health as more than simply not getting COVID. Health also means accepting that living is about more than simply not dying.