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On Tuesday, the pharmaceutical company AstraZeneca halted clinical trials of its promising coronavirus vaccine candidate, one of three in late-stage testing in the United States, after a patient developed an inflammation in her spinal cord.
Scientists and public-health officials were quick to stress that the incident was less a bad omen than a sign of things working properly: Clinical holds are routine in trials as large as AstraZeneca’s, and because it’s not yet known whether the patient’s condition was caused by the vaccine, the halt may ultimately have very little effect on its development.
Still, the news seemed to briefly puncture the prevailing faith, promoted not least by the president himself, that a “shockingly good” vaccine is just over the horizon. What if it’s not? How will the pandemic progress if a vaccine takes years rather than months to arrive, and what will happen if it doesn’t work as well as we hope? Here’s what people are saying.
Waiting for a medical miracle
Interminable as the wait for a pandemic-ending vaccine may feel, it’s worth remembering just how extraordinary it is that we expect one at all: In the history of medicine, no vaccine has ever been created in less than four years, as Dr. Siddhartha Mukherjee notes in The New York Times Magazine. Given the unprecedented global effort to find one for the coronavirus, scientists are hopeful about beating that record, but those Dr. Mukherjee spoke with said that 12 to 18 months from the beginning of the pandemic — i.e., spring or summer of 2021 — is still about the soonest we should expect a candidate to be approved. And even then, it will have to be mass produced and distributed — an easier task than creating the vaccine in the first place, perhaps, but not by much.
“With all the challenges regarding developing, testing, manufacturing and distributing a safe and effective vaccine — no matter how much effort so many scientists and companies put on the problem — it could still take years or even longer,” Dr. George Yancopoulos, the chief scientific officer of the biotechnology company Regeneron, told Dr. Mukherjee.
What would happen in the meantime? According to one team of Harvard epidemiologists, the pandemic’s trajectory in the coming years would hinge largely on how long natural immunity lasts. If immunity is permanent, they wrote in Science magazine, the virus could disappear within a matter of years, barring any significant mutations. If it isn’t, the virus might stay in circulation, much like the flu, causing annual or biannual outbreaks depending on how quickly immunity wears off.
Many of the potential costs of a protracted pandemic are already plain to see. As we enter the ninth month of the crisis, Ed Yong argues in The Atlantic that the United States risks becoming habituated to the horror of mass death. “The desire for normality might render the unthinkable normal,” he writes. “Like poverty and racism, school shootings and police brutality, mass incarceration and sexual harassment, widespread extinctions and changing climate, Covid-19 might become yet another unacceptable thing that America comes to accept.” And on an economic level, the uneven nature of the recovery may worsen inequality, with most of the gains flowing to wealthy people who can afford to isolate as the rest of the country stagnates.
One (relatively) good piece of news, though, is that people won’t necessarily be stuck in an indefinite state of lockdown, Megan Scudellari writes for Nature. She notes one June report on 53 countries, compiled by a team at the MRC Centre for Global Infectious Disease Analysis at Imperial College London, that suggests that personal behavioral changes such as hand-washing and wearing masks have helped stem the tide of infections in some places even as lockdowns lift. Another study concluded that if at least 50 percent of people are cautious in public — if they wear masks, wash their hands and avoid large gatherings — social-distancing measures could be gradually eased every 80 days over the next two years without overwhelming hospitals or causing a new peak in cases.
Waiting (and waiting) for a medical mediocrity
Over the past few months, the arrival of a coronavirus vaccine, whenever it happens, has become synonymous with resolution, the herald of a near-immediate return to prepandemic life. But as Carolyn Y. Johnson writes in The Washington Post, that scenario is very far from the likeliest one. “The declaration that a vaccine has been shown safe and effective will be a beginning, not the end,” she says.
That’s because no vaccine is 100 percent effective, and only some confer lifelong immunity. Whereas the measles vaccine, one of the best at preventing disease, is 97 percent effective and has to be administered only twice, influenza vaccines are on average about half as effective and have to be administered every year. For a coronavirus vaccine to meet the Food and Drug Administration’s approval threshold, it will have to prevent or reduce severe disease in only 50 percent of people who receive it. That’s why, as one expert in drug development put it to Ms. Johnson, “the first generation of vaccines may be mediocre.”
What would a “mediocre” vaccine do? As Sarah Zhang writes in The Atlantic, it might limit Covid-19’s severity without entirely stopping its spread. That could still be a great help in suppressing case rates and saving lives, but according to the experts Ms. Zhang spoke with, it would not make the virus simply disappear. “For context, consider that vaccines exist for more than a dozen human viruses but only one, smallpox, has ever been eradicated from the planet, and that took 15 years of immense global coordination,” she writes. “We will probably be living with this virus for the rest of our lives.”
But as Dr. Dhruv Khullar argues in The New Yorker, an exceptionally effective vaccine is not the only way to get the virus under control. The public, he says, has been trained to think of the coronavirus like polio, which was eradicated in the United States after a “silver bullet” vaccine was introduced in 1955. But the path the coronavirus takes could end up being more similar to that of tuberculosis. Like polio, tuberculosis ravaged the United States in the 1900s, but it has no comparable vaccine, and was instead beaten back incrementally with an array of imperfect medical advances and public-health strategies.
“Unless you have a perfect vaccine, which very few are, you’ll always have people who end up getting sick,” Dr. Anthony Fauci, the federal government’s top infectious disease expert, told Dr. Khullar. “With or without a vaccine, we’re going to need other treatments.”
Fortunately, Dr. Khullar writes, there are already three types of therapies in development:
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Antiviral drugs, which, in contrast to vaccines, tend to be administered after the body has already been infected. Antivirals are perhaps best known as a treatment for H.I.V., though they’re also used to treat herpes and influenza. Only one antiviral, remdesivir, has been shown to be effective against the coronavirus, but researchers are working to develop more powerful ones. Dr. Khullar raises the possibility that such drugs could eventually be prescribed prophylactically, much as H.I.V. antivirals have come to be in recent years for those at high risk of contracting it.
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Antibody drugs, which mimic the immune response of a recovered patient. Regeneron, Dr. Yancopoulos’s company, has developed an antibody drug that entered Phase 3 trials in July. Regeneron received a $450 million contract from the federal government to start manufacturing the drug, so if the trials go well, it will be available soon after their conclusion.
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Immunomodulating drugs, which don’t stop the virus from replicating but help prevent the immune system from overreacting to an infection. Last week, the World Health Organization confirmed that cheap, readily available steroids can reduce the risk of death in patients critically ill with Covid-19 by one-third in this way, and other drugs already in use are being tested for the same purpose. “With immunomodulators, we’re in a land of riches,” Michael Mansour, an infectious-disease doctor and an assistant professor at Harvard, told Dr. Khullar.
None of these interventions are likely to be sufficient on their own, Dr. Khullar argues, but together, they could lower the fatality rate of the coronavirus enough to end what he calls “the world-stopping phase” of the pandemic. “Alone or in combination with a vaccine,” he says, “they could help us turn the tide.”
Do you have a point of view we missed? Email us at debatable@nytimes.com. Please note your name, age and location in your response, which may be included in the next newsletter.
MORE ON THE RACE TO FIND A CORONAVIRUS VACCINE
“Yes, we need a vaccine to control Covid-19. But we need new treatments, too” [Stat]
“A New Theory Asks: Could a Mask Be a Crude ‘Vaccine’?” [The New York Times]
“A Vaccine That Stops Covid-19 Won’t Be Enough” [The New York Times]
“What will happen if we can’t produce a vaccine?” [The Conversation]
“Gerald Ford Rushed Out a Vaccine. It Was a Fiasco.” [The New York Times]
WHAT YOU’RE SAYING
Here’s what readers had to say about the last debate: “What’s the Point of All These Polls?”
Keith from Missouri: “If my experience is any indication, the late voter support for Trump was bolstered by two things: Most everyone believed that Clinton was sure to win; consequently, many independents and a few Republicans who disliked Clinton and knew that Trump was a joke voted for him anyway, believing that he would still loose. I don’t see this phenomenon happening again.”
Jerry from Texas: “A 95 percent chance that Clinton could have won means that there was a one in 20 chance that Trump could have won. The mere 78,000 votes that swung Wisconsin, Michigan and Pennsylvania represent that one in 20 chance. Readers need to understand what probability means.”
Anne from California: “You mentioned in your newsletter that people are not picking up their phones. Could that be because the callers are not identifying themselves? … I would not mind talking to a pollster if one happened to call me, which is possible as I get a lot of unidentified long-distance calls. So my advice to polling organizations everywhere is, allow caller ID.”
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