I recently listened to a talk on viral biology and COVID, and I learned so much. This is illuminating for several reasons. Although I see, treat, and think about COVID a lot, there are always opportunities for ongoing learning. I'm quite comfortable with the clinical aspects of treating hospitalized and critically ill COVID patients. But understanding viral biology - its structure, where mutations happen, how it compares to other coronaviruses, the enzymes it uses - gave me insight on why clinical COVID behaves the way it does. For example, now I have a better sense of why the incubation period can be several days, how the Delta variant mechanistically increases transmissibility, and where the evidence that vaccinated patients who get infected shed less virus comes from. None of these may change my day-to-day clinical practice per se, but I still think they are valuable to know.

It also reminds me of how much burnout affects clinicians. Early in the pandemic, I was able to find the time, energy, and focus to keep up with the plethora of COVID-related articles, lectures, and updates. But one of the consequences of extended burnout is that this becomes harder and harder. We keep up with what's necessary to take care of our patients, but burnout makes it harder to follow information that is not directly relevant. Of course, at the same time, the amount of COVID research has exploded so it may be impossible for anyone to keep up with everything. I greatly appreciate those who are able to curate the research, data, and relevant articles for me to study.

Lastly, this talk showed me how much incredible work has gone into understanding COVID. Researchers and scientists from institutions around the world have done an incredible amount of work in a compressed time. The money, effort, time, and brilliant minds dedicated to this have been fruitful. But we also see how much more we have yet to learn about this pathogen that did not exist two years ago. Many questions still remain that may help us develop novel therapeutics and plan for future epidemics.

I fear we have failed in understanding human psychology, motivation, and decision-making. The science of the COVID-19 vaccines is clear; vaccination is safe, effective, and our current best strategy against this pandemic. Yet nearly half of the United States still has not been fully vaccinated.  

How do we improve these numbers? We have tried many different methods including making vaccination free, bringing vaccines to people's homes, education, outreach from community leaders, incentives, and mandates. Even private businesses have tried to encourage vaccinations with free rideshares to vaccination sites, incentives, discounts, and requiring proof of immunization. Finally, the vaccine received full FDA approval instead of emergency use authorization.

Yet we are still far from widespread vaccination. Finally, the federal government announced the most encompassing mandate yet, potentially requiring millions of Americans to be vaccinated and holding large companies responsible for vaccinating their employees.

Is this the right decision? I don't know. Absolutely we need more people vaccinated. But we also need cohesion rather than division. During this pandemic, other mandates involving masks, businesses, and travel have not come across very well. I worry this new mandate will further polarize the country. Nobody, including myself, wants to be told what to do, even if it is clearly the right decision. I believe although more people will get vaccinated, the minority that has pushed back against rules during this pandemic will become more adamant.

Have we exhausted all our options? What else can we do? I don't know. We need to tap into expertise in human psychology and behavior. How do we help people make informed decisions based on fact and science, hopefully leading to vaccination? How do we lower barriers to getting a dose? How do we connect with those of different social or cultural backgrounds? What kind of incentives work best? Is there an alternative to forcing people to do something they have not yet accepted? Can we divorce policy decisions in the pandemic from politics?

Unfortunately, the severity of the Delta wave happened because we failed at widespread vaccination despite various carrots and sticks. This mandate feels like a last desperate attempt to tamp down numbers that have gotten out of control. But it is not without consequence, and I think we must also employ other ways of helping people understand the remarkable benefits of immunization to themselves, their families, and their communities.

Is Delta variant COVID clinically different from the "original" strain? This is not so easy of a question for me to answer. As a bedside physician, I see each patient as an individual microcosm with his or her own risk factors, physiology, and clinical course. It's hard to get a big picture of how COVID now compares with COVID before. Nevertheless, looking at news reports and nationwide statistics, I suspect that the Delta strain acts differently than the original coronavirus. Never before have we worried about pediatric intensive care units filling up. And though some of it may be explained by more infections from schools and daycares compared to last year, I worry that COVID has adapted to infect younger patients. This is frightening, especially since we are not yet vaccinating children, and we've already seen outbreaks originating in classrooms.

Similarly, I think the increase in younger adults hospitalized with COVID suggests this Delta variant really is more severe. Although locally, we haven't seen a significant increase in deaths, this is most likely related to our own improvements in hospital protocols, treatment regimens, and clinical care. While we scramble to improve our medical therapies and systems, the virus is mutating to increase its virulence and lethality. Unfortunately, I suspect this parallel escalation will continue.

This is worrisome. There aren't that many diseases which have gotten dramatically worse over time, especially in the short time frame of a year and a half. It makes me think of HIV and its rapidly developing resistance to antiviral medications or maybe the obesity epidemic which has escalated in the last few decades. But there are few comparisons, and this suggests to me that we need new frameworks to think of this disease's danger, not only in the current moment, but also in its unknown potential in the near and far future.