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Calling Omicron ‘Mild’ Is Wishful Thinking

We are far past the point of hoping that this variant will spare us.

Source: The Atlantic by Katherine J. Wu

For weeks, the watchword on Omicron in much of America has been some form of phew. A flurry of reports has encouraged a relatively rosy view of the variant, compared with some of its predecessors. Omicron appears to somewhat spare the lungs. Infected laboratory mice and hamsters seem to handily fight it off. Proportionally, fewer of the people who catch it wind up hospitalized or dead. All of this has allowed a deceptively reassuring narrative to take root and grow: Omicron is mild. The variant is docile, harmless, the cause of an #Omicold that’s no worse than a fleeting flu. It is so trivial, some have argued, that the world should simply “allow this mild infection to circulate,” and avoid slowing the spread. Omicron, as Senator Rand Paul of Kentucky would have you believe, is “basically nature’s vaccine.”

These dismissals of the variant as trifling—desirable, even—represent “a very dangerous attitude,” Akiko Iwasaki, an immunologist at Yale, told me. At the core of the problem sits the word mild itself, a slippery and pernicious term that “doesn’t mean what people think it means,” Neil Lewis, a behavioral scientist at Cornell, told me. Less severe forms of COVID-19 can certainly be experienced by individual people, especially if they’re vaccinated. And there are true reasons to think that Omicron, particle for particle, might be less toothy than Delta. But Omicron’s unfettered spread has sowed a situation that is not mild at all. And right now, the notion of mildness is making the pandemic worse for everyone.

Much of our Omicron problem can be traced back to a false binary: That the variant is less of a danger too often gets misconstrued as the variant is not a danger at all. Severity works in degrees, which is indeed what we’re seeing. Per capita, Omicron seems less likely than Delta to hospitalize or kill the people it infects. In South Africa, one of the first countries to be hit by the variant, cases have already crested at a record-shattering peak, but hospitalizations, admissions to intensive-care units, and deaths remain far below the heights of prior waves; infections also appear to be decoupling from severe disease in parts of continental Europe. Even in the United States, where the pandemic is as bad as it’s ever been, early data are pointing to a blunting in the propensity of Omicron cases to turn severe.

It’s tempting to attribute all of this to the virus, but doing so would be overly simplistic. Disease always manifests as an interaction between pathogen and host, which means there are two main reasons that Omicron cases can present with softer symptoms: a more resilient human, or a more docile microbe. In this current surge, we’re likely seeing both effects collide.

The first part of the equation is entirely about us. Two years into a pandemic that’s left hundreds of millions with known infections and prompted billions to sign up for shots, Omicron is knocking up against populations that are better defended than ever. In the United Kingdom, where more than 80 percent of people over 12 are at least doubly vaccinated, the shots are clearly lowering the risk of hospitalization among those infected with Omicron, especially among the boosted. A high number of prior infections from past COVID surges may have had a similarly mollifying effect in South Africa, where the average age of the population is also very young, and thus better steeled against severe COVID-19.

The second part of the equation—the inherent potency of the virus itself—unfortunately gets harder to parse when the world is more immune, Roby Bhattacharyya, a microbiologist and infectious-disease physician at Massachusetts General Hospital in Boston, told me. Still, even unvaccinated people with Omicron seem less likely to end up hospitalized, in the ICU, or on ventilators. Laboratory rodents infected with Omicron don’t seem to be getting all that sick either, perhaps because the new variant is less adept than Delta at colonizing the lungs, where the wildfire-like inflammation of serious respiratory disease often ignites. Similarly, researchers are finding that Omicron isn’t keen on infecting human tissue extracted from the lung, and may prefer to cloister itself in loftier sites like the throat, Ravindra Gupta, a virologist at the University of Cambridge, told me. What happens in a rodent or a plastic dish can’t recapitulate what happens in a human body. But Iwasaki still thinks “there is something intrinsically less virulent about Omicron.”

It’s fair, then, to say that the average Omicron case is indeed “less severe.” And there are plenty of people for whom the math will work out well. They’re hosts who are young, healthy, and up to date on their vaccines, squaring off with a pathogen that packs an oh-so-slightly weaker punch, at least compared with Delta. Keep in mind, though, that Delta is probably nastier than its already-awful ancestors, so to simply call the virus “mild” massively undersells the danger it still poses, especially when it finds its way into unvaccinated or vaccinated-but-still-vulnerable hosts. Even people who are thrice-vaccinated can’t exempt themselves from Omicron’s risk, especially not while cases are rising at such high rates, and exposures are so frequent and heavy.

The variant offers a harsh lesson in multiplication: So many people have been infected that a relatively small percentage of medically severe cases has still erupted into an absolutely staggering number. In the United States, where most of the population has at least one risk factor for severe COVID-19 and a quarter of people have yet to receive a single dose of a vaccine, the untethering of severe disease from cases is shaping up to be a substantially muted echo of what’s been seen abroad. Hospitalizations have already hit a new pandemic peak. Among them are huge numbers of kids, many of whom are still too young to be vaccinated. When Omicron finds vulnerable hosts, it can still exact SARS-CoV-2’s worst. And Omicron is finding them.

COVID-19 doesn’t have to be medically severe to take a toll. Lekshmi Santhosh, a critical-care physician at UCSF, has seen Omicron exacerbate chronic health issues to the point where they turn fatal. “You could say they didn’t die of COVID,” she told me. “But if they didn’t have COVID, they wouldn’t have had this issue.” Iwasaki, of Yale, also worries about the storm of long-COVID cases, which can sprout out of infections that are initially almost symptom-free, that may soon be on the way. “Some of these people are bedridden, unable to return to work for months,” she told me. “There is nothing mild about it.”

In high-enough numbers, any Omicron infection can wreak havoc. Across the country, people are entering isolation in droves, closing schools and businesses, and hamstringing hospitals that can already ill-afford a staffing shortage. In many parts of the country, hospital capacities are already being reached and exceeded, making it difficult for people to seek care for any kind of illness. An overstretched system could also, ironically, mask the extent of Omicron’s tear: When hospitals are full, they cannot accept more patients, artificially deflating recorded rates of severe disease, even as total cases continue to rise. “Omicron may be more mild at the individual symptom level,” Duana Fullwiley, a medical anthropologist at Stanford who has studied how the term mild has affected people’s experience of sickle-cell anemia in Senegal, told me. “But we’re not talking about the severity of Omicron as it’s impacting the system.”

Omicron also still harbors dangerous unknowns. The variant may snub the lungs, but it still accumulates quickly in the throat and mouth—real estate that positions it to spill easily out of infected people. That, compounded with Omicron’s ability to dodge certain immune defenses, makes it a threat to more of us at once. Subdued symptoms, too, can come with a catch if infected people ignore them and continue to mingle. (And the variant seems to be tougher to detect early in infection with certain rapid antigen tests.) Researchers also don’t yet have a good handle on just how much immunity Omicron infections—especially the gentlest ones—may leave behind.

Stephen Goldstein, an evolutionary virologist at the University of Utah, told me that Omicron might turn out to be about as inherently virulent as the original SARS-CoV-2 variant, the version of the virus that kick-started all this misery. If that’s the case, it would be ironic. Two years ago is also when mild and COVID-19 first insidiously intertwined: Roughly 80 percent of cases could be described as such, reports noted at the time, inviting dismissive and misleading comparisons to the flu, and jeering calls to push Americans back to work and school. Mild became shorthand for piddling; that soothing framing took hold, then lingered, “diminishing the sense of urgency in prevention,” as the medical anthropologist Martha Lincoln has written, even through the billions of infections, and the many millions of hospitalizations and deaths, that followed.

Today, news reports are using mild and COVID-19 together more than ever before, Elena Semino, a linguist at Lancaster University, in the United Kingdom, told me. Medically, the term mild originated as an academic catchall for all SARS-CoV-2 infections not severe enough to get someone admitted to a hospital—everything from asymptomatic cases all the way up to people just short of going into respiratory failure. But most of that range squares poorly with mild’s colloquial connotations regarding “temperate, pleasant, generally benign” food, weather, even people, Semino said. Mild, to most of us, is whatever, something that blows almost imperceptibly by.

That’s the trap of mildness: the underlying sense of fatalism it engenders. “People say, it’s inevitable; it’s mild; I hope I can catch it and move on,” Santhosh, of UCSF, told me. Calling Omicron “mild” implies that the virus is spontaneously domesticating itself; it punts the responsibility of harm reduction to the pathogen, and away from us. But Omicron is not our deus ex microbe. As Goldstein, of the University of Utah, points out, a virus’s imperative is only to spread—not, necessarily, to treat its hosts more genially. (Omicron is not even descended from Delta, so we can’t frame their severities as a stepwise evolutionary drop.) The attitude that Omicron is hardly anything to worry about is compounding the disaster we’ve found ourselves in: The more opportunities the virus has to enter new hosts, the more variants will arise. And there’s no telling what harm the next SARS-CoV-2 iteration will bring.

It’s worth remembering, then, that severity, or lack thereof, is not up to the virus alone. We, as hosts, dictate its damage at least as much—and that’s the side of the equation we can control. SARS-CoV-2 can’t be counted on to pull its punches, but we have the vaccines to pummel it right back. If mildness is what we’re after, that future is largely up to us.