Members of the John Snow Project editorial board were part of the Delphi consensus¹, which set out how to address the challenges posed by SARS-CoV-2 and end the pandemic. The measures proposed include regular testing, paid sick leave, and use of respirator masks. The full set of recommendations can be found here.

Instead, governments have abdicated their duty to protect and promote public health, demanding that we each assume personal responsibility to assess risk and take individual precautions^2,3. While some government agencies technically still advise people to reduce their number of infections by getting vaccinated, testing, and wearing masks⁴, this message does not feature prominently in the public discourse and as a result the majority of the general public in most countries has returned to pre-2020 behaviours, treating SARS-CoV-2 no more seriously than a common cold. But SARS-CoV-2 is not a common cold. Acute COVID-19 is still one of the leading causes of death in many countries^5,6 and the long-term impacts of SARS-CoV-2 are likely to play some role in the excess deaths still being seen around the world⁶.

Anecdotally, many say that if the virus posed a real threat, then governments would act to protect us. Some politicians and prominent public health and scientific figures initially told the public that vaccination turns COVID-19 into a mild seasonal illness^7,8, and celebrated a return to normal^9,10. Some public figures still cling to this view despite growing evidence that infection and repeat infection can cause serious harm^11,12. The weight of this evidence has resulted in some government and public health agencies changing their guidance to warn that there are serious risks attached to infection and that reinfection can increase those risks^4,13. It seems there may be a gradual shift among public health agencies towards an acceptance that SARS-CoV-2 is not as benign as some of the messaging has suggested.

Whether communicating risk or downplaying it, governments around the world have said that each individual must perform their own risk assessment and implement their own precautions. This requires individuals to assume personal responsibility for risks for which they lack reliable data and over which they have little or no control. This has happened before with tobacco - ‘the individual decides’ was the prevailing approach until approximately the late 1980s and 1990s, when governments around the world legislated to establish common social standards around smoking¹⁴.

The difference with SARS-CoV-2 is that it is a highly communicable disease. People cannot properly assess the risk of, for example, attending a wedding, for two reasons:

1. Lack of data. The immediate information required to assess risk is absent. Most governments have stopped tracking the spread of the virus, and few countries have accurate indications of prevalence in the community¹⁵. Testing is not a habit in most countries, so there is no way to know how many people might be infected at a gathering. Variant surveillance has been curtailed around the world¹⁶, and the results of what little is still being done are not widely communicated, so it is much more difficult to assess whether prior vaccine or infection immunity will protect against infection by circulating variants. People aren’t really being asked to assess risk for themselves; they are being asked to just hope for the best each and every time they expose themselves to potential infection.
2. Lack of understanding. We don’t understand the long-term effects of SARS-CoV-2 infection¹⁷. We don’t know what repeat infection by this novel coronavirus will do to human health, but the World Health Organization, the US Department of Health and Human Services, and other public health agencies are already advising that repeat infections are harmful and to be avoided^4,13. Long Covid clinics are full of people who didn’t understand the impact SARS-CoV-2 would have on their health – they were denied critical information to enable them to properly assess risk¹⁸.

Nor do most people have the freedom and means to minimize the risk of exposure in a society that has completely given up on preventing infection. There are no COVID-19 safety precautions in most workplaces, schools and other public settings, and mask wearing is increasingly awkward¹⁹, frowned upon and even actively discouraged (as it is the "scarlet letter" of the pandemic that reminds us it is not really over²⁰).

When SARS-CoV-2 first emerged and began to claim lives, there was a lot of wartime talk from world leaders^21-23, but in reality we never engaged in the sort of concerted effort needed to meet such a persistent and challenging threat. Governments took some measures to limit infections, but that was only to "flatten the curve" (i.e. prevent total healthcare system collapse), not to properly solve the problem by fully stopping the spread; instead they relied on vaccines to enable the world to return to pre-pandemic economic and social behaviours²⁴.

The approach hasn’t worked, at least anywhere near well enough. The ongoing toll on human health is being felt around the world in higher mortality^25,26, overstretched healthcare systems^27-29, and mass disability^30,31. Even the goal of "saving the economy", in the name of which so many lives were sacrificed, hasn’t been achieved – the economic costs of the long-term impacts of infection seem unsustainable, with the Long Covid burden accumulated so far estimated to cost the US economy $3.7 trillion, through the resulting staffing crisis, and disability and health care costs³². The virus mutates quickly and so far, it has shown no signs of slowing down, which means it is constantly evolving to escape immunity^33-35.

Admitting we have a problem is the first step to finding solutions, but governments either don’t understand the scale of the problem we might be facing, or, if they do, they are deliberately minimizing the threat. Government scientists, subject matter experts and advisory bodies have variously told us, the virus isn’t airborne^36,37, children don’t catch the virus^38,39, they don’t transmit the virus^40-42, masks don’t work⁴³, immunity is long-lasting and reinfection will be rare^44-46, we can reach herd immunity^47-50, SARS-CoV-2 doesn’t infect or harm the immune system^51,52, vaccines prevent infection^53,54, the virus will be slow to evolve^55,56, efforts to prevent infection are worse than the infection itself^57,58. All these statements were false, and many of those who opposed such ill-informed views at the time were dismissed as alarmists.

The Delphi consensus¹ addresses the information gap which hinders individuals' ability to assess the risk posed in a given situation by recommending testing, genomic surveillance, and other practical public health measures that collect and disseminate relevant data in a timely manner. 

Solving the second information gap about long-term risks is more challenging, and it is here that we believe governments need to re-engage the wartime mentality so many of them spoke of in 2020. We need a Project Warpspeed 2 that focuses on answering some important questions about SARS-CoV-2, in the context of widespread repeat infection through people’s lives. We’ve set out ten priorities below. This research needs to be coordinated at government level and directed with purpose. We cannot rely on the market incentives of private industry or research priorities of academia to answer such urgent and important questions.

1. What is Long Covid and what is the extent of its impact?
   Long Covid is a patient-created term to cover a wide range of post-acute and ongoing symptoms⁵⁹. The ubiquity of the ACE2 receptor⁶⁰ and the role played by platelets (see below) during infection might go some way to explaining the wide variety of symptoms and affected organs and symptoms. The US Department of Health and Human Services has advised people that repeat infections increase the risk of developing Long Covid⁴. As a recent Nature review of current knowledge around the immunology of Long Covid suggests, our understanding of the condition is incomplete⁶¹. In the context of risk or increased risk with reinfection, it is critically important policy makers understand the condition. They also need to better understand the social and economic costs of increasing numbers of people suffering with Long Covid. The analysis by David Cutler of Harvard Kennedy School, which suggests the cost of Long Covid is $3.7 trillion³², is likely to be an underestimate in the context of reinfection. We also need to better understand the implications of Long Covid in the younger generation. The US National Institutes of Health has recently advised that children experience the same Long Covid outcomes as adults and can suffer serious complications⁶².
2. What is SARS-CoV-2 doing to immune systems young and old?
   SARS-CoV-2 infects B and T cell lymphocytes^63-66 and infects, harms and alters other immune cells^67-71. What has infection done to population health? Are we seeing ongoing surges of RSV^72,73, dengue^74-76, adenovirus^77,78, and other pathogens around the world because of harm or impairment to our immune systems? What are the long-term implications of repeat infection of B and T cell lymphocytes? What harms are being caused to the wider immune system? Looking specifically at children, while some commentators assert there have been no changes to young immune systems⁷⁹, the surges in RSV and other pathogens seem to be affecting children and young adults in unexpected ways^80-82. For example, prior research suggests monocytes may play a role in severity of adenovirus infection⁸³ in children and SARS-CoV-2 has been shown to cause depletion and dysfunction of monocytes^71,84. SARS-CoV-2 has also been found to be persistent in a significant proportion of children and has been shown to infect their lymphocytes⁶⁶. There has been a rise in type 1 diabetes in children^85,86 which is an immune mediated disease, suggesting there is immune dysfunction in at least some children as a result of SARS-CoV-2 infection. Diabetes has a significant impact on morbidity⁸⁷, mortality⁸⁸ and healthcare costs⁸⁹ and this connection needs to be better understood in the context of repeat infections. B cells have a feedback system in the thymus⁹⁰. How is SARS-CoV-2 impacting this and what will happen as the thymus involutes? Infectious disease induced immune dysfunction can often lead to autoimmune conditions such as type 1 diabetes, systemic lupus erythematosus, and many others⁹¹. Will children who have been repeatedly infected by SARS-CoV-2 be at greater risk of developing such conditions?
3. What are the neurological consequences of SARS-CoV-2 infection?
   There is growing evidence SARS-CoV-2 impacts the brain, affecting cognitive performance and increasing the risk of neurological conditions^92-95. COVID-19 has been found to cause a rapid progression of dementia⁹⁶. It has also been found to cause Alzheimer's-like signaling⁹⁷. Will these findings translate to a rise in dementia in the population? Do repeat infections represent a cumulative risk?
4. What are the consequences of SARS-CoV-2 on reproductive health?
   With accumulating evidence of changes in reproductive health^98-103, what risk is posed by reinfection by SARS-CoV-2?
5. What is the impact of SARS-CoV-2 on human development?
   There is growing evidence of the impact of in-utero SARS-CoV-2 infection on health and development^104-110. What ongoing risk does this pose in the context of reinfection?
6. What are the long-term implications of infection of the bone marrow?
   SARS-CoV-2 has been shown to infect bone marrow megakaryocytes^111,112 and disrupt normal platelet formation^111,113,114. There were suggestions prior to 2020 that coronaviruses could persist in the body in low-replication states in privileged sites¹¹⁵. Are some presentations of Long Covid a consequence of persistent infection of the bone marrow? If so, what are the implications? If not, and infection of the bone marrow clears, what are the implications of repeat acute infection of the bone marrow through the human lifetime?
7. What is the impact of repeat infections of SARS-CoV-2 on cardiac health?
   SARS-CoV-2 infection causes an increased risk of thrombotic events during the acute phase of infection and for a significant period afterwards^116,117. People with Long Covid often have abnormal clotting and microclotting¹¹⁸. Increases in thrombotic conditions such as disseminated intravascular coagulation are seen as complication of sepsis and infectious diseases such as HIV^119-121 and Dengue^122-124. True DIC (by ISTH criteria) is rare in COVID. Instead, we see a distinct pattern of sepsis-associated coagulopathy and thrombosis without it fulfilling ISTH DIC diagnostic criteria¹²⁵. Infection of bone marrow megakaryocytes is a common feature of thrombotic conditions associated with other viral infections^126-129. The link between megakaryocyte infection and COVID-19 induced cardiac injury needs to be fully understood. According to the British Heart Foundation, the UK has seen an excess of almost 100,000 cardiovascular deaths since the start of the COVID-19 pandemic¹³⁰. US research has found excess cardiovascular deaths are temporally linked with COVID-19 waves¹³¹. SARS-CoV-2 damages the cardiovascular system^132-136. It is crucial we understand the long-term impact of SARS-CoV-2 reinfection on cardiac health, elucidate the mechanisms, quantify the risks and communicate them to the public, and identify methods of  preventing and treating acute and post-acute cardiac conditions associated with SARS-CoV-2 infection.
8. What are the risks of epigenetic changes?
   There is evidence SARS-CoV-2 infection restructures the host cell^137-139. What are the risks of this process and how are they impacted by repeat infections over the course of a person’s lifetime?
9. What is the impact of repeat SARS-CoV-2 infections on cancer incidence?
   The first proposed molecular mechanisms by which SARS-CoV-2 might cause or exacerbate cancer were identified in 2020^140-142 and further research has supported those initial findings^143-147. There is accumulating evidence of increased detection and incidence of cancer after SARS-CoV-2 infection^148,149 and some evidence of a worse prognosis for cancer patients who are infected by SARS-CoV-2^150-152. Given the social, healthcare and economic costs of cancer, and increased morbidity and mortality, it is vitally important we understand the role, if any, SARS-CoV-2 might be playing in tumorigenesis and cancer progression.
10. What is the long-term impact of SARS-CoV-2 on pulmonary health?
    Severe COVID-19 can cause acute respiratory distress syndrome, which can lead to pulmonary fibrosis, irreversibly compromising respiratory function¹⁵³. Shortness of breath or dyspnoea is common more than 4 weeks after the onset of acute COVID-19  symptoms¹⁵⁴.  In a recent study, a cohort of young people with ongoing Long Covid symptoms were found to have a 10% reduction in lung volume compared to controls¹⁵⁵. Pulmonary embolism is a common complication of COVID-19¹⁵⁶ and can lead to long-term sequelae¹⁵⁷. It is important policymakers understand the potential impact of reinfection on pulmonary health and the long-term implications on the healthcare system of any impact.

Admission is essential to solve the challenges of SARS-CoV-2

We call on governments to admit there is an ongoing problem with SARS-CoV-2. This is the first step to changing course and to implementing public health and clean air policies that will reduce transmission. We recommend the resumption of data collection and reporting that will enable people to genuinely assess their individual risk, and we ask governments to urgently answer questions that might have a profound impact on the long-term health of vast numbers of people. Some of the adverse outcomes of these unanswered questions might not present themselves for years, by which time they could impact far greater numbers of people. As scientists studying Long Covid have already said⁶¹,

“The oncoming burden of long COVID faced by patients, health-care providers, governments and economies is so large as to be unfathomable, which is possibly why minimal high-level planning is currently allocated to it. If 10% of acute infections lead to persistent symptoms, it could be predicted that ~400 million individuals globally are in need of support for long COVID.”

If we keep adding to the number of people who will suffer long-term complications down the line, that burden will only increase.

If you’d like to reduce your risk of SARS-CoV-2 infection, you can find practical advice here.