Predictions for 2021: Welcome to the New Uncertainty

This could be a “hinge year” in history: the opportunity to grasp a new and improved future for ourselves, our children, and our planet—or not.

“Uncertainty is a quality to be cherished, therefore—if not for it, who would dare to undertake anything?” – Auguste de Villiers de l’Isle-Adam

As 2021 dawns, the annus terribilis of 2020 is ending with the tragedy of a pathogen surging and mutating, and the splendid news of a vaccine for what we now call simply “the virus.” As thousands, millions, and then hopefully billions of people are inoculated in the coming year, this will usher in a different kind of uncertainty from what we have experienced since last March: The high anxiety that comes after a crisis, not during.

This is where we find out if humanity learned valuable lessons from this disaster and will act to correct mistakes made and to improve our world—doing things like actually preparing for a pandemic next time—or if we will slide back into some version of the old normal.

During the pandemic, we saw what science can do using an all-hands-on-deck urgency—when the brainpower and passion of scientists, physicians, and millions of others was hyper-focused on battling a single problem. We also saw what happens when effective policies and political leadership are AWOL during a disaster. When leaders posture, play petty politics, and actively undermine the roll-out of collective solutions, people die.

Voters in the United States responded to a lethal trashing of science and facts by electing a new president who respects both. Yet America remains divided, with 70 million people voting for Donald Trump and a jaw-dropping 42 percent of Republicans still saying “no” to taking a vaccine, according to a poll from the Kaiser Family Foundation released on December 15, although the number of no’s is decreasing. (In contrast, 86 percent of Democrats say “yes.”)

Beyond these two overarching themes that emerged in 2020—the rise of a hive mind laser-focused on beating the virus and the cautionary tale of world leaders playing politics with people’s lives—I’d like to humbly offer up several predictions for the readers in this new year and perhaps beyond.

First, the bad news. In terms of the pandemic, COVID-19 sadly is not really over yet until we reach the magic moment when we can take off our masks, hug people, dance, and press an elevator button without the fear of dying. Recently, Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, suggested the corner could be turned by late summer if 75–80 percent of people are immunized in the United States, or much longer if only 40–50 percent roll up their sleeves.

Watching the Trump Administration already fumbling the distribution of the vaccine—they promised 20 million doses by the end of 2020; we actually got 2.7 million—it’s hard to feel confident that we will reach the magic 75 percent or more coverage by the end of summer. But we do have a new administration riding into town on January 20. It will take time to undo the damage from the gang that couldn’t shoot straight, but we can hope that President-elect Joe Biden and crew, who have been working feverishly to be ready to launch a D-Day-level assault to get out the vaccine, will correct course.

One silver lining to the uncertainty around “how long” is that I think many people who lean anti-vaxxer will nevertheless take this vaccine so long as side effects are minimal, it seems to work, and they think it will return them faster to what Fauci recently described as “some degree of normality that is close to where we were before.”

Desperation for normality comes as experts estimate that cases of depression have tripled since last February as “pandemic anxiety” spikes and isolation takes its toll. Look for this alarming bruising of tender gray matter to become the new public health crisis of 2021 once we see COVID-19 cases and deaths falling. Job losses, evictions, failing businesses, will exacerbate this, as will grieving for a staggering 1.7 million deaths globally—so far. We will also need to better understand and treat the impacts of those with mental fog, fatigue, depression, and other pathologies that linger long after their primary viral symptoms go away.

In 2021, also look for some novel neuro-technologies to address these mental health concerns from companies like Miro Health, which just had its online, self-administered, neurobehavioral assessment tests receive a breakthrough device designation by the U.S. Food and Drug Administration (FDA). This is part of a growing trend of using online devices instead of drugs to treat and diagnose neuro maladies—with companies like Akili, which was granted approval by the FDA for EndeavorRx, its neuro-gaming platform to treat attention deficit hyperactivity disorder (ADHD) in children; and Pear Therapeutics, which uses apps to help treat substance abuse, insomnia, and other diseases.

This is where we find out if humanity learned valuable lessons from this disaster.

Next comes the biggest question of all: What have we learned from 2020? It’s an easy prediction to make that another virus will pop up sooner or later. But will we be better prepared for the next contagion? Answering this will require a robust post-mortem of what went right and wrong, and an aggressive reimagining of policies to amass the resources, personnel, and materiel like PPE in advance, just as the military prepares for war, and the Federal Emergency Management Agency (FEMA) prepares for hurricanes.

Attitudes also need adjusting to preserve and perhaps codify the idea of a nimble, hive-mind approach to solving scientific challenges, one that mostly has put people ahead of profits, academic rivalries, and red tape—even if these forces will try mightily to reassert themselves once the crisis is over. 

A prime example is the COVID-19 Host Genetics Initiative, launched in mid-March literally with a tweet from Italian biostatistician Andrea Ganna of the Institute for Molecular Medicine in Helsinki, Finland. Ganna and colleagues called on researchers working at biobanks around the world—repositories of DNA collected from millions of people to study diseases and traits—to radically join forces. Incredibly, over 700 researchers at 140-plus biobanks from Canada to Qatar to South Korea tore down barriers of institutional and academic independence and bureaucracy to share data, resources, and insights. Their urgent goal: To study the genetics behind why some people react with severe cases of COVID-19, while most do not.

Other initiatives include the masksim simulator, an AI model built by a group of friends—a top data scientist in Hong Kong, a physician-researcher in London, an AI expert and molecular biologist in Cambridge, a population biologist in Finland, and an economist and modeler in Paris—who created the first serious AI-based model proving that if 80 percent of people wore masks, COVID-19 would largely be tamed. Their collaboration started in a COVID-19 chat group that included other friends and experts who egged them on.  

The scientific mind-meld and massive infusions of cash devoted to shutting down SARS-CoV-2 also provide a blueprint for designing, testing, and approving vaccines for future malevolent viruses. “With what we’ve learned from this virus, it should be much easier to adapt the methods used for the COVID-19 vaccine for what comes next,” said synthetic biologist Andrew Hessel of the Center of Excellence for Engineering Biology. 

Researchers used novel mechanisms to shut down SARS-CoV-2, including strings of messenger RNA that basically shut down the virus’ spike proteins so they can’t dock with human cells. This mechanism differs from most vaccines, which use disabled forms of the virus itself, or its proteins. Although all viruses are different—and SARS-CoV-2 mutates slower than most—the breakthroughs using RNA and other novel methods should speed our response time up in the future, although it’s not clear if the massive resources expended for the novel coronavirus will be repeated. 

Work is underway to better understand the impact of the virus on the human microbiome, the “good” bacteria that live inside us and can be negatively impacted by what we eat, stress, and, yes, by pathogenic viruses. Researchers are also studying the virus’ impact on the metabolome, which are the hormones and chemicals inside us that cause and regulate reactions in the body. In 2021, the impact of COVID-19 on different “omics”—including genomics, microbiomics, and metabolomics—is already a part of an expanding effort to go beyond genomics to keep people healthy and treat disease.

We can only hope that this glorious moment, which won’t last long, maybe a few months or a year or two, will be something akin to what happened in the United States after World War II.

We should also see a spike in our understanding of epigenetics vis-à-vis viruses, the process used by our bodies to turn on and off genes in response to a disease like COVID-19. 2021 could be a hinge year for epigenetics, when this relatively new field might swing into becoming core to the development of newfangled vaccines and drugs that can trigger or stop epigenetic changes impacting everything from stress and trauma to other infectious diseases and cancer.

As the post-pandemic era nears its dawn, hopefully in the spring or summer of 2021, perhaps the most critical prediction is the historic window of opportunity that will open-up as the vaccines take hold and the lockdowns end. We can only hope that this glorious moment, which won’t last long, maybe a few months or a year or two, will be something akin to what happened in the United States after World War II. That’s when the hive-mind effort to defeat fascism ended with a massive recalibration of society to embrace science and to build a new world order—although we also got the Cold War. 

The end of the pandemic will be different. For one thing, we are not nearly as unified as we were in 1945, nor are our friends and foes so clearly defined as they were during that long-ago conflagration. But one could argue that the impact in terms of deaths from COVID-19 elevates this crisis to that long-ago calamity. By the time we receive the all clear, there may be more Americans who will have died of coronavirus than the number who died in World War I and World War II combined.

I suspect that the science of biomedicine—if the public believes that they were saved from COVID-19 by science—will in fact come roaring out of the pandemic poised for a surge in funding, innovation, and initiatives in fields ranging from synthetic biology and bionics to the use of AI and robotics in biomedicine, and more. But it’s equally possible that those pesky powerful interests that have long resisted change will nip this “pandemic spring” in the bud, reverting back to a fragmented and decentralized health care system, an academic and research establishment that tends to play it safe and keep discoveries close to the chest, and industries like big pharma that tend to focus on drugs with blockbuster profit potential over compelling human need.

This leaves us with the biggest uncertainty of all as 2021 dawns: Which way the hinge will swing in 2021. How will we apply the lessons of 2020 once we no longer have coronavirus as our sole obsession? Will we continue for the greater good with the hive mind, or revert to old, selfish aims and gimme mine?

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