The Perfect Enemy | Needed: A COVID course correction
August 10, 2022
Read Time:4 Minute

President Biden’s rebound case of COVID-19 has highlighted the continued public health threat posed by the rapidly spreading BA.5 variant. COVID infections are becoming more common, with cases spiking in most states just when population immunity is dropping. Many infected people are being laid low for several days by serious flu-like symptoms. Hospitals are filling up again with COVID admissions, rising over 41,000 on any given day. Consequently, public health experts are issuing warnings that BA.5 portends the continued evolution of more serious variants and the need for caution and behavior changes.

But despite COVID being on the rise once again, there seems to be little public concern about it. Simultaneously, politicians are acting as if COVID is over by refusing to appropriate additional funds to support public health upgrades, buy vaccines and therapeutics, accelerate vaccine and therapeutics research and development, or trigger advance purchases of necessary drugs, tests, or next generation vaccines. It seems most Americans have decided “everyone is going to get COVID” and have resigned themselves to the inevitable. So life has largely returned to what it was in 2019: no masks and no restrictions.

How should the federal government navigate the disconnect between a public health emergency and a population that seems inured?

The only sensible approach is to accept the public’s attitude and work with — or around — it. If the public won’t listen, the advice of public health experts — no matter how urgent, persistent, and loud — is not going to be effective. This means policymakers need to pivot, instituting passive measures to blunt transmission and tailor interventions to public acceptance.

Public health officials need to accept that SARS-CoV-2 is now endemic and will constantly evolve. On this the American public is right. The language of “beating the virus” or “getting past COVID” is misleading and alienates the public. Next steps require accepting COVID will be with us forever, and “normal life” requires living with the virus.

COVID also seems to have induced Americans to recalibrate their risk tolerance up — substantially. In exchange for fewer restrictions on masking, travel, and socializing, Americans now seem willing to accept 150,000 to 200,000 COVID deaths annually — about 400 per day — which is three times bad flu seasons. This would make COVID the fourth leading cause of death in the United States. They also seem to either dismiss or minimize the risks of long COVID. Public acceptance of more risk requires increasing thresholds for issuing public health recommendations and restrictions.

Accepting the public’s position also means forswearing closures of schools, offices, bars and restaurants, and all the other public venues, even when high levels of transmission are occurring or likely. That is what endemic means — living with the virus.

But this doesn’t mean doing nothing. Public health policy makers need to adopt the air bag model for COVID — safety measures that work in the background without individuals needing to take initiative to get substantial benefit.

One thing that can be done is to improve indoor air quality. COVID is an airborne illness and improving indoor air quality can reduce transmission and keep people healthy. Mandating schools, public buildings, and other indoor venues to upgrade HVAC systems or use germicidal UV light is critical. Air quality also needs to be improved on planes, trains, buses, and other forms of transportation. Action is occurring across the nation, but very slowly.

The public health system also needs to be upgraded with real time data collection infrastructure, broadened wastewater and home test kits to include detection of multiple pathogens, and the addition of a permanent cadre of community health workers targeted at vulnerable populations.

Similarly, because of the high contagiousness of BA.5 — and possibly other subsequent variants — there needs to be paid medical and family leave for all workers. One of the most damaging economic effects of BA.5 is worker absence leading to plane cancellations, supply chain disruptions, and other economic strains, such as closure of stores and offices because everyone contracted COVID. This is often the result of infected workers spreading COVID to co-workers. Paid medical leave will help reduce transmission of COVID and other respiratory viruses.

There also needs to be a change to the vaccines, with priority given to making them one dose per year with long durability and broad immunological breadth. Research should also focus on medication that can be sprayed in the nose or mouth to would inhibit SARS-CoV-2 from latching onto cells and causing infection. It might be effective for only a few hours, but it would make going to social events safer.

COVID has revealed the public’s limit on adjusting their lives to an emergency. And Biden proves COVID rages on, and new transmissible, virulent variants will continue to emerge. An ideal response would have people masking up in areas with high case counts. But urging that would be like déjà vu — repeating the same mistakes and incurring the same mortality and economic pain. Instead we need to institute measures beyond this, in ways that do not burden Americans. Time to course correct.

Dr. Ezekiel J. Emanuel is vice provost for Global Initiatives and codirector of the Healthcare Transformation Institute Perelman School of Medicine and the Wharton School at the University of Pennsylvania.