So you want to lift public health precautions?

Then continue to take those precautions seriously for now, as case numbers and test positivity rates are still high

As an apparent “outspoken advocate of continued masking” I figured I should express that sentiment a bit more thoroughly than is explained in the article.

Blanket policies won’t work given global and regional differences. To paraphrase a famous political campaign quote: “It’s the virus, stupid.”

So, if you want to talk about precautions to protect ourselves and each other from the virus, we have to be willing to acknowledge local and regional differences, and understand that arbitrary dates and blanket statement only feed COVID-denialism narratives and have the opposite effect of actually respecting the data and the evidence.

Regional differences in case rates
National levels of cases, hospitalizations, and deaths

This map and these charts are all from the NY Times — notice that while cases in this Omicron surge are dropping, they are still well above their prior highest peak. Hospitalizations are still near their highest, and deaths continue to rise.

So you want to lift some precautions like masks?

Successfully drive those numbers down and, barring future variants, then you can likely lift some non-pharmaceutical interventions (NPIs) like masks. But when those numbers go back up or new virulent and transmissible variants emerge, we must also be willing to re-engage them as well.

How?

Get people vaccinated and, importantly, “boosted.” Get better ventilation and filtration indoors. Utilize testing to improve tracking and prevention, including improving access to rapid tests along with the use of pooled testing in schools or regularly occupied indoor spaces so long as case numbers and test positivity rates are still high (hint: they are). And yes, continue to wear better masks. These are choices, and choosing against precautions is making an active tradeoff between your own minor inconvenience over someone else’s health or family or job.

An excellent Twitter thread on these tradeoffs from Gregg Gonsalves

But do masks work? Yes. Both aerosol and droplet physics as well as real world testing demonstrates that masks work, both to reduce transmission and keep schools open.

Here’s some resources:

But if we aren’t willing to do this “dance” of lifting some precautions and then re-implementing them as needed— a reference to The Hammer And The Dance by Tomas Pueyo early in the pandemic — then we will never do a particularly good job of managing this pandemic going forward.

We have the tools now that should enable us to do this; however, there is a deep strain of anti-intellectualism and science-denialism in America in which any change to these policies — regardless of whether the appropriate response to the data at the time — will be met with a deep skepticism and drive further doubt in the institutions guiding them.

This has become so deeply entrenched in politics that COVID-denialism and the associated opposition to reasonable public health precautions has essentially become an identity, particularly on one side of the political divide.

From KFF.org — data from November 2021

To be clear, I am very specific in using the word precautions and not using the term “restrictions” because asking people to get vaccinated or add ventilation and filtration to indoor spaces or wear masks or utilize testing are mitigation measures and precautions against transmission and are not, in fact, “restrictions” and most certainly are not “draconian” — a word that the anti-mask crowd leans on hard to push their narrative, though is fundamentally untrue.

Lifting precautions with the very real possibility and even high likelihood of needing to re-implement them will require strong leadership and effective communication of the strategy and metrics as well as which precautions can be lifted or will be re-implemented. For example, lifting precautions while community transmission and hospitalizations are low, re-implementing precautions like increased testing and masking with better masks in public indoor spaces when those numbers go back up or when new highly virulent and transmissible variants emerge. And I truly mean when we know that a new variant is identified, not when we finally detect the rapid rise in cases in the US or locally — because every time that we have waited, we were too late.

This also applies to any future travel bans, which are actually restrictive and should never be implemented again in the future because, as with re-implementing precautions, in our globally connected world these bans will always be implemented too late.

If leadership is not able to effectively communicate this plan and get society at large to understand the principles upon which we are basing loosening of precautions and ramping them back up again, I fear that when the time does come to ramp them back up again we may collectively be far worse off, as more of society could become even more reluctant to implement any mitigation efforts.

Some seem to want to argue that Omicron is “mild” and, therefore, we no longer need to be concerned or continue mitigation efforts or precautions. That statement is fundamentally untrue. Evidence shows that the intrinsic virulence is 75% as severe as the Delta variant, which has been the most virulent form of the virus that had widespread transmission, and is still more severe than the original strain and Alpha variant. This is not just “the flu” or a “common cold” as people may have been led to believe. However, for people who are fully vaccinated, particularly with an additional dose or “booster,” they are likely to have a more mild course of illness. Additionally, vaccination appears to provide some level of protection against long-COVID, as noted in both the Lancet and Nature, which continues to be a concern as massive numbers of people continue to be infected.

Another common yet meaningless refrain that I have heard is that “COVID is endemic” as if that means that we should no longer have to continue mitigation efforts or take reasonable public health precautions. The dramatic and rapid rise in cases in cases as Omicron surged has been followed by increased hospitalizations and deaths, with over 6500 deaths from COVID in just the last week alone. Those numbers should not be normalized. That amount of death is not normal nor acceptable. Those numbers certainly do not indicate that we are at or approaching endemicity. Endemic means that the overall case rates are static, and as we have seen with a rapid and massive surge, we continue to be far from that point. However, even the term endemicity is meaningless as a disease can be endemic and still be widespread, cause significant disability and death, and be worthy of policy action. There are numerous examples of endemic viruses in which we have made significant advancements and policy commitments to address. Smallpox and polio were both endemic. Yet through bold initiatives and policy measures, we completely eradicated smallpox and have nearly eradicated polio globally.

The analogy to polio has additional valence in that polio is a highly transmissible virus which causes a typical viral syndrome of “flu-like” symptoms such fevers, muscle aches, fatigue, headaches, and gastrointestinal symptoms like nausea, vomiting, and stomach pain and leads to severe outcomes such as paralysis or death in approximately 1% of those infected. Yet, even given those symptoms and that percentage of severe outcomes from an endemic virus, we dedicated the resources and political will to not just mitigating, but entirely eradicating the virus from our country and beyond. We are capable of doing so, and the suggestion otherwise is disingenuous. Polio was first identified in 1908. The iron lung was invented in 1929. By the 1950s, polio had become one of the most serious communicable diseases among children in the United States. Salk first gave his vaccine to his family in 1953, and the first campaigns to roll out the injection vaccine publicly started in 1954. The oral vaccine was rolled out in 1963 with more widespread uptake. Finally, polio was considered eradicated from the US in 1979, and only remains endemic in two countries today— Afghanistan and Pakistan.

Those 71 years of endemicity in the US were marked by multiple waves of epidemics. This should provide some perspective, as we are now only two years into our first wave of COVID. We have dramatically improved tools today as compared to during the epidemics of polio, with the efficient development of safe and effective vaccines, the means to rapidly identify the presence of the virus, and the knowledge of ways to mitigate the spread with low cost measures and minimal restrictions. The notion that we are incapable of expending the personal or political effort or the resources to adequately address this viral pandemic is absurd. The first outbreak of polio is presumed to have occurred in the US in 1894, and vaccines were only first developed and available in 1954, and more broadly utilized in 1963. Nearly 70 years of fearing an invisible disease without the resources that we have easily available at our disposal now, and yet people are not only unwilling but are actively advocating against leveraging them. I’m guessing there are some parents from the 1950s would have liked to have a word.

Another idea that has been proposed since 2020 with the Great Barrington Declaration for the population at large and then more recently proposed specifically for school age children in the Urgency of Normal toolkit has been the idea of “focused protection” and otherwise to just allow the virus to spread without mitigation, based on the idea that getting people infected with COVID will allow them to develop immunity without having to apply any mitigation efforts or push for vaccinations. This is based on the idea of “natural immunity” — which uses this specific language to leverage the naturalistic fallacy to try make this idea seem more appealing. All immunity generated by one’s own body is natural, the difference is how that immunity is induced— either from having been infected, or infection-induced immunity, or from vaccination, or vaccine-induced immunity.

The problem with the idea is that this has already proven to be ineffective, as people have been re-infected with COVID multiple times already. As the virus continues to spread, each transmission to another person creates a new opportunity for mutations which are generating new variants. New variants can have mutations in the proteins to which prior antibodies generated would bind, and have increasing “escape,” meaning that prior immunity is less effective at neutralizing the infection. The evidence has demonstrated that vaccine-induced immunity is more effective than infection-induced immunity, both in terms of preventing infections as well as severe disease and death.

An excellent Twitter thread by Ashish K. Jha explaining this point

People are getting re-infected with Omicron. Mass infection with Omicron isn’t a reasonable means of reaching an end game for COVID given that infection with Omicron isn’t even the end game for Omicron.

But how are we doing with vaccination efforts? Turns out, not so well.

The US lags far behind other wealthy nations in vaccination rates and additional or “booster” doses
You can see the direct impact of lower vaccination rates in the highest death rates

Another point to consider is that Pfizer and Moderna are developing variant-specific vaccines, which will likely be much more effective than current vaccines, given that the decreased efficacy has been due to mutations in the spike protein in the new variants as compared to the spike protein of the original wild-type strain to which the initial vaccines were designed. If we are able to develop variant-specific vaccines and if these vaccines are more effective than the vaccines designed against the wild-type strain, as expected, then utilizing these as an actual “booster” shot and having significantly improved immunity would lead to dramatic increases in prevention of infections and transmission. If we are then able to lead a more effective nationwide and global rollout of these more effective vaccines, then we may actually be able to break the chains of transmission more effectively across the globe and corner this virus with collective tracing and mitigation efforts.

Otherwise, we can be sure that we will continue to see new variants emerge and spread infection and disease through the country again. That is a matter of not only concern about illness, long-term disability, and death, but about equity as well.

The lack of paid sick leave on a state and national level has disproportionately contributed to disadvantaged communities falling behind on rates of getting vaccinated and boosted. Many people who have avoided vaccination are afraid they’ll suffer side effects that will force them to miss work, which they can’t afford. One of the arguments for lifting restrictions is that people should be vaccinated and therefore will avoid severe illness and death; however, that neglects the fact that while those with means can manage getting a “mild” infection with Omicron, which can still be a protracted and debilitating course of illness, disadvantaged communities will still face a risk to their jobs.

So yes, for now I’m going to continue to be “an outspoken advocate for masks” as well as other reasonable public health precautions so long as case rates and community transmission remains high, and I refuse to place an arbitrary date to end to those restrictions. Instead, I would offer that these mitigation efforts need to be tied to metrics, including local or regional rates of vaccination, hospitalization rates and capacity, case rates and community transmission, and the variable of the detection of new transmissible variants. Additionally, I would offer that we need to provide some leeway for adjustments on precautions within regions depending on differences in setting and local circumstances, such as in high risk settings or with high risk populations. In order to do that, communities need to agree to to be flexible in adjusting to local differences and to re-implement precautions according to those same metrics, otherwise such plans will ultimately be unsuccessful.

Doing so is not just a matter of protecting our health, but is a matter of equity, and significantly, given that this is purported to be the topic of conversation to begin with, of keeping schools open.

[Addendum:

I have seen a number of comments suggesting that children should not need to “bear the brunt” of our pandemic response, and I agree. They should not. A huge factor in that is being able to keep schools open for children to be able to be in the classroom learning and interacting with their friends and classmates in person. We all need to do everything we can to protect children and allow them to remain in school, which means that everyone should be pitching in equally to drive down community transmission rates.

But wait, what does that have to do with keeping children in school?

Schools aren’t being closed due to precautionary COVID policies, schools are being closed because too many teachers are out sick with COVID or students are getting infected and have to isolate or classes or even schools have to quarantine. As a precautionary measure, masks have shown that routine use in the community can help prevent transmission and drive down case rates. Additionally, masks help shorten both the quarantine and isolation period for infected or exposed teachers and students while ensuring that their classmates and staff remain safe and protected. Masks don’t protect students from being able to learn or to interact with their classmates, and actually, specifically help us ensure that they are able to do so.

Some people have pointed out that mask mandates have been lifted for adults in some situations such as in gyms and bars while school mask mandates remain in place. I agree that this is logically and scientifically inconsistent, and that we need to be able to enforce these precautions equally across the community. If children and teachers are putting in the effort to protect themselves and others and drive down transmission rates by wearing masks, we should be able to ask the same of adults. In fact, I would ask the adults clamoring about students no longer having to wear masks in schools if they are doing everything that they can to drive community case rates down, like getting vaccinated and wearing masks in public indoor spaces, or encouraging raid testing before gathering with friends and family, because if not, then they don’t actually care about ensuring that schools stay open for in person learning, let alone kids wearing masks in classrooms, because they aren’t even doing the bare minimum themselves.

I have also heard some variations of “kids shouldn’t have to wear masks outside” and I agree with that as well, given that this is not supported by the evidence. I base all of these conclusions on the best available evidence and weighing the risks benefits on an individual and social level. This is a point that isn’t supported by evidence so I’m in agreement that masking should not be required in outdoor settings. If students are able to go outside — such as for recess or between classes or at lunch — then they absolutely should be allowed to remove their masks outdoors or go outside for “mask breaks.”

One dilemma that I have heard from teachers is with very young students such as in preschool or early grade school and teachers reporting that the problem is not related to the mask policies or COVID policies, but that by policy they are not allowed to touch the students and therefore cannot help them put their masks back on. The problem, then, is not a COVID policy, but being able and willing to change the rules about teacher-student interactions to allow them to help re-place masks on students so that they can take them on and off as needed.]

--

--

Get the Medium app

A button that says 'Download on the App Store', and if clicked it will lead you to the iOS App store
A button that says 'Get it on, Google Play', and if clicked it will lead you to the Google Play store
Taylor Nichols

Taylor Nichols

Humanist. Emergency Medicine Physician. Health policy enthusiast. Views are my own. (He/Him)