• PublicHealthRising

About that light at the end of the tunnel

Back in November we talked about different perceptions of COVID risk (Gambling at the COVID Casino). We knew there was a gap between the sense of limited danger among the broader community and the increasing fear in public health circles. Today, that gap has never been wider. The public mood is improving with cases and deaths on the decline, lockdowns easing, and (although with frustration at a botched rollout mixed in) vaccines providing a light at the end of the tunnel. The public health anxiety index (we measure that using our home blood pressure cuff), in the meantime, points into the gloom of the abyss. Let’s take a look at three key issues from both perspectives: Why, in the U.S. at least, the public should be more worried, while public health people (like ourselves) could be more optimistic.

Variants. These are the strains of COVID that have collected enough mutations in their genetic code to create new types of COVID, some of which may lead to more cases and deaths by being more contagious, more virulent, or more resistant to vaccines and medical treatments. Many variants are being detected, and there is still a lot to learn.

-Why the public should be more worried: We’re still living in the world of COVID-19, but there are enough changes emerging that we wouldn’t be surprised if we start hearing soon about COVID-21, or have to develop a new naming system (like the one we have to track the different influenza strains that circulate annually). Research in South Africa found that some people who had evidence of prior COVID infection subsequently fell ill with a new strain, known as B.1.351 (this strain has been referred to as the South African strain, but remember we have a long history of mistakes about the origins of new illnesses, including the 1918 influenza pandemic, HIV, and more). The concept that prior COVID infection did not protect people from infection with B.1.351 sets off some alarm bells. The additional observation that some medical treatments and our current suite of available vaccines are likely less effective against B.1.351 should snap us all back to existential reality: In the U.S. we have failed to achieve COVID control with the original strain, and with pandemic fatigue and resistance to precautions on the rise, more contagious and more virulent variants can easily tip us in apocalyptic territory.

-Why public health people could be more optimistic: The single most promising development is that vaccines appear to prevent severe disease and death, even with variants like B.1.351: Vaccine-induced immunity may be more effective than natural immunity following infection. The news circulating currently, that the new J&J vaccine is 72% effective, may be missing the more promising point: it was 85% effective against severe disease and death. This would reflect an incredibly good vaccine, and will add to our lineup a single dose weapon that does not require freezers. Waiting for an even more effective vaccine would result in more cases and deaths during this waiting period, and rapid availability of a vaccine that is logistically easier to administer would be a huge step forward. Vaccine rollout continues to pick up speed and should accelerate even more quickly with more vaccine products authorized. While there has been a lot of attention on the small fraction of the total population that has been immunized, if we achieve high coverage of vaccination among the populations most likely to be hospitalized and die -- then we have successfully reduced the near-term burden of COVID. As far as new variants with even more vaccine resistance in the future, the COVID crisis has also triggered the next era of vaccine technology, and booster doses to fight off the latest variants can be produced.

Equity. We have heard a lot (and written a bit) about the disproportionate burden of COVID on communities of color, and efforts to address inequity.

-Why the public should be more worried: Despite the attention to equity and fairness in our COVID response, intent is almost entirely detached from impact at this point. Communities of color continue to carry a disproportionate burden of infection, illness, and death. Disparate privilege persists in housing conditions, with more space for fewer people in white households, allowing for better control of household COVID transmission. Vaccine rollout has disproportionately served white populations. A new national conversation is emerging with more emphasis on speed of vaccine rollout, while still trying to incorporate fairness -- but not at the expense of speed. And while focus on Black communities is apparent, it’s less clear how much energy is going towards serving Latinx communities which have likewise carried an enormously disproportionate COVID burden. Here in Denver County alone, Hispanic adults account for the majority of COVID-19 cases, hospitalizations and deaths. The burden in this community is double their proportional representation of the overall population and only 4.7% of those who have been vaccinated so far identify as Hispanic.

-Why public health people could be more optimistic: The COVID pandemic has revealed that we have a new platform in health and science: a platform that includes communities of color in positions of power and leadership. Prominent individuals in vaccine development and federal leadership may reflect a leading edge of improved representation and inclusion, longstanding institutions have an expanded platform, new initiatives have emerged, and social media (for example) has been full of Black and Brown health care professionals chronicling their journey getting the vaccine and helping ease warranted fears. Community representation and agency may be too recent, without enough time yet to reverse the long history of structural racism, including in our public health response, but there is reason to believe the terrain has changed and this may finally be feasible. The next challenges are to consolidate gains and translate intent into impact, and to see similar efforts in Latinx communities (we have found some examples and much more is needed).

New Cases. The number of new COVID infections occurring on a daily basis in the U.S. is both reassuringly declining and worryingly high.

-Why the public should be more worried: We covered much of this is in our last post. While the number of daily new infections continues to fall, we remain at extraordinarily high levels of infection and death, and the pattern in the U.S. has been rapid increase with a short decline, establishing a higher baseline than before -- and then repeat. There is no reason to believe we’ll break out of this pattern now, and our most likely trajectory is a new surge superimposed over this incredibly high baseline. Perhaps most importantly, when we see the first uptick it may already be too late, or at best there will be a narrow window for rapid, dramatic action to prevent the next surge. The culture wars over safety behavior, including consistent and correct use of appropriate face masks, seem to be intensifying. If our most recent surge overwhelmed a few health systems (which again, yes it does increase your risk of dying), the spread of more contagious variants in communities that aren’t taking strong COVID precautions could rapidly lead to mass casualty events.

-Why public health people could be more optimistic: Perhaps the declining trends will be sustained, and with the news of emerging variants people will take the risk seriously and use appropriate COVID precautions in the coming weeks and months. Or, perhaps if an uptick in cases starts to appear the public will be ready at that point to take rapid action. Out of the areas we’ve covered in this post, however, this one feels like the hardest to support from a position of optimism. We’re leaning on the vaccine as much as anything else. As mentioned above, if we rapidly achieve high coverage of vaccination among the populations most likely to be hospitalized and die, then we might avoid the worst case scenario.

Are we looking at the light at the end of the tunnel or staring into the deep of the abyss? The answer you choose can depend at least in part on your behavior and the COVID precautions you take. For us, the answer is both, at least in the U.S. Thinking globally, the story is less promising, and as we’ve written previously, when we fail to care for everyone we may fail to care for anyone.

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