5. Double the Epidemics
Not double the fun. Ignoring advice at our own peril since 1918.
There seem to be two ongoing epidemics, one that will be resolved by shots in arms, and another one that will need much more creativity to fix. On the latter, we’re not even close to a resolution.
Vaccine Saviors (for some)
In the United States, where vaccines are free and plentiful, I am more hopeful than not that we are now on the downside of the Covid-19 pandemic. This is quite an ethnocentric statement, of course, as there are some 3.5 billion people across the planet, about 50%, that have yet not been vaccinated. Most are in Africa. Many nations simply don’t have any access to the vaccine because it is economically or logistically unavailable, or have been struck by military or natural disasters. Though not all.
With enough time, and money, the world will eventually mute this epidemic. Despite lightning fast vaccine discovery, we’ve unfortunately squandered the opportunity to eradicate it because of our political divisiveness that has led to so much hesitation. This gave the virus a fighting chance. You never want to give a dangerous virus any leeway. It’s mute, not stop.
But we continue to make progress.
The Second Epidemic
The real challenge, however, is dealing with what seems to be an ambivalence to public health. There is no shot that protects us against this more persistent, and arguably more serious, peril.
It’s probably safe to assume that there are very few people who actually want to keep Covid-19 infections as part of daily life. Even for mild cases, it can be unpleasant, and not unlike typical influenza or ‘bad colds’. Nobody elects for that and I think we all agree that getting rid of Covid-19 will lead to a better society.
Where we disagree is whether society is willing to make sacrifices to reduce these infections. For the past 20 months, we’ve had a buffet of options to choose from - some more palatable than others. Wear a cloth mask or a N95 respirator? Contact trace and quarantine? Update a building or home ventilation systems? Mandate a vaccine? Shut down businesses and schools? They all work to reduce risk of disease, but all incur real social or economic costs on society. We have to find the right combination that is both effective at reducing infection, and is acceptable to the public. Whether something is effective is determined by science; whether it is acceptable is driven by community values and preference, which are diverse and fickle.
The Pandemic Playbook
And sure, the Covid-19 pandemic was a new and uncharted pathogen for public health where there was no ‘playbook’ for how to reduce its spread. But this doesn’t mean public health wasn’t prepared. The Centers for Disease Control regularly updates its preparedness and response frameworks for pandemics, though these are usually designed for influenza pandemics. But there are clear parallels between influenza and Covid-19.
What can we infer from these frameworks in how to respond to Covid-19? They recommend the use of personal and community non-pharmaceutical interventions. The answers might sound a bit familiar:
Staying home when you are sick.
Covering coughs and sneezes with a tissue.
Washing hands with soap and water or using hand sanitizer when soap and water is not available.
Staying home if you have been exposed to a family or household member who is sick.
Covering your nose and mouth with a mask or cloth if you are sick and around people or at a mass gathering in a community where the pandemic is already occurring.
Social distancing: Creating ways to increase distance between people in settings where people commonly come into close contact with one another. Specific priority settings include schools, workplaces, events, meetings, and other places where people gather.
Closures: Temporarily closing child care centers, schools, places of worship, sporting events, concerts, festivals, conferences, and other settings where people gather.
If we had only known this information as Covid-19 was spreading. Whoops, these recommendations were published in 20171.
Critical public health responses require solutions that balance intervention effectiveness with public acceptability. Across the US, there are many communities that unfortunately weigh public acceptability over anything else, and this directly impacts public health. Why could this be? Perhaps decision makers base decisions on anecdotes read in unvetted social media feeds. Or maybe some are planning to run for higher office and will do anything to keep their voters happy. Or maybe it is pure hubris.
I admit that I know very little about politics (nor do I wish to learn more). But I do know something about science, and specifically science that is directly related to mask performance. I have nothing to gain from advocating the use of masks, or closure of schools or businesses. And to be perfectly frank, I don’t particularly like wearing masks, and I know it is an extreme and risky burden when schools or business are closed.
It is amazing to see the arrogance and paternalism of elected political leaders who implement vaccine or mask mandate prohibitions against the expert advice of scientists who do this work for a living.
But I do know that what I recommend is routed in science, and I have no seedy motive that underlies that recommendation. To my knowledge, there is no cloth mask mega industry to fund my research, nor am I planning to run for president or Senate or even my local town council.
And that’s the thing about public health - its mission is to protect the entire public and not a specific industry or voter bloc or single neighborhood. It’s a political end that is driven by underlying science, and there is no cabal that seeks to steal liberties. Yes, there are some times personal sacrifices that are required, but these can only be proportional to the societal benefit that arises from these interventions. And these tools are usually inconsequential burdens compared to the hazards they avoid.
It’s been more than 20 years since I’ve been in any sort of car accident, and yet I still wear a seatbelt. I bet you do too. A tiny personal burden? Yes. Reduces a potential and serious hazard? Absolutely.
Public health also doesn’t always get it right, especially when political influence seeps in to decision making. Political influence can be immediate. Scientific influence has to wait on the reviews.
This is because science itself is slow by design - methodical, skeptical, and well-criticized science is the faster path to fact and truth than rush-to-judgement preprint papers (which are not yet reviewed by outside experts), blog pieces, or signers of groupthink statements like the Great Barrington Declaration. And sometimes, political influence on policy is driven by these non-scientific sources. Why? Because statements in these venues are fleeting and can be written without real consequences for the author, but are billed as ‘truth’ and ‘science’ by those influencing policy.
Signatories of the Great Barrington Declaration, which argued to protect only the most vulnerable and allow the pandemic to run a natural course, thereby establishing natural immunity, played an outsized role in marginalizing science. It was successful in that it was a distraction from honest discussion, flooded the public conversation with doubt and uncertainty, and brought misguided, like-minds together. This caused irreparable damage to society, and only increased global danger. It is a relief that this ignorant effort was, and is, a clear failure.
Science as the Public Health North Star
Here’s a solution: let science guide public health policy.
How, you might ask? There are thousands of public health scientists - epidemiologists, biostatisticians, community health, health policy, and yes, environmental health scientists (my personal favorite) - across the planet who have expertise in all areas of public health. Speaking for the entire public health discipline, we know this stuff.
The Centers for Disease Control already has this expertise in all of these areas, of course, but we know many times their recommendations were constrained or censored for political reasons. They are, of course, employees to an employer.
Why not build and support select public health committees for anticipated public health hazards that follows the model for clean air science advisory committee (CASAC) by the US Environmental Protection Agency. While CASAC and its subcommittees are meant to support EPA in refining air quality regulations, there is no reason why similar groups that are aligned with different public health disciplines can not serve in a similar capacity, with the added role of providing emergency responses when, and if, needed. Imagine external expert groups at the ready from across the nation for topics like personal protective equipment, vaccine handling logistics, or public health community engagement and outreach.
But for now, we are stuck with the status quo. It remains a mish mash of efforts, subjected to the political winds. But what is well known is that public health is not a zero-sum game. We can all lose if we don’t get this right.
Science-driven public health has to guide us forward.