Authored by, Wafaa M. El-Sadr, M.D., M.P.H., M.P.A., , Ashwin Vasan, M.D., Ph.D., , Ayman El-Mohandes, M.B., B.C.H., M.D., M.P.H.
Audio Interview
Interview with Dr. Wafaa El-Sadr on navigating the current moment in the Covid-19 pandemic and learning lessons from past successes and missteps. (09:54)Download
We’ve come a long way. From the early, terrifying days of a rapidly spreading deadly infection to the current circumstances in which — despite a recent steep rise in transmission rates — Covid-19 has, for many people, become no more than an occasional inconvenience, involving a few days of symptoms and a short isolation period. It’s clear that for many, if not most, people, SARS-CoV-2 infection no longer carries the same risks of adverse outcomes as it did in the early months of the pandemic. These shifts have led to a widespread assumption, fueled by political and economic priorities, that the pandemic is behind us — that it’s time to let go of caution and resume prepandemic life.
The reality, however, would starkly contradict such a belief. Covid-19 currently results in about 300 to 500 deaths per day in the United States — equivalent to an annual mortality burden higher than that associated with a bad influenza season. In addition, many people continue to face severe short- or long-term Covid-19 illness, including people who lack access to vaccines or treatment and those with underlying conditions that impair their immune response to vaccines or render them especially vulnerable to Covid-associated complications. The ever-looming threat of the evolution of a new variant, one that can evade our vaccines and antivirals, remains very real. These facts support the assumption that SARS-CoV-2 will continue to play a major role in our lives for the foreseeable future. This new reality compels us to navigate a more complex social, economic, political, and clinical terrain and to take to heart the lessons learned from the Covid-19 response thus far — both the successes and the missteps.
To date, monitoring of the effects of Covid-19 has rested on several epidemiologic and clinical measures, which have shaped the recommended or mandated protective actions. Most commonly, these measures have included estimated rates of Covid-19 cases, hospitalizations, and deaths; monitoring has also been conducted of circulating SARS-CoV-2 variants and their susceptibility to available vaccines and treatments.
Yet in the current situation, some of these traditional measures have limited value. For example, the availability of rapid antigen tests that can be conducted at home — the results of which often aren’t captured by public health surveillance systems — challenges the validity of reported case numbers and transmission rates in some jurisdictions. There is therefore a need for unbiased monitoring of transmission and infection rates by means of regular testing of sentinel populations or randomly selected representative samples of the general population.1,2 Hospitalization and death rates are certainly more reliable measures than case rates, but these measures are limited by the fact that some hospitalized patients with SARS-CoV-2 infection have been admitted for other reasons and only incidentally tested positive. Furthermore, hospitalization and death are distal outcomes, so their rates have limited value for triggering early action to control the spread of infection and averting the consequences of a surge in cases. Other measures have gained prominence and now play a critical role in defining risk for infection or severe disease. Vaccine and booster coverage and availability and utilization of treatment for Covid-19 are critical variables that affect both the risk of severe illness or death from SARS-CoV-2 and health system capacity and access.
We have gained a deeper appreciation of the breadth of the pandemic’s effects, beyond its obvious health effects. These effects have included loss of employment or housing, disruption of educational systems, and increased rates of food insecurity. Many of these negative social and economic effects were unintended results of mitigation measures, including stay-at-home orders, the shutting down of public venues, and transitions to remote learning. Although these measures were appropriate at the time, their effects weren’t evenly distributed, with some communities facing disproportionate hardship, particularly historically marginalized racial and ethnic groups and communities with limited social and economic reserves. It is thus necessary to take into account the ways in which public health recommendations and policies may differentially affect various subgroups of the population. Government and nongovernmental entities need to create clear pathways for vulnerable populations to obtain access to the resources they need, including masks, vaccines, no-cost treatment, direct economic assistance, supplemental food, rent abatement, and Internet access to support virtual learning and remote access to health services.3 Such an approach requires that the federal government continue to invest in the Covid-19 response, since private-sector investment will be insufficient to meet all needs.4
One of the key challenges that the public health community faces as the pandemic evolves is the need to move away from universal recommendations, or population-wide prevention policy, toward a more differentiated or tailored approach — one that takes into account the characteristics of various communities and the pathogen. Relevant characteristics may include those that influence virus transmission or clinical outcomes, such as vaccine and booster coverage and risk factors for severe outcomes, including chronic medical conditions, racism and discrimination based on ethnicity, and lack of adequate health insurance. The implementation of tailored guidance for specific populations, however, is complicated by the legacy of glaring health disparities, the threat of stigmatization, and prevailing mistrust of authorities in some communities. Health-equity and antiracist principles and insights from the fields of health communication and behavioral science must therefore be taken into account from the start in the development and dissemination of recommendations and the implementation of programs and policies.3,5
There is much to lament in the politicization of the Covid-19 pandemic, the spread of disinformation and misinformation, the deep divisions within the U.S. population and, globally, in people’s perceptions of the pandemic and willingness to trust guidance and embrace protective measures. These divisions should inspire a reexamination of the reasons that some public health recommendations fell flat, in addition to an acknowledgment that political expedience played a role in sowing mistrust. As the pandemic evolves, as the measures of its effects become more complex, and as guidance requires greater tailoring to specific populations, effective communication becomes even more important. Providing clear guidance, including explaining the rationale for various recommendations, acknowledging the social and economic trade-offs involved in complying with them, and offering people the resources they will need to effectively manage these trade-offs, would go a long way toward enabling the adoption of those recommendations.
Most important, attention to the engagement of trusted community leaders and spokespeople is required, as is listening authentically to communities from the start. Rather than focusing solely on what is being recommended, it’s equally important for public health leaders to focus on how recommendations are communicated and disseminated. Early engagement of community representatives is critical so that various aspects of anticipated guidance can be discussed in detail, including rationales, trade-offs, and the most appropriate communication channels and formats. Engagement must not only come in the form of an emergency response, but must involve a consistent presence, which can then be leveraged and activated further during times of urgent need.
The current moment in the Covid-19 pandemic is a pivotal one. There is an urgent need to confront a future in which SARS-CoV-2 will remain with us, threatening the health and well-being of millions of people throughout the world. At the same time, it’s important to acknowledge that objectively we are in a better place with regard to the virus than we’ve ever been and that in fact many people believe the pandemic is behind us. This reality compels us to avoid using alarmist language and to offer valid and feasible solutions to bring people along to a new, nonemergency phase of the pandemic. How we craft our policies, programs, and associated messaging in this context and who delivers the messages is as important as ever.