A last-minute deal to provide $15 billion for health costs fell apart before last week’s $1.5 trillion spending bill was passed. That will have almost immediate consequences. Money to pay for testing for uninsured patients will dry up within weeks, while funding for vaccinations for the uninsured will end within months. Spending on monoclonal antibodies will drop by nearly a third this week and run out entirely by the fall.
“I think this is a deadly mistake,” says David Eisenman, a physician at the UCLA Fielding School of Public Health. “Congress is making a potentially deadly mistake by waiting to invest until there’s another surge.”
What worries Eisenman and other public health experts is that another COVID-19 surge is not some abstract likelihood, but something that already looks predictable in the near future. Although cases have plummeted in the U.S., they have started rising again in parts of Western Europe and Asia.
Five out of the last five times there have been surges in Europe, surges have quickly followed in the U.S. There’s no reason to think the sixth time will be any different, especially with a more transmissible subvariant of omicron, known as BA.2, rising rapidly as a share of cases in the U.S. “Every time we’ve seen upticks around the world, we’ve seen upticks here,” says Chrissie Juliano, executive director of the Big Cities Health Coalition, a forum for the largest municipal health departments.
Already, cases have gone up over the past two weeks by more than a third in New York City, which has often been a harbinger for broader American surges. New York Mayor Eric Adams has been actively pleading with companies to bring workers back into offices, to help rebuild the Manhattan economy.
Adams’ stance is not unique. While Republicans have long been more wary of restrictions, even Democratic governors and mayors who imposed restrictions earlier in the pandemic have been trumpeting a return to normal. In a sense, they’re only reflecting the mood of a public that’s exhausted after two full years of pandemic disruptions. “What we’re seeing even in our community, which has in general broadly supported public health, is just true weariness and fatigue with the pandemic,” says Lisa Santora, deputy public health director for Marin County, Calif., which has among the nation’s highest rates of vaccination.
Santora notes that we have a lot more tools at our disposal than we did at the start of the pandemic, including not only effective vaccines but anti-viral pills and widely available testing. But those tools are of limited use if people aren’t using them. And the general political message of the moment – that the pandemic is receding into the rearview mirror – is making people complacent heading into potentially a dangerous time. Rather than preparing for the next wave, Congress appears more eager to end the mask mandate for air travel and public transit.
When it stops raining, you might put away your umbrella, but it makes no sense to throw it away as though it will never rain again.
“We’ve got a lot of tools that can really help us, but we can’t just stop putting the resources in place,” says Marcus Plescia, chief medical officer for the Association of State and Territorial Health Officials (ASTHO). “It’s just very frustrating to think that we’ve finally gotten to this good place and we have this impediment that Congress isn’t wanting to pay for it anymore.”
Lulled Into Complacency
Darker days are not all that far back in the past. January and February were the fourth and fifth worst months for COVID-19 deaths in the U.S., respectively, and represented the high point for hospitalizations during the whole course of the pandemic. While not as deadly as the delta variant, omicron was more transmissible. BA.2 is at least 30 percent more transmissible than the version of omicron that plagued the winter.
The nation was “lucky” that omicron was less severe than delta, Juliano says. But the exaggerated belief that it was “mild” may have altered public perceptions and led many people to lower their guard, especially if they’re up to date with their vaccinations. “There is a belief in the American psyche that COVID is mild,” Juliano says. “We may have done some collective damage there.”
Even if omicron didn’t shift the psychology, the sheer length of the pandemic may be encouraging people to shunt further concern aside. “We see this all the time with disasters,” says Eisenman, the UCLA physician. “There’s a point at which we move on and we don’t invest in the future – and we don’t learn from the disaster that we’re experiencing right now.”
The last great pandemic was the Spanish flu of 1918, which killed 50 million people worldwide, including an estimated 675,000 Americans. That pandemic endured, with a fresh wave in 1920 killing more people in several American cities than earlier outbreaks. “But virtually no city responded in 1920,” writes historian John M. Barry. “People were weary of influenza, and so were public officials. Newspapers were filled with frightening news about the virus, but no one cared.”
The New CDC Metrics
Thinking again about that protective umbrella, you might only carry it with you while the sun is shining if you see that there’s rain in the forecast. Some public health officials are worried that the nation’s COVID-19 forecasting system is becoming less sensitive. Last month, the federal Centers for Disease Control and Prevention unveiled a new set of metrics for looking at community transmission. There’s more focus on hospitalizations and less emphasis on individual caseloads.
In a lot of ways, it makes sense to move from man-to-man to zone defense. The case count is likely misleading, since more people are diagnosed through at-home tests that aren’t routinely reported. Checking levels through sewer samples may be more accurate in terms of spotting trends. And severe cases and strains on the hospital system matter more than individual cases, since most of those will be mild among the vaccinated and are now treatable for the unvaccinated (assuming they get tested in time for treatment to be effective). “Looking at serious cases is what we do for the flu and for every other respiratory infection, and I’m glad to see us treating COVID in the same way," says David Dowdy, an infectious disease epidemiologist at the Johns Hopkins School of Public Health.
Not everyone is so sanguine. Hospitalizations inevitably lag cases as an indicator. Also, the CDC’s color-coded county metrics are complicated in ways that make it more difficult for individuals and companies to gauge their own risks. Without that information, they’re flying blind. “We absolutely agree that we need to have an on-ramp back into public health policies that decrease the risk of medical surge, and that the CDC framework lags too much,” says Santora, the Marin County health official. “So, as a county, we'll be looking to the state to define what on-ramps look like.”
California, along with Colorado, Oregon and South Carolina, has released its own plan for coping with COVID-19 over the long haul, moving past the “crisis” phase. But the key is to remain proactive. Instead, several states have either shut down or are in the process of closing their testing sites.
“Transmission is low because we needed to do the things we needed to do,” Juliano says. “We were careful, we ate outside. That’s why transmission is low, not because COVID went away.”
Learning to Live With It
Dowdy notes that some of the countries that first saw the BA.2 subvariant, including the Philippines, India and South Africa, have not seen upticks in cases or in some cases are now near their low-water marks for the whole pandemic. What’s driving increasing caseloads in Europe, he suggests, is changes in behavior.
That points to the tricky dual message that public health officials are trying to present at this point. Yes, this is a moment when case counts and deaths have come down. You can take your mask off most places in relative safety. Things are a lot better than they were two months ago, so people can take a well-deserved break.
But people also have to be reminded to remain vigilant. While there’s a bit of permission to party, the party might be ending again soon. And it’s often tough to reimpose restrictions once they’ve been lifted, especially if there’s not much political support for doing so. “What a lot of residents may not understand,” Santora says, “is that when we set policies and recommendations, it's not to penalize humans, but it's to protect us from a virus.”
Public officials should be using this lull to prepare for the future. It’s OK to ease up and even be optimistic right now, but more problems are coming. Schools should be preparing to use their summer breaks to improve ventilation systems, while the federal government needs to be making further investments in testing and anti-viral treatments, rather than cutting them off. The remaining share of the unvaccinated who can be persuaded need to be reached and accommodated.
“There are a number of things that seem sensible that are getting kind of pushed aside,” says Plescia, the ASTHO officer. “It just seems like political will has atrophied, for sure.”
It’s often been said that just because we feel like we’re done with the coronavirus, the virus isn’t done with us. The highly transmissible BA.2 variant already makes up a third of U.S. cases, on its way to dominance. It will start spreading at a time when the nation is going unmasked, in a country with low levels of vaccination by rich-world standards, and with even the small share of the population that’s boosted beginning to have waning immunity.
“If there’s anything we’ve learned about this pandemic, it’s that it’s difficult to predict and we need to be prepared for the next wave,” Dowdy says. “When we talk about short-term measures, like masking, it’s reasonable to ease up. But when we’re talking about long-term preparation, we should not be easing up at all.”
