The recent Chicago public school crisis, collapse of Broadway theater in New York City, ongoing changes in NBA and NFL screening protocols for players, and extreme scarcity of rapid tests throughout the nation all serve as a deafening wake-up call for urgent revision of our national COVID-19 response plan. These and similar scenes of chaos and conflict over the reopening of American institutions and commerce reflect the absence of a coherent national plan that is responsive to the contagiousness of the Omicron variant. Central to this current failure is the need for a clear national definition of “public safety” that the American people can understand and buy into. Vague and impressionistic appeals to “safety” are riven by partisan divisions over real-world policy and implementation.
First, we must fix this definition of safety as the necessary foundation to building a robust national plan. Second, our COVID-19 policies should not abruptly lurch from scientific study to study, changing availability of vital tools, and move from federal agency to agency. Rather policies must pragmatically respond to motivators of human behavior and to a coherent view of where the pandemic is headed.
The new plan must face into current political realities.The best single predictor of Americans’ response to the pandemic has been their political ideology and partisanship. Polling throughout the pandemic has consistently revealed a deep Red State/Blue State polarization in COVID-related attitudes, behaviors and policies. Significant differences in immunization and death rates are also noted across party lines at both the state and county levels. This becomes especially relevant when considering that over the past year there was a 17 to 20-fold increase in the hospitalization and mortality rates in unimmunized versus immunized populations.
The Omicron variant’s communicability and rapid spread has further exacerbated these divisions. Most states are currently experiencing their highest yet pandemic caseloads, though starting to decline in some places. Health systems and providers are overwhelmed and burned out. At the same time schools, colleges, employers, and most segments of society are struggling to “return to normal” as they contend with pushback from key constituents over the definitions and markers of safety. As a nation we are stagnating because we simply haven’t come to grips with what we need to do.
Dr. Anthony Fauci, the President’s chief medical advisor, has recently championed, “we have to get the American people to pull together.” But patriotic appeals for bipartisan harmony are woefully insufficient to unite us. To restore our dynamism and prosperity we must forge a new national COVID-19 plan based on a pragmatic application of public health principles that encompasses both of our familiar political counter-narratives.
The liberal narrative calls for infection-avoidance at all cost and is more willing to accept socioeconomic consequences of personal and societal safety measures. Conservatives tend to have a higher risk tolerance for infection and are more willing to accept its health consequences for themselves and the public.
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Bipartisan policymaking must be evidence-driven and responsive to both political narratives. Neither counter-narrative has a monopoly on “following the science.” Omicron is politically agnostic. While the virus is blind to religion, ethnicity, race and gender, it does render the economically disadvantaged and those with underlying health conditions highly vulnerable. It also has a fierce geriatric agenda. This leads to an aspirational but achievable framework for a new national policy with four pillars responsive to Omicron’s now reasonably well-defined characteristics:
1) Change the national policy goalpost for the non-vulnerable
Our present goal is to avoid cases or infections—defined as test positives—in everyone. With the unprecedented communicability and relatively mild health outcomes of Omicron this is unsustainable and unnecessary. The new foundation and lynchpin of our national goal must be serious health outcomes (ER visits, hospitalizations and deaths) in the 260 million non-vulnerable Americans. A University of Washington review of recent studies and modeling concludes that Omicron is 90-99% less severe than Delta. This is due to a large increase in asymptomatic infections (about 80-90 percent of total), a 50 percent reduction of those who are symptomatic being hospitalized, and of those hospitalized a 5-10 fold reduction in dying. These numbers put the relative risk of serious illness from Omicron in the non-vulnerables in the same ballpark as the flu, a virus we have learned to live with.
Many non-vulnerables equate infection with fear of dying, debilitating long-term effects, and jeopardizing the safety of loved ones. These emotions are deeply-ingrained from two years of fear. This is frequently reinforced by emphasis on alarming uncertainties by our public health officials, scientists, mainstream and social media. This does not reflect a balanced data-driven risk assessment. Important concerns should be addressed by focusing on protecting the vulnerable. A robust nationwide public education campaign to build confidence in this strategy and to address fear, misconceptions and relative risk must accompany movement of the goalpost to focus on serious outcomes.
The longer we delay in making this inevitable political and cultural transition in resetting our goals from avoiding infections to avoiding serious disease, the longer this political bifurcation and conflict will continue to hamstring us.
2) Focus public health and social protection on the most vulnerable
Eighty percent of America’s COVID-19 deaths and 46 percent of hospitalizations are concentrated in older people and the immunocompromised. Over-65’s have a 95% full vaccination rate and more than half have received a booster, but they are still at risk for breakthrough infections and serious outcomes. This population continues to absorb the brunt of the pandemic’s wrath and every effort should be in place to mitigate their risk. With Omicron’s risk profile, avoiding infection is an obligatory common sense mitigation strategy only in the vulnerable population. In congregate facilities this means avoiding exposure through mandatory vaccination and rapid screening of staff and guests. We must also ensure their ready access to the remarkably effective new oral anti-viral therapies. It’s more difficult to ensure these protections in multigenerational households and public indoor settings, and this merits further consideration of housing and other indoor mitigation best practice.
3) Maximize voluntary vaccine uptake while minimizing mandates.
Vaccination is strongly protective against serious consequences caused by Omicron. Yet about 39 million Americans remain highly resistant to being vaccinated. Nearly everyone will become at least partially immune in the current surge through vaccine or natural infection-generated immunity. When the unvaccinated become infected they passively provide further public good benefit in slowing transmission—although the amount can vary considerably across individuals. Immunization policy should consider the marginal cost-benefit of general mandates under these circumstances.
The public health risk that unvaccinateds present to vulnerables should be the major driver of vaccine mandates. Policy mandates should be applied in a more targeted way focusing on high priority public health impact (eg. nursing homes and health care workers). We should avoid mandates in settings where the political friction outweighs the public health benefit.
4) Re-cast the role of preventive interventions
Policies involving masking, physical distancing, quarantine, self-isolation, and screening and surveillance testing should be re-examined to align with the new goalposts. Public policy should mandate these interventions only where interruption of transmission is of clear public health benefit in high-risk settings—defined as those directly affecting vulnerable people—such as public transport, congregate facilities and multi-generational households. The role and indications for routine rapid testing and surveillance of asymptomatic populations should be closely evaluated. Personal and institutional choice should be allowed to govern use of these preventive interventions in non-high risk settings.
Omicron’s ubiquity and much lower virulence has given us the biological signal to move on to the inevitable endemic “living with the virus” endgame. The country must now challenge itself in both the public policy and personal realm to heed its implications. Omicron has presented us with clear new bipartisan goalposts: prevent serious outcomes in 260 million non-vulnerable Americans, and infections in the remaining 70 million. Our job now is to get the ball in the end zone.
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