Covid and Citizen Public Health. Masks and a few other ideas – Dr. Michael Fine

By Michael Fine, MD, contributing writer

© Michael Fine 2023 

Good news: Data from densely populated communities and the state data suggests we are likely past the peak of the most recent surge-let, earlier than I thought.  Hospitalizations and deaths went up briefly but are now declining again.  We had many more illnesses, hospitalizations, and deaths than we should have because we didn’t mask enough, in the right places and in time.

All that doesn’t mean we are done for Covid for the winter.  It does mean there is lots of virus still around, just a little less than a few weeks ago – and it does mean we’ll likely have three to four more weeks of robust viral transmission, instead of eight to ten weeks or more.  Not perfect but better than last winter, a winter of 500 Covid deaths in Rhode Island. (I’m guessing we’ll have 100-150 Covid deaths this winter.)  It also means we are more immune than we were, that we are on a year-over-year process of declining hospitalizations and deaths despite plenty of infections, and that we are watching the evolution of community immunity happen right before our eyes, understanding that there are no guarantees, and another bad variant or virus could still evolve and start the cycle again soon.

But we are better than we were.  This is the difference between a spark in the California forests on a windy day after two years of drought, and a spark in a California forest on a windy day a week after a good heavy rain.  The underbrush will burn both times.  But we won’t see huge wildfires and the redwoods burning a week after a rain.

What’s more, we now know we have the ability to markedly reduce viral transmission, keep people from getting sick, and reduce hospitalizations and deaths now, and at every subsequent surge or surge-let – if we act together.  That’s an idea I call Citizen Public Health.

After my last email, I heard from two people who doubt the efficacy of masks and vaccines, people who were kind enough to send along evidence that they believed shows that masks don’t work and vaccines are dangerous, evidence I carefully reviewed with my collaborator Nick Landekic, because I wanted to be sure we weren’t missing something:  I’m something of a skeptic about the standard party line myself, having witnessed CDC’s interesting performance over the last few years, knowing CDC a bit from the inside, and knowing more than I want about the medical-industrial complex, which puts profit over people’s lives and the agency and vibrancy of communities.  So, Nick and I reviewed the world’s literature on masking, in part because of the pushback we got from those readers, and in part because we are hearing stories of flight attendants on airplanes asking passengers not to harass the people who are masking (only 10-15 percent of people on airplanes now, despite plenty of evidence of viral infection on airplanes), the airplane equivalent of please don’t feed the animals, in zoos.

Here’s what we found: masks work to prevent viral transmission, hospitalization, and death.  They aren’t perfect.  Even the data that those good people sent me, the ones with “masks don’t work” in the subject line, cite studies that found masks reduce transmission by 15 percent. Good studies we found suggest that number is as much as 85 percent or more, depending on the mask used and the fidelity with which they are used.

Masks work a number of ways: they stop infected people from shooting as many viral particles into the air.  They reduce the number of particles (the viral load) that an uninfected person inhales, reducing the severity of infections for some, but giving others a very mild exposure that tops up their immunity without causing disease or viral transmission, for others.  Masks also humidify the air in the respiratory tract, allowing the body to clear viral particularly (and other junk) out of the lungs quickly and effectively.

So, what’s the beef?

The beef is that people are worried about new mask mandates, particularly in schools, where masks may in fact be problematic as they impact learning, and schoolchildren themselves are at very low risk of hospitalization and death from Covid-19, although infants younger than six months turn out to have a significant risk of hospitalization.  People are worried about mask mandates from a government they don’t trust.  And we’ve let masking become politicized, the way we’ve let the flying of the American flag flying in the back of pickup trucks become politicized and the way we’ve let immigration become politicized.  Some people think masks are like flags, signifying that people who wear them are like Nazis marching in lockstep, just taking orders, that masks are some kind of social or cultural statement, and not what they are, which is a simple and effective way to spread the spread of disease during a period when viruses are spreading.  Those people think the government is trying to tell them what to do, and they don’t trust a politicized government led by politicians of all stripes who seem to be mostly about building their own careers.

I get that. But I wasn’t advocating mandates, and I didn’t call for universal school masking.  Instead, I suggested that everyone mask in indoor public places, just for the next few weeks, not forever, just until this surge or surge-let fades away; and I was and am suggesting that people over sixty-five and those with chronic disease both mask in public places and avoid bars, restaurants, and theaters, again, until community transmission drops lower.

Masks aren’t chains, handcuffs, or chastity belts.  They are just little swaths of paper that don’t do anything worse than fog my glasses. 

Why did I suggest that people over sixty-five and those with chronic disease both mask in public places and avoid bars, restaurants and theaters for the next few weeks?  Because 90 percent of hospitalizations and deaths are now in people over 65.

And I didn’t suggest a mandate, because we are at a different point in the pan/epidemic – most of us have some immunity.  That doesn’t mean we might not need a mask mandate for periods at some time in the future if we get a bad variant or a new virus that spreads through the air.  I just don’t think we need a mask mandate now.

But I also want to take a moment to call out the power of what people can do together to prevent hospitalization and death, at this moment when we have a divided, impotent (and some would say, snowflake) government, that is more about protecting commerce and getting reelected than it is about doing the job of government, which is to protect the health, safety, and well-being of its citizens.

I want, and wanted, to call attention to what we can do together, on our own, what government doesn’t seem to be able to act.  We can choose ourselves to mask and take other measures to reduce viral transmission, and together grind this old virus into the ground.

That’s what I mean by Citizen Public Health.  All of us, of many of us, or even some of us, can choose to act together, to do what makes sense, even if no government lacks courage to recommend it.

It’s not possible to project the impact of everyone masking in a densely populated community with precision.  Densely populated communities are where masking matters most, but I’d bet that universal masking in those communities, if people chose to do it on their own, might cut the number of people sick in half, and the duration of the surge period in half as well, from about six to eight weeks to three to four weeks.  (I’m not convinced that masking would have that much impact on public health in rural areas where the intensity of community spread is lower.  Masking does protect those over 65 and the at-risk population in those places though.)

Remember, there are two reasons for masking:  first, to protect yourself from getting sick, even if you are young and aren’t likely to die of Covid now, and then to protect other people, those over 65 and at higher risk.  Who wants to be sick with a fever, headache, cough and be out of commission for two to five days or more, if you can avoid it?  And risk long Covid, which seems to last for about a year.  And who wants unnecessary hospitalizations and deaths?

Think of how cool Citizen Public Health is, for a minute.  People acting on their own but together can limit the spread of a virus, save some lives, and keep a bunch of people from getting sick and missing school, their book club, weddings and so forth, just be using these little swaths of paper for a few weeks.  Think of how powerful we are, how we can limit the spreads of a virus ourselves, without the CDC and Governors, who seem to have gone AWOL anyway.

That said, I also think it is worth listening carefully to the people who are saying masks and vaccines don’t work and understanding what is worrying them. The evidence, when you look closely at it, says clearly that both masks and vaccines work to save lives.  Much of what the people who are opposed to masking and vaccines think is evidence turns out not to be evidence at all, when you look at it closely, as Nick and I have been doing.  What those people cite as evidence doesn’t show what they think it does, on close reading.  Much of what is quoted is a misreading of a scientific study or two by people without enough experience reading the breadth of the scientific literature to put one study in the context of the broad sweep of the development of knowledge.  

But let’s think, for a moment, about why good people are worried, instead of dismissing them out of hand.  I think some good people are worried because the messaging from CDC was inconsistent and contradictory, itself because the politicians who cycle through government put pressure on the CDC and state departments of health to say what they thought was the right thing to say politically, because the politicians are so busy finessing the truth for their own advantage that they forgot all their silliness would kill millions of people here and around the world, which it did.  The compromise of CDC and state department of health is a problem to be sure.

But these good people are mostly worried because we’ve let health care become for-profit. 

Here’s the rub. Good people have legitimate worries about the integrity of the recommendations for vaccination, because they understand that vaccine companies exist to sell vaccine, that there is a government-medical-industrial complex in which people in the health care biz rotate in and out of government, and so they worry that recommendations are not being made to save lives, those recommendations are being made to make money, in the echo chamber of people who don’t live in the real world, have to ever make payroll or worry about missing a car payment.  They worry and believe that they are being lied to.

And those good people are not entirely wrong. They’re wrong about the specifics, this time, mostly. There are some legitimate questions emerging about the risk-benefit ratio for booster vaccination of people under fifty in general and kids in particular.  But these are questions we in developed nations can now afford to ask, given most people are vaccinated or immune and the risk of hospitalization and death is trending slowly downward, questions that we always ask after a vaccine has been in wide use for a while, after we’ve seen its impact on five hundred million or five billion people, instead of the five thousand we study in Phase Three trials.  We’re not in the middle of a pandemic that is likely to kill millions more people if we don’t have a vaccine, anymore.  We can and should be doing a little recalibration, which is what we always do, once we have the time and space to study the situation that is evolving.

What bothers me is that no one is listening to the fears and worries of the good people who are scared. 

For-profit health care has lots of risks. It is an impure process, at best. It offers a service or products people want, but for-profit health care doesn’t put the health and safety of the population first, it puts its own profit potential first.  So, for-profit health care is always pushing to sell more product, whether people need that product or not.  Which leaves millions and millions of good people wondering – do I really need this, or is there a grand conspiracy to convince me I do, so someone else can make a profit on my back.

In this period when government is too often co-opted by people with money to do the will of those folks with money instead of doing the people’s business, those good people with doubts have legitimate fears.

For-profit health care impugns the democratic process by concentrating wealth in a few hands, and by creating a society in which some people are allowed to profit from the misfortunes of others, a certain formula for the disappearance of civic trust and societal collapse over time.

And this kind of unregulated, for-profit health care isn’t our only choice. Polio vaccine was developed without attention to profit.  So was infant rehydration solution, little packets of nutrients that save millions of children in developing nations every year.

On the other hand, now, just think of how much we’ve been able to accomplish together by acting out of a concern for the common good in our history. We’ve doubled the average human lifespan. Created democracy. Ended slavery, at least in most of the world. Fed billions. And how much more we can do, if we listen, learn from one another, and keep our eyes on the prize.

Think back with me, for a moment, about the notion of Citizen Public Health.  We can and should slow pandemics by acting ourselves, without the government-medical-industrial complex.  By acting powerfully in association.

And if we can do those things, surely, we can create a health care system that is for people, not for profit, and put the doubts of the good people who are worried to rest, while we protect the health and safety of everyone.

Many thanks again to Nick Landekic, who provided me with tons of data and publications over the last thirty-two months, and lots of wise interpretation of that data, and a sure moral compass and whose knowledge of Covid-19 is encyclopedic, and to Brianna Benjamin, who makes sure these blasts get to you. Thanks as well to the many readers who respond to these emails and help keep me honest. 

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Michael Fine, MD is currently Health Policy Advisor in Central Falls, Rhode Island and Senior Population Health and Clinical Services Officer at Blackstone Valley Health Care, Inc. He is facilitating a partnership between the City and Blackstone to create the Central Falls Neighborhood Health Station, the US first attempt to build a population based primary care and public health collaboration that serves the entire population of a place.

He has also recently been named Health Liaison to the City of Pawtucket. Dr. Fine served in the Cabinet of Governor Lincoln Chafee as Director of the Rhode Island Department of Health from February of 2011 until March of 2015, overseeing a broad range of public health programs and services, overseeing 450 public health professionals and managing a budget of $110 million a year.

Dr. Fine’s career as both a family physician and manager in the field of healthcare has been devoted to healthcare reform and the care of under-served populations. Before his confirmation as Director of Health, Dr. Fine was the Medical Program Director at the Rhode Island Department of Corrections, overseeing a healthcare unit servicing nearly 20,000 people a year, with a staff of over 85 physicians, psychiatrists, mental health workers, nurses, and other health professionals.

He was a founder and Managing Director of HealthAccessRI, the nation’s first statewide organization making prepaid, reduced fee-for-service primary care available to people without employer-provided health insurance. Dr. Fine practiced for 16 years in urban Pawtucket, Rhode Island and rural Scituate, Rhode Island. He is the former Physician Operating Officer of Hillside Avenue Family and Community Medicine, the largest family practice in Rhode Island, and the former Physician-in-Chief of the Rhode Island and Miriam Hospitals’ Departments of Family and Community Medicine. He was co-chair of the Allied Advocacy Group for Integrated Primary Care.

He convened and facilitated the Primary Care Leadership Council, a statewide organization that represented 75 percent of Rhode Island’s primary care physicians and practices. He currently serves on the Boards of Crossroads Rhode Island, the state’s largest service organization for the homeless, the Lown Institute, the George Wiley Center, and RICARES. Dr. Fine founded the Scituate Health Alliance, a community-based, population-focused non-profit organization, which made Scituate the first community in the United States to provide primary medical and dental care to all town residents.

Dr. Fine is a past President of the Rhode Island Academy of Family Physicians and was an Open Society Institute/George Soros Fellow in Medicine as a Profession from 2000 to2002. He has served on a number of legislative committees for the Rhode Island General Assembly, has chaired the Primary Care Advisory Committee for the Rhode Island Department of Health, and sat on both the Urban Family Medicine Task Force of the American Academy of Family Physicians and the National Advisory Council to the National Health Services Corps.