What we’ve done. And what lays ahead. Covid-19 in 2022, Part 1 – Michael Fine

by Michael Fine, contributing writer, opinion

Introduction

What follows is the first of four essays about Covid, our culture, our time, and the moral responsibility we share for what we have, where we are and what we’ve done.

Part 1: What We’ve Done.  And What Lays Ahead. Covid-19 in 2022

© Michael Fine 2021 

Here are the numbers: Rhode Island had 260 deaths in January of 2022, almost as many as in the second six months of 2021 – and all likely preventable.

The good news in Rhode Island is that community spread, and hospitalizations appear to be dropping as most epidemiologists predicted — and I hope and pray that deaths will start dropping as well.  Rhode Island has done an amazing job of using antivirals and monoclonal antibodies to reduce deaths.  But 44 percent of deaths were still in vaccinated people in December and January. That’s 172 vaccinated Rhode Islanders who died only because our political leaders refused to endorse simple public health measures like masking, and because we fought with one another about these small inconveniences, which made those political leaders unwilling to lead.   All those deaths were preventable if we had focused on community transmission instead of pizza and Christmas shopping.  But dead people don’t vote. Whether live people will remember and vote these people out is an open question. 

The bad news is that we still have lots of virus around, and no way to predict when the next bad variant, or bad virus, hits. And since immunity to Covid waxes and wanes, it is still possible to get a cluster of cases in a business or school, although as Omicron recedes, I think that will be progressively less likely, at least until the next variant hits. I’m hoping that Omicron will have spread enough to whip up robust but transitory immunity in enough people to make community spreads less likely, but that isn’t possible to predict with certainty, and it is unwise to count on it, in this disease we are just starting to understand — forewarned is still forearmed.

And we still aren’t prepared for the next time — we continue to fail to require indoor masking regardless of vaccine status and have allowed large events and bars and restaurants to open freely despite wide community spread, even when we had near universal spread in fact. Our schools still don’t have the resources they need to do rapid testing on every student once a day, so we can expect to see outbreaks at schools. We’ll probably have 100-200 Rhode Island deaths in February, all preventable.

To make life more complicated yet, the measures we were using to steer policy by, have changed.  Omicron appears to cause fewer hospitalizations and deaths as a percentage of people infected, but we don’t yet know how many fewer. The meaning of number of new cases/100,000/day has become fuzzy in a time when lots of people are using rapid tests at home.  The number of hospitalizations and deaths is more useful as data, but they are a trailing indicator – they tell us about the level of community spread two to four weeks prior, but not much about community spread today, and community spread is the most significant risk factor for hospitalizations and deaths in the at-risk population – the unvaccinated, and those over 80, 65, and those with chronic disease, vaccinated and unvaccinated. 

So, if we were serious about trying to prevent hospitalizations and deaths, we should be very, very careful, and not start moving about again and unmasking until the number of  hospitalizations and death are very small– in Rhode Island, likely less than 5 Covid deaths per week, which is about the level of death we see from yearly flu. That means we may be delaying moving about and unmasking a few weeks unnecessarily – but I think that caution, though frustrating, makes sense, because we can’t get the lives lost back. But we’ll lose bars and restaurants, you might say. We are losing more every day.  That stinks.  I love a good dive bar.  Still, you can support and restart bars and restaurants, is my answer. But you can’t bring back a loved one who died unnecessarily from a preventable disease.

The challenge now is to think out what we are now trying to achieve and to focus on those goals.

We should be working on two things: continuity of operations – what to do when a bunch of people who work or live together get sick at once — and the prevention of preventable deaths.  And we have to answer the question about when we can stop masking in schools, an answer to which is made hazy by way too much fake news and propaganda spread by people and governments who only want to divide and confuse us. The announcement by governors of some states that they will end school masking in March – or February – is irresponsible political pandering. I don’t know, and neither does any governor, what the level of community spread, and associated hospitalizations and deaths will be in March, or whether we’ll have a new variant by then, and until we know those things we should not change or promise to change mask rules.  The level of community spread will likely jump up again the moment we loosen restrictions if we do so too early, and our governors will cause more hospitalizations and death if we don’t already have full access to antivirals, monoclonal antibodies, and an airtight system for getting those medications to people at risk who get infected as soon as they become symptomatic before we liberalize restrictions.

Doctors would get sued for malpractice if we did something like these governors propose.  Governors will be morally culpable for these preventable deaths — should be held to the same standard that health professionals are – but aren’t.  By anybody, not even themselves.

Continuity of operations is a big issue in schools, which are at reasonable risk for disease transmission because not enough kids are vaccinated (only about 40 percent of kids 5-11 and 60 percent of those 12-18 are vaccinated), but whose students are at low risk for hospitalization and death, although staff over 65 have some risk, particularly if they are unvaccinated.

To make things worse, school principals, school boards, unions and administrators are beset by a zillion complicated guidelines and mandates, almost none of which are clear enough to steer by or make any sense, and many of which appear more influenced by the politics than they are by the science.  The focus of all these guidelines should be on keeping schools open, understanding that when virus hits a class or a school, many people – students and staff—are likely to get sick at once and have to stay home to recover – which makes it hard to operate a class or a school.

There isn’t really enough science to help schools choose how to handle continuity of operations. Or make good decisions about masking.

I think there are two rational approaches to school opening and closing, understanding that in a rational world we’d already have required kids to be vaccinated as a condition for school attendance, and have found ways of letting teachers and staff over 65 work from home as long as community transmission is high.  Neither of those things are happening, as far as I can tell.

The most conservative approach for schools is for a class to go virtual for two weeks once there are more than two people in it sick inside twenty-four hours, and for a school to go virtual for two weeks once two classes have had to go virtual. That approach will likely keep too many classes and too many schools virtual if there is robust community transmission, which stinks from an educational and mental health perspective.  But it will contain spread and keep classes and schools from getting to the point they must close because there aren’t enough teachers, staff, or students to operate.

This approach is the best way to keep schools from contributing to community spread, although it is unclear whether schools do that, or whether it is community spread that infects schools.  Studies so far suggest the latter, but I’m not convinced by them.  Those studies have lots of methodological problems which I won’t go into here.  I’m guessing the right answer is that both happen, and the likelihood of one versus the other is a function of community population density, socioeconomic status, and the transmissibility and virulence of different viruses and different viral strains.

The most liberal approach is to operate until a school has lost so many students, teachers, or staff to illness that it can’t operate, and then go virtual for two weeks. That approach will keep classes and schools open longer, but more people will get sick; it will put some older teachers and older staff at small but measurable risk of hospitalization and death, and likely contributes to community spread instead of helping stop it.

And to be clear, there is no definitive science that tells us which approach keeps schools open and in person better, which approach protects the health and safety of students and staff better, or which approach prevents hospitalization and death in the wider community better.  If I had to bet, I’d bet that the conservative approach works better in densely packed low-income areas and the liberal approach works better in the suburbs.

In a more perfect world, we would be pouring resources into the schools of the densely packed low-income areas so they could run the more conservative approach without hurting the educational and mental health of the students who live there, who are already disadvantaged by a society that tolerates way too much inequality in our kids. 

So overall I favor the first approach because it likely protects staff and reduces community spread best – which means it places greatest value on the value of human life, and by so doing teaches kids about civics and democracy as well as the three Rs.  But it’s the harder pathway politically, takes more courage, and asks political leaders to lead with moral integrity instead of finessing the politics.

The question about masking in schools has a similar answer:  I’d use an abundance of caution approach, both to assure continuity of operations and to prevent community spread and protect the most frail. The virus will exploit any opportunity we give it.  Stop masking while there is robust community spread and the virus will spring back.  It’s a snake waiting to strike the moment we take it out of the box. 

In the best of all possible worlds, we’d be rapid testing every kid every day for the rest of the school year and could stop masking about a month after a school doesn’t have a class that hasn’t had two cases in 48 hours, or about a month after Rhode Island drops below five positive Covid tests a week. If we’re not testing every kid every day, I’d probably wait until we drop below five deaths a week. So, likely not until May. That stinks but there are no short cuts that won’t cost class or school closures and lives.

To prevent hospitalizations and deaths at this point, we need to focus on reducing community transmission, vaccinating everybody, masking in public places, testing everyone who enters a public venue every day, and cocooning the elderly and those with severe chronic disease. 

All that changes in late March or early April, when effective anti-viral and monoclonal antibodies become widely available.

Then the focus needs to pivot to making sure anyone at risk who gets sick gets tested and treated within twenty-four hours, which itself is a big lift in a state and a nation without a health care system that cares for everyone, and in a culture with a very short attention span. But if we get this organized and I’m right, and that approach works to radically shrink hospitalizations and deaths, then and only then can we dump the masking and social distancing IF we don’t get a bad variant by then – and only after we know that approach works, not before. Which means we should be hard at work now, making sure we are building a seamless system that gets everyone at risk tested and treated at home within twenty-four hours of symptom development, a system with an 800 number, and test-and-treat flying squads.

I’m guessing that we won’t see another bad variant until next fall, if we see one at all. If we were smarter than we usually appear to be, we’d plan for that eventuality, and restructure school vacation schedules, so there are a couple of ten day breaks between Halloween and Martin Luther King’s Birthday, which might be expected to slow disease transmission, and a shorted summer vacation, seeing as how few kids in Rhode Island now have to work with their families on family farms, which was the reason we started long summer vacations in the first place

Thanks for reading.

Michael

Many thanks again to Nick Landekic, who provided me with tons of data and publications over the last twenty months, and whose knowledge of Covid-19 is encyclopedic; to Deborah Faith, MPH, for her unending editorial support and great editorial suggestions, and to Kendra Tanquay, for her support of my writing over many months.  Thanks as well to the many readers who respond to these emails and help keep me honest.  Part of one of these emails was written in response to a very good question.  Thanks for that question, Matt.

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Michael Fine, MD was the Director of the Rhode Island Department of Health from February of 2011 until March of 2015. His career has been devoted to healthcare reform and the care of under-served populations. He served as Medical Program Director at the Rhode Island Department of Corrections; and 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, and rural Scituate, RI. He is the former Physician Operating Officer of Hillside Avenue Family and Community Medicine, 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 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.

Dr. Fine is past President of the Rhode Island Academy of Family Physicians, has served on a number of legislative committees for the RI General Assembly, chaired the Primary Care Advisory Committee for the RIDOH, 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.