Atlanta, Georgia - January 28, 2022: US Centers for Disease Control and Prevention (CDC).

Unmasking Public Health

By Jane Moriarty

One of the U.S. Centers for Disease Control and Prevention’s stated “essential public health services” is to “create, champion, and implement policies, plans, and laws that impact health.”

Yet, as the U.S. slogs through its third COVID winter, one thing is clear: personal responsibility and autonomy are at the heart of public health messaging. As CDC director Dr. Rochelle Walensky famously said, “your health is in your hands.”

In other words, CDC and other public health bodies now highlight personal responsibility and autonomy, and minimize the institutional ability to champion policies and laws that would improve the health and safety of the citizenry.

Given the comparatively poor results that the U.S. has had compared to other similarly-situated countries that focus more on the common good, it is time for our public health entities to reinvigorate their role as a force of legal and moral suasion to protect the public’s health.

The moral value of protecting the health of the public should be at the forefront of their messaging. Personal responsibility and autonomy are no match for the reality of commodified and unavailable health care, internet disinformation, health vulnerabilities, age-related vulnerabilities, the lack of paid sick leave, poverty, and the plight of the institutionalized.

Where we are now

For many Americans, COVID fears have receded. Few appear to be paying much attention to the disease, in line with President Biden’s statement that “the pandemic is over. if you notice, no one’s wearing masks. Everybody seems to be in pretty good shape.”

Indeed, hardly anyone is wearing a mask, and most have returned to some semblance of “normal.” The mRNA vaccines have dramatically reduced mortality and, more visibly, morbidity, and the bivalent booster continues those trends. Paxlovid is available for many (although not all) people at higher risk, reducing the severity of the disease and potentially reducing the risk of “long COVID.”

This is all very good news, particularly in comparison to where we were pre-vaccine.

Yet there is bad news, confusion, and uncertainty. The pandemic continues to spread, and not everyone is in “pretty good shape.” By the end of January 2023, over 1,100,000 Americans had died from COVID, and the 400-500 deaths a day continue, particularly among older adults and the elderly. Additionally, the CDC map reflecting only hospitalizations for COVID, and not the prevalence of the disease, misleads the public.

The virus continues to mutate, often in ways that are more immune evasive, while “scrabble variants” continue to evolve. And as the virus mutates, the available tools for protecting those at-risk wobbles. Evusheld has been rendered ineffective against the latest variants, putting immunocompromised individuals at great risk, and the last monoclonal antibody available has been shelved, due to its lack of efficacy against new variants.

Starting in November, 2022, hospitals began experiencing a tidal wave of multiple viral illnesses; what Dr. Peter Hotez termed a “septo-demic.”

The explosion of RSV, COVID, influenza, and other viruses has been particularly horrific for children and the medical professionals who care for them. In mid-November, the American Academy of Pediatrics and the Children’s Hospital Association asked the Biden administration to declare an emergency, given the unprecedented levels of viruses impacting care in hospitals.

Additional data have begun to indicate that while an original infection poses a broad array of risk to human health, reinfection may further increase the risk of death, hospitalization, and sequelae in multiple organ systems. And “long COVID” continues to take a serious toll on a substantial minority of the infected population.

Whither public health?

So where is public health guidance in the middle of this confusing and disturbing information? Dr. Ashish Jha, White House Response Coordinator, echoes the autonomy and self-responsibility mantra about COVID:

If you have testing, if you have medical care, and if you get treatment — lots of “ifs.”

Where public health messaging, testing, and information were incredibly helpful during the earlier stages of the pandemic, that is no longer true. A true picture of COVID’s prevalence and current damage is hindered by the lack of testing (other than private, rapid antigen testing), the lack of consistent reporting that existed earlier in the pandemic, and the absence of financial support from the government for public health measures. Congress has blocked additional funding for COVID-19, which has led to “inadequate replenishing of at-home tests and PPE within the national stockpile, suspension of free test distribution, reduced domestic testing capacity, and lack of support for the development of new vaccines and treatments.”

And public health officials continue to play a single tune: get vaccinated and stay up-to-date with the booster. Excellent advice, no doubt. But this message is both missing its target and neglecting other critical advice.

The vaccine messaging falls on a largely disinterested or even hostile populace. Most who have recovered from COVID assume (inaccurately) they are now immune due to infection. More chillingly, anti-science/anti-vaccination sentiment has never been higher in this country.

The booster rate in the United States is low, with less than half of seniors receiving their bivalent booster, despite its availability since September. Among the general population, the numbers are worse, with fewer than 30% of Americans getting the updated bivalent vaccine.

Reliance on vaccines as the sole method of protection is not sufficient, particularly for the elderly, the immunocompromised, infants, and those who have a healthy desire not to get COVID. COVID vaccines, while keeping many from death and hospitalization, are not a panacea. Alone, they cannot keep the virus from spreading — particularly as so few people are getting the shots. COVID’s toll on racial minorities is “staggering,” and the continued burden on health care workers is both unconscionable and unsupportable.

Even among those who are up to date with boosters, some do not experience asymptomatic or mild “breakthrough” illnesses, but more serious courses of the disease, with long recovery times and the need for anti-virals. While CDC Director Dr. Rochelle Walensky could stay home, treated with Paxlovid, and out of the public eye for two weeks while ill with COVID, most Americans must return to work five days after testing positive, if they have been fever-free for 24 hours.

As many have no sick pay, they will work while ill, often unmasked, continuing to spread the virus.

So why have public health officials not encouraged more universal masking, testing, social distancing, and improved air quality to protect public health? Masking has proven efficacy in reducing the spread of disease. Universal masking “lowers the amount of virus exhaled into shared air, reducing the total number of cases of COVID-19 and making indoor spaces safer for populations that are vulnerable to its complications.” In community and school settings, mask-wearing has been an “important piece of layered risk-mitigation strategy” to reduce the transmission of COVID. Improved air quality likewise reduces the spread of the virus.

Though data indicate that multiple methods of mitigation provide better protection, public health messaging about them has evaporated. The messaging and actions could do so much more. Public health is the obligation to focus on the health of populations, not just individuals.

Instead, public health messengers mention that individuals can choose to mask. Rather than recommend universal precautions, public health entities have acquiesced to mass infection. Indeed, it is difficult to avoid COVID-19 infection, as a recent study explained, because: “large reductions in contact rate are required to reduce the risk of infection.” In other words, at-risk populations have been shunted to the sidelines of public life.

And, despite the continued death rate of between two-to-four thousand people a week in the U.S., the pandemic “emergency” is soon to be declared over. Thus, these risk-mitigation strategies will be even further discouraged, and available protections (such as Paxlovid) will likely be less available.

Granted, the public were tired of masking and social distancing from the beginning. But many schools, businesses, and airlines were still following public health guidance and dampened the spread of the virus until public health entities encouraged dropping of masks in February 2022.

While there was some mention that universal masking would be required again in times of need, no such advice was forthcoming, even amid spikes in hospital admissions. Dr. Walensky, noting the jump in COVID cases in early December, again encouraged the individual approach: “One need not wait on CDC action in order to put a mask on,” she said. “We would encourage all of those preventive measures — hand washing, staying home when you’re sick, masking, increased ventilation.”

But navigating one’s health in a pandemic with dodgy transmission maps, little guidance about public health other than to get boosted, and uncertainty about the dangers of multiple infections is a challenge, even for those with knowledge. For those without knowledge of these matters, it is an impossibility.

It is time, once again, for CDC and other public health entities to act upon their authority and fulfill their mission to protect the health of the populace. Make no mistake: the power is there. But the will is lacking.

Jane Moriarty is the Associate Dean for Faculty Scholarship, the Carol Los Mansmann Chair in Faculty Scholarship, and Professor of Law at the Thomas R. Kline School of Law of Duquesne University

The Petrie-Flom Center Staff

The Petrie-Flom Center staff often posts updates, announcements, and guests posts on behalf of others.

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