With the discovery of omicron, US leaders should make it clear what, exactly, the point of new precautions would be.
It’s the most important question since March 2020: When will the Covid-19 pandemic end?
The omicron variant, as well as other unexpected twists and turns with the coronavirus, have made the question a difficult one to answer. But, since the beginning, so has the lack of consensus on what level of Covid-19 the US and world are willing to tolerate. Even as government officials have ramped up and scaled down restrictions, they’ve seldom given clear standards — goals with specific metrics attached to them — explaining what’s driving the changes. All of that stands to replay with omicron.
“It’s been a major problem,” Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security, told me. “If you’re not articulating what the metrics are that are driving your public health decision-making, it makes everything more opaque to the general public.”
The initial objective was to “flatten the curve.” But that was vague: The idea was to keep Covid-19 spread, and ultimately hospitalizations, down to avoid overwhelming the health care system. But there was never a defined standard for how low cases or hospitalizations should be, and what threshold was too high.
Then even that goal seemed to fall by the wayside. Instead, officials across the country seemingly adopted and eased rules based on media attention, political sentiments, and public backlash.
For many people, life might already seem back to normal. Yet there are still some rules in place, including mask mandates in some jurisdictions and many restrictions on schools, with no clear signal on when they will end. And the Covid-19 death toll in the US is still at more than 1,000 a day.
With experts now widely in agreement that “Covid zero” (true elimination of the virus) is impossible, the lack of clear goals is even more jarring: It seems as though the country will have to accept some level of Covid-19 in the foreseeable future, but there’s no clarity on what that means.
How many cases, hospitalizations, or deaths are we willing to tolerate? Or are those even the right metrics? Public officials, at least, aren’t offering clear answers.
“It’s like when you’re a kid and the teacher asks you to show your work,” Adalja said. “Oftentimes, [public officials] didn’t show their work. They just said, ‘This is how it is.’”
Some places have done better. Australia, for one, invoked clear guidelines for its harsh lockdowns throughout the pandemic. As “Covid zero” has become impossible, it has tied its rules to higher vaccination rates and individuals’ vaccination status.
Clear goals, signaling when restrictions would lift, would have the advantage of transparency. They might have bigger benefits as well, like rebuilding much-needed trust in public health officials and communications and motivating the public to better follow the rules. If omicron ends up causing more surges of infections and deaths, and officials respond with new restrictions, providing a light at the end of the tunnel could help show people why such steps are necessary and possibly push more of the population to adhere to the measures.
But for that to be the case, America has to decide on its end goal with Covid-19 — and, so far, it hasn’t. “We haven’t learned,” Adalja said. “The same mistakes are still being made.”
The metrics used matter — and may change over time
The basic idea, experts told me, should be for US leaders to provide clear goals that the public can easily track, and tie all remaining and new Covid-related rules around the new objectives. “If you have a set of policies that restrict people’s behavior, having pretty clear guidelines about when you will pull those back seems like a reasonable thing,” Robert Wachter, chair of the University of California San Francisco Department of Medicine, told me.
Right now, the most logical endpoint is to reduce the number of cases: If the idea is to minimize the spread of Covid-19, then what better way to guarantee that than to ensure actual infections are below a certain threshold? At this point, we have plenty of evidence that case numbers predict the worst outcomes of Covid-19 too, with a clear trend since the start of the pandemic that cases rise, hospitalizations rise roughly two weeks later, and deaths rise roughly two weeks after hospitalizations.
So what’s the right number of cases? This is, admittedly, going to be an arbitrary threshold no matter what. In the past, some organizations, including Vox, have cited four daily new coronavirus cases per 100,000 people as an acceptable standard. But 4.1 daily cases per 100,000 isn’t really all that much better than 3.9 cases per 100,000; four is an arbitrary cutoff. Still, some number has to be set for any of this to work, and it should be low enough to ensure the Covid-19 virus really isn’t spreading too quickly.
It’s also important to make sure a drop below, say, four per 100,000 is sustained. Otherwise, there could be a yo-yo effect in which restrictions abruptly come and go as the number of cases moves a little below and a little above four per 100,000. One way to get around this would be to require that cases stay below the standard for some time — say, two weeks — and don’t rise in that period. (The US is still above this threshold, although underreporting during Thanksgiving has led to data gaps nationwide.)
Over time, cases may come to matter less. With the vaccines, there is a “decoupling” of cases and serious Covid-19 outcomes: The vaccines don’t perfectly and durably protect from infection, with that protection waning over time, but they do appear to sustainably protect at very high rates — 90 percent and higher — from hospitalization and death. So someone might contract Covid-19, registering a case, but be at much lower risk of death than she would have been a year prior.
“We’re not there yet,” Crystal Watson, senior scholar at the Johns Hopkins Center for Health Security, told me. Because of vaccine hesitancy, “we still have significant proportions of the population and pockets of individuals who are still very susceptible and may be susceptible to severe illness.”
But if a decoupling does happen, then the country would likely want to pay less attention to the number of cases and more to hospitalizations.
As with cases, the acceptable level of hospitalizations will be a bit arbitrary. There are also important distinctions: If the goal is to ensure as few people as possible suffer from Covid-19, then a lower threshold may be warranted. If the goal is to ensure the health care system isn’t overwhelmed, the bar could potentially be set higher.
Another potential goal is a higher vaccination rate. There’s no agreement among experts about what the right number is here. And since more vaccination is always better for public health, any threshold is going to be — you’ve heard this before — arbitrary. But 80 or 90 percent vaccination rates in a community, with significant uptake of boosters (particularly in older and immunocompromised populations), is the kind of range experts have generally mentioned in recent weeks.
Yet another possible goal could be the availability of vaccines and other effective treatments.
With vaccines, for example, restrictions could ease once the shots are truly accessible to everyone for two months. At this point, people who choose not to vaccinate themselves or their children are knowingly taking a risk. And while it really would be better for everyone, including the vaccinated, if the unvaccinated got their shots (since the vaccines still appear to reduce transmission), most of the risk will fall on the unvaccinated while the vaccinated will be by and large shielded from the worst of Covid-19.
So continuing to enforce restrictions around Covid-19, the logic goes, is essentially asking vaccinated people to continue to make sacrifices for unvaccinated people even though the unvaccinated have decided to take a risk with their own health. That seems unfair. So once vaccines are truly available to everyone for long enough, it’s time to move on. (Another way to get at this would be to tie restrictions to individuals’ vaccination status, but so far there’s no political appetite for that in the US.)
“This is not a perfect plan,” Lucy McBride, an internist in Washington, DC, who writes a Covid-19 newsletter, told me. But she argued that prolonged restrictions can cause harm too, as the world has seen with learning loss following school closures. “Covid is one very important threat to our health and well-being. But, for children in particular, so is not being in school without masks.”
The one complication, McBride added, is if a variant appears that hits kids harder or can significantly evade immunity. In that case, the overarching goal could have to change to match the reality on the ground.
All of the goals above don’t have to be exclusive. They could be looked at in combination. But, above all, they should be made explicit.
Maybe clear goals would get more people to follow the rules
The biggest benefit to clearer goals would be transparency.
For much of the pandemic, there’s been little clarity on when restrictions come and go, with officials seemingly following vague readings of the news, evidence, and public opinion. This can make the process of reopening and closing, masking and not, and adopting or ditching any other Covid-related measure feel arbitrary. Particularly in conservative circles, it’s led to charges that Democratic leaders are merely trying to assert control over the population and don’t ever intend to ease mandates.
The lack of transparency is one reason, experts say, that public health communication has frequently faltered throughout the pandemic. As Watson put it, “Uncertainty, and constantly changing expectations without providing reasoning, doesn’t inspire confidence. It confuses people.”
Establishing clear guidelines could help alleviate this. If the goal is to get below four daily new cases per 100,000 people for at least two weeks, for example, then it’s not going to feel arbitrary when a given region surpasses that threshold and restrictions are tightened again. Charges that the goal is to merely control the population and not ever ditch restrictions will be less credible by virtue of there being a clear end goal.
With Covid-19, the world has learned things can quickly change, whether as a result of people prematurely shirking precautions or variants coming seemingly out of nowhere. Clearer goals can’t stop variants, but they can at least offer a baseline for when things are truly turning for the worst and action is warranted. That would not only help people understand why precautions are necessary, but it could help ease panic as people have a baseline to work around instead of vague notions that things might be getting bad again.
An extra benefit, experts said, is clearer goals could motivate people to heed precautions. If people have no idea what they’re working toward and it feels as though the pandemic and related restrictions might last forever, they may wonder if putting their normal lives on hold indefinitely is really worth it. But if they know that there is a clear, set light at the end of the tunnel, they may take the precautions more seriously to get to that light more quickly — and therefore get their lives back.
This concept is intuitive. But experts acknowledged that there’s no good research or data showing that it’s true — and Covid-19, after all, has consistently done a good job wrecking intuitive ideas.
“I can’t say that there’s great empirical evidence that works, and I think we’ve sometimes gotten ourselves in trouble playing amateur sociologists,” Wachter said. “I think it’s logical to believe that people will be comforted knowing that there is a potential endgame here and a goal they can aspire to. But whether it motivates individual behavior? I don’t know.”
Still, given that clearer goals would have their own benefit in more transparency, they’re still worth setting. And if they also have the benefit of pushing more people to heed precautions to defeat the virus, that’s a great bonus.
If nothing else, clearer goals could help add some clarity to a pandemic that’s often been confusing. After a year and a half of uncertainty, giving people something more reliable is a worthy goal on its own.