In the aftermath of America’s Omicron wave, public concern about COVID has fallen off a cliff. The political will to combat the coronavirus appears to have evaporated to the point that Congress isn’t even prioritizing pandemic funding anymore. It feels like a wide swath of American society has just decided that the pandemic is over. But while there are many meaningful ways that we are better off now than we were two years, a year, or even six months ago, the pandemic is definitely not over. COVID is still killing more than a thousand Americans every day. There are legitimate concerns that the BA.2 Omicron subvariant, which is now causing problems in numerous countries abroad, will lead to another wave of infection in the U.S. The virus could exploit weak points in our pandemic armor, like waning immunity, the low uptake of booster shots, and the stubbornly partisan lens through which many Americans view all things pandemic. I spoke with Stanford infectious-diseases doctor Abraar Karan to get his sense of where the country is, what might be coming next, and why we should keep our N95s handy.
A lot of COVID experts seem to be ripping their hair out right now in response to the collective pandemic tune-out. How are you taking it?
I can basically feel the COVID wins by the patients that I see because I take care of people who have gotten organ transplants and who are immunocompromised. So in early January, when everybody was saying Omicron is mild and not a big deal, I was seeing tons of COVID cases in the hospital. We were getting consulted on patients who are immunocompromised and very sick and trying to figure out how to get them therapeutics to treat COVID. Now that’s slowed down, so I’m on the organ-transplant infectious-disease service again. Very, very few COVID calls right now, because as incidence goes down, fewer people will get infected. So the chance of seeing COVID cases in the hospital is now lower, but I also know that we have these waves where there are multiple factors playing at the same time.
What factors are those?
One is immunity either from prior infection, vaccination, or booster shot. Another is what variant we’re dealing with, how immune evasive it is, and how the timing of those two things overlaps. How well are vaccines providing protection against that variant? Then there are mitigation measures: What are we doing, individually and collectively, on non-pharmaceutical interventions like masking and distancing, and minimizing high-risk situations?
I think the problem is that politically, socially, culturally, if you don’t pull back a little bit when incidence is low, then people feel like they’re being pushed to be on high alert all the time.
As you mentioned, there is still is a lot of COVID spreading, there are still deaths and hospitalizations, but this is all relative. People only think relatively, so they’re going to compare what they perceived from last spring or from Delta to now. The ironic part is that even though people’s perception may be that Omicron is more mild, we actually had just as many deaths, more hospitalizations, and more cases from Omicron in a relatively vaccinated population.
Now we’re seeing other countries taking a pretty heavy hit from Omicron, especially amongst older people. This includes places where there were low vaccination rates among the elderly, such as Hong Kong, as well as places with high vaccination rates among the elderly, like South Korea. So my biggest fear and concern right now is that the timing is really not playing in our favor, because the U.S. has very low rates, relatively speaking, of boosting, and many people got their first and second doses early last year. A lot of time has passed, and some people don’t even think they need a booster and aren’t concerned about this. I worry that as our immune memory starts to fade and we’re dealing with BA.2 (which is certainly here already), it will move faster than we’ll be able to detect, or than we’ll be able to respond to, both politically and from a public-health standpoint.
Particularly when so many people seem to have decided to stop worrying about COVID.
BA.2 is going to creep up on us, as every wave has crept up on us. But at least with Delta and Omicron, a lot of people were getting vaccinated around that time or had just been vaccinated with their second doses. We’re not seeing the same with boosters. I think if you look at the data for people above 65, it’s 60-something percent, which isn’t bad but isn’t great. If you look at ages 18 to 64, it’s 30 percent or lower. I think that’s a problem.
Even if COVID doesn’t kill you and you’re in one of the younger age groups, the risks of long COVID inflammatory syndromes are becoming more clear. We’re getting more data, and research is eventually going to show what these effects are, but we’re only two years into the pandemic. We’re basically gambling with unknown longer-term costs to people’s health. For instance, we’re seeing people who are getting issues with clotting, issues with autoimmune diseases that they hadn’t identified previously, and then other vascular effects, cognitive effects. We see physiological studies showing effects on the brain and the heart and other organs, so there are a lot of costs here. It’s not the run-of-the-mill cold that we’re dealing with, or even flu. Yeah, I am concerned.
How worried are you about BA.2, specifically?
Looking at the discussion among evolutionary virologists, which obviously is not my primary field, it does seem quite distinct from BA.1. It’s coming right on the heels of the BA.1 surge coming down, so it’s hitting a population that’s just exhausted, tired, ready to be over with mitigation measures, and poorly boosted. I think it’s a big problem that will fall behind the politics, because a lot of politicians are probably thinking about midterm elections, thinking about what’s popular. We work within these short election cycles so you’re not thinking long term, necessarily, as a leader in this country.
During the Omicron wave, there was a lot of attention — at least from the Biden administration and in some states — on the importance of wearing better face masks. The federal government finally started trying to distribute free N95s to the public. Then there was a rapid drawdown in mask mandates everywhere, even in places that have typically been pretty aggressive against COVID. How do you feel about all that?
I don’t think the biggest problem is pulling back mitigation; the problem is that when new cases start to rise exponentially fast, there’s going to be a lag when you put mitigation measures back in place. Once you’re caught in that lag, then exponential spread takes over and it’s too late to do anything about it. Governments can start requiring people to mask again, but they’re going to be weeks behind. The spread is going to be way too fast.
And that’s assuming political leaders even try to get people to mask up again.
Yes, who knows if they’re even going to try? Politicians may feel like the strategies they used before cost them a lot of money. It didn’t seem to stop the spread, or it didn’t seem to stop any big outbreak. You’re always weighing what you did against the unknown of what would have happened if you did nothing. That’s the discussion we’re seeing in countries seeing a surge in BA.2 cases.
The zero-COVID countries.
Yeah. I think there are people who at this point are like, “Okay, it’s another variant. This is never going to end. COVID is not going away.” People always make decisions based on risk-benefit calculations, and I think many may have come to a tipping point where they said, “Okay, I’m going to wait until I get vaccinated. I’m going to get boosted, or get two doses and whatever happens after that. It is what it is, because I don’t want to live like this any longer. I’d rather things just be open, I’d rather we just deal with it like it’s another medical problem that the health system will have to handle as time goes on.”
There are some people who feel that way, and there are others who are still ready to do everything possible to hold off. There is a benefit to delaying infection. Even if it’s inevitable you’ll get infected at some point, right now we know a lot more than we did two years ago. We’re better at managing COVID now, and we’ll be even better at it a year from now.
There are some doctors who feel like we’re good enough now, we can keep people alive for the most part. We have antivirals, we have other therapeutics that we can use in the hospital, so there’s no reason that we need to keep pushing mitigation, because now we can actually keep people alive. But then there’s the morbidity point: We don’t know what the consequences and complications of long COVID are going to look like over time.
Following the recent spikes in COVID deaths in some countries, there has been some renewed debate about the difference between dying from COVID or with COVID. What’s your sense of that?
I think the way that it’s simplified by people who are not clinicians is a total mischaracterization because you can have very sick patients who then are tipped over by COVID. So, COVID is causing inflammation, COVID is causing all sorts of other effects, and they end up dying. If you didn’t have COVID in the picture, those people may have survived. Are there people who come in for other things and incidentally are found to have COVID and they were detecting an old infection or something more mild? Yes, that happens. But it’s a case-by-case basis, and making any sort of broad, sweeping generalizations about that as a way to comment on whether COVID is a big deal or not is just totally misinformed.
When and where do you think people should still be wearing masks at this point?
I think that right now, your safest bet would be to wear your N95 when you’re in big public crowds indoors. The detection of BA.2 is going to be slow, but we know that BA.2 is increasingly taking over the percentage of new U.S. cases. Some may say this is a little bit early to recommend masking up in crowded indoor areas, but I think that we’ll get caught pretty quickly. When is that going to happen? My guess would be by April, maybe mid-April, we’ll start to see a significant rise. By the time we detect that, it means there’s already been a lot more spread.
I’m not saying don’t leave your house, don’t socialize, don’t do things. I think people should do that because right now, relatively speaking, incidence is lower. But I think the safest bet is to keep masking in these higher-risk settings for the next few weeks. If people would rather take the risk that they’ll get infected, as it’s important for their mental health to socialize, to see friends and family — I would say this is a better time to do it than a month from now, most likely. But for those who don’t feel that’s really important to them, or who can socialize outdoors, I would say keep wearing your N95 in indoor crowded settings for sure. And if you’re immunocompromised, it’s a different ball game — you should still be wearing masks no matter what.
Six days of the week, I’m in the hospital and I’m seeing way fewer COVID cases now than I did in early January. I suspect that a month from now I’ll be seeing more again, but I can’t give a guarantee of any sort. Everyone should realize that BA.2 is a threat and that they may get it if they’re in high-risk indoor settings over and over again in the next few weeks.
Right. And public-health officials and politicians should be extremely transparent about the fact that BA.2 is spreading and what the risk is. This is one of the things that continues to frustrate me. We get warnings at the appropriate amplified volume if there’s a big snowstorm or a hurricane coming. That gives the public the advantage of time to prepare. It absolutely saves lives. If we had a system like this for communicating COVID risks, people could make more informed decisions about when to take precautions, even if their state leaders aren’t taking the threat seriously.
When the CDC last updated its mask guidance, it recommended wearing masks indoors based on community-level COVID risk. But I don’t know how many people go to the CDC website to read that versus listening to CDC director Rochelle Walensky, who called masks the “scarlet letter” of the pandemic. The confusing messaging hasn’t helped.
Also, Biden had this plan to distribute 400 million free N95s. That’s been a mixed bag; I haven’t seen any free N95s near me. And some models are much better than others, comfortable enough that people would actually wear them. You’ve got some really good, comfortable N95 mask options like the 3M VFlex and the 3M Aura. I think Auras were distributed through the Biden plan here and there. But I think they handed out a lot of these cup-style N95s, and people didn’t really like them.
There should have been one style, or maybe one or two styles. Make it clear, make it recognizable, maybe make it a certain color so that you know it’s coming from the administration. But it wasn’t done that way. Maybe the Biden administration’s giving away masks was just a move to show people they were doing something. It was definitely a little messy.
Parents who are still concerned about the risk of their children catching COVID seem to be in a really tough spot right now. School mask mandates are basically gone nationwide. So parents might worry about their kid having to pay a social cost in school if they’re one of the only ones still wearing a mask. I’ve heard some parents wonder if it’s even worth it, if their child is still going to take their mask off to eat in a crowded lunchroom every day. What advice would you give to these parents?
Risk is additive and multifactorial, so duration of time, duration of exposure is important. Just because you have to take off your mask for a few minutes doesn’t mean there is no point in wearing it all for the rest of the day. It’s still beneficial to wear it at certain times, even if you have to take it off at other times.
I think it’s a tough problem, socially, for parents and kids. There’s going to be a lot of social pressure to unmask. But I think that, again, we’re weighing the unknown costs of long COVID on kids. It would be great if we already had an authorized vaccine for kids under 5, but we don’t.
Community incidence of COVID is what predicts incidence in schools, so I think at least for a short time, parents can feel reassured. There’s a risk with anything you do, obviously — there’s a risk crossing the street. But are we going to see masks reinstated in schools if and when community incidence is high? I don’t know. Even though I probably fall on the more conservative end of mitigation, I still recognize that incidence is low right now. That’s the only point of reassurance, and I don’t think that’s going to last very long.
Right. There’s good weather right now. Everyone should enjoy it. But don’t throw away your raincoat. Don’t throw away your face masks.
I would definitely keep your masks. Having that supply of masks at home, as it becomes clear what’s going to happen with BA.2, means you individually can still protect yourself. The government may not have done much for ventilation or rapid tests yet to the extent that we need it, but you can still protect yourself. That’s not good enough, of course. That is not a pandemic strategy. But well-fitted N95 masks work. They’ll protect you, much more than a cloth mask or even surgical mask will.
So that’s one thing that’s in our favor. Another is that the incidence of COVID is still much lower than it was a month or two ago. And we’ve got the Paxlovid antiviral drug, we’ve got more people vaccinated, so there are things that are playing to our advantage. But our immunity wall is also breaking apart as time goes on. That’s just how it works.
This interview has been edited and condensed.
