Before Covid-19 vaccines, public health officials fought off the pandemic with the only tools they had: mask-wearing, social distancing, school closures, and limits on the size of gatherings.
Now, with cases surging again in much of the United States due to the highly transmissible Delta variant, those tools could still make a measurable difference at a critical moment — but not if the public is unwilling to use them.
A year and a half after Covid restrictions were first implemented, people have had it with the pandemic. Other than highly effective vaccines, which haven’t been accepted by enough people to quash spread of the new SARS-CoV-2 variant, there are no new tools in the public health toolbox, and people have absolutely no interest in reusing the ones that it does contain.
Those sentiments are, in effect, tying the hands of exhausted health officials.
“There aren’t a lot of moves left to make, I think, because we’ve moved beyond most non-pharmaceutical measures and I don’t think the political appetite is really there to reimplement them,” Caitlin Rivers, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health, told STAT.
Some jurisdictions, notably in Southern California, have again mandated indoor mask-wearing; some, like New Orleans, are advising it. But, in other areas, the public hostility toward mask-wearing and social distancing makes it unclear whether these tools would still be effective if health authorities tried to resort to them again, said Wendy Parmet, director of the Center for Health Policy and Law at Northeastern University School of Law.
“It’s also possible that the use of [these] authorities in certain locations would be ineffective or even counterproductive, because people are so dug in,” she said.
More transmissible than its predecessor, Delta is causing a spike in cases in a number of parts of the U.S., largely though not exclusively among people who are unvaccinated. States with low vaccination rates — Arkansas, Louisiana, Mississippi, to name a few — are seeing steep increases. On Tuesday, Rochelle Walensky, director of the Centers for Disease Control and Prevention, revealed that 83% of the sequenced viruses in the U.S. are now Delta variant viruses.
Nirav Shah, director of the Maine Center for Disease Control and Prevention spent last weekend trying to strategize on how deal with Delta. Among the “what ifs” he debated with himself was whether people in his state would agree to wear masks again, if authorities in Maine made that recommendation.
On the one hand, he thought, it would be mostly an effort to try to persuade vaccinated people — people who had already “demonstrated a predilection towards taking care of themselves and others” — to re-embrace masks. On the other hand, those people have already done what they were asked to do; they got vaccinated. Telling them the thing that was supposed to be their Covid off-ramp wasn’t the end of the journey — that might not go down well, he thought.
“I was telling my wife … in public health we like a belt-and-suspenders approach,” said Shah. “For vaccinated people, it’s going to be belt or suspenders. And in their minds, they got their thing. They got their belt. So, it’s going to be a challenge.”
People have moved on, mentally, from the pandemic, Shah said, noting the virus didn’t even come up when he was talking with neighbors recently. Instead, they were worrying about their children getting tick bites during a hiking outing.
“As humans, we only have so much mental bandwidth to be afraid of things. And because Covid is no longer mysterious and a novelty, I think in the minds of a lot of people they’re done,” he said.
Shah, who is president of the Association of State and Territorial Health Officials, noted that authorities in some states face a structural problem when they are thinking about Covid control measures now. Some governors have ended the state of emergency in their jurisdictions. As a result, some of the special orders that were used earlier may be out of reach.
And in a number of others states — those where resistance to Covid control measures ran high — elected officials have put some of public health’s tools off limits. North Dakota enacted legislation barring health authorities from requiring anyone to wear a mask, for any reason. Montana banned the practice of quarantining people who have been in contact with a person infected with a transmissible pathogen — robbing health authorities of one of the oldest known disease control techniques.
A report released in late May by the National Association of County and City Health Officials and the Network for Public Health Law revealed that at least 15 states had taken steps to tie the hands of health authorities. Parmet, who worked on the report, said some of these measures, adopted in the heat of the moment, are likely going to have implications on control of diseases like measles and tuberculosis after Covid is just a bad memory.
Courts, too have overridden some public health measures, including those that limited the number of people who could attend in-person religious services. In Wisconsin, the state Supreme Court overturned a stay-at-home order — at a time when even the Trump administration was urging people to restrict their movements to slow spread of SARS-2.
Traditionally the courts and legislatures have been supportive of emergency public health actions, Parmet said. But not so much anymore.
“Now you’ve got to think two, three, four times: ‘Can I do this? Do I have to start giving religious exemptions? And if I have to get religious exemptions, how do I enforce it for everybody?’” she noted. “There’s definitely an attitude of questioning public health authority on the federal bench and in some state courts.”
Rivers thinks many of the control measures used earlier in the pandemic aren’t enforceable now, though she thinks people could be persuaded to resume wearing masks. She believes, though, that the way to make it palatable is to link the need for the measures to the vaccination of little children, who cannot yet receive their shots; once children under 12 can be immunized, people should be told masks can be put away.
“I think there needs to be some sort of exit strategy,” she said. “I think that’s what helps people to understand that it isn’t forever.”
The use of vaccine mandates by some employers or institutions should also help, Rivers said, though in the absence of a national vaccine mandate — which isn’t in the cards — the effect will be piecemeal, benefiting the community in which a company or a university, say, is located. “The large institutions can reach quite deep into communities,” she said.
Jeffrey Duchin, health officer for the Seattle and King County public health department, shares the frustration and concern of others in his field. But he thinks communities will take steps to try to control Covid — when they reach the point where they believe the threat to them is real.
“I think people may change their way of thinking as Delta becomes more prevalent and they see more illnesses, hospitalizations, and deaths in their immediate personal experience,” said Duchin, who is also an infectious diseases professor at the University of Washington.
“With respect to the toolbox, we’ve got great vaccines. We’ve got mitigation measures that we know work like masking, distancing, improving indoor air quality. So, you know, when people decide they want to do something, we’ve got tools that will work,” he said. “I think you have to take the long view because it’s not going away.”
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