Politics

The CDC Shifted the Pandemic’s Burden to the Vulnerable


This time last week, nearly all Americans were still being urged by the nation’s leadership to please, keep those darn masks on. Then the Great American Unmasking Part Deux began. On Friday, the CDC debuted a new set of COVID-19 guidelines that green-lit roughly 70 percent of us—effectively, anyone living in a place where hospitals are not being actively overrun by the coronavirus—to doff our masks in most indoor public settings. The stamina of mask policy had been flagging for quite some time: Governors and mayors had already been weeks deep into vanishing their own mask mandates (and other pandemic precautions), including in schools. But the CDC’s decision still marks a substantial cross-continental change, delivering a final blow to what little remained of the country’s collective approach to quashing the pandemic.

In the new playbook, recommendations for individual people, not communities, sit front and center, and mitigation frequently falls under the purview of medicine rather than public health—heaping more responsibility on the already dysfunctional American health-care system. “It is public health’s job to protect everybody, not just those people who are vaccinated, not just those people who are healthy,” says Theresa Chapple-McGruder, the director of the Department of Public Health in Oak Park, Illinois. I asked Chapple if the CDC’s new guidelines meet that mark. “Not at all,” she said. (The CDC did not respond to a request for comment.) Throughout the pandemic, American leaders have given individuals more responsibility for keeping themselves safe than might be ideal; these revised guidelines codify that approach more openly than ever before. Each of us has yet again been tasked with controlling our own version of the pandemic, on our own terms. “The onus of public-health measures has really shifted away from public and toward vulnerable individuals,” Ramnath Subbaraman, an infectious-disease physician and epidemiologist at Tufts University, told me.

In his State of the Union address, President Joe Biden said, “We’re leaving no one behind or ignoring anyone’s needs as we move forward.” The CDC’s recommendations, too, say they’ve been written to prioritize “protecting those at highest risk of severe outcomes.” But in their details, several experts told me, is the exact opposite message: Those most susceptible to serious cases of COVID-19—those who have borne the virus’s burden the most—are now being asked to bear another load more.


This particular moment is arguably a reasonable one in which to shift the national stance. Coronavirus case numbers are in free fall; vaccines and, to a lesser degree, viral infections have built up a wall of immunity that can blunt the virus’s impact overall. Several experts stressed that certain aspects of the CDC’s new guidelines are genuinely improving on the framework the country was using before. “The timing feels right to make some kind of change,” Whitney Robinson, an epidemiologist at Duke University, told me.

But protection against SARS-CoV-2 isn’t spread equally. Millions of kids under 5 are still ineligible for shots. Vaccine effectiveness declines faster in older individuals and is patchy to begin with in many immunocompromised people. The chances of serious illness go up in high-exposure settings, too, and the CDC’s list of COVID-risky health conditions remains long. The pandemic has also, since its early days, disproportionately pummeled communities of color and people in low-income brackets—structural inequities that big, nationwide trends can easily obscure.

The CDC’s new stance on mitigation glosses over all that, Julia Raifman, a policy expert at Boston University, told me. In her ideal, the country might turn off mask mandates while making clear that they could turn back on if community threat levels warrant it. Mandates are tough to tolerate in the long term, but maybe enough Americans are still on board: A smattering of recent polls suggests that a slight majority of U.S. residents still favor certain pandemic-caliber protections while the virus continues to run rampant.

So maybe the CDC swung the pendulum too far in the other direction, experts told me. The agency also updated its risk guidelines to focus primarily on hospital burden rather than local transmission alone. By the old metrics, nearly all American counties should be masking; under the new standards, that recommendation applies to only about 37 percent, designated orange on the agency’s map, at a “high” COVID-19 community level. In another 23 percent of counties, at the “low,” green-colored level, no one needs to mask. Smack in between, in the 40 percent of American counties currently at the “medium,” yellow-tinted level, some people—if they’re “high risk” or immunocompromised—maybe should? The CDC’s best advice to those people: “Talk to your healthcare provider about whether you need to wear a mask and take other precautions (e.g., testing).”

Emily Landon, an infectious-disease physician at the University of Chicago, told me she finds the yellow-category recommendations wishy-washy at best. As someone who takes immunosuppressive drugs to manage rheumatoid arthritis, she appreciates the nod to the immunocompromised, but she and other experts don’t see how many Americans could follow these guidelines. About a quarter of U.S. residents don’t have a primary-care provider; millions are uninsured. And plenty of people with coverage don’t have the time or funds to seek professional advice on masking, especially if it requires an in-person visit. Plus, health-care workers, already overwhelmed, can’t afford to be inundated by requests for bespoke masking plans. Bertha Hidalgo, an epidemiologist at the University of Alabama at Birmingham, also points out that “a lot of people don’t trust the health-care system,” about masking or anything else, and will simply decide not to ask. Medical opinions can’t be treated as universal gospel either: She’s seen physicians in her state advocate against masking in crowded settings.

A medical framework—almost resembling a prescription model—is not public-health guidance, which centers community-level benefits achieved through community-level action. People act in the collective interest, a tactic that benefits everyone, not just themselves. Where the CDC leaves us now feels especially disorienting when we consider where most mask-up messaging began: with the idea that masking was an act of communal good—“my mask protects you, your mask protects me.” Now masking is about, as the CDC puts it, “personal preference, informed by personal level of risk.”

The guidance around diagnostics and other mitigation measures have similar problems. High-risk people are told to simply “have a plan” for testing. But tests are still expensive and not always easy to find, disadvantaging already vulnerable communities. That muddies the road to another essential intervention—treatments, such as oral antivirals, which also remain in short supply. Biden last night announced a “test to treat” initiative that could clear some of the hurdles that stand between positive test results and COVID pills, and that addresses some of the issues around drug supply. But the plan still requires most people to seek out diagnostics at pharmacies or community health centers, which aren’t easily accessible health-care venues for many Americans, especially in rural regions and low-income neighborhoods. The CDC’s new guidelines do emphasize the importance of ensuring the “access and equity” of crucial pandemic tools. Yet they offer few, if any, concrete stepping stones, Tuft’s Subbaraman told me, to pave that path.


A better system was possible, experts told me—one that could have allowed us to stretch our pandemic-weary legs while developing strategies to unite communities and better shield them as a cohesive unit. For starters, the categorization scheme could have loosened far less. The new model recommends universal masking at more than double the community case count of the old one, and only if the virus is starting to fill a consequential number of hospital beds. That pushes higher-risk people to mask solo for much longer before anyone else is expected to join in; the vulnerable, in other words, must bear the brunt of the pathogen’s burden at the front end of every surge. “Asking people to take individual measures to protect themselves is much less effective than whole-community interventions,” Andrea Ciaranello, an infectious-disease physician at Massachusetts General Hospital, told me. Even close contacts of people who are at high risk are told to merely consider testing or wearing a mask until the health-care system is once again feeling the coronavirus’s crush. The focus on super-serious disease also neglects the many consequences of infection that can happen outside of, or prior to, hospitalization, including long COVID; massive amounts of less severe disease, too, can overload the health-care system until it buckles. The goal of blocking transmission, Robinson told me, seems to have fallen off the map. “It looks like reducing hospital overwhelm is all we’re trying to do,” she said.

Landon, of the University of Chicago, said she’s okay with flickering masks off somewhere around the new high-medium boundary, when the strain on the health-care system is starting to ease and population immunity is fairly fresh. In the old system, she told me, “we were actually keeping masks on too long.” But it’s impractical to use the same thresholds on the downswing and the upswing. When cases are hurtling upward, waiting until hospitalizations are shooting up means waiting “way too long,” she said. One recent analysis, for instance, found that by the time “high”-level protections turn on, it would be too late to stop the nation from hitting 1,000 deaths a day. Donning masks—an explicitly preventative measure—earlier, at the new low-to-medium transition, for instance, perhaps even before, has a much better chance of dampening a surge. Early action would also better safeguard people in high-exposure jobs or living situations, who can end up imperiled on a wave’s leading edge, Raifman said.

Several experts also noted that they wished the CDC had delayed its updates until kids under 5 were eligible for vaccination or effective treatments were widely available. “We should not be moving forward until everyone has the same opportunity to get vaccinated,” Chapple, who has a 3-year-old daughter, told me. In her version of the playbook, her community would also need to meet a vaccination rate of at least 80 to 85 percent. Studies modeling infection mitigation in schools, including one led by Ciaranello, have found that fewer on-campus measures are needed to keep transmission under control when vaccine uptake is high. There’s no explicit vaccination-rate requirement in the CDC’s new guidance, Subbaraman said. That makes it tough to emphasize the importance of vaccine equity as another marker of a community’s resilience, he added: Disproportionate dosing runs the risk of concentrating harm in vulnerable groups.

There’s nothing technically stopping individual cities, counties, or states from shooting for higher goals themselves. But now that the CDC has slackened its grip, it’s gotten that much harder for everyone else to go stricter, Chapple said. Her community—Cook County, Illinois—was marked at “high” transmission last week. Now it’s a calming, green “low,” and no one has to mask. Most local schools are no longer requiring face coverings either, as of this week. That means the risk to a vulnerable person, including her unvaccinated child, is that much higher. With these changes, Chapple has decided that her daughter won’t be visiting public indoor venues until she’s vaccinated, or until community case rates drop down to the old definition of moderate—fewer than 50 cases per 100,000 people over seven days. Neither milestone feels terribly close. On Sunday, her family embarked on one final indoor outing together, to the grocery store. It will be their last until the forecast clears.




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