The problem with the promise of a vaccine is that people may now feel they are in the home stretch and can relax their precautions, whereas the reality is it will be months before most people can be inoculated. The next six months are going to be a trying and dangerous time. JL
Isaac Chotiner interviews Celine Gounder, member of the Biden-Harris Covid Advisory Board, in The New Yorker:
It’s the people we trust most whom we’re most likely to infect and who are most likely to infect us, because we’re not going to take those same precautions. You need to be as targeted as possible, and you need to explain the science behind it. One of the ways the federal government can encourage states is through funding. So, if you tied funding to testing, if you tied funding to data reporting and staffing that you need to recruit and train, and so on, that is going to be your greatest lever—the carrot of funding.This month, the United States reached a record number of coronavirus cases, with an average of a hundred and fifty thousand new cases per day and the highest number of patients hospitalized since the pandemic began. Unlike in the initial surge, in the spring, which saw enormous outbreaks in urban centers such as New York, the virus is now tearing through the entire country. The onset of winter weather and the mass migration of people travelling to celebrate the holidays are likely to lead to both more cases and new shutdowns. Death rates remain lower than they were in the spring, but the country is likely to reach a death toll of two hundred and fifty thousand within days, which approaches the number of Americans killed in combat during the Second World War.I recently discussed the state of the pandemic with Céline Gounder, an infectious-disease specialist and epidemiologist at Bellevue Hospital and N.Y.U.’s Grossman School of Medicine. She is the host of the “Epidemic” podcast and a member of the Biden-Harris transition team’s covid-19 advisory board. During our conversation, which has been edited for length and clarity, we discussed how public-health professionals should approach their messaging this winter, the continuing importance of “flattening the curve,” and the challenges of planning the next Administration’s coronavirus response.
Why exactly have things got so bad again? Is it people not wearing masks? Is it activities that we shouldn’t be doing? Was it inevitable? How do you understand it?
I think the No. 1 reason is that the weather is getting cooler and people are spending more time indoors. There’s no question that that is a big factor. We typically do see colds and the flu increase during this time of year, and the coronavirus is very similar in that it’s another respiratory viral illness. So this is something we have been predicting. We have been saying it’ll slow down a little bit, relatively speaking, over the summer, but it will not go away, and then it will surge again in the fall and winter, and that’s precisely the pattern that we’re seeing now. The other thing is that it’s become very clear that social gatherings, whether they are in restaurants or at home, are major drivers of this in terms of the transmission.
So this would be some combination of people letting their guard down and government policies not being strict enough in terms of the restaurant angle.
The challenge with restaurants is that you cannot eat and drink with a mask on, and if you are indoor-dining you also have the loss of ventilation, and you’re in close proximity with other people. So restaurants and bars, at least indoors, are really some of the worst places from the perspective of transmission. In terms of the bigger picture, I’ve heard a lot of people say things like “Well, I trust so-and-so about spending time with them or maybe celebrating the upcoming Thanksgiving holiday with them.” And I think it’s really important to understand that the coronavirus hitches a ride on our trust and our love for our family and friends. It’s actually the people we trust most whom we’re most likely to infect and who are most likely to infect us, because we’re not going to take those same precautions with the people we love and trust.
How do you combat that? What’s the message?
Despite there being vaccines that are now about to emerge from the pipeline and that will soon have emergency-use authorizations—likely in the next month or so, between the Pfizer vaccine and the Moderna vaccine—it’s still going to be a long road ahead before those are widely available to the general public. So we’re really going to have to focus on the basics of public-health control here—that’s mask wearing, social distancing, outdoors versus indoors, testing and contact tracing. And, with respect to masks, masks are cheap, highly effective, and they do not shut down the economy. They’re really as close to a vaccine as anything that we have available to us right now. And, unfortunately, they have been politicized. The way I think about masks is that masks are like toilet paper. This should not be a political statement. This is really a basic hygienic measure.
When we saw a surge in the spring, it was pretty clear that there were some failures from the federal government, such as a lack of testing. Are there some large-scale structural failures going on right now that are exacerbating this? Or is it more matters of messaging, and things like that?
Well, messaging has really been a problem in terms of what the current Administration has been saying and communicating to the public throughout the pandemic. You mentioned testing, and this current Administration has really discouraged testing, because it really did not want to see and did not want the public to know what was truly happening with coronavirus transmission and the scale of the problem. The challenge is that it is impossible to contain an invisible enemy, and the problem with the coronavirus is that many of the infections are asymptomatic or mildly symptomatic, so people have no or few symptoms. So what we are seeing in hospitals, in terms of people getting really sick and dying, is really the very tiny tip of the iceberg. Even though many, many people are getting sick and dying, there are far, far more who are getting infected and transmitting the virus. The only way to see what are essentially invisible infections is to massively scale up testing. So the message should have been: get tested. That has been a major failure. We also talked about masks, and that has also been a major failure of communication.
Is a lack of testing still a problem in your mind?
Yeah. We still need to scale up our testing. In New York, for example, as the positivity rate has gone up, and people have become aware that there is increasing coronavirus transmission in New York City, people have been seeking out testing at higher rates. And what we have found is that some of the testing centers have had very, very long lines, which then discourages people from going and also results in longer turnaround times. So we really do need to be scaling up testing dramatically across the country, and doing so in a way that we have short turnaround times, ideally within twenty-four hours, because this information needs to be actionable. You need to know that you’re infected so that you can go into isolation, so that you’re not transmitting to others. If you have to wait a couple days, a lot of people will keep on doing what they would normally do and will not change their behavior until they have a positive test result. And, by that time, you’ve already done the bulk of your transmitting to others. So it’s really defeating the purpose not to have widely available, conveniently available testing with short turnaround times.
What do you think we’ve learned about school closures and school openings, and how should we view what we’ve learned in the context of things getting much worse across the country?
I think, big picture, we have moved from what I would call coronavirus control 1.0 to coronavirus control 2.0. In the spring, we were not a hundred-per-cent sure how much of this was spread through droplets versus airborne transmission versus direct contacts. So now we have a much better understanding of that. This is clearly a respiratory virus, first and foremost. And, in terms of schools, we’ve also learned that younger children really do not seem to be major transmitters to adults. We’re not entirely sure why that is, although we have some theories. But what that means is that, while the risk is not zero, the risk of keeping kids—especially younger kids—in school was probably overestimated in the beginning. We can now really make it safe for younger students, twelve and under, to be back in school, especially if we institute safety measures like social distancing, mask wearing, ventilation.
Having kids in school is what I would call one of the more essential services, and it’s relatively low risk. So, recently, Governor Gretchen Whitmer announced new restrictions in Michigan, and you’ll note that—based on what we’ve learned, where schools have the ability to provide those safety measures—they’re keeping schools for younger kids open. They’re closing high schools and colleges to in-person learning, because that’s riskier. Another example of understanding transmission better: they’re closing group classes in gyms but, where the appropriate safety measures are in place, leaving open the option of individual exercise at a gym. They are leaving open outdoor dining and takeout but closing indoor dining. So we can be a lot more targeted and measured than we were in the beginning, when we were much more blunt.
That was going to be my next question, which is what we learned about shutdowns and what we can do differently this time, because it seems like people are probably going to be less willing to take necessary measures.
Yeah. I think the key is that you need to be as targeted as possible, and you need to explain the science behind it. In New York City, we saw a surge of coronavirus in the last couple months in certain neighborhoods—in Brooklyn, for example. And we took a very geographically targeted approach, on the basis of Zip Codes, to really scale up testing, ramp up contact tracing, and close certain places that seemed to be contributing to transmission. We were able to take that much more geographically targeted approach because we had the surveillance data.
The other thing I was going to say is that stimulus is a really important component of this, and the Republicans really do need to take action on the stimulus now. Senator McConnell needs to take that up. We cannot be waiting until the Biden-Harris Administration takes office, in January, because people really do need those economic and social safety nets in order to get through and survive this. These restrictions can be cumbersome and burdensome for families. We are well aware of that, and we also need to do what we can to mitigate that.
And, in addition to the importance that this has for people’s well-being and their families, and so on, it seems that it’s also one way of getting people to go along with rules and guidelines.
You’re supported through the process, yeah.
The holidays are coming up, so how are you thinking about this in terms of your family—in terms of what you’re going to do? Should people really be changing their behavior or taking extreme steps that you might not have counselled a few months ago?
We are all staying home. My husband and I and our two dogs will be celebrating Thanksgiving in person, just the four of us. And we will be doing a virtual celebration with my family in Houston, my family in San Francisco, and family in Seattle. None of us will be travelling for the holidays. And, on a personal level, it’s sad. I have a niece who is five, another niece who is one, and we’ve missed out on seeing them during a really formative time. In terms of broader advice, and when it comes to travel, what worries me more is less the travel itself. There are things you need to think about when you fly: you absolutely should be wearing a mask and, ideally, avoiding eating and drinking on the plane, because that requires you to take off your mask. But, regardless of how you travel, whether that’s by train or plane or bus or car, what concerns me is the idea that you are going to go to some place where, probably if you’re around family and friends, the temptation is going to be not to wear a mask, to be hugging, to be close, to be indoors because the weather’s cooler, to be sitting around a table, eating and drinking and celebrating. And it’s really those activities, as opposed to the travel itself, that is really concerning, because we know that these social gatherings are the fire for more transmissions.
I think people engage in a lot of activities in which they can tell themselves that they are behaving well. They went to the market and they socially distanced, or they did outdoor dining and they put their mask on when the server got near, or they went on a plane and then stayed at a hotel, and every time they were around other people they had their masks on. But I think, if everyone does that, you’re still engaging in activities that have some risk level, and if enough people do them there’s going to be some risk to them. So how do you assess us doing things like this as cases spike?
Right. Well, additively, if in every one of those families getting together for the holidays only one person out of ten transmits, or is infected with coronavirus, that still ends up being many, many people across the country. I’m realistic, and I understand that people are going to do this—some people will decide if the risk is worth it—but even if people do take all of the measures possible there is risk involved and there will be some transmissions. And for this to be happening in the middle of a big surge . . . we know that there’s exponential spread with this virus—it’s only going to be that much more of an acceleration that we’ll see around the Thanksgiving holiday.
It seems like a vaccine is on the horizon, so how do you think that should or shouldn’t change any messaging from health professionals?
I think the fact that we have two vaccines that are going to be submitted quite soon for emergency-use authorizations from the F.D.A., and that we’ll probably have them available for high-risk populations and front-line workers at the end of this calendar year, or at least start that process, is very promising. And I think hope is an empowering emotion. It’s something that we really need to have in order to get through the upcoming months, when we will still have to be doing things like masking and social distancing. It’s important to have this sense of a light at the end of the tunnel, and that what we’re doing now matters—that we can save some lives now, many lives now, by doing those things—but that eventually there will also be a vaccine. So I think of it in terms of giving people some concrete hope.
Correct me if this is wrong, but the idea about flattening the curve, initially, was that the medical system should not be overwhelmed by a sudden surge in cases. But it seems there’s an additional value to it with a vaccine, in that we’re not just kicking the can down the road—there’s some chance of lowering the total number of people who are going to get sick and die.
Yeah, it’s genuinely saving a lot of lives now, and these are lives, because we’ll have a vaccine eventually, that will remain saved lives. So I think it’s important to understand that by taking these measures now these are people who will not get infected now, and they will live through a vaccine and not get infected and die later, either.
Trump and his Administration have shown an unwillingness to recognize the incoming Administration. How is that impairing the Biden-Harris team’s ability to do its job?
I think about it as though we’re at war with the virus. It would be like being in the middle of a world war, and you are the incoming President and you have no idea where your aircraft carriers and your tanks and your troops are. Yeah, you can come up with broad-strokes plans, especially given the very deep bench of scientific and public-health and policy expertise that we have—we can be drawing up our own parallel blueprint and operational plans. But in the absence of that critical information, which I think of as national-security information, it creates some blind spots and puts us all very much at risk.
What can the federal government in a Biden Administration do if some states refuse very common-sense preventative measures?
Historically, one of the ways in which the federal government can encourage states is through funding. So, for example, if you tied funding to testing, if you tied funding to certain data reporting, if you tied funding to certain staffing that you need to recruit and train, and so on, that is going to be probably your greatest lever—the carrot of funding.
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