The *New* New Phase of the Pandemic

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S1: Megan, where is the weirdest place in your house that you’ve found a mask?

S2: Oh, my goodness. Probably inside my son’s sock.

S1: Now I called up Dr. Megan Ranney. She’s an ER physician at Brown University, because I wanted to ask her what I should do now with all of these masks. I feel like I’m surrounded by masks like they’re in the glove compartment. Like the worst is the masks that are hanging on the knobs of the kitchen cabinets.

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S2: Totally. Oh, they’re everywhere.

S1: In just a few short weeks, much of the United States has upended its relationship with masks.

S3: We’ve reached a new moment in the fight against COVID 19, where severe cases are down a level not seen since July of last year. Just a few days ago, the Center for Disease Control and Prevention issued a new mask guidelines. Under the new guidelines, most Americans and most of the country can now go mask free.

S1: Joe Biden laid out the reasoning here at the State of the Union

S3: based on projection, more of the country will reach a point across that point across the next couple of weeks, thanks to the progress we’ve made in the past year. COVID 19 no longer need control our lives.

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S1: I know some are. More than 70 percent of all Americans now live in a place where, according to the federal government. Masks are optional. Schools and businesses are tossing out their mask requirements, too. Is the CDC done with COVID?

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S2: Gosh, no. I think that this is actually much more of the CDC recognizing that we really are at a different moment in this pandemic than we were two months ago, much less two years ago.

S1: I think the thing that’s hard is that I’ve heard we’re in a new phase of the pandemic over and over again for a couple of years.

S2: I feel like we’ve heard mission complete over and over again for a couple of years. People keep trying to say it’s over right. It was July 4th of last year that we were all going to be able to celebrate the way that I read. This is actually not a this is over, but rather let’s kind of celebrate that right now we’re in a decent spot, but let’s also think ahead and prepare.

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S1: Today on the show, the CDC takes another whack at pandemic guidelines this time. Is it possible they got it right? I’m Mary Harris. You’re listening to what next? Stick around. The last time we spoke, the CDC had just released a different set of guidance about masks. This was a little less than a year ago. The guidance back then was a lot simpler. It was like if you’ve gotten a vaccine, you can ditch your mask. The guidelines now are not like that. Can you explain the difference?

S2: There’s a couple of big differences here. The first is that guidance last year was, as you and I discussed, both premature and didn’t recognize the way that human behavior works. If they told vaccinated people they could take their mask off, everybody was going to take their mask off. And we had so many folks across the country that hadn’t gotten vaccinated yet. We knew that the Delta surge was on its way. It was a premature change of guidelines. It also provided no on ramp in case of future surges. It assumed that it was a once in future recommendation. The difference today is that we are first in a different space in terms of vaccinations. We’ve now vaccinated all kids aged five and up, or at least the opportunity to vaccinate everyone age five and up. We’ve had boosters. We have treatments like packs loaded. And here’s the most important part is that the CDC guidance recognizes that it’s both about relaxing some of those non-pharmaceutical interventions, like masks, but also other things as surges wane and having a road to put them back in place if and when there are future variants or future dangerous surges. It also, and this is the other important part about this new guidance. How it really is moving us into a different phase of the pandemic is that it’s no longer about stopping COVID. I think many of us in the public health world have recognized for months and months that that was not going to be an achievable goal, but rather it’s about minimizing severe harm. It’s about minimizing severe disease, hospitalizations and deaths and maintaining health care capacity. And so I see the CDC guidance as being deeply different.

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S1: So can you walk me through exactly what the CDC is doing with this new guidance?

S2: Absolutely. So there’s three different indicators that they have and have put into a little menu of metrics. Those indicators are first the case rate. So how many COVID cases are there per 100000 people per seven days? Second, what are the number of new COVID 19 hospital admissions? And third, what percent of staffed inpatient beds are occupied by COVID 19 patients? They put those three together, did some fancy science and came up with three levels of risk. There’s low risk, which can only apply if you have low case rates. In those low risk situations, they basically say Get vaccinated, maintain ventilation, but you can go about your life as per 2019 normal for the most part, medium risk, which is when hospital beds start getting taken up or when case counts go up. They talk about if you’re high risk, start to wear masks again. If you are a policymaker, start to think about what will come next. Make sure that you have good ventilation. Think about testing. And then the high risk is what much of us have known for most of COVID. That’s when there’s high cases and high hospital utilization. That’s when they say everyone should be masking indoors. We should go back to greater, you know, doing just regular screening testing as well as symptomatic testing.

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S1: You talk about on ramps and off ramps with this guidance. Do you think the on ramps and off ramps are at the right place? Like how many people are going to have to be sick for the CDC to say, OK, everyone mask up?

S2: So that’s the debate, right? That is the societal debate of what level of illness and hospitalization and honestly death are we willing to accept as a society before we say we’re going to all put masks on again to to protect each other?

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S1: What’s the CDC’s answer?

S2: So the CDC is the answer, according to one of my colleagues here at Brown, a woman named Alyssa Berlinski, who’s a statistician and policy researcher. She’s calculated it out and has found that the CDC the answer correlates with about a thousand deaths a day. Hmm.

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S1: That’s a lot of deaths.

S2: It is.

S1: What do you think about that?

S2: It is higher than I’m personally comfortable with. I’ll tell you, for me, that medium level on the CDC’s guidance to me is one where I would mask up.

S1: Part of what’s funny to me about this new guidance is that it feels like it was just a few weeks ago that my local health department was telling me to upgrade my mask. They were like, Listen, cloth masks won’t do. You really need a Cayenne KN95? And you know, we were back to ordering boxes of masks on Amazon. Does that kind of bend your brain to?

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S2: So I think we should have recommended the can ninety fives, ninety fours and ninety five far earlier in this wave. It was so clear from the beginning of the Omicron wave that it was more transmissible and that we needed to up our game back in early December. So I think this was a case of the health department’s being a little behind the eight ball, but today is different from three weeks ago. I mean, our cases are at around 80000 per day versus, you know, 800000 per day about a month ago. One of the really important things that I know this is so difficult for us as humans to understand is that every day the number of cases of COVID changes and the level of risk changes.

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S1: There are a couple of groups of people who I think this guidance is less useful for. But maybe you can explain. I’m thinking particularly of immunocompromised people, but also kids who are too young to get a vaccine. How do these guidelines help them or not?

S2: So the most important thing that we can do for High-Risk folks, either those for whom the vaccines don’t work or those who have not yet been vaccinated is to get case counts down. And right now, Omicron case counts are going down almost regardless of what we do, because that’s just what happens during a surge. The most important thing that we can do for those folks outside of keeping cases down is making sure that we have treatments available. And again, masking around them, making sure we don’t bring infections into the house if and when a surge does start again.

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S1: But what you’re saying is for those kinds of people, the immunocompromised kids who aren’t vaccinated. There’s not much they themselves can do. They’re relying on the people around them

S2: for immunocompromised folks. Unfortunately, it is going to fall on them to a certain extent to wear high quality masks when they’re out and about. I will say that wearing a high quality mask, a good fitting off 94 can 95 or N95 mask is tremendously effective in protecting even someone who’s immunocompromised from catching COVID,

S1: even if everyone around them is not masked,

S2: even if everyone around them is not masked. I mean, I’ll tell you, I’ve been working in an E.R. for the last two years. I wear an N95 when I’m in my emergency department. I have knock on wood, not cacovid. Despite taking care of hundreds of COVID patients, intubating them, being in the room with them when they were unmasked, looking in their throat, having them cough on me. An N95 works really well if you wear it right. I actually think that there is this moment for most of us that have been very Kogut cautious, where it feels weird to relax these precautions, that these have been the one thing that we can control. And I want to acknowledge that I want to acknowledge that it’s normal to feel like you’re, you know, questioning, am I still a moral person if I’m taking my mask off? Am I going to put myself at risk? First, you don’t have to unmask. But secondly, you can feel comfortable as case counts drop, starting to go back to indoor restaurants, going back to work, getting back towards normal. COVID is going to be with us forever, and we can’t live as if it’s an all or nothing disease because the world is different today than it was three months ago, much less two years ago.

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S1: More with Dr. Megan Ranney in just a minute. At some point I realized the reason loosening these COVID restrictions was giving me pause wasn’t because I thought the whole world should be masking forever. It was because I wasn’t sure that anything was being done at a structural level to either guard against a new COVID wave or fix what the last COVID wave broke. I wonder if that kind of logic makes sense to you.

S2: Mary That is exactly right, and that has been so many of ours protests throughout this pandemic, right? The folks in charge weren’t taking it seriously, weren’t learning from the last wave. I will say, and I have been critical of the CDC and the current administration, as well as the previous administration around COVID response. But the plan that the White House released that ninety six paisa is actually pretty good. It, if put into effect, will set up the systems to protect us next time around.

S1: What stood out to you that you were like, Oh, this, this is a good idea.

S2: Setting up data systems that we can keep good track of when a surge is starting, setting up ways to distribute those great, amazing treatments like packs loaded to those who need them, their test and treat program is just one of my favorites in there. The idea that you can when you have a positive test at the pharmacy, the pharmacist can then dispense the medication right away.

S3: If you get COVID 19, the Pfizer pill reduces your chances of ending up in the hospital by 90 percent. I’ve ordered more pills than anyone in the world has. And now we’re launching the Test to Treat initiative so people can get tested at a pharmacy and if they prove positive, receive the antiviral pills on the spot at no cost.

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S2: It’s just terrific, and we’ll make a big difference. The emphasis on improving genomic surveillance so that we can identify variants. The emphasis again on trying to maintain staffed hospital beds and thinking ahead about how to handle if there is another surge so that we never have to get back in the situation where we’re canceling surgeries or, you know, shutting down parts of hospitals due to staffing overload. There were just a lot of different parts of that plan that I’m really enthusiastic about. I will say that one thing Mary that deeply needs attention and this is probably my biggest issue with the CDC guidance, is that it puts too much responsibility on the individual, not in low risk moments, but in those moments where the on ramp is starting. Most people aren’t going to be paying attention to COVID counts, and we need to provide them with guidance saying the safest thing for you right now is to mask.

S1: Yeah, it’s interesting because I was thinking it’s not just that people won’t be paying attention to COVID counts. I’m not sure people are going to be paying attention to this CDC tool. Like I went to the website, I checked it out and I was like, Oh good, I’m going green, which means low risk area. But there are lots of CDC recommendations I straight up ignore. I always eat the cookie dough, you know?

S2: That’s exactly right. And I’ll say there are a lot of CDC recommendations that I ignore, too. You know, their job is to provide the best possible guidance to keep you the healthiest you can. But the difference between eating the cookie dough and following COVID precautions is that eating the cookie dough pretty much just puts you at risk not wearing a mask in the midst of a surge. It’s not just you at risk, but also those around you.

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S1: So you think it’s more important for the CDC to be more aggressive?

S2: I do, and my hope is that these CDC guidelines not only guide individuals, but also guide policymakers.

S1: You work in a hospital, and so you’ve seen how wave after wave have impacted the staff who make staying healthy possible. I’m wondering if you think the administration is doing enough to shore up what’s happening with health care workers?

S2: Yeah, Mary people are truly at the breaking point. The continued surges of COVID make us feel like, you know, we’re out there doing everything we can. But there are no reinforcements coming. I know so many people who over the last two or three months during this latest surge threw up their hands and said, That’s it. I cannot continue to do bedside care and either left health care or left clinical positions.

S1: I think you said one of the nurses, she’s just regularly 10 nurses short.

S2: Yeah. So that was one of my charge nurses. So one of the nurses that helps run the emergency department. It was a Friday evening and we were 10 nurses short for that evening, which meant we had to shut us down. We just couldn’t get people to take, you know, we were asking people to take double time offering incentives. Couldn’t get enough folks in that scene, Nurse told me that when when you’re out at triage, you know, basically folks come up to the window and say, I’m here with an emergency. You take their vital signs. Find out what their complaint is and that and if there are no staffed beds in the back, you have to tell them to go, sit and wait. And she said she feels like she’s on the firing line because she’s looking at this mass of humanity who’s sick, who she wants to help. And she literally can’t. There’s nothing she can do to help them because the people keep coming and there’s not enough space to care for them. It’s nearly impossible for me to describe to someone who’s not in health care what that feels like. So is the new Biden plan doing enough? Time will tell. It’s going to take more than a plan from the White House, though it’s going to take Congress stepping up to.

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S1: OK. Given everything we’ve said here about both fewer people wearing masks, but also more treatments being available, I guess the first question is. Do you think there’s going to be another wave in the next year?

S2: I think it’s almost inevitable that there will be another wave. However, if I have learned anything from COVID, it is that my crystal ball does not work.

S1: So my neither?

S2: I know, right? Darn it all, I. Yeah. So I can’t say, when is there going to be a wave? Will it be more dangerous? We don’t know. And that’s part of the point of this. Part of the point of that new plan is that we need to be monitoring so that we can see when a surge comes, we can see if it’s more dangerous or not. We can see if it’s really quote unquote, just like the flu or if it’s more like the COVID that we’ve known for the past two years, which is significantly more dangerous than the flu. And then we will titrate our response accordingly. It may be that there’s another variant that’s milder and we say, All right. People are going to get COVID, but they’re not going to fill the hospital. Wear a mask if you’re high risk, otherwise you might get sick, but you’ll be OK. There’s also a chance that there’s going to be another variant that’s going to break through our vaccines more effectively. It makes more people sick that transmits even more quickly than on the crime has. And in that case, we’re going to have the system set up to provide those policy recommendations to mask, to roll out those treatments in case you’re exposed and are high risk, and to help support our health care workers to provide that surge capacity so that we can keep taking care of people the way that they deserve to be cared for.

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S1: How are you preparing mentally but also otherwise for what you think will be a coming surge? But then again, you don’t quite know what that surge will look like.

S2: Right? It’s almost impossible to think ahead of saying, Well, I’ve got to be prepared, but I don’t know when or how bad it will be. I think of it a little bit like, you know, I live on the East Coast in a in the ocean state. I think I’ve a little bit like prepping for a hurricane or for a blizzard where I can expect that there’s probably going to be another hurricane at some point. So I have a few things that I keep in my house always. And when I hear a forecast that a hurricane’s coming, I go out and get some extra stuff and do extra preparation, right? And I think of preparing for the next surge of COVID the same way we’re building up our stockpile so that we have PPE. We’re thinking about how to create surge capacity for staffing. We’re creating if then models for masking and other changes. But when we start to see those early signs of increase in cases, that will probably come again. Right. Those early signs that a surge may be happening, that will be the moment when we increase our planning even a little more. The trouble, of course, is that some of the stuff that we need for a surge isn’t stuff that we can obtain overnight, so we need to stockpile PPE. We’re talking about stockpiling some of those meds. And that’s a dance between hospitals, state governments, federal government and of course, there’s a financial aspect as well.

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S1: Do you feel like the support is there from the government financially and otherwise?

S2: Not today. Our country doesn’t have a great history of investing in preparation or protection. My hope is that Congress takes this protecting the health care system, protecting the health of Americans as seriously as it takes the military or national security. To me, this is an issue of national security. We need to be able to keep our economy open. Also protecting lives, and that’s going to take some proactive investment going forwards.

S1: Dr. Ranney, thank you so much for joining me. I’m really grateful.

S2: Thank you for having me on. Here’s to a lovely spring and a healthier and less anxiety filled future.

S1: Yeah, I’ll drink to that. Dr. Megan Ranney is an E.R. physician at Brown Medical Center. And that’s our show. What next is produced by Carmel Delshad Mary Wilson, Elaina Schwartz and Danielle Hewitt. We’re led by Alicia Montgomery that I’m Mary Harris. I’ll be back in this feed. Bright and early tomorrow morning.

S4: Catch you then.