A Marathon, Not a Sprint: The Race Between COVID-19 Vaccines and Variants

SHANOOR SEERVAI: When you look back to this time last year, late March, what’s the one thing you feel you were most wrong about?

ERIC SCHNEIDER: Yeah. It’s hard to look back a year given what we’ve been through, but I’m pretty sure the thing I was most wrong about was that I had a solid belief that the federal government, in particular the CDC, would act to contain the virus. I had known for 20 years as a public health faculty member that the government had a pandemic preparedness plan. That was a plan they developed after 9/11, the anthrax scare. It was updated several times during H1N1, and it was actually war-gamed not too long ago by the Department of Homeland Security under the Obama administration. So I thought, of course, they’ll execute the plan and we should be fine.

SHANOOR SEERVAI: The brutal winter surge of COVID-19 appears to be slowing down, and the number of Americans getting vaccinated is going up, but the pandemic is far from over, in part because the coronavirus is mutating. Many variants detected abroad are spreading across the U.S., and unfortunately some spread faster and more easily than others. I’m Shanoor Seervai, and on today’s episode of The Dose, we’re going to be talking about the race between the COVID-19 variants and the vaccine. My guest, Eric Schneider, is a doctor and senior vice president for policy and research at the Commonwealth Fund. Eric has been tracking the spread of the pandemic closely, and I’ve asked him to bring us up to date on the challenges ahead.

Eric, welcome to the show.

ERIC SCHNEIDER: Thank you for having me, Shanoor.

SHANOOR SEERVAI: So, Eric, are we in a race between the COVID-19 vaccines and the variants?

ERIC SCHNEIDER: Yes. Yes, we’re in a very-high-stakes race. We’re lucky that vaccine production is accelerating. Many states are getting better at putting shots in arms, but the variants are exploding, especially in Europe. There have been detected throughout the U.S., especially B.1.1.7., which is a serious threat. It’s more contagious. It’s more lethal, we’re now learning. We can’t ignore right now the other tool that we have to win the race against the virus, and that’s masks and distancing. Even if we took just those two actions, we could break the back of the virus and the variants. If we wear masks, avoid eating indoors in close quarters in restaurants and bars, even if businesses and schools reopen, we know that masks and distancing can be as effective as vaccines at slowing the spread. And we even know from some studies that mask mandates are effective, which means that relaxing them is likely to cause problems.

SHANOOR SEERVAI: So Eric, why didn’t the U.S. institute a mask mandate?

ERIC SCHNEIDER: It’s an American unwillingness to give up liberties that makes Americans resistant to mandates of all kinds. Seatbelts were sort of my favorite example from public health. It took years to pass seatbelt laws in states, even though we knew they reduced death, and Americans have a relatively low trust in the federal government. That said, when there are mask mandates in states, even states like Texas which prioritize liberty, people do tend to follow them. Like I say, the evidence shows that those mandates are effective.

SHANOOR SEERVAI: Are you worried about what’s going to happen in Texas now that the governor has recently lifted the mask mandate?

ERIC SCHNEIDER: Yeah, I’m very worried. I mean, the past is prologue in this case. We’ve had people ignoring lockdowns in Arizona. We saw it in the Dakotas. We saw it in Southern California. And reopening too soon repeatedly has shown us that there’ll be a week or two where it looks like things are going okay, and then the virus will find more susceptible individuals.

SHANOOR SEERVAI: Let’s talk about this new threat, the variants. Why are we worried about them, especially if more and more Americans are getting vaccinated every day?

ERIC SCHNEIDER: Well, there are two reasons to be worried. One is that even if more and more Americans are vaccinated, the transmission will really only slow once we reach what’s called herd immunity, which most people believe is above 60 percent of people have to be immune. It might be as high as 70 percent or 80 percent, and actually with the variant B.1.1.7., the herd immunity threshold would have to be even higher because its greater contagiousness and higher likelihood of killing people mean that more people would have to be immune in some way, either vaccinated or naturally.

There’s also a worry that the variants can reinfect people who’ve already been infected with a different variant. And then third is the worry that the vaccines won’t be as effective against the variants. So we’re really using our vaccine strategy and our masks and distancing public health measures to control the virus at a level where the variants don’t emerge, where they can’t take hold. Because even with vaccination, we could end up in the fall in a situation where the virus is still transmitting, it’s still reaching people who are susceptible, it’s reinfecting people who’ve already been infected once, and causing all the problems that we’ve seen over the past year.

SHANOOR SEERVAI: So as we are vaccinating the adult population, I understand that there is an attempt to develop vaccines that are safe for children, but we’re still a long way away from the point at which children would actually be getting these vaccines. Can we talk more about that?

ERIC SCHNEIDER: Sure. So we’re actually just beginning clinical trials. One of the vaccines has started in children less than 12. Vaccinating children is tricky, because children have a much lower risk of severe illness or death from the virus, and so the clinical trials to prove that the vaccine is effective take larger numbers of people over potentially longer amount of time. We may not find ourselves able to recommend, on an evidence-base, vaccinating children until sometime next year because of just the time it takes to do these studies. The good news is that we know that children are less likely to transmit coronavirus in general, especially those under 5, and we’ve also seen that it’s possible in many studies to open schools safely, as long as protocols are followed around ventilation, distance, mask-wearing, and testing of teachers on a routine basis and testing of students potentially.

SHANOOR SEERVAI: So let’s shift gears a little bit and talk about, again, what the vaccine is allowing people to do. CDC guidelines say that fully vaccinated people can be indoors together with each other, and people are really itching to gather again. They want to go indoors to restaurants. They want to celebrate. A lot of things have been put on hold for this last year. What’s going to happen when fully vaccinated people do start gathering in large numbers?

ERIC SCHNEIDER: Yeah, we’re going to be in a sort of middle phase here where many people are vaccinated, many people are not, and that’s going to complicate things. The CDC is likely to be cautious about their guidance on this, and here are the issues. The vaccines are not 100 percent effective. They never are. Ninety-five percent is outstanding, but with the variants coming in and the possibility of mutations, the effectiveness of the vaccines could be somewhere between 60 percent and 90 percent, so that means that there is still a risk. Even though the risk is much lower, it’s not eliminated or it’s not zero, so even vaccinated people gathering, there’d be some risk that transmission could occur.

We’re still gathering evidence too on how effective the vaccines are at reducing transmission. We know they can prevent severe illness and death, hospitalization. What we are less sure about is how well they prevent transmission. There’s some emerging evidence that they may be very effective at reducing transmission as well, and once that evidence is clearer, there will be a possibility of reducing the restrictions even more and allowing people to gather without masks around a table. But again, this is going to be a sort of ongoing process. People have likened it to a dimmer switch where we may have to turn it up or turn it down. The restrictions will turn up or turn down depending on what we understand about the effectiveness of vaccines and what the community transmission rates are. At the end of the day, that’s actually the thing that most determines the risk level is how much transmission is happening in your community, your local community.

SHANOOR SEERVAI: Mm-hmm. And of course there is variance in the rates of transmission in the U.S., but on an international level, it is actually quite astounding, and we don’t understand why some countries have been hit much, much harder than others. We have seen very different responses though. Can we talk about why some countries have done much better at responding to the virus than others?

ERIC SCHNEIDER: Sure. So this is a fascinating area, and I think international comparisons in general are complicated. There’s so many factors that differ between countries, geography, culture, economics, and a variety of other things. Countries have had different experiences, like I said earlier, with prior infections. So if you look at Taiwan, China, South Korea, New Zealand, they’ve been all very effective at controlling the virus, getting it under control to the level where people can go about normal life, but each of those countries is so different from the U.S. culturally and by size, by their ability to control who enters or leaves the country, so the comparison I find most instructive is actually with Australia. The U.S. and Australia share a common sort of historical origin and a frontier. They have federal and state governments and a mix of public and private insurance. They have also high levels of inequity that are a result of their cultural history of minority indigenous communities, oppression.

The coronavirus experience, despite all those similarities, has been remarkably different, night and day between the U.S. and Australia. Australia instituted lockdowns early. They instituted travel restrictions between countries and within the country. They had strict quarantines for people entering the country, and they really hammered the virus down to zero right at the outset. And then they had outbreaks in the summer last year, and they instituted very comprehensive regional lockdowns whenever cases appeared. The results of all of that have been stunning. The U.S. has over 530,000 deaths at this point. Australia has experienced fewer than a thousand deaths, only 900 deaths in the past year, and the last deaths in Australia were recorded in October of 2020 as best I can tell. Their economy is open at this point because they’ve contained the virus and kept it contained.

SHANOOR SEERVAI: So Australia sounds like a real success story, but what about Europe? When we think about countries like Germany, which are also similar to the U.S. — large federal structure and very strong, resilient health care systems — why has Germany had been hit so bad, especially with this most recent winter wave?

ERIC SCHNEIDER: Yeah, it’s interesting. Germany was one of the success stories early on. They had control of the virus throughout most of 2020, and people were actually speculating about why Germany’s case fatality rate was so low as well. In retrospect, it’s probably mostly related to the way the virus entered the population. It was mostly younger people, initially travelers coming from outside the country, but they were very good at early-on testing and containment strategies. What might’ve happened later is somewhat the politics that we’ve seen in the U.S., where there was a very active antimask, antirestriction, antilockdown movement that got underway in the fall. Europe in general had eased travel restrictions among the countries quite a bit over the summer months, and it’s very likely that a lot of virus was introduced into the various European countries because of those limited travel restrictions.

SHANOOR SEERVAI: And then what about this other big mystery, which is the developing world? I think perhaps with the exception of Latin America, rich countries have been hit much, much harder than poor countries. Do we have any idea why this is the case?

ERIC SCHNEIDER: Yeah. There’s quite a lot of speculation about this paradox. There’s a general belief that developing countries are more susceptible to infectious disease threats, and that has been the case with things such as Ebola and other infectious diseases. There’s a report out of the U.N. Conference on Trade and Development from December of 2020 that speculated that it’s probably a combination of underreporting of deaths and less widespread testing and case-counting, but that doesn’t really explain all of it. Even if those undercounting were significant, other things seem to be at work and other features that we’ve seen in other countries, even the U.S., that areas with lower population density, where a larger share of the population lives in rural areas tend to have a slower spread, at least initially. And in low-income and middle-income countries, many more people live in rural areas or a higher proportion live in rural areas compared to high-income countries.

There’s also something about the way the disease enters the population. I was struck that really air travel is what spread the virus initially from China to all of the other countries in the world, and it’s possible that low- and middle-income countries were spared initially and then had time to develop containment measures like testing, quarantine, and contact-tracing. Low- and middle-income countries generally invest quite a lot in public health containment because of their weaker health care systems. They realize they have to be effective at prevention. There’s still a concern, ultimately, that the low- and middle-income countries, and we’re seeing it in some countries already, Brazil and others, that they will ultimately be hit hard because of the infrastructure challenges.

SHANOOR SEERVAI: In the United States context, this has been a very sobering conversation. Is there any hope on the horizon that we can look to?

ERIC SCHNEIDER: Yeah, there are a few things that, in what seems like a sea of darkness otherwise, give me hope, and maybe I’m just an optimist. But the first is, and this has been noted by others, we’re incredibly lucky to have the science that’s given us three and probably additional effective vaccines. If we can produce and distribute these vaccines effectively and quickly, we could really escape further carnage. This is actually an unprecedented accomplishment in the history of science. It’s a new technology platform that we’ll be able to use in the future, so I’m optimistic the vaccines will eventually help us get this under control.

The other interesting glimmer of making lemonade out of lemons, I suppose, is that there’s been a political shift in the U.S., and we’ve just seen the passage of an almost historic relief legislation that is addressing many of the issues that the pandemic has revealed about inequality in our country and the effects of poverty, particularly for children. Whether it’s a durable turning point, we don’t know, but the effort to reduce childhood poverty is something that was unimaginable at the start at 2019 as the economy was humming along.

And then the other hope I still hold is that we’ll learn a lesson about pandemic preparedness. We’ve so underinvested in our public health infrastructure and practices. These are the things that have protected other countries, and they could protect us from the next emerging disease threat. We tend to rely on our ability as the richest country in the world to just spend on medical care and rescue people. That’s the general orientation of our system, but these people didn’t have to be sick in the first place if we had taken the proper prevention measures. So, I think it’s a good time to get those pandemic preparedness plans out of the trash cans. We’re seeing that start at CDC and other agencies, and really to take a hard look at what investments we need to make to strengthen public health so we can prevent or mitigate a future pandemic.

SHANOOR SEERVAI: As you talk about childhood poverty and sort of supporting the most vulnerable parts of our population and also about strengthening public health, it does sort of diminish the glory of the vaccines for me, because we’re lucky to have these vaccines, but we’re not doing a great job at reaching those who need them most. Can we talk about the vaccine distribution problem?

ERIC SCHNEIDER: Yeah. We’ve had successes and challenges. I think the successes are the nursing homes. They were the first to get vaccinated. We’ve seen death rates falling in nursing homes. Willing health care workers have been vaccinated. That’s reducing a level of stress of our health care workforce. The embedded inequities in our system really are coming to light in the way our vaccine is rolling out. We have trouble vaccinating those who are at the greatest risk of contracting and dying from COVID-19.

If you just think about the offer on hand to someone who has been in the health care system, actually has not been in a health care system, they can’t get access to a doctor. They don’t have insurance coverage. They have insurance, but it’s not enough. Their employer won’t let them take sick leave. There are all these barriers for many people in the U.S. among the working poor and the poor to getting health care at all, and then we turn around and come to them and offer a vaccine and say, “We want you to come and get a vaccine.” You can’t help thinking why wouldn’t people be suspicious of that? You’ve never been able to give me access to any other thing I needed from the health care system. I can go to the emergency room, sure, or I can just sort of tough it out at home, and now suddenly I’m supposed to trust you when you say you want to give me a vaccine.

There are solutions. People are implementing solutions. They’re trying to reduce the friction around vaccine appointment websites and the need for tech savviness to get scarce appointments. The mass vaccination sites, they’re beginning to now go to federally qualified health centers and community health centers and pharmacies where people don’t have to drive for hours when they don’t have cars. There’s much more dedication to getting the vaccine into mobile units, so you can reach people who aren’t able to travel. So, I think we’re seeing some progress. It’s uneven. Some states are doing better than others, and this challenge will continue to be with us even as the supply of vaccine increases.

SHANOOR SEERVAI: Are you hopeful that we will also see a shift in some of the ways in which we build trust, we reach out to communities that have historically been underresourced?

ERIC SCHNEIDER: Yeah. I worry that we’re treating vaccination rollout as a one-off. In the interest of speed, we’re sacrificing an opportunity to strengthen local public health departments and strengthen primary care. There’s been a lot of commitment to mass vaccination sites, pharmacies, and sort of alternative vaccination sites that bypass the delivery system. If all of that infrastructure goes away and we still have the public health system and the primary care clinics that are underfunded, we’ll have missed a terrific opportunity, and that would be tragic.

SHANOOR SEERVAI: One of my recent guests, Magdala Chery, talked about how there hasn’t really been a real apology to communities of color, and so now we talk in terms of vaccine hesitancy, but we don’t reflect upon the fact that Black, Latinx, Native American populations have been so badly hit by this disease, and we haven’t really reckoned with the national blame we should for the impact on these populations.

ERIC SCHNEIDER: Yeah, I think that’s right. The mistrust runs deep, and I think the trust has to be earned by the system. Apology would certainly be a first step. It wouldn’t be enough, and I don’t think it can be just about vaccines. I think it should be a reckoning with all of the health services that have been unavailable because of structural racism, the financing of our health care system, some of the predatory activities around people who are facing surprise bills or other health care bills that they just have no chance of paying back because of their income. And I think until we are reckoning with all of those issues and really making a commitment to all health services being equitably and fairly available, it’s very hard to overcome the legacy.

SHANOOR SEERVAI: So, Eric, I have one final question. If you don’t mind, can you tell us if you have been vaccinated?

ERIC SCHNEIDER: I have not yet successfully navigated the websites, but actually I’m not eligible yet, so I feel fortunate that I’m in a position to wait my turn.

SHANOOR SEERVAI: And so when you are able to get vaccinated, what’s the one thing that you can’t wait to do?

ERIC SCHNEIDER: Well, I am really eager to share a meal with my children and grandchildren around a table with our masks off, and if President Biden’s announcement was correct, it seems like that could be a real possibility by July 4th.

SHANOOR SEERVAI: All right. Well, I hope you get to have that meal, and thank you so much for joining me today.

ERIC SCHNEIDER: It’s been a real pleasure, Shanoor. Thank you.

SHANOOR SEERVAI: The Dose is hosted by me, Shanoor Seervai. I produce this show for the Commonwealth Fund along with Andrea Muraskin, Naomi Leibowitz, and Joshua Tallman. Special thanks to Barry Scholl for editorial support, Jen Wilson and Rose Wong for our art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions, with additional music from Podington Bear. Our website is thedose.show. There you’ll find show notes and other resources. That’s it for The Dose. Thanks for listening.