The Pandemic Won’t End Until We Strengthen Our Safety Net

SHANOOR SEERVAI: Various parts of the globe are experiencing COVID-19 surges. Some countries like China are doubling down on lockdowns. Others, like Denmark, have declared the pandemic all but over. In the United States, people seem divided. There’s both an overwhelming desire to move on, and some very real trepidation about what could come next as cases climb.

I’m Shanoor Seervai, and today on The Dose, we’re going to talk about out how we’ll know when the pandemic is over, and if over is even a realistic expectation. My guest, Dr. Celine Gounder, is a Senior Fellow and Editor-at-Large for Public Health at the Kaiser Family Foundation and Kaiser Health News. She’s also a physician at Bellevue Hospital and Clinical Associate Professor of Medicine and Infectious Diseases at New York University. Dr. Gounder has been chronicling our dance with COVID-19 from the start, and maybe even before that. As an epidemiologist, she has been concerned about pandemic preparedness for years. And she continues to look ahead in the hope of helping our health systems navigate what comes next.

Dr. Gounder, thank you so much for joining me.

CELINE GOUNDER: It’s great to be here.

SHANOOR SEERVAI: Let’s start with where we are today, which is confusing for many of us. We are witnessing a strong divergence of opinion among public health experts; those who say the vaccinated are safe and done, and those who want to keep masks and other restrictions in place. Why has this rift emerged?

CELINE GOUNDER: I think much of this depends on whether you’re approaching this problem from what I would call a clinical perspective versus a public health perspective. So when we approach issues from a clinical perspective, we’re really just concerned with the individual who’s in front us and we’re thinking about what are the tools we have to help them either prevent disease or treat disease. Those are going to be tools, like tests and treatment and vaccination. That’s slightly different from the public health approach, where the goal is really to protect or treat at a population level. And so you’re much more concerned with: Does everybody have access to testing and treatment and vaccination? Does everyone have the means to protect themselves? That’s really, I think, what’s driving this rift in the public health community is where are they on that spectrum with respect to individual versus population.

We are seeing that there are widening disparities now in terms of access to testing, treatment, and vaccination. This is in part the result of the expiration of the HRSA Uninsured Program, which was reimbursing providers who might have provided diagnostic testing or treatment or vaccination to patients. And so uninsured people now are being asked to pay out-of-pocket. And remember the uninsured are poor in general, and so it’s really a steep climb for them to access some of these services now.

SHANOOR SEERVAI: So as you talk about the uninsured, I think about how the pandemic has starkly revealed inequities and structural weaknesses in our country. Do you think it could prompt us to look with more empathy at those as a society we’ve never really cared about? So people of color, people with low incomes, the immunocompromised, and others we’ve historically ignored. Is this our chance to do things differently?

CELINE GOUNDER: I would like to think so. I think what we’re already seeing is that there’s a very quick forgetting and moving on. I think unfortunately we’re likely to see the same disparities that the health care system generates being reproduced yet again. The American health care system is really notorious for how it creates health disparities. We have barriers in terms of payment, in terms of bureaucracy. We have disparities related to race, to gender, geography. Those are not unique to COVID. The system is designed in such a way that it creates those disparities. And if you are falling back or defaulting back to the health care system, as opposed to a public health approach for preventing and managing the COVID problem, you are going to see those disparities replicated.

SHANOOR SEERVAI: And if we think about this COVID moment, you suggested a number of solutions, like guaranteed paid sick leave, improving indoor air quality, strengthening public health surveillance, expanding coverage, moving away from this overreliance on pharmaceutical measures, and addressing structural problems, just to name a few. Which are the likeliest to gain traction in the near term, and then in the longer term?

CELINE GOUNDER: Well, we are seeing increased interest in how do you improve indoor air quality? So you could think of indoor air quality as sort of the 21st century issue that water quality was back at the turn of the 20th century, where at that time you were not guaranteed safe drinking water. I think now most people would expect that to be the norm, that you open your faucet and that you can drink that water. Now, to be clear, that’s actually not true in some parts of the country, but that is the expectation. I think we’re now starting to see interest in how do we make our indoor air safer, in particular in K through 12 schools and other public buildings? There is government funding available to do this, but I think the expertise and political will, in some cases at the local level, hasn’t yet translated into action.

SHANOOR SEERVAI: So is this then going to fall on local businesses or other organizations to pay for improving indoor air quality?

CELINE GOUNDER: There is funding in the American Rescue Plan, infrastructure bill, and other legislation that did provide funding; some $200 billion for K through 12 schools to make these kinds of improvements. But it’s not just a question of the federal government allocating the money. Then you have to have local school districts making a plan, so that means assessing their buildings, assessing their ventilation and air filtration systems, coming up with a plan, contracting with vendors, applying for the money. So it’s sort of like having money on a table that’s just too high to reach. These local school districts need to have the capacity to access that funding.

SHANOOR SEERVAI: What about some of the other things? Could we talk a little about paid sick leave?

CELINE GOUNDER: This again does not necessarily have to be all on the federal government to accomplish. Some states like California, for example, have implemented regulations, laws around paid sick and family medical leave. So states and local jurisdictions can decide this is something they think is a priority. Some of this can be funded through local taxes, as well as employers. Employers can decide this is a benefit they want to offer their employees. My employer, the Kaiser Family Foundation, starting April 1st of this year, started to implement paid sick and family medical leave. This is something that the organization has realized over the course of the pandemic was really important.

The question is, why is this important? Because if you’re sick and you feel like you’re going to miss out on wages, you’re going to miss out on a day of paid work, you may still go to work sick. If your child is sick and you don’t have any other affordable form of childcare, you may send your child to school anyway, as opposed to perhaps staying home with that child. So this is a really important measure to reduce transmission in the community.

SHANOOR SEERVAI: And I’m noticing since we talked a little bit earlier about the people who are being left behind and ignored, it doesn’t sound like we’re going to be taking them into account in the near-term future. We have vaccines, but it seems like, besides that, people are being left to their own devices.

CELINE GOUNDER: I think, unfortunately, that is what it looks like the future holds. I think we tend to frame things in terms of individual responsibility. And so once you have those pharmaceutical products, whether it’s a test or a treatment or a vaccine, by and large, we really leave it up to the individual and the health care system to do the rest. And again, not everybody has equal access to health care. Not everybody has health insurance, or maybe they don’t have very good health insurance. They may not be able to take time off work to access those services. They may not have the knowledge and education to know what to ask for, to navigate the system. There are a whole host of reasons why relying on the health care system does not result in an equitable outcome.

SHANOOR SEERVAI: And if we can’t rely on the health care system, what should we do? What would be a more positive outlook for our future?

CELINE GOUNDER: Well, I think first of all, creating safety nets. Some of what we’ve already talked about certainly are important in terms of prevention, but then safety nets in terms of, well, if you do get sick, do you have health insurance? Over the course of the pandemic, there were measures taken to expand who was on Medicaid, to provide more generous subsidies if you were signing up on the Obamacare marketplace insurance plans to make them more affordable. So I think anything that can be done — and there’s many policy approaches to how to do this — but anything that can be done to expand health insurance to more people so that if they do get sick, that they are covered would certainly help. Medical debt, I think, is the number one cause of bankruptcy in this country.

SHANOOR SEERVAI: So this isn’t the first time that you’re working on pandemics and trying to get us to think more long term about these issues. For years, we moved from public health emergencies like Zika and Ebola, to ongoing challenges like malaria, and you repeatedly made the case that our public health infrastructure is woefully unprepared. What has COVID changed about that?

CELINE GOUNDER: COVID has really further battered and beaten down the public health system. Over the course of the pandemic, we’ve seen public health leaders quit. They’ve been fired. They’ve been retired and perhaps not replaced. And so we’ve seen the loss of a tremendous amount of public health leadership and institutional memory. And so that leaves us actually in a much weaker place. On top of that, you have public health workers who are really burned out, those who’ve remained. And so we’re really just trying to dig out of a very difficult last two years, and have really yet to begin building and strengthening.

SHANOOR SEERVAI: Where is your work headed? Could you talk briefly about why you’re focusing your attention on communication — writing, speaking — rather than your clinical practice?

CELINE GOUNDER: I think one of the things I’ve learned over, I mean, it’s about 25 years now that I’ve been working in public health in one form or another, is that communication is one of the most important tools of public health. How do you convince people to take action? How do you educate people? How do you address disinformation? These are all projects of communication. There are very few people, at least until the pandemic, who really focused in this space of how do you translate science and public health into stories and easy-to-digest nuggets of information or nuggets of messages? That’s really what I’ve been trying to do.

SHANOOR SEERVAI: You talked about misinformation and I feel like right now, both the public and our leaders are awash in misinformation, and even disinformation in the public health space. What does it mean to try and address these problems as public health issues?

CELINE GOUNDER: First, it might be helpful just to distinguish. So misinformation is incorrect information, but it doesn’t necessarily have an agenda. So somebody could retweet somebody else’s misinformation, but they’re not necessarily trying to do harm. Whereas disinformation is really with an intent to do harm, to profit in some way. It could be financially or politically. And so there is a difference there.

They’re slightly different in terms of how you approach them. Misinformation, because there’s not an agenda, it’s really more about just correcting and providing facts. Whereas disinformation, because there’s an agenda very much, again, around either financial profit or political profit, that is much more difficult to combat. You also are facing the power of the social media algorithms, which are far more likely to spread disinformation because it tends to have a certain emotional urgency to it and people respond to that. And even if you pump out as much good information as there is mis- or disinformation, the algorithms tend to amplify the mis- and disinformation so much more. That does require a slightly different strategy, and a lot of that is really about trust and building community to help amplify your message.

SHANOOR SEERVAI: Can you talk a little bit about your work on both these fronts?

CELINE GOUNDER: I started to pivot toward science communication in 2013, so about a decade before the pandemic, and really got pulled into some of the conversations around Ebola, which hit in 2014. We were in the middle of our own midterm elections here in the U.S., the West African countries were in the midst of their presidential elections, and so the terrain was ripe, so to speak, to see disinformation spread because you were in the middle of elections. A lot of what I learned during that period of time, during that year or two of writing and doing television interviews around Ebola, really translated directly to what I was seeing during COVID in terms of an agenda driving the message and shaping how science was being communicated, as opposed to science really driving that.

SHANOOR SEERVAI: And if we fast-forward to where we are today, again, we have this huge problem on our hands. There’s a lot of people out there with inaccurate information, some of that is being spread by actors with the intention to spread inaccurate information. What are we going to do about it? How do we take control of the narrative here?

CELINE GOUNDER: There are a lot of different ways this needs to be approached. Some of this is regulatory, which is really outside of my purview as a science communicator. It’s really the wheelhouse of Congress and others like that. But for me as a science communicator, I think where I and others can really have an impact is through broadcast media, through writing. It’s not just through national television. I think one of the spaces where we really need to be present is in local news. There’s really been the collapse of local news in many parts of the country. There may no longer be a local paper, but very often there may still be local TV or local radio where people do get their news. And I think these are information deserts where we can have a real impact.

SHANOOR SEERVAI: Well, let’s look forward now a little bit given your tightened focus on communication. So if zero COVID is not the right or relevant goal, what is?

CELINE GOUNDER: COVID, or SARS-CoV-2, cannot be eliminated or eradicated. It is biologically not possible for a number of reasons, including the fact that you have nonhuman animal hosts. You have a disease with a very, very short incubation period, much shorter than smallpox, for example, which has about a 14-day incubation period. Smallpox is the only disease known to man to have been eradicated thus far. So for a whole host of reasons, you can’t eradicate SARS-CoV-2. So, what should be the goal? Well, I think the goal is really, how do you mitigate the impact? How do you control it so that you’re reducing as much as possible, hospitalizations and deaths, and as much as possible, weighing that in the balance with what are the social and economic impacts?

SHANOOR SEERVAI: So will we live with what some people have described as a viral underclass with the accompanying stigma that weakness is why some people are getting sick?

CELINE GOUNDER: I think we have had a viral underclass all along. I think that will only become even more pronounced as we emerge from the pandemic, because in the U.S. we tend to default to the health care system to deal with all of these issues. We don’t have a very robust public health system. Public health is thinking more about disease control from a population perspective, with a focus on the most vulnerable. And so when you have a system that is instead focused on the individual, intends to prioritize the most privileged individuals, you will see a viral underclass emerge.

SHANOOR SEERVAI: And you don’t think this has prompted America to think more about strengthening the public health system?

CELINE GOUNDER: I think it has prompted those of us who believe in public health, who have probably been saying for years, decades, we need to strengthen public health. I think for us, it is just a reminder that this is an ongoing need. And also it’s a moment of desperation where we do not see those investments occurring.

SHANOOR SEERVAI: What are we going to do every time there’s a surge in cases or a new variant if we assume that the vaccines will at least continue to protect the majority against death and severe disease?

CELINE GOUNDER: I think this is where having those safety nets becomes really important because if you have, for example, improved indoor air quality or paid sick and family medical leave, or better access to health insurance, you don’t necessarily need to change what you’re doing all that radically when there is an increase in cases, because you already have that backstop in place. The problem with being reactive, as opposed to proactive, is it takes time to react. And so you may be well into a surge before you start to implement measures. There is fatigue with asking people to take individual-level interventions, say, for example, masking. Whereas the systemic measures, so like improving indoor air quality, you don’t have to take action as an individual, except that you’re walking into a space that has better air quality.

SHANOOR SEERVAI: Right. I mean, there does seem to be this real desire to quote unquote, get back to normal, and not a lot of appetite for restricting large indoor gatherings anymore, even if we have large outbreaks afterwards. But is indoor air quality enough to protect everyone who might walk into one of those rooms?

CELINE GOUNDER: None of our interventions are enough in and of themselves. So vaccination is not going to prevent all infections. It will dramatically reduce hospitalizations and deaths. So vaccination should of course be a key intervention here, but you need to layer other things, and indoor air quality is one of those other things.

SHANOOR SEERVAI: When we think about risks, is it up to the individual to manage that, or can we hope that our institutions and society at large will help?

CELINE GOUNDER: Well, it’s a combination of both. I think individuals, if they are given the information, they are given the tools cheaply, conveniently, rapidly, then yes, there’s going to be some level of individual responsibility, but we haven’t done that. We haven’t provided all of these tools in that way. I think, secondly, there’s also a societal obligation. I think it’s in all of our interests not to have collapsing health care systems, to see what we’ve seen over the last two years with hospitals and ICUs overloaded with patients, that compromises the care for everybody. So it’s a combination of both the individual and the societal.

SHANOOR SEERVAI: What is your vision for what the new normal should look like? You’ve argued that hospitals in the U.S. are not really ready for this new normal. Is there any way to more evenly distribute the burden of care among hospitals in anticipation of the next crisis?

CELINE GOUNDER: Well, some of that is a question of surveillance. So being prepared and knowing what’s coming. I think we’ve been overly reliant on counting cases, which is never going to be accurate. But especially now that more and more people are testing at home, not all of that data is coming into the CDC and health departments. Some people never tested or had poor access to testing.

So what are some of the better ways where you could have your finger on the pulse, so to speak? Some of this is what we do for other diseases. We don’t count cases of everything for other diseases. So random population-level surveillance, where you randomly sample people and get an estimate that way. Syndromic surveillance, which is where you count the number of people who come in, say to the hospital with cough and fever, and you get a sense of trends that way. Wastewater surveillance, where we’re looking for the virus in sewage water. That is not a perfect tool. We’re still working on optimizing that, but that could also be a really important barometer of when hospitals should be staffing up and preparing for a surge.

SHANOOR SEERVAI: What about anticipating the burdens on hospitals at an earlier stage? What can we do to prevent, or at least mitigate, the impact of the next pandemic?

CELINE GOUNDER: I think we need to staff up. We’ve been retrenching our health care workforce, especially on the front lines, whether it’s primary care providers or hospitalists. We’ve been cutting back on hospital beds and closing hospitals over the last couple of decades. And so I think there needs to be given thought to how much capacity we actually need, how much slack we need in the system. So sort of being prepared as opposed to reactive at the last moment. I think that’s going to be a real change in mindset because much of the motivation to cut back on workforce and hospital bed capacity has been driven by the bottom line.

SHANOOR SEERVAI: Dr. Celine Gounder, thank you so much for joining me today.

CELINE GOUNDER: Oh, sure. It’s my pleasure.

SHANOOR SEERVAI: This episode of The Dose was produced by Jody Becker, Mickey Capper, Naomi Leibowitz, and Joshua Tallman. Special thanks to Barry Scholl for editing, 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. Our website is thedose.show. There you’ll find show notes and other resources. That’s it for The Dose. I’m Shanoor Seervai. Thank you for listening.