Friday, January 13, 2023

The Mild COVID Myth and a Missed Public Health Messaging Opportunity

 by Michael C. Dorf

For three years I managed to avoid getting COVID, but my luck ran out last week. Well, not really. My luck didn't change. My precautions did. Until August, when Sherry died, I was extremely careful, not wanting to expose her (with immunity weakened by chemotherapy drugs) to the virus. But since then, like a lot of people in the last year, I let my guard down. Maskless, I taught a class of 73 nearly-all-maskless students three days each week. I resumed eating in indoor restaurants. I went to a couple of Cornell hockey games and even to a sold-out Madison Square Garden to see the Knicks. So it was inevitable that I would be exposed.

My first day my symptoms were similar to a mild cold. In fact that's what I thought I had for that first day, as my rapid test came back negative. However, on the morning of day 2 I took another rapid test, which came back positive. My daughter, whose symptoms preceded mine by a couple of days and who had also tested negative at first, also tested positive, so I trusted the result. Even so, I thought, this will be no big deal. I'm fully vaccinated and multiply boosted, including with the bivalent booster. I'm still in my 50s, so not especially high risk due to age, and I'm otherwise in generally excellent health. No big deal, right?

Days 1 and Day 2 included some modest fever and chills, but still not as bad as I've had with the flu in the past--although honestly it's hard to be certain about a frame of reference, given that I went the previous three years without catching anything. I followed the protocol: I isolated in my bedroom (and meanwhile the daughter home for winter break who also tested positive was isolating in her room, while the other daughter home for winter break was catering to us while avoiding us, so that she could remain uninfected); I figured I would read a lot and nap and then I would go about my normal routine masked up on Days 6 - 10, per CDC guidelines. Then came Days 3 and 4, during which the fever and chills were gone, but I had the worst sore throat of my life.

A little Googling revealed that "worst sore throat of my life" is quite common with Omicron, especially with BA.5, although whether it's equally common with  XBB.1.5 or whatever sub-variant I caught is unknown to me. I do know that Days 3 and 4 were extremely unpleasant. (Today is Day 9. Now I have the remnants of a cough and slight congestion that feel like the tail of an average cold.)

I recognize that, compared to hospitalization, death, or long COVID, it looks like I did in fact have a mild case. I'm grateful for the vaccines that very likely played a role in helping me avoid a worse case. I'm not kvetching only for the sake of kvetching. Rather, I want to observe that the unpleasantness I experienced reveals a missed opportunity for public health messaging.

Very early in the pandemic, it was unclear whether masks inhibited COVID spread. Within a relatively short time, it became clear that they do. The fact that the guidance changed was then used by anti-maskers and their allies to try to discredit the new wisdom that masks should be worn in public. Over time, as the virus has evolved and knowledge of it has also evolved, it has become clear that some masks (N95 or equivalent) are substantially more effective than others.

For now, I want to dwell on a period, still early in the pandemic, when the prevailing wisdom held that masks may provide just a little bit of protection to the wearer but mostly protect others against infection coming from the wearer. In a strongly libertarian country, that fact--that masks (mostly) protect against harm to innocent third parties rather than protecting wearers from a risk they might choose to assume for themselves--ought to have been enough to lead to widespread acceptance of masking and mask mandates. Whereas libertarians object to paternalism, they don't generally object to regulation that aims to prevent them from harming others, at least if they are not batshit crazy libertarians.

But of course many American libertarians are batshit crazy, so they objected, on grounds of individual liberty, to taking measures to protect others. Some objectors to masks were not necessarily members of the batshit crazy libertarian right; they were conspiracy theorists who denied that COVID was even a real disease. That said, I'll bet there's substantial overlap between the batshit crazy libertarian right and the conspiracy theory right.

Even so, I doubt that the two groups completely overlap. Some of the anti-vax/anti-mask crowd are left-leaning new-age yoga/wellness enthusiasts. And some of the people objecting to vaccine and mask mandates really did just not want the government telling them what to do. Thus, even in the jurisdictions where vaccine hesitancy is highest, older people--who generally skew more conservative and thus are more likely to get their (mis)information from Tucker if not Alex--have had higher vaccine uptake than younger folk, reflecting their rational processing of the fact that COVID is for them a greater risk.

So now my question: what if, in addition to promoting vaccines as a means of greatly reducing the risks of hospitalization and death from COVID, the government had also aggressively promoted masks, distancing, and other measures to avoid catching COVID as a means of avoiding the very serious problem of long COVID and a potentially hellish few days with a once-in-a-lifetime sore throat? Few of the most committed anti-vaxxers and anti-maskers would have changed their behavior. But for some people (like yours truly) it would have perhaps made a difference.

Motivating people to avoid COVID in order to avoid being only "mildly" or "moderately" sick from COVID would have been good for everyone, because with fewer people getting sick, there would be less COVID in circulation and thus fewer severe cases leading to hospitalization or death. Whether such a policy would have made more than a marginal difference is hard to know, but with a disease that has already killed 1.1 million Americans, even a marginal difference could have meant thousands of lives saved.

The tragedy now unfolding in China shows the same missed opportunity. Overreacting to the popular revolt against the overly restrictive lockdowns that were part of the Zero-COVID policy, the Chinese government shifted its messaging to emphasize the low death rate from Omicron. But with relatively ineffectual vaccines and low vaccination rates among the most vulnerable, Omicron poses a grave risk to millions of people in China.

The good news is that mask wearing remains more widespread in China than in the U.S. The bad news is that, judged by overfilled hospitals (because one cannot judge by the unreliable official numbers), COVID is nonetheless now very widespread in China. Perhaps something like this was inevitable, but perhaps not. Suppose that, when China first eased its Zero-COVID restrictions last month, the authorities had also issued very serious warnings about the impact of COVID even for people who don't end up hospitalized or dead.

Even now, it's probably not too late to adjust the messaging in time for Chinese New Year gatherings. The main reason why the Xi government likely won't is to avoid further embarrassment from whiplash--first Zero-COVID, then don't-worry-about-COVID, and now, if there were a further change, worry-about-COVID-but-not-under-citywide-lockdown. But that's a political, not a public health, consideration. And if the last month and a half has taught the Chinese authorities anything, it ought to be that basing public health policy on politics makes for bad public health policy and eventually for bad politics too.

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