We Are Not Done
Today, for the first time in two years, my high school children are able to see their friends’ faces in the classroom. They can finally see the broad range of expressions on their teachers’ faces. They can greet the custodian in the hallway with a long overdue thank-you smile for keeping the campus safe.
Perhaps like yours, my kids are mostly excited about removing their masks but have mixed emotions, too: Worry that taking off their mask might signal carelessness toward other people; empathy for their friends who have underlying medical conditions or nervousness about uncovering their face and who still want or need to mask; and ambivalence about change—even though it's what they both want.
My college-aged son also will be able to unmask on campus in a few weeks. In the meantime, the school’s dining hall reopened for the first time in two years. It actually opened for two weeks in February—then promptly closed because of an uptick in reportedly mild COVID cases among students. When it closed after that brief window, my son decided to write to the President of the University—a polite and data-informed letter advocating to allow indoor dining given the low risk of COVID to the 99-percent-vaccinated campus and the importance of dining facilities for community-building and campus culture.
Perhaps not surprisingly, his letter garnered lots of support but also significant hostility. Indeed not everyone is ready or able to eat indoors. He learned quite a bit from this foray into advocacy, namely about the diverse array of medical, financial, social, and emotional vulnerabilities on college campuses—and indeed in life—plus the risks of speaking up during a heated time. The dining hall did open. Students flock to eat together. My son reports that tensions are down and morale is up. Meeting fellow students for the first time—and engaging in hard conversations—is more productive and gratifying than he imagined.
For two years we’ve talked as a family about how the pandemic has laid bare and exacerbated educational, economic, and health disparities along racial and ethnic lines. My kids recognize their privilege and their intrinsic responsibility to others. They also recognize that taking their masks off is only the beginning of a long healing process for our country—and for each of us, individually.
Indeed by removing mask mandates, we’ve further shifted the responsibility of COVID-19 risk mitigation onto the individual. My friend Monica Gandhi MD MPH wrote one of the first papers in April 2020 calling for universal face masks for COVID-19; she has also written extensively about masks in the current moment. In a nutshell: just because mask mandates are no longer appropriate doesn’t mean masks can’t help an individual reduce their personal risk if need be. Just last week I recommended continued masking in crowded spaces for one of my high-risk patients until she’s able to get Evusheld (see below). Whether she will or will not mask will be up to her depending on the circumstance.
In other words, the main reason we’re lifting mask mandates in schools right now is because the benefits of mandates in reducing in-school transmission are still unclear and the harms of ongoing mandates are increasingly apparent. At this phase of the pandemic, it’s time for people to assess their own risk and wear a mask if they want or need to. It’s also time to give each other a little latitude as we adjust.
(Note that last week, two new studies on school mask mandates were released, both suggesting that mask mandates do work to reduce in-school transmission of the virus. It would be tempting for me to jump on the bandwagon with experts who’ve instantly called these studies “garbage”—in part to counter the other side’s reflexive declaration that these studies “prove without any doubt” that mandates work. Instead, I plan to take my time understanding these studies alongside my epidemiology and public health brain trust, and only add them to the pro/con list about mask mandates if they actually fit. Stay tuned!)
In the meantime, hope is in the air. COVID cases continue to fall. Spring is poking her head out through the clouds. If you’re anything like me, it feels a little like deja vu. Remember last spring when we thought we were rounding the bend of COVID-19? Remember emerging from winter 2020, newly vaccinated and thinking we might actually get back to “normal?”
I do. I even wrote a piece for the Washington Post exactly a year ago about my own FONO—or Fear of Normal. Like many of my colleagues (and the CDC), I mistakenly thought we’d be through the worst of COVID-19 at the end of last spring. I pinned too much hope on the vaccines which, at the time, were fabulously effective at preventing disease and at curbing transmission of the virus to other people. The vaccines were so successful in that particular era that the CDC lifted mask mandates for vaccinated people on May 13, 2021.
Then came Delta. And then Omicron. Our risk calculations completely changed.
Here we are now, in the age of Omicron, with a whole lot more clarity about many things:
What the vaccines can and cannot do. The vaccines continue to be wildly effective at preventing death and severe disease. But unlike in the Alpha or Delta eras, the vaccines no longer do as well at preventing infection or reducing transmission (i.e. spread to other people). Vaccine expert and FDA advisor Dr. Paul Offit explains the situation beautifully right here. Indeed, celebrating what the vaccines do well and managing our expectations about what they do less well allows us to more appropriately calibrate our risk and risk tolerance—and not be surprised when vaccinated people get mild to moderately ill from COVID-19.
The power of ventilation. It’s actually been clear since 2020 that COVID is spread by airborne particles (and not surfaces), which is why it makes intuitive sense to open windows and doors in public spaces—and to work on ventilation systems in our schools and workplaces. Ventilation is a public health tool that helps everyone, invisibly, and is something we need continued institutional vigilance on, particularly as we drop lower-yield mitigation measures (from plexiglass barriers to social distancing to mask mandates).
The legitimacy of infection-acquired immunity. So-called “natural immunity” is not the way I recommend becoming immune to coronavirus, but we cannot ignore the mounting evidence that hybrid immunity (the combination of vaccine-induced and infection-acquired immunity) seems to offer superior protection against reinfection with SARS-CoV2. Of course there’s a lot of nuance here: one’s personal degree of immunity is determined by many factors including the number of vaccine doses received, the spacing of vaccine doses, a history of past infection, the amount/volume of viral particles inhaled, and our baseline immune function—among other variables. (Note: this is exactly why much of the public messaging on this complex issue has tragically created political divides when there is nothing remotely political about the human immune system.) The upshot? Get vaccinated if you are not yet immune to coronavirus. And for more specific guidance see your pediatrician or primary care provider.
Increasing population immunity compared to last year. As a result of Omicron’s high level of contagiousness, it blanketed the country with infections, even among vaccinated people. This tragically resulted in widespread loss of life. Omicron continues to cause largely preventable deaths and ongoing devastation in people who are living. The resulting immunity from Omicron infections is of course not what anyone wanted. It’s simply that Omicron infected so many people that, as a result, we have ended up having more total immunity as individuals and as a population. This should offer some protection against future variants and outbreaks, but how much and for how long? Only time (and people a lot smarter than me) will tell.
Therapeutics. We now have preventatives and treatments for high-risk patients (that are not to be used as a substitute for vaccination). Evusheld is a twice yearly injection of monoclonal antibodies as a preventative. Paxlovid is an oral antiviral tablet prescribed if and when high-risk patients are diagnosed with COVID. These two developments are reason for hope for our most vulnerable populations.
But how can we have hope amidst chaos? How can we lift mask mandates when COVID continues to run roughshod through the world? Last week I wrote about “holding paradox.” It means thinking about things as “both-ands” instead of “either-ors.” It’s about abandoning absolutism and black-or-white thinking. It’s about grappling with existential crises like war, climate change, and structural racism while simultaneously living our lives. To me, holding paradox feels like a necessary skill in these highly polarized times.
Indeed, by removing mandated face coverings, we’ve unmasked other problems. We are more divided than ever. Economic, social, and educational inequities have widened. We’re still woefully behind in vaccinating our highest-risk populations, ventilating indoor public spaces, and understanding long-COVID.
As individuals, we’re behind on our cancer screenings and check-ups. We’re due for some rest and reconnections with loved ones. We need to thaw out from the winter and shore up energy for the next COVID wave—whether it’s six months, six years, or six decades from now.
So no—I don’t have FONO right now. I have a fear of not improving on our old normal. I want my kids unmasked. But I mostly want a better future for them and for all kids—a future where they can express differing opinions and engage in meaningful conversations. Where our children appreciate the diversity of people’s lived experiences and still challenge the status quo. Where the world is more equitable and fair. Where public health messaging is rooted in facts and nuance and stripped of shame and fear. Where our children can protect themselves from disease and despair in tandem.
In closing, I’ll tell you my personal paradox of the moment. It’s the thing that’s giving me sorrow and joy ALL AT ONCE: My wonderful assistant and medical mentee, Mariam, is leaving me this week to become a doctor. She and I have stood shoulder to shoulder throughout the entire pandemic. I couldn’t be more grateful to her. I also couldn’t be prouder. She gives me hope for the future of medicine. Let’s wish her all the best.
I will see you next week. Until then, be well.