Health Wanted Show Notes: COVID-19, Five Years Later
We’re looking back on the COVID-19 pandemic: what we learned, what we could have done better, and what we still need to address.
COVID-19 is the disease caused by the SARS-CoV-2 virus, a member of the coronavirus family, so named for the crown, or “corona,” of spikes the virus presents on its exterior.
Coronaviruses are what’s known as enveloped RNA viruses, meaning they have a covering made of their own plasma.
And while this may sound like the sort of thing that would protect it from the elements and help it survive on surfaces for a long time, it actually means the virus is more sensitive to things like pH, heat, dryness, and disinfectants.
While coronaviruses make up a fair portion of the common colds we experience every year, they have gone off the rails before.
There have been previous outbreaks of more serious illnesses caused by coronaviruses.
The original outbreak of SARS-CoV-1 (which we just called SARS at the time, short for “Sudden Acute Respiratory Syndrome”) happened between 2002-2004 and was mostly concentrated in Asian countries.
It infected over 8,000 people and had a case fatality rate of around 10%.
In 2012, MERS, or Middle East Respiratory Syndrome, was discovered in the Middle East.
This version of a coronavirus is spread by contact with infected camels (and to a much lesser extent infected people), and in the 12 years since its discovery there have been around 2600 confirmed cases with a case fatality rate of 36%.
Which brings us to the topic of COVID-19’s origins.
I can understand why the lab leak theory, which is the idea that COVID escaped from the Wuhan Institute of Virology, is appealing: It gives us a place to put our anger at the upending of the world.
But the overwhelming evidence is that the virusjumpedfrombats (which are known carriers of coronaviruses) to an intermediary animal, and then from that animal to humans, which is the same thing that happened with the original SARS outbreak.
Having a virus jump from animals to humans is not new. It’s what happened with HIV, certain influenzas, Ebola, and mpox, among other diseases.
A big deal had been made of the fact that the Wuhan Institute of Virology did work on coronaviruses and also existed in the same area as the first documented cases of COVID-19.
But it’s not that surprising when you think about it: virology institutes are likely to be in places where the viruses they study are found.
News about the pandemic started slowly and then happened all at once.
In the U.S., it began with many people learning of the existence of a place called Wuhan for the first time or reading news reports of lockdowns and overwhelmed hospitals in China.
Then suddenly Italian health care workers were posting about their long hours and collapsing medical centers.
Cruise ships were stuck off the coast of Japan as the virus ripped through the passenger list.
By late January, the U.S. had their first case of COVID, and by early March the first cases were identified here in Atlanta.
What went wrong with our attempts to contain COVID?
The answer is “a lot,” and I think most of the errors have to do with the way we communicated, or didn’t communicate, important information around COVID.
For me, one of the biggest issues was trying to convey that information will change and be updated, and that makes it hard to speak in absolutes.
Take the often referred to example of Anthony Fauci, then head of the National Institutes for Allergies and Infectious Diseases, saying that the public did not need to wear masks. This recommendation would change as a few things became clear.
In a crisis where health care workers need protective gear more than the public, if COVID was originally thought to predominantly spread through heavy droplets that require close contact to get, keeping space between people might be a reasonable mitigation strategy without masking, but we eventually learned this wasn’t the case for COVID.
Another, arguably more important, point was that someone can be infected with COVID and spread it to others before they develop symptoms, or even with no symptoms at all. So, masking in seemingly healthy individuals was more so about preventing them from possibly infecting others, rather than preventing them from becoming infected (both of which are still things masks can do). And that was really not communicated enough.
Similarly, the 6-foot “physical distancing” rule could have used more explanation.
I often saw complaints that 6 feet seemed arbitrary, and that people doubted the virus magically stopped at the 6-foot mark, kept within an invisible forcefield. And it’s true that at the time of the recommendation, we did not have research to support 6 feet exactly as the limit of the virus’ ability to travel.
But we do have research that shows that close contact spreads viruses, and in the case of a new virus, where we don’t know a lot about how it spreads, or impacts the body, but do know that it kills people, “don’t get too close to each other” is actually good advice.
There were other choices during the heaviest days of the pandemic that maybe felt good because it really seemed like efforts were being made but ultimately were not super useful.
Think of the big show a lot of places made about hygiene, cleaning surfaces in movie theatres or other common areas when fomite transmission (that is, transmission via contaminated surfaces or objects) wasn’t a huge factor.
Or getting your temperature checked when people could spread the virus without any symptoms, and some people became ill without ever having a fever.
And then there’s the issue of so-called “lockdowns.”
Our stay-at-home orders were incredibly disruptive, closing businesses and restaurants and other places of congregation, but people were not kept isolated in their homes the same way they were in places like China.
Many groups have found that the compulsory aspects of our stay-at-home orders did have some impact on disease spread or mortality. But the impact differed based on the intervention and came with large economic or social costs.
The question is really whether we could have had the same, or better, outcomes if we had focused more on messaging around voluntary behavior change and saved the compulsory orders for things that have high potential for super spreader events, like large gatherings and venues.
It’s hard to look back and wonder “what if” but I do think at the time, when the hospitals were so overwhelmed and so many people were dying so quickly, it’s justified to act based on assumptions to save others’ lives.
They may have worked better if we had acted more quickly.
Just like the ongoing measles outbreak in west Texas is showing us right now, waiting to act until you see the disease present itself already means you’ve waited too long.
It can take between two and 14 days for symptoms of COVID to appear after someone has been infected, which means waiting for symptomatic cases to seek care leaves as much as two weeks of time for the virus to have already spread to others.
Which is why, when it hit the U.S., it felt like an explosion.
Suddenly our hospitals were overwhelmed, and I was working 6 days a week, often 10-12 hours a day, trying to enroll people in clinical trials for treatments.
It’s hard to treat a virus as you are learning about the ways it impacts organ systems.
Because viruses depend on our cell machinery to replicate, it can be really hard to make antivirals that both effectively target the virus and don’t damage our bodies further.
Remdesivir, which was originally developed as a potential Ebola treatment, showed some promise early on, but now is mostly beneficial in people who are hospitalized but don’t require ventilation.
Dexamethasone, a common steroid, was found to improve outcomes in people who required oxygen support.
Paxlovid, an antiviral for early treatment of COVID not requiring hospitalization, was seen as extremely promising in clinical trials for its ability to reduce the risk of disease progression and shorten symptoms. But data now points to it being most effective in people over 60 who are unvaccinated, which is good because that is one of the age groups at greatest risk for severe outcomes.
Two interventions that do not work are hydroxychloroquine and ivermectin. Outpatient prescriptions for each of these medications had a two- and ten-fold increase, respectively, during the first three years of the pandemic, totaling over $270 million in spending on the drugs, which have been repeatedlyshown to be no better than a placebo at preventing or treating COVID.
An ounce of prevention is worth a pound of cure, as they say, so thank goodness for the development of effective vaccines, even if they are another area that needed communication improvements.
The trauma of the pandemic meant that people were so desperate for good news, so we all grabbed onto the headline of COVID vaccines being 95% effective at preventing infection and didn’t stop to communicate the limitations.
These data came at the three-month point after vaccination with two doses. More should have been done to explain that we need to see if this efficacy remains high over time or wanes (a thing we now know happens, along with high potential for mutations).
At the time the vaccine trial results came out, we weren’t even sure if natural infection gave life-long immunity, which would have been a clue as to if vaccines should be expected to be able to do the same.
It’s estimated that vaccines prevented 20 million deaths globally in their first year of use, and they continue to prevent severe illness and death in the most at-risk groups today.
But I do wonder if we might have had a better time, emotionally, if we’d emphasized vaccines as a tool to help end the pandemic, rather than our holy grail, singular answer.
Messaging around the development of vaccines was meant to inspire people, but it also had the opposite effect.
Treating mRNA vaccines as a sort of wunderkind might have had the intention of getting people excited about the application of scientific development, but I do think it contributed to skepticism around the vaccines.
“Vaccine technology that’s been decades in the making could be the solution to our current problem” is decidedly less sexy of a headline compared to something like “new technology sets record for vaccine development.”
It is a massive, incredible feat that we were able to go from spike protein sequence to vaccines in arms in under a year, but it was only possible because of the decades of work on mRNA vaccines that had been happening all along.
Many people didn’t realize that mRNA vaccines had been in development since the 1960s and were first used in humans in 2013 for a potential Ebola virus vaccine.
A lack of understanding about how clinical trials work also contributed to vaccine skepticism.
Trials can be a lengthy process for a few reasons, and many of those reasons were removed during the early days of the pandemic.
Trials can take a long time because of lack of funding to move the stages along—that wasn’t an issue with COVID
They can take a long time because of the time it takes to write up reports and submit them to the FDA and then be worked into the FDA’s schedule to review—that wasn’t an issue because everyone was united in the desire to move the process along, so the review of data was a top priority.
Some of the biggest limiting factors of trials have to do with participant recruitment and reaching end goals.
For the COVID vaccines, we had an incredible number of people who wanted to participate and help test the vaccines, which made enrolling the necessary number to reach statistical significance much faster.
In studies like this, it’s not until a certain number of people get whatever disease you’re studying that you can unblind the researchers (meaning you can let them see if each person got a vaccine or placebo) to see if there’s a difference in the group.
We hit our required number of COVID cases extremely quickly because there was so much COVID circulating in the population, which then let us see the overwhelming number of cases were in the unvaccinated group.
The speed with which we hit all the benchmarks for a successful trial caused some people to think it was rushed, when in reality we collected the exact same data we would have if all three phases had taken 10 years to accomplish.
People also had visceral reactions to vaccine mandates.
If no one has taken the time to explain the vaccine development process, the benefits and limitations, or the technology behind the vaccines to you, then it makes sense you might have reservations about taking a vaccine.
But when people talk about the evils of vaccine mandates, I feel like it comes from a place of viewing public health as an evil entity.
The less generous, more conspiratorial views of vaccine mandates seem to frame them as a way for public health professionals to get rich, and don’t often talk about how mandates were put in place as an economy-stimulating choice as well.
The government and employers wanted employees to be able to return to work without the risk of shutdowns due to widespread illness.
Vaccines have drastically changed the landscape of COVID today.
The population’s mixed immunity (meaning most of us have antibodies from prior infections, vaccines, or both) has significantly reduced COVID deaths.
In 2022, COVID was the fourth leading cause of death in the U.S. In 2023, it was the 10th, dropping more than 70% over the last year.
Vaccination has also been shown to significantly reduce the risk of developing one of the greatest mysteries of the COVID pandemic, long COVID, even in children.
We now know that a big contributing factor to severe COVID is the dysregulation of the immune system—when an overactive immune response creates a level of inflammation that does more harm than help, and people can experience respiratory failure.
COVID also appears to increase blood clotting, which puts people at risk for neurological symptoms as the immune cells of the brain are activated and attack their own healthy brain cells.
For a portion of the population, the symptoms of COVID can persist for months after the acute infection ends, resulting in what we now call “long COVID.”
It’s extremely difficult to estimate the prevalence of long COVID, because many surveys conducted for the task rely on things like self-reported COVID infections and symptoms.
If someone doesn’t test for an infection, it’s possible they could develop symptoms and not know that it could be the result of COVID.
Even if the prevalence of long COVID in the U.S. is under 4% (which is where some estimates put it), that’s still a huge number of people.
