In 2020, the arrival of SARS-CoV-2 offered the world an unwanted crash course in infectious-disease prevention. Mask up. Congregate outdoors. Test, and test again. Two and a half years later, what have people taken away from it? And how might people use that information in the future in order to stay healthy?
I set out to discuss what COVID-era lessons we should—and shouldn’t—apply to other illnesses with the professor, epidemiologist, and physician Jay K. Varma, who formerly worked for the CDC. Our conversation ended up veering toward a much more fundamental question: Have we actually learned from COVID? And does that even matter? Infectious diseases are, after all, collective-action problems. An individual can only do so much to prevent themselves from getting ill.
Varma noted that some of the good lessons that have come out of the world’s COVID experience are counterbalanced by an increase in vaccine misinformation and the undermining of the nation’s public-health entities. I asked him what he saw as the lingering weak spots on the individual level. His answer surprised me—the biggest wasn’t vaccine hesitation or being anti-mask or neglecting to use hand sanitizer. It was a lack of civic action: “I want individuals to demand that their elected officials take health security as seriously as they take physical security.”
Our conversation has been edited and condensed for clarity.
Caroline Mimbs Nyce: We are entering cold-and-flu season. How might people apply the lessons of COVID to various illnesses this fall in a productive way?
Jay K. Varma: Let’s talk about prevention. The first lesson is that wearing something that covers your nose and mouth, ideally a high-quality medical face mask, can reduce your risk of all types of infections. Number two, of course, is the long-standing guidance about the importance of staying up to date on your vaccinations. A lot of the vaccines that we give children and adults prevent respiratory infections, including pertussis or measles. And then, of course, there’s the annual flu shot.
Once you do get sick, it’s a good idea to stay home and not try to force yourself to go to work when you’re coughing or have other symptoms that could be contagious. Now, this presumes, of course, that you have paid sick leave or can work from home. And so it assumes a certain level of economic security and privilege that many people don’t have.
That also relates to school. I’m a parent of three kids. When they were younger, there were many times that we would have our kids go to school after their fever had resolved. But they still had an occasional cough or weren’t necessarily feeling perfectly great or had the sniffles. And we just didn’t think anything of it. And certainly that’s not something that we should have done or that other people should do on a regular basis. Again, asking people to keep kids home also assumes a certain amount of privilege.
I wish there was a really good way for individuals to know how likely they are to infect other people with the flu or other respiratory viruses.
Nyce: Why don’t we have rapid at-home flu or strep tests?
Varma: This is really an important issue. For many years, the basic paradigm that existed was that all tests for infectious diseases should be restricted to some type of health-care setting, that a nurse or doctor or somebody else should do the tests; people should not do their own tests at home. That’s different, of course, from pregnancy. We allow pregnancy tests. We allow people to use a thermometer. But we haven’t let people use infectious-disease tests.
One of the biggest innovations was at-home HIV testing. But that was different, because you collected your test at home but didn’t interpret the result; the specimen got sent somewhere.
COVID has really changed that paradigm. Let’s think about another health problem that’s not related to respiratory viruses: a urinary-tract infection. How many women get urinary-tract infections all the time and are basically having to struggle to find a doctor that will prescribe them, digging out old antibiotics that they stockpiled from their last infection or trying to borrow them from their friends? If women could use a urine dipstick at home—which isn’t perfect—in combination with symptoms, you can save medical visits and save people a lot of time and expenses.
I’m hoping that there’s a shift over time to the COVID experience now extending to other infectious diseases. For a lot of diseases like the flu or other respiratory viruses, we’re getting to an era in which you can make very-easy-to-use home tests that are very reliable. Think about the power of having that diagnostic information available to you.
Nyce: What are some of the lessons of COVID that are not universal, that are really more COVID-specific?
Varma: Let’s just run through all the things we recommend for COVID.
Doing activities outdoors: In general, most of the diseases that we talk about being transmitted person to person are not transmitted outdoors unless you’re talking about a vector-borne disease, like a mosquito- or tick-borne disease, or a disease that requires skin-to-skin contact. But for respiratory viruses, being outdoors is good. So that’s generally applicable.
Ventilation: Again, generally applicable to most respiratory infections.
Vaccination: We only have some diseases that are vaccine preventable, so it’s not applicable, obviously, to everything.
The next would be diagnostic testing. Pre-COVID, it was not necessary for everybody to get tested for respiratory symptoms. But unfortunately, in the era of COVID, because any type of respiratory symptoms could be COVID, it’s probably a good idea for everybody to get tested.
Hand-washing and hygiene. Even though I know there are a lot of questions about how much COVID is transmitted based on surfaces—and most of us believe that’s a very uncommon, and probably extremely rare, event—we know that surfaces do harbor many other viruses and bacteria, and that cleaning the physical environment can also be beneficial.
I do think that probably our balance as a society is a little off—we should be cleaning the air indoors more than we do. But I think there’s tremendous value in keeping your physical surfaces clean for everything. And that may be more relevant to norovirus, for example, which causes the stomach flu or some other infections, but not so important for COVID.
Nyce: I did want to talk about surface transmission, because we started off the pandemic being told to wash our hands and not touch our face. And then that turned out to be low risk. How should we be thinking about surface transmission in general? What illnesses can we get from surfaces?
Varma: A lot of the concern about physical surfaces comes from the experience in hospitals and other health-care facilities, where there is very clear evidence that contamination of physical surfaces can make both patients as well as medical providers sick. The other place where this happens a lot is restaurants or kitchens. We know that surfaces—and that doesn’t just mean the counter; it means utensils or prepping equipment—can harbor viruses and bacteria that cause gastrointestinal diseases.
So what does that mean for the average person? I think it’s important to primarily focus on washing your hands, because we know that hands are kind of the intermediary between a physical exterior surface and you infecting yourself. And there’s actual data about this: There’s a very elegant study done in Bangladesh about, gosh, maybe 10 or 15 years ago, where they randomized different households getting soap (either regular or antibacterial) and basically looked at the incidence of a whole range of different infections in kids in those households compared to those that didn’t get any soap at all. They looked at skin infections, pneumonia, and gastrointestinals. The homes that got rigorous hygiene interventions had a lower risk of all of those outcomes.
Nyce: So what if we narrow the scope to respiratory diseases? Say a friend is sniffly or coughing. Maybe you have her over for dinner. How diligently should you be masking up versus worrying about surfaces? Are you generally pretty safe if you’re outside, at least in the respiratory family?
Varma: I think so. The reality is we can’t give you an absolute risk percentage. We can just do relative risk. The more likely you are in a place where there is good movement of air, where there’s a wind current, where there’s sunlight—which has a disinfecting property—and the greater distance you are away from somebody, the lower the risk that a virus flying out of your nose or mouth lands in their nose or mouth. In general, when we talk about respiratory viruses—so cold and flus—then yes, outdoors is always going to be safer than indoors.
Covering your nose and mouth with a high-quality mask will also lower your risk of infection. Now, do you care enough to do that? People say, “Look, if it’s not COVID …” Even for COVID, obviously, there are many parts of the country where people don’t really worry about it anymore.
Nyce: Are there COVID lessons that you worry we’ve overlearned?
Varma: It’s not so much COVID lessons that we overlearned; it’s probably misinformation that has been learned. COVID has emboldened the anti-vaccine movement. We’re now seeing polio transmission in the United States. And there is no doubt in my mind that that is linked to the anti-vaccine sentiment of the pandemic as well as the disruption of health-care services. The other harmful lesson is this notion that somehow, public-health agencies are authoritarian, that public health is about restricting liberties rather than trying to balance risks and benefits of people living and working together.
Nyce: Do you think that the pandemic has been a net-positive or a net-negative in terms of getting public-health messaging out around personal-prevention tactics?
Varma: It’s a very difficult question to answer, because I think we’re not going to know until sometime in the distant future. Positive outcomes can come from horrible humanitarian disasters. The flu pandemic of the World War I era led to the field of epidemiology getting its heyday and countries adopting universal-health-care systems. HIV brought in this massive revolution in molecular biology that’s given us the ability to do PCR testing really quickly and also changed a lot of the role of community in getting FDA regulations changed so drugs could be brought quicker to the market.
There are going to be positive outcomes that come from COVID. But it’s very hard to balance that with all the harms that have occurred. There’s been a tremendous loss of credibility in the United States for public-health agencies, the CDC being the most notable. And that is hugely harmful to public health, because public health relies on credibility. That’s really its major currency.
And so it’s hard for me right now to see the positives that have come out of the pandemic for public health, simply because the negatives are balanced against some of the good things.
Some of the good things that have come out of the pandemic are a better recognition of the importance of ventilation in indoor air quality, faster movement by the FDA to make diagnostic tests available to people, including their ability to use them in their homes. Third is that there’s a lot of interest among young people in public health. That’s a good thing for society.
The one last thing I would add is public awareness about the risk of pandemics, and the fact that we are now living in an age of pandemics. Humans are interacting with animals and the environment in ways that they haven’t in the past. A number of factors—globalization, urbanization, climate change, deforestation—are combining to make diseases emerge and spread faster.
So hopefully, that will change people’s perspective on both their personal behaviors and their investment in getting elected officials to actually care about public health.
Nyce: You mentioned the threat of future pandemics. Where are the lingering weak spots for you, in terms of personal prevention and awareness?
Varma: The biggest weakness is the one I just talked about. I want individuals to demand that their elected officials take health security as seriously as they take physical security. To me, that is the single biggest personal weakness that’s out there. If people start clamoring for more investment in public health to keep them safer, then they’re likely to be safer.
I will turn the question around on you a little bit, which is that if you asked me the same question—“What is the biggest thing an individual can do to stop crime in their community?”—there’s not a lot they can do, right? There’s no evidence that purchasing a firearm makes you safer in your home. And in fact, there’s a lot of evidence to show that it makes it more dangerous. There’s not a lot of evidence that security cameras are the things that help you. But investing in your local community makes it safer.
Nyce: Is it just that getting sick is fundamentally a communal problem?
Varma: Yes. That’s what public health is all about.
Nyce: [Laughs.] We just got to the definition of public health.
Varma: Yeah. You can do individual interventions. But they are less important than all of the things that we do at a community level. If you look at how mortality has changed in the past 150 years, the biggest improvements came from cleaning water, cleaning the air, making roads safer. All of these are things that governments, not individuals, have control over.