Keeping safe from COVID: Apparently it's all up to you

The most recent COVID-19 subvariants, currently accounting for at least half of US infections (and probably comparable world-wide) are the BA.4 and BA.5 subvariants of the Omicron variant. The bad news is that they are spreading rapidly, infecting many people. The good news is that a high percentage of those infected are getting milder illness, and the percentage of people requiring hospitalization or dying is lower than for previous infections (such as the original Omicron variant and its first variant from last winter, BA.1). This is explained (see “Family Practice News” article, here on MEdge) by the fact that we have (a bit simplistically) two different types of lymphocyte cells that produce immunity. B-cells produce antibodies (called humoral immunity), while T-cells directly attack invading germs that they have been primed to recognize by prior exposure through infection or immunization, which is called cellular immunity. Essentially, the new subvariants have mutated to avoid detection by antibodies (thus resulting in more infections) but not to resist destruction by T-cells (thus the less severe infections).

The other piece of bad news is that you can still get sick, can still get hospitalized, and can still die from COVID. And, of course, you can still infect other people, whether in public or in your home, and if some of those are more susceptible with lower immunity (say, older parents or grandparents, or those with chronic disease) and are infected by you, they can die. You will have been, sorry to say, the vector for their death. Like a deer who carries a tick that carries Lyme disease. And then there is “long COVID”, persistent serious symptoms lasting for months or years (from the CDC, over 13% at one month, several percent at a year, over 30% in people who were hospitalized). Sometimes getting infected is essentially unavoidable; people do have to go out, and even if they have been immunized, and boosted, and take care like wearing masks and staying reasonably distanced, and not eating indoors at restaurants, they can still get infected. But I have just listed a lot of things that a lot of people could do and many are not doing, and to the extent that they are not, infection is much less “unavoidable”. When you cross the street, you can be careful, cross on the green in a crosswalk, look both ways, and still be hit by a person careening around the corner at high speed who isn’t looking. But if you cross in the middle of a busy street, with no light, trying to dodge cars, you have greatly increased your risk. There is, to put it mildly, a LOT of misinformation about COVID that persists (see cartoon!)

 

A lot of people talk these days about individual responsibility and not being able to trust the government, and they definitely have some justification. But they often are looking at the wrong problems and coming up with the wrong solutions. No matter how many guns you carry, or how fast they shoot, or how big the magazine is, you can’t shoot the virus. You can do the things I mentioned above (get vaccinated and boosted, try to not be indoors with lots of other people, wear a good mask if you have to be in public, and also a mask if you are around vulnerable family or friends). A note on masks: any mask will help protect other people from you because it is right in front of your mouth and nose. Unfortunately, for you, this isn’t protective if other people are not wearing masks, certainly the norm these days. To protect yourself from others, you need an N-95, well and tightly fitting, since if folks are infected they will have been spewing virus all over.

Government agencies (and they don’t always have their acts together and agree even at the federal level, not to mention all the 50+ states and territories and thousands of local jurisdictions) have generally not been requiring masks recently. The federal government has been sending access to home test kits, and they and local governments have been closing sites that can do more accurate testing. Getting a vaccine is not always so easy, even if you want one. The CDC and FDA and Secretary of HHS Xavier Becerra and Anthony Fauci (whatever his title) often seem to not agree with each other, and often disagree with something else that they recently said themselves. And what agency is responsible for doing and saying what is a mystery to most people. Yes, sometimes the pronouncements of these agencies and individuals change because the scientific knowledge has changed – this is what Fauci is fond of saying, even when he contradicts himself because the science did not change – but there is another major reason, and, sadly, this gets back to you and to me.

Governments make policy and implement it (more or less effectively -- less, in general, for mask mandates) but they are nothing if not political. Political means that they (or those who appointed them) need to be elected and re-elected, and this is their main goal. If they pursue policies (like, say, mask mandates) that people find intrusive and don’t want to do, they can lose votes. And if they pursue policies that keep people from working and shopping and such then businesses lose money, and the politicians can and will lose donations. So they try to walk a fine line between encouraging some restrictions (sotto voce) and loudly proclaiming that things are getting better, that society should open up, that our economy will be growing, and you can go back to work.

So, those of us who are concerned about us and our families getting COVID and maybe getting very sick and maybe dying, and even more likely suffering the continuing problem of “long COVID”, should be very cautious about jumping on the “things are getting better; you should go back to normal” bandwagon. Things are not the “old” normal, but everywhere you go people have taken the “blue pill” (The Matrix, 1999 reference), drunk the Kool-Aid (Jonestown, 1978 reference) or are on soma (Brave New World, 1932 reference) and are not being careful, so you need to be extra careful. There are a lot of places to get infected, and they are sometimes places that you hadn’t though about or planned for. A friend recently went to an outdoor concert with adequate distancing, wearing masks – but prior to entering was in a tightish line to get in. And got COVID. Waiting in the passport control line at an international airport, people were jammed together, and few were wearing masks. Being safe most of the time doesn’t protect you from when you are not safe. [see: Anything. Because something didn’t happen once, or twice, or fifty times, doesn’t mean it won’t happen next time.]

There are a lot of really bad things going on now. Domestically, the Supreme Court (#SCOTUS-6) is doings its best to put you and everyone else at risk, abandoning Roe v. Wade, increasing the probability people with die, allowing almost anyone to walk around with almost any kind of gun, increasing the probability people will die, limiting what the government can do to slow (forget prevent!) global warming increasing the probability people will die, threatening democracy, which will not necessarily direct cause people to die but increases the risk of all the others. They are moving on to making almost anything else that will protect us illegal with one hand, while things that put us at risk are legalized with the other. Plus the world, the wars including that in Ukraine, and world-wide climate change. That is how they get you – how many things can you worry about, fight to change? Well, it has to be all of them. Including the virus causing a world-wide pandemic that could kill you.

Government needs to make easy free effective accurate testing widely available on virtually every corner, not depend on home tests which are not only much less accurate but do not allow accurate data collection. It needs to make it very easy and free to get immunized. It needs to require masks for people gathering indoors. It needs to have a consistent and broad policy on the use of paxlovid and other treatments. It needs to enforce effective protections – only the BEST kind of masks and respirators – for healthcare workers, particularly in hospitals. It needs to, with all the problems listed above, not be distracted by actual red herrings, like refugees and immigrants.

But too much of this will be politically unpopular. Many of us want to stay in the Matrix, at least while we can. Amazingly, the American Public Health Association (APHA) has just announced that masks will be optional at its November meeting in Boston! Can any public health person tolerate this? Do they understand the optics?

So if APHA won’t mandate masks, the government probably won’t take the risk. So you have to take care of yourself and your family. Do what you can, do more, be extra cautious.

Maybe it will help enough.

The Fourth Surge? The Fifth? Guess what: It’s still not safe out there!

The US recently passed a million deaths from COVID-19. There have been a lot of articles marking this dubious milestone, notably in the NY Times as in this Briefing by Jonathan Wolfe, and this Daily podcast.  The Wolfe piece includes two important graphics, one showing the number of new cases by day. It also contains shows hospitalizations and deaths, and makes the several “waves” very clear. And that this Spring’s wave is huge. The second graphic shows deaths, by time and by race/ethnicity in the key non-child, not old, age range of 25-54. A lot of deaths, and while the particular minority group that is most affected varies among the different surges, Blacks and Latinos are disproportionately dying.

A million people is a lot of deaths. It is, as Wolfe points out, more Americans than have died in all the wars in our nation’s history. It is more people than have died in any other country. It remains about 20% of the world’s deaths. I have often written about how the US healthcare system is far inferior to that of many other countries, particularly the wealthy ones that are our appropriate comparison group. It is unfortunate that this area, where we are but certainly should not want to be #1, demonstrates our lack of an effective public health system and the inadequate coverage for healthcare of so much of our population.

 

It demonstrates more than that, as anyone can tell you, regardless of the group that their political position demands be blamed. People are getting out more, mingling more, interacting more, going to physical workplaces more – and getting infected more. Not a day has gone by recently where I have not heard from a friend or relative about something that they did for the first time in a long time – go to a concert, or to an indoor restaurant, or get together with a group of people in someone’s home. And every single one of these stories has ended with someone, the friend or relative or one of the people that they interacted with, getting sick and testing positive (and possibly, likely, others to follow). I have learned more than I ever expected to about the unreliability of home test kits, which have sometimes been falsely negative two or three times in a sick person before the result of a more definitive test came back a couple of days later. The amount of virus (“antigen” if you want to be cool) that you need to make you sick is less than that required to generate sufficient antibody (what your body makes to fight the virus) to turn these tests positive.

It is tempting to say people are behaving badly or stupidly, but what is true is that people’s behaviors – tentative or full-throttle efforts to move back to a “normal” pre-pandemic life – have increased the number of infections. And that the increase in the number of infections leads to an increase in the number of hospitalizations and deaths. These are sometimes, but not always, in the people adopting the “risky” behavior. Sometimes they are in the people (often older, sicker, more vulnerable) that they live with.

Both my wife and I have traveled abroad recently, and it makes us nervous. She went to India, and we both are now in Europe. We tried to be as safe as we could on an airplane where the pilot and staff announce regularly that “you are not required to wear a mask, but please respect the decision of other people to mask or not mask”. I guess that means that there have been at least arguments, and likely fights, on planes over this issue. A federal judge in the US, in the middle of this current surge in infections, ruled that the government could not require people to wear masks on planes, and the administration did not appeal it. Thus, in traveling from India, through Dubai, everyone was masked until my wife got off at O’Hare – and most people were not. There are legal scholars who disagree with this judge’s ruling, but the key point, whether you agree with it or not, is that she ruled that the Constitution does not give the federal government the right to require people to wear masks on planes. She did not rule (and of course, could not rule!) that not wearing a mask was safe. This distinction seems to be lost on many people.

Including judges, of course. We just learned that 70 New York State judges went to a retreat in Montauk, NY, and that (as of May 19) 20 of them have tested positive for COVID, and many are sick. And there will likely be more. The fun of that retreat included a big karaoke party, a really effective way to spread the droplets that cause the infection. And these are the people who issue the rulings about what is allowed and what is not. Makes me feel really secure; how about you?

On a more chilling note, a close relative just told me about a longtime friend who has not been vaccinated,  won’t do it, and refuses to wear a mask. But he does not refuse to travel or to go out and interact with others, even in settings where evidence of vaccination is required. He lies and says he is vaccinated. “Luckily” for him (and, of course, unluckily for the rest of us!) he shares his father’s name, so he uses his father’s evidence of vaccination to access these venues. Think about that. Think about how reassured you are when you are with a group of acquaintances and “everyone” is vaccinated or tested negative. Or are on a plane where “everyone” has had to present proof of vaccination. Do you feel secure? You should, actually, at least feel more secure. The odds are very much lower in these settings. And in private groups, of course you trust your friends and relatives. On the other hand, it might not be everyone. One of them might be this guy. Or one of the thousands, probably millions, like him.

Recently, a ruling by a federal judge has blocked the federal government from ending Title 42, a public health regulation invoked by Trump to keep migrants coming from Mexico out of the US  based upon the possibility of their bringing in COVID, which has been continued until now. But it is not migrants who are spreading COVID; it is infected Americans who have not been vaccinated, will not wear masks, and openly mingle in public (and private) places.

In small villages in India everyone is wearing a mask. At O’Hare, or your local restaurant, or even on an airplane or in a convocation of judges, people are not. Luckily they are vaccinated. Unless, of course, they’re not. Since people’s desire to “open up more” began, early in the pandemic, I have been saying “opening = death”. Vaccines have helped a lot, and there area lot fewer deaths and hospitalizations when folks are vaccinated even when they are infected.

Sadly, there are too many people who are doing their best to try to make it worse.

COVID is still with us. Vaccine resistance is real, and it is dangerous

That there are a lot of people who are vaccine-resistant will be news to no one at this point. I wrote about this on May 17, 2021 (COVID, Vaccine, Racism, and Masks: Changing for better or for worse?), and while many people who were initially resistant have now changed their minds and have gotten (or in many cases, are trying to get) vaccinated, there is a hard-core residual group. There are a variety of reasons that people have, and sometimes articulate, for not getting vaccinated.  These include a lack of knowledge (hard, I know, given the amount of discussion) and a mindset that disbelieves those who are in power (also in some ways understandable; they do lie a lot). This is complicated for some parts of the population, particularly members of minority groups like African-Americans and Native Americans, by the fact that the US history is loaded with stories of exploitation and oppression and infection, from the passing out of measles and smallpox-infested blankets to Indians to the Tuskegee experiments that denied treatment for syphilis to Black men and many other crimes.

But at this point, there are no responsible people at all who are urging folks to not get vaccinated. Virtually all doctors, epidemiologists, and scientists have been (with some effectively evil exceptions, such as Joseph Mercola, DO (The Most Influential Spreader of Coronavirus Misinformation Online). Inversely, I mean anyone who is (which unfortunately includes many politicians, FoxNews personalities, and other “influencers”) is not responsible. COVID is real, it is infectious, the Delta variant is more infectious, it makes people really sick, and it kills people. A lot of people. Irrespective of whether they believe it is “real” or “dangerous” or not. Indeed, most of the people dying now (over 95%) in the US are those who have not been vaccinated. There is definite evidence that people who are vaccinated CAN get infected, and maybe even a few of them will die, but this is also definitely being overplayed by the media. Most of the media does not lie, exactly, but most people don’t go beyond the headlines and a very large number have no concept of relative risk or odds (I would assume, therefore, that poker players have been vaccinated!) You can cross the street very carefully, on a green light, at a corner, looking both ways, and still be hit and killed by a car driven by a lunatic speeding around the corner. But it is pretty unlikely compared to, say, running across a busy 6-lane highway without looking. Most folks can get that kind of relative risk, and it is not really unlike the risk of being vaccinated or not. This graphic illustrates that risk:                                                

Another way to express it, with a more traditional line graph, by county:

A recent article in the NY Times, “Workplace vaccine mandates reveal a divide among workers” describes another way that workers are being divided, not just by whether they are willing to be vaccinated, but by whether their employers are willing to mandate (and pay for) vaccination for them. Apparently, they are for white collar workers who they want back in the office (not clear why) but not necessarily for the blue collar workers, those who actually do work that cannot be ‘phoned (or Zoomed) in’ but requires their physical presence, those people who have often been called essential workers. Walmart, for example, ‘announced mandatory inoculation for employees at its headquarters and for managers who travel domestically. For a sense of scale, about 17,000 of Walmart’s 1.6 million employees are expected to work in new headquarters in Bentonville, Ark.’ The argument for this seems to be that companies like Walmart need lots of workers and don’t want to alienate those who don’t want to be vaccinated by mandating it. But somehow it is ok for office workers. I am not sure that I understand this, but it must have something to do with pay: if you get paid a reasonable living wage you are more likely to be willing to get a mandatory vaccine, and you should anyway. It seems to me that if Walmart and other companies wish to increase the demand for their jobs, the better way to do it is: pay more!

We read that ‘Trump's COVID-19 testing czar warns the unvaccinated: 'You’re going to get the delta variant' (The Daily Kos article’s author notes that they didn’t remember that #TFG had  a testing czar. Neither did I.) Of course, a lot of people regret having not been vaccinated once they end up sick, hospitalized, and on a ventilator, like conservative radio talk show host Phil Valentine and others covered in a recent article in Rolling Stone. The NY Times also had an article titled “They Spurned the Vaccine. Now They Want You to Know They Regret It”. I heard from a friend about a hospital-based health professional (not a physician) they knew who had been vaccinated but ended up on a ventilator, which was very concerning. A few weeks later, we called to follow up. Guess what? Turns out they weren’t vaccinated; they and their whole family were lying. Embarrassed. Reassuring, in one sense, but also very worrying that folks are lying.

I hope that others who have reservations will take their advice and get vaccinated. It is, of course, a bit disingenuous; if they knew they were going to get sick and maybe die they would have gotten vaccinated. If we had known  that the roulette wheel was going to come up black, we would never have bet on red! You can’t be sure what will happen to you, but the important point is that you have to do it because you might, and at least as important, because you can infect others.

But there are many people who steadfastly believe that being vaccinated is not for them, and some who believe that it is not for anyone. They are getting sick, and will continue to get sick, and infect others, and cause others to die. They will not wear masks, and they will not wear signs. When they say that vaccine mandates, or mask mandates, are oppression, they are being, frankly, ridiculous.

The pandemic is not over. Delta is very serious. Get vaccinated. Wear a mask indoors.

I cannot resist including two other posts that make that point: 

  

COVID Vaccine and Privilege: When is it not about you?

Recently, an article from CNN, “A vaccination site meant to serve a hard-hit Latino neighborhood in New York instead serviced more Whites from other areas”, was posted on a medical social justice page of which I am a member. Among a number of others, I expressed my displeasure at this, but I also posted a comment in which I unfortunately said “People are scum”. It did not specifically refer to the white people who had obtained these vaccines, perhaps inappropriately, but certainly could be seen as that. I was called out for that comment, and that was appropriate. People are not scum, for better and worse. Scum is a substance that exists without intentionality. People, however, do have intentionality, and that can make them do things that are very good and very bad and everything in between. Certainly, doing something bad, or wrong, does not make a person bad; many religions have doctrines that are more or less comparable to “hate the sin, love the sinner”.

More to the point is whether the people referred to in the article did anything wrong or objectionable at all. While those quoted in the  article were very critical of this behavior, some of those posting comments on the page felt that these people (presumably people who otherwise met the current criteria in NY for the vaccine, by age or health status) were just trying to do what they could, and not trying to use their privilege to obtain vaccine intended for the minority community. They agreed that the system, and the structure for distributing the vaccine was severely flawed and probably inequitable, but that the individuals pursuing the vaccine should not be condemned. They acknowledged that some people, by virtue of education, wealth, computer-savvy, connections to other family members who may be more computer-savvy, and other characteristics, are more able to avail themselves of benefits. Even when this results in preferentially vaccinating white people rather than the minorities for whom it was intended (by placing vaccination sites in minority communities), it does not mean those individuals (many of whom are sick and elderly) are doing a bad thing, still less are bad people, or certainly scum. Nonetheless, the result is the result; the New York Times on January 31, 2021 reports that “Data showed that while 24% of city residents are Black, only 11% of vaccine recipients were. White New Yorkers received a disproportionate share of the shots.

The CNN report was not the only one critical of people “jumping the queue”. In a NY Times Op-Ed on January 28, 2021, Elisabeth Rosenthal MD, editor of Kaiser Health News, writes “Yes, It Matters That People Are Jumping the Vaccine Line”:

For weeks Americans have watched those who are well connected, wealthy or crafty “jump the line” to get a vaccine, while others are stuck, endlessly waiting on hold to get an appointment, watching sign-up websites crash or loitering outside clinics in the often-futile hope of getting a shot.

She adds, agreeing with some of the points made by the commenters on the site, “I don’t blame the lucky recipients; after all, hospitals would just offer the unused vaccine to the next person on the list,” but also notes that “The problem is that often, people are not really being “offered” the vaccine; in some cases, they are grabbing it through position, influence or deceit.” How often? I don’t know, and probably Rosenthal does not either. Or, for that matter, those who posted comments on the page, although they seem to be from NY and likely to know a lot more about the situation there than I do.

Most likely, the predominantly white recipients of the vaccine being offered in minority neighborhood represent a spectrum of people. They would include those who consciously believe that they are special and privileged and deserve to be at the head of the line, those who believe in equity but let that concern be overcome by their self-interest, and those who are appropriately candidates for the vaccine in the current phase but are desperate, confused, and, with no negative or ignoble intent, found their way to that place and time. Defending the latter, however, does not excuse the former, and there are certainly many of them. Freeman’s Law (which I should probably rename “Freeman’s First Law” so as not to confuse it with Freeman’s Second Law, to which I referred in my blog post of January 28, 2021, “Vitamin D, false nostrums, and conspiracy theories: The world has enough real problems,”) states that in any program designed to help a group of people, no matter how narrowly defined, those with the relatively least need are most likely to benefit. Thus in a program designed, say, to help homeless pregnant teenagers with HIV living under bridges, those who have some greater resources (a bit more education, a slightly less traumatic childhood, etc.) will be the ones who are able to access it first. The larger the universe of people who are targeted, the more people who would qualify for services, the greater the disparity is likely to be. This is of course especially true in the case of COVID vaccine, where the target population is, ultimately, everyone.

Another aspect of the comments posted that was interesting to me was that they referred to those seeking to get the vaccine as “patients”. Perhaps this is understandable on a medical site, and it is quite possible that some of those involved were patients of those doctors who made the comments. I have sometimes been critical of the use of the term “patients”, noting that it was the “medical” word for what in English are called “people”, and that it could tend to diminish their humanity. I am quite sure this was not the intent of those using it, but in this context it has quite another flaw. Calling folks “patients”, especially when they are not your patients, carries a connotation of dependency, needing help from their doctor. Calling them “people” implies more that they have agency, the ability to make decisions, prioritize needs and values, and act on them. While it is often true that many people, particularly the sickest and oldest and least educated and least empowered do need help, it is also true that when the affected universe is the entire population, it includes all of us, all people, adults and children, young and old, Black and White, rich and poor, doctors and “patients”. It includes those who are the wealthiest, most educated, most connected, and most empowered, who are often find ways to get to the head of the line. Thus, prioritizing who should get the vaccine first and enforcing that is critical. Social justice is about promoting equity, which means giving more help to those who have the least and need it the most, and reducing the temptation to give in to those whose privilege or loud voice is most demanding.

Rosenthal writes:

The United States has allowed its public health system to become a hollowed-out underfunded mess, and many vaccination clinics are being run and staffed by contracted private companies. And the private sector has so far proved too vulnerable to private favoritism.

Until the supply is sufficient, the government needs to give the shots to the people and places that need it most, and find ways to ensure that the plan is followed; the system could prioritize ZIP codes that have high Covid-19 infection rates or target low-income populations who might otherwise have a difficult time securing an appointment.

She is absolutely correct, but clearly targeting certain ZIP codes is not sufficient, as the Times describes on February 2, 2021 in ‘Even in Poorer Neighborhoods, the Wealthy Are Lining Up for Vaccines’ (Feb 3 print title: ‘Where poor suffer most, wealthy find vaccines’). And a 52-year old celebrity on-line fitness trainer got the vaccine as an ‘educator’.  Meanwhile the COVID surge most hurts those in the poorest neighborhoods, as in LA. And people behaving as though the doors were opening at a department store the day after Thanksgiving is not just a NY problem. a friend in another city, on seeing the pushing and shoving, both literal and figurative, that went on when they went to get their vaccine, said “I wouldn’t want to be in a concentration camp with those people.”

The problem, if you think it is a problem, of empowered people going to poor neighborhood to get their vaccines is real and ongoing. I think that folks who do so are doing a selfish thing, a bad thing. This in itself does not make them bad people, or certainly scum. However, for the record, I personally believe that there are indeed bad people, and that doing enough bad things often enough, predictably enough, and bad enough does make someone a bad person (see, e.g.,”Nazis”).

We should have compassion for those with need, and the most compassion for the greatest need. And recognize that “me” is not the hallmark of social justice.

Protecting the community: Essential workers, nursing homes, and the incarcerated

The COVID-19 pandemic continues, resurging across the US and in many other places. Different strategies have been adopted in different places, with varying degrees of success in slowing the spread of infection and death. This should provide us with information on what works well, and what strategies we should be adopting. For one example, family medicine colleagues in São Paulo, Brazil, report on their experience in nursing homes in the Royal Australian Journal of General Practice. They used public health management techniques including no visitors, rigid use of testing, recommended PPE and isolation, and others, as well as medical management and psychosocial management working with families and patients to help them through this process. They have had only 4 cases in the last 90 days (as of the November publication date), no people in isolation, and a low death rate.

 In Arizona, as in the US, case rates and mortality continue to rise.  We have more cases than ever, and fewer hospital and ICU beds. The state has chosen to address this issue by lifting restrictions on businesses, opening restaurants, bars, salons and gyms. Based on all evidence from everywhere, this is likely to further increase infections and deaths (“Health chief changes benchmarks so no Arizona business will be shuttered in pandemic”.)

Thie new policy is clearly in response to business owners concerned about their livelihoods and the probability that they will even survive. This is a real problem for them, and for us, in the horrific economic downturn that has accompanied the pandemic for most people (for major investors, however, the stock market has done well). Pima County, where Tucson is, has taken a more aggressive and restrictive approach; after more than 320 cases reported among county employees, including the chief health officer, it has furloughed 20% of the work force for 3 weeks. Of course, this will be an economic hardship for those people’s families.

Thus we have the situation where we know what to do to prevent increased infections and deaths, but have to also address the serious financial impact on regular people who lose their jobs and businesses and incomes. Sadly, efforts to reopen have been almost linearly associated with increased infection rates and deaths. The efforts taken by our Brazilian colleagues were effective in an important and high-risk, but ultimately limited, venue, that of nursing homes. The fact that the increased infection and death rate in our communities will take its greatest toll on the elderly and those with chronic disease, not those whose exposure to others in workplaces, schools, and meetings (although they are also at risk, and not immune) makes it even more complicated. The leadership at the federal level, sometimes inaccurately described as “lack of leadership” when in fact it is actively leading us in entirely the wrong direction, is making things much worse, and creating and exacerbating an incorrect understanding of the disease among many people.

Those who work in high-risk occupations, who cannot “phone (or Zoom) it in” but rather have to be present, most often among the lowest paid, those who live in multi-generational and multi-family households, are paying the highest price. These people are not only members of racial and ethnic minority groups, but those groups are far over-represented in their numbers. A recent article in the New York Times again makes the point that Black and Latinx people are hardest hit, not because of any genetic or biologic reason but because of their social and economic situation resulting from centuries of structural racism. Race, it is clear but requires repeating, is a social, not a biological construct. The negative impacts on health, income, longevity, education, and everything else is not from “race” but from “racism”; indeed, the only significance of “race” is that it is the basis for racism.

Now there is a vaccine (actually, two, maybe soon three, vaccines) and administration of them is rolling out, especially in the wealthy countries that have acquired most of the doses (of course, in the US the Trump administration jeopardized this by passing on an opportunity to acquire more doses of the Pfizer vaccine, and this was certainly not to help out the poor parts of the world!) The debate now moves to who should get it first and in what order. In most places in the US, priority is going to health care workers and nursing home patients, which makes sense. They are, respectively, the most likely to contract and transmit the infection and the most likely to die from it. And then? Who? Those with the highest risk or those with the best connections? In many hospitals we hear reports of the C-suite executives (the “front office”) being at the front of the line for vaccine, despite the fact that they do no health care. Nice of them to want to “model” behavior, but the vaccine should go first to those who see patients. The priority should be those who not only interact with the public, but who cannot do their jobs if they don’t actually show up for work, and among those, people who would be the worst off if they lost their jobs (and those who have already been laid off but might be able to come back and begin working again). The last would be those who can continue to work from home, or are retired without major health risks, and can continue to isolate themselves.

Another major group that is finally getting some media attention, even if it is unlikely to get much vaccine, is the incarcerated population. The AP reports that “1 in 5 prisoners in the US has had COVID-19, 1,700 have died”. This could be predicted; it is a group crowded together, unable to isolate, often with pre-existing conditions, and essentially without agency – they have to do what they are told. There are, broadly, two reasons for immunizing them. The first is human – they are human, and they are at very high risk, and they are already being punished; they should not be further punished by getting this disease. The second is practical; prisoners are not, actually, entirely separate from the rest of the population. In addition to guards and others who move between the inside and the outside, many prisoners are released; this is most especially true for jails, where the length of stay is short (usually awaiting a court appearance for those who cannot post bond), and thus is really part of the community from which inmates come – and go back to. Nathaniel Lash makes this case convincingly in the New York Times Sunday Review, “The coronavirus has found a safe harbor”. For example,

Cook County Jail was the site of the largest detected outbreak in the country early in the pandemic. In recent weeks, it has exceeded that — there were 340 active cases among inmates on Dec. 16. The population, meanwhile, has returned to levels typical before the pandemic, about 5,500 people.

We should have fewer people in jail.  It is outrageous that people are incarcerated because they cannot pay bond, overt discrimination against the poor, and cannot afford to support the very politically powerful bail-bond industry. This was true before COVID, and is more true now. ‘“There’s no question with a new peak in infections that we have to be decarcerating now,” said Dr. Emily Wang, the director of Yale School of Medicine’s Health Justice Lab. “If we don’t have larger-scale decarceration efforts, we won’t control Covid.”’ The answer is bail reform that corrects these inequities – vicious inequities with frequently fatal outcomes. But the opposition continues to cloak itself in the mantle of morality rather than greed, public safety rather than racism. ‘“We’re seeing the extent of the opposition to bail reform: They so strongly oppose it they will do it in the face of a pandemic,” said Andre Segura, legal director for the American Civil Liberties Union in Texas.’

The US incarcerates more people than anywhere in the world, a lot for relatively minor drug offenses. This does not prevent crime, especially violent crime, and it continues to rise even as crime rates decrease. In 2020 it is out of control, it is inhumane, and it is a significant cause of the spread of COVID. 

We need to get the vaccine out there soon, especially to those at highest risk of both dying and transmitting it to others. Clearly, the incarcerated population must be included.