The covid-19 pandemic will end with public health tools, not clinical onesBMJ 2022; 377 doi: https://doi.org/10.1136/bmj.o1561 (Published 24 June 2022) Cite this as: BMJ 2022;377:o1561
As a clinician, I rarely see a patient die from covid-19 anymore. Those who end up in the hospital these days have benefited from the immense advances in clinical science that have brought us vaccines, monoclonal antibodies, and antivirals, and taught us how best to use these and other existing medications, such as steroids, to save our patients’ lives. Collectively, this is an enormous accomplishment. It’s not, however, the end of the pandemic.
The end of covid-19 will not be a clinical feat, but a public health one.
For months, doctors and health officials have been reminding people that they “have the tools”—specifically, the clinical tools—that mean most people won’t end up hospitalised or dead. But many people are still getting sick from infection, enough so to miss work; end up in the emergency department for evaluation; or end up with longer, lingering side effects, the consequences of which we cannot fully appreciate yet. Our current vaccines are not effective enough at stopping transmission1; and while future vaccines, such as intranasal formulations, may be, we are still several months away from these at best.
This month, as covid cases climbed in the US,2 my own infectious disease team was down from five doctors to just two—me and one other—because of staffing shortages at the hospital due to covid-19. This meant some consultations had to be moved to the next day, while others couldn’t wait. I had to work well past the end of my shift to make sure patients received the care they needed. This is unsustainable, and these are real costs that are harming not only our healthcare system but also many other industries where sick employees are unable to work. Big surges of infection are inherently disruptive to the functioning of our society.
I personally was able to avoid infection for two years until this past January when I was infected for the first time; I was then infected again just five months later in May. I had to miss work both times to enter isolation, meaning another infectious disease doctor had to leave their research laboratory to cover for me. The first time I felt quite ill and had lingering symptoms—especially fatigue—for a few months afterward. Both times, I was likely exposed by a loved one who became sick first and was staying in my small apartment. By the time we diagnosed them, it was too late to prevent onward transmission.
Surges make life less safe for everyone, but particularly those who have serious health conditions or are old enough that covid-19 may never be an afterthought for them. We are only as protected as the people who are around us; they are only as protected as those in their extended circles, and onwards. With the level of viral transmission we’ve had during omicron, most people now have no idea how or where they were infected. This is at least in part because of super spreading, whereby one person can infect a disproportionately large number of other people. This can occur even after the contagious person has left the area as infectious aerosols that linger in the air can infect people.3
With covid able to spread in this way, the idea that we can indefinitely protect ourselves as individuals breaks down very quickly. We cannot expect every person we come into close contact with to follow all public health prevention measures perfectly at all times—and to stop transmission of a virus that is this contagious, that is what would be needed if we only depended on the actions of individuals. Instead, strategies should be focused on preventing super spreading. This would likely stop big surges of infections now and in the future when we are confronted again with new variants.
Colleagues of mine have taken matters into their own hands: one has cleaned the air in his child’s classroom through building and installing low cost ventilation and filtration devices.4 What if all public shared spaces had these so that our air was constantly cleaned and exchanged the way it is in hospital airborne isolation rooms? In California, for instance, the public transportation system in San Francisco known as The BART has advanced air filtration systems that provide over 50 changes in the air per hour.5 With this in place, super spreading in these train cars would be unlikely. We need public health innovation from our governments to prevent transmission.
As more people survive from covid-19, we are still learning about and being surprised by the clinical complications that arise soon after infection. These may or may not be related to their initial infection, but since they started weeks to months afterwards, it suggests to us that they may be connected. I now often hear doctors saying, “This could be related to covid.” More data are needed and are being gathered over time, but this is a reminder that governments that are allowing widespread infection solely because there are fewer deaths are still gambling with people’s health.
Clinical tools are excellent—as a doctor, I use them every day to save patients’ lives. But as a public health researcher, I know that the pandemic will only end when we successfully minimise airborne transmission.
Competing interests: Abraar Karan had served as a paid research consultant to the Independent Panel on Pandemic Preparedness and Response in 2020.
Provenance and peer review: not commissioned, not peer reviewed.