Americans who felt that life might be slowly creeping back to normal this fall were taken by surprise when a much more infectious variant of COVID-19 arrived in the United States in early December. This surge prompted experts to point to the importance of global vaccine equity, but domestically it also put into focus just how unprepared the country continues to be in dealing with new surges. It also brought into light the faults in the Biden Administration’s vaccine-only approach to the pandemic as well as the media’s problematic propensity to continuously frame COVID as approaching endemicity.
To understand how the Administration can change course, how to ensure a pandemic response based in equity, and how we can better prepare for the next variant, Associate Editor Sophia Crabbe-Field spoke with Boston University Professor of Public Health Julia Raifman, who tracks both COVID-19 policy and the economy and evaluates how policy responses to COVID-19 are shaping the pandemic, mental health, and economic precarity. They spoke on Friday, January 21st.
Sophia Crabbe-Field: Joe Biden has been much more heavily criticized lately for his COVID response. Do you feel that there was a point at which Biden was doing significantly better than Trump in responding to COVID and at what point do you think things went wrong for the Biden Administration? And why do you think they went so head first into the vaccine only approach to COVID?
Dr. Julia Raifman: I think Biden entered office with a very good plan for addressing the pandemic. And I think, with that plan and with his campaigning based on controlling the pandemic, earned the trust of the public, but then did not implement virtually any aspect of the plan, including with the vaccine rollout, but especially with the other elements of the plan.
SC-F: What were some of those elements that he didn’t end up implementing?
JR: On vaccination, he promised a vaccine campaign of unprecedented scale in several languages with a focus on equity. And we have not seen that campaign materialize. Here in Boston we have doctors already working overtime to support patients, hanging up flyers in other languages to tell people where vaccine clinics are on the weekend. It’s just not clear to anybody or easy for anybody to navigate getting vaccinated as easily as it should be. I think a lot of people experienced that when they tried to get boosted. I heard several stories of people having to go to several clinics and try to do walk-in appointments and be forced to make appointments through onerous online systems.
Right off the bat, the Administration deprioritized essential workers for vaccination relative to older people. People 65 and older are about twice as likely to be white as Black and Hispanic. And so right away that set up an inequitable vaccine campaign that still affects us today.
Then the Administration sort of signaled “back to normal” with the end of the mask guidance in May, before even half the population was vaccinated and when the vaccination campaign had been very inequitable the whole time. This coincided with ending the move toward an OSHA workplace safety standard. There had been a lot of business lobbying of the Administration and of Jeff Zients related to that OSHA standard; the businesses said that they would protect workers themselves. And they said that maybe the CDC guidance would change based on vaccines. And that’s just what happened after all of the lobbying, the CDC changed the mask guidance. But we did not see that workers were protected. And now, in our data, we see that workers who are lowest income are four times more likely to report missing work due to COVID relative to the highest income workers.
SC-F: And why do you think that he took that approach? Do you think it was the result of lobbying, do you think he felt Americans were tired of the pandemic, or that he believed it really was the end?
JR: I think we were all very hopeful at the time. I think that some experts have been confidently making wrong predictions since the beginning and that made it into the major papers and some of them are likely working with the White House. And so I think that they were overconfident that the pandemic was ending. There were businesses saying that they didn’t want these standards. I think that was ultimately shortsighted from the perspective of the businesses, as well as for the whole of our society; that ultimately the businesses need workers who are healthy and happy and at work, not quitting, not sick, not hospitalized.
I think that having someone with public health expertise in charge of the COVID response could have helped inform a stronger response, but the person in charge of the COVID response is someone who comes from the business world [Editor’s Note: White House Coronavirus Response Coordinator Jeffrey Zients], who has no public health expertise, who’s a mega donor.
SC-F: I’ve definitely seen a lot of criticism by certain public health experts of the job Jeffrey Zients has done. But I’ve also seen a good deal of criticism of CDC head Rochelle Walensky. So I’m wondering, is that criticism fair and in what capacity do you think that she and the CDC are also responsible for some of the ways in which things have gone wrong recently? Are you also of the opinion that the CDC is making decisions that are overly political and influenced by the business community?
JR: Yeah, the former communications director of the CDC said that to have these joint briefings between the White House and the CDC is more akin to the politicization of the CDC under the Trump Administration than under any prior administration. So the CDC director is a political appointment and has been fully politicized. I think a strong CDC director with a strong public health background and strong implementation background might have been able to foresee some of the downstream consequences and that the upfront costs of preparing to reduce the toll are far less than the cost of not preparing. I think the CDC director comes from a very well-respected academic background, but has not been able to inform a stronger response. We also see that from the picture that the White House released of the planning meeting for Omicron that she was not even in the room.
SC-F: Were any of the people in the room people with strong public health backgrounds?
JR: Not really. And certainly none of them were from the populations most affected by the pandemic. So the people in the room were Jeff Zients, Ron Klain, and Anthony Fauci, who is a well-respected physician, but he too does not have a PhD in public health. And what you need in public health is to focus on the whole of the population and on equity. And what seems to be the dominant narrative guiding the White House response is this “return to normal.” As Omicron approached, they said if you’re vaccinated, everything will stay normal. And the consequences are the worst for the people who are most underserved, the low-income people who’ve had the least access to vaccines, the least access to expensive masks and tests, the least ability to protect themselves the whole time. Ultimately underserving them underserves the whole of our society.
SC-F: The next thing I wanted to ask you was, why do you think the government has, after laughing off the idea of free rapid tests, after not really doing much to promote the use of N95s or KN95s, why do you think they seem to have sort of turned around on that to some extent? And do you think these responses have been sufficient?
JR: I think it’s an important acknowledgement that the pandemic and the need to address it continue. And I think it’s just a small step forward in what needs to be a complete reset and preparations for the next surge, which begin now.
SC-F: And what was your response to some of the acknowledgement that Biden made on Wednesday during his speech about his failings on COVID? Do you have any optimism that there could be a turning point at this stage?
JR: I think what’s most important is that we select new leaders who can lead and manage a public health response to a public health crisis that is affecting every sector of our society. I don’t see the President acknowledging the enormous toll of the pandemic on American lives and our society. I see him touting the success of the economy and saying that he is satisfied with the response. And I see that he has not fulfilled any aspect of the January 2021 plan that he released when he came to office. And that contains everything that we still need to do. And we need leaders who will do it.
SC-F: Something else that I wanted to ask you about is I know that there’s still a great number of young people and children who have yet to be vaccinated. What are some of the ways that we can bring those numbers up, especially as children are going back to school? And, along with that, is there a way for children to go back to school safely and is there anywhere in the country where they’re implementing the steps necessary for children to go back that can be emulated at all?
JR: Yes, and the smartest thing we can do is implement vaccine mandates for as many people as possible, as soon as possible. There will be up-front pushback from some, but the harm of that is minor relative to the harms of not implementing vaccine mandates.
I think we still need a vaccination campaign focused on equity. We need resources for equitable delivery and to invest in community organizations that have been leading so much of the work to deliver vaccines to their community. We saw so much investment in consulting companies that really didn’t achieve equitable vaccine distribution. And some of the community organizations like the Black Doctors COVID Consortium and La Colaborativa here in the Massachusetts area, they’ve really been leaders and we should invest in them to scale up the good work that they’ve done. I think that’s really important, as is delivering it through schools routinely and delivering all vaccines through walk-in clinics that don’t require appointments.
I think there’s been a lot of misinformation that COVID is no big deal in kids. And I think it’s important for people to recognize that COVID harms kids. There are a record number of children hospitalized right now for COVID and there will likely be a record number of deaths and new variants can change and can be more harmful to kids. And I think that’s what we see with Omicron. I think we should recognize that COVID spreads in all crowded indoor settings, including and especially schools where masking may be more imperfect because of the children’s age and because of eating lunch in crowded cafeterias.
I think we have to recognize that mask policies are the most effective way to reduce spread in schools and the spread in schools harms the students themselves with acute illness, with some unknown number who get Long COVID symptoms, with some who die, with many more who have their parents die. Tens of thousands of kids have their parents die in every surge. And their teachers and staff members: We don’t have good data on COVID by occupation, but what data we have suggests that people with high exposure have much worse rates of COVID illness and death. So reducing spread in schools is important for everyone and for communities because ultimately the spread doesn’t remain only within a school.
SC-F: What is your response, when we hear politicians, public health officials, so forth, making comments like “COVID is becoming endemic,” or saying “oh, well, everyone will get Omicron”? And, second to that, what is an acceptable level for getting back to normal or for an “endemic” infection?
JR: I think that’s a societal conversation, but what’s clear to me is 70 million cases and several hundreds of thousands of deaths just since July is not acceptable. Before the pandemic, I used to write all of my papers about HIV and I would start each paper by saying “There are 38,000 cases of HIV in the United States each year. And this is why it’s a critically important problem. And the NIH invested 10 percent of their budget in addressing HIV, because it was such an important problem that 38,000 people got it each year.” And so 70 million cases that we know of and more than 800,000 deaths since the beginning and 250,000 and counting deaths since July is incredibly destructive and devastating. And for people to suggest that that is acceptable is devastating.
Often the people suggesting that come from places of privilege and will not personally suffer that toll or are far less likely to suffer that toll. We see that the pandemic continues to be most destructive in low-income communities and Native American, Black, and Hispanic communities. There’s a mistaken notion that policies to reduce COVID harm the economy. I work on both and that’s just not true. Controlling COVID controls the volatility that affects the whole of our society to the benefit of our health, our lives, our social lives, our economy, our businesses, our schools, our health-care workers, and our society as a whole. When we don’t control it, it harms every facet of our society.
SC-F: And do you think, likewise, saying that everyone is going to get Omicron leads to this idea that it’s just normal and we don’t have to do anything to try to minimize it?
JR: Yes, it really does encourage acceptance. And when it’s entirely possible to reduce the toll a great deal. Every person whose child is out of school or daycare right now should know that we could have reduced the chances of that by half. Every person who loses a family member or who missed Christmas or the holidays with their family should know we could have reduced the chances of that by half. Every health-care worker should know that we could have reduced the overload on the hospital by half. Every person in our society who has experienced disruption and sadness or COVID cases and the anxiety or hospitalization or deaths due to that should know that it could be reduced by half.
SC-F: You’ve spoken a lot about equity and I’m wondering, to you, what are the key ways of looking at our policy response to address inequity based on race, class, gender, ability and so forth? And are there inequities that have really stood out to you that maybe a lot of people might not realize, especially if they’re in a more privileged position, that they should keep in mind?
JR: I think we have to see this as a societal challenge and only by explicitly working to better serve the underserved populations in our society and populations that face structural racism and structural inequities can we best address the pandemic as a society. We knew when President Biden entered office we had seen enormous racial disparities in COVID and the vaccine campaign needed to explicitly focus on reducing those inequities, but then it explicitly exacerbated inequities when we deprioritized essential workers and prioritized people 65 and older who were twice as likely to be white.
We always needed to continue the work to deliver vaccines to populations that had less access to health care, less Internet access, less transportation access, less trust of vaccines because of a long history of medical racism. And we always needed to work harder to vaccinate Black, and Hispanic, and Native American populations who had been disproportionately affected the whole time, and low-income populations.
SC-F: At the beginning of the surge in Omicron, I feel like there was little bit more recognition about the issue of global vaccine inequity. And I think I’m seeing a bit less about that now. Do you feel like there’s still a push or any hope of the Administration doing more to help scale up global production or in leading on the TRIPS waiver?
JR: I really appreciate that that leaders in global health have been calling on the Administration to lead in improving global vaccine equity. And the waiver being a critical structural step for doing that. I completely agree that we need the Administration’s leadership on that as well as domestically. It’s really interesting talking to policymakers because they are much more interested in pushing on that issue than domestic issues. And I think so much of that has been misinformation about whether people will wear masks or what will happen if there’s a vaccine mandate or a mask mandate.
And, ultimately, I think it’s a very small percentage of the American public that is very opposed to any of these COVID control measures. It’s very small and it’s very organized. They’re organized in the sense that I see two to three people who are collaborators, who have several headlines in major papers, making these points, talking about off-ramps for masks. And it never reflected expert consensus and remarkably to me it does not reflect the American public’s consensus despite so many of these headlines by these extremist people who are in academic institutions. Most of the American public supports mask policies during surges. Again and again, we see 60 to 70 percent in every poll. And we see a very small percentage are totally opposed to these, but they’re organized. They are organized in the sense that there are a few experts working to spread these extreme perspectives and are given very large platforms. Being featured in one newspaper often leads to being featured in other newspapers and featured on television and other media.
So much of the pandemic discourse is shaped by this very small number of academics who have these very extreme perspectives. There was some good work recently covering a Koch-funded school group. They had compiled all of the articles that these individuals had written into a letter to then make the case against mask policies in their schools, and also coordinated with the groups that do protests. And the protests are part of something even worse than that, which is they have social media accounts. They really target individuals and several individual leaders in public health who are doing the best work in their communities and have people show up at their house with the intention of violence.
And all of this is coordinated. And I don’t think the academics explicitly work with the people who are organizing the protests, but I think that there are groups working to coordinate what’s happening in local government, the defunding and a removal of power from public health authorities. It’s an extremist movement that then is governing the United States to the detriment of us all. I think it’s important for people to realize just how extremist these views are. When they’re espoused by a professor from an esteemed university, it’s hard to see it but there’s a lot of misinformation that comes even from people who are considered experts, but who are espousing extremist views.
SC-F: And so do you think that this calls for better coordination to counter these groups?
JF: Yes. Part of what’s happening is that these groups are very organized, like I was saying, so they’ll collate everything, they’ll use it, then they’ll also coordinate the protest. But I think part of what’s happening too is that the first communications guidance from the CDC’s CERC (crisis and emergency response communications) manual says to be first and be right, to be the first person to put out information and to put out correct information and anchor it in the facts.
And so when you hear someone in the Administration say, “Well, we didn’t expect misinformation,” they did, it’s in the plan in January 2021. And the best counter to that is for the Administration to clearly, consistently, frequently, and correctly put out information. Some of what they might say is that the pandemic is serious, it causes serious harms, we need to come together to protect each other by getting vaccinated and wearing a mask. But a lot of what they’ve said is “If you’re vaccinated everything is back to normal and if you’re not vaccinated, you’re going to overflow the hospitals.” And that doesn’t capture the societal upheaval that will happen for everyone, regardless of vaccination status. It doesn’t capture that the people who are unvaccinated are largely unvaccinated because it’s been very hard for them to get vaccinated. They don’t have easy access to it or good information about it and to then point the finger at them as they suffer the consequences of being underserved is devastating to watch.
SC-F: So you’ve said a couple of times that a lot of people who are unvaccinated it’s because they haven’t been able to access it. Do you see data that explains for how much of the unvaccinated population it’s because of these barriers to vaccination? Are you saying then that we’ve magnified the extent to which these few extremists who don’t want to get vaccinated or are very anti-vaccination represent the core of the unvaccinated population?
JR: What we see is that the lowest income people are about four times more likely than the highest income people to not be vaccinated, lowest income being people who reported earning less than $25,000 a year in 2019, and the highest income being people who earned $200,000 or more in 2019. And we see that more of the lowest income people who are not vaccinated report that they would be willing to consider getting vaccinated than not. And then, from personal experience, I’ve heard a lot from journalists actually who tried to get boosted, who said, “Well I went to four different pharmacies before I could get it.” I went to Fall River at the beginning of our Delta surge in Massachusetts in November and I delivered masks and looked into where to tell people to get vaccinated at a walk-in clinic. And I couldn’t find a walk-in clinic. And I called the pharmacies and they said, “You need a vaccine appointment.” And I asked about health insurance and she said, “You can’t get vaccinated without health insurance.” And I pushed back and she said, “Well, yeah I guess you can. But we really prefer health insurance.” That really doesn’t make it easier.
SC-F: The last thing I wanted to ask you was, taking for granted that we’ll have more variants and maybe even another pandemic at some point soon, what are the key lessons from Omicron that we should be heeding to make sure that we’re better prepared next time?
JR: I think that we should recognize that the virus is characterized by surges. The pandemic did not end this summer. We’ve seen very deadly and destructive surges in July, November, and December. And we are likely to see more surges, whether that’s due to seasonality or waning immunity or new variants. One thing that’s happening right now that is remarkable and disappointing to me is to see some of the world’s most respected researchers declaring that the pandemic and policies to control it have ended, that so many people got Omicron that they won’t be susceptible in the future. And I just don’t think that we have enough data to say that with confidence. I think we’ve seen that in the past they’ve made confident predictions that have been wrong.
We can and should prepare for the next variants. And, again, those are often people of privilege who will not be affected by it as much. I think we need a lot more humility across the board. I really don’t make predictions about the pandemic. When the mask mandate ended in May, I started communicating a lot with concern that a new surge might happen in five years and we would be unprepared. That it ended up happening in a couple of months surprised me, but I have humility to know what we don’t know about the virus, which is quite a lot. What I do know is that, when each person’s actions affect so many other people, only policies and leadership on policies can help us coordinate our actions to protect each other.
SC-F: Can you say, just a little bit more precisely, what those policies are in terms of say production of, and availability of, masks and public health infrastructure. Are there any things that particularly stand out to you in terms of ways that we would be better prepared?
JR: I think, ideally, we would prepare by sending out free masks and tests at the start of every surge, several for each American. We would have data-driven mask policies because masking together is most effective and so data-driven mask policies would turn on that at the start. It doesn’t cost anything to turn that on and it has been very effective in the past. I think it would also be smart to implement data driven ramping up of other protections and to make hard decisions about when do we close what, but in a planned way.
So do we close restaurants and provide compensation for restaurant employees so that they can have enough to eat and to pay rent during their restaurant closure? Or do we close schools? Or maybe we need to close both if things are really bad. Remote school: No one wants to do it for a year again, but it could protect many people if we had a variant that was very lethal for children or something like that. I think we should plan for these scenarios. Some people talk about planning for the next pandemic and the pandemic is upon us. We should no longer be surprised by surges and variants. We should plan for them and data-driven policies are a smart approach as are surging supplies and investing in supplies now and vaccine mandates. The sooner we have more widespread vaccine mandates—governors and mayors and employers can all still mandate vaccines—for school children, for the state populations, for everyone. I think that is a really key step to helping reduce the toll.