So what now?

Thankfully, case numbers are plummeting throughout the country. As we emerge from the holiday surge, we find ourselves in a similar situation as last spring, grateful for a reprieve. Hospitalizations and deaths are still pretty high, but those numbers lag, and I expect they will come down too.

How do we de-escalate? This is a real challenge in medicine; we're better at adding interventions than taking them away. But now's the time to figure out how to do this rationally and safely. Unfortunately, the issues are entangled with politics as mask mandates expire and vaccine efforts flag. How do we think about this? What should we be doing now?

I acknowledge that I live in a very COVID-careful part of the country and work in a COVID-cautious industry. As I've written and rewritten this blog, I've come to the conclusion that one question we have to ask ourselves is whether the role of public health is to protect the community at large or the most vulnerable individuals in our community.

For the average person, as prevalence of disease declines, it may be reasonable to shift from broad mandates to community, local, or individual decision-making. I'd prefer to wait until absolute numbers sink below pre-Delta levels, but I recognize the political capital for that is waning. Here, we weigh fatigue for rules, the importance of creating movement towards normalcy, and recognition that immunity protects healthy people significantly. We also recognize the counterarguments against mandates that we've heard time and again: personal choice, freedoms, overreach of government. I understand the many countries, states, and geographies letting restrictions lapse.

But for the vulnerable individual, the unvaccinated, the immunocompromised, the transplant patients, the very young children, COVID still poses a genuine risk. If the goal of public health is to protect those who need protection the most, then the answer is clear: we need to continue wearing masks, vaccinating more people, and developing advanced treatments.

The role of government and public health depends on one's political philosophy, and I don't make any pronouncements on what it should be. But I think we now live in two worlds: one in which immunized, healthy people can treat COVID as an endemic disease, and one in which the vulnerable still need to take precautions. The pandemic has worsened many societal inequalities, from wealth to race to jobs where we can or cannot work from home. This is a new inequality, and I worry it will persist and fracture our communities.

Ultimately, we cannot pretend the pandemic will never end in the same way we cannot pretend that there is no pandemic. It is definitely a good thing that the latest surge is waning and our society is opening up once more. We can talk about things that may have been taboo for many of us for the last two years: travel, concerts, celebrations, Disneyland, dancing. But our decisions must be nuanced and sensitive to those who are unlike ourselves. We must chart a path to a new normal, which may be different than pre-pandemic life.

Thankfully, the Omicron surge, which escalated so quickly, is now declining rapidly. On graphs of COVID cases, Omicron dwarfed previous surges. How did this happen, and what can we learn from it?

To me, the crux of the problem is this. As individuals, we make decisions based on our personal risk. For a young, healthy person who is vaccinated and boosted, the individual risk of COVID is low. This has been reinforced by news, public health announcements, and anecdotes that Omicron is milder. As our communities emerged from the Delta wave and struggled with the mental health effects of the last two years, we took this news as permission to do more. Individuals resumed pre-pandemic activities, feeling their own personal risk to be small relative to the benefits.

Unfortunately, the risk borne by Omicron is not at the individual level, but at the societal or systems level. As an example, the incredible contagiousness of the variant meant the community spread outstripped our testing capabilities. Individuals who developed mild symptoms couldn't find testing and ended up in our emergency department just to check for COVID. They probably would not have come to the ER otherwise; their disease was mild, and after they got confirmation, they were given instructions and sent home. But all of a sudden, our ERs took on the role of primary care provider and urgent care as well as an emergency room. This meant that when a real emergency happened - a stroke, heart attack, car accident - the ER was occupied with patients who would not ordinarily be there. Although young, healthy, immunized individuals with COVID may not need hospitalization or advanced treatments, they indirectly impact the health care system by absorbing attention, resources, time, and energy. 

The effect of individuals doing more snowballs. As more people venture into riskier and riskier activities, others feel "FOMO" or feel enabled to do more themselves. We have seen this time and again during the pandemic as the world attempts to return to pre-COVID activities and behaviors. These are normal goals and desires, but in the setting of a highly contagious variant, they lead to a dichotomy of rising cases along with rising numbers of people traveling, congregating, and socializing. For us in health care struggling with staffing shortages, overwhelmed hospitals, emotional trauma, and physical exhaustion, this generates resentment. Hospitals face a crisis, but the rest of the world doesn't seem to care. I feel this, and it is crushing.

Finally, the activities of low-risk people increase the risks for vulnerable people. I know people with cancer and transplants who have been meticulous these past two years, avoiding unnecessary activities, adhering to guidelines, and successfully avoiding COVID. They are terrified that catching the virus may put them at risk for dying. However, if COVID starts increasing in the community because people at low risk are doing more, then the odds worsen even for people taking all the precautions. There are everyday necessities that cannot be avoided: work, grocery shopping, school and childcare, doctors visits. As COVID infiltrates these areas of life, the immunosuppressed, elderly, and unvaccinated face a real threat to their health.

Now that we're leaving Omicron behind us, how do we proceed? Although much of this blog cautions against resuming pre-pandemic life, that's not what I'm advocating. I think it is reasonable and rational for each of us to evaluate our risk tolerance and adjust our activities accordingly. But we also live in an interconnected society, and our decisions impact others directly and indirectly. We need to be cognizant of what's happening at a macroscopic level and take responsibility for how our actions fit into the bigger picture.