It’s Time to Rethink Your COVID-19 Risk Tolerance
The U.S. is taking a crash course in learning to “live with the virus.” Policymakers and health experts agree that we have migrated to a less-disruptive COVID-19 endemic phase. This has produced extensive commentary on what living with the virus, and achieving the “new normal” might look like—liberating some while confusing others. Many people have spent two years avoiding and fearing the virus and are now being advised that it’s safe to unmask and to resume a normal social life. For them, this has not ushered in a comfortable sense of natural transition, but instead has caused a national emotional whiplash. Psychologists call this avoidance conflict.
CDC’s new look-up map tool for COVID-19 community risk-level attempts to balance key goals of preventing hospital overload and flattening the curve of serious disease. The agency’s previous map based on level of transmission reflected most counties as high-intensity bright red. The new map is mostly a reassuring low-risk green. Critics of this new approach say that the agency “seems to have moved the goalposts to justify the political imperative to let people get back to their normal lives.” What both the critics and supporters of the CDC’s new tool have missed is that—whether red or green—the tool doesn’t change our prior fundamental relationship to the virus which we have had since the beginning of the pandemic. We are all still advised to warily avoid it until it becomes “safe enough.” This old paradigm will not lead us to a “new normal”.
With the new CDC guidance our old paradigm dilemmas remain endless. When do I mask? Do I send my child to school with the sniffles? Can I return to work after cancer chemotherapy? Do I need a fourth shot? When do I use at home rapid tests? Should our family fly to our usual summer vacation spot?
In this era of cautious fraught optimism, few have grasped the stark reality that for the country to successfully navigate to a sustainable endemic phase, most of us must transition from avoiding to accepting transmission and infections. Let’s sit with that for a second. This should be the center-point of our endemic-phase policies and practices. This is the seismic shift that will ultimately enable us to live in a sustainable new normal.
Here are five guideposts that should help us get there:
1) Accept that we can’t outrun Omicron
Omicron is an extraordinarily communicable variant. It is ubiquitous and will eventually infect nearly all susceptible people, whether they try to avoid infection or not. The Institute of Health Metrics and Evaluation estimates that about three-fourths of the country already has “functional immunity” to Omicron, and expects this to continue to “grow through the tail-end of the Omicron wave.”
As with many respiratory viruses like the flu, colds and pneumonia, we should expect to see a seasonal pattern with more case (positive test) surges. Further outbreaks of high caseloads should not set off alarms to deviate from a steadfast endemic-phase new paradigm, as long as the vulnerable population—which suffers the brunt of the disease burden—is protected from infection. We have accepted coexistence with many other communicable pathogens with similar characteristics in the past, without undue mental trauma or physical disruption. Now it’s COVID-19’s turn.
2) Identify “vulnerable” and “non-vulnerable” risk sub-groups
The public has been conditioned by dire whole population numbers (all test-positive cases, hospitalizations, and deaths). This drives risk perceptions, and actions for much of COVID-19 policy. Throughout the pandemic this has resulted in a grossly inaccurate and distorted view of individual risk and has led to excessive mass avoidance behaviors and bad policy. This flawed lens must now be replaced.
To enable the “new normal,” Americans can be separated into two discrete risk-based sub-populations: those that if infected have a similar or lower risk of hospitalization and death than that from influenza (called the “non-vulnerables”) and those that have a far higher comparative risk of these outcomes (called the “vulnerables.”) Risk is actually a continuum from very low to very high, but this simplifying binary categorization is intended to offer clear public understanding.
The determination of vulnerability is based on three overwhelmingly dominant factors that drive severe outcomes from Omicron infection: age, immunological susceptibility, and underlying conditions. Poverty and ethnic/racial factors also confer risk, but indirectly through social and health-equity disparities.
Age is the single greatest predictor of infection outcome. A recent CDC study revealed that compared to people under 30 years of age, those over 65 year olds who are infected are 5-10 times more likely to be hospitalized and 65-340 times more likely to die. The absolute numbers are staggering. Over age 65s comprise 13 percent of the population and in January produced 80 percent of total deaths from Omicron. Those over 75 are 6 percent of the population and produced about half of the daily average 2600 deaths during the January surge.
Individual and population susceptibility is reduced through either infection or full vaccination. Either are about 80-90 percent protective against serious disease and death, with effectiveness significantly waning with age and over time. The level of susceptibility is an ever-changing dynamic equilibrium between waxing and waning forces. It should increase slowly in coming months as Omicron declines. With the expected increase in transmission and further booster uptake later in the year, we should again expect higher population immunity.
The CDC has listed over twenty underlying medical conditions with conclusive evidence of higher risk for severe COVID-19 outcomes: obesity, advanced diabetes, mental disorders have the highest association with death. Additionally there are the estimated ten million immunocompromised Americans, who have autoimmune disease, cancer, chemotherapy regimens or other reasons for immunosuppression.
In this new paradigm about 20-25 percent of the American population has a current risk of serious illness from Omicron significantly greater than that of the seasonal flu. These vulnerable people are anyone over 65, and increasing exponentially with advanced age, immunological susceptibility, and significant comorbidities. The immunocompromised of any age are also included. This group must avoid infection, which is their key prevention metric.
The remaining 75-80 percent of Americans are “non-vulnerable” as defined by having a similar or lower chance of serious outcomes from Omicron than from the seasonal flu. This group does not need to avoid infection. Their important metric is serious disease and deaths, not cases.
3) Prioritize protection of the high-risk vulnerable population
This binary scheme now produces much simpler, targeted and effective disease-mitigating framework: the non-vulnerable new normal can be similar to the old normal when interacting with other non-vulnerables. However, when non-vulnerables directly intersect with the welfare of the “vulnerable” population, specific accommodations should be required. In practice this means universal masking on public transport, vaccination, boosting and masking for health care workers and in congregate facilities, such as nursing homes. As a country we have precedents for balancing “freedom to” with “freedom from”—for example in establishing smoke-free public spaces.
For those in the vulnerable group, there is unfortunately no dramatic new normal. This is not a societal but a viral imposition. COVID-19 and its variants have taken an unimaginable and inequitable toll in the vulnerable population. Vaccines and boosters have slowed but have not stemmed this tide. Society will need to intensively work through protective public accommodations, and each vulnerable individual and household will need a viable plan.
4) Plan for the most likely scenario
Many are rightfully apprehensive about important “known unknowns” relating to COVID-19 infection. This includes the emergence of new variants, the dangers of Long Covid, the lack of an approved vaccine for infants and young children, and other possible adverse developments. These are all legitimate concerns, however the positive risk-benefit calculus for most individuals and society favors the resumption of our normal lives. Strategic decisions in war are usually focused on “most likely case” assumptions while also preparing for a “worst case.” As new information develops we must maintain the capacity to pivot quickly if things change for the worse.
5) Unite the country through minimizing restrictions
This “new normal” can perhaps take us from the rancor of partisan politics and ideology to focusing on what works for the country in saving and restoring lives. The primary issue becomes protecting the vulnerable, not masking and other interventions. Obligatory protections should focus only on the areas of intersection with the vulnerable. And hopefully many or even most Americans, no matter their political outlook, can agree on this priority.
Pulling together as a society is likely to be most effective when it is the collective embodiment of individual expression. This would not only produce public health dividends, but also boost the economy and help restore America’s full productivity and dynamism at a particularly challenging time in our history.
Adopting these guideposts will accelerate our progress to the new normal. It will take time, tenacity, and societal consensus to reach our goal. But the pandemic off-ramp is clearly in view.