Earlier this week, President Biden declared the pandemic over. This tracks with public opinion: most Americans have long abandoned their masks, and federal funds may soon dry up for testing, treatment, and even vaccines.
Of course, this doesn’t mean the virus has disappeared. In fact, hundreds of Americans are still dying each day from COVID-19, and thousands more are suffering from long COVID, a host of protracted symptoms that could lead to severe health complications down the line.
On the latest episode of The Dose podcast, host Shanoor Seervai talks to Dr. Bob Wachter about what it’s like to live with COVID in 2022. Dr. Wachter, professor and chair of the Department of Medicine at the University of California, San Francisco, is one of the nation’s foremost experts on the pandemic.
SHANOOR SEERVAI: This week, President Biden declared that the COVID-19 pandemic is over. He’s matching public sentiment — anecdotal evidence and polling show that most Americans no longer see the pandemic as an acute threat. At the same time, hundreds of people are still dying each day from COVID, thousands of people are suffering from long COVID, and those at highest risk, like older Americans or the immunocompromised, must fend for themselves.
I’m Shanoor Seervai, and on this episode of The Dose, I’m talking to Dr. Bob Wachter about what it’s like to live with COVID as we head toward a third COVID winter. Dr. Wachter is professor and chair of the Department of Medicine at the University of California, San Francisco. Since the beginning of the pandemic, he has been a huge presence on Twitter and in the media, sharing credible information on the clinical, public health, and policy issues related to COVID.
Dr. Wachter, welcome to the show.
BOB WACHTER: Thank you, Shanoor. Nice to be here.
SHANOOR SEERVAI: Right now in the U.S., COVID is not life-threatening for most people, especially the vaccinated and the boosted. But what’s worrying to many doctors and epidemiologists is the specter of long COVID. Can you explain those risks?
BOB WACHTER: Yes. And I agree with that assessment. As I think about my own personal life or the recommendations I give to friends and family, for someone who is fully vaccinated and fully boosted, the acute threat — the possibility that they may get hospitalized or die of COVID — has really gone down to nearly zero. Not quite zero, but nearly zero. And so the public’s shift in attention and focus in some ways is appropriate because Eq threat is so much less than it was and people are exhausted after two and a half years.
To me, the reason I still am relatively careful is the threat of long COVID. And long COVID is defined variously as continued symptoms for a period of time that goes beyond the acute illness. You’ll see definitions of two months and six months. And I think two months feels like a reasonable definition because it reflects the fact that the acute phase is virtually always over, and if you still have symptoms after two months, they are lingering, assuming they’re from the COVID.
There’s a second aspect of long COVID that gets less emphasis, but I am equally worried about, which is not only are there these potentially protracted symptoms, and some people a nuisance and some people disabling, but epidemiologic evidence, and it’s imperfect, but epidemiologic evidence says that a year after a case of COVID, the possibility that you will have things like a heart attack or a stroke or develop diabetes or have cognitive decline is higher if you’ve had COVID than if you haven’t. And I don’t think we’re very secure in that data yet. We’re going to have to see how that plays out over time. But if that’s real, you’re talking about literally tens of millions of people at heightened risk of some of the major killers and disablers that we have in our society.
I really think about it in these two buckets. One is lingering symptoms, the second is potentially elevated risk that may be lifetime based on a case of COVID. One more point is that people sometimes say, “Okay, that’s unpleasant, but I had my COVID already. At least I got it over with.” And that’s not a get out of jail free card forevermore, unfortunately.
SHANOOR SEERVAI: And these conditions that you’re describing are scary. What are the implications for individual patients but also for our health care system at large?
BOB WACHTER: Well, I don’t think we know yet, but if we say that these data, which are concerning, turn out to be right, you’re talking about tens of millions, maybe hundreds of millions of people at elevated risk of the most common killers that we have. And so it means a higher rate of heart attacks and strokes, and it means the system has to deal with that.
And ultimately, it may influence the way we do risk factor modification. COVID may elevate the risk enough so that someone who you would say, “Oh, I don’t have to worry that much about this person’s blood pressure or cholesterol,” well now, maybe I do because they have elevated their risk and so I may think about managing the modifiable risk factors in other ways. In terms of the level of investment and the amount of attention the medical and research community should be giving to it, my goodness, if we’re really talking about tens of millions of people at elevated risk for some of the most common diseases we have, it merits a tremendous amount of attention.
SHANOOR SEERVAI: And that was going to be my next question. Are we spending enough on research? And are we spending it in the right areas?
BOB WACHTER: I don’t think we know yet. I think there is a tendency now to still be focusing on this acute threat; that’s what’s front of mind. We still have very vivid recollections of the refrigerated morgue trucks outside of hospitals. And I don’t think we’ve made the pivot yet to a world where the acute threat is lower, but the chronic threat in all the forms of long COVID is higher, and what that means in terms of remodeling our health system for this massive number of new patients at risk and also in terms of research dollars. There have been several billion dollars put aside for long COVID research. There are no treatments that have been demonstrated to be beneficial in terms of the prevention of or the management of people with the symptomatic form of long COVID.
We’re talking about what should be front of mind. I think front of mind is millions of people who still feel crummy six months out from their case of COVID. My wife is one of them. And at this point, we don’t actually know what to do with them. Should they get another course of antiviral treatment? Should they be on a blood thinner? Should they be on antiflammatory medicine? How do we even test them for long COVID? All of those things are open questions. And even “What is going on?” is a somewhat open question. We’re getting closer to it and finding that in many cases it’s different things that are going on. But trying to find a treatment, some of this may just be empirical, we may just try some things and see if it makes a difference. But also, having a deeper understanding of what’s actually going on in your body is going to be important.
And then the research piece is we don’t even really know the prevalence. And the research in terms of these long-term threats is relatively scanting, I think. And so we’re banking a lot on a few large epidemiologic studies that show an elevated risk, for example, of heart attacks or of strokes. We’ve got to become much more sure about that. If it turns out it’s possible that those studies aren’t right, that there’s confounding, there are other things that are going on, the patients who have COVID are more likely to come in and seek medical attention and that’s making it look like they have other diseases that are just coming to attention early, that’s all possible. And so this is sort of Epidemiology 101. If you have something that is a really complicated association involving potentially tens of millions of people, we really need some of our best minds and epi and biostatistics to get together to design the trials that’ll tell us how much is the risk, and then research scientists to really help us understand what is going on that is creating this risk, which is really the only pathway that we have to figure out then how to prevent it or treat it.
SHANOOR SEERVAI: Well, first I want to say I’m sorry to hear about your wife. How is she doing today?
BOB WACHTER: Well, thank you. She’s okay. And if I said to her, “I talked about your long COVID today,” she’d say, “I don’t have long COVID.” And I’ll say, “But you feel much more fatigued than you used to, and you tell me that your brain is not quite working at 100 percent.” I’d say she would characterize herself as being 90 percent back to normal. And if you looked at her, you’d say she’s fine, and if you spoke to her, you’d say she’s fine, you read her writing, you’d say she’s fine — but she’s not fine. It’s better than it was, it gets a little bit better every week. But the stigma of calling it long COVID is such that she doesn’t really want to be characterized that way.
SHANOOR SEERVAI: Right. We’re beginning to understand something that is so amorphous and difficult to pin down anyway.
BOB WACHTER: Yes. And that’s challenging for patients, and it’s challenging for the medical profession. And the interaction between those two are hard. And we know this from other diseases over the years where people don’t feel right, but there’s no test, there’s no blood test, there’s no X-ray that shows it. And they immediately feel, and I think often quite appropriately, that the medical system is looking at them skeptically. There might very well be some mind–body interaction here, but very clearly this is a real thing.
SHANOOR SEERVAI: Right. I do want to shift a little bit back to the big picture of the acute part of the threat, which the White House has indicated that it’s ready to wind down operations on. Is this the right time to be winding down?
BOB WACHTER: Well, yes and no. I think the White House is doing it partly because Congress is not giving them the funding that would be necessary to keep up a level of intervention that, at least from my discussions with Ashish Jha and others, they believe are really quite important. What I do think is right is that the threat of COVID is real and has not gone away, and I think in some ways Congress is reading the temperature of the population that very clearly people in their day-to-day lives mostly want to move on. So I think it is appropriate to be saying, “What is this going to look like in five years? Let’s position ourselves for the long haul.” And that’s a different way than you position yourself for this acute threat.
SHANOOR SEERVAI: Of course, this is a little bit different for people who are older, people who are immunocompromised, so I just wonder about this approach of leaving things up to personal risk when there are people among us who are at much higher risk.
BOB WACHTER: Yeah, I think that’s clearly true, but I think it is a fair statement that everybody has the ability to protect themselves to a very great extent today, independent of what people around them are doing. And you might say, “That’s an unfair societal point of view or a noncommunitarian point of view to say, ‘Leave end individuals up to themselves,’” because in fact, an immunocompromised person could be infected by the person sitting next to them who’s chosen not to wear mask or chosen not to be vaccinated. That’s true. But we also don’t guarantee health insurance. We also don’t provide for decent primary care or nutrition or schools or . . . we tolerate inequities in ways that in some ways are more stark than this one. That this is one where, even for an immunosuppressed older person with the availability of vaccination, Evusheld, Paxlovid if they get COVID, and cheap masks, testing. Yes, they may limit the activities that they have, and yes, they would be marginally safer if everybody around them continued to wear a mask, but asking everybody to continue to wear a mask to marginally increase that person’s level of protection I just think is a lot to ask. And I think even if we asked it, people will rebel, and already are.
And so I think it’s a pragmatic, where we are in the pandemic, we are at a place where even the most vulnerable people, very older people or people with multiple medical comorbidities or people who are immunosuppressed, have the capacity to live life pretty fully and reasonably safely independent of whether others do around them. And as a pragmatic point, even if you ask those others to act differently to keep these other people safe, I don’t think they’re going to do it.
SHANOOR SEERVAI: On the new booster, there is a new one for the specific omicron variants we’re seeing, but we are also seeing a shift towards annual booster shots. Do you think that that’s moving in the right direction?
BOB WACHTER: I think it’s a reasonable solution to the multivaried equation that Ashish Jha and the others in the White House were trying to solve. And it’s complicated. Basically, what they have come to believe is for the average person who’s at low or medium risk, and it’s probably 80 percent of the population, if we can get them to take an annual shot, we will save a lot of lives compared to some of them taking shots and many people not taking shots. And the reason for that is even though the chances that this new booster is going to last for a year in terms of preventing infection is very, very low. The old booster against omicron and BA5, the old booster lasted two months in terms of its effect in preventing infection. The idea that this booster is going to last six times as long and get you through a whole year is very low.
On the other hand, the chances that it’s going to last for a year in terms of providing high levels of protection against you getting really sick and dying are very high, because the old booster does that. Will there be some waning in month 11? Probably. But still, you’re going to be in better shape having had that yearly booster than if you haven’t.
And I think their formulation was we already have a model for people coming in and getting a shot a year, it’s called the flu shot. Two-thirds of the American public get it, and they get it around a disease that’s less of a threat than COVID is. If we could get people to come in and get a yearly shot, we would be so much better off than if they don’t.
And their belief is some people are not getting the shot because of the uncertainty. “All right, I’ll come and get the shot now, but are you going to tell me in three months I’m going to need another one? I can’t deal.” And they’re just throwing up their arms and not doing it. Now, the two caveats there are for high-risk people, they probably are going to need more frequent shots. And you heard every statement had this caveat that was barring a nasty new variant, because if it turns out the new shot no longer is the right vaccine and we know that next January, we may be asked to take another vaccine because there’s a new variant that’s a threat, that the vaccine that we have isn’t working on.
And there was a little bit of a communication challenge of course because, in some ways, as soon as you say, “It’ll be like your flu shot,” people will quite naturally say, “Are you saying that you think COVID is a seasonal threat?” And the answer is no, COVID is not really seasonal. It’s a really complicated argument to make, but that’s what they’re thinking. And I think it was a rational way of dealing with the facts on the ground.
SHANOOR SEERVAI: Let’s talk a little bit about communication now. You’ve had a remarkable journey on Twitter during COVID, but you said that many of the people who follow you and turn to you already believe what you have to say. Did you try to reach the nonbelievers, the antivaxxers, the antimaskers?
BOB WACHTER: Well, when COVID started, I had maybe 15,000 followers. I have 280,000 today. I don’t think I’ve gotten any smarter or more interesting in the last three years. Obviously there was an audience that wanted information and made a choice to follow me, and many other people as well, as what they thought of as reliable sources of information.
I’ve tried to pull it together and be fairly personal and say, “Here’s what I am doing based on what I see out there. I am or am not eating indoors, I am or am not wearing a mask. I am getting the vaccine this weekend. This is why. This was the experience of my wife, this was the experience of my son,” all that kind of stuff. And I think many people have found that useful.
I think that’s what I would be saying to someone who is an antivaxxer. “This is what I’m choosing to do, knowing what I know.” And this is one of the great challenges we have. And it’s not just in COVID, it’s obvious in our politics, is people are going to find compatible sources of information that tend to confirm their underlying biases. And I think, for a lot of people, it has been useful. I’ve had a lot of people say, “This is just too complicated. You tell me what you’re doing, and I’ll do that.” Which I find it’s a lot of responsibility, but quite gratifying. But other people who are also thoughtful, some of them have said, “This is just too complicated, and we’re now at a stage of COVID where I’m just going to choose to do nothing. I’m going to go back to 2019. And as long as this acute threat is lower than it was, that’s the way I’m going to choose my life.” And that’s not entirely irrational.
SHANOOR SEERVAI: And how much longer do you anticipate needing to keep doing this as more and more people just want to move on?
BOB WACHTER: That’s an interesting question because I’m very sensitive to the tree falling in a forest. I won’t do it if nobody seems to want the information. At least so far, I find that there’s still . . . the number of followers I have has not gone down in the last six months. I do it much less frequently than I did in the beginning. In the beginning, I was tweeting every day because I thought there was new information coming out every day and it was incredibly dynamic. It’s less so now, but when I put out a long thread of, “Here’s what I’m doing now and why, and here’s how I the math and the odds and the probabilities,” I think it gets almost as much attention as it got a year and a half ago. Social media gives you immediate feedback about whether people are finding it useful, and at least so far it seems like people still are. And as long as they do, I’ll keep doing it.
SHANOOR SEERVAI: And on the topic of information campaigns, COVID’s devastating and disparate impact on Native Americans and Black and brown Americans was very real. In these communities, where many people had doubts about the vaccine due to their own experiences, and the structural racism baked into our health care system, there were targeted campaigns to reach and serve people. Do you think that information campaigns to reach Black and brown people have been successful?
BOB WACHTER: I think the data would say that they have in that the level of disparities, for example, if you look at vaccine rates, are less profound than I would have expected. Now, that’s a low bar and doesn’t let us off the hook because they’re still real. And you look at the toll of COVID on underserved communities or communities of color, it is definitely higher than in other populations. There are equity issues, they’re very real.
How much of them relate to misinformation? How much of them relate to access to care in some ways? How much of them relate to the kinds of jobs that people have and their ability to work from home on Zoom versus they’re out and working in a store and doing 100 other things where they actually can’t really shield themselves? I think it’s very hard to disentangle them. But when you look at the vaccine differences in populations, they cleave more on political affiliation than they do on racial and ethnic grounds.
And I have to say, I came into this with sort of an expectation that we would see the kinds of disparities that we see in cancer or treatment of hypertension or perinatal outcomes. I came into it with an assumption that we would not address disparities in a proactive way and we would be seeing what we always see, which is pretty shameful.
I think it’s been better than that. And I think part of it is the fact that COVID happened at precisely the same time that George Floyd happened and that there was a movement, and I think a legitimate movement, in health care to pay attention to equity and disparities in ways that we never have before. They’ve existed forever, we just didn’t pay attention. We certainly didn’t build structures or programs or educate people about them. That all has changed markedly. I think COVID became the first example where that was very real.
And I can tell you in San Francisco, very proud of UCSF, my institution, very quickly built a program. And built is the wrong word, because actually cobuilt a program with communities of color and some of our poorest districts of the city to do testing, to do treatment, to do vaccines, to do education. And it was profoundly successful and led to save many, many, many lives because of the assumption that if we’re not proactive about this, there will be major disparities.
And also, I think in San Francisco maybe in particular, a long tradition born of the AIDS epidemic, of real collaboration between the public health department, the university, and the community, and a recognition that if we do this from on high to the community, it won’t work. It has to be completely built collaboratively. And in many ways, the voice of this has to be the community. I think it’s gone very well. Disparities are real, but I think they’re less profound than I would’ve expected.
SHANOOR SEERVAI: I did also want to talk a little bit about testing, which has been a challenge in so many ways. We’ve had people using home tests for the past several months, and then there’s also the asymptomatic test positivity rate. Why weren’t these positive tests built into calculations of community rates all along?
BOB WACHTER: Well, there are two different questions there. One is why didn’t we figure out a way to capture the results of a home test in our reporting? And I think the answer is it’s really hard. I happen to think that the fact that I can go buy, and in some cases it was free, a home test that’s reliably tells me that I have this disease is massive progress. I think you do not want a system where I have to go in and see a doctor. If I tested positive, I would go tell my friends and family that I’ve tested positive, and you should get yourself tested. That’s all happening completely independent of the public health infrastructure, which I think is good because the public health infrastructure does not have the capacity to do that.
The asymptomatic test positivity rate . . . I use that data all the time because that asymptomatic test positivity rate to me is the best measure I can find of what’s the probability that somebody standing next to me in line at the Safeway has COVID. And so I do think that there is no equivalent that the public health departments or the CDC has developed. And there should be. There should be some metric, because it’s really the most relevant piece of data to an individual about whether you should wear a mask or whether you should do indoor dining.
The most relevant number is if you take a population of people who have no symptoms at all and test them with reliable tests, systematically what is the prevalence of COVID in that group? And from that I can calculate what are the probability if I’m in a group of 10 people sitting around me in a restaurant, what’s the probability there’ll be at least one person with COVID? The answer is about 18 percent or 19 percent. Is that high enough or low enough to wear a mask or not? To be high enough that I’m still going to wear a mask. If that number was 5 percent or 2 percent, I’d probably be comfortable taking the mask off. That’s what that number is about. And I do think there should be something like it in communities, because if you were going to get a COVID weather report to say, “Wear a mask today or don’t,” it would really come from a number like that.
SHANOOR SEERVAI: And so since we don’t have a COVID weather report like that, how can people actually assess their risk of exposure?
BOB WACHTER: The number I have come to use, which is easily findable, is the cases per 100,000 per day in your community. If you put in New York Times COVID and let’s say California, where I am, you then get basically a table of every county in California, and it gives you the cases per 100,000 per day. Now, the case rate is sort of biased and wrong in a few ways. One is that it’s missing all the home tests. So that number I’ve got to multiply by about five to give me a sense of the true case rate.
SHANOOR SEERVAI: That’s a lot of hard math to be doing to decide if you’re going to go out to dinner.
BOB WACHTER: It is. And that’s why a lot of people just say, “This is too much.” Right, a lot of people would just say, “I don’t even want to deal with this. I’m either going to dinner or I’m not.” And I completely understand that.
SHANOOR SEERVAI: Right. And so even if people want to believe that the COVID pandemic is ending, new infectious disease threats are emerging. Monkeypox was declared a global health emergency this summer, and we’re recording this conversation the day after the CDC and the WHO announced that enough polio virus has been found circulating in New York to cause the United States to be added to the list of countries with active circulation of the virus. Have we learned anything from COVID to prepare us for the future?
BOB WACHTER: First of all, the fact that polio is making resurgence is flabbergasting. As the COVID vaccine became politicized and as conspiracy theories and misinformation became rampant and became consumed, we learned a ton. In some ways, we also learned some bad things. And the bad thing is that it is possible for a threat to be sufficiently politicized that people will do things that are scientifically crazy.
And so I worry that the purveyors and consumers of misinformation have learned that it works in COVID, and so let’s do it now with other childhood vaccines that up until recently people just accepted. My school has a requirement that the kids have to get their diphtheria and their tetanus and their rubella and their polio vaccine. That was a nonissue, but now it’s going to be an issue. People are going to start questioning, “Do I need the polio vaccine?” Is it going to stop there? Maybe not. Maybe people are going to say the idea that you need a colonoscopy or a mammogram, that’s all a conspiracy theory by the health profession that has a financial interest in medicalizing everything. And I think that’s what we’re seeing now with polio. It’s unbelievable.
SHANOOR SEERVAI: What are we going to do about this? Are there new policy initiatives or changes that can be made to the health care system?
BOB WACHTER: I wish I knew. I think that is the trillion-dollar question. Because this is not just health care, this is the threat to democracy. We’re an environment where the questioning of expertise is rampant. And what we’ve learned is, in our society with its libertarian bent, the pushback against mandating things, if you have tens of millions of people that don’t believe it and don’t want it, is going to be massive. You’re going to need to find a smarter guest than me to try to figure out how to fix this because it strikes me as an almost insoluble problem. And easy solutions: we have to communicate better or get the right people from those communities to communicate, or better public health departments, or better scientific education in elementary school. All those things sound fine, but I don’t think they solve the problem.
SHANOOR SEERVAI: Well, I’ll have to be very, very lucky if I am to find a smarter guest.
BOB WACHTER: Thank you.
SHANOOR SEERVAI: Thank you so much for joining me, Dr. Wachter.
BOB WACHTER: It’s a great pleasure, and I hate to be such a bummer.
SHANOOR SEERVAI: This episode of The Dose was produced by Jody Becker, Mickey Capper, Naomi Leibowitz, and Joshua Tallman. Special thanks to Barry Schulz for editing, Jen Wilson and Rose Wong for our art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions. Our website is thedose.show. There, you’ll find show notes and other resources. That’s it for The Dose. I’m Shanoor Seervai. Thank you for listening.