Thursday, May 20, 2021

EXTRA EXTRA Unmask Madness: A Tale Of Two CDCs

 

CDC Directors Robert Redfield and Rochelle Walensky

Before tackling my main topic, the recent bombshell changes in the CDC’s COVID-19 recommendations, I want to draw a clear distinction between what’s going on now and what was going on just a few months ago. 

During Donald Trump’s reign the Centers for Disease Control – previously one of the world’s best epidemiology institutions – demonstrated a staggering mix of incompetence, bad faith, and groveling. Its chief, Robert Redfield, notoriously lied about faulty coronavirus test kits; ordered his inspectors to water down their recommendations to meat processing plants devastated by COVID-19; purged Trump’s favorite pandemic model from the CDC website within hours when its latest version strayed from the President’s fantasies; trashed sensible reopening guidelines at Trump’s behest because they might have offended evangelicals; allowed the White House to censor the MMWR (the Morbidity and Mortality Weekly Report, the CDC’s holy of holies); deleted emails to help cover up a secretive herd immunity strategy; and, when Trump’s nutcase advisors attacked his agency, lay down and rolled over.

Redfield's behavior provoked an extraordinary editorial in a scrupulously apolitical top medical journal, The Lancet, that concluded, “The CDC needs a director who can provide leadership without the threat of being silenced and who has the technical capacity to lead today’s complicated effort.”

The guy was a real piece of work. 

His successor Rochelle Walensky is, on the contrary, both intelligent and well-meaning. But I’m starting to fear that she may be in over her head. 

At the end of March she signed off on summer camp guidelines that forbad kids to eat together and said even 2-year-olds had to wear masks every moment they weren’t actively swimming or eating. Critics blasted the recommendations as irrationaldraconian, and cruel, while even the ever-tolerant Anthony Fauci admitted they were “a bit strict.”

We all saw and heard direct testimony from Walensky around the same time when, apparently near tears, she described “the recurring feeling I have of impending doom” about the direction the pandemic was taking, and said she was “calling on our elected officials to sound the alarm.” Her agency stuck to near-total bans on going barefaced, even outdoors where masks are nearly irrelevant, until the end of April. Then they allowed vaccinated individuals (only) to leave their masks at home if they were attending “small outdoor gatherings.” A week later they softened up some on those summer camp rules, saying it’s OK for some kids to take off their masks outdoors – but only the ones who’ve managed to get themselves vaccinated!!!

Two weeks later, even as COVID-19 is still killing hundreds of Americans every day and community transmission levels remain high in much of the country, Walensky rushed to the other extreme: “People who are fully vaccinated can participate in indoor and outdoor activities, large or small, without wearing a mask or physical distancing” – see the CDC website for details.

The damage was immediate. Within 48 hours governors and mayors across the country had rescinded their mask mandates. Large outfits from Walmart to Trader Joe's to Las Vegas casinos instantly declared they’ll depend on the honor system to separate the vaccinated wheat from the unvaccinated chaff (lots of luck), though CVS and many small businesses are keeping their MASKS REQUIRED signs in place. Home Depot hesitated a day or two before caving. Restauranteurs are being forced to choose between keeping their existing mask rules, at the risk of losing business to less fussy competitors, or scrapping them altogether. In a flash Republican members of Congress were strutting on the House floor without masks – likely unvaccinated, like 56% of their caucus (versus zero Democrats).

The CDC seems to think the new guidelines will nudge people to get vaccinated. What world are these people living in? Don’t they realize that letting strangers mingle ad lib will have just the opposite effect? 

The press has focussed on masks and mask mandates, but the worst aspect of the guidelines may lie elsewhere. The protection you get from face masks is limited and somewhat controversial, but the protection you get from physical distancing is major and unquestioned. The CDC guidelines deactivate both measures, even if theoretically only for the fully vaccinated, giving its involuntary blessing to jam-packed bars and nightclubs (60% of 18 to 29-year-olds are unvaccinated), to church congregations belting out hymns shoulder to shoulder (46% of white evangelicals are unvaccinated, and 26% hope to stay that way) – not to speak of ultra-orthodox Jewish celebrations (in January only 12% of Haredim planned to get vaccinated). Did Walensky really really think this one through?


Clandestine Hasidic wedding, November 2020

Public health law guru Lawrence Gostin tweeted, and later expanded, “Guidance won’t incentivize vax But will eviscerate masking and distancing.” Infectious-disease epidemiologist Lisa Maragakis said “The likely result is that almost no one will wear a mask.” Experts in lying and deception agree.

Some are suggesting the sudden leniency may have been politically motivated, aimed at boosting Joe Biden’s popularity at a difficult moment, between poor jobs reports and the situation at the border. The problem with this theory is that apparently Biden wasn’t told of the CDC’s plans until the very day of the announcement.

Walensky argues that the guidelines are based on recent (actually not so recent) evidence fully vaccinated people are very unlikely to transmit COVID-19, meaning they are not only at very low risk of getting ill themselves but also don’t pose a threat to others. Anthony Fauci is going along, despite having recently warned against loosening restrictions at least until daily new cases fall below 10,000 (they’re now around 35,000). Medscape editor Eric Topolbases his approval of the new guidelines on those transmission studies. CNN’s Sanjay Gupta is also relatively positive, though he calls the abruptness of the announcement “a critical error.” 

I say: true dat, the science is unassailable. But science is one thing, the real world another. As Emergency Room physician and public health expert Megan Ranney said, “The problem here isn't the biological science. It's the behavioral science behind what is going to happen when we tell folks that they can take their masks off.”

The key problem is, of course, that vaccination involves a needle, not a branding iron, so there’s no way to tell who’s vaccinated and who's not. So why should the unvaccinated, especially the anti-vax and anti-mask unvaccinated, wear masks anywhere any more? Imagine a cautious person who has as yet been unable to access the vaccine, or is one of the millions of immunocompromised in whom vaccines are less effective. Will she ever dare now to go to the movies or her local Starbucks? Her mask has no chance of competing with hordes of possible SARS-CoV-2 carriers all spewing virus in her direction. 

There’s also another problem, somewhat less serious. Though the CDC bases its decision on the premise that “Indoor and outdoor activities pose minimal risk to fully vaccinated people,” this is actually true only for RNA vaccines. The risk of becoming ill with COVID-19 for people vaccinated with Pfizer and Moderna is indeed reduced by at least 95%, but if they had Johnson & Johnson (or, elsewhere in the world, AstraZeneca), the risk is reduced only by 63%-72%. As though to illustrate that point, on the same day the new CDC rules came out the Yankees announced that 8 (now 9) of their staff or players had tested positive for the coronavirus despite having been vaccinated with Johnson & Johnson.

The CDC is getting pushback, with many medical colleagues as skeptical as I am, including influential ones like virologist Juliet Morrison and columnist Leana Wen. Epidemiologists in a recent survey strongly disagreed with the new approach, and Environmental engineer Linsey Marr, a point person on aerosol transmission, finds it 6 weeks premature. David Michaels, the head of the Occupational Safety and Health Administration (OSHA) under Obama, called it “A Public Health 101 failure.” Zeynep Tufekci thinks it’s far too early to lift indoor mask mandates, if we’re to protect the unvaccinated and the immunocompromised.

The nation's largest nurses’ union was virulent: “This newest CDC guidance is not based on science, does not protect public health, and threatens the lives of patients, nurses, and other frontline workers across the country’ . . . ‘Now is not the time to relax protective measures, and we are outraged that the CDC has done just that while we are still in the midst of the deadliest pandemic in a century.’” (Agreed, but the union would be more convincing if all its members were vaccinated – as of mid-March one out of 3 nurses were refusing the jab.)

The mayor of Kansas City said the honor system is “not working,” and commented “I don’t know if that’s the type of rule that was written in coordination with anyone who has been a governor or a mayor over the last 14 months.”

The Infectious Disease Society of America emphasizes that “Additional guidance is needed to clarify safe interactions in public spaces and workplaces when vaccination status is unknown.” 

What should the CDC have done instead? I don’t think it’s all that complicated. Let people take off their masks outdoors except in exceptional circumstances. Keep recommending both masks and distancing in all indoor public spaces, and emphasize new freedoms in private spaces where people’s vaccination status is known. Plus set metrics for levels of cases and/or vaccinations at a statewide or county-wide level that would allow the rules to be safely loosened (Dr. Carlos del Rio has made one reasonable proposal). Many areas of the country may reach the no-mask stage within weeks, while others won’t be there for months if ever. Finally, some attention to distancing and ventilation should in my opinion remain, in public indoor settings where vaccination status is unknown, until the pandemic is declared over.

Either the Biden Administration sets up a national system of vaccine certification (it’s been balking thus far) or the new CDC rules are a complete farce. But even with such a system, they’d still be a joke. Movie theaters and sports stadiums might theoretically card people at the door, but not your local bar, church, or hardware store. In practice these new guidelines are likely to mean the end of masking and distancing everywhere in the country. Disease surges may well follow, especially in states like Alabama and Wyoming that have abysmal vaccination rates. I sincerely hope I’m wrong.

I think Leanna Wen was spot-on when she called the new rules “a major blunder” and urged President Biden to withdraw them. The CDC’s recommendations are well-meant and scientifically impeccable, but so poorly thought out as to be dangerous. One partial solution could be for OSHA to issue strong workplace guidelines, including distancing and masks, as the White House asked them to do months ago; they may hesitate to contradict the CDC but they certainly could do so, in the service of their mission to protect workers. I know, I know, that ship has sailed and you can’t unscramble an egg. But someone can at least try to force some of the toothpaste back into the tube. 

4 comments:

  1. Jacqueline DavisMay 20, 2021 at 3:36 PM

    Hopefully, there haven't been any mask burning celebrations -and masks are being saved for a possible Fall resurgence.

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    1. Love it! Hope you don't mind my putting this on Facebook. Much love, S.

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  2. I really appreciate your thorough and rational take on this.

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