With over 300 million COVID-19 shots administered and scenes from full capacity dining, oversold airplanes and a packed Madison Square Garden, the United States feels a lot more normal. Stores have replaced “mask required” to “mask optional if you are vaccinated.” Even the Biden administration signaled a return to pre-pandemic life with the announcement of a large outdoor Fourth of July celebration, even though they simultaneously acknowledged that they would miss their target of vaccinating 70 percent of the country by the same date. As desperate as many of us are to delete the last 18 months, we are doomed to repeat our failures if we do not act with humility and haste in five critical areas.
1. Clear communication regarding the threat of the Delta variant and the Delta “plus” variant
Americans took notice when former FDA Commissioner Dr. Scott Gottlieb signaled strong concern regarding the rapid proliferation of cases caused by the Delta variant, now a variant of concern which means that it is of clinical significance. Dr. Anthony Fauci has also recently said that the Delta variant poses the greatest risk to the elimination of COVID-19. But it is not clear why that is the case — we know very little about the variant, other than its rapid ascension as the dominant variant for new cases of COVID-19, but does this mean it is more deadly?
Some studies indicate it might also present with different symptoms — if so, how should we navigate when to seek testing and for that matter, are all tests equal in detecting the variant? Are all current vaccines equal in their efficacy? Will a booster be inevitable sooner rather than later? Initial studies suggest that the mRNA vaccines (Pfizer and Moderna) have a higher efficacy against the Delta variant compared to the Johnson and Johnson vaccine. Whenever the public has more questions than answers, misinformation and doubt tend to proliferate at a more rapid rate than the virus itself.
2. Establish a “robust surveillance system” — a real one
The recent cases of myocarditis (inflammation of the heart muscle) in younger adults after mRNA vaccination have highlighted how fragmented our surveillance mechanism is to pick up events as they are happening — most of our information to date comes from largely voluntary reporting mechanisms like VSAFE, which is a voluntary app that patients have to download and then agree to use in order to report any adverse events, and VAERS (Vaccine Adverse Event Reporting System), which also depends on individual clinicians to report most data with significant burdens to enter such information into the system.
There is a network of nine health systems that have been used since 1990 to monitor real-time data from clinical records to look at any adverse events related to numerous vaccines, but the scale and speed of the COVID-19 vaccine efforts make this inadequate as well. Important first steps would be to harness clinician social media (#medtwitter) and consider a partnership between the major electronic health records, which together provide the infrastructure for almost every American in all settings.
Social media in this pandemic has become a rapid, crowdsourced database that has helped communicate how to care for COVID-19 patients and has also offered some of the earliest canaries in a coal mine. This would involve partnerships that are nontraditional for the CDC, but if ever there was a time, it is now to conduct the type of real-time monitoring that countries with more nationalized health systems have been able to do within days.
3. Children and vaccines (or the lack thereof)
Incredible progress in our case rates has allowed for many to argue that those who are vaccinated should “go make up for lost time.” However, for over 50 million households with children under the age of 12 or medical conditions which are a contraindication for vaccination, they remain in a pandemic holding pattern. For these households, there is very little guidance and even more confusion regarding how to assess the risk of various environments and situations.
Masks are also unfortunately politicized and controversial, but families and individuals are struggling to balance mixed messages about how useless they are versus their life-saving potential. Even simple, clear graphics that community the spectrum of risk for children could be useful. For example, pointing out that obese children are at higher risk of being sick and hospitalized from COVID-19 and explaining how to determine if your child meets the medical criteria for obesity.
4. Technical support for businesses, schools and other settings
Federal dollars have been allocated in silos due to the normal constraints of budgeting and appropriations, but dollars should be targeted for interagency and interdepartmental grants to municipalities, counties and local community-based organizations. These funds should be used to rapidly develop and scale technical support for various settings such as businesses, houses of worship and schools with advice on how best to navigate returning to work, testing, employer or school-based contact tracing if needed, as well as thresholds or metrics for scaling back any reopening.
The CDC has given guidance for larger communities, but most of these problems and situations are manifested locally. In a survey from the Chamber of Commerce, a majority of members said that they still feel inadequately prepared to protect their workforce. Such a grant program could be overseen by the COVID-19 Commission suggested by legislation introduced by Sens. Bob Menendez (D-N.J.) and Susan Collins (R-Maine).
5. Implement a sustainable long COVID-19 program immediately
There has been mounting evidence of the impact of long COVID-19, or symptoms and effects of a COVID-19 infection weeks to months later. It is no longer a debate amongst scientists and for millions of Americans it is reality, but one that is akin to foraging for crumbs in complete darkness. A long-term commitment to caring for long COVID-19 patients must be prioritized.
A recent Senate hearing highlighted mental health concerns of COVID as well as practical implications on other aspects of health. Yet, our current approach depends on traditional models of medical care and social services. Medical societies which issue guidelines, regulatory bodies and government agencies should work with a COVID-19 commission to chart a path for a new discipline or field in medicine, one that incorporates training and care in a similar fashion to what has been established for other chronic diseases such as diabetes, obesity or developmental disorders.
The political scientist John Kingdon famously described a framework for a narrow window for policymaking — one where the process can be situated into problems, policy and politics. Policy entrepreneurs can be the most important actors in this framework and COVID-19 is a perfect illustration of such a need — solutions that balance politics, problems and policy — the vaccination effort is one of the highest priorities, but we should not lose sight of the other issues that require entrepreneurship at a national level.
Kavita K. Patel is a physician at Mary’s Center, a federally qualified health center in Washington D.C. She was a director of policy in the Obama administration and a deputy staff director in the United States Senate.