What I've learned from COVID

I’ve written over 100 email newsletters on COVID.

I’ve discussed testing, drugs, masks, mild illness, severe illness, and death. I’ve written about the public health impact and the individual health impact. I’ve written about prevention, treatment, and end of life care. I’ve discussed the political influence of the CDC and FDA (which hasn’t stopped with a change in the occupant of the White House, by the way). I’ve covered vaccines and boosters. I’ve even discussed the lab leak theory.

And - like many of you - I’m losing interest in discussing it.

It’s not that there’s nothing left to say. Quite the opposite, in fact.

There’s a lot of newsworthy stuff happening, from molnupiravir (a promising oral antiviral drug), to greater availability of in-home rapid COVID tests (incomplete and inadequate progress, but progress nevertheless), to the ongoing catastrophe of our pandemic school and masking policies that are hurting children to protect them.

While I’m not totally finished discussing COVID, we’re at the point where I’m not going to make it the focus of this newsletter.

So if you’ve only been subscribing to learn about the pandemic, I won’t be offended if you unsubscribe now.

Moving forward, you can expect newsletters on cardiovascular disease, preventive medicine, noteworthy new scientific research, nutrition, exercise, science in the media, and other topics that I’m interested in.

In many ways, this newsletter will be reflective of a world with endemic COVID. The virus is still a part of how we live, but it’s more background noise and an ongoing chronic issue rather than the only thing to focus on.

So before we fully move on, I wanted to share some of the things that I’ve learned from COVID.

The scientific method is amazing

The vaccines are real, and they’re spectacular. Even in the world of Delta.

The almost miraculous degree of protection that they offer from severe disease, death, and even disease transmission has been completely lost in the public discourse on breakthrough infections, boosters, and vaccine mandates.

To think that we went from discovering a new virus to safe and effective vaccines a year later is almost unbelievable.

When you think about these vaccines, it’s worth remembering that the mRNA vaccines from Pfizer and Moderna are the culmination of decades of incremental scientific work. As they say, it takes 20 years of work to make an overnight success.

We also know a lot about what works and what doesn’t in COVID, thanks to some incredible clinical trialists.

We have treatments that work in mild disease and severe disease. The risk of death from COVID if you get really sick is insanely lower than it was in April 2020.

We know that surgical masks work in a community setting and cloth masks probably don’t. We know that when it comes to COVID, good ventilation is important but cleaning surfaces doesn’t matter.

That’s all thanks to people doing the work of making incremental progress by performing controlled experiments, measuring the results, and analyzing the data.

“I believe in science” is just another form of religion.

You can contrast the group of researchers doggedly advancing our knowledge from a lot of the loudest voices in the room. The ones advocating for - or implementing - policies with limited and/or questionable data behind them.

You can pick your villain here, as there are plenty to choose from.

When I hear someone say “I believe in science,” it usually means someone who is interested in cherry-picking data to back up a previously held belief.

The corollary to “I believe in science” is “I’m doing my own research.”

In the most generous interpretation, this means reading a mainstream media overview of some scientific study (which may miss context or important details in a way that gets the story wrong even if the facts are right). The least generous interpretation means that someone plans to read comments on social media or talk to a few friends.

Rapid testing is the way out of a pandemic

At one point, I wrote that the original sin of our pandemic response was “slow down the testing, please.”

No testing means flying blind without instruments.

Cheap, fast, accessible, and widely deployed tests that are decently accurate can pick up clusters of cases, help infected individuals quarantine and reduce spread, and minimize our dependence on masks.

In other words, testing regularly lets us get back to our regular lives.

Here’s a great summary of why testing works:

“We know with certainty that individuals don’t need to have symptoms to infect others with COVID-19. The virus presents itself differently in everyone and most individuals are infectious for a number of days before showing any symptoms (if ever). After infection, the virus gets itself situated, before beginning to grow very rapidly. Once it hits its stride, in a single day the virus grows from hundreds of virus particles in the nose, to billions. At that point, transmission can hit its peak, before the person has any recognition that they might be spewing out millions of virus particles with every breath. Symptoms are most frequently a result of the immune response to the virus, rather than from the virus infection itself, and the immune system doesn’t get into full stride and yield fevers until after this peak in virus transmission is achieved. This is a major reason why SARS-CoV-2 has been so difficult to contain—because maximum transmission is often occurring before the body’s sensors kick in to let people know they may be infected. Regular rapid testing can allow contagious individuals to know they are infected and isolate quickly to keep from spreading to others.”

And here’s a great article from Emily Oster on the major use cases for rapid, at home testing - they’re all ways of getting back to normal life with as little disruption as possible.

No one seems to understand the concept of risk/benefit analysis

Every single day of my life, I discuss different medical treatment options with patients. We always talk about both the risks and benefits of each thing that we might do. It’s hard to conceive of any intervention that doesn’t have a potential downside.

Sometimes the decisions are really easy, because the upside is so big and the downside is so small (or vice versa). But most of the time it’s not so straightforward.

For whatever reason, that nuance has been missing from most of the public discourse on COVID.

I think it’s worth a quick rehash on the idea of making kids wear masks.

I’ve written about masking kids before. And much smarter people have as well. This is a great example of the way that we get the quality of evidence that we demand.

Unfortunately, we didn’t do the clinical trials to tell us anything about the magnitude (or presence) of benefit here, so we’re left with data suggesting masks in kids don’t halt disease spread but a bunch of loud voices saying that we’re killing folks if we don’t make children wear masks.

So you’re left with a situation that has a clear downside with an unclear upside.

You’d think that the public discourse would try to quantify what the benefit of mask wearing is so that we can weigh it against the risks. But that’s not what we’re doing! Instead we get instructions on how to choose the right mask for your child and articles lecturing us that masks help our children learn.

It’s like many of us have never heard that there’s no such thing as a free lunch.

COVID risk is modifiable, but no one wants to hear that

Mass communication is hard in any context, and communicating about a viral respiratory illness that has a wide spectrum of disease and many different clinical presentations makes it feel impossible.

But one thing that we’ve consistently known is that the risk from COVID is based on our underlying health, a large part of which is in our control.

And even though it’s been drilled into our heads that those with underlying health conditions are at higher risk, it really hasn’t been drilled into our heads that many of those underlying health conditions are related to our behavior and choices.

The alternative health community has been onto the idea that COVID risk is modifiable since the beginning. They’ve been talking about zinc, vitamin D, natural sunlight, high quality sleep, exercise, and better nutrition since April of 2020. It’s not a coincidence that the folks who are most invested in lifestyle improvement are so focused on the idea that COVID risk is modifiable - and so livid that the rest of us aren’t.

It’s part of the perverse irony of the pandemic that we talk about diabetes as a risk factor for severe COVID but offer free donuts as a vaccine incentive.

And I’m sure that this isn’t covered because no one wants to hear it. At least that’s what it seems like based on my own data.

When I write about the fact that your own personal COVID risk is at least partly in your control, I get way fewer shares and subscribers than when I talk about vaccine boosters or Delta variant spread.

The reason everything is political is that people want it that way

Political content gets more clicks, shares, and subscribes than any other topic that I’ve covered in this newsletter.

Each time I write something political, like about Trump getting COVID or the political interference at the FDA, I get way more newsletter signups than when I write about something more relevant to our lives.

There’s an economic theory called “revealed preference” which basically says that if you want to know what people value, look at what they buy and how they spend their time rather than what they say is important.

I’ve learned that the reason the media covers everything in a political framework is that people are engaged by it.

The attention and the clicks are addicting, and it’s so much easier and more satisfying to write an article with political speculation that gets shared a lot than to read and synthesize a 94 page cluster randomized trial on the impact of community mask wearing in Bangladesh that many fewer people seem to care about.

I know this because I’ve done both and seen the impact on my numbers.

So when it comes to politics affecting everything, we are all the problem.

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