Throughout the Covid-19 pandemic, there’s been a refrain among infectious disease experts: you may be done with the virus, but the virus is not done with you. Like everyone else, health officials and providers wish the epidemic would end. At the same time, we must live in a parallel universe in which preventing and managing Covid-19 remains a daily focus when everyone else seems to have moved on. This is fundamentally what it means for a disease to becomes endemic: People with power, privilege and resources no longer view themselves at risk and consider it a problem primarily of “vulnerable populations.”
Policymakers are in a tough spot. A recent survey found that just 19 percent of Americans surveyed rate the coronavirus outbreak as a very big problem for the country. At the same time, federal funding to the Covid response is dwindling to the point that officials’ ability to buy new vaccines is threatened. As the virus continues to mutate, and elected officials choose not to implement mask, vaccine or test mandates, policymakers must identify a middle ground of approaches that are both likely to protect health and be broadly acceptable.
In the United States, public health practitioners have been through this cycle before. In the late 1980s and early 1990s, outbreaks of drug-resistant tuberculosis caused lethal outbreaks leading to massive infusions of funding to the Centers for Disease Control and Prevention and local health departments. Over the next decade, these funds succeeded in dramatically lowering TB among U.S.-born residents, but infections remained high among immigrant communities. People with TB in immigrant communities often require substantially more resources to manage, given that they are often uninsured, undocumented and suspicious of government agencies. Nevertheless, the transition of TB to a problem of immigrant communities meant that, while public health officials and hospitals continued to struggle with treating the disease, elected officials no longer felt an urgency to address it, and federal funding mostly declined in real dollars year over year.
A more instructive example to Covid-19 is what happened with H.I.V. The period of widespread fear began to ebb after the advent of highly effective drug therapy in 1996, and, in 2003, the C.D.C. announced it was shifting its H.I.V. prevention strategy away from broad-scale public awareness campaigns to focused H.I.V. testing in populations at highest risk. Since then, H.I.V. has progressively moved into the background of public concern, even though new H.I.V. infections have remained stubbornly high nationally.
Recognizing that H.I.V. was now no longer considered an emergency, public health officials began embracing what became known as “structural” approaches to prevention. Jurisdictions sought to make H.I.V. tools and services, such as testing, treatment and condoms, so widely accessible and acceptable that individuals would have to actively choose not to use them.
For example, in New York City, where I led the city’s infectious disease programs, we required emergency departments to offer H.I.V. testing to any teen or adult seeking care for any ailment, and to offer testing at gay bars and clubs. We launched a public awareness campaign to encourage H.I.V. testing as a routine part of a fun sex life.
The structural approach to H.I.V. that extends the reach of disease prevention and lowers barriers to prevention tools holds important lessons for the future management of Covid-19 in the United States.
How do you promote the use of masks without mandates, for example? Many people say they do not enjoy wearing condoms during sex, even though using them lowers disease risk. Rather than mandate condom use in places where people meet for sex, as the Thai government did with brothels in the 1990s, the New York City Health Department chose to flood bars, nightclubs and bathhouses with condoms starting in 2007. During my time overseeing this program from 2011 to 2017, we distributed tens of millions of condoms per year. Importantly, the condom availability program was paired with extensive advertising that attempted to spread the message that wearing a condom still meant fun sex, not just health benefits.
In a review of 21 studies from the United States and other countries, researchers found that condom distribution programs, particularly in venues where people meet sex partners, increased their use. The critical components of success were making condoms available, accessible and acceptable. When combined, programs increased condom use among important higher-risk groups, such as teenagers, injection drug users and gay men. Statistical modeling has shown that these increases in condom use reduced the number of people being infected with H.I.V. and other sexually transmitted infections.
Governments can increase mask use without mandates by making masks widely available in any commercial or public setting in which people spend time together indoors, especially during surges. State and local governments can do what New York City did for condoms:contract with a manufacturer for a continuous supply of high-quality (e.g., N95 or equivalent) masks.
People often make split-second assessments based on what everyone else is doing. Humans inherently worry about fitting in. I’ve been at events where I took off my mask, because it felt as if I was the only one wearing one. Similar to condoms, mask wearing needs to be actively promoted, even when there’s no requirement: Make it seem socially acceptable to wear a mask and socially unacceptable to criticize those who do.
Some may wonder if masks have become so politicized that such initiatives wouldn’t work. But I think there’s a window of opportunity to make the mask-agnostic more likely to use them. There will most likely always be a group of people who will never wear a mask, a group who will often wear one and many others in between. If you can push a fraction of the agnostic mask wears to don them during surges, that could reduce transmission when it happens across a large population. Data suggest that most Americans are supportive of masks in certain settings.
Governments can also extend this approach to Covid testing. Rapid test kits should be distributed anywhere people work or congregate indoors, especially since, unlike with H.I.V. testing, these kits require no medical personnel and no special counseling for a positive result.
While test kits and masks can alter the architecture of choice — making people choose to use these where they might not ordinarily — physical architecture can also prevent Covid-19 infections.
The White House announced a federal effort to improve indoor air quality and reduce Covid transmission through ventilation, filtration and air disinfection. In public health, the most effective interventions are those that do not require individuals to change their behavior and in which healthy options are simply available to them by default, such as clean water. At the state and local level, governments should consider comprehensive legislation that requires facilities to adhere to stricter indoor air quality standards, as well as to purchase and provide rapid test kits and high-quality masks to all employees and customers, just as many jurisdictions require facilities to have adequate equipment or services for other health and safety reasons, including appropriately sized and stocked bathroom facilities, clean running water, first-aid kits, defibrillators and fire extinguishers.
Vaccine mandates — which I greatly support — appear to have become increasingly unpopular, but deaths from Covid among groups like the elderly are inexcusable now that vaccines are available. Cities should consider bringing back vaccine checks for certain businesses and events. As a policy, they do not require anyone to be vaccinated, but they make daily life very inconvenient if you haven’t received your shots, similar to how indoor smoking bans reduce cigarette smoking by making it more difficult and less socially acceptable to do.
The history of public health shows that elected officials and the general public can only remain focused on an emergency for a limited duration. While I and other health officials worry about the ways in which this virus continues to evolve into a greater threat, many have moved on to other concerns. Elected officials are now loath to be seen as being coercive or focusing on anything other than recovery. The president, for example, recently told states to use unspent Covid-19 relief funding on crime prevention. Even using only a fraction of this funding on Covid-19 initiatives, state governments can work to make our lives safer from microscopic threats without us realizing it by shifting norms around mask wearing, testing, vaccines and indoor air quality.
Jay Varma is a professor at Weill Cornell Medical School. He is an epidemiologist focused on large-scale responses to infectious diseases.
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