5 questions with Pittsburgh doctor on rethinking covid mitigation measures

Dr. Amesh Adalja, a Pittsburgh-based infectious disease expert and senior scholar at the Johns Hopkins Center for Health Security, has said it since the beginning of the pandemic — that covid-19 was a respiratory virus and we were going to be living with it for a long time.

In a New York Daily News opinion piece last week, Adalja reiterated his view that it’s impossible “to eliminate or eradicate covid-19,” and that it’s time to break away from an “abstinence-only approach.”

In an interview with the Tribune-Review, Adalja talked about what the new approach looks like and the new tools available to help us rethink mitigation measures.

His answers have been edited for length and clarity.

Question: Regarding what you had to say in the Daily News piece, what prompted you to say that it’s time to break away from an “abstinence-only approach” when it comes to covid-19?

Answer: It’s just that we’re getting to a point where we have to start thinking about how we move to a new phase of this pandemic where people have to understand that there’s always going to be some baseline risk of covid-19. But, through technology, we have the ability to tame the virus through vaccines and monoclonal antibodies and antivirals and rapid home tests — all of that is part of making the virus something much more manageable, something much more like what we deal with on a year in, year out basis with all the other respiratory viruses we face.

Q: So, you’re calling on the country and the world to rethink mitigation measures. How do you convince the world to do this?

A: Certainly I wouldn’t say that the entire world needs to do this yet, because we’ve still got places in the world where they don’t have enough people vaccinated so they still have work to do in order to tame the virus. But I think in places where there is easy vaccine accessibility, we have to show people that this is something that they’re going to have to deal with — that 20 years from now there are going to be covid-19 cases.

If they think that now with vaccines and monoclonal antibodies and rapid home testing and oral antivirals on the verge of being approved, that if things are not safe enough for them now, it’s unlikely that things are going to be safe for them if they have that perspective 20 years from now.

Much of this has to do with the rhetoric early on where many public health authorities pursued an “abstinence only” approach instead of “harm reduction.” And that stunted the ability of those people to be able to risk calculate. Early on, we should have been saying, “we know you’re going to get together with your friends. Why don’t you do it outside, or why don’t you open a window?”

Teaching people to think about what’s higher risk, what’s lower risk? We didn’t do that. And it actually ended up bifurcating the country into two camps: one camp that’s afraid of covid-19 and it’s never going to be safe enough until it’s 2019 again for them. And another camp that thinks “to hell with it all, I’m just going to go about my life.” And I think that false dichotomy has really ruined the way that we’ve responded to this pandemic.

Q: What would breaking away from an abstinence-only approach look like?

A: It would just be giving people tool kits. I think we’re doing more of it now in November 2021 than we were early on. But imagine if you look, for example, at states like California where they had massively high rates of covid-19 but the most restrictive public health measures. So you could not eat outdoors, for example, in California. What did that do? People went indoors and ate at each other’s houses instead.

Harm reduction would have been saying, “Yes, we’ve learned about outdoor transmission. We know it’s much less likely, so let’s have outdoor dining and let people who want to get together do this outdoors. Don’t worry so much about washing your groceries down because that’s really not a major risk factor for getting it. Don’t go chasing joggers when they’re not wearing a mask. That’s not going to be a risk to anybody, just (being) much more cognizant of what we knew about transmission.”

We actually ended up creating all these political factions over covid-19 that could have been avoided if there was a much more nuanced approach that was consonant with harm reduction principles that are all through public health — except for covid.

Q: You said that we will be living with this virus — there is no covid zero — but we will be able to alter the outcomes of these cases with the new tools available to us. Explain how you see this happening?

A: The goal of covid-19 mitigation is not to get to zero;, it’s to remove its ability to cause serious disease, hospitalization and death. So, what are the tools to do that? We have the vaccines which are tremendously successful at reducing serious disease, hospitalization and death.

Just walk through a hospital and see who’s being hospitalized. It’s all unvaccinated people. We have monoclonal antibodies to give people that keep them out of the hospital. We have two antivirals that are poised to be approved, one already approved in the United Kingdom, that are going to make it a much more treatable illness. We’ve got so much more knowledge of when people get admitted to the hospital, what to expect from covid — how to intervene, how to manage their oxygen needs.

All of that has made covid-19 a much more treatable illness and a preventable illness in November 2021 than it was in November 2020. When the context changes and you’ve got new tools, it has to be reflected in how you approach the virus because it’s different now. You’ve got a tool box that’s full of new tools.

Q: Will there be a time when we think of covid the same way we think of the flu? That while it can still kill you, we’re not going to worry about it the same way we once did?

A: I think there will come a time, and it’s when we get more people vaccinated, when we get second-generation vaccines that are better and easier to give, and when we get oral antivirals, I think we’ll be well on our way to that — in the United States.