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‘Swiss cheese’ model is key to protecting the most vulnerable


N95 masks are distributed to farm workers in Medford, Ore., Aug. 28, 2021.

By David Leonhardt


With the omicron wave receding, many places are starting to remove at least some of their remaining pandemic restrictions.


This shift could have large benefits. It could reduce the isolation and disruption that have contributed to a long list of societal ills, like rising mental-health problems, drug overdoses, violent crime and, as Substack’s Matthew Yglesias has written, “all kinds of bad behavior.”


But the removal of restrictions has downsides, too. Millions of Americans remain vulnerable to COVID-19. The largest group of the vulnerable, by far, is the unvaccinated, who have the ability to protect themselves and have chosen not to.


Another group of people, however, have done what they can to stay healthy — by getting vaccinated — and yet remain vulnerable. They include the elderly and people with immunodeficiencies that put them at greater COVID-19 risk. According to the Centers for Disease Control and Prevention, more than 75% of vaccinated people who have died from COVID had at least four medical risk factors.


There are several steps, like the five below, that can help protect the vulnerable as society moves back toward normal.


At this point in the pandemic, there is a strong argument that a targeted approach — lifting restrictions while taking specific measures to protect the vulnerable — can maximize public health. The right approach, Jennifer Nuzzo, a public health researcher at Johns Hopkins University, said, involves “moving away from broad, blunt tools to more precision tools.”


The public conversation often misses this middle ground. It can sometimes seem to be a debate between doing everything to slow the spread of COVID-19 and doing nothing, said Katelyn Jetelina of the University of Texas, who writes a helpful newsletter about public health. In truth, she said, “There has to be a balance.”


Vaccines and boosters


I want to start by emphasizing the importance of the vaccines, including the booster shots.


Yes, some Americans remain so opposed to a COVID-19 vaccination that there is little chance of persuading them. But others may still choose to receive shots if they are readily available. Booster shots are vital, too, to overcome waning protection. Boosters are especially important for the vulnerable vaccinated — the elderly and immunocompromised.


“Vaccination is the most valuable intervention we can do,” said William Hanage, an infectious-disease expert at Harvard.


High-quality masks


For the vulnerable vaccinated, the best approach is what public health researchers call “the Swiss cheese model.” It’s a multifaceted approach in which each strategy, including vaccines, has holes. But when the strategies are layered on top of one another, the holes tend to disappear.


One such layer is masking with an N95 or KN95 medical mask, even if others are maskless. “One-way masking works,” as Olga Khazan of The Atlantic has written.


Joseph Allen of Harvard University has argued that somebody wearing an N95 mask and talking to an unmasked person is at less risk than somebody who’s wearing a standard surgical mask and talking to another person wearing a standard mask.


“Let’s dispense with the notion that masks are only protective if everyone is wearing them,” Allen wrote in The Washington Post.


A preventive drug


In December, the Food and Drug Administration authorized a drug called Evusheld, made by AstraZeneca. It is designed to be an additional layer of protection on top of the vaccines, to prevent COVID-19 in immunocompromised people.


The Biden administration has bought 1.7 million doses, which is not enough to protect every American who could benefit but is significant. A larger immediate problem is confusion around the distribution. Many people don’t know Evusheld exists or don’t know how to find out if they’re eligible and how to get a shot.


Rob Relyea, an engineer at Microsoft whose wife has cancer, has created an online resource, in the absence of information from official sources. The country needs a “better communication plan around Evusheld,” Relyea tweeted. “Each hospital should proactively reach out to immunocompromised patients.”


The confusion around Evusheld is another example of how the fragmented U.S. health care system harms people.


Rapid tests


One piece of recent good news is the increased availability of rapid COVID-19 tests, at drugstores and elsewhere.


Rapid tests are an important tool for allowing the elderly and immunocompromised to socialize confidently with friends and family. Stefanie Friedhoff of Brown University’s School of Public Health has written about a friend of hers who leaves a batch of tests in her hallway for people to take before they visit her husband, who has Parkinson’s disease.


Post-infection treatments


Rapid tests can also help vulnerable people find out when they have contracted COVID-19 — and quickly begin a treatment to reduce its severity. “Time is critical, as close to symptom onset as possible,” Dr. Paul Sax of Brigham and Women’s Hospital in Boston notes.


Although some post-infection treatments no longer work against omicron, others, like remdesivir, seem to. The most effective treatment may be Paxlovid, a Pfizer drug designed to fight COVID.


Unfortunately, these treatments can also be difficult to locate.


The bottom line


Vulnerable people — and their families — can take some big steps to protect themselves, including high-quality masks and rapid tests.


But government agencies, hospitals and doctor’s offices can also play a crucial role, helping people locate potentially lifesaving treatments.


“It’s incumbent upon policymakers to give people the tools to do that,” Dr. Scott Gottlieb, a former FDA commissioner, said on CBS on Sunday.


One final point: Some of these issues are not unique to COVID-19. The flu, for example, kills more than 30,000 Americans a year, most of them elderly or immunocompromised.


If COVID-19 can focus the country on finding better ways to protect them in the future, it would be one silver lining from a tragic pandemic.

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