Stop panicking about the COVID-19 variants, says UCSF’s Monica Gandhi
Dr. Monica Gandhi is not your typical epidemiologist in the era of COVID-19.
While the vast majority of experts in her field call for the most stringent business closures and other mitigation measures, Gandhi — a professor of medicine at UCSF — has called for a “harm reduction” approach that also considers other risks beyond COVID-19 infection when making public policy.
That view has not been a popular one among policymakers and experts in her city and state. But Gandhi is confident that one day, she’ll be vindicated.
The interview has been lightly edited for clarity and length.
SFGATE: You are one of the few “harm reductionists” in public health. Can you describe the difference between the “harm reductionists” and the “lockdownists,” as you’ve referred to them in the past?
Gandhi: I would say that harm reductionists like myself believe we can’t completely keep people away from each other, and that using really extreme language like “stay-at-home order,” or “see no one else” does not take into account human nature, loneliness and the economic reality that a lot of people need to go to work to survive.
I’ve long been concerned that the public health messages are only tailored to people who can work from home, people who work in tech and people with intact families and no need to see other people. Harm reductionists believe we should be giving messages that acknowledge some people will need to take some risks regarding COVID-19, and we should try to tell them how to keep safe in situations when in they’re in public or seeing others.
San Francisco was a place of harm reduction when it came to HIV and sexual health. Therefore, I was surprised that there were so few scientists in San Francisco (out loud, anyway) speaking of the need for harm reduction in San Francisco when it came to COVID-19 protection.
SFGATE: The lockdownists have much more power than the harm reductionists do in public health, and have at times expressed scorn for those with different opinions. Can you speak to what it’s been like to receive blowback for your views?
Gandhi: I have been surprised by the party lines that were drawn in terms of how to respond to pandemic, as opposed to having everyone take in new data as it comes, incorporate the data and then make decisions that can change over time.
It seems that we decided early on that there’s only one way to respond, and any dissent from standard messaging was met with dismay and criticism. For example, in terms of the winter lockdown in California, I was dismayed by the degree of profound shutdowns for outdoor playgrounds, outdoor dining and also this idea that no one from two households could see each other.
It was those three things that concerned me, since we knew outdoor spaces were safe, and going into holiday season, loneliness and the desire to see loved ones is a real phenomenon. And when I spoke out about that, I took a lot of criticism for not toeing the party line.
What I was trying to do was use harm reductionist principles, use the science we have that masks and distancing work, and then make recommendations along those lines.
What surprised me was this: My impulse in speaking out came out of a concern for the economic situations of the working class and the impacts on health that come from economic insecurity on things like housing and hunger. And those questions of, “How are they going to feed their families?” were met by scientific community with, “We’ll deal with that later, we’re only thinking about the virus right now.” And I was surprised by that.
SFGATE: What would you say is the most important thing you’ve learned during the pandemic?
Gandhi: I have learned a lot about nonpharmaceutical interventions to mitigate COVID-19 risk. I have thought deeply about the impact of mask wearing, as well as what distances are required to keep people safe, and how inexact the distancing science is. I have also learned a lot about the need for ventilation and the incredibly reduced transmission rates outside versus inside, and how prohibiting outdoor activities is counterproductive.
I have also learned a lot about the vaccines and their efficacy. And I’m surprised that the messaging today is all about how the vaccines don’t cover the variants, which is misleading. We should be spreading more optimism and talking less about mutations.
The vaccines are effective at preventing severe disease even against variants, so it’s very important not to panic.
SFGATE: Can you elaborate on that?
Gandhi: The best way to think about it is that all the vaccines down the line will offer 100% protection against hospitalization from COVID-19. During the trials, anyone who got hospitalized received the placebo in their arms. The Johnson & Johnson trial was conducted at a time the variants were circulating in both the U.S. and Latin America.
We can also quantify that 95% of the virus in South Africa when the trials were going on was the B.1.351 variant and despite that, the Johnson & Johnson single dose still offered 100% protection against hospitalization and 85% protection against severe disease, which is where you’re at home but not feeling well.
It was the same across the board whether it was South Africa, the U.K. or Latin America. The difference in the Johnson & Johnson vaccine is in mild disease; it had less efficacy against mild disease when dealing with the South African variant.
This kind of incredible efficacy is done by T cell responses, which are long-lasting and prevent the scariest thing about COVID-19, which is severe illness. I’ve been surprised by all the doom and gloom messaging about the variants and the vaccines, and I’m concerned it will lead to vaccine hesitancy. We should be pushing more optimism about the vaccines.
SFGATE: What’s the biggest thing you regret doing, saying or believing during the pandemic?
Gandhi: I’ve been extremely consistent on multiple messages around the benefits of masks and not closing schools. I was very consistent in saying we should not close schools, and once they were closed, I called for reopening them.
If I do have any hesitations, it’s that it has been difficult to not be fully embraced by the rest of the scientific community when I message the nuanced ways of learning about the virus. It’s been very difficult, and I’ve felt attacked at times.
When the outdoor dining thing came up, part of me wondered if I shouldn’t message anything and just be quiet. But I talked to a lot of people including friends, and someone said to me, “When you look at yourself in mirror when this all over, you’d rather be the person who took the trouble in the short run but was seen as being right later on.”
SFGATE: What would you say was your lowest point during the pandemic?
Gandhi: There were two low points: One was being piled on by multiple sides since I don’t toe the party line either way. I’ve already talked about the larger scientific community, but I also get lots of angry emails from anti-mask people about being pro-mask and “wanting to smother children” with masks.
The second low point was early on watching what was happening in New York, and wanting to go there while feeling completely helpless as a doctor. I remember being nonfunctional just watching the news one day. Those were two lowest points I’ve had.
SFGATE: In last week’s installment, your colleague Dr. Bob Wachter delivered a pretty strong defense of the city of San Francisco’s response to the pandemic, defending the fallout from prolonged closures by stating, “There are at least a few thousand people in San Francisco that are alive today that would not be if we didn’t respond way we did.” Do you agree or disagree with his argument?
Gandhi: I would say that San Francisco did extremely well in controlling the severity of illness, and I’m not even sure it’s all the Department of Public Health’s doing. We have the natural advantage of ventilation by virtue of our geography, so we had ventilation, mask wearing and lots of lockdowns, which gave us a fantastically low death rate.
However, San Francisco has been one of those cities where our response to other aspects besides COVID-19 has been worse than other places. So economics, school closures, mental health, substance abuse, homelessness and overdose deaths.
I’m concerned that the overemphasis on COVID means that we will have deal with the fallout for years to come. For example, I fear we have set back students in low-income communities greatly. In my mind, given the fact that vaccines are here, and given the fact that San Francisco has low disease severity, we should turn our attention at this point to all of the other collateral damage that occurs from business and school shutdowns and pay attention to that damage.
SFGATE: Do you believe we’re truly near the end?
Gandhi: Yes. I truly believe we’re panicking way too much about the variants.
It’s quite common for any RNA virus to mutate at high rate. I’m extremely optimistic that all of the vaccines will prevent severe illness — even against variants. To me, severe illness is why we started paying attention to COVID-19 in first place. Otherwise, we would have never even noticed an odd stray cold virus that came out of Wuhan.
We need to keep our eye on the most important thing about this pandemic: severe illness and death. We should be focusing less on variants, and more on the mass vaccination required to completely end the pandemic before the end of the year, which is something I believe we will accomplish.