- Two years into the pandemic, COVID 19 has taken more than 900,000 American lives.

Today's guest reflects on the experience of these last 24 months and describes the steps we need to take collectively and individually to finally put the pandemic behind us.

She's Dr. Megan Ranney, this week on Story in the Public Square.

(bright upbeat music) Hello, and welcome to the Story in the Public Square, where storytelling meets public affairs.

I'm Jim Ludes from the Pell Center at Salve Regina University.

- And I'm G. Wayne Miller with the Providence Journal.

- This week, we're taking stock of the pandemic with Dr. Megan Ranney, a practicing physician and academic dean of the Brown University School of Public Health.

Megan, thank you so much for joining us again.

- Thank you.

It's an honor to be back with you both.

- Yeah, so I think the last time we chatted with you was August of 2020.

And that seems like both yesterday and 10 years ago in pandemic time.

Can you give us a sense as we sit here in the first week of February, 2022, where are we on the pandemic?

- It feels almost impossible that it is February already.

So there's a mix of good and bad news, Jim, in terms of where we're at in the pandemic.

The good news is that on a national basis, it looks like the Omicron surge has largely peaked.

For those of us in the Northeast, we're seeing stained decreases in the number of new cases and hospitalizations week on week.

And we're starting to see that same peak and drop in cases across the country.

Of course, deaths are still rising, and there are still a lot of us across the country that have not been vaccinated or not been boosted.

So we're both on the downward slope of this surge, but there's still potentially some turbulence ahead.

- We've heard a lot in the last couple of years about just the heroic efforts of physicians throughout the healthcare system.

You're an emergency room physician, you're face to face with the reality of the pandemic on a regular basis.

How is the healthcare system holding up?

- Not well.

Truthfully, it's not just COVID at this point, although COVID is really the straw that's broken the camel's back.

What we're facing right now is tremendous burnout, moral injury, and ever increasing rates of resignations among healthcare workers across the country.

It's the combination of facing multiple waves of COVID, particularly since vaccines became available and COVID became such a largely preventable illness on top of ongoing systemic issues that preceded the pandemic around kind of the structure of hospitals, compensation for nurses and so on.

And now the fact that we're dealing with not just surges in COVID patients, but also lots of other really severe illnesses, lots of folks that have put off care for two years, delayed surgeries, delayed preventive care, lack of access to out patient treatment.

And on top of it all, a behavioral health crisis with rising numbers of patients in acute mental illness crises, opioid overdoses, violence, and so on.

We're just tired.

And we're tired of not being able to take care of patients the way that we want.

Our hospitals are at capacity, our clinics are overwhelmed.

Our social workers and mental health clinicians have waiting lists that are months long.

We are in a very bad spot across the country right now.

And this latest COVID surge has worsened it in many ways.

- Megan, you used a term there that really of jarred me.

You spoke of moral injury.

That's a term that I've heard used really only exclusively before in the context of veterans of combat who have experienced things that effectively result in a moral injury.

For the audience that might not be familiar with that term, what does that mean?

- So the term moral injury does indeed arise from the military, from the idea that in the heat of war, you see things or involved in things that hurt your sense of who you are, your value system, your sense of integrity.

It's excused in that a context, but it sits with you and injures your soul.

And that's what many of us in healthcare have been through over the past few years.

If I go back to March of 2020, we were sent out and the analogies were plentiful of us being sent into the battlefield against COVID at a point when no one knew what it was, no one knew to prevent it, no one knew how to treat it.

We were sent out there without the one thing that could protect us, that personal protective equipment, which was in such short supply.

We did it because we felt a sense of moral obligation to our patients and to our communities.

And we were begging for the tools to protect ourselves, that took a very long time to come.

As you'll remember, I helped set up an organization to get donated PPE to fellow healthcare providers, because it was in such short supply.

So that was the early phase.

But then you go through the various waves, we were no longer seen as heroes.

Instead, we were told that we were lying about COVID.

I've personally had patients tell me that I'm making it up when I diagnose them.

And we've continued to have inadequate resources to treat our patients.

So we've been faced with these, almost unimaginable choices around providing care.

We're faced with the desire to do things that are simply impossible.

One very cogent example right now is that we can't get access to the one kind of monoclonal antibody that's needed or to Paxlovid, that new Pfizer pill, that antiviral that people can take it home.

It's incredibly limited in supply and difficult to get for our patients across the country right now.

It's not the fault of any one person, but you are taking care of a patient who you wanna help and you can't.

Add onto it the overcrowding, and the fact that we now have patients who are waiting in the waiting rooms of emergency departments for hours on end in pain or vomiting, or with difficulty breathing, and they're simply not space or staff to take care of them.

That goes against every fiber of our being as healthcare providers.

It's not the care that we want to provide.

So we have to put up walls to continue to show up.

It very much feels right now like we are at war against the virus, as well as against the breakdown of the healthcare system.

And in some places across the country, it sometimes feels like we're at war against our communities as we try to put public health measures in place to stem the flow of patients into the hospital and are told that we're making it up.

- So Megan, you're describing the current situation in terms of healthcare workers, in terms of patients, in terms of people who are not getting critical needs addressed, whether it be cancer or stroke or heart attack, and of course mental health and behavioral health.

That's the current situation, but that doesn't go away.

There there's a long term impact.

Is there not?

And I'm thinking also of children.

Talk about the long term impact of all of these stresses and this situation on people, young and old.

- So this is the thing that worries me most.

G. Wayne, you know that prior to COVID, most of my work, both, I take care of every kind of emergency department patient who comes through, but a lot of my research and work outside of the emergency department has been around violence and behavioral health, around access to care and our safety net structure in the emergency department.

One of the things that deeply worries me is that there are so many simmering problems that have worsened and not only have not been addressed, but have actually worsened over the last two years.

Things like mental health and behavioral health problems, but also things like, people haven't gotten their preventive care.

Dental visits are down, mammograms are down, childhood vaccinations are down.

So all these things that we normally do to help keep people healthy, we haven't been able to do.

Add on to that the fact that we've been canceling surgeries, not cosmetic surgeries, very much needed surgeries that just happened or not be an emergency at the moment.

Those cancellations are coming home to roost.

People who didn't get their gallbladder out when it was "elective" are then gonna end up in the emergency department with an acute gallbladder crisis.

All these things need to be addressed.

And add on top of it the fact that we are seeing a lot of healthcare workers leave bedside care because of that moral injury that we discussed.

It means that there's going to be continued challenges in adequately caring for folks who have these worsening, delayed healthcare problems.

The last thing that I'll add that actually concerns me a lot about healthcare and the public health system going forwards is the partisan division in the way that we perceive public health and the science behind prevention and treatment.

I am deeply worried, and not just about our ability to care for individual patients, but our ability to adequately fund and set up systems that protect the public's health.

We're seeing some states trying to roll back mandatory vaccinations for common childhood illnesses, things like measles, mumps, and rubella, diptheria, whooping cough.

These are diseases that used to be among the leading killers of children, that we've largely eliminated from the United States, thanks to mandatory vaccinations to go to public school.

And unfortunately, thanks to the politicization of this virus, we risk not just that health of kind of individual folks who've put off care or have had problems worsen over the last two years, but I also worry about the larger public health system.

And to me, one of our biggest things that we need to do is to stand up for the importance of that preventive care, adequate data, systems, to make sure that we are all kept healthy as well as systems to make sure we can treat acute emergent problems when they arise.

- So Megan, is there a way out of this?

Is there a path that we, and I'm talking about Americans, can follow and what should be done?

Because this is a dire situation and doesn't seem to me there's any quick solution.

- Oh, there are never quick solutions to big problems, right?

- True.

That is true.

- And there's never a single solution either.

And I think that that's an important thing.

I think that's been one of our big failures with COVID messaging and COVID response.

There was never going to be a single thing to eliminate COVID.

Vaccines are the most critical bedrock of our prevention, but there are other things too that are needed, like ventilation and testing, and of course masking during surges.

So to answer your question, I am an eternal optimist.

I am totally confident that we will come out of this.

Okay, but it's gonna take some effort on all of our part.

So on an individual level, I urge folks to go and get that preventive care that they have been putting off.

To make the primary care physician appointment.

To make their dentists appointment.

To take their kid into the pediatrician.

Maybe to make an appointment for delayed mental health care as well.

On a community level, I hope that we can work with our city, county and state departments of health and our insurers to make sure both that healthcare and preventive healthcare is adequately funded.

And to make sure that it is accessible to those who need it.

Healthcare systems have to step up to the plate.

And I think it's a little bit on legislators as well, to make sure that healthcare workers are adequately compensated, particularly in the face of the last two years of trauma.

There's a lot of work that needs to be done around nurses, certified nursing assistant and home healthcare aids in particular, to grow their and support their ranks.

They really are the bedrock of the healthcare system.

And then there is larger federal and state work that needs to be done around public health systems.

And then bringing it back to the individual, what all of us can do is to raise our voices in terms of the importance of that work, to engage in community organizations or nonprofits, to engage in advocacy when appropriate, and to engage with local legislators around the importance of these systems for our day to day health.

And to legislators or policy makers who are listening, I will emphasize the fact that without physical, social and emotional health, we cannot have economic health.

When you look at the challenges that this country has been through over the last last two years, you've seen tremendous growth in times when COVID has been low.

It's not the fault of mitigation measures that we face challenges, it's the lack of health and safety.

And so investment in prevention as well as treatment is just critical to our country's strength going forwards.

- Megan, you mentioned the economic consequences of the pandemic.

And there was a recent study that, and I hope I get this right.

Essentially argued that there's been a lot of discussion of labor shortages in the American economy of late.

And this study suggests that it's long COVID, that can account for some of the people who have left the workforce.

So I guess it's a two part question.

One, what is long COVID?

And two, do you think that it is having a measurable effect on our economic health?

- So long COVID is a new syndrome that we're are still accurately defining.

But the current best definition from the World Health Organization says that it's any of a constellation of symptoms that continue more than three months after an initial COVID diagnosis.

It's thought to be caused by a combination of COVID attacking nerve and cells in the neurological system, COVID causing micro clots and micro thrombosis.

So little teeny blood clots in organs.

And the effect of COVID on our immune system and autoimmune system.

So it causes a lot of release of a lot of different immune modulators.

Symptom of long COVID include things like fatigue, kidney problems, lung problems, headaches, loss of smell and taste, in some folks, psychiatric difficulties as well.

There's a whole host of symptoms that go along with long COVID.

So we're just beginning to define this.

COVID has only been around for about two years.

So we're just beginning to define exactly what causes it, exactly what symptoms are part of it.

And we don't yet have good tests for who has long COVID versus who doesn't.

We're also just beginning to define how to treat it.

And there are a lot of long COVID clinics that are emerging across the country.

And there are also groups of us that are researching or investigating long COVID, including at the School of Public Health, we have a long COVID initiative.

And I'll say in our long COVID initiative at Brown University School of Public Health, we are working with patients, with clinicians and with employers and insurers, because of exactly the question that you ask about.

Even if you say that long COVID is gonna be experienced by one or 2% of people who have caught COVID, that's millions and millions of people across the country who are gonna have changes in their ability to work or to care for family members or to go to school.

And we gotta do something about it.

We have to create systems to support them, to keep folks in the workforce, to help them get better.

Otherwise we will lose people from the ability to participate in daily life.

And that's something that deeply concerns me and many others, both inside and outside of the healthcare system across the country.

- So Megan, you spoke earlier of the situation now, and now being the first week of February in the United States.

But you frequently, and also your boss at Brown Public Health, Dr. Ashish Jha, who's a good friend of ours and has been on the show, talk about the international situation as well.

And so can you give us an update on what that international situation is now and why what is happening overseas in other parts of the planet is so important to what happens here.

Because we're not this isolated country that is in the middle of nowhere, the world is... - I mean, gosh, COVID itself, each variant of COVID has come about because of international travel and the interdependency of our globe.

I really appreciate that question and the opportunity to emphasize that until we get more people vaccinated across the world, we are not going to get COVID permanently under control.

We are gonna continue to see variants emerge, particularly in areas with low vaccination rates.

And even today, we're seeing new subtypes of Omicron, right?

There's this new BA.2 subtype that emerged in Africa, is now being followed in Europe and has started to kind of rear its head here in the United States.

I don't think it's gonna significantly change the course of this surge.

It might make it last a little bit longer, but there's no guarantee that other variants are not behind it.

The state of the world right now, it depends on which country you're look at, just as within the US, it depends on which state you're looking at.

But it really re emphasizes, again, that interdependence, the importance of getting high quality vaccines to folks, regardless of where they are.

And I'll particularly highlight the importance of our helping our colleagues in Sub-Saharan Africa to get their populations vaccinated.

Sub-Saharan Africa, unfortunately, has some of the lowest vaccination rates in the world.

Not because of lack of desire for vaccines, but rather because of lack of access.

- So switching back to the US and realizing that you, and do not have a crystal ball, nobody does, but what do you foresee here in the United States in the weeks and months to come?

As the Omicron surge is receding, there is talk of loosening restrictions in some areas, there's talk of not necessarily getting back to the old normal 'cause we won't ever get back there.

But what do you foresee?

What's your best guess?

- Well, I think it's absolutely appropriate to relax restrictions as the surge recedes.

We should have a data system and a public health system and a society that says we need to do more when we're in the midst of a surge, but when we're not in the midst of a surge, we can go back closer to normal.

So I expect to see many indoor mask mandates get dropped in the states that still have them.

I expect to see some school mask mandates be dropped and have optional masking for kids in school.

I hope in parallel, our public health systems and our governments will continue to shore up the data systems, the access to testing, and so on that's needed so that we can be prepared if there is another surge.

And that's really the great unknown.

So I can produce that best-possible scenario, which is a lot of us are vaccinated.

A lot of us have been infected.

The best-possible scenario is we all have immunity with vaccine induced immunity or those folks that have been lucky enough to survive a COVID infection having infection induced immunity.

That's enough to hold off another surge.

The world goes much more back to normal, and we just have little seasonal blips in COVID like we do with flu.

That's our best-possible scenario.

But there is another world or another path that may happen.

And this is one in which the infection induced immunity in particular is not sustained.

We of course know that some vaccine induced immunity also weans, so it could put us at risk of a resurgence of the same variants.

And of course there could be other variants out there.

And there's really no way to predict when or where a variant will come from, nor is there any way to predict whether another variant will be milder or more severe.

We've seen a couple of variants of COVID that have been much more severe, much more easily transmissible, and others that were big nothing burgers.

I hope we have a lot of nothing burgers in the future, but there's no guarantee.

And so that's why that part of as the surge recedes, the general public can go back to normal.

But those of us in public health and policy and healthcare systems need to double down on setting up our system so that we're ready so that we're no longer responding from the back foot, so that we can get through these surges more quickly and effectively, and with less trauma for our population.

- Megan, in getting ready for this conversation with you, I read a New York Times story just published in the last couple of days about why the death rate from Omicron seems so much higher in the United States than it does in other wealthy industrial countries.

And the argument that this article advanced was that it has everything to do with our vaccination rate.

Can we talk a little bit about vaccines?

What do you say to individuals who say that the risk of the vaccine is greater than the risk of COVID, especially for young, otherwise healthy individuals?

- That is frank disinformation.

That statement is a twisting of the facts.

COVID is among the top 10 causes of death for Americans across the age spectrum, from age one through 99.

Yes, the death rate is older in older adults, but it is not nothing in younger adults.

And remember, kids and young adults don't die a lot, period.

So even if COVID is less dangerous for us, it doesn't mean that it's not relatively dangerous compared to other things.

I'll say to parents, I can't imagine them not putting their kid in a car seat or on a booster seat or not putting a bike helmet on just because it's not super likely that they're gonna get in a car crash on any given day.

You do it because you wanna protect your kid from this horrible unpredictable scenario.

And the same thing is true for vaccines.

They protect kids, young adults, middle aged adults, as well as older adults from those very serious consequences of death, hospitalization, but also severe illness and long COVID, which we just talked about.

There are studies showing that if you're vaccinated and catch COVID, you have a lower risk of long COVID compared to those who are not vaccinated.

I get so sad and frustrated with the misinformation that's out there, but I'm also committed to combating it.

And I will say I've had a number of wonderful conversations with patients in my emergency department, and with friends and community members, in which it's possible to shift folks understanding of what the truth is about the degree to which these vaccines protect them and the truth about the safety of the vaccines.

There has been this overinflated emphasis on a few very rare side effects of vaccines.

I point people to the very common and predictable side effects of actually catching COVID.

The safety of the vaccines has now been demonstrated in hundreds and hundreds of millions of doses across the country.

If these were bad, we would see a lot of people being hospitalized and dying.

And we don't.

We do see a lot of people hospitalized and dying and with other long term consequences of COVID itself.

- We've got just about a minute left.

One of the things that I hear, I work at a university, you work at a university.

when we have a vaccine mandate and a booster mandate in effect on our campus.

But I've heard from some parents who are concerned about the reproductive health risks of the vaccine.

Is there any risk that we know of from the vaccines due to reproductive health.

- There is a very real risk of COVID itself on reproductive health.

COVID is associated with increased rates of stillbirths, increased rates of preterm labor, increased rates of maternal mortality.

It's also associated with decreased sperm production, decreased sperm function, and erectile dysfunction.

The vaccine is associated with none of those.

It does not work on the reproductive system, it has no affiliation to the reproductive system.

And there have been a bunch of studies of pregnancy rates among women who got the vaccine and have shown no change in fertility and no change in birth outcomes from the vaccines.

So another piece of unfortunately twisted information that gets at people's very real fears, but is not backed up by data.

The data shows that the vaccines are safe, including for fertility.

- Dr. Megan Ranney, Brown University School of Public Health, thank you so much for being with us this week.

That is all the time we have, but if you wanna know more about Story in the Public Square, you can find us on Facebook and Twitter or visit pellcenter.org, where you can always catch up on previous episodes.

For G. Wayne Miller, I'm Jim Ludes, asking you to join us again next time for more Story in the Public Square.

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