At the beginning of the year, when omicron was surging and information about the new variant was rapidly changing, we had a conversation with UCSF’s Dr. Kirsten Bibbins-Domingo to get our questions answered.
Since then, a lot has changed: The Centers for Disease Control and Prevention (CDC) released a new tool for tracking COVID-19 transmission levels (Alameda County’s transmission level is categorized as “low”), California lifted its mask mandate, and a newer variant, BA.2, was detected in the Bay Area. During Tuesday night’s State of the Union, President Biden also announced that as of next week, households can request an additional set of four free COVID-19 tests to be delivered to their home.
With COVID-19 restrictions and the virus itself in so much flux, we reached out to Dr. Noha Aboelata, the CEO of Roots Community Health Center in East Oakland, to talk about the current state of the pandemic as it reaches the end of its second year.
The interview has been edited for length and clarity.
Two weeks ago, Gov. Newsom unveiled the state’s new COVID-response strategy, which they are calling the SMARTER plan, and said that California is entering a “new phase” of the pandemic. What do you think of the plan, and do you agree we’ve entered a new phase?
I haven’t had a chance to read the entire plan but from what I’ve seen of it, there’s really no new phase. In some ways, it’s kind of an old phase. We’ve been here before where cases are coming down, and we can expect to have a time when they come down to a reasonable baseline. We would all be wise to prepare for a summertime surge and probably another wintertime surge. So I think we’ve been through this a few times. I don’t see any demarcation that says this is a new phase, per se.
On Twitter last week you noted that the governor’s plan doesn’t include improving indoor ventilation and filtration systems. Can you explain why this is important?
When I saw the SMARTER acronym, I said to myself, “Where’s the V for ventilation?” Ventilation and filtration are such a key part of how we can improve our infrastructure to be more pandemic-proof as it relates to an airborne virus. The pandemic has shown us that maybe we haven’t paid enough attention to indoor air quality in general. There’s a huge variation that we could see between the building infrastructure even across different schools, buildings, and businesses.
This is an opportunity that we have to take to improve ventilation for businesses. And absolutely, our small businesses need that type of help and support. I just have not seen that front and center of any plan. And in fact, the plan is sort of concerning in that, in the way that it reads, it’s moving responsibility to individuals for what really is a collective problem. It feels premature to say we’re moving into a new phase where we cannot say that everyone has access to all the different tools.
When it was announced that households were going to get COVID-19 tests for free, there were valid concerns over whether residents would be able to get access to them and whether the federal government would work with local organizations to make sure severely impacted communities.
It was announced in October, and we felt good that the tests would come in time for the holidays before the winter surge. It was disappointing that the distribution was too late. I do think that this combination of reacting too late to distributing resources, and lifting protections prematurely, has proven to not be a good combination for our pandemic response. We need to reflect on those things and do what we can to correct them.
When they finally did come about, it was clear that there was no equity strategy to ensure that the people who needed them the most got them, and maybe the people who didn’t need them so much could waive them, or give them to someone else. We know that not everyone has an address where they can securely receive the mail. We are so far behind other countries in terms of making this available to people. We need to take a more equitable response, especially if we’re going to start trying to shift responsibility to individuals, we have to make sure those individuals have equal access to the resources.
As of today, only 60% of Alameda County residents are fully vaccinated and boosted. What’s a realistic goal, as we approach year two of the pandemic?
“What I worry about is that, I’m still hearing people say, ‘Oh, they haven’t gotten vaccinated by now; they’re not going to.’ And that just simply is not true. We are seeing people change their minds all the time, for their own reasons.”
The goalpost has to move because of the new variants. As the vaccine effectiveness gets lower, the number needed to be vaccinated in order to really slow transmission is going to be much higher. We’re going to potentially need newer vaccines that are more effective, maybe against multiple variants, and so on.
We are concerned about people who have never been vaccinated and never caught COVID-19 that are still completely vulnerable. These are the people that we’re still losing, unfortunately. There’s no question from an individual perspective, that the best way to protect yourself from the severe outcomes is to get fully vaccinated and boosted. In terms of reaching that threshold that will stop transmission — I think that that is a much more elusive kind of a goal.
The Black and Latinx community are still under-vaccinated compared with white residents. What else can be done to incentivize getting vaccinated and boosted?
We can’t give up. We don’t get to give up on people when maybe they don’t always follow our advice 100% of the time. We have to continue to educate. The conversation around vaccines has gotten so contentious and politicized that it can make those conversations difficult. I just encourage everyone to keep the lines of communication open always, and make sure that people don’t feel like they’re being stigmatized, targeted, or attacked because of their decisions.
It may take our community a little bit longer sometimes to be able to trust and feel that they have enough information to take action. What I worry about is that, I’m still hearing people say, “Oh, they haven’t gotten vaccinated by now; they’re not going to.” And that just simply is not true. We are seeing people change their minds all the time, for their own reasons.
If we were to say “Well, they didn’t want to quit smoking, stop talking to them about it,” that would be negligent. We have to understand this is an important clinical intervention. But people are changing their minds every day.
Our readers keep asking: Should we continue wearing masks even as restrictions are lifted? Is it safe to go indoors without a mask?
What’s most concerning about the lifting of the mask mandates is that it sends a message that we don’t need to require it anymore. It’s human nature to think that if you impose a restriction when things are bad, and then remove the restriction, it means things must be good. And that is, of course, not at all the case. We have to be better about giving people tools to understand all of that and do their own risk calculations.
What has been really challenging to get people to understand is that a blanket policy, first of all, is typically based on averages. It will impact people very differently. It is then up to schools and businesses to go above and beyond and interpret the policies. We’ve been here before with relaxing restrictions prematurely.
Are you personally going to continue wearing masks? Do you feel comfortable not wearing a mask when going to a store or being indoors with strangers?
I definitely am wearing a high-filtration mask if I’m going to be indoors with people I don’t know. That has not changed at all. There’s no objective reason why it would. We have to remember that even with cases coming down so quickly, they are still quite a bit higher than they were — even at the worst point of last summer’s surge when we were concerned about delta. The mask mandates were prematurely lifted then, and we had to quickly reverse and go back to wearing masks again.
Doing your own personal risk assessment is important. I’m definitely going to be continuing to wear my high-quality mask until cases get down to a lower level. I’m still modifying some of my activities. I’m not doing as much indoors. I’m still doing more things outdoors. Because there’s still quite a bit of SARS-CoV-2 swirling around in our environment right now.
Do you recommend KN95 or N95 masks for all environments, including the outdoors? Or should the mask type depend on the situation?
So when you’re outdoors, we’re not as worried about the aerosol transmission because of course, aerosols disperse very quickly outdoors. This means that it’s probably not necessary to wear a high filtration mask like an N95 when you’re outside. However, we still do worry about droplet transmission because if someone else is yelling or singing in your proximity, then you still can get those kinds of larger droplets that don’t have a chance to disperse, and you can actually catch COVID that way. In those kinds of settings, a cloth mask is sufficient because you’re really just trying to cover up your mucous membrane so that those droplets don’t land on you. I’ll often [carry a mask], even when I go for a walk where I don’t know if there’s going to be a lot of people. It’s good to have a mask on you just in case until you’re alone.
I think it’s important that we’re making these decisions based on facts, and being well-grounded in reality. This notion that we need to “get back to normal,” there’s personal responsibility that comes with that. If you feel like a particular gathering is something you want to be able to go to and not wear a mask, then be really thoughtful about what you’re doing for the next week. I’m not going around someone who’s immunocompromised or who’s elder who may be at risk. Thinking about your own personal risk also has to do with them. Who are you going to be exposing, potentially unbeknownst to them? We’re having to do these risk assessments with normal everyday activities, and that can be fatiguing. But I think that is going to be part of how we have to really move in order to avoid continuing to spread it or get someone else sick.
There’s a new omicron variant, BA.2, that’s been detected in the Bay Area. Do you worry about it spreading?
BA.2 is here. It is taking hold in different places at different rates. Will we be protected from it or not? There are still a lot of questions that I don’t think we have the answers to. So far, it’s at least looking like BA.2 is quite a bit more transmissible than the others. There are some people who are saying that it is so different from omicron that it should get its own alphabet letter.
“We’ve been here before with relaxing restrictions prematurely.”
Fortunately, the monoclonal antibody … is working against omicron. Unfortunately, BA.2 is evading [that antibody]. It remains to be seen whether it’s truly going to take hold in the United States. But you know, this won’t be the last variant. Until we really get global vaccine equity, until we, frankly, can get some better vaccines that can handle all these new variants, we’re going to just keep seeing more of them.
You mentioned the monoclonal antibody, which is an emerging COVID-19 treatment that can block SARS-CoV2, the virus that causes COVID-19, from entering our cells. Who is eligible and how are patients being screened to see if they qualify?
There are so many people who are eligible for monoclonal antibody treatment that I’m afraid have not gotten it. I wonder all the time about how many people we’ve actually lost who could have potentially been saved with timely treatment. Unfortunately, the eligibility criteria have had to fluctuate a bit based on availability. When we don’t have enough of a supply, it goes to the most at risk: In general, anyone with underlying conditions, anyone who’s over 65, anyone who is either unvaccinated or may not have mounted a good response to the vaccine. These are all people who may be eligible for either the monoclonal antibody treatment, which has to be started within 10 days of symptoms or Pfizer’s Paxlovid, which has to be started within five days. [Paxlovid] is a pill, so it’s much more convenient than the monoclonal antibody, which is an infusion.
We’re urging people to get a primary care doctor if they don’t have one [because] if you get an antigen test that you do at home and it’s positive, and you don’t have someone to call, you’re not going to be able to get access to that medication. If we are going to even begin to talk about the “next phase,” then everyone has to be able to get treated if they’re at risk of dying from this.
The other thing I will quickly mention, too, is that there is a treatment for people who are immuno-compromised that will give them six months of protection. It’s called AstraZeneca’s Evusheld, and it is a type of monoclonal antibody, but it’s one that you take pre-exposure to COVID, and I don’t think people know about it.
You’ve also been vocal about wastewater sampling being underutilized as a way to monitor virus transmission. Can you explain what that is?
From my understanding, it’s been a really good tool, especially for places like dorms or prisons where you have a closed system with wastewater, and where you can detect the shedding of SARS-CoV-2 happening days before people get symptoms.
People infected are already shedding SARS-CoV-2 through fecal matter. It’s possible that when one person catches COVID, you can then [detect] it in the water, and then you can go ahead and test everyone. That would be the ideal case scenario of how it could work. Now, we have municipalities that are actually implementing it [although] there’s a lot of variation on how it’s exactly being used. Ideally, it would be a way to communicate with the public that we may be heading into another surge or that we detected a new variant.
COVID isn’t the only health crisis in East Oakland. What are the other health concerns keeping you up at night?
We are bracing ourselves [for] people having long COVID and starting to have health consequences from that.
In terms of other things that are not COVID-related at all, we are definitely concerned about people having put off things for the last couple of years: screenings for cancer, maintaining the regular chronic medical conditions that they may have, like high blood pressure or diabetes. I know people have understandably been avoiding hospitals because we know that they were crowded and overwhelmed at times. But, as things seem to be retreating, this is a great time to go ahead and schedule routine screenings—checking out your blood pressure and sugar and all the things that we normally check. We’re worried about seeing health conditions that are more advanced than they needed to be. And so we want to make sure that people are attending to the usual things that we see a lot of in our community in East Oakland.
Featured image: Azucena Rasilla