Dr. Jay Varma: ‘What Discourages Me the Most is the Lack of Political Will’

COVID-19 caseloads have tripled since early April in New York City and another subvariant Omicron has taken over the bulk of new cases in a matter of weeks. The next wave (who's still counting?) has begun. But you wouldn't know if you checked in on any change in public health policies.

New York City just entered high alert for the spread of the virus under the City's color-coded alert system. The Health Commissioner Ashwin Vasan recommends wearing a mask in public indoor places, but Mayor Eric Adams has stopped short of issuing a new mandate. "We're staying prepared and not panicking," he told reporters Wednesday. "Variants are going to continue to come."

Hell Gate caught up with Dr. Jay Varma, formerly a public health advisor in the de Blasio administration who is now a professor in Population Health Sciences at Weill Cornell Medicine, to ask how he thinks the City should respond and what to make of the idea that we should all just accept getting COVID several times a year.

This interview has been lightly edited and condensed for clarity.

Sydney Pereira: Now that we are learning just how rapidly this virus can mutate, and with cases going up again, what do you feel like New York City should be doing now that it is not currently doing?

Dr. Jay Varma: I've been working with Mark Levine, the Manhattan Borough President. We released his plan in early March, and I think all the things that we proposed are absolutely critical right now.

One of the things I was a strong vocal critic of was the removal of the Key to NYC [vaccine mandate] program. The vaccine is not perfect. As we know, you can still get infected, but it is a layer of protection. By removing that layer of protection, I think you do make the city more vulnerable. I wish that that program could get reinstituted.

I think it also has a secondary benefit of sensitizing people. So even if it has no direct benefit on stopping transmission, say in a restaurant, it sensitizes people and you will get a higher proportion of people who are worried about the pandemic by doing that. It's an awareness mechanism.

Number two—the employer mandate. I'm not aware that the City is doing anything to either educate employers or to enforce that as well. Those are things that were already in place when this administration came in, and just should simply either have not [been] undone.

Remove the friction for people to get the tools that they need to protect themselves, and at the same time, sensitize them to why this is important. Literally go door to door in the city and distribute N95 or KN95 masks, rapid test kits, information on how to improve indoor air ventilation, and then give them information about access to Paxlovid, the drug. Just simply broadcasting information on the news doesn't move everybody. Sometimes they need to actually have a visceral contact with somebody to say that, "Actually, you need to be aware of this stuff."

The last point I would make is regulatory action or legislation on indoor air quality of ventilation. Something related to legislation or regulation related to indoor air quality is totally appropriate right now and will build resilience.

The Times recently reported that people shouldn't be surprised to get COVID two, three, four times a year. What do you make of that?

This is what we have to learn to accept. We know that the flu virus takes about four or five years to evolve into a form that disrupts society—to evade our immunity and cause a severe influenza season. It seems to take about four to five months at the most for this coronavirus to do that. That is not something any of us have predicted.

It does appear that this coronavirus appears to be following the pattern of other coronaviruses. Coronavirus is one of the common causes of cold—the other versions of it. You don't have just one winter peak. You almost have four seasons to it. You get colds in different parts of the year.

We have to figure out some way to manage this over time. What worries me is that the more we learn about this virus, the more we understand that the acute infection is not mild. People get knocked out for one week, two weeks, sometimes longer. There's a substantial minority of people, including children, who get really debilitating symptoms. It can cause conditions like diabetes and strokes and heart attacks. Even if an adult doesn't get sick, if they're a caregiver, they may have to stay home because their child is repeatedly getting sick—not because of isolation policy, but just because they're too sick and they need somebody to care for them. If you even look at this purely as an economic issue, it's a big economic drag, too.

I worry that we're getting to a world where it's very hard to have a rational discussion about economic trade-offs. Because there are very real trade-offs to letting people get infected repeatedly all the time. I don't know the exact answer to this because everything has to be balanced with what the public is willing to accept, and I've got plenty of very well-educated well-meaning friends who are in health care and education and other fields—they're sick of it. I'm sick of it. I do have a lot of privileges. I just know a lot of people who worry about their health but also just don't really want to put up with it anymore.

How are people who are immunocompromised or those with young kids supposed to make sense of this world that currently has basically no restrictions and people are getting COVID three or four times a year?

A disease basically becomes endemic when people with power and wealth and other resources and privilege decide that it's no longer a problem for them. That is fundamentally when a disease becomes endemic. There is nothing endemic, for example, about HIV. The difference with HIV is, at least in in New York, it's primarily disease of young, gay men, and particularly Black and brown men.

You end up in a situation where people just don't care about it anymore because they don't see it as their own issue anymore. That's what you're seeing with people who either have medical vulnerabilities or have a family member that does. They'e basically being told that we're not all in this together anymore. You're all on your own.

My family [members are] immigrants to the U.S., and I was born and raised here. I kind of get that that, unfortunately, is a lot of what America is. I don't react as angrily to it as maybe some other people do, just because I've always assumed that America was much more about individual rights than collective rights. At the same time, I think if you want to be a society that actually demonstrates that you care about people, the way you demonstrate you care is to care for the most vulnerable.

At a bare minimum, what we could do for communities like that is do the things I mentioned about literally bringing resources to them—like high-quality masks or test kits. You could set up a separate distribution program where people can just basically go online and have people come to your home and give you the tools that you need. You could get people who are vulnerable or feel they're vulnerable to call a hotline and get all this stuff delivered to them regularly.

We're over two years into this pandemic. What has New York City done really well, in your opinion, compared to other major cities?

I think the City has done a very good job in providing New Yorkers with information on a regular basis. That includes the data that's available for simple review, as well as analysis on the health department websites, as well as the daily briefings that [then-Mayor Bill de Blasio] did.

Number two is dedicating a huge amount of resources to the initiatives that were absolutely critical at different phases of the pandemic. There are criticisms that could be appropriately leveled on the breadth of all those, but let me highlight a couple.

I would say very early on, food delivery. When we knew very little about this virus, but we were telling people to stay home, food delivery became critically important. Simply being able to provide that, I think, made an enormous difference.

And then once we got out of that initial phase of March and early April, the mayor agreeing to invest money that, frankly, he didn't actually have available to him, but was hoping would become available, into this massive testing program that evolved into not just testing, but also case investigation and support for people in their homes or in hotels.

The third is the vaccine program—making clinics available, setting up mass vaccinations sites. There were clearly challenges and problems along the way, including the IT system to organize in the beginning. Nobody would ever say any of this was perfect.

One of the things I told the [former] mayor very early on was that I was pessimistic that we would get to more than maybe 50 percent of adult vaccination levels without any types of mandates. Now, I think we got to higher than that, probably without mandates, because there were a lot of incentives put in place. What really pushed things to a very high level was all of the different programs to require vaccinations. That started with Health and Hospitals workers and then it moved into all City workers. Then it moved into the vaccine verification program or Key to NYC, and then, finally, employer mandates.

Looking retrospectively, do you feel like there's anything that we failed to do? Or, at least, could have done better?

Oh, yeah, that's a long list. [laughs]

I don't think there's any of us who have worked in this who don't think all the time about the many different mistakes we made along the way and things we wish we had either known or things that we had known but that we wish we had given more weight.

In an ideal world, the City would have had more autonomy. Removing the mayor-governor problem, which was a major impediment—the City really should have closed down earlier. Had the [former] mayor had his way, it would have happened. I still think it probably could have closed down even earlier than when the mayor did it. It got delayed even further, because of Cuomo's desire to be the one to decide when that actually happened. The single biggest absolute failure, bar none. But there's lots of blame to go around about why that happened.

I wish we had taken more seriously the possibility of asymptomatic transmission and the benefit of widespread community masking. A lot of us who worked in infection prevention and control were under this long-standing assumption based on existing dogma that most infections are transmitted over short range, anything less than a high-quality mask doesn't do anything, and most people will transmit when they're symptomatic.

All three of those things turned out to be wrong.

I wish we had found a way to actually build even more capacity [for testing]. We did a good job, we got to [a goal of 100,000 a day] by building this new public-private partnership laboratory. But had I been able to see into the future and thought about Omicron and also thought about the periodic surges in demand and how you need a lot of excess surge capacity, it would've been better.

I mean, I can go on and on.

It sounds like we need to be more proactive and try to see into the future to do things earlier, as fast as possible.

It's the same exact type of problem that we run into right now. Almost invariably, if you look at the people who bet that things are going to go well and you think of the people who are predicting that things will go badly, the people who predict things would go badly, for some reason, have won out over time. Not for everything. But for the majority of situations in which somebody predicted a worst-case scenario, that has somehow come to pass—that this would be asymptomatic transmission, that it would spread over a long range, that vaccines would not have a huge impact on blocking transmission, they'd only have some impact. And that the virus would mutate so rapidly. It's still surprising to me how rapidly it continues to mutate. It's not something we would have predicted.

In your Atlantic essay, you talked about the broader goals of public health, and how public agencies have been left to just languish. What do you hope local and state governments will learn from COVID to then implement into our health systems as we move forward?

What I am hoping and have been hoping happens is that this would be a 9/11-like moment for public health departments. What happened after September 11? I'll say for good or ill, but I think many of us would believe it was mostly for ill—local police departments were basically incredibly well-resourced to buy military grade security equipment after September 11. There was a massive infusion of resources into physical security after September 11.

I would love to see, and had hoped I would see, a similar infusion of resources into local health departments. We can't just assume that this pandemic was a once-in-a-lifetime event. We need to be prepared. This is something we need to be doing continuously. And what that money should be used for is to re-bolster the infectious disease and emergency response functions of health departments around the country, so that they could scale up a testing program or a contact tracing program or a vaccine campaign or do emergency deliveries to people's homes.

What we're seeing actually happen and play out over the past few months is Congress is really at a standstill, and unfortunately, most state and local health departments have become dependent over the past 40 years on federal government dollars to fund public health. We're in this very difficult situation where I want to hope that state and local governments might pick up the tab if the federal government doesn't invest in this as it's supposed to. But I'm very pessimistic that we'll actually do that.

COVID is something that has really disproportionately affected communities of color, particularly Black and Latinx New Yorkers. Like with HIV, it's not like it disappeared—it's just affecting a different, smaller group of people who are particularly vulnerable. What does it say that something that disproportionately affected people of color over the pandemic as a whole in the past two years is now just being ignored or moved on from because it's not something everyone has to feel as worried or as scared of?

I wish I could say I was surprised. But I'm not surprised. All infectious diseases cut through the weakened seams in society. You see it everywhere. It's not just the United States, but everywhere around the world.

The same dynamic is playing out globally, where Europe and the U.S. and Canada are effectively acting as if they're done with a pandemic, even though the vast majority of people globally have no access to vaccines, test kits, high-quality masks, improved ventilation, any of the other resources that we're now seeing widely available to Americans.

I wish I had some solution to that. I'm pessimistic that we're going to be able to do very much—other than taking the best resources we have and making them equitably distributed. It's really about equity.

Do you ever feel discouraged?

I'm discouraged by basically two things. One is the thing that we can't control, which is that this virus is incredibly wily. It has found this ability to evolve and mutate into forms so that our threat is constantly changing.

That's challenging and discouraging, but at the same time, I would say it doesn't discourage me too much, because I believe that there's a sort of technological way to address that. The U.S. continues to be a great engine and support around the world of new vaccine initiatives.

What discourages me the most is the lack of political will to address all of the problems that led to one million-plus Americans dying. Some of those problems are beyond the realm of public health. They are all of the social safety net programs that are even more important to public health than the work that I do—paid sick leave, universal health care, unemployment insurance, housing. I'm discouraged that we're not looking at those as our fundamental vulnerabilities.

What else do you feel hopeful about?

I'm very optimistic about the new vaccines. Also, better quality PPE. We're seeing this initiative out of the White House to develop formal standards on improving indoor air quality. That has huge, tremendous benefits over the long-term.

Testing is a huge one. I've felt for a very long time that the U.S. is far too restrictive about the availability of diagnostic tests. A perfect example is women get urinary tract infections all the time, yet have to go to a doctor to get a urine dipstick done—a basic screening test. Those should be available over the counter. COVID finally broke through that regulatory bottleneck. There's no reason why we shouldn't be able to move to a world where you can also test for flu at home, foodborne viruses, and UTIs.

I'm very optimistic that there will be innovation. Whether that gets to the people that need it the most is the unanswered question.

I’ll give you a perfect example. There is now a home PCR test. It's called Cue Health. They've developed this really elegant and lovely device. You know who has them and how that company basically was able to survive during the innovation period? Google bought it for every single one of their employees and made an advance commitment for some huge number of very expensive test kits.

That's how that company got off the ground—one of the wealthiest companies in the world buying it for their employees, who are some of the highest-paid employees in the world. That's the metaphor for this whole thing. The technology is there. It's just not in the hands of the people that need it the most.