We’re Fighting Covid With Faulty Data

Massachusetts added a new set of figures to its dashboard in January. The difference between people who were hospitalized because of the virus and people who were there because of other reasons began to be drawn.

A Covid-positive patient in the hospitals had to be isolated because of a car crash. The effect on the state's numbers was dramatic. They were cut in half.

More than half the country is likely to have been exposed to Covid, and the US will pass 1 million deaths in the next few weeks. There will be more waves of illness, either new or seasonal. Thanks to a wall of immunity, the waves will be less deadly. Because of that, political leaders, health experts, and regular people across the country are adopting new attitudes toward risk and what costs they are willing to pay to stop transmission.

The US's fractured public health system is one of the reasons why they are making those choices with flawed information. It has made it harder to assess the consequences of the Pandemic and has helped create a vacuum that has been filled by fatigue and distrust.

Even after billions of dollars in spending and a million dead, the way we measure the risk of the virus hasn't improved. New thresholds for public health rules from the Centers for Disease Control and Prevention depend on how many people are hospitalized. It will be important to know how much vulnerability exists in communities if the virus returns, but U.S. data systems make that impossible. When more people stop testing or shift to at- home tests that don't get reported, how will we spot that wave?

The epidemic has changed. The way the country measures itself needs to be changed.

How Many Hospitalized?

One of the best ways to measure the effects of the virus is by recording hospitalizations. The number of sick and lump in the gravely ill is undercounted. Deaths come weeks or even months too late to have any value. Hospitalizations show the strain on the health system and the financial costs, as well as the impact on those who spend weeks in an inpatient bed.

In the first year and a half of the Pandemic, almost all of the Covid patients who ended up in the hospital were there because of the virus. About half of the people with Covid who entered the hospital were there for something else.

Only a few people have looked at the issue. A team based at Harvard Medical School looked at medical records to separate patients hospitalized with Covid from those hospitalized with Covid. The team at the University of California at San Francisco did the same thing. New York and Massachusetts began to break out their hospitalizations in their data. As Covid became more widespread and more people got protection from vaccines, the number of people admitted was the same.

Jeffrey Klann, an assistant professor at Harvard Medical School, conducted one of the studies. The real cost of Covid has not been counted by the country. Because the CDC and many states use hospitalizations as a core measure of the risk of the Pandemic, it means that they and members of the public have been using far-too-blunt data as well.

Although Massachusetts, New Hampshire, and New York post the data, only a few other states have done one-time surveys, according to a review of state Covid data dashboards.

How did this happen? What seems like a crucial distinction in consequences, with huge implications for how society judges risk, is only tracked by a few states.

The question has been poisoned by the politics that have engulfed Covid in the U.S.

Klann's group published its work and people were talking about how we must be anti-vaxxers because we are trying to minimize the problem of Covid.

A Question of Values

Every public health decision has a trade-off. A work-from- home order might crush the economy. It is possible to save people from dying of Covid by closing nursing homes to visitors. How many hospitalizations should we put restrictions on? Is it worth it to not have to wear masks at the airport? What if there is another variant? Or, in the future, another disease? It would be nice to have better data if you were going to make those choices.

Jay Varma, who helped lead New York City's Covid response, says these are fundamentally questions of values. He is the director of the new Center for Pandemic Prevention and Response at Weill Cornell Medicine. What is the cost you are willing to pay to do that?

The U.S. is no longer measuring those costs using the right method. It's not giving its citizens the best information about their choices.

The country is not ready to do better. There is no distinction between a hospitalization and a mask wearing, because of the CDC's new guidelines.

The agency decided not to ask hospitals for those details, according to Rochelle Walensky. Most places can't or won't report them, and a Covid-positive patient puts the same burden on hospitals. It doesn't put the same strain on limited resources such as intensive care beds, ventilators, and staff.

Walensky said she expects U.S. hospitals to stop testing patients for Covid eventually.

It's true that it's part of a pattern at the agency, which has sometimes backed away from data collection that would have provided a clearer view. Mild vaccine breakthrough infections were stopped by the CDC in the first few months of the vaccination effort. When vaccine efficacy began to fade, the agency was unable to see clearly. On April 19 the CDC launched its new Center for Forecasting and Outbreak Analytics, promising that it would help modernize efforts to better understand and predict infectious diseases.

The U.K. publishes regular updates on hospital data. The U.S. has struggled to have a national health records system for many years.

The U.S. is likely to go through another viral lull this spring and summer as public health rules are relaxed across the country. In China, Covid continues to transmit in the U.S. and around the globe. There will likely be another surge or variant that is better at evading vaccines.

Will less, worse data be the answer when that happens?

How Far Up Is Your Sandcastle?

The U.S. is already blind in one respect.

More than 90 percent of Americans have some level of immunity according to blood surveys. More than half of the population has been fully vaccineed, but less than half have gotten a booster. According to the CDC's surveys, almost half of the country has been affected by the disease. Some people have been exposed to both infections and neither, while others have only been exposed to one. All of those combinations have different levels of protection.

Although the U.S. has relatively detailed vaccination records, there isn't much data on the infections at the individual or community level. It is difficult to tell where protection is the strongest, where it is fading, and where there are holes.

Some places get hit harder than others and not always in straightforward ways. Last year, as vaccines rolled out across the U.S., researchers in Virginia began to follow how the state's different levels of immunity functioned.

Northeast Virginia has a liberal D.C. suburbs. The southwest part of the state did not. Bryan Lewis, a University of Virginia researcher who has tracked the virus and modeled how it might act, says that Northeast Virginia was spared when the wave hit.

The result was very different a few months later. The northeastern part of the state had more cases than the southwest. The pattern had changed. The efficacy of the vaccine faded over time. In the southwest, many people got sick and many died, but those that were left had relatively robust protection from the virus when it came back.

If a new wave of Covid hits the U.S., what will happen? Which parts of the U.S. will be most vulnerable? Which will be the most protected?

Lewis says that they don't know what our current supply of immunity is. How high is your sandcastle?

Lewis wants to estimate what our immunity will look like in a few months or next fall because the U.S. has never created a national health records system or linked its vaccine records to its health records.

We are going to have a decline, maybe a bit more than we had last summer, according to Lewis.

The big question is, what will this look like in the future?

Spotting the Next Wave

It might seem hard to remember, but there was a time when people wouldn't take a test if they had respiratory symptoms. You were sick three years ago.

Since the start of the Pandemic, U.S. Covid testing has been a challenge, but it is entering a new phase. Funding for Covid tests has expired. Mild cases show up at hospitals or other points of care where they can be recorded. Daily case counts are always unreliable.

What comes out is growing vulnerability, but fewer ways to spot the danger, because of waning surveillance and fading immunity.

Some U.S. states and cities are trying to change that with new methods that can spot infections without relying on people. They built networks to sample sewage for the virus. Sampling wastewater can detect a wave before it shows up in tests if people with Covid have shed the virus in their stool.

Amy Kirby is the head of the CDC's wastewater program.

The CDC plans to track visits to hospitals and clinics for things that look like Covid. In early March 2020 there was little to no testing and few other ways to identify Covid cases. A surge in patients who had similar symptoms but whose lab samples hadn't tested positive for flu was picked up by a U.S. public health network.

Fractured Ideas of Risk

What you start to see is a bigger change if you put it all together. Our response to Covid is evolving from a public-health problem to an individual one. A combination of vaccinations, therapies and prior infections means that people's risk has fallen from where it was a year ago. Not for everyone. There are more than 300 deaths a day in the country. The old, frail, and those with underlying medical conditions are the people who are most vulnerable.

We are all in this together, and everybody is on their own, is the debate we are going through right now?

Maybe that transition is going to happen. America is also a land of inequality, which has been the flip side of being the land of opportunity. When we can't agree on a common set of facts because we haven't created the data to understand where we are, individuality starts to win out. I don't understand why someone should sacrifice more when they can agree on what they're sacrificing for.

People who are very vocal from the public health community and historically marginalized communities are saying that their lives are not important. It saved many lives.

Making those transitions means giving people who are at higher risk the tools to protect themselves. He compares it to a public restroom, where nobody walks in expecting to use their own water, soap, and towel. Should anyone who might need a mask to protect themselves or others be expected to have one at all times?

You have to move to an individual approach, but we have to make that handover the way it should be.

Bill Hanage is an associate professor of epidemiology at the Harvard T.H. Chan School of Public Health. Do you have access to health care? How are you going to turn a rapid test into a prescription?

People with Covid would be able to get access to antiviral pills quickly if the Biden administration's test is successful. There is still a lack of free access to masks, emergency money for vaccines, drugs and tests has run out, and the government has purchased only a portion of the pills it might need in a new surge.

A Broken Conversation

Hanage, who is from the U.K., has dreams about the disease. When things were going badly, he dreamed he had taken off his mask to go outside, and when he returned to his house, he couldn't tell which one was his. He thought he was on the tube in London, riding along as he used to.

Hanage's dreams may be just as useful as any other method in understanding where the virus is heading and what to do about it. Feelings have influenced the reality of the response to Covid. The country has never agreed on what values are before or after the Pandemic.

Would better data make it easier to talk about values? Maybe. It's not a new, perfect view of Covid, it's the unfairness of the U.S. health-care system, which was endemic long before the virus. Death data shows people who didn't get a cancer screening because hospitals were closed. One-fifth of Americans don't have a primary care physician to talk to about their hesitations about vaccinations. The capacity levels of the hospital show how sick Covid patients were and how badly the health-care workforce has been damaged.

The people who have always lost out in health care because of bad luck, bad genes, the ravages of time or poverty are now being weighed against by the endemic phase of Covid.

Read the next part about why the next weapon for fighting covid will be snaring sprays.