Against the Urgency of Normal

Monday, February 7, 2022

On Friday, February 4th, the United States passed 900,000 deaths from COVID, a figure that far exceeds the death rate in any other wealthy country. Against this backdrop come two pushes for an end to COVID restrictions from a small but vocal minority of UCSF providers. Two UCSF physicians, Dr. Vinay Prasad and Dr. Jeanne Noble, have been involved in creating a toolkit called The Urgency of Normal, which advocates for reopening schools and eliminating mask requirements. Meanwhile, four UCSF physicians — Drs. Jennifer Nguyen, Jarrett Moyer, and again Vinay Prasad and Jeanne Noble — wrote a petition to Gov. Gavin Newsom demanding an end to certain COVID restrictions in California, especially emphasizing an end to masking in schools.

Dr. Prasad’s involvement in both statements is notable, as he has been a vocal critic of public health measures throughout the pandemic, at one point actually comparing COVID restrictions to the Holocaust. On social media, Dr. Prasad is known for taking data out of context, such as when he argued that COVID doesn’t have a much higher fatality rate than the flu while ignoring the massively higher death tolls due to greater infectiousness. He uses his Twitter account to spread misinformation about vaccines and masking, and he recently coauthored an article arguing that it’s “natural,” “normal,” and “healthy” to expose children to vaccine-preventable infections.

Some common themes throughout the petition, toolkit, and social media posts are the ideas that vulnerable people should be responsible for protecting themselves (a strategy called one-way masking), that the pandemic is essentially over now, and that the social harms of COVID restrictions outweigh the benefits of preventing infection.

I’m not going to go into refuting every point made by this group of physicians, in part because UCSF’s Dr. Taylor Nichols wrote an excellent critique which does just that. Rather, I want to talk about what we mean when we talk about “normal,” and whose lives are acceptable to sacrifice get us there.

Prior to COVID, “normal” for the United States meant profit-driven healthcare, a public health system that we had underfunded for several decades, rampant health inequities, and rising wealth inequity.

Normal meant spending more per capita on healthcare than any other industrialized country while consistently having poor outcomes.

Normal is why we are in a crisis right now.

If someone’s idea of normal means going back to restaurants, gyms, and parties, sending their kids back to school unmasked, and not having to worry about protecting other people, that signals either profound ignorance of — or at least insulation from the normal that everyone else lives with.

It means that person hasn’t seen their communities ravaged by COVID, isn’t living with a condition that puts them at increased risk of dying, isn’t caring who immunocompromised loved ones. Normal means very different things depending on who you are.

One aspect that has made the discourse around normalcy even more convoluted is how it’s intertwined with the concept of endemicity.

In the most recent edition of UCSF magazine, Urgency of Normal signer Dr. Monica Gandhi was asked, “What are you most optimistic about in 2022?” to which she replied, “That we’ll be able to keep the virus under control in the U.S. once it becomes endemic.”

Despite the U.S. reaching 900,000 deaths, the word endemic has been thrown around a lot lately, often to suggest that COVID is becoming a mild infection with which we’ll coexist without serious disruption.

An endemic is a disease that persists within a population, neither spreading exponentially nor dying out. As others have pointed out, endemicity has nothing to do with the severity, incidence, or social harms of a disease.

To take just one example, prior to COVID, the number one cause of infectious disease deaths globally was tuberculosis, an endemic disease that killed 1.5 million people in 2020 and infects 25% of the world’s population.

Tuberculosis is a good example of an endemic that kills large numbers of people, and it’s also a good example of an infectious disease that is easy for people with privilege to ignore - most of those deaths are people who are socially marginalized or live in low income countries.

When public health professionals like Dr. Gandi or SF Health Officer Dr. Susan Phillips say endemic, what they really mean is, whatever amount of disease and death we decide is acceptable. Ultimately, however, the meaning of endemicity is rooted in infectious disease dynamics. It doesn’t tell us whether we should fight a pathogen or ignore it or what our strategy should be — that’s a choice we have to make.

If COVID stops spreading exponentially, but continues to have a disproportionate impact on communities of color, will we declare the pandemic over and go back to our normal lives?

When Dr. Prasad argued for letting children fight off viruses as part of a “normal” childhood, he obviously wasn’t thinking about kids with leukemia or pulmonary conditions or primary immune deficiencies.

Are we okay with children dying of COVID if the ones who die have comorbidities? Are we okay with elders, disabled people, and immunocompromised people dying?

What about telling them that they can take actions to protect themselves, but we’re done trying to protect each other?

Applied to other infectious diseases, this thinking seems absurd. We don’t tell people that they can stop wearing condoms if it was only to protect other people. We vaccinate kids against polio even though fewer than 1% of people with polio become paralyzed — we don’t advocate for “natural” immunity.

Part of public health is taking actions you might never benefit from personally because we’ve decided other people’s lives have value.

The COVID pandemic is not over yet. What that means for the future depends on what we choose to accept as normal.

If we decide that public health is the responsibility of individuals, that high death rates among those with little political power are acceptable, and that the wants of the healthy outweigh the needs of the sick or at-risk, then the normal that brought us here will persist and the crisis will continue or worsen.

But if we decide that we should in fact care deeply about other people, that public health does not mean every individual for themself, and that the 900,000 deaths in the U.S. were not inevitable, then a better future is possible.