Leana Wen talks Covid risk tolerance and her response to critics

When at least 80 out of about 600 people who attended the swanky Gridiron Club dinner in Washington, D.C., a couple of weeks ago got Covid-19, critics called the event irresponsible and an example of why we can’t just go back to normal.

Leana Wen had a different take, writing in The Washington Post that the Gridiron Club outbreak shows what living with Covid looks like. It was a take many agree with, but which infuriated at least a subset of the public health world.

Wen is an emergency physician and public health professor at George Washington University and was previously Baltimore’s health commissioner. She spoke to STAT on “The Readout LOUD” podcast about her ideas on living with Covid more than two years into the pandemic. This interview has been edited for length and clarity, and you can listen to the full podcast episode here.

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Let’s start with that Gridiron dinner. Quite a few people got infected, but your take was largely that these kinds of events should still go on despite some of the lingering risks. Why do you think that?

One thing that has not been mentioned so much with the Gridiron dinner is that, as far as I know, no one has been hospitalized, no one has become severely ill. And actually, when we were talking about what success and living with Covid looks like when vaccines first started coming out, that was what it looked like. It looked like people still getting infected but not getting severely ill, not straining our health care system and us living with this disease. 

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I think there is an absolutism that’s taken over on both sides. There’s one side that has peddled misinformation and said that Covid isn’t real and that we never should have had any restrictions at all. And then there was another side that just can’t seem to let go of the fact that at some point you do have to move on. We have many more tools that we did back in 2020 and 2021. We can’t tell people in perpetuity that they can’t hold weddings and funerals and gatherings and retirement parties and and events. We have to be able to live with the risk of Covid as we live with the risk of virtually everything else in our lives.

Were you surprised by the amount of pushback that you did get from the opinion piece that you wrote? Particularly from people in the public health world? How do you respond to those kinds of criticisms?

I was just in clinic today speaking to my patients, speaking to my colleagues in health care, where people have returned by and large to the real world. I actually would wonder about these same people posting on Twitter — have they returned to aspects of pre-pandemic normal? I mean, if they’re going to indoor restaurants, if they’re also gathering with their loved ones, which I think is a very natural thing to do at this point, then they’re also taking some level of risk. 

I don’t judge people for the risks that they’re taking because I think we all have a different calculus of risk. I think the better question to ask is, “How much do I want to keep on avoiding Covid?” And I’m not trying to be cavalier and say there aren’t consequences to getting Covid. What I’m saying is, if it looks like all of us are going to contract Covid in the near future, what are you willing to give up in order to keep on avoiding it? 

For people who are still being really cautious, there’s a feeling of, we thought it was going to end. We thought that at some point we wouldn’t need to make those risk calculations every time we went out in public. Is it essentially just saying we have to learn to live with it because it’s not actually going to get better? Or are we not going to get to a place where the risk is actually lower for everyone?

I want to know for people who are saying it’s not time to remove mask mandates. It’s not time to go to large events. I want to know what is that endpoint for them?

My endpoint, if you will, changed really dramatically in December. I would say prior to Omicron, I was being extremely cautious. I have two little kids under the age of 5. My husband and I are generally healthy, but we tried very, very hard not to become infected ourselves, unsuccessfully. My husband got Covid prior to the vaccine, but we tried very hard to not get infected, to not infect our children. But two things happened. One is Omicron happened. It was so contagious. Very, very difficult to avoid. I’m quite convinced that everybody is going to get BA.2, if they have not gotten Omicron, in the near future. 

The other thing that happened was I saw the news that the vaccine for younger children was really nowhere on the horizon. And even if one were to come out, it’s not going to be that effective. And so my husband and I discussed this and basically decided, what are we waiting for? We started enrolling our 4-year-old in camp, including doing a lot more indoor activities. We ourselves started to engage in many more social activities, because for us, we are not willing to pay the price anymore to keep on avoiding Covid. 

I know some other people will feel differently. I would certainly advise my immunocompromised patients to continue being careful. I think those who take additional risks, including me, when we see individuals who are more vulnerable, we will take additional precautions. 

As you mentioned, we each have an individual risk calculation, but when you zoom out from the individual level, then you have the issue that policymakers face where they’re dealing with societal risks. This week, the CDC extended its requirement for masking on public transportation. How do you look at potential off-ramps on a policy level for something like that?

I can understand why the CDC has extended the mask mandate for an additional 15 days. I think the rationale is solid that they want to see what happens with BA.2. I think giving another couple of weeks to see what ends up happening is reasonable. I also think it’s reasonable to ask for an off-ramp. What happens after two weeks if the cases start decreasing? I think that there is a group of people who really want masks in perpetuity and the administration and the CDC need to say to these individuals that that’s just not realistic here in the U.S.

Masks and vaccines and so many other precautions have become so politicized, so inserted in the middle of ideological culture wars. To one side, it’s seen as about control and to the other side, it’s seen to be about respect. And we’ve lost sight of what they’re actually here for, which is public health. 

I wrote my latest piece in the Post about how I don’t think that the mask mandate should have come back in Philadelphia. And I don’t think that other cities or states should be re-implementing them at this point because I am really worried about crying wolf. I’m worried that if something that really should be saved as a last resort and used in a time of true public health crisis, which is a government-imposed mandate. If it’s being used when it’s not actually an emergency, then in the future, if there’s a new, really worrisome variant that’s really deadly and that spreads more easily and that evades prior protection and people are saying, well, I don’t believe you.

Some people have pointed out that our policies need to protect the most vulnerable people in our society with Covid. Maybe that’s people who are immunocompromised. What’s your feeling about that? 

They are right that we have to do much more to protect people who are immunocompromised, by the way, those people who are immunocompromised are also my loved ones. They’re also my patients. And those individuals also want to move on with their lives. Our job is to make it as safe as possible for them, too. And again, we have a lot more tools, and I think what we should be aiming for is getting those tools out there. We should really be getting treatments out there and telling people that if they are at risk for severe illness, that they need to understand their own treatment plan. This is what I’ve been trying to tell all my patients. If there’s even a chance of you getting infected, know your treatment plan. Are you eligible for Paxlovid? Are you taking medications that might preclude you from getting it? Can you get monoclonal antibodies? What about remdesivir? 

Immunocompromised people want to live too. People with chronic medical conditions want to get on with their lives too. So let’s not pretend that somehow there is this large cohort of people who want to stay restricted. That’s really not reality.

It would be so wonderful if people could figure out how to access these medicines. We’ve just seen the system is just not working even for really sophisticated people who are connected to health care, it’s really difficult to get these drugs. How do we make sure that these tools are getting to people who cannot easily access the medical system?

I would say this is the same with any issue in health care, and it’s a problem throughout, right? We have to do so much more when it comes to health equity, to reducing disparities, to health care access. Covid shines a light on these disparities in a way that maybe a lot of people have not seen before. The people who are privileged are going to have access to the best care. Everybody else is going to be worried about what level of care they’re going to get, how they’ll access care. There are going to be barriers like transportation, taking time off from work. They may not have primary care. I mean, this is the same throughout. 

Now I am not saying that this is justified or OK, but I’m also saying that that is not a reason to keep restrictions in place because these are systemic issues that will take everyone working together longer term. There have to be shorter term actions that can be taken as well. In the meantime, we need to give people the tools that they need, and that means before you’re ill having this plan. And I think that part is very important because people tend to not think about their health until a crisis has happened. Of course, I would very much urge Congress to provide the funding that the Biden administration really needs in order to supply antivirals, to increase testing, to treat the uninsured, and all these other systemic issues too.

Do you think that we as a society have let some of the immediacy of Covid go to waste when it comes to instituting policy changes and public health policies? Should we have done more while the country was more focused on this pandemic?

Public health suffers from this cycle of panic and neglect where during a crisis everybody cares and everybody wants to fund all these things. And then as soon as the crisis subsides, nobody thinks about it anymore. And then the public health infrastructure gets more and more eroded. 

The workforce loses morale, they lose support. There’s lack of funding. I mean, it’s a major issue. I’d also say that there have been attempts to try to remedy the situation, but I don’t know really what’s happened. There was all this funding that came to locals and to states. But I think there needs to be an investigation on what’s happened to that funding because I don’t know that a lot of the funding has actually gone to public health. As a result, that fuels this narrative that no matter how much money you throw at the problem, nothing is going to get better. 

What is the funding that was allocated? Was it actually used for public health or was it siphoned to other places? 

How do you view the risk of long Covid? Infection doesn’t come with absolutely no risk, even if you’re not at high risk of hospitalization or death. So how do you navigate that?

I absolutely believe that that long Covid is real. I’ve had patients who are suffering long-term consequences, six months, a year after. We need a lot more research into what long Covid actually is because there is no clear definition. Is it shortness of breath, fatigue after two months? Would you consider that long Covid? Or are we really talking about disabling headaches and being unable to focus on work a year after? I mean, what is the definition here?

I think there are so many unknowns about long Covid that it’s very difficult to calculate the risk for any given person. And so if somebody says, well, how do I think about my risk of long Covid, I would actually ask them the question in a totally different way, which is it going to be really difficult to avoid Covid at all? Are you willing to give up a lot in order to avoid Covid? You don’t exactly know what is going to happen once you have it, but you do know what will happen if you don’t let your kids go to camp or sleepovers or extracurriculars. You do know what happens when you are not traveling and not going to indoor events with others. I really believe that all of us, unless we take really extraordinary steps, are going to get Covid and therefore be at risk for long Covid. I accept that risk for myself. I accept that risk for my children the same way that I accept that when my 2-year-old climbs onto a play gym and her brother is there, he may very well push her off of the play gym. Now, I wish that that won’t happen. I will do my best to make sure that doesn’t happen, but that is a risk that I have to be able to tolerate. And I think of Covid in that same sense.