Make Oregon 2019 Again

This post is aimed at public-health authorities in Oregon but it applies to any state with strict non-pharmaceutical interventions (NPIs). Short version: Set goals, tells us how to meet them.

If You Don’t Know Where You’re Going, Any Road Takes You There

I’m an Oregon resident.  I’m radically pro-vaccine.  I led implementation of Smart Health Cards (a.k.a. vaccine passports) for a healthcare provider.  I administer the “Find a COVID Shot Oregon” Facebook group, where we’ve helped thousands of Oregonians find vaccines and protect their families.  You can see evidence of my work here, here, here, here, and here.  I did what I was qualified and able to do to get us to “the other side of the canyon” with the COVID-19 pandemic.  The goal was always to allow Oregonians to get their lives back as quickly as able.

I feel the state has lost the plot, however.  It’s time to communicate a transparent exit plan for COVID-19 restrictions.  Yes, even during the Omicron wave. People need to know what “done” looks like. We need to look beyond the pandemic and do what we can to “Make Oregon 2019 Again”.

Clear Goals and Endpoints Are Important

Oregon’s public-health establishment - as elsewhere - is great at identifying issues and raising awareness, but (apparently) not at setting a clear definition of success during a timebound event (e.g.: a pandemic).  The success of a given event, strategy, or campaign is determined by setting discrete goals and thresholds for success.

To this end, OHA and the Governor’s office are failing.  Honestly, I'm not surprised. Lots of public health *is* awareness and working in a cyclical universe - use condoms and clean needles, conduct annual flu-shot campaigns, etc.  There often is no end, almost by definition.  But all pandemics end.  If OHA and the Governor’s office have stated what success looks like for this one, though, it’s news to me.  Define success, then make policy to match.  We had metrics for a year, scrapping them this past summer.  At least the state had something to point to justify its policies.  Why not modify those and use them again?  Serious question.  People are tired.  We can’t expect customer-facing businesses, schools, and organizations and their current and future workers - to the extent people choose to work in them under these conditions - to enforce compliance indefinitely.  We need defined exits.  

Masks Were Awesome in 2020 but…

As I wrote in Conflation:

In early 2020, we all understood the assignment. A virus is out there, it spreads stealthily, wear some masks to protect others from you, etc. It was easy to tie behavior to risk, as everyone was on the same level. There were no vaccines, options, nor data. If you headed indoors, you were supposed to wear a mask as a best practice. If you didn’t, your behavior was pretty easily tied to outcomes - both for you and those that interact with you.

However, infections no longer correlate well to bad outcomes…unless you’re unvaccinated (more on that below). Here’s a map of the USA. Point to the states with mask mandates (from Apple News on 1/7):

I’d guess people in Idaho, Montana, Nevada, and Wyoming aren’t wearing masks. Decent chance they are in New York and New Jersey, as well as here on the West Coast. There’s almost no correlation. If masks were the way out, we wouldn’t see images like this.  Oregon’s mask mandate has been in place since early August. Did it stop the Omicron wave? It did not.

Masks That Protect Me

Now, to be clear, it’s acceptable at this point to recommend - even subsidize - good ones (read Josh Marshall’s article about masks that protect you…and even consider subscribing to his site), and people may choose to wear them 100% of the time when around others. However, mandating them doesn’t really have a basis in data any longer. The serious risk is to the unvaccinated, mostly above the age of 65. More on that below.

Masks Aren’t the Path to Normal, Vaccines Are

First, some graphs from the CDC:

Vaccinated and, even better, boosted? You’re living the high life, alive and healthy, even over 65.

But even if we just look at deaths of people that received the initial series, we see that the common denominator is vaccination:

What is true for the USA is true for Oregon, of course. According to OHA on 1/6:

[T]o date, 4% of all vaccine breakthrough cases have been hospitalized and 1.2% have died. The average age of vaccinated people who have died is 81.

OK, so vaccines keep you alive. But what about keeping you from getting sick? They’re pretty solid there, too:

Vaccines work to keep you healthy and alive.  Simple.  Prior infection with COVID-19 can do the same, to be honest…but the lowest-risk way is to get vaccinated.

Second, I started collecting and plotting data during the Delta surge, starting on 8/9.  Some results (as of mid-December):

It’s not a secret as to why most counties with vaccination rates in the top 10 in the state - including the tri-county Portland metro - are hanging out on the right side of this graph.  If we remove “ruralness” by focusing only on Oregon’s 10 counties with 100,000 residents or more, the relationship is pretty obvious:

The two counties with the highest vaccination rates are at the bottom; the four with the lowest are at the top. 

Plotted against one another, you see the correlation:

Of course there are factors that keep the correlation from being perfect - prior infection rate (Umatilla, Malheur, and Morrow had a big initial wave in 2020), median age of the county (Lincoln and Tillamook are quite old, and Umatilla and Malheur quite young, for example), or population density (Wheeler County has only ~1,500 residents) - but the trend holds - the higher the vax rate, the lower the death rate.  

Antibodies Are Cool but Adaptive Immunity is Cooler

This message has gotten muddled and public-health authorities are partly to blame.  Antibodies aren’t the whole game.  They’re just part of it.  You wouldn’t know it by listening to the discourse, however.  Focusing on antibodies incessantly is depriving the public of incredibly-important information - their immune systems have been primed to fight the virus, not just a part of it, regardless of what it looks like.

Vaccines are fire extinguishers, not body armor.  Your immune system kills invaders; it can’t stop them from invading (it’s inside your body!).  This is important because it means that we’re never going to get to zero COVID-19 cases, just as we can’t get to zero influenza cases.  We can, however, get to a point where COVID-19 is a boring disease that makes you tired, a little phlegmy, and stuffy.  It won’t be a picnic but it probably won’t be dangerous.  Why?  Adaptive immunity.  Learn about it in this series of YouTube videos from Khan Academy; or via this excellent article by Monica Gandhi, of UC-San Francisco Medical School, at Leaps.org. Much is made of “waning immunity” but that’s…how your immune system works.  The immunity that “wanes” is your first line of defense - antibodies.  When the virus is no longer trying to invade your body, they start to disappear.  However, your immune system also creates “memory” cells - B & T cells - which can detect the virus, “activate”, then make more - and better-suited - antibodies, if needed, and kill the virus and infected cells.  Get infected again?  B cells make billions more *better suited* antibodies, instantly. Per Dr. Gandhi:

…[M]emory B cells will actually produce antibodies adapted against the COVID variants if they see a variant in the future, rather than the original antibodies directed against the ancestral strain.

Oh? Look up “somatic hypermutation” or just read this article.  Your immune system anticipates future variants. So, if you’ve been vaccinated - or previously infected - your body is prepped to fight literally billions of different variations of said virus.  You might get infected more easily - you lack antibodies for that specific variant - but your illness will likely be mild, regardless of the variant, because your memory cells will attach to the new variant and make antibodies for it ASAP.  This is why you’re protected against “severe disease”.  The virus just can’t get far.  Need a visual for this?  Here you go, courtesy of Müge Çevik of the University of St. Andrews:

Who filled Oregon’s hospitals this past summer?  Overwhelmingly the unvaccinated.  Now? Same. Vaccines reliably prevent hospitalization and death, which is what they’re designed to do.  Breakthrough infections, in general, are not of significant concern for the vast majority of the public that has immunity, regardless of the viral strain.

Oregonians Have Chosen Their Normal

As I write this, the state just hit 71.8% of all residents vaccinated (one dose) with 28.3% boosted.  In December, OHSU estimated that around 85% of the state has immunity against infection right now, with 20-25% having been infected and vaccinated (this is called “hybrid immunity”), which makes them super immune. 

As impressive as these are, the growth rate of vaccination has slowed to a crawl, with every age group 12+ increasing at only about 1% per month.  You can see the rates below

Now, anyone getting their first shots or boosted on any given day is good, but the devil is in the details. What we really have is a “rich get richer” situation on our hands. Where are most vaccines being administered? If you guessed “counties with high vaccination rates”, YOU’RE THE BIG WINNER! Here’s Multnomah County (high rate):

However, here’s Douglas County (low rate), which is roughly 1/7 the size of Multnomah County:

It’s still vaccinating but at a considerably-lower rate (first and booster doses), meaning the gap is growing. To quote Matt Yglesias:

[W]e’re now divided between cautious vaccinated people who want to live their lives as normal and unvaccinated people who don’t care about the virus at all. 

Sadly, this might have something to do with it…

An r-squared value of 0.858 roughly means that if you know a county’s Biden vote margin in the 2020 presidential general election, you can predict, with 85.8% accuracy, the vaccination rate of the county. To say COVID-19 vaccination has been politicized does politicization a disservice. It’s nearly law.

Masks and Distancing were the “Bridge” to Vaccines

I know we have a Swiss-cheese situation…

…but we’re dealing with a highly-infectious, airborne virus. Avoiding gatherings will help, for sure, but social distance, substandard masks (but mandated), and handwashing will do little to stop spread with a virus whose r-nought (R0) is in the 8-10 range (super contagious). This means that stopping it is basically impossible unless you isolate yourself. But if you can live with a little discomfort for a short time? Vaccination is doing a great job of preventing or muting illness. This is no longer 2020. We have tools to make this a boring virus and they work within our bodies.

But Won’t Wearing Masks Help A Little?

Sure, I suppose. But not enough to make a big difference. Additionally, people have to actually wear them (ie: comply). The problem is that the last time OHSU included this in one of their forecasts (11/19), vaccinated Oregonians were twice as likely to wear a mask than unvaccinated Oregonians.  

Also, if you do wear a mask, you can wear any mask. You don’t need a good mask, and there are all kinds of maskless situations allowed:

• Private gatherings at homes

• Actively eating or drinking anywhere

• Group exercise classes

So, high-risk people don’t bother to wear them and those at lower risk don’t have to wear a good one.  Not very effective. But we have to wear them…which means that low-risk people (who won’t get very sick) and businesses (who have to enforce compliance) bear the brunt of the restrictions, which makes this a rather perverse incentive.  People and businesses need to know where this regime of restrictions is headed.

The Bottom Line

Oregonians have chosen their normal.  The state just hasn’t acknowledged it.   So, what are we waiting for?  Let’s set clear goals, measure our progress, then declare victory when we get there.

Does 2022 normal look like 2019 normal?  Doubtful.  I expect voluntary masking (with the good kind) and frequent DoorDash orders for some.  However, the time for mandated restrictions has passed.  The data is in: vaccines work, and they work well.  Will they stop you from ever getting sick?  No (though they do it rather well).  But they’re great at keeping you alive and home. 

It’s time to Make Oregon 2019 Again.  Let’s plot our course to get there.  Soon.