If We Knew Then What We Know Now About Covid, What Would We Have Done Differently?

We didn’t understand how great the airborne threat from Covid-19 was—that it could be transmitted by breathing tiny aerosol particles that could linger in the air and travel far beyond our 6 feet of social distancing. If we had known, we could have taken more effective measures to control the spread.

For much of 2020, doctors and public-health officials thought the virus was transmitted through droplets emitted from one person’s mouth and touched or inhaled by another person nearby. We were advised to stay at least 6 feet away from each other to avoid the droplets that would most likely fall to the ground within seconds. Since the droplets might contaminate surfaces, we washed our produce, sanitized our hands (to the tune of “Happy Birthday”), cleaned doorknobs and railings with alcohol, and opened our Amazon deliveries outdoors because the boxes might be contaminated.

A small cadre of aerosol scientists had a different theory. They suspected that Covid-19 was transmitted not so much by droplets but by smaller infectious aerosol particles that could travel on air currents way farther than 6 feet and linger in the air for hours. Some of the aerosol particles, they believed, were small enough to penetrate the cloth masks widely used at the time.

The group had a hard time getting public-health officials to embrace their theory. For one thing, many of them were engineers, not doctors.

“We were outsiders,” says Jose-Luis Jimenez, a professor who teaches aerosol science at the University of Colorado, Boulder. More than 260 scientists signed an article laying out their argument in July 2020 in the journal Clinical Infectious Diseases. In October, the Centers for Disease Control and Prevention revised its guidelines to acknowledge the potential for airborne spread of Covid-19 when people are singing or exercising in poorly ventilated areas.

“My first and biggest wish is that we had known early that Covid-19 was airborne,” says Megan Ranney, an emergency physician and associate dean at Brown University’s School of Public Health who will become dean of the Yale School of Public Health in July.

John Volckens, professor of environmental health and an aerosol scientist at Colorado State University in Fort Collins, Colo., says, “Once you’ve realized that, it informs an entirely different strategy for protection.” Masking, ventilation and air cleaning become key, as well as avoiding high-risk encounters with strangers, he says.

Instead of washing our produce and wearing hand-sewn cloth masks, we could have made sure to avoid superspreader events and worn more-effective N95 masks or their equivalent. “We could have made more of an effort to develop and distribute N95s to everyone,” says Dr. Volckens. “We could have had an Operation Warp Speed for masks.”

We didn’t realize how important clear, straight talk would be to maintaining public trust. If we had, we could have explained the biological nature of a virus and warned that Covid-19 would change in unpredictable ways.  

“The science is really important, but if you don’t get the trust and communication right, it can only take you so far,” says Bob Wachter, chair of the department of medicine at the University of California, San Francisco. In the face of a pandemic, he says, the public needs an early basic and blunt lesson in virology. They need to understand that infectious disease isn’t intuitive, that it grows exponentially and mutates, and since we’ve never seen this particular virus before, we will need to take unprecedented actions and we will make mistakes, he says.

Since the public wasn’t prepared, “people weren’t able to pivot when the knowledge changed,” says Katelyn Jetelina, an epidemiologist who writes the public-health newsletter Your Local Epidemiologist. By the time the vaccines became available, public trust had been eroded by myriad contradictory messages—about the usefulness of masks, the ways in which the virus could be spread, and whether the virus would have an end date.

Doctors and epidemiologists stepped into the information breach in an effort to clear up confusion and counter misinformation. Emily Oster, an economics professor at Brown University, used her newsletter ParentData to advise parents about vaccines, masks and their children’s schooling. The Brown-Lifespan Center for Digital Health and Harvard’s T.H. Chan School of Public Health created free Covid risk calculators to help people assess the risk of, say, bar hopping or going to a dinner party based on variables such as expected time spent, size of the gathering and ZIP Code. On Twitter, Dr. Wachter began sharing with followers everything he was learning about Covid-19 in real time and explaining how he was weighing his own personal risk in long Twitter strings that explained the changing science.

But while these efforts no doubt helped people, the absence of a single, trusted source of clear information meant that many people gave up on trying to stay current or dismissed the different points of advice as partisan and untrustworthy.

We didn’t know how difficult it would be to get the basic data needed to make good public-health and medical decisions. If we’d had the data, we could have more effectively allocated scarce resources, managed Covid cases and made key decisions about schools.

For much of the pandemic, doctors, epidemiologists, and state and local governments had no way to find out in real time how many people were contracting Covid-19, getting hospitalized and dying. Doctors didn’t know what medicines worked. Governors and mayors didn’t have the information they needed to know whether to require masks. School officials lacked the information needed to know whether it was safe to open schools. As the virus began to mutate into variants such as Omicron that were more infectious, people didn’t know whether it was OK to visit elderly relatives or go to a dinner party.

In fact, in September 2019, just months before the outbreak of the pandemic, the Council of State and Territorial Epidemiologists released a white paper detailing the urgent need to modernize the nation’s public-health system still reliant on manual data collection methods—paper records, phone calls, spreadsheets and faxes.

While the U.K. and Israel were collecting and disseminating Covid case data promptly, in the U.S. the CDC couldn’t. It didn’t have a centralized health-data collection system like those countries did, but rather relied on voluntary reporting by underfunded state and local public-health systems and hospitals. Some states reported the data daily; others weekly. Data collection was hampered by a jaw-dropping lack of technology.

In the absence of government information, doctors and scientists say they had to depend on information from Israel, the U.K. and South Africa to understand the nature of new variants and the effectiveness of treatments and vaccines. They relied heavily on private data collection efforts such as a dashboard at Johns Hopkins University’s Coronavirus Resource Center that tallied cases, deaths and vaccine rates globally.

At the Rhode Island Hospital in Providence, “we were relying on courier and fax,” says Dr. Ranney.

With good data, Dr. Ranney says, she could have better managed staffing and taken steps to alleviate the strain on doctors and nurses by arranging child care for them.

To solve the data problem, Dr. Ranney says, we need to build a public-health system that can collect and disseminate data and acts like an electrical grid. The power company sees a storm coming and lines up repair crews. It tells us when the power will go out, for how long and how to stay safe, she says. It can do that because it has the data giving it a full picture of the risks, the outages and what’s needed to minimize both. By contrast, the U.S. healthcare system is too often flying blind.

If we’d known how damaging lockdowns would be to mental health, physical health and the economy, we could have taken a more strategic approach to closing businesses and keeping people at home.

Studies on the efficacy of lockdowns that closed businesses and kept us in our homes are all over the map, but many doctors say they were crucial at the start of the pandemic to give doctors and hospitals a chance to figure out how to accommodate and treat the avalanche of very sick patients.

The measures reduced deaths, according to many studies—but at a steep cost.

In the U.S., states began their shutdowns in March 2020. In some states, such as Georgia, Alaska and Oklahoma, the shutdowns lasted barely a month, according to the CDC. In California, partial lockdowns—called stay-at-home orders—based on hospital capacity and Covid case rates lasted until June 2021. The nation’s unemployment rate shot up. Businesses closed. People delayed medical care, which epidemiologists believe has contributed to increases in deaths due to causes other than Covid. The isolation took a heavy toll on mental health, especially of young people. Drug overdoses soared. Anxiety and depression spiked among children who missed friends and school and had to endure remote learning.

The lockdowns didn’t have to be so harmful, some scientists say. They could have been more carefully tailored to protect the most vulnerable, such as those in nursing homes and retirement communities, and to minimize widespread disruption. Lockdowns could, during Covid-19 surges, close places such as bars and restaurants where the virus is most likely to spread, while allowing other businesses to stay open with safety precautions like masking and ventilation in place.  

The key isn’t to have the lockdowns last a long time, but that they are deployed earlier, according to research by scientists at the Imperial College of London. If England’s March 23, 2020, lockdown had begun one week earlier, the measure would have nearly halved the estimated 48,600 deaths in the first wave of England’s pandemic, according to the Imperial College research. If the lockdown had begun a week later, deaths in the same period would have more than doubled, according to the study.

It is possible to avoid lockdowns altogether. Taiwan, South Korea and Hong Kong—all countries experienced at handling disease outbreaks such as SARS in 2003 and MERS—avoided lockdowns by widespread masking, tracking the spread of the virus through testing and contact tracing and quarantining infected individuals.

Had we known that even a mild case of Covid-19 could result in long Covid and other serious chronic health problems, we might have calculated our own personal risk differently and taken more care.

Early in the pandemic, public-health officials were clear: The people at increased risk for severe Covid-19 illness were older, immunocompromised, had chronic kidney disease, Type 2 diabetes or serious heart conditions. The warning proved accurate, but it had the unfortunate effect of giving a false sense of security to people who weren’t in those high-risk categories. Once case rates dropped, vaccines became available and fear of the virus wore off, many people let their guard down, ditching masks, spending time in crowded indoor places. If Covid-19 is little more than a bad cold, why continue to worry about it?  

Gradually, though, it has become clear that even people with mild cases of Covid-19 can develop long-term serious and debilitating diseases. Long Covid, whose symptoms include months of persistent fatigue, shortness of breath, muscle aches and brain fog, hasn’t been the virus’s only nasty surprise. In February 2022, a study found that, for at least a year, people who had Covid-19 had a substantially increased risk of heart disease—even people who were younger and had not been hospitalized. Researchers at the CDC have found that after having Covid-19, people are at twice the risk of developing a pulmonary embolism and respiratory conditions.  

Some scientists now suspect that Covid-19 might be capable of affecting nearly every organ system in the body. It may play a role in the activation of dormant viruses and latent autoimmune conditions people didn’t know they had.

Doctors and scientists are now racing to find the causes of long Covid and possible ways to prevent it. “What we’d like to have is a simple blood test that would help people anticipate their risk—something

Labcorp

can do,” says

Jim Heath,

president and professor of the Institute for Systems Biology, a nonprofit biomedical research organization in Seattle which has identified four risk factors for long Covid. A blood test, he says, would tell people if they are at higher risk of long Covid and whether they should have antivirals on hand to take right away should they contract Covid-19.

If the risks of long Covid had been known, would people have reacted differently, especially given the confusion over masks and lockdowns and variants? Perhaps. At the least, many people might not have assumed they were out of the woods just because they didn’t have any of the risk factors. They might have been more careful in assessing their own risk, and the risk of those around them, and might have taken more precautions—such as wearing masks or eating outdoors even after the disease got milder. 

Ms. Morris is a writer in San Francisco. She can be reached at [email protected].