Covid-19 budgets are shrinking. What’s the best way to spend what’s left?

Covid-19 budgets are shrinking. What’s the best way to spend what’s left?

Covid-19 is still not done with humanity. Decorative gourd season is on the horizon, and with it, more cozy time indoors by the fire with friends, loved ones, and the latest set of SARS-CoV-2 variants. It means: We’re probably going to need to spend more time and money fighting the virus. Where should that money go?

We’ve already spent a lot of money on the pandemic. Like, really a lot, especially in the early days: health care spending increased by nearly 10 percent between 2019 and 2020, when it normally increases by only about 4 percent annually.

We were really in desperate times,” said Arthur Caplan, a bioethicist at New York University’s Langone Health Center, “and that drove expenditures.” In 2020, the knowledge vacuum on how to treat Covid-19 led to huge costs, mostly in the form of public Medicaid dollars, accounting for nearly a third of the $4. 1 trillion the US spent on health care in 2020. The nation also spent $18 billion on developing vaccines in Operation Warp Speed.

Two and a half years later, it’s hard not to wonder: At this point in the pandemic, how great are the returns on any of the Covid-19 investments American society could make? What pandemic tool is most important now?

Investments today likely face diminishing returns. Today, at least 95 percent of Americans have some immunity to the virus. There are effective Covid-19 vaccines and treatments, and the American appetite for pandemic precaution has withered.

Importantly, the trillions of dollars in federal funds committed to pandemic response have largely been spent. Of the $4. 5 trillion the US Congress has allotted to fight Covid-19, agencies have paid out $3. 9 trillion — and there’s little enthusiasm among legislators to spend more. The “what’s the worth of it now?” question is hard to answer because the benefits and costs are not easily quantified. Models have attempted to predict how effectively certain policies and programs save lives and prevent bad medical outcomes. But models can’t account for the “unknown unknowns” of the pandemic — the new variants, new beliefs, and logistical challenges that determine what the public will accept and, in the end, what actually works.

I asked six experts — among them academics and practitioners in public health and health policy, economics, security, and ethics — what’s worth investing in at this point in the pandemic. We wanted to understand their thinking on the complex issue of where our next major pandemic investment should go.

Two major areas were identified: next-generation vaccines (NGV) and air filtering.

Why next-generation vaccines are a critical part of the solution

Every expert I spoke to mentioned next-generation vaccines as a key intervention for reducing Covid-19’s impact going forward. The “next-generation” piece is important here: Experts use this term to refer to vaccines being developed with the goal of altogether preventing Covid-19 infection.

Although currently available vaccines do a great job at keeping people out of the hospital and alive, they no longer stop infections in their tracks. That matters because even when viral replication doesn’t lead to severe disease, it provides the SARS-CoV-2 virus with opportunities to evolve new variants and, potentially, to cause new cases of long Covid, an often-debilitating condition affecting one in 13 Americans, that involves a range of symptoms lasting weeks, months, or even years after an initial infection.

For this reason, experts eagerly await “not just strain updates,” like the bivalent vaccines likely to drop this fall, said Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security who focuses on emerging infectious diseases. What’s needed are “universal coronavirus vaccines, nasal vaccines, oral vaccines — something that provides more protection against infection than the current approved vaccines do.”

Although multiple universal vaccine candidates are in development, only one — developed by the US Army — is in the phase 1 clinical trial stage, which aims to assess a vaccine’s safety. These candidates are different than existing vaccines in that they attempt to harness other parts of the immune systems. The virus’s spike protein is the target of neutralizing antibodies, which are constantly changing. Other responses, such as T-cells or memory B cells, could also target parts of the virus’s structure.

If universal vaccines could induce the immune system to stop viral replication, thereby achieving a “sterilizing immunity”, Adalja explained. Adalja stated that “In general, it is best to avoid getting an infectious disease or any other infectious disease.”

Meanwhile, at least 12 nasal vaccine candidates are in clinical development. These vaccines, administered as nasal sprays, achieve high levels of protective antibodies in the parts of the nose and throat that first encounter the virus. The vaccines close the door on the virus from entering the body. Vaccines that are injected directly into muscle will deal with it once it has passed the respiratory system.

Jay Varma is an epidemiologist and physician who heads the Cornell Center for Pandemic Prevention and Response. He said that it typically costs around a billion to get a new drug on the market. While it’s unclear how much more it would cost to develop and distribute a universal coronavirus vaccine in the US, the ballpark is likely in the tens of billions of dollars. So far, only about $250 million has been committed to developing these new products.

If a next-generation vaccine really came through on a promise of sterilizing immunity, it would likely eventually be required for kids entering public schools, said Varma. In his mind, that would signal the true sunset of the pandemic: “Everybody gets vaccinated sometime between the ages of 3 and 5, and then you don’t have to worry about them arguing with you when they’re 20 years old about not getting vaccinated,” he said.

Adalja noted that if everyone who’d gotten at least one vaccine were to be vaccinated with a next-generation formulation, about 70 percent of Americans would have long-lasting protection from infection. He said that this would make a significant impact on the transmission of infection.

At a late-July White House summit on the future of coronavirus vaccines, experts discussed efforts to accelerate development of next-generation vaccines. But there’s no clear indication that any funder — least of all the US Congress — is planning a multibillion-dollar investment in next-generation vaccines.

Improving indoor air quality could dramatically reduce Covid-19 transmission without requiring behavior change — and have other wide-ranging benefits

Although investing in developing and buying vaccines may be the most important thing we can do to end the pandemic, any pandemic strategy that relies exclusively on vaccines has “a ton of limitations,” said Megan Ranney, an emergency physician and health services researcher at the Brown University School of Public Health.

Another important cornerstone of a path forward, she says, is improving air qualities in buildings. “That would be impactful, not just for Covid but for other droplet- or aerosol-borne illnesses, never mind allergies and pollution,” she said.

For decades, scientists have been aware of links between a variety of health problems and contaminated indoor air, but the pandemic has led to renewed interest and focus on the infection risks of inadequate filtration and ventilation.

In March, the White House announced a call to action urging building schools and state and local governments to use any of the $522 billion allotted as part of the American Rescue Plan to make indoor air quality improvements. (The caveat here is that those dollars can and likely will be used for other Covid-19-related expenditures.) The Environmental Protection Agency issued a Clean Air in Buildings Challenge with best practices for reducing the risk of transmitting airborne particles indoors.

Joseph Allen, an environmental scientist and air quality researcher who directs the Harvard Healthy Buildings Program, says one of the key advantages of pursuing these healthy building interventions is that they require no buy-in or even awareness from the majority of the people who benefit from them. He said that they don’t need behavior changes. It doesn’t mean you have to force people to take tests every day or put masks on them.

Achieving cleaner indoor air isn’t cheap. Compared with the nearly $5 billion price tag of the bivalent vaccines and even Operation Warp Speed’s much heftier budget, the costs of overhauling all of the schools, office buildings, and multifamily residential buildings in the US are likely much higher. While incentives may be offered to encourage building owners to upgrade their HVAC systems, they don’t necessarily have to be funded by the federal government. Because upgraded buildings have higher market value, individual building managers may want to take retrofits upon themselves.

The up-front costs “could be balanced against the potential benefits not just in preventing Covid,” said Varma, “but in preventing other respiratory infections, and potentially, in certain areas, protecting against allergic conditions, pollution, etc.” Some older modeling studies suggest that investments made in improving air filtration and repairing buildings’ existing HVAC systems yield early returns, with some investments paying for themselves in energy savings or reduced respiratory illnesses in less than five years.

Experts favor strategies whose benefits would outlast the pandemic

One of the features that distinguishes next-generation vaccines and indoor air quality innovation from other strategies is that investments in both of these areas will keep on giving well after Covid-19 is (relatively) in the rearview mirror.

For example, the dividends of a breakthrough on a universal coronavirus vaccine would have “cascading benefits” on other areas of vaccine development, said Adalja.

The benefits of sustainably improving indoor air also extend beyond the realms of infectious disease and even public health, and into increased worker productivity.

Lower air quality reduces cognitive performance among workers, and improving air quality increases productivity and reduces absenteeism, which together increase a workplace’s profitability. Improving indoor air also holds potential benefits for climate change mitigation. Allen recommends many changes that would increase energy efficiency and protect people against the negative effects of weather-related events such as wildfires. He said that there is so much potential for magic when we work together to create healthy buildings strategies that go beyond Covid.

It’s also worth noting that, despite what cost-effectiveness models say, none of the experts I spoke with favored masks or strategies with strong quarantine-and-isolation components. “Masking is probably the most cost-effective thing, but it’s the least acceptable thing” in terms of what the public is willing to do, said Varma. With Americans increasingly unwilling or unable to engage in some of the strategies that defined the early days of the response, perhaps the interventions most worth the investment are the ones that require no action on the part of the individual.

There are lots of right answers to this question

Although the experts I spoke with were generally in agreement on the important investments forward for the US as a whole, many of them told me that the right choices had a lot to do with who’s making them. “Who is ‘we’? Who’s making the decision?” said Lisa Robinson, deputy director of the Center for Health Decision Science at Harvard’s public health school. Experts have repeatedly told me that decision-makers can make decisions that are wildly different in terms of their resources, value, and liabilities. For example, a school district with a large number of low-income students — and many schools who favor vaccination requirements — might find a vaccine mandate to be a popular and low-cost way to protect students and staff. A cafe proprietor in a small town might decide that expanding its outdoor space is the best way to keep staff safe and open, while also lowering masking rates.

Different leaders in the public and private sectors have different options and different budgets when they make these choices, and they answer to different constituencies. The size and the power of the group an intervention affects changes the stakes associated with choosing those interventions. So do the time and context in which decisions are made. When elected officials perceive their popularity as being tied to the popularity of their decisions, for example, they may be incentivized to delay — or rush — certain interventions. Robinson stated that the most important aspect of fighting the virus is not the “method you use”. “It’s being thoughtful about what might actually happen if you’ve implemented policy.”

Although I asked experts to choose one most promising investment aimed at reducing Covid-19’s impact, several pointed out that improving social welfare can also pay dividends in terms of public health. The US safety net is a patchwork system that leaves people without work and their families with no food. If people are unable or unwilling to work, it can lead to a lack of income and an increase in the likelihood of getting sick.

Alongside investments in next-generation vaccines and indoor air quality, said Ranney, investments in some of public health’s most basic functions — gathering data and communicating with the public — are critical to finding a way out of the pandemic. “The fact that we’re having to say, ‘this one thing over that one thing’ is a commentary on how underfunded and under-resourced our public health system is in general,” she said.

“We should not have to decide between vaccinations or ventilation,” she stated. “But it’s also kind of reality.”

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