LA County says starting February 25, it will drop indoor mask rules at bars, gyms, and offices for fully vaccinated people. It follows Governor Gavin Newsom’s move earlier this month to drop the statewide mask mandate for vaccinated people and begin treating COVID as an “endemic” disease, meaning one we have to live with and manage.
What will this change mean for Americans with compromised immune systems? The U.S. is still reporting more than 100,000 new COVID cases a day, and life-saving therapies are in short supply.
Lindsay Ryan, an emergency room doctor at the San Francisco VA and an HIV specialist, has a rare neurological autoimmune disorder. She says she’s taken four COVID vaccine shots, and always wears her N95 mask when she leaves the house for any purpose, whether to get milk from the corner store or work a 10-12 hour hospital shift.
“My N95 mask never leaves my face. And if I'm going to … have a sip of water, it's shivering outdoors in the ambulance bay. … I never let my vigilance up for a second. I'm also blessed with co-workers who have really taken many of the patients who are febrile and have a cough off of my hands. But certainly COVID is ubiquitous enough that I still see a fair number of COVID patients.”
Ryan says it was premature for San Francisco to drop its indoor mask mandate in mid-February (before LA did), and it exacerbates inequities. She explains that while caseloads are falling, they are still high, and there is inadequate access to antivirals that could reduce the risk of hospitalization and death by some 90% if you get COVID.
If she gets infected, she says she could get antivirals because she’s well-versed in the medical system and could look at databases of which pharmacies have supplies. However, that’s not the case for her HIV patients who are severely immunocompromised, might not have housing or a reliable phone, or may not speak English as their first language.
She notes that before the pandemic, she didn’t think about her immunosuppressive medication much in day-to-day life, but COVID is a fundamentally different disease in terms of its risks and impacts on society.
“The risk to an individual immune-compromised person is a little bit difficult to pinpoint, it depends on a lot of factors. But if you look at studies, for instance, in kidney transplant recipients … the mortality rate from COVID was on the order of 20%, and that is just appallingly high.”
Ryan emphasizes that for many immunocompromised people during the pandemic, whenever they’re on the brink of freedom, it gets suddenly curtailed because society has established a risk setpoint that’s still too high for them.
“If there's more risk than the setpoint, restrictions are implemented. And if there's less risk, restrictions are suddenly relaxed. But that risk setpoint, it doesn't take into account the life of people like me. So it's a set higher than the risk that most immunocompromised people can reasonably tolerate. And so the result is that every time the risk level approaches something where suddenly I could have a freer life like I used to, the restrictions get rapidly scaled back.”
She adds, “I feel sidelined for sure.”
Ryan is just one of the people who spoke with the Atlantic science writer Ed Yong. He says about 7 million immunocompromised people reside in the U.S., which is more than the population of dozens of states.
“There's this very common stereotype that immunocompromised people are in some way holding the rest of society back. I think it's exactly the opposite. I think the rest of society, in rushing back towards normal, is dragging immunocompromised people with them, and forcing them to reintegrate at a pace that has no regard for their residually high risk,” he says.
He says for people like Ryan to live freely, buildings will need to have better ventilation standards. We’ll also need “flexible” mask mandates for essential places like grocery stores and pharmacies when cases are really high. And people will also need better access to testing and equitable access to treatments. And
“It's very hard for a lot of immunocompromised people, especially those without privilege and connections, to get their hands on these [antiviral] medicines. And that adds to the feeling of being abandoned by the rest of society and by the government, especially considering how much effort went into distributing and producing vaccines. So those are structural things.”
On the personal level, Yong says the request he heard most often was “please don’t be egregiously horrible to us.”
“Almost every immunocompromised person I've spoken to has been told by friends, by colleagues, by family members that they are overblowing their risks, that they are being irrational. A lot of them feel dismissed. … A lot of people I've spoken to have been outright told that they are burdens on society, that they don't deserve accommodations, that their death would be akin to natural selection,” he says.
Plus, the punditry and op-eds about a return to normalcy makes immunocompromised people feel like their lives don’t matter, he adds. “Society is basically telling them, ‘You shoulder the risk that remains, we’re going to move on, and that's just the way it is.’ But it doesn't have to be the way it is.”
Perfectly healthy people could even become immunocompromised in the future. “Don't you want a better world that's going to look after your health at the point when you inevitably will need it in the future?” he asks.