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Near the end of February, the Centers for Disease Control and Prevention told states they could lift masking recommendations for about 70 percent of the US population. The CDC is now using new metrics to decide when restrictions should kick in, with more focus on local hospitalizations and a higher threshold of community infections.
Even in a crowded news cycle, the usual deluge of diverging opinions quickly followed. Prominent figures in public health praised the move on social media and in op-eds, but there was also robust criticism of the substance and messaging of the new guidelines. Rolling back pandemic restrictions can be almost as difficult as rolling them out in the first place: The science of starting public health interventions is just more developed than the science of stopping them.
Some suggested it was a mistake to assume future variants would not be more severe than omicron; others wished the guidelines had included metrics based on wastewater surveillance. There were concerns about the recommendation that certain people consult their doctor about whether to wear a mask indoors, given the high proportion of Americans who are uninsured or don’t have a primary care provider. The new guidelines might not trigger restrictions such as masking until Covid-19 has spread enough to cause widespread deaths, two policy modelers added in an analysis on Twitter this week.
A third contingent of critics went further and interpreted the end of CDC’s universal mask mandate recommendation as an abandonment of masks in favor of politics, or disengagement from pandemic management altogether. One satirical video adopted the voice of the CDC and asked: “Instead of recommending that people wear masks during the pandemic, what if we just stopped caring?”
Yet the guidelines were well received among many of the people working at state and local public health agencies. Janet Hamilton, executive director of the Council of State and Territorial Epidemiologists, said her membership — epidemiologists at public health agencies across the country — generally favors the shift in focus from testing to hospitalizations. Nirav Shah, Maine’s public health chief and president of the Association of State and Territorial Health Officers, said he was “very pleased with what they’ve come up with and the direction they’re going.”
The new guidelines replaced a badly outdated framework from September 2020 that relied heavily on case counts and PCR test result positivity, even as at-home testing made those metrics increasingly unreliable. Allison Arwady, commissioner of the Chicago Department of Health, said the new recommendations were a long time coming — and were very similar to what her agency was already doing: “I’m glad there is clear guidance to the public as well as enough flexibility, I think, for states and locals to make the recommendations that make sense in their settings.”
The US struggled to smoothly implement restrictions in its pandemic fight, and if the disagreement among public health professionals is any indication, it’s going to be difficult to grind them to a halt. The CDC is running up against widespread distrust in public health institutions, and it’s working with limited data about the downsides of measures like masking — but the emerging science of de-implementation might help guide the way.
The difference between healthy debate and deeper distrust
Whenever the CDC introduces something new, “they need to put it out there and expect massive blowback,” said Tim Lahey, an infectious disease doctor and ethicist at the University of Vermont Medical Center. Disagreement about a new set of guidelines is not itself proof that the guidelines are bad, he said.
But the latest criticism may be even sharper than you might expect after a new set of recommendations. While part of the conversation struck Lahey as reasonable debate, “I also think that there are reactions that come from more of a place of fear and mistrust,” he said.
It’s reasonable to worry that loosening prevention measures will help the coronavirus spread, and to sense that vulnerable populations are in particular danger in the event of another surge. But Lahey said the public shouldn’t jump to conclusions that rollbacks will lead to catastrophe, or assume “that people who have a slightly different approach from us don’t care about those risks.”
The CDC clearly has some baggage to overcome in any communications effort. Evidence of political meddling in the agency’s early pandemic response under the leadership of its previous director has contributed to widespread distrust of the institution. Meanwhile, bungled messaging has led to skepticism that all of the CDC’s decisions are scientifically grounded and well-communicated.
It’s particularly difficult to scrap public health measures like mask mandates when they don’t seem to be causing obvious harm, according to Westyn Branch-Elliman, an infectious disease doctor at Harvard Medical School who studies de-implementation science, or the rollback of inappropriate health interventions. Branch-Elliman has shown that without good data demonstrating the negative consequences of a standing practice, people are more likely to think it’s the logical thing to do — especially when they don’t have trust in the body calling for changes. That’s one reason that lifting mask mandates in schools has been such a divisive issue, she wrote in a recent co-authored op-ed for CommonWealth magazine.
The case for rolling back preventive measures during pandemic lulls
The harms of public health preventive measures may not be as visible to people who are not in the trenches at state and local health departments, Arwady said. For example, the time-consuming work of tracking Covid-19 cases is burning out public health workers, and the black hole of pandemic response has sucked staff and resources away from other critical public health priorities.
“Folks who may not be doing this every day, they may be only thinking about the direct effects of Covid. I’m just as worried about the huge increases we’ve seen in substance use and violence,” she said, ”not to mention the school stuff.”
Showing the public that pandemic measures have an off switch — by giving everyone a break during lulls — may also encourage people to follow restrictions when they have to be turned back on. “It is critical, when we are doing well, to actually drop these requirements, because you can’t cry wolf, right? It’s no good to sort of just say, ‘We’re not quite sure what will happen, so we should keep masks,’” Arwady said. “Because if and when we need those restrictions, I want people to know those are actually based on increased risk.”
There’s a lot of room for improvement in future rollbacks of public health restrictions. It’s easier to replace an intervention with a substitution than to replace it with nothing, said Branch-Elliman. In the case of Covid-19, that might mean replacing masking with a checklist of other protective measures such as good ventilation, air filtration, and vaccination requirements. The CDC can demonstrate its transparency and gain trust by sharing lots of data supporting its decisions.
William Schaffner, a professor of health policy and infectious diseases at Vanderbilt University Medical Center, also recommended changes in the CDC’s messaging strategy. The new guidelines were announced in a press release and a media telebriefing at 4 pm on a Friday — when journalists were also covering the Russian invasion of Ukraine and President Biden’s nomination of a Black woman to the Supreme Court. Burying the announcement did nothing to bolster trust in the agency, he said, and a coordinated press conference — including commentary from key administration officials and time for reporters’ questions — might have helped bolster the authority of the recommendations.
Lahey said that alongside its new guidelines, the CDC could have communicated “pro-social” mask messaging, for example by suggesting special precautions around high-risk populations. But he also worried that the tone of experts could itself play a role in reducing trust in the agency.
The way we talk about our public health leaders has an impact, Lahey said. “We contribute to American alienation from CDC at our own peril,” he explained. If criticism of the CDC crosses the line between healthy debate and blanket distrust, we all suffer the consequences. “If they can’t have trusted communications — and if we contribute to that — who will?”
