How should we handle the next COVID?

Like everyone else, Monica Gandhi didn’t get everything right about COVID. Some of her predictions proved incorrect, and her relentless optimism outraged people who didn’t think the world was taking the pandemic seriously enough.

Take this moment, from early 2021: Gandhi, a professor of medicine at the University of California, San Francisco, appeared on The ZDoggMD Show, a YouTube show on which she was a regular. “I really need to say something,” she tells the host, ZDoggMD, early in the interview. “I need to say variants shmariants. OK? I’m sorry. I don’t know what kind of trouble that’s gonna get me in.”

Six months later, the New York Times ran the headline “American Hospitals Buckle Under Delta, With I.C.U.s Filling Up.”

NBC journalist Mehdi Hasan eventually dubbed her “the pandemic’s wrongest woman,” having her on his show in 2022 so he could list the times she’d told a news outlet that we were in some kind of “endgame” with COVID, only to be proven incorrect. For example, there was the assertion that India had reached herd immunity just before it experienced a deadly surge. “At what point, Dr. Gandhi, do you say ‘maybe I should stop making predictions about a pandemic that I keep getting dangerously wrong?’” Hasan asks. It’s an uncomfortable segment to watch.

Yet, Gandhi’s fundamental arguments about the virus have turned out to be sound. As she said again and again that it would, SARS-CoV-2 has become endemic, with population immunity—thanks to both vaccines and infections—offering us protection from serious illness. Most of us no longer worry about catching the virus outside and have ditched the hand sanitizer. Even in the case of the delta variant, highly vaccinated communities like San Francisco had “very high cases, but low hospitalizations,” as she explained to Hasan.

Now, Endemic is the title of Gandhi’s new book, which aims to offer a “post-pandemic playbook” to help prepare for future health crises. As we look ahead toward a future that involves living with SARs-CoV-2, maybe the “wrongest” woman’s plan is one we should consider.

Though she is highly regarded as an HIV expert, Gandhi had little claim to fame in the spring of 2020. Her day-to-day work involves overseeing care for HIV patients from vulnerable populations as medical director of San Francisco General Hospital’s Ward 86 clinic, as well as publishing papers on how to make HIV medications more accessible.

As the COVID pandemic began, she threw herself into the challenges presented by the new virus as a way to deal with her grief from the loss of her husband, who died in late 2019 after a long battle with cancer. Gandhi hoped the lessons she learned from HIV—a virus that has killed a staggering number of Americans, whom we nonetheless live alongside—could help inform the response to COVID. And then, suddenly, she was everywhere, giving countless comments to the press and frequently appearing on TV. She avidly took to Twitter, quickly racking up nearly 100,000 followers.

Over the ensuing three years, Gandhi became a magnet for criticism from across the political spectrum. Though she’s been described as “the mask queen,” and urged the public to keep using them even as vaccines rolled out, the COVID-cautious faction considers her dangerously reckless. On the other side, her support for vaccines and the antiviral drug Paxlovid elicits howls of protest from those who think COVID is no big deal. “When I write stuff on Twitter, everyone attacks me from both sides, so you really can’t win,” she said at her San Francisco book launch this summer.

Gandhi often ran up against the mainstream public health consensus around COVID mitigation. SARS-CoV-2 is much less likely to spread outdoors, so she argued early on that closing beaches and playgrounds didn’t make sense. She thinks restricting in-person medical care, keeping people away from their loved ones in care facilities, and prolonged school closures did more harm than good, often worsening racial and income disparities.

“They were working while their 8-year-old was at home alone online. That really bothered me.” —Monica Gandhi

Gandhi’s willingness to buck the rules has stood her HIV patients in good stead. When lockdowns were imposed in San Francisco in March 2020, she refused to shut down services for homeless patients at her clinic, which serves the city’s most marginalized people with HIV, recognizing that in-person support is key to keeping them engaged in care. “They don’t have phones. They don’t have a quiet place with a Zoom background to call the doctor. They had nowhere to go,” she said at the book launch. More recently, she has gone outside the Food and Drug Administration’s approved indication for a new long-acting injectable HIV treatment, enabling people who can’t take daily pills to achieve viral suppression for the first time.

One of Gandhi’s guiding philosophies—and a key theme of her new book—is harm reduction.

Often associated with ameliorating harms for people who use drugs, the concept is more broadly understood in the HIV field. A key lesson is that abstinence-only approaches don’t work over the long term. To be sure, HIV would end if people stopped having sex or injecting drugs, and COVID would end if people just stayed home. Given that this isn’t going to happen, condoms, clean needles, and masks can reduce risk. Harm reduction is “really this idea that we all have needs, so we have to take those into account,” she told Slate.

But to be effective, harm reduction interventions must be acceptable, sustainable, and feasible with available resources. While no one would rather use a dirty needle than a clean one, many people are unwilling to use condoms or wear masks indefinitely. What can seem like a fair, risk-reducing compromise to one person can seem like an encroachment on basic freedoms to another. This clash of opinions was a central challenge of the pandemic, ultimately driven by the question of what needs we have—aside from staying safe from COVID—and how much not getting them met matters.

Gandhi can be relatively quick, compared to other American experts, to center those other needs even in the face of a novel virus, though her approach is more common in Europe. She is particularly adamant about the harms of school closures.

“My children were in school from November 2020,” she says, explaining that they attend private school and therefore had more leeway on returning to the classroom. Her patients, in contrast, had kids in public schools who didn’t return to their classrooms for another full year. “They were working while their 8-year-old was at home alone online. That really bothered me—I felt really guilty.” The daughter of Indian immigrants, she’s also attuned to how school closures played out in lower-income countries: “In Bangladesh, the little boys went to work for their families. In Uganda, the girls went into sex work and got HIV. In India, if they had one phone and they had a boy and a girl in the house, the boy got the phone and the girl was out of luck.”

While public health can inform policy decisions, it’s not the sole arbiter, Gandhi argues. Mixing public health with politics—like making masks a symbol, rather than just a tool, or banning in-person church services while bars were open—has negative consequences, including a loss of trust.

“People were not ‘bad’ or ‘COVidiots’ if they contracted COVID-19; they were human,” she writes. “The role of public health is to educate people about how to stay safe from a virus, positively motivate the public to behave in health-promoting ways, and provide resources for such behaviors. There is absolutely no place for stigma, judgment, and a shame-based approach in public health when dealing with an infectious pathogen.” Her guiding principle is that experts like her are there to work with people’s desires and needs, not furiously explain to a beleaguered public that they shouldn’t have those desires at all. “Public health is a service industry, not a police force,” she writes.

Even with cases on the upswing and concerning new variants on the horizon, SARS-CoV-2 has all the hallmarks of an endemic virus, according to Gandhi. Hospitalization and mortality remain low thanks to a wall of population immunity from vaccination and prior infection. While antibody levels rise and fall, T-cells continue to do their job preventing severe illness. “It’s reached a stage at which population immunity has reduced the severity of disease so that it’s settled into a pattern similar to other respiratory pathogens of its ilk,” she told Slate. On this “endgame” analysis, other American experts are finally in step with her.

Today, the elephant in the room for anyone giving advice on living with SARS-CoV-2 is long COVID. Many people no longer fear acute illness or death, but the long-term consequences of infection are a nagging concern.The prevalence of long COVID remains contentious, and its causes are still poorly understood, but it’s clear that some people have chronic disabling symptoms, and there has been little progress on treatments.

“I just felt like I had this long view of infectious diseases that other people didn’t.” —Monica Gandhi

Gandhi has gotten a reputation as a long COVID skeptic. She has said it mostly affects people who had severe acute illness, much to the consternation of patients who were young, healthy, and had only mild illness before succumbing to the condition. She suspects that a leading hypothesis, viral persistence, is unlikely. “I don’t think we need to fight ongoing viral replication,” she says. “I think the pathophysiology of long COVID is inflammation.” She has suggested simple treatments like Benadryl and metformin, frustrating patient advocates including Hannah Davis, co-founder of the Patient-Led Research Collaborative, who argues that if obvious and easily accessible therapies worked, we would know it by now because everyone tries these.

But Gandhi told Slate she’s keeping an open mind. While working on her book, she consulted with HIV colleagues at UCSF who are now studying long COVID. Her 10-point road map for dealing with COVID and future epidemics, laid out in the final chapter, includes the urgent need for research on the prevalence, diagnosis, prognosis, and treatment options for long COVID.

Other points on this roadmap include avoiding school closures, considering the psychological harms of lockdowns, and doing away with mitigation measures when they prove ineffective.

Asked about what she got right and wrong over the course of the pandemic, Gandhi says she was right about the harms of school closure and the fact that “the immune system works the same way” for COVID as it does for other infections.

As for her biggest error, she thinks she talked too much. “I didn’t seem to be able to help myself from writing about it or talking about it,” she says. “I just felt like I had this long view of infectious diseases that other people didn’t.” She also acknowledges that people have different thresholds for tolerance of illness. “Everyone should be able to decide for themselves how much they want to structure their life around a respiratory virus,” she says. “That isn’t what everyone believes, so that is a personal bias.”

Ultimately, Gandhi grew weary of the political contention and personal attacks and pulled back from her public presence—aside from the book—returning her focus to HIV and raising her two teenage sons. And she’s still flummoxed by how the political ground shifted around COVID.

The cover of the book Endemic: A Post-Pandemic Playbook, by Monica Gandhi M.D.

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“What ended up happening with COVID is something got topsy-turvy, it got associated with the left to be restrictive and to close schools,” she told the San Jose Mercury News. “My positions were more consistent with red state governors, and that led to a lot of unease. I felt really uncomfortable in my own skin.”

But Gandhi still considers herself “left of left.” While many progressives have focused on behavior change, like masking and avoiding indoor dining, she leans heavily on biomedical tools, like vaccines and antivirals, having seen how antiretroviral treatment and preexposure prophylaxis (PrEP) turned the tide on HIV. After all, if all of America had achieved the same vaccination rates as her San Francisco community, delta really might have been a “variant, shmariant.”

Gandhi is adamant about the need for better access to health care in the United States and the importance of global equity in the distribution of vaccines and treatment. It took a decade before effective HIV medications were widely available in Africa, resulting in countless unnecessary deaths and new infections, and PrEP is still hard to come by. Global distribution of COVID vaccines followed a similar trajectory, with low-risk people in the United States receiving boosters before high-risk people in low-income countries got even a single dose. When cases in India exploded in 2021, contra her prediction, she penned an op-ed for Time calling on pharmaceutical companies to give up a fraction of their billion-dollar profits so that more people could be protected. “In my opinion,” she writes in her book, “one of the most important lessons of this pandemic is the need for universal healthcare coverage and the obligation to recognize healthcare as a right, not a privilege.”

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