Throughout the past fourteen-plus months, we have seen consistent recommendations to mitigate the spread of COVID-19. Yet other health practices with strong evidence of reducing COVID-19 severity have received far less publicity. So what are the most effective public health measures for mitigating COVID-19? And what role should governments take in dispensing public health advice?
Current Public Health Measures
Wash your hands. Wear a mask. Practice social distancing. These public health measures have become a standard refrain since close to the start of the COVID-19 pandemic. And for good reason: there is abundant evidence that these measures can reduce the spread of COVID-19. Lately, the push for vaccines has joined the chorus and even drowned out the original guidelines.
All of these recommendations are based on widely accepted scientific knowledge and research. Handwashing has a lengthy record of preventing infectious disease transmission. The evidence that face masks reduce the spread of COVID-19 continues to mount, from single case studies to comparisons of large populations to direct experimentation. Based on how COVID-19 spreads, we can expect that maintaining a certain distance from others while in public should mitigate transmission. Additional research indicates that state and local social distancing measures may have reduced U.S. COVID-19 cases by 600,000 in the first three weeks after implementation.
In addition to the promising initial vaccine trials, follow-up research with health care personnel showed that the Moderna and Pfizer vaccines were 90% effective after two doses. According to a recent CDC report, just 0.0075% of the 77 million fully vaccinated Americans have contracted COVID-19. Given the effectiveness of the vaccines and the seriousness of the COVID-19 pandemic, it makes sense that a significant public service effort has been made to encourage Americans to get vaccinated.
Additional COVID-19 Protection
Yet there are other health measures that can protect against COVID-19. Here, I consider the evidence for vitamin D sufficiency, regular exercise, and a healthy diet.
Consider two recent meta-analyses on the relationship between vitamin D and COVID-19. A review of 14 previous studies found that individuals deficient in vitamin D (defined as having serum 25-hydroxyvitamin D concentrations of less than 20 nanograms per milliliter) were 80% more likely to contract COVID-19 compared to those with sufficient vitamin D levels. Another review of 39 studies found that vitamin D deficient individuals had a 1.77-fold higher risk of COVID-19 infection, a 2.57-fold higher risk of more severe infection, and a 2.35-fold higher risk of death from the virus.
Even National Institute of Allergy and Infectious Diseases director Dr. Anthony Fauci has touted the benefits of vitamin D. “If you are deficient in vitamin D, that does have an impact on your susceptibility to infection,” Fauci said in a September interview. “So I would not mind recommending—and I do it myself—taking vitamin D supplements.”
Unfortunately, 41.6% of the U.S. population is deficient in vitamin D. And the rates of deficiency are even higher in Black (82.1%) and Hispanic (69.2%) populations. Unfortunately, these two groups have also been hit harder by COVID-19 than white Americans. These disparities are partly due to socioeconomic factors, though it is hard to rule out differences in vitamin D levels. However, getting regular sun exposure or supplementing daily with up to 1,000 IU provides sufficient vitamin D for most people. And at less than $0.05 per 1,000 IU dose, vitamin D is relatively inexpensive.
Exercise and Diet
Individuals who are overweight or obese or have type 2 diabetes also have a greater risk of severe COVID-19 symptoms. Yet we have known for years that diet and exercise are excellent tools for managing weight and insulin resistance. Furthermore, a recent observational study of 48,440 patients diagnosed with COVID-19 showed that those who were consistently inactive had a 2.26-fold higher risk of hospitalization, a 1.73-fold higher risk of admission to the ICU and a 2.49-fold higher risk of death due to COVID-19 than patients who meet recommended guidelines for physical activity. So in addition to the connections between excess weight and diabetes and severe COVID-19, there is direct evidence that regular exercise may reduce the risk of COVID-19.
Yet once again, Americans fall short on these health metrics. According to CDC data from 2017-2018, 73.6% of American adults are overweight, with 42.5% of adults qualifying as obese. One in ten Americans have type 2 diabetes, and the rate of the disease in children and teens is rising.
The Role of Government
Given such strong evidence, where is the CDC recommendation to get more exercise? Where are the public service announcements to eat a healthy diet in order to protect against severe COVID-19?
Let’s take a step back and look at the role of government in general. At a minimum, a government should protect citizens against harm from their neighbors (the role of police) and from foreign nationals (the role of a military). After all, that’s why our hypothetical hunter-gatherer ancestors would have banded together in the first place: to protect themselves against theft and violence from others.
In the infamous words of philosopher Thomas Hobbes, life in a pre-society state of nature, “where every man is enemy to every man… wherein men live without other security, than what their own strength, and their own invention shall furnish them withall,” would have been “nasty, brutish, and short.” Government and society protect humans from one another so that each of us doesn’t have to constantly worry about being stabbed in the back out of competition for property and resources.
Presumably, the role of a government in a pandemic is also to protect citizens from one another. When people can carry an infectious and potentially fatal disease without knowing it, they pose an unwitting threat to others. Hence the various health guidelines associated with COVID-19 that aim to minimize this threat.
Possible Criteria for Recommended Public Health Measures
So there are reasons for a government to offer certain health guidelines in response to a pandemic. But this does not answer the question of why the CDC has recommended certain health measures and ignored others.
The primary public health recommendations all have strong scientific support and require relatively little time and effort. Handwashing is (or should be) a regular part of everyone’s daily routine. Face masks can be easily put on and removed and do not hamper the wearer in most situations. Social distancing requires some engineering and alteration of routine (spacing out lines at the grocery store, separating desks at school or work). But once those controls are in place, little additional effort is required. In the most extreme example of shelter-in-place orders, citizens are actually asked to do nothing rather than to actively engage in a specific practice. And vaccines require one or two forty-five-minute blocks of time (excluding time for scheduling and travel).
In contrast, the evidence for vitamin D is not quite as strong as for the four selected public health measures. While there are myriad observational studies linking vitamin D deficiency to more severe COVID-19 infections, there is a lack of randomized controlled trials that would indicate low vitamin D directly contributes to worse COVID-19 outcomes.
Furthermore, despite the fact that vitamin D supplementation is relatively inexpensive and sunlight is free, physicians estimate that only about 50% of patients adhere to their prescribed medication plans. So even if robust randomized controlled trials showed that vitamin D supplementation reduces the risk and severity of COVID-19, there is little reason to believe the majority of the population would consume a vitamin D supplement on a regular and ongoing basis.
Exercise and Diet
The problem is even worse when it comes to diet and exercise. Adopting a healthier diet and lifestyle requires major time and energy commitments and a radical restructuring of one’s personal routine. There is a reason 80% of people abandon their New Year’s resolutions by mid-February. And given the resistance to wearing a mask and avoiding contact with people outside one’s household, it’s hard to imagine a nationwide exercise program gaining much traction.
In reality, the four public health measures pushed by the CDC are among the least demanding of the possible options. While there is evidence for vitamin D supplementation, physical activity and improved nutrition, it’s also clear why public health institutions haven’t spent much energy advocating these practices.
Government and Personal Health
On the flip side, many have argued that governments shouldn’t be in the business of making health recommendations at all. In a previous KineSophy article, I used the Swedish government’s recommendation of a high-fat, low-carbohydrate diet compared to the American recommendation of a relatively low-fat, high-carbohydrate diet as a prime example of government overreach.
“These opposing claims leave only two possibilities,” I wrote. “1) That one government has made gross, life-threatening errors in its experimental design and data collection or 2) that both sets of recommendations are relatively true since the content of a person’s diet has little effect on her health anyway… The basic conclusion to be drawn from [Sweden’s] recent reversal of Western dietary advice is that governments who fund research to provide nutritional counsel to their citizens are conducting a program that is either incompetent or unnecessary.”
The role of a government to protect its citizens looms even larger when citizens do not protect themselves.
Survival of the Fittest?
Those who are deeply concerned about their personal health likely aren’t turning to any government for wellness advice. And some might argue that everyone must live with the consequences of their health choices, whether good or bad. Unfortunately, even the healthiest among us have friends and family members on the opposite end of the wellness spectrum. Even those who endorse a theoretical survival-of-the-fittest philosophy might have difficulty giving up on unfit loved ones.
Still, there is a compelling argument that personal health is each individual’s responsibility, and governments should not infringe on individuals’ rights to make their own health decisions. Yet in the case of a global pandemic, personal health decisions have a larger-than-normal impact on others. And as described above, Americans have been largely unsuccessful at taking care of their own health. There are many reasons for this reality, from personal choice to socioeconomic circumstances to disparities in family and career obligations. But the fact remains that most Americans are overweight and at risk for a variety of health issues. If a government’s primary role is protecting its citizens, this role looms even larger when citizens do not protect themselves.
A Parallel Example
Imagine that most citizens of Acirema are poor drivers. There are a few who have taken advantage of opportunities to hone their driving abilities. This minority recognizes that being a good driver allows one to get from place to place safer and more efficiently. But the majority of Aciremans pose a risk to themselves and others every time they get behind the wheel. By what logic could the Aciremans demand that their government loosen automobile laws? How could they protest being forced to stop at stoplights, drive on the right side of the road and maintain a speed limit when most of them are dangerous even with these regulations in place?
The least demanding way to regulate driving in Acirema would be to apply and enforce those rules of the road. While weekly driver’s education classes or a cup of coffee every morning would likely contribute to safer driving, recommending or mandating these courses of action would likely not have the same effect as traffic laws. Like regular exercise, attending weekly classes requires a person to restructure his entire calendar. Like taking a vitamin D supplement, those unaccustomed to such a practice would not easily start drinking coffee every morning. And it is easier to enforce a speed limit than it is to check everyone’s caffeine levels. Governments rely on traffic laws in part because they place limits on a current practice rather than imposing additional requirements.
A Wake-Up Call for Personal Health
In short, there are reasons of simplicity and enforceability behind the current health guidelines for COVID-19. While there is strong evidence for adopting additional public health measures like exercising, eating a healthy diet and maintaining sufficient vitamin D levels, it is easy to see why the American government has not devoted as much airtime to promoting these measures. Yet that does not mean we should not adopt them ourselves.
If any positives arise from this pandemic, perhaps COVID-19 will serve as a wake-up call to a diseased nation. As I’ve advocated repeatedly on KineSophy, we should all take as much responsibility as possible for our personal health—in part so that no one else has to take that responsibility for us.