Sorting Medical Fact from Fiction, Part IV: Vaccination, Variolation, and What Doctors Do Tell You

encased in plastic bubbles

Will we see more of this?

I wrote most of this on 10/27, and the HHS update I’m referring to below happened on that date. By a couple of days later things looked massively worse, with a record one-day case count of 1082 and a real threat to our health care system and its exhausted workers. We knew fall was likely to be difficult, and it is, here and in so many places.

As I write on this scariest 10/31, I’m thinking of the Berlin Philharmonic’s concert earlier today. The full orchestra was on stage together for the first time in all these months; they had been using smaller ensembles only. More amazingly, the seats were packed with audience members, whereas last week they had been separated by empty seats in between. I was boggled and a bit jealous that they had managed this. Weren’t things a lot worse in Germany too? Then came the announcement at the end of the show telling us that the orchestra’s hall would be closed Nov. 2-30. It was fun while it lasted….

Last time I talked about the epic stupidity of the Great Barrington Declaration.  Then, a couple of days ago, I saw that someone I had long admired and followed, Lynne McTaggart, had endorsed it and was telling people to sign it.  I guess I should have expected that, but I was still in shock.

The reason I should have expected it is that Lynne’s long-term brand is What Doctors Don’t Tell You.  So when Doctors Do Tell You and what they say is actually true, if you have the point of view that doctors are always trying to deceive you, you can’t hear them.

I’m trying to come to terms with this and with the gigantic number of people who STILL, despite the catastrophic spike in COVID-19 cases across the country, refuse to understand that they need to change their behavior if we are ever to get through this.  It’s gotten to where we seem to be unintentionally running the experiment the Great Barrington people were advocating. And it’s not going well.

Something occurred to me this morning: Maybe the deniers and anti-maskers and open-everythingers are unwilling to believe the virus is really so bad because the truth is just too painful and hard to face.* I mean, every day at least once I experience a moment of shock when it hits me again that this is really happening. It’s been like a bad dream all along. Do you have that feeling, too, that you’re going to wake up any minute now, but then you never do?

If someone has that persistent feeling of unreality, and then they are bombarded with messages that the pandemic isn’t real, perhaps they can be forgiven— just a little— for trying to find refuge in the belief that it’s all a hoax, or at least the danger has been overblown, so that there’s no problem with their usual habits. Nothing having a beer with their friends in a crowded bar can’t solve.

Today [10/27] I attended the weekly web update from Dr. David Scrase, the head of the New Mexico Department of Health and Human Services. Dr. Scrase manages to inject some gentle humor into the march of facts, even when the numbers are looking as dire as they have lately, and he always speaks with compassion as well as honesty. I get to these meetings most Tuesdays, and whenever possible I also hang out with a bunch of infectious disease and public health experts on Mondays at a UNM ECHO session. These are good people, doing their best to navigate rough and uncharted seas. They are Doctors Who Do Tell Us— to the extent that anyone knows anything for sure.

I hope HHS won’t mind that I’ve grabbed a couple of today’s slides to show you. This one illustrates the dizzying rise in cases in the past couple of weeks. What I’d like you to look at here is the sharp upward swoop of the purple line, the one that shows cases in people ages 35-64. The green line showing those 18-34 is less dramatic, but it’s pretty substantial. And you can see that cases are also notably up in kids and teens as well. If you’re still thinking that only older people are vulnerable to this disease, well, you are wrong.

In some parts of the country the virus is considered to be out of control, including places like the Dakotas who hardly had it at all for so long. I hope New Mexico’s case counts don’t reach that level. I hope they haven’t already. But getting back to a better situation requires a population that is united in doing all the right things, and we aren’t seeing that.

Now for another denier contention, the idea that if you do get COVID you’ll just get over it and everything will be fine, no big deal. Uh-uh. The following slide makes it clear that long-term symptoms are not just happening to an unlucky few, but are actually very common even in “mild” cases.

Here’s more about the brain damage that can accompany all this unpleasantness:
https://www.reuters.com/article/health-coronavirus-brains-int/covids-cognitive-costs-some-patients-brains-may-age-10-years-idUSKBN27C1RN

Deniers also like to believe that if against all odds they somehow come down with the illness, it will be like the president told them, they’ll get the latest greatest treatments, which are miraculously effective. While I hope every patient will get the best possible treatments at the earliest possible time, the more patients need them at once, the less likely that becomes. The main limiting factor at this point is not so much hospital beds as skilled personnel to staff them. And one of the limitations on health care professionals being available is that some of them are getting COVID themselves.

Dr. Scrase told us that the health care personnel who get sick are usually not getting infected at work, but rather at social gatherings in the community— the same way that most of the laypeople are getting infected. The people who should know better are apparently doing the same dumb things as the rest.

At this point please imagine that I am shaking you and screaming that you don’t need to have a birthday party and invite 50 of your closest friends!

But pretty soon there is going to be a vaccine, you say, and we’re all going to be able to live our lives any way we want to again. Yes, in the next few months there is likely to be at least one vaccine that will be available to at least a few people, most likely front-line health care workers to begin with. That will start to help a little. But as you’ve probably heard, even in a best-case scenario of a very effective vaccine, it’s going to take ages to get shots to everybody who wants them. Not to mention the fact that many people will not want them. No matter how this goes, all that masking and distancing stuff that we hate is likely to be necessary for a very long time.

Now we’re going to look at how good a vaccine has to be in order to be useful, and how we can tell whether a vaccine candidate will meet that standard. What percentage of the time does a vaccine have to work in order to be considered effective? What percentage of the population needs to be vaccinated in order to create herd immunity (which is purely a vaccine-related concept, by the way)? There are formulas that can inform these decisions.

The following article is a month old, and that’s ages in COVID time. I’m including it because it gives a layperson-friendly explanation of how researchers decide whether a vaccine is working and whether it’s ready to be given to the public at large. Pfizer was supposed to have big news about its trial around the end of October, but that hasn’t happened as yet. Whether Pfizer’s effort pans out or not, this clarifies how to think about the process and what it all means.
https://www.propublica.org/article/a-real-vaccine-before-the-election-itd-take-a-miracle

I was surprised to see how few cases these momentous decisions may be based on. Especially with this unprecedentedly rushed research program, it’s hard to feel confident that we’re seeing real effectiveness, and even harder to feel confident about safety. About the same time that I read the ProPublica piece, I came across a September interview of Dr. Paul Offit by Dr. Eric Topol on Medscape, in which he expressed his own doubts. That really caught my eye. Dr. Offit has been a huge cheerleader of vaccines in general, very publicly gung-ho about them. If he is feeling cautious about COVID vaccines, I thought, there must really be something to be cautious about. He expressed some skepticism about both the drug companies’ promises and the politically compromised FDA.

“So you have this difficult-to-characterize, elusive virus that you are now about to meet with a handful of vaccine strategies for which you have no commercial experience,” he said. “I think you can assume that there may be a learning curve here.”

There are so many important points I wanted to quote in this interview that I have to ask you to go and read it for yourself. Honestly, you should. It’s a little unnerving, but it should also leave you with the feeling that there are some reasonable safeguards in place. Since it’s necessary to sign up with the Medscape site to read articles (although it is a free service), for your convenience I’ve parked a copy where you can get it easily:
https://app.box.com/s/rpammbltgrp4fbi9tmon1dzn1p6yhte0
‘Paul Offit’s Biggest Concern About COVID Vaccines’

If you don’t feel like going over to Box to grab that copy, this excerpt will give you some of the main points:

“[Offit:] We have two ways of stopping this virus: One is hygienic measures — face masks, social distancing, hand-washing — and the other is the vaccine. With those two, we will be able to bring this virus under control. But it will take both. What worries me is that if you had to pick which is the stronger of the two, I would go with hygienic measures. I mean, if I wear a mask and stand 6 feet away from you, and you wear a mask and stand 6 feet away from me, the chances that I’m going to get the virus from you or you from me is about zero. You have two things going for you. One, you have a mask, which is going to prohibit the virus’ small droplets from traveling very far. And two, even if I didn’t wear a mask and stand 6 feet away, the odds are also that you wouldn’t get it.

Topol: And by the way, if you do get it, you get a lower dose of virus, which is important.

Offit: That’s right. You might get more mild disease. On the other hand, if we have a vaccine and it’s 75% effective against moderate to severe disease, that means 1 out of every 4 people can still get sick, including very sick. It also means probably a larger percentage than that 25% could get mild infection, or asymptomatic infection, which they could still shed, even to the point of contagiousness. We’ve been asking these trials to look not only at whether they’re protecting against moderate to severe disease, but to what extent they are protecting against shed. I think that is important to know.
But people have such an unrealistic expectation of these vaccines that they see it as the panacea, as the magic bullet to make it all go away. [emphasis mine] If people have unrealistic expectations, such that they think “I’ve gotten the vaccine, I’m good. I don’t need to wear a mask. I don’t need to social distance. I can engage in high-risk activities,” then we’ve lost one of the important arms to bring this virus under control, arguably a more important arm. If, when we bring the vaccine up in terms of users, we move social distancing and masking down, we could end up having a sort of break-even effect.

Topol: Well, you’re bringing up a critical point and that is, the vaccine effect could actually increase the number of people who are asymptomatic carriers. Because they basically have protection from beyond their mucosa. But they still have the virus in their nose and their upper respiratory tract to spread. And that’s why this coupling of continued hygiene— masks, distance, and these other measures — is going to be important all the way through until we get a very dense immunity of the population, right?

Offit: There is a formula for this, actually. If you have a 75% effective vaccine against significant shedding, then you would need to immunize about two thirds of the American population to get the R0 to less than 1, meaning to stop spread, which is what you want.”

It may well be that a vaccine with 50% effectiveness will be the best we can do. It may be that there will be multiple vaccines available, with some being best for people of one age group or health status and others for other categories. Right now we don’t know much, so again I ask that everyone keep an open mind. No knee-jerk reactions, please! Whether you take every shot available or scrupulously avoid vaccinations, at this point you don’t have enough data to weigh risks against benefits. We have to have data, and we have to have clear messaging about it from the people in charge. That might be a tougher challenge than creating a vaccine to begin with.

In other sobering news this week, more evidence came in to show that immunity to COVID-19 does not appear to last very long— another blow against the Great Barrington mindset.
https://www.reuters.com/article/uk-health-coronavirus-britain-antibody-idUSKBN27C005
‘Antibodies against the novel coronavirus declined rapidly in the British population during the summer, a study found on Tuesday, suggesting protection after infection may not be long lasting and raising the prospect of waning immunity in the community.’

But all is not lost. Antibodies are not the entirety of the immune response. And with masking and distancing, those of us who don’t get sick may still be getting small doses of the virus as we go about our business, enough to teach the body how to recognize this pathogen and fight it to at least some degree. There is evidence that people who are exposed in this way tend to get infections that stay asymptomatic. Even if no really robust long-term immunity exists, some memory will develop in their immune systems, and they should be better off than they would be without any exposure. The author likens this to variolation, the strategy used to prevent smallpox before the vaccine was invented. The key would be small doses of the virus, not the uncontrolled onslaught of a big group event with no masks.
https://www.nejm.org/doi/full/10.1056/NEJMp2026913
‘Facial Masking for Covid-19 — Potential for “Variolation” as We Await a Vaccine’

So even if we have an effective vaccine, we’ll still need to do all this other stuff that we’re getting so tired of, and there’s no end to it in the near term. I’m sorry. I would like to be able to give you better news. We just have to keep muddling along as best we can. I implore you not to make the situation any worse! Don’t travel. Don’t get together with a bunch of people indoors, and be careful outdoors. No big Thanksgiving dinner with family from far and near. Wear the damn mask. Just do it. The more effort we make now, the sooner we can be done with all this.

I can’t remember where I saw this:
COMMUNITY
IMMUNITY
I’M UNITY

Unity. Let’s try it.

************************************************************************

* Later I came across this:
 ‘Left to their own devices, people chart their paths based on their personality, how they see the world, and how they relate to risk. According to Geller, many people presented with a barrage of contradictory instructions just grow tired and give up. Others become hypervigilant, their behavior calcifying against new information that might let them ease up and enjoy life a little more. Still others simply choose optimism, no matter how dangerously misguided—such as the belief that “herd immunity” is near, or the assumption that catching the virus will have no long-term consequences for them. “People will gravitate to the positive message because it’s convenient, and it’s not scary, it’s not fearful,” Geller said.’


https://www.theatlantic.com/health/archive/2020/10/pandemic-safety-america/616858/

And still later, an interview update came from Dr. Offit, in which he discusses what may happen with an emergency use authorization, and what distribution of a vaccine may look like:
https://edhub.ama-assn.org/jn-learning/video-player/18555773
He also demolishes the Great Barrington argument:
 ‘So now suddenly herd immunity induced by natural infection has become the plan, right? But the premise is wrong. The premise is that a virus could can affect enough people in the population, that would provide immunity such that that essentially the virus would put itself out of business. That’s never happened. That’s never happened for any virus. So historically there’s no support for it. Secondly, if you had to pick the perfect virus for which it would happen, it would be measles. I mean, measles is 10 times more contagious then this virus and SARS-COVID-2. It has an [inaudible], you know contagiousness index of close to 20, where this is less than two. Two, measles induces lifelong sterilizing immunity. You are protected against all manner of infection, including asymptomatic infection, that’s not going to be this virus. And nonetheless, despite that, before there was a measles vaccine every year there would be about one to two million cases of measles. There would be 50,000 hospitalizations, and there’d be 500 deaths from measles. So there’s no such thing as this Great Barrington declaration. Plus, about 30% to 40% of the population is really at high risk.’


4 Comments

Filed under health and healing, politics, psychology

4 responses to “Sorting Medical Fact from Fiction, Part IV: Vaccination, Variolation, and What Doctors Do Tell You

  1. As of November 1, the latest on vaccines:

    Like

  2. You know, I’m starting to wonder if there have been any studies on how introverts and extroverts are coping with the recommendations about masks and distancing. As an introvert, I have no problem going to work, then going home and staying there, save for a once-a-week outing to go food shopping and manage my paycheck at the bank. But if I were, say, an extrovert, I imagine I would soon get so desperate to be around other people that I would look for any excuse to ignore ‘the experts’ and head to bars, parties, etc. That might explain why many people are trying to act like nothing is happening, along with what you suggested. Or maybe people in the United States are just too selfish to care about others by mildly inconveniencing themselves. Or, if you want to get metaphysical, a spiritual writer I follow wrote that the Earth is trying to cleanse a lot of the negativity that’s built up over the centuries, and the process of releasing all that energy involves a lot of natural disasters, general insanity, etc. I have no idea if it’s true, but that would explain why so many people seem to have lost their minds all at once.

    At any rate, it probably won’t be until after the pandemic is over that we’ll finally figure out why so many people refuse to accept reality. Until that day, the best thing any of us can do is the same thing we’ve been doing for months: Wear a mask, stay away from others as much as possible, and go out as little as possible. And as individuals, this pandemic can help us realize that we are not responsible for other people’s choices. All we can do is focus on what WE can do, and if we stay alert (not panicked or afraid), stay informed, and take all reasonable precautions, we’ll get through this okay.

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    • You are a very sensible person!

      I don’t know if anyone has researched how introverts vs. extroverts are getting along during the pandemic, but I’ve definitely heard other self-identified introverts say that staying isolated is fine with them and not too different from what they usually do. I don’t mind being alone a lot myself. There are terrible downsides to it, like not being able to either attend or perform in live concerts, but I expect it’s all much easier for those of us who prefer to stay away from crowds to begin with.

      And I don’t have a great understanding of the cosmic meaning of our situation, but we can find a lot of lessons to pull from it without having to try very hard.

      Like

  3. https://www.theguardian.com/us-news/2020/sep/23/qanon-conspiracy-theories-loved-ones
    ‘The QAnon conspiracy may assert the existence of untold masses of abused children, but perhaps it is an easier pill to swallow than the unfettered chaos of present reality, where the gap between poor and ultra-rich is ever-widening, and rising sea levels threaten the future of human life on Earth – where millions of children are indeed abused, but not at the hands of a singular organization that can be eliminated with a simple mass arrest.

    ‘QAnon presents an idyllic alternate reality where the Covid-19 pandemic is a hoax rather than a deadly threat egregiously mishandled by multiple governments, where systemic racism is but a psy-op, where the universe is ordered and finite, and justice is on the horizon. Conspirators have convinced themselves of the world they wish to see.’

    Like

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