When I started writing this post, I was planning on a straightforward update on the current situation with the delta variant (sorry, I couldn’t resist the obvious title). And then a 13-year-old killed a classmate at a local middle school for no discernible reason. And then the Taliban took back Afghanistan.
The murdered boy was trying to talk his killer out of continuing to bully his friends. He stood up to him with words, doing exactly what most of us would teach our kids to do, what my daughter would do, what I would do. The right thing.
Going into Afghanistan was never the right thing. I remember writing “Can you say ‘quagmire’?” back then. Three quarters of Americans thought this war was a great idea. I was part of the other quarter. I take no pleasure in being right in this case. Afghanistan continues its reputation as the “graveyard of empires.”
In order to avenge the deaths of 3000 Americans, we killed or maimed tens of thousands more, plus tens of thousands of Afghans and then Iraqis, naturally including myriad children. We spent 20 years and a couple of trillion dollars and we accomplished what looks right now to be little or nothing.
And to begin with, the perpetrators of 9/11 were Saudis, and we never gave Saudi Arabia the slightest grief over that. We always fought the wrong battles for the wrong reasons. For so many years we, that is, our leaders knew we were failing and we just kept on going, perhaps in the belief that whenever we left things would be exactly as bad as they are now. And things were always worse than we realized.
I suppose I should not be surprised that instead of effectively fighting this pandemic and its wide-ranging ills, we spend so much of our energy fighting each other.
Pulling the Fangs Back
Anger at the unvaccinated and the irresponsible among us is real. While a more-transmissible strain like delta was bound to come along, wider uptake of vaccines and more stringent adherence to public health common sense would have helped limit the damage, and would still damp down the development of newer variants. Our US deniers and anti-vaxxers are only one aspect of this; many governments have been too poor or too inefficient to get vaccines out to the majority of their people. But seeing Americans die or cause others to get sick because they haven’t taken the most obvious steps to avoid it is maddening.
Dr. John Lapook said, on the Stephen Colbert show on 8/16, “We come into these conversations coiled.” He suggested “pulling the fangs back” when trying to convince someone that getting vaccinated would be a good idea. I didn’t realize how “coiled” I was until I ran into a certain friend at an outdoor event in July. She announced that she wasn’t hugging anyone because she wasn’t vaccinated, which she said was because of her health condition. She really does have a condition in which it’s reasonable to be extremely cautious about medications, but it could just as easily be said that she needs the vaccine all the more because of it— her situation is honestly a bit fuzzy and it’s not crazy that she has hesitated. She has also fallen for a lot of the misinformation, though, and that has been frustrating to deal with. Anyway, I lit into her. Without knowing I was going to do it, I snapped at her. That is, I snapped. She reacted just as badly. Not a productive exchange.
A doctor in Alabama has even refused to see patients who are not vaccinated. ‘“If they asked why, I told them covid is a miserable way to die and I can’t watch them die like that,” wrote Valentine, who has specialized in family medicine with Diagnostic and Medical Clinic since 2008.’ Alabama has the lowest vaccination rate in the US and a high number of residents hospitalized with COVID.
Summer Non-Vacation— Why Is This Happening?
What did you want to do this summer? I wanted to have the party I didn’t get for my 60th birthday last year. (Oh, well— at least I was alive to have another birthday!) It’s very unclear what to do now. Nothing involving a large group of people, certainly. Is it OK to have a small outdoor gathering with vaccinated family and friends? And should we stop attending any non-crucial indoor events of any kind, even with masks and good ventilation? How much have things changed now that delta has taken over?
Amanda Mull wrote a compassionate piece about where we stand with these questions, “Delta Has Changed the Pandemic Risk Calculus.”
‘Assessing risk pre-vaccination was often bleak, but at least the variables at play were somewhat limited: ventilation, masks, crowds, local spread. Now the number of additional, usually hyper-specific questions that people must ask themselves is itself a barrier to good decision making, says Jennifer Taber, a psychologist at Kent State University who studies health risk assessment. “When people feel like things are uncertain, they engage in avoidance,” Taber told me. That can manifest in disparate ways. An unwillingness to acknowledge that many new things are safe for the average vaccinated person is avoidance. So is a refusal to continue taking even minor precautions for the benefit of others.’
A big part of my job as a clinician is helping patients to sort through all the available information to answer health questions like this, and it’s not easy these days. Just as we’ve been through the entire pandemic, we’re still flying by the seat of our pants, trying to keep up with ever-changing conditions and advice. The rise of delta has been a predictable but chaotic and confusing development that hit us with a bait and switch just when we thought we were getting our lives back. It’s still new and we’re still figuring it out.
What I mean by predictable is that this is normal virus behavior. A more transmissible variant will obviously outcompete others, and it would have been a surprise had we not seen a variant like this eventually. Viruses “want” to produce as many copies of themselves as possible, and any mutation that leads to more chances to replicate is great for them.
In general, causing less illness and death is also good for viruses, because having hosts walking around spreading viral particles results in far more replication than having hosts lying isolated in hospital beds, or in graves. So over time a viral species is likely to become more transmissible but less deadly. Sadly, delta seems to cause at least as much and as severe disease as earlier forms of COVID, maybe more.
We had some small hope of getting enough people vaccinated quickly enough, as a planet, to limit the possibility of worse new variants popping up. We didn’t make it, and that too was predictable. Viruses can adapt much faster than we can. We can still hope to escape without a far more dangerous variant coming along, but time is not on our side. The more humans there are who cannot access or will not accept vaccines, and the more who refuse to take other precautions, the more opportunities the virus has to mutate.
Here’s a good way of putting it:
‘You might think of viral replication as buying lottery tickets, in which the virus accumulates random mutations that very occasionally help it spread. And the fewer lottery tickets the virus has, the less likely it is to hit the mutation jackpot. The appearance of troubling new variants may slow down.’*
The now-famous Provincetown outbreak around the 4th of July has taught us a great deal.
The area population was so highly vaccinated that the tens of thousands of visitors who descended on the place didn’t worry about getting sick. They even packed cheek by jowl into indoor venues, without a mask in sight. No one expected to need them. Here you can get a sense of just how packed together the revelers got:
Then some folks noticed they were feeling unwell or had lost their sense of smell. By that time it was dawning on us all that delta was different and that we had been wrenched into a yet another new reality where we had to learn the rules all over again.
The misinformation mill has seized on Provincetown’s experience as an example of vaccines not working. That’s not remotely the case. Yes, 74% of the infections were in vaccinated people, but with over 900 infections, there were only 7 hospitalizations and zero deaths. An unvaccinated population would have a very, very different outcome. This article explains everything you need to know about the outbreak and what it means for the rest of us:
You could just read the article, and you should, but I’m going to summarize some key points:
— Imagine a population that was 100% vaccinated. Vaccines are not perfect, so there would be some infections, and 100% of them would occur in vaccinated people.
— Infections in vaccinated people are rare, but since the vaccinated population consists of hundreds of millions of people, a significant number of people do get infected.
— The most important thing: With current strains of the virus, even if one does become infected, vaccination means essentially no chance of dying and very little chance of becoming severely ill.
— It looks like vaccinated people may harbor as much viral material in their noses as unvaccinated ones if they get infected, but infection doesn’t get as far into the body and the viral load goes down quickly as the immune system responds.
Research is ongoing to try to determine how likely an infected vaccinated person is to transmit the virus. That may be less than some studies suggest. From the same article:
‘For one, these sorts of PCR tests are good at identifying viral RNA, but they can’t tell whether that genetic material is in an intact, infectious virus particle or not. That becomes especially relevant for vaccinated people, Deepta Bhattacharya, an immunologist at the University of Arizona College of Medicine, said.
‘“Antibodies from a vaccinated person can coat the released virus and keep it from infecting other cells,” he told us. “And T cells can kill infected cells, releasing viral genetic material but not infectious particles.”
‘Second, the tests are only looking for RNA present in the nose and throat, not the lungs — even though vaccines are likely to have more of an impact there, according to previous research.
‘“Though it isn’t entirely clear how much of transmission comes from the lungs vs. the nose and throat,” Bhattacharya said in an email, “it is almost certainly some.” That would also suggest a vaccinated person with a similar cycle threshold as an unvaccinated person would be less infectious.
‘Vaccinated people also likely aren’t infected as long, since their immune systems are quicker to respond to the virus, which would also make them less likely to infect as many people as an unimmunized person.’
Here is a similar explainer, with data from the UK, where delta has run rampant:
Another highly vaccinated place that’s weathered a recent surge is Iceland.
‘Iceland, the experts say, is providing valuable information about breakthrough infections in the fully inoculated. Yet it also remains a vaccine success story.’
As with the surge in England, soccer was involved. ‘The country’s top health officials linked most of the cases to nightclubs and to residents who traveled to London to attend Euro 2020 soccer matches that some warned would be “a recipe for disaster.”’
Epidemiologist Brandon Guthrie gave some perspective in the Iceland article:
‘“We’ve handicapped ourselves in what the definition of success is,” he said. Scientists originally hoped for vaccines that were 50 percent effective, he said, and the goal was to prevent death and severe disease — not to provide blanket protection against any chance of infection.’
That is, the current reduced effectiveness of the vaccines is about as good as we hoped vaccines would be in the first place. Keep that in mind whenever you feel like despairing.
Even if it’s been quite a while since you were vaccinated, and you don’t have a lot of antibodies circulating in your blood, your T and B cells still remember how to recognize and fight SARS-CoV-2. Infection won’t get into your lungs because it will have been fought off by that time. It may take as much as 5-6 days for the body to marshal a good crop of antibodies, but generally it would take 10 or more days for a COVID infection to get as far as the lungs.
But meanwhile, kids are getting sick and being hospitalized, and some of them are dying of this disease that too many adults insist is no big deal for them. Vaccines for the under-12 cohort are on the way, but at this point the behavior of adults is the only real protection younger kids have, and in too many places adults are doing a crappy job.
“This new variant is a major contributor, but a major issue is that people’s behavior has changed,” said Gigi Gronvall, a senior scholar at the Johns Hopkins Center for Health Security. “I don’t think we can absolve people and leaders of responsibility for this because it gives them a pass. The reason kids are getting infected is because we don’t have those precautions and parents and households are getting infected.”
‘Kline said it is unclear what kind of long-term effects babies and children will face.
‘Specifically, Kline referenced the brain fog adults see after contracting the virus.
‘”How does that affect a baby who is still having a developing brain? We just don’t know.”
‘Kline said another concern is cardiac issues in children.
‘”It worries me a lot that people say sure, kids can get COVID-19 but most of them recover uneventfully,” said Kline. “We know almost nothing about what those infections could produce down the line. I think there is a real risk that a proportion of these kids will have some long-term effects.”’
And all this is before school starts in a lot of the country.
Conspiracy Theory Roundup
For the sake of readers who live in a bright future where this craziness is forgotten: Droves of parents are currently following right-wing leaders and fighting requirements to wear masks in schools, sometimes with physical violence against teachers, principles, health care providers, and other parents.
As far as I’m concerned, there is no excuse for willful failure to protect children; I suppose it relates to that tendency toward avoidance when things feel uncertain. Yet, even the parents who give the most insane reasons for refusing to let their kids wear masks believe they are doing their best for them. Some may have thought things through and come up with vaguely rational justifications, but most have surely spent too much time in the conspiracy-verse, where they find an endlessly creative cornucopia of crap being produced every day.
The funniest example going around is the claim that vaccinated people will grow tails. My first reaction to that was Cool! Unlike the claim that we become magnetic, this one cleverly avoids being immediately disproven by saying that the tails will grow at some point in the future. At least that’s how I heard it. I hope it doesn’t take too long….
For a while we were hearing that women would become infertile if they were vaccinated. Now the same scary disinformation is being aimed at men.
Oddly enough, sperm counts have actually been found to increase after vaccination! The reason is unclear, but it’s been a consistent effect.
“Sperm Parameters Before and After COVID-19 mRNA Vaccination”
President Former Guy rejected masks and publicly visible vaccinations as making him look less manly, but hey, maybe vaccines make for more manliness. I think we should really hammer on this selling point!
(Stephen Colbert pointed out that the conspiracy theory that vaccines cause a drop in fertility must be true— all those elderly people were vaccinated first, and sure enough none of them have had kids since.)
A more insidious claim is the one that COVID is being brought in by people coming over the border from Mexico; this is in line with centuries of blaming “foreigners” for disease. And of course it neatly deflects blame from the GOP fearmongers and unvaccinated Americans who are actually driving the high case counts. But this too is easily disprovable. We know that the bulk of transmission is coming from people within the US, not those coming from elsewhere, because we can track the genomes of various strains of the virus and see who is carrying which and where those strains are prevalent.
The lieutenant governor of Texas, Dan Patrick, added further venom to this trope by disgustingly blaming Black Texans for the state’s horrific rise in COVID illness and deaths. Patrick is the same guy who last year said people over 70, like him, should be willing to sacrifice their lives in order to keep the economy going. And he’s only doubled down in the face of criticism of his racist statements, which again are easily disproven.
‘Patrick acknowledged Texas’ public-health crisis — rising cases, hospitalizations, and fatalities — and said he’s aware of the criticisms of the state’s Republican leadership. But the lieutenant governor insisted the blame be directed at unvaccinated African Americans, not the GOP officials who remain passive toward the pandemic.
‘”The Democrats like to blame Republicans,” Patrick said. “Well, the biggest groups in most states is African Americans who are not vaccinated. Last time I checked, over 90 percent of them vote for Democrats in their major cities and major counties.”’
‘…In fact, the latest data suggests unvaccinated White Texans outnumber unvaccinated Black Texans by a roughly three-to-one margin.’
Meanwhile, Patrick’s cohort Governor Greg Abbott continues to interfere with requirements for masks around the state in the name of “freedom.” He’s getting plenty of pushback, but why should anyone have to use up their energy— or money— fighting for the right to protect their or their children’s health? Meanwhile taxpayers’ funds are drained away in court battles the state need never have started, instead of meeting real human needs. If only we could immunize against stupidity and self-serving political posturing.
One way out of the mess is to make masking voluntary, but as pediatrician Dr. Danny Benjamin said, a voluntary masking policy is “like having a no-peeing section in a pool.”
Onward with Delta Force
A major development just occurred: the FDA approved the Pfizer vaccine, so it is no longer being given under an Emergency Use Authorization. Moderna was later to submit data but its approval will be coming along soon. Many of the vaccine-hesitant have said this would make a difference in their acceptance of the shots.
The biggest question among my patients right now is when and where boosters will be available. I’m in the camp that wonders whether large numbers of us privileged sorts should be getting a third dose when so much of the world hasn’t even had a first one. We’re told that there are plenty of doses to go around in the US and that we can both give extra protection to Americans and send vaccines to poorer countries, but I personally don’t feel great about using a dose someone else may desperately need, and I recognize that the only way to protect everyone is to protect everyone.**
Giving a third dose to organ transplant recipients on immunosuppressants and others who have not been able to mount a strong response to their original vaccination is a different matter and a clear benefit as far as we know. For the rest of us, we’re told that we should probably get a booster about 8 months after our second shot. For me and a lot of health care workers, that’s early October, so we’ll need to decide pretty soon.
Surprisingly, it appears that flu shots give some protective effect against a range of severe symptoms of COVID. I was figuring that since I would likely stay masked this winter, and that if pandemic limitations continued we might have little or no flu season last year, a flu shot would be pretty worthless. The risk/benefit calculation has changed again. The authors suggest that for populations that have not had access to COVID vaccines, flu vaccine might be better than nothing.
“Examining the potential benefits of the influenza vaccine against SARS-CoV-2: A retrospective cohort analysis of 74,754 patients”
What about those who have already had COVID? Aren’t they immune? They do have some protection, though we aren’t sure how long it lasts. However, since the virus has ways to evade the immune system as part of its normal strategy, natural infection doesn’t confer immunity as well as the vaccine. If you have both a history of natural infection and the vaccine, you have the highest possible level of immune response. For you, a vaccine is essentially a booster. (Similarly, if you become infected despite being vaccinated, the disease has a booster effect.)
Last year when vaccines were being developed, there were breezy assurances that we would be able to tweak them to take new variants into account. Can’t we do that for delta? Well, yes, but no. The practical problem with creating vaccines against specific variants is that by the time studies are done and the product approved, that variant may be gone and another may be ascendant. If a variant comes along that completely evades current vaccines, though, we will need to meet that challenge.
Intranasal vaccines are being developed. Injecting a vaccine into the arm doesn’t teach the body to be on the lookout specifically for a respiratory virus. That is, giving a vaccine in the nose tells the body that the virus involved is going to enter through the nose and that’s where defenses need to be placed, so it’s a more efficient strategy. It should also be a bit easier on the needle-squeamish.
‘Charneau and a group of scientists in Paris have shown that natural SARS-CoV-2 infections trigger both systemic and mucosal immunity. But our current crop of COVID-19 vaccines offer only systemic protection. Developing vaccines that are sprayed up the nose, rather than injected into the arm, could change that, Charneau says. Mucosal immunity in our noses could be like a guard at the door, potentially helping stop even small infections of SARS-CoV-2 right where they start.’
I’ll leave you with another hopeful note, a story about former pastor Curtis Chang, who has been working within the vaccine-resistant evangelical community to dispel common myths.
‘Historically, the evangelical movement has baked into it a certain wariness of dominant secular institutions. And this can be captured in the saying that Jesus called us to be in the world, not of the world. We’re not of the world in the sense of just conforming automatically to the assumptions and beliefs the world. But what’s happened is that this orientation of being wary has gotten weaponized.
‘‘There’s been three main forces that I think have done that. One is that you can actually gain a lot of ratings by playing up those fears of what Washington is doing or what the left is doing. Christians are being bombarded by so much conservative media that they automatically just assume they’re out to get us. Another one is that conservative politicians have realized that you can gain a lot of votes by playing up these fears. And then the third is sort of outside conspiracy movements. QAnon, the anti-vaxxer movement—they have realized that evangelicals are fertile hunting grounds for their theories, because they are already primed to be distrustful of institutions, and so they can be easily kind of recruited into their deep conspiracies of distrust.’
Pastors, Chang says, are in a difficult position. Most of them are in favor of vaccination, but they risk backlash from their congregations if they speak too strongly about it— same problem GOP politicians have. (I would argue that both have helped create this problem.)
‘I understand that people are frustrated, that they’re losing patience, that they just want to make things via mandate, and give up trying to persuade these people. I think that’s short-sighted, for a couple of reasons. One, if you just resort to sheer coercion, it just confirms the narrative that they’re out to get us, that they are shoving things down our throat. You’re just laying the groundwork for a deepening divide. The second reason is that you have to realize that we’re still in the first or second inning of vaccine outreach, globally. You have to realize that parts of Africa and Asia are heavily influenced by Christian culture. A country like Uganda is like 90 percent Christian. Those churches, those places in Africa, they actually take their cultural cues to a great extent from American evangelicals, especially leading white evangelical voices. So America is—unfortunately, through evangelical culture—exporting its vaccine hesitancy. A lot of the same conspiracy theories and doubts and fears that we’ve been battling here, we are definitely seeing emerge and being replicated in the rest of the world. Changing American culture is not just about getting more American evangelicals to take the vaccine, it’s going to be critical to getting the rest of the world vaccinated. And ultimately, for all of us, if we don’t get the entire world vaccinated, we’re all at risk. ’
‘…What’s going to be really important is for Christians to convey to other Christians is that it’s okay to change your mind. The Christian virtues of grace and acceptance are going to be paramount here because people are going to be even more resistant if they think that in changing their mind they are going to be shamed.’
Grace and acceptance… those sure sound good right now.
TAKEAWAYS for the Delta Era:
— You can still get infected even if you’re vaccinated, though most likely you won’t.
— Remember the Swiss cheese layer concept and take multiple precautions as reasonable and available.
— Be good to yourself and others and acknowledge the effects of the unrelenting pain and uncertainty of our time.
— WEAR THE DAMN MASK!
Original source: https://www.washingtonpost.com/world/europe/iceland-covid-surge-vaccines/2021/08/14/bdd88d04-fabd-11eb-911c-524bc8b68f17_story.html
Data from the UK, May to July 2021: https://spiral.imperial.ac.uk/bitstream/10044/1/90800/2/react1_r13_final_preprint_final.pdf
“The Coronavirus Is Here Forever. This Is How We Live With It.”
Meanwhile, Israel is not waiting and has already given third doses to around 600,000 of their citizens— while Palestinians next door in Gaza and the West Bank have had so much trouble even getting a first dose. Here’s part of that sad tale, in which they were offered nearly-expired doses, for which Israel would have received fresh replacements: https://mondoweiss.net/2021/06/we-returned-them-palestinians-axe-1-million-pfizer-dose-deal-with-israel/
A new examination of the possible origins of COVID-19:
“The animal origin of SARS-CoV-2”