Love this - the EUA thing is particularly so obvious and frustrating.
Some thoughts that dovetail well with what you've said here:
I just returned from visiting my black, low-income family in Buffalo. Back in April 2020, covid swept through the family (8 older adults and 10ish young adults (18-25) living scattered through 2 houses (4 apartments)). None of my cousins my age had a symptomatic case, though we must assume in the cramped conditions everyone got sick. Of the older adults, 5 had serious cases, 1 was in the ICU for a month, and now has long covid. Another uncle of ours who lived in a nursing home died.
Fast forward to June 2021, all of the older adults are vaccinated but only 1 or 2 of my cousins are. I've tried to approach the subject with them gently, with understanding as a primary goal and persuading on the back burner. For the most part my cousins have been pretty dodgy about it, but I did get one to sit down and talk for a while. And he just had very reasonable questions: what's in it, how does it work, why do some people who get the shot still get sick, etc. "Am I going to have to miss work?" was notably *not* on the list, because he didn't even know enough about the vaccine to know there were side effects.
Now of course, all the information is readily available and he has a smartphone. But blame games are irrelevant to my point, which is that he inhabits a *vastly* different world than all of us, and his information ecosystem is just totally disconnected from ours. He doesn't read the NYT (or any other news source). His engagement with politics is nil. Any information he's getting about any of this is going to come in the form of snapchat or instagram stories, and that information is going to be super sporadic anyways. For the most part no one in his circles is going to be talking about the vaccines at all, they're talking about their annoying coworkers or some girl they're 'messing with' or the NBA playoffs. He does know that Cole Beasley, Josh Allen, and Stephon Diggs all refused to get the shot. (I will say that I do *not* think them publicly endorsing the shot would have registered on his radar at all or made a difference.)
After talking to him and calmly answering his questions, he was like "oh, I guess I'll go get one at rite-aid tomorrow." Note that my uncle had offered to drive him, and I'm not sure he'd have bothered even then if someone wasn't actively trying to give him a ride.
On reflection I think I have three takeaways:
1) One might expect that the family all having covid would provide *more* impetus to get shots, since they've seen how serious it can be. And I think that's true for the older adults. But I think my cousins reasonably think they're immune and also think that if they do get covid again, it won't be so bad. (*I* don't even understand why the vaccines would confer greater/different immunity, especially to variants, than actually having had covid. Why on earth would my cousins, who aren't not actively trying to answer that question?)
2) My cousins are, I think, reasonably representative of the norm among low-income black 20 year olds living in various ghettos. They're basically apolitical and don't engage with any mainstream channels of information or news, except sports. They were exposed to covid early on and were fine. And there just isn't a particularly compelling reason for them to go get vaxxed, nor is there anyone nagging them to do so.
3) I absolutely think they would get vaxxed if *both* a) they were offered a decent amount of money, 50 bucks seems like the right ballpark and b) the shots were *extremely* convenient - I'm talking like, walking distance. The less convenient, the more money it would take to motivate them. Mandates of various kinds might also do it - most likely as a requirement to see a Bills game, or to go to Canada, or for work (in their case, in Amazon warehouses). Only really confident in the last of these, though.
I think it's important to explicitly note that, for my cousins, this doesn't really seem to be about skepticism, at least not in any conscious or principled way. My cousin definitely said in a joking way "I don't know what sort of shit they're trying to put in my body", but he definitely didn't seem to really be worried about it. I think for him it's less of an explicit distrust of institutions than a lack of engagement with them. Hard to say how much this (or anything I said above) generalizes, but if this is broadly true among at least Dem-leaning vaccine holdouts, then that's a much better problem to have than real deep-seated mistrust.
Thought this was such a well thought out take and a really great contribution to the vaccine uptake discourse.
Just sort of a quick follow up. You note that one thing that could help is if shots were "extremely" convenient. I wonder if that's a small factor in parts of the deep south and rural areas more generally; getting to a vaccine site can take some real effort. At the very least it can take a lot more effort then where I live in the NYC suburbs. I'm wondering if real effort was made to have some sort of COVID shuttle system, it might have more of an impact then we might think. Shuttles that go right to your front door. It also makes me think that in places like the deep south, the best place to have vaccines is at churches; places that people trust and places people are already making the effort to go to anyway.
The first con they list is "you have to go to a place", and I'm constantly thinking about that for so many things. Convenience really is absolutely key.
The government should go to Walmart and even more so to Dollar General and tell them they will pay them the stores $100, an employee $100 and also will pay for $100 store credit given to every customer they get to take the vaccine.
I think we could hit 80% by September - and a quarter of the country might have had 6 or 7 shots by that point.
I've long said that we need a Vax-Mobile, like some areas have a Bookmobile for the library. I know this exists in some places, but it could exist in more.
There's a doctor in Atlanta who does a lot of (really moving) threads on her talks w/ vaccine-hesitant folks and one of the recent ones featured a woman who suggested, "it could be like a food truck. But with shots." https://mobile.twitter.com/gradydoctor/status/1416522889533267970
And she's totally right. There are mobile health vans in some places in the US, generally. Phoenix was *sort of* doing some vaccinations this way, but I think you had to reserve online ahead of time, which seemed to me to defeat the purpose a bit. If we're doing this anywhere in a pro-active, immediate way (like literally hanging out and chatting up passersby about getting vaxxed & answering questions on the spot), I sure haven't heard about it.
This doesn't sound much different from the vaccine situation in my extended family. Which is why liberals blaming "Q-pilled Trumpers" makes me want to tear my hair out.
The ironic thing is I actually do know one Qanon guy. And he's been vaccinated!
Yea, the "hard-antivax" demographic might be 10% of the country's adults. The rest are just ill-informed, lazy, busy, broke, or some combination thereof.
This could be very easy indeed if we just bribed them all. Another $200 billion or so to hand everyone $400 on getting vaccinated or if you already have been, and $800 when your area hits a given vaccination rate.
Of course, OANN will decry it as a blue-state handout by taking a map of vaccination rates by county and yelling about how those areas will get more money, but... can't win
'em all, and OANN's viewership probably is the hard core of that 10% I mentioned above.
Meanwhile, I've had to badger every one of my rural relatives about this incessantly. Get the shot.
Did you get the shot?
I'm going to keep asking until you get the shot.
Just get the shot and I'll leave you alone.
It takes ten minutes to go to Wal-Mart and get the shot!
Several have done it just to shut me up.
Then they realize there's a second shot involved... which I might have forgotten to mention.
I have a 40-yo relative who works at Walmart in Missouri. Getting a vaccine is very easy for him as they offer it at the pharmacy in the store and the 15 minutes he has to sit there after getting the shot is paid time.
He still hasn't done it for I guess mostly the same reasons you describe along with the fact that no one else he works with seems concerned about it, so why should he? He's not anti-vax nor does he think there's some great conspiracy. He (like me!) doesn't know but a couple of people who have had covid. There's just no reason from his point of view for him to stand out from the rest of the people he works with every day.
"*I* don't even understand why the vaccines would confer greater/different immunity, especially to variants, than actually having had covid."
The short answer to that question is because the vaccine _only_ causes your body to produce "disembodied" copies of the spike protein, which is a fantastic target for immune response. Some of the _other_ proteins that the live virus would program your cells to produce act to _inhibit_ immune response, which makes it harder to build up the "immune memory" you want. (It's not as bad as measles, which has mechanism to actually _erase_ immune memory so thoroughly that it can strip protection from other past vaccines -- https://www.nature.com/articles/d41586-019-03324-7 -- but it's still a problem.)
My wife is the controller for a company that operates a warehouse in exurban Atlanta, Georgia. She offered unvaccinated employees $100 to get vaccinated. Two-thirds of those who hadn’t already been vaccinated got the jab. If one employee avoids getting covid because of that, the company has saved money.
In all these discussions about vaccination I never read any mention about people with natural immunity (i.e. people that got sick and recovered). The CDC estimates that some 114 million people have already gotten COVID in the US alone.
This isn't a small slice of the population. There is also very good evidence that natural immunity is as good as or better than vaccination in terms of resistance to reinfection and reduction of severity when reinfected.
When you're interested in knowing how many people are vulnerable to infection by COVID, you have to exclude both the vaccinated population and the people who've had it already. Of course some people are in both groups, so you can't just add up the numbers, but I'm sure there's a sizable group who aren't bothering to get vaccinated because they got the disease already.
It's reasonable to assume that concentrations of such people are going to be higher in poorer, denser areas where the infection spread fast during the first and second waves (before the vaccines were available) and if those are the areas where vaccination progress is stalled, that's likely one of the reasons.
It's not clear what to do from a policy standpoint about natural immunity. It's difficult to identify and count naturally immune people. But it's clear to me that we're closer to "herd immunity" than the vaccination numbers suggest. And given that we believe COVID is now endemic (it will continue to reinfect both vaccinated and naturally immune people with mild cases forever) I don't think the that either 100% vaccination or 0 new infections are reasonable goals to aim for.
I haven't seen any evidence suggesting that natural immunity is *better* than the mRNA vaccines (both of the ones you cite just suggest it is similar), and I've seen some suggesting it is slightly worse.
It does seem to be a bit better than the adenovirus vector vaccines (J&J or AZ). But yes, to understand where we are in the process, we need to look at all of these things, and their relative effectiveness.
Slightly worse AND natural immunity likely fades more quickly. Also, from what I gather, natural immunity (from past infection) + mRNA makes for a particularly robust immunity profile. Given the possible, long term health issues associated with covid plus the non-trivial incidence of breakthrough cases plus the seemingly relentless evolution of the virus, it seems a no-brainer for previously infected persons to get vaccinated.
When you're interested in knowing how many people are vulnerable to infection by COVID, you have to exclude both the vaccinated population and the people who've had it already.
The point MY is making here is that we *don't* and also **shouldn't** care about that. We should care about how many people have received a vaccine. It's cheap, it's effective, and it's easily (easily-ish) verifiable.
Furthermore, you mention a 100% vaccination rate as not a "reasonable goal." MY agrees! His whole point here isn't that we are aiming for 100% but that we can and SHOULD push our rates up from the 55% rate here in DC to something higher like (uhh I dunno specifically) 80%. We can do that by requiring a 100% vaccination rate *for the sub-populations we can directly control* like all first responders, military members, and government employees (including teachers). MY is hoping this sends a message to everyone else, but even if it doesn't, it's good on the merits. Maybe we'll have a debate about getting to 100% at some point, but we'll need to get the low-hanging fruit first before that even becomes an issue.
You're confusing a policy question with an epistemological question. When I say "interested in knowing how many people are vulnerable" I mean that in the statistical/scientific sense. For example if it's your job to forecast the future number of hospitalizations from COVID infection and accuracy matters, then having the correct number should matter to you. Counting only vaccinated individual as not vulnerable will give you an inaccurate number.
From a policy perspective, I agree. It's hard to count naturally immune people, and a lot of people are likely to be unsure about their own status (maybe they got sick and wrongly assumed it was COVID, maybe they got COVID and were asymptomatic so they didn't notice). Thus it makes sense to strongly encourage people to get vaccinated anyways.
That's a helpful clarification, thank you! But you start with "in all of these discussions, I never read..." I think you don't read that line of thought in this article because this is an article that is about policy and not about epistemological speculation.
My whole point is that, for the purposes of this article, MY **doesn't care** about natural immunity and that we are NOT "interested in knowing how many people are vulnerable to infection" because that's tangential to the policy question of what to do about vaccines.
We live in a country where we generally don't use state coercion to get people vaccinated, thus there's an important psychological component to getting people to choose to get vaccinated.
My specific beef is about people who ask questions like "why aren't people choosing to get vaccinated?" and then postulate a list of reasons that doesn't include the possibility that those people got sick already and consider the risk of vaccination side effects not worth the benefit.
If your stance is that we SHOULD use state coercion to get everyone vaccinated, then obviously my point is irrelevant. That's a political/moral question though and I expect that the public splits on that question and agreement/changing minds is pretty much impossible.
I dunno man, I think we pretty regularly DO use state coercion to get people (children) vaccinated. For example, check out the required vaccines for public school in DC: https://dcps.dc.gov/page/school-health-requirements.
I think it's very clear from Yglesias's article that we absolutely SHOULD USE STATE COERCION to require vaccines for certain groups! Military, first responders, state employees, etc. Possibly even for public school children. He is making that exact political/moral question in the article that we are both upon which we are both commenting!
I'm perhaps reading a bit into Yglesias's point here, but I *think* he might respond to your middle paragraph and say something like this:
People often make poor risk/reward choices in deciding to vaccinate themselves and their children. From both an objective standpoint and a socially optimal standpoint, vaccination is low risk, high reward. Therefore, to encourage the public to voluntarily make a different risk/reward choice, the Government should take several actions, including permanently authorizing the vaccine (i.e. not via EUA) and the Government should also mandate vaccines for those under its direct control. In taking these actions, the Government will send a strong(er) signal to those risk/reward opt-out people and hopefully a sizable number of those individuals will revise their calculation and chose to get a vaccine. Perhaps changing minds is not possible, though I disagree, but taking those actions have independent benefits and it should be done regardless.
The thing about state coercion is that it inevitably comes with a political cost (i.e. the party in power loses votes the next election). People are fussy about vaccinations especially and if you care about Democrats getting elected you should be more than a little worried about the impact of vaccine mandates on the midterm election.
My point is that policymakers need to weight the benefits of any policy against any costs, even if in this case the benefits are to public health and the costs are purely political. It would not be smart to pay a political cost and then NOT get the public health benefit, because you were vaccinating people who already had natural immunity, for example. I'd advocate for a more targeted approach that's more certain to actually pay off, or to look at other policy approaches with the same potential public health benefits and none of the costs associated with state coercion.
It's not clear to me that we do anything from a policy standpoint about it. We have more than enough vaccine supply, so we don't need to ration it. If there's an incentive being given for getting vaccinated, you should still get it if you've already had COVID. If we're closer to herd immunity than we think we are, great, but we'd have much lower COVID cases and deaths if a lot more people were vaccinated, so that's the direction we should still be going in, and using policy to get there. If we get to 90% vaccination rates and the vast majority of cases are among the vaccinated, then we can start having the discussion about whether to continue prioritizing higher vaccination rates.
Excellent point, feels like a big oversight of MY to not mention this. The one family we know who all got covid (not a surprise as they were for the most part sharing indoor space throughout the winter) are not at all concerned about getting the vaccine. And I can't say I blame them.
Regarding the level of natural immunity, it certainly doesn't seem sufficient to keep the delta variant from becoming a significant problem, it's clear that vaccination rates need to be significantly higher, the marginal benefit from vaccinating someone who already has natural immunity is smaller than someone with no immunity but the value of making that distinction is not very high.
My hypothesis is that even with 100% vaccination, delta variant is still a problem. The best vaccines are 95% effective. The virus is incredibly contagious. Best case is that we can push the case fatality rate extremely low so that nearly all the people who get it, survive it.
If the vaccine were as contagious as measles (r0 of 20) then yeah, but I believe the r0 of delta is estimated at 5-6.
To reach herd immunity, vaccine rate * effectiveness needs to be greater than (1-1/r0). If effectiveness against delta is .95, then you need a vaccine rate of 87.7%.
People mention it. Most intelligent commentators I listen to even in mainstream sources say natural immunity is real and should be exempt from things like vaccine passports. (Totally academic because we’ll never do them in the US.)
My brother is a researcher in the Bay Area, and he said at one point the reason Berkeley was avoiding a vaccine requirement was that people of color would be less likely to have been vaccinated. So in order to not adversely impact communities of color, Berkeley enabling the spread of COVID which will... adversely impact communities of color.
So frustrating. People of color will get vaccinated if there are vaccine mandates.
And I would hope someone at Berkeley has done real statistical analysis on this to have come to the opposite conclusion, but my anecdotally-informed suspicion is that the trends among most people of color with regard to vaccine skepticism are not going to hold for people of color at *Berkeley*, for godssake. This seems so obviously to me to be a case where the intersection of class and race is paramount. (But I have definitely not tried to find data on this.)
There is also a progressive politics issue here. I'm a conventional liberal but the pandemic has turned me radically hostile to the FDA and CDC who seem to me to have contributed (unintentionally of course) to tens if not hundreds of thousands of unnecessary deaths. I believe we need a competent regulatory state but it is hard to make the case that we need these particular institutions in their current forms.
Which of their actions turned you radically hostile to the FDA and CDC? I’ve been angry with each of them at times, but haven’t turned radically hostile. Given the general lack of efficacy of European and Asian regulatory and informational responses, I’m unclear what form institution(s) that could have saved those lives would take. Seems like the CDC and FDA have been mostly acting in good faith, early masking fiasco notwithstanding.
Not all of those were the CDC/FDA, but they are still good points.
My biggest overarching complaint in all this is that the FDA failed to move on *cheap* at-home rapid COVID tests early on. Even if not perfect, they would have empowered people to make their own risk assessments and adjust behavior *when necessary*. As it is, many people just threw up their hands and did what they wanted anyway (as Matt can attest to the various house parties he saw going on despite the rules against them).
I have a PhD in and work in a semi-related field. And to that end, I felt sufficiently knowledgable to make my own risk assessments, and I read the primary literature regularly. I avoided large gatherings, wore a mask when around others, didn't dine in a restaurant, and took a number of other small measures that I felt were reasonable and justified. But I also had Thanksgiving with just under 10 extended family members (I got a test at work before going to make sure I wasn't putting *them* at risk) and I visited my parents for Christmas (again, after a test and more rigorous avoidance of interactions with others for a week to be all but certain).
Of course, it's my personal bias, but I feel like the messaging would have been better received (and perhaps more effective) if it were more about risk *mitigation* than elimination, combined with ways to do so.
And I take your point that “good faith” isn’t good enough for the agencies in charge of guiding us through the pandemic. We need actually competence. I accept that. But even the most competent public health agencies in the world didn’t get much better results for their people.
Would this be easier if we also had “someone in charge?” Some portion of the problem seems to reflect the CDC’s issuance of guidelines and advisories. As an example, many national organizations tend to cite the CDC and not the legally authoritative dictates of local authorities.
Absolutely fair. Although I never got the “trust the science” line from the FDA and CDC. That came from left internet and seems to have been 100% unhelpful to the people who were trying, in good faith, to guide us.
Fully vaccinated. Family is fully vaccinated. Not concerned.
Liberals who don’t interact with a single unvaccinated person in their urban suburb obsessing over those not vaccinated 4 state lines away sound an awful lot like conservatives in Florida obsessed with crime waves in Chicago.
All the families in liberal suburbs who have kids under 12 still can’t yet be fully vaccinated and thus any time they are with friends, at camp or school, they are being subjected to restrictions because of covid fears (rightly or wrongly). Or one of the places (they exist!) still following CDC guidance that unvaccinated people after traveling out of state must quarantine for at least a few days until getting a test before returning to camp or school. None of those families can simply say “not my problem.”
This. My kids are 4&5. The decision by some to never vax could lead to covid becoming endemic. I've already seen one child survive a life threatening 1 in 10,000 medical emergency, and I would be so angry at the people in this country if it happened again because of anti vaxxers.
There's a lot that's right about this, but I just don't see anything pointing to delta being harder to deal with than measles. The worst estimates of R0 for delta are in the 8-10 range, while measles is estimated in the 12-20 range. If we could get vaccination rates to the same level as measles vaccination rates, we absolutely could get the level of measles.
(Also, measles appears to have a similar fatality rate of about 2%, though probably not with the same age skew as covid.)
It took many years to get to measles vaccination rates. I expect that in 10 or 15 years, covid vaccination rates and measles vaccination rates will be very similar, though I worry they will both be lower than current measles vaccination rates.
You're missing the point. Fully vaccinated. Family vaccinated. Not concerned. Except until many more of the unvaccinated are vaccinated, life like we knew it before covid isn't returning, and that is the point. The French response reported in today's NY Times (no normal life for you until you get vaccinated) is exactly what we should be doing.
I've been living in Europe for the last five years, so maybe my picture is distorted, but how hard is it where you are to just act like Covid doesn't exist? Since the start of July when I got my second shot I've been going to parties, throwing parties, going to movies, going to crowded museums, and occasionally dining indoors when I want air conditioning. I fully expect to be exposed to the delta variant at some point (though probably not very soon since there doesn't seem to be much of it in Hungary), but I just don't care.
Is it impossible to live like that in the states do to the ongoing restrictions?
I think that is basically what life is like in most of the US now -- either there is enough vaccination that people feel safe again (I'm writing this from Brooklyn, where I've eaten indoors, shaken new acquaintances' hands, etc. in the last few days), or they never really changed their behavior anyway but now official restrictions are lifting (I'm going to grad school in the fall, and classes will be mostly in person). You do still see some people wearing masks outside, but it seems to be only 10% or so of people.
Tim, glad you're partying hard, enjoying life and just don't care. When was the last time you tried traveling to New Zealand or Australia or 90 percent of the world that's shut off to foreigners? Here in Brooklyn, we too are parting hard because we'd be going insane otherwise. You obviously missed the point, maybe from too much partying.
Look, I agree that we should be pushing the vaccine to save lives and restore normality at home.
But let's not pretend that pushing up vaccination rates here will suddenly get China, Australia, and New Zealand to open their doors.
It will be an incredibly difficult political transition for those nations to go from "effectively no COVID" to "we have to accept some COVID".
Even if their vaccination campaigns are perfect (and none of them are or will be anytime soon), they will suffer far more death after opening their doors than they have to date.
In China in particular, that transition is easily going to take until 2025-7. The Party has dialed up the propaganda so much that they're only going to START opening entry requirements once the cost to the economy and social stability becomes very apparent, probably sometime in 2023-4. Then they'll gradually dial back restrictions, first on Chinese nationals, then overseas Chinese, then foreign citizens.
And that assumes that they do succeed in vaccinating virtually all the populace with a Pfizer booster, because Sinovac is borderline-useless.
To illustrate, if I were to vaccinate the entire population with Sinovac, then throw the border open and do nothing further, China could expect about 450 million cases, all breakthrough, and 20 million deaths or more.
To be fair, I still don't quite get your point. You say that we need higher vaccination rates to return to normal for most of the world, but then you say below that they won't respond to what we do anyway.
Not true. You’re forgetting the podcast hipsters, yoga hipsters, and vaccine skeptical urban working class. Not saying it’s not better in the cities but it’s totally false that I couldn’t go out my apartment door and in 2 minutes find somebody unvaccinated with a man bun, who’s probably woke.
I actually find this to be very interesting. I'm related to a person who is, at least nominally, in charge of vaccine encouragement for the company. I was talking to her yesterday and I suggested that what they should do in places where they have low rates, Iowa, Missouri, etc was to offer a straight one hundred dollar bonus for proof of a vaccination.
She told me that that would be unfair to other employees who have gotten vaccinated already like most of R&D and our sales and marketing people who have both hit above 90% vaccinated rates. I said, "are you trying to make people feel good about themselves or are you trying to get people vaccinated so that people can safely go to work?"
I feel like that's where we are with vaccines nationally. We simply aren't willing to outright incentivise people to get vaccinated and we aren't willing to just approve it and mandate it. And the longer we wait to do either of those things the more the culture war battlelines will solidify until it finally goes from being a vaccine to being another signifier of ingroup/outgroup status.
If it were the government, I'd say "$400 per person vaccinated and a bonus of $800 when vaccination rates in your county hit X"
At this point X probably needs to be 90% of adults or 75% overall to really blunt Delta. At that point case numbers will look horrible but few will be dying.
Oooh I love it. Unfair or whatever but who cares. Great example of the point of the post - we could be doing so much more to get the vaccine into more people.
I find Psaki's comment on the matter somewhat disturbing. It's worth HUGE sums of money to get these shots into arms, so bribe the ever-loving fuck out of people to do it.
Of course you do it for those who've already been vaccinated! But also for the ones you want to get there.
Matt loves econ jargon, the unvaccinated are imposing 'externalities' on the rest of us, but I'd suggest a stick rather than a carrot: cut off their child tax credits, food stamps and highway funds until their state reaches an 80 percent vaccination rate.
Make version of the vaccine delivered in a sugar cube. You get the people who don't like shots out of the way.
Otherwise, as much as I want to stick mandates to these anti-vax idiots, I can't muster up the energy to spend a lot of time worrying about people who refuse the shot. Fine, get sick then and deal. Something something horse to water.
I'd worry about creating a variant breeding ground, but we're getting variants regardless given the most of the world has far lower vaccination rates than the US. With Moderna and Pfizer having boosters ready to go, we're pretty much in a world where for the vast majority of people, COVID is something you choose to become very sick from or not.
Liberals locking down in liberal cities like SF again would be basically punishing ourselves for the sins of the Q crowd.
That all said, here's an idea: health insurance companies get a waiver from covering covid care expenses in cases where someone was able to get vaccinated but refused to do so. If getting covid as an unvaccinated person means you're covering the entire hospital bill, the incentives change pretty fast.
At this point, a version of the mRNA vaccines that didn’t require a cryogenic supply and delivery chain would be an enormous step up from the status quo and we’re not likely to see that in the next ten years. A liquid that survives stomach acids? We’re not gonna see that in our lifetimes. There are unfortunately very good reasons why most vaccines are delivered as intramuscular injections rather than pills or sprays, and it’s not because nurses enjoy dealing with the needle-phobic. :(
Absolutely agree on the variant point. If we want to avoid even worse mutations, we should be moving heaven and earth to flood the rest of the world with mRNA vaccine doses.
100%! If we are truly worried about variant creation, the risk is higher in international regions with 4% vaccination than domestic regions with 30% vaccination. Even leaving aside the reality that the people in the 30% vaccination locales think it's a mind control device, or whatever, focus on getting the shots to the people willing to take them. Once you run out of those people, shift back to the idiots.
There's been study of patches that get around much of this issue (I don't know if these "dissolvable microneedles" are the same way that, say, nicotine patches work, but they do seem to avoid the worst needle bit): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8066809/
A friend of mine was working as a nurse assistant at a vaccination site when one patient had such a strong panic reaction to the needle that they had to abandon vaccination. This was the second time this had happened and they made arrangements for that patient to go to a hospital and be vaccinated while under anaesthesia.
In a population in the millions, even very rare things are, in absolute numbers, quite significant.
Um, there was a point to that anecdote, and it was this: some people can't get vaccinated for good reasons. Some of those people will just not get vaccinated rather than getting a formal exemption. You might conclude that requiring them to get an exemption (which might prove difficult for some people) would be appropriate, but it's not cost-free. And screwing over a small minority is something that liberals should be cautious about.
Should the rest of us mask up to protect those people? I have sympathy, but the answer is still "no." Similarly for the immuno-compromised. Tough situation for them, but the burden of protecting them should first be on themselves (e.g., wearing N95 masks) and not on the entirety of the population.
A lot of these people have gone uninsured for much/most/all of their lives. I seriously doubt the prospect of hospital bill collectors will get them to abandon their loyalty to patriotic distrust of Dr. Fauci and the deep state. Also, many (most?) of them think the virus is a hoax, in any event, so they're not worried about health risk.
Let’s stipulate for the moment that “the process” at the FDA has essentially failed and is in desperate need of an overhaul. I’m even reasonably on board with this idea.
But if the goal is to persuade the persuadable, I’m really dubious that changing the rules at this stage to issue formal approval faster will be of any help. The talking point on Fox/OANN/NewsMax will change from “this vaccine is experimental and not fully tested/approved” — which, as you note, is strictly true at the moment — to “they changed the rules to give approval to this vaccine without testing it like they normally would have”. And this, also, would be strictly true and worse yet would end up also being true of any _subsequent_ vaccine approved by the FDA for the rest of our lives.
I know that our host prefers to avoid double-bank-shot GAME THEORY approaches to public health and I’m largely sympathetic, but at the same time I think we need to be honest with ourselves about the depth of the abyss that we are currently on the edge of. In 2016 Trump played footsie with the anti-vaccine fringe (there were even rumors of him appointing RFK Jr as surgeon general!) but whether out of personal unpredictability or at the behest of saner voices behind the scenes ended up not paying the issue much attention as President. And for now, Rupert Murdoch seems to be trying to thread the needle on this issue. But there is no guarantee that will hold true in 2022/2024 and if the Trumpists decide that demagoguery on the topic of vaccines is their path back to power, they will absolutely do that and there are worse actors than SARS-CoV-2 waiting in the wings.
As a side note here, one of the reasons I’m looking forward to the inevitable flood of tell-all, score-settling memoirs of the Trump administration is that I am achingly curious to know the story of how Scott Gottlieb ended up at the FDA. You can make a strong case that he was the _only_ Trump appointment who was neither obviously a crook from the get-go nor simply incapable of performing his job. In fact he may have actually emerged from Trumpworld with his reputation in better shape than it started! Clearly something went very awry in the selection and vetting process there and I’d love to know what happened.
(FWIW a friend of mine was a classmate of Gottlieb’s at Wesleyan and insists that he was incredibly, forthrightly unpleasant as a human being so maybe that was enough for Donald?)
Fair counterpoint, but IIRC there were some objections to Powell on the grounds that he was somewhat untraditionally qualified -- I think Gottlieb was unusual in that he was pro-forma qualified for the position, effective in the position while he held it, _and_ not under indictment or even suspicion of petty graft by the time he left.
The bar I came to expect from Trump's team was so low that I have to think about how "general competence" should not be an excuse for "squeeing fanboy-ism" with regards to Gottlieb.
He's not only competent and not corrupt, but also not a raging asshole! How many other people wrapped up in the health sector investment community are going to get up in front of Congress and testify that artificial barriers to entry erected by proprietary drug manufacturers are bullshit and need to be crushed to bring prices down faster?
It's like the Holy Trinity in the context of Trump appointees.
Re: "changing the rules at this stage to issue formal approval faster". Maybe I missed this in MY's article or The Discourse somewhere, but to me "the rules" at the FDA for full approval of a vaccine or medicine are very opaque (hence, the discussion about the Alzheimers drug approval). So if the FDA came out tomorrow and said "full approval"--it's not obvious to me that they would have had to "change the rules" to do it (even if, behind the scenes, they did alter their normal internal rules given the pandemic context and overwhelming amount of evidence received from real world application). Instead, given that they have over a years worth of evidence about the safety of the vaccines from when they started the first trials, and so much evidence from use in the population... seems like plenty for them to say "this satisfies the [very opaque and context-specific] rules we have".
You're confusing "rules" with "interpreting complex scientific data". There are more mundane rules about how much data need to be collected and how it needs to be organized and presented.
I love the idea of paying Trump to promote the vaccine, especially if his compensation is tied to vaccination rates. I can't see him saying no to that and the reaction once this got out in Trump World would be fascinating.
The problem is that you pay Trump a truckload of money to mumble something about how the vaccine is great because he developed it and you should get if from a Republican-approved source, but then one week later he'll be back to trashing it.
That seems increasingly unlikely, for the same reasons a single infection or vaccination doesn't provide lifelong protection from influenza: fading immunity and virus evolution. I don't disagree that the overall health situation with respect to this virus is likely to look a lot better a year from now. But I think our species is looking at regular booster shots/jabs for the foreseeable future.
Maybe. Not sure how many reluctant Democrats would get the vaccination with FDA approval vice a mere EUA. On the other hand, FDA approval opens the doors to many organizations being able to mandate vaccination without fear of lawsuits.
Hi, Matt. You’ve pointed out in the past the ways in which the public health community has gotten us all into trouble with what you’ve called “bank shots” but which you might also call “saying things that aren’t true.” The classic example was the early advice on masking. Instead of saying, “We need to save our small supply of quality masks for the medical community so please don’t hoard them,” they said, “Masks don’t work, so please don’t hoard them.” I think most of us agree now that this was a mistake.
There are other examples, pretty much none of which worked as intended. The lesson seems to be that we should tell the truth and trust the public to be grown-ups who can handle the truth. And that trying to manipulate people through misinformation – or even just false confidence in the face of uncertainty – is very likely to backfire.
I worry, though, that you are sort of advocating another bank shot here in terms of vaccine approval. If someone were to say, “These COVID-19 vaccines are based on brand new medical technology that none of us had ever heard of 18 months ago and haven’t gone through the same level of rigorous testing and observation of our typical vaccines,” that’s just true. I got the vaccine anyway – as soon as I possibly could – but not because I thought it was just as safe as a measles shot. I got it because I thought it was the right thing to do despite the obvious risk.
Of course it would be great if we knew more about the long-term safety and efficacy of these vaccines. But the FDA can’t just waive away the current situation by pretending to know more than it does. The Emergency Use Authorization seems to reflect that reality: These vaccines have not gone through all the testing we’d typically expect, but under the circumstances we think they are safe enough to use anyway.
And under these circumstances, what would it even mean for the FDA to give full approval to the vaccines? It doesn’t change the actual current level of medical/scientific knowledge about them; it just sort of moves the goal posts in terms of what full approval requires. So isn’t it just another bank shot?
One thing that some of the past bank shots seem to have in common is a reluctance to ask individuals to make sacrifices for others. That’s true of the original mask debacle, but also of some of the later stay-at-home and pro-masking advice. Because we haven’t wanted to tell people that they have to make significant personal sacrifices primarily to help others, we’ve instead fudged the data a bit to make it look like it’s actually an act of self-interest rather than self-sacrifice.
Instead, as you’ve recommended elsewhere, why not just go full bore (sorry) on the truth here: Yes, these vaccines are a bit scary. Yes, they are based on brand new technology that hasn’t been tested as much as we’d like. Yes, just like with ordinary vaccines, there is certainly some risk of complications. But your country needs you to get vaccinated anyway. Not just – or even primarily – to protect yourself, but to protect more vulnerable people around you.
I love your idea of a massive marketing campaign, far more aggressive than what we have now. But rather than pretending to know that the vaccine is perfectly safe and that vaccination is in everyone’s narrow self-interest, why not send the message that getting vaccinated is an act of patriotic bravery? And refusing it is an act of selfish cowardice.
The FDA should say that they are highly confident the vaccines are safe and effective at treating COVID-19, and that everyone in America should take them. The basis for this confidence is both on trials and extensive real-world use - better evidence than they usually get, actually.
This is totally true. It is what all the individuals involved are saying. So it would be appropriate for the FDA to officially say it too.
As to why they are not following the standard process:
1) It's a pandemic, so urgency is very high
2) Because so many people have taken these vaccines outside of clinical trials, they have an unusual source of good data.
I don't think your caution that "these vaccines are a bit scary" is an appropriate summary of the actual state of medical knowledge here.
I guess the devil's advocate position would be that both the blood clot issues and reports of Guillain-Barré Syndrome - while EXCEEDINGLY rare - are real side effects of the vaccine and listed currently on the CDC vaccine monitoring page. I do think it's a fair statement that these are *a bit scary* - although we're getting into very pedantic discussion here.
I'm probably a little overconfident, but there's nothing scary about the Pfizer/Moderna technology. It's just mRNA molecules wrapped in some lipids; every cell in your body is already full of very similar stuff. These are many orders of magnitude less likely to cause unexpected problems than, say, small molecule drugs, for which we can never predict all the possible off-target effects. Such as they are, the minute potential dangers from the mRNA vaccines appear to be related to overreactions of the immune system and the like, which are possibilities for anything.
I've been waiting for someone to point this out. Literally NOTHING in this vaccine is still in my body after a few weeks. The lipids are gone, the mRNA consumed, the adjuvants excreted.
Ever since we got rid of the laundry list of metal-based preservatives and shit in vaccines after the 70's, even candidate vaccines haven't had long-term side effects other than the immune response they provoke. Those don't take 10 years to turn up, they take 6 months.
If they were going to manifest, they would have by now.
This is beside your point, but it is salient to me that LeBron James specifically does not seem to be vaccinated based on his public comments and also broader trends among athletes.
I am not privy to any inside information, but I think that sports leagues *should* be one of the things where employees are required to be vaccinated, except that the most prominent employees (the athletes) have collectively bargained contracts and I’m not sure how those deal with vaccine requirements whether or not the vaccines are formally approved.
I bring this up because
a) I’ve heard almost nothing about the issue of vaccine requirements for unionized workers, teachers or athletes or auto workers or otherwise
b) the specific case of athletes (wealthy individuals with access to lots of information with lots of exposure risk and who depend on being healthy for work) broadly not getting vaccinated (as seems to be the case based on public health data) seems like a bemusing problem to me that doesn’t affect a large number of people (there aren’t that many pro athletes) but might be a prominent indicator of other less visible trends
Given how the Chris Paul situation played out (where he was keeping his vaccination status private, and the fact that he was vaccinated came out only when he tested positive), I think LeBron is vaccinated too. NBA players are hiding their vaccination decisions to avoid social pressure to *not* get the shot from friends and family. The costs of not getting vaccinated are just way too high.
I don't know what that person has in mind, but if vaccination status is an important signifier of one's identity, then revealing to friends and family that you've been vaccinated might be as painful as revealing that you had an abortion, or that you voted for a Republican, or that you eat meat, or that you were never baptized, or any number of other identity signifiers for various communities.
If you are facing pressure not to get a shot and want to do it, the obvious move is to publicly say it’s a personal decision and let your wife/friends/etc think you didn’t get one.
My bias is showing here, but I think there's a significant contingent of Dems/libs that want the unvaccinated to "bend the knee" and admit that vaccines are good and they work. When instead they shouldn't give a flying fuck and just get as many people vaccinated as possible, through whatever means are legal.
I said a year ago that the biggest motivator for the reluctant would be Disneyland requiring a vaccine, and I'm sticking to it.
Has anyone seen a poll with something like this question. “Have you had a close friend or family member die of COVID-19?” My answer is yes, but my informal queries show nearly everyone I know would answer no. We all see the economic impact, but I wonder who among the unvaccinated just don’t seem worried. For me personally, until I actually SAW polio in Africa, I didn’t really REALLY get the importance of vaccinations. As a young man, I wasn’t anti vax, but seeing certainly made me pro vax.
I think this question doesn’t get posed enough. Like I wrote, my answer is “yes” (family member), but I have not met anyone in my extended circle who can say that. A lot of folks know of someone, but not someone close is what I’m finding. Clearly people are dying, I’m not trying to be coy or flippant, but it seems the median count among most people for someone they know is … zero.
Really? I haven't had any _direct_ acquaintance die of Covid specifically. One direct acquaintance died of complicated interactions between Covid and some other health problems, but in his case he was likely to die within a few months anyways. But I know, offhand, two friends who had parents die, and one who had an uncle die, where in all three cases the deaths were unexpected -- these were people who could've easily lived another decade or three.
I also have had multiple friends in my own middle-age cohort (call it 30-50) who have had awful experiences with the disease, including very long-lasting after-effects. One who got the bug last year is largely recovered now -- the vaccine seems to have significantly helped rein in her symptoms, for whatever reason -- the other is a healthcare worker who got infected _after_ being fully vaccinated, and has been basically out-of-commission for a solid three months.
There is no medical reason that the vaccine would help long haul symptoms. Weird it’s overwhelming women who get long Covid.
I don’t know a single person who has had long haul. I work all over the US. Different people at different job sites. I ask. It’s always a friend of a friend or a friend of a commenter.
But let’s do the math.
Population. 330M. Deaths. 609K. 1 out of every 541 people. How many people do you know have 541 friends/coworkers? Not many.
It actually gets skewed even more. Only 12% of those are under 65.
The average working aged American is going to mostly know people around there age. With exception of their kids or parents.
I can do the math… but it’s late in Brazil. But basically…. It’s extremely unlikely for anyone under 65 to know someone who died of Covid on an intimate level.
Now. If we were to survey those over 65. It would be extremely likely for them to know someone.
Now I’m not saying that Covid is fake. I’m vaccinated. I don’t want it. But… the fact remains that the average working joe is just not that impacted. Or have experience in other someone who is vaccinated.
As far as long Covid. There are whispers in the medical community that are kept quiet… but the vast majority of cases of long Covid are women between 30-50. This is also coincidentally the same demographics that has in the past been more likely to have somatic symptoms. Now are all cases of long Covid somatic… no. There are cases where people are really screwed up with lung scarring. But the prevalence of this vs somatic cases hasn’t been teased out yet. It’s a sensitive subject. But let’s just say… some
Percentage of long haul Covid cases are not physical. And a key indicator would be anyone who says the RNA vaccine mysteriously eased their symptoms.
Your assertion that there's no reason the vaccine should help is, let's say, premature. We don't really know enough about why long-term symptoms happen in the first place, to be certain about what might help. Your seeming surety about this says more about your own biases than it does about the disease.
There's been some interesting speculation around whether "long Covid", and some of the similar, contested long-term syndromes like "chronic Lyme", involve having reservoirs of the original pathogen that flare up, or whether there's some kind of shift in the immune system that puts it into a bad equilibrium. Ross Douthat (himself a chronic Lyme case) wrote about that some months back.
I’ve been critical of some of your vaccine process takes in the past (you can’t “just” rapidly spin up more manufacturing of a therapeutic like this; it’s not like making plastic widgets or whatever), but I’m on board with this one. One mechanism I could imagine is something covered by EUA could automatically trigger a data review for full authorization once you’ve treated, say, 10 million people, or some significant fraction of the treatable population. I guess the counterpoint is that it’s not large numbers of patients matters that really matters to prove safety, giving the treatment enough time in the field to make any longer term side effects known. Maybe that’s what the FDA is waiting for.
At some level, doesn't the number of cases compensate for the length of time? We've had ~340 million doses in the US (mostly mRNA) and the whole world has had >3.6 billion. If *on average* bad side effects occurred after, say, a year, wouldn't having that large number of cases give us a good idea that might occur even after, say, only six months?
The primary difference between an EUA and formal approval is the amount and type of evidence that needs to be presented. It's quality vs. quantity. It's better to get an adequate number of subjects that are carefully evaluated rather than half-baked poorly documented anecdotes coming from a population of millions. Even though the latter can be useful, there will be enough noise that you can't rule out a signal
I also don’t understand why kids under 12 aren’t allowed to access vaccines on a right-to-try basis. I understand that this case isn’t contemplated under existing right to try legislation, but in terms of increasing population vaccination rates, letting parents desperate to give their kids the vaccine actually do so sure seems like low hanging fruit.
I think this goes back to one of Matt’s other hobby-horses: the interaction between our adversarial legal system and the public health system is not good. There is no waiver you can sign that actually prevents you from suing (and making a loud noise about suing) if your child falls ill, and no guarantee that a civil court judge won’t rule that the waiver language was misleading, and a successful class action lawsuit where the plaintiffs are families with allegedly injured children? There’s your operating profit for the next decade gone.
So you get what our current status quo actually is: if your ten year old can possibly at a squint pass for 12 you can get them vaccinated (OR SO I HAVE HEARD) but the pharma companies have the additional protection of the fact that you are formally breaking the rules to do it.
I think that's often true, but in this case, my understanding is that the PREP Act of 2005 gave the HHS secretary authority to give a broad liability shield to vaccine makers and health care workers, which they seem to have done. https://www.phe.gov/Preparedness/legal/prepact/Pages/default.aspx
The kids whose parents would do that are likely to already be in high-vaccination communities. Not that it's not something, but I don't think this would be a high number, or that it would be in the places with the highest value to additional vaccinations.
On the one hand, I totally agree with you that this is not the most effective thing to do at the margin. On the other hand, I live in New Jersey where 65% of the population has received at least one shot, and the largest remaining group of unvaccinated people is kids under 12. I literally just now got a push notification that the governor is floating reinstating mask mandates. The next thing will be school closures, again. Unless anyone has any plausible reason to think that the vaccine is somehow unsafe for children, and I don't think anyone does, then let parents like me sign up to get our kids a shot so they'll be protected from an already low risk and opportunities for community spread will be lower.
Not sure if you saw this but yesterday the JCVI just advised against vaccinating children under 18 yo citing "benefits not outweighing the potential risks".
Relevant passage:
The JCVI is not currently advising routine vaccination of children outside of these groups, based on the current evidence. As evidence shows that COVID-19 rarely causes severe disease in children without underlying health conditions, at this time the JCVI’s view is that the minimal health benefits of offering universal COVID-19 vaccination to children do not outweigh the potential risks.
I think that school reopening is an underrated risk for Democrats going into the midterms. All of the real progress made on recovery from the pandemic will be undermined if parents still need to manage child care every single day and feel, not wrongly, that their kids are missing another year of education.
Whether or not it is fair, I suspect Ds will take the hit for that. Seems like an unforced error, especially when not medically necessary at all.
Love this - the EUA thing is particularly so obvious and frustrating.
Some thoughts that dovetail well with what you've said here:
I just returned from visiting my black, low-income family in Buffalo. Back in April 2020, covid swept through the family (8 older adults and 10ish young adults (18-25) living scattered through 2 houses (4 apartments)). None of my cousins my age had a symptomatic case, though we must assume in the cramped conditions everyone got sick. Of the older adults, 5 had serious cases, 1 was in the ICU for a month, and now has long covid. Another uncle of ours who lived in a nursing home died.
Fast forward to June 2021, all of the older adults are vaccinated but only 1 or 2 of my cousins are. I've tried to approach the subject with them gently, with understanding as a primary goal and persuading on the back burner. For the most part my cousins have been pretty dodgy about it, but I did get one to sit down and talk for a while. And he just had very reasonable questions: what's in it, how does it work, why do some people who get the shot still get sick, etc. "Am I going to have to miss work?" was notably *not* on the list, because he didn't even know enough about the vaccine to know there were side effects.
Now of course, all the information is readily available and he has a smartphone. But blame games are irrelevant to my point, which is that he inhabits a *vastly* different world than all of us, and his information ecosystem is just totally disconnected from ours. He doesn't read the NYT (or any other news source). His engagement with politics is nil. Any information he's getting about any of this is going to come in the form of snapchat or instagram stories, and that information is going to be super sporadic anyways. For the most part no one in his circles is going to be talking about the vaccines at all, they're talking about their annoying coworkers or some girl they're 'messing with' or the NBA playoffs. He does know that Cole Beasley, Josh Allen, and Stephon Diggs all refused to get the shot. (I will say that I do *not* think them publicly endorsing the shot would have registered on his radar at all or made a difference.)
After talking to him and calmly answering his questions, he was like "oh, I guess I'll go get one at rite-aid tomorrow." Note that my uncle had offered to drive him, and I'm not sure he'd have bothered even then if someone wasn't actively trying to give him a ride.
On reflection I think I have three takeaways:
1) One might expect that the family all having covid would provide *more* impetus to get shots, since they've seen how serious it can be. And I think that's true for the older adults. But I think my cousins reasonably think they're immune and also think that if they do get covid again, it won't be so bad. (*I* don't even understand why the vaccines would confer greater/different immunity, especially to variants, than actually having had covid. Why on earth would my cousins, who aren't not actively trying to answer that question?)
2) My cousins are, I think, reasonably representative of the norm among low-income black 20 year olds living in various ghettos. They're basically apolitical and don't engage with any mainstream channels of information or news, except sports. They were exposed to covid early on and were fine. And there just isn't a particularly compelling reason for them to go get vaxxed, nor is there anyone nagging them to do so.
3) I absolutely think they would get vaxxed if *both* a) they were offered a decent amount of money, 50 bucks seems like the right ballpark and b) the shots were *extremely* convenient - I'm talking like, walking distance. The less convenient, the more money it would take to motivate them. Mandates of various kinds might also do it - most likely as a requirement to see a Bills game, or to go to Canada, or for work (in their case, in Amazon warehouses). Only really confident in the last of these, though.
Quick follow-up thought:
I think it's important to explicitly note that, for my cousins, this doesn't really seem to be about skepticism, at least not in any conscious or principled way. My cousin definitely said in a joking way "I don't know what sort of shit they're trying to put in my body", but he definitely didn't seem to really be worried about it. I think for him it's less of an explicit distrust of institutions than a lack of engagement with them. Hard to say how much this (or anything I said above) generalizes, but if this is broadly true among at least Dem-leaning vaccine holdouts, then that's a much better problem to have than real deep-seated mistrust.
Thought this was such a well thought out take and a really great contribution to the vaccine uptake discourse.
Just sort of a quick follow up. You note that one thing that could help is if shots were "extremely" convenient. I wonder if that's a small factor in parts of the deep south and rural areas more generally; getting to a vaccine site can take some real effort. At the very least it can take a lot more effort then where I live in the NYC suburbs. I'm wondering if real effort was made to have some sort of COVID shuttle system, it might have more of an impact then we might think. Shuttles that go right to your front door. It also makes me think that in places like the deep south, the best place to have vaccines is at churches; places that people trust and places people are already making the effort to go to anyway.
Just a thought.
Several years back, The Onion had this infographic about pros and cons of childhood vaccinations: https://www.theonion.com/the-pros-and-cons-of-vaccinating-children-1819591675
The first con they list is "you have to go to a place", and I'm constantly thinking about that for so many things. Convenience really is absolutely key.
Great Onion post! Lol
The government should go to Walmart and even more so to Dollar General and tell them they will pay them the stores $100, an employee $100 and also will pay for $100 store credit given to every customer they get to take the vaccine.
I think we could hit 80% by September - and a quarter of the country might have had 6 or 7 shots by that point.
I've long said that we need a Vax-Mobile, like some areas have a Bookmobile for the library. I know this exists in some places, but it could exist in more.
There's a doctor in Atlanta who does a lot of (really moving) threads on her talks w/ vaccine-hesitant folks and one of the recent ones featured a woman who suggested, "it could be like a food truck. But with shots." https://mobile.twitter.com/gradydoctor/status/1416522889533267970
And she's totally right. There are mobile health vans in some places in the US, generally. Phoenix was *sort of* doing some vaccinations this way, but I think you had to reserve online ahead of time, which seemed to me to defeat the purpose a bit. If we're doing this anywhere in a pro-active, immediate way (like literally hanging out and chatting up passersby about getting vaxxed & answering questions on the spot), I sure haven't heard about it.
This doesn't sound much different from the vaccine situation in my extended family. Which is why liberals blaming "Q-pilled Trumpers" makes me want to tear my hair out.
The ironic thing is I actually do know one Qanon guy. And he's been vaccinated!
Yea, the "hard-antivax" demographic might be 10% of the country's adults. The rest are just ill-informed, lazy, busy, broke, or some combination thereof.
This could be very easy indeed if we just bribed them all. Another $200 billion or so to hand everyone $400 on getting vaccinated or if you already have been, and $800 when your area hits a given vaccination rate.
Of course, OANN will decry it as a blue-state handout by taking a map of vaccination rates by county and yelling about how those areas will get more money, but... can't win
'em all, and OANN's viewership probably is the hard core of that 10% I mentioned above.
Meanwhile, I've had to badger every one of my rural relatives about this incessantly. Get the shot.
Did you get the shot?
I'm going to keep asking until you get the shot.
Just get the shot and I'll leave you alone.
It takes ten minutes to go to Wal-Mart and get the shot!
Several have done it just to shut me up.
Then they realize there's a second shot involved... which I might have forgotten to mention.
I have a 40-yo relative who works at Walmart in Missouri. Getting a vaccine is very easy for him as they offer it at the pharmacy in the store and the 15 minutes he has to sit there after getting the shot is paid time.
He still hasn't done it for I guess mostly the same reasons you describe along with the fact that no one else he works with seems concerned about it, so why should he? He's not anti-vax nor does he think there's some great conspiracy. He (like me!) doesn't know but a couple of people who have had covid. There's just no reason from his point of view for him to stand out from the rest of the people he works with every day.
The way Delta is exploding in Missouri I fear he's going to know a lot of people who have had covid very soon
"*I* don't even understand why the vaccines would confer greater/different immunity, especially to variants, than actually having had covid."
The short answer to that question is because the vaccine _only_ causes your body to produce "disembodied" copies of the spike protein, which is a fantastic target for immune response. Some of the _other_ proteins that the live virus would program your cells to produce act to _inhibit_ immune response, which makes it harder to build up the "immune memory" you want. (It's not as bad as measles, which has mechanism to actually _erase_ immune memory so thoroughly that it can strip protection from other past vaccines -- https://www.nature.com/articles/d41586-019-03324-7 -- but it's still a problem.)
There's a great summary of the set of proteins Covid induces cells to manufacture on the NYTimes: https://www.nytimes.com/interactive/2020/04/03/science/coronavirus-genome-bad-news-wrapped-in-protein.html
This is awesome, thank you!
Your cousins sound like my son. We used the stick- a car insurance payment- and not a direct carrot.
My wife is the controller for a company that operates a warehouse in exurban Atlanta, Georgia. She offered unvaccinated employees $100 to get vaccinated. Two-thirds of those who hadn’t already been vaccinated got the jab. If one employee avoids getting covid because of that, the company has saved money.
In all these discussions about vaccination I never read any mention about people with natural immunity (i.e. people that got sick and recovered). The CDC estimates that some 114 million people have already gotten COVID in the US alone.
https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/burden.html
This isn't a small slice of the population. There is also very good evidence that natural immunity is as good as or better than vaccination in terms of resistance to reinfection and reduction of severity when reinfected.
https://www.nature.com/articles/s41586-021-03647-4
https://www.medrxiv.org/content/10.1101/2021.04.20.21255670v1
When you're interested in knowing how many people are vulnerable to infection by COVID, you have to exclude both the vaccinated population and the people who've had it already. Of course some people are in both groups, so you can't just add up the numbers, but I'm sure there's a sizable group who aren't bothering to get vaccinated because they got the disease already.
It's reasonable to assume that concentrations of such people are going to be higher in poorer, denser areas where the infection spread fast during the first and second waves (before the vaccines were available) and if those are the areas where vaccination progress is stalled, that's likely one of the reasons.
It's not clear what to do from a policy standpoint about natural immunity. It's difficult to identify and count naturally immune people. But it's clear to me that we're closer to "herd immunity" than the vaccination numbers suggest. And given that we believe COVID is now endemic (it will continue to reinfect both vaccinated and naturally immune people with mild cases forever) I don't think the that either 100% vaccination or 0 new infections are reasonable goals to aim for.
I haven't seen any evidence suggesting that natural immunity is *better* than the mRNA vaccines (both of the ones you cite just suggest it is similar), and I've seen some suggesting it is slightly worse.
https://directorsblog.nih.gov/2021/06/22/how-immunity-generated-from-covid-19-vaccines-differs-from-an-infection/
https://www.contagionlive.com/view/immune-response-from-mrna-covid-19-vaccines-is-more-robust-than-natural-infection
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00575-4/fulltext
It does seem to be a bit better than the adenovirus vector vaccines (J&J or AZ). But yes, to understand where we are in the process, we need to look at all of these things, and their relative effectiveness.
Same. Which doesn’t mean it’s not good or doesn’t count toward herd immunity.
Slightly worse AND natural immunity likely fades more quickly. Also, from what I gather, natural immunity (from past infection) + mRNA makes for a particularly robust immunity profile. Given the possible, long term health issues associated with covid plus the non-trivial incidence of breakthrough cases plus the seemingly relentless evolution of the virus, it seems a no-brainer for previously infected persons to get vaccinated.
I know that Portugal has a policy that people who have had a positive PCR test only need one dose of vaccine to qualify as fully-vaccinated.
I think you go wrong here when you say:
When you're interested in knowing how many people are vulnerable to infection by COVID, you have to exclude both the vaccinated population and the people who've had it already.
The point MY is making here is that we *don't* and also **shouldn't** care about that. We should care about how many people have received a vaccine. It's cheap, it's effective, and it's easily (easily-ish) verifiable.
Furthermore, you mention a 100% vaccination rate as not a "reasonable goal." MY agrees! His whole point here isn't that we are aiming for 100% but that we can and SHOULD push our rates up from the 55% rate here in DC to something higher like (uhh I dunno specifically) 80%. We can do that by requiring a 100% vaccination rate *for the sub-populations we can directly control* like all first responders, military members, and government employees (including teachers). MY is hoping this sends a message to everyone else, but even if it doesn't, it's good on the merits. Maybe we'll have a debate about getting to 100% at some point, but we'll need to get the low-hanging fruit first before that even becomes an issue.
You're confusing a policy question with an epistemological question. When I say "interested in knowing how many people are vulnerable" I mean that in the statistical/scientific sense. For example if it's your job to forecast the future number of hospitalizations from COVID infection and accuracy matters, then having the correct number should matter to you. Counting only vaccinated individual as not vulnerable will give you an inaccurate number.
From a policy perspective, I agree. It's hard to count naturally immune people, and a lot of people are likely to be unsure about their own status (maybe they got sick and wrongly assumed it was COVID, maybe they got COVID and were asymptomatic so they didn't notice). Thus it makes sense to strongly encourage people to get vaccinated anyways.
That's a helpful clarification, thank you! But you start with "in all of these discussions, I never read..." I think you don't read that line of thought in this article because this is an article that is about policy and not about epistemological speculation.
My whole point is that, for the purposes of this article, MY **doesn't care** about natural immunity and that we are NOT "interested in knowing how many people are vulnerable to infection" because that's tangential to the policy question of what to do about vaccines.
We live in a country where we generally don't use state coercion to get people vaccinated, thus there's an important psychological component to getting people to choose to get vaccinated.
My specific beef is about people who ask questions like "why aren't people choosing to get vaccinated?" and then postulate a list of reasons that doesn't include the possibility that those people got sick already and consider the risk of vaccination side effects not worth the benefit.
If your stance is that we SHOULD use state coercion to get everyone vaccinated, then obviously my point is irrelevant. That's a political/moral question though and I expect that the public splits on that question and agreement/changing minds is pretty much impossible.
I dunno man, I think we pretty regularly DO use state coercion to get people (children) vaccinated. For example, check out the required vaccines for public school in DC: https://dcps.dc.gov/page/school-health-requirements.
I think it's very clear from Yglesias's article that we absolutely SHOULD USE STATE COERCION to require vaccines for certain groups! Military, first responders, state employees, etc. Possibly even for public school children. He is making that exact political/moral question in the article that we are both upon which we are both commenting!
I'm perhaps reading a bit into Yglesias's point here, but I *think* he might respond to your middle paragraph and say something like this:
People often make poor risk/reward choices in deciding to vaccinate themselves and their children. From both an objective standpoint and a socially optimal standpoint, vaccination is low risk, high reward. Therefore, to encourage the public to voluntarily make a different risk/reward choice, the Government should take several actions, including permanently authorizing the vaccine (i.e. not via EUA) and the Government should also mandate vaccines for those under its direct control. In taking these actions, the Government will send a strong(er) signal to those risk/reward opt-out people and hopefully a sizable number of those individuals will revise their calculation and chose to get a vaccine. Perhaps changing minds is not possible, though I disagree, but taking those actions have independent benefits and it should be done regardless.
The thing about state coercion is that it inevitably comes with a political cost (i.e. the party in power loses votes the next election). People are fussy about vaccinations especially and if you care about Democrats getting elected you should be more than a little worried about the impact of vaccine mandates on the midterm election.
My point is that policymakers need to weight the benefits of any policy against any costs, even if in this case the benefits are to public health and the costs are purely political. It would not be smart to pay a political cost and then NOT get the public health benefit, because you were vaccinating people who already had natural immunity, for example. I'd advocate for a more targeted approach that's more certain to actually pay off, or to look at other policy approaches with the same potential public health benefits and none of the costs associated with state coercion.
It's not clear to me that we do anything from a policy standpoint about it. We have more than enough vaccine supply, so we don't need to ration it. If there's an incentive being given for getting vaccinated, you should still get it if you've already had COVID. If we're closer to herd immunity than we think we are, great, but we'd have much lower COVID cases and deaths if a lot more people were vaccinated, so that's the direction we should still be going in, and using policy to get there. If we get to 90% vaccination rates and the vast majority of cases are among the vaccinated, then we can start having the discussion about whether to continue prioritizing higher vaccination rates.
Excellent point, feels like a big oversight of MY to not mention this. The one family we know who all got covid (not a surprise as they were for the most part sharing indoor space throughout the winter) are not at all concerned about getting the vaccine. And I can't say I blame them.
Regarding the level of natural immunity, it certainly doesn't seem sufficient to keep the delta variant from becoming a significant problem, it's clear that vaccination rates need to be significantly higher, the marginal benefit from vaccinating someone who already has natural immunity is smaller than someone with no immunity but the value of making that distinction is not very high.
My hypothesis is that even with 100% vaccination, delta variant is still a problem. The best vaccines are 95% effective. The virus is incredibly contagious. Best case is that we can push the case fatality rate extremely low so that nearly all the people who get it, survive it.
If the vaccine were as contagious as measles (r0 of 20) then yeah, but I believe the r0 of delta is estimated at 5-6.
To reach herd immunity, vaccine rate * effectiveness needs to be greater than (1-1/r0). If effectiveness against delta is .95, then you need a vaccine rate of 87.7%.
People mention it. Most intelligent commentators I listen to even in mainstream sources say natural immunity is real and should be exempt from things like vaccine passports. (Totally academic because we’ll never do them in the US.)
My brother is a researcher in the Bay Area, and he said at one point the reason Berkeley was avoiding a vaccine requirement was that people of color would be less likely to have been vaccinated. So in order to not adversely impact communities of color, Berkeley enabling the spread of COVID which will... adversely impact communities of color.
Modern racial leftism is nonsensical on so many levels, but I think this might take the cake.
So frustrating. People of color will get vaccinated if there are vaccine mandates.
And I would hope someone at Berkeley has done real statistical analysis on this to have come to the opposite conclusion, but my anecdotally-informed suspicion is that the trends among most people of color with regard to vaccine skepticism are not going to hold for people of color at *Berkeley*, for godssake. This seems so obviously to me to be a case where the intersection of class and race is paramount. (But I have definitely not tried to find data on this.)
As woke-skeptical as I am, I’d still want corroboration and context for that one
*will be enabling
There is also a progressive politics issue here. I'm a conventional liberal but the pandemic has turned me radically hostile to the FDA and CDC who seem to me to have contributed (unintentionally of course) to tens if not hundreds of thousands of unnecessary deaths. I believe we need a competent regulatory state but it is hard to make the case that we need these particular institutions in their current forms.
Which of their actions turned you radically hostile to the FDA and CDC? I’ve been angry with each of them at times, but haven’t turned radically hostile. Given the general lack of efficacy of European and Asian regulatory and informational responses, I’m unclear what form institution(s) that could have saved those lives would take. Seems like the CDC and FDA have been mostly acting in good faith, early masking fiasco notwithstanding.
Not all of those were the CDC/FDA, but they are still good points.
My biggest overarching complaint in all this is that the FDA failed to move on *cheap* at-home rapid COVID tests early on. Even if not perfect, they would have empowered people to make their own risk assessments and adjust behavior *when necessary*. As it is, many people just threw up their hands and did what they wanted anyway (as Matt can attest to the various house parties he saw going on despite the rules against them).
I have a PhD in and work in a semi-related field. And to that end, I felt sufficiently knowledgable to make my own risk assessments, and I read the primary literature regularly. I avoided large gatherings, wore a mask when around others, didn't dine in a restaurant, and took a number of other small measures that I felt were reasonable and justified. But I also had Thanksgiving with just under 10 extended family members (I got a test at work before going to make sure I wasn't putting *them* at risk) and I visited my parents for Christmas (again, after a test and more rigorous avoidance of interactions with others for a week to be all but certain).
Of course, it's my personal bias, but I feel like the messaging would have been better received (and perhaps more effective) if it were more about risk *mitigation* than elimination, combined with ways to do so.
And I take your point that “good faith” isn’t good enough for the agencies in charge of guiding us through the pandemic. We need actually competence. I accept that. But even the most competent public health agencies in the world didn’t get much better results for their people.
Would this be easier if we also had “someone in charge?” Some portion of the problem seems to reflect the CDC’s issuance of guidelines and advisories. As an example, many national organizations tend to cite the CDC and not the legally authoritative dictates of local authorities.
Absolutely fair. Although I never got the “trust the science” line from the FDA and CDC. That came from left internet and seems to have been 100% unhelpful to the people who were trying, in good faith, to guide us.
Fully vaccinated. Family is fully vaccinated. Not concerned.
Liberals who don’t interact with a single unvaccinated person in their urban suburb obsessing over those not vaccinated 4 state lines away sound an awful lot like conservatives in Florida obsessed with crime waves in Chicago.
All the families in liberal suburbs who have kids under 12 still can’t yet be fully vaccinated and thus any time they are with friends, at camp or school, they are being subjected to restrictions because of covid fears (rightly or wrongly). Or one of the places (they exist!) still following CDC guidance that unvaccinated people after traveling out of state must quarantine for at least a few days until getting a test before returning to camp or school. None of those families can simply say “not my problem.”
This. My kids are 4&5. The decision by some to never vax could lead to covid becoming endemic. I've already seen one child survive a life threatening 1 in 10,000 medical emergency, and I would be so angry at the people in this country if it happened again because of anti vaxxers.
Right now I think this take is mostly right: https://twitter.com/WilliamBHoenig/status/1416430672948903937
Covid is going to be endemic.
There's a lot that's right about this, but I just don't see anything pointing to delta being harder to deal with than measles. The worst estimates of R0 for delta are in the 8-10 range, while measles is estimated in the 12-20 range. If we could get vaccination rates to the same level as measles vaccination rates, we absolutely could get the level of measles.
(Also, measles appears to have a similar fatality rate of about 2%, though probably not with the same age skew as covid.)
Yeah, there's just two things I'm skeptical about:
1. I have a hard time imagining getting to measles vaccination rates and,
2. Given that, I doubt delta is the end of the line for new variants
It took many years to get to measles vaccination rates. I expect that in 10 or 15 years, covid vaccination rates and measles vaccination rates will be very similar, though I worry they will both be lower than current measles vaccination rates.
Better link: https://twitter.com/WilliamBHoenig/status/1416431450526732290
You're missing the point. Fully vaccinated. Family vaccinated. Not concerned. Except until many more of the unvaccinated are vaccinated, life like we knew it before covid isn't returning, and that is the point. The French response reported in today's NY Times (no normal life for you until you get vaccinated) is exactly what we should be doing.
I've been living in Europe for the last five years, so maybe my picture is distorted, but how hard is it where you are to just act like Covid doesn't exist? Since the start of July when I got my second shot I've been going to parties, throwing parties, going to movies, going to crowded museums, and occasionally dining indoors when I want air conditioning. I fully expect to be exposed to the delta variant at some point (though probably not very soon since there doesn't seem to be much of it in Hungary), but I just don't care.
Is it impossible to live like that in the states do to the ongoing restrictions?
I think that is basically what life is like in most of the US now -- either there is enough vaccination that people feel safe again (I'm writing this from Brooklyn, where I've eaten indoors, shaken new acquaintances' hands, etc. in the last few days), or they never really changed their behavior anyway but now official restrictions are lifting (I'm going to grad school in the fall, and classes will be mostly in person). You do still see some people wearing masks outside, but it seems to be only 10% or so of people.
Tim, glad you're partying hard, enjoying life and just don't care. When was the last time you tried traveling to New Zealand or Australia or 90 percent of the world that's shut off to foreigners? Here in Brooklyn, we too are parting hard because we'd be going insane otherwise. You obviously missed the point, maybe from too much partying.
Look, I agree that we should be pushing the vaccine to save lives and restore normality at home.
But let's not pretend that pushing up vaccination rates here will suddenly get China, Australia, and New Zealand to open their doors.
It will be an incredibly difficult political transition for those nations to go from "effectively no COVID" to "we have to accept some COVID".
Even if their vaccination campaigns are perfect (and none of them are or will be anytime soon), they will suffer far more death after opening their doors than they have to date.
In China in particular, that transition is easily going to take until 2025-7. The Party has dialed up the propaganda so much that they're only going to START opening entry requirements once the cost to the economy and social stability becomes very apparent, probably sometime in 2023-4. Then they'll gradually dial back restrictions, first on Chinese nationals, then overseas Chinese, then foreign citizens.
And that assumes that they do succeed in vaccinating virtually all the populace with a Pfizer booster, because Sinovac is borderline-useless.
To illustrate, if I were to vaccinate the entire population with Sinovac, then throw the border open and do nothing further, China could expect about 450 million cases, all breakthrough, and 20 million deaths or more.
To be fair, I still don't quite get your point. You say that we need higher vaccination rates to return to normal for most of the world, but then you say below that they won't respond to what we do anyway.
Oh God, is it two Davids debating each other? 😂
That's me, not him. Maybe I need to change my username.
Not true. You’re forgetting the podcast hipsters, yoga hipsters, and vaccine skeptical urban working class. Not saying it’s not better in the cities but it’s totally false that I couldn’t go out my apartment door and in 2 minutes find somebody unvaccinated with a man bun, who’s probably woke.
I actually find this to be very interesting. I'm related to a person who is, at least nominally, in charge of vaccine encouragement for the company. I was talking to her yesterday and I suggested that what they should do in places where they have low rates, Iowa, Missouri, etc was to offer a straight one hundred dollar bonus for proof of a vaccination.
She told me that that would be unfair to other employees who have gotten vaccinated already like most of R&D and our sales and marketing people who have both hit above 90% vaccinated rates. I said, "are you trying to make people feel good about themselves or are you trying to get people vaccinated so that people can safely go to work?"
I feel like that's where we are with vaccines nationally. We simply aren't willing to outright incentivise people to get vaccinated and we aren't willing to just approve it and mandate it. And the longer we wait to do either of those things the more the culture war battlelines will solidify until it finally goes from being a vaccine to being another signifier of ingroup/outgroup status.
The other blatantly obvious rejoinder is... "Well, give them one too, if you know beyond a doubt they've been vaccinated!"
Yeah I can't imagine anyone would be that upset over sending out yet another stimulus check of $50 per person if you're vaccinated.
If it were the government, I'd say "$400 per person vaccinated and a bonus of $800 when vaccination rates in your county hit X"
At this point X probably needs to be 90% of adults or 75% overall to really blunt Delta. At that point case numbers will look horrible but few will be dying.
Oooh I love it. Unfair or whatever but who cares. Great example of the point of the post - we could be doing so much more to get the vaccine into more people.
I find Psaki's comment on the matter somewhat disturbing. It's worth HUGE sums of money to get these shots into arms, so bribe the ever-loving fuck out of people to do it.
Of course you do it for those who've already been vaccinated! But also for the ones you want to get there.
Matt loves econ jargon, the unvaccinated are imposing 'externalities' on the rest of us, but I'd suggest a stick rather than a carrot: cut off their child tax credits, food stamps and highway funds until their state reaches an 80 percent vaccination rate.
Why unfair?
There's zero reason the bonus couldn't be make retroactive.
Make version of the vaccine delivered in a sugar cube. You get the people who don't like shots out of the way.
Otherwise, as much as I want to stick mandates to these anti-vax idiots, I can't muster up the energy to spend a lot of time worrying about people who refuse the shot. Fine, get sick then and deal. Something something horse to water.
I'd worry about creating a variant breeding ground, but we're getting variants regardless given the most of the world has far lower vaccination rates than the US. With Moderna and Pfizer having boosters ready to go, we're pretty much in a world where for the vast majority of people, COVID is something you choose to become very sick from or not.
Liberals locking down in liberal cities like SF again would be basically punishing ourselves for the sins of the Q crowd.
That all said, here's an idea: health insurance companies get a waiver from covering covid care expenses in cases where someone was able to get vaccinated but refused to do so. If getting covid as an unvaccinated person means you're covering the entire hospital bill, the incentives change pretty fast.
At this point, a version of the mRNA vaccines that didn’t require a cryogenic supply and delivery chain would be an enormous step up from the status quo and we’re not likely to see that in the next ten years. A liquid that survives stomach acids? We’re not gonna see that in our lifetimes. There are unfortunately very good reasons why most vaccines are delivered as intramuscular injections rather than pills or sprays, and it’s not because nurses enjoy dealing with the needle-phobic. :(
Absolutely agree on the variant point. If we want to avoid even worse mutations, we should be moving heaven and earth to flood the rest of the world with mRNA vaccine doses.
100%! If we are truly worried about variant creation, the risk is higher in international regions with 4% vaccination than domestic regions with 30% vaccination. Even leaving aside the reality that the people in the 30% vaccination locales think it's a mind control device, or whatever, focus on getting the shots to the people willing to take them. Once you run out of those people, shift back to the idiots.
There's been study of patches that get around much of this issue (I don't know if these "dissolvable microneedles" are the same way that, say, nicotine patches work, but they do seem to avoid the worst needle bit): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8066809/
Yes the waiver idea would definitely work. Insurance companies try to screw you over when your baby needs to be in the NICU; they'll love this one.
A friend of mine was working as a nurse assistant at a vaccination site when one patient had such a strong panic reaction to the needle that they had to abandon vaccination. This was the second time this had happened and they made arrangements for that patient to go to a hospital and be vaccinated while under anaesthesia.
In a population in the millions, even very rare things are, in absolute numbers, quite significant.
Um, there was a point to that anecdote, and it was this: some people can't get vaccinated for good reasons. Some of those people will just not get vaccinated rather than getting a formal exemption. You might conclude that requiring them to get an exemption (which might prove difficult for some people) would be appropriate, but it's not cost-free. And screwing over a small minority is something that liberals should be cautious about.
Should the rest of us mask up to protect those people? I have sympathy, but the answer is still "no." Similarly for the immuno-compromised. Tough situation for them, but the burden of protecting them should first be on themselves (e.g., wearing N95 masks) and not on the entirety of the population.
A lot of these people have gone uninsured for much/most/all of their lives. I seriously doubt the prospect of hospital bill collectors will get them to abandon their loyalty to patriotic distrust of Dr. Fauci and the deep state. Also, many (most?) of them think the virus is a hoax, in any event, so they're not worried about health risk.
Let’s stipulate for the moment that “the process” at the FDA has essentially failed and is in desperate need of an overhaul. I’m even reasonably on board with this idea.
But if the goal is to persuade the persuadable, I’m really dubious that changing the rules at this stage to issue formal approval faster will be of any help. The talking point on Fox/OANN/NewsMax will change from “this vaccine is experimental and not fully tested/approved” — which, as you note, is strictly true at the moment — to “they changed the rules to give approval to this vaccine without testing it like they normally would have”. And this, also, would be strictly true and worse yet would end up also being true of any _subsequent_ vaccine approved by the FDA for the rest of our lives.
I know that our host prefers to avoid double-bank-shot GAME THEORY approaches to public health and I’m largely sympathetic, but at the same time I think we need to be honest with ourselves about the depth of the abyss that we are currently on the edge of. In 2016 Trump played footsie with the anti-vaccine fringe (there were even rumors of him appointing RFK Jr as surgeon general!) but whether out of personal unpredictability or at the behest of saner voices behind the scenes ended up not paying the issue much attention as President. And for now, Rupert Murdoch seems to be trying to thread the needle on this issue. But there is no guarantee that will hold true in 2022/2024 and if the Trumpists decide that demagoguery on the topic of vaccines is their path back to power, they will absolutely do that and there are worse actors than SARS-CoV-2 waiting in the wings.
As a side note here, one of the reasons I’m looking forward to the inevitable flood of tell-all, score-settling memoirs of the Trump administration is that I am achingly curious to know the story of how Scott Gottlieb ended up at the FDA. You can make a strong case that he was the _only_ Trump appointment who was neither obviously a crook from the get-go nor simply incapable of performing his job. In fact he may have actually emerged from Trumpworld with his reputation in better shape than it started! Clearly something went very awry in the selection and vetting process there and I’d love to know what happened.
(FWIW a friend of mine was a classmate of Gottlieb’s at Wesleyan and insists that he was incredibly, forthrightly unpleasant as a human being so maybe that was enough for Donald?)
Nah, Jay Powell has the best WAR of any Trump appointee.
Fair counterpoint, but IIRC there were some objections to Powell on the grounds that he was somewhat untraditionally qualified -- I think Gottlieb was unusual in that he was pro-forma qualified for the position, effective in the position while he held it, _and_ not under indictment or even suspicion of petty graft by the time he left.
Some of Gottlieb's initial interviews were so thoughtful I assumed he had been an Obama appointee holdover.
In March/April of 2020 he was making enough useful statements that I had this assumption as well.
The bar I came to expect from Trump's team was so low that I have to think about how "general competence" should not be an excuse for "squeeing fanboy-ism" with regards to Gottlieb.
He's not only competent and not corrupt, but also not a raging asshole! How many other people wrapped up in the health sector investment community are going to get up in front of Congress and testify that artificial barriers to entry erected by proprietary drug manufacturers are bullshit and need to be crushed to bring prices down faster?
It's like the Holy Trinity in the context of Trump appointees.
Re: "changing the rules at this stage to issue formal approval faster". Maybe I missed this in MY's article or The Discourse somewhere, but to me "the rules" at the FDA for full approval of a vaccine or medicine are very opaque (hence, the discussion about the Alzheimers drug approval). So if the FDA came out tomorrow and said "full approval"--it's not obvious to me that they would have had to "change the rules" to do it (even if, behind the scenes, they did alter their normal internal rules given the pandemic context and overwhelming amount of evidence received from real world application). Instead, given that they have over a years worth of evidence about the safety of the vaccines from when they started the first trials, and so much evidence from use in the population... seems like plenty for them to say "this satisfies the [very opaque and context-specific] rules we have".
You're confusing "rules" with "interpreting complex scientific data". There are more mundane rules about how much data need to be collected and how it needs to be organized and presented.
I love the idea of paying Trump to promote the vaccine, especially if his compensation is tied to vaccination rates. I can't see him saying no to that and the reaction once this got out in Trump World would be fascinating.
The problem is that you pay Trump a truckload of money to mumble something about how the vaccine is great because he developed it and you should get if from a Republican-approved source, but then one week later he'll be back to trashing it.
I think you've just validated non-disparagement clauses
Oh yes. I forgot. We could just sue Trump. What could go wrong?
:-)
By Fall 2022, almost everyone will either be vaccinated or naturally immune. This issue has a sell by date.
That seems increasingly unlikely, for the same reasons a single infection or vaccination doesn't provide lifelong protection from influenza: fading immunity and virus evolution. I don't disagree that the overall health situation with respect to this virus is likely to look a lot better a year from now. But I think our species is looking at regular booster shots/jabs for the foreseeable future.
Maybe. Not sure how many reluctant Democrats would get the vaccination with FDA approval vice a mere EUA. On the other hand, FDA approval opens the doors to many organizations being able to mandate vaccination without fear of lawsuits.
No, I get that that's what Matt is trying to focus on, but I'm suggesting that it may not be a good idea to pretend that we can separate these issues.
Hi, Matt. You’ve pointed out in the past the ways in which the public health community has gotten us all into trouble with what you’ve called “bank shots” but which you might also call “saying things that aren’t true.” The classic example was the early advice on masking. Instead of saying, “We need to save our small supply of quality masks for the medical community so please don’t hoard them,” they said, “Masks don’t work, so please don’t hoard them.” I think most of us agree now that this was a mistake.
There are other examples, pretty much none of which worked as intended. The lesson seems to be that we should tell the truth and trust the public to be grown-ups who can handle the truth. And that trying to manipulate people through misinformation – or even just false confidence in the face of uncertainty – is very likely to backfire.
I worry, though, that you are sort of advocating another bank shot here in terms of vaccine approval. If someone were to say, “These COVID-19 vaccines are based on brand new medical technology that none of us had ever heard of 18 months ago and haven’t gone through the same level of rigorous testing and observation of our typical vaccines,” that’s just true. I got the vaccine anyway – as soon as I possibly could – but not because I thought it was just as safe as a measles shot. I got it because I thought it was the right thing to do despite the obvious risk.
Of course it would be great if we knew more about the long-term safety and efficacy of these vaccines. But the FDA can’t just waive away the current situation by pretending to know more than it does. The Emergency Use Authorization seems to reflect that reality: These vaccines have not gone through all the testing we’d typically expect, but under the circumstances we think they are safe enough to use anyway.
And under these circumstances, what would it even mean for the FDA to give full approval to the vaccines? It doesn’t change the actual current level of medical/scientific knowledge about them; it just sort of moves the goal posts in terms of what full approval requires. So isn’t it just another bank shot?
One thing that some of the past bank shots seem to have in common is a reluctance to ask individuals to make sacrifices for others. That’s true of the original mask debacle, but also of some of the later stay-at-home and pro-masking advice. Because we haven’t wanted to tell people that they have to make significant personal sacrifices primarily to help others, we’ve instead fudged the data a bit to make it look like it’s actually an act of self-interest rather than self-sacrifice.
Instead, as you’ve recommended elsewhere, why not just go full bore (sorry) on the truth here: Yes, these vaccines are a bit scary. Yes, they are based on brand new technology that hasn’t been tested as much as we’d like. Yes, just like with ordinary vaccines, there is certainly some risk of complications. But your country needs you to get vaccinated anyway. Not just – or even primarily – to protect yourself, but to protect more vulnerable people around you.
I love your idea of a massive marketing campaign, far more aggressive than what we have now. But rather than pretending to know that the vaccine is perfectly safe and that vaccination is in everyone’s narrow self-interest, why not send the message that getting vaccinated is an act of patriotic bravery? And refusing it is an act of selfish cowardice.
The FDA should say that they are highly confident the vaccines are safe and effective at treating COVID-19, and that everyone in America should take them. The basis for this confidence is both on trials and extensive real-world use - better evidence than they usually get, actually.
This is totally true. It is what all the individuals involved are saying. So it would be appropriate for the FDA to officially say it too.
As to why they are not following the standard process:
1) It's a pandemic, so urgency is very high
2) Because so many people have taken these vaccines outside of clinical trials, they have an unusual source of good data.
I don't think your caution that "these vaccines are a bit scary" is an appropriate summary of the actual state of medical knowledge here.
I guess the devil's advocate position would be that both the blood clot issues and reports of Guillain-Barré Syndrome - while EXCEEDINGLY rare - are real side effects of the vaccine and listed currently on the CDC vaccine monitoring page. I do think it's a fair statement that these are *a bit scary* - although we're getting into very pedantic discussion here.
I'm probably a little overconfident, but there's nothing scary about the Pfizer/Moderna technology. It's just mRNA molecules wrapped in some lipids; every cell in your body is already full of very similar stuff. These are many orders of magnitude less likely to cause unexpected problems than, say, small molecule drugs, for which we can never predict all the possible off-target effects. Such as they are, the minute potential dangers from the mRNA vaccines appear to be related to overreactions of the immune system and the like, which are possibilities for anything.
I've been waiting for someone to point this out. Literally NOTHING in this vaccine is still in my body after a few weeks. The lipids are gone, the mRNA consumed, the adjuvants excreted.
Ever since we got rid of the laundry list of metal-based preservatives and shit in vaccines after the 70's, even candidate vaccines haven't had long-term side effects other than the immune response they provoke. Those don't take 10 years to turn up, they take 6 months.
If they were going to manifest, they would have by now.
Right on!
This is beside your point, but it is salient to me that LeBron James specifically does not seem to be vaccinated based on his public comments and also broader trends among athletes.
I am not privy to any inside information, but I think that sports leagues *should* be one of the things where employees are required to be vaccinated, except that the most prominent employees (the athletes) have collectively bargained contracts and I’m not sure how those deal with vaccine requirements whether or not the vaccines are formally approved.
I bring this up because
a) I’ve heard almost nothing about the issue of vaccine requirements for unionized workers, teachers or athletes or auto workers or otherwise
b) the specific case of athletes (wealthy individuals with access to lots of information with lots of exposure risk and who depend on being healthy for work) broadly not getting vaccinated (as seems to be the case based on public health data) seems like a bemusing problem to me that doesn’t affect a large number of people (there aren’t that many pro athletes) but might be a prominent indicator of other less visible trends
Given how the Chris Paul situation played out (where he was keeping his vaccination status private, and the fact that he was vaccinated came out only when he tested positive), I think LeBron is vaccinated too. NBA players are hiding their vaccination decisions to avoid social pressure to *not* get the shot from friends and family. The costs of not getting vaccinated are just way too high.
I've not followed this. Can you share more about the social pressure to not get vaccinated?
I don't know what that person has in mind, but if vaccination status is an important signifier of one's identity, then revealing to friends and family that you've been vaccinated might be as painful as revealing that you had an abortion, or that you voted for a Republican, or that you eat meat, or that you were never baptized, or any number of other identity signifiers for various communities.
The best way to avoid pressure to *not* get the shot is to (say that you) already have gotten the shot
If you are facing pressure not to get a shot and want to do it, the obvious move is to publicly say it’s a personal decision and let your wife/friends/etc think you didn’t get one.
My bias is showing here, but I think there's a significant contingent of Dems/libs that want the unvaccinated to "bend the knee" and admit that vaccines are good and they work. When instead they shouldn't give a flying fuck and just get as many people vaccinated as possible, through whatever means are legal.
I said a year ago that the biggest motivator for the reluctant would be Disneyland requiring a vaccine, and I'm sticking to it.
Has anyone seen a poll with something like this question. “Have you had a close friend or family member die of COVID-19?” My answer is yes, but my informal queries show nearly everyone I know would answer no. We all see the economic impact, but I wonder who among the unvaccinated just don’t seem worried. For me personally, until I actually SAW polio in Africa, I didn’t really REALLY get the importance of vaccinations. As a young man, I wasn’t anti vax, but seeing certainly made me pro vax.
I've been doing this everywhere I go. I travel for a living. The only person I have met who had said yes was Venezuelan. His Father died in Venezuela.
I am vaccinated, but I don't think the rabid-maskers realize how much their worry comes across as irrational, to peoples lived experience.
I think this question doesn’t get posed enough. Like I wrote, my answer is “yes” (family member), but I have not met anyone in my extended circle who can say that. A lot of folks know of someone, but not someone close is what I’m finding. Clearly people are dying, I’m not trying to be coy or flippant, but it seems the median count among most people for someone they know is … zero.
Really? I haven't had any _direct_ acquaintance die of Covid specifically. One direct acquaintance died of complicated interactions between Covid and some other health problems, but in his case he was likely to die within a few months anyways. But I know, offhand, two friends who had parents die, and one who had an uncle die, where in all three cases the deaths were unexpected -- these were people who could've easily lived another decade or three.
I also have had multiple friends in my own middle-age cohort (call it 30-50) who have had awful experiences with the disease, including very long-lasting after-effects. One who got the bug last year is largely recovered now -- the vaccine seems to have significantly helped rein in her symptoms, for whatever reason -- the other is a healthcare worker who got infected _after_ being fully vaccinated, and has been basically out-of-commission for a solid three months.
There is no medical reason that the vaccine would help long haul symptoms. Weird it’s overwhelming women who get long Covid.
I don’t know a single person who has had long haul. I work all over the US. Different people at different job sites. I ask. It’s always a friend of a friend or a friend of a commenter.
But let’s do the math.
Population. 330M. Deaths. 609K. 1 out of every 541 people. How many people do you know have 541 friends/coworkers? Not many.
It actually gets skewed even more. Only 12% of those are under 65.
The average working aged American is going to mostly know people around there age. With exception of their kids or parents.
I can do the math… but it’s late in Brazil. But basically…. It’s extremely unlikely for anyone under 65 to know someone who died of Covid on an intimate level.
Now. If we were to survey those over 65. It would be extremely likely for them to know someone.
Now I’m not saying that Covid is fake. I’m vaccinated. I don’t want it. But… the fact remains that the average working joe is just not that impacted. Or have experience in other someone who is vaccinated.
As far as long Covid. There are whispers in the medical community that are kept quiet… but the vast majority of cases of long Covid are women between 30-50. This is also coincidentally the same demographics that has in the past been more likely to have somatic symptoms. Now are all cases of long Covid somatic… no. There are cases where people are really screwed up with lung scarring. But the prevalence of this vs somatic cases hasn’t been teased out yet. It’s a sensitive subject. But let’s just say… some
Percentage of long haul Covid cases are not physical. And a key indicator would be anyone who says the RNA vaccine mysteriously eased their symptoms.
Your assertion that there's no reason the vaccine should help is, let's say, premature. We don't really know enough about why long-term symptoms happen in the first place, to be certain about what might help. Your seeming surety about this says more about your own biases than it does about the disease.
https://www.yalemedicine.org/news/vaccines-long-covid
Literally nothing in that paper except conjecture.
There's been some interesting speculation around whether "long Covid", and some of the similar, contested long-term syndromes like "chronic Lyme", involve having reservoirs of the original pathogen that flare up, or whether there's some kind of shift in the immune system that puts it into a bad equilibrium. Ross Douthat (himself a chronic Lyme case) wrote about that some months back.
https://www.nytimes.com/2021/02/02/opinion/long-covid-lyme-disease.html
If it is the case that there are residual pockets of infection hiding somewhere, repeatedly re-activating the inflammatory response while never quite being exterminated because the camoflage proteins are working ( https://www.nytimes.com/interactive/2020/04/03/science/coronavirus-genome-bad-news-wrapped-in-protein.html ), then one could imagine the vaccine amping up antibodies could help.
I’ve been critical of some of your vaccine process takes in the past (you can’t “just” rapidly spin up more manufacturing of a therapeutic like this; it’s not like making plastic widgets or whatever), but I’m on board with this one. One mechanism I could imagine is something covered by EUA could automatically trigger a data review for full authorization once you’ve treated, say, 10 million people, or some significant fraction of the treatable population. I guess the counterpoint is that it’s not large numbers of patients matters that really matters to prove safety, giving the treatment enough time in the field to make any longer term side effects known. Maybe that’s what the FDA is waiting for.
At some level, doesn't the number of cases compensate for the length of time? We've had ~340 million doses in the US (mostly mRNA) and the whole world has had >3.6 billion. If *on average* bad side effects occurred after, say, a year, wouldn't having that large number of cases give us a good idea that might occur even after, say, only six months?
The primary difference between an EUA and formal approval is the amount and type of evidence that needs to be presented. It's quality vs. quantity. It's better to get an adequate number of subjects that are carefully evaluated rather than half-baked poorly documented anecdotes coming from a population of millions. Even though the latter can be useful, there will be enough noise that you can't rule out a signal
I also don’t understand why kids under 12 aren’t allowed to access vaccines on a right-to-try basis. I understand that this case isn’t contemplated under existing right to try legislation, but in terms of increasing population vaccination rates, letting parents desperate to give their kids the vaccine actually do so sure seems like low hanging fruit.
I think this goes back to one of Matt’s other hobby-horses: the interaction between our adversarial legal system and the public health system is not good. There is no waiver you can sign that actually prevents you from suing (and making a loud noise about suing) if your child falls ill, and no guarantee that a civil court judge won’t rule that the waiver language was misleading, and a successful class action lawsuit where the plaintiffs are families with allegedly injured children? There’s your operating profit for the next decade gone.
So you get what our current status quo actually is: if your ten year old can possibly at a squint pass for 12 you can get them vaccinated (OR SO I HAVE HEARD) but the pharma companies have the additional protection of the fact that you are formally breaking the rules to do it.
I think that's often true, but in this case, my understanding is that the PREP Act of 2005 gave the HHS secretary authority to give a broad liability shield to vaccine makers and health care workers, which they seem to have done. https://www.phe.gov/Preparedness/legal/prepact/Pages/default.aspx
The kids whose parents would do that are likely to already be in high-vaccination communities. Not that it's not something, but I don't think this would be a high number, or that it would be in the places with the highest value to additional vaccinations.
On the one hand, I totally agree with you that this is not the most effective thing to do at the margin. On the other hand, I live in New Jersey where 65% of the population has received at least one shot, and the largest remaining group of unvaccinated people is kids under 12. I literally just now got a push notification that the governor is floating reinstating mask mandates. The next thing will be school closures, again. Unless anyone has any plausible reason to think that the vaccine is somehow unsafe for children, and I don't think anyone does, then let parents like me sign up to get our kids a shot so they'll be protected from an already low risk and opportunities for community spread will be lower.
Not sure if you saw this but yesterday the JCVI just advised against vaccinating children under 18 yo citing "benefits not outweighing the potential risks".
Relevant passage:
The JCVI is not currently advising routine vaccination of children outside of these groups, based on the current evidence. As evidence shows that COVID-19 rarely causes severe disease in children without underlying health conditions, at this time the JCVI’s view is that the minimal health benefits of offering universal COVID-19 vaccination to children do not outweigh the potential risks.
https://www.gov.uk/government/news/jcvi-issues-advice-on-covid-19-vaccination-of-children-and-young-people
I had not seen that. Thank you for sharing.
I think that school reopening is an underrated risk for Democrats going into the midterms. All of the real progress made on recovery from the pandemic will be undermined if parents still need to manage child care every single day and feel, not wrongly, that their kids are missing another year of education.
Whether or not it is fair, I suspect Ds will take the hit for that. Seems like an unforced error, especially when not medically necessary at all.
It’s fair.