Assess Your Risk
Thank you, dear readers, for the generous feedback on my post from last week titled “Health is More Than the Absence of Disease.” It clearly resonated!
Three things seem clear to me based on your responses:
Pandemic fatigue is real for us all and debilitating for many;
Mixed messaging about what you can and cannot do after you and/or your loved ones have been vaccinated only adds fuel to the fire of frustration and anxiety; and
People are hungry for real-time, fact-based scientific information and medical guidance that provides hope when appropriate.
So today we’ll talk further about assessing risk—and the important distinction between absolute and relative risk.
But before I dive in, a disclaimer and a nod to the lawyers in my life: advice in this newsletter is meant to be general in nature and cannot be substituted for advice from your personal physician. (I can hear my dear husband, dad, and my own attorney exhaling now.)
So I'm constantly being asked questions like this:
Can my unvaccinated daughter resume indoor swimming if the COVID case rates in our area are low?
Can I fly on an airplane to visit my mother?
Can I hug my grandkids, go to the gym, and eat indoors once I'm vaccinated against COVID-19?
These are terrific questions. And as much as I love telling people exactly what to do (just ask my kids), that's actually not my job as a doctor—even for my own patients.
Rather, my job is to arm patients with medical facts, explain scientific evidence, help them understand their unique health risks and define their health goals, and to provide a decision-making framework to make smart, safe decisions for themselves.
Because risk is relative, risk tolerance varies by individual, and everyone’s health is unique, you'll never hear me tell anyone (other than my own family—sorry, people):
“Yes, you can absolutely do that...” or “No, that’s a terrible idea.”
In other words, the question “Can I do X?” should always be reframed as “What are the risks and benefits inherent in doing X?” That way, your own doctor or I can help provide the medical facts and guidance, and YOU can make your own decision.
After all, it’s YOU, not your doctor, who has to live with the consequences.
(Note: In my humble opinion, it’s okay to sometimes skip this rubric when advising teens—oh, and husbands, too—depending on the day/mood/issue.)
Let’s take a COVID decision-making example.
My friend and journalist Brigid Schulte called me last month in a COVID quandary. She had scoured every newspaper and medical journal but still couldn’t satisfactorily answer the question: is it safe to visit her mother, a widow, for the first time in over a year for her 89th birthday and to help manage her medical appointments and her house?
(Another lob to the lawyers here: don’t worry; I told Brigid to cross-check my advice with her own doctor. She also granted me permission to tell her story.)
Brigid explained that her mother had received both doses of the Pfizer COVID vaccine. And Brigid had COVID-19 in September 2020. Based on our understanding of the current evidence, her infection has rendered her immune for at least a few more months—maybe even eight months in total according to a recent NIH study. Exactly how long immunity lasts after infection with coronavirus is yet to be determined; we need to watch infection rates among recovered patients in real time.
It’s a moving target, of course, largely due to the emergence of variants. Indeed, the more time we give the virus to infect populations, the more opportunities it has to mutate and outsmart the immune protection from natural infection.
Thankfully so far, the Pfizer and Moderna vaccines offer excellent protection against all of the variants.
Does natural infection carry that same amount of protection against the variants? Probably not, but that doesn’t mean the immune protection isn’t robust and durable. It’s just that it’s also possible that if Brigid were to encounter one of the new variants, she could get reinfected and sick.
Together, Brigid and I went through the decision-making rubric:
Know the facts
Weigh the risks
Weigh the benefits
Make an informed decision
Step 1: Know the facts about vaccine efficacy. The latest data on the Pfizer vaccine from Israel is that it’s even more effective in real life than the clinical trials suggested. The clinical trial data already was extraordinary: the Pfizer (and Moderna) vaccines are 100% protective against death and severe disease and 95% effective against any symptomatic COVID-19. And the real life data on the vaccine is thrilling. (I appeared on Bloomberg news this morning to explain this new data—I hope you take a listen!)
Sidenote: let’s take a moment to define vaccine efficacy. When we say that a vaccine is “95% effective against any symptomatic COVID-19,” it does NOT mean that 5% of vaccinated people are unprotected. It does NOT mean that one in 20 people will get sick from COVID despite vaccination. Vaccine efficacy is about relative risk. It’s not measuring the likelihood of illness in an individual person. It is measuring the risk of disease in a vaccinated population against the risk of disease in an unvaccinated population. This is a critical distinction.
As explained in this excellent recently-published article in The Lancet, “It is imperative to dispel any ambiguity about how vaccine efficacy shown in trials translates into protecting individuals and populations.”
To make it even MORE simple, think about coupons. A 50% off coupon for a $10 face mask saves $5. A 50% off coupon for a $100,000 Ferrari saves $50,000. The coupons are both 50% off. The savings (the benefits of the reduction) are relative to absolute cost. A “95% reduction in risk” in these vaccine studies means a reduction in relative risk—not a 95% reduction of the chance of disease in one person. Make sense?
If I’ve lost you, don’t worry. Let’s move on.
Step 2: Let’s now assess the risks for Brigid and her mom when socializing together. There’s the risk of Brigid getting sick herself and the risk she poses to her mom. Based on current data, the odds of Brigid getting reinfected with coronavirus are slim in the first five to eight months after infection.
Are we 100% certain that Brigid is protected from severe disease five months out from her initial COVID infection? No. Is the likelihood very high that she’s still protected from death and severe disease and that even if confronted with a new variant of COVID-19, her antibodies and T-cells would turn the coronavirus into something resembling a cold? Yes. Are these risk calculations perfect? No.
Is it possible that Brigid or her mom, each with immunity to COVID-19, could harbor coronavirus and transmit it to one another? Sure. But this, too, is very unlikely. Do we need more evidence before we can abandon masks around non-immune folks? Yes, of course. But mounting evidence supports what we suspect: that COVID vaccines not only prevent disease, they also reduce transmission. (Once again, see the Bloomberg news clip.)
Just this month, preliminary data from the UK on the Oxford-AstraZeneca vaccine plus compelling data Singapore, Spain, and Israel all point toward a reduction in transmission. Two public health experts at the Johns Hopkins School of Public Health (finally) announced last week: “Based on the performance of similar vaccines, the fact that asymptomatic people may be less likely to transmit the coronavirus, and a quickly-growing body of direct evidence from trials and campaigns, we are confident vaccination against COVID-19 reduces the chances of transmitting the virus.”
But let’s be real: even with the odd-ball chance that Brigid or her mom could carry coronavirus and infect the other, the likelihood of severe illness and death in either of them is extremely low.
Step 3: What are the rewards of a mother-daughter reunion in an isolated, lonely, God-awful time, during which human companionship and family togetherness are more essential than ever, particularly for someone near the end of her life and needing help to manage her affairs? I don’t think I need to list them here.
Step 4: Brigid made the decision to visit her dear mom. They relished their time together—unmasked, indoors, and safe. And happy. The rewards were immeasurable.
As I reminded myself when deciding to let my son George drive in a snowstorm last week, risk is everywhere. Mitigating it can save lives, reduce suffering, and improve health. Masks, distancing, hand washing, and avoiding crowded indoor spaces have never been more important.
But risk mitigation comes with a cost.
And when COVID vaccination drops our risk to a tolerable level—to be defined, of course, by the vaccine recipient—it only seems only fair to ponder the social/emotional benefits of calculated risk-taking.
When we’re armed with facts and understand risk, we can make smart decisions that do two things at once: reduce suffering and consider our broad human needs.
Brigid’s difficulty getting an answer to her question about risk is because no one but herself can decide what she values, how risk-tolerant she is, and what to do when there’s risk all around us. She simply needed the facts, science, and tools to make the decision for herself. For her and her mom, it was the right choice.
I will see you later this week. Until then, be well.
This post does not constitute or contain medical advice applicable to individual situations. Such advice must be obtained from your personal physician.