Health is More Than the Absence of Disease
I'm always thinking about you, my dear reader, when contemplating what to write next in this blog. In the shower, walking the dog, browsing for deodorant at CVS, I’m constantly noodling on ideas.
But I also can't help but indulge the inner musings of my (noisy) brain.
So here's what's going on up there: the fascinating public debate on how best to conquer the pandemic.
In brief, there’s heated dialogue between two camps: the “Zero-COVID” crowd versus the “harm reduction” club.
Let's break this down. Because at the end of the day, it affects you, too.
First let's remember that there are two main goals of vaccination against COVID-19:
preventing disease (protecting yourself) and
preventing transmission (protecting other people)
With the remarkably effective vaccines currently available (and the others in the pipeline, too), we've done a fabulous job of protecting people from disease. As you recall, both the Pfizer and Moderna mRNA vaccines are 100% protective against severe disease and death, and they are 95% protective against getting COVID-19 at all. That means that after you’ve been vaccinated, there is a tiny chance of getting COVID-19, and if you did, you’d likely have a cold or a mild flu.
In short, the vaccines de-fang and declaw the coronavirus, turning it into a boring old virus.
Even against the new variants, vaccination offers excellent protection against severe disease and death. My best advice for anyone worried about the variants is to watch this YouTube video with Dr. Monica Gandhi at UCSF (at 30:22 minutes).
(For doubters: is it possible to get very sick with COVID-19 even after vaccination?? Sure, anything is possible, but the data on tens of thousands of clinical trial participants is clear: it is very unlikely.)
And then there's the question of transmission: does vaccination prevent a vaccinated person from carrying the virus, transmitting it, and infecting other people?
Just this month, preliminary data from the UK on the Oxford-AstraZeneca vaccine plus compelling data Singapore and from Catalonia, Spain all suggest what most medical and public health experts predict: that the COVID vaccines not only protect against COVID-19, they also reduce transmission.
Another article this week in the New England Journal of Medicine demonstrated that the Pfizer vaccine appears to have a strong effect in laboratory studies against the B.1.1.7 and B.1.351 variants (also called UK & South African variants). Previous data from Moderna suggest the same. Real-life evidence from Israel supports this same conclusion.
While the risk of transmission can never be zero, the science, evidence, and biological plausibility exist with enough HEFT that two doctors at the Johns Hopkins School of Public Health (finally) came out on Monday to say this:
“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.
"It may be that protection against transmission is appreciably less than protection against severe [#COVID19] disease, but at this point it would be beyond shocking if no impact was there," write Dr. Kate Grabowski and Dr. Justin Lessler.
What does this mean? And how does this fit into the battling schools of thought on how to end a pandemic?
Let’s take a non-COVID example:
My 17-year old son George hasn’t had tons of road experience, but he has taken driver’s ed, has good hand-eye coordination, and (so far) has avoided any fender benders.
It snowed today in DC. The roads are a mix of slush and ice. So when George asked for my car keys to drive himself to his part-time job this afternoon, I paused. “It’s slippery out there.” “Visibility isn’t great….why don’t you scrape the rear window again?” With a sideways glance, he reassured me “I’m fiiiiiiiine, mom. Plus, it’s too late for me to walk.”
So he de-iced the windshield (again), flipped on the headlights, and drove away at a snail’s pace to appease his mom.
We took a risk, but we mitigated it—all for the reward of getting to work on time and avoiding a two-mile trudge on foot.
It’s worth noting, however, that if my only goal as a parent was for George not to get into an accident—that is to say, if I were an “absolutist”—I’d never let him drive a car (not to mention leave the house).
Similarly, to prevent the possibility of ever getting COVID-19—or any sort of cold—you might decide to stay home for the next few years. But after getting vaccinated, you might dare to step out, live again, and take a few calculated risks.
Indeed to most of us, health is more than the absence of disease.
In other words: not dying is important (and is essentially guaranteed with COVID vaccination); but what about living?
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.
My point? 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.
As social scientist Yaneer Bar-Yam said this week: In a rip tide, never swim against the tide (“zero-COVID”) and do not passively drift out to sea (let-it-rip). Both lead to death. Be smart and consider the third option: Swim sideways to escape the rip tide (focused protection). That saves lives.
I will see you next week with more thoughts on risk, reward, and a decision-making rubric. Until then, be well