Manage Expectations
Apparently I struck a nerve this weekend. Sitting in my bed on Saturday morning, I tweeted a comment that happened to go viral. Since then I’ve been pondering why. I wrote:
“IF, in my medical practice, I took the posture of tacking down the risk of physical harms to patients to ZERO — without considering ppl’s broad human needs — I’d recommend 1) no sex, 2) no driving, 3) no alcohol, 4) no sugar. I’d only incite fear and/or QUICKLY be out of a job.”
So why did this ditty tickle people’s fancy? First, it seems clear that people really enjoy sex, driving cars, drinking alcohol, and eating cake (not necessarily in that order). It also seems evident that people are sick and tired of hearing “no.” We want a “hell, yes!” to imbibing and canoodling.
What’s even worse than repeatedly being told “no”? Being told “yes” — and then “no” immediately after. It can start to feel like our dogs have more autonomy than we do.
The World Health Organization made a statement this weekend that made people feel one of three things: anxious, mad, or resigned. The WHO recommended that vaccinated people mask up again. This concept doesn’t make much sense given the ongoing real-world data showing that vaccinated people are strongly protected against COVID-19, including from the Delta variant against which two doses of vaccination provides 96% protection against hospitalization.
People are frustrated with what seems like a no-win scenario. Each new variant — like the new “delta plus” — seems to dim whatever light we saw at the end of the tunnel. (Just thinking about Delta plus makes me crave peanuts and more legroom.) Yet mounting evidence — and the vast experience of infectious disease doctors — suggest we probably won’t need booster shots for years. Even the scientists comprising the Oxford vaccine dream team say it's unlikely that the current or future variants will escape immune protection from the vaccine.
Discussions about “elimination” or “eradication” further agitate people who accept the reality that 1) COVID-19 is here to stay, and 2) ongoing restrictions have the potential to cause (even) more harm than good. As we’ve discussed, we need to recognize that risk is everywhere, mitigate it when possible, and broaden our definition of health (aka the principle of harm reduction).
The fact of the matter is this: Coronavirus will continue to be infectious. The virus will continue to spread largely by people without symptoms. We can’t halt human existence to stop the virus entirely, nor do we need to. In short, eradication (aka “zero COVID”) is impossible.
But what about controlling COVID? Is that even possible? Yes! We’re pretty much there in the US.
Let’s start with some definitions:
Controlling coronavirus means reducing the number of new infections (incidence) and the number of people who are currently sick (prevalence).
Elimination of coronavirus refers to halting transmission in a specific country or region, but not worldwide.
Eradication of coronavirus means the permanent reduction of COVID cases to zero worldwide.
Have we controlled viruses before? Yes. Other viruses, even those which cause no symptoms for years, have been controlled through vaccination, treatment, and other preventive measures.
Take, for example, viral hepatitis which causes inflammation of the liver and is a leading cause of liver cancer. Three different viruses can cause disease: A, B and C. Hepatitis A is caused by person-to-person transmission or contaminated food, but the vaccine (usually given in childhood) is highly effective against it. Similarly, Hepatitis B can cause chronic illness, but vaccination at birth has protected a generation of children. Hepatitis C can also cause chronic disease and is a leading cause of liver cancer. Although there is no vaccine, hepatitis C is curable through treatment.
This is what control looks like: sweeping reductions in illness and transmission and reduced incidence of disease indirectly protecting the non-immune. Although the highly effective COVID vaccines have protected many Americans, we’re still in the ground game of vaccinating all eligible adults. What’s more, global vaccine equity is critical, not only because it’s the right thing to do but also because vaccinating the world tamps down transmission and hastens control.
Vaccines already have controlled 14 diseases that were once prevalent in the US. Small outbreaks of measles, mumps, rubella, polio, tetanus, pertussis, diphtheria, and chickenpox continue, but these are only picked up when someone with symptoms gets tested.
The only disease in history to be fully eradicated is smallpox.
Infectious diseases and public health experts agree that control of SARS-CoV-2 is possible. In fact, the combination of vaccination and natural immunity (through past infection with COVID) already has reduced new cases in the US by more than 95%. We will continue to have outbreaks among groups of people who are unvaccinated, but because COVID-19 is a reportable illness (like measles), public health authorities will be able to track these outbreaks. In my humble opinion, the general public needn’t be burdened with constant reminders of the circulating virus. The top COVID headline should read: Get Vaccinated to Protect Yourself and your Community. Full stop.
Please see this excellent thread by my friend and pandemic response hero, Dr. Monica Gandhi. Her perspective as an HIV specialist is particularly compassionate, emphasizing harm reduction approaches to living with disease while preventing transmission.
Public health restrictions — masking, distancing, etc — help contain a novel virus before vaccines and treatments become available. Now that we’ve arrived in this new era, we can confidently move forward without constant vigilance. This is exactly what we already do with existing coronaviruses, measles, pertussis and many other vaccine-preventable illnesses.
Do this one thing for yourself today: make an appointment with your primary care doctor — for you and your family. Find out if your vaccination history is up to date. Ask if there are any routine screenings you should do (bummer alert: colonoscopies are now recommended at age 45, not 50). And then drop from your radar the constant news feeds on COVID-19. I promise: unsubscribing from the alerts will help you breathe and sleep better.
Meanwhile, COVID-19 will remain on my radar. I promise I’ll keep you updated. If there’s something you do need to know (such as a new booster recommendation), I will be sure to let you know. For example, to learn more about mixing and matching vaccines, read this fact-based Twitter thread from my molecular biologist friend Chise.
For now, I’ll assume you’ve gotten vaccinated and are ready to have your cake, and eat it, too.
I will see you later this week. Until then, be well.