Anger is a handy emotion. It’s action-oriented. It can make us feel powerful and motivated to “do something” — like shout down someone who disagrees with us (hello, Twitter) or dig our heels even further into our fixed, firm beliefs. But anger can do harm. When enraged, we tend to lash out or isolate, deprive ourselves or self-medicate. Anger is also a convenient proxy for other emotions that may be harder to tolerate but worthy of examination. In other words, anger can be a safe haven from honest introspection and uncomfortable truths.
I’m angry about a boatload of things (perhaps you are, too):
Widespread medical disinformation that infiltrates people’s brains and keeps them from getting vaccinated
The ongoing vulnerability of children who aren’t eligible for the vaccine and continue to suffer from the risks posed to them by unvaccinated/non-immune people around them and from pandemic restrictions themselves
The politicization of science at the expense of our most vulnerable populations. And the difficulty engaging in nuanced discussions about evolving scientific data without it being seen as promoting a political or ideological agenda
The polarization — including within the medical community — around complex issues like natural immunity, masking, and school reopening that have become reduced to all-or-nothing ideologies
The notion that COVID-19 is the only threat to our health and wellbeing — and that a a simultaneous appreciation of other health harms implies 1) a lack of empathy for sick and high-risk populations, 2) a dismissal of people’s legitimate fears around COVID, or 3) an attempt to minimize widespread suffering from COVID-19
The loudest bee in my bonnet right now? That recognizing the existence of natural immunity gets conflated with anti-vax rhetoric — even by medical folks! Allow me to explain.
Our immune system is cool.
An infection with any pathogen (like coronavirus) naturally and automatically kicks our immune system into action. To combat infection, our B cells crank out antibodies and our T cells attack infected cells. Simultaneously, our bodies make memory B and T cells that serve as templates to mount another immune response to any future exposures to the same — or similar — “bug.”
Our own immune response is partly why we feel like crap — i.e. fever, chills, body aches — when we’re sick. Recovery from COVID-19 is evidence that our immune system ultimately won the battle against the virus. (Tragically, as you know, around 640,000 Americans — and counting — have already lost that battle.)
Vaccines are a wonder of modern science.
Vaccines invite our bodies to mount an immune defense against a “bug” before we get exposed to the real thing. Those of us who've been vaccinated against COVID have learned a few things:
The COVID vaccines continue to provide excellent protection against death and severe disease. They also reduce the risk of transmitting the virus to others. They are astonishingly safe.
Despite what you might hear, there has yet to be a variant that evades immune protection from the vaccines. Click here for a superb thread about vaccine effectiveness against Delta from infectious disease/virologist and clinician, Dr. Muge Cevik.
The COVID vaccines aren’t perfect. Breakthrough infections have always been possible, and because of the highly-contagious Delta variant, they are no longer rare. While the CDC stopped tracking all breakthrough infections, it does record the ones that result in hospitalization or death. Of the over 171 million fully-vaccinated people in the US, so far approximately 14 thousand have experienced significant breakthroughs, making the current risk of hospitalization from a breakthrough infection 0.003% and the risk of death 0.0006%.
The vaccines don’t provide a fully protective force-field, off of which the virus “bounces.” The vaccines don’t prevent all infections; they simply trigger our immune systems to battle — and hopefully win against — this ubiquitous virus.
Breakthrough infections typically present as a cold or flu-like illness and are not a sign that the vaccine isn’t working. When a vaccinated person has zero or mild symptoms, that’s a vaccine success story.
The risk of getting COVID isn’t going away, but when you’ve been vaccinated your risk of dying or needing hospital care is vastly reduced. As I’ve been saying since December, the vaccines take the claws and fangs away from coronavirus and turn it into its wimpy cousin. We will all be exposed to coronavirus at some point; endemicity is inevitable (which is not synonymous with “giving up” on COVID risk mitigation).
For people ages 12 and above, getting vaccinated has been proven far safer than getting COVID-19 itself. (I wish I knew when to expect the vaccine trial data for kids ages 5-12 — “late fall” is what I hear.)
Post-vaccination antibody levels wane over time. This is normal and expected and is not itself synonymous with waning immunity. In fact, if antibody levels didn’t drop after every infection or vaccination, our blood would become a dangerously thick SLUDGE of antibodies! Instead, our immune systems smartly create memory cells as explained above. A study out of UPenn last week showed that memory B cell responses continue to increase in frequency for at least (and not limited to) six months, even as circulating antibody levels wane. For a great primer on our sophisticated adaptive immune systems, watch this video from my friend Monica Gandhi, MD.
But what about people who’ve already had COVID?
People who’ve recovered from COVID-19 itself — that is, people whose immune systems have won the battle against an infection with coronavirus — also have some protection against COVID-19 — or reinfection. Is it full protection, wherein reinfection is an impossibility? Absolutely not. Natural immunity is not perfect. (Is anything?) Once exposed to and infected with coronavirus, whether or not you become sick (develop symptoms of COVID-19) depends on both virus and host factors — i.e. how much “viral load” you were exposed to, which variant (i.e. how well it replicates inside you, etc.) — as well as your own immune make-up (host factors, such as genetics, health conditions, medications, and age). Similarly, the duration and strength of our immunity against reinfection varies tremendously based on the same factors above.
Why does natural immunity even matter?
Because people who have recovered from COVID-19 are being marginalized and not “counted” — for example, in vaccine passports to enter schools, workplaces, etc. — despite mounting evidence that a COVID-recovered person may have the same or even better protection against disease than a vaccinated person does. (To be clear: this is not a statement about whether or not I agree with vaccine passports; I’m saying that our immune systems are incredibly sophisticated but also quite variable, too.)
Many scientists and COVID-recovered people rejoiced when a large study out of Israel last week (detailed in this article for Science Magazine) suggested that natural immunity is superior to vaccine-induced immunity: “The newly released data show people who once had a SARS-CoV-2 infection were much less likely than vaccinated people to get Delta, develop symptoms from it, or become hospitalized with serious COVID-19.”
The study also found that people who had COVID plus a single dose of the Pfizer vaccine were more highly protected against reinfection than those who had recovered from COVID-19 but hadn’t been vaccinated.
Natural immunity — again, depending on the person and exposure — can also offer protection against asymptomatic infection and forward transmission to other people. Natural immunity importantly contributes to TOTAL population immunity and will help drive us further out of this hellscape. The widespread denial of basic science — and a refusal to recognize natural immunity as a possible contributor to the end of the pandemic is why so many COVID-recovered people are angry and distrustful of medical and public health folks. I get it!
So why should someone who’s had COVID get vaccinated?
So before you decide to bank on natural immunity for protection against COVID (which I do not advise right now), know this:
The above study isn’t yet peer-reviewed and — as with any single study — shouldn’t be taken as gospel. (Though many other studies have said the same thing.)
A vaccine is, by definition, a controlled dose of a substance proven to generate enough of an immune response in most people to cut the risk of death and severe disease. In other words, getting a specific amount injected into our arm controls one of the variables above (e.g. exposure) and helps level the playing field by giving everyone’s immune system similar training and prep.
Confused? I hear you. I’d be bald-face lying if I knew exactly the right thing for you, dear reader, to do about your past COVID infection, booster shot, or COVID mitigation strategy. The complexity of our immune systems is exactly why reducing public health recommendations to one-size-fits-all declarations is intrinsically problematic. That said, we cannot expect the CDC to speak to each and every person’s unique medical conditions, immunity, and extent of past or potential exposure to COVID. This is exactly why you need your own doctor.
So what do I recommend as of today to my own COVID-recovered patients?
As you might expect, it depends on the patient and clinical scenario. That said, until we have further data, my general advice for COVID-recovered patients is still to get vaccinated — with at least one dose of the Pfizer, Moderna, or J & J vaccine — to optimize protection against COVID-19.
I definitely DON’T recommend COVID infection parties or a “let ‘er rip” strategy of infection control. By not getting vaccinated, we run the risk of death and severe disease. My point is simply that denying natural immunity is to ignore basic science and — even worse — the lived experiences of so many COVID-recovered patients.
I also hope that honoring natural immunity by checking a COVID-recovered patient’s antibody levels as a start will, down the road, allow for more equitable and scientifically-sound policies. For example, an unvaccinated child who’s proven to have robust natural immunity due to an infection — with or without symptoms — might not need to test and quarantine with every school exposure to coronavirus down the road.
The upshot?
Science + politics = politics.
For example, recommending a third vaccine dose — or “booster” shot — for every American after five (or even eight) months is more about politics than it is about science. It simply doesn’t make sense medically to vaccinate already-immune, healthy individuals unless we decide that our public health goal with COVID is to reduce the chance of people getting colds. Can it hurt to get a booster? Nah. It’s just vexingly unscientific to give a life-jacket to someone who’s already got one on — and is steadily swimming to shore — when half of the world is drowning.
As New York Times’ David Leonhardt wrote this morning in another great non-alarmist article summarizing the current evidence on boosters: “One of the main messages I’m hearing from the experts is that conventional wisdom about waning immunity is problematic. Yes, the immunity from the Covid vaccines will wane at some point. But it may not yet have waned in a meaningful way.”
To be clear: I am not anti-booster-shot. (My patients who are immunocompromised, organ transplant recipients, nursing home residents, and otherwise high-risk should get a third shot.) I simply believe we should let scientific evidence — not politics, fear/”what if” thinking, misinterpreted data, or vaccine manufacturers — drive medical and public health decisions. See my newsletter from last week HERE for more info about breakthroughs and booster shots.
I’m also well aware that recognizing natural immunity gets conflated with right-wing, anti-vax rhetoric. So I will say it again: get vaccinated if you’re eligible — even if you’ve had COVID as we await more data and more nuanced guidance from the FDA and CDC.
Sigh.
Back to the part about anger. My list (above) is only part of the reason I often feel frustrated. From global vaccine inequity to panic porn in the media to the fact that I’ve lost my favorite Tweezers somewhere in the kitchen (I’d rather have chin hairs to the floor than spend $20 on another pair), I could have a bee in my bonnet all day, every day.
But living in a constant state of rage isn’t healthy or productive. Moreover, anger is a red-hot distraction from other simmering feelings — like vulnerability, fear, sadness, or shame — that deserve our attention. If you’re human, you have all of those unpleasant emotions on tap. I know I do.
Pulling the curtain back on anger and identifying the emotions behind it can be uncomfortable but can help us find calm amidst chaos. For example, I realize I’m mostly sad (more than mad) that talking about natural immunity incites so much fear and outrage. I’m fearful for our future (more than I am angry) about the polarization and tribalism among medical experts.
Sitting with unpleasant feelings — and then dispatching with the ones that spin us up out of proportion to reality can help us find calm amidst chaos. The biggest challenge? It can be hard to know the difference. Sorting through our noisy brains is kind of like cleaning out a closet: it’s not always pleasant, there’s usually something better to do, and it requires facing uncomfortable realities. In other words, it’s easy to avoid your closet when you know your jeans don’t fit and you’re pretty sure that half of your stuff should go to GoodWill.
But taking stock of our thoughts — like decluttering our closet — can help us conserve precious energy and redirect our attention to the things that matter most. At this moment of the pandemic, we’re all suffering in some way. Taking an honest assessment of how we feel — essentially fact-checking our internal narratives — can help root us in the present moment and help return our internal locus of control.
Some other ways to manage the broad array of emotions we face at this confusing and stressful moment of the pandemic? (I fully recognize that you might have more questions than answers after reading this!) Check in with the facts. Know that the medical evidence is evolving rapidly and that, sadly in the US, we’re quite good at setting up false dichotomies (i.e. masks are “good” or “bad,” boosters are “life-saving” or “useless,” school reopening is “dangerous” or “safe”) during crises. (The article linked just above made my heart SING!) Remember that life exists in the gray, that there are no easy answers to complex problems, and that any medical professional who’s certain about anything COVID-related is not someone I would trust. Figure out who you do trust. Get outside. Breathe. Talk to your therapist, dog, or empty wall. Take control of the controllable (e.g. prioritizing sleep and limiting time online), let go of the things you cannot control, and ask for help when you can’t tell the difference. I’m working on this stuff alongside you.
I will check in next week. Until then, be well.