Vax to Relax
My kids love to call me “Captain Obvious” — to which I reply “You’d rather me be Captain Obvious than Captain Oblivious, right?” Indeed, they often groan when I yell out “Drive safely!” or “Don’t jump off that rope swing without a spotter!” So I remind them: worrying is part of my job. It’s also in my DNA.
I’ll admit that issuing these reminders may sometimes simply serve to make me feel better — as if nagging actually helps prevent a car wreck or drowning. But hey, probably like you, I’m doing the best I can. As parents we’re constantly threading the needle between restrictions and freedoms for our kiddos. We want to give them just enough liberty to take healthy risks but not enough to do something stupid.
So here’s where this dog-eared dilemma is playing out in the public square: school reopening in the fall.
Note: if you’re relishing the present moment and not thinking about school reopening, enjoy!! But for anyone whose anticipatory anxiety about fall 2021 might need assuaging, read on.
I think we can agree that fall 2020 was abysmal for kids, that remote options were a decent alternative when COVID was raging, and that kids would benefit from a more normal school experience this fall. The question is this: is a normal school experience even possible with coronavirus still circulating?
The two main buckets of parental worry when it comes to thinking about the fall seem to be:
Preventing an unvaccinated and/or medically vulnerable child from contracting COVID-19, and
Preventing further learning loss and emotional distress due to ongoing pandemic restrictions (and I don’t mean just masks; I’m talking about the whole shabang — from plexiglass barriers and nose swabs to the everyday constraints on hallway hangouts, assigned bus and lunch-table spots, to the more serious feelings of perpetual social isolation, anxiety and fear).
Fanning the flames of (natural) parental anxiety is the public narrative that suggests we have to choose between a) keeping kids safe from COVID-19 or b) reopening schools — that there’s no middle ground.
But there is. We can successfully protect kids from COVID-19 and reopen schools without restrictions.
How? By accepting that risk is everywhere and by making decisions that are rooted in data over dogma, science over sensationalism, practicality over politics.
This is where I’ll gladly change into my “Make Nuance Great Again” T-shirt, go through some facts, and — with humility — offer my opinion that you’re welcome to disagree with. (See Twitter for the real fun.)
COVID-19 case rates, death rates, and hospitalizations are falling fast. We have three wonderfully effective vaccines that, for vaccine recipients, take death and severe disease off the table, disarm coronavirus (turning it into its wimpy cousin if anything at all), and prevent transmission of the virus to others. In other words, after you’ve been vaccinated, it’s hard to get COVID-19 and even harder to sicken other people.
After vaccination, it’s also more difficult to get very sick, even against the much-hyped Delta variant. Note that while case rates have gone up in the UK from Delta, death rates have not. Also note the potential for confusion over the reporting that young people are more susceptible to Delta. It’s not that Delta is more contagious among them; it’s that young people are the ones less likely to be vaccinated — and therefore susceptible. How do we combat Delta? The same way we protect against all “versions” of COVID: by getting vaccinated to protect ourselves and other, more vulnerable unvaccinated people — like kids. Two doses of the mRNA vaccines are about 95% effective at preventing hospital admission with the Delta variant. One dose is about 70% effective. (See my post from April about why we needn’t panic about variants, even this one.)
Also recall that kids are indirectly protected from COVID-19 (even the Delta variant) as adults in their midst are protected through vaccination. In other words, as more adults become immune, kids’ infection rates drop, too. We watched this unfold in Israel and the UK. The same trend is happening in the US. Widespread vaccination has dropped COVID-19 cases in kids by 82% between April 15 and June 3. Half of that drop was even before vaccinations for the 12-15 year-olds became available on May 12!
As you may have read in my co-authored Washington Post opinion piece two weeks ago, the chance that any close contact will transmit infection to an unvaccinated child given current infection rates in the U.S. — even indoors — is approximately 0.00007%. This sounds implausible, but that finite risk is because the prevalence of the virus is so low now that it’s actually unlikely you will be near someone who is infected. Of course, this assumes cases are spread evenly throughout the US — which they’re not. There are areas where access to vaccination has been more challenging and vaccination rates are lower. In general, though, the risk to kids and other unvaccinated people drops further every day as adults — the main drivers of COVID-19 spread — are increasingly vaccinated.
Kids are also at a very low risk for severe outcomes from COVID-19. My newsletter from Monday explains some of the data on kids in detail. (I also corrected two typos — thanks to my close-reading subscribers who found them!)
Kids also don’t spread the virus like adults do. There is abundant evidence to show that the main direction of transmission is adult to adult or adult to child — not child to child or child to adult. See here and here for references.
In short: The best way to protect kids from COVID-19 is through adult vaccination and simply by being a kid.
So the big question is: why are we restricting kids at all?
An initial answer seems easy: unvaccinated kids are at risk for COVID-19 and can spread the virus to others. What’s more, certain kids are at higher risk from COVID-19 and/or live with higher-risk or unvaccinated adults. There are also very valid concerns about long COVID and MIS-C, but we now know that the risks of both are low — and dropping daily as COVID case rates fall.
But in my opinion — and in the opinion of many medical, public health, and epidemiology experts — we need an endpoint for lifting pandemic restrictions that, in and of themselves, cause harm. We need to understand that we’re crushing COVID by the vaccines and by durable natural immunity (i.e. from people who have recovered from COVID), but that this virus isn’t going away. We need an on-ramp to normalcy and an off-ramp for restrictions. We need our eyes wide open to the concepts of relative risk and focused protection.
In other words, our broad public health goal shouldn’t be to rid the planet of COVID-19. Why not? First, like putting toothpaste back into the tube, it’s not even possible. Second, a zero-COVID strategy would continue to harm our ability to live, work, and recreate as humans need to do for our health and well-being. The learning losses from school closures are real and measurable. The mental health toll on kids is more difficult to quantify, but evidence is mounting that rates of depression, anxiety, addiction, eating disorders, self-harm and suicide are on the rise. I witness the uptick in these phenomena in my patients.
Just yesterday the Department of Education released a report on the pandemic's impact on children's well-being and “...its sweeping adverse impacts and trauma-inducing experiences.” Another article today about the mental health toll of pandemic restriction on kids reminds us that every intervention has downsides.
It’s time to start shifting our thinking from zero-risk-tolerance mode to relative-risk-reduction mode. After all, risk is everywhere. A risk-free existence isn’t on the menu. There are harms of doing (driving a car, jumping off a rope swing); there are harms of not doing (not getting where you need to go; not experiencing joy).
In other words, we need to learn to live with COVID-19. Not because we want to, but because we have to. There’s a word for this: endemic. Many childhood illnesses were endemic before vaccination, such as chickenpox (which claimed the lives of approximately 100 previously healthy children each year). Our goal should be to reduce the harms from COVID-19 — particularly to our most vulnerable citizens — while limiting the collateral damage from pandemic restrictions themselves. It’s to balance the risk of getting COVID-19 against the risk of depriving individuals and populations of meeting their broad human needs — like going to school and work and connecting with others.
Large studies have shown that schools in the US can operate safely irrespective of COVID prevalence. Notably, the UK, Denmark, and Norway never masked children under age 12 in school. Confident in its successful adult vaccination rate and low COVID case and hospitalization rates, the UK lifted mask mandates for teens — regardless of vaccination status — last month.
Here I’ll issue a respectful shout-out to high-risk, vulnerable, immunosuppressed, vaccine-hesitant, proudly-unvaccinated, and any other people who naturally experience fear about COVID-19: I see you. I hear you. I get it. And to the extent I don’t get it, I’m trying to. Some of you are my patients. Some of you read my newsletters. Many of you I don’t know but have thoughtfully engaged with me on sensitive issues like race, equitable vaccine distribution, suicide, end-of-life decision-making, and existential questions about quality of life.
I know that your voices aren’t well-amplified, your lived experiences are often marginalized, and you might be irritated as hell when doctors like me bask in the glow of vaccine optimism.
But at this watershed moment of the pandemic, it’s appropriate to zoom out — to take a hard look at the facts and to redefine risk and reward. At this moment, with stunningly effective vaccines; dropping rates of COVID cases, hospitalizations, and deaths; and more and more adults being vaccinated, everyone is incrementally safer from COVID with each passing day. And as the risk of this dreadful disease drops, other threats to our health and well-being — there all along — have been laid bare. Let’s name them and try to solve them, too.
What’s my take-home message for you tonight? Immunity is the desired end-state here. Whether you have it already through natural infection or full vaccination — or perhaps you’re doing both (vaccine as an insurance policy) — your protection against disease is already helping to protect those who may be more vulnerable.
The end is here, but it may not feel that way yet. We’re in a transitional phase now as we wean off of constant worry. Know that Captain Obvious here has the watch. I care about you, and I thank you for thinking and feeling so deeply about health. Onward!
I will see you next week. Until then, be well.
P.S. I’d love to hear what’s on your mind! As we move forward together, I’ll cover more topics about overall health — mental and physical — and welcome your content ideas.