And this will be a provincial U.S.-focused HAWT TAEK. To start with, it seems pretty clear that, for immunocompromised people, the notion of a third shot being a booster for those populations is incorrect: it should be viewed as part of a complete regimen. But I think in the U.S., we’ll need a third shot for most people if we want to stop the spread of COVID-19, even if the increase in protection isn’t that dramatic (some early data from Israel, which definitely needs more analysis to assess confounding factors, hints that a third shot might be extremely effective at halting transmission).
Before I go further, I want to lay out some assumptions, since in all the blather about anything COVID-related, too often the arguments devolve into proxy arguments about assumptions:
- The U.S. has failed at stopping COVID-19. Compared to most advanced nations, though not all, this should be obvious, but it does need to be stated as an important background condition. Like some developing nations, the U.S. has demonstrated that we lack the economic or political ability to mount a sustained, multi-component response to COVID-19, and we certainly will not be able to change this in a matter of months. There are enough people who are willing to behave badly, and, after two decades of seen the deficit hypothesis fail, there are no magic phrases that will alter their behavior–at least, not quickly enough, as we needed to be at around eighty percent (at least) of all people fully vaccinated in August. Yes, the capacity to change this exists, but the willingness to do so does not. It’s painful to say, but it needs to be recognized.
- As I mentioned at the beginning, Israeli data–which definitely need to be looked at in much more detail–suggest that a third shot dramatically reduces transmission. That said, I think drawing doom-and-gloom predictions from Israeli data were unfounded due to confounding factors, so we should be careful about this.
- Masking is important, and, for that reason, I call for more of it indoors repeatedly on this crappy blog. But in too many places in the U.S., masking is simply not happening and will not be enforced. Even in D.C., hardly a MAGA stronghold, I encounter too many people who refuse to wear a mask. In other places, mask requirements are explicitly banned. So like it or not (and obviously I don’t), in too many places, masking won’t be a key element in stopping (or slowing) spread.
- Ventilation, filtration and so on also are important, but, like masking, not feasible. Possible, yes, but not feasible. We can’t even distribute rent-related pandemic relief, which is simply shoving electrons from one ledger to another (though sometimes mailing some pieces of paper is also involved). Installing or improving new ventilation systems at the scale required seems unlikely, and has been hit or miss in the U.S. It will happen in some places, but, again, not in enough places.
- Testing is another failure. Right now, rapid, at-home tests are too expensive. If a family of four were to test once per week, that would be a $1,300 annual expense–this is why I’ve argued that if testing of kids doesn’t happen in schools, it won’t happen at all for too many children (and that lights one of the Biden Bucks checks on fire). Even in places like D.C., where there is ready access to testing, the results are not returned quickly enough (i.e., day of, or day after returning of results). It doesn’t have to be like this, but we have not mobilized resources to fix this, nor does it appear we will do so quickly enough (or at all).
While I endorse other non-vaccine mechanisms for slowing spread–and to the extent they can be enacted, they absolutely should be–there is no reason to think the U.S. is capable of sustaining these efforts in enough places for a sufficient length of time. When it comes to COVID-19, given our repeated failures over eighteen months, we should be viewed as a developing nation, even though there is no reason for us to be one.
Of course, someone could look at my objections and reasonably ask how they wouldn’t apply to vaccination. The key difference with vaccination is that vaccination is ‘fire and forget.’ One can’t decide to ‘stop being vaccinated’ because of misinformation and propaganda–or just sheer exhaustion. It doesn’t require major infrastructure overhaul or rapid deployment of new technology at an affordable price. This is why vaccination programs are so successful and important in the developing world: there isn’t a lot of infrastructure associated with vaccination that needs to be maintained (there is some, but the U.S. already has that–and even we can’t fuck that up, though one should never underestimate anti-vaccination Republicans). We don’t need a sustained effort for successful vaccination–once someone is vaccinated, that’s it–and if we have numerous vaccine requirements, most people will get vaccinated out of necessity: the caterwauling notwithstanding, most people do get vaccinated when confronted with mandates.
So what does that lengthy prelude have to do with boosters? Given the R0 of delta, we will need a very effective vaccine distributed to most of the U.S. population, probably to somewhere around 90% of the population. Right now, while the vaccines are very effective at stopping hospitalization and deaths, and they do seem to limit spread, that limiting of spread likely isn’t sufficient to stop spread–though it will, in conjunction with other measures, buy time–and in those places that aren’t dysfunctional, decrease prevalence. But there seems to be some thought–though who the hell knows–that a third shot would stymie transmission. If that’s the case, then vaccination might be the way to the other side of this. Yes, that would require vaccination requirements, but those could be enacted–and we do this for many other vaccinations already. Would there be fierce opposition to this? Yes. But we underestimate in many regions of the U.S. how much anger there is heading in the other direction by the vaccinated at the unvaccinated.
It shouldn’t be this way. If our polity weren’t fractured, if our social, economic, and political systems of governance weren’t broken, we would have affordable at-home testing, people wouldn’t be WATBs when they have to wear masks indoors, and we would have improved ventilation, not just in schools, but in all public places. That, however, is not the America in which we live. America in 2021, the Year of Our Gritty, with respect to COVID-19, is a developing nation with a fractured polity. As such, we need highly effective vaccines, ones that check transmission, not just symptoms, and that likely–though again, definitely not certainly–requires a third dose. To me, this seems the least difficult to implement, compared to testing, nation-wide building overhauls, or convincing people to consistently wear masks. This is a desperate hope, especially if the effect of a third shot on transmission is transitory, but I think it’s all we have. A ‘Slow Burn Strategy’ seems like a kinder, gentler Great Barrington Declaration*:
cdc recommending 3rd dose of vax w/ limited data
b/c we can't collectively commit to non-pharm prevention measures (masks, space, ventilation)
and we can't solve significant vaccine inequity
and we're scrambling
b/c in the US public health isn't a public effort at all
— Sarah C. DeSilvey, DNP, FNP (she/her) (@sarcandes) September 25, 2021
It’s humiliating and shameful that things are this way, but that’s where we are. Because America and enough Americans are broken.
*The overlap between those who argue that worries about losing a day of work due to vaccination side effect are legitimate and those who blissfully ignore what missing one week or more of work (and unscheduled) means to those same people is, unfortunately, quite large.