COVID Booster Shot Meets Health Care Monopoly

This post is part of an occasional series on health care. Here’s the prologue to the series, which originally preceded the post below.

Here’s a fairly straightforward story from The New York Times from a few days back, reminding us of the fact that immunity from some of the COVID vaccinations is limited in time, and may well require a booster shot.

 WASHINGTON — Biden administration health officials increasingly think that vulnerable populations will need booster shots even as research continues into how long the coronavirus vaccines remain effective.

Senior officials now say they expect that people who are 65 and older or who have  compromised immune systems will most likely need a third shot from Pfizer-BioNTech or Moderna, two vaccines based on the same technology that have been used to inoculate the vast majority of Americans thus far. That is a sharp shift from just a few weeks ago, when the administration said it thought there was not enough evidence to back boosters yet.

On Thursday, a key official at the Centers for Disease Control and Prevention said  the agency is exploring options to give patients with compromised immune   systems third doses even before regulators broaden the emergency use authorization for coronavirus vaccines, a step that could come soon for the Pfizer    vaccine.

Skipping a bit:

Pfizer’s continuing global study of its clinical trial participants shows that four to six months after the second dose, the vaccine’s effectiveness against symptomatic infection drops from a high of 95 percent to 84 percent, according to the company.

As a (then) full-time hospital worker actively exposed to high concentrations of COVID, I got my second dose of the Pfizer-BioNTech shot on January 6. If the vaccine’s effectiveness definitely drops from 95% to 84% in four to six months, then I’m well past my due date for a booster. Though I’m no longer a full-time hospital worker, I’ve been waiting for twelve weeks now for the paperwork to go through on my bid to work per diem for Hunterdon Medical Center’s OR. Assuming it goes through, I’ll be back in the COVID-intensive environment I previously inhabited. And if it doesn’t go through, I intend to apply to do the same work at a different hospital. So one way or another, I intend to make my way back to hospital work, and (by implication) to re-immerse myself in COVID.

But even if I never return to hospital work, I kind of like being vaccinated at 95% effectiveness. It’s been nice (mostly) to take off my mask(s). And I don’t feel guilty about having gotten vaccinated despite no longer working in a hospital. It’s not as though there’s been any shortage of vaccinations in the United States. On the contrary, one of the few things the US did right during the pandemic was its vaccine roll-out, which both produced and distributed vaccines en masse faster and more effectively than virtually any other country in the world, with the possible exception of Israel. Israel started administering its booster dose of the Pfizer-BioNTech vaccine, at least to Israeli citizens, two weeks ago. Granted, Israel is a much smaller country than the US, and granted that in apartheid fashion, it has not taken seriously its responsibility to vaccinate the inhabitants of the Occupied Territories. But bracketing that, Israel has done an excellent job of vaccinating its own population. Instead of emulating Israeli apartheid, perhaps we should be emulating the Israeli approach to public health. 

Oddly, though, despite the propaganda that the CDC et al has put out about the need to get vaccinated, the FDA now seems to be expressing hyper-caution about the need for the booster, fighting Pfizer’s contrary claims, and arbitrarily moving the goal-posts on its conception of “the goal” of vaccination, as though the federal government’s conception of that goal was the only legitimate one:

With so little data yet public, many health officials and experts have spoken cautiously about booster shots. Dr. Paul A. Offit, a member of the Food and Drug Administration’s outside advisory committee of vaccine experts, said a rise in mild or moderate cases of Covid-19 among vaccinated people did not necessarily mean a booster was required.

“The goal of this vaccine is not to prevent mild or low, moderate infectious disease,” he said. “The goal is to prevent hospitalization to death. Right now this vaccine has held up to that.”

Three things are worth noting about this statement.

First, note the slide from “so little data yet public” to the apparent need for “caution,” not only about administering booster shots but about verbally preparing the public to receive them. The slide from “little data” to “can’t give booster shot” involves a non-sequitur. There is no principle of statistics, ethics, or public health that implies that unless you have hard “data” in hand that absolutely demonstrates the necessity of getting a booster shot, you must not give one. That isn’t how medicine works in ordinary clinical contexts, and it’s not how it works in public health, either. Nor is it how the CDC has itself done things throughout the pandemic. The absence of data indicating “necessity” (whatever that would be) is perfectly compatible with giving shots in a spirit of risk-averse precaution. The “data” to which the article alludes would of necessity include breakthrough cases, something we’re trying to avoid. Why wait until cases break through before we take steps to avoid them?

It’s worth noting that experts in public health have, throughout the pandemic, helped themselves opportunistically to the precautionary principle: when the stakes were sufficiently high, they have not consistently taken lack of data to entail inaction; they’ve often inferred the reverse.** Suddenly, the FDA has decided, out of the blue, that the precautionary principle is to be thrown to the winds, in favor of what, for lack of better terminology, can be called epidemiological gambling. Now, we’re obliged to wait until they’re absolutely sure that the vaccine will give out before they permit us to be vaccinated. But the fact that the vaccines have been approved under an Emergency Use Authorization implies that they weren’t sure at the outset, and had no problem overlooking the relative “absence of data” involved in authorizing the vaccine. If anything, we ought by now to be more sure that the vaccines are safe than we were when the EUA was first granted. So the hesitation over booster shots is puzzling.

Second, note the dogmatic assertion that there is exactly one legitimate goal of getting the vaccine, a goal decided not by patients, or by providers, or even by drug manufacturers, but by regulators, i.e., the one party to vaccination whose presence is not a matter of the informed consent of the other three. Somehow Paul Offit, not even formally an official at the FDA, has decided that a rise in “mild or moderate cases” of COVID is really not such a big deal. If you get mild or moderate COVID, too bad; avoiding that clinically trivial event was not what the vaccine was really for.

One problem with this claim is that “mild or moderate” is a very vague descriptor: there is no clear, clinically demonstrable cut-off between a “moderate” and a “severe” case of COVID. There are both borderline and hybrid cases, as there are with most clinical phenomena.

Beyond that, there is substantial evidence that “moderate” cases are actually pretty debilitating, and have (as-yet unknown) long-term adverse effects.  Supposedly “moderate” cases will put you out of commission for long enough to put you out of work. What then? Is Paul Offit or the FDA going to come in and bail you out once you’re out of work, now that pandemic-related unemployment benefits are being phased out? Being sick and unemployed isn’t quite as bad as being hospitalized or dead, but it’s not a great place to be.

It’s remarkable that there is no discussion here of the need to vaccinate anyone but the immunocompromised (or the elderly, considered as immunocompromised), as though everyone but the immunocompromised were dispensable, and everything but hospitalization and death a mere triviality.

Put it this way: I’m not immunocompromised. But I clean and set up hospital operating rooms. Does Paul Offit think that I should go back to what I was doing before I got the vaccine, namely, walking into COVID-infected rooms and cleaning them without the protection of the vaccine? Does he think the same thing of the surgeons, anesthesiologists, nurses, respiratory technicians, and people in sterile processing who were (and are) my colleagues in the OR? We’ll be the break through cases. If we get sick because the FDA decided to wait around for “The Science” to deliver its verdict, discounting the so-called “moderate” cases in the process, who is going to run the hospitals while we nurse our “moderate” COVID? Once enough of us start calling out, or falling down, Science will suddenly decide that yes, it is time for a booster! There’s no need to wait that long. The time is now. Our arms are ready.

But forget hospital workers. I’ve played my OR EVS card here, but I shouldn’t have to. No one should be begging for a vaccine that anyone and everyone can and should be getting, whether they work in a hospital or not. The vaccine can be rolled out. It’s safe. The Paul Offits of the world should be facilitating access to it, not impeding access for no discernible or articulable reason.

And that leads me to my third observation. Paul Offit’s Vaccine Essentialism–the thesis that the vaccine has One Goal dictated by One Supreme Authority–would not get off the ground if the government had not arrogated to itself supreme authority on all matters of vaccine distribution. It’s a question why exactly it enjoys this authority. The FDA does not manufacture the vaccine. Nor does the FDA stick it into people’s arms. Nor does it coordinate its distribution. It simply vetoes the distributing and the jabbing. Why is there a need for veto power if there are manufacturers willing to manufacture, providers willing to provide, and patients willing to receive–in the context of an agency wielding veto power over their desire for safety while professing uncertainty about what to do?

In other words, a government (and its supporters and enablers) uncertain about whether a booster shot is needed insists on the authority to supervise what it claims not to understand. There appears to be no principle at work here beyond the desire for ultimate control, along with the demand to take public health authorities on faith, and to induce the rest of us to accept our role as a sacrifice to their conjectures and provisos.

 Dr. Camille Kotton, an infectious disease expert with Massachusetts General Hospital, told the panel that some patients, especially those who are more educated or “empowered to take care of their own health care,” are managing to get a third dose on their own, despite the lack of a green light from the  government.

“Many have taken matters into their own hands,” she said. “I am concerned about them doing this kind of in an unsupervised fashion,” she said, while doctors’    hands are tied because of the lack of regulatory approval.

“Many have taken matters into their own hands.” Isn’t it a mantra of biomedical ethics that our “own” health belongs in our “own” hands? What other hands are supposed to supersede the patient’s when the patient’s health is at issue? Is it so unreasonable to want to err on the side of caution with respect to a disease that has killed 600,000 Americans, and killed millions of people around the globe–setting aside the numbers it has debilitated, hospitalized, and put out of work? Apparently it is, as far as the FDA and its enablers are concerned, even with respect to their own colleagues in health care itself.

Sorry, Democrats (and liberals), but the Republicans are right on this one (however hypocritical it is for them to be right at this late stage of the game):

At Tuesday’s hearing of the Senate’s health committee, several senators grilled administration health officials on how soon they would act on the question of boosters. Senator Mitt Romney, a Utah Republican, said he was unhappy that officials could not provide a better timetable.

Senator Richard M. Burr, a North Carolina Republican, noted that Israel was already offering some of its most vulnerable citizens a third shot. “Why aren’t we making the same decisions?” he asked.

Dr. Rochelle Walensky, the director of the C.D.C., testified that scientists were studying the vaccines’ efficacy in tens of thousands of people, including nursing home residents and more than 5,000 essential workers.

“Fortunately, we’re anticipating that this will wane and not plummet,” she said of their efficacy. “As we see that waning, we — that will be our time for action.”

“As we see that waning…” If anyone can give me an English translation of Rochelle Walensky’s nonsensical answer to Senator Burr’s eminently sensible question, I’d be much obliged. But as one of the people who will be part of the “waning” to which Walensky so delicately alludes, what she seems to be saying is that my OR colleagues and I are to function as guinea pigs in an unconsenting epidemiological experiment, assuming the risks of “mild to moderate COVID” while we clean out operating rooms for $14 an hour–and while well-compensated FDA bureaucrats decide whether it’s worth their while to authorize a booster shot that America’s favorite ally started administering two weeks ago. All I can say is, I don’t know about whether my not getting COVID is worth your while, Rochelle, but it’s certainly worth mine.

Frankly, I don’t really care about the FDA’s (or anyone else’s) arbitrary “goal” for the vaccine. My goal in getting it was to push the chances of illness—any discernible illness, not just severe illness—as close to zero as possible. Part of the rationale was to stay working rather than have to go on unemployment for a second time. But part of it was simply that I hate getting sick. That, after all, is why I get the flu shot every year–something public health officials are pretty adamant about insisting that we do. I don’t get the flu shot because I’m immuno-compromised, or because I fear being hospitalized or killed by the flu. I get it simply to avoid getting the flu. And a bad flu, after all, is just like a “moderate” case of COVID. If it’s obligatory to get a flu shot right now to avoid the flu, why isn’t it permissible to get a COVID booster right now to avoid a moderate case of COVID? Evidently, though, permission is required in the latter case.

If my aversion to getting COVID  means getting an “unsupervised” booster, you can bet that I’ll try my best to get one, regardless of what any FDA bureaucrat thinks, or even what my colleagues Dr Offit and Dr Kotton think. Evidently, they think that they have the authority to dictate whether or not I can get a booster, and that my “education” and “empowerment” are an obstacle to their bureaucratic goals. In that case, I can only reciprocate by regarding their rhetoric as an obstacle to my personal health, and their bureaucratic goals as subversive of the larger enterprise, health care, which we all take ourselves to be promoting.

“Single payer health care” is a feel-good slogan, but the preceding scenario is its inevitable consequence and downside. Once the government controls health care, as it would under a single-payer arrangement, both patients and providers lose the option of going around it to exercise and act on their own judgment. There ceases to be an “around it” in that case; the single-payer then becomes the only health care game in town. That, after all, is what “single payer” means: governmental or quasi-governmental judgment supersedes individual judgment as regards payment (as well as distribution), and supersedes collective judgment not affiliated with the State. The predictable result is the delusion that uniformity of opinion guarantees positive health care outcomes, a claim that has less going for it in terms of data than the COVID booster shot now causing such puzzlement.

It should be obvious at this point that public health officials under both the Trump and Biden Administrations have done their share of bluffing and bullshitting the public about COVID.  I’m not one to demonize Anthony Fauci, but I find the uncritical valorization of powerful bureaucrats like him an embarrassing trend among liberals. There is no effective difference between dealing with the faceless bureaucrats at Aetna or Blue Cross, or the ones at CMS or the FDA. None of them are saints or angels, and none should ever be taken on faith. But single-payer arrangements often (perhaps inevitably) require us to take government officials (and their private sector enablers) on faith, closing off alternatives to the arbitrary judgments that they turn into enforceable regulations.

Liberals and leftists zealously eager to defend “single payer” health care ought to take the dangers of monopoly more seriously than they typically do. It’s well and good to insist that “single payer” would expand access to health care services beyond what our current system does. But it would do so at the price of concentrating the health care decision-making process in the hands of the single monopoly payer that holds all of the relevant cards, and calls all the relevant shots. “Medicare for All” means CMS regulations for all. It means “Paul Offit’s clinical decisions govern all.” It means that the mantras about “patient empowerment” that people nowadays like to spout are all window dressing for perpetual disempowerment. I myself don’t regard that as a conclusive, fool-proof argument against single-payer. It’s just one part of a more complex story. But defenders of single-payer health care ignore it at the price of realism and credibility. That may be a recipe for getting it passed into law some day, but it’s not a recipe for defending it to the rational satisfaction of anyone looking to get some.


*My use of the term “pragmatist” is not meant to conjure up images of “hard nosed pragmatism,” as per colloquial use; it’s meant to indicate an affinity with the American Pragmatist tradition associated with Charles Peirce, William James, and John Dewey.

**Classically, the precautionary principle has been applied so as to restrain rather than encourage the use of an untested technology. But the underlying principle holds that it is rational to act so as to avoid significant risks even if we lack certainty or hard evidence that the risks will materialize.

I am a full time employee at Aergo Solutions, and am pending per diem status in OR EVS at Hunterdon Medical Center. The views expressed here are solely my own, and do not necessarily reflect the views of either of my employers.

14 thoughts on “COVID Booster Shot Meets Health Care Monopoly

  1. Pingback: Health Care: A Series | Policy of Truth

    • Vaccinated people may spread the virus if they get infected, which one recent study found had happened to less than 0.1% of the vaccinated in the US (https://www.nbcnews.com/health/health-news/breakthrough-covid-cases-least-125-000-fully-vaccinated-americans-have-n1275500). The recommendation for vaccinated people otherwise not in high-risk categories to return to vigilant masking is a clear case of the CDC taking the precautionary principle. You’re right that it’s inconsistent for public health officials to reject it out of hand in similar contexts. Perhaps the more sensible idea would be: we should give higher priority to preventing severe cases requiring hospitalization than to preventing mild and moderate cases that don’t, and we should give higher priority to getting vaccines in people who haven’t had any than to getting boosters, especially since it’s not clear that people need them. I’m not sure that’s right either, but it’s less silly than the view you’re criticizing above.

      Your objections to single-payer health care would be stronger if the realistic alternative did not suffer from pretty much the same problems, but more. Health-care decisions are still largely in the hands of bureaucrats more interested in profit than in health. Maybe it would be worse under a single payer system than it is now, but do you really think so? Of course we can theorize alternatives that would be better, but as someone who has suddenly needed to pay a lot of money to various health care professionals, I am less interested in theoretical alternatives than in realistic ones. I’m lucky to have decent insurance for my needs, but if I didn’t, it wouldn’t be very easy to find an affordable alternative that gave me more options.

      Ok, I am just procrastinating now. To work!

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      • No one really knows how easily vaccinated people can be infected once the vaccine itself starts to lose efficacy. And no one really knows how long it is before it starts to lose efficacy. We’re now starting to witness a rise in breakthrough cases for vaccinated people. Yes, of course, at first the incidence will be very low. But there is no reason to wait for it become higher before we finally conclude that we should take booster shots to keep the incidence as close to 0 as possible.

        Masking is one application of the precautionary principle, but a very weak and unreliable one, especially for hospital workers. It’s the bare minimum, but we should be able to do better than that. One mistake with a mask can undermine its efficacy. One mistake with PPE in a hospital can undermine its efficacy. There is a huge difference between going into a COVID+ room with full PPE but unvaccinated, and going in with both. In the first case, the anxiety you feel interferes with your work. In the second, it tends not to. Even if boosters were not indicated for the general population, they seem clearly indicated for hospital workers who were vaccinated more than six months ago. Right now, if I walk into a COVID+ room, I have no idea what my January-vintage Pfizer shot is doing for me. I’ve already run into vaccinated health care workers getting COVID. So I don’t really see what the FDA is waiting for.

        I don’t have an overall position on single-payer versus other alternatives, but in the case at hand, I think it’s clear that FDA approval is an obstacle to rational health-care decision-making. If manufacturers, providers, and patients are all willing to manufacture, provide, and take the booster, and rationally should be doing so, then the one obstacle to rationality is the FDA’s monopoly power. Subtract it from the equation, and people can make their own choices about whether or not to get the booster.

        As to the larger picture about single-payer, I actually do think single-payer could be worse than, or at least no different from, our current system. I don’t have an all-things-considered judgment (yet), but I would dispute your contrast of “theoretical versus realistic” options, as though to imply that single-payer is a realistic option and others are merely theoretical. Actually, it is single-payer that is purely theoretical. People are under the reverse impression because other countries have single-payer, and it seems to work there; the inference then runs that if, say, Canada has single-payer, single-payer is surely a realistic option, hence it remains a realistic one when imported to the US. But the very last part of that inference (after “hence”) is a non-sequitur. You can’t validly infer that because single-payer works elsewhere, it will work here. You can’t even infer that since single-payer is superior to what we have, instituting it here will be superior to what we have. American health care is distinctive–distinctively good where it’s good, and distinctively screwed up where it’s screwed up.

        This is a long, complicated topic which I’m not (yet) fully competent to discuss. But the short version is just to repeat what I said in the post: there is no real difference between government bureaucrats and bureaucrats at commercial health insurance companies (or bureaucrats within the Billing and Accounts Receivable departments of hospital systems). Commercial health insurance companies want to maximize profits; government bureaucrats want to cut costs. At a fundamental level, neither of them is particularly interested in the internal goods of health care, much less in the well-being of some particular account holder.* Their attention is focused elsewhere.

        But give me a year, and I’ll give you a better answer.

        *We rarely refer to people as “patients” in revenue management, only as “accounts.” For instance, to say that a patient has had several procedures, we say, “This account has multiple units.” It’s very discomfiting to remember that “accounts” is elliptical for “a human being with a medical condition who sought treatment and incurred a bill, possibly involving several appointments and several bills.” So we don’t do it. But it’s no different with us than it is at CMS. They don’t do it, either. This is what I was trying to convey in my post on Code Green. The revenue side of health care is a moral Twilight Zone, no matter who employs you.

        Code Blue to Code Green: EVS, RCM, and Health Care

        PS. I’m very sorry to hear that you’ve been experiencing health problems, by the way. For a moment there, I forgot that you were a living, breathing human being named “David Riesbeck,” and merely conceptualized you as an account with a low dollar balance, essentially paid in full by third party payor, hence irrelevant to my work list.

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  2. In a postscript to your story, the WHO issued a moratorium on booster doses today through September. The rationale given for the decision is that vaccine supplies need to be shunted to poorer countries where vaccination rates are low and death rates are high. The data cited in the press release that are intended to support this assertion are that in wealthy countries, the vaccination rate averages 100 doses per 100 people, while in poor countries it averages 1.5 doses per 100 people, with “lack of supply” accounting for the disparity. No citation of data for that last part. I’m skeptical that this is as much of a zero-sum game as the WHO seems to think it is. Specifically, it is not clear to me how stopping a healthcare worker in New Jersey from getting a booster puts a dose #1 in the arm of a street peddler in Cairo. We have had vaccines available for 9 months now. In that time, 4.25 billion doses have been administered, and a significant percentage of doses that have been manufactured are in storage, yet to be administered. Maybe the WHO has other data that more clearly draw a causal link between having supply and getting people in poor countries vaccinated.

    But these numbers don’t seem to add up to a simple zero-sum game in which simply commandeering supply addresses all the variables related to actual vaccination of individuals in these countries. An article in Nature has made it fairly clear that if you combine the current capacity of all the manufacturers, they are capable of manufacturing 13 billion vaccines in a year, and have been on roughly that clip since each of them have started production (which was a staggered start beginning before December 2020). At this point, with all of them producing vaccine, that’s over a billion vaccines a month. The current world population is 7.9 billion, to whom at this point about 4.3 billion doses have been given (55 doses per 100 people worldwide). By that math, that seems to be a lot of vaccine made that is sitting waiting to be administered. There is almost no way to take those numbers and make a plausible case that logistical and vaccine resistance factors do not play a large role in the low levels of vaccination in poor countries (or even the suboptimal levels in some wealthy countries). So unless there’s some part of the WHO’s missive that magically and automatically addresses those factors that I don’t know about, I don’t see justification for halting booster vaccinations. In fact, I think this whole class war angle is beside the point. People in rich countries, like everyone, have an interest in investing resources in increasing vaccination rates in poor countries, but no country should give up any of its supply of vaccine without some firm understanding of exactly what plan is in place to guarantee that every dose finds its way into a person. The data set on booster vaccinations is incomplete. I think we should let that data set be completed before people start poisoning the waters with a veiled allegation that booster shots are just an amenity of the rich.

    In other news, and to your points about the CDC, this is (as always), a very incisive and informative piece from Zeynep Tufekci: https://www.nytimes.com/2021/08/04/opinion/cdc-covid-guidelines.html?action=click&module=Opinion&pgtype=Homepage

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  3. Here is that Zeynep Tufecki piece again for better visibility. There are days when I think that Zeynep Tufecki is the only person left in public health with any degree of common sense:

    I had an argument on LinkedIn a few months ago with someone whose view was that LinkedIn should in effect outsource its online moderating to the CDC, allowing CDC consultants to call the shots on what counts as misinformation and what doesn’t, and what ought to be permissible to say on LinkedIn and what ought not. When I mentioned Tufecki’s work on the CDC’s messaging problems, my interlocutor brushed her aside as “good for the NPR crowd,” but really not what the doctor ordered when it came to the messaging COVID-19 to the rest of the country. Instead, we have Rochelle Walensky at the helm, messaging to flyover country. That’s working well.

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  4. Here’s a piece in this morning’s New York Times that manages to combine every fallacy about the booster shot in one place, as though for purposes of epidemiological one-stop-shopping:

    Apoorva Mandavilli: “Most studies indicate that immunity from mRNA vaccines, like Pfizer’s and Moderna’s, are long-lasting.” How many studies have been done?

    Elsewhere, in a different news article, Mandavilli herself had put it this way:

    The vaccines made by Pfizer-BioNTech and Moderna set off a persistent immune reaction in the body that may protect against the coronavirus for years, scientists reported on Monday.

    The findings add to growing evidence that most people immunized with the mRNA vaccines may not need boosters, so long as the virus and its variants do not evolve much beyond their current forms — which is not guaranteed. People who recovered from Covid-19 before being vaccinated may not need boosters even if the virus does make a significant transformation.

    From “may” and “might” (on June 28) to “is” (on August 4). How? By magic?

    Preventing infections isn’t the primary aim of the vaccines, Apoorva explains, even though they protect against that as well. “They were designed to prevent hospitalization and death,” she says, “and they’re doing that very well.”

    The argument here is: The primary aim of the vaccinations was the prevention of hospitalization and death. Since it’s succeeded in that aim, it ought not to be administered for any other purpose. Why not? The “ought” is just a non sequitur. The primary aim of the flu shot is also to prevent hospitalization and death. It doesn’t follow that one can’t administer it for other, additional reasons.

    At the moment, Apoorva told me, the only people who seem to need extra shots are those who are immunocompromised.

    What about people who work in hospitals, and have exposure to heavy viral loads? What about anyone who has exposure to heavy viral loads?

    A lot of scientists believe that shots should first go to unvaccinated people in poor countries — including health care workers and older people — rather than giving boosters to people who are unlikely to get very sick. Sending shots abroad has humanitarian benefits, Apoorva explains, but also scientific ones: If fewer people around the globe get the virus, it makes it harder for new variants to evolve.

    In that case, the scientists in question have a defective understanding of the logistics of vaccine roll-out. How does an injection administered to me in Flemington, New Jersey deprive anyone in, say, India, Pakistan, or Bangladesh of a COVID shot? There is no shortage of shots, and no shortage of capacity to roll them out, such that one person’s getting a shot should detract from another person’s capacity to get one. What planet do these people inhabit?

    The government, too, isn’t entirely sure about the issue.

    Last month, Dr. Anthony Fauci said people didn’t need boosters yet, given that more than 90 percent of people being hospitalized with Covid were unvaccinated.

    How did bureaucratic uncertainty become the measure of individual risk thresholds? The government doesn’t know whether we need boosters, hence we don’t need them. That’s a textbook instance of a fallacious appeal to ignorance. But these people are supposedly experts at public messaging.

    A government that isn’t “sure about the issue” is somehow sure that no one should be getting booster shots until it demonstrates their “necessity” by unspecified criteria. Are 10% of hospitalized people vaccinated? If so, why is that figure insignificant? Aren’t 10% of hospitalized cases a fair number? It’s amazing to me that Fauci is simply recycling the dumbest cliche of the anti-lockdown crowd: what doesn’t hospitalize or kill you makes you stronger, so don’t worry about it. We spent a year battling that misconception, only to have it revived by the likes of Anthony Fauci. I’d like to see just one of these people turn an OR over on an EVS unit while sick with a “moderate” case of COVID. It can’t be done, you fools.

    Pfizer, which is a for-profit company, has been making its own case for booster shots. Last month, the company reported that the power of its two-dose vaccine wanes slightly over time, but continues to offer lasting protection against serious disease. “It’s in their interest to say third doses are required,” Apoorva says.

    She notes that it’s in Pfizer’s interest to say that third doses are required but somehow omits saying that it’s in the government’s interest to say that third doses aren’t required. Government has so far been covering the costs of vaccination. Surely it has an interest in cost containment? So why wouldn’t it have an “interest” in claiming that no booster was required?

    What’s sad is that between them, the science journalists and public health officials have done so poor a job of messaging that they’ve managed to turn their natural allies, health care workers, against them. Even the Times article quotes a physician as saying that he’s looking to get a booster. Any sensible person who’s spent time in a hospital would want one. I don’t mind putting it in print: I’m getting one at first opportunity.

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    • To put the broader issue in perspective, the abyss into which we are currently plunging with Delta in the US is not primarily the fault of the public health community; it’s primarily the fault of people who’ve refused the vaccine. It does not require that much teaching or coaching to understand the benefit vs. risk of the vaccine/no vaccine decision for a person living in the US over the past 9 months. The same people do much more complex things with much less conscientious and expert guidance all the time: buy a car, buy a house, apply for a mortgage, seek a job, invest money in the stock market, choose a wireless plan. So while there’s plenty to criticize in how public health officials are doing their jobs, it’s important to note that they still are performing to a higher standard at being informative and conscientious than their contemporary car salespeople, real estate agents [rim shot], bank loan officers, human resource recruiters, financial advisors, and Jayden from the Verizon store. No one is rushing to address the supposed shortcomings of these people when someone is worse off for having decided on the wrong car, house, mortgage, job, investment, or wireless plan. So while criticism of the CDC is warranted and important, it’s frankly wrong for it to dominate the dialogue about vaccines and variants. While talking about the fact that people who are making stupid decisions are killing us is repetitive and not intellectually as interesting, it’s the real lead story, and everyone has made too many excuses for not framing the dialogue and covering the story that way.

      That said, it needs to be pointed out at every turn when public health officials try to talk over the heads of the public they’re supposed to be guiding, especially when it’s done to skirt actual engagement. Two prime examples in your citations above:

      1. I’ve been hearing it said now for a few months that there are “studies” demonstrating effectiveness of vaccines years out from inoculation. Who did these studies, Marty McFly and Doc Brown? When laypersons hear a claim like this, it’s appropriate to be skeptical. For a group of people who are such militant empiricists 99% of the time, they seem to be glossing over the fact that it hasn’t become 2024 in the past 4 months, so any conclusion about longitudinal vaccine effectiveness is necessarily based on assumptions and/or simulations. It is disturbing that when these claims are made, an explanation of the methodology of the studies is not a part of the communication. That’s not something that would be too hard for laypersons to understand, and it’s not trivial. More so, it supports a narrative about the public health establishment that has made the whole pandemic harder than it’s had to be: that when public health officials speak, their chief goal is to elicit a certain public behavioral response, rather than to tell the public the thing they supposedly came to tell. While I’m loath to throw mud on Anthony Fauci after all he’s been dragged through, he often has been just terrible in this regard.
      2. Epidemiologists engage in a lot of very sketchy utilitarianism, and behave as though whatever utilitarian calculus they throw out about population health must go unchallenged because damn it, they’re scientists, and no one wonks out harder on this stuff than they do. This attitude has plagued their policy and communications about anything in the pandemic where distributive decisions have to be made: PPE, drugs, vaccines, money. They seem oblivious to the fact that assigning a certain utility to putting a resource in place A rather than place B necessarily involves normative value judgments, which necessarily need to be justified on some grounds. It is far from settled that there is more value in withholding a booster from a willing and able recipient to earmark it for redistribution to an unvaccinated bird-in-the-bush individual who still has to get to where it can be administered and consent to receiving it after not having done either of those things for 9 months. People need to actually debate this rather than spinning off into tangents about class.

      In many ways, the communication part of a public health official’s job is very similar to the communication part of a doctor’s job: You need to first understand the science. Then you need to get an accurate read of how much of the science your lay audience will grasp in the course of the conversation. Then you have to communicate clearly in language the audience can understand, and in a manner that promotes informed decision-making at a level of urgency commensurate with the situation, without dumbing it down so much that the actual science loses its integrity in the endeavor. In medical practice, when hospital administrators, insurance companies, and overzealous family members insinuate themselves in the conversation and try to pre-empt the dialogue and control the decisions, dysfunction ensues. The same is true when public health officials are sent by politicians to handle the public.

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  5. From Becker’s Hospital Review:

    https://www.beckershospitalreview.com/hospital-management-administration/7-ways-this-covid-19-surge-is-different.html?origin=BHRE&utm_source=BHRE&utm_medium=email&utm_content=newsletter&oly_enc_id=1283H6255556C6F

    The relevant passage, in case the link doesn’t work:

    Hospitals are grappling with labor shortages. Nationwide, organizations are experiencing labor and talent deficits, both of which have been exacerbated by the pandemic. COVID-19 has left many professionals exhausted, with nearly 30 percent of physicians, nurses and other healthcare workers reporting that they have considered leaving healthcare altogether because of pandemic-related burnout, according to a survey by The Washington Post and the Kaiser Family Foundation. At the end of July, PeaceHealth St. John Medical Center in Longview, Wash., said it was facing “unprecedented patient volumes,” with its workforce alleging that a staffing crunch is leading to poor working conditions, according to The Daily News. On the other side of the nation, two North Carolina hospitals have at least 700 unfilled nursing positions — each, reported WNCT-TV. In South Carolina, there are more open positions for registered nurses than any other job in the state, with 4,955 openings, according to a May data analysis by WYFF.

    It doesn’t seem to have occurred to American public health officials (or the WHO) that a hospital labor shortage (during an imminent surge), the phasing out of unemployment benefits, and uncertainty about the durability of shots given eight months ago, is not a smart combination. Prudent people would know well enough to try to nip this problem in the bud.

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  6. So here’s the changing story on COVID boosters over about two or three weeks of August, mostly drawn from The New York Times:

    The same government that confidently believed that the Afghan government would hold out against the Taliban is now telling you that they’re kinda pretty sorta sure you don’t need a booster, even though our bff’s the Israelis are administering them.

    Actually, no; maybe everyone needs a booster:

    Remember when “The Science” was telling us that breakthrough infections are just not that big a deal? Yeah, that was a whole two weeks ago. Now the same science reporters who were minimizing the dangers of breakthrough infections start quietly ramping up apprehension about them.

    So maybe we should give the Biden Administration credit for coming around on booster shots after a few weeks of vacillation and confusion. At least they came around.

    Here’s NPR, yesterday, taking a much more aggressive line:

    https://www.npr.org/sections/goatsandsoda/2021/08/20/1029628471/highly-vaccinated-israel-is-seeing-a-dramatic-surge-in-new-covid-cases-heres-why

    Two weeks of mainstream reporting.

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