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As a card-carrying member of the public health community (OK, there is no actual membership card, but you get the idea)- I loathe to oppose official public health policy pertaining to COVID, or any topic for that matter, for fear of aggravating an established distrust.
Be that as it may, I write to share misgivings about the prevailing approach to boosters, which seems composed in equal parts of “more is better” and “one size fits all.”
COVID vaccines have done a great deal of good and accelerated our incremental return to pre-pandemic norms. To be blunt, I am an unreserved proponent.
But the vaccines are, of course, imperfect, both in their efficacy and in their safety, and thus should be doled out always and only with careful attention to risk/benefit tradeoffs- the constant barometer of medical propriety. I am not convinced that is being done.
First, the idea that we should simply keep increasing the number of boosters to defend against new strains of SARS-CoV-2 is more of a leap of faith than science. I am not aware of any prior vaccination campaign that operated this way.
Boosters, historically, are used in three settings: (1) to rejuvenate an immune response attenuated by a lengthy period (e.g., on the order of a decade) of non-exposure. Here, good examples are immunizations for measles and tetanus; (2) to enhance the initial antibody response in people with impaired immunity. Here, a two-dose flu vaccine in the frail elderly is a good example; and (3) finally, vaccine variants are at times developed to address new microbial strains. These are not exactly boosters, but close enough; the annual flu shot is the best example here.
The repetitive dosing of SARS-CoV-2 vaccines is none of the above. Rather, it is an attempt to compensate for the “strength” of the immune response which is lacking in its specificity. In other words, if the antibodies are not quite right for the current viral strain in circulation, bumping up their count may- in theory- compensate.
To be fair, this is more than theory now, with studies showing enhanced protection with boosters. But the relevant metric is not just the gross intended effect, but the net margin of benefit over risk. That means defining benefit appropriately, and capturing all relevant risk.
The benefit of vaccination against a now endemic virus is not reliably measured by counting cases, but rather by disease severity. If in certain groups the risks of severe illness with and without additional boosters are commensurately low, the calculus of benefit must adjust.
The risks of provoking inflammation, which is what stimulating the immune system repeatedly does, include potential contributions to slowly evolving conditions, such as heart disease, diabetes, neurodegenerative diseases, autoimmunity, and cancer. Maybe some number of COVID boosters does none of this- but we should concede it will be some time before we know.
One thing we do know is that most medical interventions are bounded by a therapeutic window, where the right dose is better than either less, or more. The correct answer is almost never “more is better,” so if that is true of COVID boosters- they are an anomaly.
Yet that may be the lesser issue. The greater issue is that millions upon millions of us have been infected with COVID, and a sizable plurality if not majority of us millions by more than one strain. Native immunity is never irrelevant, yet our public health policy is all but mute to it. For those of us who have had COVID, our first vaccine was a booster; our second was another. How many are we supposed to get? What, for us, is the incremental benefit of each additional booster- if any?
As for risks, however modest they may be, they wax in significance as benefit wanes. In my personal case, I’ve had COVID more than once, and been vaccinated twice. My symptoms of long COVID, only now subsiding after well over a year, were exacerbated by vaccination. Since I have reason to doubt any meaningful benefit of further boosting given my blend of naturally acquired immunity and prior immunization, I am disinclined to chance even modest risk. My position is far from radical, and I think our public health policies should accommodate it.
They do not. My wife, whose situation is similar to mine, is a volunteer at an area non-profit helping refugee women establish new careers in the U.S. She loves the work, and the sisterhood, and they love her. But she cannot return, because I have advised her against more “boosting”- and the official policy is that boosters are required. With natural immunity plus two vaccines, she has been boosted- but our persistently blinkered pandemic policies are blind to it.
Such, then, are my impassioned qualms; shared only with reluctance. That reluctance is by no means an excess of diffidence - I have spent a career speaking my truths to relevant powers, and dealing with whatever consequences ensued (quite unpleasant at times). Rather, for policy in public health to do its intended good, there must be trust in it. When those of us with relevant credentials battle one another on public display, that trust is jeopardized.
I would go further and say that such internecine battles over all matters of public good- from COVID response policies, to addressing climate change, to what diet is best for health, to voting rights and the defense of democracy, and many other matters besides – are the great blight of our time. The rampant flow of disinformation and the amplification of every idle opinion in the Internet echoes is fuel to ravaging conflagrations.
But debate and disagreement are healthy; they are the vital forces of dialogue. So, too, are civility, respect, and a capacity to listen. Those systems are beleaguered; they, not dissent, are the deficiency. Like a body with some working organ systems and others in failure, the whole regresses to the depths of its greatest weakness.
So it is that this is a bad time for dissent. But it is always a bad time for submission to dogma, too. I regret them both.
To be clear, this is dissent along a middle path- the “alt middle” as a friend would say- that neither treats current public health policy as sacrosanct, nor throws it under the bus. To gain and retain the trust of us all, I implore my colleagues in positions of public health authority to speak to us all in our diversity of circumstances. They might do well to recall that the “public” is a fiction in the service of statistical summation; in reality, there are just us- individuals, in our varied multitudes.
My hope is that the best way to make things right for all is to assert with calm candor what we keep getting wrong for one.
David L. Katz, MD, MPH, FACPM, FACP, FACLM, is the Founding Director (1998) of Yale University’s Yale-Griffin Prevention Research Center, and former President of the American College of Lifestyle Medicine. He has published roughly 200 scientific articles and textbook chapters, and 15 books to date, including multiple editions of leading textbooks in both preventive medicine, and nutrition. He has made important contributions in the areas of lifestyle interventions for health promotion; nutrient profiling; behavior modification; holistic care; and evidence-based medicine. David earned his BA degree from Dartmouth College (1984); his MD from the Albert Einstein College of Medicine (1988); and his MPH from the Yale University School of Public Health (1993). He completed sequential residency training in Internal Medicine, and Preventive Medicine/Public Health. He is a two-time diplomate of the American Board of Internal Medicine, and a board-certified specialist in Preventive Medicine/Public Health. He has received two Honorary Doctorates.
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