Once again, we find ourselves in a novel turn of this labyrinthine pandemic experience.
In my home town in Connecticut, things feel substantially, if not quite pristinely-pre-pandemic, normal. One sees occasional masks, presumably worn by those who opted out of vaccination, but they are decisively a small and seemingly shrinking minority. Otherwise, it is mask-free business as usual, more or less.
But even as ever more of the U.S. makes its way to some variant on that theme of life as we knew it before meeting SARS-CoV-2, the entire country of Austria is enacting a lockdown, and the first comprehensive vaccine mandate for any Western democracy. This, of course, is a response to a pandemic surge. Austria has relatively low vaccination rates, and in tandem with that now, the highest COVID transmission rates in the EU.
We have, from my point of view, showed little or no propensity for learning the lessons of this pandemic in real time. We keep lurching from excesses (and deficiencies) in one direction, to their counterparts in the opposing direction. But perhaps we have at least learned that pandemics are global, and that there is no meaningful distinction between here and “over there.”
Accordingly, surges in Europe have the authorities here in the U.S. fretting about the prospects of yet another surge. In response, along with legal and ideological battles over vaccine mandates and the overall vaccination rate, there is an expanding focus on boosters. As I write this, booster vaccines for all adults have been approved by the FDA, with official policy now awaiting the corresponding verdict from the CDC.
I have the same challenge to the matter of boosters that I have been whistling into the pandemic wind on nearly every aspect of our collective responses from the start: is this, really, a one-size-fits-all scenario?
I am tempted to use myself as an illustration of my concern. I had COVID19 last January. Fully in accord with my expectations, based on my general health status, my case was mild- requiring no medical attention, and never causing me any anxiety. But it was no Sunday picnic, either.
I had the fairly standard suite of symptoms and was sick enough to spend the better part of several days in bed, something I have done in response to acute illness not more than 2 or 3 times in the 40-year-span of my adult life. I lost my sense of smell suddenly and completely, and it took quite a few weeks for it to return incrementally. (For an oenophile, this was a real worry.)
I experienced something else in common with millions of others infected by SARS-CoV-2: the production of antibodies. As confirmed by a test for IgG, I had developed natural immunity to the pandemic virus.
At that time, last winter, we had no evidence to suggest that mRNA vaccine-induced immunity was more protective than immunity engendered by infection, and much precedent to suggest just the opposite. As an example, the measles vaccine is excellent- but the immunity derived from a bout of the measles is more robust still.
Accordingly, with confirmation of IgG directed at SARS-CoV-2 at significant levels in my blood, when my age group reached the front of the queue, I wondered about the need for vaccination.
To be clear, I am ardently “pro vaccine.” This is a somewhat silly expression, implying an ideology. The risk/benefit tradeoffs that populate sound medical and public health decision making should involve no ideology. I favor, in any medical situation, that option representing greatest and most likely benefit, least and most improbable risk.
The panoply of effective vaccines, from smallpox to measles, tetanus to polio, count among the greatest advances in the history of public health not because they service some ideology. Rather, because they confer a genuinely massive benefit with attendant risks that are never zero, but reside in the realm of rounding error. Little in all of medicine compares in its capacity to preserve life and protect health with relative risk so low.
I am thus “pro vaccine” in that context, where epidemiology prevails over ideology. But vaccines are as vaccines do, and the aim they serve is function, not form. In other words: the goal of any immunization campaign is to achieve effective immunity as safely as possible. Since I was already immune, what was the point of vaccination?
As my regular audience already knows, I did get vaccinated, twice, with the Moderna offering by mere luck of the draw. I did so for two reasons. First, I had long COVID symptoms (and still do, with continued improvement over time), and had read anecdotes of symptomatic improvement with vaccination. (For those wanting to know: I experienced the converse; my symptoms worsened considerably after my second vaccine.) Second, I shared our common desire to get back to life and living, and the “system” was seemingly prepared to recognize vaccination status, rather than immune status. I was vaccinated in part to facilitate that recognition, so I could, for instance, visit my children or parents without hindrance.
There was a third reason for vaccination post-infection that has emerged in the scientific literature only recently: the mRNA vaccines may, in fact, confer a more protective immunity than the native infection itself. This is unusual, but not implausible, and certainly relevant for anyone in the situation now that I was in then.
Which returns us to the matter of boosters- in a context of déjà vu, all over again. Just under a year ago, I was already immune to SARS-CoV-2, and vaccines were recommended. Now, I have native immunity to SARS-CoV-2 followed by two vaccines- boosters, in effect- and boosters are recommended. Do I need one?
My medical training suggests that with infection and vaccination twice, I am well and truly “boosted” already- i.e., my antibody levels have bumped up to robust, protective levels. If I already have the intended benefit of a booster, then I should not be at the receiving end of advice to get one. Given my experience with the vaccine sequence- worsening of my long COVID symptoms- I am far from eager to get a booster from which I will not benefit.
My point? We need public health guidance that is responsive to our current reality. Millions of us have had COVID19; millions have not. We are immunologically distinct, and that should be recognized. Failure to do so figures among the reasons why trust in public health is at a deplorable low.
I am most assuredly not trying to talk anyone out of a booster vaccine; there’s a limit to how many times in the same column I should restate that I am ardently pro-vaccine. Rather, I am trying to talk our public health authorities into the neglected application of nuance. There is no “public;” the public is a fiction derived for statistical convenience. There is only people- you, me, everyone else- individuals all. We are more alike than different, we Homo sapiens, but all different even so. Those differences are ignored with one-size-fits-all decision making, and ignored at our collective peril.
The finest expressions of both art and science in medicine are carefully customized. Good medical care is personal. Public health is such care at scale- but scale does not, and should not, obviate attention to our individuality. This is reflected in cancer screening protocols that are specific to age and sex, regimens of disease prevention targeted with comparable finesse. This far into the current pandemic, with so much accrued understanding of risk differentials, there is no longer any good excuse for the management of SARS-CoV-2 to be an exception.
Much of the political discord and social turmoil attendant upon this pandemic is the result of individuals rebelling against one-size-fits-all policy, the implication that we are one, homogeneous fiction: the public. The last thing we want to do at this late stage of our shared pandemic journey- is boost that basis for discord and dissent.
David L. Katz, MD, MPH, FACPM, FACP, FACLM, is the Founding Director (1998) of Yale University’s Yale-Griffin Prevention Research Center, and current 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.