We're getting immunity wrong

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Hi,

Here's everything that happened this week in health.

Let's start with the good pandemic news. We got some meaningful reassurance about longer-term COVID immunity this week. According to a big study in Science, protection after mRNA vaccination is lasting a very long time, without signs of waning even in the face of new variants.

This helps address a key question, since the vaccines were based on the genomes of the original strain, not the delta (or other) variants. Apparently that's okay, though. Our immune systems are savvy and abide strongly by the "fool me once" ethos. We recognize the new strains despite their changes in attire and conspicuous growth of facial hair. Our antibodies do decline in the months after getting the shot (confirming what's been expected and demonstrated already), the longer-term memory mechanisms are "robust."

This means "booster" doses are even less likely to be of value for most people, for now, than initially imagined. At least, for those who got Pfizer or Moderna. On Friday, a panel of experts consulting to the FDA voted unanimously to authorize a second dose of the J&J vaccine for those who already received one. The group framed this not so much as a "booster" as a second dose, effectively. The same framework applies with third doses of the mRNA vaccines in high-risk groups. (I'm all for doing away with the term "booster" as it's a little misleading, implying universal benefit in the if-a-little-is-good-then-more-must-be-better way that we Americans tend to approach ... consumption generally.)

All of this news is interesting and worth knowing about, but I worry it's also missing the point. It gives the sense that we're all set as long as we've got durable vaccines and available boosters. That's not a sustainable approach to real, enduring immunity.

For most of us, so far, the stakes of the boosting decision are low. My general advice to friends/family is not to stress about it. Most of us are unlikely to benefit, but we're also extremely unlikely to be harmed, and there's room here for much more personal preference than in the initial vaccination stage. Transmission after vaccination still seems to be rare, and "breakthrough cases" are very likely to be mild or symptom-free. I know of doctors who already availed themselves of a third dose, and others who think it baseless. My friend and mentor Dr. Howard Forman and I spoke this week about his decision not to get a third dose—despite being 9 months removed from his initial vaccination, having a couple decades on me, and working in an emergency department. He's not suggesting that it would be harmful, but isn't rushing to do it, because the evidence is so compelling that current vaccines are holding up well. Plus vaccine doses are urgently needed elsewhere. As the chief of the World Health Organization put it this week, widespread use of boosters is "immoral, unfair, and unjust."

It's not just that. We're not only focusing too much on boosters; we're doing so at the expense of more meaningful, moral approaches. We need to think beyond vaccine boosters. And definitely beyond new COVID pills. We need to think more comprehensively about immunity.

Before we do, though, programming note: Halloween is on.

Kids won't quite have vaccines in time—the FDA committee will deliberate on the authorization of the Pfizer vaccine for kids 5 to 11 on October 26th, and then CDC will meet the week after to decide on guidelines for eligibility—but that's not stopping Dr. Fauci. This week, already fully costumed as Cousin Greg from Succession (unfortunately not really), the nation's leading infectious disease expert decreed that we can all get back to honoring the dead by going door to door asking for candy in exchange for withholding a terrible curse upon the house.

We're reminded this Halloween, though, not to forget that even as pandemic fears subside, the old safety rules still apply. Among them, be careful crossing the street. Don't go into any dark houses just because the door creaks open and a long finger emerges from a cape to beckon you inside. Also, make sure that any and all treats procured from knocking on strangers' doors are unopened and not loaded with recreational drugs.

Though I also can't recommend whatever's in regular Cheetos.

To be clear, the deliberate stoning of unwitting candy-seeking children isn't a documented phenomenon, only a peculiar hypothetical. Widely distributing edibles to kids would require a combination of malevolence and wealth that seems unlikely among consumers of "Stoner Patch Dummies." I suppose there's some chance of a mix-up, and these products are also clearly violating intellectual property rights (see State of Colorado v. Chester Cheetah), but our FDA does kind of have its hands full at the moment ... The agency may even have a commissioner soon. After all, it's October. The leaves are turning and it's time to consider appointing someone to lead the oversight of vaccination approvals in the midst of a pandemic.

This bit might seem a little wonky, but it's really central to every health issue of the moment.

The person being vetted is Rob Califf, as Politico reported this week. It's been difficult for the administration to find someone qualified, willing, and politically viable, since Senate approval requires threading a needle: placating the legislators who value consumer protection, transparency, and safety, while also appealing to those who prefer campaign donations from the pharmaceutical industry. But now, finally, that person may have been found. Califf's qualifications for the job of FDA commissioner include, most notably: prior job experience as FDA commissioner. Though that doesn't mean the Senate will deem him qualified expediently, or necessarily ever. The current acting commissioner Janet Woodcock has been climbing the ranks at FDA since 1986 (so, not coming from the pharmaceutical industry as past commissioners have.) But Woodcock couldn't garner the political support necessary to make confirmation likely, in part because Senator and shadow president Joe Manchin of West Virginia disapproved of Woodcock's involvement in the failure to reign in opioids. (West Virginians have suffered inordinately from the failures at many levels. On behalf of the state, Manchin has called for a thorough cleansing and reform of the FDA.)

As a former head of FDA during the height of the opioid crisis, Califf is also plausibly implicated (if only by those who believe he didn't do enough to address the crisis and reform the system that allowed it to happen). In 2016 his nomination was overwhelmingly approved by a Senate vote of 89 to 4, but among the dissenters was ... occasional absolutist Joe Manchin. He was so vehemently opposed as to threaten filibuster over Califf's ties to the pharmaceutical industry. So it's unclear why he'd support the nomination now. But if the Senate votes against a new nominee, that means Woodcock stays at the helm. So the choice would effectively be between Califf and Woodcock, to the dismay of everyone like Manchin who sees the FDA as too cozy with the pharmaceutical industry and in need of overhaul. Who knows what he'd prefer. Plus he's pretty busy blocking plans for clean electricity and social programs.

The thing is: We clearly do need a new iteration of FDA that's more autonomous and independent. That's not a fringe opinion, and it's not just Manchin's. It's also ... Rob Califf's. In 2019, seven former FDA commissioners came together to call for a systemic restructuring of the agency. I personally witnessed and reported on six of them saying it at a conference in Aspen in 2016, when they were lamenting an inability to keep up with dietary supplements, much less opioids.

(That was also the trip when I purchased some Sour Patch Kid edibles, for journalistic purposes.)

In my head, all this seemingly disparate news is part of the same puzzle. As we move into the less urgent stages of this pandemic, and we focus again on less dramatic measures to prevent disease and maintain immunity, we have an opportunity to build that "robust" immune memory at every level, rather than once again just declaring victory and going right back to our old ways because case numbers are declining.

There's so much more to immunity than vaccines. They're like graduate school for our immune systems. Or like teaching a professional dancer a new routine. In the prime of their career, it's simple. But the further from prime you get, the less you take cognitive and bodily functions for granted. Consider the above mention of "long-term memory." As antibodies fade, the lasting protection depends on a more elaborate response to be orchestrated, involving other cellular players, namely "B cells" and "CD4 T-cells." They function sort of like an external hard drive for your immune system. They don't act as instantly as antibodies, but as soon as you dust off the hard drive (and find the cable to connect it, and a USB adapter), your body's defenses come roaring back. (Also iTunes starts playing some mp3s of Counting Crows that were on the hard drive, so everyone wins.)

In youth, and in health, that orchestrated process happens seamlessly and brilliantly for most people. But it inevitably gets creaky and less reliable. There are also a million tiny ways we accelerate the fading and chip away at that ability. Your immune system is boosted, or un-boosted, in subtle ways all the time. By sleep deprivation, by stress, by low-quality food, air pollution, isolation, and on and on. These are not incidental factors in our health. They are the foundation of our immune system. They maintain the body so that when we need to teach it a new dance move, it can learn.

A country that aspired to Build Back Better would address all these things, as well. But we do not, and are poised to half-heartedly address them somewhat. This will not suffice. We are far behind. Consider paid family leave, which the U.S. is the only OECD country not to support.

(Note to self: learn more about Estonia)

Meanwhile in a country that purports to care about family values, even those whose jobs do offer family leave can experience repercussions for actually taking it. As reported in Politico this week, new father and transportation secretary Pete Buttigieg has been on what might be called Paternity Leave Lite (not Estonia level, and not even fully away at all ... but "mostly offline except for major agency decisions and matters that could not be delegated" for four weeks.)

Still the Men are emotional ...

If only Buttigieg had said he was at his country club golfing.

There are very real supply-chain issues unfolding now that date to pre-pandemic problems, acutely exacerbated. The price of bacon is up 7 percent, and Ikea is out of unpronounceable credenzas. Americans are being advised to do their holiday gift shopping now because global commerce is grinding to a halt: Do not wait until Black Friday because there will be fewer products to fight over, and Americans have more guns than ever, and the people storming the sliding glass doors will be especially irritable due to bacon deprivation. The only available last-minute gift will be shipping containers.

This isn't great, but the idea that the problem traces to one guy taking a few weeks offline is exactly the issue. We can't countenance basic, effective public-health measures like paid family leave not because they're actually radical, but only because they're not at the center of an arbitrary U.S. political spectrum.

The problem isn't radicalism; it's people who behave in extreme ways but actually stand for nothing. Their morality is guided by whatever winds prevail at a given moment. To hear the policy dynamics of pandemic recovery reported, it would seem that we only have a few reasonable, non-partisan legislators who are pushing back against radical concepts like family leave, affordable prescription drugs, sustainable energy, et cetera. Even though the individual policies are widely popular, basic features of other countries. And at the center of this phenomenon is Joe Manchin, who has occasionally purported to care deeply about public health. In his own state, he noted recently, "Last year alone, we lost 1,373 West Virginians to drug-related overdoses. It’s our responsibility to provide our family, friends and neighbors with the support and recovery services they need and deserve.”

Addiction is an extremely costly scourge. Beating the opioid epidemic, as with the pandemic, comes down to short-term investment in systems that create and sustain health, and keep our immunity to recurrence robust, and save money in the longer term. To focus on the immediate cost is not austerity. As Greg Puckett wrote this week in the Charleston Gazette-Mail, paid leave could help fight addiction in West Virginia. As would the certainty and prosperity that come with transitioning to a sustainable energy economy, and being able to afford proper medical care, and a college education, et cetera. The pandemic should have made abundantly clear to us that these are not separate problems. The core solutions are one in the same. Crises cost us dearly. Preparation and investment in frameworks for resilient, cohesive communities do not.

But instead of taking this rare moment to stand for what he has long purported to, Manchin spun the Wheel of Centrism and it landed on $1.5 trillion. It remains unclear where that number comes from, or how it could be achieved, or why. It's like being in charge of a shipping company with 100 employees, where the engineers calculate that you need to invest in 100 life jackets, and then saying "I can do 34. That's where I'm at is 34." It's not a solution; it's just a number. Its goal is defiance. This is the interminable chaos of centrism; of defining yourself via your position relative to others rather than by what you actually stand for.

On a final, maybe slightly more upbeat note, I was reminded this week that public health hasn't always been so divisive. I was a guest on a podcast about the pandemic that never happened. Long story short, in 1976 President Gerald Ford raised urgent alarms about a flu strain that ended up killing one person. The vaccine rollout was hurried, and the ordeal shook a lot of people's faith in public-health messaging. It's an interesting tale of erring too far to the side of caution.

But it's also nice to remember that there's nothing inherently ideological about vaccination. It wasn't always a wedge issue. And the damage done by raising a false alarm is in no way comparable to the damage done by ignoring and denying the existence of an alarm that everyone can hear.

Get a flu shot! It's fine to at the same time you get a COVID booster, if you do.

Finally, on another presidential note, Bill Clinton is reportedly hospitalized for a "non-COVID-related infection" which is both weirdly specific and vague. Traditionally it's more like "hospitalized but in good condition and expected to make a full recovery." Now I'm mostly curious about the infection that can't be named.

Take care, keep in touch,

Jim

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