A year after the United States bombed its pandemic performance in front of the world, the Delta variant opened the stage for a face-saving encore. If the U.S. had learned from its mishandling of the original SARS-CoV-2 virus, it would have been better prepared for the variant that was already ravaging India. Instead, after a quiet spring, President Joe Biden all but declared victory against SARS-CoV-2. The CDC ended indoor masking for vaccinated people, pitting two of the most effective interventions against each other. As cases fell, Abbott Laboratories, which makes a rapid COVID-19 test, discarded inventory, canceled contracts, and laid off workers, The New York Times reported. Florida and Georgia scaled back on reporting COVID-19 data, according to Kaiser Health News. Models failed to predict Delta’s early arrival. The variant then ripped through the U.S.’s half-vaccinated populace and once again pushed hospitals and health-care workers to the brink. Delta’s extreme transmissibility would have challenged any nation, but the U.S. nonetheless set itself up for failure. Delta was an audition for the next pandemic, and one that America flubbed. How can a country hope to stay 10 steps ahead of tomorrow’s viruses when it can’t stay one step ahead of today’s? America’s frustrating inability to learn from the recent past shouldn’t be surprising to anyone familiar with the history of public health. Almost 20 years ago, the historians of medicine Elizabeth Fee and Theodore Brown lamented that the U.S. had “failed to sustain progress in any coherent manner” in its capacity to handle infectious diseases. With every new pathogen—cholera in the 1830s, HIV in the 1980s—Americans rediscover the weaknesses in the country’s health system, briefly attempt to address the problem, and then “let our interest lapse when the immediate crisis seems to be over,” Fee and Brown wrote. The result is a Sisyphean cycle of panic and neglect that is now spinning in its third century. Progress is always undone; promise, always unfulfilled. Fee died in 2018, two years before SARS-CoV-2 arose. But in documenting America’s past, she foresaw its pandemic present—and its likely future. More Americans have been killed by the new coronavirus than the influenza pandemic of 1918, despite a century of intervening medical advancement. The U.S. was ranked first among nations in pandemic preparedness but has among the highest death rates in the industrialized world. It invests more in medical care than any comparable country, but its hospitals have been overwhelmed. It helped develop COVID-19 vaccines at near-miraculous and record-breaking speed, but its vaccination rates plateaued so quickly that it is now 38th in the world. COVID-19 revealed that the U.S., despite many superficial strengths, is alarmingly vulnerable to new diseases—and such diseases are inevitable. As the global population grows, as the climate changes, and as humans push into spaces occupied by wild animals, future pandemics become more likely. We are not guaranteed the luxury of facing just one a century, or even one at a time. It might seem ridiculous to think about future pandemics now, as the U.S. is consumed by debates over booster shots, reopened schools, and vaccine mandates. Prepare for the next one? Let’s get through this one first! But America must do both together, precisely because of the cycle that Fee and Brown bemoaned. Today’s actions are already writing the opening chapters of the next pandemic’s history. Internationally, Joe Biden has made several important commitments. At the United Nations General Assembly last week, he called for a new council of national leaders and a new international fund, both focused on infectious threats—forward-looking measures that experts had recommended well before COVID-19. But domestically, many public-health experts, historians, and legal scholars worry that the U.S. is lapsing into neglect, that the temporary wave of investments isn’t being channeled into the right areas, and that COVID-19 might actually leave the U.S. weaker against whatever emerges next. Donald Trump’s egregious mismanagement made it easy to believe that events would have played out differently with a halfway-competent commander who executed preexisting pandemic plans. But that ignores the many vulnerabilities that would have made the U.S. brittle under any administration. Even without Trump, “we’d still have been in a whole lot of trouble,” Gregg Gonsalves, a global-health activist and an epidemiologist at Yale, told me. “The weaknesses were in the rootstock, not high up in the trees.” The panic-neglect cycle is not inevitable but demands recognition and resistance. “A pandemic is a course correction to the trajectory of civilization,” Alex de Waal, of Tufts University and the author of New Pandemics, Old Politics, told me. “Historical pandemics challenged us to make some fairly fundamental changes to the way in which society is organized.” Just as cholera forced our cities to be rebuilt for sanitation, COVID-19 should make us rethink the way we ventilate our buildings, as my colleague Sarah Zhang argued. But beyond overhauling its physical infrastructure, the U.S. must also address its deep social weaknesses—a health-care system that millions can’t access, a public-health system that’s been rotting for decades, and extreme inequities that leave large swaths of society susceptible to a new virus. Early last year, some experts suggested to me that America’s COVID-19 failure stemmed from its modern inexperience with infectious disease; having now been tested, it might do better next time. But preparedness doesn’t come automatically, and neither does its absence. “Katrina didn’t happen because Louisiana never had a hurricane before; it happened because of policy choices that led to catastrophe,” Gonsalves said. The arc of history does not automatically bend toward preparedness. It must be bent. On September 3, the White House announced a new strategy to prepare for future pandemics. Drafted by the Office of Science and Technology Policy, and the National Security Council, the plan would cost the U.S. $65 billion over the next seven to 10 years. In return, the country would get new vaccines, medicines, and diagnostic tests; new ways of spotting and tracking threatening pathogens; better protective equipment and replenished stockpiles; sturdier supply chains; and a centralized mission control that would coordinate all the above across agencies. The plan, in rhetoric and tactics, resembles those that were written before COVID-19 and never fully enacted. It seems to suggest all the right things. But the response from the health experts I’ve talked with has been surprisingly mixed. “It’s underwhelming,” Mike Osterholm, an epidemiologist at the University of Minnesota, told me. “That $65 billion should have been a down payment, not the entire program. It’s a rounding error for our federal budget, and yet our entire existence going forward depends on this.” The pandemic plan compares itself to the Apollo program, but the government spent four times as much, adjusted for inflation, to put astronauts on the Moon. Meanwhile, the COVID-19 pandemic may end up costing the U.S. an estimated $16 trillion. “I completely agree that it will take more investment,” Eric Lander, OSTP director and Biden’s science adviser, told me; he noted that the published plan is just one element of a broader pandemic-preparedness effort that is being developed. But even the $65 billion that the plan has called for might not fully materialize. Biden originally wanted to ask Congress to immediately invest $30 billion but eventually called for just half that amount, in a compromise with moderate Democrats who sought to slash it even further. The idea of shortchanging pandemic preparedness after the events of 2020 “should be unthinkable,” wrote former CDC Director Tom Frieden and former Senator Tom Daschle in The Hill. But it is already happening Others worry about the way the budget is being distributed. About $24 billion has been earmarked for technologies that can create vaccines against a new virus within 100 days. Another $12 billion will go toward new antiviral drugs, and $5 billion toward diagnostic tests. These goals are, individually, sensible enough. But devoting two-thirds of the full budget toward them suggests that COVID-19’s lessons haven’t been learned. America failed to test sufficiently throughout the pandemic even though rigorous tests have long been available. Antiviral drugs played a bit part because they typically provide incremental benefits over basic medical care, and can be overly expensive even when they work. And vaccines were already produced far faster than experts had estimated and were more effective than they had hoped; accelerating that process won’t help if people can’t or won’t get vaccinated, and especially if they equate faster development with nefarious corner-cutting, as many Americans did this year. Every adult in the U.S. has been eligible for vaccines since mid-April; in that time, more Americans have died of COVID-19 per capita than people in Germany, Canada, Rwanda, Vietnam, or more than 130 other countries did in the pre-vaccine era. “We’re so focused on these high-tech solutions because they appear to be what a high-income country would do,” Alexandra Phelan, an expert on international law and global health policy at Georgetown University, told me. And indeed, the Biden administration has gone all in on vaccines, trading them off against other countermeasures, such as masks and testing, and blaming “the unvaccinated” for America’s ongoing pandemic predicament. The promise of biomedical panaceas is deeply ingrained in the U.S. psyche, but COVID should have shown that medical magic bullets lose their power when deployed in a profoundly unequal society. There are other ways of thinking about preparedness. And there are reasons those ways were lost. In 1849, after investigating a devastating outbreak of typhus in what is now Poland, the physician Rudolf Virchow wrote, “The answer to the question as to how to prevent outbreaks … is quite simple: education, together with its daughters, freedom and welfare.” Virchow was one of many 19th-century thinkers who correctly understood that epidemics were tied to poverty, overcrowding, squalor, and hazardous working conditions—conditions that inattentive civil servants and aristocrats had done nothing to address. These social problems influenced which communities got sick and which stayed healthy. Diseases exploit society’s cracks, and so “medicine is a social science,” Virchow famously said. Similar insights dawned across the Atlantic, where American physicians and politicians tackled the problem of urban cholera by fixing poor sanitation and dilapidated housing. But as the 19th century gave way to the 20th, this social understanding of disease was ousted by a new paradigm. When scientists realized that infectious diseases are caused by microscopic organisms, they gained convenient villains. Germ theory’s pioneers, such as Robert Koch, put forward “an extraordinarily powerful vision of the pathogen as an entity that could be vanquished,” Alex de Waal, of Tufts, told me. And that vision, created at a time when European powers were carving up other parts of the world, was cloaked in metaphors of imperialism, technocracy, and war. Microbes were enemies that could be conquered through the technological subjugation of nature. “The implication was that if we have just the right weapons, then just as an individual can recover from an illness and be the same again, so too can a society,” de Waal said. “We didn’t have to pay attention to the pesky details of the social world, or see ourselves as part of a continuum that includes the other life-forms or the natural environment.” [Read: How the pandemic now ends] Germ theory allowed people to collapse everything about disease into battles between pathogens and patients. Social matters such as inequality, housing, education, race, culture, psychology, and politics became irrelevancies. Ignoring them was noble; it made medicine and science more apolitical and objective. Ignoring them was also easier; instead of staring into the abyss of society’s intractable ills, physicians could simply stare at a bug under a microscope and devise ways of killing it. Somehow, they even convinced themselves that improved health would “ultimately reduce poverty and other social inequities,” wrote Allan Brandt and Martha Gardner in 2000. This worldview accelerated a growing rift between the fields of medicine (which cares for sick individuals) and public health (which prevents sickness in communities). In the 19th century, these disciplines were overlapping and complementary. In the 20th, they split into distinct professions, served by different academic schools. Medicine, in particular, became concentrated in hospitals, separating physicians from their surrounding communities and further disconnecting them from the social causes of disease. It also tied them to a profit-driven system that saw the preventive work of public health as a financial threat. “Some suggested that if prevention could eliminate all disease, there would be no need for medicine in the future,” Brandt and Gardner wrote. This was a political conflict as much as an ideological one. In the 1920s, the medical establishment flexed its growing power by lobbying the Republican-controlled Congress and White House to erode public-health services including school-based nursing, outpatient dispensaries, and centers that provided pre- and postnatal care to mothers and infants. Such services were examples of “socialized medicine,” unnecessary to those who were convinced that diseases could best be addressed by individual doctors treating individual patients. Health care receded from communities and became entrenched in hospitals. Decades later, these changes influenced America’s response to COVID-19. Both the Trump and Biden administrations have described the pandemic in military metaphors. Politicians, physicians, and the public still prioritize biomedical solutions over social ones. Medicine still overpowers public health, which never recovered from being “relegated to a secondary status: less prestigious than clinical medicine [and] less amply financed,” wrote the sociologist Paul Starr. It stayed that way for a century. During the pandemic, many of the public-health experts who appeared in news reports hailed from wealthy coastal universities, creating a perception of the field as well funded and elite. That perception is false. In the early 1930s, the U.S. was spending just 3.3 cents of every medical dollar on public health, and much of the rest on hospitals, medicines, and private health care. And despite a 90-year span that saw the creation of the CDC, the rise and fall of polio, the emergence of HIV, and relentless calls for more funding, that figure recently stood at … 2.5 cents. Every attempt to boost it eventually receded, and every investment saw an equal and opposite disinvestment. A preparedness fund that was created in 2002 has lost half its budget, accounting for inflation. Zika money was cannibalized from Ebola money. America’s historical modus operandi has been to “give responsibility to the local public-health department but no power, money, or infrastructure to make change,” Ruqaiijah Yearby, a health-law expert at Saint Louis University, told me. Lisa Macon Harrison, who directs the department that serves Granville and Vance Counties, in North Carolina, told me that to protect her community of 100,000 people from infectious diseases—HIV, sexually transmitted infections, rabies, and more—the state gives her $4,147 a year. That’s 90 times less than what she actually needs. She raises the shortfall herself through grants and local dollars. Trifling budgets mean smaller staff, which turns mandatory services into optional ones. Public-health workers have to cope with not just infectious diseases but air and water pollution, food safety, maternal and child health, the opioid crisis, and tobacco control. But with local departments having lost 55,000 jobs since the 2008 recession, many had to pause their usual duties to deal with COVID-19. Even then, they didn’t have staff to do the most basic version of contact tracing—calling people up—let alone the ideal form, wherein community health workers help exposed people find food, services, and places to isolate. When vaccines were authorized, departments had to scale back on testing so that overworked staff could focus on getting shots into arms; even that wasn’t enough, and half of states hired armies of consultants to manage the campaign, The Washington Post reported. [Read: Six rules that will define our pandemic winter] In May, the Biden administration said that it would invest $7.4 billion in recruiting and training public-health workers, creating tens of thousands of jobs. But those new workers would be air-dropped into an infrastructure that is quite literally crumbling. Many public-health departments are housed in buildings that were erected in the 1940s and ’50s, when polio money was abundant; they are now falling apart. “There’s a trash can in the hallway in front of my environmental-health supervisor’s office to catch rain that might come through the ceiling,” Harrison told me. And between their reliance on fax machines and decades-old data systems, “it feels like we’re using a Rubik’s cube and an abacus to do pandemic response,” Harrison added. Last year, America’s data systems proved to be utterly inadequate for tracking a rapidly spreading virus. Volunteer efforts such as the COVID Tracking Project (launched by The Atlantic) had to fill in for the CDC. Academics created a wide range of models, some of which were misleadingly inaccurate. “For hurricanes, we don’t ask well-intentioned academics to stop their day jobs and tell us where landfall will happen,” the CDC’s Dylan George told me. “We turn to the National Hurricane Center.” Similarly, George hopes that policy makers can eventually turn to the CDC’s newly launched Center for Forecasting and Outbreak Analytics, where he is director of operations. With initial funding of about $200 million, the center aims to accurately track and predict the paths of pathogens, communicate those predictions with nuance, and help leaders make informed decisions quickly. But public health’s longstanding neglect means that simply making the system fit for purpose is a mammoth undertaking that can’t be accomplished with emergency funds—especially not when those funds go primarily toward biomedical countermeasures. That’s “a welfare scheme for university scientists and big organizations, and it’s not going to trickle down to the West Virginia Department of Health,” Gregg Gonsalves, the health activist and epidemiologist, told me. What the U.S. needs, as several reports have recommended and as some senators have proposed, is a stable and protected stream of money that can’t be diverted to the emergency of the day. That would allow health departments to properly rebuild without constantly fearing the wrecking ball of complacency. Biden’s $7.4 billion bolus is a welcome start—but just a start. And though his new pandemic-preparedness plan commits $6.5 billion toward strengthening the U.S. public-health system over the next decade, it might take $4.5 billion a year to actually do the job. [Read: The coronavirus is here forever. This is how we live with it. ] “Nobody should read that plan as the limit of what needs to be done,” Eric Lander, the president’s science adviser, told me. “I have no disagreement that a major effort and very substantial funding are needed,” and, he noted, the administration’s science and technology advisers will be developing a more comprehensive strategy. “But is pandemic preparedness the lens through which to fix public health?” Lander asked. “I think those issues are bigger—they’re everyday problems, and we need to shine a spotlight on them every day.” But here is public health’s bind: Though it is so fundamental that it can’t (and arguably shouldn’t) be tied to any one type of emergency, emergencies are also the one force that can provide enough urgency to strengthen a system that, under normal circumstances, is allowed to rot. When a doctor saves a patient, that person is grateful. When an epidemiologist prevents someone from catching a virus, that person never knows. Public health “is invisible if successful, which can make it a target for policy makers,” Ruqaiijah Yearby, the health-law expert, told me. And during this pandemic, the target has widened, as overworked and under-resourced officials face aggressive protests. “Our workforce is doing 15-hour days and rather than being glorified, they’re being vilified and threatened with bodily harm and death,” Harrison told me. According to an ongoing investigation by the Associated Press and Kaiser Health News, the U.S. has lost at least 303 state or local public-health leaders since April 2020, many because of burnout and harassment. Even though 62 percent of Americans believe that pandemic-related restrictions were worth the cost, Republican legislators in 26 states have passed laws that curtail the possibility of quarantines and mask mandates, as Lauren Weber and Anna Maria Barry-Jester of KHN have reported. Supporters characterize these laws as checks on executive power, but several do the opposite, allowing states to block local officials or schools from making decisions to protect their communities. Come the next pandemic (or the next variant), “there’s a real risk that we are going into the worst of all worlds,” Alex Phelan, of Georgetown University, told me. “We’re removing emergency actions without the preventive care that would allow people to protect their own health.” This would be dangerous for any community, let alone those in the U.S. that are structurally vulnerable to infectious disease in ways that are still being ignored. Biden’s new pandemic plan contains another telling detail about how the U.S. thinks about preparedness. The parts about vaccines and therapeutics contain several detailed and explicit strategies. The part about vulnerable communities is a single bullet point that calls for strategies to be developed. This isn’t a new bias. In 2008, Philip Blumenshine and his colleagues argued that America’s flu-pandemic plans overlooked the disproportionate toll that such a disaster would take upon socially disadvantaged people. Low-income and minority groups would be more exposed to airborne viruses because they’re more likely to live in crowded housing, use public transportation, and hold low-wage jobs that don’t allow them to work from home or take time off when sick. When exposed, they’d be more susceptible to disease because their baseline health is poorer, and they’re less likely to be vaccinated. With less access to health insurance or primary care, they’d die in greater numbers. These predictions all came to pass during the H1N1 swine-flu pandemic of 2009. When SARS-CoV-2 arrived a decade later, history repeated itself. The new coronavirus disproportionately infected essential workers, who were forced to risk exposure for the sake of their livelihood; killed Pacific Islander, Latino, Indigenous, and Black Americans; and struck people who’d been packed into settings at society’s margins—prisons, nursing homes, meatpacking facilities. “We’ve built a system in which many people are living on the edge, and pandemics prey on those vulnerabilities,” Julia Raifman, a health-policy researcher at Boston University, told me. Such patterns are not inevitable. “It is very clear, from evidence and history, that robust public-health systems rely on provision of social services,” Eric Reinhart, a political anthropologist and physician at Northwestern University, told me. “That should just be a political given, and it is not. You have Democrats who don’t even say this, let alone Republicans.” America’s ethos of rugged individualism pushes people across the political spectrum to see social vulnerability as a personal failure rather than the consequence of centuries of racist and classist policy, and as a problem for each person to solve on their own rather than a societal responsibility. And America’s biomedical bias fosters the seductive belief that these sorts of social inequities won’t matter if a vaccine can be made quickly enough. But inequity reduction is not a side quest of pandemic preparedness. It is arguably the central pillar—if not for moral reasons, then for basic epidemiological ones. Infectious diseases can spread, from the vulnerable to the privileged. “Our inequality makes me vulnerable,” Mary Bassett, who studies health equity at Harvard, told me. “And that’s not a necessary feature of our lives. It can be changed.” “To be ready for the next pandemic, we need to make sure that there’s an even footing in our societal structures,” Seema Mohapatra, a health-law expert at Indiana University, told me. That vision of preparedness is closer to what 19th-century thinkers lobbied for, and what the 20th century swept aside. It means shifting the spotlight away from pathogens themselves and onto the living and working conditions that allow pathogens to flourish. It means measuring preparedness not just in terms of syringes, sequencers, and supply chains but also in terms of paid sick leave, safe public housing, eviction moratoriums, decarceration, food assistance, and universal health care. It means accompanying mandates for social distancing and the like with financial assistance for those who might lose work, or free accommodation where exposed people can quarantine from their family. It means rebuilding the health policies that Reagan began shredding in the 1980s and that later administrations further frayed. It means restoring trust in government and community through public services. “It’s very hard to achieve effective containment when the people you’re working with don’t think you care about them,” Arrianna Marie Planey, a medical geographer at the University of North Carolina at Chapel Hill, told me. In this light, the American Rescue Plan—the $1.9 trillion economic-stimulus bill that Biden signed in March—is secretly a pandemic-preparedness bill. Beyond specifically funding public health, it also includes unemployment insurance, food-stamp benefits, child tax credits, and other policies that are projected to cut the poverty rate for 2021 by a third, and by even more for Black and Hispanic people. These measures aren’t billed as ways of steeling America against future pandemics—but they are. Also on the horizon is a set of recommendations from the COVID-19 Health Equity Task Force, which Biden established on his first full day of office. “The president has told many of us privately, and said publicly, that equity has to be at the heart of what we do in this pandemic,” Vivek Murthy, the surgeon general, told me. Some of the American Rescue Plan’s measures are temporary, and their future depends on the $3.5 trillion social-policy bill that Democrats are now struggling to pass, drawing opposition from within their own party. “Health equity requires multiple generations of work, and politicians want outcomes that can be achieved in time to be recognized by an electorate,” Planey told me. That electorate is tiring of the pandemic, and of the lessons it revealed. Last year, “for a moment, we were able to see the invisible infrastructure of society,” Sarah Willen, an anthropologist at the University of Connecticut who studies Americans’ conceptions of health equity, told me. “But that seismic effect has passed.” Socially privileged people now also enjoy the privilege of immunity, while those with low incomes, food insecurity, eviction risk, and jobs in grocery stores and agricultural settings are disproportionately likely to be unvaccinated. Once, they were deemed “essential”; now they’re treated as obstinate annoyances who stand between vaccinated America and a normal life. The pull of the normal is strong, and our metaphors accentuate it. We describe the pandemic’s course in terms of “waves,” which crest and then collapse to baseline. We bill COVID-19 as a “crisis”—a word that evokes decisive moments and turning points, “and that, whether you want to or not, indexes itself against normality,” Reinhart told me. “The idea that something new can be born out of it is lost,” because people long to claw their way back to a precrisis state, forgetting that the crisis was itself born of those conditions. Better ideas might come from communities for whom “normal” was something to survive, not revert to. Many Puerto Ricans, for example, face multiple daily crises including violence, poverty, power outages, and storms, Mónica Feliú-Mójer, of the nonprofit Ciencia Puerto Rico, told me. “They’re always preparing,” she said, “and they’ve built support networks and mutual-aid systems to take care of each other.” Over the past year, Ciencia PR has given small grants to local leaders to fortify their communities against COVID-19. While some set up testing and vaccination clinics, others organized food deliveries or educational events. One cleaned up a dilapidated children’s park to create a low-risk outdoor space where people could safely reconnect. Such efforts recognize that resisting pandemics is about solidarity as well as science, Feliú-Mójer told me. The panic-neglect cycle is not irresistible. Some of the people I spoke with expressed hope that the U.S. can defy it, just not through the obvious means of temporarily increased biomedical funding. Instead, they placed their faith in grassroots activists who are pushing for fair labor policies, better housing, health-care access, and other issues of social equity. Such people would probably never think of their work as a way of buffering against a pandemic, but it very much is—and against other health problems, natural disasters, and climate change besides. These threats are varied, but they all wreak their effects on the same society. And that society can be as susceptible as it allows itself to be. from https://ift.tt/3kR3Tb7 Check out http://natthash.tumblr.com
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Editor’s Note: This article is part of our coverage of The Atlantic Festival. Learn more and watch festival sessions here. The vaccine timeline for young kids is looking a little more solid. This morning, Pfizer submitted data to the FDA showing that its COVID-19 vaccine is effective and safe for children ages 5 to 11. And this afternoon, the company’s CEO, Albert Bourla, said that trial results for even younger kids, aged 2 to 4, will be available in a couple months’ time. “Before the end of the year,” he confirmed in an interview with Craig Melvin, the Today news anchor and MSNBC anchor, at The Atlantic Festival. Submission to the FDA will follow soon thereafter, Bourla said. The wait for COVID-19 vaccines comes during an ongoing surge of cases among children. Vaccines are taking this long to reach kids because the trials follow the classic strategy of age de-escalation. Manufacturers first tested their shots in adults, then teens, and most recently kids as young as 2. Pfizer is also running a pediatric trial for the youngest children, aged six months up to 2 years old. Bourla did not specify a timeline for this cohort, but expect results sometime after those from the 2-to-4-year-old group. Once the results for each age cohort are collected, Pfizer will submit them to the FDA to review for safety and efficacy. The agency doesn’t work on a set timeline, but for context, emergency use of Pfizer’s vaccine took 21 days from filing to authorization for adults and 31 days for teens age 12 to 15. If that precedence holds, then kids 5 to 11 will likely be able to get shots around Halloween and those 2 to 4 will be eligible by early next year. (Don’t be surprised if those timelines stretch, however.) All eyes are on Pfizer’s vaccine because its pediatric trials are furthest along. Moderna and Johnson & Johnson, the two other companies whose COVID-19 vaccines have been authorized in the United States, haven’t yet released any data from their trials running in children under 12. (Like Pfizer’s trial, these also go down to children as young as six months.) The first shot available to kids will almost certainly come from Pfizer. The adult and pediatric trials of COVID-19 vaccines do differ in a couple of key ways. First of all, Pfizer is testing a smaller dose in kids. For adults and teens, each shot of Pfizer’s two-dose regimen contained a 30-microgram dose. For kids 11 and under, the dose was reduced to only 10 micrograms a shot, and then reduced even further to 3 micrograms for kids six months up to 2 years of age. Based on Pfizer’s announcements, the data the company has collected so far suggest that the smaller dose is indeed safe and coaxes a strong immune response out of the 5-to-11-year-old cohort; their antibody responses are similar to that of adults who got the higher dose. Speaking of that immune response, scientists are evaluating the vaccine’s efficacy in kids somewhat indirectly—this is another way these adult and kid trials differ. The COVID-19 vaccine is already known to be effective in adults, so researchers are looking at antibody responses rather than counting the number of vaccinated versus unvaccinated people who get COVID-19, as they did in the original adult trial. Studying efficacy by waiting for enough kids in a trial to get COVID-19 would require a much larger trial—and much more time to complete it. These trials that focus on antibody response are called “immunobridging” studies and are standard in studying vaccines. Even when young kids are able to be vaccinated, however—and polls right now suggest that many parents are still hesitant—the coronavirus is unlikely to go away. This is why pharmaceutical companies including Merck, Roche, and Pfizer are also racing to develop antivirals to treat patients with COVID-19. This week, Pfizer announced that it is studying an oral pill that could block the replication of the coronavirus. Trials are “ongoing right now” to see whether the pill can mitigate or prevent COVID-19, Bourla told Melvin, and the first results are expected before the end of the year. The world is heading into a third year with the coronavirus, but this time with many more pharmaceutical defenses in the arsenal. from https://ift.tt/3ohsO9W Check out http://natthash.tumblr.com Editor’s Note: This article is part of our coverage of The Atlantic Festival. Learn more and watch festival sessions here. A week after FDA and CDC advisory committees clashed on the nuances of when and whether to recommend COVID-19 booster shots, Anthony Fauci told my colleague Ed Yong that he still believes third doses of the mRNA vaccines are crucial, suggesting once again that they will eventually be part of a standard regimen. As those committees deliberated, the experts considered qualitative evidence on the shots’ safety and efficacy, but also kept getting stuck on two larger conceptual questions. First: What, exactly, is the point of offering third shots? Skeptics of large-scale boosting argue that the COVID-19 vaccines were designed to prevent severe hospitalization and death, while third shots seem more likely to offer (temporary) protection against infection and mild disease. In their view, boosting wouldn’t offer any meaningful gains. “I reject that,” Fauci, who serves as Joe Biden’s chief medical adviser and the director of the National Institute of Allergy and Infectious Disease, said at The Atlantic Festival today. “I think we should be preventing people from getting sick from COVID even if they don't wind up in the hospital.” The second big question that tripped up the experts: Are third shots of an mRNA vaccine really boosters to remind our immune systems how to fight off the enemy, or are they essential for everyone to reach full protection? Put another way, can you be “fully vaccinated” without one? Fauci has previously suggested that third shots could become common practice, and today took an even stronger tack: “it is likely, for a real complete regimen, that you would need at least a third dose.” In addition to booster shots, Fauci and Yong spoke about the Delta variant, global vaccine equity, and how the U.S. can prevent the next pandemic. Their conversation below has been lightly edited for length and clarity. Ed Yong: In May, you said to The Washington Post that if 70 percent of adults were vaccinated by the fall, then we’re going to get out of the epidemic stage [of COVID] and much more into the control stage. Well, it’s now the fall. Around 65 percent of adults are vaccinated, but things don’t seem very controlled and hospitals are still struggling. Death rates are high. What went wrong? Anthony Fauci: I’m not so sure anything went wrong. Something came onto the scene that made everything really very different: the Delta variant. We have about 70 million people in this country who still are not vaccinated. That is particularly problematic when you do that in the context of the Delta variant, which is really substantially more transmissible than what we were dealing with [in the spring]. I don’t think we should say, “Well, there’s nothing we could have done better,” but I don’t think you could say something went wrong. These kinds of surges that we’re seeing regarding Delta are not isolated to the United States. I mean, the entire world virtually has been hit by this. So now that we are in this situation, how do we address it? We do know that the vaccines do work really quite well against Delta. There were breakthrough infections, but that’s because no vaccine is 100 percent effective. What they’ve done quite well thus far is prevent people from getting to the hospital and ultimately dying. So the bottom line is that we have within our grasp, within our power, the ability to have a major impact on what we’re seeing now with the numbers of infections. We’ve been well over 100,000 infections for quite a while now, and hospitalizations were up and deaths were up. Right now, it looks like we’re turning the corner a bit with a diminution in the number of cases and a diminution in the number of hospitalizations. Deaths are still going up, but that’s usually a lagging indicator of what’s going on in the community. Yong: Many of the folks I’ve spoken to who work in public health and other disciplines have suggested that the U.S. has put too many eggs into the vaccine basket and, in some cases, traded them off against other interventions that are important. The move away from indoor masking in the spring, as one example; the continuing interferences in testing as another. Do you think that we have overemphasized vaccines at the expense of other strategies? Fauci: I think we’ve placed a lot of emphasis on what is known historically and in real time now as a very high-impact, pharmacologic intervention in the form of a vaccine. Masking has really been a very complicated issue. The CDC made that change in the mask guidance at just the time when Delta was starting to really go up. I think now, if they were to look back at that decision, they would say, given the context of what Delta has done, that it likely should not have been the policy back then. In fairness to them, they quickly went back when we saw that Delta was a really quite a formidable foe here. It would have been preferable had that been done earlier. On the testing thing, you do have a point. I’ve always said that we should be flooding the system with easily attainable at-home testing so people can get a good feel for themselves, their families, their workplace about who is infected and who is not. Just the fact that we had very highly effective and safe vaccines should not make us move away from the intensity of testing. Testing is going to be very important, particularly when you have a virus [that will produce] breakthrough infections. If the vaccine prevents you from getting sick, prevents you from losing work time, prevents you from getting to the hospital and prevents you from dying, that’s a really, really successful vaccine, even if you have a breakthrough infection. But if you do have a breakthrough infection, you are still capable of transmitting that infection to someone else. And that’s the reason why, among other reasons, we really need to do a lot of testing and make it very available. I mean, I have conversations with our British colleagues and they are very much tuned in to making testing widely available to virtually anybody on their own at home or wherever [and making it] very easy accessibility- and price- and convenience-wise. Yong: Do you think the U.S. can get to that point? Fauci: I hope so. And I think we can, because we can’t be unidimensional in our approach to this outbreak. Yong: You seem to be quite bullish about using boosters. And you’ve defended the administration’s decision to talk about widespread availability before the FDA had a chance to weigh in. What is your stance on the role that they should play in the pandemic going forward? Fauci: First of all, Ed, let me put this in context. I believe that people need to understand that, at the time we’re giving boosters here and in other countries of wealth, it is important to make sure that we do more than just pay attention to the developing world, that we give them enough resources, enough doses, and enough capability to make vaccines. I believe we can do both and we shouldn’t do our boosters at the expense of getting vaccines to the developing world. Having said that, I’ve made it clear that my opinion has always been that I believe that a third-shot booster for a two-dose mRNA [vaccine] should ultimately and will ultimately be the proper, complete regimen. The vaccine is very successful. The durability of it is something that’s a subject of considerable discussion and sometimes debate. I supported and continue to support what the FDA did on the basis of the information they had and on the advice of their advisory committee. I support what the CDC has done, and I think that Dr. Walensky made a very good, informed, and courageous choice. She took the advice of the [Advisory Committee on Immunization Practices] under advisement and she made a modification. As a physician and as a scientist and a public-health person, I think it is not entirely correct to make this very strong dichotomy between waning protection against hospitalization and death and waning immunity against infection and mild-to-moderate disease. It is an assumption that it’s okay to get infected and to get mild-to-moderate disease as long as you don’t wind up in the hospital and die. And I have to be open and honest: I reject that. I think we should be preventing people from getting sick from COVID even if they don’t wind up in the hospital. Ultimately I believe that the optimal regimen for the mRNA [vaccines] is going to include that third booster shot. Yong: And do you feel that that’s been communicated, the idea that the whole plan was always going to be three doses? Fauci: We did not always know that a third dose would likely be an important part of the proper complete regimen. In the early trials we started off with a prime followed by a booster. And the results were so strikingly good, both in the animal model and in the Phase 1, Phase 2 trials, that we didn’t have the luxury to say, “Wait a minute, we’re going to try multiple different doses and make sure we get it just right.” We were in an emergency situation, so we went with what was really good. Already the track record has shown you that it has saved millions of lives. What we did not fully appreciate—and there was no way of knowing it—is what the durability of that would be. I’m an immunologist and I know what other immunologists say is true: The antibody level going down doesn’t necessarily mean that you’re not protected, because you have memory B cells, you have T cells. But the clinical phenomenon is the thing that you need to pay attention to. And that’s what we were seeing: Over time, protection against hospitalization was going down, starting off with the elderly and then even occurring across age groups. Without a doubt, the protection against clinically recognizable disease was going down. We did not know that during the clinical trials. What we’re starting to see now and fully appreciate is that it is likely, for a real, complete regimen, that you would need at least a third dose. Now, the question is going to be, does that mean we have to boost people every single year? We don’t know that now. What I hope is going to happen is that this is going to get to the human immune system, in vaccinated people, that degree of maturation of response, that will really give much more durability to it. Yong: A lot of other scientists and health experts have said that focusing on an incremental gain for immunity for people who have already been vaccinated works against the goal of broadly immunizing the rest of the world. You’ve said that we can have both of those two things together. Why do you believe that to be the case? And if that is the case, then why haven’t we made better progress with global vaccine equity to this day? Fauci: My feelings and my track record on global equity and global accessibility are available for anybody to examine. So I do feel that we have that obligation. On the issue of one dose versus two doses: [It's not an issue] if you have enough, that only becomes an issue when you really do have a scarcity of doses. But when you have enough doses, you should go with the full regimen at the time. Experience has shown us that although there is some protection and there’s no doubt about it, you can’t get by with one dose. It is not adequate. And we have seen various people who have been vaccinated with a single dose to not have nearly as much or even adequate protection. They have some protection. But if you look at studies comparing one dose versus two doses in multiple different parameters of infection—of getting infected with variants, of clinical disease, of hospitalization—you do get some protection with one dose, but it is not nearly as good as two doses. And that’s the reason why we wanted to make sure, to the best of our ability, we get people vaccinated with both doses. Yong: We talked about pandemics and preparing for them back in 2018, well before COVID. You and many others told me about these cycles of panic and neglect where a crisis hits, everyone pays attention, investments flow, and then inevitably our willingness to do what is necessary to prepare against future pandemics slips. Do you think that we’re destined to repeat that cycle? What can the U.S. be doing right now to avert tomorrow’s pandemics? Fauci: I have been in the unfortunate situation of having lived through multiple cycles of the phenomenon that you are just now describing, of semi-panic and promising that we will not let this kind of thing happen again. We’ve been through HIV and we’ve been through pandemic flu and we’ve been through Zika and we’ve been through Ebola—and now we have a historic outbreak with COVID-19. I really do sincerely hope, having been through all of that myself personally, that we will not allow what we’ve been through over the last 20 months to slip from memory, which means we have to and we are starting right now to prepare for the next pandemic. I think what we’ve learned now is that, given the jumping of viruses from one species to another—what we’ve seen with Ebola, HIV, SARS-1, MERS—we’ve got to be prepared from multiple standpoints. Pandemic preparedness is not unidimensional. It’s everything from global cooperation to communication to surveillance, both at the animal level and the human level, to have a basic and fundamental clinical-research endeavor where you’re able to do things like take a pathogen, recognize it, and get vaccines ready to go into people. That’s what we’re talking about now. We’re talking about tens of billions of dollars that will be needed. I really do hope that when we get through this, which we will, we don’t then start focusing and concentrating on another problem that takes our mind off this extraordinarily difficult period that we will have lived through. from https://ift.tt/3EZc3q0 Check out http://natthash.tumblr.com Editor’s Note: This article is part of our coverage of The Atlantic Festival. Learn more and watch festival sessions here. For some of us, booster shots have finally arrived. But they’ve charted quite a meandering course to get here. First, last month, President Joe Biden announced that most Americans would be able to nab third doses of mRNA vaccines eight months after their second shots. Then, last week the FDA narrowed the eligible population, before a CDC advisory committee suggested tightening the boundaries even further. Hours after that panel shared its recommendation, the agency’s director, Rochelle Walensky, reversed course and ballooned the guidance back out to more closely align with the FDA’s much broader guidelines—though she stopped short of urging the shots for everyone. It is all, frankly, a bit confusing. Millions of Americans are now in a sort of immunological limbo, wondering which expert advice to heed, and how soon to reroll up their sleeve, as the guidance coming from up top shifts seemingly by the day. Boosters are, at this point, offering more whiplash than protection. I spoke with Walensky today at The Atlantic Festival to see if we could make sense of some of the current situation—her unconventional move to break from the advisory committee’s guidance, and the tough choices millions of Americans face as they navigate the months ahead. “What I want to say is, this is a ‘Walk, don’t run’ situation to go get your boost,” she told me. Booster shots, when doled out at the right time, to the right people, are a boon. They jog the microbe-specific memories of immune cells, reinvigorating the body’s defenses against the pathogens that trouble us—a sometimes-essential shoring up, when immunity wanes, viruses shape-shift, or exposure rates soar. But in setting the CDC’s guidelines, at least one choice, Walensky said, was “a scientific close call.” [Read: What we actually know about waning immunity] The FDA, under advisement from an independent panel of experts, had green-lit a third shot, at least six months out from dose two, for Pfizer recipients who are over 65 or who are at high risk of getting severe COVID-19 because of health status or increased exposure to the virus. The CDC had a different job—to say who should get the shots. The agency’s Advisory Committee on Immunization Practices actively recommended them only for the 65-plus population, residents of long-term-care facilities, and those 50 and older with underlying health issues. The 18-to-49 crowd, the committee said, may opt to get shots as well if they had chronic medical issues; healthy people in high-risk occupations or living situations didn’t yet need the jabs at all. In our interview, Walensky said that endorsing boosters for the oldest among us, as well as people living with high-risk health conditions, was essentially a no-brainer, and in line with what other experts have been calling for; this, she said, was where the data supporting the potential benefits of boosters were the strongest. Putting people who are at higher risk because of their environments back into the guidance, against advice, was the tougher call, she said. That’s part of why younger people and high-risk workers within her recommendation fall under the category of “may get a booster,” rather than should. Translated practically, that means consulting an expert such as a physician or pharmacist, she said, “so you can identify whether you’re in a place that a booster is right for you.” This type of individualistic decision making has, as my colleague Ed Yong has written, dominated much of the pandemic discourse. In prior months, Walensky herself has told the public that masks, vaccines, and more come down to personal risk-benefit analyses. She herself does intend to get a booster at some point, she told me. As a health-care worker, she qualifies, under her own recommendation. But she didn’t specify a timeline, and said that she doesn’t see herself as particularly high-risk at the moment. “Much of the government is remote,” she told me. “I want to make sure that people who are in higher-risk categories than myself, I’m not crowding them out.” For any one person, though, gaming out who fits into that higher-risk-than-me category is tricky, precisely because risk isn’t just about the individual. Infectious diseases are, well, infectious; all danger is communal, and personal decisions affect those around us. That can be a difficult message to convey with vaccines, or most other public-health interventions, because it’s not a typical way for Americans to think. But Walensky points out that these societal metrics factored into her decision making over booster recommendations. Better defense for health-care workers and teachers, for instance, slashes the likelihood that they’ll have to be away from patients in need, or students who have already endured a year of remote learning. Right now, the government’s booster guidance applies only to people who have gotten the Pfizer shot, which has effectively created millions of Moderna and Johnson & Johnson orphans. Official guidance on Pfizer effectively sorted these populations into groups considered “high risk”—and yet, these individuals are without federally sanctioned options to bolster their immunological defenses. (To date, the CDC’s website still says that even moderately to severely immunocompromised people, many of whom didn’t respond well to their initial immunization, who got J&J aren’t technically eligible for a boost.) I asked Walensky how people in these seemingly forgotten groups should be taking the recent, Pfizer-specific news. Here, she backpedaled a bit. “The vaccine effectiveness is still working really quite well,” she told me. And that’s certainly true, especially if thresholds are drawn high: Across populations, the COVID-19 shots continue to stave off hospitalization and death to a spectacular degree, especially in people who are younger and healthy. But Walensky pointed to long COVID, which can unspool after initially mild infections, and noted that “even moderate disease can actually be pretty severe and debilitating.” After “due process,” she said, the Moderna and J&J booster authorizations are coming in a matter of weeks, and will be treated with urgency. “We have not forgotten about J&J and Moderna.” The agency is moving deliberately in part to buoy public confidence in the scientific process and the data that back it, she said. Once a new round of boosters is authorized, people can, apparently, choose to move at their own pace. from https://ift.tt/3EXwDXS Check out http://natthash.tumblr.com President Joe Biden’s new vaccine mandate for large businesses is a strange one, in that it does not actually make vaccines mandatory for the roughly 80 million Americans it’s aimed at. Tucked plainly into the rule is a singular and obvious opt-out: Unlike federal employees and contractors, those in the private sector can test for the coronavirus on an at-least-weekly basis, a no-jab alternative that makes the White House’s decision quite a bit gentler than it could have been. “It’s a stick, but it’s sort of a soft stick,” Julia Raifman, a health-policy researcher at Boston University, told me. The two-pronged approach is certainly more flexible, and perhaps more politically palatable, than pushing shots alone. Recent polling suggests that a majority of Americans are on board with mandates, at least when they’re doled out as a double scoop. “People like choices,” Syra Madad, an infectious-disease epidemiologist at Harvard and for the New York City Health System, told me. That’s long been true for public-health carrots as well: In places such as Israel, the European Union, and parts of Canada, negative test results are among the “passport” options that can green-light residents for entry into restaurants, bars, gyms, clubs, and travel hubs; a smattering of similar policies have been in place at certain American businesses for months. The details of Biden’s new mandate are still being worked out by the Occupational Safety and Health Administration, and the logistics will differ among states and individual companies. But it’s one of most prominent iterations of the test-vax binary to date—and potentially one of the most troubling. The United States isn’t set up to handle a sharp rise in diagnostic demand, should a big fraction of affected workers go the testing route. What’s more, including the testing clause at all “does undermine, to some degree, the scientific and public-health purpose of the mandate,” Tom Bollyky, the director of the global-health program at the Council on Foreign Relations, told me. Vaccines and testing are simply not interchangeable. And the false equivalence that the mandate implies could push us to, once again, play either-or with pandemic mitigation measures, when the best move has always been to use them in combination. Vaccines and tests were designed for explicitly different purposes. COVID-19 shots are proactive, forward-looking measures: They offer viral anatomy lessons to immune cells in advance of an encounter, schooling them on how to fend off a pathogen without actually forcing them to fight it. Infections of all severities are uncommon among the vaccinated. When they do occur, they’re milder, briefer, and less likely to spread to others, and they almost never end in hospitalization or death. Vaccines are an investment in the long term, a sustainable preventive against disease; they bolster the body’s defenses, upping a person’s chances of coming away from a viral encounter unscathed. Tests, while powerful in their own right, don’t offer any of those perks. They’re measuring tools that home in on snippets of viral genetic material or hunks of viral proteins in someone’s airway, and can only identify infections that have already begun. That makes them reactive by default, Saskia Popescu, an infection-prevention expert at George Mason University, told me. Tests offer one result at a time, a snapshot—at the moment of sampling, you had a detectable smidge of virus in your nose or mouth, or you didn’t—with zero bearing on what’s to come. “You incur no protection from a test,” Susan Butler-Wu, a clinical microbiologist at the University of Southern California’s Keck School of Medicine, told me. “With a vaccine, you are protected, and you are protecting.” The Biden administration, of course, is not billing tests as functional vaccines. But as written into the mandate, tests are still being cast in an understudy role that they were never meant to play. “It’s an unacceptable alternative,” Jennifer Nuzzo, an epidemiologist and senior scholar at the Johns Hopkins Center for Health Security, told me. Tests can’t be swapped in for vaccines for the same reasons a smoke detector can’t sub in for fireproofing, a car speedometer can’t replace a seat belt, and a weather report can’t take the place of an umbrella. Noticing the problem isn’t the same as blocking it. (The White House did not respond to repeated requests for comment.) Realistically, the mandate probably needed a fail-safe like this to survive the political climate. “Policy makers have to operate in the realm of what’s possible,” which doesn’t always match up with what’s scientifically ideal, Bollyky said. Having a testing clause, he added, will help buffer the policy against legal challenges—which are already being lobbed its way—that might have otherwise driven it entirely into the ground. A squishy mandate is probably better than a doomed one. And of the available options, testing was, perhaps, the best alternative on a very short list—something tangible, implementable, with FDA-okayed products already in place. Plus, regular screens can truly make workplace settings safer, well in line with the mandate’s primary objective. Every infection that’s caught is one that can potentially be managed, treated if necessary, and contained before it spreads further, if the positive result is acted upon. Months of studies, many of them run at universities with large laboratories and funding pools that the average private business might not have access to, have shown that repeated testing of students, staff, and faculty has smoothed the transition back to in-person learning, and helped catch and corral outbreaks. But a glut of data has also proved that testing, even when mandated, can’t halt infections alone; the strategy’s been most successful when paired with masking, physical distancing, and, more recently, vaccines. Tests aren’t perfect. Some cases will inevitably slip by unnoticed, while some virus-free individuals will be mislabeled as infected. The reach of tests also hinges heavily on human behavior: People actually have to “take action to be protected,” Nuzzo said, isolating themselves after receiving a positive result and reporting their status, formally or informally, so that they can alert others who were potentially exposed. Vaccines juice up immune systems so that viral defense becomes a reflex; tests just flag the issue, then wait for users to make the next move. Dan Larremore, a mathematical modeler at the University of Colorado at Boulder, who’s crunched numbers on the contagion-curbing effects of frequent testing, told me that tests can absolutely “reduce cases by a substantial amount.” But given a choice, “transmission is reduced more effectively and more cost effectively by vaccination.” The bare minimum test frequency needed to meet the mandate standard—once a week—also isn’t terribly compatible with good mitigation. People tend to become contagious within about four to six days of getting infected, likely a shade sooner with the speedster Delta variant. And a big fraction of transmission happens before the infected show symptoms, if they ever do. A weekly screen could leapfrog that entire window and end up being “too little, too late,” Valerie Fitzhugh, a pathologist at Rutgers University, told me. (Even the EU health passports that accept negative test results expire after just two to three days.) The situation could get even murkier if employees need to wait several days for their results, as is often the case with test samples that must be routed through labs. Rapid tests could circumvent that delay, but they’re not very good at zeroing in on low-level infections, and have been shown to operate best, as Larremore and others have found, when used as near-daily screens—a quantity patch for their quality flaws. Employers could opt for testing more often than once a week to bridge some of these gaps. But frequently testing multiple employees stands to bleed time from the workday, incur heavy financial costs—which could potentially fall on the company, its employees, or both—and stress the nation’s already insufficient diagnostic supply. Demand for testing has skyrocketed since the start of the summer, thanks to Delta’s ongoing crush. Meanwhile, many of the community testing sites that closed in the winter or spring never reopened; at-home tests, now available over the counter, have grown difficult to find in stores and online. After grappling with nearly two years of SARS-CoV-2 testing, Butler-Wu, who runs a clinical laboratory that processes hospital samples, worries that a massive influx of workplace testing will deplete resources that could otherwise be used to diagnose very sick patients, especially as the nation barrels into the winter months, when many pathogens thrive. “How are people with symptoms going to get tested?” she said. Laboratory workers, she noted, have been stretched to the breaking point since the pandemic’s start. “There is not an infinite capacity to do this.” The Biden administration has made moves to increase the availability of rapid tests and lower their price points. But the experts I spoke with were skeptical that the supply surge would happen in time, or at a large enough scale. (At this point, it’s still unclear what types of tests will qualify as valid under the mandate, whether they’ll need to be done on-site, and whether their results will need to be reported to public-health officials.) There’s some hope, Nuzzo said, that the testing slice of the equation will be such a headache for everyone involved that vaccination will look more appealing in comparison and become the default. But even that scenario cloaks what would be the actual ideal: wielding vaccines and tests in combination, alongside masks and many of the other measures we’ve been talking about for months. Immunized people pose a lower transmission risk to others, but not zero. “If your goal is to minimize transmission in the workplace, you want to do both,” Nuzzo said. Still, if the comparison has to be made, vaccines “will always come out on top,” Madad, the New York epidemiologist, said. Putting them on the same tier as other measures, and blurring the differences among them, threatens to obscure our best shot at ending the pandemic. This is why, perhaps, we’re calling the not-vaccine mandate a vaccine mandate. It’s a wishful nickname, one that highlights, rather than cloaks, just how powerful immunizations can be when all of us buy in. from https://ift.tt/3m1fWC3 Check out http://natthash.tumblr.com As the pandemic drags on into a bleak and indeterminate future, so does the question of its origins. The consensus view from 2020, that SARS-CoV-2 emerged naturally, through a jump from bats to humans (maybe with another animal between) persists unchanged. But suspicions that the outbreak started from a laboratory accident remain, shall we say, endemic. For months now, a steady drip of revelations have sustained an atmosphere of profound unease. The latest piece of evidence came out this week in the form of a set of murkily sourced PDFs, with their images a bit askew. The main one purports to be an unfunded research grant proposal from Peter Daszak, the president of the EcoHealth Alliance, a global nonprofit focused on emerging infectious diseases, that was allegedly submitted to DARPA in early 2018 (and subsequently rejected) for a $14.2 million project aimed at “defusing the threat of bat-borne coronaviruses.” Released earlier this week by a group of guerilla lab-leak snoops called DRASTIC, the proposal includes a plan to study potentially dangerous pathogens by generating full-length, infectious bat coronaviruses in a lab and inserting genetic features that could make coronaviruses better able to infect human cells. (Daszak and EcoHealth did not respond to requests for comment on this story.) The document seems almost tailor-made to buttress one specific theory of a laboratory origin: that SARS-CoV-2 wasn’t simply brought into a lab by scientists and then released by accident, but rather pieced together in deliberate fashion. In fact, the work described in the proposal fits so well into that narrative of a “gain-of-function experiment gone wrong” that some wondered if it might be too good to be true. Central figures in the coronavirus-origins debate were involved: Among Daszak’s listed partners on the grant were Ralph Baric of the University of North Carolina at Chapel Hill, an American virologist known for doing coronavirus gain-of-function studies in his lab, and Shi Zhengli, the renowned virus hunter from the Wuhan Institute of Virology. (Shi Zhengli has not responded to a request for comment. A UNC spokesperson responded on behalf of Baric, noting that “the grant applicant and DARPA are best positioned to explain the proposal.”) There is good reason to believe the document is genuine. The Atlantic has confirmed that a grant proposal with the same identifying number and co-investigators was submitted to DARPA in 2018. The proposal that circulated online includes an ambitious scheme to inoculate wild bats against coronaviruses, carried out in concert with the National Wildlife Health Center, a research lab in Wisconsin. A spokesperson for the U.S. Geological Survey, which oversees the center, acknowledged this connection and affirmed the identifying number and co-investigators, noting that the agency’s involvement in the project ended with DARPA’s rejection of the grant proposal. “This is the proposal that was not funded,” USGS Acting Press Secretary Rachel Pawlitz said after reviewing the PDF. She could not, however, vouch for the document in its entirety. Jared Adams, DARPA’s chief of communications, said in an emailed statement that the agency was not at liberty to discuss proposals submitted as part of its emerging-pathogenic-threat program, which was launched in January 2018, and that DARPA has never funded “any activity or researcher associated with EcoHealth Alliance or Wuhan Institute of Virology.” An article about the proposal published yesterday in The Intercept points to a tweet by Daszak last weekend, before the PDF was widely shared, that refers obliquely to the release of unfunded grant proposals. For anyone looking for the great, final vindication of the lab-leak hypothesis, this document will leave you wanting. Does the SARS-CoV-2 pandemic have an unnatural origin? The answer hasn’t changed: probably not. But we have learned something quite disturbing in the past few days, simply from how and when this information came to light. The pandemic-origins debate is a big, confusing mess—but it’s an important mess, so bear with us. The hottest news in the leaked proposal concerns the researcher’s plan to sift through a large trove of genomic-sequence data drawn from samples of bat blood, feces, and other fluids, in search of (among other things) new kinds of “furin cleavage sites.” When these are encoded into just the right spot on the spike protein of a coronavirus, they allow that spike to be opened up by an enzyme found in human cells. According to the proposal, “high-risk” versions of these sites, once identified, would then be introduced via genetic engineering into SARS-like coronaviruses. Why does this matter? We’ve long known that the presence of such a site in SARS-CoV-2 increased its pathogenic power; and we also know that similar features have not been found in any other SARS-like coronavirus (though we may find them in the future). For lab-leak proponents, these facts—combined with certain details of the furin cleavage site’s structure—strongly hint at human intervention. As the science journalist Nicholas Wade argued in an influential lab-leak-theory brief last spring, this genetic insertion “lies at the heart of the puzzle of where the virus came from.” The virologist David Baltimore even told Wade that the structure of the SARS-CoV-2 furin cleavage site was “the smoking gun for the origin of the virus.” (Baltimore later walked back his claim.) As many scientists have since pointed out, the mere presence of the furin cleavage site is not dispositive of a Frankenstein experiment gone wrong. For example, the same genetic feature has come about, quite naturally and independently, in plenty of other, more distantly related coronaviruses, including those that cause the common cold. According to a “critical review” co-authored by 21 experts on viruses and viral evolution that was posted as a preprint in July, “simple evolutionary mechanisms can readily explain” the site’s presence in SARS-CoV-2, and “there is no logical reason” why it would look the way it does if it had been engineered inside a lab. “Further,” the authors wrote, “there is no evidence of prior research at the [Wuhan Institute of Virology] involving the artificial insertion of complete furin cleavage sites into coronaviruses.” But the apparent DARPA grant proposal complicates these arguments, at the very least. The engineering work that it describes would indeed involve such an artificial insertion. We don’t know whether that work was ever carried out—remember, DARPA rejected this proposal. Even if it had been, several experts told us, the genetic engineering would have happened at Ralph Baric’s lab in Chapel Hill, about 8,000 miles away from where the SARS-CoV-2 outbreak started. Yet now we know that the idea of inserting these sites was very much of interest to these research groups in the lead-up to the pandemic. “This is the first time they reveal that they are looking for these sites,” said Alina Chan, a scientist in Boston and a co-author of the forthcoming book Viral: The Search for the Origin of Covid-19. Stephen Goldstein, a postdoctoral researcher in evolutionary virology at the University of Utah and one of the co-authors of the pandemic-origins critical review, considers it “unlikely” that any such work would have gone forward in Wuhan. It would be unusual—even unethical—for a lab in China to pursue experiments that were originally proposed by one of its collaborators in the United States, he told us. Another co-author of the critical review, the Johns Hopkins University microbiology postdoc Alex Crits-Christoph, noted that the proposal doesn’t specify the virus into which any novel cleavage sites would be inserted. Unless the Wuhan lab had already isolated a SARS-CoV-2-like virus that could carry this insertion—which Crits-Christoph doubts, given the wording of the proposal—researchers at WIV would not have had enough time between early 2018 and the fall of 2019 to construct (and then mistakenly release) the virus at the root of the pandemic. Still, these scientists agree that the very fact that these experiments were even on the radar raises significant concerns. “I recognize this revelation opens up legitimate lines of questioning that are serious and need to be addressed by the people involved,” Goldstein told us via email. Crits-Christoph said it pushed the existing evidence “one step closer to the lab-engineering hypothesis”—but added that, given the improbable timeline, it moved things “one step further as well.” With discussions of the lab-leak hypothesis being how they are, other scientists took a different point of view—one less skeptical of the idea that the experiments could have been carried out in China. Jesse Bloom, a computational biologist and expert in viral evolution at the Fred Hutchinson Cancer Research Center in Seattle, called the timeline “plausible … certainly possible.” Chan pointed to other recent reports that the team at the Wuhan Institute of Virology had already been sampling very close relatives to SARS-CoV-2, and that it was testing, in humanized mice, genetically engineered SARS-like coronaviruses that were more infectious than natural strains. “WIV was fully outfitted to run all these experiments themselves,” she said. Like we said before, this is all a big, confusing mess. Even if it is authentic, as it appears to be, the DARPA proposal does not prove the lab-leak hypothesis, nor does it come close to changing the consensus view that the pandemic started from a natural source. Instead, what this week’s news really points to is how things got so messy in the first place—and they remind us that things didn’t need to be this way. Why did this proposal have to be leaked by an anonymous whistleblower, in the form of a wonky PDF, to a group of amateur sleuths? In May 2020, only a few months into the pandemic, EcoHealth’s Peter Daszak ridiculed discussions of the furin cleavage site and whether it might be bioengineered as the ranting of conspiracy theorists. Six months later, Daszak was involved in two major, international investigations into the pandemic’s origins, organized by the World Health Organization and the British medical journal The Lancet. Now it appears that, just a few years earlier, he’d delivered a detailed grant proposal to the U.S. government, with himself as principal investigator, that described doing exactly that bioengineering work. “It’s just shocking,” Chan said. The pattern here is unmistakable: At every turn, what could be important information has been withheld. Two weeks ago, The Intercept published 528 pages of documents, obtained only after a litigated FOIA request to the National Institutes of Health and a 12-month delay, that describe experiments on hybrid coronaviruses that some experts consider risky, carried out in Wuhan with the support of EcoHealth and the U.S. government. (These experiments could not have led directly to the pandemic. A spokesperson for the NIH told The Intercept that the agency had reviewed data from the experiments and determined that they were not dangerous.) In June, Bloom, the Seattle computational biologist, discovered that several hundred genetic sequences drawn from very early COVID-19 patients had been mysteriously deleted from a public database. (They’ve since been restored.) Other facts that could be relevant to the origins debate have trickled out from obscure student work and other surprising sources. Even as a natural origin remains the most plausible explanation, these discoveries taken as a whole demonstrate beyond a reasonable doubt that good-faith investigations of these matters have proceeded in the face of a toxic shroud of secrecy. Vaughn Cooper, who studies pathogen evolution at the University of Pittsburgh, told us that he hasn’t changed his view that SARS-CoV-2 is extremely unlikely to have been created in a lab—but the lack of candor is “really concerning.” The DARPA proposal doesn’t “mean that much for our understanding of the origins of the pandemic,” he said, “but it does diminish the trustworthiness of the research groups involved.” “I find it disappointing and disturbing that something like this is coming out in the form of a leak,” Bloom told us. “If there’s information that is relevant or informative to this discussion—anything that people could conceivably think is relevant—it needs to be made available.” Until that happens, or unless that happens, the mess will only spread. from https://ift.tt/2Zka13l Check out http://natthash.tumblr.com The definition of full vaccination against COVID-19 has, since the winter, been somewhat difficult to nail down. It takes one dose of Johnson & Johnson, but two doses of an mRNA vaccine. The CDC counts you as fully vaccinated as soon as you get your last shot, but tells you that you won’t be fully vaccinated until two weeks after that. People have a hard time knowing exactly when it might be safe for them to venture into restaurants, wedding venues, or mask-free offices. Now, in the age of booster shots and breakthrough cases, the phrase has gotten even murkier. Early this morning, the CDC officially backed booster shots for tens of millions of Americans who are six months past their second Pfizer dose: those over 65, those in long-term-care facilities, and all adults who have an underlying medical condition that puts them at high risk of severe COVID-19 or who are at high risk of getting sick from occupational or institutional exposure to the coronavirus. During a two-day meeting of the CDC’s Advisory Committee on Immunization Practices this week, the CDC’s Sara Oliver advised the committee that the agency’s definition of fully vaccinated would not change—at least for now. That makes it much less useful as a category: Will some fully vaccinated people be more vaccinated than others? And it leaves open the possibility that the definition could change as more information becomes available: If you’re fully vaccinated now, could you become un-fully vaccinated a few months down the line? These questions go beyond semantics. As more and more Americans are mandated to be “fully vaccinated” in order to work—see here, here, and here, for example—continued clarity on what that category means, and who belongs in it, will be crucial. Fully vaccinated didn’t originate with the coronavirus. The term has been used for other vaccine series that require multiple shots, such as those for measles, hepatitis B, and HPV. Currently, the CDC considers people to have achieved full vaccination against COVID-19 “2 weeks after their second dose in a 2-dose series, such as the Pfizer or Moderna vaccines, or 2 weeks after a single-dose vaccine, such as Johnson & Johnson’s Janssen vaccine.” The agency’s website does include a caveat: For the immunocompromised, being fully vaccinated might not be the same as being fully protected, so a third shot is a good idea. Part of the problem is that the difference between full vaccination and full protection has been explained less than perfectly to the American public. The truth is, no one is 100 percent protected from the coronavirus after vaccination, regardless of how healthy their immune system is; that’s simply not how vaccines work, especially in the context of a pandemic virus that hasn’t stopped evolving. “You cannot definitively say, until we have finally beat the virus or gotten it to a point where it is no longer killing people, that you are [fully] protected,” says Ruqaiijah Yearby, a health-law expert and co-founder of Saint Louis University’s Institute for Healing Justice and Equity. Even before booster shots were a mainstream possibility, the concept of full vaccination could lead people to develop what Saskia Popescu, an infectious-disease epidemiologist at George Mason University, calls a “Superman complex.” After getting their J&J shot or their second mRNA dose, some people feel immediately invincible, she told me, as though nothing they do is dangerous to themselves or the people around them. The ongoing discussion about boosters could be an opportunity to undo the Superman complex by adding some nuance, reminding the public that no vaccine is perfect and that we all must work together to get the pandemic under control. Such a rethinking could even go beyond COVID vaccines. “Maybe we need to reimagine how we communicate vaccines in general,” Popescu said. A sudden injection of nuance could confuse a lot of people, though, and even discourage some from getting their first shot by making the process seem especially convoluted or onerous. For schools, businesses, and other institutions that have implemented vaccine requirements over the past few months, it would likely be a nightmare. If getting two shots doesn’t guarantee that you’re fully vaccinated, then who should be allowed to come to work? Will schools need to interview every teacher who was vaccinated before April about their medical history? Now that the CDC has recommended that a select swath of the population gets a third dose to help keep them from getting sick and spreading the virus, institutions that require full vaccination will be faced with some difficult choices. Should they demand that immunocompromised 40-year-olds get a third shot, while asking nothing more of 40-year-olds with healthy immune systems? Should they require proof of booster shots from only those who got the Pfizer vaccine, because they’re the only ones for whom boosters have been authorized so far? Or would it make more sense for companies to stick with the definition of fully vaccinated that they’ve been using to this point? Seema Mohapatra, a visiting law professor at Southern Methodist University, told me that setting up different rules for different people probably would not create legal liabilities for the mandating party, but it could lead to “practical, administrative problems.” Restaurants and theaters, for example, have no way of verifying their patrons’ health status, so they can’t know who is in a booster-eligible category. HR departments would be hard-pressed to track which vaccine Carol from accounting received, how long it’s been since her last dose, and how that lines up with her 65th birthday. There are also ethical problems to consider: Even if it’s legal, is it really fair to ask essential workers and immunocompromised people to get more doses than others in order to make a living, or even just to go out to eat? Given that plenty of underserved communities still have trouble accessing the shots, asking even more of the most vulnerable among us—without accompanying policies to bring them shots where they live and work, guarantee them paid time off, and offer them hazard pay—would be hard to justify. The problem isn’t just with updates that affect different people differently, but also with constant, complicated shifts in policy, according to Jason Schwartz, a vaccine-policy expert at the Yale School of Public Health. If employers and schools update their mandates with every incremental change to the CDC’s recommendations, he told me, their tweaks could backfire and discourage vaccination. It would be better to wait for the CDC to recommend universal boosters, and then update the rules for everyone at the same time. On the national level, mandates probably won’t change much in the immediate future. Anthony Fauci, the director of the National Institute of Allergy and Infectious Disease and Joe Biden’s chief medical adviser, told The Atlantic this week that for at least the next few weeks, “any vaccine mandates would have to go with the original vaccine regimen.” Paul Offit, who directs the Vaccine Education Center at the Children’s Hospital of Philadelphia and serves on the FDA advisory committee that recommended authorizing third Pfizer doses for a select group last week, told me that as far as a three-dose mandate goes, “I just don’t think it’s right now.” Continued clarity over who counts as fully vaccinated wouldn’t just help employers set rules. It would also give researchers more precise language with which to investigate breakthrough infections and vaccine efficacy. Popescu pointed out that a reworked definition of fully vaccinated could allow for multiple definitions of partially vaccinated too. Are those who haven’t gotten their second mRNA dose really in the same category as those who got their second shot more than six months ago but haven’t yet gotten a booster? Should a breakthrough infection in the first group be given the same weight as one in the second, for the purposes of assessing how well the shots are working or who can safely be invited to your dinner party? One common critique of the push for boosters is that it has no limits, that we may end up needing a fourth booster, or a fifth, or a shot every six months for the rest of our lives. “I do think that the endgame in a year or two will likely be a vaccination program that regularly updates the vaccine and is administered on a set schedule for everyone,” Schwartz said. COVID shots might even be combined with annual flu shots. If that’s what happens, employers and schools will have new choices to make about mandates, such as whether to require shots for their employees every year and whether to provide those shots on-site. The longer we live with endemic COVID, and the more normal and predictable boosters become, the easier these conversations will be. Katherine J. Wu contributed reporting. from https://ift.tt/3o46IYl Check out http://natthash.tumblr.com On Saturday morning, I finally rolled up my sleeve for the vaccine I’d been waiting for all summer: my annual flu shot, a technological marvel that I opt to receive every fall. During non-pandemic times, the flu vaccine is a hot autumn commodity that holds a coveted place in the public-health spotlight. As of late, though the shot’s been eclipsed by the prominence of its COVID-blocking cousins, fueled by debates over boosters and mandates. It’s also been a while since we’ve had to tussle with the flu directly. Thanks to the infection-prevention measures the world took to fight SARS-CoV-2 when the pandemic began, many other respiratory viruses vanished. Last winter, we essentially had “no flu season at all,” Florian Krammer, a virologist at Mount Sinai’s Icahn School of Medicine, told me. The human attention span is short; the flu’s brief sabbatical might have purged it from our minds at an inopportune time. An absent virus isn’t necessarily an extinct one, and the flu’s return was always going to be a matter of when, not if. And as the weather cools, experts are worried that skipping a season of sickness could come with costs, if we don’t raise our antiflu shields anew. Immune defenses can rust and crumble; flu viruses might return to find a slew of hosts more vulnerable than they were before, especially now that kids are back in classrooms and mask ennui continues to balloon nationwide. “I worry that we are not paying attention,” Hana El Sahly, an infectious-disease physician and vaccine expert at Baylor College of Medicine, told me. Flu shots, then, are particularly valuable this year—perhaps more so than they’ve been in quite some time. Concerns about resurgent flu aren’t new. Back in February, when I first wrote about the lull in flu cases, experts were already warning the bugs’ truancies could make them more unpredictable. Flu viruses, already a familiar threat to our immune system, spread less easily than SARS-CoV-2, which made them easier to stamp out with masks, physical distancing, school closures, and international travel bans, even when adherence was spotty. Cases around the globe plummeted. But “no one expected flu to go away forever,” Mary Krauland, an infectious-disease modeler at the University of Pittsburgh, told me. Now we’re teetering on the edge of the year’s chilly turn as pandemic restrictions wax and wane. Many experts suspect that we might be in for a flu season worse than the previous one, in part because the previous one was so mild. The threshold for an outbreak this year could very well be lower. “I’m probably 60–40: 60 we will have a season, 40 we won’t,” Richard Webby, an influenza expert at St. Jude Children’s Research Hospital, in Tennessee, told me. “My gut feeling is, if it does come back, there’s going to be a little more punch.” The flu’s absence did have positives. It spared health-care workers, hospitals, and the general population a second winter swell of sickness, atop an already overwhelming pandemic. Our not-flu season also starved the viruses of hosts in which to multiply and shapeshift and persist. Some experts are hopeful that certain lineages might have been squeezed out of existence entirely, or at the very least came close. That could mean that we have fewer flu flavors to contend with, and vaccinate against, in the future, though their disappearance isn’t yet certain. . But the previous season also left our sometimes-forgetful immune cells without an important annual reminder: Flu viruses do, in fact, exist, and can wreak serious havoc on the body. Reasonably good flu-vaccine coverage last winter certainly jogged our bodies’ memories. But without the additional alarms raised by actual illness—which during normal times hits many millions of people in the United States alone—people’s bodies might not be as tuned up as they should be. “You really need the seasonal waves to drive up population-level immunity and prevent large outbreaks,” Helen Chu, a physician and immunologist at the University of Washington, told me. Infants and young kids might be especially vulnerable this year because a higher number of them than usual may have never met a flu virus. Schools are open again, many without mask requirements, adding risk for both children and those who interact with them. “When it comes to influenza,” El Sahly said, “children are the engines of transmission in the community.” A preview of this pattern already unfolded in the spring and summer with respiratory syncytial virus, another airway-loving pathogen that hits kids particularly hard. Like flu viruses, RSV all but evaporated last winter, but it was able to wriggle its way back into the American population around the start of April, when many COVID-19 restrictions relaxed. [Read: The pandemic broke the flu] Two recent models from Krauland and her colleagues at the University of Pittsburgh, posted in preprint papers last month, hint at the toll of missing out on our yearly immune boost. Flu cases and hospitalizations, the studies found, could both experience a bump this year, potentially beyond that of typical seasons—an additional burden that the pandemic-battered health-care system can little afford. That’s especially likely if COVID precautions keep falling away, or if we’re hit with an especially contagious flu strain that our bodies don’t recognize well. Worryingly, other experts pointed out, flu viruses and SARS-CoV-2 might even invade some of the same individuals at once, which could fuel very serious bouts of illness among the vulnerable. These aren’t foregone conclusions, Kyueun Lee, who led one of the studies, told me. Our social behaviors still aren’t back up to their pre-pandemic levels; even intermittent masking, distancing, and the like could put a damper on the flu’s upcoming campaign. In Australia, a nation that countries in the global North usually look to as an epidemic bellwether, flu levels have stayed fairly low, which could bode well for the United States, Ibukun Kalu, a pediatric-infectious-disease physician at Duke University, told me (although she added that the American approach to COVID containment has been “vastly different” from the Australian one). Case counts could end up between last year’s startling low and the pre-pandemic norm. We also have an extraordinarily powerful, yet underused, tool in our arsenal: an immunity-boosting vaccine. The flu shot typically reaches only about half of the U.S. population, but Lee thinks that ratcheting up that percentage this year is essential, because it could help seal some of the cracks that COVID mitigations left in our antiflu armor. “Getting a flu vaccine this season may be particularly important,” Lynnette Brammer, who leads the CDC’s domestic influenza-surveillance team, wrote in an email. But there’s yet another catch. Normally, surveillance centers stationed around the globe are able to amass many thousands of viral genome sequences to get a good read on which versions of flu viruses are bopping around—which ones might be poised to make a resurgence if given the opportunity. Scientists mine this wealth of data when selecting strains for the yearly shot. But last winter, that genetic wellspring dried up. “It’s hard to pick if you don’t have a clear picture of what’s out there,” Krammer told me. But there was enough data to make an informed decision, experts reassured me. “The match is always a gamble,” said El Sahly, who was a member of the committee that advised on the FDA’s final vaccine formulation. “Even having high transmission beforehand doesn’t guarantee strain selection is going to be spot-on.” Generally speaking, flu-shot effectiveness against disease tops out at roughly 60 percent. But like most other immunizations, the vaccine is stellar at curbing the severity of symptoms and keeping people out of the hospital; even a somewhat mismatched vaccine could make an enormous dent in the viruses’ impact. “No matter what, it’s going to protect you at least a little bit,” Chu said. Flu shots are also good at hedging bets. The standard “quadrivalent” formulation contains safe, inactivated representatives from four branches on the flu tree: H1N1 and H3N2, subtypes that belong to the influenza-A family, and B/Victoria and B/Yamagata, lineages in the influenza-B family. Flu-A viruses generally shape-shift more rapidly than their B-list cousins, so those ingredients change more often. The shot I got this weekend contained two updates, compared with last year’s recipe, that will hopefully prepare me better for the flu strains du jour. (Kalu pointed out another perk: We’re still waiting for the official green light on the COVID-19 vaccines for the under-12 crowd, but the flu shot is available now for kids as young as six months old.) Regardless of how the flu collides with us this winter, my recent vaccine is an insurance policy: Either way, I’m better protected than I was. Getting the shot was also easy. I was able to get an appointment on my first try; the injection itself, which was free and painless, took only a second at my local CVS. (Flu shots and COVID-19 shots, by the way, can be administered at the same time.) It was clearly the awakening my body needed: Within hours, my arm had swelled up a bit; eventually, so did the lymph nodes next to it, likely as they filled with hordes of grumpy, flu-sensitive immune cells, some likely roused from a two-year slumber. I felt a little achy, a little tired. I felt so much better than I had before. from https://ift.tt/3zvt47b Check out http://natthash.tumblr.com I watched the entirety of Couples Therapy from my childhood bedroom while visiting my parents in July. It was as apt a time and place as any for entertaining some heavy psychoanalytic ideas that would, no doubt, cause me to reflect on my life. The Showtime docuseries follows Orna Guralnik, a real-life psychologist in New York, as she works with couples over the course of several months. Deep into the second season, Guralnik challenges one woman to consider that the bursts of anger she feels toward her husband aren’t actually about him, but are instead motivated by anxiety inherited from a demanding mother who considered herself a failure. “Anxiety tells you something about your parents’ unhappiness, and your being recruited to do something about it,” Guralnik tells the woman. At this point, I had to close my laptop and stare at the wall for a few minutes. Had I been running emotional errands for the two people down the hall without realizing? I wasn’t sure whether it was wise, or fair to my parents, to apply what Guralnik had said to my own life, but I had some ideas about how I might do so. Couples Therapy makes for good TV: The couples come off as vivid and earnest, but there’s still lots of drama, if not quite the over-the-top kind you can find on reality shows like The Bachelor and Real Housewives. They point fingers, reach stalemates, and struggle to see how past trauma has shaped the way they treat their partners. With time, some of them do make progress, coming to understand their role in negative relationship dynamics and learning to take a more empathetic view of their partner. The show belongs to a budding genre—let’s call it “therapy voyeurism”—in which real counseling sessions are recorded and packaged for mass consumption: In addition to Couples Therapy, there’s Viceland’s The Therapist and Esther Perel’s couples-therapy podcast, Where Should We Begin?, both of which debuted in 2017. (The former lasted one season, while the fourth season of Perel’s podcast came out last year.) My own experience watching Couples Therapy led me to wonder whether therapy voyeurism can be more than just entertainment. Right now, people would have good reason to turn to these shows as a stand-in for or supplement to actual therapy. The pandemic has ushered in a profound mental-health crisis, and although many people were kept out of therapy in normal times because of a lack of time and money, even those who are actively pursuing treatment now have been stymied by a shortage of therapists with openings in their schedules. Coincidentally or not, a Showtime spokesperson said that streaming viewership of Couples Therapy had doubled from its debut season, in 2019, to its second season, which came out in April. I reached out to some psychologists to get their take on the phenomenon, and they were very clear: Therapy voyeurism is not real therapy—but that doesn’t mean it’s totally pointless either. [Esther Perel: Why happy people cheat] In all likelihood, viewers won’t walk away from an episode (or even a season) of Couples Therapy with a how-to guide for managing their anxiety, lifting their depression, and solving their relationship problems. But in the most basic sense, watching Guralnik guide couples toward the root of their conflict through a combination of questions and observations can give you a better understanding of how to work through your feelings. This, says Steven Tuber, a professor of clinical psychology at the City College of New York, isn’t so different from the outcome of actual therapy, in which psychologists are generally less keen on telling their patients exactly how to handle a situation than giving them a new way to think about their problems. “If you give a person a fancy interpretation, they’ll feel a lot better that day,” he told me. “But if you teach them to think psychologically, they can do that for a lifetime.” Guralnik certainly got in my head. After watching the show, I found myself considering my own role in perpetuating certain dynamics in my relationship, rather than assuming that they begin and end with my boyfriend. I became more open to the possibility that my negative reaction to something he does might have more to do with my existing anxieties than his inherent wrongness. (Though, sometimes, yes, he’s dead wrong.) Reckoning with these ideas didn’t make me feel like I was uniquely bad at relationships—after all, I’d just watched several other people do the same. Another potential benefit of therapy voyeurism, Tuber said, is that these shows could encourage people to seek out a therapist by showing them what treatment actually looks like. (Assuming, of course, that they can get an appointment in the pandemic rush for mental-health support.) While the stigma around therapy has diminished over time, it remains a significant barrier for many people who could benefit from getting help. “If [the psychologist] comes off as thoughtful and multidimensional, it will make it easier for people on the fence to say, ‘This isn’t so scary, I’m going to look into this,’” he said. People who are already in therapy stand to gain something too: They can see how they respond to different approaches, making them more informed consumers and potentially compelling them to find a therapist who better fits what they’re looking for. [Read: Why your shrink wasn’t offering virtual therapy until now] Last month, I reached Guralnik over Zoom, and she confirmed that I’m not alone in using Couples Therapy as a lens through which to look at my own life. (Her dog, Nico, an Alaskan Klee Kai and a delightful presence on the show, was asleep on the couch behind her.) “People typically watch the show with other people,” she said. Parents and children, romantic partners, and friends tune in together, and they’ll hit pause throughout to discuss their own relationships. “They’ll say, ‘Oh, he reminds me of you,’ or ‘He reminds me of me,’” Guralnik said. “We didn’t know that was going to happen.” Guralnik doesn’t see Couples Therapy as a replacement for, well, couples therapy. “Hopefully people are not going to use the show to do that,” she said. But in her view, it can be helpful for the same reason it’s not an adequate substitute: It’s not about you. Just as children’s make-believe games allow them to engage with scenarios that they may encounter later in life, Guralnik sees her show as a space where adults can imagine their own issues played out from a safe remove. This distance frees us up to think more creatively, come up with different solutions, and hold greater compassion for ourselves and others. But what that means is that therapy voyeurism is just one of many activities that provide us with this kind of productive distance from ourselves. In fact, they’re all around us: Books, movies, games, and even sports can all serve a similar function. In a couples-therapy program she teaches, the Chicago psychotherapist Karen Bloomberg assigns Alain de Botton’s The Course of Love, a novel that tells the story of a long-term romantic relationship and ends each chapter with an analysis of the couple’s dynamic. “It sounds kind of hokey, but it’s very well done,” she told me. She and her husband ended up discussing their own relationship after they’d both read it, and she recommended it to their adult children. As with therapy shows, it provides a new way of seeing your problems: “It’s not you, but it could be you, and it could hold the space until you’re ready to look at yourself in that way,” she said. [Read: The quick therapy that actually works] None of the psychologists I talked with mentioned any major downsides of consuming therapy shows and podcasts, though it seems possible that some viewers might overextrapolate from them in the same way that WebMD can spur people into thinking their minor problems are actually cancer. But the irony of therapy voyeurism is that its potential benefits may be limited by the genre’s reach. Tuber said he was skeptical that therapy shows would penetrate beyond the relatively narrow slice of the population that is already open to the therapeutic process: In 2019, less than 20 percent of adults had received mental-health treatment in the past year, according to the CDC, and those who did were far more likely to be white and female. “Overwhelmingly, when people are struggling with issues, they talk to a family member, religious figure, or their general practitioner way before they go see a therapist,” Tuber said. (Guralnik said she has heard from viewers all over the world, though Showtime would not provide details on the demographics of the show’s viewership.) I’d bought into the idea of therapy well before I heard about Couples Therapy, and the show appealed precisely because I already wanted to go deeper into that world. Watching it made me feel good about myself: smarter, because I could clearly see when someone was assigning too much blame to their partner; more benevolent, and maybe a bit saintly, because I learned to empathize with those on the show who struck me as absolute villains at the outset. These lessons, if not the self-aggrandizement, were a good thing, and they were largely possible because of the neutrality and emotional buffer I was afforded as an outside observer. But while that buffer can be useful, it has to come down if you want to truly dig into your own psyche. Unfortunately, bingeing a show has not fixed all the problems in my life. “We talk a lot about ‘bringing something into the room.’ What that means is really experiencing the vulnerability right there, in the moment, with the therapist,” Bloomberg said. “That’s what doesn’t happen when you’re watching.” from https://ift.tt/3AAqRbZ Check out http://natthash.tumblr.com Boghuma Kabisen Titanji was just 8 years old when the hyper-contagious virus swept through her classroom. Days later, she started to feel feverish, and developed a sparse, rosy rash. Three years after being fully dosed with the measles vaccine, one of the most durably effective immunizations in our roster, Titanji fell ill with the very pathogen her shots were designed to prevent. Her parents rushed her to a pediatrician, worried that her first inoculations had failed to take. But the doctor allayed their fears: “It happens. She’ll be fine.” And she was. Her fever and rash cleared up in just a couple days; she never sickened anyone else in her family. It was, says Titanji, now an infectious-disease physician and a researcher at Emory University, a textbook case of “modified” measles, a rare post-vaccination illness so mild and unthreatening that it doesn’t even deserve the full measles name. The measles virus is ultra-infectious, much more so than SARS-CoV-2, and kills many of the uninoculated children it afflicts. But for those who have gotten all their shots, it’s a less formidable foe, which we’ve learned to live with long-term. That’s the direction that many experts hope we’re headed in with SARS-CoV-2 as it becomes endemic, as my colleague Sarah Zhang has written. We’re not yet at the point where we can officially label post-vaccination COVID-19 cases as “modified”; maybe we never will be. Some immunized people are still getting dangerously sick. But the shots are softening COVID-19’s sharp edges: On average, breakthrough infections seem to be briefer, milder, and less contagious. Among the fully immunized, catching the coronavirus doesn’t mean the same thing it did last year. “It’s a very different kind of infection than in people who are immunologically naive,” Lindsey Baden, an infectious-disease physician and COVID-19 vaccine researcher at Brigham and Women’s Hospital in Boston, told me. If this virus becomes as inescapable as the culprits behind the colds and flus that trouble us most years, we could all have to grapple with one of these infections, and learn that lesson on a personal level. That’s the social tax of a forever virus: Nearly everyone may eventually know what it is to get COVID-19—but a tamer, more domesticated version of its pre-inoculation self. Since the start, COVID-19 has been tough to define. Part of the problem is that COVID-19 is the disease, not the virus. Actual microbes, compared with the problems they cause, are arguably neater conceptual packages. SARS-CoV-2 is a knowable pathogen, a tangle of genetic material swaddled in a protein coat; COVID-19 has fuzzier boundaries, dependent on both the virus and how our bodies react to it. To understand that interaction, researchers had to, unfortunately, wait for a decent number of people to get sick—to observe the virus screwing with us in real time. Next to other airway-loving viruses, such as the ones that cause the flu and common colds, SARS-CoV-2 can be a bit of an oddball. It lopes almost indiscriminately throughout the body, invading a plethora of tissues; it winds up certain immune responses, while dialing others down, sparking bouts of inflammation that can afflict everything from brain to toe. COVID symptom lists that at first focused on the virus’s ground zero--the respiratory tract—eventually ballooned to include nausea, vomiting, changes in mental status, and chest pain. Infection severity operates on a continuum, and SARS-CoV-2 occupies its spectrum fully. Many people never realize they’re infected; others might have a two-day tickle in their throat, while some weather the disability of long-haul COVID for months; a fraction end up ventilated in the ICU. The experience of having COVID is now poised to splinter further, along immunological boundaries largely defined by vaccines. Inoculated bodies are less hospitable to SARS-CoV-2, making it harder for the pathogen to infect them; when it still manages to, it seems to be purged much faster, affording it less time to cause symptoms—especially the bad ones—and fewer opportunities to hop into other hosts. “I think about it as defanging the virus,” Natalie Dean, a biostatistician at Emory, told me. A recent study from the United Kingdom illustrates this well. Researchers surveyed nearly 4.5 million people through a cellphone app, asking whether they’d tested positive for the virus, and if they were experiencing any of about two dozen symptoms. Roughly 1 million of them had received at least one vaccine dose. Among the fully immunized, nearly all the symptoms—including fever, nausea, and brain fog—were rarer. Many of the cases were totally asymptomatic. Even rates of long COVID, which can sprout from initially silent infections, seemed to be substantially slashed by shots. These qualitative shifts aren’t easy to capture, especially with the studies coming out now that measure vaccine effectiveness in the real world. Most of them gravitate toward metrics at two opposite ends of the SARS-CoV-2 spectrum—how well the vaccines protect against all infections, or against severe disease, hospitalizations, and death—with less precision around the murky hinterlands of mid-level symptoms that exist in between. (The most serious outcomes are, to be fair, what vaccines are intended to prevent, and what inoculated immune systems are best at staving off, making that metric a pretty good one to concentrate on.) Focusing on the extremes, though, blurs the texture in the middle. In studies of effectiveness against severe disease, anything too “mild” to be considered a serious illness—warranting hospitalization, for instance—ends up collapsed into a single category. At the other end of the spectrum, counting all infections equates every positive test to a case of concern, regardless of how gentle the viral encounter was. All of this makes it very difficult to characterize what post-vaccine COVID actually is—and to know whether immune responses are diluting the disease’s sting. “Just looking at the rate … loses that point,” Holly Janes, a biostatistician at the Fred Hutchinson Cancer Research Center in Seattle, told me. The experience of infection can be “considerably different for someone who was vaccinated.” [Read: We’re asking the impossible of vaccines] This isn’t an easy dilemma to solve. During the vaccine makers’ clinical trials, researchers were able to study participants closely enough to examine how well the shots were blocking any symptomatic cases of COVID-19. (Studying only the severest disease, which are relatively rare events, wouldn’t have been feasible without making the trials even larger, or stretching them out longer.) “Real-world studies are like the wild, wild West,” Dean told me. Researchers often have to wrestle evidence out of electronic medical records, which aren’t logged consistently, or they have to depend on people to seek out tests and accurately remember their symptoms. They might monitor only the worst infections, because they’re more likely to prompt people to seek clinical care and are easier to document and study. Milder cases, meanwhile, are squishier, more subjective; not everyone will interpret an ache or a pain in the same way, or follow up on it with a professional. The studies that have tackled the task of measuring real-world vaccine effectiveness against all symptomatic disease may not always count the same COVID-19 symptoms, experts told me, potentially inflating or deflating numbers. Thorniest of all may be the data investigating long COVID, which still lacks a universal case definition, after vaccination, Lekshmi Santhosh, a critical-care physician at UC San Francisco, told me. “Most studies aren’t even looking,” she said. Important variations exist, even at SARS-CoV-2’s extremes. Some hospitalized patients might be admitted for just a couple days, while others need weeks of critical care or die. Early evidence hints that vaccines are batting away the worst blows here as well, another nuance lost when hospitalizations are lumped together. Positive test results, too, can be misleading. Tests, which hunt for precise pieces of the pathogen, can’t distinguish between viruses that are intact, or that have been blown to smithereens by a protective immune response; SARS-CoV-2 carnage, especially in a person who’s immunized and asymptomatic, doesn’t guarantee disease or transmission. “It doesn’t mean the same thing to test positive if you’re vaccinated,” Julie Downs, a health-communications expert at Carnegie Mellon University, told me. Still, some infections among immunized people will pose a low-but-not-nonexistent transmission risk, especially to the vulnerable among us, and we can’t yet afford to tune the milder cases out. A much larger fraction of the global population will need protection before COVID-19 can truly be considered mellower than before. But the fates of the inoculated and the uninoculated are clearly already forking, a potential preview of what’s to come, Baden, the Boston physician, told me. “If I were a betting man, I’d say, years from now, this will be another common cold.” Titanji, of Emory, has already confronted the likelihood that her childhood bout of modified measles might foreshadow her experience with the coronavirus. When she sees patients in her clinic in Georgia, she tells them, “We’re all very likely going to have COVID, including myself. But it is okay. I have a vaccine that will prevent me from landing in the hospital.” COVID-19’s march toward diminution won’t be linear or uniform. Immune cells forget; viruses shape-shift; our vaccines will need touch-ups or boosts. Behavioral slipups—vaccine refusals, spotty masking during outbreaks—will create cracks for the pathogen to wriggle through. But on a population level, our future could look quite good. Most people will end up getting COVID-19 in their lifetime. In most cases, it won’t be so bad. Eventually, silent or mild infections will feel less catastrophic, because many of us will have confidence that they are unlikely to progress. Outbreaks might be smaller and slower-spreading, and breakthroughs will no longer be headline-making news. Positive test results, in the absence of symptoms, could generally be shrugged off, and infection will no longer feel quite so synonymous with disease. Our bodies will come to see the virus as familiar—not necessarily a welcome guest, but not quite the intruder it was before. Data alone won’t define our experience here; our understanding of post-vaccination infection will need to come firsthand, too. For me, the pandemic anxiety that dominated much of 2020 is slow to fade, and the idea of getting COVID-19 still feels far worse than getting the flu, even if the symptoms were identical. “It takes time to get over that,” Downs told me. [Read: Your vaccinated immune system is ready for breakthroughs] A small number of post-vaccination infections are now trickling into my social circles, and it’s actually been sort of comforting to hear some of the stories. A few days ago, I talked with Jayne Spector, who just became mother-in-law to one of my best friends. Spector tested positive for the coronavirus a couple weeks ago—shortly after attending her grandmother’s funeral, where she’d hugged and kissed dozens of family members. Among them was her daughter, who was, at the time Spector received her test result, about to have her wedding, just 11 days later. “I was really worried I had infected my soon-to-be-married daughter,” Spector told me. And had Spector not been vaccinated, “I think it would have been a disaster.” But Spector was vaccinated. So were almost all the family members she mingled with at the funeral—her daughter included—and not a single one of her contacts has tested positive. (They also kept a lot of the interactions outdoors, and wore masks inside.) Spector isolated at home, where she dealt with what she compares to a nasty but relatively fast-resolving cold—a paltry echo, she suspects, of the sickness she would have had, if not for her shots. “The fact that I’m vaccinated means that it’s tolerable,” she told me. “I took the precautions; I stayed away from others. Now I’m going back to my life.” Her daughter’s wedding was this past Saturday. All 18 people in attendance were fully vaccinated, and tested negative before the ceremony. Spector was one of them. from https://ift.tt/39lWXfP Check out http://natthash.tumblr.com |
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