Public education is almost always contentious in this country: Evolution! The pledge of allegiance! The Founding Fathers’ complicity in felonious (oft murderous) abduction & torture!
Now, we’re also arguing over whether it’s safe for schools to be open at all!
At the school board meeting, a white woman stood up at the podium, ripped off her mask, and said “I can’t breathe.”
(Unfortunately, I assume the resonance with the BLM protests was intentional. When I went to pick up my kids from school last week, a white mother was wearing a t-shirt with the traditional white on black BLM layout that said “Drunk Wives Matter.” My hometown is within a half hour’s drive of the national KKK headquarters.)
As is the way of things in our country right now, about half the parents in attendance were aghast. The other half cheered.
“The masks don’t work! Everybody knows the masks don’t work!” people shouted.
Oddly enough, though, the people saying “the masks don’t work” are actually correct. But so are the people who say that masks work. The word “work” is pretty nebulous!
As Joseph Allen & Helen Jenkins wrote in a recent New York Times editorial, many well-meaning people have been unhelpfully vague when defining goals for our pandemic response. Are we trying to minimize lifelong harms from all causes? Are we trying to minimize the number of deaths that occur this year? Are we trying to eradicate the virus that causes Covid-19?
Each of these goals would require that we take a different set of actions.
Masks “work” in the sense that when people are wearing face masks, there’s a lower probability of Covid-19 transmission during any interaction.
Masks reduce the number of viral particles that exit a person’s airspace as they speak or exhale. Of course, this presupposes that the person wearing a mask actually is shedding viral particles. But that’s the tricky thing about Covid-19 (or influenza)! Some people feel fine!
Masks also might reduce the likelihood of transmission when an unexposed person who is hoping to avoid or delay illness wears a mask. (Masks probably help with this, but it’s less well tested.)
Universal mask requirements are a great tool to delay transmission!
When worn selectively – for instance, only during hospital visits, or only when inside nursing homes – masks can also skew the demographics of transmission. With Covid-19, skewing the demographics of transmission is a great goal!
Even back before we had safe, effective vaccines, we could’ve saved huge numbers of lives by skewing the demographics of transmission! Some people are much more likely to recover from Covid-19 safely than others! (Major risk factors include advanced age, diabetes status, and probably smoking status. But there are also unknown risk factors – we don’t know why certain young healthy people can get so sick from this.)
Masks don’t “work,” though, if the goal is to prevent cases of Covid-19.
By May of 2020, it was already clear that Covid-19 would become endemic. We’d spread the virus too widely by then. The virus will never go away. Cases will never fall to zero.
Everyone alive today, and everyone born in the future, will be exposed to Covid-19 eventually. (With the possible exception of people who happen to die of other causes within the next few years.)
There’s still a strong argument for using masks to delay Covid-19 transmission: with more time, more people can be vaccinated! The vaccines work, by which I mean that the vaccines save lives.
Everyone will be exposed to Covid-19! The people who have been vaccinated are much more likely to survive! This front page article in my local newspaper is fear mongering; it’s a sort of fear mongering that I wholeheartedly endorse!
Vaccination is a safe, effective, time-tested medical practice. The principles behind vaccination were independently discovered centuries ago by scientists and healers in Africa, India, and China. Their discoveries were the basis for Edward Jenner’s smallpox vaccine.
When scientists say that vaccines “work” – vaccines save lives – we mean something very different than when we say that masks “work” – masks delay exposure!
In conjunction with vaccination, masks can be helpful!
Which is why the argument that children should currently wear masks in school is reasonable. Covid-19 tends not to be very dangerous for children, but occasionally it’s deadly. There’s a definite cost to wearing masks in school – muffled voices, hidden facial expressions, increased hassle – but children could be kept safer by delaying their exposure to Covid-19 until after a vaccine is approved for them.
(I feel lucky that my kids have already safely recovered from Covid-19 – I’m not beset by the same fear over this that other parents are navigating. But I understand their concern: raising children often feels terrifying because my heart would shatter if anything happened to these tiny, willful, fragile creatures.)
Most of the people who say “masks don’t work” are planning not to get the Covid-19 vaccine. Which means, weirdly, that they’re right! Without the end goal of eventual vaccination, masks don’t work! Even if universal masking policies were kept in place forever, Covid-19 is so infectious that everyone would still be exposed eventually!
The vaccines can save lives; masks cannot.
Obviously, I’m not arguing that you should ignore local mask requirements: I’m currently wearing a face mask as I type this! And there are lots of people who do want to be vaccinated who don’t have access yet – this isn’t much of an issue for adults in the United States, but vaccine access is an incredible privilege for most of the world’s population.
Because Covid-19 can be transmitted by people who feel fine, wearing a mask is a way to protect others. And personal preference isn’t a good reason to endanger the lives of the folks around us! That’s why we have traffic laws! Even if I think it’d be fun to go out driving while buzzed on booze, or to cruise on the left-hand side of the road, I shouldn’t be allowed to do it!
But also, I think it’s worth acknowledging that, within the full context of their actions, people’s denunciations of masks are actually scientifically accurate.
“Follow the science” is an unhelpful slogan – scientific analysis doesn’t result in a monolithic set of inarguable conclusions. At the heart of any policy, there are goals and priorities. These are set by philosophical or ethical considerations, not scientific fact.
“Follow the scientific findings that help us all achieve my goals for the world” doesn’t have the same pithy ring to it, though.
The shape of things determines what they can do. Or, as a molecular biologist would phrase it, “structure determines function.”
In most ways, forks and spoons are similar. They’re made from the same materials, they show up alongside each other in place settings. But a spoon has a curved, solid bowl – you’d use it for soup or ice cream. A fork has prongs and is better suited for stabbing.
In matters of self defense, I’d reach for the fork.
On a much smaller scale, the three-dimensional shapes of a protein determines what it can do.
Each molecule of hemoglobin has a spoon-like pocket that’s just the right size for carrying oxygen, while still allowing the oxygen to wriggle free wherever your cells need it. A developing fetus has hemoglobin that’s shaped differently – when the fetal hemoglobin grabs oxygen, it squeezes more tightly, causing oxygen to pass from a mother to her fetus.
Each “voltage-gated ion channel” in your neurons has a shape that lets it sense incoming electrical signals and pass them forward. Voltage-gated ion channels are like sliding doors. They occasionally open to let in a rush of salt. Because salts are electrically charged, this creates an electric current. The electrical current will cause the next set of doors to open.
Every protein is shaped differently, which lets each do a different job. But they’re all made from the same materials – a long chain of amino acids.
Your DNA holds the instructions for every protein in your body.
Your DNA is like a big, fancy cookbook – it holds all the recipes, but you might not want to bring it into the kitchen. You wouldn’t want to spill something on it, or get it wet, or otherwise wreck it.
Instead of bringing your nice big cookbook into the kitchen, you might copy a single recipe onto an index card. That way, you can be as messy as you like – if you spill something, you can always write out a new index card later.
And your cells do the same thing. When it’s time to make proteins, your cells copy the recipes. The original cookbook is made from DNA; the index-card-like copies are made from RNA. Then the index cards are shipped out of the nucleus – the library at the center of your cells – into the cytoplasm – the bustling kitchen where proteins are made and do their work.
When a protein is first made, it’s a long strand of amino acids. Imagine a long rope with assorted junk tied on every few inches. Look, here’s a swath of velcro! Here’s a magnet. Here’s another magnet. Here’s a big plastic knob. Here’s another magnet. Here’s another piece of velcro. And so on.
If you shake this long rope, jostling it the way that a molecule tumbling through our cells gets jostled, the magnets will eventually stick together, and the velcro bits will stick to together, and the big plastic knob will jut out because there’s not enough room for it to fit inside the jumble.
That’s what happens during protein folding. Some amino acids are good at being near water, and those often end up on the outside of the final shape. Some amino acids repel water – like the oil layer of an unshaken oil & vinegar salad dressing – and those often end up on the inside of the final shape.
Other amino acids glue the protein together. The amino acid cysteine will stick to other cysteines. Some amino acids have negatively-charged sidechains, some have positively-charged sidechains, and these attract each other like magnets.
Sounds easy enough!
Except, wait. If you had a long rope with dozens of magnets, dozens of patches of velcro, and then you shook it around … well, the magnets would stick to other magnets, but would they stick to the right magnets?
You might imagine that there are many ways the protein could fold. But there’s only a single final shape that would allow the protein to function correctly in a cell.
So your cells use little helpers to ensure that proteins fold correctly. Some of the helpers are called “molecular chaperones,” and they guard various parts of the long strand so that it won’t glom together incorrectly. Some helpers are called “glycosylation enzymes,” and these glue little bits and bobs to the surface of a protein, some of which seem to act like mailing addresses to send the protein to the right place in a cell, some of which change the way the protein folds.
Our cells have a bunch of ways to ensure that each protein folds into the right 3D shape. And even with all this help, something things go awry. Alzheimer’s disease is associated with amyloid plaques that form in the brain – these are big trash heaps of misfolded proteins. The Alzheimer’s protein is just very tricky to fold correctly, especially if there’s a bunch of the misfolded protein strewn about.
Many human proteins can be made by bacteria. Humans and bacteria are relatives, after all – if you look back in our family trees, you’ll find that humans and bacteria shared a great-great-great-grandmother a mere three billion years ago.
The cookbooks in our cells are written in the same language. Bacteria can read all our recipes.
Which is great news for biochemists, because bacteria are really cheap to grow.
If you need a whole bunch of some human protein, you start by trying to make it in bacteria. First you copy down the recipe – which means using things called “restriction enzymes” to move a sequence of DNA into a plasmid, which is something like a bacterial index card – then you punch holes in some bacteria and let your instructions drift in for them to read.
The bacteria churn out copies of your human protein. Bacteria almost always make the right long rope of amino acids.
But human proteins sometimes fold into the wrong shapes inside bacteria. Bacteria don’t have all the same helper molecules that we do,.
If a protein doesn’t fold into the right shape, it won’t do the right things.
If you were working in a laboratory, and you found out that the protein you’d asked bacteria to make was getting folded wrong … well, you’d probably start to sigh a lot. Instead of making the correctly-folded human protein, your bacteria gave you useless goo.
But fear not!
Yeast can’t be grown as cheaply as bacteria, but they’re still reasonably inexpensive. And yeast are closer relatives – instead of three billion years ago, the most recent great-great-grandmother shared between humans and yeast lived about one billion years ago.
Yeast have a few of the same helper proteins that we do. Some human proteins that can’t be made in bacteria will fold correctly in yeast.
So, you take some yeast, genetically modify it to produce a human protein, then grow a whole bunch of it. This is called “fermentation.” It’s like you’re making beer, almost. Genetically modified beer.
Then you spin your beer inside a centrifuge. This collects all the solid stuff at the bottom of the flask. Then you’ll try to purify the protein that you want away from all the other gunk. Like the yeast itself, and all the proteins that yeast normally make.
If you’re lucky, the human protein you were after will have folded correctly!
If you’re unlucky, the protein will have folded wrong. Your yeast might produce a bunch of useless goo. And then you do more sighing.
There’s another option, but it’s expensive. You can make your human protein inside human cells.
Normally, human cells are hesitant to do too much growing and dividing and replicating. After all, the instructions in our DNA are supposed to produce a body that looks just so – two arms, two eyes, a smile. Once we have cells in the right places, cell division is just supposed to replace the parts of you that have worn out.
Dead skin cells steadily flake from our bodies. New cells constantly replace them.
But sometimes a cell gets too eager to grow. If its DNA loses certain instructions, like the “contact inhibition” that tells cells to stop growing when they get too crowded, a human cell might make many, many copies of itself.
Which is unhelpful. Potentially lethal. A cell that’s too eager to grow is cancer.
Although it’s really, really unhelpful to have cancer cells growing in your body, in a laboratory, cancer cells are prized. Cancer cells are so eager to grow that we might be able to raise them in petri dishes.
Maybe you’ve heard of HeLa cells – this is a cancer cell line that was taken from a Black woman’s body without her consent, and then this cell line was used to produce innumerable medical discoveries, including many that were patented and have brought in huge sums of money, and this woman’s family was not compensated at all, and they’ve suffered huge invasions of their privacy because a lot of their genetic information has been published, again without their consent …
HeLa cells are probably the easiest human cells to grow. And it’s possible to flood them with instructions to make a particular human protein. You can feel quite confident that your human protein will fold correctly.
But it’s way more expensive to grow HeLa cells than yeast. You have to grow them in a single layer in a petri dish. You have to feed them the blood of a baby calf. You have to be very careful while you work or else the cells will get contaminated with bacteria or yeast and die.
If you really must have a whole lot of a human protein, and you can’t make it in bacteria or yeast, then you can do it. But it’ll cost you.
Vaccination is perhaps the safest, most effective thing that physicians do.
Your immune system quells disease, but it has to learn which shapes inside your body represent danger. Antibodies and immunological memory arise in a process like evolution – random genetic recombination until our defenses can bind to the surface of an intruder. By letting our immune system train in a relatively safe encounter, we boost our odds of later survival.
The molecular workings of our immune systems are still being studied, but the basic principles of inoculation were independently discovered centuries ago by scientists in Africa, India, and China. These scientists’ descendants practiced inoculation against smallpox for hundreds of years before their techniques were adapted by Edward Jenner to create his smallpox vaccine.
If you put a virus into somebody’s body, that person might get sick. So what you want is to put something that looks a lot like the virus into somebody’s body.
One way to make something that looks like the virus, but isn’t, is to take the actual virus and whack it with a hammer. You break it a little. Not so much that it’s unrecognizable, but enough so that it can’t work. Can’t make somebody sick. This is often done with “heat inactivation.”
Heat inactivation can be dangerous, though. If you cook a virus too long, it might fall apart and your immune system learns nothing. If you don’t cook a virus long enough, it might make you sick.
In some of the early smallpox vaccine trials, the “heat inactivated” viruses still made a lot of people very, very sick.
Fewer people got very sick than if they’d been exposed to smallpox virus naturally, but it feels different when you’re injecting something right into somebody’s arm.
We hold vaccines to high standards. Even when we’re vaccinating people against deadly diseases, we expect our vaccines to be very, very safe.
It’s safer to vaccinate people with things that look like a virus but can’t possibly infect them.
This is why you might want to produce a whole bunch of some specific protein. Why you’d go through that whole rigamarole of testing protein folding in bacteria, yeast, and HeLa cells. Because you’re trying to make a bunch of protein that looks like a virus.
Each virus is a little protein shell. They’re basically delivery drones for nasty bits of genetic material.
If you can make pieces of this protein shell inside bacteria, or in yeast, and then inject those into people, then the people can’t possibly be infected. You’re not injecting people with a whole virus – the delivery drone with its awful recipes inside. Instead, you’re injecting people with just the propeller blades from the drone, or just its empty cargo hold.
These vaccine are missing the genetic material that allow viruses to make copies of themselves. Unlike with a heat inactivated virus, we can’t possibly contract the illness from these vaccines.
This is roughly the strategy used for the HPV vaccine that my father helped develop. Merck’s “Gardasil” uses viral proteins made by yeast, which is a fancy way of saying that Merck purifies part of the virus’s delivery drone away from big batches of genetically-modified beer.
We have a lot of practice making vaccines from purified protein.
Even so, it’s a long, difficult, expensive process. You have to identify which part of the virus is often recognized by our immune systems. You have to find a way to produce a lot of this correctly-folded protein. You have to purify this protein away from everything else made by your bacteria or yeast or HeLa cells.
The Covid-19 vaccines bypass all that.
In a way, these are vaccines for lazy people. Instead of finding a way to make a whole bunch of viral protein, then purify it, then put it into somebody’s arm … well, what if we just asked the patient’s arm to make the viral protein on its own?
Several of the Covid-19 vaccines are made with mRNA molecules.
These mRNA molecules are the index cards that we use for recipes in our cells’ kitchens, so the only trick is to deliver a bunch of mRNA with a recipe for part of the Covid-19 virus. Then our immune system can learn that anything with that particular shape is bad and ought to be destroyed.
After learning to recognize one part of the virus delivery drone, we’ll be able to stop the real thing.
We can’t vaccinate people by injecting just the mRNA, though, because our bodies have lots of ways to destroy RNA molecules. After all, you wouldn’t want to cook from the recipe from any old index card that you’d found in the street. Maybe somebody copied a recipe from The Anarchist Cookbook – you’d accidentally whip up a bomb instead of a delicious cake.
I used to share laboratory space with people who studied RNA, and they were intensely paranoid about cleaning. They’d always wear gloves, they’d wipe down every surface many times each day. Not to protect themselves, but to ensure that all the RNA-destroying enzymes that our bodies naturally produce wouldn’t ruin their experiments.
mRNA is finicky and unstable. And our bodies intentionally destroy stray recipes.
So to make a vaccine, you have to wrap the mRNA in a little envelope. That way, your cells might receive the recipe before it’s destroyed. In this case, the envelope is called a “lipid nanoparticle,” but you could also call a fat bubble. Not a bubble that’s rotund – a tiny sphere made of fat.
Fat bubbles are used throughout cells. When the neurons in your brain communicate, they burst open fat bubbles full of neurotransmitters and scatter the contents. When stuff found outside a cell needs to be destroyed, it’s bundled into fat bubbles and sent to a cellular trash factories called lysosomes.
For my Ph.D. thesis, I studied the postmarking system for fat bubbles. How fat bubbles get addressed in order to be sent to the right places.
Sure, I made my work sound fancier when I gave my thesis defense, but that’s really what I was doing.
Anyway, after we inject someone with an mRNA vaccine, the fat bubble with the mRNA gets bundled up and taken into some of their cells, and this tricks those cells into following the mRNA recipe and making a protein from the Covid-19 virus.
This mRNA recipe won’t teach the cells how to make a whole virus — that would be dangerous! That’s what happens during a Covid-19 infection – your cells get the virus’s whole damn cookbook and they make the entire delivery drone and more cookbooks to put inside and then these spread through your body and pull the same trick on more and more of your cells. A single unstopped delivery drone can trick your cells into building a whole fleet of them and infecting cells throughout your body.
Instead, the mRNA recipe we use for the vaccine has only a small portion of the Covid-19 genome, just enough for your cells to make part of the delivery drone and learn to recognize it as a threat.
And this recipe never visits the nucleus, which is the main library in your cells that holds your DNA, the master cookbook with recipes for every protein in your body. Your cells are tricked into following recipes scribbled onto the vaccine’s index cards, but your master cookbook remains unchanged. And, just like all the mRNA index cards that our bodies normally produce, the mRNA from the vaccine soon gets destroyed. All those stray index cards, chucked unceremoniously into the recycling bin.
The Johnson & Johnson vaccine also tricks our cells into making a piece of the Covid-19 virus.
This vaccine uses a different virus’s delivery drone to send the recipe for a piece of Covid-19 into your cells. The vaccine’s delivery drone isn’t a real virus – the recipe it holds doesn’t include the instructions on how to make copies of itself. But the vaccine’s delivery drone looks an awful lot like a virus, which means it’s easier to work with than the mRNA vaccines.
Those little engineered fat bubbles are finicky. And mRNA is finicky. But the Johnson & Johnson vaccine uses a delivery drone that was optimized through natural selection out in the real world. It evolved to be stable enough to make us sick.
Now we can steal its design in an effort to keep people well.
Lots of people received the Johnson & Johnson vaccine without incident, but we’ve temporarily stopped giving it to people. Blood clots are really scary.
You might want to read Alexandra Lahav’s excellent essay, “Medicine Is Made for Men.” Lahav describes the many ways in which a lack of diversity in science, technology, and engineering fields can cause harm.
Cars are designed to protect men: for many years, we used only crash test dummies that were shaped like men to determine whether cars were safe. In equivalent accidents, women are more likely to die, because, lo and behold, their bodies are often shaped differently.
Women are also more likely to be killed by medication. Safety testing often fails to account for women’s hormonal cycles, or complications from contraceptives, or differences in metabolism, or several other important features of women’s bodies.
Although more than half our population are women, their bodies are treated as bizarre.
For most people, the Johnson & Johnson vaccine is safe. But this is a sort of tragedy that occurs too often – causing harm to women because we’re inattentive to the unique features of their bodies.
I haven’t been vaccinated yet, but I registered as soon as I was able – my first dose will be on April 26th. Although I’ve almost certainly already had Covid-19 before, and am unlikely to get severely ill the next time I contract it, I’m getting the vaccine to protect my friends and neighbors.
As a society, we’ve made enormous sacrifices during the Covid-19 pandemic. We’re wearing masks; we’re staying home; children are missing school.
We’re all cooperating to protect the people who are most at risk.
The risk profile for Covid-19 is opposite the risk from climate change. Covid-19 is more dangerous for the old. Climate change is more dangerous for the young, and for generations not yet born.
There’s another way to phrase this – Covid-19 is more dangerous for the wealthy, and climate change is more dangerous for those who currently have little or nothing. This is true both temporally and geographically.
(Wealth obviously protect individuals from Covid-19. Despite all his buffoonish posturing, when Donald Trump was infected, he received higher quality, more expensive medical care than almost anyone else. But on a population level, increased wealth is correlated with increased risk. Wealthy people are privileged to live longer, and in our capitalist society, people often accumulate wealth as they age.)
People with low risk from Covid-19 are making enormous sacrifices to protect others from it. But those with low risk from climate change are, in general, making no efforts to stop it.
Which conveys a clear message:
Younger people, you must solve this problem on your own. Despite your willingness to make sacrifices to protect us, we will not make sacrifices to protect you.
If we knew in March 2020 what we know now, we wouldn’t have closed schools. If you’re interested in some of the reasoning behind this, you should read this February 24, 2021 New York Times editorial from Nicholas Kristof.
We are hurting kids under the guise of protecting older people. But we’re not even succeeding. Schools have such low rates of Covid-19 transmission that we’re hurting kids without accomplishing anything.
People from “my” political party have orchestrated this harm, which makes it feel all the worse.
The New York Times recently printed an editorial from someone at the right-wing American Enterprise Institute chiding us for our totally un-scientific school closures. Members of the Republican party are positioning themselves as the defenders of public education.
The Republican party has been trying to undermine public schools ever since the Supreme Court decided that maybe Black kids deserve an equal chance to learn. And we’re letting them posture as the defenders of education?
During the vaccine roll-out, the New York Times set the stage for a big reveal – younger people were never in huge amounts of danger from Covid-19.
I don’t want to sound cavalier about this – Covid-19 is dangerous to people of all ages. It’s very similar to influenza.
Many people have a misconception that influenza is relatively harmless – sniffles & a runny nose – unless you’re elderly.
That’s not true.
Although the majority of cases of seasonal influenza are mild, it’s a deadly disease. Young healthy people die of influenza every year.
Most influenza deaths are recorded as “pneumonia” during post-mortem reports. To compare the dangers of Covid-19 to influenza, we’d want to measure how many more pneumonia deaths we’ve seen recently.
In a typical year, there are about 130,000 pneumonia deaths in the United States – these might be caused by influenza, coronaviruses, rhinoviruses, etc.
Many if not most of these deaths are caused by influenza – the column of numbers reporting verified influenza deaths is so low because we don’t always test for it, and when we do we typically use a low-quality antigen test.
Last year, though, was much worse – between January 1, 2020 and February 24, 2021, there were 670,000 pneumonia deaths in the United States. During those 14 months, five-fold more people died from this set of symptoms than we’d expect during a normal year.
We’ve also had about five times as many infections. Usually, about 30 million people contract seasonal influenza each year. The CDC estimates that perhaps 100 million people contracted Covid-19 during the ten months from February 2020 to December 2020.
That’s why the CDC’s roughestimates for the “infection fatality ratio” of Covid-19 are about the same as for influenza.
Last year, more people died from Covid-19 than would be expected from a typical year’s burden of seasonal influenza, but that’s because there were many more infections.
Seasonal influenza and Covid-19 are both deadly diseases. And it’s worth comparing them because the pandemic might be declared “over” once Covid-19 deaths fall to influenza-like levels.
That’s what most public health experts said when they were interviewed by Alexis Madrigal for an article in The Atlantic – that a reasonable goal is for Covid-19 “to mirror the typical mortality of influenza in the U.S. over a typical year.”
Which seems like a bit of a cop out. You’re going to call it “over” while people are still dying?
But we have to. Covid-19 will probably be with us forever. Like the coronavirus OC43, which we picked up from cows and which probably killed over a million people during the 1890 pandemic, Covid-19 will continue to make humans sick indefinitely.
Elderly people – especially those who weren’t exposed to Covid-19 as children – will always be particularly susceptible.
Early on during the pandemic – when we already had a good sense that younger people weren’t in much personal danger but also knew that we could only slow the spread of Covid-19 if younger people made sacrifices – we concocted a narrative that healthy young people were at high risk, too.
In March 2020, the New York Times printed an editorial from Fiona Lowenstein, a 26 year old who became tragically ill, saying “Millennials: if you can’t stay at home for others, do it for yourselves.”
In May 2020, the New York Times printed an editorial from Mara Gay, a 33 year old who became tragically ill, saying “I want Americans to understand that this virus is making otherwise young, healthy people very, very sick. I want them to know, this is no flu.”
This year, healthy young people have gotten very sick and even died of Covid-19 – which is tragic, but not unusual. Every year, healthy young people get very sick and die from influenza. This past year, with about five-fold more infections of an equivalently deadly disease, we’ve seen about five-fold more of these tragic young people’s deaths.
Now that a vaccine is available, though, the narrative has shifted.
In the February 28, 2021 New York Times Magazine, Kwame Anthony Appiah’s “Ethicist” column says that “Health care workers who are in their 20s and don’t have certain medical conditions aren’t at high risk if they contract Covid-19. Perhaps we could save more lives if we left them [to be vaccinated] until later.”
Now that we have a limited supply of vaccines, older, wealthier people benefit if young people are less afraid of Covid-19.
By delaying Covid-19 infection, young people increased their personal risk. Early during the pandemic, the virus was not particularly dangerous for young people. By now, though, there have now been millions of transmission events – millions of opportunities for mutant variants to arise.
And indeed, in February 2021 the New York Timesreports that “it is likely that the [new Covid-19 virus] variant is linked to an increased risk of hospitalization and death.”
Currently, we’re rationing the limited supply of Covid-19 vaccines based on age.
This is hypocritical, and potentially misguided.
When people develop such severe complications from Covid-19 that they require ventilation in order to have a chance of surviving, a younger person is more likely to benefit from the treatment. This holds both in terms of absolute number of lives saved, and is even more dramatic if you consider the years of life saved.
With a limited supply of ventilators, you can accomplish most by reserving them for the young – and we said that would be horrible.
In a March 2020 article for the New York Times, Sheri Fink wrote that the health department’s civil rights office would ensure “that states did not allow medical providers to discriminate on the basis of … age … when deciding who would receive lifesaving medical care.
In April 2020, Joel Zivot wrote for Medpage that “Rationing ventilators by age is wrong.”
Although we declared that it would be unethical to ration healthcare (ventilators) by age, we’re now rationing healthcare (vaccines) by age. The difference is that a different group of people – older, on average wealthier – benefits.
Rationing vaccines by age doesn’t even save the most lives.
Based on the CDC data, if both a 50-year-old and a 70-year-old are infected with Covid-19, the 70-year-old is about ten times more likely to die. That’s scary!
The major benefit of the vaccine is that it reduces the chance of severe illness if you are exposedto Covid-19. But we also know other ways to reduce the odds of exposure – a person can stay home, wear a mask near others, minimize the number of unique individuals they come into contact with.
If the 70-year-old has retired, they should be able to reduce the number of unique individuals they see each week to ten or fewer. But a 50-year-old grocery store clerk might see a thousand or more unique individuals each week, and have to spend time in fairly close proximity to each.
If the 50-year-old is at least ten-fold more likely to be exposed to Covid-19, then you’ll save more lives by giving the vaccine to them instead of to the 70-year-old.
Not only did we declare that rationing healthcare by age was wrong when it benefited younger people, but now we’re doing it even though it doesn’t save the most lives.
The unfairness is even more dramatic if we consider the risk of hospitalization. According to the CDC chart above, if both a 20-year-old and a 70-year-old are infected with Covid-19, the 70-year-old is about five times as likely to be hospitalized. But Medicare will pay the hospital bill. If a 20-year-old is hospitalized, they might face ruinous medical debt.
It’s quite likely that the obligations of most 20-year-olds – going to school, going to work, taking care of family – make them at least five times as likely to be exposed to Covid-19. We could stop lives from being ruined by medical debt if we vaccinated 20-year-olds first.
A friend of mine works in a take-out & delivery pizza restaurant in Chicago. For other people to be able to stay home and order food, he had to go in to work. His risk of exposure to Covid-19 was much higher than other people’s. As a healthy athlete in his late twenties, he wasn’t at high risk, but he was unlucky – when he got sick, he was so ill that he spent weeks in the hospital. He’s still recovering from his ruptured lung. He has no idea how to pay the $200,000 medical bill.
Because we’re rationing care by age, we’re not protecting people like him. Even though his risk – interacting with customers all day – made it possible for others to stay safe.
The Covid-19 pandemic has been awful, but I was pleased that people took fewer plane flights. Our carbon emissions briefly dropped.
Now that older people have received vaccines, though, they’ll resume flying.
For a February 17, 2021 article in the New York Times, Debra Kamin writes that “When the coronavirus hit, Jim and Cheryl Drayer, 69 and 72, canceled all their planned travel and hunkered down in their home in Dallas, Texas. But earlier this month, the Drayers both received the second dose of their Covid-19 vaccinations. And in March, armed with their new antibodies, they are heading to Maui for a long overdue vacation.”
“Americans over 65, who have had priority access to inoculations, are now newly emboldened to travel – often while their children and grandchildren continue to wait for a vaccine.”
Newly protected against Covid-19, they’ll increase their contributions to climate change.
Climate change has the opposite risk profile from Covid-19. Covid-19 is most dangerous for the old; climate change is most dangerous for the young, and for generations not yet born.
In some sense, it’s trivializing to even compare these. The risk from climate change is so much more severe.
If we make our planet inhospitable – if our crops fail due to storms or heat waves – the carrying capacity of Earth could easily fall by half.
We will see billions, not millions, of deaths.
Someone who is elderly today is unlikely to survive long enough to experience the worst effects of climate change – although it’s true that in severe weather events like Chicago’s fluke summer heat waves or Texas’s fluke winter storms, elderly people who live alone are exceptionally vulnerable.
Still, younger adults will have to endure worse calamities. They’ll live through more years of severe weather, crop failures, dangerous heat, lingering smog. And, since society will be forced to spend more money each year to maintain humanity’s precarious place on this planet – rebuilding after fires or floods – younger adults will face an increasingly inhospitable world with less wealth at their disposal.
Today’s children will encounter even worse. They’ll experience every disaster that today’s young adults will survive to see, and then some.
Generations not yet born may inherit a nightmare.
When people who currently have wealth were in danger, we created a narrative that everyone needed to make sacrifices. The largest sacrifices came from those who benefited least.
We’re still keeping children out of school – for almost no benefit in terms of Covid-19 transmission – in order to protect older, wealthier people.
Climate change is and has been caused primarily by those with the most wealth. If you can buy more meat, if you can take more plane flights, if you can purchase a bigger home, then you’re able to cause more climate change.
To stop climate change, we need wealthy people to make sacrifices. Buy less, fly less, eat plants.
But why would they?
Currently wealthy people aren’t in danger.
And – worse – currently wealthy people often became wealthy by treating the world as a competitive place. Now we’re asking them to cooperate? To make sacrifices for the sake of others?
Meat tastes good. Flying to Maui is fun. Doesn’t a person who worked hard deserve an enormous home?
A curious thought about the Gamestop stock trading phenomenon: Many small investors – often younger people – were convinced through emotional arguments to buy a few shares of stock and hold them with “diamond hands.”
Don’t sell, even if the price dips!
There was a strange cooperative / competitive system going on. The cooperative portion would have been illegal had it not been done in public – people were colluding to make the shares hard to get, which forced the hedge fund to pay more in order to cover their short sales.
Short sales: a hedge fund had borrowed many shares of the stock and sold them, hoping the price would fall and that new shares could be purchased more cheaply when it was time to return them. So the hedge fund had basically announced, “On such & such a date, I must have this stock, no matter the price!” If other people all cooperate and say, “On that day, don’t sell it for less than $420.00,” then the hedge fund has to pay $420.00 per share, even if the company that the stock represents is worthless.
But here’s the competitive portion – the company, Gamestop, is probably going out of business eventually. Driving to a strip mall to buy a video game cartridge instead of downloading it? The stock isn’t worth much money. So people wanted to cooperate to hurt the hedge fund, but people were also forced to compete because nobody wanted to be holding the stock at the end of the day.
Everyone would like to sell it for a bunch of money, but not everyone will get to sell it.
Even if more than a hundred percent of shares are short sold, not everyone will get to sell it – the hedge fund can satisfy all their contracts by buying a share, returning it to someone, buying the same share back from that person, returning it to someone else, and so on.
So if you know that everybody else has put in a “sell order” at $420.00, because they think it’s a funny number, you benefit by putting in a sell order at $419. That way you get almost as much money as anyone else, but you’re guaranteed to sell yours, whereas only a fraction of the people with $420 sell orders get to trade their (worthless) stock for money.
But then, if you know that other people are going to plug in a sell order at $419, you benefit from selling yours at $418. Because what if too many people sell their shares at $419?? You might still be left out!
So there was an incentive for savvy investors – wealthy people who might have thousands of dollars on the line – to convince other people to hold onto the stock no matter what … even while selling their own.
Billions of dollars changed hands. Some people “made” a lot of money. And it wouldn’t have happened without cooperation – lots of people colluding against the hedge fund.
But the particular people who benefited were determined by a con. By selling shares while promoting a narrative that “if we all hold with diamond hands, this is going to the moon!”
In some ways, our response to Covid-19 encourages me.
So many people – especially younger people – have shown themselves to be willing to cooperate.
A cloth mask traps your exhalations. Wearing a cloth mask makes your life worse, but it protects other people. Almost everybody in my home town wears a mask. Every young person at school wears a mask.
Young people are willing to make sacrifices to protect older people. But therein lies the con.
We’re not making sacrifices to protect them.
Our carbon emissions are no different from pulling off this face mask and intentionally coughing in a young child’s face. We ought to feel ashamed.
We’re fast approaching flu season, which is especially harrowing this year.
We, as a people, have struggled to respond to this calamity. We have a lot of scientific data about Covid-19 now, but science is never value-neutral. The way we design experiments reflects our biases; the way we report our findings, even more so.
For example, many people know the history of Edward Jenner inventing the world’s first vaccine. Fewer are aware of the long history of inoculation in Africa (essentially, low-tech vaccination) that preceded Jenner’s work.
So it’s worthwhile taking a moment to consider the current data on Covid-19.
Data alone can’t tell us what to do – the course of action we choose will reflect our values as a society. But the data may surprise a lot of people – which is strange considering how much we all feel that we know about Covid-19.
Indeed, we may realize that our response so far goes against our professed values.
Spoiler: I think we shouldn’t close in-person school.
Since April, I’ve written severalessays about Covid-19. In these, I’ve made a number of predictions. It’s worthwhile to consider how accurate these predictions have been.
This, after all, is what science is. We use data to make an informed prediction, and then we collect more data to evaluate how good our prediction was.
Without the second step – a reckoning with our success or failure – we’re just slinging bullshit.
I predicted that our PCR tests were missing most Covid-19 infections, that people’s immunity was likely to be short-lived (lasting for months, not years), and that Covid-19 was less dangerous than seasonal influenza for young people.
In my essays, I’ve tried to unpack the implications of each of these. From the vantage of the present, with much more data at our disposal, I still stand by what I’ve written.
But gloating’s no fun. So I’d rather start with what I got wrong.
My initial predictions about Covid-19 were terrible.
I didn’t articulate my beliefs at the time, but they can be inferred from my actions. In December, January, and February, I made absolutely no changes to my usual life. I didn’t recommend that travelers be quarantined. I didn’t care enough to even follow the news, aside from a cursory glance at the headlines.
While volunteering with the high school running team, I was jogging with a young man who was finishing up his EMT training.
“That new coronavirus is really scary,” he said. “There’s no immunity, and there’s no cure for it.”
I shrugged. I didn’t know anything about the new coronavirus. I talked with him about the 1918 influenza epidemic instead.
I didn’t make any change in my life until mid-March. And even then, what did I do?
I called my brother and talked to him about the pizza restaurant – he needed a plan in case there was no in-person dining for a few months.
My next set of predictions were off, but in the other direction – I estimated that Covid-19 was about four-fold more dangerous than seasonal influenza. The current best estimate from the CDC is that Covid-19 is about twice as dangerous, with an infection fatality ratio of 0.25%.
But seasonal influenza typically infects a tenth of our population, or less.
We’re unlikely to see a significant disruption in the transmission of Covid-19 (this is the concept of “herd immunity”) until about 50% of our population has immunity from it, whether from vaccination or recovery. Or possibly higher – in some densely populated areas, Covid-19 has spread until 70% (in NYC) or even 90% (in prisons) of people have contracted the disease.
Population density is hugely important for the dynamics of Covid-19’s spread, so it’s difficult to predict a nation-wide threshold for herd immunity. For a ballpark estimate, we could calculate what we’d see with a herd immunity threshold of about 40% in rural areas and 60% in urban areas.
Plugging in some numbers, 330 million people, 80% urban population, 0.25% IFR, 60% herd immunity threshold in urban areas, we’d anticipate 450,000 deaths.
That’s about half of what I predicted. And you know what? That’s awful.
Each of those 450,000 is a person. Someone with friends and family. And “slow the spread” doesn’t help them, it just stretches our grieving to encompass a whole year of tragedy instead of a horrific month of tragedy.
Based on the initial data, I concluded that the age demographics for Covid-19 risk were skewed more heavily toward elderly people than influenza risk.
I may have been wrong.
It’s difficult to directly compare the dangers of influenza to the dangers of Covid-19. Both are deadly diseases. Both result in hospitalizations and death. Both are more dangerous for elderly or immunocompromised people, but both also kill young, healthy people.
Typically, we use an antigen test for influenza and a PCR-based test for Covid-19. The PCR test is significantly more sensitive, so it’s easier to determine whether Covid-19 is involved a person’s death. If there are any viral particles in a sample, PCR will detect them. Whereas antigen tests have a much higher “false negative” rate.
Instead of using data from these tests, I looked at the total set of pneumonia deaths. Many different viruses can cause pneumonia symptoms, but the biggest culprits are influenza and, in 2020, Covid-19.
So I used these data to ask a simple question – in 2020, are the people dying of pneumonia disproportionately more elderly than in other years?
I expected that they would be. That is, after all, the prediction from my claims about Covid-19 demographic risks.
For people under the age of 18, we’ve seen the same number of deaths (or fewer) in 2020 as in other years. The introduction of Covid-19 appears to have caused no increased risk for these people.
But for people of all other ages, there have been almost three times as many people dying of these symptoms in 2020 compared to other years.
In most years, one thousand people aged 25-34 die of these symptoms; in 2020, three thousand have died. In most years, two thousand people aged 35-44 die of these symptoms; in 2020, six thousand have died. This same ratio holds for all ages above eighteen.
Younger people are at much less risk of harm from Covid-19 than older people are. But, aside from children under the age of eighteen, they don’t seem to be exceptionally protected.
Of course, my predictions about the age skew of risk might be less incorrect than I’m claiming here. If people’s dramatically altered behavior in 2020 has changed the demographics of exposure as compared to other years – which is what we should be doing to save the most lives – then we could see numbers like this even if Covid-19 had the risk skew that I initially predicted.
I predicted that four or more years would pass before we’d be able to vaccinate significant numbers of people against Covid-19.
I sure hope that I was wrong!
We now know that it should be relatively easy to confer immunity to Covid-19. Infection with other coronaviruses, including those that cause common colds, induce the production of protective antibodies. This may partly explain the low risk for children – because they get exposed to common-cold-causing coronaviruses so often, they may have high levels of protective antibodies all the time.
Several pharmaceutical companies have reported great results for their vaccine trials. Protection rates over 90%.
So the problem facing us now is manufacturing and distributing enough doses. But, honestly, that’s the sort of engineering problem that can easily be addressed by throwing money at it. Totally unlike the problem with HIV vaccines, which is that the basic science isn’t there – we just don’t know how to make a vaccine against HIV. No amount of money thrown at that problem would guarantee wide distribution of an effective vaccine.
We will still have to overcome the (unfortunately significant) hurdle of convincing people to be vaccinated.
For any individual, the risk of Covid-19 is about twice the risk of seasonal influenza. But huge numbers of people choose not to get a flu vaccine each year. In the past, the United States has had a vaccination rate of about 50%. Here’s hoping that this year will be different.
Which means that elderly people will always be at risk of dying from Covid-19.
The only way to protect people whose bodies have gone through “age-related immunosenence” – the inevitable weakening of an immune system after a person passes the evolutionarily-determined natural human lifespan of about 75 years – will be to vaccinate everybody else.
Depending on how long vaccine-conferred immunity lasts, we may need to vaccinate people annually. I worry, though, that it will become increasingly difficult to persuade people to get a Covid-19 vaccine once the yearly death toll drops to influenza-like levels – 50,000 to 100,000 deaths per year in the United States.
(Note: you may have seen articles in the New York Times suggesting that we’ll have long-lasting protection. They’re addressing a different question — after recovery, or vaccination, are you likely to become severely ill with Covid-19? And the answer is “probably not,” although it’s possible. When I discuss immunity here, I mean “after recovery, or vaccination, are you likely to be able to spread the virus after re-infection?” And the answer is almost certainly “yes, within months.”)
And I wrote about the interplay between short-lived immunity and the transmission dynamics of an extremely virulent, air-born virus.
This is what the Harvard public health team got so wrong. When we slow transmission enough that a virus is still circulating after people’s immunity wanes, they can get sick again.
For this person, the consequences aren’t so dire – an individual is likely to get less sick with each subsequent infection by a virus. But the implications for those who have not yet been exposed are horrible. The virus circulates forever, and people with naive immune systems are always in danger.
It’s the same dynamics as when European voyagers traveled to the Americas. Because the European people’s ancestors lived in unsanitary conditions surrounded by farm animals, they’d cultivated a whole host of zoogenic pathogens (like influenza and this new coronavirus). The Europeans got sick from these viruses often – they’d cough and sneeze, have a runny nose, some inflammation, a headache.
In the Americas, there were fewer endemic diseases. Year by year, people wouldn’t spend much time sick. Which sounds great, honestly – I would love to go a whole year without headaches.
But then the disgusting Europeans reached the Americas. The Europeans coughed and sneezed. The Americans died.
And then the Europeans set about murdering anyone who recovered. Today, descendants of the few survivors are made to feel like second-class citizens in their ancestral homelands.
In a world with endemic diseases, people who have never been exposed will always be at risk.
That’s why predictions made in venues such as the August New York Times editorial claiming that a six- to eight-week lockdown would stop Covid-19 were so clearly false. They wrote:
Six to eight weeks. That’s how long some of the nation’s leading public health experts say it would take to finally get the United States’ coronavirus epidemic under control.
For proof, look at Germany. Or Thailand. Or France.
Obviously, this didn’t work – in the presence of an endemic pathogen, the lockdowns preserved a large pool of people with naive immune systems, and they allowed enough time to pass that people who’d been sick lost their initial immunity. After a few months of seeming calm, case numbers rose again. For proof, look at Germany. Or France.
Case numbers are currently low in Thailand, but a new outbreak could be seeded at any time.
And the same thing is currently happening in NYC. Seven months after the initial outbreak, immunity has waned; case numbers are rising; people with mild second infections might be spreading the virus to friends or neighbors who weren’t infected previously.
All of which is why I initially thought that universal mask orders were a bad idea.
We’ve known for over a hundred years that masks would slow the spread of a virus. The only question was whether slowing the spread of Covid-19 would cause more people to die of Covid-19.
And it would – if a vaccine was years away.
But we may have vaccines within a year. Which means that I may have been wrong. Again, the dynamics of Covid-19 transmission are still poorly understood – I’ll try to explain some of this below.
In any case, I’ve always complied with our mask orders. I wear a mask – in stores, at school pickup, any time I pass within six feet of people while jogging.
To address global problems like Covid-19 and climate change, we need global consensus. One renegade polluting wantonly, or spewing viral particles into the air, could endanger the whole world. This is precisely the sort of circumstance where personal freedom is less important than community consensus.
The transmission dynamics of Covid-19 are extremely sensitive to environment. Whether you’re indoors or outdoors. How fast the air is moving. The population density. How close people are standing. Whether they’re wearing masks. Whether they’re shouting or speaking quietly.
Because there are so many variable, we don’t have good data. My father attended a lecture and a colleague (whom he admires) said, “Covid-19 is three-fold more infectious than seasonal influenza.” Which is bullshit – the transmission dynamics are different, so the relative infectivity depends on our behaviors. You can’t make a claim like this.
It’s difficult to measure precisely how well masks are slowing the spread of this virus.
But here’s a good estimate: according to Hsiang et al., the number of cases of Covid-19, left unchecked, might have increased exponentially at a rate of about 34% per day in the United States.
That’s fast. If about 1% of the population was infected, it could spread to everyone within a week or two. In NYC, Covid-19 appear to spread to over 70% of the population within about a month.
(To estimate the number of infections in New York City, I’m looking at the number of people who died and dividing by 0.004 – this is much higher than the infection fatality rate eventually reported by the CDC, but early in the epidemic, we were treating people with hydroxychloraquine, an unhelpful poison, and rushing to put people on ventilators. We now know that ventilation is so dangerous that it should only be used as a last resort, and that a much more effective therapy is to ask people to lie on their stomachs – “proning” makes it easier to get enough oxygen even when the virus has weakened a person’s lungs.)
Masks dramatically slow the rate of transmission.
A study conducted at a military college – where full-time mask-wearing and social distancing were strictly enforced – showed that the number of cases increased from 1% to 3% of the population over the course of two weeks.
So, some math! Solve by taking ten to the power of (log 3)/14, which gives an exponential growth rate of 8% per day. Five-fold slower than without masks.
But 8% per day is still fast.
Even though we might be able to vaccinate large numbers of people by the end of next year, that’s not soon enough. Most of us will have been sick with this – at least once – before then.
I don’t mean to sound like a broken record, but the biggest benefit of wearing masks isn’t that we slow the rate of spread for everyone — exponential growth of 8% is still fast — but that we’re better able to protect the people who need to be protected. Covid-19 is deadly, and we really don’t want high-risk people to be infected with it.
I’ve tried to walk you through the reasoning here — the actual science behind mask policies — but also, in case it wasn’t absolutely clear: please comply with your local mask policy.
You should wear a mask around people who aren’t in your (small) network of close contacts.
I’m writing this essay the day after New York City announced the end of in-person classes for school children.
A major problem with our response to Covid-19 is that there’s a time lag between our actions and the consequences. Human brains are bad at understanding laggy data. It’s not our fault. Our ancestors lived in a world where they’d throw a spear at an antelope, see the antelope die, and then eat it. Immediate cause and effect makes intuitive sense.
Delayed cause and effect is tricky.
If somebody hosts a party, there might be an increase in the number of people who get sick in the community over the next three weeks. Which causes an increase in the number of hospitalizations about two weeks after that. Which causes people to die about three weeks after that.
There’s a two-month gap between the party and the death. The connection is difficult for our brains to grasp.
As a direct consequence, we’ve got ass-hats and hypocrites attending parties for, say, their newly appointed Supreme Court justice.
But the problem with school closures is worse. There’s a thirty year gap between the school closure and the death. The connection is even more difficult to spot.
The authors link two sets of existing data: the correlation between school closures and low educational achievement, and the correlation between low educational achievement and premature death.
The public debate has pitted “school closures” against “lives saved,” or the education of children against the health of the community. Presenting the tradeoffs in this way obscures the very real health consequences of interrupted education.
These consequences are especially dire for young children.
The authors calculate that elementary school closures in the United States might have (already!) caused 5.5 million years of life lost.
Hsiang et al. found that school closures probably gave us no benefit in terms of reducing the number of Covid-19 cases, because children under 18 aren’t significant vectors for transmission (elementary-aged children even less so), but even if school closures had reduced the number of Covid-19 cases, closing schools would have caused more total years of life to be lost than saved.
The problem – from a political standpoint – is that Covid-19 kills older people, who vote, whereas school closures kill young people, who are intentionally disenfranchised.
And, personally, as someone with far-left political views, it’s sickening for me to see “my” political party adopt policies that are so destructive to children and disadvantaged people.
So, here’s what the scientific data can tell us so far:
We will eventually have effective vaccines for Covid-19. Probably within a year.
Covid-19 spreads even with social distancing and masks, but the spread is slower.
You have no way of knowing the risk status of people in a stranger’s bubble. (Please, follow your local mask orders!)
Schools – especially elementary schools – don’t contribute much to the spread of Covid-19.
School closures shorten children’s lives (and that’s not even accounting for their quality of life over the coming decades).
An individual case of Covid-19 is about twice as dangerous as a case of seasonal influenza (which is scary!).
Underlying immunity (from prior disease and vaccination) to Covid-19 is much lower than for seasonal influenza, so there will be many more cases.
Most people’s immunity to Covid-19 probably lasts several months, after which a person can be re-infected and spread the virus again.
So, those are some data. But data don’t tell us what to do. Only our values can do that.
I was walking my eldest child toward our local elementary school when my phone rang.
We reached the door, shared a hug, and said goodbye. After I left, I called back – it was a friend of mine from college who now runs a cancer research laboratory and is an assistant professor at a medical school.
“Hey,” I said, “I was just dropping my kid off at school.”
“Whoa,” he said, “that’s brave.”
I was shocked by his remark. For most people under retirement age, a case of Covid-19 is less dangerous than a case of seasonal influenza.
“I’ve never heard of anybody needing a double lung transplant after a case of the flu,” my friend said.
But our ignorance doesn’t constitute safety. During this past flu season, several young, healthy people contracted such severe cases of influenza that they required double lung transplants. Here’s an article about a healthy 30-year-old Wyoming man nearly killed by influenza from December 2019, and another about a healthy 20-year-old Ohio woman from January 2020. And this was a rather mild flu season!
“One of the doctors told me that she’s the poster child for why you get the flu shot because she didn’t get her flu shot,” said [the 20-year-old’s mother].
These stories were reported in local newspapers. Stories like this don’t make national news because we, as a people, think that it’s normal for 40,000 to 80,000 people to die of influenza every year. Every three to five years, we lose as many people as have died from Covid-19. And that’s with vaccination, with pre-existing immunity, with antivirals like Tamiflu.
Again, when I compare Covid-19 to influenza, I’m not trying to minimize the danger of Covid-19. It is dangerous. For elderly people, and for people with underlying health issues, Covid-19 is very dangerous. And, sure, all our available data suggest that Covid-19 is less dangerous than seasonal influenza for people under retirement age, but, guess what? That’s still pretty awful!
You should get a yearly flu shot!
A flu shot might save your life. And your flu shot will help save the lives of your at-risk friends and neighbors.
For a while, I was worried because some of my remarks about Covid-19 sounded superficially similar to things said by the U.S. Republican party. Fox News – a virulent propaganda outlet – was publicizing the work of David Katz – a liberal medical doctor who volunteered in a Brooklyn E.R. during the Covid-19 epidemic and teaches at Yale’s school of public health.
The “problem” is that Katz disagrees with the narrative generally forwarded by the popular press. His reasoning, like mine, is based the relevant research data – he concludes that low-risk people should return to their regular lives.
You can see a nifty chart with his recommendations here. This is the sort of thing we’d be doing if we, as a people, wanted to “follow the science.”
And also, I’m no longer worried that people might mistake me for a right-wing ideologue. Because our president has once again staked claim to a ludicrous set of beliefs.
Here’s a reasonable set of beliefs: we are weeks away from a safe, effective Covid-19 vaccine, so we should do everything we can to slow transmission and get the number of cases as low as possible!
Here’s another reasonable set of beliefs: Covid-19 is highly infectious, and we won’t have a vaccine for a long time. Most people will already be infected at least once before there’s a vaccine, so we should focuson protecting high-risk people while low-risk people return to their regular lives.
If you believe either of those sets of things, then you’re being totally reasonable! If you feel confident that we’ll have a vaccine soon, then, yes, delaying infections is the best strategy! I agree! And if you think that a vaccine will take a while, then, yes, we should end the shutdown! I agree!
There’s no right answer here – it comes down to our predictions about the future.
But there are definitely wrong answers. For instance, our current president claims that a vaccine is weeks away, and that we should return to our regular lives right now.
That’s nonsense. If we could get vaccinated before the election, then it’d make sense to close schools. To wait this out.
If a year or more will pass before people are vaccinated, then our efforts to delay the spread of infection will cause more harm than good. Not only will we be causing harm with the shutdown itself, but we’ll be increasing the death toll from Covid-19.
On October 14th, the New York Times again ran a headline saying “Yes, you can be reinfected with the coronavirus. But it’s extremely unlikely.”
This is incorrect.
When I’ve discussed Covid-19 with my father – a medical doctor specializing in infectious diseases, virology professor, vaccine developer with a background in epidemiology from his masters in public health – he also has often said to me that reinfection is unlikely. I kept explaining that he was wrong until I realized that we were talking about different things.
When my father uses the word “reinfection,” he means clearing the virus, catching it again, and becoming sicker than you were the first time. That’s unlikely (although obviously possible). This sort of reinfection happens often with influenza, but that’s because influenza mutates so rapidly. Covid-19 has a much more stable genome.
When I use the word “reinfection” – and I believe that this is also true when most laypeople use the word – I mean clearing the virus, catching it again, and becoming sick enough to shed the viral particles that will make other people sick.
The more we slow the spread of Covid-19, the more total cases there will be. In and of itself, more cases aren’t a bad thing – most people’s reinfection will be milder than their first exposure. The dangerous aspect is that a person who is reinfected will have another period of viral shedding during which they might expose a high-risk friend or neighbor.
If our goal is to reduce the strain on hospitals and reduce total mortality, we need to avoid exposing high-risk people. Obviously, we should be very careful around nursing home patients. We should provide nursing homes with the resources they need to deal with this, like extra testing, and preferably increased wages for nursing home workers to compensate them for all that extra testing.
It’s also a good idea to wear masks wherever low-risk and high-risk people mingle. The best system for grocery stores would be to hire low-risk shoppers to help deliver food to high-risk people, but, absent that system, the second-best option would be for everyone to wear masks in the grocery store.
Schools are another environment where a small number of high-risk teachers and a small number of students living with high-risk family members intermingle with a large number of low-risk classmates and colleagues.
Schools should be open – regions where schools closed have had the same rates of infection as regions where schools stayed open, and here in the U.S., teachers in districts with remote learning have had the same rates of infection as districts with in-person learning.
Education is essential, and most people in the building have very low risk.
A preponderance of data indicate that schools are safe. These data are readily accessible even for lay audiences – instead of reading research articles, you could read this lovely article in The Atlantic.
Well, I should rephrase.
We should’ve been quarantining international travelers back in December or January. At that time, a shutdown could have helped. By February, we were too late. This virus will become endemic to the human species. We screwed up.
But, given where we are now, students and teachers won’t experience much increased risk from Covid-19 if they attend in person, and schools aren’t likely to make the Covid-19 pandemic worse for the surrounding communities.
That doesn’t mean that schools are safe.
Schools aren’t safe: gun violence is a horrible problem. My spouse is a teacher – during her first year, a student brought weapons including a chainsaw and some pipe bombs to attack the school; during her fourth year, a student had amassed guns in his locker and was planning to attack the school.
Schools aren’t safe: we let kids play football, which is known to cause traumatic brain injury.
Schools aren’t safe: the high stress of grades, college admissions, and even socializing puts some kids at a devastatingly high risk for suicide. We as a nation haven’t always done a great job of prioritizing kids’ mental health.
And the world isn’t safe – as David Katz has written,
“If inclined to panic over anything, let it be climate change … Not the most wildly pessimistic assessment of the COVID pandemic places it even remotely in the same apocalyptic ballpark.”
At the end of “Just Use Your Thinking Pump!”, a lovely essay that discusses the evolution (and perhaps undue elevation) of a particular set of practices now known as the scientific method, Jessica Riskin writes:
Covid-19 has presented the world with a couple of powerful ultimatums that are also strikingly relevant to our subject here. The virus has said, essentially, Halt your economies, reconnect science to a whole understanding of yourself and the world, or die.
With much economic activity slowed or stopped to save lives, let us hope governments find means to sustain their people through the crisis.
Meanwhile, with the din of “innovation” partially silenced, perhaps we can also use the time to think our way past science’s branding, to see science once again as integral to a whole, evolving understanding of ourselves and the world.
True, the world has presented us with an ultimatum. We must halt our economies, reconnect science to a whole understanding of ourselves and our world, or die.
Riskin is a professor at Stanford. Her skies are blackened with soot. In the words of Greta Thunberg, “Our house is on fire.”
For many years, we’ve measured the success of our economy in terms of growth. The idea that we can maintain perpetual growth is a delusion. It’s simple mathematics. If the amount of stuff we manufacture – telephones, televisions, air conditioners – rises by 3% each and every year, we’ll eventually reach stratospheric, absurd levels.
In the game “Universal Paperclips,” you’re put in control of a capitalist system that seeks perpetual growth. If you succeed, you’ll make a lot of paperclips! And you will destroy the planet.
Here in the real world, our reckless pursuit of growth has (as yet) wrought less harm, but we’ve driven many species to extinction, destroyed ancient forests, and are teetering at the precipice of cataclysmic climate change. All while producing rampant inequality with its attendant abundance of human misery.
We must reconnect science to a whole understanding of ourselves and the world, or die.
We are in danger. But Covid-19 isn’t the major threat we’re facing.
I consider myself to be more cautious than average – I would never ride a bicycle without a helmet – and I’m especially cautious as regards global pandemic. Antibiotic resistance is about to be a horrific problem for us. Zoogenic diseases like Covid-19 will become much more common due to climate change and increased human population.
I’m flabbergasted that these impending calamities haven’t caused more people to choose to be vegan. It seems trivial – it’s just food – but a vegan diet is one of our best hopes for staving off antibiotic resistant plagues.
A vegan diet would have prevented Covid-19. Not that eating plants will somehow turbocharge your immune system – it won’t – but this pandemic originated from a meat market.
And a vegan diet will mitigate your contribution to climate change, which has the potential to cause the full extinction of the human race.
Make our planet uninhabitable? We all die. Make our planet even a little less habitable, which leads to violent unrest, culminating in warring nations that decide to use nukes? Yup, that’s another situation where we all die.
By way of contrast, if we had made no changes in our lives during the Covid-19 pandemic – no shutdown, no masks, no social distancing, no PCR tests, no contact tracing, no quarantines – 99.8% of our population would have survived.
Indeed, we often discuss the Covid-19 crisis in a very imprecise way. We say that Covid-19 is causing disruptions to learning, that it’s causing domestic violence or evictions. On the front page of Sunday’s New York Times business section, the headline reads, “The Other Way that Covid Kills: Hunger.”
Covid-19 is a serious disease. We need to do our best to avoid exposing high-risk people to this virus, and we should feel ashamed that we didn’t prioritize the development of coronavirus vaccines years ago.
But there’s a clear distinction between the harms caused by Covid-19 (hallucinogenic fevers, cardiac inflammation, lungs filling up with liquid until a person drowns, death) and the harms caused by our response to Covid-19 (domestic violence, educational disruption, starvation, reduced vaccination, delayed hospital visits, death).
Indeed, if the harms caused by our response to Covid-19 are worse than the harms caused by Covid-19 itself, we’re doing the wrong thing.
In that New York Timesbusiness article, Satbir Singh Jatain, a third-generation farmer in northern India, is quoted: “The lockdowns have destroyed farmers. Now, we have no money to buy seeds or pay for fuel. …. soon they will come for my land. There is nothing left for us.”
Covid-19 is awful. It’s a nasty disease. I’m fairly confident that I contracted it in February (before PCR tests were available in the United States), and my spouse says it’s the sickest she’s ever seen me.
Yes, I’d done something foolish – I was feeling a little ill but still ran a kilometer repeat workout with the high school varsity track team that I volunteer with. High intensity workouts are known to cause temporary immunosuppression, usually lasting from 3 to 72 hours.
My whole family got sick, but I fared far worse than the others.
It was horrible. I could barely breathe. Having been through that, it’s easy to understand how Covid-19 could kill so many people. I wouldn’t wish that experience on anyone.
And I have very low risk. I don’t smoke. I don’t have diabetes. I’m thirty-seven.
I wish it were possible to protect people from this.
Obviously, we should have quarantined all international travelers beginning in December 2019. Actually, ten days probably would have been enough. We needed to diecitine all international travelers.
By February, we had probably allowed Covid-19 to spread too much to stop it.
By February, there were probably enough cases that there will always be a reservoir of this virus among the human species. 80% of people with Covid-19 feel totally fine and don’t realize they might be spreading it. By talking and breathing, they put viral particles into the air.
By the end of March, we were much, much too late. If you look at the numbers from New York City, it’s pretty clear that the preventative measures, once enacted, did little. Given that the case fatality rate is around 0.4%, there were probably about 6 million cases in New York City – most of the population.
Yes, it’s possible that New York City had a somewhat higher case fatality rate. The case fatality rate depends on population demographics and standard of care – the state of New York had an idiotic policy of shunting Covid-19 patients into nursing homes, while banning nursing homes from using Covid-19 PCR tests for these patients, and many New York doctors were prescribing hydroxychloroquine during these months, which increases mortality – but even if the case fatality rate in New York City was as high as 0.6%, a majority of residents have already cleared the virus by now.
The belated public health measures probably didn’t help. And these health measures have caused harm – kids’ schooling was disrupted. Wealthy people got to work from home; poor people lost their jobs. Or were deemed “essential” and had to work anyway, which is why the toll of Covid-19 has been so heavily concentrated among poor communities.
The pandemic won’t end until about half of all people have immunity, but a shutdown in which rich people get to isolate themselves while poor people go to work is a pretty shitty way to select which half of the population bears the burden of disease.
I am very liberal. And it’s painful to see that “my” political party has been advocating for policies that hurt poor people and children during the Covid-19 pandemic.
Because we did not act soon enough, Covid-19 won’t end until an appreciable portion of the population has immunity – at the same time.
As predicted, immunity to Covid-19 lasts for a few months. Because our public health measures have caused the pandemic to last longer than individual immunity, there will be more infections than if we’d done nothing.
The shutdowns, in addition to causing harm on their own, will increase the total death toll of Covid-19.
Unless – yes, there is a small glimmer of hope here – unless we soon have a safe, effective vaccine that most people choose to get.
Yes, there are clear positive externalities to vaccination, but I think this sounds like a terrible idea. Ethically, it’s grim – the Covid-19 vaccines being tested now are a novel type, so they’re inherently more risky than other vaccines. By paying people to get vaccinated, we shift this burden of uncertainty onto poor communities.
We already do this, of course. Drug trials use paid “volunteers.” Especially phase 1 trials – in which drugs are given to people with no chance of medical benefit, only to see how severe the side effects are – the only enrollees are people so poor that the piddling amounts of money offered seem reasonable in exchange for scarfing an unknown, possibly poisonous medication.
Just because we already do an awful thing doesn’t mean we should make the problem worse.
And, as a practical matter, paying people to do the right thing often backfires.
To illustrate, consider the recent introduction, in many Indian states, of schemes of cash incentives to curb sex-selective abortion. The schemes typically involve cash rewards for the registered birth of a girl child, and further rewards if the girl is vaccinated, sent to school, and so on, as she gets older.
These schemes can undoubtedly tilt economic incentives in favor of girl children. But a cash reward for the birth of a girl could also reinforce people’s tendency to think about family planning in economic terms, and also their perception, in the economic calculus of family planning, that girls are a burden (for which cash rewards are supposed to compensate).
Further, cash rewards are likely to affect people’s non-economic motives. For instance, they could reduce the social stigma attached to sex-selective abortion, by making it look like some sort of ‘fair deal’ — no girl, no cash.
What happens if it takes a few years before there are sufficient doses of an effective vaccine that people trust enough to actually get?
Well, by then the pandemic will have run its course anyway. Masks reduce viral transmission, but they don’t cut transmission to zero. Even in places where everyone wears masks, Covid-19 is spreading, just slower.
I’ve been wearing one – I always liked the Mortal Kombat aesthetic. But I’ve been wearing one with the unfortunate knowledge that masks, by prolonging the pandemic, are increasing the death toll of Covid-19. Which is crummy. I’ve chosen to behave in a way that makes people feel better, even though the science doesn’t support it.
We, as a people, are in an awful situation right now. Many of us are confronting the risk of death in ways that we have not previously.
More than 37 percent of deaths in 1900 were caused by infectious diseases, but by 1955, this had declined to less than 5 percent and to only 2 percent by 2009.
Of course, this trend will still hold true in 2020. In the United States, there have been about 200,000 Covid-19 deaths so far, out of 2,000,000 deaths total this year. Even during this pandemic, less than 1% of deaths are caused by Covid-19.
And I’m afraid. Poverty is a major risk factor for death of all causes in this country. Low educational attainment is another risk factor.
My kids am lucky to live in a school district that has mostly re-opened. But many children are not so fortunate. If we shutter schools, we will cause many more deaths – not this year, but down the road – than we could possibly prevent from Covid-19.
Indeed, school closures, by prolonging the pandemic (allowing people to be infected twice and spread the infection further), will increase the death toll from Covid-19.
School closures wouldn’t just cause harm for no benefit. School closures would increase the harm caused by Covid-19 and by everything else.
I live in a college town. Last week, students returned.
Yesterday’s paper explains that dire punishment awaits the students who attended a Wednesday night party. In bold letters atop the front page, “IU plans to suspend students over party.”
In the decade that I’ve lived here, many parties have led to sexual assaults, racist hate speech, and violence. The offending students were rarely punished. But this party was egregious because “there were about 100 people there.”
IU officials “have seen a photo … that shows a large group of young people standing close together outside a house at night, many of them not wearing masks.”
I’ve seen the images – someone filmed a video while driving by. There they are – a group of young people, standing outside.
Science magazine recently interviewed biologist Dana Hawley about social distancing in the animal kingdom.
When spiny lobsters are sick, their urine smells different. Healthy lobsters will flee the shared den. Leaving is dangerous, since the lobsters will be exposed to predators until they find a new home, but staying would be dangerous, too – they might get sick. To survive, lobsters have to balance all the risks they face.
My favorite example of social distancing in the animal kingdom wasn’t discussed. When an ant is infected with the cordyceps fungus, it becomes a sleeper agent. Jennifer Lu writes in National Geographic that “as in zombie lore, there’s an incubation period where infected ants appear perfectly normal and go about their business undetected by the rest of the colony.”
Then the fungus spreads through the ants body, secreting mind control chemicals. Eventually, the fungus will command the infected ant to climb to a high place. A fruiting body bursts from the ant’s head and rains spores over the colony.
Infection is almost always lethal.
If an ant notices that a colony member has been infected, the healthy ant will carry the infected ant away from the colony and hurl it from a cliff.
The herd immunity threshold isn’t an inherent property of a virus – it depends upon our environment and behaviors. In prisons, we’ve seen Covid-19 spread until nearly 90% of people were infected. In parts of New York City where many essential workers live in crowded housing, Covid-19 spread until 50% of people were infected.
In a culture where everyone kissed a sacred statue in the center of town each morning, the herd immunity threshold would be higher. If people wear masks while interacting with strangers, the herd immunity threshold will be lower.
In a world that maintains a reservoir of the virus, though, someone who hasn’t yet been exposed will always be at risk.
The New York Times recently discussed some of the challenges that colleges face when trying to reopen during the epidemic.
Most schools ban … socializing outside “social pods” – the small groups of students that some colleges are assigning students to, usually based on their dorms.
Most administrators seem to believe that a rule banning sex is unrealistic, and are quietly hoping that students will use common sense and refrain from, say, having it with people outside their pod.
In 2012, The Huffington Post published a list of the “Top 10 sex tips for college freshmen.” Their fourth piece of advice (#1 and #2 were condoms, #3 was not having sex while drunk) is to avoid having sex with people who live too close to you. “Students in other dorms = fair game. Students in same dorm = proceed with caution.”
I had a big group of friends for my first two years of college. After a breakup, I lost most of those friends.
This is crummy, but it would be much worse if I’d lost my friendships with the only people whom the administrators allowed me to spend time with.
We can slow the spread of Covid-19, but slowing the spread won’t prevent deaths, not unless we can stave off infection until there is a highly effective vaccine. That might take years. We might never have a highly effective vaccine – our influenza vaccines range in efficacy from about 20% to 80%, and we have much more experience making these.
Our only way to reduce the eventual number of deaths is to shift the demographics of exposure. If we reach the herd immunity threshold without many vulnerable people being exposed, we’ll save lives.
A college would best protect vulnerable students and faculty by allowing the students who are going to socialize to host dense parties for a few weeks before mingling with others. This would allow the virus to spread and be cleared before there was a risk of transferring infections to vulnerable people.
I’d draft a waiver. Are you planning to socialize this semester? If so, come do it now! By doing so, you will increase your risk of contracting Covid-19. This is a serious disease – it’s possible for young, healthy people to die from it. But, look, if you’re gonna socialize eventually, please just get it over with so that you don’t endanger other people.
With this plan, some young people might die of Covid-19. But some young people will die of Covid-19 even if everyone practices social distancing – slowing the spread of infections doesn’t save lives, it delays deaths. And fewer young people would die of Covid-19 than die of influenza each year.
When confronting cordyceps, which is almost always fatal, ants throw sick colony members off cliffs.
When ants confront less lethal fungal infections, they protect the colony by shifting the demographics of exposure and by ramping up to the herd immunity threshold as quickly as possible.
Malagocka et al. discuss demographics in their review article, “Social immunity behavior among ants infected by specialist and generalist fungi.”
Outside-nest foragers, who have the highest risks of acquiring pathogens from the environment, have limited access to the brood area with the most valuable groups, and are recruited from older individuals, who are less valuable from the colony survival perspective.
Konrad et al. discuss intentional exposure in their research article, “Social transfer of pathogenic fungus promotes active immunization in ant colonies.”
When worker ants encounter an infected colony member, they intentionally inoculate themselves. “Social immunization leads to faster elimination of the disease and lower death rates.”
It feels disquieting for me to defend the behavior of frat guys. Personally, I’d like to see the whole fraternity system abolished. And in March, when we knew less about Covid-19, I was appalled that people went out partying over spring break. But I was wrong. Perhaps inadvertently, those young people were behaving in the way that would save most lives.
the nurse called back and told us to use bleach on anything we touch, she said wash everything in hot water, insisted we won’t treat you if you’re asymptomatic, we won’t, and made us an appointment anyway. so we waited and waited with the dog-eared magazines and recall posters
It’s horrible to face the end. It’s almost worse to know that the things you fear are harmless to others. All the asymptomatic cases are like a slap in the face to those whose friends and family have died.
Braun et al. recently published a study in Nature showing that a large number of people who’ve never encountered Covid-19 may already have significant immunity. Parts of the Covid-19 virus are similar to the viruses that cause common colds, and exposure to those viruses might provide the immunity that lets people recover without ever feeling sick.
I believe we should be doing more to protect young people. Gun control, ending farm subsidies, fighting climate change. Enacting privacy laws to reign in the surveillance capitalists. Breaking up monopolies. Providing good careers despite automation. Making sure that everyone has clean air to breathe and clean water to drink. Getting nutritious food into our nation’s many food deserts. Providing equitable access to health care.
But, punishing young people for socializing?
We’re not making them safer. And we’re not making ourselves safer, either.
Seriously, I know we humans are selfish, but we have to be able to handle an epidemic better than ants.