by Sanjay Gupta
Truth: Once vaccinated, you are very well protected against severe illness, breakthrough infections, and the possibility you could still be contagious. Still, we need to practice infection prevention precautions until a large percentage of the country—and world—is immunized. In areas of the world where there is still significant viral transmission, while unlikely, the odds are higher you could become an unwitting carrier, even after being vaccinated. It’s as simple as that. Mask wearing may be recommended in certain situations and environments until enough people are immunized, which will likely coincide with a very low rate of new cases—when the average daily rate of people testing positive in a given area is much less than 5 percent. That number reflects a time when this coronavirus response could go from mitigation to containment. We could finally get our arms around this and test, trace, and isolate the last few embers of the disease. Even if the virus is out there at that point, it would be far less consequential.
Myth: Everyone around me has already been vaccinated, and the pandemic is under control, so why bother getting vaccinated? Can’t I stay unvaccinated in the herd?
Truth: We do not know what level of immunity in the community confers “herd” immunity. The exact percentage required for community immunity for COVID is a moving target. Herd immunity for measles, which is highly contagious, requires around 95 percent of the population to be immunized. In spring 2021, based on the contagiousness of the virus, the target is close to 75 percent for COVID. New variants, however, continually change the community immunity equation. The more contagious the virus becomes, the higher the percentage of people that need to get vaccinated. On top of that, the distribution of vaccines on a global scale is uneven, so pockets of unvaccinated communities may remain to fuel variants ready to hop on a plane and threaten those living in vaccinated areas. The imbalance between low-income countries and high-income nations, especially those that can produce their own vaccines, will likely continue until we have equitable global access through programs such as the Vaccine Alliance (known as Gavi) and the Coalition for Epidemic Preparedness Innovations (CEPI). Unlike other products of intellectual property, vaccines are not easily reproducible by lifting patents and sharing recipes. There’s an art to developing vaccines, and it takes years of experience. Moreover, it’s hard to set up a new manufacturing site quickly with all the equipment, infrastructure, and vaccine ingredients, not to mention bringing in an experienced staff to produce a large number of high-quality vaccines. Finally, keep in mind that adults make up roughly 75 percent of the population in the United States, but not all adults are willing to be vaccinated, and some may choose not to vaccinate their children that make up the other 25 percent. The more we encourage vaccination across all ages, the closer we get to community immunity.
Myth: The variants are going to come get us eventually and continually outpace the vaccines. Why be the recipient of a useless vaccine? They don’t even prevent infection or transmission from what I’ve heard.
Truth: Combating the variants starts with aggressive vaccination to prevent the virus from replicating and changing. And the vaccines are not useless even when they are weakened by a variant. They are the bullets against the virus whether they hit the middle target or otherwise disable the fitness of the virus.
With regard to infection, Dr. Redfield highlighted a counterintuitive detail to me about the virus-vaccine relationship that most people miss: Vaccines are not necessarily intended to prevent infection. What they do is modify the viral-host interaction. They tip the scales in favor of the host, making it less likely for the virus to cause disease. That means we can be vaccinated, be showered with viral particles by a nearby sneezer, and become infected. The virus can still get in, but the host is no longer a very hospitable environment, and that means the virus might not replicate as well, or enough, to cause symptoms. Powerful new strains like Delta, however, could potentially transmit from vaccinated individuals. So vaccines don’t necessarily prevent infection, but they do a much better job at dampening transmission and illness. They also, not so unimportantly, are nearly 100 percent effective at keeping you from dying of the disease. Note too that you may not necessarily have to follow the same brand or type of vaccine for future booster shots. A mix-and-match approach may prove to be even more effective at protecting you.
Myth: I have a lot of underlying conditions, including chronic inflammation, allergies, and chemical sensitivities to a lot of environmental exposures. The vaccine is one giant exposure I know my body can’t handle.
Truth: Having underlying conditions that can worsen and further complicate a COVID illness is all the more reason to get vaccinated. In fact, people with high-risk medical conditions, including cancer, autoimmune disease, and heart conditions, are prioritized for vaccines. The vaccine is not an “exposure” that will exacerbate an underlying illness. For those with serious concerns about their conditions and the potential side effects from the vaccine, it’s a good idea to partner with a doctor to help you through the decision. But again, we cannot confuse serious adverse events with the expected side effects of getting the vaccine. About 10 to 15 percent of vaccine recipients can expect to experience side effects such as headache, arm pain, fatigue, and fever. These clear up after a day or so. Again, it shows the vaccine is doing its job—preparing your immune system to fight against the coronavirus.
Sleeping Giants
The oldest virus ever directly sequenced belongs to an extinct lineage of hepatitis B.20 It came from a man likely in his mid- to late twenties who lay down to die seven thousand years ago in a valley that is now in central Germany. He was probably a farmer. Our genetic tools today managed to lift a tantalizing clue from a tooth to explain his young death: a piece of viral DNA code that infected his liver. Although hepatitis B can be prevented now with vaccines, it continues to infect hundreds of millions of people around the world and remains a major global health problem. And while it targets and infects the liver, it also enters the bloodstream and circulates through the body, winding up in bones and teeth, where it can be preserved. The WHO is leading vaccination campaigns to immunize the world against this ancient plague.
It may feel disheartening to know that we may have to live with COVID—a newly emerging plague—in our environment for the rest of our lives. But that may be the least of our worries going forward as we pull through this pandemic and prepare for another one someday. Many pathogens, some much deadlier than COVID, lie in wait for a close encounter with our kind. Viruses in particular have an advantage over other pathogens because they are not alive, so they can theoretically hide out for as long as it takes to strike when the settings are right.
Case in point: A few years ago, scientists in France awakened a gigantic, ancient virus from its 30,000-year-long slumber in Siberian permafrost that’s ready to infect again.21 Now, this virus, dubbed Pithovirus sibericum, only infects single-celled amoebas (whew!). But the discovery has scientists wondering what other microbes are hidden in melting permafrost awaiting another chance to find a new host. If a 30,000-year-old virus can maintain its infectious abilities, other microbes are capable of revisiting humanity in catastrophic fashion, which is to say: There may be no such thing as total eradication of a virus. Devastating diseases like smallpox could come back to haunt us if we’re not careful.
The good news is that we have modern science—and the lessons we’ve learned—on our side.
PART 2 Becoming Pandemic P.R.O.O.F.
It is illusion to think that there is anything fragile about the life of the earth; surely this is the toughest membrane imaginable in the universe, opaque to probability, impermeable to death. We are the delicate part, transient and vulnerable as cilia. Nor is it a new thing for Man to invent an existence that he imagines to be above the rest of life; this has been his most consistent intellectual exertion down the millennia. As an illusion, it has never worked out to his satisfaction in the past, any more than it does today.
—Lewis Thomas, Lives of a Cell: Notes of a B
iology Watcher, 1974
On a single day sometime in spring 2020, I received roughly 14,000 emails—about one email every six seconds. Each time the watch on my wrist vibrated, I looked, and my brain was taken in a new direction. Ten times a minute, even when I should’ve been asleep. Never before in my life had I been this inundated and this busy, and that counts my chief residency in neurosurgery, when I regularly worked over a hundred hours a week. By the time I started responding to one email, several more had buzzed in, sometimes urgently requesting a response to a note I had yet to read.
My wife jokingly asked me what all the emails were about. I smiled and said I wasn’t sure, but thought they had something to do with a new breed of calico cat. She asked if I happened to receive any emails about the novel coronavirus. I shook my head and said, “No. What’s that?” The exchange made for therapeutic comedy relief. And I really needed it!
We have all gone through one of the most historic events in our lifetime. It has taught us a lot about ourselves, our relationships, our environment, and the planet’s delicate balance. Although scientists have accurately predicted such a pandemic for decades, it still came as a surprise for many; perhaps we’d been in denial and diverted our attention to prepare for other, more immediate threats, such as terrorist attacks and cybersecurity breaches. It can be hard for us humans to prepare for something not yet visible or tangible—something that neither we nor our parents have experienced before. Some of us do take the necessary steps to mitigate the consequences of natural disasters such as hurricanes because they happen with frequency and predictability. But a public health crisis on the scale of COVID? If you had been forewarned in 2010 of what could unfold a decade later, you might have been skeptical; a once-in-a-century pathogen that sweeps across the globe decimating societies and their economies seemed inconceivable.
The truth is that the chances of a pandemic happening are the same tomorrow as they were yesterday and remain today. But something important has changed immensely: our perceptions. Friends of mine outside the world of medicine and public health have received a crash course in viral dynamics, antibodies, and vaccines. These are the words spoken in different places, cultures, and languages all over the world. We have been given a painful reminder that we share the planet with organisms of all kinds, and every now and then, those organisms leave their native habitat in search of new hosts.
We will live increasingly with the threat of a germ, probably of viral origin, making a jump from another animal to a human, causing illness, accelerating in the shape of human-to-human transmission, and then hopping on an airplane, train, or boat in an unsuspecting host to wreak global havoc. The confluence of climate change, deforestation, habitat loss, human migration, mass rapid transit, and aggressive conversion of wildland for economic development paves the way for making outbreaks of disease more common and more dangerous. These are sometimes nefarious pathogens that prey on the vulnerable and take advantage of the most human of all interactions—a handshake, a hug, a kiss, that is, any interaction where we touch or share air with one another. And once these pathogens arrive, they will likely want to stay.
According to Bob Redfield, “This virus is with us probably for as long as this nation’s a nation. It’s not gonna disappear.” The 1918 flu never left either. Its descendants are still around in the form of a more predictable seasonal flu.
But Redfield is also hopeful. We will learn how to dance—how to coexist with this virus as it changes, mutates, and responds to the pressures we put on it through vaccines and naturally occurring immunity. With every passing month as more people develop immunity and their defenses are bolstered against the virus, the kinetics of the virus will change. It’s a two-way street: As we learn about the virus, the virus learns about us. As we adapt, the virus also adapts. That is the race. Build our defensive immunity before the virus learns how to breach the gate. Then tap-dance our way through a planet we cohabitate on with microbes and pathogens. A deeply religious man, Redfield still abides by a core pillar of public health: never leave science on the shelf. He often recalls an old lyric from an American war song: “Praise the Lord and pass the ammunition.”
So what does all of this mean for next time? Beyond having science rescue us in the form of marvelous vaccines, how do we individually inoculate ourselves from the next disastrous pathogen and keep our families safe? How do we protect our bodies, and also our minds? What are the practical lessons to follow now to protect your future health and that of loved ones? And what if there is no obvious end, and you become a long-hauler with chronic health challenges stemming from the infection? The answers to those questions—and so much more—are in this part of the book. Life ahead of us is not about vaccines only—it’s about vaccines and.
Through hundreds of hours of my conversations with experts from all disciplines of our society, a theme emerged: As audacious as it may sound, it is possible for a society to become essentially pandemic proof. As much as we think of national security or even Internet security, pandemic security requires lots of investment, planning, and hard work, so I’ve taken all the wisdom I’ve gleaned from experts around the world to design the pandemic-proof plan, and it entails the following P.R.O.O.F. acronym:
P Plan ahead. We should never be caught off guard again.
R Rethink and rewire risk in your brain. Evaluate uncertainty and deal with unseen threats.
O Optimize health. Prime the body for pandemic proofing.
O Organize family. Learn how to live everyday life anew (with a twist).
F Fight for the future of us. Your health depends on everyone else’s around the world.
Lewis Thomas was one of the world’s most brilliant thinkers and writers of his era. A poet-philosopher of medicine, he was president of the Memorial Sloan-Kettering Cancer Center and dean of the medical schools at New York University and Yale, but he was most famous for his lucid essays in which he translated the mysteries of biology for ordinary people. In his classic book The Lives of a Cell, which won the National Book Award in 1974, he writes about our fragility as humans who live on an otherwise robust planet. This perspective dovetails with what I’ve often thought about: What if we humans are the virus? Think about it. The metaphor holds up: We have found a willing host in planet Earth and are using up its resources. We’ve been taking our host to the edge of death, but allowing her to stay alive—a shell of her former self. We have caused a fever in the form of global warming, and we have gradually shut down Earth’s perimeter defenses just like a virus slowly disables the body’s own immune system. We are now even starting to search for new hosts on other nearby planets like Mars. How far will we go? How can we survive?
World War C is a call to action in many ways, written with the belief that there is a right balance between humans and host—yes, the virus and humans, but also humans and Earth. The real question is: How do we continue to coexist and even thrive on Earth, protecting our planet as a gracious, giving host and also learning to live with the ongoing threat of emerging pathogens ready to strike—COVID among them?
Welcome to a better normal.
CHAPTER 5 P: Plan Ahead
We Should Never Be Caught Off Guard Again
Across the border to our north, Dr. Bonnie Henry was among the select few in North America who was not caught off guard when the virus landed in British Columbia (BC), where she’s the provincial health officer. She had already settled in and buckled her seat belt in preparation for her province’s response long before anyone in the United States had a sense of what was to come. A source of vital information through her regular addresses to the public, Henry became a household name in BC—a voice of reason through her now-famous mantra to “be kind, be calm, be safe.”1 Henry has been hailed as “one of the most effective public health figures in the world” who “aced the coronavirus test.”2
Like Debbie Birx, Henry was no novice. She’d been trained to recognize patterns in data—not just of how viruses spread but of how
government agencies tend to forget the lessons learned after each outbreak. Also like Birx, Henry had her own hard-won experience she could rely on to inform her efforts to contain and mitigate the virus’s spread. British Columbia was fertile ground for the virus to flourish; it is close to Washington State, where some of North America’s first cases erupted, and its large population often travels back and forth to China, where the outbreak began.
But BC didn’t get clobbered, at least not initially. Under Henry’s leadership, the province took decisive action the second week of January 2020 and effectively communicated to people what they needed to do to stay safe, along with the reasons and the means to do it. Let me repeat those three ingredients of the effective response: communicate what to do, why you are doing it, and how we will help you get it done. For example, for those who were dealing with an exposure or infection in the family, she sent her team to their homes to assist in their isolation and ensure their basic needs were met—that they had food, that the children were cared for, that the dogs were walked, and that everyone had their medications. “And then we could focus on the recalcitrant,” Henry told me with a smile.
I don’t want to suggest this was easy sailing for Henry. She had to convince the government to spend money and advocate massive changes in behavior that included closing schools and bars, isolating the infected, and enforcing strict social distancing. As in parts of the United States, Henry met with opposition and defiance toward some of her stay-at-home measures. Her early public warnings about expecting to “see cases soon” were also met with disbelief and anger. The premonition even struck a nerve with her superior, the deputy minister of health. To build trust with people she served, however, she knew that being forthright and open was essential despite the dire situation and the disruption to life that was about to occur. As Dr. Henry’s predictions proved increasingly prescient, her relentless efforts won out. From the first time she heard about an “atypical pneumonia” emerging in China, she was also extra cautious about something few had initially considered: confidentiality. British Columbia is home to many people of Asian descent, and as in the United States, anti-Asian racism and hate crimes have been on the rise since the beginning of the pandemic. In British Columbia, this was especially true in the pandemic’s early stages when cases were linked solely to China and people were calling it “the China virus” or “Wuhan flu.” Anticipating that infected citizens would be targeted unfairly and discriminated against by neighbors, Henry demanded discretion when teams were deployed to people’s homes.
