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Do It For Felix

Although I’m not out of my COVID isolation period, I’m feeling much better today.  Despite the fact that I have a history of lung problems, my vaccines (including my four month old booster) have held the line.  My oxygen saturation stayed good.  I didn’t get hospitalized or intubated.  I’m still here.  The shots seem to be doing what they are supposed to do. And the baby in the picture is my first cousin (once removed) Felix -  we will get to him in a bit.

I've had a typical winter viral illness with a cough, a runny nose and some brief muscle aches and chills.  I've had to shut down my practice.  I've been sitting alone in a room.  And now that I'm better, I've been keeping busy playing virtual reality 
mini golf and ping pong with my sons, and writing to you.  When I think of what might have been, especially remembering the terror of my two hospitalizations in 2018, I am incredibly grateful to everyone involved in creating these medical miracles in record time.

Staying alive for me is a big value-add, but it's not why I'm writing to you today.  There is another good reason why vaccination is crucial.  I recently read two articles on that topic that prompted me to write this - a 
substack by the brilliant Eric Topol and an editorial by the president of the AMA.  I encourage you to read the originals, especially Topol's piece which is brief, appropriately detailed, clearly written and accessible to a non-medical audience.

To simplify an important concept, a pandemic happens when a virus can - on average - spread from one person to more than one other person, creating a progressively growing population of infected people.  The degree of transmissibility is measured using the R number (also known as the reproduction number or R
0), which takes into account both how inherently contagious the virus is, and how protected the population is from it through vaccination or previous infection.  That means that R0 is specific to a particular place and time

If the average person with a virus give it to two people, R
0 is 2.  If R0 is less than 1, the virus eventually becomes extinct or retreats to small reservoir populations (becoming endemic).  If it's bigger than 1, it spreads widely over time.  For some context, R0 for the original COVID-19 in a population with no immunity at all was 2.5.  For measles (in an unvaccinated group) it's 15.  A recent estimate for the Omicron variant in the UK is 3-5.  This means that Omicron is significantly more contagious than the original version because that number is calculated in a population with a lot of past infection and vaccination.

So how do we get R
0 below 1 for any virus?  Like most professionals in this field, I don't like the term "herd immunity" for the pandemic because it's inappropriate in this context and not really applicable to a global population.  But we definitely CAN manage COVID so that we don't have to keep on living like we have been for the past two years.

Spread can be limited in four ways - the virus can become intrinsically less contagious, it can be made less contagious by mitigation efforts (masking, lockdowns, case isolation, ventilation, etc..), more people can get infected with it and recover, or more people can get vaccinated. 

Evolution wouldn't seem to favor a virus that's less contagious.  Mitigation requires ongoing personal efforts, social and economic costs, and regulations.  It's a good short term containment tool, but it's pretty clear that all of us hope to move past mitigation someday soon (many already have!).  So that leaves us with vaccination and infection.  Vaccination is by FAR the better option, and here is why.

Some people have said that Omicron is SO transmissible, that it may actually be the thing that gets us herd immunity.  I can see how it looks tempting to just drop all of our isolation and mitigation measures and let it rip.  But not only would that not necessarily end the pandemic, it would have huge costs. 

First of all, that would mean an astronomical number of cases.  And even with a 
less lethal variant and significant decoupling, that would still mean a huge number of deaths, as well as lots of people with lingering disability and possibly late complications.  Natural immunity without vaccination doesn't even seem to provide as good an immunity wall as do the vaccines.  Finally, even if unrestrained Omicron did manage to get R0 below 1 for a population with all of the associated costs, it would just be a temporary reprieve as new variants, waning immunity and travel quickly wash away that protection.

The original estimated percentage of protected individuals needed for COVID herd immunity in a relatively isolated  population (which we don't have) was 70%.  More current estimates are in the 90% range (measles territory), and remember that's just for one point in time.  And since a significant percentage of the population simply refuses to be vaccinated, that makes herd immunity even less likely to ever be achieved.

The other major problem with just hoping that Omicron will bring about global herd immunity is that every infection, unlike every vaccination, becomes a factory for making new variants.  That's how evolution works - the more reproduction, the more new organisms, the more rolls of the genetic dice, and the more chances for a new strain.  There is no reason to suspect that Omicron will be the last form of COVID-19, and future variants might be more lethal, more vaccine evasive or both.

Getting people vaccinated and boosted works.  It worked for smallpox, it worked for measles (2 shots), it worked for polio (4 shots), and it worked for diptheria (5 shots plus boosters).  It worked for a lot of diseases that used to terrify our parents and grandparents.  My cousin Felix's parents Sam and Anna didn't have that option.  Instead, they had to watch their only child suffocate to death, when he got diptheria just before his 8th birthday.  Just like his aunt Rachel, who didn't even make it to age two before dying of the same thing.

And it works without having to sacrifice thousands of lives, chasing that elusive and temporary goal of "herd immunity" through natural infection.  It can take time - polio eradication took decades, with a public fairly united behind the vaccination campaign.  Is vaccination a zero risk endeavor?  Of course not, nothing is, especially at that scale.  Not seat belts, not antibiotics and not any of the many other vaccines that are near universally required to attend school.  But close to ten billion COVID shots have been given worldwide, so we have an excellent understanding of the risks.  Adverse vaccine reactions are meticulously tracked, and they are tiny, especially compared to the risk of COVID-19.

With a very contagious variant, there are going to be a LOT of breakthrough cases (like mine).  That DOESN'T MEAN that there is no point in being vaccinated, as I discussed above.  But it DOES mean that relying on vaccination status to determine who is safe to be unmasked around in public - like we 
currently do with restaurants - really doesn't make sense any more.  It doesn't even make sense for boosted people but it's especially pointless for vaccinated and unboosted people more than 5 months out, who still unfortunately satisfy the current requirement for indoor dining.

We have this pandemic on the run, and we have the tools to end it.  We need everyone to understand the reasons why vaccination is the exit ramp.  Please share this information with anyone you know who is holding out on getting vaxxed and boosted.

Even though I wasn't able to do this for my own body, I still hope that you will join me and help to #stopthespread.