Most of my posts discuss the pandemic in the United States, and I think this is a shortsighted view. Watching the news on countries like India, I am shocked, dismayed, and heartbroken. My thoughts and prayers go out to the people and healthcare workers in India grappling with this truly dire situation. The surge right now shows how superspreader events can transform a relatively controlled situation into an unbearable tragedy. It reminds us that our healthcare resources are finite, and when that capacity is overwhelmed, the unnecessary loss of lives can be tremendous. It warns us how we cannot let our guard down until vaccines are widespread, and how responsibility must be shared by individuals and governments for keeping the pandemic tamped down. Much of this we know from the surges over the past year in the United States, but the importance of these lessons cannot be overstated.

Currently in my community hospital in the Bay Area, most of our sickest critical care patients with COVID-19 are travelers from India. They require so much nursing, respiratory therapy, and physician attention. I cannot imagine the situation in India where even basic interventions like supplemental oxygen are scarce. Seeing the influx of these patients reminds me of the international and interconnected nature of our society; what happens in a faraway country will immediately impact us at home. We must help other countries. Even beyond the immediate and imperative humanitarian reasons, it is necessary for global health. We will not have ended this pandemic until we have all ended this pandemic.

One of the biggest lessons we must learn from this pandemic is that public health depends on trust and clear messaging. This is not an easy task. At the beginning of the pandemic, a lot was unknown, and unknowns cause panic. Many were dying, and we knew little of the virus. Medical experts and the government had limited information yet had to issue messages and guidance. The mixed messaging on distancing, masking, asymptomatic carriers, testing, hydroxychloroquine, and other related issues muddied the waters a lot. Some of this is understandable; we used the word "unprecedented" a lot a year ago because it was all new territory. We balanced the goal of getting information out against the rigors of the scientific method. We struggled with the politicization of public health recommendations. We had to revise mistaken information as we learned more. We struggled with conspiracy theories, misinformation, and the Internet. These are no small challenges. Unfortunately, this process cost us public trust.

Science is rarely straightforward. New evidence can change longstanding practices; hormone-replacement therapy comes to mind as an example. Those of us in medicine understand this, and our training teaches us to evaluate trials and data, maintain skepticism, and continually improve our practices. However, public health messaging suffers with uncertainty and retractions. Especially in our current society and the way we consume media, we cannot expect most people to spend hours deep-diving into nuances of data. We want the headline, the quick summary, the TikTok sized newsbite. That is a problem, but not one we will solve today. So we need to guide our messaging to consumers who expect quick soundbites.

Eroding trust hurt us during the winter surge. I believe there were significant excess infections and deaths resulting from too much travel and too many gatherings. I believe this could have been mitigated with earlier, more consistent, and stronger messaging. People will make their own choices, of course, but the government and public health system could have been more effective had it preserved more trust.

I think on this again with the recent pause in the Johnson and Johnson vaccine. I applaud many things including that it is another vaccine helping us fight this pandemic, and that scientists have detected these adverse events. We must investigate further so that we do not cause significant harm with our vaccinations. Transparency, too, is important. However, in a climate of hesitancy, vaccine-skepticism, and soundbites, a headline of vaccine stopped due to serious side effects may cause more harm than good. It will certainly erode trust and consistent messaging about the vaccine (though, of course, a dearth of transparency would do that too). 

COVID-19 is still killing hundreds of Americans every day, and pausing a highly effective vaccine for a handful of adverse events involves a challenging risk-benefit calculation. However, as I have written before, we don't know when an infection is prevented or life saved from a vaccine. But we do know when someone has a complication. That creates a bias for weighing adverse events more than prevented deaths.

But even more than those whose vaccines have been delayed, we must now acknowledge those who were on the fence, and now don't want the vaccine. Those who have lost the tenuous trust in our public health messaging and vaccine science. It will take significant work now to convince them that the benefits of immunization outweigh the risks. As a bedside physician, I understand the value of trust, a strong patient-doctor relationship, and consistent clear messaging. This is the same at the macroscopic scale. I hope going forward, and in the next crisis, we improve these intangible yet critical foundations of public health.

The idea of "vaccine passports" is a controversial topic for which I don't have a clear answer. The concept is that businesses, events, or travel guidelines may treat people differently based on their vaccination status. For example, imagine a cruise requiring all passengers have proof of immunity or concerts with different sections, one with social distancing and one without. Depending on whether someone is immune or has a recent negative test, he or she may be able to get better benefits.

There are certainly pros and cons to this setup. From a purely epidemiological standpoint, I think it is reasonable to consider vaccinated and unvaccinated individuals differently. The risks of infection, asymptomatic carrier status, and spreading the virus are significantly reduced when one has immunity. Ideally, we weigh public health against the curtailing of social freedoms, and this balance changes with the vaccine. Additionally, as we discuss how to approach economic recovery responsibly, I think there is a strong argument for letting businesses do more if it is safe. 

On the other hand, "vaccine passports" risk significantly worsening societal inequalities. Vaccine supply remains limited, and distribution has been unequal; racial minorities and low-income populations lag behind in immunizations. Vaccination status might actually be a proxy for demographic factors and minority populations. Treating people differently based on that will worsen societal divides.

Especially in light of this last year, the medical system must be more proactive against racism. Even if the intent behind a "vaccine passport" is in the right place, we cannot discount the profound consequences it may have on dividing our society if vaccine status reflects a richer, better-educated, or whiter population. We must take steps to improve vaccination outreach and availability. This is important for many reasons. What will hamper our recovery from the pandemic is the residual pockets of society that remain unvaccinated. Uneven coverage will lead to a patchwork of vulnerable sectors where COVID will continue to circulate. We must reach out to minorities, rural areas, and even anti-vaccine groups to educate and encourage immunization. 

In the end, I do not know what the right answer is. I think there is significant risk that "vaccine passports" will worsen societal inequities. But the underlying problem may not be with "vaccine passports" themselves, but with the bigger problem of uneven vaccinations. Our current governments, federal, state, and local, have made headway into this problem, but there is still significant room for improvement.

We should not be alarmed when people who are fully vaccinated come down with COVID. None of our current vaccines are completely protective, though they come close. The Pfizer and Moderna vaccines are around 95% effective. So among vaccinated individuals who are exposed to coronavirus, for every 20 people who would have gotten COVID, 19 would be protected, but 1 would still be infected. This is why we must continue to wear masks, distance, and live our lives responsibly. While numbers and exposures remain high, vaccines will significantly reduce cases but not eliminate them. 

More importantly, vaccine studies show that they reduce the incidence of severe disease requiring hospitalization. All of the vaccines appear to be highly protective against life-threatening disease. After watching our health care system buckle under the weight and complexity of cases last year, I think this is paramount. I can envision a world in which we (collectively) have enough antibody protection that although we won't eliminate COVID, it will become a disease similar to (dare I say it?) influenza. That is, coronarvirus may become an endemic disease for which we get regular vaccination to hopefully keep us out of the hospital. 

The protective effect of vaccines is evident. We are seeing fewer older people hospitalized and fewer admissions from nursing homes. Instead, the sicker COVID patients now are younger, who have not had the opportunity to get vaccinated but may have jobs or living situations that put them at risk of exposure. Our scope and rate of vaccinations are directly influencing who gets admitted to the hospital with this disease.

One last thing about vaccination. Like any preventive health measure, its benefits can be difficult to discern at the individual level. We do not notice when we avoid illness. We proceed happily with our day and our lives blissfully unaware that our immune system has fended off an attacker. But we remember when someone who has been vaccinated gets sick or if someone gets side effects from the vaccine. This recall bias makes us think vaccines are less effective than they actually are. So it is important to analyze data at a macroscopic level to see the effect of our interventions.