Recently, I was part of a pro-con debate as to how we in medical circles should advise people regarding restrictions after they get vaccinated, and received some backlash that devolved into personal attacks. I believe how professionals handle disagreement in the time of a global crisis illustrates broader challenges we face with tribalism, virtue signaling and politics.
Medicine is rapidly becoming a tribal field, and I learned this the hard way. For taking a side in a debate, I was accused of being indifferent to death or ill-motivated. Both are untrue. The attacks included cropped, out-of-context screenshots of my Twitter feed with no link to my op-ed, and tagging my employer in these tweets. I just think people have a right to choose risks that are right for them.
Few made an effort to rebut my points, and I believe this is because of the gap between what is said in public versus what people are doing in private. I know some vaccinated people are taking risks they wouldn’t advertise on Twitter. Meanwhile, I believe that this messaging, “Despite being vaccinated, I will continue to wear a mask and social distance” is a form of virtue signaling. It further divides us into the bad people (those who spread COVID) versus the good ones (those who fight it). This has been unhelpful the entire pandemic. It sanctifies folks who have the privilege to detach themselves from society. And it divides people who should be seeking honesty and middle ground. I see it as a base human reaction to fear and anxiety.
My proposition is simple: If a person gets vaccinated and completes 2 doses, and has an additional 14 days where they feel fine, that person can relax some restrictions. They can meet other vaccinated people for dinner, relax the mask in private, or even hug a loved one. A few strands of evidence led me to this place.
To recap: the vaccine is 95% effective, but that is the relative difference in getting symptomatic COVID, not the absolute chance of getting it. If you get both doses, and feel fine two weeks later, the chance you will be free of symptomatic COVID beyond that point till the end of the study was 99.92% in the Moderna trial and 99.95% in Pfizer. That’s amazing! These results have been confirmed in the “real world.” Israel just reported if you complete two Pfizer shots and go seven days, the chance of not getting COVID-19 is 99.99%.
Second, rates of severe COVID went from 30 cases in the control arm of the Moderna study to zero in the intervention arm. There was just one case in the Pfizer vaccine arm. The vaccine is marvelous at stopping this bad and highly infectious outcome. Finally, there is evidence that the rate with which the virus can be detected (asymptomatic PCR carriage) is lowered 60% with vaccination. Because vaccination primes the body to fight off SARS-CoV-2, you are massively less likely to get sick and less likely to infect others. Some ask about the new variants, but data out from Moderna are reassuring.
In my commentary, I make the case to relax restrictions, I point out that no one is chasing a zero-risk life. In fact, that is a mirage. Instead, we all want reasonable safety. Relaxing restrictions is reasonably safe, and the truth is I am aware of many, many, many doctors who are privately doing it.
Finally, all of the evidence we have that supports restrictions — for example masking in private or not eating lunch together indoors — is applicable only to people who are unvaccinated. For folks who ask me for evidence that it is safe to stop the restrictions, I counter by asking for evidence that restrictions offer any benefit for someone already vaccinated.
The truth about medicine is our tools generally work less and less well — to the point of not working at all — as risk of bad outcomes get lower and lower. This is just a property of life. We don’t know exactly how much these restrictions help, but however much that is, it is massively diminished after vaccination. The irony is of all the precautions we take against the vaccine, vaccination is the one with the massive benefit! I believe folks in Europe recognize this, here is their messaging:
For these reasons, I contend that strictly on the merits, it makes sense to be honest about restrictions after vaccination. And the truth is, doctors are voting with their feet. Many are meeting privately for drinks or dinner with colleagues or visiting their parents, whom they have not touched since March, and this will surely continue.
The other day on a public radio station in San Francisco, I heard the story of elderly people crying when they are vaccinated, and saying how much they look forward to hugging their grandchildren. There is no world where risk is 0%, and these folks are all making their own internal risk calculation. Is some very low risk worth it to hug a mother or grandson? I think that is entirely reasonable.
Lessons From the Bone Marrow Transplant Service
When I previously worked at Oregon Health & Science University, I attended on bone marrow transplant during my last five years there. These patients often left the hospital with some degree of an impaired immune system. They often asked what is safe, and it required a long and personal conversation. It was always about values, and physicians never took the hard stance that one has to forgo things in life — like hugging a grandchild — in pursuit of zero risk. We just did our best to counsel and advise.
The #MedTwitter Message
But now, there is a powerful messaging bloc on social media that thinks this message is not just wrong, but dangerous, harmful, and misinformation. They favor the narrative that despite vaccination, they will continue to do what they have been doing.
Some of these people even try to think a step ahead. What would it mean if we tell people that it is reasonable to relax mask-wearing, would they then neglect the pandemic? Take new risks? Would folks lie about being vaccinated? Would unvaccinated folks feel marginalized — like we are not in it together? Alternatively, if we say vaccination is a path to normalcy, will more want the vaccine? Will it overcome hesitancy?
I am deeply uncomfortable with scientists filtering their messaging and interpretation of data with these thoughts. We have no training in predicting how people respond to our messaging. And it is fundamentally not scientific. I do not know how to weigh the risk of people lying about vaccination versus excitement to get vaccinated, and no one does.
If you want everyone to continue to mask at stores — and I think that is reasonable — it can be a store policy. But we should not pervert the evidence to say we are truly worried about vaccinated people spreading virus in stores. In other words, we should be honest about why we want people to do it. A recent article by Julia Marcus echoes this point.
What’s The Harm?
A trainee in a program messaged me to say that at his hospital, an email was sent out telling vaccinated residents and fellows (14 days out from last dose and asymptomatic) they are not allowed to eat lunch together. It sounds like a small thing, but it matters.
Frontline health care providers are dealing with moral anguish. The camaraderie of peers is what sustained me through my six tough post-graduate education years. I do not think the benefits of this policy outweigh the harms. In other words, lowering a theoretical and infinitesimally small risk of spread does not outweigh robbing hard-working, emotionally tired people of human interaction. And I believe this policy is linked to the hard-line stance on #MedTwitter that these interactions are unsafe. That rhetoric has real consequences.
Public Versus Private Ideas
The disconnect between what people are doing and what they are saying astounds me. I tweeted this joke to illustrate it, and perhaps that explains some of the response I got. But the joke reveals a core truth, which is that I doubt folks are privately doing what they publicly admonish.
Only on Twitter can vaccinated docs take a break from their busy schedule of planning dinner parties, reunions, dates, and vacations to criticize my article that it’s okay to relax restrictions 14 days after the second dose of the vaccine….
…. Now back to packingâ Dr. Vinay Prasad MD MPH, Associate Professor (@VPrasadMDMPH) January 21, 2021
And Some Vaccinated People Could Develop COVID-19
I want to be clear that I believe that even after mass vaccination, it is likely that some person will someday develop COVID-19 after vaccination. It is also possible that a vaccinated person spreads SARS-CoV-2 to another person, eventually. However, just because this outcome is almost certain to happen when sample sizes reach tens of millions, does not mean the benefit of continued restrictions outweighs harms in the future, nor this moment.
Some critics felt that I should not even espouse my views lest the public get confused. During a crisis, we need uniform messaging. I would submit that this is possible and desirable from the CDC, or the federal and state governments, but it is not possible from every scientist on earth.
In an era of social media, some academics — well-intentioned, smart people — will disagree with policies or summaries of other academics. They will, almost certainly, say so somewhere and sometime. The choice in the modern world where the wall between academia and the real world has crumbled is either uniformity and silencing of some views, or a plurality of voices and mixed ideas. I think there is no question in a free society that the latter is the only possible choice.
These views are my own and not my institution’s.
Vinay Prasad, MD, MPH, is a hematologist-oncologist and associate professor of medicine at the University of California San Francisco, and author of Malignant: How Bad Policy and Bad Evidence Harm People With Cancer.
Last Updated January 28, 2021