It’s the Boosters, Stupid
In a climate of fear, the strict “follow the science” path is not one the Biden administration can afford to take
In 2013, I interviewed the father of the first child in the world crippled by polio that year. His name was Usman, and he came from the Swat Valley, the home of the Pakistani Taliban. We met in secret because he worried that the Taliban might come after him for speaking to me, and the doctors who arranged the interview were definitely afraid the Taliban would come after them.
Usman’s left leg was bent like a parenthesis from his own bout with childhood polio, and he limped painfully, just as his two-year-old son, Musharaf, did. For years, he said, he had made sure his first three children were vaccinated. But then he began ordering the vaccination teams away from his door.
“But why?” I asked. “You’ve had polio. You know how awful it is. How could you do that?”
“You Americans have caused pain in my community,” he said. “Americans pay for the polio campaign, and that’s good. But you abused that humanitarian mission for a military purpose.”
He hadn’t always hated Americans, Usman said. He used to drive tourists around and he liked our friendliness. He had a cousin working in a gas station in Virginia.
But when the C.I.A. was hunting Osama bin Laden, it hired a hepatitis B vaccination team to try to get into his compound and aspirate blood from his children to test for DNA. That failed stunt had nothing to do with polio, but the polio-eradication campaign paid the price. It has been stalled in Pakistan ever since, and dozens of vaccinators have been assassinated by Taliban gunmen.
Also, Usman had seen a friend’s son killed by an American drone. The explosion had ripped his head off.
“We would respect you if you came into our valleys and fought us face-to-face,” he said. “But you don’t. You kill us with these machines.”
So he began believing the rumors that the vaccine was a Western plot against Muslims — and his son suffered.
What’s my point?
That vaccines are always political — and emotional. You cannot divorce the shot from the fantasies woven about the motives of the people offering it.
People question vaccines, especially unfamiliar ones. We easily forget that, a year ago, before the vaccines were emergency-authorized, many now fully vaccinated people initially had serious doubts and let others go first.
But in risk calculations, the fear of death changes everything.
Hence, we see many anti-vaxxers and vaccine-hesitaters shun the shots, boasting that they “won’t be guinea pigs” — and then plead for monoclonal antibodies as soon as they fall ill, even though the monoclonals are less well tested, don’t work if they’re given late and have scarier potential side effects, including pneumonia.
This is where our booster-shot debate is now. Advisory panels to the F.D.A. and C.D.C., medical experts on television and science writers are discussing this as if it was solely a medical decision: Are boosters needed? For whom? The immunocompromised? Nursing home residents? Health care workers? Over 65s? Over 50s? Over 12s?
Hyperfocused as they are on the data, they are forgetting a crucial angle: politics and emotion.
What the White House seems to perceive, while medical experts do not, is that much of this country is now living in a vortex of anger and fear.
Only about 30 percent of adults in this country have completely dodged even one shot.
In the other 70 percent, there is a growing sense of fury. In their eyes, the unvaccinated are prolonging the pandemic, putting our children at risk, keeping the economy crippled, and forcing the rest of us to wear masks. If not for them, it could all be over by now, at least among adults and teen-agers. Moreover, before they die, the unvaxxed panic and try to grab more than their fair share of the scarce, expensive monoclonals.
That rage becomes visible on venues like the Herman Cain Awards subreddit and SorryAntiVaxxer.com. Readers wallow in ugly, gleeful schadenfreude, posting screenshots from the social media feeds of people who publicly sneered at masks or vaccines and then died of Covid. (This isn’t new. It was blood sport in pre-Facebook days: AIDS activists published the names of prominent H.I.V. skeptics who had died of AIDS.)
Many normally rational Americans are now mortally afraid of getting a breakthrough infection with a bad outcome: hospitalization, death or Long Covid. That fear may be exaggerated — the chances are actually low — but fear is fear.
They are afraid for their unvaccinated children — that they will go back to work, catch a mild case, and then come home to infect their babes. Or that they themselves will need hospital care for some other reason, but face jammed ICUs.
Hospital workers are especially afraid. They face the virus every day while they are overworked and exhausted and know their immunity is slowly fading. Many have children at home. These are our front-line troops. We used to clap for them at 7 o’clock every evening. Now they are as forgotten and taken for granted as our soldiers in Afghanistan were for much of the last 20 years. Denying boosters to health-care workers would be like denying our troops Kevlar vests, saying “well, the data are still iffy.” I’m very glad that Dr. Rochelle Walensky ignored her science advisers and protected doctors and nurses.
Booster shots have now become for the vaccinated what monoclonals are for the unvaccinated: the golden lantern that can light their way out of the valley of the shadow of death.
So they won’t abide waiting.
Yes, it’s morally repulsive that Americans will get three shots before most Africans get even one.
Nonetheless, I fear it must be done. And I say that as someone who spent much of his New York Times career helping make sure that Africa got AIDS drugs, mosquito nets and other life-saving interventions.
Because if the average sane American believes even for a minute that Joe Biden is preferentially giving shots to Africans while they and their children shiver in fear, then Donald Trump is President again.
Before he left office, Mr. Trump’s imbecilic choices cost over 400,000 Americans their lives. He also quit the World Health Organization, ignored its vaccine-sharing proposals and dismissed the whole continent as the land of “shithole countries.” Neither we nor Africa want to go through that again.
(Also, statistics from sub-Saharan Africa are weak, of course, but as of today, fewer than 200,000 Africans have died of Covid versus 680,000 Americans. That’s one in 500 Americans versus about one in 6,000 Africans. For all of our wealth, we are doing much worse than they are.)
A pandemic is akin to war. Fuzzy eleemosynary sentiments about foreign aid and pan-global unity are quickly garroted. Vaccines become political footballs, just as destroyers bound for Britain were in 1940: to sell Lend-Lease to voters, F.D.R. had to pretend it was a fair swap. Vaccine nationalism, ugly as it is, is inevitable.
As Bill Gates pointed out early in the pandemic: you cannot expect American taxpayers to pony up $11 billion to create products that no private company would shoulder the risk of making — and then docilely stand in line for only 5 percent of them because we are only 5 percent of the world’s population. American voters would rebel, and the next time a pandemic arrives, would be disinclined to help anyone else.
India, facing the same dilemma, made the same choice. It was slated to be the heroic vaccine-supplier to the world, but as soon as it hit a crisis, Prime Minister Narendra Modi curtailed exports. China appears to have done the same.
Dr. Michael J. Ryan, the widely admired head of the W.H.O.’s emergency program, has acidly observed that booster doses amount to “handing out extra lifejackets to people who already have lifejackets while leaving others to drown.”
Although he is correct, most Americans are convinced that their lifejackets are leaky. Speaking rationally to them is no more effective than speaking rationally to vaccine denialists. Reams of studies suggest that, under stress, facts backfire and make people dig deeper in.
(Also, experience suggests that those lifejackets will eventually get leaky. Just two shots is rarely enough. The C.D.C. schedule for children is six shots against tetanus, whooping cough and diphtheria, four against polio, at least three for hep B, Hib and pneumonia and so on.)
I think the Biden administration is right — politically rather than morally — to pursue the two-pronged policy he announced Wednesday: helping poor countries get vaccines while simultaneously making sure Americans get boosters.
Also, as Dr. Bruce Aylward, the W.H.O. official in charge of fast-tracking vaccines, pointed out on Thursday, the world is manufacturing 1.5 billion shots each month while wealthy countries are using only 1 billion of them. There will soon be a surplus — it might even arrive while we are rolling out our boosters, and as our Delta variant surge drifts back down to baseline.
In poor countries, logistics may become a bigger problem than supply.
Even though they don’t need the Arctic temperatures we once thought they did, the delicate mRNA vaccines are logistical nightmares. Anyone who has covered vaccine campaigns in rural Africa or Asia has seen thousands of doses spoiled by power failures, intense sun, bad roads or corrupt local officials who pocket the money they were issued to buy freezers. Outside of major cities, I doubt Pfizer or Moderna will be practical.
Since, like us, the whole world will need boosters eventually, we need to aggressively pursue the more forgiving vaccines like the Baylor College of Medicine candidate that grows in yeast. We can subsidize the distribution of the Chinese, Russian and Indian products that have been shown to work — maybe not to the F.D.A.’s satisfaction yet, but the F.D.A. is just moving too slowly.
I’m not surprised that the highest-tech vaccine-makers are reluctant to share their tech with local companies they do not oversee. It’s not just about patents and profits. Vaccines are much harder to maintain quality-control on than drugs. As Moncef Slaoui, the former head of Operation Warp Speed, said: “if you just look at a bioreactor wrong, you can ruin the whole batch.”
In 1959, Jonas Salk subcontracted his new polio vaccine to several companies. Cutter Laboratories in Berkeley made a single bad batch that paralyzed or killed more than 200 children. Were anything like that to happen today — with anti-vaccine activists shamelessly spreading lies — it would destroy not just the Indian or Thai or South African subcontractor, but the mother ship’s product. The AstraZeneca vaccine, an excellent product used in Canada, Britain and 100 other countries, was torpedoed here by reports of blood clots, low efficacy, factory screwups and AstraZeneca’s cherry-picking of data. All were partially true but very much overblown, and the vaccine now has a scarlet “Go Back, Wrong Way” sign on it in the U.S.
The Biden administration can both help the world and offer boosters — and shots to children — here. Like it or not, the politics of fear dictate that the administration has to nail shut the lid on our pandemic’s coffin before another surge can spring howling out.