If you’re unvaccinated, I am not asking you to get a shot; I’m asking you to give your decision a second thought and what it means to others - Leonard Woolsey
image by: Col Gaughan
Near the close of the First World War, Ferdinand Foch, the Supreme Allied Commander, rejected a ceasefire request from the Germans. The two sides were actively negotiating the Armistice; it was clear that the end of the war was imminent. Still, the negotiations continued for several more days, and between Foch’s refusal, on November 8, 1918, and the signing of the Armistice, just after 5 a.m. on November 11th, nearly seven thousand men were killed and thousands more were injured. News that the war would end at 11 a.m. that day was transmitted immediately to both Allied and Central commanders. Still, as Adam Hochschild detailed in a 2018 essay for The New Yorker, the fighting continued: there were more casualties on the final day of the First World War than on D Day, in 1944. The last American killed in combat died at 10:59 a.m.
A century later, we are again losing Americans to a war that could already have ended. Nearly all covid-19 deaths in the United States are now avoidable. According to the Centers for Disease Control and Prevention, data suggest that more than ninety-nine per cent of covid deaths in recent months were among Americans who weren’t fully vaccinated—a finding so extraordinary that one might question its accuracy if similar statistics weren’t being reported in study after study after study. Six months after the covid vaccines became available, more than forty per cent of American adults have not been fully vaccinated. The broad numbers don’t tell the full story: vaccine uptake is hugely variable across the U.S., and so more contagious variants are struggling to spread in some communities while inflicting real damage in others. Democrats are far more likely than Republicans to have been immunized; Vermont’s immunization rate is roughly twice that of Mississippi, where fifty-seven per cent of adults have not been fully immunized. Last month, half of American adults said that they lived in a household in which everyone had been at least partially vaccinated, even as a quarter reported that no one in their household had received a single dose. We are, increasingly, living in two Americas.
Early in the pandemic, when I was caring for covid-19 patients during New York City’s apocalyptic surge, I met Scott Aberegg and Tony Edwards, two critical-care physicians from the University of Utah who’d flown in to help. At the time, most of America remained unaffected by the virus, but New York State was recording a tenth of all the new cases in the world; hundreds of doctors, nurses, and respiratory therapists from across the country had volunteered to help a city reeling from thousands of covid deaths each week. In early April, 2020, Aberegg, Edwards, and I stood around a nursing station in a makeshift I.C.U., covered from head to toe in P.P.E., as alarms pinged and monitors flashed all around us. I felt a mix of gratitude and awe. The virus had shut the city down; we didn’t know how to treat it; nurses and doctors had died of it. And these guys had run toward the fire.
Since then, Aberegg and Edwards have cared for I.C.U. patients in each subsequent covid wave: the surge that hit the South last summer, then the viral inferno that engulfed the nation in the winter. Earlier this month, Aberegg sent me an e-mail. “The unvaccinated are dying en masse out west,” he wrote. Aberegg described one man who had “looked pretty good on arrival” but was dead within thirty-six hours; he said he’d seen husbands and wives, both unvaccinated, who were dying of covid-19. In the U.S., a fourth wave is under way. It’s smaller, more circumscribed, and more manageable—and yet it is especially tragic, because it comes at the eleventh hour.
When I caught up with Aberegg by phone, he told me that, last month, the number of covid admissions in his I.C.U. had slowed to a trickle. But, by the end of June, cases had started to rise. He began fielding calls from hospitals in neighboring states asking if they could transfer their critically ill patients to his facility, at the University of Utah. By the Fourth of July, half of his hospital’s medical I.C.U. beds were occupied by covid patients. Most were in their fifties; some were in their thirties, he said. The oldest patient he could remember was in his sixties.
Aberegg told me about a recent case. In late June, he received a call from a small-town hospital in a neighboring state. A man in his late fifties was struggling to breathe, and doctors were debating whether to intubate him. The man’s hospital, like some others in that area, didn’t have full-time critical-care doctors, and so throughout the day Aberegg offered guidance by phone. Eventually, the team of doctors decided to fly the man to the hospital where Aberegg works, in Salt Lake City. He learned that the man’s wife was also ill with covid-19.
In Utah, the man was intubated. “We thought he would just kind of ride it out,” Aberegg said. “That it would be a two-week ordeal, then he’d start to get better. But that night the bottom fell out.” Despite various ventilator maneuvers, the man’s oxygen levels plummeted; his blood pressure cratered and, eventually, his heart stopped. When it was clear that he wouldn’t live, his wife—who was now receiving care at Aberegg’s hospital, as well—was wheeled into the room so that she could hold his hand as he took his final breath.
During our conversation, I asked Aberegg how it felt to care for so many critically ill covid patients, many of them middle-aged or younger, at a time when life-saving vaccines are widely available. “There’s a big internal conflict,” he said. “On the one hand, there’s this sense of ‘Play stupid games, win stupid prizes.’ There’s a natural inclination to think not that they got what they deserved, because no one deserves this, but that they have some culpability because of the choices they made.” He went on, “When you have that intuition, you have to try to push it aside. You have to say, That’s a moral judgment which is outside my role as a doctor. And because it’s a pejorative moral judgment, I need to do everything I can to fight against it. But I’d be lying if I said it didn’t remain somewhere in the recesses of my mind. This sense of, Boy, it doesn’t have to be this way.”
Aberegg shies away from raising the topic of vaccination with critically ill patients and their families. “It’s a very uncomfortable conversation,” he said. “You don’t want to point fingers or assign blame. Because people are so sick, so many of our conversations in the I.C.U. are already fraught and emotional and challenging. The last thing I want is to invite more of that. It’s become almost a third rail.” Aberegg’s hospital requires visitors to show proof of prior coronavirus infection or vaccination before they enter the I.C.U. Because of this policy, he said, “We end up doing a lot of telephone updates.”
Aberegg, who’s originally from northeastern Ohio, sees vaccine hesitancy not just in his work but in his personal life. His parents, who are politically conservative, got immunized only because he has been an I.C.U. physician fighting the coronavirus for the better part of a year and a half. Many of their friends and acquaintances remain unvaccinated. He told me about the father of a good friend who was recently injured in an occupational accident that left him with multiple broken bones. Even as a bedbound septuagenarian with a neck brace, he refuses to get vaccinated. He described another older acquaintance who told him, “We’re not drinking that Kool-Aid.”
“I said, ‘The unvaccinated are dropping like flies around here!’ ” Aberegg recalled. “But they just blow me off. People want to make their own decisions, even if they’re poor ones. They don’t want to be forced to do anything. It’s part of their identity. But it does make you wonder how informed their choices are. It’s like riding a motorcycle without a helmet. The wakeup call always comes too late.”
Tony Edwards, who trained under Aberegg, now works at a community hospital about twenty miles southwest of the University of Utah, on the outskirts of Salt Lake City. When I spoke with him in early July, he, too, told me that coronavirus cases had increased markedly at his hospital. (Utah currently has the nation’s sixth-worst coronavirus outbreak.) In early June, there were days when not a single medical I.C.U. room at Edwards’s hospital housed a covid patient; now they account for about a third of the critically ill patients in his I.C.U. The most striking feature of this wave is that “they’re all young,” Edwards said. “I can’t remember treating a single older covid patient in the past couple months. It feels like they either got it, and they’re gone, or they got vaccinated, and they’re safe.”
Like Aberegg, Edwards told me that it’s not unusual for families to be admitted to an I.C.U. together; when we spoke, he was caring for two couples in their forties. Unlike Aberegg, however, he is very direct when speaking with patients’ families about getting vaccinated. “The first few times unvaccinated patients came in, I wouldn’t bring it up—it felt too raw,” Edwards said. “But I’ve gotten so frustrated that I now have no problem being straight with them. It’s the most aggressive I’ve been with any medical recommendation in my career.” In Edwards’s experience, families almost always say that they’ll get immunized as soon as possible. “Everyone is, like, Yeah, O.K., you’re right, head nod, head nod,” he said. “Then I follow up in a few days and they just kind of look at me sheepishly.” Recently, the wife of a critically ill patient told him that she would get vaccinated that day. She didn’t, and, not long after, she became a patient along with her husband. “I walk in one morning and I’m, like, Oh, there’s two patients with the same last name—what’s up with that?” he said.
With the advent and availability of vaccines, Edwards assumed that he wouldn’t be gearing up for another coronavirus wave. But four in ten adults in Utah are not fully vaccinated. “I try not to feel angry, but it’s hard,” he said. “I try to be fair. I know I’m a well-off white doctor who understands science and medicine. The vaccine came to my place of work and I just rolled up my sleeve. I get that it’s harder for other people. But at this point it’s, like, C’mon, man, this is the most important thing you can do for your health. I’m frustrated, and I don’t know what to do to make myself un-frustrated.”
I’ve followed a similar path in my own thinking. Before the coronavirus pandemic, I assumed that the seeds of vaccine hesitancy—directed, usually, toward shots for diseases like measles—lay in the success of vaccination; if someone had never confronted the devastating paralysis of polio, or the rib-fracturing cough of pertussis, it might be easy for them to question the efficacy or safety of vaccines. The risks of illness might seem distant and amorphous, whereas the risks of vaccination—however spurious—could feel vivid and tangible. As the coronavirus began to spread, I figured that it would change that equation. Surely, faced with a lethal, contagious, economy-destroying pathogen that had upended every aspect of society, even ardent vaccine skeptics would get on board.
That prediction, it turns out, was incorrect. The coronavirus has unleashed unprecedented havoc, killing more than six hundred thousand Americans and potentially leaving millions more with lingering symptoms; covid vaccines are safe, effective, free, and accessible. Still, millions of Americans remain susceptible to death and disease by choice. Having developed vaccines of astonishing efficacy, we have failed to convince huge segments of the population that those vaccines are worth taking. Scientific success has foundered on the rocks of tribalist mistrust.
What would it take to reach something closer to full vaccination? There are four main levers available to policymakers. Education is the most obvious one: after a year of vaccine talk, it may feel like there’s nothing left to say, but many people still have questions about whether, where, and when they can get vaccinated; recent polling suggests that a majority of Americans—including four in ten who’ve been immunized—either believe or are unsure about at least one vaccine myth. At the same time, more than eighty per cent of unvaccinated individuals say that they would turn to a doctor when deciding whether to get a shot. So it is not too late for conversation to change minds.
Incentives are another lever: states are experimenting with everything from free beer and lottery tickets to college scholarships and cash payments. (Evidence on the effect of these initiatives is mixed, but some research suggests that they may temporarily boost uptake.) Full F.D.A. approval is another: nearly a third of those who remain on the fence say that such an approval would make them more likely to get vaccinated. (Currently, even though hundreds of millions of doses have been administered, covid shots are given under an Emergency Use Authorization; Pfizer and Moderna recently applied for approval, but it’s unclear how soon they might receive it.) Finally, there are mandates. Increasingly, vaccination is a requirement for living on a college campus, working in an office, flying internationally, attending a concert. (Although the public is evenly divided on vaccine passports, many Republican governors have issued orders or signed laws prohibiting or constraining their use; the Biden Administration has said that it will not introduce a national vaccine mandate or registry, but, according to the Equal Employment Opportunity Commission, businesses can require on-site employees to get immunized.) It’s possible that all of these factors—combined, perhaps, with fear of the Delta variant—could push some holdouts over the line.
I asked Edwards what, if anything, he thought might tip the scales for people unsure about the covid vaccines. He was at a loss, but connected me with two women he works with at one of his hospital’s clinics, who, despite helping people suffering from the aftereffects of covid-19, have elected not to get vaccinated. (The medical center where they work strongly encourages staff and patients to get immunized.)
Ashlianne Carroll worked in a car dealership before starting as the clinic’s receptionist, in December of 2019. She’s pregnant with twins, due in January, and nearly everyone in her family—her father, her three brothers, their wives and children—has been immunized. Carroll herself gets the flu vaccine every year, but “that’s been around forever,” she told me. “We know the long-term effects. I don’t trust the covid vaccine yet. There hasn’t been enough testing. All the stuff you hear about side effects makes it not worth it to me.” Carroll said that she’d read reports online of the vaccines’ being linked to stillbirths. “Even if there’s a small chance, why risk it?” she said. To her, contracting the coronavirus seems like the less ominous possibility. Her husband, his parents, and his siblings all got covid last year; none were hospitalized. “I feel like I’m in good enough health that it won’t be an issue for me even if I do get it,” she said.
Nicole Howard, who works closely with Edwards as a medical assistant, has similar views. Howard had a mild case of covid in January—low-grade fever, chest congestion, body aches. But she told me that this prior infection, and the immunity it confers, has no bearing on her decision not to get immunized. (The C.D.C. recommends that even people who’ve had covid be vaccinated, to better prepare their immune systems to fight reinfection.) “I hear about these variants, and I do wonder if it’s possible I could get it again,” she said. “But I’m thirty-one. I’m healthy. I don’t have any underlying medical conditions.” In her clinic, Howard regularly encounters people suffering from the short- and long-term consequences of covid-19. I asked her how it felt knowing that some of the coronavirus patients she cares for are younger than she is. “Most are older,” she said. “I’m not afraid of covid. I won’t live my life in fear.”
Howard emphasized that she takes other precautions against the coronavirus: she wears a mask in public, maintains physical distance, and washes her hands frequently. But, when it comes to covid vaccines, at least for the time being, she’s made her decision. “You can put me in a lottery, you can give me free Starbucks for a year, but it’s not going to change my mind,” she said. “Because it’s not about that for me. It’s about what the vaccine could do to me in the future. My personal feeling is that the covid vaccines got pushed out too fast. They weren’t studied for long enough. We don’t know what’s going to happen five years down the road. You see these horror stories. Blood clots, stroke, myocarditis. I’m in my childbearing years. Will it cause fertility issues? Will it negatively impact my unborn child?” (The covid vaccines do not alter your DNA, cause infertility, or affect fetal development; the Johnson & Johnson vaccine has been linked to extremely rare instances of dangerous blood clots, and the mRNA vaccines to a marginally higher risk of myocarditis, especially in young men—but, in both cases, the benefits of vaccination far outweigh the risks, and over all the covid vaccines are among the most intensely monitored and effective in history.) Howard said it’s possible that she’ll reconsider “in a year or two,” if “there’s been more testing and more long-term follow-up,” and if she doesn’t see any issues. What of the possibility of infection—from Delta or another, even more infectious variant—between now and then? “Well,” she said. “I guess that’s just a risk I’m willing to take.”
In the days since speaking with Carroll and Howard, I’ve considered the reasons for the gap between my views and theirs. It’s not that they think covid-19 is a hoax; they have witnessed firsthand the consequences of infection, just as I have. It’s not that they belong to social networks that are deeply skeptical of vaccines; on the contrary, they work in a medical setting, and most of their friends and family members have been immunized. Still, having weighed the strength of the vaccine science, the likelihood of low-probability events, and the unknowns that remain, they have arrived at conclusions very different from mine.
I used to think that fear could push many hesitant people to get vaccinated—that watching covid put a friend on a ventilator would make one rush to get a shot. But fear seems to work in unpredictable ways. It’s possible to shift one’s gaze away from the gravely ill and onto those who contracted the virus but escaped unscathed. It’s possible to be more afraid of the vaccine than of the virus. Perhaps the psychology of risk plays a role: for the willfully unvaccinated, it may be easier to accept the preëxisting risk of contracting covid than to embrace the incredibly small but unfamiliar risks posed by the vaccines. Many people seem to believe either that they won’t contract the virus or that their illness won’t be that bad—a natural and attractive view for younger Americans, but a risky one. Nearly ninety per cent of Americans over the age of sixty-five—people of all races, ethnicities, income brackets, and political persuasions—have received at least one dose of a covid vaccine. Those facing the greatest risk seem to have an easier time taking an accurate measure of it.
But smaller risks can still be considerable—and, with more infectious variants on the rise, the virus is growing more dangerous to those who remain susceptible. In states where vaccine hesitancy is high, its consequences are already stark. In recent weeks, some of the country’s low-vaccination areas have begun driving a national doubling of daily coronavirus cases, and experiencing a spike in hospitalizations and deaths.
Death is a loss in all its forms. Still, some ends are more comprehensible than others. We might take as inevitable the loss of life in the pitch of war, but casualties suffered in the battle’s final moments, when peace is so clearly at hand, carry with them an added senselessness. Today’s coronavirus deaths are senseless. We’ve been offered a ceasefire. It’s past time we take it.
Source: Dhruv Khullar, Treating the Unvaccinated, The Economist, July 16, 2021.