January 23, 2022


Why I’m for COVID vaccines, but against vaccine mandates.

In the heated debate over vaccine mandates, science and logic have often been lost amid politics and fear.

Read Time 14 minutes

Tomorrow we’ll be releasing a follow-up discussion with Drs. Marty Makary, Zubin Damania, and Monica Gandhi on all things COVID. This episode was put together in response to the overwhelming, if not staggering, response to our first episode, released on January 3 (Monica was not on that one, but she is a brilliant addition to part 2). In this episode we aim to address most of the topics that so many of you have asked us to expand upon.

On the heels of this podcast, I want to write about something that we discussed on the podcast, something that is sure to upset some reading this or listening to the episode, whichever side you find yourself on: Vaccine mandates.

The goal of this article is not to irritate you for the sake of irritating you. My hope in writing this, first and foremost, is to invite you to think. In the heated debate over vaccine mandates, science and logic have often been lost amid politics and fear. Ever-evolving circumstances – such as the emergence of variants with radically different levels of infectiousness or virulence – have only further separated opinion from facts. (After all, if facts are changing, why haven’t opinions changed, too?)

Of course, I’d like to convince you of my point of view (denying this would simply be disingenuous—why else do we write or argue a point?). But if that fails, I hope, at least, that this newsletter may serve as a reminder that exchanging rational decision-making for fear and blind partisanship is a recipe for injustice, discrimination, and policies that may do more harm than good. Scientific policy must be based on scientific truth — otherwise it will be ineffective in the present — and damage credibility for the future.

Let’s start with my priors: COVID vaccines save lives.

COVID vaccines absolutely save lives. Full stop. My opposition to vaccine mandates does not in any way diminish my belief in the data supporting the efficacy of vaccines in preventing severe disease and death, particularly in people over 65 and in those with comorbidities. So, I’m not going to spend much time extolling the virtues of vaccines beyond sharing some data that should always be examined for any medical intervention: what is the benefit, in different risk groups, in both relative and absolute terms?

Deaths of Unvaccinated vs Vaccinated (mRNA vaccines only, at least 1 dose). Data collected from the Veterans Affairs system between December 2020 and March 2021.

The data above show that for people over the age of 18, the relative risk reduction (RRR) of death is between 84 and 88%, regardless of age. This is very close to the 90% risk reduction that was touted at the time of vaccine approval a year ago. But if you’ve paid attention to anything I’ve spoken and written about for the past 10 years, you will recall that we should always pay attention to absolute risk reduction (ARR) also. If the relative risk reduction is 90% (to make the math easy), you still don’t know if the risk is being reduced from 100% to 10% or from 0.1% to 0.01%. And this matters greatly.

Consider the following example: Let’s say we faced a virus that killed 100% of those who contracted it. A vaccine with a 50% RRR (i.e., only “50% effective”), meaning it reduced deaths by half, would save over 150 million lives in the U.S. But if we faced another virus that killed 0.1% of those who caught it, even a vaccine with 99% RRR (i.e., “99% effective”) would “only” save about 300,000 lives (by lowering the death rate from 0.1% to 0.001%). In other words, in this scenario the vaccine that is 50% is far more valuable—and saves orders of magnitude more lives—than the one that is 99% effective that reduces deaths from 0.1% to 0.001%. How is it possible that a vaccine that is only 50% effective could save more than 150 million lives, while one that is 99% effective can only save 300,000 lives? Because of absolute risk reduction. The 50% effective vaccine is up against a virus that infects and kills every single person in a given population, so in absolute terms it is wildly effective, literally saving one out of every two lives of the people who take it. Conversely, the vaccine that is 99% effective is up against a virus that only kills 1 out 1,000 people who encounter it.

Returning to the actual data for COVID vaccines, take a look at the absolute risk reduction column. Here, two things stand out. First, the absolute risk reduction (ARR) increases with age. Why? Because the older you are, the more likely you are to die from COVID, so the benefit from the vaccine is greater. Second, the ARR numbers are very small, especially for people younger than 65. A quick way to get an intuitive understanding of this is to take the reciprocal of the ARR. This number is known as the “NNT” or number-needed-to-treat, which tells you how many people you need to treat to save a life. If the ARR is 50%, the NNT is 2 (1/0.5). If the ARR is 0.1%, the NNT is 1,000 (1/0.001). Based on this data set from the VA (which I chose because of the age stratification), the the number of people you need to vaccinate to save one life in the 18-64 group is 10,000, versus 2,857 in the 65-74 group , and 1,370 in the over-75 group. By comparison, the NNT for a statin is between 50 and 200, depending on the study and patient population studied.

This is not to imply that COVID vaccines are ineffective or somehow useless. Far from it. A quick glance at the recent CDC data, covering more than 1.2 million people who completed their primary vaccination between December 2020 and October 2021, bears this out. In this broader group, 0.015% had a severe case of COVID and 0.0033% died. Not surprisingly, the risk of death was highest among people over 65 and among those who were immunocompromised or had significant comorbidities. But overall, the risk of death among people who were vaccinated was infinitesimal.

In fact, the rate of death from COVID if you are vaccinated is on par with, and likely less than, that from influenza. According to  CDC data from 2017 to 2018, there were approximately 41 million symptomatic cases of influenza that year. This resulted in over 710,000 hospitalizations and nearly 52,000 deaths, which means a fatality rate of 0.126%. Looking at the same data for 2018 to 2019, we can see the death rate was 0.095%. It is abundantly clear: If you are vaccinated, your risk of severe illness or death from COVID is very low, even compared to influenza.

So, why not mandate vaccines, then?

There are many reasons I have heard put forth for why vaccines should be mandated, but one dominant argument stands out: Mandating vaccines will protect vaccinated people from unvaccinated people. This argument assumes three things:

  1. Vaccines DO NOT provide complete protection to the vaccinated (or else why would we care about what the unvaccinated do),
  2. Prior infection DOES NOT confer immunity on par with vaccination, and
  3. Vaccines DO prevent transmission of the virus (which is why we want the unvaccinated vaccinated, even if we don’t care about their health, per se).

Well, we’ve largely addressed the first point in an effort to get our facts straight on vaccine efficacy, and as we’ve seen, the basic assumption fueling this concern is valid at its surface: vaccines do not provide complete protection to the vaccinated. That is, they are not 100% effective at preventing infection, hospitalization, and death. In fact, although vaccines significantly reduce risk of detectable infection in the few months after vaccination, this protection drops precipitously once circulating antibodies decline, though protection against severe infections and death persists. Still, the protection isn’t absolute, and some risk of death remains even among those who have been vaccinated. However, the good news is that the risk is very low today. This was not necessarily the case 18 months ago, but three things have evolved over the past year-and-a-half to compound the risk-reduction of vaccines:

  1. Novel therapeutics have been developed specifically to treat COVID, including monoclonal antibodies, paxlovid, and molnupiravir, all of which reduce the risk of hospitalization and death by anywhere from 50% to 90%.
  2. At least one existing drug (fluvoxamine) has been repurposed to treat COVID successfully, reducing both hospitalizations and deaths by 66% and 91%, respectively, based on per protocol usage.
  3. Far more sophisticated critical care knowledge has evolved, specifically, to address COVID, including the use of dexamethasone and better strategies of ventilation.

The net result of these advances, layered on the benefits of vaccination, imply that a vaccinated person infected with COVID today is in a far less risky position than they were a year ago. And this says nothing of the fact that when it comes to the Omicron variant, which today accounts for >99% of document cases in the U.S., the risk goes down much further. Why? Because the data are unambiguously clear that Omicron is much less virulent than Delta and Beta and Alpha.

How much less virulent is Omicron?

Well, if we look at the most up-to-date information at the time of this writing (still in pre-print), analyzing data from Kaiser Permanente in Southern California between November 30, 2021 and January 1, 2022, there were a little over 52,000 documented cases of Omicron in the patients in their medical system, compared with nearly 17,000 cases of Delta (today these numbers skew much more to Omicron, of course, based on the current distribution of Omicron in the U.S.).

  • 235 (0.5%) of these Omicron patients required admission to the hospital, compared to 222 (1.3%) of the Delta cases;
  • of the 235 Omicron cases, zero required mechanical ventilation, compared to 11 patients with Delta;
  • one patient with Omicron died, compared to 12 patients with Delta; and
  • 84% of patients hospitalized with Omicron left the hospital in less than 2 days, compared to 31% of patients hospitalized with Delta.

Of course, none of this should be surprising given what we know from the data out of South Africa, where Omicron originated, which demonstrated the reduced severity of Omicron relative to Delta, even in a country with very low vaccination rates. Omicron is a very mild infection, compared to Delta, Beta, or Alpha, and based on the emerging data I’ve presented above, it seems to be mild even compared to influenza.

Therefore, we can conclude that while the vaccinated are not immune to COVID infections, their risk of severe illness or death is very low because of the following:

  1. The vaccines greatly reduce hospitalization and death, and
  2. We have a slew of novel and repurposed drugs that are very effective at treating COVID, and
  3. Our hospitals and ICUs are far better equipped to treat COVID patients based on nearly two years of empirical and trial data, and
  4. The dominant variant, Omicron, is a very mild virus (even to the unvaccinated).

How does natural immunity stack up to vaccines?

Next, let’s examine the assumption that prior infections do not provide immunity on par with vaccine immunity. Of the three sub-arguments in the case for mandates based on protecting the vaccinated, I find this the hardest to understand. I am not aware of any other virus from which a recovery does not confer immunity (and yet a vaccine does). In other words, the null hypothesis around this point, at the outset, should be that natural immunity is indeed as good as vaccine immunity, pending data to prove that assumption false. Looking back at the close coronavirus cousins of COVID, SARS and MERS, the data are overwhelming that patients who survived those infections had lasting immunity, even 12 years after infection. Do data exist to suggest natural immunity doesn’t exist for this particular coronavirus? No. To the contrary, there is ample evidence that natural immunity is robust and durable. In fact, the data suggest that recovery from COVID provides longer lasting and stronger protection against subsequent infection, symptomatic disease, and hospitalization caused by the Delta variant, compared to vaccination.

A quick examination of this figure from the CDC data released on January 20 shows that there is virtually no difference in hospitalizations from COVID between the vaccinated and unvaccinated, if a prior COVID infection took place.

In fact, if you look at Table 1 from the paper, and run the calculations yourself, you’ll see the risk of hospitalization is lowest in the group that was not vaccinated, but previously infected. I’ve summarized the data here for the fraction of each group that required hospitalization following a COVID infection:

This simple table, based on data from nearly 22 million COVID positive cases in California between May and November 2021, makes three points so abundantly clear, it’s hard for me understand how there can be any vestigial ambiguity:

  1. Vaccines unquestionably reduce the risk of hospitalization in previously uninfected people (by a factor of 16.5x), and
  2. In people who are previously infected vaccines offer zero additional benefit with respect to hospitalization, and
  3. In vaccinated people, being previously infected reduces the risk of hospitalization by a factor or 2.5x.

Can the case be any clearer, simultaneously, for both the efficacy of vaccines and natural immunity?

How do vaccines affect virus transmission?

Finally, let’s consider the rationale for mandating vaccines to prevent the unvaccinated from transmitting the virus to the vaccinated. A perfect vaccine would not only completely abrogate the severity of the virus on the host, but it would also completely prevent the host from transmitting it to another person, vaccinated or not. This is clearly not the case for any of the current COVID vaccines. In fact, it seems that they only slightly reduce the risk of transmission, and that vaccinated and unvaccinated persons with detectable infection have the same viral loads, despite the reduction in disease severity for the former group. Using a metric called the secondary attack rate (SAR), it’s possible to look at infection rates in household contacts stratified by contact vaccination status and index case vaccination status, and based on such analysis, it seems that vaccination only slightly prevents transmission. Vaccination does not reduce the peak viral load in the infected (though it does appear to reduce the duration of viral shedding, which may translate to the reduction in SAR). An important caveat here is that such analyses have been carried out prior to Omicron’s arrival, but considering everything we know about the mild nature of Omicron, the risk of transmission to vaccinated people is, again, likely much less.

What about mandating vaccines to prevent hospitals from being overrun with COVID cases?

It’s true that hospitals are stretched very thin right now with the n-th surge of COVID. But a few things are worth keeping in mind. During a bad flu season in the U.S. (recent examples would be 2017-2018, 2014-2015, and 2012-2013) it is common for 50,000 to 70,000 patients to be hospitalized at any one time across the country. This is not very different from what we see today (which says nothing of the fact that roughly half of the hospitalized COVID patients have incidental infections. That is, they are there for another reason, but also test positive for COVID). The difference, today, is that the hospital workforce is greatly reduced, relative to a bad flu season. Why is that? According to a survey by Morning Consult, approximately 18% of healthcare workers have quit their jobs since February 2020, while another 12% have been fired or laid off.

Furthermore, many people fail to realize that hospitals routinely function at 90% capacity in their ICUs. A reduction in workforce of even 10% is horribly disruptive to a system flying so close to the sun. It’s kind of like what happens when one of the OPEC nations, even if “only” producing 3% of the world’s oil, goes offline. Complete and total breakdown of the world’s energy markets ensues. It’s called a marginal supply problem.

Perhaps there was a rationale to mandate vaccines in healthcare workers 12 months ago, but given how many of them have quit or been fired for not being vaccinated, despite the fact that they undoubtedly have the highest rates of natural immunity of any profession, it seems illogical to continue to keep unvaccinated healthcare workers away because their immunity came from the actual virus, and not a vaccine.

So where does this leave us?

  • We have a virus that is far less lethal than the one that started the pandemic two years ago.
  • We have very effective vaccines that reduce the severity of illness and death by about 90%.
  • We have ample treatments to further reduce severity of illness in death (in vaccinated and unvaccinated alike) by another 90% or so.
  • We have better methods of providing in-hospital care to the infected.
  • For all their benefits, vaccines are not very effective at preventing transmission.

None of this is opinion. These are simply the facts upon us.

Politics and healthcare will always interconnect to some extent. So, the right question to ask at this time is not why are they’re intertwined, but rather: to what extent should they be?

As some of you heard me outline in my recent interview on Joe Rogan (#1735) and again during my podcast with Drs. Makary and Damania on January 3rd, there is an important distinction to be drawn between Science and Advocacy. Clear lines should be drawn between those two concepts. Vaccine mandates are a prime example of how those lines are often blurred.

Science is not a noun. It is not a person, or group of persons. It is a process. And it’s a process by which you perpetually adapt and evolve through the rigor of always testing your best guesses and seeking to disprove your own assumptions and firmly held beliefs. You welcome uncertainty in the interest of getting just one inch closer to the truth. Speaking in absolutes is not the aim.

Politics, one could argue, is radically different. Political leaders are criticized for speaking with uncertainty and punished for changing their minds. In that sense, politics is the antithesis of the scientific process.

None of the above is a new phenomenon, and little about this dichotomy is likely to change. However, the crux in which we now find ourselves is the present impact of this divide, manifested strongly in our current political policy and juxtaposed with our current scientific knowledge.

Another question that we don’t seem to be asking ourselves is, what, exactly, is the definition of unvaccinated? It’s becoming more and more subjective each day. Today, unvaccinated apparently applies to an 18-year-old college student who “only” received the full 2-shot vaccine dose, but did not receive a third booster shot. Such a student can’t attend a college for which their tuition has been paid. If they concede to the third dose, when will they require a fourth? A fifth? If we’re using circulating antibodies as our metric of immune success, we’ll need to give boosters every 3 months to keep antibodies high. And for what? Certainly not to help us avoid severe disease, hospitalization, or death. For that we can rely on the memory B-cells and T-cells we developed in response to an actual infection or to our first vaccination.

What is the impact of vaccine mandates?

Let’s consider the following examples of the impact vaccine mandates are having right now:

    • In my birthplace of Canada, an unvaccinated person cannot board a plane or a train, let alone go into a restaurant, gym, or skating rink. This is especially interesting, given that the rate of infections in Ontario is now higher in vaccinated than unvaccinated persons, a transition that occurred with the arrival of Omicron in late December. This finding presumably speaks to the low efficacy of the current vaccines at preventing Omicron infections.

  • A Canadian friend of mine, this week, was prohibited from seeing a medical doctor for a corneal abrasion because the doctor refused to see unvaccinated patients (including those with natural immunity from a prior COVID infection). Bear in mind that this is occurring in Canada, a country with universal access to healthcare—a hallmark of Canadian values.
  • A Virginia man in need of a kidney transplant was removed from the transplant list, denying him a life-saving procedure, because he was not vaccinated (though he was previously infected with COVID).
  • In September, Canada’s Prime Minister, Justin Trudeau said that the unvaccinated are part of an extreme group that also included misogynists and racists.
  • Here in the U.S. some are even calling for the deployment of the National Guard “to ensure that people without proof of vaccination would not be allowed, well, anywhere.”
  • A previous guest on my podcast, who asked to remain anonymous, was recently fired from their job as a professor at a very prestigious university for not being vaccinated. This person was fired with cause, which meant they were not even able to apply for unemployment insurance.

The bottom line.

I have been clear about my support for vaccinations. They are an excellent tool to protect us against severe infection and death from COVID. What they are not, however, is a monolithic tool to be used as a sword against our citizens, rather than a shield against a virus. When we call the unvaccinated misogynists and racists as Mr. Trudeau has, or when we make it our goal as a society to make the lives of the unvaccinated as miserable as possible, as French President Emmanuel Macron has said, what are we hoping to achieve? Is this a strategy to increase vaccination rates, or to exact a vengeance?

Even though the U.S. Supreme Court last week struck down the federal government’s proposed vaccine mandate for large corporations, hundreds of U.S. companies and universities are still putting in place mandates of their own, which come with stiff financial penalties and even job losses.

As you consider this thorny issue, I urge to consider the following questions:

Even if you felt vaccine mandates made sense one year ago, when the Beta and Delta variants were raging, when it was too soon to say how well the vaccines would work in the real world, when we had few excellent treatments for infected, and when ICUs were still struggling to understand how to treat COVID, can we really say with a straight face we’re in the same difficult situation, today, especially with the Omicron variant?

What is the scientific evidence to support vaccine mandates today? Today, we have vaccines that are very effective at preventing severe disease in the vaccinated. Today, we have many treatments to further reduce the severity of illness, if infected. Today, we have enormous expertise to treat infected patients in hospitals. Today, we have a dominant variant in Omicron that is nowhere near as virulent as its predecessors. If this were really about science, why would we not allow previous infection, which confers all the benefits of vaccination, if not more, the same rights? Does it not seem that mandates are having the opposite effect to what is desired? Instead of increasing vaccination rates are mandates instead hardening and alienating the unvaccinated further?

If we are being honest with ourselves, are the mandates truly for the protection of the vaccinated, or do they exist to punish the unvaccinated?

How will history evaluate these mandates?

How will history evaluate us for how we have treated the unvaccinated?

And as we look at future science-based policy discussions, even beyond COVID, we need first to agree on the questions we are actually trying to answer. From there, we can begin to explore different possible solutions and debate their costs and benefits in a rational and civil manner. And always, we need to ask ourselves honestly: are we picking sides based on assertions and talking points (Advocacy) or testable hypotheses (Science)?

injecting injection vaccine vaccination medicine flu man doctor insulin health drug influenza concept - stock image

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  1. Although the arguments made in the article are sound, I think there are other points worth mentioning, and for the purpose of this discussion, I would define “unvaccinated” as having never received any vaccination. First, the issue of cost to the healthcare system was not addressed. The article presents data showing that vaccines reduce the risk of hospitalization by a factor of 16.5x. Hospitalizations, in particular those requiring intensive care unit stays, are extremely expensive. These costs are either covered by US taxpayers in the case of Medicare/Medicaid patients or by presumptive future premium rate hikes in the case of costs initially absorbed by private insurance. Monoclonal antibody and other novel therapies are also quite expensive. It seems that there are abundant data suggesting that the costs of caring for unvaccinated hospitalized patients far outweigh the cost savings associated with vaccine non-administration. Second, I think it is safe to posit that errors in viral genomic replication in an infected host are a requirement for the creation of novel variants. Vaccination reduces the risk of transmission and the duration of viral shedding, whether “slightly” or not. The article discusses limitations of vaccination benefits in the context of the less virulent Omicron variant, but I don’t think anyone can guarantee that a future variant will not be more virulent or that vaccination would not provide at least some protection against such a variant. Although the article does not present data (and perhaps these data do not exist), it seems likely that there would be a benefit to minimizing the percentage of the population that is both unvaccinated and without previous infection to reduce that population as a potential reservoir for variant creation. As a thought experiment, would anyone argue that had worldwide vaccination been possible in late 2019 or early 2020, we would not be in a better place than we are now? Finally, although the author unambiguously supports vaccination, the article does not address the weakness of the arguments against vaccination. If vaccination were associated with high rates of adverse effects, non-vaccination would be more defensible. I have yet to meet someone who has presented a compelling argument against vaccination (except in those small populations with known risk factors for adverse effects from vaccination), so although I generally oppose mandates, I feel that the anti-vaccination argument is quite weak. We don’t see large-scale vocal opposition to seat-belt and motorcycle helmet mandates. While I anticipate the response that these mandates do not involve any significant risk to those compelled to comply, as far as I am aware, the data strongly suggest that the risks of vaccination are very low and the risks associated with COVID infection outweigh the risks of vaccination for most of the population.

  2. “Tyrrany is the deliberate removal of nuance” – Albert Maysles
    Thank you for speaking truth through nuance and the logical scientific discourse.

  3. Nothing will make me trust any vaccines (if you want to call it vaccines) from any of the pharmaceutical companies at this time. Interestingly enough they are fighting to not disclose what is in them. I have seen too many results of adverse reactions to even consider getting inoculated.

  4. I don’t agree with you, as a doctor, not encouraging everyone who is eligible to get vaccinated. You sound as if it is o.k. To get Omicron. Who want to get it period, even with new meds etc. not to cool for a doctor to ask if we want to punish the unvaccinated. I don’t. I want them to get vaccinated. I want to stop the spread of the virus. Don’t you?

    • Just adding DR. to your title only let most assume that you also belong to the corrupt and logic diluted community – I wouldn’t walk around announcing as such.

    • Hi Linda,
      Can you please provide your epidemiological results showing how being vaccinated reduces the spread of the virus, then please elaborate on how countries with high vaccination rates (ie. Israel) are still seeing the spread?

      • I see you chose israel with high vax count n high covid positive tests count. Well i mean you chose it now with 63,000 positives a day not back in the month of may when it was 15 … yes fifteen cases a day. Do you not think this proves the vaccine works ? But it also proves vaccine wanes doesnt ?
        This is why the mandate is necessary. We all start from “protected” the numbers will drop off and as all of our protection wanes it wont matter near as much. With less sick there are less to make others sick which means less sick to make oth… you get it right ?
        You may not understand how vaccines work. Because they work so well you just dont know. Vaxd arent just get a shot 100% protection. They never were. They are really only so effective because they strangle the supply of new cases. Which inturn reduces the ability to get a new infection.
        Ive had to get a booster for my first responder HEP B vax and that was a 3 shot series to start with.
        Polio vax is 4 or 5 shots. Tetnus is every 10 years. MMR is 2 doses spread out over a couple years.

    • Linda, you’re turning it around. Mandating means forcing, when the unvaccinated do no want to get vaccinated. I will never get vaccinated. Why cant you leave me with my decision as an adult human being? Yes, the risk i’m taking is Omicron. The doctor just explained the risks involved, something I already knew but now its harder for people in favour of mandates to deny the facts. We need doctors to speak out this way. It is a immense blessing in dark times.

    • But the vaccine doesn’t work. People still get Covid even after 2 boosters. So why do you want unvaxxed people to get it? There are so many side effects, including severe ones from this. It’s not like any of the vaccines in the past.

  5. Overall your comments are well stated and well supported. However, you stated above: “Vaccines unquestionably reduce the risk of hospitalization in previously uninfected people (by a factor of 16.5x),”

    So if more people were vaccinated, the overall number of people hospitalized because of Covid would probably decline. If mandates increase the vaccination rate, that has a beneficial impact on our health care system which you acknowledge is under strain.

    • Bulls-eye.
      There is an unprecedented backlog in Health care. We do not know how many will / have died or had their lives been negatively affected by not receiving the care they should / would have had without the pandemic.

      So – if everyone were vaccinated, there would be fewer people in the hospital and more non-covid related people would receive treatment.

      I live in a country with free health care – but I see it like this:
      – If I do not pay for my car insurance – how can I expect or demand to be taken care of if I crash my car?

      Likewise – if the national health authorities say I need to take the vaccine and I don’t. How could I then expect and demand to be treated for the illness I refused to get vaccinated against?

      It doesn’t make sense. You can’t be partially part of a society – if you want to reap the goods of medicare, you have to do your part as well.

      • There are lots of unwise things people do to harm their health but we don’t discriminate against them. We don’t discriminate on the basis of lifestyle choices that cause harm. Or should we start denying care for the alcoholic, the obese, diabetic, rock climbers, race car drivers where does it end?

    • I agree with you Steven when we apply this logic to those unvaccinated and not previously infected…. a point being made, which you may have missed is that if people can prove prior infection, logically, we probably should be regarding them the same as the vaccinated…. ? shoudln’t we? the data suggest so…. AND, BTW I am all in favour of preserving hospital capacity as I work running a surgery Division, so we want our beds back!

    • Forcing people to get any kind of medical treatment is tyrrany. Especially when one cannot sue if there are problems from the vaccine. So if the vaccine is so safe, why have a consent form, and why eliminate all responsibility on the part of the pharmaceutical companies?

  6. Two comments:
    1. Does the infectiousness of Omicron change the calculus of the impact of the unvaccinated on the vaccinated? What if the inevitable next variant has Omicron’s efficiency and Delta’s morbidity?

    2. The unpreparedness of the U.S. healthcare system has made timely testing and distribution of treatment modalities hit-or-miss. It does no good if our medical advances are not available when and where needed (see article in 1/23/22 SF Chronicle about a doctor’s difficulty in getting tests and drugs needed for his immunocompromised parents https://www.sfchronicle.com/opinion/openforum/article/Omicron-is-deadly-Here-s-what-it-took-to-get-16794051.php

  7. Peter, you did a great job talking about numbers and studies of vaccinated individuals and you generate your claim that “It is abundantly clear: If you are vaccinated, your risk of severe illness or death from COVID is very low, even compared to influenza.” But what are you comparing this too? Isn’t it true that is you are unvaccinated, your risk of severe illness or death from COVID is also very low? Why not compare these two groups and data? Why didn’t the CDC in their study? This is why so many of us have unanswered questions, 2 years into a situation that has been full of these situations with half complete pictures of what is happening.

  8. Interesting article as always but, if you want to continue with your example of Canada, please note the many thousands of Canadians who’ve been denied medical care, including cancer treatment, because limited medical resources have been reallocated to Covid patients, the vast majority of whom have been unvaccinated. That doesn’t make them misogynists or bigots, but it sure strongly suggests they’re selfish assholes who, having “conducted their own research”, have opted to listen to Tucker, Joe and Sean, and conflated freedom with personal responsibility

  9. Personally I go back and forth about the policy sense around mandates. I have a few conerns about the piece.

    1) You seem to think the evidence about Omicron is clear. The folks over at This Week in Virology seem to exercise more caution. I don’t know if this matters for the argument.

    2) I live in Canada. I literally have never heard any individual who is vaxinated say they want mandates to protect themselves. It is always one of more of either institutions or vulnerable populations or both. I think most people understand the vax does not provide sterilizing immunity.

    Thanks for your work

  10. 1. I have spent a career in CA hospital systems. I have never seen, in 30 years plus, elective surgeries/other treatment modalities on a broad scale cancelled due to hospital census overload. The unvaccinated are the demographic filling our med/surg and ICU beds. Huge, life changing repercussions on others, so yes, not unreasonable to call out the unvax.
    2. Viral loads in unvax remain high three times as long they do in the vaccinated. If I’m in a restaurant, movie theater, dinner party, etc, I would much prefer to take my chances with short duration viral shedders.
    3. Readily available therapeutics? Fluvoxamine efficacy is still controversial… endpoints of major studies, eg 6 hr hospitalizations are questionable. Paxlovid, sotrovimab are and will be incredibly difficult to procure for months.

  11. Curious of the relative rates of immunity per variant? Example: Does the Alpha variant provide more/less/equal immunity for an infected person than the Omicron variant?

  12. I really appreciated this article and thought it carefully explained how vaccinations and natural immunity help lower the risk and severity of future infection. I came down with Covid April 2021, three weeks after my first Pfizer shot. It was extremely mild. I had to cancel my 2nd shot because of my infection but decided to get it a month or so after my Covid episode. I haven’t gotten the booster and might not because of my natural immunity. I have concerns about the risk side of the vaccination equation – vaccine injuries. I know it is impossible for Peter to quantify that risk as he has done on the efficacy of vaccinations and natural immunity. It is very hard to get our arms around the VAERS information. Still, I’d feel better if that issue were discussed. I’d love to see an article or podcast on VAERS and the risk side of vaccinations.

  13. One often hears the phrase, “When talking to climate-change skeptics, present the facts, as that is all you need.”

    Decades of this approach has shown that it not only doesn’t work, the more you use science to persuade, the more dug in the opposition becomes.

    Public policy — which is really a culmination of having your finger on the pulse of emotional sentiment — is ultimately formed on what is achievable among a largely emotionally-driven public forum.

    Regardless of the facts, you’re using entirely the wrong approach for persuasion… well, except for those who already agree with you, and let’s be really honest here: MOST of them don’t need the science. Their politics are already in alignment.

    We’re talking about public policy, and like climate change, the end goal may very well be sparked by unambiguous facts and circumstances, but if you want to reach the broader audience, lead with far different arguments. Granted, this is really really hard. By comparison, science is dreadfully easier. This is why we have far more successful scientists than politicians.

    To have a truly informative debate on this, you should invite those with expertise in public policy, and discuss how certain highly controversial (and scientifically-based) laws were passed in the face of public (and political) opposition: seat belt laws, a variety of smoking laws, and yes, even vaccine mandates (such as California school systems). There are far more variables to consider when considering not just IF mandates should be instituted, but the subtle nuances in HOW.

  14. A good discussion of the current state of affairs. But I think a thorough discussion of the risks of vaccination side effects is next. There is far too much static in the air about this topic to leave it unattended. The number of elite athletes dropping dead or suffering career ending cardiac events has dramatically increased during this time of Covid. And in the general population, there are other events happening that the antivax crowd talks about. I’d like to hear a sane discussion about all of it.

  15. Dr. Attia,
    I truly appreciate your breaking down your arguments against mandates. I personally tend to lean against the mandate argument myself. Several people have posted that more people have gotten vaccinated due to the mandates and with the decreased severity of illness that this emphasizes the need for the mandates. I wonder how many people got vaccinated due to the mandate, who would have not gotten vaccinated without it? There are many nurses who have quit healthcare, some due to the mandate and some due to the myriad of other reasons practitioners quit every day. We are all tired and worn out but part of this fatigue is also due to the constant pollicization of of mandates, lack of staffing, not seeing desired outcomes, earned distrust in the pharmaceutical industry, and the lack of focus on ways to be healthy versus treating illness, to name a few. I am vaxxed and boosted but at a cost, as I personally paid for two ER visits due to my reaction to the vaccines, which really disrupted my control of my Type 1 Diabetes (which I have had for over 45 years now). I did not get this disease at the age of 5 due to obesity, poor health practices, or so on. I find it hard to escape the bias that is developing towards people who have chronic illnesses, despite people’s attempts to control said illnesses. The financial costs are high to the healthcare system but the financial and emotional costs are high for the sufferer of said illness too, not to mention the impact the illness may have on their ability to earn enough money to pay for their treatment. What I am trying to get at, through a very convoluted process, is that each person has very nuanced situations and reasons for their decisions to be vaccinated or not vaccinated. I find the villainization of people based on their personal decision to be vaccinated or not to be abhorrent in the healthcare setting. We are starting to villainize people more for having chronic health conditions which may or may not be due to personal choices, but rather than meeting people where they are in their decision process and understanding, we have devolved into shaming, blaming, harassing, and emotionally and mentally abusing them. We live in am imperfect world, utilize an imperfect system, treat imperfect people by imperfect providers, and lose the sight of the importance of respectful, honest discourse and meeting our patients where they happen to be. Thank you for your time and efforts in providing calm, thoughtful discussion of your choices. My hope is that more people in the healthcare system can follow your example in their discussions and choices, whatever they may be.

  16. Thanks for your opinion! This made my decision easier to cancel my subscription! Thanks for your content. Thorsten

  17. My personal concern is for my 97 y.o. mother in a nursing home with nurses and caretakers exposing her to the virus; for my 80 yr. old husband with asthma and CAD; and my 2 yr old grandson who goes to nursery school. Please DO NO HARM

  18. First principles of the scientific process includes observation and measurement so attempts to quantify, measure and explain the kinetics of COVID infection have to account for what we have observed. As a physician I can assure you I have never in my career seen thousands of admissions and hundreds of deaths from influenza as I have seen with COVID in the last 2 years and surely with almost a million deaths in 2 years nationally we can acknowledge that this is a major public health issue, I find the attempt to conflate influenza with COVID rather disingenuous. It is nearly impossible to discuss the Omicron experience without first discriminating vaccinated from non vaccinated populations, certainly in our hospital 85-90% of hospitalized COVID19 infected patients are non vaccinated and they have again led to the need to curtail outpatient hospital services and served as a barrier to deliver urgent health care to those in need. In Chicago where I live we again see businesses limited by the uncontrolled pandemic and thousands who have been hospitalized. While there may be truth that the Omicron variant is less virulent, that past infection confers immunity and treatment modalities have improved it fails to explain the observable data that in the last month there have been hundreds of thousand admissions and thousands of deaths as a result of COVID. The additional experience of those of us on the ground have shown that vaccine resistance is based on verifiably untrue assumptions (leads to thousands of deaths, causes infertility, government attempt to follow, etc), often associated with refusal to acknowledge the role of masks in public and highly tracks with political affiliation should maybe cause you to re-evaluate why patients refuse vaccination. It is somewhat ironic in the call for science rather than advocacy that you have brought a thinly veiled Libertarian approach which I think uses data in a misleading fashion. COVID is a public health issue far different than dyslipidemia and statin treatment, one in which pursuit of selfish and often illogical goals place others at avoidable risk and harm. Louis Brandeis reminds us that “your right to throw a fist ends at my nose”

  19. Thank you for this. I can’t tell you how much I appreciate a physician willing to speak out on the mandate issue.

    My husband has been putting Covid patients on ECMO since the beginning of the pandemic. He’s triple vaxxed, I am double vaxxed (and Covid recovered). We are far from “anti vaxxers”— however, we chose not to vaccinate our teenage boys (who’ve both had Delta and recovered). That decision alone will make you a pariah in physician circles, I’ve learned.

    I know first hand the horrors heath care workers have seen in treating dying Covid patients. I know they are tired, worn out, and even a little scarred. But it’s been revolting to me, hearing physicians freely advocate for denying treatment to the unvaccinated.

    We’re all starting to realize the lockdowns went a little too far (anecdotally, addiction- driven endocarditis cases spiked here due to lockdowns). We need to be thankful that Omicron can help us off ramp on the vaccine mandates too, before we create more societal damage. Convince, don’t coerce.

  20. What do you say for those not vaccinated and have not had the virus? Are you suggesting that they should risk getting the virus and hope for the best. Also, ample pill treatments must be taken within 2-4 days of symptoms. Have you tried to make an appointment recently with your doctor? Treatment is only available through prescription. Walk-in clinics won’t allow you in if you have symptoms. Many will miss the window of opportunity. Finally, hospitals are better at treating the virus, but good luck finding a hospital bed due to higher rates of infections for those unvaccinated.

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