What the Booster Debate Is Really About
Hint: It’s not just the efficacy numbers
The debate over Covid-19 boosters continues to heat up. The demand is enormous — about 1 million Americans have already received boosters, many by lying about being immunosuppressed or prior vaccination. Meanwhile, WHO Director-General Tedros Adhanom Ghebreyesus, PhD, has scolded developed countries for rolling out boosters when so little of the developing world is vaccinated.
Most of the booster discussion has focused on the arcana of vaccine efficacy: Is Moderna holding up better than Pfizer? Is the decline in efficacy only for so-called mild infection or does it include infections that can lead to hospitalization and death?
I believe that the debate is actually about something more interesting and subtle than numbers — namely, whether one should view the booster question through an individual or societal lens. This is an age-old tension, and one that aligns with the different ways that two groups of experts, physicians and public health professionals, think about the world.
Physicians are trained to practice medicine with individual patients in mind. Our nation’s individualistic ethos and fragmented health care system reinforce this perspective. (Countries with single-payer national health systems are more apt to consider the trade-offs between optimizing care for individuals and the entire group.) Whether deciding on a treatment for cancer or migraines, physicians in the U.S. are socialized to consider the benefits versus the risks to the individual patient, and to offer treatment when the former outweighs the latter.
Public health professionals, on the other hand, think first about what’s best for society. They recognize that providing the best possible care, without considerations of cost or scarcity, to every individual patient is destined to create “have nots” — nearly always the less privileged. It follows that public health tends to focus on scalable interventions such as clean water, improved nutrition, and the like. And yes, vaccinations.
Questions about boosters are rooted in this tension between societal and individual perspectives. And, if this weren’t tricky enough, dealing with a contagious disease adds additional complexity. In this light, let’s consider the most common arguments against boosters:
1. The vaccines are still highly protective against severe illness
First, protection against severe cases has waned as well, just not as much as against symptomatic cases. Second, most people (including me) would prefer to avoid getting a “mild” case if possible. Mild Covid-19 (that is, not needing hospitalization) can be everything from a cold-like syndrome to feeling like you’ve been run over by a bus. Moreover, some fraction of breakthrough cases — probably about 10% — will lead to long Covid, with symptoms lasting longer than a month. And people with breakthrough cases can infect others, though a bit less readily than unvaccinated people. Taken together, when viewed through the perspective of individual benefit versus risk, the scales tip toward boosters.
2. “We should concentrate on vaccinating the unvaccinated” (domestic version)
If domestic vaccine supply were scarce, society might be better served using a dose to vaccinate an unvaccinated person rather than giving someone a booster, particularly someone at low risk. But there’s a glut of vaccine in the U.S. (we’ve discarded 15 million doses), and I haven’t heard any convincing case about how, specifically, boosters would damage our already-frustrating efforts to get the unvaccinated to take their shots. Would a booster program further convince unvaccinated people that they don’t need to be vaccinated? Perhaps, but I worry more about the impact of the unvaccinated population seeing more people with breakthrough infections.
3. “We need to concentrate on vaccinating the world”
While this is an attractive moral argument, it has several problems. First, we have enough domestic vaccine, already purchased and mostly distributed, to provide boosters without impinging on global supply. Second, the approximately 100 million doses needed to boost high-risk Americans will barely make a dent in the several billion doses needed to vaccinate the world. Third, we sometimes hear appeals to enlightened self-interest: more doses abroad, goes the reasoning, make it less likely that we’ll see the emergence of variants even worse than delta. I don’t buy it — a rational self-interested American will choose to boost his or her waning immunity with a single shot rather than hope that the same shot would meaningfully lower the chances of nasty variants in the future. Finally, I know of few countries that would be willing to leave their own citizens vulnerable in order to improve the care of people in other nations. We certainly don’t do that in treating patients with heart attacks, cancer, or diabetes.
From my perspective as a practicing physician, in individuals at higher risk of a bad outcome from Covid-19 (such as people over 60) and those with lots of exposure to cases or to vulnerable people (such as health care workers), the benefits of boosters outweigh the negligible risks. It seems logical to offer boosters to these groups. In the two to three months that it takes to vaccinate these people, we’ll learn more about the benefits and risks of boosters in lower-risk individuals, and we should base decisions about them on these data.
Meanwhile, we should be doing all we can to increase vaccine supply and distribution to people around the world. This will allow us to serve both masters — providing the best care to individuals in the U.S. while doing all we can to preserve the health of society, both domestically and globally.
