Covid Delta surges continue to torture many states. While in some places the number of cases is starting to level off, hospitalization numbers remain insanely high.

Covid hospitalizations continue to overwhelm health care workers and systems. It’s still overwhelmingly the unvaccinated who are ending up in the hospital.

One number definitely going up is the number of deaths. Again, almost all people who are dying are people who didn’t get vaccinated. Over 1900 deaths a day — so tragic since so preventable.

Today Im going to talk about Boise and boosters.

A mantra I heard early in the pandemic has stayed with me: When you mix science and politics, you get politics.” Our maps of surges and deaths and the unvaccinated and the unmasked are a reflection of many things, but the biggest of these is education and politics.

In general, it’s our red states who are getting absolutely creamed by Delta. Red states tend to have lower vaccination rates and lower rates of masking. These unvaccinated states are the ones with higher and more horrible surges, and more overwhelmed hospitals, and now more deaths.

In a horrifying turn of events, places like Idaho have begun instituting “Crisis Standards of Care” which means — plain and simple — rationing health care.

  • “Crisis standards of care” means saying, “Aunt Petunia’s niece Meghan in Minden is 18 and Uncle Maskless’ brother Bruce in Boise is 81. Both have Covid and both need an ICU bed but there’s only one bed left. Who gets it?”
  • (Or, even worse, Bruce from Boise is already on a breathing machine in that ICU bed and Meghan from Minden can’t breathe — she needs that bed and that machine. Then what?)
  • It means saying, “We can’t get you a dialysis machine in Idaho. Or Washington. Or Oregon. And Alaska.”
  • It means saying, “No brain surgery for the new brain tumor patient. No heart surgery for the new heart attack…or the stabbing…or the intestinal bleeding…No beds for the cancer patient’s chemo, the child with appendicitis, the infected leg, the paralyzed stroke victim, the new MS patient….” It goes on and on and on. My friends write me one god-awful story after another. This is happening right now. As we speak.

Can you imagine the horror of these choices, both for the families and for the health care workers? Choosing who lived and who died like this happened in Katrina and those health care workers still live with that anguish.

Rationing has no doubt taken place covertly in the US during Covid (maybe it happened when NYC was overwhelmed; maybe it happened along the Texas border during the winter when they simply ran out of rooms).

But it’s never taken place overtly; it’s never been announced in newspaper articles. But now medical rationing is happening — really happening — in places like Boise. Dreadful.

We can be reassured, however, that we’re not going to see Crisis Standards of Care and rationing in states with high vaccination rates — even with kids going back to school — because those states have BUILT A WALL of protection around their children.

In the states and cities with high vaccination rates (and masking and ventilation and testing), kids are safely going back to school. Cases will happen now and again, but most schools following science-based guidelines are not seeing significant outbreaks.

But in unvaccinated states, we are seeing horrid numbers of kids getting sick and even on occasion hospitalized.

If I lived in an anti-science state with high transmission rates I would be doing the following:

  • I would try to remember I can still get Covid even if vaccinated and that there are safer and unsafer ways of conducting my business.
  • I would stay out of tight indoor spaces (church, restaurants, small rooms with low ceilings), I would test myself and my family a lot (a lot of docs are buying BionaxNow home tests on-line or haunting their local Walgreens), and I would be very actively and consciously masking with the best masks I could find (KN95s and good double-ply cloth masks with a filter or wearing two masks).
  •  I would constantly be in my head going through my EIICCC (Eternal Infernal Internal Constant Covid Calculus), always acknowledging while I can’t get to no risk, I can get to low risk.
  •  I would be alert to try to figure out how to handle risky situations:
    • maintaining the MOST distance
    • with the MOST ventilation
    • spending the LEAST amount of time
    • with the LEAST number of unvaccinated people
    • with the MOST strongest mask.

The big talk this week is on boosters. Here’s another mantra for you: “When you have no science, you have talk shows.”

The reason there’s so much talk is because there’s so little science. We need some real science to be able to say who definitively needs another shot and for that we need to accumulate good data through good studies that go on for a while and contain a sizable number of people.

What we do know is that it looks like people who are severely immunocompromised will benefit from getting a third dose (and by “severely immunocompromised” we mean things like heart transplant patients, not just Aunt Petunia putting some steroid ointment on her poison ivy).

Once you get past the low-hanging fruit of the severely immunocompromised, is there another group who would benefit from a booster?

The answer is: “We don’t really know yet.” Why? Because once again we’re “building the plane while we fly it.”

The fundamental question that really needs to be answered is who is getting breakthrough infected? Is it people of a certain age? People over 70? 60? People living in long-term care facilities? Front-line workers with lots of potential exposures? The people who got their shots too close together? One brand or another? And who gets the rare severe case after vaccination?

Since we don’t really have these answers yet, people talk about the theoretical or philosophical or best-guess reasons for additional shots.

Here’s some of the ways people are thinking about this right now, and what will be considered by the FDA.

No: we shouldnt start boosters yet:

  • Let’s wait until we have the science to tell us who really needs a third shot.
  •  The two shots are doing a fabulous (unbelievably great) job of preventing severe disease, hospitalizations, and deaths
  •  If community transmission in your area is low you have a low chance of catching it
  •   We aren’t yet certain about third-shot safety or impact long-term. (Short-term safety in small studies looks fine.)
  •   It may be just a temporary fix since maybe antibodies decline again (and what about cellular immunity?).
  •   Global equity: 2% of the world’s population hasn’t gotten one vaccine and are dying by the thousands every day. Why give it to rich people who don’t want to get a bad cold? We have almost a billion shots sitting around the US, we should send them to other countries!

Yes: we should get going on boosters for everybody:

  • We have accumulated enough science to be very concerned about waning immunity. It’s not great science, but it’s enough.
  • We know a lot of diseases (Hepatitis B and tetanus for starters) need a third shot to get long-term protection. There’s a lot of precedent for this approach.
  • It is reasonable to want to decrease the number of cases:
  • We don’t want our health care workers out of work for ten days.
  • We don’t want our HCW quitting in fear.
  • It’s not “just a cold.” It’s TEN DAYS out of the mainstream.
  •  We don’t want long covid.
  • More cases at some point will mean more hospitalizations and system stress.
  • There’s some evidence boosters help our immune system recognize all variants.

If I ran the FDA (thanks, but no) I personally would go for the Wait for the science to guide us.”

But there’s lots of other pressures and there’s some science and it’s hard to watch other countries take up the booster banner, so my guess is we’ll soon end up with some kinds of boosters for at least some of us. And maybe all of us when the science starts to come in.

And then maybe annually, or combined with a flu shot. It’s hard to predict; the only thing that’s for sure is that the science will figure it out and that it’s the science that will save us.