You may have heard that the delta variant of the coronavirus is more transmissible than other strains, that it’s responsible for the catastrophic outbreak in India, that it’s spreading so fast in the U.S. it will soon become the dominant strain here. But Dr. Monica Gandhi wants you to rethink all that. COVID numbers are much better now, in her hospital and across the country. Deaths dipped below 300 a day nationwide, hospitalizations are plummeting, and the national infection rate is creeping ever closer to 10,000 per day—the benchmark Anthony Fauci set for when he’d begin to consider the virus under control. So why all the doom and gloom in the media? On Thursday’s episode of What Next, I spoke to Gandhi, a professor at the University of California, San Francisco specializing in infectious disease, about why the current messaging around COVID reminds her of the early days of HIV and how scientists and journalists should be talking about the risks now. This conversation has been condensed and edited for clarity.
Monica Gandhi: At the very beginning of the HIV epidemic, everything seemed scary. Any possible risk of getting HIV seemed scary. So it was why the words “stay away from each other” and “don’t have sex” was used instead of “actually, oral sex is really safe, and let’s do that” or “let me show you how to stay safe with other types of sex.” And those lessons were learned later. So actually, the way that scientists are talking now was how scientists were talking at the beginning of the HIV epidemic. It took some time, and everyone was scared and screaming, just like we are now, at the beginning of the HIV epidemic.
And it led to distrust. Because the public knew, just from experience, that this type of sex was more risky to get HIV than this type of sex. They just knew it, they saw what was happening. And that led to distrust of public health officials and politicians who said everything was scary, and who used doom and gloom to message. And actually it led to a paradoxical rise in infections. And what harm reduction means is you’re trying to decrease infections, by taking into account the totality of everyone’s experience, what they need out of their life, intimacy needs, being around people. In the case of COVID, wanting to see other people and not being socially isolated. You take the totality of experience, and you try to decrease infections that way.
Mary Harris: It led to a rise in infections because people just threw all the advice out the window?
Yes. Because people distrust if you blanket, when it’s quite obvious that not every exposure was as risky as other exposures. And then people distrust the public health official, and then that can lead to covert activity that leads to an increase in infections. A good example is Christmas holidays in the winter in the United States, where there was so much with COVID. Saying that the only way is just stay at home, lock your door, do not go outside, that led to distrust, and then people went inside, and there were rises of infection.
That kind of alarmist tone was present back in March, during a Centers for Disease Control and Prevention press conference with Director Rochelle Walensky. She was clearly worried. Of course, we did not see the surge that she feared. I wonder if you as a doctor have seen patients talk about moments like that and use them as ammunition for “I just can’t trust anything.”
Yes. I think that kind of messaging is to go back to “let’s scare people so they’ll stay with their restrictions.” Someone said to me, “If my doctor said that to me, and I had cancer, and they said, ‘There’s nothing you can do, it’s just all doom, I’m so scared,’ I would throw that doctor out the window.” That’s what my patient said, because what my patient was trying to say is inspire confidence, inspire faith in the science.
Everything changed once we got vaccines. We’re gonna have bumps and ups and downs, and we’ve had a few ups and downs. But actually, steadily, since we started rolling out vaccines, it’s been pretty smooth. And I’m so grateful for that. And so, as a public health messenger, as a scientist, I would have messaged the effectiveness of the vaccines. It’s actually why on May 13, when Dr. Walensky and Dr. Fauci and everyone talked about taking off your mask when you’re vaccinated, it seemed completely out of the blue—because there hadn’t been a consistent messaging up to that point that the vaccines are really effective and that the vaccines will work against the variants. That wouldn’t have seemed out of the blue and so startling to people if there had been a steady, calm messaging of optimism the entire time.
You seem really confident in the fact that you’re just not worried about these variants. But I talked to plenty of researchers and reporters back in the winter who were really concerned, and their concern was not necessarily about the individual variants but the buildup of variants and the fact that the more the virus mutates, the less effective a vaccine might be. So why don’t you have that fear?
Because of immunology. So, very early on, in January, there was a paper from the U.K. that showed that as B.1.1.7, or alpha variant, was rising in the U.K., anyone who had had the infection before couldn’t get B.1.1.7, and they did a deep dive on T cells. It was a preprint that showed that T cells go across the entire spike protein so that you can’t evade T cell immunity from the variants. And then I knew something else from HIV, which is that a virus can’t keep on mutating forever. HIV, the virus, mutates a lot to evade our antiretroviral medications, and it becomes less fit by mutating, there’s actually a fitness cost. It compromises itself to mutate to become more transmissible. So I knew it couldn’t become more transmissible, more virulent, and evade the vaccines at the same time.
There’s one other thing I want to add. Not just T cells, but there’s something called memory B cells—when you get infected or you get a vaccine, you produce memory B cells, and they go into these hidden places like your lymph nodes and bone marrow. We’ve seen them, and there was a paper just last week that showed us that these memory B cells, if they see a variant in the future, they’ll make the perfect antibody for that variant. They’re not going to make an old antibody for an old type of strain they saw. They adapt their antibodies to that variant.
And this is because it’s familiar with the entire spike protein, so little changes on the spike protein they can adapt to? It’s formed a response to the whole thing?
Yes, exactly. The memory B cells are sitting in your bone marrow ready to fight if they see that virus again. And this paper just from last week showed us that if you see a variant, those memory B cells are going to make antibodies that are perfectly adapted for that variant, because that’s what memory B cells do: They come out with antibodies to fight the virus that they see, not the virus that they remember.
I’ll see headlines that say things like the delta variant could create two Americas, or Anthony Fauci is declaring the delta variant the greatest threat to the nation’s efforts to eliminate COVID. But then when you read the reporting in full, the story’s a little bit more nuanced, and it really focuses on vaccination. It basically shows that the delta variant is spreading and potentially causing surges in undervaccinated areas of the country. That’s an editorial choice, to say the variant is the problem versus the lack of adequate vaccination. I wonder what you think about that.
Yes. I think what you just said is a brilliant way to explain it. I think they’re using more scary terminology because they’re trying to motivate vaccination. But actually vaccination’s still going well. So the concern is places where we have distrust of vaccinations. And I keep on thinking, What’s a better way to increase trust?
I would be more trustful if I saw a headline that said something less scary. Like, “Let me tell you about this effectiveness that is going to work against the delta variant. Actually, it’s going to work really well. And let me explain to you why I think you should get vaccinated and let me make it easy for you.” And actually that is reporting. Maybe that isn’t scientists. Maybe that’s just how it’s reported. And then that would have to go back to you all in the media, and what’s going on on that end.
I know you’re pushing back against the fear-based messaging, but the way I see it is you need both at different times. Like, to get people to take the virus seriously in the beginning, we needed that phone call where Nancy Messonnier from the CDC said our lives are going to change, because that gets your attention. But then, as we go, we need to modify. And the question is really just how quickly we move from one kind of messaging to another.
Yeah, I think that’s really fair, and maybe injecting more fear in it than I have is appropriate at times. And maybe we need someone like me, who’s often very optimistic, and then we need someone on the other end, who’s very fearful, and then you put it together and that’s the right thing. I’m not gonna say I know the best answer to that. But all I can say is that I will never get over that we created a vaccine to this this fast, and all I want is for everyone in the world who need it to get this vaccine. And it makes me so happy that we don’t have to go through what we went through with the 1918 influenza pandemic, where 50 million people died, as opposed to 4 million right now and counting. And if we could get everyone the vaccine, we wouldn’t be in any situation where anyone had to die.
We might have listeners who are trying to figure out what to do with themselves in the world with this variant out there. Like, should I send my kid to camp this summer? Should I go on a trip, especially to a place where maybe there’s not as much vaccination? What would you say to folks about how they need to be thinking through their summer given the emergence of the delta variant?
I would say that if they’re vaccinated and their children are unvaccinated because they can’t yet get the vaccine, children are not more susceptible to the delta variant, they’re threefold less likely to get any infection with any variant with any ancestral strain, and they’re half as likely to spread it. And they can mask on the plane, as they should. You yourself are completely protected against the delta variant, and you should go and enjoy your summer. It’s been a hard time, and people should have their summer. Delta variant, delta shmariant.
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