Whom the Vaccines Leave Behind

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S1: Dr. Lindsey Ryan thinks a lot about how to convince her patients to get vaccinated. She works in an E.R. in San Francisco, sees all kinds of people, she says, even the hesitant ones she thinks are reachable.

S2: A lot of people, even if they might not be totally conscious of this fact, have some internal conflict around it. Why do you say that? I say that because most people’s lives have been heavily affected by the by the pandemic. Most people want a sense of normalcy. There’s often a little bit of tension if you explore it, between the fact that people are scared of coronavirus. People have seen it affect their loved ones, their family, their co-workers at this point. And there’s some security. There’s benefit to protection.

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S1: Lindsay simply believes it’s possible to convince anyone to get the covid vaccine. She believes in this so much that she started training college students to go out into communities and just talk to people about it, listen to their concerns, always with the goal of getting more shots in arms. Do the students talk about how effective the vaccines are?

S2: Yes, I would say that’s been shown to be a pretty convincing argument because these are some of the best vaccines ever made their way more effective than vaccines like the flu shot. And I think a lot of people don’t know that they’re almost 100 percent effective except in people like me.

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S1: You might have missed what Lindsey said just there.

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S2: They’re almost 100 percent effective except in people like me.

S1: Lindsay’s got an autoimmune condition, even though she’s a doctor, even though she was vaccinated back in December, she’s almost 100 percent unprotected.

S2: Do I find it hard to do this teaching? Sometimes I do. For me, there’s a certain bittersweet element, right? I care so strongly about people getting vaccinated. I want to send skilled students out into the world to plug the vaccine. And it’s a little bit difficult for me doing multiple trainings about a vaccine that I know is much, much less effective for me.

S1: Today on the show, the pandemic is not on the wane for everyone. So what do you do when everyone else is hot? Summer could easily become your worst nightmare, a Mary Harris. You’re listening to what next? Stick around. Can we talk about why you’re still at risk from covid, like when you’ve written about this, you have this funny way of putting it. You’ve said you’re Bissell’s love extracurricular activities. What do you mean by that?

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S2: Sure. So B, cells are meant to recognize foreign pathogens, foreign invaders in the body, different germs, whether those be bacteria or viruses, an autoimmune disease. The B cell mistakes your own body as a foreign invader.

S1: So you’re attacking yourself.

S2: You attack yourself. And so one of the potential solutions to that are medications that wipe out the cell pool. And that means you can’t attack yourself, which is great. You can feel a lot better. It also means that your ability to attack things like the coronavirus is severely compromised because you can’t produce these antibodies that the vaccine is meant to elicit.

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S1: So my understanding is you’re on this drug called Rituxan and the drug, it holds back your B cells. And that means both that you are more vulnerable to covid and the vaccines work less well on you.

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S2: It’s definitely a double whammy. I’m both more susceptible to severe disease, death, almost all of these bad outcomes across the board and not we’re not talking more susceptible by 10 percent or 20 percent. We’re talking more susceptible by multiple fold and the vaccine works much less. Well, to me.

S1: That’s scary.

S2: It’s scary. Yeah, it’s scary. But one of the things, you know, there’s this this may be a little off topic, but there’s a paper that I love. It’s from the early 1980s, actually, and it looked at rheumatoid arthritis patients in England. And it’s a sociology paper and it’s about the idea of illness, particularly chronic illness, as an experience of biographical disruption. Normally we write narratives of our lives and we project that story forward to some degree. And with illness, you learn over time to rewrite that story with new limitations upon yourself as the protagonist. And you over time you adjust to that. But I think of the lack of vaccine efficacy in immunocompromised people as another big biographical disruption. You have to rewrite your story again with even more limitations, and that is really devastating.

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S1: Yeah, I kind of wonder if when the pandemic hit, obviously it was devastating. You’re a doctor. You were probably seeing awful things, but in some ways it felt like there was a sense of camaraderie because everyone was immunocompromised, everyone was at risk. Everyone had to take precautions in the way that you were thinking about already.

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S2: I think one of the hardest things when you’re sick or at risk of getting sick is the uncertainty. I think that’s almost as difficult as disease not to be able to project forward what’s going to happen to you. And I think that was a new experience for many people during the pandemic, the fact that anyone could be sick or get sick in a really, really dangerous way in a matter of days. And there was a sense of solidarity about because everyone was scared. Everyone was grappling with an uncertainty and a potential mortality hanging over them in a way that hadn’t been true for a lot of people in a way that a lot of people had never experienced.

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S1: So when you heard about the vaccine, I wonder if you were optimistic. Like for so many people, it was this relief that there was some kind of option to prevent covid. And I wonder if you felt the same way when you heard about it.

S2: I did feel optimistic, but my optimism was tempered from the beginning. I knew that I might have an attenuated or non existent vaccine response

S1: as a doctor. Lindsay knew she was at the front of the line to get a covid vaccine to be ready for that moment. She delayed her normal immunosuppression treatments for over four months. It was not a decision she made lightly. Were you feeling bad?

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S2: Eventually.

S1: But Lindsey wanted to make sure she gave the vaccine a chance to spark a response in her body, she was relying on those B cells that she normally tamped down to develop coronavirus neutralizing antibodies. She wound up getting her shots in December. Then came the task of figuring out if any of it had worked. She gave blood sample after blood sample and then she waited for the results.

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S2: You know, I talk to people I know who are quite interested in researching this. It’s actually like a quite fascinating topic immunologically. So I was able to enroll in a study. I was pretty invested in, you know, hearing back, I was certainly waiting for these emails with a certain amount of anticipation.

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S1: So when you got the email, was opening that email hard?

S2: Yes, I think I expected an attenuated result. I didn’t expect to have no neutralizing antibodies.

S1: And attenuated just means like like a a result saying like, OK, you didn’t have the full response.

S2: Exactly. Yeah.

S1: So you get this result that is pretty conclusive and not what you hoped for. How soon after getting that result were you going back to the E.R.? To see patients,

S2: I mean, you know, within a few days, was that

S1: more difficult?

S2: It was a little bit more difficult. I think I had expected some vaccine response. So I started to be a little bit more relaxed at work, a little bit more relaxed in my daily life. And it was particularly hard because by then, you know, the vast majority of my coworkers were vaccinated and really didn’t have much concern going into the rooms of patients with covid and, you know, could could let down their guard at work, you know, over the break room table was barely inhabited for most of the year. And usually the break room table is filled with cake and coffee and Filipino sweets. And people started, you know, going to the breakroom, socializing. There’s a lot of camaraderie in the E.R. and TAFTA at 1:00 a.m. go get my Kentucky Fried Chicken from the breakroom and to have to duck out some random exam room and eat it alone while everyone’s hanging out in the breakroom. Sure. That’s that’s that’s difficult.

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S1: After the break, there are millions of Americans just like Lindsay out there. So what is returning to normal look like for her? When Dr. Lindsey Ryan found out the covid-19 vaccine didn’t really work on her suppressed immune system, she sat down with a notepad. She made a list of the things she could safely do and the things she couldn’t. Small gatherings outside. Yes, visiting her relatives, sure. But she’d ask them to get tested beforehand, even though they had already been vaccinated. Spending time with her close friends. Yes, she’d need them to stay sane, she figured. Taking a vacation with them, though. No, not safe enough. Going to the grocery store. The pharmacy, yes. But where? And 95 mask. I made mental lists like this, too. I think all of us did at various points during the pandemic. But now most of us are tossing our lists out. Lindsay, she’s dusting her list off, squinting at it, updating it.

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S2: It’s a really hard, emotional state, right? There’s a there is a bit of a schism because on the one hand, you are really happy for people. And on the other hand, it’s so tough. There’s a sense of loss over these small pleasures and bigger ones, too. People’s lives are beginning to accelerate to go back to normal now. And there’s a group of people who have been left behind. These vaccines just don’t work. And we still live in a state of uncertainty, just feeling so hemmed in.

S1: You’ve said you’ve even turned down jobs because you don’t feel like in the current state of covid you can go work at, say, a tuberculosis clinic. That’s a major decision.

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S2: It’s certainly tough to see. You know, many of my friends on career trajectories I wish I could have. And I also am someone who a lot of my work has been out of the U.S. You know, I was planning to go for Doctors Without Borders. I worked clinically in South Africa for a couple of years. So I structured my life around certain plans that for now are on hold indefinitely.

S1: I wonder if your decisions to not do certain things, whether you see them, is about kind of taking care of yourself personally or something else to like as a doctor, you know that people like you are immunocompromised. It’s not just that you can get sick, but if you get sick, if you get infected, you can kind of become this reservoir of virus, a place where the virus can mutate. And so I wonder. I wonder if that factors into your decisions or whether it’s all about the personal, like, I wonder how you think about it.

S2: It is partially about the personal, but yes, I don’t want to spread the virus. And, you know, I have friends who are little kids and aren’t vaccinated, but also at work. I’m in contact with people in my situation a lot, where I’m in contact with people, you know, extremely old people with multiple diseases who may not have had a perfect response to the vaccine either, although it’s pretty effective and. I don’t want to be in the position of passing it on to someone else.

S1: Yeah, as an era doctor, you must see everyone, all kinds of people, all kinds of feelings about the vaccine. I wonder if you ever find yourself face to face. With a patient who may just be refusing to get vaccinated, have a lot of questions about it and how you deal with that, when you’re looking at a patient who has maybe made some choices where you feel like, oh, why wouldn’t you go get the vaccine that will protect you and maybe allow me to be more open to how do you deal with that? How do you walk through that conversation?

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S2: I find it tough. I won’t lie. I think ideally. You know, you approach it with a certain amount of quiet curiosity and humility about someone’s motivations and thought processes, that’s not always easy to do. There’s a lot of barriers to people getting vaccinated. People are scared about their immigration status, for instance, although at the very least here in San Francisco. But I imagine everywhere getting the vaccine doesn’t put people at risk in terms of immigration status. People are scared. It’s too new, as I said. So I try to address those concerns and I probably try to do it more than most people in a busy E.R. because I’m so invested in it. But do I find it tough? Yes. I mean, one of the extraordinarily gratifying, lovely things about being a doctor during the pandemic has been a huge amount of support for frontline workers. And to me, the way that that support can really be shown to me, the greatest form of respect is to get vaccinated so that I’m not put at risk of a virus that would be lethal also. So the kid down the block that you don’t know how sickle cell doesn’t die so that the mother down the block for you have no idea, has a kidney transplant, doesn’t die. Hmm.

S1: So this week, California fully reopened. The governor said 70 percent of Californians have had at least one dose of the covid vaccine. I wonder what that felt like for you, like whether there was a sense of relief or stress,

S2: there is a sense of stress. I think, you know, it’s very hard because I think what I’m often facing as a doctor, right. Is a schism in my brain between what makes sense on an academic or clinical level and how I feel personally and viscerally. And and, you know, I think a certain degree of opening reopening does make sense at this point. And on the other hand, it makes my life tougher. You know, obviously, if other people aren’t masked, I’m at higher risk. So am I going to wear a ninety five more often indoors than I had to previously? Probably.

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S1: Do you ever let yourself have just the full visceral response?

S2: Yes, but rarely.

S1: If you had to describe what that feeling is, that visceral feeling, how would you describe it?

S2: You know, I think despair might be a little bit of too strong a word, but I do think there’s at least some version of that. Because when the vaccines came out, people could see a light at the end of the tunnel. And I feel like for a lot of immunocompromised people, we are still stuck in that tunnel looking for that light and we don’t know how long we’re going to be trudging through that tunnel. And that is tough.

S1: The CDC got so much criticism last month when they put out these new guidelines saying vaccinated people could do nearly everything without a mask. And the pushback was because of people like you. Basically, doctors were saying, listen, not enough people are vaccinated yet. People are going to mishear this. They’re going to think they can go massless no matter what their vaccination status is. I wonder, were you upset about the guidance at the time, because you’re in this interesting position where I’m sure you understand as someone who’s training people to go and talk to vaccine hesitant people, I’m sure you understand that, like offering them a Maskell’s future is very enticing and may, in fact, get some folks to get a vaccine who might not otherwise, but at the same time. It’s like the cost of doing that is everything you’re talking about, that that despair you’re feeling.

S2: Yeah, I was I mean, I think I, like many people, was upset about the guidance and I was upset about the guidance, not because I think it’s necessarily bad guidance if everyone followed the letter of the law. I mean, there’s increasing evidence that vaccinated people transmit virus at a far, far lower rate. But I also think realistically, the way human behavior works, if vaccinated people toss their mask, unvaccinated people are going to toss their masks, too. And I obviously have no way of distinguishing those people. So the CDC is in a tough spot, right. They have to go by the evidence and they can’t have the nation locked down indefinitely. But it’s true. That step, I think, made things a lot more dangerous for immunocompromised people.

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S1: For people with suppressed immune systems, it’s still hard to figure out what’s risky, what’s not only one thing is clear. The health of everyone around you matters a lot. Remembers when she read the news headline last month that the U.S. is unlikely to reach herd immunity.

S2: That, I think, was a moment, a stomach dropping moment because with herd immunity, there was a possibility of near eradication in the US. You’re never going to have total eradication. Someone might come on a plane from another country. But the prospect of this just indefinitely circulating is incredibly difficult because then the the possibility of getting infected, even if it’s small, is always hanging over your head. And, you know, I live in a city in San Francisco with very low infection rates, but urban centers are also porous. People visit San Francisco all the time. Now that mask mandates are dropping in California. I think the governor is going to push, you know, planning on pushing for more tourism. And so the difficult thing is it’s always going to hang over my head that, you know, someone I’m sitting next to in a restaurant could be visiting from a state with much higher covid incidence and could have covered. So that latent possibility is not going to go away. And that’s, I think, quite difficult.

S1: Yeah, I wonder if you can even picture yourself sitting indoors at a restaurant anytime soon.

S2: I can’t picture myself sitting indoors at a restaurant any time soon.

S1: Dr. Ryan, thank you so much for joining me.

S2: Thanks so much for having me.

S1: Lindsey Ryan works at the San Francisco General Hospital and the San Francisco VA Medical Center in California. And that is our show, What Next is produced by Carmel Delshad Davis Land, Danielle, Hewitt, Alena Schwartz and Mary Wilson were led by Allison Benedikt and Alicia Montgomery. And I’m Mary Harris. You can always track me down on Twitter. Tell me what you thought about the show. I’m at Mary’s desk. Make sure you stay tuned to this feed tomorrow, because Lizzie O’Leary will be here with what next TBD. That is our Friday show. Thanks for listening. I’ll catch you back here on Monday.