The Good and Bad News About the Delta Variant

I’m Ezra Klein, and this is “The Ezra Klein Show.”

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So before we jump in today, we are still getting ready for the Ask Me Anything episode and still taking questions. So if you’ve got anything you would like to hear me answer, send it to [email protected]. Again, that is [email protected].

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Today is a coronavirus show because it is on my mind. Think it’s probably on everybody’s mind. And my Lord, I have a lot of questions.

So in May, the CDC said that vaccinated people no longer need to wear masks indoors, which was a sweet moment. You could walk around to see people’s faces, smile at them, breathe freely. It was great.

But then recently, the CDC changed course. They said that even vaccinated people should be wearing masks indoors in places with substantial or high Covid transmission. What that means seems to differ from place to place. I’m in San Francisco. We have a pretty low absolute level of Covid, although cases have been going up. But we are back now to the universal indoor masking even though we’ve incredibly high vaccination rates too.

So behind all this is the Delta variant, which can spread through the vaccinated, rips through the unvaccinated. I mean it is as contagious, it seems, as chickenpox, which is wild.

In the CDC’s very vivid phrase on this, “the war has changed.” But I don’t think the messaging here has been very clear. I mean, how has it changed and for whom? And much more to the point, how does it get won? Like what is the vision here for victory? What is the end game? What level of risk can we get to? What level of risk will we tolerate? What are the risks here to children? What if you’re just gutted to be putting the mask back on and you realize now that even vaccination won’t end this, which is something that we were told it would do?

So yeah, I have a lot of questions. And Dr. Celine Gounder, thankfully, has unusually clear answers. Dr. Gounder is an epidemiologist at NYU medical school. She’s a CNN contributor and host of the Covid podcast, “Epidemic.” We spoke on Tuesday, August 3, the same day she joined New York City Mayor Bill de Blasio to announce the first-in-the-nation, essentially, vaccine mandate in New York City. So we talked a bit about that too, and what happened in Provincetown, and much more.

As always, my email, [email protected].

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Dr. Celine Gounder, welcome to the show.

It’s great to be here.

So I want to begin with Delta, on everybody’s minds. How does Delta differ from, I don’t know, shall we call it Covid classic?

Delta is different. Delta is more infectious than prior strains. It evades the immune system more effectively than prior strains, and it may even cause more severe disease than prior strains. And this is because the Delta variant fundamentally arrives at much higher levels of virus in the nose and the throat than previous strains.

So if you imagine, you’re sitting next to me, I have Delta. And I am breathing that out through the air, those Delta virus particles. If I am sending out a thousand times more virus particles into the air than I would have with an earlier strain, you’re way more likely to get that. If I have more Delta virus in my body, it’s more likely to make me sicker. There’s just a lot more of those virus particles fighting my body and making me sick.

And as I mentioned also, the Delta variant does evade our immune defenses. Especially if you had a natural infection and we’re counting on that immunity to protect you, that just does not seem to be robust immunity against the Delta variant.

Some of the numbers I’ve seen on this seem shocking to me. I’ve seen the estimate that people can have a thousand times the viral load with Delta. Is that accurate?

That is accurate. And I think another way of framing this is in terms of time because we think of exposure is dose times time. So when the CDC, at the beginning of the pandemic, said 15 minutes indoors with somebody without a mask, that’s a close contact, if you’re looking at a thousand times the amount of virus in somebody’s nose and throat today versus what you would have seen at the beginning of the pandemic, that 15 minutes is now the equivalent today of one second. That does not mean in 15 minutes, you would have gotten infected at the beginning of the pandemic. That does not mean that one second today means you’re infected. But that does constitute a close contact today and does constitute a real risk today.

Wonderful. Thank you for talking with me, Dr. Gounder. I’m going to go walk into the ocean now.

[LAUGHTER] I’m going to go into all the horrors of this, but just nerd out with me for a second. Biologically, what did Delta evolve to be able to do this?

So the virus evolves to replicate more quickly, more effectively. It evolves really to survive. So how does the virus survive? It survives by making more of itself. It survives by escaping our immune system better so that it can replicate. It doesn’t really evolve to necessarily make us sicker or kill us, but some of these other mutations that help it survive better can also affect how deadly it can be, how disease-causing it can be for us.

But it seems to me, as a layman who, like some other laymen, has begun moonlighting as a virus expert, in my just experience as a human being, you don’t tend to see year to year in the flu, or even see within a season in the flu, jumps that at least feel like this, right? Where you go from, I think the estimate is that Covid originally was a reproduction rate of two to three deltas, somewhere in the five to nine range. It’s chickenpox levels, which is very, very scary, the sort of 1,000 times heavier viral load.

For something that’s not been around that long, this — from the, again, uneducated perspective of somebody who’s not a trained virologist — seems like a really, really profound jump in efficacy for the virus. Is that true? Is this an unusually capable evolutionary player?

So when we see new viruses emerge, very often — almost always, in fact — they result from a spillover event, what we call a zoonotic transmission from an animal host to a human host. We see this with the flu, in fact, with bird flu, with swine flu. We’ve seen this with Ebola from primates and bats, and any number of other infectious diseases — Zika, HIV, and so on. So this is a classic pattern.

What happens in the initial years after that spillover event where humans start to get infected is that there’s adaptation of the virus to the host. So you see a much higher rate of mutation with many of these viruses in those first couple of years, and then you start to see a plateau of mutation. That said, some of these viruses still continue to mutate at very high rates — the flu virus, in particular.

So that’s why with the flu, we end up with seasonal flu shots. We see a lot more genetic mutation in the flu, even though it’s something we have been facing for a long time. With Covid, we don’t think it’s going to be that same rate of mutation after the first few years. And that we do think eventually, we’ll see a plateauing in the rate of mutation.

So Delta’s much more contagious. It is somewhat better at escaping immune defenses. Is it more lethal?

This is a tough question to answer because you have to also look at many of the other factors that are unfolding at the same time — Who’s getting vaccinated? At what rates? What’s the timing of when Delta hit?

With all those caveats aside, it does seem like Delta may be more virulent. So in other words, causes more severe disease. And the reason the Delta variant could potentially be more virulent or more deadly, more disease-causing, is that it reaches much higher levels of virus in the body. It’s replicating so quickly. There’s so much of the virus in the nose, in the throat, in the lungs. And so this may be why the Delta variant could be causing more severe disease.

Early in the pandemic, for example, we said kids don’t get too sick from Covid. They’re not too likely to transmit Covid to other people, whether it’s to other kids or to adults. And we are seeing a shift now where even kids are getting sick with Covid, with the Delta variant. Even kids are ending up in the hospital, young adults ending up in the hospital. And there’s clearly a change in the virulence of the Delta variant, which we think is related to this higher viral load.

So I want to hold on this with kids for a minute, because this seems very, very important to me. I’ve been asking this question of different people, Dr. Ashish Jha said he didn’t see evidence that Delta was more virulent in kids. I think in some of your writings, I’ve seen the suggestion that maybe it is. We certainly are seeing doctors say they’re seeing more kids end up in the hospital, though that could be just because of more contagion. We’ve been told again and again, this is like the flu for children, that it is not really more dangerous than that. Is that no longer true with Delta?

We’re not sure. We are certainly seeing more kids hospitalized, more kids ending up in the ICU. Now is this simply that more kids are getting infected and some percentage of kids are going to get sick, be hospitalized, end up in the ICU? Or is it that the virus itself is more deadly for kids? That’s a little hard to tease out. It’s a bit too early to say.

But many of us are concerned. We’re concerned about school reopening in the fall. And this really emphasizes the importance of using all the tools at our disposal to protect kids, to protect school staff. So that includes, obviously, vaccination, but kids under 12 aren’t eligible yet. So we really do need to do things like mask, and improve ventilation, and all the rest of the things we’ve been talking about for almost two years now.

But to hold on this for a second, it seems to me, a world where you have a version of Covid — in this case, Delta — that is significantly more dangerous for kids, which I recognize you’re saying we don’t quite know, but you’re also saying it might be, that is a world in which a lot of our theories of how to return to normalcy are about to collapse, because the kids are not eligible for the vaccine. And so I wouldn’t just trust, and we’re not saying for adults, just trust ventilation and masking. We’re saying you need the vaccine. Like the entire societal infrastructure is mobilized to get adults the vaccine.

If we’re saying that this is going to become potentially more dangerous for people who cannot have the vaccine and also are the people in society that, on some level, we care about most, that are most likely to create a panicked reaction, I mean, that seems to me like you’re painting a pretty worrying picture of where we might be about to go. Can you allay any of those fears or is that just where we are?

Well, this is precisely why the CDC has been tightening up on its guidance again. The administration, Biden administration, as well as many state and local health officials are very concerned about what the Delta variant means for us. As I said, the Delta variant is different, and we need to be very humble. We need to understand that there are things about this that we don’t fully understand, including what this means for kids.

And kids under 12 are the biggest group that, right now, still cannot get vaccinated. There are a couple other small groups — perhaps people who’ve had allergic reactions to a first dose, although there is now data that we can actually get around that. I can understand pregnant women in their first trimester might want to wait until a little bit later in pregnancy to get vaccinated. But those are really the only reasons not to get vaccinated. And kids under 12 are by far the biggest group there.

So let’s talk a bit about the vaccines, and maybe we’ll come back to kids, because I do have more questions there. But the vaccines, to the extent anything is a firewall here, it’s them. But if you go back a couple of months, let’s say June 1st, the story that is being told about the vaccines is we have these miracle vaccines and they are basically fully protective against death, almost fully protective against hospitalization, overwhelmingly protective even against infection. And my understanding is now, what we would say about them is different. So how has the story on the vaccines changed under Delta?

From the beginning, we’ve been saying the vaccines are highly, almost perfectly protective against severe disease, hospitalization, and death. And that was for the Johnson & Johnson vaccine, as well as for the Pfizer and Moderna vaccines. We got very lucky that the Pfizer and Moderna vaccines were so good that they also protected against most infection. And that’s pretty atypical, not typical for a vaccine to be that good. And in some ways, that created this standard, this perception that anything less than that was not good enough.

What our vaccines are really intended to do is to prevent severe disease, hospitalization, and death. We don’t vaccinate against the common cold. We vaccinate against real infectious disease killers. And so I think that message needs to be reinforced again, that it is not in vain, it is not useless to get vaccinated. We save lives through vaccination, and we continue to do so now.

But once you’re saying we need to tell people it’s not useless, it’s not in vain to get vaccinated, you’re already talking a little bit behind the eight ball. So tell me what you think the state of vaccination is right now. If we had run the trials under Delta, what do you think we would have been saying about vaccines from the beginning?

If we had run the trials under Delta, I think we would have been saying these are vaccines that will protect you against severe disease, hospitalization, and death. But until the vast majority of people can get vaccinated, you need to continue doing some of these other things. So like wearing a mask when you’re indoors, in particular, around people who may or may not be vaccinated; that you continue trying to socialize outdoors as much as possible; that we optimize indoor ventilation, which by the way, can be as simple as opening doors and windows to create a cross-breeze; and that we continue to do things like testing and contact tracing; that we need to continue using all the tools in the toolbox until most people who want to be vaccinated can be vaccinated and more.

So what do we think the — What do you think the prevalence of breakthrough infections is right now? If before, we thought the vaccines were, if I’m not wrong, sort of in the 90s on preventing infection, what do we think is true about them now? And I guess the question nested in that is, is there a big difference between particularly the dual-dose mRNA vaccines and Johnson & Johnson?

Yeah. According to the Kaiser Family Foundation, less than 1% of fully vaccinated people are getting breakthrough infections, with reports ranging from 0.01% in Connecticut to 0.29% in Alaska. It would seem that the Pfizer and Moderna vaccines are more protective against infection. So in other words, you may have more breakthrough infections among people who got the one-dose Johnson & Johnson.

I do think it’s important to understand that with the Johnson & Johnson vaccine, that vaccine has been studied, it is being studied as low-dose, high-dose, one-dose, two-dose. They went forward first with low-dose, one-dose, because if you think about it, that’s the way to spread that limited vaccine supply across the most people. And it actually performed really well where one dose provided really good immunity. But we are expecting data from Johnson & Johnson, probably by the end of this week, if not next week, about its other dosing regimens. And we do anticipate there’s probably going to be some tweaking of dosing regimens, whether it’s J&J, Moderna, or Pfizer because of what we are seeing with some of these breakthrough infections.

So what is the difference for me between getting Covid as a fully vaccinated person and let’s say somebody who got a double dose of mRNA and a non-vaccinated person?

I think Lindsey Graham said this quite well yesterday. He would have gotten a lot sicker had he gotten Covid as an unvaccinated person. He would have been far more likely to end up in the hospital. And yeah, he doesn’t feel well. He has to stay home and quarantine, but he’s not that sick.

Most people who are having breakthrough infections are not having any symptoms at all, or if they have symptoms, it might be like a bad head cold, maybe a bit of a fever, some muscle aches, essentially a bad flu. They’re not getting sick with low oxygen levels, needing to be in an ICU, needing to be on a ventilator. And so that’s a huge win, that we’re preventing all of that really severe disease.

This is, in some ways, my big question, because I think that how it falls really says a lot about what we’re targeting in policy. If I am vaccinated, fully vaccinated, and I get Delta, how do my outcomes compare to getting the seasonal flu?

A lot of people have compared Covid to the flu. And to be very clear, Covid is not the flu. But through vaccination, we could turn Covid into something like the flu, where yeah, you might get a bit sick, you might not feel well enough to go to work or to school, might feel sort of achy and nauseous, and have a bit of a fever, have the sniffles, but you don’t end up in the hospital. And through vaccination, we could turn Covid into something like the flu.

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So there’s this leaked CDC document that The Washington Post got. And this was the document that was behind the change in their masking guidance. It then got out. And it’s terrifying in a lot of ways. But on page three, they have this set of charts, and they’re comparing, based on the data they have, outcomes for infection, for hospitalization, for death among the unvaccinated and the vaccinated. And the point of these charts is that you’re eightfold less likely to get the virus if you’re vaccinated. And then you’re 25-fold less likely to be hospitalized or to die.

So you’re getting to fatality levels here that are beneath that of the flu. The seasonal flu is about 0.1% in terms of how many people it kills. So if that number holds, and I recognize these can all change, that means for the vaccinated, coronavirus is now at a risk level, it seems, comparable to other things that we simply live with, like the flu.

If anything, your risk of death, if you are a vaccinated person who gets Covid, is much lower than somebody who gets the flu, but who’s one of these people who doesn’t get a yearly flu shot.

I mean, I find that very encouraging, actually. I’ve been talking to people about this question. The scariest of my conversations, and I say this with unbelievable admiration for him, was with Bob Wachter at UCSF. One of things he was saying was that the thing that worries him is that the underlying numbers aren’t stable, that we could be seeing vaccine decay, that their effectiveness might be waning in the six to eight month period — particularly, the people who got them first or were older or health care workers, or that Delta is getting worse, or that immunity is dropping off, and so that we’re going to kind of be in a very difficult race here. So do you think that is true in an extended way or just true for the moment?

The groups in which I’m seeing the most concerning data in terms of immunity is, frankly, the most highly immunosuppressed people. So these are people, for example, who have had organ transplants, lung transplant, kidney transplant, people who are on highly immunosuppressive drugs for autoimmune diseases like rheumatoid arthritis, people with blood cancers, people with HIV/AIDS. This is actually the group that concerns me the most, where we do not see them achieving high levels of antibodies, even very soon after vaccination, and where there is data that they may well benefit from an extra dose of vaccine.

In terms of the elderly, people over the age of 80, we know, respond less well to vaccination. Just like you’re not as spry and strong, and your bones aren’t as dense as they were when you were age 20, your immune system is not as strong at age 80 as it was at age 20. And so we are seeing less robust antibody responses among the truly elderly.

I do think it’s a bit of a reach for countries like Israel, the UK, France, Germany to be expanding extra doses of vaccine beyond the highly immunosuppressed and the most elderly. Some of these countries are planning to give extra doses to folks 60 and up, and I think that’s a bit aggressive.

Why do you think that’s a bit aggressive? Why not just make the bet?

Well, for a couple of reasons. One, we don’t see that reduced immunity, immune response in what I would call the younger elderly, so the 60- 70-year-olds. And secondly, if you’re thinking about the fact that we are still in a world with limited vaccine supply, if I’m thinking about, say, I don’t know, a nursing home where you have a lot of elderly people, we get a lot more bang for our buck with each of those vaccine doses being given to a caregiver caring for those elderly persons, as opposed to giving an extra dose to those elderly persons, residents of the nursing home. You just get much more protection for them as well, the added benefit of protecting the caregiver.

I think if there’s any lesson from the Delta variant also, it’s that when you allow the virus to spread anywhere in the world, doesn’t have to be here in the US, that that does lead to more mutations, more emergence of variants that can be threatening to all of us. And that’s another reason to be really careful about how we allocate that limited vaccine supply. And I just don’t think that optimizing our individual protection is actually what’s going to be most protective to all of us.

All right. So you would not go yet for the third booster shot. What about mix and match? What if you’re somebody who got Johnson & Johnson single dose in the current regime? Should you rush over to Walgreens and try to get a hit of an mRNA?

We do see that the Johnson & Johnson vaccine is less protective, especially against infection. It is still, even with Delta, quite protective against severe disease, hospitalization, and death. But if you are one of these higher risk groups — elderly, immunosuppressed — that is a group where if I got Johnson & Johnson, I would consider getting an mRNA to follow up that J&J.

One of the things we’ve seen with mixing and matching of vaccine types, whether it’s a Johnson & Johnson with Pfizer or Moderna, or AstraZeneca with Pfizer or Moderna, is that we get much more robust immune responses. And so I think we’re going to see a lot of changes in vaccine recommendations over time. Some of that will be about mixing and matching, some of that will be about the timing, and some of that will be about the number of doses. We haven’t perfected those dosing regimens yet.

So stepping back, it sounds like you’re still pretty confident that certainly, the heavier vaccination regimes are effective enough to bring this down to a risk level that, at the very least, we accept elsewhere in life. So is that the steady-state policy goal now, that we are just trying to get enough people vaccinated, that this becomes the flu? Like we’re not doing herd immunity anymore. We’re just trying to get people protected enough that if you catch it, it’s not such a big deal. Is that, in your view, the goal?

Yeah. I think the goal is to live with Covid. Covid is not going away. The idea here is to really transform Covid through vaccination into something that we can live with. So I anticipate where we are headed is that Covid vaccinations will eventually become part of routine childhood immunizations because eventually, it will reach the point where older people have all been vaccinated, so it’s really just catching up with the youngest, and that those vaccinations prevent folks from getting really sick with Covid, that we’ll just have some mild coronavirus cough, cold, flu kind of symptoms, but no one will be getting really sick except for those maybe few who remain abstainers of vaccination.

Does the possibility of long Covid change that at all? When I’ve asked others about this, this is one of the caveats they offer, that there’s some evidence of these long Covid symptoms, that they can happen for breakthrough infections. And so in that way, it’s not clear that a vaccine, even if it does protect against hospitalization and death, it’s not clear it protects this kind of grinding struggle some people seem to have with the after effects of the disease. Does that change your calculation at all?

Yeah. It’s a really good question. There’s so much we still don’t know about long Covid and that we’re still learning, in part because we only know what we know since the start of the pandemic. And we certainly are seeing people who have long-term neurologic issues, what they describe as a brain fog, people who have long-term cardiac issues, kidney issues and the like. And that is something we are still learning about.

I do anticipate that there will be people who have long Covid, and that’s not going to be the majority, but we will still see some people like that. We have this grab bag of people who have what we call chronic fatigue syndrome. We think a lot of those people are actually people who’ve had viral infections that have set up those symptoms. And I think long Covid will be eventually part of that grab bag.

Do I wish anybody long Covid? No. Do I want to get long Covid? No. However, we run that risk in our everyday lives, that we run the risk of getting one of these viral infections that, for most people, are very mild, but that can very rarely set off something like chronic fatigue syndrome or an autoimmune disease. But that’s a risk we tolerate.

I want to pick up on that idea of risks we tolerate, because behind this whole idea of Covid getting to the flu-like level of risk is the reality that the flu actually kills a lot of people every year — I mean tens of thousands of people, just in America. And we tolerate it, in part, because the flu itself has become background noise. There isn’t a ton of coverage when people die from the flu. There are no headlines when somebody famous gets the flu. If Lindsey Graham got the flu, I wouldn’t know about it.

And so one question about whether or not we can get to this world is that there is the objective risk of the coronavirus to people who are vaccinated. And then there is the perceptual risk, the salience of the risk, the way we all treat the risk in our everyday lives. I mean, another good example, this is the way people began treating terrorism after 9/11. It was still vanishingly rare and very unlikely that your mall in Idaho was going to be targeted by Al-Qaeda, but people were very scared. And so how do you think about the potentially different paths between the risks we’re able to lower through vaccinations and then the way that we are now just societally, particularly in areas that have been taking this very seriously, tuned to be afraid of it, and to, I think, psychologically want the risk to be closer to zero, even though that’s not the way we treat other risks in our lives?

I think part of how we view risk is also how novel it is. Have we had a chance to adapt to it, to get used to it? Another good example of this is what’s happening in some of the East Asian countries that have been very good, very compliant with things like masking and social distancing, where even in those societies, we’re seeing attrition in those behaviors, that people are just tired. And I think there’s something similar that happens when you are on alert for so long due to a danger, that eventually, you start to say to yourself, it’s just not that dangerous anymore. You start to feel less worried, less threatened, even if the threat itself has not changed.

And I think that is, frankly, contributing to some of our issues right now in terms of trying to get people vaccinated, trying to get people to go back to masking in some parts of the country where transmission rates are very high. People have just learned psychologically to live with that risk and just don’t see it as the threat perhaps they did when it was brand new.

So, recently, the Centers for Disease Control and Prevention, they updated their guidance. They said you should have universal masking indoors, even among the vaccinated in places with high transmission. Some particular places have taken that pretty far. Like I live in San Francisco, where I think something like 70% of the population is vaccinated. But we’ve just gone, as of today, back to universal masking, even though we are seeing some rise in cases, but we don’t have a Louisiana-style outbreak. And so I want to ask a question this way. Given what you’ve said about the risk of Covid to the vaccinated, why are the vaccinated being asked to wear masks?

I disagree with the CDC’S recommendation back in May that fully vaccinated people did not need to keep masking indoors. The reason for that is we had no system to verify that vaccinated people were the only people who were shedding their masks. And what we really saw was once the CDC said that, everybody shed their masks.

I think, unfortunately, many of these behaviors, especially if it’s a behavior that’s very obvious to the outside, people behave in ways that fit their cultural norm, what their family and friends tell them to do. And I think masking is a classic example of this, where it’s really not about the risk of viral transmission in the community. It’s not really about whether they are vaccinated or not. It’s whether that is what their social circle endorses or not. And so the problem with that recommendation is that people were not behaving based on risk or vaccination status. They were behaving based on social norms.

And in a sense, this reinstitution of mask mandates or recommendations depending on the place, regardless of vaccination status, is really reflecting that reality, that there are still many people in the community who are not yet vaccinated. We still have a lot of transmission. And really, the only way to get the unvaccinated to mask up is for all of us to mask up and make it a social norm.

But so then you agree with the perception I’ve seen among some that what is being asked here is not that the vaccinated mask up for their own protection, but that the vaccinated mask up for the protection of the unvaccinated, that it’s kind of a risk transfer.

I think that’s the primary reason for vaccinated people to mask up. It’s really to make it socially acceptable for everybody to do so. There are some other benefits to masking if you are vaccinated. It does further lower your risk of breakthrough infection. So if you’re somebody who’s concerned about that, it certainly adds to your protection. And as you said, there’s still much we don’t know about long Covid. And so if you are somebody who is more risk averse and wants to further reduce your risk, it does make sense to continue masking, at least for now.

But this seems weird to me, to be honest, particularly in this respect. It seems peculiar to me to have a mask mandate where you say to people who have gone and done the prosocial thing of getting vaccinations, OK, now you’re going to do more, you’re also going to put on a mask, as opposed to having a vaccine mandate in which the people, at least who are eligible who have not done the thing of getting a vaccine, have to go out and do the thing that would help get them more protection. It just seems odd to continue placing more burden and protective measures on the people taking them while the more effective thing is not being asked of the people who are not.

Well, I don’t know that I would say unvaccinated people are not being asked to take some steps here, make progress in terms of getting themselves vaccinated. Just today, I joined the mayor in a press conference announcing the Key to New York City Pass, which is a first-in-the-nation vaccine requirement, we’re the first place in the country to do this, where workers, customers, will be required to show this Key to New York City Pass for indoor dining, for indoor fitness, for indoor entertainment and performances, to demonstrate that we have received at least one dose of vaccine. So I think many places are really trying to attack this from multiple fronts.

I think that’s one of the problems we’ve had throughout this pandemic, is we’ve looked for silver bullets, simple solutions, and there’s not one simple solution here. You really do have to combine multiple different public health measures. So that includes encouraging people to mask up again indoors, especially if there’s a lot of transmission, while at the same time, incentivizing people who are not yet vaccinated to get vaccinated for them to be able to return to a more normal life, for all of us to be able to return to a more normal life.

So I have a lot of questions about the Key to the City program because I think that’s really, really interesting. But the one thing I’ve observed is that the CDC is putting forward this nationwide masking demand, whereas New York City is the only city in the country, to say nothing of state or national, that has put in place anything that looks like a vaccine mandate. And that’s where this seems a little bit odd to me. And it seems odd to me on both the level that it seems like we’re targeting the less effective measure more aggressively, but it also seems odd to me or worrying in the sense that I’m also seeing lots of people who are vaccine-hesitant say, well, look. Even when everybody’s got the vaccine, everybody’s ending up in masks anyway and getting breakthrough infections. So what do I care?

I think there’s a slightly perverse way where people need to see a vision of what success looks like to be able to take what feels to them like a risk and take the vaccination. So the places that have a mask mandate but not a vaccine mandate slightly seem to me like they’re putting the burden in a weird place.

I think this comes down to, in some ways, how public health is structured in this country. So the CDC cannot mandate. The CDC can only provide technical advice and guidance. And then it’s really up to state and local health departments, state and local officials, to decide whether they’re going to mandate something, whether they’re going to recommend something. And obviously, that gets filtered through the politics of different local jurisdictions, through the social norms of those local jurisdictions. And I think that’s what leads to some of this disconnect.

In terms of what will the future look like once we’re all vaccinated, I think the Provincetown outbreak that’s gotten a fair amount of coverage is actually a really good example of what the future holds. And the Provincetown outbreak shows that we can, through vaccination, turn Covid into something much more like the flu. Yeah, a lot of people had cough/cold symptoms, but very few, just a handful ended up in the hospital, and no one died. And that’s a huge success. And to me, that’s how to frame that story of this is where we could get to if everybody would get vaccinated.

Can you say more about the Provincetown outbreak, because I happen to a little bit about it, but I think people don’t know what is being described there? So this is the outbreak. It is a case study that was important for the CDC’S new guidance. But can you just talk a bit about what was going on in Provincetown, why that was an interesting case study, and then what we actually saw in it?

Yeah. So Provincetown, it’s sort of an interesting study in terms of culture, as well as epidemiology. Provincetown, Massachusetts, is out on Cape Cod. It’s a place where a lot of gay men will go and party and have fun. July, you have a couple different weeks. You have Bear Week, you have Twink Week, you have Circuit Week, where different subsets of gay men and other LGBT folks will go. And it’s a really good time. It’s sort of like, I don’t know, Cancun over spring break. It’s not really that different from that.

And I have a lot of friends in the community here in New York. And it was probably a week after the 4th of July, I started getting a lot of texts about I had this cold or this cough after I came back from Provincetown. I’m not sure whether to be worried about it, but I’ve been vaccinated. And many of us in the infectious disease community said, well, it doesn’t hurt to get tested. Go get tested.

A lot of these guys survived the years of the ‘80s, ‘90s, of the worst of HIV. And so they remember how important it is to be really proactive on these issues and get tested, and so, many did. And that’s how we picked up on these breakthrough infections among people who had been vaccinated.

The vaccination rates among that community — They’re very science and health literate. They’re very proactive in protecting themselves. The vaccination rates are quite high. And they were also very proactive in getting tested.

I think what was really cool is some of these guys, themselves, started to gather the data. They alerted the CDC. And they said, hey, we think there’s something going on here. You guys should come and investigate. And so the CDC got involved, the Massachusetts Department of Health. And this really also speaks to the power of contact tracing and testing when people work with public health departments.

So instead of having to pull teeth of getting lists of contacts, in this case, you had some of these guys who had put together Excel spreadsheets of all the different contacts, where they’d been in contact, what degree, that level of detail. I mean, as somebody who works in epidemiology, we never get that. I mean, this is amazing, which is why I’ve called this real-citizen science, where these guys really helped the CDC and Massachusetts Department of Health get to the bottom of this, and we learned a lot as a result.

Yeah. It’s a totally remarkable story. And to just add to what you’re saying, this was a very rainy weekend. So a lot of people are inside, partying during the Delta outbreak, vaccinated, but a lot of close contact with other people, to put it mildly. And you have something that ends up looking kind of fluish. There are no deaths.

And it gets reported because it leads to this changing CDC guidance of maybe the vaccines aren’t working that well. But it does seem plausible that another read of it is actually, the vaccines worked great. They got a huge stress test here during a very, very tough variant. And some people got sick, but nobody died. There was very little in the way of hospitalization. That this should make you confident in what’s going on because most of us are not going to anything that is on the level of Cancun or Provincetown most of the time. Yeah, I think that’s right.

This was a massive stress test to the vaccines, this partying indoors, in bars, in hotels in Provincetown in early July. That was a massive stress test to would the vaccines hold up in the face of the Delta variant. And they really did. And so this really shows that even with a massive stress test like that, the vaccines hold up really well.

So that, I think, underscores this idea that what we do want to do is get people vaccinated. So tell me a little bit more about the New York City program. And I’m particularly interested here in just, what is its infrastructure? Like how will you prove you got the Key to the City? What if you got your vaccination in another city or state? What if they entered your data wrong, right?

It’s an important thing, if you got vaccinated, to actually be able to move around in your daily life. And it’s a lot of people with a lot of room for bureaucratic error. So how is this being carried out?

Yeah. So there are three different ways that you can show proof that you’ve been vaccinated. There’s the New York State Excelsior app. There’s the New York City Covid SAFE app. So both of those are digital apps you can download to your phone, whether you have an Android phone or an iPhone, either platform.

And then there’s always the good old-fashioned paper system, which is the CDC paper cards. Now we know that there have been issues with people forging those cards. That is still a very small proportion of people who are doing that. And I think big picture, most people will just get vaccinated, won’t go in search of these forged cards. They will make use of the apps or the CDC paper card. And I think the key here is not to let perfect be the enemy of the good, but to try to really get most people vaccinated, acknowledging some people will try to skirt the system, and just realize that that will be the case.

Yeah. I’m not I’m not very worried about the card forgery issue. I agree with you. That’s pretty small. My bigger worry is people who got vaccinated and have trouble proving it. So if you got vaccinated months back and you lost your CDC card, or you got vaccinated somewhere else that isn’t in New York’s recordkeeping and you lost your CDC card, what do you do?

New York State has a vaccine registry. So for people who’ve been vaccinated in New York, that data would be pulled from the registry. This is how the apps work. They actually download that data from the registry to your phone, and then you get this QR code on your phone that serves as proof of that record.

But there are gaps, as you note. And this is something that I’ve already raised with the mayor’s office as well. So some of that could be, for example, if you participated in the clinical trial. Some of that could be maybe you got vaccinated overseas. Maybe you got AstraZeneca in the UK. Will that be recognized?

And then, yeah, there are some people who just didn’t do a very good job of tracking their CDC card. But this is where having the digital overlap does help with at least some of that, because if you were vaccinated in the state, the registry, the state registry will have a record of that.

It just seems wild how much we’re asking cards to do here. I mean, I lose everything. And by some miracle, I still have my CDC card. But I do worry about people who are less digitally literate. Maybe they don’t have a smartphone; or I know a lot of people who have old smartphones, so they are constantly running out of batteries; or they dropped it, but now they don’t know where their card is or they don’t have a card on hand.

I’m a very, very, very big proponent, in theory, of these vaccine mandates. I think it’s clear that it’s a direction we should go in, particularly in the places where the politics will support it. I recognize that there are other issues, as much as it breaks my heart, in the places where there would be vast resistance to it. And so maybe, even though the policy makes sense, you can’t implement it. But in places that you can, it makes sense to do.

It’s just, the thing that scares me, as somebody who covered, say, the rollout of healthcare.gov or the collapse of state unemployment insurance offices during the pandemic under the increased demand, is what if you have a high error rate and all of a sudden, a lot of people need help, and you don’t know how to give it to them or the system is overloaded? I’m worried about someone rolling something out, and then it becomes a negative example that dissuades other places from doing it.

But I saw something interesting here, which is that it is going to roll out well before it goes into effect, which struck me as smart. Can you talk a little bit about the staging of it?

Yeah. So they’re launching the Key to New York City in middle of August, August 16th. And the city won’t begin enforcing vaccination status requirements until September 13th. So that really gives us about a month to figure out what are some of the issues with the system, to fine-tune things, to troubleshoot.

One group I can think of off the top of my head, where I run to this issue with patients in the hospital with is the homeless population. When you’re homeless, you don’t have a place to store things, you lose your identification, you lose — The chances that you’re able to hold on to a smartphone and be able to use it effectively are pretty low. We find ourselves having to work with social work to help people apply for their driver’s license or Social Security card or other ID. I mean, that happens all the time, that people have misplaced those basic documents.

And so there is no question, there are people for whom, whether it’s a digital verification system or a paper system, it’s going to be a challenge. One of the good things about these digital systems is they allow for printing of the record, even if you don’t, yourself, have a phone. And so I think that will also serve as a bridge for some of these people.

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I want to ask you some questions that are forward-looking now. And I want to go back to kids to begin, because what you said about Delta in kids at the beginning is worrying. We cannot currently get them vaccinated. So one question is, do you think that we are going to see the age recommendations drop in the near future for children? I mean, should I be able to get my two and 1/2 year old vaccinated?

I think we’re going to have data for the 5 to 11 age group for the Pfizer and Moderna vaccines by September or October at the latest. And then it’ll take the FDA, say, three weeks, four weeks to come through with an authorization for that 5 to 11 age group. So I think by October/November, we’ll start to see vaccination in that age group. I think for kids under five, it’ll be a little bit longer. And so we will indeed have to continue taking measures to protect those youngest kids.

In a world where Delta is spreading and you think it does have an effect on kids, do the benefits outweigh the costs of going back to school?

Very good question. Very difficult question. I think we have seen very real impacts on mental health, on education, especially among those with the greatest socioeconomic disadvantage in this country. For example, in New York City, the mayor was very hesitant to close schools, understanding that for a lot of these kids, that might be where they get most of their meals, the free lunch programs. So there are many reasons why we are thinking very carefully about what this will mean for schools.

I do think it remains possible to reopen in-person learning, but it will mean that we really do need to combine interventions to reduce transmission. So that means kids and staff would be masking. It means optimizing ventilation. It means continuing testing. And it means anybody who’s eligible to get vaccinated needs to get vaccinated. But we need to do all of those things because our youngest of kids won’t be eligible for vaccines yet, and so we need to use all the tools in our toolbox in the meantime.

So is there a steady state coming where we’re not masking anymore? I mean, is that even foreseeable in the future, or are we just in, from here on out, we just live in Covid world, and it’s endless waves of you take them off for a couple of months, you put them back on, you take them off, and this is just what life is like now?

I do think we’re looking at more waves and possibly surges of Covid for at least the next several months, if not the next year. And so much of that is going to depend on how quickly we can vaccinate. So the faster we can vaccinate, the faster we can bring sort of that phase to a close.

There’s some of the lessons we can take from SARS, for example, in East Asia, countries like China, Japan, and so on, is that they’ve continued to wear masks during cough/cold/flu in the winter. And is that something that might stick long-term, at least in some parts of the country? I think that’s certainly possible.

Me, working in the hospital, if I have a patient who has the chickenpox virus, we mask when we go into that patient’s room. So I think there are certain contexts where if you’re in contact with somebody who’s highly infectious, even if you’re vaccinated, or in the case of chickenpox, even if you’ve had the chickenpox, that you would still continue to do things like mask.

Do you think we’re headed for a almost a two-tiered, or at the very least, a multi-tiered society when it comes to Covid risk, and certainly, to Covid measures? And what I mean by that is we have these layering policies that are being taken up by places that have taken this very seriously.

So I’ll use New York City as the example here. New York City will have both masking indoors and it will have vaccination mandates, whereas there are other places that have made it illegal to impose masking or vaccination mandates or that certainly are not imposing them. And so you have a really, really sharp disconnect between the level of measures you see in functioning, like a lot of blue areas and cities, and the level of measures you see elsewhere. So does that create the likelihood that we’re not going to have one state, we’re going to have multiple?

I am really afraid that that is what is going to happen. This really does concern me. I think to some degree, it will depend on how scared people are by what they bear witness to in places that are experiencing surges right now — places like Florida, Missouri, Arkansas. Does that scare them enough to change their behavior? I don’t know. And I think part of the problem is that some of this is unfolding in an invisible way to the lay public because it’s behind doors in a hospital, and that may not be obvious enough for some people in a community what the impact is.

That’s a scary thought. I always think about this as being vivid in a way that you can’t really ignore, but I guess I take the point that you can ignore almost anything if it takes place in the quarantine unit of a hospital.

Yeah, I mean, as somebody who bore witness to this in New York, I walked by those mortuary trucks that were parked outside the medical examiner’s office across the street from Bellevue. I walked right by those trucks every day on my way into Bellevue last March and April. And so for me, that was basically like seeing dead bodies in the street. But I think for other people who are not health care workers, who are not quite seeing what we see in the hospital, it just may remain invisible to them, even if there is a surge in deaths in their community.

I think that is an appropriately sober place to come to an end. So let me ask you what’s always our final question. What are three books you would recommend to the audience that you either learned from or maybe even took comfort in over the past couple years?

So one is the book I read a few years ago now. It’s called “Wired for Culture: Origins of the Human Social Mind” by Mark Pagel. He’s an evolutionary biologist in the UK, and he studies how evolution imprints on human behavior, everything from language to culture. And he looks at why humans form tribal groups. And I think this is really important in this current context with Covid. Our tribal groupings are really how we cooperate and work with other humans. And we form all these different social and psychological rules to make sure these small groups function well, that we can work well together.

I think these rules also help explain why people are willing to risk their health and even their lives on behalf of their culture and their social affiliations. It’s why people enlist in the Army, for example. And it’s really a form of altruism on behalf of that in-group. So I think for me, that book really helped me understand some of the behaviors around masking, around whether people want to get vaccinated right now, and to think about how to maybe leverage some of that to encourage those kinds of behaviors. So that’s the first one.

The second one, I read last year, and it’s called “Rule Makers, Rule Breakers: How Tight and Loose Cultures Wire Our World.” It’s by Michele Gelfand. And she’s a cross-cultural psychologist, which means she studies human behavior around the world to understand these cultural codes that drive behavior. And she looks at how different societies might be more strict with respect to their social norms, and how that predicts how we might behave in a crisis like what we’re seeing right now.

So like if you were to compare, say, the cultures of countries like Singapore or Japan or even Germany, those would be considered tighter cultures. And then you have other cultures like, say, Brazil or Greece or the US that would be considered looser cultures. And one of the big predictors of whether you’re a tight culture or a loose culture is that culture’s historical experience with natural disasters or famines or attacks from the outside, invasions, that sort of thing, perhaps even infectious diseases.

And what she has found in her research is that countries with tight cultures and efficient governments are really the countries that have, at least in the beginning of the pandemic, and I would say, arguably, still, these are the countries that have been able to slow the spread of Covid the most effectively and that are now having success, if they have supply of the vaccine, having success in rolling out the vaccine more so than others.

And then finally, the third book is “Stuck: How Vaccine Rumors Start and Why They Don’t Go Away.” This is by Heidi Larson. This came out quite recently. Heidi as an anthropologist and she’s the founder of the Vaccine Confidence Project. And so it’s a group of people with backgrounds in everything from political science to mathematical modeling to psychology. And in a sense, they function like a weather room, where they watch how things are moving and how fast they move.

So in the case of vaccine rumors, it’s keeping track of words or phrases or pieces of news or rumors, and where does that information go? Who picks it up? Who amplifies it? And very often, these sort of seeds of misinformation, disinformation get embellished by local cultures, local politics, local anxieties, and history, and sort of tracking the evolution of these rumors around the world.

One of the things that I thought was so interesting, both reading Heidi’s book but also talking to her, is how much disinformation originates here in the United States. We’re actually the biggest or one of the biggest disinformation exporters about vaccines to the rest of the world. And so to me, that’s really interesting, because on the one hand, not only are we behaving in a nationalistic way with respect to our vaccine supply, we are then, as a nation, actively discouraging people around the world from getting vaccinated by exporting, generating and exporting all of this misinformation and disinformation about vaccines.

Dr. Celine Gounder, thank you very much.

Oh, it was a pleasure. [MUSIC PLAYING]

“The Ezra Klein Show” is a production of New York Times Opinion. It is produced by Jeff Geld, Roge Karma, and Annie Galvin. Fact-checking by Michelle Harris, original music by Isaac Jones, and mixing by Jeff Geld.

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