The complex psychology of post-vaccination safety - STAT - STAT

A friend invited me to her home for a birthday party. “Ten of us will be there,” she wrote. “I’m pretty sure we’ve all been vaccinated, so we should be OK.”

It was the first invitation to an indoor dinner I had received in almost a year.

Six other friends are planning a tropical vacation and invited me to join them.

“Aren’t you worried about Covid?” I asked, feeling a bit nerdy for raising the question.

“Not really. Two of us have gotten both our vaccines.”

“What about the others?”

“Two have gotten one vaccine each, and the other two have been very careful.”

And this from another friend: “I feel like I just got into Harvard Law School!” she wrote. “I just got my first vaccine! But is it now OK to fly if I wear a mask the whole time?”

These people are struggling with the same questions about safety I’m struggling with, having just been vaccinated. We are wondering how to change our behaviors and interactions, and understand just how protected we and the others we encounter are — or aren’t.

In early March, the Centers for Disease Control and Prevention released guidelines stating that fully vaccinated people can visit each other or members of a single unvaccinated household indoors without wearing masks or physically distancing themselves. These clarifications, along with the fact that millions of Americans are now getting shots, are welcome news.

But how will Americans respond? In the next weeks and months, millions of people will confront myriad nuanced and complex individual choices — which gatherings to attend, with whom, and how certain we need to be that we are indeed safe from spreading or receiving the virus.

The problem is that humans aren’t good at gauging risks.

Maskless young people are now thronging bars. Texas Gov. Greg Abbott decided to fully open his state. As his decision indicates, many people may now also engage in risk compensation, in which they act in riskier ways if they have taken measures that they feel are protective. Seat belt use, for example, has failed to lower fatal car accidents, since drivers wearing seat belts then compensate and drive faster or less carefully. Sunscreen use has increased melanoma rates because users feel they can now expose themselves to more sun.

Vaccines are absolutely essential for stopping Covid-19, but they reduce — not wholly eliminate — the odds of being infected with the virus. The Pfizer and Moderna vaccines are around 95% effective at reducing severe disease, while the Johnson & Johnson vaccine is about 85% effective. Those are high numbers for vaccines, but not guarantees of safety. For every 20 people who receive the Pfizer or Moderna shots, one could still acquire Covid-19 and become seriously ill.

Covid-19 and other viruses also mutate, sometimes rapidly. As billions of cells in millions of humans replicate the virus, its genetic material constantly changes, sometimes in ways that circumvent our defenses and vaccines. At least one vaccine has been found to be significantly less effective against one such mutation. Current vaccines may not end up protecting against all the new variants.

Scientists also aren’t sure how long the vaccines’ protections will last, and whether vaccinated individuals can get infected and spread Covid-19, even if they themselves don’t get sick.

The human brain evolved to face simple risks, like whether a certain plant is safe to eat. But far more complex and nuanced dangers now fill our world. Neurocognitively, we commonly assess risks using so-called fast thinking, which is essentially gut feelings. As the anthropologist Mary Douglas wrote in her classic book, “Purity and Danger,” people tend to divide the world into the two realms of “risky” and “safe” — what is dangerous and to be avoided vs. what isn’t — or essentially bad vs. good. Our brains see these dichotomies in black and white rather than shades of gray. We don’t deal well with ambiguities or notions of relative safety, and like to think of situations as merely either completely safe or unsafe, rather than as partially or relatively safe.

Public health officials have long recognized such complex realities about harm and safety. To address them, they’ve pursued so-called harm reduction strategies. The fight to control HIV is an example. Some people who injected opioids or other drugs into their veins shared needles, spreading HIV and hepatitis, which can lead to disease and death. Over decades, federal and state and local governments spent hundreds of millions of dollars trying to stop addiction, but with limited success. One solution to stop HIV from spreading was by providing clean needles — a harm reduction approach. Although many states have staunchly opposed this tactic, fearing it would fuel addiction, it works in significantly cutting HIV infections and not fostering addiction.

In the months ahead, many people will face complex decisions with no easy answers. Though desires to feel safe against Covid-19 run deep, we need to accept, and adapt to, far more complex realities, like how comfortable we are that everyone at a dinner party has indeed been fully vaccinated and hasn’t then entered a relatively crowded subway, bus, store, bar, or other area without a mask.

The CDC, Food and Drug Administration, and other federal, state, and local public health agencies, along with elected officials, hospitals, physicians, and medical associations, urgently need to work to enhance public understanding of these issues through appropriate public health messaging campaigns. These messages need to convey the complexities of risks: the fact that being vaccinated is not a 100% guarantee of safety.

We each need to remain careful. Research suggests that until the vast majority of people get vaccinated and wear masks and social distance when they should, Covid-19 will remain around us in schools, stores, and elsewhere.

I got more information about the birthday party and learned that all of those attending would be fully vaccinated before the event. So I’m going. I also decided to join the beach trip, but will drive, not fly, and will continue to wear a mask and social distance.

I look forward to more invitations, but I’m not sure how I will respond.

Robert Klitzman is a professor of psychiatry at the Vagelos College of Physicians & Surgeons and the Joseph Mailman School of Public Health, both at Columbia University, director of the university’s online and in-person masters of bioethics programs, and author of “The Ethics Police?: The Struggle to Make Human Research Safe” (Oxford University Press, 2015).

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