"It's time to adopt a mindset that this may be what our lives are like," says Dr. Bob Wachter of UCSF. (Photo/Courtesy UCSF)
"It's time to adopt a mindset that this may be what our lives are like," says Dr. Bob Wachter of UCSF. (Photo/Courtesy UCSF)

Herd immunity? ‘Not going to happen,’ says UCSF doctor

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Since the pandemic began, Dr. Bob Wachter has been a voice of reason and science, both through UCSF’s “Medical Grand Rounds” video series as well as interviews with the New York Times, the San Francisco Chronicle and J. the Jewish News of Northern California.

When J. spoke with Wachter in May 2020, there was no vaccine, and orders to shelter in place were still new. At that time, he discussed case numbers and the city’s public health response, and how bad things could get.

A year and a half later, Wachter, who chairs UCSF’s Department of Medicine, sat down (virtually) with J. again, to talk about how long we’ll be dealing with Covid and how he’s making his own personal decisions on how to live and work.

J.: I know that you’ve been quoted saying recently that we’re in a sort of “new normal.” Tell me what you mean by that.

Dr. Bob Wachter: I think we’re entering a time where the forces of good and evil sort of balance each other out. As more people get vaccinated, that’s the main force for the good. On the other hand, as that happens, people typically let their guards down, and that’s a force that will drive cases up.

It’s time to adopt a mindset that this may be what our lives are like. The things that give us pleasure — forgoing them for a year was one thing. Forgoing them forever is a different thing, and I think leads to a different set of decisions. It’s leading me to make some choices that probably are a little riskier than the ones I would have made a year ago, because I don’t think the cavalry is coming.

I’m OK now eating indoors at a restaurant. I went to see James Taylor last week, indoors. I wouldn’t have done those things six or eight months ago. But I’m still doing them [now] — with a mask. If you told me there’s not a vaccine requirement [at the venue], I probably wouldn’t go. When I go shopping in the supermarket, I’m still going to wear a mask, even if the rules change and say you don’t have to, because to me a mask is nothing.

But this is not a binary decision. It’s like, “OK, we’re in a new normal, throw caution to the wind, you know, you’ve gotten vaccinated, you’re as protected as you’re going to get, now just don’t worry about it.”

I still act on the mantra that I still don’t want to get Covid. So I’m going to be as careful as I can be, but not with the mindset “just hunker down, six months from now you won’t need to do this because things are going to get better.” My mindset is, I’m now making choices that I really need to be comfortable with for the next five years.

So we’re going to be living with this for a long time. Covid isn’t going away?

We’re never going to reach that herd immunity mythic goal that we had. That if we just get to this number of people immune, then the virus goes out of our lives. If that’s on your wish list, you can take that off. It’s just not going to happen.

I can understand once we get to a very low case rate, [people] just say, “I want the simplifying assumption that life is back to 2019. I’m going to live the way I used to live.” But you know, they’re taking a small chance that they will get Covid. And a small chance on top of that, that it will be a case of Covid that they will regret having gotten.

We owe a lot of our protection to immunity, but immunity is unstable. [In the Bay Area] we have a very, very high level of immunity largely from vaccinations. But we know that over time, the protection of the vaccinations is waning. So we’re going to be increasingly dependent on those people going back and getting another shot. And I’d say the vast majority of them will, but it’ll take time.

The analogy I’ve been using is the “repainting the Golden Gate Bridge” analogy, like the minute you’re done, you’ve got to start all over again.

There could be a game changer. One is the virus mutating into something that’s much more benign. Seems pretty unlikely. The second is we come out with a pill that you take once you have Covid that is massively effective. The Merck pill that just got a lot of press two weeks ago lowers the rate of hospitalization deaths by 50 percent, but the game changer would be one that lowers it by 90 percent, 95 percent.

If you look at the curve of cases in the United States, it peaked a month or so ago, six weeks ago. It’s come down pretty nicely and now it’s plateaued. I think that plateau is probably these sort of forces pushing against each other.

If I had to put a bet down — are things likely to be a little worse or a little better? — I’d probably put “worse” because of waning immunity issues that will have an impact over time.

What about vaccinating kids? Do you see that making any kind of big change?

I think it helps. Of course, it’s totally dependent on how many kids get it. The better way of thinking about it is that the higher the level of immunity in the community, the harder it is for the virus to gain a toehold, and the less likely it is that there are going to be significant surges.

How do institutions or workplaces decide what’s safe? Even counties have different masking requirements.

It’s very hard to have national policies because there [always] will be major regional differences. But even local policies are tricky.

You know, the synagogue could say, “We’re open, and you don’t have to wear your mask!” But if I’m 75, I might still want to wear my mask. Certainly if I was immunosuppressed, I’d want to wear my mask. You’re weighing the risks and benefits of everything. For physicians, we’re used to that. In terms of [giving a patient] medication or a test, it’s how we think about decision-making. I think for regular people, it’s relatively new and really annoying, and exhausting.

How has the Bay Area done throughout the pandemic, in your opinion?

As I think about 2020, I saw the Bay Area as the least dysfunctional area in the country. When the issues were straightforward — we need a mask requirement, people need to take vaccines — there was almost no pushback in the Bay Area. The schools were tricky, because the issues were not at all straightforward. It’s easy to look back and criticize and say we really harmed the kids by keeping the schools closed too long. But there was no way to know that exactly in the beginning.

I look at San Francisco and see we’re not even up to 600 deaths yet in the entire city, a per capita death rate that’s about a quarter of the national rate. If the country had mirrored San Francisco and the Bay Area’s performance, there’d probably be half a million people alive today that are now dead. So I see very little to criticize, and a lot to celebrate.

Any recommendations for how to handle Thanksgiving, when people often gather with family they haven’t seen for a while?

If you are going to say, “I am not going to visit family over Thanksgiving, because it doesn’t feel safe enough,” first of all, that’s a rational thing to say. I think we’ve got to be very careful about criticizing individual decisions, when they truly are individual and they don’t harm the community. But if you really want to get together with your family and you say the conditions now are not safe enough for that, I don’t see any good reason to think that they’re going to be better by next Thanksgiving, or the Thanksgiving after that.

I’m flying to visit my 91- and 85-year-old parents in Florida. I’m going to wear an N95 [mask] on the airplane. My wife and I are vaccinated, my parents are vaccinated. I’m going to be as careful as I can be. But the idea of saying I’m not going to do this — there’s a reasonably high probability that my dad won’t be alive a year from now. This seems like too high a cost.

Maya Mirsky
Maya Mirsky

Maya Mirsky is a J. Staff Writer based in Oakland.