There have been many developments related to the substance of two most recent Insight newsletters in the past week: one on vaccine prioritization (by age versus essential workers or a combination thereof) and another on running a trial for single-dose or spaced out booster for the mRNA vaccines.
I’ll write an update to the vaccine prioritization later (big deal). I’d first like to talk about the potential single-dose trial, especially on how it relates to domain expertise, social media and the public sphere distortions, expertise, groupthink and how institutional structures interact with all this.
Shortly after writing the Insight post, I teamed up with an immunologist to co-author a New York Times piece on advocating for a single-dose and/or delayed booster trial for the mRNA vaccines. Here’s a short excerpt from the piece:
Crucially, though, we should begin immediate single-dose trials, recruiting volunteers from low-risk populations who are first in line for the vaccinations….
Is it very risky for those volunteers? There are scientific reasons to believe that the risk is not that high. For one thing, the initial shot — the prime — is clearly providing some immunity, and even if low-risk people are exposed to the virus later on, the natural infection in them could act like the booster: bolstering their immune system even further without causing severe, or even mild, disease. The rarity of reinfections from natural infections supports that line of thinking. Second, what we know about the immune system and Phase 1 and 2 data suggests that older people’s immune systems do not respond as strongly to the single dose, which means that we should keep both this trial and the possibility of a single dose reserved for lower-risk groups: healthy people under 65 without significant multiple comorbidities. The key question we’re looking at is the durability of the immunity provided by that dose, whether it wanes over time and by how much. Immunity is not a switch that gets turned off overnight; we could monitor these volunteers monthly and stop the trial quickly if a significant uptick was detected.
The numbers need not be huge to provide us an answer. The benefit, however, is great. For one thing, we could double the number of lower-risk groups we could cover, especially essential workers who have suffered so much during this pandemic as they do not have the luxury of working from home. Second, we’d be able to roll out the vaccine much more quickly — now, the United States is planning to hold off half the doses in freezers, delaying vaccination. And a quicker rollout would help us get the pandemic under control much faster.
There were three broad reactions that I encountered in response. The first one was worries on whether this op-ed would encourage people to skip the second dose (even though the op-ed did not advocate for that at all, but it’s certainly something to consider). The second one was the idea that this might be unethical or unwise, because we had a dose schedule that had already been through trial (an important topic as well). The third category of reaction, the most interesting from a public sphere point of view, was a version of “how dare I write about this”—given, obviously, that I am not an immunologist or a vaccine expert. I will write future posts about the first two—and I believe those are very important questions—but let me say something about the third first
Of course, it’s definitely true that domain expertise really really really matters, especially for a topic like this. Which is exactly why I had co-authored with someone with excellent credentials, Michael Mina who is, among other things, an MD and a PhD and an “assistant professor in immunology and infectious diseases at the Harvard Chan School and associate medical director in clinical microbiology (molecular diagnostics) in the Department of Pathology at Brigham and Women’s Hospital, Harvard Medical School.” I had also reached out, to the best of my ability, to a range of domain experts and asked them if this was a terrible idea, even if my co-author and a few others had already thought it to be something worth trying. The response I got was not a uniform agreement that this would work (which wasn’t the claim) but certainly enough assurance that there was strong scientific merit to the suggestion. So I went ahead and co-wrote it.
On social media, where there was a wide range of responses, but a more noticeable “this has no scientific merit/how dare you as an outsider” reaction compared to when I reached out to experts within the field.
One of the reasons for this discrepancy is that, on social media, the dynamic for in-group status assertions and status competition is strong—and getting stronger for this topic as the pandemic rages on. I’m no stranger to this dynamic, as it is something that’s very common among social movements (something I’ve studied at length) and, well, pretty much any human group. Who’s in and who’s out of the group is a key force for group-based species like ours and thus “stay-in-your-lane” assertions and wagon-circling against criticisms from perceived outsiders is forceful in any human group or profession. As the pandemic progresses, and as the field feels more and more under attack (and much of it quite unfair and terrible) the dynamic strengthens, often to the detriment of the field.
However, on the other hand, of course, expertise and domain knowledge matters and there’s no doubt that the assumption that one can waltz into a topic people have put in a lifetime of work and hand-wave some solution they all missed is often not just wrong, and it can be dangerous or deadly in a pandemic.
On the other, other hand, experts are not immune from groupthink and conflating in-group signaling with protecting domain knowledge from ignorance. Outsider challenges are not always without merit, even if they are often misguided, ignorant and sometimes even downright dangerous.
One really interesting pattern in all this status-justling as well as substantive and important gatekeeping has been that sometimes, the people with the highest status—leaders in a scientific field—can be less caring of the status aspect of all this. In fact, that is one of the advantages of the academy and the process of tenure. The same dynamics that produces the occasional curmudgeon Nobel laureate in chemistry who makes ridiculously wrong claims about epidemiology produces, in my impression, an often larger number of people on top of their fields who are beyond status competition and can be bold.
For example, shortly after we wrote our piece, Keith Klugman tweeted this:
Keith Klugman is not a random person in the field. He currently heads the Pneumonia program at the Gates Foundation but he is so much more than that. Here’s a short excerpt from his bio:
Keith is a past president of the International Society of Infectious Diseases and a past chair of the International Board of the American Society for Microbiology. In 2015, he was elected to membership of the National Academy of Medicine in the United States. He has chaired or served on numerous expert committees for the World Health Organization (WHO), the Wellcome Trust, and the Centers for Disease Control and Prevention (CDC).
As an M.D. and Ph.D. specializing in infectious diseases and microbiology, Keith has made major contributions in the field of pneumococcal research, including antimicrobial resistance. His work demonstrating pneumococcal conjugate vaccine efficacy in the developing world has led to interventions that have saved millions of lives, especially in Africa. He has published more than 600 scientific papers which have been cited more than 30,000 times to date.
Klugman doesn’t have to care about the credentials of either co-author of the piece. I mean, obviously, I have none in his world, but even my very credentialed co-author is a wee baby compared to professor Klugman. But Dr. Klugman took the time to write to Michael, to thank him for the piece, and to tweet publicly in support of the idea—even more aggressively than our op-ed’s more modest suggestion to be honest. (More on that part and the ethics and considerations of it all in the future newsletter).
And as far as I can tell, there has been no response from the social media contingent who had been relatively loud against the idea early on, especially by harping on the credentials of the authors (well, lack thereof, meaning me, of course!).
Of course, I do want to emphasize, once again, lack of credentials is a concern in topics like this, and not everyone who steps over their initial lane is right or to be trusted. I am no exception, and never claimed to be. I realize the big dangers of my own approach, and talk about it openly all the time. But it’s also a pandemic, and there is need and room for a lot more challenging of the other side of the danger, the groupthink, the slowness, the institutional inertia more appropriate for times that are not a crisis period like this, with so much at stake.
All this reminded me of an interesting episode, early in my career, when I was looking for an academic job on the social impacts of technology, algorithms, platforms, business models, social movements, etc. Surprisingly, I got noticeably more interest in my ideas and more advocates for the idea of hiring me either from very top, elite schools (who didn’t care about my lack of Ivy League pedigree) or “low-status” schools—the small “directional” university somewhere, but almost nothing in the middle.
Why? The high-status schools had more people who didn’t have to care about my lack of status because they had so much to spare themselves. The low status schools had none and also had more people who could just chase ideas and people they thought interesting.
The ones in the middle, the ones trying to climb and claw their way up the pack? I think they looked at my CV and quickly realized I had no status to bring—no Ivy League degree, no top journal article, no high status anything. Never heard a peep from them. It was an eye-opening experience, one I never forgot. The top schools, I understand. Theirs is the freedom that comes from privilege. But the episode also gave me an appreciation for the ones with nothing to lose—those “directional” schools always struggling with their budget and the workload that could think outside the box, and just roll with what they hoped would be a colleague with interesting ideas. They were in many ways the outsiders, but they didn’t have as many chips on their shoulders because they weren’t playing the game in the first place. They weren’t weighed down with the status-climbing because they didn’t have a chance. They were free. In many ways, the open nature of status-climbing efforts on social media has taken away some of that freedom and reconfigured it, and how to recognize its distorting effects is worth thinking about.