To the Editor:
COVID hit the world like a tsunami. Millions were bewildered and panicked. This includes political leaders, medical professionals, and public health officials. Initial decisions were made in a fog as it was difficult to get accurate data. As time passed and more data became available, however, it was incumbent upon our leaders to make decisions that were clear-headed and that more precisely balanced the tradeoffs inherent within the extra protection needed to defend against COVID. The decision to open schools in the Fall of 2020 stands out as an example of where the costs of protection were steep while the reduction in the COVID death rate was small (as per here, here, and here). The leaders who made these decisions faced a critical response that insisted on continued closures and a significant portion of the population that was still gripped by fear. These leaders displayed courage under fire.
Other leaders and many people in the general population were so panicked that they implemented what felt like the safest option. In the process, relevant data at the time was ignored and it was nearly impossible to have a reasonable conversation. The students in those regions, like in the United States and Israel, have experienced significant learning loss.
With this in mind, it is worth reflecting on an online essay published by this esteemed journal on October 20, 2020, by Dr. Sharon Galper Grossman and Rabbi Dr. Shamai Grossman, titled “Halakha Approaches the COVID-19 Vaccine.” At first glance, it will seem strange that this Letter to the Editor responds to a three-year-old essay. But the death and illness from the COVID pandemic, as well as the consequences of the human response to it are still with us. This letter is not meant to criticize the authors. They heroically stepped into the breach to supply a bewildered community with medical information and halakhic guidance.
We need to reflect on the COVID pandemic. The passing of time and the relaxing of restrictions eases the sense of urgency and allows for a data-driven conversation and reflection on how the Orthodox Jewish community performed. We cannot turn back the clock, but we should, however, set the record straight, reflect on the advice given by public health officials, trusted institutions, and the decision-making process within the Orthodox community. This is required in order to establish trust where the public feels that it has been eroded and to have a better system and process in place for the next crisis. Both underreaction as well as overreaction can cause serious harm and need to be avoided.
Below, I will highlight what I believe to be specific shortcomings in the article:
Though specifically addressing the COVID vaccine, the essay makes important framing assumptions about the risk of COVID and the proper epidemiological response. The authors write, “while the virus is too new to allow us to quantify the true risk of infection, the fatality rates for COVID-19 in the United States and Israel are 3% and 0.6%, respectively (as of this writing).” This, however, misleads by presenting a broad statistic. In October 2020 it was documented that COVID was not considered life threatening for those who are healthy and below age 40, while being quite dangerous for the elderly and those with underlying medical conditions.
The framing of COVID’s IFR impacts a proper epidemiological response. Halakhic public policy obligates individuals to limit their autonomy to protect others. Even if an individual is not at personal risk, his or her ability to transmit the virus to those who are at risk places limits on their action. The authors therefore state that “all members of the community are obligated to be vaccinated in order to avoid infecting others, help achieve herd immunity, and ensure the safety of the community, even if their personal risk of infection is low.” This “also helps to eradicate a disease.”
Before discussing the vaccine’s efficacy, it is worth reflecting on why the authors reject “relying on the development of immunity through infection alone (the Swedish model for dealing with COVID-19) [since it] has been considered ineffective.” The article cited by the authors relies on Sweden’s higher infection rate per 100,000 residents. This would be a logical metric when using general population based IFR. Sweden, however, navigated the pandemic better than the US, UK, and EU because a better metric is using a mortality rate per 100,000. Today, Sweden’s COVID death rate is about 210 per 100,000 residents, while the United States and United Kingdom (each over 300 per 100,000), and the European Union (over 250 deaths per 100,000). At the time of the essay’s publication, the US and UK had a higher mortality rate, though the EU was lower. Other factors, and in this case an age-based IFR, would lead one to emphasize mortality rates instead of infection rates.
In fact, as more children and young adults developed COVID antibodies herd immunity would be achieved and provide greater protection for the elderly and most vulnerable. By rejecting the Swedish epidemiological response, the authors are forced to conclude that “[vaccination] is ‘how the world will be saved’ in general, and specifically from the COVID-19 pandemic.
Coming to these conclusions at the date of the essay’s publication also seems premature. The essay was published on October 20, 2020. At that time, the COVID vaccine was being tested. Pfizer-BioNTech announced their vaccine’s efficacy on November 9, 2020, and the vaccine received Emergency Use Authorization (EUA) from the Food and Drug Administration (FDA) on December 11, 2020. Moderna announced the success of its vaccine on November 16 and received its EUA from the FDA on December 18. In October 2020, there was very little publicly available data.
Dr. Galper Grossman and Rabbi Dr. Grossman came to their conclusion about the soon to be announced COVID vaccine based on statements by “Dr. Stephen Hahn, the director of the FDA, [who] has stated that the agency will approve a COVID-19 vaccine with an efficacy of 50% or greater” and similarly published material. They also presumed that data and halakhic opinions related to other vaccinations, like polio, would apply to the COVID vaccine.
Each support is lacking. It is not clear whether the “efficacy” referred to by Dr. Hahn refers to preventing severe illness or even transmission. A deeper dive into the phase III trials already in place at the time would have revealed that efficacy was being defined more narrowly than the authors understood from Dr. Hahn. In fact, two days after this essay was published, Dr. Tal Zaks, the chief medical officer of Moderna unequivocally stated, “Our trial will not demonstrate prevention of transmission because in order to do that you have to swab people twice a week for very long periods, and that becomes operationally untenable.” The FDA’s Vaccines and Related Biological Products Advisory Committee (VRBPAC) meeting on December 17, 2020 reached a similar conclusion, “Data are limited to assess the effect of the vaccine against transmission of SARS-CoV-2 from individuals who are infected despite vaccination.” The study on the Moderna vaccine’s efficacy published in the New England Journal of Medicine on December 30, 2020, measured efficacy of transmission by the presentation of symptoms, not by swabbing the participants in the study for the presence of antibodies.
One can also not compare data and halakhic rulings from other vaccines to the Pfizer and Moderna COVID vaccines, as they are qualitatively different from vaccines produced until then. The most effective vaccines, like the polio vaccine, use replicating viruses. Other vaccines, like for tetanus, use an inactivated toxin. But the Pfizer and Moderna COVID vaccines use an innovative gene technology known as mRNA or messenger RNA.
The shot reacted so differently from other vaccines that the CDC changed its definition of vaccine from “to produce immunity to a specific disease” to “to produce protection to a specific disease” (emphasis mine) so that the COVID vaccine could be included. It is widely acknowledged that the vaccine temporarily reduces symptoms but does not prevent transmission. It might minimally reduce transmission for some COVID strains for a short period of time.
Not enough scientific data in October 2020 was available to know the individual’s obligation to vaccinate based on u-shmartem meod or one’s communal obligation based on halakhic rulings from other vaccines. In determining public policy, however, the authors write that “we believe that failure to vaccinate violates the prohibition to stand idly by another’s blood” and therefore based on the rulings of certain poskim, they advocate for social pressures and exclusion being brought to bear on the non-vaccinated. Their article’s framing question addresses a hypothetical mother, Rachel, who “delayed vaccinating herself and her children because she did not want to be the first to receive a new vaccine.” The authors agree that an airline would have been correct to deny boarding to the unvaccinated. They furthermore state that schools may require COVID vaccination and exclude unvaccinated students, since “it is well established that halakha allows the excommunication of people who pose a public risk or endanger the lives of others.” That Rachel is going to see her parents who have not seen their child and grandchild for close to a year does not seem to play the determinative role in their halakhic discussion. Other mental health consequences are also not discussed.
In January 2021, a reasonable, though not only, data-driven halakhic conclusion would have been that those over 50 or those with an underlying condition would be obligated to vaccinate. Without data about the vaccinated transmitting COVID, social exclusion should not have been utilized as a consequence of non-compliance. Furthermore, our current knowledge of the COVID vaccine would seem to require an update to the essay.
An essential component of the scientific method is self-correction. As a quarterly journal of Jewish thought, TRADITION is uniquely positioned to have a higher standard for evidence and lead its community through a review about the pandemic.
Rafi Eis is the executive director at the Herzl Institute.