Republicans' New Vaccine Restrictions Codify a False Healthy/Unhealthy Dichotomy

Denying vaccine access to the "healthy" makes no sense, not least because anybody can become disabled by a single COVID infection

Trump’s FDA has recommended that going forward, COVID-19 vaccines be approved only for the elderly and so-called “vulnerable”. Those who are “healthy,” meanwhile, will not qualify for updated shots without new clinical trials to demonstrate durable efficacy at reducing infections, something that new shots may not show. Nonetheless, reducing risk of hospitalization and death is worthwhile- as is reducing the risk of Long COVID, something that those in power rarely acknowledge.

Complicating matters, the shots we refer to as boosters are in fact updated shots that reflect ongoing mutations to the virus. Vaccine makers work to match each fall’s new shots to circulating variants; the closer the strain in the vaccination to the circulating COVID variant genetically, the more effective it will be.

Viral mutation is one reason that getting updated shots is important for everyone who is medically able- not just the “vulnerable”. As COVID continues to spread far and wide with no containment strategy in place, mutation will continue to occur. Right now, we’re seeing the new variant NB.1.8.1 take off in China. Our current vaccines are formulated for the KP.2 variant (in the case of the mRNA shots) and JN.1 (in the case of Novavax). These strains were both dominant last summer, with XEC also producing a winter spike. But many people only received the initial shots, which were formulated for the original, wild-type strain.

The public largely fails to understand that having had two or three shots back in 2021 does not make them fully vaccinated. In fact, 2021 COVID vaccines are doing little to protect them in 2025. The previous vaccine formulas are no longer authorized; if you wanted to get a 2021 formula vaccine, you couldn’t, because it’s outdated. You’d get a 2024-2025 formula vaccine, and later this year, you’d hopefully get a new formula shot.

Along with the genetic mutations the virus has undergone over the past four years, our vaccines do not produce long-lasting immunity, with significant waning in efficacy shown after the three-month mark. In 2024, a research team at Emory University discovered why, finding that the mRNA vaccines “fail to generate mature and durable antibody-producing cells in the bone marrow.” Their results were published in Nature Medicine as reported in NIH Research Matters:

The scientists found that they could readily detect long-lived plasma cells that target tetanus and influenza. In contrast, while shorter-lived antibody-secreting cells specific to SARS-CoV-2 were abundant, long-lived ones were mostly absent. Even among five participants who had recent SARS-CoV-2 infections and vaccinations, long-lived plasma cells against the virus were scarce in the bone marrow samples.

This study provided an explanation for a phenomenon that had already been observed in vaccine efficacy data: rapid waning of efficacy with time. Take, for example, the VISION data looking at efficacy of the updated 2023-2024 monovalent booster, formulated for the XBB strains, collected between September 2023-March 2024. This data found that among immunocompetent adults, the booster reduced risk of both an ER visit and hospitalization by 50% at 7-60 days after vaccination. However, by 120-179 days after vaccination, or 4-6 months, risk of hospitalization was reduced only 25%, and risk of an ER visit was reduced not at all. Over the course of just a few months, vaccine protection was significantly lowered- halved, in the case of hospitalization, and wiped out in the case of needing the ER. For immunocompromised people, the numbers were, of course, worse; at 60 days, risk of hospitalization was reduced 38%. By 4-6 months, risk of hospitalization was reduced only 14%.

Being honest about both the capabilities and limitations of our current vaccines is critical for building a functional, holistic COVID response with science at its heart. If the public had been educated about the inability of our current vaccines to provide strong, lasting protection across years and variants, that would increase demand for additional interventions like clean air, sick leave, testing, and masks, as well as for research funding for next generation vaccines. It would also have increased demand for “booster” shots, rather than driving demand down. However, both parties have pushed the narrative that the pandemic is “over”, that COVID became “mild” during Omicron wave 1, and that the initial vaccine rollout “ended” the threat.

Now, Republicans are using the public’s complacency to push the few tools we have left out of reach. In fact, in FDA Commissioner Marty Makary and Center for Biologics Evaluation and Research Director Vinay Prasad’s NEJM piece arguing for the restriction of vaccines, they specifically call out Americans’ reluctance to get boosted as part of their justification for limiting access, noting, “Less than 25% of Americans received boosters each year, ranging from less than 10% of children younger than 12 years of age in the 2024–2025 season to 50% of adults over 75 years old”. Would this abject failure to boost the country have occurred if the public had been informed that their vaccines were waning significantly by the 4-6 month mark? That immunocompromised people’s protection from hospitalization at month 6 was 14%? That new variants require new vaccines?

The decision to limit access to new “boosters” is a decision to limit access to COVID vaccines, full stop. These shots don’t simply “top up” protection from shots you’ve already received; they contain protection to genetically distinct strains of the virus that your body won’t be able to easily recognize without a new vaccine.

This is a decision based, not in science, but in the false belief that the “unhealthy” are a static, unchanging group of people, and that public health is an individual choice, not a collective pursuit of government. This belief is held by both Republicans and Democrats, and has been pushed into the mainstream by most major media outlets over the last five years as widespread, repeated COVID infections were normalized.

These beliefs- that only a small population of “at risk” people need concern themselves with COVID, and that it’s not the government’s responsibility to control infectious disease- have enabled our leaders to abandon collective mitigation efforts while shredding the meager tools we did have in place early on. Not only is the public invited to believe that COVID only threatens “at risk” people, we are also encouraged to “other” and stigmatize at-risk people via mixed messaging.

Despite clear CDC guidance that many remain at elevated risk of death and poor outcomes from COVID, nobody in positions of power will wear a mask in public, creating the impression that mitigations are wrong, outlandish, and out of step with their own issued advice. This makes it impossible for most people to either identify themselves as high-risk, or to identify high-risk people as allies with aligned interests. In fact, collective public health benefits all, not only those currently in high-risk categories.

Reviewing the list of conditions that make one high-risk for poor outcomes from COVID, we all know plenty of people who fit the criteria on the list. People with asthma, diabetes, people who smoke or are pregnant, people with cancer, even people with mental health conditions like depression and people who are overweight are all included in the “high risk” category. Yet years of stigmatizing messaging about those who chose to protect themselves from COVID- that they are weak, weird, bad, and crazy- makes people in all of these groups unlikely to take individual measures to protect themselves. A perfect example is our former President Joe Biden. An 82-year-old man experiencing cognitive problems and prostate cancer, he waved a mask around jokingly when exposed to COVID. He could not conceptualize of himself as “high risk” because when “high risk” people are otherized, nobody wants to assign themselves to a stigmatized group.

When the public believes that “most” people don’t have to fear COVID, and they automatically categorize themselves as “most people,” they see no need to mitigate the out-of-control spread of the virus in public spaces; thus, the state has no need to upgrade indoor air quality, no reason to provide paid sick leave and preserve work from home, no reason to provide free masks and tests, and no reason to encourage masking and testing behaviors.

It’s certainly true that some people have more health conditions and risk factors than others. But those categories are highly porous, and people move across the border from “healthy” to “unhealthy”- and even back the other way- every day. One of the fastest ways to move between the amorphous “healthy” and “unhealthy” categories is to get infected with COVID-19 and fail to recover, a condition known as Long COVID. Vaccines cannot eliminate your chance of developing Long COVID, but they can reduce your risk. A systematic review of 12 studies published by the European Centre for Disease Prevention and Control (ECDC) found that vaccination reduced the risk of Long COVID by 27%.

Long COVID is not an uncommon outcome of a COVID infection. Estimates vary widely because “Long COVID” is an umbrella term that can comprise both severe chronic illness, and a variety of post-COVID health conditions. But a review study in the Lancet found that 45% of COVID patients had at least one unresolved symptom four months after their COVID infection. This speaks to the extraordinarily high health burden of ongoing, repeated infections. Additionally, risk of Long COVID is cumulative, meaning that every infection increases your risk of developing long-term health complications.

It should be noted COVID vaccines provide very limited protection against infection. A Journal of Infection study looking at the VE of the Comirnaty [Pfizer] XBB.1.5 vaccine found that it reduced risk of infection by 70.63% at 14 days after vaccination, but “VE declined rapidly and by approximately weeks 9–12 post vaccination, the VE point estimates were close to zero with considerable uncertainty in the estimates from day 60 onwards".

That’s why vaccines should not be the end-all be all of a robust response to COVID, but rather, part of a larger strategy that would actually blunt and significantly curtail viral waves in our communities.

This is where we get into the media’s complicity with the narrative Republicans are deploying to limit vaccine access. For years, the media has claimed that “COVID is over” for the community at large; only at-risk individuals need to prioritize measures to protect themselves. This vaccine policy simply follows that rubric. It pushes the logic that at-risk individuals (which, in reality, comprises everyone) are the only ones who are under threat from COVID, and that they can simply chose to protect themselves with their lone vaccination.

Even without the introduction of this anti-science policy, the media and the two-party embrace of the you-do-you approach to the pandemic had already decimated vaccine uptake. As of April, only 23% of adults had taken this year’s shots. That means that even without restrictions, most people had already arrived at the conclusion the Trump administration is now imposing: it’s only a problem for others, not me.

In August 2024, ABC News reported on the newly updated vaccines under the headline, “The new COVID vaccine is out. Why you might not want to rush to get it” with the subhead “Many healthy people have immunity from vaccines and previous infection.”

From the piece:

If you're in a vulnerable population and waiting to get vaccinated until closer to the holiday season, Schaffner said, it makes sense to wear a mask and avoid big crowds, and to get a test if you think you have COVID.

Throughout the last four years, reporting has imagined the so-called “vulnerable” people can somehow exist outside of the society that is freely spreading the virus they need to avoid. Simply “avoid crowds”. If you have to work in a grocery store, ride on a bus or a subway, or hey, seek treatment at an ER? Or if your spouse does? If your child attends a school, like every other child? Well, we won’t get into that. We haven’t really thought it through.

Why would ABC News advise only “vulnerable” people to test if they think they may have COVID? Who exactly does ABC News think these vulnerable people are catching COVID from in the first place?

By otherizing the “vulnerable” population, everyone is free to imagine themselves safe from the worst ravages of COVID; it isn’t me at risk, it’s those people.

Downstream of this belief are various ideas that are damaging and destroying public health: the idea that a healthy person cannot move into the category of “vulnerable”.

The idea that each person can and should make an individual risk assessment based on their individual health status, which doesn’t change and isn’t affected by those around them.

The idea that public health is something we can each do for ourselves.

The idea that none of us owe anything to one another.

The idea that if I don’t feel well, I shouldn’t take a COVID test because I’ll probably recover just fine, an idea equally at home in a Vinay Prasad blog and apparently ABC News.

This is what the new vaccine restrictions once again invite Americans to do; imagine that only some people are at risk from COVID. And if only some people are at risk from COVID, I can imagine I’m not one of them. And if I’m not one of them, I have no incentive to care about the collective project of viral mitigation and elimination. It once again reinforces the false idea that we can know who will be harmed by the virus and how.

President Biden used to assure us that “we have the tools” to fight the scourge of COVID in our communities. Over the past four years, those tools have been under constant attack from the state. Now, we face down new COVID variants with limited vaccine access, masks stigmatized and even criminalized, tests expensive and out of reach to many, remote work under attack, and paid sick leave never codified. Most critically, the conversation around upgraded indoor air quality has never meaningfully gotten underway. Until we see COVID for what it is: a public health crisis affecting us all, rather than an individual problem affecting a few, it’s certain that we’ll continue to wallow in endless waves of the virus.