Reviewer:  Sandra Moss, MD

March 20, 2024

Terrors of polio summers (ask any octogenarian about the polio summers before the Salk and Sabin vaccines) and wards of Drinker respirators are today thankfully forgotten.  Vaccinated children are no longer called upon to pay the price of congenital rubella or suffer the rare but serious side effects of measles, mumps, and chicken pox.

For the past four years, the Covid pandemic has confounded the world, yet the rapid development of a successful vaccine has been a bright light to overcome the darkness of disinformation and misinformation that has clouded the public’s understanding.

Paul Offit, a Philadelphia-based pediatrician specializing in infectious diseases, renowned vaccinologist, and celebrated author, explains Covid (from the words, “Coronavirus disease”)

lucidly, scientifically, thoughtfully, and fairly.  Offit’s account, at once sophisticated and accessible, brings together heroes and villains (human as well as sub-microscopic), triumphs and tragedies, and informed speculation on an uncertain future.

The first Covid case report appeared in January 2020.  A lot has happened since then.  Offit clearly explains the protocols and frantic scientific pathways to successful vaccine trials, official approval, and distribution of a generally safe Covid vaccine, occurring within months, rather than years.  With a tip of the hat to Star Trek, the project was dubbed, “Operation Warp Speed.”

As Offit observed, “There’s no such thing as alternative medicine.  There’s only medicine that works and medicine that doesn’t.” Sometimes, for some patients, “medicine that works” doesn’t work—and some victims of Covid could not be saved, even as effective treatment strategies evolved rapidly.  Medical progress is messy, miracle drugs are selectively miraculous, physicians and scientists are often fallible and sometimes careless (and occasionally deluded), and the inevitable gadflies and rabble rousers play to an anxious and gullible crowd, to the detriment of all.  

For most of 2020, Covid ran wild, effective (or at least partially effective) therapies would not begin to appear until late autumn.  Dead ends and some sloppy science were inevitable—witness the early hydroxychloroquine fiasco, dreamt up by a rogue French researcher and demonstrated by properly conducted randomized trials to be completely useless for treatment or prevention.  By mid-June 2021, the FDA withdrew its hasty and premature support for hydroxychloroquine. 

President Trump’s grandiose and garbled pronouncements (including suggestions for bleach cocktails and research into blasts of high-dose ultraviolet light—not to mention oleandrin extract (as promoted by TV’s “My Pillow” huckster guy)—were uninformed, ineffective, and potentially toxic.

Offit clearly explains the vaccine developmental process—usually measured in years for most vaccines—as proceeding logically through successful trials, approval, and safe distribution of a Covid vaccine for general use, within months.  Americans eagerly (and impatiently) signed up on government waiting lists; some traveled across state lines to get their “shot.”  Vaccine administration sites opened in large regional facilities, with plenty of space for social distancing.

Despite pressure from Trump to release the Covid vaccine prematurely, the carefully supervised roll-out was both rapid and, with very rare exceptions, safe.  The vaccines, produced with rigorous FDA oversight by three pharmaceutical companies, proved to be ninety-five percent effective.

Although rare, but serious, vaccine side effects inevitably occurred, the epidemic was made much more severe by the irrational actions of anti-vaxxers and those refusing to follow simple public health measures, such as masking.  As Covid spread, the anti-vaxxers were reenergized.  Accordingly, the United States soon fell behind other countries in Covid vaccination rates with a predictable uptick in Covid deaths.  As Offit observed, “public health had morphed into private decisions.”

Among the leading anti-vaxxers was Robert F. Kennedy, Jr., an attorney with a bully pulpit and instant name recognition.  At the Lincoln Memorial (where better?), Kennedy deceitfully warned an adoring crowd that the Covid vaccine was potentially lethal in one of five recipients.  Robert Malone, once a brilliant scientist whose research contributed to the early stages of general vaccine development, would turn to the dark side, ranting about violations of the Nuremberg code and the inevitable criminalization of the scientists and clinicians whose vaccines were nevertheless saving countless lives.  In Offit’s analysis, Malone and other irresponsible anti-vaxxers were credited for what amounted to a brutal epidemic of needless deaths.

Who were these vaccine rejectors?  Many clung to Trump, the political spilling over into the scientific.  Others were members of insular religious communities (a New Jersey enclave of ultraorthodox Jews paid a heavy price) or ardent followers of charismatic self-promoters.  Nutty conspiracy theorists flourished.  Some crusading anti-vaxxers turned to violence against health care workers.  Others faked vaccination certificates.  Not surprisingly, while highly vaccinated communities had, in general, much lower rates of Covid deaths, this fact eluded the anti-vaxxers.  And Offit is also mindful of those Americans who, for a variety of reasons, including poverty and isolation, lacked timely information, nearby medical facilities, or access to trusted health professionals.  

Workplace vaccine mandates proved to be another sore point.  Some states extended benefits to workers who were fired, or quit, due to their employers’ vaccine requirement.  Deaths of prominent anti-vaxxers had no apparent effect on vaccine critics.  Some health care workers were targeted by rabid anti-vaxxers, while others blithely provided fake documentation of vaccination for presentation to employers.

Happily, some Americans took a positive and constructive stance.  Ala Stanford, a determined young black pediatric surgeon, took her team, her mobile van, and her clear and patient vaccine message to underserved Philadelphia communities of color.  Ultimately, Stanford’s team vaccinated some 50,000 residents.  

A chapter titled, “Booster Confusion” might have been subtitled, “Viruses are just so darn smart.”  Predictably, the vaccines, while preventing much illness and death, were not perfect.  Even as the Covid vaccines and drug regimens were saving lives, there was confusion about vaccine booster protocols.  Factors such as severity of symptoms and, most importantly, disease-specific incubation periods, figured into the calculus of Covid’s clinical trajectory and booster efficacy.  

Viral shapeshifting added to the complexities.  Variants, identified by Greek letters, threatened to stretch from alpha to omega.  And the American presidency shapeshifted, too, as Trump, and then President Biden, attempted to lead with their wildly different strategies, styles, and coherency.  Both presidents contracted the disease—one early and serious, and the other later and mild.

Offit turns to treatment strategies, directed initially at the virus and later at the induced effects on the immune system.  Military metaphors have often been utilized in the world of infectious diseases.  Covid is no exception, as armies of scientists, clinicians, and assorted gadflies went to war with Covid and each other.  Some early medication strategies (steroids, hydroxychloroquine, ivermectin, and familiar antibiotics) proved useless, though we can sympathize with the despair of waves of frontline physicians plunged into a nightmare medieval scenario with no proven pharmaceutical options.  By late 2022, however, effective antivirals were saving many.  Monoclonal antibodies battled with some success against the shapeshifting virus.  

Apparent recovery from the ravages of Covid, in both adults and children, was gratifying—until “long Covid” (multisystem inflammatory syndrome) struck a cruel blow.  Was it a new attack by quiescent reservoirs of SARS?  An immune system storm?  A form of small vessel vasculitis; an unidentified submicroscopic predator?  All or some of the above?  One thing is certain: it isn’t “just” malingering or depression.  These clouds will take some time to clear. 

Offit considers the possible future of Covid vaccines, including such factors as duration of efficacy, addressing variant strains, and alternative modes of administration.

The final chapters lay out the status of Covid today: lessons learned (or not), the status of testing and masking, and possible novel vaccine strategies.  Medically sound, but noisily contested, public health measures, such as mandatory vaccines for school students raise issues of Constitutionality and the ever-looming parental rights objections.  Is there a Constitutional right to endanger one’s children and their classmates?  In Offit’s view, “It’s a dangerous game to play.” 

Finally, what do we make of Offit’s book title—Tell Me When It’s Over?  The answer lies in one of New York Yankees catcher Yogi Berra’s brilliant philosophical insights, “It ain’t over ‘til it’s over.”  But, whether epidemics of Covid or other yet unknown microscopic or submicroscopic shapeshifters, “it” will never really be “over”—it will just have a different name or number and it may well be much worse.  And, to continue flogging the baseball metaphor, the next global pandemic is likely to appear straight “out of left field.”

With dedicated physicians and researchers and spokespersons like Offit, the home team has a good chance to win the pennant, and maybe the World Series.  And the children Offit and his fellow pediatricians care for will live and thrive, as will their parents and grandparents.  At least that’s the dream.  “Play ball!”

Editor’s Note:

Dr. Moss here provides an appealing review of an important new book that sets the story straight about the Covid pandemic.  Dr. Offit’s book is noteworthy for its incisiveness, credibility, and clarity of expression.  To paraphrase the eminent Yogi Berra: “Ninety percent of Dr. Moss’ review is descriptive; the other half is fun to read!”