The Two Rituals

What Leviticus knows about COVID, Fauci, and measles in Lancaster County

When I lecture or write about infectious disease and the policy questions they raise, I often try and find historical references or precedents to broaden understanding of the concept. In a few lectures I use the bible, particularly the book of Leviticus (I was a token atheist at a K-8 Catholic school, so I have some standing). Leviticus 13 is particularly important for these purposes as it contains directives for dealing with a “defiling” skin disease (sometimes thought to be leprosy). In such cases, the priest is to examine individuals and isolate them for 7 days after which a re-examination is warranted and there are secondary steps to take enumerated for various reasons. It seems, to me, to be a laborious process but one that is premised on asking questions, observations, and attempting to discern what the condition is and what contagiousness level it represents, if any.

Contrast this to Leviticus 16, in which Aaron performs the annual rite of atonement for the people. He takes two goats and casts lots over them. One is sacrificed. Over the head of the other he lays both hands and confesses the sins of the whole population, transferring them onto the animal, which is then driven into the wilderness. Importantly, that goat is chosen by lot — there’s no examination or observation akin to the process of Leviticus 13. It is chosen by availability and chance, not deliberation.

These are, on their face, two different problems. Leviticus 13 concerns an affliction of the body. Leviticus 16 concerns transgression against a deity. But both are impurity, both threaten the population, and both are the same leader’s responsibility. What Leviticus offers is not a theory of disease but a system for handling contamination — and that system has exactly two operations. Examine the afflicted, at length, and reach a determination about what they actually have. Or gather the pollution onto a designated carrier — a scapegoat — and drive it out. The second method is fast and requires no real objectivity.

This biblical context has been active in my mind for some reason (I blame the nuns) as I think about the controversies that have engulfed the field of infectious disease since the COVID-19 pandemic. What we witnessed — what we are still witnessing — is a society that increasingly cannot perform the first ritual, and reflexively performs the second. The examination is laborious and yields answers that differ from person to person, satisfying no faction. The goat is fast and yields unanimity. When the pandemic demanded an examination, one camp inflated every danger and another denied them, and when it ended neither camp reckoned with what it had gotten wrong. Both went looking for a carrier instead. The carriers have accumulated. First the officials, then the agencies, then the countermeasures themselves, and now the discipline as such — the proposition that infectious disease medicine is a body of knowledge rather than an instrument of control.

Four Questions

When any infectious disease emergency, outbreak, or issue arises that becomes a subject for government in the form of health departments or more there are four questions (among many others) that arise. For this piece, I am going to use these four to frame the discussion.

1. How dangerous is the disease (does it cause death, hospitalization, healthcare utilization?) and to whom?

2. How well do the medical countermeasures (treatments, vaccines, post-exposure prophylaxis) work, if any are available? And for whom?

3. What does the medical countermeasure strategy cost?

4. What is the cost of inaction?

The answers to these questions are not going to be one-size-fits-all but stratified. For example, a measles outbreak poses a wholly different threat to a newborn too young to be vaccinated versus a 40-year-old who has had 2 doses of the MMR. What does a school closure policy cost a tenured college professor vs. a single mother? This distribution of answers is why policy is complicated and why adept, principled thinkers could conclude a unified policy isn’t possible and that a stratified policy is best.

The last question — the cost of inaction — is one that is frequently skipped. For example, while it is easy to find people warning of the alleged danger of the use of genetically modified mosquitoes to combat malaria, how many times is there active discussion of the risks and costs of not doing it? The quantification of a counterfactual is difficult but is a mark of a thorough analysis.

The errors run in a direction, and often the direction is set by the conclusion someone seeks. Deny the danger and you don’t have to act. Inflate it and you never have to stop. This is the same failure with different destinations. Every factor gets pushed whichever way protects a conclusion already reached.

I argued in The Hill in December of 2021 that abstinence-only messaging had crowded out harm reduction, and that the abandoned middle was where the honest answers were. 

An examination that produces nuance or different answers for different persons is unusable to anyone who needs a mandate or a grievance. So, both groups skipped it, and both summoned Leviticus’ goat.

The Emergency That Cannot End

In 2022 I published an essay in Areo arguing that the pandemic’s end would be settled by a moral question rather than a virological one. The position I was arguing against held that the emergency could not be declared over while anyone remained vulnerable. Commentators called the CDC’s revised isolation guidance grotesque; the immunocompromised were defined as the population whose existence should govern everyone else’s behavior. The premise was that a countermeasure which leaves anyone at residual risk has not done enough, and that until it does, the restrictions should stay.

It is true that in the pre-vaccine period, SARS-CoV-2 was dangerous enough that ordinary implied consent did not cover it. Temporary, metric-directed measures aimed at protecting hospital capacity were justified after the government squandered 2 ½ months doing nothing except the wrong things.

But run this position through the four questions and the failures are systematic. Question one is inflated and, more importantly, frozen — the disease was treated as equally dangerous to everyone, forever, as though a 30-year-old with three doses and hybrid immunity occupies the same position as an unvaccinated transplant recipient in 2020. Question two is where the real damage happens. Vaccines worked. Antivirals worked. Home tests worked. Monoclonal antibodies worked. Those who will not let countermeasures change their conclusion have stopped examining anything, because the entire purpose of a countermeasure is to alter the calculus. Question four went largely unasked by this group.

The refusal to consider risk stratification, risk calculation, and harm reduction was a failure. The honest answer to COVID-19 would produce different guidance for different people — and different guidance is unusable to anyone who needs a universal rule. The immunocompromised patient deserved a real conversation about their specific residual risk and the additional tools available to them. What they got instead was conscription into an argument about everyone else’s behavior.

The Emergency That Never Was

The mirror image runs the other way. The disease is no worse than the flu. The vaccine does not work, or works so briefly it doesn’t count. The vaccine’s harms are catastrophic and concealed. And doing nothing costs nothing at all.

This is not inquiry, which would be welcome. What happened instead was that every one of the four questions above was answered in advance by a conclusion already held, and the answers moved as needed to protect it.

The vaccine-risk claims should be considered seriously. Myocarditis after mRNA vaccination in young males was a real but rare phenomenon. The Cutter incident was real. The 1976 swine flu GBS signal was real. What makes the modern claim insidious is decoupling — an adverse event severed from its magnitude, from its base rate, and from question four. Myocarditis is more common after COVID infection than after vaccination. Guillain-Barré is more common after influenza than after influenza vaccine. The events are real; the ledger is invalidated by leaving the other columns blank.

And this pattern predates COVID entirely. Wakefield published in 1998. The MMR panic ran its full course — inflated countermeasure risk, denied disease risk, uncounted cost of inaction — twenty-two years before anyone closed a school. All that transpired in 2020 did not create this. It just changed who held the position.

There is something else that has never been adequately explained.

In March and April of 2020, nineteen of the twenty-six Republican governors issued stay-at-home orders. Ron DeSantis signed Florida’s on April 1st and the state did not fully reopen until September 25th. Two weeks before he signed it, the White House task force had told governors that in states with evidence of community transmission, schools should close, and so should bars, restaurants, food courts, and gyms. His own campaign book barely acknowledges that he was the one who signed the order. The President whose task force issued that guidance later ran advertisements against the tyranny it produced. Greg Abbott told Texans that together they would heal their state. Kay Ivey brought a preacher to the podium. President Trump criticized Governor Kemp for reopening his state earlier than he wanted him to.

None of this is contested. It is all on the record, in their own words, in their own orders.

Then it vanished. Not repudiated, not defended, not explained — simply removed from the account. The men who had signed the orders then became the leading voices arguing that the emergency had been a fabrication from the beginning.

That requires an explanation.

Why It Worked

The explanation is not that they were lying. It is that they were shamed, and the shame worked because they shared the premise of the people shaming them.

That premise is close to universal and rarely stated: you answer for deaths traceable to your decision, and you do not answer for harms nobody can trace to you. It fails under one specific condition — when the untraceable harms are as large as the traceable ones. March 2020 was that condition, in its most extreme form. Deaths from acting too little would be counted, dated, photographed, and attributed to a named person. Harms from acting too much — the closed business, the missed screening, the interrupted childhood — were diffuse, delayed, statistical, and belonged to no one.

This is why the Imperial College model mattered so much more than its assumptions warranted. It converted future statistical deaths into a specific number that could be assigned, in advance, to whichever official failed to act. And it is why “if it saves just one life” became an unanswerable argument. Consider two sentences a governor might have said that spring:

I closed the schools to save lives.

I kept the schools open because closing them would cause greater harm.

Both are empirical claims. Both could be checked. Only one could be said aloud. The difference is only the first is framed as costing the speaker something.

What that asymmetry reveals is a moral standard operating underneath the policy argument, one that measures an act’s goodness by what it costs the actor rather than by what it accomplishes. Acting to protect what you value is one thing. Treating the cost to yourself as the thing that makes the act right is another, and the second is what made the argument unwinnable.

Blame asymmetry helps explain why politicians feared the visible consequences of underreacting, but it does not explain why bearing personal or societal costs came to serve as evidence of moral seriousness. That requires a deeper moral premise: that sacrifice itself confers moral credit, regardless of whether the sacrifice actually improves the outcome. Philosopher Benjamin Bayer of the Ayn Rand Institute has developed this in detail. Under a standard that equates virtue with sacrifice, risk stratification cannot even be proposed. A recommendation with no sacrifice in it offers nothing to be credited and does not register as a moral position at all.

The governors accepted a bill they could not pay, using a premise they could not repudiate. There is only one exit from that position: deny the deaths were ever coming. Which requires denying the danger. Which requires denying the science that established it.

The conspiracy theories, which partly represent a reversion to some pre-modern credulity in which disease and a lower standard of living are embraced, are actually load-bearing.

The evidence for this is documentary. The campaign book that omits its author’s own order, the advertisement that campaigns against its author’s own guidance. People do not delete what they are not ashamed of.

Custody of the Victim

I have written elsewhere about where the anti-vaccine movement’s epistemology came from — the postmodern critique of scientific authority, the flattening of expertise, the treatment of consensus as a species of power. That genealogy explains how people acquired the confidence to disbelieve expert claims. It does not explain why vaccines became the object. Nobody organizes against statins. Nobody holds rallies about dialysis.

The answer, I think, is that vaccination is the one medical intervention routinely justified to the patient as an obligation to other people. Get it to protect the immunocompromised. Get it for your grandmother. Get it for herd immunity. Every other intervention in medicine is offered on the grounds that it will help you. This one, uniquely, is pitched as something you owe.

That framing is well-intentioned and largely true. It is also precisely what made vaccination available to a critique about bodies being conscripted for collective ends. When a field argues its case in the language of what you owe the collective, it should not be surprised when someone predisposed to see medicine as social control finds the evidence in its own words. And there is a second cost: by making the case in terms of what you owe others, public health left the benefit to you underemphasized for decades.

The obvious inference is wrong. It is tempting to read the anti-vaccine movement as resisting a demand for sacrifice — as a kind of frustrated individualism. It is nothing of the sort. The thinkers it borrowed from were never opposed to sacrifice; they objected to who was benefiting from it. And the movement itself is relentlessly, conspicuously altruistic. They say they are protecting children. They say they are defending the injured. They are bringing pharma and biotech to heel. They describe careers ruined and reputations destroyed in service of a warning nobody wants to hear. Robert F. Kennedy Jr.’s entire public posture is martyrdom on behalf of harmed kids.

The standard is fully intact. Only the beneficiary has moved.

Which is why the argument cannot be settled with evidence. Both sides agree that moral authority comes from bearing a cost on behalf of a victim. The dispute is over custody of the victim.

The Goat

A ritual has an advantage no examination can offer: it settles the account without itemizing it.

If one man deceived the country into lockdowns, then nothing requires assessment. Not the nineteen governors. Not President Trump. Not the question of what you yourself believed in April of 2020, or why. The sins were real and they were collectively owned — that is what makes the ritual work. There is nothing to transfer if nobody did anything.

I said in July, after the Senate hearing, that the proceeding was performative — that it was not a venue for examining pandemic policy but an occasion for scapegoating Anthony Fauci for failures that were never his alone.

Scapegoating is not the same as criticism, and I have done the second. I objected publicly when the CDC reversed its masking guidance for vaccinated people on the basis of the Provincetown outbreak, because the data did not support the reversal and the reversal cost the agency credibility it could not spare. I objected when the eight-month booster interval was announced from the White House podium before the advisory committee had met, because the sequence inverted the process that gives such recommendations their authority. Those were criticisms of specific decisions, made on specific grounds, and each could have been answered.The difference is that criticism is an examination. It has to identify what was done, on what evidence, and what should have been done instead. It can be wrong. It can be rebutted. It produces findings about particular decisions. It produces exactly the kind of differentiated, unsatisfying answer that the first ritual always produces.

The goat is chosen by lot. Nothing about it is examined, because examination is not the point — the point is that the pollution leaves with it, and everyone else goes home clean.

The Carrier Keeps Growing

The trouble with expulsion is that it doesn’t work. Leviticus prescribes the rite annually for a reason — the sins come back. Infectious diseases keep arriving, which means a larger carrier is required each time.

So, the carrier has grown. First the officials. Then the agencies that employed them. Then the countermeasures themselves — not this vaccine or that recommendation, but vaccination as a category. And now, increasingly, the discipline: the proposition that infectious disease medicine is a body of knowledge rather than an instrument for managing populations.

This last step is different in kind. Someone who disputes a myocarditis rate is working inside the field. They have accepted that the question has an answer and that evidence bears on it, and they can be met with evidence. Someone who understands infectious disease medicine as a control narrative has not made a claim about any finding. They have rejected the field’s standing to produce findings. You cannot answer that with data.

The position did not arrive from nowhere. Public health supplied a great deal of the material. The CDC’s remit expanded well past communicable disease control. Population health was elevated over individual health as a matter of doctrine. Emergency authority was sometimes used to move policy that had nothing to do with the emergency. I have been making this argument for years, and I was making it before it became useful to people I disagree with. A field that claims authority over everything begins to look like the thing it now stands accused of being.

The overreach is real. The conclusion drawn from it is not. Those two ideas have to be held at once even though almost nobody is willing to.

Lancaster County

Measles is where the argument runs out of alibis.

There is no novel pathogen here. No emergency authority, no modeling uncertainty, no evolving guidance. The vaccine is sixty years old. The disease was eliminated from this country in 2000. A generation of American physicians completed training without seeing a case. Whatever one believes about 2020 — about the closures, the mandates, the officials, the reversals — none of it is in play. There is nothing here to resist.

Run those four questions and the answers are not close. The disease is dangerous, and dangerous in a way that is well characterized and stratified by age and immune status. The countermeasure works, with sixty years of evidence behind it. Its costs are small, known, and quantified. And the cost of inaction is being paid right now, in Pennsylvania, by children.

This is what tells you the accusation was never really about any particular policy. The ritual has outlived the thing it was performed over. It was supposed to be about lockdowns, about mandates, about a government that overreached in a genuine emergency. Those are arguments worth having, and I have engaged in them. But the goat is still being sent out, and there is no emergency left to justify it — only a vaccine that has worked since before most of the people refusing it were born.

Clean and Unclean

The priest in Leviticus 13 examines a spot on the skin. He waits seven days. He looks again.

The procedure, in this context, was right. Observe. Wait. Observe again. Reach a determination about this case and be willing for the determination to differ from the last one. Three thousand years later we have better instruments and the same procedure, and the procedure is what matters. It is the only method anyone has ever found for telling what is actually there. Despite its biblical provenance, it is an ancestor of the scientific method.

What it will never do is produce unanimity. It yields answers that differ by person and by circumstance, satisfying no faction and vindicating no side. That is not a defect in the method.

The other ritual asks nothing. It requires no findings, no waiting, no revision. It is available at all times, to anyone, and it feels like justice.

Consider what you lose when you decide the method is corrupt. You do not lose an official, or an agency, or a set of recommendations you disliked. You lose the examination itself. There is no one left with standing or a method to say what is clean and what is not — and the spot on the skin is still there.

Died Of, Died With, Died in a Vacuum

Pennsylvania had a hard 48 hours to communicate and chose the hardest possible way to do it.

On Tuesday, the Governor of Pennsylvania, Josh Shapiro, stood in a hospital in Lancaster County and said two measles deaths were completely preventable.

On Tuesday, the Pennsylvania Department of Health called those same two deaths "measles-associated."

On Tuesday, the Lancaster County Coroner, Dr. Stephen Diamantoni, said no measles deaths had been handled by his office.

Those statements are not consistent. If the deaths were “measles-associated” rather than measles-caused, the governor’s is not easily defensible. Assembled without a bridge between them, they are a weapon, and by Wednesday afternoon RFK Jr, the Secretary of Health and Human Services of the United States, was suggesting the deaths might have been fabricated.

That escalation was not inevitable. It was manufactured out of an information vacuum that the Commonwealth created and then declined to fill.

Where the outbreak actually is

Pennsylvania has 424 confirmed measles cases this year, 94 of them diagnosed in the past week. Seventy-three people have been hospitalized. Roughly half the cases are in Lancaster County, where kindergarten MMR coverage has fallen from 95.5 percent in 2017 to 87.6 percent in the last school year. These are the first measles deaths in Pennsylvania in thirty-five years and the first reported in the United States this year.

The outbreak is also no longer a southeastern Pennsylvania story. Jefferson County has become a second hotspot in the western part of the state and accounted for at least one of the cases diagnosed in Pittsburgh. There are cases in over two dozen of Pennsylvania’s counties, including in Butler County, where I grew up, and where kindergarten coverage sits at 93.1 percent — respectable, still short of the 95 percent that reliably stops transmission of a virus this contagious.

That is the operational picture. Almost none of the last forty-eight hours has been spent on it.

The newborn

The Lancaster County Coroner has said his office is investigating the death of a newborn who tested positive for measles and died of a splenic laceration. He has said the cause of death was not measles. Postmortem testing showed measles antibodies.

Here is what nobody arguing about this on X is doing: asking the right question.

A splenic rupture or laceration is a mechanical event. The capsule tears and the infant bleeds. Measles does not rupture a spleen. What measles might do — the literature on this is sparse — is produce splenomegaly, and an enlarged spleen is considerably more fragile under the mechanical stress of delivery than a normal one. So, the question is not "measles or rupture." The question is whether measles had any role in enlarging this spleen enough that an otherwise survivable delivery inflicted a lethal splenic laceration.

Answering it requires an actual workup which would include, at bare minimum:

·      Revealing whether the antibodies found in the infant were IgG antibodies transferred from the mother trans-placenta or evidence of new infection (IgM)?

·      Was PCR testing done?

·      Maternal serology, vaccination status, and if there was a maternal rash

The state announced a conclusion in language that declined to conclude anything. The coroner, more carefully, offered a cause of death while the investigation that would establish it was still open — and that determination traveled far faster and far further than the caveats attached to it. Neither office got ahead of the science. Both got ahead of the public’s ability to interpret them.

"Measles-associated" is correct, and it was a catastrophe

The Department of Health uses "measles-associated" when laboratory or epidemiologic evidence of measles is present but the medical certifier or coroner has not determined measles to be the immediate cause of death. That is the right epidemiologic category before a causal workup is complete. It is honest uncertainty, properly labeled.

The failure is that a hedge and a certainty were deployed by the same administration inside twenty-four hours. You cannot say "we are not yet asserting causation" through your health department and "completely preventable" through your governor and expect anyone to read the pair as coherent. Pick one and hold it. Either you believe measles caused these deaths and you show your evidence, or you do not yet know and you publish the timeline on which you will.

Pennsylvania did neither, and got the worst of both.

Confidentiality was a choice, not a wall

The Department declined to release any detail that could identify the decedents, citing privacy as a core responsibility. Age, location, clinical course, community affiliation — all withheld.

Pennsylvania's confidentiality provision for communicable disease case reports is 28 Pa. Code § 27.5a. The section does make case reports confidential. It also contains an express exception: disclosure is permitted when necessary to carry out a purpose of the Disease Prevention and Control Law of 1955, as determined by the Department. Preventing further deaths during an active, accelerating outbreak sits about as squarely inside the purpose of a disease control statute as anything can.

And confidentiality was never the binding constraint anyway, because there is an enormous space of disclosure that identifies no one in a county of half a million people:

·      Age band

·      Vaccination status of the decedent, and of the mother where relevant

·      Whether hospitalized, and the clinical course

·      The specific complication

·      Whether measles is expected to appear on the death certificate

·      The date by which a final determination will be made and announced

None of that is a name. None of that is an address. The Commonwealth chose the narrowest available reading of an exception it was legally free to read generously, and then appeared surprised when the silence filled with something considerably worse than the truth.

 What the vacuum is for

The anti-vaccine movement does not need to win an argument. It needs a gap.

And it did not need to invent anything here, because the frame was pre-built. "Died OF versus died WITH" is not a new argument about measles. It is the COVID death-certificate template, recycled intact, down to the capitalization. Lancaster County commissioner Josh Parsons deployed it on X within hours. The movement had the artifact ready and waiting; Pennsylvania supplied the occasion.

This is why institutional silence functions as an accelerant. To an already skeptical public, a health department that will not answer an answerable question does not read as careful. It reads as concealing something — which is precisely the story that has been told about public health institutions for two hundred years, and the single most durable asset the movement owns.

None of which excuses what came next. When the sitting Secretary of Health and Human Services says on national television that no measles deaths can be found in Lancaster County and floats the possibility that a state fabricated them, that is not a fringe rumor on a forum. That is the most powerful health official in the country lending an official seal to a counter-narrative, about children, during an outbreak his own department is nominally helping to contain. He owns that. He also did it into a vacuum he did not have to create, because Harrisburg built it for him.

The trap

Not all deaths in Pennsylvania are referred to a coroner or medical examiner, and Dr. Diamantoni might not yet have had situational awareness. He offered several ordinary explanations for the gap between his numbers and the state’s: his office may simply not have received the information yet, or a severely ill patient may have been treated at a specialized facility outside Lancaster County, in which case that county’s coroner would handle the death. Asked directly whether the discrepancy was a matter of state classification, he said he couldn’t speak to what the Governor or the state would decide.

The coroner was describing his office's formal case log. The Governor was describing the outbreak's toll. Two officials, two data systems, two different questions, both answered accurately, and nobody behind a podium in the Commonwealth stood up and explained why both could be true at once until the contradiction had already hardened into evidence of a cover-up.

A press operation's entire job in an outbreak is to make sure that gap never becomes visible. This one made it the story.

If I were teaching public health communication, I would use this week as the case study in how not to do it. It is an unforced error, and it is much better to be transparent than to spend the week trying to score points against Robert F. Kennedy Jr.

My stake in this is not abstract. I am an infectious disease, emergency medicine, and critical care physician who takes care of patients in Pittsburgh and Butler County hospitals, and I spend a large part of every week explaining this virus — to reporters, to audiences, and to people who are not ideologues but are genuinely unsure what to believe. This week made every part of that job harder. The anti-vaccine movement is emboldened, and it did not have to earn it. Pennsylvania’s health officials now look to a substantial portion of the public like people who were being either dishonest or manipulative, which is corrosive in a way that outlasts this outbreak by years. And the person who was merely hesitant last month has now watched a governor, a coroner, and the Secretary of Health and Human Services contradict each other about whether two people died, which is precisely the kind of spectacle that converts hesitancy into conviction. That conviction does not stay in the exam room. It becomes unvaccinated kindergarteners, and unvaccinated kindergarteners become measles cases, and measles cases eventually become the thing everyone this week has been arguing about whether we actually had.

What Harrisburg should do tomorrow

1. One statement, three signatures: DOH, the Lancaster County Coroner, and the Governor's office jointly, explicitly reconciling "measles-associated" with "no measles deaths handled by our office," and stating plainly why both are true.

2. Release the non-identifying clinical details on both deaths now — including everything in the list above regarding the infant death. It identifies no one and it ends the speculation.

3. Publish the investigation timeline: Which tests are running — genotyping, IgM/IgG serology, histopathology — and the date a determination will be announced. Give the vacuum a stated expiration.

4. Rebut "fabricated" with evidence, not with adjectives. Lab confirmations, genotype, epidemiologic linkage, and an invitation to independent verification. Calling something a conspiracy theory and stopping there is not a rebuttal; it is a press release.

5. Get ahead of the next data point rather than answering it a news cycle too late.

This is an operational response, not a political one. It needs politics removed from it — from both parties — so that public health workers and infectious disease physicians can get control of an outbreak that is still growing.

Decreasing the susceptible pool is more important than who wins

Vaccine exemptions in Pennsylvania have tripled. School is starting right now, which means the densest mixing of the age group most likely to be under-vaccinated is about to occur in all 67 counties simultaneously.

The virus does not care whether the Governor or RFK Jr. wins the argument. It does not wait for a coroner's report. All it requires is susceptible hosts sharing air, and there are more susceptible people in the United States right now than at any point in the modern era.

Every week spent on political oxygen instead of vaccination appointments leaves that pool exactly the size it is today. The biology is indifferent to all of it, and the biology is the only thing here that gets a vote.

Rented Immunity

What the Marketing of “Vaccine Alternatives” Reveals

In August 2021 — several months after COVID vaccines became available — Florida ran an experiment nobody quite recognized as one. Governor Ron DeSantis opened the first state-run monoclonal antibody sites in the country, pushing Regeneron's antibody cocktail through drive-through clinics and stadium parking lots. By the time the last site opened, Florida had administered more than 130,000 monoclonal treatments, and DeSantis was touring hospitals crediting the antibodies with significant drops in new admissions. This was the same governor fighting vaccine mandates and vaccine passports in court. The message, unstated but unmistakable, was that the antibody was the acceptable form of pharmaceutical intervention and the vaccine was not.

Then, on January 24, 2022, the FDA revoked the emergency authorizations for REGEN-COV and Eli Lilly's bamlanivimab-etesevimab. Omicron had mutated the spike protein enough that both drugs lost clinical value. They still bound the old virus and no longer touched the one circulating. Every Florida monoclonal site went dark. DeSantis called the decision reckless and said the FDA had acted "without a shred of clinical data," and threatened to sue.

While the FDA officially revoked those authorizations it was Omicron that rendered those monoclonal antibodies obsolete. The vaccines, meanwhile, built through a different mechanism — a broad, evolving immune response with T cells and memory B cells, not a single locked-in antibody shape — kept doing what they'd been doing all along: keeping vaccinated people out of the hospital, even against omicron, even without an update. That's the whole story of monoclonal antibodies versus vaccines compressed into one news cycle, and almost nobody draws the right lesson from it.

The lesson matters now because the same dynamic is back, dressed differently — and this time it isn't a governor improvising. It is federal policy.

Most of the current wave of drug-based prevention is a genuine advance and the products are true values. XOCOVA (ensitrelvir), which I've consulted on for its maker Shionogi, is the first drug approved specifically for post-exposure prevention of COVID — take it within 72 hours of a known exposure and trials showed a 67% reduction in symptomatic infection. That's a real tool for a real window: the days between exposure and infection when vaccination, already administered or not, can't retroactively do anything. DoxyPEP — a dose of doxycycline after sex — is now genuine standard of care for preventing bacterial STIs in high-risk populations, though it's a strategy that consumes its own advantage: gonococcal resistance to tetracycline is climbing as uptake rises, with models projecting meaningful efficacy loss within five to twelve years. And lenacapavir as HIV pre-exposure prophylaxis is close to invaluable, because after forty years of trying, there is still no HIV vaccine. Nobody markets doxyPEP as a substitute for a syphilis vaccine, because there is no syphilis vaccine and post-exposure prophylaxis was never trying to do a vaccine's job in the first place. Similarly, travelers have taken malaria chemoprophylaxis for generations; nobody called it a vaccine alternative, because no malaria vaccine existed for it to replace. These tools fill actual voids.

The distinguishing question isn't whether something comes from a needle or a pill or an IV bag. It's whether the product is filling a genuine immunological gap — a hole no vaccine can plug — or an ideological one, giving people a way to look like they're doing something about a preventable disease without doing the one thing that actually prevents it durably.

What's changed is that the federal government is now working both sides of that question at once.

BARDA's mRNA vaccine portfolio, roughly half a billion dollars of it, was cancelled outright; ARPA-H's own chief data officer resigned over the decision. Several vaccines were struck from the CDC's childhood recommendation list. An executive order took aim at MMR. Whatever one thinks of any individual decision, the aggregate effect is not in dispute: a population now exists that wants protection against infectious disease and either cannot get vaccinated or has been told by its own government that it probably shouldn't bother.

That population is not a clinical category. It is a market. And the same government that manufactured it is now funding the supply.

Consider the current director of ARPA-H.

Alicia Jackson, sworn in last October after six years at DARPA, told Fierce Biotech in January that her agency can help make the vaccine controversy a thing of the past — by rendering vaccines obsolete. "It's funny how we always talk about vaccines," she said. "There's actually a multitude of other technologies that you can use to protect people against infectious disease." Her agency has put up to $30 million behind an antibody-generating AI platform at Vanderbilt, part of a broader $204 million effort.

Read as pure biotechnology optimism, none of that is remarkable. Monoclonals are a marvel, longer-acting antibodies are a worthy research goal. Read in context — an administration that has spent a year denigrating vaccines and dismantling the infrastructure that produces them — it is something else. It reframes vaccines as one option among many for which there are alternatives, rather than the platform every other option is usually a narrower complement to. When a private company says that, it's marketing. When the federal research agency says it, it's industrial policy.

Anna Durbin, who directs the Johns Hopkins Center for Immunization Research, put it plainly in the same article: monoclonals have a role, especially for people who cannot receive vaccinations, but they don't trigger immune memory the way vaccines do, so they must be given again and again and again, each time you want protection. For flu, where we vaccinate annually anyway, an antibody may be fine. For measles, mumps, rubella, varicella, polio, vaccination provides long-lived protection that monoclonal antibodies cannot. They are given by infusion. They cost far more.

Add to that what Florida already demonstrated: Evusheld, a pre-exposure monoclonal antibody for the immunocompromised who have suboptimal vaccine responses, was withdrawn in January 2023 when omicron subvariants mutated past its binding site — the exact mechanism that killed the Regeneron and Lilly drugs a year earlier. AstraZeneca's successor, sipavibart, was discontinued after resistance emerged in late-stage trials. Invivyd, another company I have consulted and done press for, took the financial risk of developing and fielding Pemgarda when no other company was willing to chase a shrinking, high-cost, high-liability niche, and Pemgarda is the reason that population has any pre-exposure option at all. They deserve praise and accolades for the successful development of this product. However, an antibody is leased protection: recurring cost, recurring appointment, recurring vulnerability to the virus simply changing shape. Active immunity from a vaccine is a trained capability your own immune system owns outright.

There's an irony worth thinking through. The movement that built its identity on distrust of pharmaceutical dependency is being offered, as its flagship alternative, more highly pharma-dependent products. And the administration promoting antibodies as the way past the vaccine debate has simultaneously put Beyfortus and Enflonsia under FDA scrutiny for perceived safety concerns. Neither is a vaccine. Both, similar to vaccines, are available to be given to healthy infants on a schedule — which appears to be the operative quality that draws fire.

None of this means the products shouldn't exist, or that companies are wrong to build them. A firm facing a regulator that keeps closing its narrower, more defensible lanes is going to find the lane that achieves a return on investment. That's not a scandal; it's what companies do, and I don't fault them for it. Aiming a product at people who "can't, or won't, get vaccinated" is nonetheless fraught, and the two halves of that phrase are not alike. "Can't" is a real population — infants too young for MMR, transplant recipients, patients on B-cell-depleting therapy, people for whom vaccination genuinely doesn't take. "Won't" is not an immunological category. What separates an eligible, unvaccinated child from immunity is a choice, not a biological hole.

The scandal, if there is one, sits upstream. An HHS leadership that spends a year making the word "vaccine" radioactive should expect the market to route around it, and monoclonal antibodies marketed as vaccine alternatives are exactly the kind of routing that predictable policy failure produces. The people who created that arbitrage bear more responsibility for it than the companies cashing it in.

The question to keep asking isn't whether antibody therapies should exist. Of course they should — they're a marvel, and in the populations they were built for, they save real lives. The question is whether we're going to keep letting a preference masquerade as an indication.

Ten Years Gone

A decade of asking questions nobody has answered

Ten years ago today, D.A. Henderson died. I have written to him every year since — a list of questions I would have walked down the hall to ask him if he were still in his office. His absence is a standing deficit, a chair at the table nobody has filled. Ten years of these letters has produced a ledger, and this year's ledger is worse than last year's, which was worse than the year before that.

Here is some of what I would ask him.

Ebola Unchained

DRC declared its seventeenth Ebola outbreak on May 15, in Ituri Province, not long after the previous one ended. The virus is Bundibugyo, not Zaire, and there is no licensed vaccine and no approved treatment for it. It is the deadliest outbreak in DRC's history, the fastest-spreading ever recorded, and second in the world only to West Africa in 2014–16 which it is projected to eclipse. Most cases emanate from unknown chains of transmission, most deaths (which number over 2300) occur outside Ebola treatment units, and the population has not accepted the need for safe burial practices and other standard public health interventions. There has been real consideration of the idea of this area of the DRC becoming endemic with Ebola — a frontier of Ebola necessitating neighboring areas remaining eternally vigilant.

During the largest Ebola outbreak in 2014 you and I once argued that the fastest way to stop an outbreak like this is to concentrate everything on the small number of people doing most of the transmitting rather than chasing every contact evenly.

How would you do that in this context? Use the Merck Zaire strain vaccine — which has some anecdotal evidence of cross protection against Bundibugyo — in rings? What are the top three things you think need to be done to gain some semblance of control of the outbreak? What is the realistic time frame for control (1 year, 2 years)? How was neighboring Uganda able to act so decisively and delimit their 20 cases?

The soda-bottle EO

On August 10, President Trump signed an executive order instructing HHS to develop separate single-disease measles, mumps, and rubella shots, on the theory that giving three diseases' worth of vaccine at once is somehow excessive — he has compared it to pouring a bottle of soda into a child's body. The order also cuts the vaccines recommended for every child from seventeen down to eleven, shifting the rest into a vaguer shared-clinical-decision-making category. I’m glad you didn’t have to watch it.

You ran the campaign that made a human disease disappear from the planet with one shot (or scrape) per arm aimed at getting a single dose into as many arms as possible. Your method was to subtract complexity, not manufacture it.. You had no patience for controversies invented to solve problems that did not exist.

I imagine the clarity and authority of your booming voice on 60 Minutes dismantling the disinformation apparatus of RFK Jr. and his minions, reassuring the public (as you did all of us during the anthrax attacks), championing the value of vaccinations and the legacy of Jenner (which you completed). I think these minuscule gnats would shrivel just at the sight of you.

The US has confirmed 2,566 measles cases this year, the worst count in decades, and PAHO will review whether the country keeps its elimination status in November. You thought measles was a harder eradication target than smallpox, precisely because it spreads faster and more quietly, and you were skeptical of global measles eradication for that reason — but you lived to see the Americas declared measles-free in 2000 and treated it as a real accomplishment worth defending.

What do we do now? Measles is on a trajectory to become endemic in the US again and a resource consuming public health and healthcare system problem. Once our designation is gone, is there a version of elimination worth the fight to reclaim, or was 2000 a one-time achievement that doesn't come back around twice?

The platform works, the institution doesn't

The FDA approved mFlusiva on August 5 for adults fifty and older — an mRNA influenza vaccine roughly 27% more effective than the standard shot — six months after the same agency refused to review it and then reversed course. But ACIP has issued no recommendation for it. ACIP itself is littered with RFK Jr.’s acolytes and is non-functional. You judged a countermeasure by whether it worked, full stop — never by which political tribe had claimed it as a mascot.

What do you make of a government that approved the best flu vaccine in decades and embedded it in a maze that keeps it out of people's arms? How do we keep the promise of mRNA technology — so critical for pandemic preparedness against avian influenza — alive in this toxic disinformation-laden environment?

Medications favored over vaccines

Xocova was approved as the first oral pill to prevent COVID after exposure, cutting symptomatic infection by 67% when started within 72 hours of contact. DoxyPEP — a dose of doxycycline after sex to prevent bacterial STIs — is now becoming standard of care even as it consumes its own advantage: surveillance in San Francisco and King County already shows gonococcal tetracycline resistance climbing in step with doxyPEP use, and models project meaningful loss of efficacy within five to twelve years even at modest uptake. HIV PrEP, with the addition of lenacapavir, is revolutionary. Nirsevimab, the preventive antibody against RSV in infants, is changing the face of pediatric RSV while pemivibart protects the most immunocompromised against COVID-19.

I remember sitting with you in briefings about the potential smallpox antiviral tecovirimat and seeing your steadfast loyalty to the vaccine — the tool you used to beat the virus back and foreclose its ability to ever harm humans again.

Now all these medications are all genuine advances that provide valuable (or in the case of HIV PrEP, incalculably valuable) additions to the armamentarium. But, keeping on the theme of my questions, I wonder if some of them are being conceptualized not as tandem products to vaccines but as vaccine substitutes. For example, the head of HHS ARPA-H said: “There's actually a multitude of other technologies that you can use to protect people against infectious disease.” That seems to me to be coded language against vaccine technology.

So, how do we balance drug-based prevention with vaccination, knowing that there is more than a hint of irrational anti-vaccine sentiment partially driving it?

***

Better tools, weaker resolve

Every question I posed DA above has the same shape. Mastering infectious disease is no longer an exclusively scientific, technological, or medical problem. What we have is an implementation problem driven by a larger philosophical one: the return of the primitive in the form of Dark Ages’ mentalities that are openly advocating for a lower standard of living, for civilization to march backward.

DA spent his career on the inverse problem — a bifurcated needle, a jet injector, an index card, and institutions with enough authority and credibility to make those crude tools work anyway. I would love to know what he could do with the technologies we have today.

Ten years of asking DA these questions hasn't made the exercise less useful. It has made it more damning of us. I believe DA would have found this year infuriating rather than tragic. Infuriating things can still be fixed but the task is inestimably harder with his chair still empty.

I do not believe that our cause is finally lost, because it is based on truth, reality, logic and reason with an aim to improve individual human lives. But I wish DA were here to tell me how he would win because I know the nihilist forces we face would be no match for him mantled with the prowess of Jenner and Pasteur.