This morning, I offered the traditional Hawaiian pule pale “noho ana ke akua i ka nāhelehele” asking for protection and received a blessing from the Kahu. I then went to my friends at the local public health department and asked for a controlled inoculation of COVID-19.

Like most viruses, the lethality of a COVID-19 infection has five drivers: the viral load of the initial exposure, comorbidities including age, predetermined genetic susceptibility, acquired or passive immunity, and random chance. Of these, the only variable that can be tested in a controlled environment is the initial viral load.  The larger the initial load, the greater the risk of lethality. As with most things in life, the relationship is not likely to be strictly linear.

What is my risk of lethality?  Based on the best risk stratified data I can find, less likely than the overall death rate for the entire Marine Corps from 2003 to 2006 during Operation Iraqi Freedom. Certainly less than the one year casualty rate of most front line combat troops.  Assuredly less than 98% – 300% casualty rate of the 442nd Infantry Regiment during World War II. If this COVID-19 pandemic is the moral equivalent of war, why should I not take less of a risk than a 19 year old from Appalachia who volunteered after 9/11 or a young Japanese American after Pearl Harbor who recently graduated from McKinley High School and volunteered for the 442nd? Analogies to a new “Greatest Generation” during the COVID-19 pandemic should be examined within historical context.

Public Health departments in the United States at the local, state, and federal levels have always been the unsung dedicated heroes, being largely unrecognized until times of crisis.  Occasionally they may be mentioned during the yearly influenza season, but even then rarely. In spite of lack of recognition and funding, they continue to quietly and tirelessly work on the vitally important but mundane issues of nutrition for women, infants and children, breastfeeding, immunizations, mental health, and sexually transmitted diseases.  Even in the middle of a pandemic, the media tends to avoid public health interviews in favor of well dressed articulate young photogenic physicians in full-on makeup, who would never appear like that in the middle of a busy emergency department at the risk of being mercilessly mocked by their colleagues let alone their inability to function.

Outside of personal protective equipment, what do the nurses, first responders, nurse practitioners, physician assistants, physicians, researchers, and public health officials on the front line need?  Data. Preferably controlled reproducible data.

Prior to modern medicine, variolation was used to combat deadly smallpox. Like COVID-19, smallpox is primarily transmitted via respiratory droplets.  Variolation is the process by which a small amount of fluid from the pustule of a patient with active smallpox is inserted under the skin of a healthy patient in order to produce a less severe response.  After variolation, the patient would develop signs and symptoms of smallpox, though much less severe. With recovery, immunity was conferred. Physicians in the past were active practitioners as well as recipients of variolation.

Looking to the past for guidance in the present, I could be inoculated in the nasopharynx with a small, but gradually increasing viral load, until immunity was conferred.  Under a controlled setting, a viral load which conferred immunity and minimized risk of morbidity and mortality could be derived. If others were to volunteer for a controlled inoculation, an ideal viral load could be risk stratified. This could be done much more rapidly, a matter of weeks, than it would take for an effective risk free vaccine to be developed.

This pandemic will invariably disproportionately affect those in manufacturing, the trades, and service industries.  If you or someone you know owns a pickup truck or knows what “The Sandbox” refers to, you likely fall into this category. The tourism industry in Hawaii has already seen potentially devastating layoffs, and the ripple effect through the Hawaiian economy could be incalculable.  Key economic sectors in other states are assured to be similarly affected.

Some have questioned whether a future barren economic landscape filled with depression, domestic violence, alcoholism, and methamphetamine addiction is worth 3 million lives saved. As an alternative, the possible death of tens, even hundreds of volunteers resulting from a variolation program, instead of 3 million deaths, changes the trade-offs significantly. There is no easy answer, but surely it is worthy of discussion as our knowledge and data become better and more robust.

Those who minimize the cost of a future great economic depression are those least likely to be affected by it: knowledge workers, those that work alone from home, and those with sufficient financial resources to weather the coming storm.  Those with any sympathy to the trade off argument are those who have benefited from the recent increase in jobs over the past three years. Having known significant economic hardship in the recent past, they are likely to think more deeply about the question.

I want to be clear.  I am not suggesting that one should go out and altruistically and deliberately expose oneself to COVID-19 in the hopes of furthering the fight against the pandemic. Doing so would be even more dangerous to others than the current indulgent fad of ignoring social distancing.

So far my requests at a controlled inoculation have met with an interesting mix of sympathetic but firm “No”’s combined with offers to refer me to people that may be willing to indulge me. I hope a fully informed consent should assuage the fears of any internal review board.

If COVID-19 pandemic is the moral equivalent of war, then those of us who can, should volunteer for controlled inoculation.  Perhaps then, references to the “Greatest Generation” may eventually apply.