A vaccine discussion worth having. BY MATTHEW YGLESIAS

A vaccine discussion worth having

MATTHEW YGLESIAS

JUN 21, 2023

Not whether they’re good but how to get people to take them

I more or less agree with everyone who thinks it wouldn’t be constructive for scientists to participate in a live debate about vaccines with Robert F. Kennedy, Jr. and certainly not on the Joe Rogan show.

And even though it’s not the subject of this post, I do want to say that I think it’s really sleazy and gross for the hosts of the All-In podcast to be engaging in this Kennedy boosterism as a bank-shot way of harming Joe Biden’s reelection prospects. Notwithstanding the recent convergence around Russia policy, Kennedy represents precisely the strand of progressive thought that right-of-center businesspeople have rightly spent the better part of a century bemoaning — his is an anti-progress, anti-technology, ultimately anti-human worldview that stands against biomedical progress, against energy progress, and against human flourishing. If they do succeed in supercharging Kennedy’s campaign, they will greatly set back the state of political argument in the United States.

Back to vaccines, though.

While I don’t think there’s anything new or interesting to say about the scientific or medical issues, I do think the time is probably right for a renewed discussion of the policy issues surrounding vaccination. Because the basic question here is interesting. Vaccines are good for the people who take them — the private benefits far exceed the costs. That said, there are a lot of personal health practices whose benefits exceed the costs; a lot of Americans would benefit from getting on a weightlifting program, for example, but nevertheless haven’t done so. What’s special about vaccines isn’t that they benefit the vaccinated, it’s that they have large social benefits beyond their private benefits, which means we have a compelling public interest in strongly encouraging people to get vaccinated.

To the extent that various vaccination mandates are already in place and are uncontroversial, that seems like a good enough solution. But I think we saw clearly during Covid that they are not always uncontroversial. Flu vaccines are non-mandatory, but that just means they usually have low uptake. And when we hopefully invent even more vaccines in the future, that will once again pose the question of the best way to get people to actually take them.

Getting mad is not a solution

The other day, I wrote on Twitter: “An interesting topic to debate would be ‘what should we do about the fact that the social value of vaccination exceeds the private value to the vaccinated, while the vaccinated themselves bear the downside risks which, however small, are not zero?’”

This inspired multiple doctors to yell at me that the private value exceeds the private risks, which does not contradict what I said. Nonetheless, I got accused of “playing footsie with anti-vaxxers” and all manner of other sins for simply stating the problem correctly.

And I think that actually illustrates the dilemma here. Most people, it seems, are against telling “noble lies.” This is to say they don’t believe people in positions of power should say things that aren’t true just because deception might have instrumental benefits. At the same time, one can of course speak a quite misleading version of the truth without lying at all. Imagine a publication whose only stories about the Covid vaccine were accurate recountings of genuine adverse reaction incidents. They wouldn’t need to make anything up — it’s a big country (330 million people) and a bigger planet (nearly 8 billion people), and rare side-effects are not so rare that it’s impossible to find examples to write about.

But covering those stories extensively while totally ignoring the benefits of vaccination would paint a particular picture for the public.

And this picture would be quite harmful. Harmful not only to the specific individuals who are duped but harmful to society writ large. That’s different from Kennedy’s claim that wifi causes cancer. If you want to be a weirdo and not have wifi in your house, that’s not really my business. It sounds like a crazy thing to believe, but people believe lots of weird stuff about personal health. There’s a robust market for overpriced produce, for bogus supplements, for tarot card readings, and for who knows what else. The thing that makes anti-vaccine propaganda unusually harmful is the externalities — the social benefits — which is why among pro-social people, anti-vaccine propaganda is stigmatized even though some elements of the propaganda campaign reach some technical threshold for accuracy.

The problem is that just saying “well, people shouldn’t do that” doesn’t answer any questions or solve any problems. If this were 1957, the heads of the three television networks could get together and agree that any coverage of vaccine side effects will be undertaken in consultation with the surgeon general in order to promote pro-social goals. But in the internet era, information blockades are leaky. And the more you try to wage pro-vaccine memetic warfare, the more you feed the superstitions of the superstitious.

It would be nice if transparency fixed everything

I would love to say that in a world without gatekeepers, the best policy is radical transparency.

Side effects and adverse reactions are real, they’re just rare. It’s true that serious Covid illness among the non-elderly is rare, but not as rare as serious vaccine side effects. And while mild vaccine side effects aren’t rare at all, they also aren’t as bad as a mild case of Covid. And while unfortunately the Covid vaccine doesn’t prevent you from getting Covid, it does substantially reduce the extent and severity of the symptoms. It would be nice to think that when people get the facts, when they have the information, they’ll do the right thing.

But unfortunately, I think it’s a bit utopian to believe that possessing accurate information about personal health will cause people to do the right thing. If you just look around, there are lots of people who don’t exercise or eat their vegetables. The quality of nutrition research is very low and it’s hard to find accurate credible information about lots of things. But the people buying bags of Fritos at the store aren’t confused about whether or not Fritos are healthy.

And I think it’s a mistake to take anti-vaxxers’ stated views too literally. Lots of people are a little bit lazy and a little bit selfish, and many maintain some version of a slightly odd body purity paranoia (I again point you toward organic produce or the European terror of GMOs), and plenty of people don’t like to be stuck with needles. Any parent can tell you that children are often pretty unhappy about getting their shots and they don’t need conspiratorial YouTube videos to make them grouchy about it.

Speaking personally, before Covid hit, I was actually pretty misinformed about routine childhood vaccinations. My sense of the normal MMR and TDAP shots was you got your shots when you were a kid and you were good to go forever, immune to measles, mumps, and rubella. I had no idea about immunity waning over time or “breakthrough” infections. It seemed like everyone got their measles shot when they were a kid, and so nobody was getting measles — a scientific miracle. It turns out that vaccines are not as foolproof as I’d thought, and that herd immunity is doing a lot of the work. But that’s just to say that my prior overestimate of vaccine efficacy was pro-social. The more people overrate the private benefits of vaccination, the more vaccine uptake you’ll see. And the more uptake you see, the more apparently effective the vaccines will be.

The mandate conundrum

Traditionally (and the “traditionally” part here is important), we have resolved these dilemmas by making vaccination mandatory. If you want to enroll your kid in school, you need a note from the doctor saying that he has his shots.

There was never a mainstream political debate about this, and I never really had cause to second-guess it. But it’s actually a bit odd. When I did political philosophy, we learned about John Rawls’ first principle of justice, which states that in a just society, “each person is to have an equal right to the most extensive total system of equal basic liberties compatible with a similar system of liberty for all.” That would seem to rule out vaccine mandates, but I never recall anyone discussing that as either an objection to Rawls’ principle or as a policy reform that they supported in reflective equilibrium after considering Rawlsian arguments. Similarly, on the popular “harm principle” view of the world, there’s no justification for forcing someone to get vaccinated. It’s true that getting vaccinated has social benefits. But so does donating blood, and we don’t view declining to donate blood as a means of harming someone. It’s a decision not to help. Nobody supports mandatory blood donation as far as I know, not even from people with valuable O-negative blood.

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What makes it especially odd is that medical ethics and normal public policy thinking are kind of at odds here.

The public policy view is that vaccination is important because of the externalities; we want to mandate vaccination because it helps protect the whole community.

The medical ethics view is that it’s never acceptable to push treatment on someone for the sake of other people; officially, vaccine licensing is supposed to be done purely on the basis of benefits to patients.

So you end up with an odd rhetorical dynamic.

“Gotta get your shots.”

“Why? I don’t wanna!”

“To safeguard the community.”

“Fuck off, man, I’m young and healthy I don’t need this in my body.”

“No you don’t understand, the FDA has determined that the expected value of vaccination is highly positive for you, that’s why you’ve gotta get your shots.”

It’s conventional enough that it’s easy not to think about it, and I’ve never had a problem with it. But try to extend some cognitive empathy here. We know that there are tons and tons of healthy behaviors that the government doesn’t mandate. You’re allowed to buy a bag of Fritos and ignore the side of broccoli. Nobody is going to force you to lift weights or maintain adequate hydration or get a good night’s sleep. I think it’s significant and non-coincidental that a lot of vaccine resistors are actually pretty conscientious about their personal health, and that “it’s good for you therefore you must do it” is very much not the normal way public policy is made in the United States.

I think a non-paranoid person would just say “buddy, that’s life.” I can give you a sociological explanation for why alcohol is regulated more lightly than cannabis, but there’s no logical reason for it. By the same token, vaccine mandates are deeply embedded in American civic culture. George Washington issued a mandatory smallpox vaccination during the Revolutionary War, which is to say that vaccine mandates predate both the Constitution and virology as a field. Progressives found themselves citing this during the vaccine mandate wars of 2021, but of course “that’s how they did it in the 1780s” is not an argument people generally accept as a sound guide to just conduct. It’s just true, factually, that this is a well-entrenched way of handling vaccinations, and it’s been surprising and distressing to see that consensus breaking down.

Is there a better way

One reason I emphasize the sheer weight of tradition as a factor here is that even pre-Covid, I was interested in the poor uptake of the flu vaccine.

This is partly because the flu is just not that scary to most people. But it’s also true that mumps, for example, while bad, was not a super-deadly illness pre-vaccination. It’s also because the efficacy of the flu vaccine is relatively low (and this was common knowledge pre-Covid), in part because there are so many different flu strains flying around, and the public health community is kind of guessing each year what vaccine they should give people. But fundamentally, it’s still the case that the flu makes lots of people unpleasantly sick each year, and some of them — primarily the elderly — die. Getting a flu vaccine is good for your personal health, and it’s very good for the community. Not only do high levels of vaccination slow the spread of flu, but reducing the overall wintertime burden on health care infrastructure ensures that those who need care can get it.

And if someone wanted to make flu shots mandatory, I wouldn’t personally object to that. I don’t have anti-paternalist principles. I would like to persuade people to adopt more stringent regulations of alcohol and junk food and gambling, so why not flu shots? But I also think it would be crazy and almost certainly counterproductive to start a partisan political fight over this.

Maybe we could just be more realistic about the fact that a bunch of people don’t like getting shots, but it’s better for society if they do. So every time you get your annual flu shot, you get a check. After all, notwithstanding George Washington’s precedent, I think this is what a normal economics textbook would prescribe for a situation where the social value of some activity exceeds its private value — just pay the money. And applying a similar logic to childhood vaccinations would function as a de facto child poverty program, like the expanded Child Tax Credit, but sidestepping the work requirement issue because it’s a vaccination payment that everyone is eligible for. Lula created a program along these lines in Brazil called Bolsa Familia and it seems to have worked well.

Maybe people have other ideas. I’m interested! But I do think it’s important to acknowledge that we really do want people to get vaccinated for reasons beyond the personal benefits to themselves, and that further injecting vaccine mandates into partisan politics is probably not a successful strategy for accomplishing that.

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Sidebar: If you are an eligible blood donor, you should really consider stepping up.