Hello! First off, let me apologize for forgetting to post a discussion thread yesterday. No excuse, I just messed up. I will try to be better in the future.
Second, if you like seeing me yak, check out my BloggingHeads with Bob Wright where we talk about Substack, foreign policy, and everything in between.
Now onto the main event: vaccine hesitancy.
I published a piece in the Washington Post’s Outlook section recently titled “Not All ‘Anti-Racist’ Ideas Are Good Ones.” This piece was kind of wide-ranging, but it contained a passage that prompted some pushback from someone whose opinion I value, and I want to revise and extend my remarks to concede the basic truth of his critique.
The overall theme of the piece is that the post-Kendi move of pointing to every disparity and labeling it “racism” is not a super-useful way to analyze problems. One example I gave was the extent to which in basically every American city, you can see more vaccinations done in white neighborhoods than in non-white neighborhoods. The disparity is a serious issue, but it seems to be more driven by a gap in demand than anything else, and it needs to be addressed through that lens.
I think that’s correct. The main point of this post is to consider what we can do about vaccine hesitancy — which, to be clear in a way that some coverage has not been, is actually mostly a question of white Republicans — but the way I glossed over the roots of that hesitance in the Post piece was wrong.
Here is what I wrote:
For example, maps of various American cities now sail across social media depicting higher vaccination rates in White neighborhoods than in Black ones. A Kendi-type analysis would conclude that gap is racist, full stop. And certainly it is often framed that way, as if city officials were making vaccinations available on a discriminatory basis.
Perhaps that is true, in some cases. But surveys also show that Black Americans are considerably less eager than White Americans to get vaccinated. That’s a serious problem on its own terms. But it’s not a problem of overt discrimination (although the distrust gap may stem from past medical discrimination). Insisting that all gaps reveal racism elides the critical question of what’s actually happening and how to fix it.
My core point here, which I think is valid, is that we need to distinguish between three types of situations:
There is a deliberate discriminatory pattern of steering vaccines away from Black patients in need (a lot of GI Bill mortgage programs were like this).
The vaccine is being rolled out in a way that has a disproportionate impact on a city’s Black residents. For example, if you need a car or a fast broadband connection to get a shot (this happens a lot in America and a lot in big cities — class and race are so closely correlated that it can be tempting to collapse them, especially if disparate-impact legal strategies have a chance of working).
The vaccine is being rolled out in an equitable way, but Black residents are less likely to want it.
The point is not that these aren’t all bad situations, but that they are all different situations, and they imply different remedies. Based on the available evidence, it seems like we are looking at some of (2), and then specifically in big cities where the white people are generally liberals, there’s a good dose of (3). The parenthetical I wrote about “past medical discrimination” was an effort to nod at the idea that the racial trust gap is not a wholly different thing from racism as a subject, even though it still is quite different as a specific diagnosis of the vaccination situation.
That said, “oh it’s the past” can be a comforting way of minimizing what is really a persistent lack of legitimacy in social institutions.
“The past” isn’t really past
April Dembosky from the Bay Area public radio station KQED ran a great story a few days after my piece published titled “No, the Tuskegee Study Is Not the Top Reason Some Black Americans Question the COVID-19 Vaccine.”
To me, it was like a breath of fresh air. Obviously the Tuskegee study is a real thing that happened, and studying it is a good lens on the history of biomedical ethics in the United States. But referencing it as a cause of present-day behavior just sounded way too much like educated people showing off their historical knowledge than a real explanation.
One thing she notes is that Black reluctance to participate in biomedical research is a big issue in biomedical research, so there is actually a fair amount of biomedical research on the subject. A big study by Ralph Katz, Stefanie Russell, Nancy Kressin, Lee Green, Min Qi Wang, Sherman James, and Cristina Claudio concluded that, to quote Demosky, “while Black people were twice as ‘wary’ of participating in research, as compared to white people, they were equally willing to actually participate. And, there was no association between knowledge of Tuskegee and willingness to participate.” Indeed, both Pfizer and Moderna took special steps to ensure adequate non-white representation in their clinical trials and ended up with samples that are very slightly less-Black but more-Hispanic than the aggregate national population, and that gave them enough statistical power to state with confidence that the technology works well in people of all ethnic backgrounds.
But not every trial is like that, and it is not clear to me that the care taken in the COVID-19 vaccine trials is well-known. Inadequate testing leads to a genuine gap in doctors’ ability to treat Black cancer patients as effectively as they treat white ones, because getting patients enrolled in trials is a legitimate method of treating cancers when other options have been exhausted.
Back to Dembowski, the issue is a sense based on current experience that the medical system does not serve Black patients well, and that therefore a high degree of skepticism is warranted.
“It's ‘Oh, Tuskegee, Tuskegee, Tuskegee,’ and it's mentioned every single time,” says Karen Lincoln, a professor of social work at the University of Southern California. “We make these assumptions that it's Tuskegee. We don't ask people.”
When she asks the Black seniors she works with in Los Angeles about the vaccine, Tuskegee rarely comes up. People in the community are more interested in talking about contemporary racism and barriers to health care, she says, while it seems to be mainly academics and officials who are preoccupied with the history of Tuskegee.
“It's a scapegoat,” Lincoln says. “It’s an excuse. If you continue to use it as a way of explaining why many African Americans are hesitant, it almost absolves you of having to learn more, do more, involve other people – admit that racism is actually a thing today.”
Racial disparities in pain treatment, for example, have been well-documented in recent years, in part due to the ironic fact that it may have led to less opioid addiction among African-Americans. A lot of treatments of the racial life expectancy gap focus on socioeconomic factors. But a comprehensive 2002 report from the National Academies of Medicine that didn’t attract much attention back before the Great Awokening concluded that a significant gap remained, even with full socioeconomic controls. They found instead clear statistical evidence of actual (though perhaps unintentional) bias in the quality of treatment offered to Black patients.
If you look back pre-COVID-19, the racial life expectancy gap was actually improving much more rapidly than socioeconomic conditions were converging, so it’s plausible that there was a happy story in there about health care professionals becoming less racist since the NAM report came out.
The point, however, is that we’re not talking about distrust sown in the misty past — we’re talking about people living in a world of biased care and improperly done clinical trials. And it leads to suspicion.
Last but not least, it should be emphasized that the stark racial gap maps are mostly coming from America’s big cities where the white population is mostly well-educated liberals — the most pro-vaccine demographic in the country. If you pull out, of course, most white people are Republicans, and most of the vaccine-hesitant population is white Republicans.
Vaccine resistance is mostly white Republicans
I had sort of been conceptualizing the disproportionate media focus on Black vaccine hesitancy as a consequence of the Great Awokening — white liberals are expressing concern about their Black neighbors. But I think Adam Serwer and Deen Freelon are reading it the other way here: the media is criticizing Black America for being vaccine reluctant while ignoring the quantitatively larger problem of white Republicans’ behavior.
Twitter avatar for @AdamSerwer
Either way you look at it, the data is unmistakable — not only do white Republicans outnumber Black people, but a larger share of that larger population is vaccine skeptical. And to make matters worse, reluctance is declining markedly among the Black population over the course of the rollout, and it is not among Republicans.
This raises the specter of a continuing COVID-19 epidemic that kind of bounces around in different conservative, rural areas indefinitely, perhaps spawning new variants and mutations that cause problems for society at large.
One thing all the experts say about this (see Derek Thompson and German Lopez) is that we should not understand vaccine skepticism as a single phenomenon. It is, instead, multiple different phenomena that occur in different ways in different communities. I do want to complicate that a little bit. Read Perry Bacon and you’ll see that it’s common for Republicans to believe white people and Christians face a great deal of discrimination in the contemporary United States. I think that’s mistaken. But if you’re interested in group psychology, it’s probably worth conceding some similarity here. White Republicans’ subjective understanding of the world is that they are a marginalized community and they don’t trust the media, the medical establishment, etc., who they see as inattentive to their concerns. The fact that this is 80% BS doesn’t change the relevance to selecting messages and messengers.
The good news is that precisely because the white Republican perception that society is rigged against them is false, there are lots of high-profile validators who they trust and who could be recruited to spread the good word.
Let Trump take credit for the vaccine
In particular, the most potent validator of all would be Donald Trump. He at least sometimes likes to take credit for the vaccines’ development and should perhaps be encouraged to do so.
The former president and his wife have both been vaccinated, and while it was hardly the focus of Trump’s CPAC address, he did say there that its development was one of his administration’s accomplishments and that everyone should get it.
Twitter avatar for @maggieNYT
Trump is famously not a super-cooperative person. But there are surely businessmen out there who are friendly with Trump and who have a vested interest in getting things reopened as quickly as possible. It would be smart for anyone in a position of authority to reach out to those folks and see if they can nudge Trump to be more vocal about this, offering assurances that the Biden White House will be chill if Trump wants to brag about Operation Warp Speed.
It seems unlikely that he’ll be a great champion here, but he could do something. It’s also worth reaching out to Mike Pence, who I think has always done a good job of putting forward a more normal face for Trump — it’s easy to imagine him doing some good public whining about how the media and the deep state never give Donald Trump enough credit for Operation Warp Speed which developed three safe and effective vaccines faster than Dr. Fauci thought was possible. Own the libs, says Mike Pence, by getting the vaccine.
Tucker Carlson has occasionally flirted with crankiness about the vaccines as part of his larger anti-expertise schtick, and it would be really useful to try to do some targeted outreach to him. The key, again, would be to present a pro-vaccine message in a manner that’s consistent with cranky right-wing politics. Alex Tabarrok from Mercatus and George Mason University does lots of good stuff about how the FDA is too cautious about the vaccine and he would be a great guest to talk with Tucker about how amazing all the vaccines are — even the AstraZeneca one, which the establishment won’t let us take — and how even just one shot of an mRNA vaccine is actually super-effective. Other conservative media influencers like Sean Hannity and Glenn Beck are really important here, too.
Ultimately, getting conservative America vaccinated is going to require aggressively pro-vax policy measures from red state governors, and that means trying to have a conservative media ecology where it’s understood that vaccinating as many people as quickly as possible is the way to stick it to the public health scolds who want everyone wearing masks forever.
What’s worked with past vaccines
Right now, we’re in a bit of a weird situation where even though vaccine reluctance is high, there are also more people who want a vaccine than can get one.
The normal vaccination situation is different from that. Vaccines provide benefits to the vaccinated, but they also provide significant external benefits to society. Consequently, left to their own devices, people get vaccinated at sub-optimal rates even when there are plenty of doses available. So while we don’t have a huge historical track-record of the exact best way to handle the March 2021 situation, it seems like by May we will be in a more normal situation where the pharmaceutical industry’s capacity to manufacture doses exceeds the number of people who want one.
And this is something that’s been studied quite a bit, primarily in terms of trying to get parents to give their kids the MMR vaccine for measles, mumps, and rubella.
It’s worth emphasizing that the hurdle here is genuinely quite big. Precisely because Americans are widely vaccinated against these diseases, your kid’s odds of contracting any of them if he skips the vaccine are nonetheless very low. As a society, it is very important that we maintain high levels of childhood vaccination. But for an individual, the benefits of vaccination are very low in a way that’s not true with the current COVID-19 vaccines.
So what do we know? Julie Jacob looked at vaccine hesitancy in the United States and found that it was historically widespread in lower-income communities. But the rollout of S-CHIP brought poor parents and their kids into more routine contact with the health care system and greatly increased vaccination rates, leaving the non-vaccinated rump as a group of often affluent parents with weird ideas (these are the “antivaxxers” as we knew them pre-COVID-19).
One implication here is that as we shift into non-emergency conditions, making the Johnson & Johnson vaccine available through normal doctors’ offices could be a potent tool in pushing vaccination rates up further. Practicing MDs are actually not pharmacological experts, but the evidence is very clear that people count on their personal clinician as their main source of advice on this question. Low-income people (and particularly low-income Black men) tend not to have a stable primary care provider, which is going to be a hurdle, but also a case where better overall health care policy can help in the long run. But in the shorter-term, plenty of those vaccine-hesitant Republicans are middle-class people with regular doctors, and making the vaccine available that way will help.
Kaiser’s research also indicates that the one-shot format is appealing to some hesitant people — I think baseline dislike of being stuck by needles may be an underrated issue in vaccine hesitancy, so telling people it’s one and done is useful.
Twitter avatar for @KFF
Some of this is kid-specific stuff (showing parents videos about vaccines, discussing vaccination with pregnant mothers), but some of it isn’t. They find that in communities with low levels of vaccination, it’s helpful to make home visits, for example, and then to set up reminder/recall systems.
They also find that kind of flooding the zone works well:
Community-level approaches are the most challenging to implement, as they require the greatest amount of time, human labor, and financial resources. However, efforts that encourage community buy-in and involvement are often high-impact (i.e. reach a large number of participants). In a study aimed at reducing recognized childhood immunization disparities between inner-city, urban, and suburban children, immunization coverage among inner-city children 24 months old increased by 29 percentage points from 1993 to 1996 as a result of the combined reminder, recall, and outreach (RRO) intervention. More impressively, however, this community-based strategy to improve immunization uptake decreased immunization disparities between suburban and inner-city children from 18% to 4% within 6 years. Collaborations between healthcare organizations and other stakeholders such as pharmacies and daycares also improve rates; a county-wide, school-based vaccination campaign resulted in 26–75% of elementary school children receiving the influenza vaccine. Offering vaccines to eligible children in 2 emergency departments resulted in increases of 8–11%. Finally, one community-based study reported an increase in coverage from 40.6% to 80.5% over 2 years through incorporating immunization promotion activities into pre-established community programs.
I think the important thing to note about this is that the scarcity of “financial resources” reflects the fact that in normal times, the United States is pretty stingy with public health. We currently have trillions of dollars in COVID-19 relief churning out, so the money should be there. The key thing is that to make it work, I think you need Republican governors to want to make it work — both as cheerleaders and facilitators of big, community-level pushes.
The big lesson from non-COVID-19 vaccination campaigns, I would say, is that ease and friction really count.
People aren’t dichotomously pro- or anti-vax, and both assistance and nagging kind of work. When supply is plentiful, we should be setting up vaccination stands in shopping malls, partnering with churches in low-uptake communities, driving vaccine vans up to popular parks, whatever it takes. We should also think about how we are financing vaccination. Right now getting a COVID-19 vaccine is free. But administering a Covid vaccine isn’t necessarily lucrative for the vaccinator. That’s fine for now. But relatively soon, we are going to want to switch to a paradigm where it is highly profitable (as in the government should pay a high unit rate; the vaccine should still be free to consumers) for Walmart or Giant or CVS or whomever to administer a vaccine to a previously non-vaccinated person. If you set a bunch of big national chains against each other in a competitive environment, they are pretty good at marketing.
What all the experts say about the COVID-19 shot, in particular, is that acceptance tends to rise when you know other people who’ve gotten the shot — vaccine demand spreads virally in other words, since there’s no proof like direct, personal confirmation that nothing terrible happens.
Time to consider vaccine mandates?
Where the experts do not yet seem to have gone is the idea of making the vaccine mandatory.
The military has been dealing with stubbornly high levels of vaccine reluctance and keeps saying they would like to make it mandatory, but can’t because it’s currently available under an Emergency Use Authorization.
The variations make it harder for leaders to identify which arguments for the vaccine are most persuasive. The Food and Drug Administration has allowed emergency use of the vaccine, so it’s voluntary. But Defense Department officials say they hope that soon may change.
“We cannot make it mandatory yet,” Vice Adm. Andrew Lewis, commander of the Navy’s 2nd Fleet, said last week. “I can tell you we’re probably going to make it mandatory as soon as we can, just like we do with the flu vaccine.”
As far as I know, every single person working at the FDA, CDC, NIH, DOD, and other relevant agencies thinks the vaccine is safe and people should take it. So does the President of the United States, and so does his defeated rival Donald Trump. So do Mitch McConnell and Nancy Pelosi.
I don’t understand exactly the bureaucratic or legal issue with the EUA vs. regular authorization and military policy. But if there is absolute unanimity among the scientific and public health communities that the vaccine is good, if military officials say vaccination is good for readiness, and if all the political leaders of both parties say people should get vaccinated, then they ought to work out whatever the issue is and move to make it mandatory for service members.
Mandatory vaccination while supplies are scarce feels a little perverse to me, so I can understand not doing it.
But we shouldn’t underestimate the extent to which people make inferences about the science based on the rules. If indoor dining is open, many people infer that eating indoors is safe and socially responsible, even if it isn’t. And if the military normally requires flu vaccines but is saying there’s some FDA issue causing them to not require the COVID-19 vaccine, that implies there’s something dodgy about the COVID-19 vaccine. The military is not a libertarian institution — it orders people to do things all the time. When the country is in a state of ample supply, they should make it mandatory with whatever exemptions they offer for the flu vaccine.
By the same token, the Department of Education should start encouraging universities to require the COVID-19 vaccine along with whatever other immunizations they require. You obviously can’t require kids in K-12 schools to take it if it’s not approved for teens, but you can require it for teachers and staff.
In my view, mandates — again, once supplies are ample — are good not just because they mechanically push up compliance but because they demonstrate confidence. Right now, I think a lot of people look at the “everyone get your vaccine but also keep behaving cautiously once you get it” messaging as kind of shady. Flipping the script to “everything is open and everyone can go do whatever, but we’re going to be making large swathes of the population take this vaccine” as soon as possible is a good way of demonstrating confidence that the vaccine works, and the imperative is just to get it into people’s arms. There are a few known unknowns surrounding the duration of immunity and possible future evolution of the virus, so we should be at least conceptually prepared for a world where there’s a big variant-optimized booster push in 2023 or something. We want to be forceful about it the way we are with the MMR shot rather than dancing around it like vaccine authorization is a delicate flower.
