Enough with Persuasion

I made this point yesterday. I wanted to restate it here and add some further points: The best and most equitable path forward is to restrict non-essential public activities to those who are vaccinated or have non-subjective medical reasons for not being vaccinated.

Now, I say this recognizing that in our current political reality this is highly unlikely to happen. Red states won’t do this and rightwing courts will limit our ability to do this at the federal and state level. But it is important to understand and articulate what the right policy is even if it can’t or won’t be implemented fully. You cannot get anywhere without at least knowing where you are trying to go. At present we are in the perverse position of beginning to add new burdens to the vaccinated/responsible population (mask mandates) to make up for the persistent irresponsibility of the non-vaccinated. The social cost of low vaccination rates should be borne as much as possible by those causing the problem, the voluntarily unvaccinated. So restrict non-essential public activities to those who are vaccinated.

Once it became clear how effective the vaccines were, especially before the Delta variant took hold, many people starting saying that the logical policy was hands off. Either choose to get vaccinated or choose not to and get sick or die – a sort of nirvana of free choice and personal responsibility. If you were still harping on people to get vaccinated what was your problem? You’re just the ultimate liberal fussbudget getting into other people’s business when it doesn’t affect you. But it’s now clear that’s not the case. The vaccinated are themselves endangered by the wide prevalence of Delta variant swirling around them. Sure, the risk to the unvaccinated is vastly greater. But that’s on the unvaccinated who can now show up at pretty much any pharmacy chain in the country and change that right away. Why should I incur that additional risk, even if it’s comparatively small? And why should it be on me to take further precautions because of someone else’s irresponsibility?

That isn’t only equitable. It’s also the best way to get people vaccinated. Many people are now committed anti-vaccination diehards. But a substantial and probably larger group is less set in its opinions. Increasing the cost of non-vaccination is the clearest way to get people vaccinated.

A few days ago the Times published a heartbreaking and mind-numbing article about the spread of COVID in low vaccination places like Arkansas. The lede is bracing and telling …

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When the boat factory in this leafy Ozark Mountains city offered free coronavirus vaccinations this spring, Susan Johnson, 62, a receptionist there, declined the offer, figuring she was protected as long as she never left her house without a mask.

Linda Marion, 68, a widow with chronic pulmonary disease, worried that a vaccination might actually trigger Covid-19 and kill her. Barbara Billigmeier, 74, an avid golfer who retired here from California, believed she did not need it because “I never get sick.”

Last week, all three were patients on 2 West, an overflow ward that is now largely devoted to treating Covid-19 at Baxter Regional Medical Center, the largest hospital in north-central Arkansas. Mrs. Billigmeier said the scariest part was that “you can’t breathe.” For 10 days, Ms. Johnson had relied on supplemental oxygen being fed to her lungs through nasal tubes.

Ms. Marion said that at one point, she felt so sick and frightened that she wanted to give up. “It was just terrible,” she said. “I felt like I couldn’t take it.”

Yet despite their ordeals, none of them changed their minds about getting vaccinated. “It’s just too new,” Mrs. Billigmeier said. “It is like an experiment.”

None of these reasons are crazy. They’re not about microchips or cockamamie constitutional theories. But they’re each wrong in different ways. To me these examples illustrate the real impact of public advocacy against vaccines. None of these women are explicitly referencing the vaccine scare stories you hear on Fox News. But there’s little question this kind of foot-dragging or passive resistance is sustained by a cultural climate of vaccine resistance that the one that is dominant in their state.

What will shift people?

I think there are two main things. One, quite simply, is people’s own doctors. One thing I’ve seen consistently in the polling on this issue is a response among the hesitant that they’re going to wait to discuss it with their doctor at their next physical. I mean, why wait? But people have relationships with their doctors – if they’re lucky enough to have a relationship with a single physician – that transcends much of the public debate which is politicized and performative. It’s also private. For a large slice of the population, even if they’re been hesitating or indifferent, when their doctor tells them to get a shot and they’re already there they’ll get a shot. Perhaps I’m underestimating the degree of politicization of the medical community in Trump country. But I think that will move a lot of other people.

The second is simply incentives – more things you can’t do if you’re not vaccinated or more costs you incur. That moves people. Private organizations, private employers should also take up this responsibility. But to do this we need to get the vaccines fully authorized. We tend to forget that all these vaccinations are still only approved under emergency authorizations. That’s an excuse for many people who say they don’t want to get vaccinated. But what’s more important is that it’s a bar to many of the restrictions, especially non-governmental restrictions, I’m describing. Based on a case out of Texas, a federal court has ruled that employers, at least in many case, can make vaccination a condition of employment. But many big organizations clearly don’t feel they can mandate this for employees or consumers short of this full approval. The military for instance is waiting on full FDA approval to even consider mandating them for military personnel.

The latest I heard was that FDA and FDA watchers see full approval as something coming in early 2022. But that’s a long time. To the extent there’s a utility in rushing vaccines into service that’s precisely what the emergency authorization process is for. But clearly full authorization makes a significant difference.

It’s worth remembering that this is the first time the FDA has dealt with regulatory authorizations for vaccines or therapies during an epidemic of a novel disease to which the entire population was vulnerable. That merits giving consideration to whether the standard procedures should apply. I assume there’s some sort of established process that yields a date estimate like that. But there’s never been a historical context anything like the present one. Over 150 million people have gotten these vaccines – mostly Pfizer and Moderna – just in the United States. That’s an incalculable amount of data and to the extent we’re thinking about conceivable longterm impacts or side effects it doesn’t seem like we’ll know significantly more on that front in six months. I don’t know what the process is. But it’s seems worth speeding the process up or adding into the calculation that the lack of formal, complete approval is having big real world impacts. That needs to be figured into the calculus, whatever it is.

It’s not clear to me that the people shepherding that process are attuned to the real world impacts of delay.

Where genuine persuasion is most likely to take place is in the depoliticized, non-performative and frank context of the doctor’s office. All the public outreach should continue certainly. Invite young influencers to the White House and the like. But we should put our hopes on incentives – specifically placing the social, economic and clinical costs of non-vaccination on those not getting vaccinated.

That, as I said, is the best and most equitable path forward.

There’s also this.

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