Let's get more people vaccinated

It all starts with actually approving the vaccine....

One great piece of news about life in the United States of America in July of 2021 is that widely available mRNA vaccines made by Pfizer and Moderna are highly effective against the SARS-Cov-2 virus. They greatly reduce your chances of becoming ill as a result of infection by the virus, and dramatically reduce your chances of dying from it.

Another great piece of news is that while children under 12 are not yet eligible for vaccination, the virus has never been a significant threat to children’s health. American society needed children to abide by certain restrictions on their activities because kids can transmit the virus and we needed to protect more vulnerable members of society. Today, however, the vulnerable can be protected by the Pfizer and Moderna vaccines.

The bad news is that the Delta variant appears to spread like wildfire, with infected individuals shedding tons of virus.

That means that the level of population immunity needed to suppress outbreaks is now really high, and very little of the country is at that kind of really high level. Delta, therefore, poses a few different kinds of threats to the population:

  • Despite fairly high vaccination rates among the elderly, it’s going to kill a bunch of people if it spreads uncontrollably in the unvaccinated population.

  • Even mild cases of Covid seem unpleasant, and sensible people would rationally prefer to avoid them, especially given the possibility of Chronic Fatigue Syndrome and other long-term consequences.

  • Overprotective parents may respond to Delta outbreaks in ways that are harmful to their unvaccinated kids’ education and emotional well-being.

  • America’s already frayed civic fabric is not well-suited to another round of contentious debates about non-pharmaceutical interventions.

I take a somewhat libertarian attitude toward all this. With vaccines widely available, it does not make a lot of sense to try to impose stringent non-pharmaceutical interventions, especially because the non-vaccinated population almost perfectly overlaps with those who don’t comply with NPI rules. If people want to protect themselves against Covid, they should get vaccinated. If they don’t, that’s on some level their problem. I do worry about the impact of outbreaks on families with young kids (my son is six), but given all the available evidence, I think public health communicators should emphasize the low risk level rather than try to use children as a bludgeon to return to high social distancing.

But it doesn’t make sense to have a purely libertarian view of this. Vaccination involves meaningful externalities. The Delta risk to my vaccinated self or to my kid is extremely low but not zero. The risk to my vaccinated father, stepmother, and in-laws is a bit higher. Every marginal person who is vaccinated reduces our risk levels further. And of course, even the spread of nonfatal illnesses damages the economic recovery and other things we care about. The aggregate burden on our healthcare system and our healthcare workers is also a big deal.

Long story short, we should be trying to get more people vaccinated. And even though I get the sense that people feel we’ve tried almost everything and are now deep in the wells of diminishing returns, I think the truth is we’ve barely tried.

The FDA should approve the vaccines

To me, the most striking, glaring, and obvious problem with the current state of the U.S. vaccine rollout is that the Food and Drug Administration has not given official approval to any of the vaccines that we are using. Instead, they have been given Emergency Use Authorization.

Any time you criticize any element of the American public health bureaucracy these days you get assailed by swarms of pro-system tweets, in this case usually accusing me of “not understanding the process.” But I actually think it’s the process-trusters here who don’t understand the process, and if you do you’ll see it’s a process that’s a poor fit for the situation.

After all, when you step back and think about it, the FDA approach to medications is at least a little bit odd. In many cases it’s perfectly legal to sell things that have no scientifically demonstrated medical benefits — that’s the whole world of unregulated supplements. And of course you can sell people things like beer, M&Ms, and cigars that everyone knows are harmful and have no offsetting medical benefits. Selling medicine is subject to a special, unusually high bar because we are trying to safeguard the public interest from a particular class of scam.

For example, a company might come along with a $56,000 Alzheimer’s pill that doesn’t have any clear evidence of efficacy. If you want to try to sell a $56,000 dietary supplement, then that’s between you and your sucker customers. But there is a general presumption that programs like Medicare, Medicaid, and subsidized private insurance plans will cover authorized prescription medications. So there is a real opportunity to damage the public interest with scammy products here. And we need the FDA to protect us. Now as it happens in the case of this drug, the FDA isn’t protecting us. But that’s its function; that’s why we need a fussy scientific agency with a high bar for approval.

But then in a crisis, you maybe want to be less fussy. Hence the FDA, rightly, was handing out EUAs like candy for various Covid treatments all throughout 2020.

In the crisis, we don’t really worry that we might be wasting money on convalescent plasma. We don’t have rigorous evidence that it works, but there are some general medical science reasons to think that it might work. And if a patient and his doctor want to try it, it seems counterproductive to block them. If nothing else, letting the treatment move forward is a good way to gather more data. But the FDA rightly emphasizes that it is not actually endorsing convalescent plasma, just as the FDA does not endorse dietary supplements. They are saying that in light of the emergency, and given that there’s no widely available and clearly superior treatment, they’re not going to stop you from trying the experimental therapy.

But that is not what doctors, scientists, and public officials say or believe about the vaccine.

Everyone wants people to get the vaccine

If you just listen to what anyone is saying about the Covid vaccines, they are endorsing them.

The acting director of the FDA and her Trump-era predecessor are encouraging people to get vaccinated. The director of the CDC and her Trump-era predecessor are encouraging people to get vaccinated. The President of the United States is loudly encouraging people to get vaccinated, and his predecessor is quietly doing so. The Surgeon General says you should get vaccinated. Dr. Fauci says you should get vaccinated. It’s possible these people are all lying and full of shit or something, but as a journalist, I am simply conveying what’s clearly true — all the people in positions of authority are endorsing the Covid vaccines and encouraging you to take them.

In other words, they are acting about the Covid vaccines the same way they’d act about a long-approved antibiotic or the measles vaccine, not the way they’d act about a dietary supplement. They are not saying you are allowed to get vaccinated, they are saying you should get vaccinated. Indeed, that’s not just their medical advice to you — it’s their stated belief (and I agree) that getting vaccinated is a pro-social means of safeguarding your entire community.

So I am saying, with a full understanding of the process, that the FDA ought to bring the official regulatory status of mRNA Covid vaccines into line with the scientific community’s actual understanding and attitude toward the vaccines.

The government is not worried that Pfizer and Moderna might be running a scam on us. They are charging $20 a dose, not $56,000. We are begging people to take these shots. So we should act like it.

Formal approval matters

Some people have convinced themselves that formal approval is irrelevant because everyone who’s not vaccinated at this point is like a Q-pilled Trump fanatic who wouldn’t possibly believe what the government says.

I am skeptical.

Donald Trump got 5% of the vote in the District of Columbia, and I know at least one Trump-voting D.C. resident who is definitely vaccinated. But according to the New York Times, only 61% of D.C. residents are fully vaccinated. Only 75% of D.C. seniors are fully vaccinated. Those are not all Trump voters.

They have their own reasons for suspicion of the medical system and that’s all well known; I’m just saying they’re not living in a hermetically sealed information ecosystem. And right now if someone says to you “look, the mayor and the president don’t want to mention this, but these are experimental vaccines that the FDA hasn’t even approved,” that’s not misinformation — that’s true.

Now if I went around tweeting all day “don’t take the vaccines unless you’re highly vulnerable, they’re experimental treatments the FDA hasn’t approved because they say they don’t have enough safety data yet” people would (rightly) get very mad at me. Spreading that message would (rightly) be considered an anti-social and chaotic thing to be doing. But the message is true, and a good way to cut down on its spread would be to make it not be true, rather than trying to informally stigmatize saying it.

And really scroll around the map.

  • In LA County, 62% of adults are fully vaccinated.

  • In the Bronx, 56% of adults are fully vaccinated.

  • Even in a really high-vax county like Multnomah in Oregon (Portland), it’s only 75% of adults.

It’s true, obviously, that the best places to boost vaccination would be the big low-vax swathes of the country in red America. But there are clearly lots and lots of people who are not hard-core right-wingers who still haven’t gotten vaccinated, and I think part of it is that progressive America is not actually aligning around this in an appropriate way.

Low-hanging mandate fruit

Another issue about the lack of authorization is that many institutions, including the U.S. military, believe they legally cannot or should not mandate a vaccine that is available exclusively under EUA. There turns out, inconveniently, to not really be any case law on this. But I think it’s understandable that most major institutions want to tread cautiously here in the absence of a clear FDA thumbs up.

I also think that sensible people are, rightly, a little wary of poking the bear too hard with mandates.

Right now some conservative elites have been very irresponsible in their vaccine-related statements, but others have been constructive. What we don’t want to do is create a meta-issue that induces responsible conservatives to start doing lots of anti-mandate politics and further exacerbate polarization. We ought to tread somewhat cautiously with mandates. But “somewhat cautiously” still means “bolder than what we’re currently doing.”

  • The military, in particular, is a big lever. Servicemembers are routinely required to get vaccinations, including annual flu vaccines, and the military is not an institution where individualism is a core value.

  • Tony Evers and Gretchen Whitmer shouldn’t launch divisive fights about this, but solidly blue states could make vaccines mandatory for K-12 teachers, staff, and eligible students without too much fuss.

  • The CDC’s current rules on international travel feature a testing requirement that should be switched to a vaccination requirement.

  • It should not be hard to nudge private colleges and universities into adopting vaccine requirements.

  • OSHA has been fairly derelict throughout this whole pandemic in terms of specifying Covid-safe work conditions. They ought to tighten the screws around ventilation, provision of quality masks, and other relevant criteria while also making clear that vaccination is a good alternative form of compliance.

We should also forcefully address the concern that vaccine side effects will force you to miss a day of work by finding a way to interpret the special Covid paid leave law as covering vaccine recovery. That will put some people’s minds at ease. Plus some people might go get vaccinated, experience zero side effects, and take the recovery day anyway because people like time off. That would be great! The point is to get more people vaccinated.

One thing that I think is a little underrated in the discourse is that if you inhabit a social circle where the conventional wisdom is that Covid has been overblown from the start, young and healthy people have nothing to fear, and the whole thing is hysteria driven by panicky libs, then you may need an excuse to get vaccinated. If you and all your friends talked yourself into the idea that holding Thanksgiving dinner last fall and continuing to dine indoors through the winter of 2020-21 was a heroic act of courage, then it’s reasonably likely that going to get vaccinated looks like an act of cowardice. And that can be true even if you, personally, would rather hedge and get the shot.

But if you get the shot not because you’re “afraid” of Covid but because you have to for school or because you’ll otherwise have to wear an N-95 mask at work or because it’s a good way to scam yourself into a day off, then that’s fine.

Market like it matters

To the extent that one of the things we want to say is that over and above your personal preferences, you are doing good for society by getting vaccinated, then we ought to pay people to get vaccinated.

You can get a good debate going on the internet by arguing over how much we are dealing with “hesitancy” to get vaccinated versus structural barriers to vaccine “access.” But one thing that helps people overcome barriers to access is money. And one thing that helps people to overcome psychological reluctance to do something is money. In general, one of the great virtues of money in life is its flexibility that allows you to bypass the need for a structural diagnosis of exactly what is needed.

This program in D.C. where you get a $51 gift card seems good to me, and I only wonder why it isn’t more broadly publicized.

But this brings up another example of the utility of full authorization. American media is full of commercial advertising campaigns aimed at getting people to “ask your doctor” about various kinds of prescription drugs.

You can’t market off an EUA, and the vaccine makers have been persuaded to accept low margins for these products. Give a full authorization, bump up the payment rate, and watch the Pfizer and Moderna marketing campaigns explode. Give Donald Trump a bunch of money to be a Moderna pitchman and give LeBron James or whoever a bunch more to do it for Pfizer.

Start with the easy stuff

My big point about this is that the elite discussion of vaccine resistance seems a little bit perversely focused on the hardest problems. How do you persuade distrustful people who live in communities where trust and vaccination levels are so low that you need to be obsessed with avoiding political backlash? I’m not sure.

So we should start with the easy stuff.

Get the FDA to stop fueling vaccine resistance. Let institutions that don’t need to worry about backlash roll out mandates. Somehow Los Angeles County is reacting to Delta by trying to re-impose a county-wide mask mandate but hasn’t mandated vaccination for its own sheriff’s department. In D.C., we’re hand-wringing about schools in the fall but we’re not mandating vaccination for teachers or kids over 12. Offer people some money and some time off to get their shots.

All of this will improve the vaccination rate, which is good. It will also increase the share of the non-vaccinated population who have people in their social circle that have been vaccinated and may serve as validators.

For all the talk right now, we’re really barely doing the minimum to encourage vaccination and we really ought to step it up before our hospitals get in trouble and a new wave of efforts to impose restrictions on social and economic life go back to tearing the country apart.