Like most healthcare professionals, I am worried about unvaccinated adults. Currently, just shy of 50% of Americans have been fully vaccinated, and there is a sizable percentage of adults -- even older adults -- who remain unvaccinated. These people are taking tremendous personal risk of getting severely ill from SARS-CoV-2, and we must consider bold and innovative tactics to overcome their access issues and hesitancy.
Yet, each day on Twitter and in the op-ed pages of the news, I read more and more calls for force to be applied. We have seen suggestions for vaccine passports -- used at movie theaters, restaurants, sporting events, and bars. We have seen calls to ban unvaccinated individuals from attending colleges or universities. Finally, many have asked private employers to issue vaccine mandates, and fire workers who don't comply. The federal government has issued a vaccine mandate, but federal employees who are unvaccinated can remain employed if they undergo testing, masking, and distancing requirements. Some have said this doesn't go far enough, and their employment should be contingent on vaccination. Finally, most recently, some have cited Supreme Court precedent that would lay the grounds for the federal government to mandate vaccination, under threat of fine or worse (notably the CDC director says this won't happen).
Easy tiger! Look, I share the frustration, but I also want to think through the consequences of applying more and more pressure to vaccine-hesitant and vaccine-curious individuals. I want to explore just one key question: Will it work?
Right now, it might be tempting to cite data about seat belt compliance after laws were passed, smoking rates over time, or childhood vaccination uptake when schools began to require it, but those data are not relevant to the moment. What we have is truly unprecedented. We are more politically and tribally divided than ever before. And, more to point, the behavioral change we desire -- getting vaccinated -- has to happen in the next days to weeks. It can't happen over the course of years, as some of these public health efforts required. Changing seat belt use took decades of laws and persuasion. That's just too slow for vaccines. For these reasons, these data are simply irrelevant.
What we do know is that polling shows that about 13% of people are definitely opposed to vaccination, and about 6% or so state they will get it, but "only if required." Because people are reluctant to admit unpopular views, and people who hold unpopular views may be less likely to participate in polling, these results may be a distorted version of America. I suspect the true percentage of people willing to take the vaccine only if required is smaller, and the percentage stubbornly opposed is larger.
As we start applying pressure to increase vaccination, we will see gains. I suspect those gains will max out around 5% -- real world results are usually less than expected -- but there will be some consequences. Some kids will not go to college. Some people will be fired. Some folks will be banned from the local restaurants and bars.
And so, the key question becomes: What will these people do instead? Will they be happy? I doubt it. Displaced individuals may congregate together -- groups of unvaccinated people -- and have a party in lieu of going to a bar. Unemployed individuals may head to bankruptcy, eviction, depression. Some college kids who decline vaccination may forgo higher education. Could these negative social consequences increase -- rather than decrease -- the total viral spread in the nation? These consequences may increase the cumulative replications of the virus, and ergo, the potential for a new variant to emerge. It is easy to think that all it takes to get people vaccinated is pressure, but sometimes pressure is like squeezing a balloon.
Worse, we are living in a volatile country, meaning there is the risk that some unvaccinated individuals who get pushed out of college, a job, or the bar engage in an act of violence. In this case, any COVID-related health gains earned by these efforts are simultaneously damaging to other aspects of health and well-being.
It's easy to feel frustrated, but that just means it is time to think outside of the box. Sometimes the direct solution is not the best. Allow me to offer some alternatives.
Some Bold Solutions
First, I must begin with the most important disclosure. You will never make substantive progress unless you carefully experiment and measure what you achieve. I would use stepped-wedge or cluster design for all my suggestions and test and scale up what works, and abandon what doesn't.
My second suggestion is that you prioritize the people you need to overcome hesitancy the most. In this case, the top priority is employees of long-term acute care (LTACs) hospitals and nursing homes. The reason is obvious -- they care for the most vulnerable.
Now, for my suggestions:
- Offer cash prizes for vaccination. $500, $1,000, even $10,000 to get vaccinated. Current financial incentives, such as the $100 New York City is offering, don't go far enough. I suspect for LTAC workers, tens of thousands of dollars may not only be cost-effective but cost-saving. This can be offered at the place of work.
- Offer beer, parties, travel, tickets, laptops, and other prizes. And deliver these and vaccines where people are -- at workplaces, grocery stores, restaurants, churches, and music venues, in exchange for vaccination.
- Identify and empower local ambassadors. Reach out to church and community leaders. Give them resources without restrictions to encourage vaccination.
- Tie vaccination to binding legislation that we can never reinstitute restrictions again. Pass a bill that says if 70% of the population gets vaccinated, governments cannot institute mask mandates for a 5-year period or businesses cannot be closed if local vaccination rates exceed 75%. Pick the percentages, and times, and make it binding. It's worth the risk of losing one tool, and like all agreements, renegotiation may be possible if needed.
- Last call for vaccines. Announce that at the end of the month we are going to ship all the vaccines to India, Brazil, and Argentina, and make good on that promise. If you don't get it now, you can never get it. A deadline can be a powerful incentive.
- Quit while you are ahead. Eventually, the campaign to vaccinate the hesitant will need to end.
The sad truth is that our politics are so poisoned that there may come a point where we are stuck. We absolutely won't get the vaccination rate any higher. When that point comes, the reality is we have to live with it. The risk of severe illness and hospitalization to a vaccinated person -- even with Delta -- is still very low. Trials for vaccinating kids are ongoing. Randomized trials for boosters in vulnerable adults can be studied. And after all these efforts, successive waves of coronavirus will still strike, until natural immunity fills in the gaps.
When we truly max out on vaccination, harm reduction is the best we can hope for. This isn't a sad conclusion, but a conclusion that our ancestors have known for thousands of years. Life is not zero risk, but we get on with it anyway.
Vinay Prasad, MD, MPH, is a hematologist-oncologist and associate professor of medicine at the University of California San Francisco, and author of Malignant: How Bad Policy and Bad Evidence Harm People With Cancer.