The triumph of the Covid-19 pandemic has been the development of safe, effective vaccines in mere months. Vaccines are costly and slow to develop, and yet we had two, from Pfizer/BioNTech and Moderna, available within about eight months of the arrival of Covid-19 in the US, each with more than 90% efficacy. That is a remarkable technical achievement and represents the culmination of years of investment in the development of mRNA as a viable vaccine delivery platform. The rollout of vaccines at the beginning of 2021 was met with deserved enthusiasm, and predictions of a “summer of freedom” when sufficient numbers of people would be vaccinated to have essentially curtailed the spread of the Covid-19 pandemic.
And yet, once vaccines were made widely available, uptake was far slower than had been generally anticipated in the euphoria. While a substantial proportion of Americans rushed to get vaccines—and we were among that group—the number of people willing to get vaccinated soon stalled, with more than a third of Americans hesitating or downright refusing. This, reasonably enough, occasioned its fair share of public consternation and discussion about how best to increase the proportion of Americans vaccinated.
This conversation inevitably turned to mandating vaccines for adults, recognizing that that would create the conditions for a more rapid return to “normal” functioning. Many workplaces did indeed mandate vaccination, leaning on their prerogative to create safe workplaces. This was initially a phenomenon of private workplaces, but soon extended to public sector employers such as fire departments and schoolteachers. The question then of course extended to whether we can, or should, mandate vaccines for all adults.
We shall leave to others to discuss the ethics of vaccine mandates for adults, but note here our concerns about such an effort that emerge from a pragmatic understanding of the problem at hand.
First, the mechanics of widespread vaccine mandates for all adults are daunting and next to impossible in a pluralist society. Operationally, how would we identify defiant adults and would we penalize or arrest them?
Second, restricting public services that are available to those who are unvaccinated quickly starts to restrict access to fundamental needs of citizenship, putting the very idea of vaccine mandate at odds with what we think citizens can reasonably expect. Would we, for example, deny access to post offices, to social security offices, to hospitals to the unvaccinated?
Third, while the vaccines that are available are extraordinarily safe and effective, we suggest that the bar for a state-mandated treatment or vaccine of any kind needs to be sufficiently high as to be, without the shadow of a doubt, not only completely safe but also necessary. The evidence on the waning pandemic suggests that we are likely to reach a point of few Covid-19 deaths and a low rate of new infections without blanket mandates being necessary.
Fundamentally, applying a whole population vaccine mandate would need to weigh whether the cost in mistrust and antagonism would be justified. It is hard to square how the inevitable scenes of resistance to the vaccine that would undoubtedly harden opposition—even if among a few—can be justified given the profile of this particular pandemic, with low severity except among small subgroups of the population.
All in all, we fall on the side of extreme caution when it comes to considering efforts such as mandating population-wide vaccines. The price to be paid for generalized vaccine mandates going awry may well come back to haunt us in the future when such an effort may truly be needed. Covid-19 is not that instance.
Michael Stein & Sandro Galea
As we re-emerge from the pandemic, 2021 stands to be a turning point year for public health. In The Turning Point’s weekly essays, we reflect on what we learned during 2020, and what we are learning during 2021, that can guide us to the creation of a better, healthier world.
Please note, this week’s The Turning Point does not include a video.
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