Strong-Arm Tactics Won't Get America Vaccinated | MedPage Today
Strong-Arm Tactics Won't Get America Vaccinated
— It's time for bolder solutions
by Vinay Prasad, MD, MPH August 3, 2021
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. [and worse- they are involuntarily subjecting unsuspecting members of their family, community, school, church, and work site{this could amount to thousands in a week]to the same deadly threat especially if they survive and our debilitated by the strong haul disorders. Plus the unvaccinated persons could be incubating the Virus that could lead to further mutations and transmitting these viruses to their children and others in the community. You are glossing over this directly attributable risk especially if the Rt is over 1.5 for instance. Velandy Manohar, MD}
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.[And they suffered devastating consequences in 2020 in every state- The Mathematic Report in CT documents this. My communications on Covid-19 posted on CAC website associated with OHS-CT will attest to this as well the posts at my website velandymanoharmd.com addresses a wide spectrum of challenges we have experienced and addressed at my company and worked in the Community Engagement and Outreach Standing committee of CAC of OHS -CT]
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.[You are so cavalier about this. It is shocking, You know we can’t get to 755 of the whole population if we don’t have a safe and effective vaccine to protect children under 12. The proportion of children being infected and hospitalized has multiplying exponentially as the rest of the population. This is totally unwise because this Virus could have mutated many times and produced malignant COVID -19 forms. Further by the time we reach 70% target the people who received vaccines in spring of 2021will need booster doses or even a newly designed Vaccine especially for immune suppressed individual. Further by the time we get these revaccination targets done and vaccinate previously hesitant persons we will have lost thousands of unvaccinated persons to the Virus before the day long into the future we reach the 75% vaccinated target.VM] 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.[This totally unethical and medically untenable to withhold requisite care that they are entitled to are from persons who are hesitant for any one of several reasons in extremely patriarchal authoritarian manner. Plus , we will need to vaccinate for the first time Children under 12 and with a safe and effective vaccine across all population groups in expeditious manner to allow them to go to school in person.VM
- Quit while you are ahead. Eventually, the campaign to vaccinate the hesitant will need to end. [You are totally off the mark . The virus is changing all the time and the immune response generated by the current vaccines to a particular strain of the virus will be losing its capability to elicit protective immune responses. The campaign to vaccinate against COVID- SARS-2 variants is not likely to stopped until we have slowed the transmission and reduce the Rt to 0.9 or less. And we determine how best to keep up the protected proportion of the population by continuing preventive measures, testing for positivity rates -PCR tests would be most helpful, and typologically tracking the changes in the variants and the capacity of the currently administered vaccines to protect people even if they are carrying the virus in their naso-pharynx.
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.