Surely Right

Sure is on fire. From the comments to my post, Yglesias on Operation Warp Speed and the Republicans.

As a crazy person who argued for skipping phase III and going directly to an open label, voluntary phase IV study I think the real problem came with the mandates.

The right has a very strong personal independence streak and above all they despise it when some mandarin explains that the government, but also major corporations and academics, can bring the full force of law to bear to compel compliance (particularly in a world where any attempt to do so for right-coded things like abortion is suddenly the coming of the apocalypse). It is one thing to have a guy like me point out the historical track record for the side effects of vaccines (pretty much universally among the lowest for any type of medical intervention ever tested), it as another to have organized campaigns where people get fired. And it is particularly galling when the basic science shows these sorts of mandates are woefully wrong. Job loss doubles the risk of suicide, which means that for any cohort outside of the elderly and severely immune compromised, a vaccine mandate enforced by recission of employment is expected to kill more people than could have been reasonably avoided with even wildly effective vaccine mandates.

And it was further made much, much worse when the public health folks doubled down on medically illiterate standards….And of course any comparison about how people making decisions that fostered disease transmission with Covid and HIV is going to be very hard to avoid a bunch of cultural diktat that rubs conservatives the wrong way.

As in many cases, vaccines ran afoul of the ability of folks to increase their petty empires. They became a way for the goodthinking folks to exercise control and dominion over the ignorant. And exactly as predicted by culturally competent medicine or any cursory study of human nature, these high-handed methodolotrous actions will not induce much compliance, but will instead polarize the medicine and risk one of the greatest medical achievements of all time – childhood vaccinations.

So where do we go from here? I would submit that it is going to require some clear and objective limitations on public health powers. It is going to require public apologies and maybe compensation for folks who made medically valid claims that their prior infection resulted in sufficient immunity to avoid vaccination or repeated boosters. Some public and high profile olive branches are going to need to be offerred to the resistant. And it is going to have to involve some tradeoff between the rights of corporations to dictate the terms of business they offer and the rights of individuals to make medical decisions free of compulsion going forward. At the very least we are going to need to have some semblance of similarity between how corporations can handle folks who are HIV+ (or likely to become so) and how they handle folks who are unvaccinated.

…But will not mandates work? Well empirically they failed massively with Covid.

…Well among health care workers in 2019 (i.e. before Covid mucked everything up), health care workers were ~80% vaccinated against influenza. And if you had a straight requirement to get vaccinated? It brought the number up to 97%. Which is fine, except for the fact that resistant healthcare workers self-select into non-mandatory positions (e.g. long-term care positions). Absent a safety valve into remunerating work, we see the same fracas that happened with Covid.

So adults, even among the most medically literate professions with the strongest mandates for uptake, still do not vaccinate enough to prevent epidemics.

So how did we get vaccination to work in the first place? We had a brief window in the mid 20th century when people remembered their kids dying from these diseases and were wildly more trusting and cooperative than ever before in American history (you back when we set records for church attendance, trust in politicians, and marriage rates). And we created a strong cultural norm that kids get vaccinated before going to school.

That is weird. It does not fit with normal American practice. And for the love of God do not muck with it. If the kids ever revert to the natural habits of their parents we are talking about very bad juju.

Which is precisely why the only sensible position is to advocate for early and widespread vaccine access, be highly critical of all the politicking about vaccine timing around the election, and to avoid mandates unless you intend to enforce them at gunpoint. Keep the damn vaccines out of politics because once they go in, it is damn hard to get them out. Give people as early of access as they want and be straight forward that we will continue phase IV safety studies even as we roll out access. And we will not do mandates absent a direct democratic initiative to give it all the legitimacy in the world.

Because we live in a world where the default is not to vaccinate, politics poisons everything it touches, and the childhood mandates are historical accidents that could very well fall to concerted political action.

Eat the horse a bite a time, educate the patients, and pay the danegeld to Trump to soften the blow. But going all high handed and making this political (at all, in any direction)? I can think of few stupider things to do.

For more on reactance see also Bardosh et al. The unintended consequences of COVID-19 vaccine policy: why mandates, passports and restrictions may cause more harm than good, an excellent piece I am still stunned was able to make it into the BMJ (kudos to them.)


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