Thursday, July 15, 2021

None dare call it politics

When it comes to addressing Covid-19 vaccine hesitancy, public health campaigns fall down on the job. 

I'll focus on one example. It's an article published at the University of Michigan Health website, titled "Who has the right to ask if you're vaccinated?" (url at <https://healthblog.uofmhealth.org/wellness-prevention/who-has-a-right-to-ask-if-youre-vaccinated>, accessed May 9, 2021). It sets out to expose what it calls the "false controversy" about "covid passports." Covid passports refer to the idea that businesses and certain government services, such as schools, should have the authority to require their patrons and charges to prove they have have been vaccinated against covid-19. Presumably, one way to facilitate that would be to issue documents, or "passports," that the vaccinated can show to gain entry.

The arguments the article makes seem designed to convince no one. They make a caricature of the objections that people may have about covid passports and about the covid vaccines generally. In doing so, they represent the way that public health campaigns often fail to promote public health.

The argument

The article's key argument is that the state and private businesses ought to have, and have had, the longstanding and acknowledged authority to predicate access to services on vaccination or immunity to diseases. Common practice and the U.S. Supreme Court have all validated mandates against, for example, smallpox, and those mandates were more stringent than anything people are currently proposing for covid-19 vaccinations. 

The article also says that current requirements still allow for choice. People are not literally forced to take vaccines. But when they decline, they face certain consequences, among them denial of services or entry. Further, it notes that most compulsory vaccine regimes allow for religious or medical--and sometimes, more recently, "philosophical"--exemptions. Finally, the article notes that patient privacy provisions of HIPAA, the Health Insurance Portability and Accountability Act, offer no exemption, and claims to the contrary represent a misunderstanding.

Where the article goes wrong

Circular reasoning

The article quotes a historian of medicine:

They [covid passports] don't take your freedom away....In fact, they increase your freedom because they allow you to travel where you want to go and do what you want to do....
And yet, the reason they "allow you to travel...," etc., is because they exist in the first place. Removing or not implementing vaccine requirements would also allow you to do those things. Of course, part of what that person probably means is that a system of vaccine requirements allays fear of disease, and allaying that fear goes a long way to "freeing" us to do the types of things we want.

Over-relying on precedent

The article repeatedly makes the point that vaccine requirements are quite common and have been for a long time. It notes that before covid, most people had to fulfill vaccine requirements to do such things as attend school. It also notes that in the past, public health mandates, including vaccine requirements and other more intrusive measures, have been implemented in regulating travel and immigration. Those are all examples of

...the long-established right for public institutions such as schools, employers, governments and businesses to protect the health of others by requiring individuals to provide proof of vaccination or of a past infection, or seek a medical or religious exception.

The article's point should be heeded. Covid passports and mandatory vaccines are indeed part of an established way of doing things. They're not some novel usurpation of our rights. It's important to point that out because most of us, even the historians among us, tend in our day-to-day lives to think of developments as unprecedented.

Still, we should be wary of the "it's always been done this way" justifications for policy. Even if we assume that prior policies were always justified and well calibrated to the needs of the time, we should be prepared to demonstrate why we should impose similar measures this time. Maybe precedent gives us a guide, in the sense that mandatory vaccines seem to have worked in the past, so it will probably help now. But the demonstration still needs to be done.

Add to that point the possibility that mandatory vaccine regimes and other public health measures sometimes worked against what at least some of us might call justice. The article notes that immigrants arriving at Ellis Island could be turned back if they couldn't prove that they had a smallpox vaccine or that they had had smallpox. It also notes that "from the late 1980s until 2010, people with HIV/AIDS could not travel or immigrate into the United States...."

Might makes right

While making an idol of precedent, the article also makes an idol of power. It links to the 1905 case of Jacobson v. Massachusetts, which according to the article affirmed states' authority to require vaccines. As far as I can tell, the case did just that, and subsequent court decisions have upheld most (all?) vaccination mandates. Those precedents do indeed suggest that vaccine mandates are within the pale of established policy options.

But let's remember that relying on judicial precedent is also another way of saying you have the strength of the state on your side. If you challenge the mandates, the state is powerful enough to win. Therefore, you shouldn't try because the pro-vaccine policy is stronger and you'll lose.

Maybe that's good advice. The likelihood that you will lose is a pretty good prudential argument against lodging a protest. But that doesn't mean the protest is in therefore wrong or that the policy protested is therefore right. I can think of other practices the courts have authorized that I wouldn't endorse. You probably can, too.

When you invoke the state's power, you're playing a potentially dangerous game. The same power that sides with you might shift against you. Even the Jacobson decision makes a similar point. While it did indeed uphold the states' power impose vaccines, the decision left open the possibility that the power to require vaccines might not be absolute. To wit [bold added by me]:

....it might be that an acknowledged power of a local community to protect itself against an epidemic threatening the safety of all, might be exercised in particular circumstances and in reference to particular persons in such an arbitrary, unreasonable manner, or might go so far beyond what was reasonably required for the safety of the public, as to authorize or compel the courts to interfere for the protection of such persons.

"Watch out, it could be worse"

I don't know if this is an according-to-Hoyle fallacy or just a manipulative move, but the article does a little two-step that strikes me as disingenuous. It goes over the very robust vaccine mandates that eradicated smallpox in the U.S. and the world. It then says,

No one is saying all Americans must get vaccinated against COVID-19, unlike the mandatory smallpox vaccination requirements of the early 20th century that made it possible for the entire United States to become free of outbreaks by the late 1940s.

That strikes me as equivalent to saying, "you think you have it bad now, at least it's not [cue in some thing everyone acknowledges to be worse]." That's a pretty handy trick. During the Iraq War, it was possible to say, "at least this isn't Vietnam and at least there's no draft." During Vietnam, it was possible to say, "at least this isn't World War II." I'm not sure what people could say during World War II ("at least it's not the Thirty Years War...."?). But you get my point.

As for "no one is saying" all people must get vaccinated, that's probably technically true in the sense that (almost) everyone allows for an element of choice in vaccination. And I'm not aware of anyone suggesting criminal charges or fines in the way that, say, the Jacobson case addressed. (Those refusing a smallpox vaccine were fined five dollars, a hefty sum in 1905.) In fact, today, you're likely to be rewarded with lottery tickets, free donuts, pizza, and other prizes.

But the "no one is saying" trope is misleading, too. The premise behind even the gentlest vaccine mandates is that all people eligible for vaccines will face some negative consequences if they choose not to. Sure, "all eligible people" is different from literally everyone. And "face some negative consequences" is softer than "must." But "eligible" in today's situation seems to boil down to traits you can't control (age, proven allergy to vaccine ingredients). And "negative consequences" are still negative, even if they're designed to inconvenience people as little as possible.

If you wish to impose obligations on people and you have good reason to do so, then do it. But don't pretend you're not. And don't hide behind the fact that in other scenarios even more stringent obligations have been imposed.

Misconstruing privacy objections

The article takes on people's misunderstandings of HIPAA, the Health Insurance Portability and Accountability Act, and particularly the privacy provisions of that act. I didn't know this before I read the article, but some people who oppose vaccine mandates (and mask mandates) claim that those mandates violate HIPAA affirmed privacy protections. 

The article says that's a misreading of HIPAA. The act applies only to certain agencies and forbids them to release private health information without the patient's consent. It doesn't forbid businesses and government to require disclosure of one's vaccine status.

The article is probably right about HIPAA. But there is another privacy concern that vaccine mandates entail, especially if they're translated into covid passports. The mandates compel people in some circumstances to disclose that whether they've undergone a medical procedure, a procedure in which someone injects into their body a foreign substance that recalibrates their immune system. While most vaccines have been proved to be very safe, they still come with some risks for some people for some of the time. And there simply hasn't been enough time to find out if covid vaccines are as safe as those vaccines.

Another privacy concern: Some people have philosophical and religious objections to vaccines. A mandate requires them to choose whether to honor those objections and to make their very personal beliefs public. I admit that that particular concern doesn't strike me as very ominous or intrusive, but that's easy for me to say as someone who doesn't hold those beliefs.

No, vaccine mandates don't violate HIPAA, but they do touch on privacy concerns.

The denial of politics

The article denies politics. That's a poor choice for a public health announcement.

The denial is not total. The article accepts that vaccine mandates are political in the sense that they've become a partisan issue, a feature of what people like to call the "culture war." 

But the article is denying politics in a deeper sense. It's a type of politics which feeds the partisan divide but which would remain even if the divide were to vanish. This is the type of politics that comes from people using power to convince other people to do something they don't want to do.

Vaccine mandates identify a public interest. It's an interest in herd immunity, in easing the stress on our health care system, and in limiting the number of people who contract and spread a potentially devastating and fatal disease. To serve that public interest, vaccine mandates compel some people to get a vaccine even if they don't want one. "Compel" may seem like a harsh word because the types of compulsion under discussion are mild. But predicating access to some services on vaccination status, which is what covid passports do, is a form of compulsion nonetheless.

The article calls concerns about covid passports and vaccines a "false controversy." Its author seems to fear that if we call those concerns a real controversy, we legitimate them.

An analogy (my analogy, not theirs) would be "teaching the controversy" between young earth creationism (the belief that the earth was created by god about 6,000 years ago) and evolution in a biology class. In that case, teaching those opposing views of the world suggests a controversy where none exists. While there are some outliers, almost all biologists base their understanding of biology on evolution. In fact, the field of modern, professional biology is so tied up with evolution-based explanations that it's unquestionable and one must go beyond the field of biology to challenge it. Similarly, it's probably true that most scientists and public health officials really do agree that the vaccines are generally safe and that some sort of mandate falls within the pale of common and acceptable practice.

But I can think of two ways that analogy falls short. First, the public health consensus on the safety and effectiveness of the covid vaccines is of  necessity provisional. There's a lot we don't know and cannot know at this early date. And while most public health officials probably endorse some form of mandatory vaccines, they might not necessarily agree about where to draw the line.

Second, the controversy is indeed real as long as a significant number of people dislike the mandates and don't wish to get vaccinated. Otherwise, public health officials wouldn't spend so much time demonstrating that the controversy is "false" in the first place. (Similarly, young earth creationism vs. evolution is also a real controversy outside of biology. If we're talking about politics, sociology of religion, or philosophy, young earth creationism then merits a more respectful hearing even if one ultimately argues against it.)

Maybe I'm engaging in circular reasoning of the sort I accuse the article of above? Possibly, but if so, it's circular reasoning with legs. It's not a controversy only because I'm assuming it into existence. It's also a controversy because a significant number of people are so hesitant about the vaccine that other people are considering, arguing for, and justifying coercive measures to compel people to take the vaccine. So yes, maybe I'm saying "it's a controversy because it's a controversy." But it's a controversy nonetheless.

What to do?

It's easy for me to criticize others. The question is what's the alternative?

Be honest

Why not at least acknowledge the conflict? Public health advocates can say something like this:

Yes, this is political and yes, we are compelling you to do something very personal to yourself against what you see as your best interest. It's regrettable that we have come to the point where we are doing this, but we're going to try to do this in the least intrusive and most respectful ways possible. We'll never hit the sweet spot, where what we mandate is perfectly tailored to all persons' sensitivities and needs and where the mandates are in every instance fair. But we'll try our hardest to get closer to that point.

If you disagree, then we may very well choose to invoke the power of the state or encourage private businesses to restrict your access to their services. While we will choose to do that, we respect the fact that you disagree.

Show that while you're relying on the stick, you're doing so in what is probably one of the least intrusive ways possible. Or if there is a less intrusive way, own and account for your decision to be more intrusive (e.g., "we hope to get a greater number of people vaccinated....").

Acknowledge there's probably risk involved to vaccines. If the data so far suggest the risk is very minimal, then say so. But when the data is provisional, acknowledge that as well.

You can rely on precedent to demonstrate that today's response is not really out of the ordinary. But at least acknowledge that "we've always done it this way" isn't much of an argument, even when it's true. 

Will it work?

I was going to argue that nobody reads a public health announcement, like the one issued by the University of Michigan, and then jettisons all their concerns and embraces whatever the announcement advocates.

But I can imagine a couple objections to my "let's be honest" approach.

Crocodile tears

First, it sounds a little like crocodile tears, a perfunctory expression of regret for doing something you were always going to do and which you don't regret all that much anyway. I suppose that can be a turnoff. 

Persuasion works in mysterious ways

Second, it's quite possible that I'm more pro-vaccine (and pro-covid vaccine) than not thanks to the general attitude that public health officials have adopted. If they had chosen a more ambiguous position (and yet one justified by available evidence), perhaps I'd be much more hesitant. 

The face is that I tend to trust what Very Serious People In Power tell me. I say that even though I consider myself a science skeptic. I suppose I'm a little like the anti-vaccine politician who is among the first in line to get the new vaccine.

So maybe my recommendation won't work. Or more likely: it will work along some margin and among some people, but it may very well steel a number of others in their opposition.  It might even discourage people who might otherwise be open. All that said, I do think my approach would work better than the politics denial the University of Michigan article--like so many others--engages in.

Truth is a value

People--yes, even non-credentialed non-scientists and even people who vote for the presidential candidate you oppose--tend to respect and believe in truth. There's something to be said for honesty for its own sake. Honesty is almost always the right way to go.

To be clear, I'm personally not a believer in radical honesty. I think it's sometimes okay to lie. I believe that the good part about lying sometimes outweighs the bad for practical reasons. I also believe that lying is sometimes, though very rarely, morally right. I can even envision hypothetical situations in which a responsible public health official might have to utter a "noble lie" for the greater good. 

Even so, those cases, in my view, are rare. If you do adopt the approach of dishonesty, then make sure you're choosing wisely. As the article preaches, "actions have consequences."

Sendoff

In case you haven't figured it out, I'm pro-vaccine and pro-covid vaccine. I urge most people who are eligible for the vaccine to get it unless they have some risky counter-indication for it.

I'm also not theoretically opposed to "covid passports." I do worry about how they'll work in practice. Who issues them? Will there be a fee? What if someone loses theirs? What about the inevitable instances where someone's passport is defective and a business, etc., doesn't honor it? Would the unvaccinated be forbidden to access certain essential services, like grocery stores and health care?

But at the end of the day, most means for mandating vaccines are, in my opinion, minimally intrusive. I'm willing to consider them.

For those who choose not to get the vaccine, I try not to judge. At the same time, I try to stand firm in what keeps me and others safe and in what policies I endorse after due balancing of interests. I often fail in my efforts. I judge others when I should try to understand, and I refuse to draw lines when I otherwise ought to.

So again, please consider getting vaccinated. Please weigh what evidence we have and please weigh how your actions may affect others. And please be honest with yourself about what you're choosing.

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