Nudging: Rights not to be Vaccinated come with Obligations

​As the world is confronted with  the phenomenon of  people  who insist on their rights not to be vaccinated,  several questions are being raised: Who are they? What are their reasons? Why their resistance to what the science is saying?  How to achieve national and global solidarity?
 
This blog is being written when the Delta  variant among others is leading to an upsurge in the incidence of the coronavirus, globally.  According to the latest CDC projections,  the US is poised to achieve the single worse week with 200,000  COVID cases per day,  leading  Dr. Saju Mathew,  National Institutes of Health (NIH) Director, to pronounce  that  “the Unvaccinated are sitting ducks”. In the Caribbean, The Hon. Gaston Browne, Prime Minister of Antigua and Barbuda, Chair of the Caribbean Community, speaking at the Inauguration of the new CARICOM Secretary General,  Dr. Carla Barnett of Belize,  said that  in many of CARICOM  member states, the percentage of the population that has been vaccinated remains unacceptably low.  The latest figures from the Caribbean Public Health Agency (CARPHA) suggests 23 percent.  In addition, inequitable access to vaccines  has  been further complicated by pervasive vaccine hesitancy.
 
GOFAD combed the literature for empirical research on vaccine hesitaters that would help in the response to the  who, what, why and how raised above.  The most  enlightening analysis was a interview by Ed Yong, a staff science  writer in an article America Is Getting Unvaccinated People All Wrong in The Atlantic July 22, 2021  with Dr.  Rhea Boyd, a pediatrician and public-health advocate. https://www.theatlantic.com/health/archive/2021/07/unvaccinated-different-anti-vax/619523/    
 
The  conclusion to be drawn is that ‘the unvaccinated’ are not a monolith: “they’re not all anti-vaxxers, and treating them as such is making things worse.” They are a diverse group with many reasons for avoiding vaccination.  Some are concerned that COVID-19 vaccines aren’t safe  or that potential side effects aren’t worth the risk of taking them. Others think the risk of getting COVID themselves is low; so, why bother?.  Still others have a resistance to government intervention and see taking the vaccine as capitulation to government overreach and a bane to personal freedoms.  Othersare skeptical of taking vaccines that have not been officially certified by WHO. A small number are simply opposed to all vaccines. What is more, public opinion about vaccination include varied and deep-seated beliefs. These are a  result of the tension between divergent cultural viewpoints and value systems. Several key cultural perspectives stem from individual rights and public health stances toward vaccination, various religious standpoints and vaccine objections, and suspicion and mistrust of vaccines among different global cultures and communities. 
 
Protecting Individual Liberties vs Safeguarding Public Health 
 
Two  studies advance the need to understand the difference between the individual and public health stances. Helen Riess argues for building empathy in health care, requiring public health officials to recognize and respect diverse social and cultural perspectives toward immunization policies, and help support their success and acceptance.                   
 https:greatergood.berkeley.edu/article/item/building_empathy_in_healthcare. Many countries for example require citizens to receive certain immunizations such as those required for children to enter school.  Historically there  have been controversies over the efficacy, safety and morality of these mandatory vaccinations stemming from these two divergent goals.
 
Another perspective is presented in Hendi Larson’s recent book, Stuck: Why Vaccine Rumors Start and Why They Won’t Go Away.  She advises that a more understanding view around vaccine hesitancy is to approach people with respect and dignity, even if you disagree with them. Her main conclusion is to build empathy in health care requiring good public health policies to balance both individual rights and community needs. These are best illustrated by religious objections to vaccines and suspicions and mistrust of vaccines and even political leaders who advocate for their use.  Religious objections are based generally on the ethical dilemmas associated with using human tissue cells to create vaccines,  and beliefs that the body is sacred, should not receive certain chemicals or blood or tissues from animals. They  believe it should be healed by God , prayer  or natural means.  However in most recent statement Pope Paul captures a different spirit when he states that “vaccination is a simple but profound way of promoting the common good and caring for each other.  It is an act of love“  https://www.today.com/health/pope-francis-urges-people-get-vaccinated-calling-it-act-love-t228635
 
 
At the same time, suspicion and apprehension about vaccination are best understood in a social and historical context of inequality and mistrust. For example, the legacy of racism in medicine and the Tuskegee Syphilis Study, a clinical trial conducted with African Americans who were denied appropriate treatment opportunities, are key factors underlying African Americans’ distrust of medical and public health interventions, including vaccination. https://www.cdc.gov/tuskegee/index.html
 
How to get the Vaccine Hesitant to change their Minds : Nudge not Sludge 
 
The question,  how to resolve this public  health dilemma is not straightforward. In a fascinatingly engaging  book by Professor Richard Thaler (University of Chicago), 2017 Nobel prize in Economics and Professor Cass Sunstein (Harvard University) entitled Nudge: Improving Decisions About Heath, Wealth, and Happiness (reviewed by GOAD  May 25, 2019) they make   the essential point that most human beings do not make decisions in the way that is often characterized in elementary economic text books.  In a  follow up publication,  Nudge - Final Version  release August 3, 2021 they provide some interesting recommendations for policy makers intent on combating the coronavirus  to “nudge for good” with well-designed warnings using the power of social norms.  This approach they argue will blunt the “sludge” (barriers, fake news etc.)   by “choice architects” that sponsor the cause of antivaxxers out of self-interest  or even  malicious intent.  Reject mask mandates and social distancing despite scientific evidence of their absolute necessity are the most obvious examples. https://bookshop.org/books/nudge-the-final-edition/9780143137009
 
 
When anti-vaxxers sow distrust about vaccines they successfully sow distrust about unvaccinated people as a whole. This is the reason why it is necessary to ensure that credible and  consistent scientific  information reaches everyone since what is becoming more evident is that the  information gap is driving the vaccination gap.  The language of policy makers  that blames the unvaccinated is sludge because it  misses the critical point that structural barriers maybe a major reason. So for example, Black people in the USA  are one of the least vaccinated groups, in part because they have the least access to preventive health-care services. On a global scale the comparison  is "vaccine apartheid"  between the developed and the developing countries.
 
Yet those who are unvaccinated should not be made a protected class nor should governments  be nudged into giving their personal choice the same anti-discrimination status as race, gender and religion. Instead the emphasis should be to nudgerather than mandate people toward an intervention that maintains freedom of choice and  steers them  in a particular direction.
 

• Hospitals to  require  their employees to be vaccinated for the safety of their  patients. 
• Governments and private sector to require safe workplaces. 
• Verification of vaccination or certification of negative COVID tests for entry into public spaces including travel by  airline and cruise ships etc.
• Imposition of mask mandates and social distancing.  

 
Conclusion 
 
There is so much more to Nudge  Final Version to be explored further (in another blog). However the lessons learned are that nudges  targeting vaccine hesitation should aim to:
 

•  Protect third parties and prevent further public health disasters with dire economic consequences that inequitably affect the poor and dispossessed. 
• Implement  resolute measures to address this growing divide, failing which COVID‑19 will continue to claim lives and destroy jobs, inflict lasting damage to investment, productivity, and growth in the most vulnerable countries.  
• Satisfy certain constraints by  transparent rather than covert or hidden policies. 
• Take into consideration  the interests of the people, consistent with their values. 
• Subject policies to political safeguards, in the sense that if the people don’t like them e.g. uncertified vaccines), they should be able to say, “We don’t want that one" 
• Present policies and programmes that are consistent with national constitutional understandings. 
• Narrow the pandemic divide by collective action to boost access to vaccines, secure critical financing, and accelerate the transition to a greener, digital, and more inclusive world.

 
In the final analysis for nudges  to achieve their objectives they must be compatible with human dignity. They should make people feel safer, better and agree that they have individual rights but also obligations to their communities, nations, and regions to bring an end to the pandemic. There will however always be those "beyond nudging". Imposing sanctions may yet be the only alternative. Above all nudges must be aimed to achieve global solidarity in recognizing that this worldwide  pandemic will further disrupt the lives of the most vulnerable, and countries will see a rise in extreme poverty and malnutrition, shattering all hope of attaining the Sustainable Development Goals.
 
 
Eddie Greene