In a nation which enshrines the “pursuit of life, liberty and happiness” in its founding document it comes as no surprise that Americans approach many things from the “what’s in it for me” perspective. For many Americans that includes how they think about COVID-19 vaccinations. For many it comes down to a personal risk benefit analysis. In January of 2021 there were over 200,000 new cases of COVID infection per day, with over 3,500 deaths per day. At the time the elderly were much more likely to die from these infections than younger people. For elderly Americans the risks were high. Though the vaccine’s were new, side effect profiles from well run clinical trials indicated the risks associated with getting the vaccine were relatively low. Across the country the first wave of people eligible for vaccines rushed to sign up. The pursuit of life, liberty and happiness was working synergistically with the public health goal of rapidly vaccinating high risk populations.
As more people become eligible, who are at lower risk for bad outcomes from COVID-19 infections, we see a reduction in the eagerness for vaccinations. New infections and deaths have declined and news about possible rare but dangerous side effects have emerged. Add a strong dose of conspiracy theories:
- Bill Gates is using the vaccine to inject micro chips into all Americans
- COVID-19 is not as bad as people say
- Doctors in hospitals are exaggerating the number of deaths to earn more money
And we find ourselves in a situation where for many people the personal risk benefit calculation has begun to shift away from vaccination.
Using life, liberty and the pursuit of happiness as the only navigation tool in life works fine in many settings. My two children attended a very unusual private school that built its entire governance structure around protecting the pursuit of happiness of every member of the school community. This works very well in a school environment where larger social issues such as war, global warming and economic justice are outside the school community’s purview. For a glimpse of life at the Sudbury Valley School (SVS) see some of my blog posts on the SVS web site.
The theory and practice behind vaccination hail from the field of public health. The logic and goals of public health policy do not always run parallel to the founding fathers notion of “life, liberty and the pursuit of happiness”.
Why were British Sailors called Limies?
Though the origins of public health are diverse, the desire for nation states to maintain effective naval forces at sea for long periods of time has been been central to the development of public health as a field of study. The placing large number of people into the tight quarters on navel vessels for long periods of time magnify many of the issues that have come to define public health. Problems caused by poor hygiene, limited diet and infectious illnesses, can effect everyone, but can be particularly devastating to a ship bound population.
Scurvy serves as a perfect example. Scurvy, a disease that causes weakness and death, has plagued seafarers since ancient times. We now know that the illness is caused by a lack of vitamin C in the diet. Many times in history seafaring people learned that by including certain foods in their maritime diet Scurvy could be avoided. In 1747, James Lind, the naval surgeon on HMS Salisbury, conducted what is believed to be the first randomized controlled clinical trial. Sailors with scurvy were randomly assigned to 6 different dietary changes. The group assigned to 2 oranges and a lemon each day experienced a large reduction in symptoms. Because lemons were imported from Europe, the British turned to limes grown in various parts of the British empire to supply the navy with a regular supply of citrus. From this bit of public health history the term “Limies” was born.
Why does this CDC official look like she’s in the Navy?
Though I was personally very disappointed with the US Center for Disease Control’s early response to COVID-19, the CDC is considered by some to be the world’s premier public health organization. Staff of CDC serve as part of the US Public Health Service, which is one 7 “Uniformed” services in the United States. In a nod to the role played by the navy in the development of public health science, the Public Health Service uniform is very similar to that of the U.S. Navy.
With the possible exception of the Athenian Navy during the Peloponnesian War, Navies are not generally thought of as bastions on democracy. Throughout history, ship captains, military and civilian, have be granted wide powers of authority over their crews and passengers, from conducting marriage ceremonies, to the administration of justice. In many cases, while at sea, a ship captain assumes the power of the state. A far sighted ship captain may recognize the role of morale in maintaining an effective crew, and therefor give some weight to the “happiness” of the crew. However, this ulterior motive for individual happiness should not be confused with the founding fathers central focus on the life, liberty and happiness of the citizenry.
The mission of navel forces are of necessity not focused on the happiness of the individual. They are focused on the efficient functioning of the larger whole made up of the individuals serving in the navy. This focus on the larger whole remains a defining element of Public Health.
Years ago a friend of mine told a story of her time as a county public health official. On a steaming hot weekend, she was called to a pool facility to test the water. The pool water failed the safety test. She told the facility management that they would have to immediately close the pool. The incredulous management could not believe that the public health official had this power. After confirming with local government that she had the authority, the pool was closed. Here we see how public health elevates the needs of the larger whole over the interests of individuals. The pool facility management was clearly not made happy by the decision, its likely many patrons in the pool were not made happy by the decision. But the public health officer, representing the health interests of the larger community, closed to pool to prevent illness among pool patrons.
It goes without saying that the policies and criteria behind the test that caused the pool to closed are and should be subject to full public scrutiny. Poorly formed rules will result in poorly executed policy. But once a community has decided on a set of public health rules, public health officials have the authority to execute decisions based on those rules that may not be consistent with the pursuit of happiness for all of the individuals impacted.
This is the nub of the problem with current vaccination campaign against COVID-19 in the United States.
… ask what your vaccination can do for your country
To understand how the logic of vaccination requires valuing the benefit to the whole over that of the individual, lets look at a disease that is currently fairly well controlled in the US: Measles.
Figure 1 shows the number of measles cases in the US during the last decade. Most of cases are associated with outbreaks triggered by someone travelling from a country where measles is less well controlled to the United States. Measles is a highly contagious disease, probably at least 4 to 5 times more infectious than COVID-19. The fact that outbreaks have been small in the US over the last 10 years illustrates the effectiveness of Herd Immunity and the ability of our public health system to contract trace and control small infectious disease outbreaks. Currently about 91% of Americans have been vaccinated against measles. So despite being highly infectious, 91% of the people that an infected person in the United States might encounter will have protection from measles. With a disease as infections as Measles, a 91% vaccination rate is not sufficient for herd immunity. It is estimated that 95% of the population needs to be vaccinated for true herd immunity. However, with aggressive contact tracing and targeted vaccination campaigns when outbreaks occur, the outbreaks of the last 10 years have all remained relatively small. Its interesting to note that 2020, the year we were all asked to social distance and wear masks, the US had the lowest number of measles cases of the decade.
With number like those in figure 1, the chance of any one person in the United States getting measles is very near zero. So for 2020 with 13 cases and a population of 330 million, the chances of getting measles in 2020 was less than 1 out of 25 million.
Though the risk from a measles vaccination is very low, all vaccinations have some risk. A very small number can result is severe side effects. It is quite likely that in years with very few measles cases like 2020, the risk of getting measles is lower than the risk of getting more than a trivial side effect from the vaccine. Just to illustrate the obvious, consider the situation where the US achieved complete herd immunity to measles, and there were zero infections for a whole year. It is no surprise that the risks posed by the vaccine, no matter how small, would be greater than the risk of contracting measles. If that situation occurred, would public health officials cease to advocate measles vaccinations? Of course not. The public health goal is to protect the whole community from the risk of measles, not to minimize the risk experienced for any one individual. Keeping the vaccination levels at or above the level of herd immunity protects the entire community, when it comes to vaccinations, that is the mission of public health.
As it was with measles, so it may be with COVID-19. If the vaccination campaign is successful enough, the number of cases in the US will continue to decline. At some point the risks posed by the vaccine itself will exceed the risk of contracting COVID-19. Even when this happens, public health science will continue to advocate for people to be vaccinated. As this happens, public health officials will continue to evaluate the risks of vaccinations, modify recommendations to minimize risk to individuals, and explore the development of new vaccines with lower risk. But the goal of a vaccination campaign sufficient to achieve herd immunity will remain the over arching goal. This is what is best for the nation (and the world) as a whole.
So when you consider being vaccinated, ask not what the vaccine will do for you, but ask what the vaccine can do for your country. We each need to accept a very small amount of risk, not to make ourselves happy or safe, but to make out entire community happy and healthy.
Coronavirus Epidemiology 