Speaker 1: Pushkin from Pushkin Industries. This is Deep Background, the show
Speaker 1: where we explore the stories behind the stories in the news.
Speaker 1: I'm Noah Feldman. I didn't feel a thing well done.
Speaker 1: That's Vice President Mike Pence last Friday, just after receiving
Speaker 1: a coronavirus vaccine on national television. President elect Joe Biden
Speaker 1: has also been vaccinated. But what about the rest of us?
Speaker 1: The distribution of the coronavirus vaccine raises massive practical and
Speaker 1: ethical questions. Here to walk us through some of them
Speaker 1: is Michelle Mellow. Professor Mellow teaches at the Stanford Law
Speaker 1: School and holds a joint appointment at Stanford's School of Medicine.
Speaker 1: She's an expert on medical liability, public health law, pharmaceuticals
Speaker 1: and vaccines, and importantly ethics and governance associated with all
Speaker 1: of those things. Michelle, thank you so much for joining us.
Speaker 1: I knew the minute that we hit this stage of
Speaker 1: the vaccine process where we have vaccines that appear to
Speaker 1: work and now we have to struggle with the practical
Speaker 1: and ethical questions and the legal questions around distribution, that
Speaker 1: I wanted to hear your input. So let's just dive
Speaker 1: in and I want to start with the priorities that
Speaker 1: different actors have been setting for who gets vaccines when,
Speaker 1: and ask you, what do you think that those priorities
Speaker 1: should be. So, I actually think that the ethical framework
Speaker 1: that the National Academy of Sciences and Engineering Medicine Committee
Speaker 1: came up with is spot on. They start with a
Speaker 1: series of both substantive and procedural ethical principles, and the
Speaker 1: substantive principles are the ones that are most salient for
Speaker 1: figuring out who's in what priority group, and they are
Speaker 1: equity or addressing health inequities, assuring maximum benefit, what they
Speaker 1: call equal concern, which is the idea that every person
Speaker 1: is of equal moral worth and should be protected from discrimination.
Speaker 1: And then there are also a series of these procedural
Speaker 1: ethical principles that they articulate, which include fairness and transparency
Speaker 1: and hewing closely to the evidence. So unpacking those a
Speaker 1: little bit more, you know, what is it. I've talked
Speaker 1: a little bit about what equal concern means. It doesn't, however,
Speaker 1: mean that it's not right to make decisions based on
Speaker 1: a person's societal role, like the instrumental value that they
Speaker 1: bring to fighting COVID, for example. But beyond that, we
Speaker 1: want to protect people from nvidious discrimination. The maximum benefit
Speaker 1: principle I think they did a very good job of
Speaker 1: describing as pertaining both to the reduction of serious comorbidity
Speaker 1: and mortality, so finding people who are especially like they
Speaker 1: get really bad COVID and also eliminating transmission to the
Speaker 1: maximum extent possible. Those are both important elements of maximal benefit.
Speaker 1: They also refer to the fact that people who are
Speaker 1: in roles that are essential for societal functioning should be
Speaker 1: vaccinated because performing their role brings about additional benefits to society.
Speaker 1: In terms of the mitigating inequities, the committee is interested
Speaker 1: in the communities that have been especially hard hit by
Speaker 1: the disease, and then interesting also as their focus on
Speaker 1: respecting tribal sovereignty as a form of respecting vulnerable groups.
Speaker 1: Can I ask a skeptical question, every single principle that
Speaker 1: you just articulated, drawn from this National Academy of Sciences approach,
Speaker 1: Every single principle is a good principle, but it's not
Speaker 1: at all obvious to me how they work together. In fact,
Speaker 1: some of those principles seem like in practice they would
Speaker 1: be in contradiction with other principles. I mean, generally, aiming
Speaker 1: for maximal benefit does mean treating people not as individuals
Speaker 1: on their own, but seeing them in terms of the
Speaker 1: role that their physical bodies will play in transmission. I mean,
Speaker 1: if someone is especially likely to transmit, we should stop
Speaker 1: that person from transmitting by vaccinating that person. The idea
Speaker 1: of moral weight doesn't really come into that. We're thinking
Speaker 1: of the society as a collective and the greatest good
Speaker 1: for the greatest number. But the other principles are to
Speaker 1: a certain degree very much based in a tradition that
Speaker 1: says each human being has equal value and equal weight
Speaker 1: and shouldn't be treated differently from any other person on
Speaker 1: the basis of some quality that's not directly connected to
Speaker 1: their moral worth. So do these principles talk at all
Speaker 1: about how to reconcile the potential conflicts or is this
Speaker 1: one of those cases where you just list a lot
Speaker 1: of good moral principles and then the devil is in
Speaker 1: the details. Well, it's a really important question, and they
Speaker 1: don't go into great death. But I think the clear
Speaker 1: intent is that when they say it's appropriate to let's
Speaker 1: use the word discriminate, but here it's not in a
Speaker 1: negative way. It's picking out people for priority. It's appropriate
Speaker 1: to do it on that basis when the role concerns
Speaker 1: the virus. So we're not talking about valuing some lives
Speaker 1: more than others because they're not criminals, or they're just
Speaker 1: better citizens, or they pay more taxes where they are
Speaker 1: engaged in industries like I don't know, tech that we
Speaker 1: think bring really innovative products to us. That's not what's
Speaker 1: going on here. They're talking about people who, by dint
Speaker 1: of their social roles, are either big transmitters or serving functions,
Speaker 1: serving professional functions that help us contain the epidemic, or
Speaker 1: that otherwise help us maintain some symblance of normal civil
Speaker 1: life by providing food, transportation, essential infrastructure. So I think
Speaker 1: they've tried to tow the line there by drawing this
Speaker 1: boundary around what they are willing to consider when evaluating
Speaker 1: a person's role. Do teachers come up here, because they
Speaker 1: seem like a fascinating case to me, because on the
Speaker 1: one hand, teachers are fulfilling a fundamental social role. Without them,
Speaker 1: we can't open the schools, at least not in person.
Speaker 1: But then again, they're not frontline health responders. So teachers
Speaker 1: have been one of the most interesting points of discussion
Speaker 1: in the broader debates about vaccine allocation, because you know,
Speaker 1: to a large degree, we're talking about relatively young people
Speaker 1: who are relatively robust and able to withstand this virus,
Speaker 1: and you know, the emerging evidence suggests that at least
Speaker 1: smaller children are not particularly big vectors. So the teachers
Speaker 1: perceive themselves to be at high risk, but actually might
Speaker 1: not be as quite a high risk as they worried
Speaker 1: that they would be early on. Having said that, there's
Speaker 1: no denying the fact that they are the backbone of
Speaker 1: the most critical infrastructure outside of maybe the provision of
Speaker 1: food and housing. You know, the economy does not run
Speaker 1: when kids are not as school and so as a result,
Speaker 1: the Nation Committee and I think most states will put
Speaker 1: teachers in Phase two, behind healthcare workers and nursing home
Speaker 1: residents and perhaps a few others, but toward the front
Speaker 1: of the line, because again they're playing a role in
Speaker 1: making an essential sector work. You just raised an issue
Speaker 1: that's also of great interest to me, and that is
Speaker 1: you mentioned that it's the states that are going to
Speaker 1: be making the actual decision. So first we talked about
Speaker 1: this framework produced by a kind of blue ribbon panel
Speaker 1: of the quasi governmental but not really governmental, National Academy
Speaker 1: of Sciences, so it's not technically part of the government.
Speaker 1: The governments that will be making the decisions about allocation
Speaker 1: of vaccines are state governments. Why isn't this something that
Speaker 1: should have been decided by the federal government. Well, I
Speaker 1: think really the only way one could answer that is
Speaker 1: just by saying, it's always been the states that have
Speaker 1: run immunization programs. It's just kind of always been that way.
Speaker 1: That there are are federal bodies, most prominently the Advisory
Speaker 1: Committee on Immunization and Practices that you might have heard
Speaker 1: referred to as ASIP, that make recommendations, highly informed, expert
Speaker 1: credible recommendations about who to vaccinate, how to vaccinate them,
Speaker 1: when to vaccinate them. And then states pick up the
Speaker 1: ball and they do it, and they can tweak those
Speaker 1: recommendations if they want to, but it's their game. If
Speaker 1: you were to start over here and design yeah, but
Speaker 1: let's make you the czar and design it not for
Speaker 1: this time, but for the next time. You know. I
Speaker 1: think that there are critical logistical differences among the states
Speaker 1: that cause it to make sense to have them in
Speaker 1: charge of implementation. But I don't appreciate a significant reason
Speaker 1: for the prioritization to be different across states. If it's
Speaker 1: evidence based and it reflects very careful deliberation about important
Speaker 1: values that are shared, it's not clear to me why
Speaker 1: it should be tweaked at the state level. That leads
Speaker 1: me to a very practical question. I mean, what I've
Speaker 1: been sort of picturing is, if you're a hospital worker
Speaker 1: or a frontline worker, you'll get the vaccine through your hospital,
Speaker 1: or if you're a policeman or a fireman or a firefighter,
Speaker 1: or you'll get it, you know, at your firehouse or
Speaker 1: you know, in the police department and so forth. But
Speaker 1: I've been picturing for the vast majority of the population
Speaker 1: that doesn't fit into one of those categories lining up
Speaker 1: in big numbers outside of some large facility, sort of
Speaker 1: the way that testing is sort of happening in some
Speaker 1: places now. Is that wrong? The allocation frameworks mostly are
Speaker 1: putting healthcare workers, nursing home residents, and a few others
Speaker 1: at the front of the line phase one A or
Speaker 1: one B, and then we get down to people with
Speaker 1: significant comorbidities, and then we get down to a phase two,
Speaker 1: where we're dealing with other important people for infrastructure and
Speaker 1: people who have milder comorbidities. And if that's how we
Speaker 1: get to a phase three where there's wide availability the
Speaker 1: vaccine that it starts to penetrate the general population and
Speaker 1: eventually reach younger adults and children. And at that stage, yeah,
Speaker 1: I think we're talking about mass vaccination clinics. But in
Speaker 1: the early stages, when we're trying to identify people who
Speaker 1: are eligible for vaccination under these allocation frameworks, it has
Speaker 1: to work through organizations that already have that information. We're
Speaker 1: not going to have a corner Kiosk vaccinating people asking
Speaker 1: them to show proof of diabetes. And it's not because
Speaker 1: we just don't have enough vaccine yet to reach the
Speaker 1: larger numbers of people. I mean, presumably the moment there
Speaker 1: are enough doses to start lining people up. We want
Speaker 1: to do that. We want to do that, but you
Speaker 1: have to understand the logistical hurdles involved in getting this
Speaker 1: vaccine out and administering it, particularly for the fiser vaccine
Speaker 1: that has to be stored, as you know, at this
Speaker 1: extremely cold temperature, and if your facility doesn't have one
Speaker 1: of those freezers, you're out now. With MADERNA coming online,
Speaker 1: it'll be a little easier. But that's just one example
Speaker 1: of the kind of logistical challenges in scaling this program up.
Speaker 1: So it is going to take some time. Even if
Speaker 1: all of these doses were warehouse right now, not all
Speaker 1: states would be ready to give them to all people.
Speaker 1: Do you have I realized that nobody knows a definitive
Speaker 1: answer to this, and I don't mean to put you
Speaker 1: on the spot, but do you have an instinctive answer
Speaker 1: as to how long this is going to take in
Speaker 1: the different phases? I have heard people say with some
Speaker 1: confidence that at least they speak with confidence that by
Speaker 1: next end of next August beginning of next September, when
Speaker 1: the twenty one twenty two school year begins, people should
Speaker 1: overwhelmingly have been vaccinated. But do you think that is
Speaker 1: actually unrealistically optimistic? I mean, that's consistent with what I'm hearing.
Speaker 1: I don't have any inside information about this. I think
Speaker 1: that's realistic, probably for adults. Kids are the big question
Speaker 1: mark at this point, because, as I'm sure you know,
Speaker 1: you have to have a separate set of clinical trials
Speaker 1: to demonstrate the safety and effectiveness of the vaccine for
Speaker 1: children Right now, I think no trial has gone below
Speaker 1: age sixteen, so those trials are just getting underway. And
Speaker 1: as you probably remember, there is a debate about whether
Speaker 1: to end the adult trials early. There will be similar
Speaker 1: debates for these trials as to how long to run
Speaker 1: them before you get the initial approval for children. So
Speaker 1: there's just a lot more uncertainty about when approval will
Speaker 1: come through. You know, once it does come through, I
Speaker 1: would expect things to happen relatively quickly because we will
Speaker 1: have experience at that point with supply chain and with
Speaker 1: setting things up in clinics, and we will have providers
Speaker 1: enrolled in the program and so forth. But it could
Speaker 1: take some time. And then, of course there's going to
Speaker 1: be the inevitable resistance when we talk about vaccinating children.
Speaker 1: That brings us to the resistance question, which I really
Speaker 1: want to explore with you. So let's start by just
Speaker 1: asking whether you think there are justifiable reasons that individuals
Speaker 1: could use to say I don't want to be vaccinated
Speaker 1: or I don't want my kids to be vaccinated. What
Speaker 1: distinguishes this vaccine from other vaccines that we choir for
Speaker 1: kids is that it's new and not only is it new,
Speaker 1: but it is for some of the makers based on
Speaker 1: a new kind of approach to making vaccines, this mRNA approach.
Speaker 1: So I think it's not unreasonable that people are voicing
Speaker 1: concerns or having questions about safety. It's very unusual, for example,
Speaker 1: for US to require children to accept a vaccine that
Speaker 1: is novel on the market. Obviously take a very extraordinary
Speaker 1: set of circumstances. The other thing, of course, that makes
Speaker 1: these fears not unreasonable is the process through which the
Speaker 1: vaccines have been approved. You know, I think two months
Speaker 1: ago I would have said it's very reasonable for people
Speaker 1: to have concerns about that. Since then, I've personally been
Speaker 1: reassured by the process that has emerged from FDA, the
Speaker 1: director asserting his independence, the transparency around the basis for
Speaker 1: approval that have certainly not heard anyone who has independently
Speaker 1: reviewed those data packages voicing concerns about well, were they
Speaker 1: careful enough or was this the right standard? Their decision
Speaker 1: was also made a lot easier by the fact that
Speaker 1: these were not close cases in terms of efficacy. You know,
Speaker 1: they had set this initial bar it has to be
Speaker 1: fifty percent or more effective, and these things just absolutely
Speaker 1: vaulted over that bar. So I think there's a lot
Speaker 1: to feel good about now relative to where we were
Speaker 1: a couple of months ago, and my own personal apprehensions
Speaker 1: about this I think have been relieved by what I've
Speaker 1: seen over those months. Having said that, anybody who's hesitant
Speaker 1: about regular vaccines is definitely gonna be hesitant about this
Speaker 1: one because it's new. What I think we have going
Speaker 1: for us again is that by the time we get
Speaker 1: to kids, there will be millions and millions and millions
Speaker 1: of doses having been delivered to adults, and we will
Speaker 1: know a lot. So even though it will be new
Speaker 1: in terms of months or years, in terms of doses delivered,
Speaker 1: it might look a lot more like the knowledge base
Speaker 1: that we have about older vaccines. We'll be right back, Michelle.
Speaker 1: You're a highly rational, logical thinking person, and your description
Speaker 1: of what count as reasons to be concerned we're all
Speaker 1: derived from logic and reason there but I presume that
Speaker 1: you share my view. Maybe I shouldn't that some of
Speaker 1: the reasons that people are skeptical of vaccines generally may
Speaker 1: be grounded in formal logical reason, but others are grounded
Speaker 1: in other features. You know, whether that's religious faith, which
Speaker 1: sometimes by its own self description, is grounded in something
Speaker 1: other than logic or reason, not for everybody but for some,
Speaker 1: or in paranoia or structural distrust of science or of
Speaker 1: the government. So what about people who say, you know,
Speaker 1: I don't like vaccines in general, forget about for my kids,
Speaker 1: but for me, and I don't want to be vaccinated.
Speaker 1: Here how tolerant in your view? Should the government be
Speaker 1: of the kind of a response, And then from government
Speaker 1: will move on to private businesses and so forth. Yeah,
Speaker 1: I mean, look, I'm very familiar with the range of
Speaker 1: different concerns. I get lots of mail from folks in
Speaker 1: the anti vACC community expressing their hopes and dreams for
Speaker 1: my family and my own health and safety, and so
Speaker 1: I'm aware all of them very positive, a certain very sweet.
Speaker 1: As a recipient of occasional hate mail myself, I'm sure
Speaker 1: that the loving spirit that pervades all hate mail is
Speaker 1: present in yours too. So I know that people who
Speaker 1: are hesitant or resistant of vaccines really run the gamut
Speaker 1: in terms of how well informed their beliefs are, what
Speaker 1: their beliefs are, why they have these concerns. So the
Speaker 1: question is, what do we do about it. I guess
Speaker 1: my own feeling is that one thing we have going
Speaker 1: for us here is that we don't need ninety percent vaccination.
Speaker 1: We don't need ninety five percent. The best estimates are
Speaker 1: somewhere in the sixty to eighty percent range, probably seventy
Speaker 1: to eighty percent coverage in order to really kill this
Speaker 1: thing because the vaccine is so effective. I mean, we're
Speaker 1: actually getting lucky there. If theaccine we're less effective, we
Speaker 1: would need more people to take it. But even more
Speaker 1: critical than that is what we call the ar not,
Speaker 1: the reproductive number for this virus, which you know, as
Speaker 1: you probably know, is around one somewhere right now in
Speaker 1: most parts of the country. In California here, I think
Speaker 1: it's at one point two right now, which is the
Speaker 1: worst it's been in a while. Compare that to measles,
Speaker 1: where we've got an ar not of twelve to fifteen.
Speaker 1: That means for every person with measles, they're going to
Speaker 1: infect on average, twelve to fifteen additional people. And because
Speaker 1: of that, we have to have close to ninety five
Speaker 1: percent vaccine coverage in order to kill measles in the population.
Speaker 1: So what this all means is we can let a
Speaker 1: few go, we can let more than a few go,
Speaker 1: And in fact, I think we're going to have to
Speaker 1: because there's going to be enough vaccine to get to
Speaker 1: that place of ninety plus percent coverage for quite a
Speaker 1: long time. So what's been interesting to me and having
Speaker 1: conversations about this topic is how much we pivot back
Speaker 1: and forth from talking about who get to get it,
Speaker 1: who gets to be in the line to get it too,
Speaker 1: who has to get it? We're having like these both
Speaker 1: of these conversations at the same time, and the reality
Speaker 1: is that's not going to take place at the same time.
Speaker 1: There's going to be a long time where the question
Speaker 1: is only who gets to get it, and way down
Speaker 1: the line where everybody who would like to get it
Speaker 1: has gotten it, then we can talk about whether there's
Speaker 1: a need to do anything about the remaining whatever it
Speaker 1: is ten twenty percent, thirty percent, forty percent, we'll see.
Speaker 1: But at that point we'll know a lot more about
Speaker 1: the effect of population vaccination on the spread of this virus,
Speaker 1: and my expectation is we won't have to do a
Speaker 1: lot of chasing people that we will get to where
Speaker 1: we need to be with voluntary vaccination as long as
Speaker 1: we do a decent job on two things. One is
Speaker 1: bringing the vaccine to people where they are at zero cost,
Speaker 1: with zero logistical barriers, and the second is learning how
Speaker 1: to talk to people about this vaccine in a way
Speaker 1: that resonates with them. Do you think there might actually
Speaker 1: be an interesting cultural effect of this sequencing that you're describing,
Speaker 1: where if a lot of people really really want the
Speaker 1: vaccine and are trying to get it, that might actually
Speaker 1: create a norm that the vaccine is desirable and reduce
Speaker 1: some of the objections. Because the way many people say
Speaker 1: experience vaccines is you know, they're saying their kids to school,
Speaker 1: or their kids have just been born, or at the
Speaker 1: relevant check up age, and then the government or or
Speaker 1: the doctors speaking on behalf the government says it's time
Speaker 1: for the vaccine. So people see it as a coercive structure.
Speaker 1: And what's more, because those vaccine programs are on the
Speaker 1: whole relatively successful, people don't really see the diseases that
Speaker 1: they would be getting, you know, if they weren't vaccinated. Here,
Speaker 1: we've all seen the effects of COVID. We've seen most
Speaker 1: of us in the United States now, no people who've
Speaker 1: gotten sick and in many cases we know people who
Speaker 1: have unfortunately died, So there's a kind of you know,
Speaker 1: maybe if everyone wants one, it will reduce the likelihood
Speaker 1: that people will be skeptical of taking it. I mean,
Speaker 1: they're probably a certain people in the population who think
Speaker 1: in those terms. I think what will be more influential
Speaker 1: is just the experience of seeing with your own eyes
Speaker 1: friends and family getting vaccinated, being fine, shedding tears of relief,
Speaker 1: and being able to resume their lives in ways that you,
Speaker 1: as an unvaccinated person can't or shouldn't. So what is
Speaker 1: scary about this vaccine, as I mentioned to a lot
Speaker 1: of people, is that it is new, it's unknown, and
Speaker 1: quite understandably, they don't want to be in line first
Speaker 1: for something that they have concerns about. But one hundred
Speaker 1: million doses later, I think people will start to feel differently.
Speaker 1: It's going to take special outreach to certain populations to
Speaker 1: be sure, including racial and minority communities who need to
Speaker 1: hear this from particular kinds of messengers. And then also
Speaker 1: this time around people on the right who you know,
Speaker 1: quite curiously, given the President's investment in vaccine development, share
Speaker 1: the vaccine skepticism of many in the vaccine resistance community,
Speaker 1: which have traditionally been more left leaning women. So there's
Speaker 1: this bizarre concentration or constellation of people who have concerns
Speaker 1: about the vaccine that we're going to have to figure
Speaker 1: out how to reach. But you know, there will be
Speaker 1: people that it will be pretty tough for. My stepmom
Speaker 1: is a retired corrections officer. She lives in rural Iowa,
Speaker 1: and she's you know, elderly and at some risk for
Speaker 1: serious cummorbidities. And when I talk to her about the vaccine,
Speaker 1: she says, hell, no, I'm not getting no vaccine full stop.
Speaker 1: There's not a lot to work with there in terms
Speaker 1: of you know, we talked about with rational reasons. There's
Speaker 1: there's just not a lot there other than distrust. And
Speaker 1: you know, we're going to have to figure out how
Speaker 1: to turn some of the messaging around to reach out
Speaker 1: to people who see vaccination as part of a broader
Speaker 1: set of intrusive measures perpetrated on the public by left
Speaker 1: leaning public health officials and governors. Can you imagine a
Speaker 1: scenario where we actually aren't able to vaccinate enough people
Speaker 1: to reach her community because of widespread skepticism. I mean
Speaker 1: that would be massive crisis. I mean, here we are,
Speaker 1: people like us are sitting around in universities, and the
Speaker 1: moment that the vaccines were reported as working, we all
Speaker 1: breathed an enormous sigh of relief. Right, I mean science worked.
Speaker 1: You know what a relief. Life will return to normal.
Speaker 1: What a relief. And I don't think I've heard serious
Speaker 1: discussion in the last few weeks, let's say, since the
Speaker 1: good numbers came in, of oh, what if we just
Speaker 1: cannot convince a sufficient number of people to take it,
Speaker 1: to get the R not down below one. I mean,
Speaker 1: I look that. I think those discussions are happening. There's
Speaker 1: still so much interest. I'm hearing and talking about mandates
Speaker 1: and you can employers required and can schools require it?
Speaker 1: This is not, to be clear, something that state officials
Speaker 1: are talking about, or even many employers. There's very little
Speaker 1: appetite for that among the employers that I know of,
Speaker 1: but reporters want to talk about it. People are curious
Speaker 1: about that, And my answer is always, I just don't
Speaker 1: think we need to go there right now. I think
Speaker 1: we have massive challenge over the next six months in
Speaker 1: getting this to the people who want to get it,
Speaker 1: and at that point, when we've done that, I think
Speaker 1: it will be less of a crisis atmosphere. We will
Speaker 1: know a lot more about the safety profile of the vaccine.
Speaker 1: People will know more people who've gotten the vaccine and
Speaker 1: feel a little bit more personally comfortable with it. And
Speaker 1: so while it's possible that at that time we might
Speaker 1: have to revisit this conversation about can we make people
Speaker 1: get it, I don't think it does the effort any
Speaker 1: good to go there now. We don't need to do it,
Speaker 1: and it's just going to foment the concerns that are
Speaker 1: causing a problem. I hear the pragmatics behind what you're saying.
Speaker 1: If you and I are you with other journalists have
Speaker 1: conversations about the ethics of coercion by the government or
Speaker 1: by private employers, as you say, that will just rile
Speaker 1: up the opponents. So I get it. What I wonder, though,
Speaker 1: is whether it might not be a mistake not to
Speaker 1: start talking about it now for the following reason. I
Speaker 1: take it that one of the big differences between eighty
Speaker 1: or ninety percent of the population getting a vaccine and
Speaker 1: fifty or sixty percent getting a vaccine, even a very
Speaker 1: effective vaccine is whether COVID nineteen is eliminated altogether, or
Speaker 1: whether it becomes a recurring but relatively low likelihood disease
Speaker 1: that's out there. It's still circulating and flares up every
Speaker 1: so often and kills of you know, a handful of
Speaker 1: people here there or in the other place. And that
Speaker 1: that does seem to be a huge difference. And I
Speaker 1: wonder if maybe we would do ourselves a disservice by
Speaker 1: not laying out the case now for actually eliminating the
Speaker 1: disease the way that smallpox was, at least in principle eliminated.
Speaker 1: You know, it's not that it's not worth thinking about,
Speaker 1: and I think people have thought about it. I've written
Speaker 1: about it, you know, I've written a list of trigger
Speaker 1: criteria that I think would have to be satisfied in
Speaker 1: order for us to be able to justify a mandate
Speaker 1: for adults. And only you know certain adults. What kinds
Speaker 1: of criteria are in your trigger list, Christia? Number one
Speaker 1: is you tried the voluntary thing and it didn't work right.
Speaker 1: And not only did you try it, you set up
Speaker 1: a vaccination program that has a high likelihood of success,
Speaker 1: meaning that you have the vaccine is free, and it
Speaker 1: is brought to people where they can access it physically
Speaker 1: and logistically, and there is a compensation program in place
Speaker 1: for healthcare workers who are injured by the vaccine, and
Speaker 1: you know, and others who are as a practical matter
Speaker 1: required to have it who are injured. And then beyond that,
Speaker 1: you know, there's an assessment that that program, having run
Speaker 1: for a limited period of time, has not produced the
Speaker 1: necessary levels of population immunity. And there are certain other
Speaker 1: criterion places as well, like transparent communication with the public,
Speaker 1: sufficient supply of vaccine, and so forth. I think it'll
Speaker 1: be really interesting to see where Donald Trump himself comes
Speaker 1: down on this. So far, because the vaccine was developed
Speaker 1: while he was president, he seems eager to take credit
Speaker 1: for it. Just recently. There was a big public to
Speaker 1: do when the vice president was vaccinated, and so if
Speaker 1: the president, when he's no longer president, continues that narrative,
Speaker 1: that might be a plus from the standpoint of convincing
Speaker 1: people who follow him to be vaccinated. There is of course,
Speaker 1: always some danger with Donald Trump that he'll flip and say,
Speaker 1: you know, the vaccine was great when I was president,
Speaker 1: but now that I'm not president. There's reasons to be
Speaker 1: skeptical about how it's being implemented, and therefore my followers
Speaker 1: shouldn't take it. I mean, I pray that he doesn't
Speaker 1: do that, but you know, you can never say never
Speaker 1: with Donald Trump. Do you have some sense of how
Speaker 1: the politics that are going to play out? I mean,
Speaker 1: you mentioned that there is now a meaningful component of
Speaker 1: right wing anti vaxxers to go alongside with left wing
Speaker 1: anti vaxers. Yeah, I do think it would be helpful.
Speaker 1: They have more key opinion leaders in the Republican Party,
Speaker 1: including the President, talking not only about the vaccine, but
Speaker 1: about vaccination. And to me, the President's actually being curiously
Speaker 1: muted on this point. Given the magnitude of the achievement
Speaker 1: of his Operation Warp Speed, you'd think he'd want to
Speaker 1: take credit for getting the vaccine into people, not just
Speaker 1: to get it through the FDA. Well, that's what I'm
Speaker 1: worried about. I mean, I'm worried that, as is always
Speaker 1: the case the Trump he's keeping his options open, and
Speaker 1: that if he thinks that his base is going to
Speaker 1: be anti vax then he doesn't want to be too
Speaker 1: connected to the vaccine, and that's why he sent out
Speaker 1: Mike Pence and didn't have the picture of himself being
Speaker 1: vaccinated apart from the fact that he's already been infected.
Speaker 1: So I think what's more, much more helpful is, for example,
Speaker 1: what Mitch McConnell said recently about vaccination, which is, you know,
Speaker 1: first of all going to do it, Secondly you should
Speaker 1: do it too, and third you know, we all kind
Speaker 1: of owe this to one another. And it's not a
Speaker 1: difficult message for those on the right to say to people, Look,
Speaker 1: you don't like the economy being shut down, you don't
Speaker 1: like being told to stay home. There's a fix, now,
Speaker 1: do it. I want to close with that question of
Speaker 1: communal responsibility and what we owe to one another with
Speaker 1: respect to a vaccine, because we have a tendency to
Speaker 1: think about issues of government coercion solely in terms of
Speaker 1: the individual's right to resist a government mandate, and to
Speaker 1: forget that when it comes to vaccines, the mandate isn't
Speaker 1: just that the government wants you to be healthy, but
Speaker 1: that the government doesn't want you to infect others, and
Speaker 1: that the presence of disease in a population has generally
Speaker 1: harmful effects. Because even a vaccine that's ninety five percent efficacious.
Speaker 1: That means that you know, one in twenty people who
Speaker 1: have the vaccine could still potentially be infected under the
Speaker 1: right set of circumstances. So when you think about the
Speaker 1: ethics of vaccination, do you start with the collective or
Speaker 1: do you start with the individual? I do start with
Speaker 1: the collective, because that is the purpose of vaccinations. That
Speaker 1: it is to produce true heard immunity, not the kind
Speaker 1: where we let everybody get infected and hope for the best,
Speaker 1: but the kind where your body is trained to become
Speaker 1: immune to the virus. That's what the purpose of vaccines is.
Speaker 1: And and no vaccination or you know, outside extraordinarily high
Speaker 1: risk context, is ever an individually rational decision. You know,
Speaker 1: all vaccines have risks of some side effects. For most diseases,
Speaker 1: we've more or less wiped them out as long as
Speaker 1: everybody stays vaccinated. So for any one of us, it
Speaker 1: makes more sense not to get vaccinated than to get
Speaker 1: vaccinated from a risk benefit standpoint. But we do it
Speaker 1: because we know, like any collective action problem, if everybody
Speaker 1: acted that way, we'd all be worse off because the
Speaker 1: disease would search And we know that it happens over
Speaker 1: and over again. When we have dips in coverage for
Speaker 1: diseases like measles, mumps, and pertusses, we see outbreaks every year.
Speaker 1: So that's the way we have to think about it,
Speaker 1: is that every individual is doing their part to maintain
Speaker 1: this collective good. That we all benefit enormously from the
Speaker 1: collective good, albeit in ways that, as you said, are
Speaker 1: usually invisible. Now, where does individual liberty come into this.
Speaker 1: The courts, as you know, have been very clear that
Speaker 1: the reasons that people can opt out of mandated vaccinations
Speaker 1: are pretty narrow. There's no question that a valid medical
Speaker 1: condraindication is a valid reason to opt out. Religious bases
Speaker 1: for opting out are tougher. The Supreme Court has never
Speaker 1: held that states a acquired to offer that many states
Speaker 1: choose to do it, but increasingly they're choosing to restrict those.
Speaker 1: And then there are these other sort of philosophical reasons
Speaker 1: why people object to vaccines, which is maybe the most
Speaker 1: trenchant avenue to focus on in this context, because although
Speaker 1: we've heard a lot about certain religious communities, and during
Speaker 1: COVID nineteen, it's actually pretty hard to find a religious
Speaker 1: faith then rejects vaccines outright. They tend to when you
Speaker 1: sort of scratch below the surface, most of those religious
Speaker 1: beliefs are more a set of philosophical beliefs about the
Speaker 1: body and about the spirit and the body healing itself.
Speaker 1: It doesn't tend to be connected to what the courts
Speaker 1: think about as religions. So the liberties that are being
Speaker 1: implicated here are mostly of this last variety here, of
Speaker 1: this idea that simply I just don't believe in vaccines
Speaker 1: or I just don't want it, and for a disease
Speaker 1: like COVID or any of the other even more serious
Speaker 1: diseases for which we require vaccinations, it's just really hard
Speaker 1: to square that as a weighty interest against what's at
Speaker 1: stake here. On the whole, I think the story you're
Speaker 1: telling is a relatively optimistic one, and I'm grateful for that.
Speaker 1: This might be the first genuinely optimistic COVID related episode
Speaker 1: of a deep background that we've had in the last
Speaker 1: nine or ten months. But at the same time, you
Speaker 1: gave us a very realistic account of what the ongoing
Speaker 1: challenges are. So thank you very much for that, and
Speaker 1: thank you for your time, and thank you for the
Speaker 1: amazing work you're doing. Thanks very much for having me
Speaker 1: listening to Professor Mellow made me realize that things are
Speaker 1: both simpler and more complicated when it comes to the
Speaker 1: distribution and implementation of the COVID vaccines than I had
Speaker 1: previously thought. In a sense, they're simpler because the frameworks
Speaker 1: expressed by the National Academy of Medicine are mostly being
Speaker 1: followed by most of the states, and they're does not
Speaker 1: seem to be at least thus far, any major public
Speaker 1: outcry objecting to them. They're more complicated because the values
Speaker 1: and principles laid out in those standards are actually pretty
Speaker 1: under specific with respect to what to do in situations
Speaker 1: of conflict. The values expressed are all wonderful values, but
Speaker 1: if you really drill down, there probably would be tensions
Speaker 1: between them. But it may well be that no one
Speaker 1: fundamentally objects to the process by which vaccines are being distributed,
Speaker 1: and that enough vaccine may soon be available that people
Speaker 1: who want to get the vaccine can get their hands
Speaker 1: on it. If we don't have a moment of shortage,
Speaker 1: then there need not be any intense public debate over
Speaker 1: the question of who gets the vaccine first. That, of
Speaker 1: course leads to the question of what will happen when
Speaker 1: lots of people have gotten the vaccine and some begin
Speaker 1: to say that they don't want to take it. And
Speaker 1: here Professor Mellow's view is, let's not worry about that
Speaker 1: problem yet. Let's focus in the short term on getting
Speaker 1: the vaccine to as many people as possible and encouraging
Speaker 1: people to take it. And then if we get into
Speaker 1: circumstances where the government or schools or private actors want
Speaker 1: to obligate people to have vaccines, we will deal with
Speaker 1: that problem when we come to it. That's a highly
Speaker 1: sensible attitude, and I promise that if and when the
Speaker 1: question of coercing people to get vaccines does arise, we
Speaker 1: will revisit the issue. Here on Deep Background. We at
Speaker 1: Deep Background are going to take a short holiday break now,
Speaker 1: and we hope you'll be able to also until I
Speaker 1: speak to you next time. Get some rest, Be careful,
Speaker 1: be safe, and be well. Deep Background is brought to
Speaker 1: you by Pushkin Industries. Our producer is Lydia Gencott, our
Speaker 1: engineer is Martin Gonzalez, and our showrunner is Sophie Crane mckibbeck.
Speaker 1: Theme music by Luis Kara at Pushkin. Thanks to Mia
Speaker 1: Lobell Julia Barton, Heather Fain, Carlie mcgliori, Mackie Taylor, Eric
Speaker 1: and Jacob Weisberg. You can find me on Twitter at
Speaker 1: Noah Rfeld. I also write a column for Bloomberg Opinion,
Speaker 1: which you can find at bloomberg dot com slashfeld. To
Speaker 1: discover Bloomberg's original slate of podcasts, go to Bloomberg dot
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Speaker 1: deep background