WEBVTT - Vaccinating America 0:00:15.396 --> 0:00:23.836 Pushkin from Pushkin Industries. This is Deep Background, the show 0:00:23.836 --> 0:00:26.956 where we explore the stories behind the stories in the news. 0:00:27.276 --> 0:00:31.756 I'm Noah Feldman. I didn't feel a thing well done. 0:00:32.316 --> 0:00:36.796 That's Vice President Mike Pence last Friday, just after receiving 0:00:36.836 --> 0:00:41.836 a coronavirus vaccine on national television. President elect Joe Biden 0:00:41.996 --> 0:00:45.956 has also been vaccinated. But what about the rest of us? 0:00:46.556 --> 0:00:51.116 The distribution of the coronavirus vaccine raises massive practical and 0:00:51.196 --> 0:00:54.476 ethical questions. Here to walk us through some of them 0:00:54.716 --> 0:00:59.476 is Michelle Mellow. Professor Mellow teaches at the Stanford Law 0:00:59.516 --> 0:01:04.116 School and holds a joint appointment at Stanford's School of Medicine. 0:01:04.396 --> 0:01:08.836 She's an expert on medical liability, public health law, pharmaceuticals 0:01:08.836 --> 0:01:14.236 and vaccines, and importantly ethics and governance associated with all 0:01:14.356 --> 0:01:19.796 of those things. Michelle, thank you so much for joining us. 0:01:20.156 --> 0:01:23.596 I knew the minute that we hit this stage of 0:01:23.956 --> 0:01:26.436 the vaccine process where we have vaccines that appear to 0:01:26.476 --> 0:01:29.156 work and now we have to struggle with the practical 0:01:29.156 --> 0:01:32.396 and ethical questions and the legal questions around distribution, that 0:01:32.476 --> 0:01:35.836 I wanted to hear your input. So let's just dive 0:01:35.876 --> 0:01:40.076 in and I want to start with the priorities that 0:01:40.276 --> 0:01:43.636 different actors have been setting for who gets vaccines when, 0:01:44.196 --> 0:01:48.436 and ask you, what do you think that those priorities 0:01:48.596 --> 0:01:53.956 should be. So, I actually think that the ethical framework 0:01:54.076 --> 0:01:57.316 that the National Academy of Sciences and Engineering Medicine Committee 0:01:57.316 --> 0:02:00.956 came up with is spot on. They start with a 0:02:01.076 --> 0:02:05.436 series of both substantive and procedural ethical principles, and the 0:02:05.516 --> 0:02:08.436 substantive principles are the ones that are most salient for 0:02:08.636 --> 0:02:11.836 figuring out who's in what priority group, and they are 0:02:12.036 --> 0:02:18.236 equity or addressing health inequities, assuring maximum benefit, what they 0:02:18.276 --> 0:02:21.716 call equal concern, which is the idea that every person 0:02:21.916 --> 0:02:25.676 is of equal moral worth and should be protected from discrimination. 0:02:26.276 --> 0:02:29.676 And then there are also a series of these procedural 0:02:29.836 --> 0:02:33.316 ethical principles that they articulate, which include fairness and transparency 0:02:33.356 --> 0:02:37.276 and hewing closely to the evidence. So unpacking those a 0:02:37.276 --> 0:02:39.236 little bit more, you know, what is it. I've talked 0:02:39.236 --> 0:02:42.916 a little bit about what equal concern means. It doesn't, however, 0:02:43.036 --> 0:02:46.116 mean that it's not right to make decisions based on 0:02:46.156 --> 0:02:50.036 a person's societal role, like the instrumental value that they 0:02:50.116 --> 0:02:53.996 bring to fighting COVID, for example. But beyond that, we 0:02:54.036 --> 0:02:58.556 want to protect people from nvidious discrimination. The maximum benefit 0:02:58.676 --> 0:03:01.276 principle I think they did a very good job of 0:03:01.356 --> 0:03:06.036 describing as pertaining both to the reduction of serious comorbidity 0:03:06.036 --> 0:03:09.436 and mortality, so finding people who are especially like they 0:03:09.476 --> 0:03:14.156 get really bad COVID and also eliminating transmission to the 0:03:14.156 --> 0:03:18.796 maximum extent possible. Those are both important elements of maximal benefit. 0:03:19.316 --> 0:03:22.996 They also refer to the fact that people who are 0:03:23.036 --> 0:03:27.316 in roles that are essential for societal functioning should be 0:03:27.396 --> 0:03:32.276 vaccinated because performing their role brings about additional benefits to society. 0:03:33.236 --> 0:03:37.276 In terms of the mitigating inequities, the committee is interested 0:03:37.316 --> 0:03:40.556 in the communities that have been especially hard hit by 0:03:40.596 --> 0:03:43.116 the disease, and then interesting also as their focus on 0:03:43.516 --> 0:03:48.116 respecting tribal sovereignty as a form of respecting vulnerable groups. 0:03:48.876 --> 0:03:51.876 Can I ask a skeptical question, every single principle that 0:03:51.916 --> 0:03:56.676 you just articulated, drawn from this National Academy of Sciences approach, 0:03:57.036 --> 0:04:00.756 Every single principle is a good principle, but it's not 0:04:00.796 --> 0:04:03.716 at all obvious to me how they work together. In fact, 0:04:03.756 --> 0:04:05.876 some of those principles seem like in practice they would 0:04:05.876 --> 0:04:09.596 be in contradiction with other principles. I mean, generally, aiming 0:04:09.636 --> 0:04:14.156 for maximal benefit does mean treating people not as individuals 0:04:14.196 --> 0:04:16.956 on their own, but seeing them in terms of the 0:04:17.076 --> 0:04:21.476 role that their physical bodies will play in transmission. I mean, 0:04:21.516 --> 0:04:24.476 if someone is especially likely to transmit, we should stop 0:04:24.516 --> 0:04:28.076 that person from transmitting by vaccinating that person. The idea 0:04:28.116 --> 0:04:31.356 of moral weight doesn't really come into that. We're thinking 0:04:31.356 --> 0:04:33.756 of the society as a collective and the greatest good 0:04:33.756 --> 0:04:37.556 for the greatest number. But the other principles are to 0:04:37.596 --> 0:04:40.396 a certain degree very much based in a tradition that 0:04:40.476 --> 0:04:43.556 says each human being has equal value and equal weight 0:04:43.916 --> 0:04:46.636 and shouldn't be treated differently from any other person on 0:04:46.676 --> 0:04:49.316 the basis of some quality that's not directly connected to 0:04:49.356 --> 0:04:53.516 their moral worth. So do these principles talk at all 0:04:53.556 --> 0:04:57.596 about how to reconcile the potential conflicts or is this 0:04:57.636 --> 0:04:59.196 one of those cases where you just list a lot 0:04:59.236 --> 0:05:01.156 of good moral principles and then the devil is in 0:05:01.156 --> 0:05:04.076 the details. Well, it's a really important question, and they 0:05:04.076 --> 0:05:06.276 don't go into great death. But I think the clear 0:05:06.316 --> 0:05:11.356 intent is that when they say it's appropriate to let's 0:05:11.436 --> 0:05:13.676 use the word discriminate, but here it's not in a 0:05:13.716 --> 0:05:17.076 negative way. It's picking out people for priority. It's appropriate 0:05:17.116 --> 0:05:21.996 to do it on that basis when the role concerns 0:05:22.076 --> 0:05:26.036 the virus. So we're not talking about valuing some lives 0:05:26.076 --> 0:05:30.236 more than others because they're not criminals, or they're just 0:05:30.316 --> 0:05:33.196 better citizens, or they pay more taxes where they are 0:05:33.276 --> 0:05:36.836 engaged in industries like I don't know, tech that we 0:05:36.916 --> 0:05:40.076 think bring really innovative products to us. That's not what's 0:05:40.076 --> 0:05:42.716 going on here. They're talking about people who, by dint 0:05:42.756 --> 0:05:49.276 of their social roles, are either big transmitters or serving functions, 0:05:49.276 --> 0:05:52.436 serving professional functions that help us contain the epidemic, or 0:05:52.476 --> 0:05:56.436 that otherwise help us maintain some symblance of normal civil 0:05:56.516 --> 0:06:01.436 life by providing food, transportation, essential infrastructure. So I think 0:06:01.476 --> 0:06:04.276 they've tried to tow the line there by drawing this 0:06:04.396 --> 0:06:08.756 boundary around what they are willing to consider when evaluating 0:06:08.796 --> 0:06:12.436 a person's role. Do teachers come up here, because they 0:06:12.436 --> 0:06:14.396 seem like a fascinating case to me, because on the 0:06:14.436 --> 0:06:18.876 one hand, teachers are fulfilling a fundamental social role. Without them, 0:06:18.876 --> 0:06:20.876 we can't open the schools, at least not in person. 0:06:21.836 --> 0:06:25.396 But then again, they're not frontline health responders. So teachers 0:06:25.396 --> 0:06:28.356 have been one of the most interesting points of discussion 0:06:28.396 --> 0:06:31.476 in the broader debates about vaccine allocation, because you know, 0:06:31.796 --> 0:06:35.156 to a large degree, we're talking about relatively young people 0:06:35.276 --> 0:06:40.156 who are relatively robust and able to withstand this virus, 0:06:40.196 --> 0:06:42.956 and you know, the emerging evidence suggests that at least 0:06:43.036 --> 0:06:46.996 smaller children are not particularly big vectors. So the teachers 0:06:47.276 --> 0:06:50.316 perceive themselves to be at high risk, but actually might 0:06:50.356 --> 0:06:53.076 not be as quite a high risk as they worried 0:06:53.116 --> 0:06:56.676 that they would be early on. Having said that, there's 0:06:56.756 --> 0:07:01.156 no denying the fact that they are the backbone of 0:07:01.396 --> 0:07:05.356 the most critical infrastructure outside of maybe the provision of 0:07:05.356 --> 0:07:07.956 food and housing. You know, the economy does not run 0:07:08.196 --> 0:07:11.076 when kids are not as school and so as a result, 0:07:11.156 --> 0:07:14.756 the Nation Committee and I think most states will put 0:07:14.836 --> 0:07:18.636 teachers in Phase two, behind healthcare workers and nursing home 0:07:18.636 --> 0:07:21.556 residents and perhaps a few others, but toward the front 0:07:21.556 --> 0:07:24.276 of the line, because again they're playing a role in 0:07:24.956 --> 0:07:28.516 making an essential sector work. You just raised an issue 0:07:28.556 --> 0:07:30.836 that's also of great interest to me, and that is 0:07:30.876 --> 0:07:33.156 you mentioned that it's the states that are going to 0:07:33.236 --> 0:07:36.276 be making the actual decision. So first we talked about 0:07:36.316 --> 0:07:40.076 this framework produced by a kind of blue ribbon panel 0:07:40.676 --> 0:07:44.596 of the quasi governmental but not really governmental, National Academy 0:07:44.596 --> 0:07:47.076 of Sciences, so it's not technically part of the government. 0:07:47.476 --> 0:07:50.236 The governments that will be making the decisions about allocation 0:07:50.276 --> 0:07:55.196 of vaccines are state governments. Why isn't this something that 0:07:55.236 --> 0:07:59.876 should have been decided by the federal government. Well, I 0:07:59.916 --> 0:08:02.116 think really the only way one could answer that is 0:08:02.156 --> 0:08:04.516 just by saying, it's always been the states that have 0:08:04.596 --> 0:08:08.116 run immunization programs. It's just kind of always been that way. 0:08:08.116 --> 0:08:11.796 That there are are federal bodies, most prominently the Advisory 0:08:11.836 --> 0:08:14.556 Committee on Immunization and Practices that you might have heard 0:08:14.596 --> 0:08:20.036 referred to as ASIP, that make recommendations, highly informed, expert 0:08:20.156 --> 0:08:24.436 credible recommendations about who to vaccinate, how to vaccinate them, 0:08:24.476 --> 0:08:27.396 when to vaccinate them. And then states pick up the 0:08:27.436 --> 0:08:29.796 ball and they do it, and they can tweak those 0:08:29.796 --> 0:08:33.316 recommendations if they want to, but it's their game. If 0:08:33.316 --> 0:08:36.436 you were to start over here and design yeah, but 0:08:36.756 --> 0:08:38.516 let's make you the czar and design it not for 0:08:38.556 --> 0:08:40.876 this time, but for the next time. You know. I 0:08:40.916 --> 0:08:44.756 think that there are critical logistical differences among the states 0:08:44.796 --> 0:08:47.316 that cause it to make sense to have them in 0:08:47.436 --> 0:08:52.156 charge of implementation. But I don't appreciate a significant reason 0:08:52.836 --> 0:08:56.276 for the prioritization to be different across states. If it's 0:08:56.316 --> 0:09:02.356 evidence based and it reflects very careful deliberation about important 0:09:02.396 --> 0:09:05.396 values that are shared, it's not clear to me why 0:09:05.436 --> 0:09:08.436 it should be tweaked at the state level. That leads 0:09:08.436 --> 0:09:10.676 me to a very practical question. I mean, what I've 0:09:10.716 --> 0:09:14.356 been sort of picturing is, if you're a hospital worker 0:09:14.396 --> 0:09:17.356 or a frontline worker, you'll get the vaccine through your hospital, 0:09:17.436 --> 0:09:19.756 or if you're a policeman or a fireman or a firefighter, 0:09:19.836 --> 0:09:22.636 or you'll get it, you know, at your firehouse or 0:09:22.876 --> 0:09:24.796 you know, in the police department and so forth. But 0:09:24.876 --> 0:09:27.516 I've been picturing for the vast majority of the population 0:09:27.516 --> 0:09:30.196 that doesn't fit into one of those categories lining up 0:09:30.236 --> 0:09:34.676 in big numbers outside of some large facility, sort of 0:09:34.716 --> 0:09:37.396 the way that testing is sort of happening in some 0:09:37.436 --> 0:09:41.676 places now. Is that wrong? The allocation frameworks mostly are 0:09:41.676 --> 0:09:45.476 putting healthcare workers, nursing home residents, and a few others 0:09:45.476 --> 0:09:47.956 at the front of the line phase one A or 0:09:47.516 --> 0:09:50.676 one B, and then we get down to people with 0:09:50.796 --> 0:09:54.196 significant comorbidities, and then we get down to a phase two, 0:09:54.316 --> 0:09:58.556 where we're dealing with other important people for infrastructure and 0:09:58.596 --> 0:10:01.356 people who have milder comorbidities. And if that's how we 0:10:01.396 --> 0:10:03.716 get to a phase three where there's wide availability the 0:10:03.796 --> 0:10:07.156 vaccine that it starts to penetrate the general population and 0:10:07.196 --> 0:10:11.236 eventually reach younger adults and children. And at that stage, yeah, 0:10:11.236 --> 0:10:14.156 I think we're talking about mass vaccination clinics. But in 0:10:14.156 --> 0:10:16.796 the early stages, when we're trying to identify people who 0:10:16.836 --> 0:10:21.396 are eligible for vaccination under these allocation frameworks, it has 0:10:21.436 --> 0:10:25.516 to work through organizations that already have that information. We're 0:10:25.556 --> 0:10:29.836 not going to have a corner Kiosk vaccinating people asking 0:10:29.876 --> 0:10:32.876 them to show proof of diabetes. And it's not because 0:10:32.916 --> 0:10:35.436 we just don't have enough vaccine yet to reach the 0:10:35.516 --> 0:10:37.956 larger numbers of people. I mean, presumably the moment there 0:10:37.996 --> 0:10:41.756 are enough doses to start lining people up. We want 0:10:41.756 --> 0:10:43.796 to do that. We want to do that, but you 0:10:43.836 --> 0:10:46.516 have to understand the logistical hurdles involved in getting this 0:10:46.596 --> 0:10:50.396 vaccine out and administering it, particularly for the fiser vaccine 0:10:50.436 --> 0:10:51.956 that has to be stored, as you know, at this 0:10:52.116 --> 0:10:55.476 extremely cold temperature, and if your facility doesn't have one 0:10:55.476 --> 0:10:58.796 of those freezers, you're out now. With MADERNA coming online, 0:10:58.796 --> 0:11:01.116 it'll be a little easier. But that's just one example 0:11:01.156 --> 0:11:04.796 of the kind of logistical challenges in scaling this program up. 0:11:05.556 --> 0:11:07.716 So it is going to take some time. Even if 0:11:07.756 --> 0:11:11.236 all of these doses were warehouse right now, not all 0:11:11.276 --> 0:11:13.556 states would be ready to give them to all people. 0:11:14.636 --> 0:11:17.116 Do you have I realized that nobody knows a definitive 0:11:17.156 --> 0:11:18.556 answer to this, and I don't mean to put you 0:11:18.596 --> 0:11:21.196 on the spot, but do you have an instinctive answer 0:11:21.716 --> 0:11:23.836 as to how long this is going to take in 0:11:23.836 --> 0:11:26.516 the different phases? I have heard people say with some 0:11:26.636 --> 0:11:30.996 confidence that at least they speak with confidence that by 0:11:31.156 --> 0:11:34.076 next end of next August beginning of next September, when 0:11:34.476 --> 0:11:39.036 the twenty one twenty two school year begins, people should 0:11:39.156 --> 0:11:42.596 overwhelmingly have been vaccinated. But do you think that is 0:11:42.676 --> 0:11:47.276 actually unrealistically optimistic? I mean, that's consistent with what I'm hearing. 0:11:47.276 --> 0:11:50.116 I don't have any inside information about this. I think 0:11:50.356 --> 0:11:54.076 that's realistic, probably for adults. Kids are the big question 0:11:54.116 --> 0:11:56.516 mark at this point, because, as I'm sure you know, 0:11:56.676 --> 0:11:59.076 you have to have a separate set of clinical trials 0:11:59.116 --> 0:12:02.276 to demonstrate the safety and effectiveness of the vaccine for 0:12:02.396 --> 0:12:05.196 children Right now, I think no trial has gone below 0:12:05.196 --> 0:12:09.236 age sixteen, so those trials are just getting underway. And 0:12:09.556 --> 0:12:12.116 as you probably remember, there is a debate about whether 0:12:12.196 --> 0:12:15.476 to end the adult trials early. There will be similar 0:12:15.516 --> 0:12:17.636 debates for these trials as to how long to run 0:12:17.676 --> 0:12:20.396 them before you get the initial approval for children. So 0:12:20.636 --> 0:12:24.956 there's just a lot more uncertainty about when approval will 0:12:24.996 --> 0:12:27.356 come through. You know, once it does come through, I 0:12:27.356 --> 0:12:30.436 would expect things to happen relatively quickly because we will 0:12:30.476 --> 0:12:33.316 have experience at that point with supply chain and with 0:12:33.556 --> 0:12:36.076 setting things up in clinics, and we will have providers 0:12:36.196 --> 0:12:38.796 enrolled in the program and so forth. But it could 0:12:38.796 --> 0:12:40.756 take some time. And then, of course there's going to 0:12:40.796 --> 0:12:44.676 be the inevitable resistance when we talk about vaccinating children. 0:12:45.796 --> 0:12:48.116 That brings us to the resistance question, which I really 0:12:48.156 --> 0:12:52.276 want to explore with you. So let's start by just 0:12:52.396 --> 0:12:58.396 asking whether you think there are justifiable reasons that individuals 0:12:58.436 --> 0:13:01.876 could use to say I don't want to be vaccinated 0:13:02.156 --> 0:13:05.396 or I don't want my kids to be vaccinated. What 0:13:05.556 --> 0:13:09.716 distinguishes this vaccine from other vaccines that we choir for 0:13:09.876 --> 0:13:13.556 kids is that it's new and not only is it new, 0:13:13.596 --> 0:13:15.876 but it is for some of the makers based on 0:13:15.916 --> 0:13:20.196 a new kind of approach to making vaccines, this mRNA approach. 0:13:20.716 --> 0:13:24.276 So I think it's not unreasonable that people are voicing 0:13:24.396 --> 0:13:29.636 concerns or having questions about safety. It's very unusual, for example, 0:13:29.676 --> 0:13:32.916 for US to require children to accept a vaccine that 0:13:33.036 --> 0:13:35.716 is novel on the market. Obviously take a very extraordinary 0:13:35.716 --> 0:13:38.956 set of circumstances. The other thing, of course, that makes 0:13:38.996 --> 0:13:42.676 these fears not unreasonable is the process through which the 0:13:42.796 --> 0:13:46.036 vaccines have been approved. You know, I think two months 0:13:46.036 --> 0:13:47.996 ago I would have said it's very reasonable for people 0:13:48.036 --> 0:13:50.556 to have concerns about that. Since then, I've personally been 0:13:50.596 --> 0:13:53.836 reassured by the process that has emerged from FDA, the 0:13:53.876 --> 0:13:59.116 director asserting his independence, the transparency around the basis for 0:13:59.236 --> 0:14:02.996 approval that have certainly not heard anyone who has independently 0:14:03.036 --> 0:14:06.036 reviewed those data packages voicing concerns about well, were they 0:14:06.036 --> 0:14:09.796 careful enough or was this the right standard? Their decision 0:14:09.876 --> 0:14:11.836 was also made a lot easier by the fact that 0:14:11.876 --> 0:14:15.636 these were not close cases in terms of efficacy. You know, 0:14:15.676 --> 0:14:17.436 they had set this initial bar it has to be 0:14:17.476 --> 0:14:21.356 fifty percent or more effective, and these things just absolutely 0:14:21.436 --> 0:14:24.476 vaulted over that bar. So I think there's a lot 0:14:24.556 --> 0:14:27.316 to feel good about now relative to where we were 0:14:27.356 --> 0:14:30.676 a couple of months ago, and my own personal apprehensions 0:14:30.716 --> 0:14:33.356 about this I think have been relieved by what I've 0:14:33.396 --> 0:14:37.156 seen over those months. Having said that, anybody who's hesitant 0:14:37.196 --> 0:14:40.396 about regular vaccines is definitely gonna be hesitant about this 0:14:40.436 --> 0:14:43.076 one because it's new. What I think we have going 0:14:43.116 --> 0:14:44.956 for us again is that by the time we get 0:14:44.956 --> 0:14:48.556 to kids, there will be millions and millions and millions 0:14:48.556 --> 0:14:51.356 of doses having been delivered to adults, and we will 0:14:51.676 --> 0:14:53.716 know a lot. So even though it will be new 0:14:53.876 --> 0:14:57.716 in terms of months or years, in terms of doses delivered, 0:14:57.996 --> 0:15:00.316 it might look a lot more like the knowledge base 0:15:00.396 --> 0:15:13.316 that we have about older vaccines. We'll be right back, Michelle. 0:15:13.316 --> 0:15:18.236 You're a highly rational, logical thinking person, and your description 0:15:18.396 --> 0:15:22.316 of what count as reasons to be concerned we're all 0:15:22.356 --> 0:15:26.436 derived from logic and reason there but I presume that 0:15:26.916 --> 0:15:29.836 you share my view. Maybe I shouldn't that some of 0:15:29.876 --> 0:15:32.836 the reasons that people are skeptical of vaccines generally may 0:15:32.876 --> 0:15:36.716 be grounded in formal logical reason, but others are grounded 0:15:36.716 --> 0:15:39.956 in other features. You know, whether that's religious faith, which 0:15:39.996 --> 0:15:43.356 sometimes by its own self description, is grounded in something 0:15:43.436 --> 0:15:46.676 other than logic or reason, not for everybody but for some, 0:15:47.476 --> 0:15:52.356 or in paranoia or structural distrust of science or of 0:15:52.356 --> 0:15:56.196 the government. So what about people who say, you know, 0:15:56.236 --> 0:15:58.956 I don't like vaccines in general, forget about for my kids, 0:15:58.956 --> 0:16:02.756 but for me, and I don't want to be vaccinated. 0:16:03.196 --> 0:16:07.156 Here how tolerant in your view? Should the government be 0:16:08.076 --> 0:16:11.156 of the kind of a response, And then from government 0:16:11.156 --> 0:16:13.676 will move on to private businesses and so forth. Yeah, 0:16:13.716 --> 0:16:15.876 I mean, look, I'm very familiar with the range of 0:16:15.876 --> 0:16:19.676 different concerns. I get lots of mail from folks in 0:16:19.716 --> 0:16:22.156 the anti vACC community expressing their hopes and dreams for 0:16:22.236 --> 0:16:25.596 my family and my own health and safety, and so 0:16:25.796 --> 0:16:28.796 I'm aware all of them very positive, a certain very sweet. 0:16:28.836 --> 0:16:31.636 As a recipient of occasional hate mail myself, I'm sure 0:16:31.676 --> 0:16:34.156 that the loving spirit that pervades all hate mail is 0:16:34.196 --> 0:16:37.516 present in yours too. So I know that people who 0:16:37.596 --> 0:16:41.196 are hesitant or resistant of vaccines really run the gamut 0:16:41.236 --> 0:16:43.796 in terms of how well informed their beliefs are, what 0:16:43.876 --> 0:16:46.796 their beliefs are, why they have these concerns. So the 0:16:46.876 --> 0:16:49.156 question is, what do we do about it. I guess 0:16:49.196 --> 0:16:52.116 my own feeling is that one thing we have going 0:16:52.156 --> 0:16:55.636 for us here is that we don't need ninety percent vaccination. 0:16:55.676 --> 0:16:59.236 We don't need ninety five percent. The best estimates are 0:16:59.276 --> 0:17:02.196 somewhere in the sixty to eighty percent range, probably seventy 0:17:02.196 --> 0:17:05.116 to eighty percent coverage in order to really kill this 0:17:05.236 --> 0:17:07.796 thing because the vaccine is so effective. I mean, we're 0:17:07.796 --> 0:17:10.236 actually getting lucky there. If theaccine we're less effective, we 0:17:10.236 --> 0:17:12.356 would need more people to take it. But even more 0:17:12.356 --> 0:17:14.236 critical than that is what we call the ar not, 0:17:14.356 --> 0:17:17.716 the reproductive number for this virus, which you know, as 0:17:17.716 --> 0:17:20.436 you probably know, is around one somewhere right now in 0:17:20.476 --> 0:17:22.876 most parts of the country. In California here, I think 0:17:22.916 --> 0:17:24.476 it's at one point two right now, which is the 0:17:24.516 --> 0:17:27.396 worst it's been in a while. Compare that to measles, 0:17:27.436 --> 0:17:29.916 where we've got an ar not of twelve to fifteen. 0:17:30.036 --> 0:17:32.276 That means for every person with measles, they're going to 0:17:32.356 --> 0:17:36.836 infect on average, twelve to fifteen additional people. And because 0:17:36.876 --> 0:17:39.356 of that, we have to have close to ninety five 0:17:39.396 --> 0:17:43.796 percent vaccine coverage in order to kill measles in the population. 0:17:44.476 --> 0:17:47.036 So what this all means is we can let a 0:17:47.036 --> 0:17:49.356 few go, we can let more than a few go, 0:17:50.036 --> 0:17:52.036 And in fact, I think we're going to have to 0:17:52.076 --> 0:17:55.476 because there's going to be enough vaccine to get to 0:17:55.556 --> 0:17:59.436 that place of ninety plus percent coverage for quite a 0:17:59.436 --> 0:18:02.676 long time. So what's been interesting to me and having 0:18:02.716 --> 0:18:07.116 conversations about this topic is how much we pivot back 0:18:07.156 --> 0:18:09.796 and forth from talking about who get to get it, 0:18:09.956 --> 0:18:11.876 who gets to be in the line to get it too, 0:18:12.116 --> 0:18:14.396 who has to get it? We're having like these both 0:18:14.436 --> 0:18:17.316 of these conversations at the same time, and the reality 0:18:17.436 --> 0:18:19.356 is that's not going to take place at the same time. 0:18:19.356 --> 0:18:21.556 There's going to be a long time where the question 0:18:21.676 --> 0:18:24.676 is only who gets to get it, and way down 0:18:24.716 --> 0:18:27.676 the line where everybody who would like to get it 0:18:27.716 --> 0:18:29.996 has gotten it, then we can talk about whether there's 0:18:30.036 --> 0:18:33.196 a need to do anything about the remaining whatever it 0:18:33.276 --> 0:18:37.236 is ten twenty percent, thirty percent, forty percent, we'll see. 0:18:37.956 --> 0:18:41.676 But at that point we'll know a lot more about 0:18:41.796 --> 0:18:45.716 the effect of population vaccination on the spread of this virus, 0:18:45.756 --> 0:18:47.836 and my expectation is we won't have to do a 0:18:47.836 --> 0:18:50.236 lot of chasing people that we will get to where 0:18:50.236 --> 0:18:54.956 we need to be with voluntary vaccination as long as 0:18:55.236 --> 0:18:57.796 we do a decent job on two things. One is 0:18:57.916 --> 0:19:00.716 bringing the vaccine to people where they are at zero cost, 0:19:00.756 --> 0:19:04.236 with zero logistical barriers, and the second is learning how 0:19:04.276 --> 0:19:06.716 to talk to people about this vaccine in a way 0:19:06.876 --> 0:19:09.956 that resonates with them. Do you think there might actually 0:19:09.956 --> 0:19:13.116 be an interesting cultural effect of this sequencing that you're describing, 0:19:13.636 --> 0:19:16.636 where if a lot of people really really want the 0:19:16.716 --> 0:19:19.876 vaccine and are trying to get it, that might actually 0:19:20.036 --> 0:19:23.276 create a norm that the vaccine is desirable and reduce 0:19:23.396 --> 0:19:25.756 some of the objections. Because the way many people say 0:19:25.756 --> 0:19:29.116 experience vaccines is you know, they're saying their kids to school, 0:19:29.196 --> 0:19:31.116 or their kids have just been born, or at the 0:19:31.116 --> 0:19:34.756 relevant check up age, and then the government or or 0:19:34.796 --> 0:19:36.836 the doctors speaking on behalf the government says it's time 0:19:36.836 --> 0:19:39.316 for the vaccine. So people see it as a coercive structure. 0:19:39.716 --> 0:19:42.516 And what's more, because those vaccine programs are on the 0:19:42.516 --> 0:19:46.196 whole relatively successful, people don't really see the diseases that 0:19:46.236 --> 0:19:49.716 they would be getting, you know, if they weren't vaccinated. Here, 0:19:49.796 --> 0:19:53.116 we've all seen the effects of COVID. We've seen most 0:19:53.116 --> 0:19:55.236 of us in the United States now, no people who've 0:19:55.276 --> 0:19:57.796 gotten sick and in many cases we know people who 0:19:57.796 --> 0:20:00.956 have unfortunately died, So there's a kind of you know, 0:20:01.036 --> 0:20:04.836 maybe if everyone wants one, it will reduce the likelihood 0:20:04.836 --> 0:20:07.716 that people will be skeptical of taking it. I mean, 0:20:07.756 --> 0:20:10.636 they're probably a certain people in the population who think 0:20:10.636 --> 0:20:13.396 in those terms. I think what will be more influential 0:20:13.596 --> 0:20:15.756 is just the experience of seeing with your own eyes 0:20:15.876 --> 0:20:20.716 friends and family getting vaccinated, being fine, shedding tears of relief, 0:20:21.076 --> 0:20:23.516 and being able to resume their lives in ways that you, 0:20:23.596 --> 0:20:27.996 as an unvaccinated person can't or shouldn't. So what is 0:20:27.996 --> 0:20:29.836 scary about this vaccine, as I mentioned to a lot 0:20:29.876 --> 0:20:32.316 of people, is that it is new, it's unknown, and 0:20:32.556 --> 0:20:34.916 quite understandably, they don't want to be in line first 0:20:34.996 --> 0:20:37.836 for something that they have concerns about. But one hundred 0:20:37.876 --> 0:20:40.796 million doses later, I think people will start to feel differently. 0:20:41.076 --> 0:20:44.236 It's going to take special outreach to certain populations to 0:20:44.276 --> 0:20:48.156 be sure, including racial and minority communities who need to 0:20:48.196 --> 0:20:51.596 hear this from particular kinds of messengers. And then also 0:20:51.636 --> 0:20:54.156 this time around people on the right who you know, 0:20:54.236 --> 0:20:59.836 quite curiously, given the President's investment in vaccine development, share 0:21:00.156 --> 0:21:05.076 the vaccine skepticism of many in the vaccine resistance community, 0:21:05.076 --> 0:21:09.316 which have traditionally been more left leaning women. So there's 0:21:09.316 --> 0:21:12.996 this bizarre concentration or constellation of people who have concerns 0:21:13.036 --> 0:21:15.196 about the vaccine that we're going to have to figure 0:21:15.236 --> 0:21:17.996 out how to reach. But you know, there will be 0:21:17.996 --> 0:21:20.876 people that it will be pretty tough for. My stepmom 0:21:21.036 --> 0:21:24.916 is a retired corrections officer. She lives in rural Iowa, 0:21:24.996 --> 0:21:27.716 and she's you know, elderly and at some risk for 0:21:28.076 --> 0:21:31.156 serious cummorbidities. And when I talk to her about the vaccine, 0:21:31.676 --> 0:21:35.276 she says, hell, no, I'm not getting no vaccine full stop. 0:21:35.316 --> 0:21:37.316 There's not a lot to work with there in terms 0:21:37.356 --> 0:21:39.756 of you know, we talked about with rational reasons. There's 0:21:39.796 --> 0:21:42.956 there's just not a lot there other than distrust. And 0:21:43.156 --> 0:21:44.676 you know, we're going to have to figure out how 0:21:44.676 --> 0:21:47.116 to turn some of the messaging around to reach out 0:21:47.156 --> 0:21:51.436 to people who see vaccination as part of a broader 0:21:51.996 --> 0:21:56.636 set of intrusive measures perpetrated on the public by left 0:21:56.716 --> 0:22:00.436 leaning public health officials and governors. Can you imagine a 0:22:00.476 --> 0:22:04.356 scenario where we actually aren't able to vaccinate enough people 0:22:04.396 --> 0:22:08.636 to reach her community because of widespread skepticism. I mean 0:22:08.676 --> 0:22:10.956 that would be massive crisis. I mean, here we are, 0:22:11.116 --> 0:22:13.996 people like us are sitting around in universities, and the 0:22:14.036 --> 0:22:16.756 moment that the vaccines were reported as working, we all 0:22:16.836 --> 0:22:20.876 breathed an enormous sigh of relief. Right, I mean science worked. 0:22:21.036 --> 0:22:23.916 You know what a relief. Life will return to normal. 0:22:23.996 --> 0:22:27.516 What a relief. And I don't think I've heard serious 0:22:27.556 --> 0:22:30.556 discussion in the last few weeks, let's say, since the 0:22:31.356 --> 0:22:35.316 good numbers came in, of oh, what if we just 0:22:35.516 --> 0:22:38.876 cannot convince a sufficient number of people to take it, 0:22:38.956 --> 0:22:41.796 to get the R not down below one. I mean, 0:22:41.996 --> 0:22:44.556 I look that. I think those discussions are happening. There's 0:22:44.596 --> 0:22:48.276 still so much interest. I'm hearing and talking about mandates 0:22:48.316 --> 0:22:51.596 and you can employers required and can schools require it? 0:22:51.996 --> 0:22:54.196 This is not, to be clear, something that state officials 0:22:54.196 --> 0:22:56.676 are talking about, or even many employers. There's very little 0:22:56.676 --> 0:22:58.836 appetite for that among the employers that I know of, 0:22:59.316 --> 0:23:01.596 but reporters want to talk about it. People are curious 0:23:01.636 --> 0:23:05.116