By Ari Schulman
Thursday,
December 02, 2021
Can the common good justify vaccine
mandates in a fractured age?
American history offers two defining
images of mass-vaccination campaigns. One is from April 12, 1955, when across
the land, to the sound of church bells heralding the news that the first polio vaccine
was a success, people poured into the streets to celebrate. The other is from
three months ago, when a lugubrious President Biden announced a sweeping
federal vaccinate-or-test mandate for workplaces while scolding, “Our patience
is wearing thin.”
Our country has precedent for vaccine
mandates, including ones with narrower exemptions. State laws nationwide
mandate childhood vaccinations to attend school. In 1905, in Jacobson
v. Massachusetts, the U.S. Supreme Court upheld the right of Cambridge, Mass.,
to fine unvaccinated residents. And in the winter of 1777, an alarmed General
Washington ordered the mass inoculation of Continental troops against a looming
smallpox epidemic, writing, “Necessity not only authorizes but seems to require
the measure, for should the disorder infect the Army . . . we should have more
to dread from it, than from the Sword of the Enemy.” Compulsory vaccination
goes back to the country’s founding, in the fight for its very freedom.
But those moments also feel distant from
ours. Their precedent does not seem to relieve us of qualms about a mandate to
be enforced by the Labor Department’s Occupational Safety and Health
Administration (OSHA). Can it be legitimate to infringe on individual liberty
for the sake of common purpose at a moment when the very idea of our common
purpose seems so tenuous?
As public-health historian Elena Conis
tells it, writing in The American Historian, the social movements
of the 1960s fractured what made the polio moment possible. Vaccine skepticism
arose in part from the feminist movement, which “urged women to become informed
medical consumers in every doctor–patient interaction.” In the 1970s, doubts
about childhood vaccines appeared in Mothering magazine, Conis
notes, and mothers began to take on a significant role in the movement
questioning vaccines. Skepticism was also fueled by environmental concerns
about the perils of technological control of nature. Parents formed
organizations to push for vaccine safety; for these advocates, Conis writes,
revelations about pesticides in “Rachel Carson’s Silent Spring, the
1962 bestseller that helped usher in the environmental movement, . . . held a
moral that applied to vaccines.” As the authors of DPT: A Shot in the
Dark, published in 1985, put it: “Just as we have polluted our environment
with man-made chemicals, we may well be polluting ourselves with a myriad of
man-made vaccines in our quest to eradicate all disease and infection from the
earth.”
All this was wrapped up in a broader
movement to defend the bodily autonomy of patients against a genuinely
overweening, paternalistic, often abusive medical establishment. Amid an
unsettled culture, Americans developed the language of conscience, autonomy, and
resistance to medical authoritarianism that has been spoken during Covidtide.
One of the perplexities of the pandemic is
that we have managed to become nightmarishly enmeshed in fights over social
obligation without ever really hearing the language of the common good or the
national interest, the kind we might have imagined from an FDR or the
prophesied nationalist incarnation of President Trump. Yes, in an obvious
sense, for two years we have heard nothing but demands for personal liberty to
give way to the greater good. Yet we haven’t heard much talk about the “greater
good” and “civic duty” as such. Instead, the pressure to mask and get
vaccinated has been articulated lightly as This is in your
self-interest and heavily as You must do this to protect others.
These rationales can’t bear the weight
placed on them. Indeed, the cracks became evident in President Biden’s speech,
with his insistence, “The bottom line: We’re going to protect vaccinated
workers from unvaccinated co-workers.” In the same speech, the president
minimized this very danger, reassuring the public that, “if you’re fully
vaccinated, you’re highly protected from severe illness, even if you get
COVID-19.” And in another context, seeking to encourage ongoing masking,
Biden’s own CDC has broadcast doubts about how well vaccines actually reduce
transmission of the Delta variant. There is a partial truth in each of these
ideas, but taken together they offer an incoherent view of the vaccine drive’s
rationale and give support to those who want to dismiss it all as pretext.
There is a real and fundamental conflict
between safety-minded restrictionists and rights-minded dissidents. But there
is also something beyond safetyism at work in the ongoing insistence of many
healthy, vaccinated people that it’s not safe for them to return to normal
life. The “your right to swing your fist ends at my nose” type of protectionism
is a matter of principle, not a matter of whether the fist really packs a
punch. It bears a family resemblance to the committed “don’t tread on me”
opponent of restrictions.
We have been approaching the pandemic as a
grueling boundary dispute over the line between the individual and the group.
No longer is the medical power that threatens my autonomy merely some
patronizing doctor. It is the city that requires masking, the masses demanding
my compliance, the whole Regime. Or it is the city that refuses to
require masking, and every stranger I pass on the street, merely by his
exhaling. Because he has new power over my body, I have a new personal claim on
his. What a mess.
* * *
There are of course many other issues
at stake in the vaccine debate. We sense them, yet we have struggled to find a
public language to say what they are.
One thing we have struggled with is scale.
A pandemic simply demands that we think about medicine in the aggregate — group
abstractions such as “population health” and “herd immunity” that Americans
rightly find awkward or dangerous.
There is a deeper issue here than a simple
collective-action problem. Because of the wildly varying risk profile of COVID,
many critics, understandably, have said that vaccination is needed only for the
most vulnerable. Or as some have put it, “Grandma is going to die anyway”
(understood as someone else’s grandma), and whatever we do to protect her, it
should not come at the expense of society’s vital core.
But consider two counterintuitive
findings. One recent study found that retirement-age Americans (age 65 and up)
who died of COVID lost, collectively, a staggering 4 million years of life. But
working-age Americans (age 25 to 64) who died of COVID lost 5 million years.
Similarly, increases in mortality rates above typical levels have actually been
highest not among the elderly but among adults in their prime parenting years:
In 2020, people age 85 and older were 15 percent more likely to die than in
prior years, while 20- to 40-somethings were 27 percent more likely to die.
If my normal risk of dying is very low,
even a hefty bump makes it still low, and it might seem reasonable for me to
play the odds. But taken together, all those bumped-up risks amount to a series
of catastrophes for American society: three years of life expectancy lost for
black people, untold numbers of widowed young mothers, 121,000 children who
lost a primary caregiver — a greater toll for American parents than Vietnam,
and in far less time.
This brings us to the other scale we have
struggled to talk about: the personal. What are the moral stakes of my getting
sick? The American Enterprise Institute’s Tim Carney, offering a “conservative
argument for getting vaccinated,” appeals to the duty I have to others to
reasonably avoid my own illness. The unvaccinated father who
dies, or is just laid up for weeks or months (COVID is far less choosy about
what ages it selects for hospitalization than for death), leaving in the lurch
his children, wife, or parents, saddled with medical bills, has been reckless.
Even if he never infects anyone else, he has failed in his basic obligations.
The shared problem is not some of
us potentially getting infected against our will but simply so many
of us getting seriously ill and dying at once and all that follows from this.
The toll shows up in countless other aspects of our shared life, encompassing
much more than the death count. Just gesture broadly at everything: factory
lines disrupted by outbreaks, churches hit by superspreading events, patients
denied elective procedures, a third academic year with Zoom schooling, economic
shocks, the empowering of experts as rulers, people cowering in mutual
loathing, the whole sad grueling COVID moment of American history.
* * *
‘Common good” talk may seem even more
perilously capacious than “protect others” and “slow the spread.” But really it
is a more encompassing view of all the social layers and their attendant goods
that have been imperiled. It offers a more porous sense of the border between
individual and group, showing a more complex network of intimacies and dependencies
that we are already caught up in and that cannot be translated fully into the
language of liberty and black-or-white obligation. That we have been doggedly
trying to do so might help explain why we have been at each other’s throats
these past two years.
While all this suggests an even stronger
case than we have been hearing for the good of vaccination, it also suggests a
less strained obligation. Helping to significantly reduce the number of people
in my community who get seriously ill, starting with myself, is a more
definable, achievable goal than the nebulous “protect others.” The shared
picture relieves us somewhat of fists swinging at noses, and of the debate
about whether vaccines “prevent” transmission in some absolute sense. Instead
it draws our attention to the whole picture, that mass vaccination is plainly a
powerful measure to move us all away from the COVID era.
Once that picture comes into view, we can
better see where mandates are appropriate and where they are inadvisable. Some
further history is useful here. Despite our image of the 1950s, during the
polio campaign little coercion or nationalistic appeal was needed. The March of
Dimes, a nonprofit founded by FDR to find a cure for polio, sought donations by
using celebrity-led campaigns, posters showing children in iron lungs, and
door-to-door outreach. Two-thirds of Americans eventually donated. Millions
volunteered their children as “Polio Pioneers” — test subjects — and the public
closely watched the trials. Teachers instructed children to write thank-you
letters to Jonas Salk. It was one of the most successful
top-down-meets-grassroots political campaigns in American history.
Invigorated, federal health officials grew
more ambitious, targeting over a dozen viruses. Many were less severe. Though
Americans had come to regard some, such as measles, as tolerable nuisances, the
aim now was full eradication. These were harder sells, and so emerged something
novel: nationwide laws mandating a broad array of childhood vaccines, even
against diseases, such as mumps, that are dangerous mostly to adults.
Expansive mandates may be a slow-burning
engine of backlash. The anti-vaccine movements of the 19th century, Conis
notes, were imported by waves of European immigrants who had been subject to
mandates in their origin countries. In our day, childhood mandates have struck
some parents as a new medical paternalism that treats children as vehicles for
adults’ aims. For many, these mandates have been a gateway to doubt about
vaccines generally.
One must be careful not to overinterpret
this history. But COVID-vaccine mandates seem to have had the most success when
imposed at the lowest level, where we can see how our individual presence bears
on some clear shared good. The scattered way in which vaccination requirements
were showing up in hospitals, offices, universities, and some restaurants and
cultural and sports venues suggested a more organic process of codifying
obligations that, by and large, we already recognized. Given the intensity of
vaccine controversy in America, it is striking how little pushback there has
been to these discrete mandates.
The Biden administration has been in a
hard place amid the Delta surge, and perhaps progress on vaccines has simply
been too slow. Under emergency conditions, we cannot afford the 20 years that
the polio campaign took to build its success, and some degree of protective
coercion is inevitable and appropriate. But the OSHA mandate disrupted an
already unfolding, closer-to-home process. However much good the mandate might
achieve, it is a gamble whose stakes are the country’s already frayed
relationship with vaccination. It pits the common good against the conditions
that make it truly shared.
* * *
The simplest way of getting at what
is at stake in mandates, and indeed in the entire way we approach vaccination
campaigns, is with the question of participation. And participation
is a matter less of consent than of legitimate belonging.
It is easy enough to see the individualism
in vaccine hesitancy. But there is just as much a socializing force at work, a
cry of them-vs.-us. Chris Arnade, the chronicler of “back row” America, writes
in his newsletter that, outside of college-educated neighborhoods, dissent “is
worn as a badge of honor, a club membership card, among people who have never
trusted authority, and see being unvaccinated as a way to take a little control
of the situation.”
The polio drive was not some
science-communication effort eased by existing social trust; mass public
participation in the campaign was an engine of social trust.
But for many, it is now opposing vaccination that is the better avenue of
solidarity. It is a chance to belong with people who do not detest me, to
participate in an effort not by giving dimes but by posting studies on social
media.
It is imperative to recognize that the
tangible reasons that drive resistance to vaccines cannot be explained as
“misinformation.” Amid plenty of nonsense, skeptics make important points that
are often ignored. There is good evidence that natural immunity offers
protection as strong as vaccination, and that mandates aren’t needed for people
who can prove past COVID infection. The case for mandatory COVID vaccination of
children, who are at vanishingly low risk, is weak. The remarkable improvement
in the safety of vaccines over the decades owes something to past pressure from
skeptics, and lapses along the way to the lack of it.
Many people are not “anti-vaxxers” in any
committed sense but simply uneasy about something they feel is being pushed on
them. The get-with-the-program-you-ingrates tenor of many calls for vaccination
is thus fuel for the contrarian fire. But it is also a profound missed
opportunity. A full-on effort not to educate the dissenters but to find ways to
learn from them, to make tangible changes that accommodate their worries, might
itself offer a form of participation — an earned sense that the effort is not
just something happening to us, but something we share in. It is the closest
thing to a new March of Dimes we can hope for anytime soon.
More than the sum of their tangible
worries, the reasoning for many vaccine dissenters amounts to “I refuse to
comply.” Something terribly important is conceded here: the ability to
distinguish the good of the regime from the good of the polity. The very things
needed to build trust are what we hold hostage when trust is lost. Any step
away from this broken state will feel unearned, like grace. But someone
will have to go first.
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