Monday, December 6, 2021

Vaccine Mandates and the Body Politic

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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