Carrot or Stick? Tackling British and American Vaccine Hesitancy

A young man in a blue shirt and blue mask receiving a Covid-19 vaccination in his left arm by a gloved and surgically masked woman in a white lab coat

Despite a rocky start earlier in the pandemic, both the United Kingdom and United States have seen an astronomical vaccine take up which impressed much of the Western world. In both countries, restrictions were slowly lifted and impressive numbers of the groups most vulnerable to Covid were vaccinated, surpassing some expectations. These expectations were partly formed from early worries about what’s known as vaccine scepticism or vaccine hesitancy, defined by the WHO as “[…]delay in acceptance or refusal of vaccines despite availability of vaccine services.” The UK, a country that has seen its own homegrown anti-vaccine movement rise and fall in 2000s, was able to boast a voluntary take up higher than most other developed nations, as predicted by preliminary opinion polling from January. The US, regardless of large political polarisation on the topic, has also managed higher than expected vaccination rates among the most vulnerable groups in terms of age and disability. But even more impressively, this summer everyone in both countries who was eligible to be vaccinated has already been offered one. Make no mistake, this is an incredible achievement not to be scoffed at. In the UK an estimated 60,000 lives were saved thanks to the use of vaccines and notwithstanding a recent spike in case numbers, hospitalisations and deaths have been at rates hospitals can comfortably handle. Both countries, however, are at a crossroads:

Despite both the UK and US having steady progress over their neighbours for the first half of 2021, these two nations are now beginning to have their total number of vaccine doses plateau even with ample access to vaccines. The reason is simple: those who remain unvaccinated either cannot or refuse to take the vaccine and this is a serious problem.

Large numbers of unvaccinated people remain a problem if we are to set reasonable goals in tackling this pandemic, or at the very least, the goal for a tolerable amount of infections. How we define “tolerable” is an equally logistical and moral question; there are hard limits as to what our economies and healthcare infrastructures can handle in the raw numbers of quarantines and hospitalisations, just as we must decide how much death and illness is acceptable part of social risk. For much of the last 18 months, the UK and US have unified these logistical and moral limits towards the same policy goal of an incredibly high level of vaccine protection so we can cut spread and allow infection rates to exist at levels which at the very least ensures that our medical infrastructure avoids boiling point. Alas, with vaccination levels not reaching herd immunity yet, there remains significant risk of hospitalisation and reaching overcapacity should the virus circulate freely (as we’re currently seeing quite acutely in America’s least vaccinated states). Simply put, at current levels of vaccine hesitancy, the central policy goal of a tolerable amount of infection remains unachievable in both the UK and US.

So the central questions remain: How do we achieve the unachievable? How can we ensure people can protect themselves and others even though they don’t want to? And importantly, what are the moral guidelines we are using to achieve the goal of a tolerable amount of infection? For the answers, we can look no further at the UK and the US in the coming months; the UK and the US are great case studies as both share very similar stories of early vaccine success and a significant voluntarily unvaccinated subset of the population, however, each nation is radically diverging in plans to tackle this existing problem.

The Carrot

In the United States, one could say that the prevailing consensus has now been to offer the “carrot” over the “stick”, that is to say, positive incentives to get those who are vaccine hesitant to get their jab. We’ve seen much of this play out in the earlier stages of the pandemic where lottery tickets, prepaid debit cards, and private sector prizes (even free guns) have been offered to entice the vaccine hesitant into getting their jabs. In the face of the existing plateau of total vaccinations, US President Joe Biden has called on state governments to provide $100 payments to the newly vaccinated in order to ramp up numbers. Indeed, there has been much national discussion in the US about how incentives should be delivered and at what cost, given the federal nature of the US political system there has been plenty of opportunity to compare different state and local authorities to experiment in how they can incentivise vaccines. Meanwhile, similar calls have been made in the UK by Liberal Democrat leader Ed Davey to directly pay young people (a particularly hesitant group) to take the vaccine.

The Stick

The United Kingdom’s general approach however is quite different from that of the US. Despite prior denials and attempts by the government to pour cold water on the idea, the opposite approach, the “stick”, has been the go-to solution for vaccine hesitancy, more specifically the institution of so-called “vaccine passports” for domestic use. Current UK plans have been limited to ensuring proof of vaccination would be required for large scale events and areas such as nightclubs and strip clubs. Restrictions would hope to provide the kind of negative incentives that would encourage people to get jabbed in order to regain access to various public places but there have been talks of extending the scheme further to other venues such as pubs. The concept is not totally alien, as much of Europe and the United States is also moving to proof of vaccination as a prerequisite for international travel. Nevertheless, the White House has explicitly rejected any form of domestic vaccine passporting, although later comments partly contradicted this.

Much like a lot of policies to tackle Covid from the start, we now face a twofold analysis of both of these proposed solutions to vaccine hesitancy:

1) Would these policies actually work in increasing the number of vaccinations, bringing either country towards herd immunity?

2) Are either, or any, of these policies morally permissible and acceptable from a political or philosophical perspective?

Let’s try to answer both of these.

Firstly, there is little data on what actually convinces hesitant people to get vaccinated but we do have some nuggets of information to suggest what the case is. We could look at opinion polls but have to exercise some caution since when it comes to predicted hesitancy vs actual vaccination rates we can see a lot of mismatch, such as in the UK’s experience. That said, one UCLA study has found that large portions of unvaccinated people in the US would get vaccinated in response to financial incentives. Meanwhile in France, the threat of compulsory vaccinations and other sanctions (such as domestic Covid passports) has made visible headway in boosting vaccination rates. While it is too early to tell how large of an impact negative or positive incentives would make, it is guaranteed that they would both make at least some headway in bringing vaccination numbers up. Furthermore, it is difficult to determine how much positive incentives from the private sector or restrictive ones on international travel have already had in persuading hesitant people to be vaccinated.

The second question is a lot harder to answer. In modern liberal democracies we place a strong amount of value on consent and personal liberty but the pandemic has offered us the kind of once-in-a-lifetime emergency that makes the restriction of freedoms arguably necessary for the greater good. We all fall on a scale of restriction tolerance from those who opposed any and all restrictions on one end to those who want to see heavy restrictions last permanently on the other. Even for those of us who are somewhere between these extremes, in these crucial final stages of the pandemic we all have to examine the core principles of our moral philosophies to determine which approaches we use to tackle to the virus. There is no doubt that an underlying sense of fairness may lead many people to oppose what would essentially be money from the pockets of largely vaccinated taxpayers into the pockets of those deemed too selfish to have been vaccinated on time. Equally, fairness and equality might tempt many others to oppose a regime of restrictions that creates a two-tiered society that imposes surveillance from the backdoor.

Should we even attempt any of these at all? Or try to think outside the box? Considering that young people and ethnic minorities often form the core of the currently unvaccinated, should we target our efforts at these groups specifically? What if we try other opportunities like paid time off to get vaccinated or pop up vaccination centres? Would people even respond to those?

These are tough questions for which there is no universally agreed answer and no easily predictable outcome. But if we are serious about tackling vaccine hesitancy we have to consider some form of action fast lest we risk the pandemic lasting far longer than it should.

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