As the COVID pandemic continues to evolve it seems we are entering a phase that many are calling a “pandemic of the unvaccinated”. Recent data, for example, shows that people who are unvaccinated are:

7 times more likely to test positive for COVID-19 than vaccinated people
49 times more likely to be hospitalized than vaccinated people
32 times more likely to die from COVID-19 than vaccinated people.

These numbers vary by region, but are fairly representative. The Delta variant is partly responsible for the recent surge, but the COVID vaccines collectively continue to be about 80% effective against infection. We are now debating and studying who should get a booster when, in order to maximize vaccine effectiveness. About 55% of the US population is fully vaccinated, with 64% getting at least one dose. We probably need to hit 80% or more to have effective herd immunity. How do we get there?

The phenomenon of vaccine hesitancy is complicated. One factor that consistently emerges as a major cause is distrust of the government. These are now entrenched views, often tied to political and ideological identity. Generally speaking, information cannot counter distrust, because the information itself will not be trusted.

Fear of side effects is another major cause of hesitancy, but it may be difficult to disentangle this issue from lack of trust. In cases where trust is not the real underlying issue, fear of side effects can be effectively countered with information alone. People generally fear an immediate, tangible, and active harm (such as from getting a vaccine) more than a remote theoretical and passive harm (such as failing to prevent contraction of COVID). Rationally, we should just run the numbers and do a risk vs benefit analysis, but humans are only semi-rational. But information, especially from a trusted source like one’s personal doctor, can be effective in these cases.

Recent research focuses on a perhaps-neglected portion of those who are not vaccinated – people who generally believe that the vaccines are safe and effective but have still not been vaccinated. There are many potential reasons for this disconnect – people may simply be busy or too distracted, tend to procrastinate, or have practical barriers to getting vaccinated. This group may be the low-hanging fruit among the unvaccinated, and likely a better use of resources than trying to convince entrenched anti-vaxxers or partisan refusers.

The researchers leveraged the phenomenon of cognitive dissonance to see if they could impact the behavior of subjects in this group. They had the intervention group advocate for best practices in the pandemic, including getting vaccinated, wearing a mask, and social distancing. They then had them recall recent behavior where they failed to follow these best practices. The disconnect was meant to provoke a psychologically uncomfortable feeling that psychologists call cognitive dissonance. They then followed up a week later, along with subjects from three different control groups without dissonance. They report:

We found that dissonance participants complied more with guidelines and were more likely to seek vaccination than participants in three non-dissonance control conditions.

Implementing these findings may be challenging. The authors suggest, for example, using contests where participants would have to craft a pro-vaccine ad campaign, with prizes awarded for the winners. Perhaps ad companies can be engaged – they have a long history of leveraging psychological factors to change customer behavior (including exploiting cognitive dissonance).

The most important finding is perhaps the bigger picture that efforts to increase COVID vaccine uptake should focus on the persuadable and those who don’t need actual persuading, just a push in the right direction. Trying to convince the hard-core antivaxxers at this point is likely to have extremely low returns.

It also remains to be seen what the ceiling is on increasing vaccine uptake through persuasive methods alone, which leads into the debate over vaccine mandates. There are increasing calls for such mandates, and the debate seems to be shifting toward the details of how best to implement mandates, rather than if there should be any. Of course, no one is talking about or seriously considering forced vaccinations (which has never been a policy in the US), but there is a long history of vaccine mandates in many situations – to attend school, to travel, and for certain professions such as health care workers.

The idea is that being unvaccinated, while continuing to be an allowed personal choice, should be made as inconvenient as possible. Companies have the right to protect their workers by requiring vaccination (always, of course, with an exception for actual medical reasons). Professions have a duty to protect others by requiring their members to be vaccinated. Being in necessarily crowded close quarters (such as on a plane) is also a privilege that can come with proof of vaccination.

These are common sense public health policies. Protests based on the principle of personal freedom are not valid, because these are decisions that affect the personal freedom of others. No one has a right to speed on the highway, because it puts other drivers at risk. Smoking has largely been banned in public places because of its health effects on others.

The bottom line is that there is a valid and consistent principle here that collectively society has the right to limit personal behavior in public spaces that affects public safety. No one has the right to put other people into harm’s way. People are also economically harmed by the ongoing damage the pandemic is doing to the economy, damage that is extended and increased by the unvaccinated. There is more than enough legal, historical, ethical, and logical justification for vaccine mandates, and no serious argument against them. They may also be necessary in order to achieve herd immunity.

Author

  • Founder and currently Executive Editor of Science-Based Medicine Steven Novella, MD is an academic clinical neurologist at the Yale University School of Medicine. He is also the host and producer of the popular weekly science podcast, The Skeptics’ Guide to the Universe, and the author of the NeuroLogicaBlog, a daily blog that covers news and issues in neuroscience, but also general science, scientific skepticism, philosophy of science, critical thinking, and the intersection of science with the media and society. Dr. Novella also has produced two courses with The Great Courses, and published a book on critical thinking - also called The Skeptics Guide to the Universe.

Posted by Steven Novella

Founder and currently Executive Editor of Science-Based Medicine Steven Novella, MD is an academic clinical neurologist at the Yale University School of Medicine. He is also the host and producer of the popular weekly science podcast, The Skeptics’ Guide to the Universe, and the author of the NeuroLogicaBlog, a daily blog that covers news and issues in neuroscience, but also general science, scientific skepticism, philosophy of science, critical thinking, and the intersection of science with the media and society. Dr. Novella also has produced two courses with The Great Courses, and published a book on critical thinking - also called The Skeptics Guide to the Universe.