Vaccine mandates have been upheld as Constitutional since 1905
The Supreme Court explicitly upheld vaccine mandates against deadly diseases in Jacobson v Massachusetts where it explained: "the rights of the individual in respect of his liberty may at times, under the pressure of great dangers, be subjected to such restraint, to be enforced by reasonable regulations, as the safety of the general public may demand." We live in a country of ordered liberty, not individual autonomy that paves the way to the deaths of others. In short, it is not the right of every American citizen to catch and transmit a potentially fatal infection." Public health and safety supercedes individual rights every time.
The anti-science and anti-vaxxer movement existed long before Covid and those opposed to mandates were already not getting vaccinated.
I agree mandates have their place in public health, but disagree that everyone who pushed back against Covid vaccine mandates was already opposed to vaccines. There were a lot of people who were fine with childhood vaccine mandates (or didn’t think about them much) who felt uncomfortable with the COVID vaccine mandates. I agree there are some people who are going to push back against any and every vaccine, but that doesn’t describe everyone (or even most people) who disagreed with Covid vaccine mandates. If we ignore this “hesitant middle” and treat them the same as extreme antivaxxers, we risk alienating them even more, which I’m concerned will only make things more challenging for public health.
it seems many of us want flat, simple answers to life's issues, we don't want uncertainty to confuse that simple answer that holds up forever, and we don't want complicated explanations about the uncertainty, so if that expectation can be addressed early on, it might help folks to understand the fluctuating 'facts' and explanations and be more willing to 'go with the flow' that comes with uncertainty and changing facts of viruses.
A vaccine is a man made substance that is designed & able to produce a level of protective immune response in the subject - human or animal.
The effectiveness of every vaccine to date is a complex interaction between virus & host. No vaccine is without its potential benefits, potential risk & imperfect efficacy.
All of the COVID available today fit that definition.
Viz-a-viz vaccine mandates, recall that COVID vaccines were granted Emergency Use Authorization (EUA) from their outset in mid-December 2020 and granted full approval on August 2021.
It was and is illegal to mandate a vaccine that is subject to EUA provisions.
“Mandate” means the government requires you to receive the vaccine under specific circumstances. Until the EUA status became full FDA approval, the government could not mandate the vaccine under any circumstance.
What happened instead was that private entities, especially employers, made COVID vaccination a condition of continuing current employment status.
That could be a hard choice indeed, but it was a choice. If you worked in a hospital, you were not only essential to our response, you were working in a high exposure environment as soon as you walked through the door. Hospital administrators felt obliged to optimize protection for workers & patients. What else was rational?
Many people preferred to believe that their personal choices had no ramifications for others, even in the context of a novel respiratory virus. That belief is simply wrong.
Don’t misunderstand, the underlying failure was a failure of effective Crisis Communication: leaders (elected & public health) did not explain what was at stake & how (realistically) vaccination would add benefit by reducing serious disease that required hospitalization. Too often they used jargon & postured as “the smartest guy in the room.” Problem is, nobody likes that guy.
Our task going forward is to look deeply and objectively at what aspects of our response worked, what didn’t work, and why.
That has yet to happen & until it does, we will not have gained the vital wisdom needed to perform better in the face of the next, inevitable national emergency.
This is an important and coherent analysis. Yet, speaking as an 82 year old family doc and public health practitioner, you have missed an very important factor: When you write, "When value judgments—like “promoting public health is more important than protecting individual liberty”—are presented as an objective truth like science itself, trust in “science” takes a big hit," you have overlooked the massive change in values in the public square over the past 60 years (which you probably have not personally experienced). You are not alone. This caught the public health establishment unawares in 2020.
Coping with the Great Depression and WW II, required values of cooperation, communal and personal responsibility and "neighborliness." Coasting on the era of prosperity starting in the 1960s (and magnified by persistent failure of government programs to solve major problems while promoting unnecessary wars) the values of individual freedom and liberty came to predominate over the past 60 years. This loss of "social capital" was well described and predicted in Robert Putnam's BOWLING ALONE, published in 2000.
In the 1950s everyone praised the development of polio vaccines and eagerly stood in line to get them. Then came MMR, etc and school mandates and the public praised and adopted the scientific successes. Mandate or not they wanted scientifically produced protection for themselves and their children. (Yes there were similar, fabulated right wing protests about fluoridation, but it was a fringe movement.)
So there is a deeper aspect to this discussion which is based on an understanding of the atrophy of social capital in the United States. This is important because this not only impacted public health strategies, it is the same phenomenon that is fueling the current turmoil feeding the MAGA movement and DJT.
This is 💯on the money, and so well stated. I am old enough (at 75) to remember Mom taking us to get our polio vaccines. The lines were long; everyone was on board. I can’t envision that happening in the current environment. Along with Putnam’s excellent book, I highly recommend Theda Skocpol and her colleagues on the issue of lost social capital. (One her many insightful books, and that goes to this point, is “Diminished Democracy: From Membership to Management in American Civic Life.”)
I would offer another perspective, which I trust will be understood as an entirely compatible adjunct, not a criticism.
Promulgating & communicating policy is the duty of elected officials. Such officials must consult with & be facile & confident in their understanding of the science.
While good, valid science & discerning scientists must be the source of such knowledge, the scientists’ first job is to convey that knowledge to leadership.
I believe our expectation & insistence that elected leaders formulate & communicate policy is a foundational strength of our system of government.
The onset of the pandemic could have been and should have been our leaders’ “Winston Churchill Moments” with the public, based upon the principles of effective Crisis Communication.
Their primary message: we are asking everyone to do everything they can to contribute to victory. If we do this, we will prevail; if we do not, we risk catastrophe. Blunt. Not a mandate, but a call to action.
Social pressure, not legal “mandates” would have been more effective & accepted, since individuals would have been empowered to choose & act.
Looked at objectively, we in the US did prevail, but as this series points out, we are left with a very dangerous situation where distrust & distain for legitimate authority has reached unprecedented levels. In all sobriety, I believe this is a national security risk: another global or national emergency is inevitable. We place ourselves at serious, avoidable risk if too many loud & influential voices urge the public to do the opposite of what is recommended, believing that such guidance is the result of governmental stupidity, duplicity, or even more nefarious motives.
Lastly, keep in mind that “Science” has two meanings in modern parlance. Yes, it is the content & product of valid research that adheres to the methods described in this YLE installment. “Science” is also the social institutions that support such work. As such, “Science,” as with all social institutions, has its built in priorities that are not always without bias & at the very least, are not always clear to the public.
Leadership at many levels fell short: some by inches, some by light years. The message from the top is, naturally, what sets the tone and what came from the very top was cacophony.
I agree! I truly appreciate this series and am learning a lot in the comments, too. I especially appreciate the last paragraph here. As a social scientist, I am worried about some of the recommendations in this article, such as this one: "be clear where the data ends and opinions begin." The fact is that all science and data are shaped by values and opinions. The ways we design our research questions, the frameworks we choose, the people who are perceived as capable in conducting experiments, the previous data we pay attention to .... and so on --- all of this matters and shapes "objective" data. So, I don't think it's a simple choice or very easy to pay attention to "data"/science as objective fact versus opinions, which are based on backgrounds and values (as well as data!). These things are messy and mixed. I don't have an answer for how to address this in the next epidemic. There are no easy answers. But I think, in general, we should be wary about drawing such clear lines about data versus opinions. This seems much more in line with the final conclusion of learning how to better "communicate scientific uncertainty." Thank you!
John Hellerstedt - that would only work when the leaders could be trusted to tell the truth. In the case of Covid, some of the leadership was lying deliberately. That was another huge factor in the loss of public trust in the whole issue.
Would you kindly elaborate on some of the leadership was deliberately lying? If you are speaking of politicians; I don’t personally rely on that source for information but rather scientific consensus, experts in their respective field such as YLE and my own physicians.
Thank you for this excellent post, capping off an invaluable series. It has led me also to think about how and why my own level of trust in governmental public health guidance has plummeted as a direct result of its communicating around COVID—and I am someone who was fine with and remains fine with mandates as public health measures. Here are some thoughts:
1. As an older person at higher risk of death when the pandemic struck, COVID was a dismaying eye-opener for me of how widespread treatment of older people as disposable is in our society at large—and definitely not confined to one side of the political aisle. The worst of this was the Great Barrington declaration, which translated to lock up the old folks in their homes and let everyone else go about their business as if nothing had changed. In my community, I watched as strapping young men received vaccines at the local public health site, while folks like my 88 year old neighbor, living on his own, frantically searched for a vaccine, finally (with my help to locate the site) having to drive 4 hours in 2 round trips to get the first two doses. This was replicated over and over again.
2. On masks, we were directly lied to by our government, likely to prevent a run on masks. I spent countless hours, as many did, trying to find trusted interlocutors to learn how masks worked and what the best ones were to use (my eternal gratitude to Linsey Marr, above all). I ended up writing up what I learned for my community. As one neighbor said on receiving the information, “it is just a shame that this fell to a private citizen. Where is our government?” I also scrounged N95 masks, at exorbitant prices, to distribute them to older neighbors. The list goes on.
3. Because governmental communicating was so problematic—for precisely the reasons described in this YLE post—I spent countless hours over many months trying to find trustworthy interlocutors on public health overall. Dr. Jetelina and Team YLE are peerless in this and have proved their excellence in that regard durably over time. THIS, not government, is now my go-to source for public health information.
Rebuilding trust in government on these issues is going to be a vertical climb. I come out of this experience with zero trust in government to tell me the truth when it comes to either my health or the public’s health. For these reasons, I am grateful to Team YLE beyond measure.
As a scientist, I found the shift in understanding about COVID transmission from droplet to aerosol as primary route to be fascinating (from the historical perspective and the original roots back to TB). It also seems it took some pushing from physicists who study fluid dynamics to get the biologists to shift perspective. This is how science works.
But what the public saw was: wash your hands, stay 6ft apart, don’t worry about masks. Then they saw mask mandates. The shift was very confusing and I think we lost many at that point, even before we got to the vaccine rollout and mandates. (And as others have noted, all masks were treated equally, which just isn’t valid.)
For me, the biggest revelation was that asymptomatic infection & transmission were, in effect, the rule & not the exception. Based on other coronaviruses, transmission required symptoms. This mistaken assumption allowed the virus to spread rapidly, undetected & unsuspected. “Fire behind the walls,” as my emergency management colleagues were fond of saying.
The public health / public policy message should have been: NONE of our countermeasures will be 100% effective. If there were such a thing, we wouldn’t need anything else. While not perfect, all the countermeasures are beneficial & their benefits are additive. So, practice as many as you can, as often as you can. Everyone do their part & we will get through this.
There was absolutely NO way that we could pass through this pandemic without having to endure unequal suffering , anxiety, uncertainty & great cost. That was inevitable, but our leaders never prepared us for that reality.
There in lies the source of our post-pandemic distress & distrust, in my opinion.
Trust can only be restored after public confidence is earned.
If a stranger merely says, “Trust me,” the wise person says, “Prove it!”
Traditional vaccines have been around for decades and have a demonstrated safety and efficacy record.
The covid vaccine is a glorified flu shot at best. The trials lasted 4 months and showed no mortality or hospitalization benefit....or any effect on transmission (which wasn't even studied).
Mandating these shots was outrageous. Period. This authoritarianism and politicization of science will take a generation to recover from. It was that bad.
As a physician, I thought that some of the initial public health reactions were illogical. Specifically, the idea that screening for symptoms and fever would prevent transmission flies in the face of all of the viruses that are contagious before the patient is sick or even without the patient becoming sick. Then the idea that a surgical mast would work as well as an N95 mask until proven otherwise seemed like just a move to prevent a rush on N95 masks.
With the original SARS, just a few years earlier, the reason it did NOT become a worldwide pandemic was precisely because people infected with the virus were not contagious until they became sick , so an approach of isolating those who had symptoms worked to stop the epidemic. It was plausible at first that SARS-CoV-2 would behave the same way — sadly it turned out that it did not. (Though I think it remained true that infected people with definite symptoms were MORE infectious to others than infected people with no or mild symptoms.)
Yes, it was a move to preserve the supply of N95 & KN95 masks. The latter were needed in ICUs, for example, where the virus was demonstrably airborne due to ventilated patients, among other factors.
Protecting the healthcare workforce, especially hospital capacity, was the first priority. If that had crashed, panic would have ensued. Panic is chaos & chaos is the prelude to catastrophe.
You're absolutely right. My lament is that the opportunity for effective Crisis Communication - courageous truth-telling, if you will - was bungled from the start, especially at the highest levels.
Values? Such BS! I'm old enough to remember POLIO. Each year before school started we HAD to get the polio shot. Later replaced with a sugar cube. We HAD to get the measles shot. These were NOT OPTIONAL. OK… maybe a little optional. The local Catholic schools did permit parents to skip these mandatory shots. Of course the kids in those schools became more ill each school year.
The covid risk was downplayed because most deaths were old people (like me). No big deal that over a million old people died before old man Biden declared the pandemic over.
I've always maintained that had children 10 and under were dying at the same rate as old people, then things like values would have been much less apparent. I guess we'll have to wait for the next pandemic to sort this one out.
Parenthetically, the younger brother of an elementary school classmate had polio. We visited him in his iron lung in their home living room one day. The next time we went to visit, maybe a week later, he was gone. Try that value on for size.
Agree that the public - and I hope leadership as well - would indeed have been more receptive to following unwelcome, unwanted & “intrusive” guidance if the virulence, morbidity or mortality profile had been even slightly altered, for example, higher rates of severe illness in infant and children.
1) Are vaccine mandates ever morally justifiable for a non sterilizing vaccine? The public was told that people who got the vaccine couldn’t transmit the virus to others and wouldn’t get infected. This was never true, even before omicron. PH knew this wasn’t true, but promises were made to the public like (by Fauci), "When you get vaccinated, you not only protect your own health and that of the family but also you contribute to the community health by preventing the spread of the virus throughout the community. In other words, you become a dead end to the virus. And when there are a lot of dead ends around, the virus is not going to go anywhere. And that’s when you get a point that you have a markedly diminished rate of infection in the community.”
2) Once PH realized the vaccine wasn’t living up to its promise, they took way too long to lift the mandates. There was never a clearly drawn line in the sand for when mandates ended or why, leaving families to bicker at holiday gatherings and employees and students to bicker with their institutions. Public Health neglected the Public. The mandates simply disappeared with no formal acknowledgement. Can anyone find an official announcement spelling out the date mandates were lifted, why and by whom? Or did PH pretend like the mandates never existed in the first place, leading to confusion, arguments and the feeling we had all been gaslighted?
3) The decision of whether to mandate a particular vaccine cannot be made in a vacuum. If the reasoning was rushed and/or incorrect, the public will eventually realize this, and other mandates for mainstay vaccines like polio and measles will be called in to question.
Where I reside, vaccine and mask mandates were implemented at the state level. Conveying nuance by PH officials at the federal level and understanding of such by the general population played a role in issues with clear communication.
The federal government mandated covid vaccines for: federal contractors, healthcare workers, private sector employees (100 or more employees), federal government employees, military personnel and noncitizen air travelers. That's probably over 50% of the population.
The authority for mandates ranged from Secretary of Defense, OSHA, to Presidential Proclamation from Biden himself - all federal government.
States often mirrored federal mandates to fill in the gaps (students, small business, etc).
It wasn’t until May 11, 2023 that the federal government QUIETLY lifted any remaining national vaccine mandates.
Not going to go on a lengthy diatribe today - weather too gorgeous :)
Anyway, here is why I, as a Pro-Vax, Pro science, Democrat chose not to get vaccinated for what it is worth, which comes down to three reasons. None of which were due to appeals to Libertarianism:
1) Inductive reasoning. Extremely low odds, that the fastest to market vaccine (by a magnitude!), against a mutating class of respiratory viruses we have tried and failed to develop successful vaccines for decades, would work. Appeals to the promise of mRNA being the solution had me wondering "well if this platform is so great and we had proof of concept for decades, why haven't we used it on the flu or one of the other circulating coronaviruses?" It just seemed extremely unlikely, but I was hopeful strong data would prove otherwise. Instead I got:
2) Weak data from Pfizer and Moderna. I get it, we are in a rush, there is panic setting in, but no excuse not to be testing daily for asymptomatic infection. No excuse not to continue following both arms in a prospective cohort study to see what happened as time progressed. No excuse not to turn over the raw data, especially after the Peter Doshi piece in BMJ pointing out that there were 20x more suspected Covid cases in both arms in the Pfizer trials. Now, while I was not finding the early data compelling, I still planned to take it until...
3) People were having horrible reactions from the shots. "I never felt so sick, so imagine just how bad Covid must be!" was the common refrain. I am not sure about your reactions Kristen, but Katelyn has been honest about how crappy they made her feel which is why she switched to Novavax.
My wife got her Moderna shot 1/6/21, and it KNOCKED HER OUT. She was in bed for 2 days. High fever, clammy, muscle aches. She had to call out of work (as did her partner - so now her hospital without vascular coverage for 48 hours), which is unheard of. 40 years old, extremely fit and healthy, and should have had covid numerous times given working in a hospital with a loose fitting surgical mask, our kids in school, etc, but it was the Moderna shot that finally dropped her.
My wife's reaction wasn't a "one off". It was the common outcome. I saw people talking about on Facebook, in YLE comment sections, in the news. Schools were closing down not from Covid, but from too many teachers calling out because of vaccine side effects. None of this was mentioned btw in Pfizer or Moderna studies.
Why would I want to take the chance when I became eligible a few weeks/months later of becoming so sick? That is why I didn't bother, and 4 years later, I feel confident I made the right choice.
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Not nitpicking, but regarding this statement:
"The virus mutated, and the science was in flux. Waning vaccine immunity and the unexpected Thanksgiving arrival of Omicron meant the data driving decisions to implement national vaccine mandates in September 2021 was out of date just a few short months later."
Why was "the science in flux"? We have known that ILI including influenza and Coronaviruses mutate, and we believe that is a large part of why our flu vaccines are regularly ineffective and why previous attempts at Coronavirus vaccines failed.
Where did the belief that this particular Coronavirus was special and wouldn't behave like all other Coronaviruses come from?
How was the "data driving decisions...out of date just a few short months later"? The data was out of date when the September mandates were rolled out, not months later. Why wasn't Public Health aware that the virus wasn't impeding infection by end of summer 2021?
All eyes were on Israel late summer, having one of the earliest vaccine rollouts of any nation in the world, yet cases by September 9th eclipsed both their previous waves in September 2020 and February 2021.
Rather than pause and consider that perhaps the vaccine wasn't impacting transmission at all, the White House pressured Social Media to censor people pointing this out.
Again, Public Health should be embarrassed it was Alex Berenson who figured out Covid was running through Israel's vaccinated population unchecked and not, you know, Public Health.
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I think that is a piece missing here over these last 4 essays - the lack of self-reflection by PH which overpromised and underdelivered. Where is the introspection to figure out HOW Public Health could have gotten so much wrong on so many extraordinary claims (Cloth masks, vaccines stopping transmission, Sweden, risk profile, etc).
This well-intentioned series of posts gives the vibe "We were right, we just should have communicated we were right better".
Instead, why not try to figure out how people like Alex Berenson figured out the vaccines weren't impeding transmission before Public Health did? Why not examine PH was fooled into making children wear useless cloth masks?
Your point about Democrats and Republicans should be able to reproduce the same study - agree - why didn't this happen?
The excuses of "science changed" "working with best data we had" etc fall short of explaining how PH repeatedly fell for extraordinary claims.
Cloth Masks are an absolutely perfect example.
We knew as of 2019 that cloth masks were useless against respiratory viruses. “The Science was Settled” as “The Science” likes to say.
And we agree now, in 2024 that cloth masks don’t work, right? They aren’t “Better than nothing”, right? They simply don’t work.
Then I arrive at the biggest problem – how could we find that they did work?
How could science conjure out of essentially thin air, evidence they did work, and why wasn't this garbage evidence summarily rejected the moment it was attempted to be published?
Why did the Zhang et al 6/11/20 paper "Identifying airborne transmission as the dominant route for the spread of COVID-19" become the most cited paper on masks of all time, despite having a retraction request signed by scores of researchers (including Michael Mina of all people)? How did science let this bad paper shape policy?
Why did the CDC promote "Absence of Apparent Transmission of SARS-CoV-2 from Two Stylists After Exposure at a Hair Salon with a Universal Face Covering Policy — Springfield, Missouri, May 2020" rather than criticize the authors for such a ridiculous paper?
Why didn't the CDC bother to replicate the claims of the equally ridiculous "Trends in County-Level COVID-19 Incidence in Counties With and Without a Mask Mandate — Kansas, June 1–August 23, 2020" MMWR which took me roughly 45 minutes to reproduce and falsify?
Bottom Line, the Cloth Mask Hysteria scares me because it demonstrated how easy The Science could be fooled so long as we wanted something to be true strong enough.
But as I said, I am not going to go on a lengthy diatribe today - weather too gorgeous :)
It seems to me that vaccine mandates are like traffic laws. Sure speed limits are a restriction on freedom, but it’s to prevent innocent people from being killed or injured. People who don’t vaccinate endanger others, in addition to make herd immunity less likely. It’s good science to point this out.
Sometimes, like during world wide pandemics that are leading to health system collapses and mass graves and morgue refrigerator trucks overflowing, you have to be heroic. The vaccines showing 95% VE at that stage of the game were heroic tools. They saved 14-20 MILLION lives. If you want to see the ugly revisionism and societal manipulation of these basic truths, review the congressional oversight hearings orchestrated by Jim Jordan (R).
“ These discussions should have been between a patient and their doctor. But instead, the Biden Administration inserted itself and defiled the sacred relationship that we as Americans
have always treasured between the doctor and the patient, who knows you, understands you. But there was no discussion with the doctor that you know and trust. The government was
`because I said so; was supposed to be good enough. Hardly bedside manner. No discussion on side effects, who is at risk, treatment options, et cetera. Worse still, the vaccine did not prevent the spread of the virus, a fact already evident by the time the mandates were imposed. Actually, we know from the trials that even vaccinated patients could get COVID. No matter how much President Biden or others claimed or wish that the vaccine stopped the spread of the virus, the science didn’t ;t support it. And if the vaccine does not prevent you from getting sick, then what is the utility in forcing you to get vaccinated? That is a question
many people asked. It is a legitimate question that they can have a conversation with their doctor. What are the pluses? “
14-15 million lives, and hundreds of millions of less long covid disabilities.
That quote from Jordan is extremely interesting, Ryan—and I think goes to the heart of a societal problem. That is, on its face, Jordan’s comment could make total sense if we were dealing with a matter of individual, rather than public, health. Though not the only cause, I do think the Biden administration really fell down on making the case for public health, which in turn helped enable Jordan to get traction with observations like this that seemed facially reasonable. (It reminds me a bit of the argument many make in favor of balancing the federal budget by analogizing to family budgeting.)
Leslie’s comment, at the head of the post, includes a quote that, to me, gets to the heart of what we, as a society have lost, which is that we are part of a larger community and have a duty to care for one another. (In this regard, I thought John Hellerstedt’s observation that this could have been a Winston Churchill moment, was excellent, and just what was needed—though I am of course in no way sanguine, that given the extreme polarized environment in which we find ourselves now, it would have had the same traction as Churchill did—or FDR, as another example.)
Here’s the quote from Leslie: “The Supreme Court explicitly upheld vaccine mandates against deadly diseases in Jacobson v Massachusetts where it explained: "the rights of the individual in respect of his liberty may at times, under the pressure of great dangers, be subjected to such restraint, to be enforced by reasonable regulations, as the safety of the general public may demand. We live in a country of ordered liberty, not individual autonomy that paves the way to the deaths of others. In short, it is not the right of every American citizen to catch and transmit a potentially fatal infection."
That quotation is perfectly on the mark, and it also marks perfectly our societal failure to instill in each of us this very duty to community.
Excellent framing of the problem, and I appreciate the quote above! I don't think any Churchill moments were possible with the extreme polarization, either... unless there is a really overwhelming disaster/terrorist attack. And I guess the revisionism and conciliatory tone towards people who blame public health/epidemiologists/policy leaders just doesn't jive with me. It was a very personal, individual threat for healthcare workers amid the collective crisis... but we all faced it to some degree:
"The beginning of the COVID-19 pandemic featured scrambles for personal protective equipment in hospitals throughout the United States. Healthcare workers were among the most vulnerable in those early days, as they could not shelter in place and they interacted with many patients affected with the disease.
An investigation that was published in April 2021 by The Guardian and Kaiser Health News found that more than 3,600 US healthcare workers who responded to COVID-19 had died by then. Almost one third were nurses, and close to one fifth were physicians."
“It was a very personal, individual threat for healthcare workers amid the collective crisis.” Absolutely, and we are all eternally in your debt. Indeed, I would say it is not only very hard indeed to be forgiving in the face of that threat, but also I am not even sure it should be expected, let alone required. (As I think you will sense from my own comment😎, I am not in the least ready to forgive or forget what older people were contending with.)
My thought here is that, no matter how justifiable our fury, it is still necessary to find a way to communicate across the divide, to the extent possible. For one, public health is and will remain further imperiled unless and until we can find a way to do that. Let me assure you, given the state of affairs in our country, I am not the least sanguine we can—but we do have to try, as best we are able, to make the attempt. (I hope this doesn’t sound too terribly preachy, particularly when it comes to you, as one who works so hard and generously to communicate outward. You are definitely one of the good ‘uns.)
95% VE is a relative risk reduction (not absolute) over a 4-month period for symptomatic covid that tells you absolutely nothing in terms of real-world impacts (mortality, hospitalization, transmission).
The people who are trying to "regain trust" have to stop lying first
Great series, Dr. Panthagani! And you bring up critical issues to factor into public health decisions during the next crisis.
However, I do have some problems with the values part of your discussion, since you don't include (nor did much public health information during the Covid pandemic, as I recall) the point that "individual autonomy" is not a limitless "good", even if many Americans have been duped into assuming that it is.
There needs to be a clear recognition that the cost of that autonomy, depending on the circumstance, can be the serious illness or death of an innocent bystander, or a loved one---or even hundreds of casualties. Similar to the concept that no one has the right to yell "Fire!" in a crowded theater just for fun, I don't think that individual autonomy should be allowed to stand on its own, without considering the potential dangers. Kind of like the right to "bear arms"... I think we all need to be brave enough to let the public know that sometimes, our choices have consequences not just for ourselves, but for others too. And that calculation is critical to public health decisions like mandates.
I understand why all masking all the time mandates were a spark for rebellion. However, couldn't we now get a compromise to help keep seniors and other susceptible people safer? I call for first 1.5 hours of each day mask only in groceries and pharmacies. Let the staff rip off their masks after that. Also I call for all mask all the time in inpatient medical facilities, but in outpatient facilities I would ask for mask only (staff and patients) for the first 3 hours of each clinical day. That way those of us who are vulnerable could schedule our medical appointments early in the day and do our necessary grocery and pharmacy shopping early. Let the mask deniers have the rest of the day. It would also be fantastic to make all government buildings be ventilated and air purified to specific standards. My proposal would limit the spread of Covid (and other respiratory diseases known and those yet to become a thing) to the 18 % of US people who are over 65 and to other vulnerable people.
I appreciate all the commenters. Let me add to this. By the way, my background is 37 years in emergency medicine, 8 years in public health as medical director of a county health department, and 9 years as a coach working with doctors who are burned out and increasingly struggling to navigate the system they work in. So consider this:
Beliefs + data = opinion
Beliefs are formed based on one’s worldview- a product of genetics, upbringing and experience- it is the lens thru which data is absorbed and interpreted. Data/facts- observable, reproducible observations- are then grafted upon beliefs. This is why two people can look at the same data or observation and come away with different interpretations and meaning. This is why two people can look at mandates and see some very different threats. The brain is especially attuned to threats because its prime job is survival and does so by fending off threats.
I/we cannot convince anyone of anything; only they can change their mind/opinion. Challenging one’s beliefs is really hard; it’s tantamount to challenging one’s self image and self worth. If you believe government is not trustworthy and authorities lie, then you will look for every angle that supports that- ie confirmation bias is so strong. We are wired to trust beliefs because, well, this has gotten us by so far, and one’s brain main job is to craft a path forward in the face of uncertainty. Moreover, one’s response to a dilemma- a situation with multiple valuable but competing factors- is managed in the parts of the brain outside awareness, in what Shankar Vedentam termed the Hidden Brain. This where we factor the impact of data into worldview, not in the aware, deliberative, analyzing parts, contrary to popular belief.
And the handling of the pandemic demonstrated how difficult it is for people to grasp science. We are used to science doing its thing- reaching a concensus thru repeated testing of theories that might explain the observed circumstances- but in the case of the pandemic, we were doing the science in real time. So of course, there would be changing explanations as more was learned. But people are used to getting the ‘answer’ after all the work is done.
No wonder this left room for ‘alternate’ explanations to fill the void. One’s brain works by seeking patterns and doesn’t need all the information to then fill in the blanks. And the brain’s preference is to rationalize, justify, and defend that story- it just takes less energy to do so and the brain is always trying to preserve energy because it does not know what’s coming next. Some people claiming that officials were lying is one way to fill in the blanks based on their worldview about government and not having all the facts and seeking an explanation that ‘must be correct.’
The current tension between ‘me vs we’ has been building since the 1980’s. As it did for so many trends, the pandemic catapulted this to top of mind and produced preferences one way or the other. Contrast that with the outpouring of neighbors helping neighbors as we are seeing right now here in western North Carolina. Just to make the point that grafting the circumstances onto beliefs and worldview can yield differing balances in this tension.
So to regain trust will take individuals being open and willing to challenge the stories their brains have crafted in order to survive. The ethicist Onora O’Neill defines trust as taking 3 things- 1) not over promising, ie only committing to things one can actually do. 2) have the skills and ability to do what is promised 3) Follow thru on what is promised.
Experience indicates that it will take repeated opportunities over time to demonstrate trustworthiness. By doing so, this gives individuals, one step by one step, the opportunity to adjust their stories and enough ‘data’ to reach a tipping point where they find that the current story/narrative their brain has crafted is no longer the best avenue for success and survival.
Consistency is key. Our job is to give people an opportunity to trust, not to convince them to trust. Just as our job during the pandemic was to give individuals an opportunity to ‘rethink’ how they balance ‘me vs we’ in their worldview. You can make a good case that this is still our job.
Vaccine mandates have been upheld as Constitutional since 1905
The Supreme Court explicitly upheld vaccine mandates against deadly diseases in Jacobson v Massachusetts where it explained: "the rights of the individual in respect of his liberty may at times, under the pressure of great dangers, be subjected to such restraint, to be enforced by reasonable regulations, as the safety of the general public may demand." We live in a country of ordered liberty, not individual autonomy that paves the way to the deaths of others. In short, it is not the right of every American citizen to catch and transmit a potentially fatal infection." Public health and safety supercedes individual rights every time.
The anti-science and anti-vaxxer movement existed long before Covid and those opposed to mandates were already not getting vaccinated.
We were never going to reach these people.
I agree mandates have their place in public health, but disagree that everyone who pushed back against Covid vaccine mandates was already opposed to vaccines. There were a lot of people who were fine with childhood vaccine mandates (or didn’t think about them much) who felt uncomfortable with the COVID vaccine mandates. I agree there are some people who are going to push back against any and every vaccine, but that doesn’t describe everyone (or even most people) who disagreed with Covid vaccine mandates. If we ignore this “hesitant middle” and treat them the same as extreme antivaxxers, we risk alienating them even more, which I’m concerned will only make things more challenging for public health.
it seems many of us want flat, simple answers to life's issues, we don't want uncertainty to confuse that simple answer that holds up forever, and we don't want complicated explanations about the uncertainty, so if that expectation can be addressed early on, it might help folks to understand the fluctuating 'facts' and explanations and be more willing to 'go with the flow' that comes with uncertainty and changing facts of viruses.
If the Supreme Court has upheld vaccine mandates, we need a clear definition of what qualifies as a "vaccine."
What are the characteristics of a vaccine that can be mandated per the Supreme Court, and do the covid shots fit?
I’ll take a stab at a definition.
A vaccine is a man made substance that is designed & able to produce a level of protective immune response in the subject - human or animal.
The effectiveness of every vaccine to date is a complex interaction between virus & host. No vaccine is without its potential benefits, potential risk & imperfect efficacy.
All of the COVID available today fit that definition.
Viz-a-viz vaccine mandates, recall that COVID vaccines were granted Emergency Use Authorization (EUA) from their outset in mid-December 2020 and granted full approval on August 2021.
It was and is illegal to mandate a vaccine that is subject to EUA provisions.
“Mandate” means the government requires you to receive the vaccine under specific circumstances. Until the EUA status became full FDA approval, the government could not mandate the vaccine under any circumstance.
What happened instead was that private entities, especially employers, made COVID vaccination a condition of continuing current employment status.
That could be a hard choice indeed, but it was a choice. If you worked in a hospital, you were not only essential to our response, you were working in a high exposure environment as soon as you walked through the door. Hospital administrators felt obliged to optimize protection for workers & patients. What else was rational?
Many people preferred to believe that their personal choices had no ramifications for others, even in the context of a novel respiratory virus. That belief is simply wrong.
Don’t misunderstand, the underlying failure was a failure of effective Crisis Communication: leaders (elected & public health) did not explain what was at stake & how (realistically) vaccination would add benefit by reducing serious disease that required hospitalization. Too often they used jargon & postured as “the smartest guy in the room.” Problem is, nobody likes that guy.
Our task going forward is to look deeply and objectively at what aspects of our response worked, what didn’t work, and why.
That has yet to happen & until it does, we will not have gained the vital wisdom needed to perform better in the face of the next, inevitable national emergency.
I should have read this before posting my comment above---exactly what I meant, Leslie. Well put!
This is an important and coherent analysis. Yet, speaking as an 82 year old family doc and public health practitioner, you have missed an very important factor: When you write, "When value judgments—like “promoting public health is more important than protecting individual liberty”—are presented as an objective truth like science itself, trust in “science” takes a big hit," you have overlooked the massive change in values in the public square over the past 60 years (which you probably have not personally experienced). You are not alone. This caught the public health establishment unawares in 2020.
Coping with the Great Depression and WW II, required values of cooperation, communal and personal responsibility and "neighborliness." Coasting on the era of prosperity starting in the 1960s (and magnified by persistent failure of government programs to solve major problems while promoting unnecessary wars) the values of individual freedom and liberty came to predominate over the past 60 years. This loss of "social capital" was well described and predicted in Robert Putnam's BOWLING ALONE, published in 2000.
In the 1950s everyone praised the development of polio vaccines and eagerly stood in line to get them. Then came MMR, etc and school mandates and the public praised and adopted the scientific successes. Mandate or not they wanted scientifically produced protection for themselves and their children. (Yes there were similar, fabulated right wing protests about fluoridation, but it was a fringe movement.)
So there is a deeper aspect to this discussion which is based on an understanding of the atrophy of social capital in the United States. This is important because this not only impacted public health strategies, it is the same phenomenon that is fueling the current turmoil feeding the MAGA movement and DJT.
This is 💯on the money, and so well stated. I am old enough (at 75) to remember Mom taking us to get our polio vaccines. The lines were long; everyone was on board. I can’t envision that happening in the current environment. Along with Putnam’s excellent book, I highly recommend Theda Skocpol and her colleagues on the issue of lost social capital. (One her many insightful books, and that goes to this point, is “Diminished Democracy: From Membership to Management in American Civic Life.”)
It was not solely an American problem, but it was most effective there. The death rates prove it.
So well put.
I would offer another perspective, which I trust will be understood as an entirely compatible adjunct, not a criticism.
Promulgating & communicating policy is the duty of elected officials. Such officials must consult with & be facile & confident in their understanding of the science.
While good, valid science & discerning scientists must be the source of such knowledge, the scientists’ first job is to convey that knowledge to leadership.
I believe our expectation & insistence that elected leaders formulate & communicate policy is a foundational strength of our system of government.
The onset of the pandemic could have been and should have been our leaders’ “Winston Churchill Moments” with the public, based upon the principles of effective Crisis Communication.
Their primary message: we are asking everyone to do everything they can to contribute to victory. If we do this, we will prevail; if we do not, we risk catastrophe. Blunt. Not a mandate, but a call to action.
Social pressure, not legal “mandates” would have been more effective & accepted, since individuals would have been empowered to choose & act.
Looked at objectively, we in the US did prevail, but as this series points out, we are left with a very dangerous situation where distrust & distain for legitimate authority has reached unprecedented levels. In all sobriety, I believe this is a national security risk: another global or national emergency is inevitable. We place ourselves at serious, avoidable risk if too many loud & influential voices urge the public to do the opposite of what is recommended, believing that such guidance is the result of governmental stupidity, duplicity, or even more nefarious motives.
Lastly, keep in mind that “Science” has two meanings in modern parlance. Yes, it is the content & product of valid research that adheres to the methods described in this YLE installment. “Science” is also the social institutions that support such work. As such, “Science,” as with all social institutions, has its built in priorities that are not always without bias & at the very least, are not always clear to the public.
Brava, YLE!
The comparison to a Churchillian approach is brilliant, and just what was needed. Great insight.
Thank you.
Leadership at many levels fell short: some by inches, some by light years. The message from the top is, naturally, what sets the tone and what came from the very top was cacophony.
I agree! I truly appreciate this series and am learning a lot in the comments, too. I especially appreciate the last paragraph here. As a social scientist, I am worried about some of the recommendations in this article, such as this one: "be clear where the data ends and opinions begin." The fact is that all science and data are shaped by values and opinions. The ways we design our research questions, the frameworks we choose, the people who are perceived as capable in conducting experiments, the previous data we pay attention to .... and so on --- all of this matters and shapes "objective" data. So, I don't think it's a simple choice or very easy to pay attention to "data"/science as objective fact versus opinions, which are based on backgrounds and values (as well as data!). These things are messy and mixed. I don't have an answer for how to address this in the next epidemic. There are no easy answers. But I think, in general, we should be wary about drawing such clear lines about data versus opinions. This seems much more in line with the final conclusion of learning how to better "communicate scientific uncertainty." Thank you!
John Hellerstedt - that would only work when the leaders could be trusted to tell the truth. In the case of Covid, some of the leadership was lying deliberately. That was another huge factor in the loss of public trust in the whole issue.
Yes, that is a serious problem, and it’s going to take enormous work to rebuild trust as a result.
I truly believe that deliberate lying was the rare exception.
Willful ignorance & deliberate arrogance were the main culprits from where I sat.
I will admit that in practice & effect, these traits come off as lying when viewed in retrospect.
Thank you JD. There is so much to unpack.
Would you kindly elaborate on some of the leadership was deliberately lying? If you are speaking of politicians; I don’t personally rely on that source for information but rather scientific consensus, experts in their respective field such as YLE and my own physicians.
Thank you for this excellent post, capping off an invaluable series. It has led me also to think about how and why my own level of trust in governmental public health guidance has plummeted as a direct result of its communicating around COVID—and I am someone who was fine with and remains fine with mandates as public health measures. Here are some thoughts:
1. As an older person at higher risk of death when the pandemic struck, COVID was a dismaying eye-opener for me of how widespread treatment of older people as disposable is in our society at large—and definitely not confined to one side of the political aisle. The worst of this was the Great Barrington declaration, which translated to lock up the old folks in their homes and let everyone else go about their business as if nothing had changed. In my community, I watched as strapping young men received vaccines at the local public health site, while folks like my 88 year old neighbor, living on his own, frantically searched for a vaccine, finally (with my help to locate the site) having to drive 4 hours in 2 round trips to get the first two doses. This was replicated over and over again.
2. On masks, we were directly lied to by our government, likely to prevent a run on masks. I spent countless hours, as many did, trying to find trusted interlocutors to learn how masks worked and what the best ones were to use (my eternal gratitude to Linsey Marr, above all). I ended up writing up what I learned for my community. As one neighbor said on receiving the information, “it is just a shame that this fell to a private citizen. Where is our government?” I also scrounged N95 masks, at exorbitant prices, to distribute them to older neighbors. The list goes on.
3. Because governmental communicating was so problematic—for precisely the reasons described in this YLE post—I spent countless hours over many months trying to find trustworthy interlocutors on public health overall. Dr. Jetelina and Team YLE are peerless in this and have proved their excellence in that regard durably over time. THIS, not government, is now my go-to source for public health information.
Rebuilding trust in government on these issues is going to be a vertical climb. I come out of this experience with zero trust in government to tell me the truth when it comes to either my health or the public’s health. For these reasons, I am grateful to Team YLE beyond measure.
As a scientist, I found the shift in understanding about COVID transmission from droplet to aerosol as primary route to be fascinating (from the historical perspective and the original roots back to TB). It also seems it took some pushing from physicists who study fluid dynamics to get the biologists to shift perspective. This is how science works.
But what the public saw was: wash your hands, stay 6ft apart, don’t worry about masks. Then they saw mask mandates. The shift was very confusing and I think we lost many at that point, even before we got to the vaccine rollout and mandates. (And as others have noted, all masks were treated equally, which just isn’t valid.)
For me, the biggest revelation was that asymptomatic infection & transmission were, in effect, the rule & not the exception. Based on other coronaviruses, transmission required symptoms. This mistaken assumption allowed the virus to spread rapidly, undetected & unsuspected. “Fire behind the walls,” as my emergency management colleagues were fond of saying.
The public health / public policy message should have been: NONE of our countermeasures will be 100% effective. If there were such a thing, we wouldn’t need anything else. While not perfect, all the countermeasures are beneficial & their benefits are additive. So, practice as many as you can, as often as you can. Everyone do their part & we will get through this.
There was absolutely NO way that we could pass through this pandemic without having to endure unequal suffering , anxiety, uncertainty & great cost. That was inevitable, but our leaders never prepared us for that reality.
There in lies the source of our post-pandemic distress & distrust, in my opinion.
Trust can only be restored after public confidence is earned.
If a stranger merely says, “Trust me,” the wise person says, “Prove it!”
Traditional vaccines have been around for decades and have a demonstrated safety and efficacy record.
The covid vaccine is a glorified flu shot at best. The trials lasted 4 months and showed no mortality or hospitalization benefit....or any effect on transmission (which wasn't even studied).
Mandating these shots was outrageous. Period. This authoritarianism and politicization of science will take a generation to recover from. It was that bad.
No vaccine is perfect. Some, like the measles vaccine are amazing. Others, like influenza are more limited, but beneficial nonetheless.
The differences in vaccine efficacy reflect both the fundamental limitations of current vaccine science & the complexity of the virus-host response.
As a physician, I thought that some of the initial public health reactions were illogical. Specifically, the idea that screening for symptoms and fever would prevent transmission flies in the face of all of the viruses that are contagious before the patient is sick or even without the patient becoming sick. Then the idea that a surgical mast would work as well as an N95 mask until proven otherwise seemed like just a move to prevent a rush on N95 masks.
With the original SARS, just a few years earlier, the reason it did NOT become a worldwide pandemic was precisely because people infected with the virus were not contagious until they became sick , so an approach of isolating those who had symptoms worked to stop the epidemic. It was plausible at first that SARS-CoV-2 would behave the same way — sadly it turned out that it did not. (Though I think it remained true that infected people with definite symptoms were MORE infectious to others than infected people with no or mild symptoms.)
Yes, it was a move to preserve the supply of N95 & KN95 masks. The latter were needed in ICUs, for example, where the virus was demonstrably airborne due to ventilated patients, among other factors.
Protecting the healthcare workforce, especially hospital capacity, was the first priority. If that had crashed, panic would have ensued. Panic is chaos & chaos is the prelude to catastrophe.
I agree, but I don’t think that is how it was presented.
You're absolutely right. My lament is that the opportunity for effective Crisis Communication - courageous truth-telling, if you will - was bungled from the start, especially at the highest levels.
Values? Such BS! I'm old enough to remember POLIO. Each year before school started we HAD to get the polio shot. Later replaced with a sugar cube. We HAD to get the measles shot. These were NOT OPTIONAL. OK… maybe a little optional. The local Catholic schools did permit parents to skip these mandatory shots. Of course the kids in those schools became more ill each school year.
The covid risk was downplayed because most deaths were old people (like me). No big deal that over a million old people died before old man Biden declared the pandemic over.
I've always maintained that had children 10 and under were dying at the same rate as old people, then things like values would have been much less apparent. I guess we'll have to wait for the next pandemic to sort this one out.
Parenthetically, the younger brother of an elementary school classmate had polio. We visited him in his iron lung in their home living room one day. The next time we went to visit, maybe a week later, he was gone. Try that value on for size.
Agree that the public - and I hope leadership as well - would indeed have been more receptive to following unwelcome, unwanted & “intrusive” guidance if the virulence, morbidity or mortality profile had been even slightly altered, for example, higher rates of severe illness in infant and children.
Thank you for this series.
This post sidesteps three important issues:
1) Are vaccine mandates ever morally justifiable for a non sterilizing vaccine? The public was told that people who got the vaccine couldn’t transmit the virus to others and wouldn’t get infected. This was never true, even before omicron. PH knew this wasn’t true, but promises were made to the public like (by Fauci), "When you get vaccinated, you not only protect your own health and that of the family but also you contribute to the community health by preventing the spread of the virus throughout the community. In other words, you become a dead end to the virus. And when there are a lot of dead ends around, the virus is not going to go anywhere. And that’s when you get a point that you have a markedly diminished rate of infection in the community.”
2) Once PH realized the vaccine wasn’t living up to its promise, they took way too long to lift the mandates. There was never a clearly drawn line in the sand for when mandates ended or why, leaving families to bicker at holiday gatherings and employees and students to bicker with their institutions. Public Health neglected the Public. The mandates simply disappeared with no formal acknowledgement. Can anyone find an official announcement spelling out the date mandates were lifted, why and by whom? Or did PH pretend like the mandates never existed in the first place, leading to confusion, arguments and the feeling we had all been gaslighted?
3) The decision of whether to mandate a particular vaccine cannot be made in a vacuum. If the reasoning was rushed and/or incorrect, the public will eventually realize this, and other mandates for mainstay vaccines like polio and measles will be called in to question.
Where I reside, vaccine and mask mandates were implemented at the state level. Conveying nuance by PH officials at the federal level and understanding of such by the general population played a role in issues with clear communication.
The federal government mandated covid vaccines for: federal contractors, healthcare workers, private sector employees (100 or more employees), federal government employees, military personnel and noncitizen air travelers. That's probably over 50% of the population.
The authority for mandates ranged from Secretary of Defense, OSHA, to Presidential Proclamation from Biden himself - all federal government.
States often mirrored federal mandates to fill in the gaps (students, small business, etc).
It wasn’t until May 11, 2023 that the federal government QUIETLY lifted any remaining national vaccine mandates.
Thanks. Yes, I’m aware of that.
Not going to go on a lengthy diatribe today - weather too gorgeous :)
Anyway, here is why I, as a Pro-Vax, Pro science, Democrat chose not to get vaccinated for what it is worth, which comes down to three reasons. None of which were due to appeals to Libertarianism:
1) Inductive reasoning. Extremely low odds, that the fastest to market vaccine (by a magnitude!), against a mutating class of respiratory viruses we have tried and failed to develop successful vaccines for decades, would work. Appeals to the promise of mRNA being the solution had me wondering "well if this platform is so great and we had proof of concept for decades, why haven't we used it on the flu or one of the other circulating coronaviruses?" It just seemed extremely unlikely, but I was hopeful strong data would prove otherwise. Instead I got:
2) Weak data from Pfizer and Moderna. I get it, we are in a rush, there is panic setting in, but no excuse not to be testing daily for asymptomatic infection. No excuse not to continue following both arms in a prospective cohort study to see what happened as time progressed. No excuse not to turn over the raw data, especially after the Peter Doshi piece in BMJ pointing out that there were 20x more suspected Covid cases in both arms in the Pfizer trials. Now, while I was not finding the early data compelling, I still planned to take it until...
3) People were having horrible reactions from the shots. "I never felt so sick, so imagine just how bad Covid must be!" was the common refrain. I am not sure about your reactions Kristen, but Katelyn has been honest about how crappy they made her feel which is why she switched to Novavax.
My wife got her Moderna shot 1/6/21, and it KNOCKED HER OUT. She was in bed for 2 days. High fever, clammy, muscle aches. She had to call out of work (as did her partner - so now her hospital without vascular coverage for 48 hours), which is unheard of. 40 years old, extremely fit and healthy, and should have had covid numerous times given working in a hospital with a loose fitting surgical mask, our kids in school, etc, but it was the Moderna shot that finally dropped her.
My wife's reaction wasn't a "one off". It was the common outcome. I saw people talking about on Facebook, in YLE comment sections, in the news. Schools were closing down not from Covid, but from too many teachers calling out because of vaccine side effects. None of this was mentioned btw in Pfizer or Moderna studies.
Why would I want to take the chance when I became eligible a few weeks/months later of becoming so sick? That is why I didn't bother, and 4 years later, I feel confident I made the right choice.
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Not nitpicking, but regarding this statement:
"The virus mutated, and the science was in flux. Waning vaccine immunity and the unexpected Thanksgiving arrival of Omicron meant the data driving decisions to implement national vaccine mandates in September 2021 was out of date just a few short months later."
Why was "the science in flux"? We have known that ILI including influenza and Coronaviruses mutate, and we believe that is a large part of why our flu vaccines are regularly ineffective and why previous attempts at Coronavirus vaccines failed.
Where did the belief that this particular Coronavirus was special and wouldn't behave like all other Coronaviruses come from?
How was the "data driving decisions...out of date just a few short months later"? The data was out of date when the September mandates were rolled out, not months later. Why wasn't Public Health aware that the virus wasn't impeding infection by end of summer 2021?
All eyes were on Israel late summer, having one of the earliest vaccine rollouts of any nation in the world, yet cases by September 9th eclipsed both their previous waves in September 2020 and February 2021.
Rather than pause and consider that perhaps the vaccine wasn't impacting transmission at all, the White House pressured Social Media to censor people pointing this out.
Again, Public Health should be embarrassed it was Alex Berenson who figured out Covid was running through Israel's vaccinated population unchecked and not, you know, Public Health.
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I think that is a piece missing here over these last 4 essays - the lack of self-reflection by PH which overpromised and underdelivered. Where is the introspection to figure out HOW Public Health could have gotten so much wrong on so many extraordinary claims (Cloth masks, vaccines stopping transmission, Sweden, risk profile, etc).
This well-intentioned series of posts gives the vibe "We were right, we just should have communicated we were right better".
Instead, why not try to figure out how people like Alex Berenson figured out the vaccines weren't impeding transmission before Public Health did? Why not examine PH was fooled into making children wear useless cloth masks?
Your point about Democrats and Republicans should be able to reproduce the same study - agree - why didn't this happen?
The excuses of "science changed" "working with best data we had" etc fall short of explaining how PH repeatedly fell for extraordinary claims.
Cloth Masks are an absolutely perfect example.
We knew as of 2019 that cloth masks were useless against respiratory viruses. “The Science was Settled” as “The Science” likes to say.
And we agree now, in 2024 that cloth masks don’t work, right? They aren’t “Better than nothing”, right? They simply don’t work.
Then I arrive at the biggest problem – how could we find that they did work?
How could science conjure out of essentially thin air, evidence they did work, and why wasn't this garbage evidence summarily rejected the moment it was attempted to be published?
Why did the Zhang et al 6/11/20 paper "Identifying airborne transmission as the dominant route for the spread of COVID-19" become the most cited paper on masks of all time, despite having a retraction request signed by scores of researchers (including Michael Mina of all people)? How did science let this bad paper shape policy?
Why did the CDC promote "Absence of Apparent Transmission of SARS-CoV-2 from Two Stylists After Exposure at a Hair Salon with a Universal Face Covering Policy — Springfield, Missouri, May 2020" rather than criticize the authors for such a ridiculous paper?
Why didn't the CDC bother to replicate the claims of the equally ridiculous "Trends in County-Level COVID-19 Incidence in Counties With and Without a Mask Mandate — Kansas, June 1–August 23, 2020" MMWR which took me roughly 45 minutes to reproduce and falsify?
Bottom Line, the Cloth Mask Hysteria scares me because it demonstrated how easy The Science could be fooled so long as we wanted something to be true strong enough.
But as I said, I am not going to go on a lengthy diatribe today - weather too gorgeous :)
It seems to me that vaccine mandates are like traffic laws. Sure speed limits are a restriction on freedom, but it’s to prevent innocent people from being killed or injured. People who don’t vaccinate endanger others, in addition to make herd immunity less likely. It’s good science to point this out.
Sometimes, like during world wide pandemics that are leading to health system collapses and mass graves and morgue refrigerator trucks overflowing, you have to be heroic. The vaccines showing 95% VE at that stage of the game were heroic tools. They saved 14-20 MILLION lives. If you want to see the ugly revisionism and societal manipulation of these basic truths, review the congressional oversight hearings orchestrated by Jim Jordan (R).
“ These discussions should have been between a patient and their doctor. But instead, the Biden Administration inserted itself and defiled the sacred relationship that we as Americans
have always treasured between the doctor and the patient, who knows you, understands you. But there was no discussion with the doctor that you know and trust. The government was
`because I said so; was supposed to be good enough. Hardly bedside manner. No discussion on side effects, who is at risk, treatment options, et cetera. Worse still, the vaccine did not prevent the spread of the virus, a fact already evident by the time the mandates were imposed. Actually, we know from the trials that even vaccinated patients could get COVID. No matter how much President Biden or others claimed or wish that the vaccine stopped the spread of the virus, the science didn’t ;t support it. And if the vaccine does not prevent you from getting sick, then what is the utility in forcing you to get vaccinated? That is a question
many people asked. It is a legitimate question that they can have a conversation with their doctor. What are the pluses? “
14-15 million lives, and hundreds of millions of less long covid disabilities.
https://www.congress.gov/event/118th-congress/house-event/116287/text
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9537923/
That quote from Jordan is extremely interesting, Ryan—and I think goes to the heart of a societal problem. That is, on its face, Jordan’s comment could make total sense if we were dealing with a matter of individual, rather than public, health. Though not the only cause, I do think the Biden administration really fell down on making the case for public health, which in turn helped enable Jordan to get traction with observations like this that seemed facially reasonable. (It reminds me a bit of the argument many make in favor of balancing the federal budget by analogizing to family budgeting.)
Leslie’s comment, at the head of the post, includes a quote that, to me, gets to the heart of what we, as a society have lost, which is that we are part of a larger community and have a duty to care for one another. (In this regard, I thought John Hellerstedt’s observation that this could have been a Winston Churchill moment, was excellent, and just what was needed—though I am of course in no way sanguine, that given the extreme polarized environment in which we find ourselves now, it would have had the same traction as Churchill did—or FDR, as another example.)
Here’s the quote from Leslie: “The Supreme Court explicitly upheld vaccine mandates against deadly diseases in Jacobson v Massachusetts where it explained: "the rights of the individual in respect of his liberty may at times, under the pressure of great dangers, be subjected to such restraint, to be enforced by reasonable regulations, as the safety of the general public may demand. We live in a country of ordered liberty, not individual autonomy that paves the way to the deaths of others. In short, it is not the right of every American citizen to catch and transmit a potentially fatal infection."
That quotation is perfectly on the mark, and it also marks perfectly our societal failure to instill in each of us this very duty to community.
Excellent framing of the problem, and I appreciate the quote above! I don't think any Churchill moments were possible with the extreme polarization, either... unless there is a really overwhelming disaster/terrorist attack. And I guess the revisionism and conciliatory tone towards people who blame public health/epidemiologists/policy leaders just doesn't jive with me. It was a very personal, individual threat for healthcare workers amid the collective crisis... but we all faced it to some degree:
"The beginning of the COVID-19 pandemic featured scrambles for personal protective equipment in hospitals throughout the United States. Healthcare workers were among the most vulnerable in those early days, as they could not shelter in place and they interacted with many patients affected with the disease.
An investigation that was published in April 2021 by The Guardian and Kaiser Health News found that more than 3,600 US healthcare workers who responded to COVID-19 had died by then. Almost one third were nurses, and close to one fifth were physicians."
https://www.medscape.com/viewarticle/987902
“It was a very personal, individual threat for healthcare workers amid the collective crisis.” Absolutely, and we are all eternally in your debt. Indeed, I would say it is not only very hard indeed to be forgiving in the face of that threat, but also I am not even sure it should be expected, let alone required. (As I think you will sense from my own comment😎, I am not in the least ready to forgive or forget what older people were contending with.)
My thought here is that, no matter how justifiable our fury, it is still necessary to find a way to communicate across the divide, to the extent possible. For one, public health is and will remain further imperiled unless and until we can find a way to do that. Let me assure you, given the state of affairs in our country, I am not the least sanguine we can—but we do have to try, as best we are able, to make the attempt. (I hope this doesn’t sound too terribly preachy, particularly when it comes to you, as one who works so hard and generously to communicate outward. You are definitely one of the good ‘uns.)
95% VE is a relative risk reduction (not absolute) over a 4-month period for symptomatic covid that tells you absolutely nothing in terms of real-world impacts (mortality, hospitalization, transmission).
The people who are trying to "regain trust" have to stop lying first
Read the second link, man.
"Models" aren't evidence of anything. They can produce whatever results the model creators want to show.
Great series, Dr. Panthagani! And you bring up critical issues to factor into public health decisions during the next crisis.
However, I do have some problems with the values part of your discussion, since you don't include (nor did much public health information during the Covid pandemic, as I recall) the point that "individual autonomy" is not a limitless "good", even if many Americans have been duped into assuming that it is.
There needs to be a clear recognition that the cost of that autonomy, depending on the circumstance, can be the serious illness or death of an innocent bystander, or a loved one---or even hundreds of casualties. Similar to the concept that no one has the right to yell "Fire!" in a crowded theater just for fun, I don't think that individual autonomy should be allowed to stand on its own, without considering the potential dangers. Kind of like the right to "bear arms"... I think we all need to be brave enough to let the public know that sometimes, our choices have consequences not just for ourselves, but for others too. And that calculation is critical to public health decisions like mandates.
I understand why all masking all the time mandates were a spark for rebellion. However, couldn't we now get a compromise to help keep seniors and other susceptible people safer? I call for first 1.5 hours of each day mask only in groceries and pharmacies. Let the staff rip off their masks after that. Also I call for all mask all the time in inpatient medical facilities, but in outpatient facilities I would ask for mask only (staff and patients) for the first 3 hours of each clinical day. That way those of us who are vulnerable could schedule our medical appointments early in the day and do our necessary grocery and pharmacy shopping early. Let the mask deniers have the rest of the day. It would also be fantastic to make all government buildings be ventilated and air purified to specific standards. My proposal would limit the spread of Covid (and other respiratory diseases known and those yet to become a thing) to the 18 % of US people who are over 65 and to other vulnerable people.
I appreciate all the commenters. Let me add to this. By the way, my background is 37 years in emergency medicine, 8 years in public health as medical director of a county health department, and 9 years as a coach working with doctors who are burned out and increasingly struggling to navigate the system they work in. So consider this:
Beliefs + data = opinion
Beliefs are formed based on one’s worldview- a product of genetics, upbringing and experience- it is the lens thru which data is absorbed and interpreted. Data/facts- observable, reproducible observations- are then grafted upon beliefs. This is why two people can look at the same data or observation and come away with different interpretations and meaning. This is why two people can look at mandates and see some very different threats. The brain is especially attuned to threats because its prime job is survival and does so by fending off threats.
I/we cannot convince anyone of anything; only they can change their mind/opinion. Challenging one’s beliefs is really hard; it’s tantamount to challenging one’s self image and self worth. If you believe government is not trustworthy and authorities lie, then you will look for every angle that supports that- ie confirmation bias is so strong. We are wired to trust beliefs because, well, this has gotten us by so far, and one’s brain main job is to craft a path forward in the face of uncertainty. Moreover, one’s response to a dilemma- a situation with multiple valuable but competing factors- is managed in the parts of the brain outside awareness, in what Shankar Vedentam termed the Hidden Brain. This where we factor the impact of data into worldview, not in the aware, deliberative, analyzing parts, contrary to popular belief.
And the handling of the pandemic demonstrated how difficult it is for people to grasp science. We are used to science doing its thing- reaching a concensus thru repeated testing of theories that might explain the observed circumstances- but in the case of the pandemic, we were doing the science in real time. So of course, there would be changing explanations as more was learned. But people are used to getting the ‘answer’ after all the work is done.
No wonder this left room for ‘alternate’ explanations to fill the void. One’s brain works by seeking patterns and doesn’t need all the information to then fill in the blanks. And the brain’s preference is to rationalize, justify, and defend that story- it just takes less energy to do so and the brain is always trying to preserve energy because it does not know what’s coming next. Some people claiming that officials were lying is one way to fill in the blanks based on their worldview about government and not having all the facts and seeking an explanation that ‘must be correct.’
The current tension between ‘me vs we’ has been building since the 1980’s. As it did for so many trends, the pandemic catapulted this to top of mind and produced preferences one way or the other. Contrast that with the outpouring of neighbors helping neighbors as we are seeing right now here in western North Carolina. Just to make the point that grafting the circumstances onto beliefs and worldview can yield differing balances in this tension.
So to regain trust will take individuals being open and willing to challenge the stories their brains have crafted in order to survive. The ethicist Onora O’Neill defines trust as taking 3 things- 1) not over promising, ie only committing to things one can actually do. 2) have the skills and ability to do what is promised 3) Follow thru on what is promised.
Experience indicates that it will take repeated opportunities over time to demonstrate trustworthiness. By doing so, this gives individuals, one step by one step, the opportunity to adjust their stories and enough ‘data’ to reach a tipping point where they find that the current story/narrative their brain has crafted is no longer the best avenue for success and survival.
Consistency is key. Our job is to give people an opportunity to trust, not to convince them to trust. Just as our job during the pandemic was to give individuals an opportunity to ‘rethink’ how they balance ‘me vs we’ in their worldview. You can make a good case that this is still our job.