By Ana Santos Rutschman
As several pharmaceutical companies approach the U.S. Food and Drug Administration (FDA) seeking authorization to bring COVID-19 vaccines to market, concerns about vaccine mistrust cloud the prospects of imminent vaccination efforts across the globe. These concerns have prompted some commentators to suggest that governments may nudge vaccine uptake by paying people to get vaccinated against COVID-19.
This post argues that, even if potentially viable, this idea is undesirable against the backdrop of a pandemic marked by the intertwined phenomena of health misinformation and mistrust in public health authorities. Even beyond the context of COVID-19, paying for vaccination is dubious public health policy likely to backfire in terms of (re)building public trust in vaccines.
The Problem of Vaccine Trust
The ongoing problem of diminished trust in vaccines is not specific to the COVID-19 pandemic. Already in 2019, the World Health Organization listed vaccine hesitancy – defined as “reluctance or refusal to vaccinate despite the availability of vaccines” – as one of the top threats to global health. Several pre-COVID studies showed that public confidence in vaccines has been dipping for years. As a result of growing vaccine hesitancy, vaccination rates in several geographical areas or communities have dropped, and vaccine-preventable diseases like measles have caused multiple outbreaks in recent years.
The COVID-19 pandemic has introduced a renewed sense of urgency in debates about how to best increase vaccination rates among populations indicated to receive COVID-19 vaccines. This debate has unfolded in an environment marked by heightened mistrust in many of the institutions operating in the public health space, and, in particular, those involved in vaccine regulation, such as the FDA.
To be sure, there have long been trust issues surrounding public perceptions of public health-oriented agencies in the United States. But a series of recent faux pas at the FDA – largely in connection with emergency use authorizations, the same regulatory pathway through which the use of COVID-19 vaccines will likely be greenlighted – have further compromised public trust in emerging COVID-19 vaccines. As a result, multiple studies have found it likely that the rates of COVID-19 vaccination will remain well below the levels required to achieve herd immunity – even after initial problems of vaccine scarcity are overcome. This lack of trust is especially pronounced among the Black and Latino communities, which are also the communities on which COVID-19 has taken a disproportionately high toll.
In the face of these problems, proposals suggesting that governments should pay people to get vaccinated against COVID-19 have gained ground in late 2020. However, this seemingly simple potential solution is misguided on many levels.
Tracing the Idea: Incentivizing COVID-19 Vaccination Through Payment
One of the earliest proponents of a COVID-19 vaccine payment nudge in the United States was Robert Litan, who laid out the concept in a Brookings op-ed in August 2020. Reacting to then-emerging news of lack of trust in emerging COVID-19 vaccines, Litan presented the idea as an “adult version of the doctor handing out candy to children.”
In his view, the prospect of a payment would incentivize otherwise vaccine-hesitant individuals to receive the required shots of a given COVID-19 vaccine. Litan concedes that the proposal would likely be prone to overcompensation, as individuals willing to be vaccinated would still be able to reap the reward, but his focus is on capturing vaccine-hesitant individuals – and from that perspective, Litan argues, governments should be prepared to overspend, as opposed to dealing with the protracted economic and public health effects of the pandemic.
Litan’s proposal assumes that it would be desirable to vaccinate 80% of the United States population, or 275 million individuals (even though COVID-19 vaccine clinical trials for children are far behind other trials, and ongoing trials have excluded pregnant adults and other subpopulations). Litan proposed a payment amount of $1,000 per individual, which would mean a grand total budget of US $275 billion for the incentive system.
When pondering how much a given individual should receive in exchange for agreeing to be vaccinated against COVID-19, Litan freely admits that “I know of no hard science that can answer that question, but my strong hunch is that anything less than $1,000 per person won’t do the trick.” This means that a family of four “would get $4,000 (ideally not subject to income tax) – a lot of money to a lot of families in these difficult times, and thus enough to assure that the country crosses the 80 percent vaccination threshold.”
Litan’s proposal was heartily embraced by economist N. Gregory Mankiw, who wrote an opinion piece in the New York Times in September, arguing that in order “to get the economy back on track” Congress should pass a law implementing the payment incentive scheme immediately.
By November, as the number of COVID-19 cases began to sharply rise again, the idea of a payment nudge gained further traction. In early November, Oxford philosopher Julian Savulescu published an article in the Journal of Medical Ethics arguing that payment for vaccination is preferable to penalties for failure to comply with vaccination mandates. The piece quickly permeated popular media, often being quoted in support of payment nudges outside the context analyzed by Savulescu. Throughout November, permutations of Litan’s proposal were seemingly ubiquitous. For example, in former presidential candidate John Delaney’s version, described in the Washington Post, the federal government should pay every American $1,500 upon proof of vaccination against COVID-19.
These proposals rest on thin math: the initial proposed amount of $1,000 appears to have been conjured up with no support from behavioral economics or any kind of data. And the estimated number of individuals to whom payment would be offered (and hence budgeted for) appears to include sub-populations for which a COVID-19 vaccine might not even be authorized in 2021. Nonetheless, it is the non-economic aspects of these proposals that are the most troubling.
Problems with Payment-based Incentives to Vaccination
Vaccines have long been one of the most polarizing types of health technology. From the enduring legacy of the now discredited Wakefield study to the ways in which the National Vaccine Injury Compensation Program is often misconstrued in anti-vaccine discourse, this remains a highly idiosyncratic field. Any intervention designed to promote vaccine uptake cannot ignore this reality. The proposals for COVID-19 vaccination payment nudges in the United States, however, do not pause to reflect on the underlying roots of vaccine mistrust, the probable spectrum of reactions to being offered payment in exchange for vaccination, and the post-COVID-19 effects of establishing a payment system for vaccination.
While highly heterogenous, vaccine mistrust is most commonly rooted in hesitancy about the technology itself or the entities mandating or endorsing vaccination, such as federal or state agencies or departments in the United States, international actors like the World Health Organization, and, more recently, funders of vaccine development and vaccination campaigns, like the Gates Foundation. In recent years, social media have fueled the spread of content that is disproportionately anti-vaccine. Some of the same groups that spread misinformation about United States electoral and political themes also spread content about vaccines – in some cases spreading both pro- and anti-vaccine content on social media, with the sole goal of using vaccine debates to further increase political divisiveness in the United States.
COVID-19 further complicated this landscape. Anti-vaccine groups or accounts on social media grew exponentially since the beginning of the pandemic. In the United States, the politicization of vaccine debates reached levels never seen before. And the reputation of the FDA – the market gatekeeper for COVID-19 vaccines – has sustained tremendous damage during the pandemic, with public health experts criticizing the data the agency relied on to issue emergency use authorizations on hydroxychloroquine, chloroquine and convalescent plasma, not to mention the FDA Commissioner’s overstating of data on convalescent plasma. As a result, the states of California, Washington, Oregon, Nevada and New York have announced their intention to conduct an independent review of any COVID-19 vaccines authorized or approved by the FDA. Similarly, citing distrust of the FDA, the National Medical Association announced a committee of Black doctors that will also review COVID-19 vaccines.
Against this complex backdrop, imagining that individuals or communities that experience profound distrust towards vaccines or the authorities that endorse vaccination will be moved by a $1,000 nudge seems disconnected from what is happening on the ground. Passing a law establishing a $1,000-1,500 “reward” for getting vaccinated against COVID-19 would likely accomplish marginally little in terms of increasing vaccine uptake. More importantly, though, it would likely cause great damage to both short- and long-term efforts to build trust around vaccines.
In discounting behavioral complexity, the idea of payment in exchange for vaccination is bound to be instrumentalized in anti-vaccine discourses. Consider the case of the current compensation system for vaccine-related injuries, currently in place not only in America, but also a part of the legal system of several other countries: its mere existence has been used by several commentators espousing anti-vaccine views to suggest that the government uses monetary compensation as a mechanism to impose a harmful practice (vaccination), hush up criticism of governmental action, and pursue deep-state or otherwise hidden agendas through vaccination. A law establishing compensation for COVID-19 vaccination would immediately join the ranks of the arguments traditionally presented to challenge the public health value of vaccines, or be spun as “proof” of vaccine-related conspiracies. And it would do so in ways that would outlive the pandemic.
Adding to instrumentalization issues, payment-based solutions to vaccination problems also reinforce paternalism towards lower-income individuals and communities, as well as racial minorities – again, groups that have endured the largest public and personal health toll of the COVID-19 pandemic. As expressly stated in the Litan formulation of the proposal, the amount offered by the government is meant to somehow override either the belief or inertia of an individual or family. Wealthier individuals, who might not consider $1,000 an amount that will influence their behavior, are presumably free to ignore the nudge, while poorer individuals and communities are theorized to switch behaviors in exchange for money. Because many of the poorer individuals and communities across the United States are disproportionately non-Caucasian, the vaccination “reward” taps into societal worldviews that indirectly differentiate populations – and individuals – according to their race and socioeconomic status.
These problems are not limited to the current pandemic. The ways in which we seek to build vaccine trust during the COVID-19 pandemic will help shape vaccine sentiments for years and possibly decades to come. They will affect public and individual responses to vaccines targeting other pathogens – and overall levels of vaccine trust were already waning before COVID-19. A monetary reward for vaccination will likely be instrumentalized to reinforce suspicion and conspiracism, while embodying a form of paternalism that misguidedly draws on socioeconomic and racial vulnerabilities. Yes, we face a problem of vaccine trust in the COVID-19 pandemic. Paying for vaccination, however, is not the solution.
Ana Santos Rutschman is an Assistant Professor of Law at Saint Louis University School of Law.