Tag Archives: Lancet

Some Cheery COVID Research Tidbits

16 Thursday Jul 2020

Posted by in Pandemic, Public Health, Uncategorized

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Here’s a short list of new or newish research developments, some related to the quest to find COVID treatments. Most of it is good news; some of it is very exciting!

Long-lasting T-cell immunity: this paper in Nature shows that prior exposure to coronaviruses like severe acute respiratory syndrome (SARS) and even the common cold prompt an immune reaction via so-called T-cells that have long memories and are reactive to certain proteins in COVID-19 (SARS-CoV-2). The T-cells were detected in both C19-infected and uninfected patients. This comes after discouraging reports that anti-body responses to C19 are short-lived, but T-cells are a different form of acquired immunity. Derek Lowe says the following:

“This makes one think, as many have been wondering, that T-cell driven immunity is perhaps the way to reconcile the apparent paradox between (1) antibody responses that seem to be dropping week by week in convalescent patients but (2) few (if any) reliable reports of actual re-infection. That would be good news indeed.”

The herd immunity threshold (HIT) is much lower than you think: I’ve written about the effect of heterogeneity on the HIT before, here and here. This new paper, by three Oxford zoologists, shows that the existence of a cohort having some form of prior immunity, innate or acquired, reduces the number of infections required to achieve the HIT. For example, if initial transmissibility (R0) is 2.5 and 40% of the population has prior immunity (both reasonable assumptions for many areas), the HIT is as low as 20%, according to the authors’ calculations. That’s when the contagion begins to recede, though the final infected share of the population would be higher. This might explain why new cases and deaths have already plunged in places like Italy, Sweden, and New York, and why protests in NYC did not lead to a new wave of infections, while those in the south appear to have done so.

Seasonal effects: viral loads might be decreasing. From the abstract:

“Severity of COVID-19 in Europe decreased significantly between March and May and the seasonality of COVID-19 is the most likely explanation. Mucosal barrier and mucociliary clearance can significantly decrease viral load and disease progression, and their inactivation by low relative humidity of indoor air might significantly contribute to severity of the disease.”

The BCG vaccine appears to be protective: this is the bacillus Calmette-Guérin tuberculosis vaccine administered in some countries, This finding is not based on clinical trials, so more work is needed.

Is there no margin in plasma? No subsidy? This is the only “bad news” item on my list. It’s widely agreed that blood plasma from recovered C19 patients can be incorporated into an immune globulin drug to inoculate people against the virus. It’s proven safe, but for various reasons no one seems interested. Not the government. Not private companies. Did Trump happen to mention it or something?

C19 doesn’t spread in schools: this German study demonstrates that there is little risk in reopening schools. One of the researchers says:

“Children act more as a brake on infection. Not every infection that reaches them is passed on…. This means that the degree of immunization in the group of study participants is well below 1 per cent and much lower then we expected. This suggests schools have not developed into hotspots.”

Also worth emphasis is that remote learning leaves much to be desired, as acknowledged by the National Academies of Science, Engineering and Medicine, which has recommended that schools reopen for younger children and those with special needs.

Can angiotensin drugs (ACE Inhibitors/ARBs) reduce mortality? This meta-analysis of nine studies finds that these drugs reduce C19 mortality among patients with hypertension. The drugs were also associated with a reduction in severity but not with statistical significance. These results run contrary to initial suspicions, because ACEI/ARB drugs actually “up-regulate” ACE-2 receptors, to which C19 binds. Researchers say the drugs might be working through some other protective channel. This is not a treatment per se, but this should be reassuring if you already take one of these medications.

Tricor appears to clear lung tissue of C19: this research focused on C19’s preference for an environment rich in cholesterol and other fatty acids:

“What they found is that the novel coronavirus prevents the routine burning of carbohydrates, which results in large amounts of fat accumulating inside lung cells – a condition the virus needs to reproduce.”

Tricor reduces those fats, and the researchers claim it is capable of clearing lung tissue of C19 in a matter of days. This was not a clinical trial, however, so more work is needed. Tricor is an FDA approved drug, so it is safe and could be administered “off label” immediately. Tricor is a fibrate; the news with respect to statins and C19 severity is pretty good too! These are not treatments per se, but this should be reassuring if you already take one of these medications.

Hydroxychloroquine works: despite months of carping from media and leftist know-it-all’s dismissing the mere possibility of HCQ as a potential C19 treatment, evidence is accumulating that it is effective in treating early-stage infections after all. The large study conducted by the Henry Ford Health System found that treatment with HCQ early after hospitalization, and with careful monitoring of heart function, cut the death rate in half relative to a control group. Here’s another: an Indian study found that four-plus maintenance doses of HCQ acted as a prophylactic against C19 infection among health care workers, reducing the odds of infection by more than half. An additional piece of evidence is provided by this analysis of a 14-day Swiss ban on the use of HCQ in late May and early June. The ban was associated with a huge leap in the C19 deaths after a lag of less than two weeks. Resumption of HCQ treatment brought C19 deaths down sharply after a similar lag.

Meanwhile, a study in Lancet purporting to show that HCQ was ineffective and posed significant risks to heart health was retracted based on the poor quality of the data.

Remdesivir also cuts death rate: by 62% in a smaller controlled study by the drug maker Gilead Sciences.

Pet ownership might confer some immunity: this one is a little off-beat, and perhaps the research is under-developed, but it is interesting nonetheless!

I owe Instapundit and Marginal Revolution hat tips for several of these items.

Trump and Coronavirus

26 Tuesday May 2020

Posted by in Pandemic, Public Health, Risk Management, Stimulus, Trump Administration

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It’s a bit early to fully evaluate President Trump’s performance in dealing with the coronavirus pandemic, but there are a number of criteria on which I might assign marks. I’ll address some of those below, but in so doing I’m reminded of Jerry Garcia’s quip that he was “shopping around for something no one will like.” That might be how this goes. Of course, many of the sub-topics are worthy of lengthier treatment. The focus here is on the pandemic and not more general aspects of his performance in office, though there is some unavoidable overlap.

General “Readiness”

Many have criticized the Trump Administration for not being “ready” for a pandemic. I assign no grade on that basis because absolutely no one was ready, at least not in the West, so there is no sound premise for judgement. I also view the very general charge that Trump did not provide “leadership” as code for either “I don’t like him”, or “he refused to impose more authoritarian measures”, like a full-scale nationwide lockdown. Such is the over-prescriptive instinct of the Left.

Equally misleading is the allegation that Trump had “disbanded” the White House pandemic response team, and I have addressed that here. First, while the NSC would play a coordinating role, pandemic response is supposed to be the CDC’s job, when it isn’t too busy with diseases of social injustice to get it done. Second, it was John Bolton who executed a reorganization at the NSC. There were two high profile departures from the team in question at the time, and one one was a resignation. Most of the team’s staff remained with the NSC with the same duties as before the reirganization.

Finally, there was the matter of a distracting impeachment on false charges. This effort lasted through the first three years of Trump’s administration, finally culminating in January 2020. Perhaps the Administration would have had more time to focus on what was happening in China without the histrionics from the opposition party. So whatever else I might say below, these factors weigh toward leniency in my appraisal of Trump’s handing of the virus.

Messaging: C

As usual, Trump’s messaging during the pandemic was often boorish and inarticulate. His appearances at coronavirus briefings were no exception, often cringeworthy and sometimes featuring misinterpretations of what his team of experts was saying. He was inconsistent in signaling optimism and pessimism, as were many others such as New York Governor Andrew Cuomo and New York City Mayor Bill De Blasio. It shifted from “the virus is about like the flu” in February to a more sober assessment by mid-March. This was, however, quite consistent with the messaging from Dr. Anthony Fauci over the same time frame, as well as the World Health Organization (WHO). Again, no one really knew what to expect, so it’s understandable. A great deal of that can be ascribed to “the fog of war”.

Delegation and Deference: B

Trump cannot be accused of ignoring expert advice through the episode. He was obviously on-board with Fauci, Dr. Deborah Birx, Dr. Robert Redfield, and other health care advisors on the “15 Days to Slow the Spread” guidelines issued on March 16. His messaging wavered during those 15 days, expressing a desire to fully reopen the nation by Easter, which Vice President Michael Pence later described as “aspirational”. Before the end of March, however, Trump went along with a 30-day extension of the guidelines. Finally, by mid-April, the White House released guidelines for “Opening Up America Again“, which was a collaboration between Trump’s health care experts and the economic team. Trump agreed that the timeline for reopening should be governed by “the data”. There is no question, however, that Trump was chomping at the bit for reopening at several stages of this process. I see value in that positioning, as it conveys an intent to reopen asap and that people should have confidence in progress toward that goal.  

International Travel Bans: A

If anyone wonders why the world was so thoroughly blindsided by the coronavirus, look no further than China’s failure to deliver a proper warning as 2019 drew to a close. Wuhan, China was ground zero; the virus spread to the rest of the world with travelers out of Wuhan and other Chinese cities. The White House announced severe restrictions on flights from China on January 31, including a two-week quarantine for returning U.S. citizens. In retrospect, it wasn’t a minute too soon, yet for that precaution, Trump was attacked as a racist by the Left. In early February, WHO actually said travel bans were unnecessary, among other missteps. Other bans were instituted on entry from Iran and Brazil, as well as entry from Europe in early March, as countries around the globe closed their borders. Trump’s actions on incoming travelers were prescient, so I’ll score this one for Trump. Some of these travel restrictions can and should be eased now, and certainly that is expected in coming months, so we’ll see how well that process is managed.

Deference to States: A-

As a federalist, I was pleased that Trump and his team left most of the specifics on closures and bans on public gatherings up to state and local governments. That allowed more targeted mitigation efforts as dictated by local conditions and, to some extent, public opinion. This is a classic case of “laboratory federalism” whereby the most effective policies can be identified, though as we’ve seen, there’s no guarantee less successful states will emulate them. I grade Trump well on this one.

On reopening, too, Trump has been a consistent advocate of allowing flexility where local conditions permit, though he wrongly claimed he had “total authority” over ending social distancing rules. It’s hard to square that remark with his general stand on the issue of autonomy except as a tactic to strong-arm certain governors on other points.   

CDC/FDA Snafus: D

I applaud the Administration for its emphasis on the salutary effects of deregulation, but Trump went along with some major pieces of “expert advice” that were not only poor from regulatory perspective, but an affront to federalism. One was a directive issued by the CDC to delay “all elective surgeries, non-essential medical, surgical, and dental procedures during the 2019 Novel Coronavirus (COVID-19) outbreak“. (See my post “Suspending Medical Care in the Name of Public Health“.)

This is exactly the kind of “one size fits all” regulatory policy that has proven so costly, sacrificing not just economic activity but lives and care for the sick, creating avoidable illnesses and complications. The idea was to assure that adequate health care resources were available to treat an onslaught of coronavirus patients, but that was unneeded in most jurisdictions. And while the contagion was in it’s early “exponential” phase at the time, a more nuanced approach could have been adopted to allow different geographic areas and facilities more discretion, especially for different kinds of patients, or perhaps something less than a complete suspension of care. In any case, the extensions into May were excessive. I must grade Trump poorly for allowing this to happen, despite what must have been extreme pressure to follow “expert advice” on the point and the others discussed earlier.

That’s not the only point on which I blame Trump for caving to the CDC. In a case of massive regulatory failure, the CDC and FDA put the U.S. well over a month behind on testing when the first signs of the virus appeared here. Not only did they prohibit private labs and universities from getting testing underway, insisting on exclusive use of the CDC’s own tests, they also distributed faulty tests in early February that took over a month to replace. The FDA also enforced barriers to imported N95-type masks during the pandemic. Trump tends to have a visceral understanding of the calcifying dangers of regulation, but he let the so-called “experts” call the shots here. Big mistake, and Trump shares the blame with these agencies.  

Health Resources: B-

The question of disaster preparedness is often characterized as a federal obligation, but the federal government’s role is not to replace state and local efforts, but to backstop them with a form of risk sharing across all 50 states. The obligation to have sufficient medical resources on-hand for a pandemic falls on hospitals, state and local governments, and certain federal agencies like FEMA. In terms of readiness for this pandemic, there were successes and failures at all of these levels.

The first question was having adequate hospital space in terms of the beds and ICU beds to handle a potential surge in coronavirus patients. Again, the CDC directive on elective procedures and non-essential medical care, along with general fear of the virus, helped to empty hospitals across the country. That proved to be unnecessary and should have been suspended in most regions by mid-April. There were a few “hot-spots”, New York City being the most noteworthy. Trump arranged to get Navy hospital ships deployed quickly to NYC and LA. Federal funds were also provided to create a temporary hospital at the Javits Center in NYC and a field hospital in Brooklyn. All of these facilities went virtually unused. Nevertheless, for this I give Trump some credit for effectively responding to requests from state and local leaders.

Another important dimension of preparedness has to do with the availability of personal protective equipment (PPE) and equipment such as respirators and ventilators. On this I give the Administration a harsher evaluation, but many hospitals and states were also culpable for failing to maintain adequate inventories. Even more culpable is China, which did its best to cache supplies before the virus became a real crisis in the West. In an incredible goof-up intended as charity in January, the State Department sent many tons of donated ventilators and PPE to China, leaving U.S. health care workers without adequate protection (Canada did too). On the other hand, Trump arranged to get resources mobilized to produce PPE and ventilators quickly, but on balance, this one gets Trump’s grade knocked down.

Managing the emergency distribution of PPE and ventilators to states did not go as smoothly as might have been hoped. The shortage itself left FEMA with the unenviable task of allocating quantities that could never satisfy all demands. A few states were thought to have especially acute needs, but there was also an obligation to hold stockpiles against potential requests from other states. In fact, a situation of this kind creates an incentive for states to overstate their real needs, and there are indications that such was the case. Trump sparred with a few governors over these allocations. There is certainly blame to be shared, but I won’t grade Trump down for this.

Vaccines and Treatments: C+

The push to develop vaccines might not achieve success soon, if ever, but a huge effort is underway. Trump gets some of the credit for that, as well as the investment in capacity now to produce future vaccine candidates in large quantities. As for treatments, he was very excited about the promise of hydroxychloraquine, going so far as to take it himself with zinc, a combination for which no fully randomized trial results have been reported (the recent study appearing in the Lancet on HCQ taken by itself has been called into question). Trump also committed an unfortunate gaffe when the DHS announced the results of a study showing that sunlight kills coronavirus in a matter of minutes, as do bleach and other disinfectants. Trump mused that perhaps sunlight or some form of disinfectant could be used as a treatment for coronavirus patients. He might have been thinking about an old and controversial practice whereby blood is exposed to UV light and then returned to the body. Later, he said he used the term “disinfectant” sarcastically, but he probably meant to say “euphemistically” …. I’m not sure he knows the difference. In any case, his habit of speculating on such matters is often unhelpful, and he loses points for that.

Fiscal Policy: B

The several phases of the economic stimulus program were a collaboration between the Trump Administration and Congress. A reasonably good summary appears here. The major parts were the $2.3 trillion CARES Act in late March and a nearly $500 billion supplemental package in late April. These packages were unprecedented in size. Major provisions were direct cash payments and the Paycheck Protection Program (PPP), which provides loans and grants to small businesses. The execution of both was a bit clunky, especially PPP, which placed a burden on private banks to extend the loans but was sketchy in terms of qualifications. The extension of unemployment compensation left some workers with more benefits than they earned in their former jobs, which could be an impediment to reopening. There were a number of other reasonable measures in these packages and the two smaller bills that preceded them in March. A number of these measures were well-targeted and inventive, such as waiving early withdrawal penalties from IRA and 401(k) balances. The Trump Administration deserves credit for helping to shape these efforts as well as others taken independently by the executive branch. 

Trump’s proposal to suspend payroll taxes did not fly, at least not yet. The idea is to reduce the cost of hiring and increase the return to work, if only temporarily. This is not a particularly appealing idea because so much of the benefits would flow to those who haven’t lost their jobs. It could be improved if targeted at new hires and rehires, however.

Trump’s proposal to grant liability waivers to reopened private businesses is extremely contentious, but one I support. Lockdowns are being eased under the weight of often heavy public and private regulation of conduct. As John Cochrane says in “Get Ready for the Careful Economy“: 

“One worry on regulation is that it will provide a recipe for a wave of lawsuits. That may have been a reason the Administration tried to hold back CDC guidance. A long, expensive, and impractical list of things you must do to reopen is catnip when someone gets sick and wants to blame a business. Show us the records that you wiped down the bathrooms every half hour. A legal system that can sue over talcum powder is not above this.”

Indeed, potential liability might represent a staggering cost to many businesses, one that might not be insurable. Accusations of negligence, true or false, can carry significant legal costs. Customers and employees, not just businesses, must accept some of the burden of risks of doing business. I give Trump good marks for this one, but we’ll see if it goes anywhere.

Some of the proposals for new stimulus legislation from democrats are much worse, including diversity initiatives, massive subsidies for “green” technologies, and bailouts for state and local government for unfunded pension liabilities. None of these has anything to do with the virus. The burden of pension shortfalls in some states should not fall on taxpayers nationwide, but on the states that incurred them. The Trump Administration and congressional Republicans should continue resisting these opportunistic proposals.

The Grade

Without assigning weights to the sub-topics covered above, I’d put the overall grade for Trump and his Administration’s handling of matters during the pandemic at about a B-, thus far. When it comes to politics, it’s often unfair to credit or blame one side for the promulgation of an overall set of policies. Nevertheless, I think it’s fair to say that Trump, could have done much better and could have done much worse. We will learn more with the passage of time, the continued evolution of the virus, the development of treatments or vaccines, and the course of the economy.

 

 

 

 

 

 

 

Statists Might Like To Vaccinate Against Many Things

25 Monday Nov 2019

Posted by in Vaccinations

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The vaccine debate illustrates a widespread misunderstanding about the meaning of an “advanced society”. It does not mean that difficult social problems must be dealt with always and everywhere in a uniform way, as supporters of vaccine mandates seem to assume. Instead, it often means that society can respect differences in the preferences of individuals by allowing varied approaches to problem-solving across jurisdictions, as well as across public and private institutions. This latter notion of advancement respects individual freedom and facilitates experiential social learning. But is that varied approach wise in a world of communicable diseases?

One standard of “community” protection assumes that vaccines work with a high degree of certainty within groups of individuals, especially with a second booster. The share of the population vaccinated against most common childhood diseases is fairly high. In fact, these shares mostly exceed their respective “community protection thresholds” — the percentage required to prevent a particular disease from spreading. That means achieving so-called “herd immunity”. Of course, that will not be true across many local subgroups. Nevertheless, if one accepts this standard, a runaway contagion in the U.S. is an extremely remote possibility, affording some flexibility for respecting preferences for and against vaccination.

My Friend, the Vaccine Resistor

One of my best friends is a passionate vaccine resistor (VR). I won’t say he’s “vaccine hesitant” because that doesn’t come close to his position. I won’t call him an “anti-vaxxer” because he doesn’t mind if others avail themselves of vaccines (and besides, the term has taken on such derogatory connotation. He’s a fine fellow, very smart, lots of fun to be with, and we have plenty of mutual interests. We’ve argued about vaccinations before, and a few other medical and nutritional issues, but we mostly stay out of each others’ ways on these topics.

But I recently witnessed my pal get into a “debate” on social media with a mutual acquaintance and some of her connections. She happens to be a nurse. She’d posted a photo of an attractive young woman in a t-shirt imprinted, “Vaccines Cause Adults”. My buddy spoke up and said “Not for everyone!’, and he posted a link to an article that he felt supported his position. Of course, a number of barbed responses came his way. Okay, some of those were fair debate points, though barbed, but others were quite derisive, ad hominem attacks on him. He responded by posting links to more articles and research, which might not have been productive. It’s usually a waste of time to argue with people on social media. But to his great credit he maintained his equanimity. The episode made me feel a bit sad. People can be such assholes on social media. I was put off by the nurse’s refusal to moderate . That’s a typical pattern: posters allow their other friends to hurl terrible insults at anyone who disagrees, even when it’s an old friend. Mind you, I stayed on the sidelines in this case, except that I originally “liked” the nurse’s meme.

Later, I had a private exchange with my friend. I’m on board with vaccinations. I believe that widespread immunization contributes to public health, but I told him there are certain points on which I can sympathize with VRs. Without knowing the details, he encouraged me to write a blog post on the subject. I’m not sure he’ll like the results. However, as noted above, I’m willing to make a few concessions to my buddy’s side of the argument, and I wish we could identify a path that would settle the debate.

My Standpoint

This is one part my pal won’t like. Are VRs anti-science? First, VR’s come in several varieties. Some might resist only some vaccines and not others. But VRs do not disavow empiricism, as they claim their own set of empirical findings to support their position, however one might regard the research quality. 

I believe many VRs are misled by a serious post hoc ergo propter hoc fallacy: after this, therefore because of this. For example, for many observers, the purported link between autism and the measles, mumps and rubella vaccine was put to rest when the British medical journal Lancet retracted the original article supporting that claim as faulty. That doesn’t wash with more radical VRs, many of whom seem to have someone on the autism spectrum in their own families. They are understandably sensitive, but please forgive me: that suggests a need to find some external explanation, a source of blame not related to genetics.

Radical VRs are selective proponents of the precautionary principle: any risk of harm from a vaccine delivered in any amount is too great a risk. They seem reluctant to acknowledge the reality of a dose-response relationship, which bears on the risks of exposure to certain compounds often present in vaccine formulations. VRs will not acknowledge that vaccines present a manageable risk. And then there are the misleading references to disease incidence counts, as opposed to disease incidence rates, that are all too common (though my friend is almost certainly innocent on this count).

Vaccine resistance is not a new phenomenon, as the cartoon above from 1802 illustrates. Certain people will always find the idea of injecting germs into their systems deeply unsettling. Of course, that’s a very natural basis of resistance. A person’s body is their own property, after all. My default position is that an individual’s control over their own body is inviolable, and parents should always be the first authority over decisions about their children. The real issue, however, is the question of whether unvaccinated children inflict external costs on others.

Points of Contention

The major objections of VRs fall into several categories: 1) preservatives; 2) multiple viruses; 3) vulnerable infants; 4) contra-indications; 5) inefficacy; and 6) free choice. There may be others, but I’ll go with those.

Preservatives: Some vaccines still use a form of mercury, but a much more innocuous variant than the one VRs found so objectionable a few decades ago. Still, they object. And they object to many other compounds used in minute quantities as preservatives, such as formaldehyde, which occurs naturally in our bodies. I think the following test is helpful: if it were proposed that VRs take new versions of the vaccines that had zero preservatives, many would still refuse, especially if they were asked to pay the additional cost of providing them in that form. Thus, preservatives are revealed to be something of a side show.

Multiple Viruses: VRs object to the administration of vaccines that inoculate against several viruses in one dose or within a short window of time. This objection has some plausibility, since an injection of several different “bugs’ at once might place excessive stress on the body, even if the risk is still small. But again, would VRs volunteer to take single strain vaccines in a schedule over a lengthier period of time? Probably not.

Vulnerable Infants: VRs say it’s too risky to vaccinate infants in their first few months of life. This too is a plausible objection, and it would seem like a relatively easy concession to make in the interests of compromise … except, it won’t ever be good enough. Radical VRs will not agree to having their children vaccinated at any age.

Contra-Indications: There are undoubtedly genetic factors that pre-dispose certain individuals to an adverse reaction to certain vaccines. These might be rare, so an effort to compromise by requiring a thorough genetic profile before vaccination would be costly. I believe profiling is a reasonable demand for individuals to make, however, provided they pay the cost themselves.

Inefficacy: My friend posted an intriguing article about the drastic declines that occurred in the incidence of various diseases before the introduction of vaccines to prevent those diseases. This might not be the same link, but it makes the same argument. That doesn’t mean vaccines don’t work, of course. There is a vast literature that shows that they do. Bing it! And in cases such as smallpox, the use of “folk applications” of puss to a small scratch in the skin were in use long before the vaccine was available. Nevertheless, the VRs contend that the historical rates of disease incidence provide evidence against vaccinating. They also contend that diseases like measles are not serious enough to warrant precautions like vaccines. Measles can be deadly, though not as deadly as the flu.

Free Choice: This is the point on which I’m most sympathetic to VRs. Again, we own our own bodies and should have authority over our own minor children, yet communicable diseases seem to be a classic case of externality. Susceptible individuals may inflict a cost on others by refusing vaccination or segregation. Other people own their bodies too, and they have a right to avoid exposure. They too can isolate themselves or take precautions as they deem necessary. If both parties wish to participate in society, then both hold rights they allege to be threatened by the other. That complicates the task of reconciling these interests in private, voluntary ways, and yet they often are reconciled privately.

Solutions?

The debate today often revolves around mandatory vaccination, which would be an extreme measure relying on the coercive power of the state. The rationale is that even a vaccinated majority would be subject to an unnecessarily high risk of infection when in frequent contact with an unvaccinated minority. It’s difficult to endorse such broad intrusiveness when we’re dealing with a negative externality of such minute probability. And such a policy is not at all defensible without exceptions for individuals for whom a vaccine is contra-indicated.

Tolerating differences in vaccination rules across cities, school districts, or even states, may be a reasonable approach to settling the debate in the long run. These variations allow empirical evidence to accumulate on the efficacy of different vaccine regimes. It also allows individuals and families to “vote with their feet”, migrating to jurisdictions that best suit their preferences. These are the basic foundations of federalism, a principle of great usefulness in preserving freedoms while addressing regional differences of opinion on contentious issues.

Michigan has a policy allowing unvaccinated children to attend schools, but a waiver must be obtained requiring the child’s parents to attend a vaccine education program. The policy is credited with increasing vaccination rates. The problem is that VRs tend to view this requirement as an infringement on their rights. Advocates of the policy might argue that the situation should be viewed as an arms-length, voluntary exchange between two parties, in this case a family and a public entity. The vaccine education program is just the price one must pay in lieu of vaccination. The exchange is not arms length, however, as it would be if the school were a private entity. The VR parents who refuse the waiver are not rebated for taxes paid for local schools. In fact, like all taxes, the payment is coerced.

It’s not always necessary to appeal to some form of government action, even at local levels. For example, private schools may require vaccination among enrollees, and private businesses, especially health care providers, may require staff to be vaccinated. Life and health insurers may wish to price risk differently for the unvaccinated. VRs might object that they are subject to discrimination by institutions requiring immunization, or who price discriminate in favor of the immunized, but VRs are free to form competitive institutions, even on small scales or as mutual companies. To the extent that such private rules are unjustified, the institutions who discriminate are likely to learn or lose eventually. That’s the beauty of market solutions. In these ways, non-coercive private governance is far preferable to action by the state.

Dr. Jeffrey Singer is an advocate of immunization who opposes mandatory vaccine laws, as he explained a few years ago in “Vaccination and Free Will“. He suggested elsewhere, in “Seeking Balance In Vaccination Laws“, that schools, instead of requiring immunization, could mitigate the risk of a contagion by insisting that unvaccinated children be held out of school when a particular threat arises and remain out until it passed. That’s a reasonable idea, but I suspect many pro-vax parents would fear that it doesn’t go far enough in protecting against the introduction of a disease by an unvaccinated child.

Conclusion

Recent increases in the incidence of diseases such as measles, mumps and whooping cough are extremely troubling. Whether these outbreaks bear any relationship to patterns of vaccination in the population is certainly a valid question. To the extent that more families and individuals wish to be immunized, and that private institutions wish to take action to increase vaccination rates within their sphere of influence, I’m all for it. Vaccination laws are a different matter.

Political action at the local level might mean that school districts and other public entities will require vaccinations or vaccine education programs. Alternatives exist for those refusing to vaccinate, but broad mandatory vaccination is too coercive. Such measures carry significant costs, not least of which is a loss of liberty and normalization of losses of liberty. It’s not clear that a vaccination mandate at the national level, or even a state vaccination mandate, can offer benefits sufficient to justify those costs. Nudges are irritating and may be costly, but forcible intrusions are way out-of-bounds. Unfortunately, there are parties that simply can’t resist the temptations of behavioral control, and that’s worthy of resistance. Let’s continue to muddle through with an essentially federalist approach to vaccination policy. I regard that as a hallmark of an advanced society.