Punishing the unvaccinated is the wrong medicine for COVID-19

After more than half of a million Americans died of COVID-19, a seeming miracle occurred: the development of multiple vaccines found to be safe and extraordinarily effective against Sars-cov2. Yet not everyone has bought into the miracle. While about 53% of Americans  have taken the vaccine, 47%  of the population remains unvaccinated. The number of people who have had at least one shot is extremely high in states like Vermont (76%) and Massachusetts (75%) and promising overall in the northeast and west coast. However, it remains low in many Southern and Mountain Region states such as Mississippi (46%), Texas (56%)and Idaho (44%). 

And now we’re witnessing the fallout. Unvaccinated people have become a reservoir for the far more contagious Delta (and other) variants, allowing infection to spread—even among the fully vaccinated. COVID infection rates and deaths, which dropped to record lows last spring, are now at some of their highest levels in some states. Hospital beds are rapidly filling up and non-COVID patients are being turned away. Alarmingly, the city of Orlando, Florida recently asked residents to reduce their use of water because the liquid oxygen they use to purify water is in short supply due to the pandemic. Even with the recent FDA approval of the Pfizer vaccine, it’s not clear whether vaccination rates will appreciably change without vaccine mandates and verification systems.

Amidst these increased demands on our already-strained health care system, some medical providers have raised an important ethical question: should hospitals deprioritize care for unvaccinated patients? An internal memo leaked from a Texas doctors’ group asked about whether, in the case of overrun health systems, doctors should consider vaccination status when giving lifesaving treatment. Though this group backtracked on their query after the leak, the reality is that there are likely many frustrated (vaccinated) Americans who believe that excluding the unvaccinated from lifesaving resources is essential and even just.

Here is the problem with such claims: triaging unvaccinated patients does nothing to address the underlying social conditions  that have allowed such wide swaths of the US population to remain unvaccinated in the first place.

To be sure, it’s enraging and heartbreaking to hear the stories about the ways that some unvaccinated patients and their families have abused health care workers. And for many parents with children who are too young to be vaccinated, it is difficult to be sympathetic to the adults who have contributed to COVID-19’s community spread, kept children out of school, and contributed to the increasing disease burden among children and adults. 

In facing these pandemic challenges while trying to follow public health guidelines to protect their children, it is even understandable that such parents and other concerned citizens might experience a little schadenfreude after reading stories about anti-vax public figures who encouraged others not to take the vaccine and subsequently passed away from COVID. Focusing on such individualistic/personal stories, however, makes it easy to ignore the more abstract factors that have brought us to this resource crisis. The reason why there are so many unvaccinated people is not just about individual people each “refusing,” to be vaccinated — it’s about our vast social inequalities, pandemic of misinformation, and failures of policy.

First, treating vaccination (or the lack thereof) as an individual choice completely ignores the glaring inequities in access to medical care and other relevant resources. Lack of adequate medical facilities and infrastructure has long been a problem in rural areas. Because of this, rural Americans are less likely to have access to facilities to receive vaccines, and they are also less likely to have transportation. 

Similarly, transportation and lack of appropriate accommodations have posed formidable barriers to vaccine access for many disabled Americans. Racial/ethnic disparities are also pervasive. Black and/or Hispanic Americans, who have been historically excluded from unionized jobs with benefits, are less likely to have health insurance or sick leave compared to their non-Hispanic white counterparts. This means that they often don’t have time off to get the vaccine or recover from the common (temporary) effects of the second shot. Further, they are more likely to contract covid due to workplace conditions that leave them vulnerable.

Second, our ongoing war against vaccine misinformation has escalated during the current pandemic. Anti-vaccine attitudes are as old as vaccines themselves, yet the modern anti-vaccine movement has been allowed to proliferate largely unchecked as a mere difference of opinion even as it expanded its focus from vaccines to broader anti-public health platforms. Anti-vax activities, combined with broader public distrust of the pharmaceutical industry and the medical profession, have fueled vaccine mistrust in general. During the pandemic, these factors have been exacerbated by the politicization of the virus, perceptions that the vaccine was developed and approved too rapidly, and effective, targeted misinformation campaigns on social media. Given all the uncertainty and disinformation about COVID risk, it’s not surprising that people are choosing not to get vaccinated or are hesitant to get the vaccine.

Third, including vaccination status in medical triage decisions is almost certain to disproportionately affect the most vulnerable Americans. During the beginning of the pandemic when health care resources became strained, hospitals discussed triaging patients who were considered to be at risk for poor clinical outcomes. Disabled people and older adults were frequently de-prioritized in emergency protocols. Similarly, due to systemic racism, Black Americans and other people of color, as well as those of low socioeconomic status are more likely to have risk factors that place them at higher risk for COVID-related mortality. Yet, with the exception of older adults, all of these groups are often less likely to be vaccinated. As such, the decision to de-prioritize these groups will almost certainly reinforce existing inequities. 

None of this means that we should give up hope. So many everyday heroes have stepped up to the plate to get their communities vaccinated and provide them with a trusted source of information — many of them women of color. Yet relying solely or even mostly on individuals to fight disparities is (to borrow an analogy from a good friend of mine) like using a child’s plastic water pail to extinguish a five-alarm fire. In the short term, our federal and state governments should ensure that companies are providing sick leave and paid time off, particularly for the many essential workers at nursing and retirement facilities who are excluded from federal COVID relief. In the longer term, we must rebuild our badly frayed public health infrastructure, pursue evidence-based strategies against vaccine misinformation (including the social media companies that allow it to proliferate), and address the vast inequities in access to medical care, transportation, and other vital resources. 

At the end of the day, vaccines have never been the sole solution for ending the pandemic.  Punishing unvaccinated people by deprioritizing their medical care certainly won’t help us conquer COVID-19. This doesn’t mean that people aren’t responsible for their choices. However, these choices cannot be divorced from our political and social contexts. We need to look beyond vaccination as simply a personal choice and focus on and address the social systems that put thousands of people at risk of being unvaccinated.