Vaccine denialism kills

New research confirms the Republican-embraced war on vaccines has been a huge setback for science and public health

There is no denying that among advanced industrial nations, the U.S. mounted the worst public health response to the 2020-23 COVID-19 pandemic. Nearly a third of our population caught COVID, and over 1.1 million people died from the disease. Our death rate of over 340 per 100,000 population was surpassed by only a handful of former Soviet bloc countries and a few in Latin America.

To analyze why the U.S., which spends more on health care than any other country, mounted such a poor response, one must begin by recalling the trajectory of the pandemic. In the first year, coastal states with the largest exposure to foreign travelers like New York, New Jersey and California were hardest hit. But it quickly spread to every state.

It was immediately apparent that certain sub-populations were particularly vulnerable to the new pathogen: seniors, people who are obese, and people with chronic medical conditions. Among the general population, workers in critical service occupations, who could not work remotely, and the poor, disproportionately minority, who could not or were not allowed to take time away from work, experienced the highest death rates.

It didn’t help that the pandemic landed on our shores while the second-most polarizing president in U.S. history (the grand prize still goes to Abraham Lincoln) was running for re-election. The administration’s first-year actions, which ranged from the bumbling to the irresponsible, made it inevitable that our fragmented public health system would fumble its initial response.

The scientists at the Centers for Disease Control and Prevention, the National Institutes of Health and state public health agencies recommended masking, social distancing, and economic lockdowns. But the success of those measures depended on wartime-like social discipline, i.e., near total adherence. That might work in countries like Japan or Singapore, but it simply wasn’t going to happen in a Donald Trump-led America.

Vaccine mandates — an American tradition

The Trump administration did get one thing right, though. It pursued Operation Warp Speed, which developed an effective vaccine in record time. Its introduction in April 2021 offered a solution that was solidly within longstanding American law, and reflected a scientific tradition that supported mandatory vaccination campaigns.

More than a century ago, the Supreme Court ruled that the federal government could mandate smallpox vaccines. In the 1950s, the nation’s children lined up for the new polio vaccines. And within a decade, almost every state-run public school system required vaccination against childhood scourges like measles and mumps before kids could attend school.

However, in the two decades before COVID-19’s arrival, the societal consensus behind mandatory vaccination began to break down. It was fed by the theory, propounded in a small study in the Lancet that was later retracted, that trace mercury used as a preservative in vaccines caused autism. Robert F. Kennedy Jr., who is now challenging President Joe Biden in the Democratic primaries, became a leader of the anti-vaccination movement after publishing a long article embracing the vaccines-cause-autism theory in Rolling Stone and Salon, which almost immediately pulled the story from its website.

However, the genie was out of the bottle. Vaccine hesitancy, which began as a fringe movement, moved into the mainstream. When the COVID vaccine arrived, a substantial minority of the population, overwhelmingly supportive of the Republican Party in its voting pattern according to numerous polls, rejected the idea of getting the two-shot regimen or the subsequent booster shots. When the Delta wave hit in the summer and fall of 2021, the COVID mortality rates surged in Republican-run states where vaccine hesitancy was strongest.

The Florida petri dish

The New York Times on Sunday documented this phenomenon in Florida, whose Gov. Ron DeSantis is challenging Trump for the Republican nomination for president in next year’s primaries. Here’s that article’s conclusions, which were based on a careful review of the state’s mortality data before and after the arrival of vaccines:

On the single factor that those experts say mattered most in fighting Covid — widespread vaccinations — Mr. DeSantis’s approach proved deeply flawed. While the governor personally crusaded for Floridians 65 and older to get shots, he laid off once younger age groups became eligible.

Tapping into suspicion of public health authorities, which the Republican right was fanning, he effectively stopped preaching the virtues of Covid vaccines. Instead, he emphasized his opposition to requiring anyone to get shots, from hospital workers to cruise ship guests.

While Florida was an early leader in the share of over-65 residents who were vaccinated, it had fallen to the middle of the pack by the end of July 2021. When it came to younger residents, Florida lagged behind the national average in every age group.

That left the state particularly vulnerable when the Delta variant hit that month. Floridians died at a higher rate, adjusted for age, than residents of almost any other state during the Delta wave, according to the Times analysis. With less than 7 percent of the nation’s population, Florida accounted for 14 percent of deaths between the start of July and the end of October.

Despite such promotion of vaccine hesitancy, the vaccine ultimately proved highly successful at reducing the mortality rate for people who contract COVID. On Monday, JAMA Internal Medicine published a study by Yale researchers that documented how voters in two Republican-run states – Florida and Ohio – responded to the arrival of vaccines.

Using publicly available voting, vaccination and death records from 2018 to the end of 2021 for more than a half million people in those two states, they found that the “excess death rate” for Republican voters, who skew older, was 2.8 percentage higher before May 1, 2021 (when vaccination began) but 7.7 percentage points higher during the subsequent eight months. They found the gap was largest in counties with lower vaccination rates.

“If differences in COVID-19 vaccination by political party affiliation persist, particularly in the absence of other pandemic mitigation strategies, the higher excess death rate observed among Republican voters may continue through subsequent stages of the pandemic,” the authors concluded.

Doubling down on doubt

It’s difficult to fathom why a political party would embrace a public health strategy that disproportionately killed off its own supporters. But that appears to be where the Republican Party has landed as its leading anti-Trump candidates race to position themselves to the right of the former president.

I’m not holding my breath awaiting the Republican Party to miraculously rediscover the benefits of modern medicine and the scientific basis of our civilization. But even in the unlikely event that it does, the anti-public health movement it promoted in recent years will have a lasting legacy courtesy of a court system now dominated by Republican-appointed rightwing jurists. As three law professors led by Lawrence Gostin of Georgetown University wrote on the JAMA Network yesterday, the courts “have blocked most federal vaccine requirements, interpreting agency powers narrowly.”

Here's their catalog of federal court decisions handed down since the beginning of the COVID pandemic:

• The Supreme Court struck down the Occupational Safety and Health Administration’s emergency rule requiring large businesses to either vaccinate or test employees.

• The Fifth Circuit Court of Appeals struck down the president’s directive to vaccinate federal employees.

• Lower courts struck down mandates for Head Start workers and federal contractors even though the Supreme Court upheld a Centers for Medicare & Medicaid Services mandate for health workers.

• Congress last year banned COVID-19 vaccination mandates in the military, despite the Department of Defense’s concern that unvaccinated troops could undermine battle readiness.

At the state level, more than half the states have enacted laws blocking COVID-19 vaccination mandates. Yet, even as the legal scholars enthusiastically endorsed the effective of vaccine mandates, especially in school settings (“surrendering this ground would likely have devastating consequences”), they questioned whether population-wide mandates are worth defending given the current political environment.

“Population-wide are useful but more fraught means of ensuring wide vaccine coverage,” they wrote. “Enforceability is critical, making colleges and businesses the optimal loci for mandates. Where mandates are not feasible, government can boost vaccine uptake through evidence-based nudges and supports.”

Social discipline is needed, not voluntarism

This voluntary approach, it seems to me, is a recipe for failure during the next pandemic. What’s needed now is a full public accounting of why the U.S. did so poorly during the 2020-23 COVID-19 pandemic. The Biden administration should appoint a commission to hold public hearings and publish a definitive report.

Hopefully, that would embolden a frank discussion by responsible political leaders about what will be needed to combat the next pandemic. At the heart of that agenda should be educating the public about the need for social unity – especially when the science is uncertain and evolving as it always is in the early phases of any major public health threat.

If COVID-19 taught us anything, it is that the anti-science hysteria promoted by irresponsible political leaders is antithetical to public health. It undermines every potentially successful approach to combating new and dangerous health threats, which are certain to appear more frequently as the earth warms.