Abigail Cartus, Ph.D, MPH
Justin Feldman, Sc.D, MPH
Seth J. Prins, Ph.D, MPH
The United States has largely failed in its response to the coronavirus pandemic. Unlike other countries that have eliminated community transmission or suppressed it to low levels, US officials have allowed high levels of the virus to circulate and tolerated the subsequent mass death that has accompanied such a lax public health approach. In addition to needless, preventable sickness and death, another consequence of this state failure has been to shift the moral burden of pandemic decisionmaking onto individuals. As anyone who has tried to get a vaccine appointment lately can tell you, navigating these moral issues is not trivial: should I get a vaccine if offered, even if I’m not eligible? What if I’m eligible in a nearby state but not my home state? Should I jump the line if the risks I incur at my job aren’t factored into the eligibility determination? Is it morally defensible to jump the line in order to see friends and get back to normal?
Some of these questions are so tricky because when we make decisions about personal risk and safety, we’re also unavoidably contributing to social risks and the potential harms and inequities they entail. These harms and inequities are well-documented. As just one example, compared to their white counterparts, Black Americans are more likely to be exposed, more likely to be infected, and nearly twice as likely to die from COVID-19. People of color are overrepresented in the in-person workforce, where they are structurally disempowered to shield themselves from exposure. Inequities persist even in healthcare, where Filipinx nurses, who account for only 4% of the nursing workforce, have absorbed over 30% of COVID-19 deaths among nurses. The fact remains that COVID-19 is caused by a respiratory virus that spreads when people breathe on each other in close proximity. This means every decision about personal risk tolerance is also a decision about subjecting other people to risk.
That last part—that individual risks and social harms are interdependent during an infectious disease pandemic—might come as a surprise to anyone who follows certain elite media outlets. These outlets traffick in a particular “individual consumer” style of pandemic coverage. Their pages have become a place for privileged professionals to propose behavioral norms for life in the pandemic that downplay or ignore issues of social harms and responsibilities. And one convention of this type of writing is to sidestep difficult moral questions by applying a seemingly apolitical scientific rationality. A recent Atlantic article by Brown University economics professor Emily Oster is an archetypal example, although the article has provoked a great deal more controversy than other similar pieces.
This might be due to the article’s controversial central claim (also repeated in an accompanying interview in Slate): that for the purposes of planning a summer vacation, “your unvaccinated kid is like a vaccinated grandma.” Oster did a back-of-the-envelope calculation comparing vaccine efficacy estimates for older Americans to the risk of severe disease and death among children in the US. Because it involves numbers, this calculation carries the imprimatur of data-driven objectivity. But the calculation is actually an analogy, and, like all analogies, it is a rough approximation of reality. That roughness can obscure just as well as it edifies.
Let’s address what the unvaccinated-kid-as-vaccinated-grandparent analogy elucidates and what it obscures. It elucidates the low risk of hospitalization and death from COVID among children, but does this somewhat imperfectly. It’s true that, in the US, the death rate for ten-year-olds is about 98% lower than the death rate for 80-year-olds. Hospitalization rates are far lower for ten-year-olds too. But that’s not quite as good as vaccination, where clinical trials have found no deaths and no hospitalizations at all for the three authorized vaccines in the US.
Inequities persist here, too. Though very few children have died of COVID-19 in the US, nearly all of those who have died have been children of color. Compared to white children, American Indian/Alaska Native children are 7.6 times more likely to die, Black and Latinx children are five times more likely to die, and Asian and Pacific Islander children are twice as likely to die. Incidence of multisystem inflammatory syndrome in children (MIS-C), a severe long-term complication of COVID-19, is also disproportionately higher among Black children. And of course, a tiny percentage of a big number is still a big number: although severe outcomes of COVID-19 are exceedingly rare in children, allowing more infections to occur among children means that a larger absolute number of children will experience severe outcomes.
Where the “vaccinated grandparent” analogy really falls apart, though, is in relation to protecting others from coronavirus transmission. There is growing evidence that vaccines are fairly effective at preventing people from infecting those around them. An unvaccinated child, however, can transmit the virus to any susceptible person. In other words, the guiding analogy of Oster’s article cannot accommodate risk to others. This obscures the relational moral calculations about power and risk that are actually at play. Unvaccinated people, including children who themselves may be “low risk,” pose a substantial risk to other unvaccinated people. Managing this risk is not entirely a matter of personal choice or individual cost-benefit calculus; as more states lift restrictions, more workers may have to return to jobs in service or hospitality before they can be vaccinated.
Oster later clarified in a Twitter thread a strong assumption underpinning her analysis, namely, that per the Biden administration’s promise, every adult in the US will be eligible for a vaccine by May 1st in anticipation of a “return to normal” by the July 4th holiday. The Biden administration is rapidly increasing the pace of vaccinations, which is commendable. However, even if every adult is eligible to be vaccinated, given the state of the vaccine rollout, it is difficult to say with certainty that every eligible adult will have been able to receive their shot(s) by the summer. This is especially true if vacation plans involve international travel, as patent regimes essentially cut much of the world off from available vaccines entirely.
Many critics of the article focused on the perception that Oster was overstepping her disciplinary bounds—that as an economist, she should not be dispensing epidemiological advice. While some of this criticism has merit, the more interesting point is that economists do not have a monopoly on individualism. Part of the reason that COVID-19 has been such a massive crisis in the United States is a focus on technocratic, individual-level, consumer-choice responses at the expense of centrally planned collective action to reduce transmission (i.e., emphasis on individual choices to wear a mask and “maintain social distance,” instead of short but comprehensive shutdowns of non-essential businesses and activities with social support). This hyper-individualistic focus is common in economics, in epidemiology, and in many of the quantitative social sciences whose tools and expertise have been marshaled to respond to the pandemic—the article is just a particularly extreme example.
Analogies and metaphors are indispensable, especially in a time of global public health emergency, for communicating science to laypeople and scientists alike. However, as mathematician Norbert Wiener warned, “the price of metaphor is eternal vigilance.” While the unvaccinated-kid-as-vaccinated-grandparent analogy communicates one essential truth (low risk to most individual children), it omits another, equally essential truth—a high risk of transmission to others.
The availability of vaccines does not dissolve our moral responsibility to one another. Despite how painful and difficult it is, neither does state failure to control COVID-19. It has never stopped being true, at any moment over the past 13 months, that the risk to the most privileged and insulated members of our society is a direct function of the risk that less privileged workers have been forced to assume. Maybe it’s time for new analogies that affirm our interconnectedness and shared humanity. ♦
Seth J. Prins, Ph.D, MPH, is an assistant professor of epidemiology and sociomedical sciences at Columbia University.
Justin Feldman, Ph.D, MPH, is an epidemiologist and a Health and Human Rights Fellow at the Harvard FXB Center for Health and Human Rights.
Abigail Cartus, Ph.D, MPH, is a perinatal epidemiologist.