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Kilgore 20 (Kilgore, Christine. Freelance Medical Journalist, Penn State Graduate. "Social distancing impacts other infectious diseases," MDedge Pediatric News, 9/11/2020. https://www.mdedge.com/pediatrics/article/228372/coronavirus-updates/social-distancing-impacts-other-infectious-diseases) //Ulven

Diagnoses of 12 common pediatric infectious diseases in a large pediatric primary care network declined significantly in the weeks after COVID-19 social distancing (SD) was enacted in Massachusetts, compared with the same time period in 2019, an analysis of EHR data has shown.

The term “quarantine” originally refers to self-quarantine or quarantine of selective individuals who are suspected to be carriers of the infection, however, a new term mass quarantine” is emerging nowadays, which primarily refers to the enforced quarantine of a population by the government to prevent the spread of a disease outbreak.[13] A major purpose of mass quarantine is to flatten the curve of the spread of the disease. The curve in this scenario refers to the projected number of people that will be infected by COVID-19 over a period of time. The curve takes on different shapes, depending upon the rate of spread. A steep curve indicates the exponential spread of the disease in a shorter time. A steep rise will lead to the overloading of the health care system (as it was seen with Italy recently during the COVID- 19 outbreak). This is particularly of more importance in countries with a high density of population and limited health care facilities like in India. However, a steep curve has a steep rise as well as steep fall, which means after the infection has affected as many people as it can the case numbers will drop at a faster rate as well.[13,14] So flatening the curve primarily means to slow down the rate of infection.[14] It means the same number of people will get affected but over a longer period of time, which leads to lesser stress on the health care system, and in this case, may also provide us time to search for definitive therapeutic modalities like an antiviral drug or a vaccine. The mass quarantine strategies used by countries like Italy and India are aimed to flatten the curve of COVID- 19 infections in these countries. As far as WHO is concerned, in the past, it has not recommended broad quarantine measures in general. However, recently in the report of the WHO-China Joint Mission on controlling the spread of COVID, China's efforts have been praised, which include measures like enforced travel restrictions on an enormous scale and mass quarantine.[15] Willem Roper in his online report has mentioned how effectively China was able to drop down the daily admission rate of COVID patients from more than 1600 per day to less than 8 per day in less than a span of 1 month.[16] Many authors in the past, especially after the SARS outbreak in 2006, have published articles recommending the use of aggressive quarantine strategies for controlling the spread of rapidly emerging infectious diseases.[17,18,19]

Choe et al 20 (Young June Choe*, Bo Young Ryu**, and Hyo Eun Yun. *MD, PhD, Assistant Prof in the Department of Social and Preventive Medicine @ Hallym University College of Medicine. **MPH, Division of Infectious Disease Response, Korea Disease Control and Prevention Agency. “Impact of social distancing on incidence of vaccine-preventable diseases, South Korea”. Journal of Medical Virology; 93:1814-1816. Published 10/16/20. https://onlinelibrary.wiley.com/doi/pdfdirect/10.1002/jmv.26614. DOI: 10.1002/jmv.26614. Accessed 7/15/23) //Ulven

In this study, we found a decreased incidence of VPDs since the implementation of social distancing in South Korea in the early half of 2020. Social distancing measures had been practiced since February after a large surge of COVID‐19 cases. There was no draconian restriction of the movement, and all measures were either voluntary‐based or administrative sanction‐based actions. The Korean education system postponed the start of the new school year in March. In the setting of loosening the social distancing in May, elementary, middle, and high schools have reopened stepwisely. All public and private places were mandated to follow the infection control policies and guidance. It is important to note that the vaccination coverage has sustained fairly during the observed period. Compared to January and March 2019, the vaccination coverages in 2020 were comparable for hepatitis B (3rd dose, 94.6% in 2019 vs. 94.1% in 2020), DTaP (3rd dose, 92.1% in 2019 vs. 91.4% in 2020), pneumococcal conjugate vaccines (4th dose, 89.9% in 2019 vs. 88.8% in 2020), MMR (2nd dose, 94.8% in 2019 vs. 92.9% in 2020), and hepatitis A (2nd dose, 93.8% in 2019 vs. 94.9% in 2020) vaccines, which were provided in both private and public healthcare services.4 The decrease in incidence of the VPDs since February seemed to have a public significance that the social distancing had a positive impact on preventing transmission of communicable diseases. During the same period, a decrease in influenza activity was reported which was likely to be affected by social distancing, showing the impact of social distancing on the spread of influenza virus.5 Sustained immunization rate in South Korea has been maintained above a certain level despite the shutdown of healthcare systems and the decline of health‐seeking behavior due to social distancing, has likely to have additive effects on a decline of the VPD incidences.

The “no jab, no pay” policy has harms beyond the physical: it may unfairly deny funds to people who already suffer from hardship. While much attention is given to the half of non-vaccinators who consciously refuse, people have failed to vaccinate for other reasons such as having an ill child, or being caught up in what may be an already difficult separated family situation.∂ People who do not vaccinate for reasons other than disagreement and concern tend to have lower household incomes (60% have a household income less than A$50,000) and lower education levels (34% have year ten or less education). Single-parent households are also over-represented in this sub-population – 21% versus 15% of families nationally.∂ For such people, a policy that links vaccination to family benefits may simply increase their disadvantage. It may even add fuel to family tensions if the problem arises because of a separated family situation and parents with differing views.∂ Yet another potential harm resulting from the policy is that mandating vaccinations fails to respect individual autonomy. This tension between individual rights and the public good has been labelled the “central dilemma” in public health.∂ The counter-argument to these harms is that childhood vaccination can and does save lives. But we now know that not all vaccinations are 100% effective. If they were, there would fewer emotional appeals along the lines of “the anti-vaccine movement threatens us all”

“This study found there was just no major change to that vaccine-objector group with the ‘no jab, no pay’ policy,” Beard said. “But on the positive side, a substantial number of people did catch up vaccination which led to modest increases in overall vaccine coverage. It was always thought by experts that the policy might have little impact on vaccine refusers. This study certainly provides evidence to support that.”∂ Prof Julie Leask, an expert on vaccination attitudes and behaviour from the University of Sydney, said the policy simply served as a prompt for people already happy to vaccinate their children – but did not work on those who actively rejected vaccines.∂ “We did in-depth interviews with this group for up to two hours, and we have done a number of studies with these vaccine-refusal groups now, and what we hear from them is that when you take away choice it causes a psychological reaction and it’s an anger towards having one’s choice removed,” Leask said.∂ “That caused people to dig down more, and we saw that coming through in this study with parents continuing not to vaccinate despite the policy, and in fact it suggests some who were on the fence said, ‘That’s it, if they force me I won’t do it at all.’ ”∂ Leask was concerned that by removing the conscientious objector exemption, which required people to have a signed note from their doctor or nurse, it removed an opportunity for healthcare providers to engage with those who refused vaccinations.∂ “At least there was more of a chance of engagement with mainstream medical services which would continue to give parents opportunities to review their decision,” she said.∂ “Another aspect often ignored in thinking about no jab no pay is that it means significant financial hardship for a minority of families who are vaccine refusers and that doesn’t just impact the parents, it means the kids are missing out too.”

Another Biden administration requirement that employees get vaccinated against COVID-19—this time for federal workers—was blocked by a federal district court in Texas on Jan. 21. The directive is now on hold pending a Justice Department appeal of the ruling.

The ruling follows on the heels of the U.S. Supreme Court blocking the Biden administration's vaccine-or-testing directive for large employers last week. However, the Supreme Court lifted the stay on a vaccination directive for health care providers that are Medicare or Medicaid recipients.

Our key findings highlighted:∂ The ineffectiveness of welfare conditionality in facilitating people’s movement off social security benefits and entry into, or progression within, the paid labour market over time.∂ The profoundly negative personal, financial, health and behavioural outcomes triggered by benefit sanctions.∂ Deficiencies in much of the mandatory support available and the pivotal role of appropriate and personalised support in triggering and sustaining movements into paid work and the cessation of problematic and anti-social behaviour.

Despite numerous critiques of neoliberal economic policies (Peck 2010) and strong paternalism in social security policy in Australia (Carney 2019), the overall direction of income support and labour market policies remains largely unchanged. Indeed, in recent decades Australian governments have introduced new forms of conditionality, including CIM policies. Income management policies see a portion of affected benefit recipients social security payments placed on an issued debit card which limits where, and on what, these funds can be spent. This approach represents both a continuation and escalation of the activation agenda, extending the imposition of conditions such that individuals are not only required to meet rigorous eligibility and compliance obligations in order to receive funds, but are also denied autonomy over these funds (Mendes 2015; Peterie et al. 2019a). These policies were initially trialled on Indigenous Australians in the Northern Territory, but have since been rolled out across other sites over Australia. Australian legal scholars such as Shelley Bielefeld (2014, 2018) have consistently drawn attention to the racist and punitive aspects of these sets of policies. A key justification of recent iterations of these policies has been the perceived need to help benefit recipients to overcome (assumed) substance abuse and rejoin the workforce (Lovell 2016).The relentless moralisation of work through income support policy settings is confining policy communities to predictable circuits of thought. As Frayne (2015: 15) states, In a context where those who resist work are so readily disparaged, reviled and feared it becomes increasingly difficult to foster an open-minded and intelligent debate on the future of work . We live in a time when political slogans like the best form of welfare is a job (Liberal Party of Australia 2019) are substituting for policy action, while concerns about adequacy of social security payments continue to fall on deaf ears. Governments have ramped up punitive policies towards those on social security benefits rather than address demand side problems in the labour market. Activity for activity s sake has become normal, along with a populist dose of what the Canadian writer Jean Swanson (2001) aptly refers to as poor bashing in mass media representations of low-income Australians. On the other side of the equation, the operational arm of conditional welfare to work programs, the marketised employment services model of non-profit and for-profit providers, is financially incentivised for short term placements, with few resources to address non-vocational barriers to employment. The front-line workers of these employment services have found their job satisfaction and working conditions deteriorating in the face of an unrealistic contractual and performance management regime (Considine et al. 2015; Murphy et al. 2011). The end result has been a human service enterprise that has lost its most experienced and skilled workers, precisely at the same time when the front-line of welfare to work has become more complex and demanding, as more groups are cajoled into meeting participation requirements that should lead somewhere, but frequently lead nowhere (Murphy et al. 2011). This is not good policy or good practice, and yet successive governments persist with the model. The lock-in effects of the program logic have become opaque and solidified and policy makers now find it hard to imagine other possibilities (Standing 2019). Certainly, there are cracks and fissures in the workfare policy edifice and some refusals by non-profits to refer people for sanctions in the early 2000s resulting in a softening of some harsh measures (Wright et al. 2011). However, these temporary victories have not been enough to disrupt the policy logic in the long-term. The challenge to alter path dependency in social security policy is both cultural and economic. We are confronted by a perverse situation in which the highest-ranking workers work long hours, whilst growing numbers of people find their labour power is no longer useful for the generation of profit, with the obvious consequences of increasing unemployment and underemployment. But the unemployed are not free from work in any meaningful sense. They exist in a dead-zone , degraded by social isolation, social security sanctions, and financial worries and controls. As Bertrand Russell (1932) proclaimed in his famous essay on the virtues of idleness and intelligent leisure, unavoidable leisure time has been turned into a universal source of unhappiness in late modernity. In cultural terms, we have become a society of people who are financially and psychologically dependent on an activity that is becoming more unevenly distributed with a less clear cost benefit analysis between sacrifice and rewards (Frayne 2015).

Our study found that offering financial incentives actually reduced vaccination intentions by about 19% compared to the control group, with the strongest negative effect observed in Uzbekistan and Kazakhstan. Country-level results ranged from no meaningful effect on vaccination intentions (Tajikistan) to a decline of up to 22 percent (Uzbekistan and Kazakhstan).∂ We also asked respondents about their views on vaccination incentives, and found that the majority disapproved of them, particularly in the countries where the experiment showed negative effects. About three quarters of respondents in Uzbekistan actively opposed providing cash incentives for vaccination. In Kazakhstan, 58 percent said they disagreed with paying incentives. Only in Tajikistan, where the experiment failed to find any systematic effect on vaccination intentions, did just 18 percent say they disagreed with paying incentives.∂ The results were a stark contrast with the well-established positive effects of monetary incentives studied elsewhere and suggest that the effectiveness of vaccination incentives is not universal. Several similar studies—including from Rutschman and Wiemken, and Robertson et. al.—have suggested heterogenous effects depending on norms and customs, which can vary both between countries and within countries with diverse communities. In novel contexts where they have not been used before, incentive payments could also signal inferiority or disutility. For instance, a person might ask “nobody has ever offered me money for a routine vaccination before, what is so bad about this vaccine that they have to pay me to take it?” Following our study, several public health experts in Central Asia offered variations of this explanation.

Paying people to get vaccinated against COVID-19 might be a reasonable policy if it were necessary to achieve herd immunity. Yet payment-for-vaccination proposals are not only unnecessary, but problematic.∂ First, people have a moral duty to be vaccinated, including a duty to promote their own health, a duty to others to promote the community benefit of vaccination, and a duty to society for individuals to do their fair share in putting a stop to the pandemic. Being vaccinated in order to receive a $1000 or $1500 incentive robs the act of moral significance. However, it is morally appropriate to offer payment to people who are vaccinated to reimburse reasonable vaccine-related expenses or as a form of compensation for the time and effort expended to become vaccinated, analogous to the modest payment offered to citizens summoned for jury duty. Such payments may even be morally imperative if they are necessary to overcome barriers to vaccination.∂ Second, paying a substantial sum as an incentive to overcome vaccine hesitancy and to promote vaccine uptake is not a prudent investment. It is likely that a majority of the population will be eager to get vaccinated as soon as possible in view of the extremely high and increasing number of SARS-CoV-2 infections and COVID-19–related hospitalizations and deaths. Moreover, some of the documented reluctance may naturally dissipate as individuals observe others—trusted figures such as Anthony Fauci, MD, nationally prominent politicians, and even their own clinicians—being vaccinated without adverse health effects and as reports of vaccine-related adverse effects remain quite rare. Accordingly, it would be a substantial waste to pay $1000 or more to the millions of individuals in the US who are already highly motivated to receive the vaccine without expecting or seeking an incentive payment and also to those who require only reassurance. There are opportunity costs associated with using money for cash incentives. Some of the proposals for paying people to get vaccinated would come with high costs, possibly requiring many billions of dollars; the money would be more efficiently spent addressing the pandemic in other ways.∂ Third, some might feel that a substantial monetary incentive for vaccination is coercive. While this is a misconception that confuses an offer with a threat, there is a genuine ethical concern about the influence of such an incentive on decision-making.10 Offering payment as an incentive for COVID-19 vaccination may be seen as unfairly taking advantage of those US residents who have lost jobs, experienced food and housing insecurity, or slipped into poverty during the pandemic. COVID-19 has shone a spotlight on the substantial inadequacies of the social safety net in the US. As individuals and families struggle, some people might feel they must accept a vaccine in order to, for example, purchase food or pay rent. They might feel they have no choice but to be vaccinated for cash. It is deeply problematic that the government would offer cash incentives to promote vaccination when it has failed, in numerous instances throughout this pandemic, to offer money or other supports needed to ensure that the basic needs of many people are being met. This concern may be particularly pronounced in Black and Brown communities, which have been disproportionately affected by both the health and economic consequences of the pandemic. Although these communities would be expected to benefit from high levels of vaccination, other methods are more appropriate to promote this end than trading on financial insecurity.∂ Fourth, COVID-19 vaccine hesitancy is rooted in concerns such as the warp speed development and approval of vaccines, politicization of the broader pandemic response, and even denial that the pandemic is real. It is unclear that offering incentive payments can or will overcome apprehensions like these. Rather, cash incentives might reasonably be expected to heighten these apprehensions or raise new ones, as offers of payment are often understood to signal that a behavior is undesirable or risky.3 In a climate characterized by widespread distrust of government and propensity to endorse conspiracy theories, those who are already COVID-19 vaccine hesitant might perceive that the government would not be willing to pay people to get vaccinated if the available vaccines were truly safe and effective. Incentive payments might also stoke new fears and, perversely, increase resistance to vaccination.∂ A policy of paying people for COVID-19 vaccination should be adopted only as a last resort if voluntary vaccine uptake proves insufficient to promote herd immunity within a reasonable period of time. Public funds would be better spent advancing other evidence-based proposals to increase voluntary vaccine uptake.

But in states such as Arkansas, vaccination rates remain low despite incentive programs. And while incentives in other states have had better luck, their success has been short-lived in many cases, including Ohio's. In an interview with NPR's Ari Shapiro on All Things Considered, behavioral economist and University of Pennsylvania professor Katy Milkman said that cash incentives tend to work on groups within the population known as "the movable middle" — people who are on the fence about getting a vaccine, but not totally opposed.∂ "​​If someone is adamantly opposed to vaccination, they have a strong reason that they would never get a vaccine, paying them $100 is very unlikely to change their minds," she said.∂ So what targets all groups? Marketing. Experts like Stanford professor of medicine and economics Kevin Schulman have argued that the money states have used to incentivize people to get a vaccine could have been better spent promoting vaccines themselves to groups unwilling to get them.∂ "I would go back to those lottery states and ask how much did you spend on the lottery and how much could you have spent on Facebook ads that could appeal to those populations?" Schulman said.

Trust plays an even more salient role in people's vaccine decision‐making during the present COVID‐19 pandemic due to greater presence of misinformation about COVID‐19 and increased polarization of the society (Gollust, Nagler, and Fowler 2020). Scholars have found strong evidence that trust is closely linked to various health mitigation measures, including COVID‐19 vaccination attitudes and intentions. For example, trust in the World Health Organization (Bayram and Shields 2021) and trust in science (Kreps and Kriner 2020; Sulik et al. 2021) predict adherence to COVID‐19 social distancing guidelines. A study conducted in 17 countries found a link between trust in scientists and health‐care professionals and vaccine hesitancy (Rozek et al. 2021). Similarly, trust in experts as well as trust in mainstream media news sources was positively correlated with COVID‐19 vaccination intentions (Callaghan et al. 2021; Woko, Siegel, and Hornik 2020). On the other hand, distrust of experts and intellectuals lowered public's compliance with COVID‐19 mitigation behaviors (Merkley and Loewen 2021). Besides trust in medical personnel, trust in government also affects willingness to receive a COVID‐19 vaccine (Lazarus et al. 2020). Studies conducted in Austria (Schernhammer et al. 2021), the United States (Daly, Andrew, and Eric 2021), and simultaneously in multiple countries (Trent et al. 2021) found that people with greater trust and confidence in their government were more willing to receive a COVID‐19 vaccination. Overall, trust plays a key role in people's health behavior during the COVID‐19 pandemic and absence of trust appears to be central to understanding why there has been such a significant resistance to COVID‐19 vaccination.

We make two contributions to the growing literature linking trust to COVID‐19 vaccine hesitancy. First, we investigate the relationship between three aspects of trust and COVID‐19 vaccine uptake. Trust is a complex and multifaceted phenomenon that is difficult to define and measure (Guillemin et al. 2016; Hupcey et al. 2001; Li 2007). It is plausible that low trust of the public in vaccines, people who administer them, and the government institutions providing vaccines all drive attitudes on COVID‐19 vaccination. However, this nuance is often overlooked in the scholarship. Studies that investigated the relationship between trust and COVID‐19 vaccine hesitancy mostly focused on only one aspect of trust, such as trust in government (Daly, Andrew, and Eric 2021; Lazarus et al. 2020; Schernhammer et al. 2021) or trust in science (Kreps and Kriner 2020).1 For this reason, it might be difficult to evaluate the relative importance of different aspects of trust when it comes to the decision to receive a COVID‐19 vaccination. In our study, we simultaneously investigate the relationship between three facets of trust and COVID‐19 vaccine hesitancy—trust in physicians, trust in government, and interpersonal trust. We hope these fine‐grained results will help clarify the relationship between trust and COVID‐19 vaccination behaviors.

Lack of trust in government needs to be addressed before almost any other issue in the United States.

In one of my recent posts, I discussed the lack of trust in our biggest institutions as one of the most significant factors affecting COVID vaccination rates. I’ve been thinking more about that lack of trust recently — specifically the lack of trust in government.

Of all economic claims, the idea that “people are more likely to do what you ask if you pay them” is probably one of the least controversial. After all, paying money in exchange for something is one of the most basic features of commercial activity. Nonetheless, some policymakers were cautious about using financial incentives to encourage vaccination during the COVID-19 pandemic.  Many wondered if paying people to get vaccinated was an atypical case and could be riskier than more traditional approaches, such as information campaigns and vaccination mandates.

A recent spate of formal evaluations has shown that most incentives either increased vaccination rates during the pandemic or, if they didn’t work, at least had no harmful effects. For instance, results from a paper recently published in the journal Nature was entitled “Financial incentives for vaccination do not have negative unintended consequences,” based on a randomized controlled trial in Sweden. This and other studies from the COVID-19 pandemic add to what was already a large literature on the positive effects of vaccination incentives. For example, in 2010, Banerjee and co-authors found that financial incentives significantly increased vaccination rates among the poor in India. A rigorously evaluated vaccination incentive program in Nigeria is one of the top-rated charity recommendations from GiveWell, an organization that assesses the value of aid programs.

Nevertheless, human behavior is not always as simple as implied by traditional economic models. Violations of these models have been long reported by researchers from psychology and behavioral economics. Indeed, leading behavioral scientists have recently suggested that paying financial incentives for COVID-19 vaccinations may not only be ineffectual, but could actually backfire by reducing overall vaccine uptake. As Volpp, Loewenstein, and Buttenheim (2021) argue, ‘considerable research shows that payments in some contexts can send the signal that an action is undesirable, unpleasant, or even dangerous and not worth taking based purely on personal benefit. Financial incentives are likely to discourage vaccination (particularly among those most concerned about adverse effects)

Incentives could be ineffectual or backfire for multiple reasons. First, when people are motivated to get the vaccine for intrinsic motivations, like being a good citizen and contributing to the public good, an extrinsic motivation, like a cash payment, may ‘crowd-out’ the intrinsic motivations. The motive to be a good person may actually be stronger than the motive to earn a few bucks, and the two motives may not comfortably co-exist in a given context, like vaccination. Second, people may see the choice to accept a vaccine (putting a foreign body in their own bodies) as a ‘sacred value’ that is unaffected by monetary incentives. This concern relates to a broader problem of ‘commodification’, and whether everything can and should be priced.

Vaccination status, it might be contended, is not readily verifiable. Age requirements to purchase alcoholic beverages require a state-issued ID that uses advanced technology to screen out forgeries. And state governments, in turn, may have no political appetite for entering into the vaccination verification business.

These arguments overstate their case. Fulfilment of immunization requirements for school and work are already being certified by healthcare providers in the private sector. Some states have created vaccination databases, which allow individuals to verify their vaccination status.[78] Individuals vaccinated at CVS or Walgreens can obtain proof of vaccination through their apps or online.[79] There will be a strong incentive for private entry into the vaccination verification market, just as there are private firms currently verifying credit scores. Work in this area is already being undertaken by the MIT Media Lab,[80] IBM81 and other private firms.

We first study the concern that offering financial incentives may reduce future vaccination uptake and other health behaviours when no payments are offered. Using administrative data on vaccination uptake, Fig. 1 and Table 1 show no evidence that participants in the financial incentives condition were less likely to take an unincentivized second dose of a COVID-19 vaccine (if anything, uptake increased; OLS regression, B = 0.055, standard error (s.e.) = 0.033, P = 0.097) or to delay the uptake of the second dose (OLS regression, B = 0.046, s.e. = 0.033, P = 0.164). We also do not find any effects on second-dose uptake when we restrict the sample to those who took the first dose (OLS regression, B = 0.049, s.e. = 0.035, P = 0.158). Using data from the first survey, we do not find evidence that offering monetary incentives affected the intention to take the third dose (OLS regression, B = −0.026, s.e. = 0.044, P = 0.560) nor the willingness of participants to take a third dose if they were hypothetically offered SEK 100 (OLS regression, B = 0.001, s.e. = 0.043, P = 0.983) or SEK 500 (OLS regression, B = −0.008, s.e. = 0.043, P = 0.850). Using data from the second survey, we do not find negative effects on self-reported actual third-dose uptake (OLS regression, B = −0.007, s.e. = 0.046, P = 0.879), the delay to take the third dose (OLS regression, B = 0.030, s.e. = 0.046, P = 0.524) or third-dose uptake when we restrict the sample to those who took the second dose (OLS regression, B = −0.016, s.e. = 0.049, P = 0.745).

Fig. 1: Regression-estimated effects of offering financial incentives for first-dose uptake on further COVID-19 vaccination, other health behaviours, morals and civic responsibility, perceived safety, efficacy and trust, and other concerns.

Vaccine mandates are aligned with our nation’s founding documents, laws, and history. They are necessary for our country to continue to provide the opportunity for life, liberty and the pursuit of happiness. Americans should get vaccinated for the common good of our nation and the world.

Our country is more than a collection of independent men living free to do whatever they want without regard to their fellow Americans. We live in an interconnected society and must live and work together to promote the general welfare as mandated in the preamble to our Constitution.

We fear it is only a matter of time before we face a deadlier and more contagious pathogen, yet the threat of a deadly pandemic remains dangerously overlooked. Pandemics now occur with greater frequency, due to factors such as climate change, urbanization, and international travel. Other factors, such as a weak World Health Organization and potentially massive cuts to funding for U.S. scientific research and foreign aid, including funding for the United Nations, stand to deepen our vulnerability. We also face the specter of novel and mutated pathogens that could spread and kill faster than diseases we have seen before. With the advent of genome-editing technologies, bioterrorists could artificially engineer new plagues, a threat that Ashton Carter, the former U.S. secretary of defense, thinks could rival nuclear weapons in deadliness. The two of us have advised the president of Guinea on stopping Ebola. In addition, we have worked on ways to contain the spread of Zika and have informally advised U.S. and international organizations on the matter. Our experiences tell us that the world is unprepared for these threats. We urgently need to change this trajectory. We can start by learning four lessons from the gaps exposed by the Ebola and Zika pandemics. Faster Vaccine Development The most effective way to stop pandemics is with vaccines. However, with Ebola there was no vaccine, and only now, years later, has one proven effective. This has been the case with Zika, too. Though there has been rapid progress in developing and getting a vaccine to market, it is not fast enough, and Zika has already spread worldwide. Many other diseases do not have vaccines, and developing them takes too long when a pandemic is already under way. We need faster pipelines, such as the one that the Coalition for Epidemic Preparedness Innovations is trying to create, to preemptively develop vaccines for diseases predicted to cause outbreaks in the near future. Poinkt-of-Care Diagnostics Even with such efforts, vaccines will not be ready for many diseases and would not even be an option for novel or artificially engineered pathogens. With no vaccine for Ebola, our next best strategy was to identify who was infected as quickly as possible and isolate them before they infected others. Because Ebola’s symptoms were identical to common illnesses like malaria, diagnosis required laboratory testing that could not be easily scaled. As a result, many patients were only tested after several days of being contagious and infecting others. Some were never tested at all, and about 40% of patients in Ebola treatment centers did not actually have Ebola. Many dangerous pathogens similarly require laboratory testing that is difficult to scale. Florida, for example, has not been able to expand testing for Zika, so pregnant women wait weeks to know if their babies might be affected. What’s needed are point-of-care diagnostics that, like pregnancy tests, can be used by frontline responders or patients themselves to detect infection right away, where they live. These tests already exist for many diseases, and the technology behind them is well-established. However, the process for their validation is slow and messy. Point-of-care diagnostics for Ebola, for example, were available but never used because of such bottlenecks. Greater Global Coordination We need stronger global coordination. The responsibility for controlling pandemics is fragmented, spread across too many players with no unifying authority. In Guinea we forged a response out of an amalgam of over 30 organizations, each of which had its own priorities. In Ebola’s aftermath, there have been calls for a mechanism for responding to pandemics similar to the advance planning and training that NATO has in place for its numerous members to respond to military threats in a quick, coordinated fashion. This is the right thinking, but we are far from seeing it happen. The errors that allowed Ebola to become a crisis replayed with Zika, and the WHO, which should anchor global action, continues to suffer from a lack of credibility. Stronger Local Health Systems International actors are essential but cannot parachute into countries and navigate local dynamics quickly enough to contain outbreaks. In Guinea it took months to establish the ground game needed to stop the pandemic, with Ebola continuing to spread in the meantime. We need to help developing countries establish health systems that can provide routine care and, when needed, coordinate with international responders to contain new outbreaks. Local health systems could be established for about half of the $3.6 billion ultimately spent on creating an Ebola response from scratch. Access to routine care is also essential for knowing when an outbreak is taking root and establishing trust. For months, Ebola spread before anyone knew it was happening, and then lingered because communities who had never had basic health care doubted the intentions of foreigners flooding into their villages. The turning point in the pandemic came when they began to trust what they were hearing about Ebola and understood what they needed to do to halt its spread: identify those exposed and safely bury the dead. With Ebola and Zika, we lacked these four things — vaccines, diagnostics, global coordination, and local health systems — which are still urgently needed. However, prevailing political headwinds in the United States, which has played a key role in combatting pandemics around the world, threaten to make things worse. The Trump administration is seeking drastic budget cuts in funding for foreign aid and scientific research. The U.S. State Department and U.S. Agency for International Development may lose over one-third of their budgets, including half of the funding the U.S. usually provides to the UN. The National Institutes of Health, which has been on the vanguard of vaccines and diagnostics research, may also face cuts. The Centers for Disease Control and Prevention, which has been at the forefront of responding to outbreaks, remains without a director, and, if the Affordable Care Act is repealed, would lose $891 million, 12% of its overall budget, provided to it for immunization programs, monitoring and responding to outbreaks, and other public health initiatives. Investing in our ability to prevent and contain pandemics through revitalized national and international institutions should be our shared goal. However, if U.S. agencies become less able to respond to pandemics, leading institutions from other nations, such as Institut Pasteur and the National Institute of Health and Medical Research in France, the Wellcome Trust and London School of Hygiene and Tropical Medicine in the UK, and nongovernmental organizations (NGOs have done instrumental research and response work in previous pandemics), would need to step in to fill the void. There is no border wall against disease. Pandemics are an existential threat on par with climate change and nuclear conflict. We are at a critical crossroads, where we must either take the steps needed to prepare for this threat or become even more vulnerable. It is only a matter of time before we are hit by a deadlier, more contagious pandemic. Will we be ready?

The World Health Organization named vaccine hesitancy one of the top 10 threats to global health in January 2019 — nearly a year before whispers of a mysterious illness in Wuhan, China. The reasons why people may be reluctant or refuse vaccines are complex, the WHO wrote, but include complacency and a lack of confidence in the shots or their health officials. The agency estimated that 1.5 million lives could be saved globally if vaccines were more widely accepted. What's happened in the U.S. during the Covid pandemic is a prime example of the deadly toll that can occur that can accompany vaccine hesitancy. The Kaiser Family Foundation estimates that nearly a quarter million Covid deaths from June 2021 through March were among the unvaccinated. This represents 60 percent of Covid deaths reported in that time period. But vaccine hesitancy is not new. People have been questioning vaccines since they were first introduced in the 18th century to combat smallpox, which, at the time, was killing up to half a million people a year in Europe alone. In 1910, Canadian physician Dr. William Osler wrote that he remained resolute in the benefits of smallpox vaccinations, despite anti-vaccine sentiments of the time. "I do not see how anyone who has gone through epidemics as I have, or who is familiar with the history of the subject, and who has any capacity left for clear judgment, can doubt its value," Osler wrote. The New England Journal of Medicine later published his writings. He went a step further and offered to take 20 people — half of them vaccinated and the other half unvaccinated — into a smallpox outbreak, predicting that half of those who refused the vaccines would ultimately die. "I will make this promise — neither to jeer nor to jibe when they catch the disease, but to look after them as brothers," Osler wrote. "And for the four or five who are certain to die, I will try to arrange the funerals with all the pomp and ceremony of an antivaccination demonstration." (It's unclear, however, whether anyone took Osler up on his offer.)