The politics of vaccine-stretching

If our goal is to promote good consequences (such as human welfare or health or life expectancy), then we would choose whatever policy seems likely to be most effective at promoting the consequences we care about, based on the all the information available.  However, once the FDA approved the two-dose protocol, many people believe that any alternative dosing regimen can only be justified by evidence that is as “strong” as the randomized trial evidence that was used to approve the vaccines initially.  This way of thinking puts a high burden of proof on anyone who wishes to justify an alternative policy – a burden of proof that cannot be met except by taking months to run additional trials.  This makes no sense from a consequentialist perspective, especially in the middle of a pandemic, but given that many people believe it, including many public health experts and government policy makers, any effort to abandon conventional procedures is bound to generate public controversial.

This controversy might be acceptable to the President and his advisors, except for the problem of hindsight bias and the risk that hindsight bias will be weaponized for political advantage.  If we switch to first-doses-first, it is inevitable that a few people who only get one dose will get sick, and some will die.  These deaths of identifiable people will inevitably make the evening news, and Republicans can be counted on to keep the outrage dialed up to 11.  In contrast, all the lives saved by giving one dose of vaccine to tens of millions of additional people will be invisible.  The same problem arises with using half-doses.  And if we delay vaccination for healthy people who have had Covid-19, no doubt a few will get sick again, and some will die.  Again, all the lives saved of people who were only vaccinated because we delayed vaccination for those with natural immunity will be invisible.

How can these political obstacles be overcome?  How can we reduce the conflict between the policy goal of saving lives and reopening the economy, and the political goal of avoiding controversy and maintaining public support?  There are promising strategies, some of which could still be used here or in other countries to alleviate shortages.

Ask people who are eligible to voluntarily give up one dose

We could simply ask people who are eligible to agree to wait for a second dose, or to take half doses, so that others can get a first dose.  We could also ask people who have been naturally infected to wait, or to take just one dose. 

Another approach would be to let eligible people split doses with a friend or relative who is not eligible.  For example, an 80 year old might give a dose to a younger spouse who is not yet eligible to be vaccinated, or to a child or a friend with a serious comorbidity.  (Or they could each get two half-doses, which might be better.)

I believe that many people would welcome the opportunity to make a personal contribution to the fight against covid.  The president could go on TV and tell Americans who voluntarily share doses that he is proud of their personal heroism.  He could promise to monitor the situation carefully and reverse course quickly if data shows there is a problem, such as a drop in immunity over time.  To reduce hindsight bias, the government could publicize a running estimate of the number of lives saved by the generosity of volunteers. 

Let people who are not currently eligible volunteer for single or half doses

A second approach would set aside (say) half the vaccine supply for people who are willing to take single doses or half doses but who would not otherwise be eligible.  In this case, it would be difficult to politically weaponize any deaths among those who are half-vaccinated, since people who received half doses would not have been eligible for any doses under existing prioritization rules, and it will be difficult to identify people who would have been eligible for two shots if some vaccine had not been set aside for first doses.

Let states decide

A third approach would be to push the decision down to the state level.  Governors could be given the discretion to delay second doses.  I suspect that several would take this option.  This would allow President Biden to avoid being swept into a partisan battle over vaccination policy.

Mix and match

These approaches could be used together and tailored to specific situations.  For example, the federal government could allow use of first-doses-first or half doses in emerging hot spots, such as Michigan.  The departure from standard operating procedure could be justified as a response to the surge in cases caused by new covid variants.  To create a political buffer for the President, the decision to authorize first-doses-first could be made by the governor of Michigan.  The federal government could make additional doses available in Michigan on a temporary, emergency basis to people who agree to delay second doses, and justify this as an experiment to test the effectiveness of vaccine surges for use in future epidemics. 

The big lesson – don’t ignore politics

Economists tend to treat policymaking as a purely technocratic exercise.  They advocate for policies they believe are justified on utilitarian grounds and criticize policies they believe are harmful.  The political constraints facing policymakers are often ignored or treated as a second-order consideration. 

The controversy over first-doses-first shows how costly this technocratic orientation can be.  Vaccine-stretching policies were always going to be a difficult political lift in the United States because of political polarization and the fact that the vaccine supply was expected to increase relatively rapidly.  It is quite possible that none of the ideas suggested above would have moved the needle on policy.  But public opinion and political risks matter in a democracy, especially in a democracy that is as polarized as ours, and economists ignore politics at their peril.