Every American state has laws requiring vaccination. If you want your children to attend kindergarten, you must vaccinate them against rubella. Most parents comply because they don’t want anyone going deaf from congenital rubella. And if that isn’t convincing enough, then there is the ominous threat of having to homeschool.
But these laws have holes, and more people are going through them. In the past decade, the number of people seeking “philosophical exemptions”—meaning they don’t need to comply with the law, because, effectively, they disagree with it—has steadily increased. At least partly as a result, measles outbreaks are now verging on common in places where the disease was once totally eradicated. At the same time, more stringent laws may increase skepticism of vaccines, as people conflate concerns about vaccination with objections to being made to do … anything at all.
Americans clearly object to sticks, even during this pandemic: States including Montana, Arkansas, and South Carolina have already banned COVID-19 vaccination requirements, before they could even be proposed. But carrots? Carrots we like. Instead of threatening punishment or withholding access to basic services such as education, some places are starting to offer incentives, largely in the form of free stuff. Get a shot and you can chase it with doughnuts, beer, baseball tickets, or all three. Earlier this month, Ohio Governor Mike DeWine upped the ante with a bombastic plan to enter vaccinated people in a $1 million lottery. It seems to have resulted in a surge in vaccination, and this week both New York and Maryland announced similar lottery prizes.
These are just some of the not-so-creative-but-possibly-very-important approaches that states should take seriously. More than half of American adults have gotten at least one shot, but they were likely the most eager and, perhaps, most at-risk. Vaccinating the second half will be equally important but much more challenging.
There will be places, such as schools and hospitals, where vaccine requirements are simply necessary. Some companies will deem requirements for employees vital to their business. But the solution that’s most likely to trigger minimal backlash is the same one that got almost everyone—even the most die-hard, rugged individualists—to carry a tracking device in their pocket. Ultimately, the free market, lauded by so many who object to vaccine requirements, may persuade holdouts to get a shot. Science has taken us very far, but from here on out, ending the pandemic will be up to what America does best: marketing.
If behavioral economics is to be believed, people can be prompted to do things by way of small reminders known as “nudges.” These are meant to be gentler and more palatable than rules or requirements. There’s something darkly paternalistic about the term nudge, which makes me feel like I’m being manipulated into walking off a cliff. But in the classic example, nudges do things like get people to register as organ donors, by making organ donation the default. In marketing, similar approaches are used to drive sales. For example, restaurants may include certain menu items that are deliberately overpriced in order to nudge people toward an option that’s meant to seem reasonably priced in comparison.
Marketing excels at creating the illusion of autonomy for the purpose of taking people’s money. But in cases of public health, nudges can feel condescending or confusing: They imply that people are stupid, and so they need to be nudged to do basic things that keep them alive. The beep that reminds you to buckle your seatbelt is helpful, but also makes me want to smack the car. The enormous label on cigarettes that says you might die if you smoke them raises questions about whether public-health officials think we don’t already know that.
But even if they become annoying or eerie, nudges can feel justified when they’re used to help us sidestep distractions or misinformation. They can help people decide to do vital, prosocial acts—such as getting vaccinated to help end a pandemic that has brought life to a standstill and killed millions of people—that they wouldn’t have otherwise done. Everyone needs nudges sometimes, and no one more so than doctors themselves. A medical-record system that prompts doctors to ask every patient if they’ve gotten a vaccine—and, if they haven’t, to whip one out and offer it on the spot—can eliminate simple oversights. This sort of prompt pairs well with easy, ubiquitous access to vaccines. People could be offered a vaccine every time they walk into a pharmacy, or in places where they have time to kill, such as an airport. The goal would be to reach everyone who’s ambivalent or feels they’re too busy to get one, by making vaccination so convenient that they don’t have to go out of their way at all to get vaccinated. Instead, they’d essentially have to go out of their way not to.
The nudges can even responsibly veer into the domain of small incentives. The best ones will probably involve decisions people are already familiar with making, such as deeming a lottery ticket worthwhile. The more diverse and quotidian the incentives, the greater the odds of meeting people where they are, and avoiding the divisiveness and politicization inherent in laws and requirements.
If people object to this, then they have a lot to object to in American life. We lovers of freedom may protest being made to do many, many things. But we excel at consumerism, and seem to relish the belief that we are behaving autonomously. When we decide that the jeans everyone is wearing these days would also happen to look good on us, we buy them not because we feel we’ve been manipulated into doing so, but because we actually believe they’ll make us happier. The grand illusion is not new or foreign; it is our default state.
The idea that vaccine hesitancy is entirely a result of lacking empathy or intelligence is dismissive and unproductive. The decisions we make in life are a result of weighing incentives for and against everything, usually shaped by emotion and personal experience. Whether these decisions are conscious or not, someone almost always has a finger on the scale. Did you really choose to eat at McDonald’s? Or did you do it because of some ads you saw as a kid, which led you to try and subsequently love McNuggets, and so now you choose to get some McNuggets?
The marketplace of information that’s driving people’s decisions about vaccination is already immensely cluttered with bad takes and gut instincts. Sometimes the best anyone can do is help nudge people toward a clearer view.