Earlier this month, I wrote an Insight post, followed by a New York Times editorial with immunologist and epidemiologist (and medical doctor) Michael Mina of Harvard, advocating for an immediate trial exploring single dose (or delayed booster) for the Moderna and the Pfizer BioNTech vaccines (both mRNA vaccines). There is a lot more to say about the idea—the United Kingdom just approved two vaccines and announced that it will prioritize getting the initial single dose to people, and will follow up with a booster later. But whatever one thinks of the idea of the trial, one objection has been whether this should have been part of a quiet advocacy campaign rather than in a major newspaper. Perhaps, the argument goes, it could have been a letter in a medical journal like the Journal of the American Medical Association or the New England Journal of Medicine. Public advocacy itself might cause people to skip the second booster, according to our critics. I disagree with that for a variety of reasons (and I had considered that, since thinking about the public sphere is a big part of what I do) but it is a real consideration, one that should be taken seriously. With that in mind, here’s a new Counter on that, by Matthew Noah Smith—an associate professor of philosophy at Northeastern University who specializes in moral and political philosophy. I’m going to stop here and publish his substantive objections below! I’ll follow up soon with a response to this one. I’ll also respond to the Counter published yesterday by Dr. Robinson on age-prioritization and will check-in with the debate over Trump’s attempt to steal the election! 

Of course, the back-and-forth exchanges in this newsletter do not have to be black and white disagreements, but I promise not to seek some middle-ground for the sake of agreement. I’ll fully flesh out the debate and my thoughts on it. I look forward to hearing your views as well! See you in the comments. -z

Against Publicly Advocating for a Single-Dose Vaccine Trial

A Counter by Matthew Noah Smith

Northeastern University, matthew.smith@northeastern.edu

In a recent NY Times editorial, Michael Mina and Zeynep Tufekci advocated for a trial of using a single dose of the Covid-19 vaccine instead of two doses, followed up with a press conference by Michael Mina. I assume that there ought to be such a trial. But, should well-known authorities on Covid-19 like Mina and Tufekci advocate publicly for this research? They shouldn't. It is the wrong time to elevate the question of whether a single dose of either the Moderna or Pfizer vaccines would be sufficient.

If a trial is warranted, then we ought to have some confidence that a single dose of either vaccine would be effective. But we also should have sufficiently low confidence that a single dose would be effective. This is exactly why a trial is necessary. It is important to keep these confidence levels in mind when assessing whether to publicly advocate for a single-dose trial. For all we know, it may turn out that a single dose is not sufficient.

The question we face, then, is how to get a trial up and running? One route is to publish opinion pieces in the national paper of record and to hold a press conference at Harvard University to publicize the idea. This spurs the mass media to popularize the proposal and gives the proposal the imprimatur of our nation's most prestigious university.

This approach seems both efficient and innocuous. After all, the idea of using one dose instead of two is already out there, isn't it? Yes and no. Ideas do not exist on their own, in some sort of Platonic realm, waiting for individuals to see them by the light of pure reason. All propositions are asserted in a conversational context. That context determines both the semantic content of the utterance and its practical effect.

For example, suppose we are standing on top of the Empire State Building and I gasp to someone: "They jumped." The literal meaning of this utterance is obvious: Someone has jumped. But the context adds semantic content so that it makes sense to interpret the claim "they jumped" as, "Someone jumped off the edge of the building." If it turns out that I am reporting that my friend Don merely jumped up and down once, you would rightly complain that I've misled you into believing that someone had jumped off the building.

With all this in mind, then, should we assess a substantial public intervention arguing for a single-dose vaccine trial? After all, everyone agrees that these vaccines are our only way out of the greatest public health disaster (unrelated to war), of the past century.

Structural Injustice

While the development of the mRNA vaccines currently being distributed in the US is a remarkable scientific achievement, the far rather more difficult challenge we face is the successful distribution of hundreds of millions of doses of these vaccines. The logistical hurdles - the problem of the 'last mile' - are massive. The vaccines must be kept cold. They must be delivered to the right place, received, and then transferred to the correct end-point distribution facilities. There needs to be sufficient numbers of trained staff to administer the vaccine. Individuals need to know when and where to go to get vaccinated. Which vaccine they receive needs to be tracked so that they can get the correct booster at the correct time.

Just as importantly, everyone who is receiving the vaccine must buy in to this entire project in a way that meshes with the complex distribution system. If people do not show up to get their vaccine, then what? Do we need to find them to vaccinate them? Eradicating smallpox in India required teams effectively chasing down the virus, using innovative public health tools to eventually eradicate the disease on the subcontinent. Will we need similar tools here?

It would be wonderful if only a single dose of the Covid-19 vaccine were needed. But we cannot be sure yet. Many experts believe that two doses will be required. So, in the absence of a successful single-dose trial, we should at least not create conditions where a two-dose regimen would become difficult to implement. And yet publicly advocating for a trial into a single-dose regimen is likely to do that.

Many of the people who have suffered the most from Covid-19 are people of color and poor people. These populations often lack regular doctors, and instead rely upon urgent care centers and the emergency room. This population also is the most likely to have stable housing upended by pandemic-related loss of income. They may therefore be unusually transient in the coming months. This will further destabilize any regular relationship with the health care system. In short, a huge proportion of those most vulnerable to Covid-19 also have the most precarious relationship with the health care system.

Overcoming the precariousness of this relationship for the sake of non-emergency medical care requires a focus and sacrifice unfamiliar to people who have good, stable insurance plans through their employers. The introduction of doubts about the need for a second vaccine provides the basis for delaying getting that second shot.

Most people who skip essential medical care do not do so because they are irresponsible. They do not skip such care because they do not value their lives. Rather, people skip essential medical care because in the United States getting medical care is difficult. It can be expensive. It can require filling out pages worth of forms online when all you have is an old cell phone and no wifi. The appointments can be at inconvenient times, and your boss may not give you paid time off (or any time off without further penalty). For some, it can be a deeply unpleasant experience because doctors, nurses, and pharmacists are just as likely to be racist as the next person. What is the rational response to hearing that elite professors argue for a single-dose vaccine trial? It would be excusable for someone to infer from this that they could skip or delay getting the second shot.

In general, we do not bear sole responsibility for the inferences we make on the basis of a short conversation. The speakers also bear some responsibility for the inferences their audiences make. After all, that I said "They jumped!" instead of "They jumped to their death!" does not relieve me of blame for my audience interpreting what I said as a report that someone jumped off the building. I was (at the very least) negligent in how I spoke.

Those who speak publicly about how the vaccine ought to be rolled out bear significant responsibility for how their comments will be interpreted. Even though the public message is that we should trial a single-dose vaccine, it is reasonable for someone unfamiliar with how medical research works to infer from a news story about the proposal that a single dose would be sufficient for vaccination. Furthermore, it is reasonable for someone who sees a story on TV about a study of single test efficacy to then describe it to acquaintances as a story about how only one dose of the vaccine is needed. After all, isn't it rational for these non-experts to infer from respected professors aggressively advocating in public for a single-dose trial that a single dose would be sufficient? Why else would they be so vocal and so insistent on the urgency of a trial?

The history of the health care establishment failing to speak truthfully to disadvantaged communities has produced mass distrust towards the health care establishment. Word of mouth within those communities is typicallyseen as a reliable source of information about health care. It is a kind of epistemic oppression to require that members of these same communities distrust the testimony of their peers around medical questions. Hearing from a trusted community member that a single dose of the vaccine is sufficient is, at least, often a reasonable basis for planning one's medical care.

It is therefore essential to show that advocating for a single-dose trial would not help generate a widespread, popular view that a single dose of the vaccine is sufficient. Importantly, merely repeating that one is advocating for a trial – and not defending the sufficiency of a single dose – is not enough to prevent the public from inferring that only a single dose is required. Experts cannot police the inferences non-experts make. This level of control requires shaping both historical and existing political and cultural contexts, which is impossible.

Weaponization

We are all familiar today with the way that many on the Right weaponize both the narrow constitutional right to free speech and the broader Millian, liberal defense of freedom of speech. They use appeals to the right to free speech and to the value of free expression as tools to beat back a variety of speech codes that prohibit, for example, outright hate speech, and to protect the right of wealthy individuals and corporations to spend money freely on political campaigns.

In the same vein conservatives in the US have weaponized normal scientific uncertainty to sow doubts about the reliability of local, regional, and national public health leaders. Whether GOP politicians' concerns about the pandemic response policies are sincere or cynically deployed for political gain, many individuals have uncritically accepted those objections as accurate.

The most familiar instance of this is controversy around masks. While it is true that Dr. Fauci and others botched the initial guidance around masks, they eventually settled on a fairly clear message. The proposition that Dr. Fauci and other public health officials erred was subsequently weaponized by conservatives. In particular, it has been and continues to be used as a tool to sow doubt about the motives of these officials. It has fed into both a nihilistic selfishness and paranoid visions of state repression. Subsequently, some of these people threatened public health officials and politicians who advocated for a range of pandemic control measures.

There are obvious ways in which reasonable scientific disagreement can be repackaged as incompetence or even malevolence. Could the proposal to trial a single-dose vaccine be weaponized by conservatives to sow doubt about whether public health officials can be trusted?

The dynamic progression in scientific understanding involves backwards and forwards movements in confidence in hypotheses, often with experts disagreeing with one another about how to interpret the evidence, or even about what counts as evidence. For example, the well-known virologist Vincent Raccaniello disagrees with epidemiologists that epidemiological data is high quality evidence for the novel phenotypic traits in the worrisome SARS-CoV-2 variant being tracked in the UK.

Such disagreement is not an indication of epistemological breakdown. Rather, it is a sign of a robust process of inquiry. But this same disagreement can be weaponized to sow doubt about scientists' reliability. We see this in the discourse around climate change as well as in public campaigns against vaccination. Both of these matters are of existential concern. In the first case, it is an increasingly less abstract question of species-level extinction. In the second, it is a question about the health of one's children. The intensity of emotions around these issues does not make trivial, often ersatz, scientific disagreement less likely to be perverted into a tool to discredit even the most widely accepted views.

It may seem shockingly irresponsible for conservatives to sow doubt about experts' recommendations regarding a two-dose vaccine course. But, such irresponsibility is now habitual. We should expect grandstanding efforts to spread the anti-expertise gospel. Any public scientific communications suggesting a vehement challenge to expert recommendations around the vaccine will probably be weaponized by many conservatives as evidence that vaccine experts cannot be trusted. At the very least, responsible communicators should plan for that.

What will happen if rhetoric supporting a single-dose trial is weaponized? It is difficult to determine. We have some evidence from both this pandemic and the anti-vax movement that non-trivial portions of the population might, on the basis of the weaponization of public advocacy for a single-dose trial, reject public health guidelines around vaccination. The best-case scenario is that they would get only one shot. The worst-case scenario would be members of the public trying to disrupt vaccine distribution, either via the production and amplification of anti-vax propaganda or, worse, threatening or restricting those who are distributing the vaccine.

While it is impossible to prevent cynical politicians from weaponizing science for short-term gain, simple precautions should be taken. One tactic is to avoid turning a scientific disagreement into acrimonious public disagreement. It is more difficult to weaponize technical language used in academic journals and grant applications than it is to weaponize exasperated charges of epistemic irresponsibility made in places like Twitter. For this reason alone, we should restrict calls for single-dose trials to venues where experts engage other experts.

The Cruelty is the Point

Bad actors with power have regularly harmed marginalized communities in the name of science. This same pattern of oppression could be reproduced when it comes to vaccine distribution. This should be distinguished from existing structural threats to equitable distribution covered in #1 above. In those cases, systemic forces are work. In this case, the inequity is intentionally produced by individual policy makers. The rhetoric around a single-dose trial could be twisted by people as a pretext for denying second doses the marginalized.

Both the current official protocol and popular culture representation of vaccine distribution is centered entirely on health care workers. Given the tremendous failures of vaccine distribution, where vaccines were often just dropped off at hospitals with no further support given to states in financing and planning mass distribution, it would be simple for a governor to announce that, for the time being, people who are not connected with hospitals will get only one dose, while health care workers receive two doses.

This plays into the pernicious pandemic wartime imaginary we've all been invited to take up. Doctors and nurses are "heroes" who have been at the "front lines," and hospitals are "war zones." Once we couple this with the firm conviction among conservatives that the police are a beleaguered identity group, an easy strategic choice in response to vaccine distribution woes will be to deny poor communities and communities of color both doses of the vaccine until all those "battling" the virus receive two doses. All they need is quasi-scientific cover for unequal spatial distribution of a two-dose vaccine distribution.

This is not the same as weaponization, where a proposition is cynically used to undercut the epistemic bona fides of an opposing point of view. Rather, this is a straightforward case of racist policies being pretextually justified on the basis of the intentionally false representation of a scientific proposal. There is a grim history of this sort of behavior, and there is no reason to suppose that it will not happen when it comes to vaccine.

Racist elected officials cannot do this on their own, though. The federal government's failure to develop and implement a robust logistics of vaccine distribution that is responsive to the country's geographic and demographic diversity contributed to the problem. This is less a question of the federal failure to produce ethical guidelines than it is the federal government's failure to help states produce answers to a nested set of questions around transportation, urban planning, housing, health care delivery, and so on. This creates a policy vacuum that governors and other officials must fill with discretionary judgments. If these judgments are made by racist governors and their lackeys, then we can expect racist policies.

It is therefore essential for responsible public health discourse around vaccine distribution to stand as a bulwark to these sorts of bad actors. At its best, it can aim to offer proposals against which governors' discretionary judgments can be measured. Ideally, public health officials would be able to supply policies that detail, at a granular level, how vaccines ought to be distributed in each state. This admittedly impossible result would go some distance towards blocking the sacrifice of the marginalized for our "troops" at the "front lines." At least, then, all parties should prioritize boosting the message that equitable distribution of the vaccine is essential.

While the justification for a single-dose trial is that the most vulnerable communities can potentially be vaccinated more quickly, advocating for such a trial typically has not explicitly centered itself on an analysis of either systemic racism or the overt racism of political leaders. At least on Twitter, where journalists often formulate understandings of a variety of policy questions, it often ends up decanted into intricate contestations around questions in vaccinology and immunology. That is, after all, the discourse single trial advocates like Mina use professionally. But, the ascent into scientific disputation is the cover that bad actors need in order to use the single-dose trial proposal as pretext for denying two doses to marginalized communities.

Public advocacy for a single-dose trial would be justified, then, if we could be assured that advocacy would be unlikely to be deployed as a cover for denying two doses to marginalized communities. After all, it could be the case that two doses are required. It would be an ironic and horrible injustice if this argument in favor of a policy that could speed vaccination ended up being used as a justification for refusing a second dose of the vaccine to members of the communities that have suffered the most during this pandemic.

I cautiously endorse the view that a single-dose vaccine trial is essential. While there may be ethical and other reasons not to have a trial, I am convinced by both Tufekci and Mina that the balance of reasons supports a trial. But, I think the public advocacy of a trial is reckless. Instead, communities of scholars and policy makers who support a single-dose trial should seek to meet privately with Moderna and Pfizer officials and with members of the incoming Biden administration to plan a trial.

Funding will have to be secured no matter how public the advocacy is. There is no obvious reason public advocacy is more likely to produce funding than private advocacy. For the reasons outlined above, private advocacy for funding should be the default approach until it fails.

Moderna, in particular, is a target for a private pressure campaign, as it is located in Cambridge, MA, with deep ties to the academic community that is home to the fiercest advocate for a single-dose trial. Why not start there in a precautionary effort to do no harm before risking a public campaign for a single-dose trial?