With the vaccines for Covid-19 soon to be made available and in light of the high rates of Israelis who do not want to be the first to get the vaccine - IDI expert Prof. Yuval Feldman explains how to encourage public cooperations in getting COVID-19 vaccines.
1. Prime Minister Netanyahu has announced that he will be first to be vaccinated. In order to achieve maximum public cooperation with a mass vaccination program, who should be first in line for vaccinations, and why should doctors and scientists—rather than politicians—be the ones to provide a personal example by being vaccinated? Who should be vaccinated next after doctors and scientists?
Most of people’s worries about being vaccinated have to do with the fear of the unknown, and thus the people most suited to alleviate these concerns are the experts in biology and medical science. Assuring public trust in science is critical for dispersing fears, and thus is definitely the correct first step. Because there is little public trust in decision-makers and in key state institutions in Israel—the Knesset, the government, and the political parties—it is best for respected professionals who are independent of the government to be the ones explaining the benefits of vaccination to the public.
Alongside doctors and scientists, it is also important to identify opinion leaders, who have influence on different population groups and whose opinion and behavior carry special weight with those groups. These include religious leaders, celebrities, social activists, and various opinion-leaders. The pandemic has brought into even greater focus the community component of Israeli society, and thus it is important to reach out to the right people and try to persuade them to participate in the vaccination program in the earliest stages.
How significant is it that the prime minister is vaccinated first, and what advantages does this hold?
From a rational viewpoint, the fact that politicians (including the prime minister) are among those vaccinated is not a source of reassurance, in that the potential benefit to politicians from the vaccine in terms of public approval are far greater than the benefit to private individuals who are not dependent on public approval. Thus, the fact of Netanyahu being vaccinated is not in itself reassuring. However, there is certainly significant emotional value in leaders offering a personal example, and the ethos of “leading from the front” is particularly strongly embedded in many segments of the Israeli public. Perhaps in order to foster a sense of solidarity and mutual responsibility, it might be worth having all 120 members of Knesset receive the vaccine at the same time. This would serve as an impressive and unifying act of leadership, and would separate the vaccination program from the political squabbles that have accompanied it (almost inevitably, given the current political situation in Israel).
2. Do you anticipate that the vaccination program will foster complacency in the general public, leading to more infections and hospitalizations (at least until all the population are vaccinated)?
Some have put forward this argument, in the same way that wearing a seatbelt makes some people drive faster, or wearing sunscreen can encourage people to spend longer in the sun. However, it is too early to conclude that the same will be true in the case of vaccinations. We should not forget that in the early stages of the pandemic, many experts argued against widespread public wearing of masks on the grounds that it might encourage complacency and a lack of attention to maintaining social distancing, but I think we all now understand that those fears were misplaced.
3. What steps should be taken in order to get the public onboard? What should the Ministry of Health’s campaign look like? (And should the Ministry be in charge of the vaccination campaign, given that the public has not shown a great deal of trust in it?)
Getting vaccinated should be made as easy as possible. Thus, people should receive notification by phone or by mail, ideally with a calendar invitation, of the time and place they are due to receive the vaccination without having to wait in line. In addition, people should receive reminders about their vaccination appointment, as well as a clear message about the economic and social cost that will be caused if they fail to turn up and are not vaccinated.
The largest problem is that many people will prefer not to decide whether to be vaccinated, and will delay their appointment under the assumption that putting off their decision is not really a decision. Therefore, it is important to make it clear to the public that giving up their vaccination appointment might leave them in limbo, without a clear time for another appointment. While it is correct to give the clear message that there are enough vaccines for everyone, it is also true that a sense of limited supply can drive people to hurry to get vaccinated as early as possible, as has been the case with the flu vaccine. Similarly, while it might be medically true to state that it is sufficient for around half the public to be vaccinated in order to achieve herd immunity, such messages are problematic from a behavioral viewpoint because they significantly weaken the individual commitment of each citizen to be vaccinated.
In addition, studies carried out by the IDF Home Front Command have shown that people are more afraid of infecting others than being infected themselves, and the studies being conducted by my colleagues and myself in Israel and in the United States have demonstrated the importance of a sense of solidarity and moral commitment in obeying coronavirus social distancing laws. I believe that this approach can also be used with vaccines. That is, we should directly address the younger generation and persuade them that by getting vaccinated they can dramatically increase the likelihood that they will not infect their relatives who are in high-risk groups, rather than trying to persuade them that they should do so for their own benefit.
4. What incentives should be offered, and why might a “green passport” and conditional entry to malls and tourist sites work, while financial rewards might actually reduce the motivation to get vaccinated and undermine the sense of social solidarity?
Incentives are very important, not only so that people get vaccinated but so that they are eager to be vaccinated early, and do not put off the decision. In general, the public is disapproving of any “commercialization of values” (such as selling organs for transplants), and thus when designing incentives it is important to give consideration to this issue, to avoid causing public dissatisfaction.
Thus, if people are concerned for their health, the solution is not financial reward but scientific information campaigns and publicizing data. On the other hand, it is certainly an option to offer benefits to those who do get the vaccine, such as entry into green zones, access to flights, or immunity from self-isolation.
The incentive here derives from having taken action such that one no longer presents a health risk to others, and thus it does not involve commercialization. Two of my colleagues, Ido Erev and Ori Plonsky from the Technion, who have served with me on several coronavirus planning teams, have shown for example that when it comes to encouraging people to download track and trace applications, saving them time and inconvenience can be a significant incentive (for example, by excusing them from pre-registration, standing in line, or having their temperature taken for various events and facilities). In a similar fashion, I believe that it would be enough to offer the opportunity to be excused from undergoing testing or from entering isolation when returning from abroad in order for many people to want to be vaccinated. Of course, there are cryptographic challenges involved in ensuring that anyone vaccinated can prove that they have indeed had the vaccine, but solutions to these challenges already exist.
5. Why are you recommending giving stickers to everyone who gets the vaccine? Can this really accelerate mass vaccination and create social trends?
This recommendation is based on studies such as those conducted by Katherine Milkman from the University of Pennsylvania, according to which stickers can serve as a form of social signaling that can create strong encouragement for people to be vaccinated, in order to align themselves with a social norm. I believe that if, for example, people widely displayed car stickers such as “Because I got vaccinated, business owners can make a living”; “Because I got vaccinated, children can go to school”; “Because I got vaccinated, children can visit their grandparents”; or “Because I got vaccinated, theaters and concert halls (or synagogues for religious communities) can reopen,” then slowly people who do not get the vaccine and do not have one of these stickers will feel more and more uncomfortable. Similarly, intelligent use can be made of social media, which can transmit even more quickly a sense of social advantage for those who are vaccinated, and conversely, imply a social cost for those who are not.
6. Why should vaccination not be mandatory, or sanctions imposed on anyone refusing to be vaccinated, and why might such steps amplify the crisis of trust in the political leadership? At the end of the day, vaccinations are for the public good, to protect public health.
While a study in Germany, for example, found that cities in which mask wearing was made mandatory experienced a sharp decline in infection rates, the same will not be true for vaccinations because there are real health concerns involved, and thus making them mandatory may well invoke such a strong counter-reaction that the entire program could be put at risk.
There is no danger involved in wearing a mask, and thus requiring it by law can be justified as a public good. However, fears of a possible health risk are not something that can be overcome using sanctions. Moreover, it is not at all clear that this approach is necessary. In my opinion, correct use of public information campaigns, incentives, and complementary behavioral tools will be enough to ensure that the majority of the public are vaccinated, without the need for mandatory enforcement. In any case, mandatory enforcement would likely be challenged in the courts, leading to significant delays and fostering rhetoric that would only benefit anti-vaxxer groups.
7. You argue that the state should bear the cost of sick days for people suffering from side-effects of the vaccine. Will this persuade the public to get vaccinated? It seems that the public is mainly concerned at the prospect of new and worrying side-effects that have not appeared yet. In that case, how can we help the public overcome its fears?
Clearly, paying for sick days will not allay public fears; this can only be addressed by public information campaigns and publicizing data. But covering the cost of sick days is part of an overall reward-based approach, just like compensation for IDF reserve duty service. That is, the approach that the state must publicly adopt is that you should get vaccinated because it’s the right thing for you, for your family, and for your community. If, as a result of you doing the right thing for these reasons, you end up suffering economic harm, then the state should take responsibility and compensate you for any side-effects you experience. This is a very different concept from being paid to be vaccinated; rather, it is a promise of compensation for any harm that may be caused to you.
8. How might coronavirus vaccines influence the Israeli public’s future attitudes toward vaccination? Will we see more people getting vaccinated against flu and against other illnesses for which vaccinations are not currently mandatory?
There is no doubt that there is more suspicion toward the coronavirus vaccine than toward vaccines that have been in use for decades, as we simply do not have long-term data regarding side-effects.
Consequently, I am not convinced that the state should use the coronavirus vaccine as a test case for its policies regarding vaccinations that have a far richer history. At the same time, I hope that all the technologies developed concerning the logistics of the vaccination program, and the behavioral approaches that are gaining more prominence during the pandemic, will also be used in future vaccination policy. I also hope that the state learns important lessons about the potential of voluntary public collaboration and about the limits of power.
9. Are there already examples of countries that have created promising plans for a national vaccination program?
There is a constant stream of reports and ideas being published. It is difficult at this stage to determine what will succeed and what will fail, because nothing has been tried yet.
10. Can you provide historical examples (positive or negative) of cases of other large-scale programs in which positive public attitudes and public cooperation had to be secured? What steps were taken, and what can we learn from them that is relevant to our current situation?
While we have mandatory military conscription in Israel, in practice, the central element of choosing combat service, and certainly with regards to reserve duty, is voluntary. Thus, the state has considerable experience in gaining public cooperation.
Projects such as “Salute” (an initiative providing benefits for soldiers who complete their mandatory service and for active reservists) are based on ideas from behavioral economics, and they also involve attempts to think about the social component of incentives, in order to prevent any erosion of values.
In the environmental protection realm, there are also many examples of attempts to secure public cooperation via information campaigns and setting social norms. The clichéd example is that of the campaigns to protect wildflowers in Israel, but we can also point to public cleanliness campaigns or campaigns against smoking in enclosed public spaces, in which the public has displayed a large degree of voluntary cooperation. Of course, success is not always a given: When it comes to recycling, for example, it is clear that voluntary public cooperation is not enough, and additional methods are also being pursued.
The article was published in the Times of Israel.