Vaccines and the Tightrope of Progress

The 99% Good Principle and the Problem with Moderate Vax Skepticism

The increasing strength of the anti-vaccine movement has really bothered me. I think it’s good to flesh out a little bit why that is, and why I think it’s still worth talking about not just covid vaccines themselves, but the metadebates surrounding the issue.

In my experience, discussions are difficult to have because there are three strands of vax skepticism. They all feed off of one another, and people will often switch from one position to another even in the midst of a single conversation. The first strand is associated with pure deniers, or those who think that covid vaccines have either been dangerous or ineffective. The second strand focuses on some narrow cost-benefit question, like say whether it makes sense to give mRNA vaccines to young boys, or kids more generally. Finally, there are the anti-mandate people.

Dealing with the pure deniers is simple: they don’t know how to use data, and make arguments that are just wrong. Getting any vaccine was clearly a good idea for almost any adult, even if they weren’t at a high risk of dying from covid. It’s a little more complicated to explain what’s wrong with the other two strands of vax skepticism. Even if they are occasionally correct on a small narrow set of empirical and moral arguments, their overall contribution to culture and public policy is overwhelmingly negative. This is because the two other strands of vax skepticism require the arguments of the pure deniers to motivate people and have a political impact. In making this point later, I’ll introduce what I call the 99% Good Principle.

Given that covid is now something most people want to forget, why relitigate these issues? Well, the coronavirus pandemic reminded us that society often faces novel and difficult challenges. Making things better requires something like walking a tightrope. The public health community came out and basically said people should hide their faces and stay in their houses forever. Others argued that the entire virus was fake and nothing could be done. You therefore had the nanny state hysterics, representative of the modern left, and the small-minded ignorance of the right. Now, I generally think modern states are too biased towards counterproductive action, so most of the time I prefer the live and let live attitude of the right, even if it means denying the existence of real problems. But over time, conservatives became so anti-vaccine that they started to take up causes like trying to stop health care facilities from requiring vaccinations for employees, an insane position, and now DeSantis criticizes Trump for actually pushing ahead with Operation Warp Speed (OWS) in the first place.

Yglesias has already discussed the policy implications of the conservative anti-vaxx position. Basically, what intelligent conservatives have been saying about the FDA was proved correct during Operation Warp Speed. Even smarter liberals, at least those of an Enlightened Centrist orientation, recognize this now (and here’s Ezra Klein on DeSantis being completely right on lockdowns and prioritizing vaccines). Instead of seizing on that victory and building momentum for bipartisan reform, which Democrats seem open to, it’s now become much more difficult to do anything similar in the future.

The tightrope of progress means that in the world of public policy there are so many ways things can go wrong, and usually only a very narrow path to the desired location. You must avoid the kind of risk-aversion and safetyism elites seem prone to, and also being swamped by populist stupidity, with its distrust of anything new or different. It’s a miracle anything good gets done, and when it does, we have to be unequivocal in defending legitimate policy accomplishments.

What has really annoyed me about the public health community is that they sort of miss the whole point of public health. It’s not just to save as many lives as possible regardless of costs, otherwise nobody would ever go outside. It’s figuring out the rare targeted interventions that can make a large enough difference to be worth it. Economists seemed to understand this much better than epidemiologists.

Learning the real lessons of Operation Warp Speed and its aftermath will help us not only get vaccine policy right going forward, but provide insight into how we spur medical and other types of innovation, in part by opposing the kinds of movements and arguments that are used to try and stop it.

Pure Deniers Are Simply Wrong

I remember having a friend who in 2021 was at an event with other right-wingers, mostly lawyers and intellectuals in their 30s and 40s. Some of the attendees came down with covid and ended up coughing their lungs out for weeks afterwards. My friend was an exception, because he had gotten vaccinated, likely under my influence, as were a vaccinated girlfriend and a vaccinated wife of two of those who got sick. We ended up laughing at all the other idiots at the event and their toxic masculinity. I’ve known people who’ve had bad reactions to the covid vaccines, but it’s never been more than a day or two of feeling under the weather. I’m telling this story in part to demonstrate how silly and fundamentally unserious highly educated conservatives have been on the issue, thanks to their adoption of an oppositional culture. Whenever I’m around them, they’re shocked at how pro-vaccine I am, as the median position seems to be that you’re crazy to get one unless you’re old and fat. Of course, my anecdotes don’t prove anything, and we still need to look at data. So let’s see what it says.

It’s true that covid has always hit the elderly much worse than the young. But the idea that it didn’t affect the young is wrong. According to one study, for the period between August 2021 and July 2022, covid was the seventh leading cause of death for infants and those 1-4, sixth for 5-9 year olds and those 10-14, and fifth for 15-19 year olds. See also here. Now, to be fair, being the 5th to 10th leading cause of death among young people doesn’t mean something is that big of a killer, because young people thankfully rarely die in our society. At the same time, keep in mind that death is only the worst outcome. Any virus that is bad enough to kill some people is going to likely make many others undergo a great deal of pain and suffering, as my un-vaxxed acquaintances learned in 2021. While some vax skeptics think it’s important to differentiate between “died of” covid and “died with” covid, it must be noted that data on excess deaths shows that if anything we’ve been undercounting, not overcounting, how bad the disease has been.

For young people, and society as a whole really, covid was never a big enough problem to shut down schools or make people wear masks all day. The Great Barrington Declaration was basically correct in its argument in favor of focusing on protecting the particularly vulnerable. But, even for the young, covid was a big enough problem that it was worth it to get two shots that could reduce the risk of a serious outcome down to practically zero.

That is, unless you think that the vaccines are worse than covid. Nothing has emerged to suggest this is the case.

Efficacy is easier to show than demonstrating safety, because the latter involves proving a negative. Let’s start with how we know that covid vaccines reduced the risk of hospitalization and death. The gold standard in social science and medicine for establishing causation is the randomized control trial (RCT). From the abstract of one meta-analysis:

28 RCTs (n=286,915 in vaccination groups and n=233,236 in placebo groups; median follow-up 1–6 months after last vaccination) across 32 publications were included in this review. The combined efficacy of full vaccination was 44.5% (95% CI 27.8–57.4) for preventing asymptomatic infections, 76.5% (69.8–81.7) for preventing symptomatic infections, 95.4% (95% credible interval 88·0–98·7) for preventing hospitalisation, 90.8% (85.5–95.1) for preventing severe infection, and 85.8% (68.7–94.6) for preventing death. There was heterogeneity in the efficacy of SARS-CoV-2 vaccines against asymptomatic and symptomatic infections but insufficient evidence to suggest whether the efficacy could differ according to the type of vaccine, age of the vaccinated individual, and between-dose interval (p>0.05 for all). Vaccine efficacy against symptomatic infection waned over time after full vaccination, with an average decrease of 13.6% (95% CI 5.5–22.3; p=0.0007) per month but can be enhanced by a booster. We found a significant non-linear relationship between each type of antibody and efficacy against symptomatic and severe infections (p<0.0001 for all), but there remained considerable heterogeneity in the efficacy, which cannot be explained by antibody concentrations. The risk of bias was low in most studies.

Here are the results for symptomatic infections across 28 RCTs.

I’ve seen anti-vaxxers on twitter say that RCT studies often haven’t shown any significant results for likelihood of death. From the same metanalysis, here is the relevant data.

As you can see, many studies have either 0 deaths in both the control and vaccination groups, or just 1-3 deaths in the control group. Based on the chart above alone, the evidence of covid vaccines preventing death seems pretty weak. But, and I can’t stress this enough, this is an extremely stupid way to analyze data. Death is not some separate outcome that is unrelated to injury. Imagine you had data showing that wearing a seatbelt reduces the odds of going to the hospital after an accident by 90% or so, but we had no data on deaths, because passing away in a car accident is such a rare outcome. Would you say that the jury is still out on whether seatbelts are likely to save lives? You’d only put forth such an argument if you were already determined to make the case against seatbelts.

It is true that efficacy wanes over time. The answer to this seems to be boosters, which also work. Now that everyone has either had covid, gotten a vaccine, or both, the disease is much less of a threat. We’re at about 50 covid deaths a day, down from 500 in the winter. I’m guessing future winters will look more like January than July, which means the disease will probably kill at least tens of thousands of Americans a year for the foreseeable future. Most of those will of course be old, which means that the number of life-years lost won’t be that high. Boosters should continually be used for high-risk groups and probably most adults, although the larger point for our purposes is that what was really important was getting people vaccinated at the start so that their first encounter with the disease wasn’t an infection.

I personally got two vaccines initially and then two boosters. My last one was a year or two ago now, and I haven’t kept up simply because my risk is low anyway, and I just place a high value on my time. But it would probably be good for me and the rest of society if I did get another booster. It’s the healthy and pro-social thing to do.

What about safety? There are all kinds of crazy ideas out there about covid vaccines leading to an increase in excess deaths in young people. Ron Unz did an excellent analysis showing that excess deaths were high only in countries where covid had gone rampant. Countries that had little covid but large-scale vaccination did not see any increase. This is consistent with previously mentioned research showing that throughout the pandemic we’ve been undercounting covid deaths, meaning that the disease is actually more dangerous than official numbers suggest.

I’ve looked into the stronger anti-vaxxer claims, and what’s really depressing is that the community seems to be made up of people who really like the idea of looking at data but don’t know what to do with it. For example, many of them rely on the Vaccine Adverse Event Reporting System, which is nothing more than a collection of unverified claims that anyone can make. It’s basically #DiedSuddenly but you report it to the government instead of social media. Of course, given that a lot of people hate the covid vaccines and there’s been a lot of propaganda against them, we should expect many unverified reports to be made. To make an analogy right wingers will appreciate, this reminds me of the rise in “AAPI Hate Incidents” that the media talked about around the time it was trying to create yet another narrative that we were drowning in white bigotry. Other anti-vaxxers will find instances where a locality or nation had an increase in deaths as vaccines were rolled out, and attribute deaths to the vaccine, which is just a classic example of the old “correlation must equal causation” mistake. RCTs are how you best establish causation, so they will always trump correlational data. One can also look at deaths by vaccination status, although the results shown below could be in part due to healthy user bias, or less sick and more responsible people getting the vaccine. At the very least, vaccinated people being much less likely to die refutes nonsense claims about vaccines being dangerous.

Behind RCTs, the data reflected in the chart above is the second-best form of evidence we have on vaccine efficacy and safety, despite its shortcomings. In my experience, anti-vaxxers ignore the most compelling forms of data, and rely on weak signals instead to make their case. Another interesting finding is that, while the political orientation of a state or locality didn’t really predict covid deaths in the first year of the pandemic, people in Republican areas started dying at higher rates after vaccines became available.

This is strongly consistent with the view that lockdowns and mask mandates were pretty useless, while vaccinations were the one public health intervention that was clearly worth it.

There’s a hierarchy of data, with RCTs at the top, and everything else below it. People can argue about how important the two charts above are, but since they’re consistent with RCTs and point in the same direction we can take them as credible pieces of evidence. Things like VAERS, or observations of random athletes dropping dead, are not worth paying attention to.

Alex Berenson is probably the clearest example of someone who abuses data on this issue. He seems to believe that quantity of data makes up for his inability to understand what it means. I went to his Substack some months ago, and one of the first posts I saw was an essay arguing that because the stock of one funeral company was going up it meant that mRNA vaccines were killing people. Really.

Most intelligent conservatives I know don’t listen to Alex Berenson. But I think what’s happened is that they see him as part of their tribe, so they think that the truth must be somewhere in the middle between what he says and the CDC. Hence, conservatives end up with the “vaccines were only good for the olds and fats” position, but it’s just wrong.

What About Long-Term Effects?

It’s true that there aren’t studies on the long-term effects of mRNA vaccines. The problem with putting too much emphasis on this is that there is already overwhelming evidence that a bad case of covid can be seriously debilitating for a while. See the chart below on the rise in disability among the working-age population.

Some on the right have argued that there’s a psychological component to this, as it seems that liberal women are particularly prone to getting long covid, or at least talking about it. Yet the coronavirus is a pretty nasty disease, and I know conservative young men who lost their sense of smell for months, and I doubt they’re imagining things. Long-term effects of respiratory infections are common. This goes back to the previously made point that anything that kills large numbers of people is likely to have other negative effects. You also see a rise in heart disease deaths among young Americans starting in 2020, which anti-vaxxers want to blame on vaccines but was clearly from covid.

Maybe everyone drops dead exactly five years after getting their second dose of Moderna. It’s theoretically possible, but I really can’t see any reason to suspect this is true. It’s been a few years already with billions of doses of mRNA vaccines given across the world, and little credible evidence to indicate much in the way of damages. This is unlike covid, where you can see the spike in disability claims starting at the beginning of 2020, in addition to the excess deaths that would’ve been obvious from the data even if nobody had ever known a new respiratory virus was infecting people.

With all these debates, there seems to be a bias towards government inaction. Whether short term or long term, negative effects from vaccines are seen as much worse than negative effects of disease. This is simply irrational, and the kind of thinking that makes it harder to solve problems, because it means people will always judge institutions and individuals that try to make things better more harshly than those that allow the status quo to continue.

The 99% Good Principle

Enough with the pure deniers. When it comes to the other two categories of vax skeptics, they’re not completely wrong about everything, or at least not obviously so. Does it make sense to give mRNA vaccines to 12-year-old boys who have already had covid? What if they’ve had covid twice? Perhaps not. It seems to me that just the 24-48 hour sickness that often accompanies vaccines and boosters is usually more of a legitimate worry than myocarditis, and this can also apply to girls and other age groups too.

As for policies requiring vaccination, I think one would have to be a fool to reject all vaccine mandates on first principle grounds. Even from a libertarian perspective, mandatory vaccination in certain cases is, in any economics textbook, the canonical example of justified government coercion, because getting sick has obvious negative externalities for society.

That said, I think that the vaccines were so good that we really didn’t need mandates. A pure cost-benefit analysis focusing on health alone and ignoring second order effects could have justified them, but the practice created such a backlash that I’m pretty sure it wasn’t worth it.

There’s a problem with focusing too much on such arguments, however. That’s because I adhere to what we can call the 99% Good Principle. It means that, when something is 99% Good, people who go out of their way to focus on the 1% that is bad are acting out of stupidity, bad faith, tribalism, or some other unsympathetic or unhealthy motive. It’s important not only to be right on specific issues, but have the proper orientation towards things in the world, that is, recognizing good things are good and bad things are bad.

There’s simply no way to justify prioritizing moderate vax skeptical positions without relying on the arguments and assumptions of pure anti-vaxxers. There is an endless number of government and employer mandates that are part of living in a modern society. People generally ignore the ones that they think either don’t matter or are mostly beneficial, focusing instead on those that are particularly burdensome or unjust. If you were going to make a list of the 1,000 worst things government does to you, a sane person would put vaccine mandates at the bottom of the list. They’re often for your own good, and even if they don’t pass a cost-benefit test for an individual, they’re overall barely harmful for him and positive for society as a whole.

If you have a teenage boy, him getting myocarditis from an mRNA vaccine is pretty much the last thing in the world you should be worrying about. A study from a group of Nordic countries showed that for males between 16-24, there were somewhere between 9 and 28 cases of myocarditis or pericarditis per 100,000 shots after a second dose of the Moderna vaccine. These conditions are generally not that big of a deal, and mostly clear up without any long-term damage. Meanwhile there are about 32 million young men in the US between 18 and 29. According to the CDC, between 2020-2023, there have been 4,285 covid deaths among males in that age range. This translates into 13 deaths per 100,000, about the same risk of getting myocarditis from the vaccine. Vaccinations could have eliminated at least 90% of those deaths. Note that I’m using ages 18-29 for covid deaths and 16-24 for myocarditis and pericarditis, because of the way the data is presented in the Scandinavian study and by the CDC. But I think the overall point is that getting myocarditis from an mRNA shot is in about the same ballpark of risk of death from covid for young boys and men.

Since death is much worse than myocarditis, even for young males covid was always a bigger threat. When you throw in the chances of being hospitalized with covid, this adds to that case, even if you don’t care about the lives of old people at all. Yes, you can play around with the analysis. What if you consider natural immunity? What if there’s over or underreporting in either direction? Does a fourth or fifth booster make sense? I think overall, it was always better even for young boys to get vaccinated than risk a covid infection with an immune system completely unprotected against the disease. One can discuss boosters or what to do after getting natural immunity, but what’s most relevant for our purposes is that not much actually hinges on such debates, because both the risk of covid and the risk of myocarditis from an mRNA vaccine are extremely low.

I don’t think people on either side of the debate over boosting young men are crazy, but the only way you can be convinced that vaccinating them has been some great crime against humanity is if you agree with the anti-vaxxers, which means either exaggerating the side effects of the vaccines or downplaying the risks of covid. If science gave you vaccines that saved countless lives and all you want to talk about is one small demographic and one particular kind of vaccine where, very arguably, a cost-benefit analysis at the individual level did not suggest getting the shots was a good idea, you’re missing the point. In deciding whether the products of OWS belong in the 99% Good category, consider also the fact that the technology behind mRNA vaccines is one of the most promising new developments in the fight against cancer.

I apply the 99% Good Principle elsewhere. I’m very skeptical of people who frame issues as “the problem with capitalism” or who bash markets more generally. Capitalism and markets are in the 99% Good category. Does that mean you should never say bad things about them? Most of the time, yes. The “bad” parts are nowhere near as bad as the downsides of government, religion, the media, or any other institution you might think worthy of critique. When you do express disappointment with some aspect of capitalism, care should be taken to frame the argument in a way that doesn’t give any credence to the views of people who dislike markets as a general matter, and therefore opens up a path for them to have more influence.

Recently, the FTC under Lina Khan went after Amazon for allegedly making Prime too hard to cancel. It’s highly unlikely that this was objectively a big enough problem to draw the attention of the federal government. What happened was that many people dislike Amazon because it’s successful and they think markets are icky, despite the fact that the company produces an overwhelming amount of value for society. Even if I agreed then, in theory, that Prime is too hard to cancel and it is the proper role of government to do something about this, what is more important is that Amazon is easily in the 99% Good category and this anti-trust investigation is clearly a way for people who hate the company to play the role of the proverbial camel getting its nose in the tent. This is a common strategy of people who hate good things, to concentrate on the 1% everyone can agree is bad to discredit them in their entirety. Those of us who like good things need to be on guard against it. There are a lot of things in the world that are 50% Good or even 5% Good. You should focus on their flaws rather than nitpicking through attacks on the 99% Good category.

When it comes to vaccines, very few people who just oppose mandates or mRNA shots for young boys stop there. They often complain about OWS, and argue that the vaccine should have been delayed further. They treated anti-vaxx nurses as heroes for fighting for the right to infect their old and elderly patients. While it’s true that vaccinations don’t 100% stop transmission, they do make transmission somewhat less likely by preventing infections in the first place, meaning that health care facilities are reasonable in requiring them for staff.

I’m on the RNC email list, and even before all mask mandates were lifted and all schools returned to normal, they were fundraising off their fight against Biden’s vaccination requirements. They may have been right on the narrow issue of mandates, but this was the wrong priority, and, worst of all, it generally signaled that Republicans were becoming the party of anti-vaxxers. Thus, Trump is now ashamed of his biggest accomplishment, and DeSantis thinks he can win over voters by hating vaccines enough. Last year he even called for a grand jury to be convened to investigate Pfizer and Moderna, which is one of the worst things I can remember an American politician doing in a long time.

One could argue that the 99% Good Principle can be counterproductive. By implementing mandates and going too far with covid censorship, people became more anti-vaxx. Not letting skeptics have their say and not granting them their arguments may indeed backfire. I think that’s to a large extent true, and it’s the reason why I believe mandates were overall a negative. That being said, with any undesirable societal outcome there’s a hierarchy of blame, and it’s important to keep that in mind. Individuals and groups who advocate for a position are more to blame than people who did things that had second order effects that led to the people advocating the harmful position being more likely to succeed. Liberals who refuse to condemn gangbangers but get emotional about the “root causes” of crime tend to make that mistake.

Those most to blame for anti-vaxx sentiments are those that advocate against vaccines, the RFKs and Alex Berensons of the world. At one step below are leaders and politicians who have told their audiences that of all the infringements on liberty in the world, vaccine mandates were the ones to worry about, and who no longer will even say Operation Warp Speed was a good thing. They violate the 99% Good Principle, making them not as bad as vaxx deniers, but worse than overreaching liberals on this issue. Heavy-handed public health bureaucrats are in a distant third place. Though they deserve to be condemned in the strongest terms possible for school closures, mask mandates, and other NPIs, to the extent that they made major mistakes when it came to vaccines it was the result of not putting more faith in them to allow us to get back to normal life sooner.

Debates and Metadebates

A good analyst does not simply focus on what is true or false in a narrow sense, as it’s worth having metadebates — that is debates about the debates we are having. While anti-vaxxers are simply wrong, it’s important to realize that moderate vax skeptics are doing harm even when they’re arguably right on a constricted set of issues. This may seem like a striking claim to make, but we all recognize that often, metadebates are worth having. For example, in the aftermath of the song Rich Men North of Richmond becoming a hit, some in the media have noticed that the artist has watched anti-Semitic videos. I haven’t seen conservatives doubt the truth of this reporting, but they question the motives behind it, correctly seeing it as part of an attempted cancellation.

We therefore all acknowledge that sometimes people can be correct in a narrow sense but wrong to emphasize or put too much stock in a fact about the world. My view on the vaccine debate therefore goes something like this:

1. The development of covid vaccines was a great thing that saved countless lives.

2. The lesson we should take from this experience is that the public health establishment is too risk averse in the face of serious public health issues, at least when it comes to approving pharmaceutical therapies. The FDA clearly should have allowed the covid vaccines to be distributed much faster than it did. Trump was right.

3. It’s fine to have questions on the costs and benefits related to the very narrow issue of mRNA vaccines for young boys. In the end, though, very little hinges on such questions because the dangers of both covid and mRNA vaccines are really really low for this group.

4. Government mandates were not worth it in the end, even though I think private businesses and especially health care facilities should always have had the right to implement them.

5. Those who focus on questions surrounding #3 and #4 at the expense of #1 and #2 are either misinformed or have their priorities screwed up, and should be opposed on that basis.

Operation Warp Speed was not just an accomplishment of Trump. It was a complete vindication of everything intelligent conservatives have been saying about the evils of the regulatory state, and how we need to cut through it to accomplish great things. Now, tragically, when discussing Operation Warp Speed, conservative politicians are more likely to argue that the process went too fast.

The tribal thing to do, of course, is to blame all of this on liberals for failing during covid, and favoring policies that included vaccine mandates. But usually, I’m not a big fan of “root causes” analysis. As with crime, I would rather focus on those directly responsible, and think that those who try to shift the blame are deflecting from inconvenient facts they don’t want to talk about. I am also a major critic of oppositional culture, whether in the inner cities or among right wing media figures. Letting the flaws of one’s opponents excuse your own bad behavior is the path to ruin. It’s not only bad for a community itself, but contributes to a vicious cycle. Whenever conservatives complain about liberal behavior during covid, my response is can’t they say the same thing about whether your side can be trusted, given that it’s now boosting Alex Berenson and RFK, Jr?

Another problem here is that government is always going to suck and make mistakes. If your attitude is “no medical progress until government is perfect,” then it’s an excuse not to ever do anything worthwhile. This is in fact the way people think, hence the system we have.

There is simply no contest between the benefits of Operation Warp Speed and the harms of mandates. This is especially true when you consider the likely future influence of the relevant technology with regards to areas like treating cancer. Next time government does something heroic, trust me, it’ll screw it up in certain ways. Such is life. Criticize them for that, but the answer can’t be to never try and solve problems. I actually think that the harms of lockdowns and mask mandates were such that we should be doing things to make sure public health officials never abuse their positions in the same way again, and I applaud recent efforts to take away their power.

But vaccines and medicine are different, as the general orientation of this same establishment is to be too biased in favor of expanding their own power and against letting capitalists bail us out of problems through innovation. What is necessary is to keep in mind two seemingly contradictory ideas: elites need to be restrained in certain ways, and empowered to cut through bureaucracy in others. Maybe that’s too complicated for most people, but it is the job of responsible intellectuals and leaders to thread that needle.

Conservative elites have been the only group that has been consistently correct about how terrible the FDA is, and the evidence during covid was so overwhelming that it convinced many of their opponents. Unfortunately, the fears, prejudices, and irrationality of many right-leaning voters has caused Republican leaders to put forth arguments that make them sound no different than those on the left who cost lives by originally calling for the vaccines to be delayed.

Operation Warp Speed is a case study in why progress is so difficult. We already know that when government officials get things wrong, a risk averse public is going to make them suffer consequences for it. If politicians who take risks are going to be crucified even in cases when they end up being right, there’s truly little hope for us.