U.S. COVID deaths have surpassed U.S. war deaths from World War II, Vietnam, and Korea. The unvaccinated are a fifth column that has ushered in a wave of nasty COVID variant infections in the United States, with their attendant deaths, costs, and disruptions to society. We need to stop debating the tone in which we address the unvaccinated and label their sabotage for what it is. We need to start treating the willfully unvaccinated with derision, contempt, and disgust. They do not have our nation’s best interests at heart. They are a venal and lied-to group of marks who have become unmoored in the contemporary world and crave self-actualization through a Manichean reinterpretation of the narratives surrounding our country. And so, we need to change our carrot and stick approach to reflect that these are adults making tantrum-level decisions.
Those refusing vaccination argue that it is a matter of individual choice. That is, of course, a lie. No matter how healthy they are as individuals and how mild they expect their own cases of COVID are likely to be, their bodies serve as breeding grounds for variants and mutations that threaten to infect the rest of us. And this ignores the growing body of evidence that long-term cognitive deficits and other symptoms are associated with even exceptionally mild cases. Allowing yourself to be a part of this process of spread and mutation is imbecilic, unpatriotic, and rabid. In addition, those who choose to not be vaccinated are putting the extraordinarily rare albeit extraordinarily tenuous population who truly cannot be vaccinated due to medical contraindications at even higher risk, as well as the population who have been vaccinated yet have immune systems too weak to develop fully protective antibodies against this killer.
The costs and consequences of not being vaccinated are being borne by our polity at large, and that is encouraging wildly irresponsible free-loader behavior. The old parental saw, “You can make that choice when you are old enough to pay for it,” needs to become policy. Individuals who skydive find it difficult to buy disability insurance. Smokers pay more for health insurance. America shouldn’t fund the high wire act of the unvaccinated, who assume—without any guilt—that they can rely upon the rest of us to rescue them by paying for their high-priced medical care. And this is coming from a usually vocal “Don’t tread on me” crowd. Irony dies a thousand deaths. Adults willfully foregoing vaccination should have to buy supplemental COVID insurance. Some states have offered compensation to those who get vaccinated, but in addition to dangling a carrot in front of people, we immediately need to levy a real cost for not doing it—one that actually prices in the externalities of a wildly vicious and mutating pandemic and the hospital beds denied to vaccinated patients in need.
Public health departments are finding challenges in breaking down new cases and deaths between those refusing vaccination and those who are either vaccinated or too young to be eligible. To the extent the unvaccinated believe it is their individual choice to put themselves, their families, and their communities at risk, they should favor wholly separate reporting. Clarification of the term “breakthrough” infection is also critical—a vaccinated person is, indeed, just as susceptible to have a virus find a beachhead in their upper respiratory tract, and may even test positive. That, in and of itself, is not vaccine failure. Significant illness and death, however, are, and this distinction is critical in maintaining public trust in vaccine efficacy.
Many who choose to not be vaccinated claim that the vaccine carries with it substantial risks—risks they are not willing to take, and they would readily choose a severe COVID infection over a risky vaccine. Indeed, these vaccines do carry small but non-zero risks. Adverse events occur. Some have been severe. But humans are notoriously bad at risk/benefit assessments and comparisons of risk. As surgeons, we address risk assessment in our practices on a daily basis. We routinely remind our patients (and ourselves) that nothing is without risk, including the decision not to treat. The notion that conservative treatment means foregoing medical or surgical care is a false one and can often carry much graver risks than an intervention. COVID vaccines carry certain risks, but the risks of not being vaccinated are orders of magnitude higher. Insurance actuaries can readily calculate individual risks of not being vaccinated and should tag them on to premiums with a simple click.
While we are not proposing a vaccine mandate, the willfully unvaccinated should be treated as the adults they are and given the privilege of owning their decisions completely. And returning to the martial metaphor of the fifth column, we should remind ourselves that in war, “casualties” do not simply include the war dead, they include the maimed. And we can add to that the devastated families who experience tragedy and loss. We will be accounting for the damage that COVID-19 is wreaking for decades, and we will be paying for that damage for decades. The unvaccinated insist on a certain moral clarity that rings utterly hollow. There is no longer any ambiguity. They are a danger to themselves and others. Treat them as such.
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