Katie Attwell @ Fondation Merieux OCT 2017 - transcript
https://youtu.be/uZuQBsmBwwQ
0:00
..do not hear that there have been recent policy changes in various jurisdictions with regard to vaccines becoming
so-called mandatory and I'll explain that 'so-called' in a minute.
But of course California in 2015 removing all exemptions except medical exemptions for compliance with vaccination requirements.
0:20
Australia in 2016 we spend a lot of time at the last meeting for those who are here talking about 'No job no Pay,' so I've deliberately not included any discussion of that this year. But of course I'm sure it will come out in the in the discussion if people want.
0:34
Then this year we've had both Italy and France announced that they're introducing policies with mandatory vaccinations.
0:41
so I think the first question we need to ask ourselves and a lot of this a lot of what the slides you're seeing are the consequences of me thinking through some of these questions.
And of course you may think them through differently and if so you know I'd love to hear about it at the end.
0:55
When I asked myself what vaccine mandates are seeking to govern, it was fairly self-explanatory to me that they were seeking to govern acceptance rather than access but as I'll demonstrate in a moment there are potentially some other ways we could think about this as well.
1:10
But one of the things the reason I said so-called when I talked about mandates is that there's not actually a clear established definition of what we mean when we talk about vaccines being mandatory. So we don't actually know what it is that we're referring to. And we don't know what the tipping point is that suddenly might make something mandatory or not mandatory.
1:29
So there's this term will be used in discourse and in political discourse and within our field but people might be meaning different things when when they say mandatory.
1:40
So I made a slide and what I've thought to do in this slide is - we like Continuum's in this research area - so I made a continuum that on one side is is sort of the settings in which vaccination is completely voluntary and that the other end includes what I would regard to be the most harsh measures the state could take against those who don't vaccinate.
2:02
And that's fines and imprisonment and but I will get to this in a moment all right. Because there's it's not this simple But anyway imagine it is just for a moment - imagine we just look at it according to what the kind of stated policy is.
2:18
Then in the top line I've talked about requirements that are linked to public goods and by public goods I mean things like you know, public daycare and public schools.
2:27
So along the kind of more voluntary end of the axis you can have requirements about vaccinations that say 'you've got to be vaccinated to access these public goods' but there can be exemptions available for those who don't want to comply.
And the next more strict level of that is where there's requirements related to access to public goods and the - oh there's not really exemptions only for medical situations down here.
I've said that as I've suggested it's a separate category when it's actually not public goods but in financial incentives I think there's a qualitative difference with regard to money coming into your pocket then there is with regard to accessing something in your community.
3:07
So the equivalent is you know you can get the goodies if you if you comply but you can also get out of complying with some effort and still get the goodies or this one over here - you can't get the goodies unless you comply and only a medical exemption will still get you the goodies.
3:24
Now the last thing I wanted to do is ask myself that question around how each of these kind of effects both the access and the acceptance equation.
3:34
But I found it wasn't helpful to think about access and it was more helpful to think about this term complacency that we also encounter in the literature about vaccinations which I know is a qualitatively different thing.
3:47
But in terms of thinking what thinking through who mandates are supposed to work on, I thought about you know, because we don't need to worry about the people who are going to turn up anyway. And we do need to think about access but I'm trying to kind of keep that out of this picture at the moment.
4:00
But there's clearly a group of people that we might regard as - and access can certainly play a role in this but I'm not going to conflate the two - who just for various reasons might not be getting to the clinic. And this is all kind of working in a setting which I realize is not the real world in which we assume that vaccines are available and easily accessed.
4:18
So in that imaginary setting the people who wouldn't get them ever complacent and those who actually don't want them.
So at the voluntary end of the spectrum there is no compulsion for either category: it's all about once you've got all the access levers in place. It's really all about many of the techniques we've talked about today in terms of getting people that's drawing in that I liked from the social marketing discussion.
Actually just getting people to get off their butt and get in and get vaccinated.
4:46
Once we start moving onto requirements linked to public goods and also financial extensive, sorry financial incentives with exceptions. So either way you can get the goodies if you're not vaccinated with some effort.
5:01
I've suggested what's going on here is the state is queuing us a complacency. These policies are really about getting people off their butt and into the clinic and that's precisely because rejecters can access them with effort so they're not
really about accessing rejectors so much.
5:15
It's actually about saying you know we'll try and get people in and if you don't want to come in and you go to a bit of effort: that's okay. At this end I'm suggesting again the state is queuing for complacency but by excluding or denying rejecters the policy is actually actively targeting these people to in either form.
5:35
Once they get to this end I sort of speculate that the policy is now actually about motivating those who are rejecters. And the policy is working on the complacent, because they don't want to face the penalty, but now I'm suggesting that certainly in the cut..
5:51
I'm not suggesting this has always been the case in context where these have been introduced but I'm suggesting now perhaps the way we might frame these is that you know you're coming with a penalty and that's going to get everyone off their butt and those who really don't want to get off their butt: they're going to face the penalty.
So that's a very oversimplified version of it but that's how I've kind of conceptualized it.
6:12
But as I said it's really not that simple and it doesn't work on just one continuum. It's almost like you need multiple dimensions of 'continui' (if that is a word) at work here and some questions that of course underpin and problematized the slide I just showed you. One it is really are all related to - is it really mandatory? and go back to this idea that we don't actually have a fixed definition.
6:35
So one question of course is if there are exemptions, are they easy or difficult to get?
6:40
so nevermind what type as we talked about in the previous paper for whatever there is how is your difficult other to get and how often do you have to get them? vis a vis how often one might have to get a vaccine?
And then just some you know interesting other points like some US states have criminal consequences.
6:58
So they're right back at the harsh end but they've got exemptions and I didn't mapthem on my continuum - but just showing you it can be more complex.
And then also you know, just some interesting things that can happen with exemptions. For example in Washington once and we heard about this earlier .once people had to start going to see a medical you know, a health care worker in order to have their - any type of exemption validated - what what one study reports is that people started get even though they were able to get other kinds of exemptions, the number of medical exemptions arose.
7:29
so that's kind of interesting. I'm just offering this is the kind of details that can play out when policies are implemented.
7:37
Then there's a whole bunch of questions around requirements. So they might be you know they might appear to exist but who enforces them well or are they enforced? and how often and for whom?
You know, which category of person is going to experience the consequence of this?
And is it going to be a universal thing or a certain categories of people going to be targeted?
And then what are the one of the consequences of their non-compliance? what is going to happen to them?
So how do these consequences bite and who do they bite? Again going back to the earlier question of, - are they going to be applied to everybody or certain categories?
And really the take-home from this is that just because a policy exists doesn't mean it's going to be enforced and it's if it's not enforced then can it really be said to exist in in the way that it might appear to be presented?
8:23
Now I want to spend a little bit of time looking at rationales that states may offer or that we may be able to explore and expose for why mandates might be introduced. And here this is not me offering any endorsement of these policies or rationales: it's me again thinking through, well you know in what situations might we see these coming in and the kind of conversations that would come around that.
8:45
So the first I've categorized as 'moral.' And in my own country of Australia there's been a discourse that's been introduced by the right of politics for over a decade and that's this term 'mutual obligation.' And what it really means is if you're going to get goodies from the state it doesn't come with no strings.
And it's quite a it's quite an unpleasant discourse in my opinion and it's been used to target the vulnerable such as job seekers or welfare recipients.
9:15
With the job seekers, it's been used to require them to complete very onerous job search diaries, work for the dole for perhaps three days a week
9:24
So you've got a dual, you've got to do a lot of work in order to get unemployment benefits. And now we're seeing the same discourse introduced with regard to welfare recipients.
9:36
And there's trials ongoing right now of people to see if they're taking drugs. And if you're taking drugs you can actually have your (illegal drugs obviously) you can have your welfare money quarantined.
So this term has explicitly also been employed by the government, the right-leaning government in Australia to bring to this vaccination concept as well and mandatory vaccination.
9:57
But I would suggest under this moral heading as well there can be a I guess a nicer or a more appealing version of the moral argument.
10:05
And this is around you know, linking it to the public good and saying that if other people in the community are
accessing this public good and this can be with regard to things like child care and schools. If if you're not vaccinated and you're going there, it can actually affect the entitlement of other people to be able to enjoy these public goods.
So it's a different kind of moral argument about communities.
10:30
Then there can be a whole crisis rationale and I think that's certainly what we're seeing at the moment. And the crisis might be unfolding you know that something like the Disneyland measles outbreak could be regarded as at the time there's a kind of unfolding crisis.
10:46
Then there might be an impending crisis. So this is someone's looking at the numbers and getting worried and starting a conversation about what the numbers might mean?
And of course there's also the idea that a crisis could be manufactured by you know both certain forces as well. So I think here we have to ask us you know what are the numbers tell us about, about any kind of crisis discourse and the legitimacy of using this crisis framing?
11:09
Then I have suggested that there might be a rationale around effectiveness. So if you know the questions around aren't so called mandates - whatever they are - targeting the population that you intended to target? And are they working?
11:22
So one thing that I want to be clear on is that I believe that mandates are about changing behavior but not beliefs.
11:32
And you don't always have to change beliefs to change behaviors, we would like to - but then it's an empirical question of well 'is it?' 'does it?' 'is it is it actually having that effect?'
And then finally I've included this term 'affective,' alluding to the idea of affect or our affect, our personal experience of emotion. And here what I'm trying to get at is we might want to stop and ask ourselves - who is this policy actually working for?
12:00
And what I refer to here is the work by a Scholar of International Relations called Lee Jones who looked at when countries impose sanctions on other countries for contravening international law or international norms.
12:14
And of course this is always a pertinent conversation right now as well.
So what he found was that when people or when States seek to impose sanctions on other countries everyone's kind of like 'yeah you know we'll impose the sanctions. That'll show them!'
And he actually when he wanted to uncover that process and say: well, do the sanctions work? Do that you know everyone thinks sending sanctions is the kind of end point but the end point surely has to be: Do they work?
12:40
And so he went in and had a good look and found - surprisingly or unsurprisingly depending where you sit - but frequently they didn't work. And frequently they didn't have that effect. And what he is suggested and found in his research was that actually the sending of the sanctions was often much more about the sender than the recipient.
12:57
so I'm suggesting in this context it could be about a kind of emotional experience for those wanting to punish people who don't comply with vaccinations. But also it might serve political ends as Jones found in his own study. Sending sanctions might mean a lot more at home than it does overseas where you sought to send them, if that makes sense.
13:21
And finally, I want to suggest the idea that occurring within this this imposition of mandates, may actually be a form of trickery.
So if there is sort of political demand or demand in the community - something you know resembling a mandate might emerge. But the devil might lie in the detail and perhaps it was never really going to be a mandate after all.
13:42
So having explored this, I now just want to kind of categorize mandates within the forms of governance available to
states, with regard to vaccinations. And this won't be anything new to any of you but I'm hoping it might just be an interesting and thought-provoking way of framing mandates within the other activities that we're here to discuss at this meeting.
14:01
So there are various tools that the state has at its disposal to control us. And the most old-fashioned and kind of well-known would be hierarchy. And this is really the state using its monopoly of coercive power and its control of economic means to do stuff with money and laws basically legislation and finance.
14:24
And so it's this is where mandates fit right this is kind of old-fashioned top-down control.
14:31
Then there's the stuff that those of us in this room are much more comfortable with one of which is persuasion which of
course can include campaign social marketing communications strategies.
And here I suggest that this is again something that governments, you know a key involved in, but they can have
partners that include us. Whoever we are.
14:48
And then you know some scholars and I agree with them and now framing nudge is something different than persuasion. The key distinction being that persuasion is about engaging with us as active agents who consciously are involved in making decisions. And it's kind of giving us a lot of credit and working with our capacity to reason and reach good conclusions.
15:10
Whereas nudging can be much more about orienting towards uncritical acceptance. And again it's you know, this is
something governments can be doing. It's also something healthcare providers can be doing with regard to the presumptive approach that Opel has written about for example. But also you know, recall reminder schemes at the practice level.
15:27
So I think there's a distinction there between those two modes of governance. But I think that both of them are
probably a lot more appealing to the people in this room perhaps than this top kind.
15:37
And of course the point to make is we start to think about societies that are introducing mandatory vaccinations in whatever mandatory means, is that persuasion and nudge don't go away. They remain open to policy and practice actors in societies with mandates. And the state can also structure and make use of these tools.
15:54
And of course if governments are smart they will do so, right? like if you use these forms of governance in association with each other, they're likely to be effective in the goal of actually changing the behavior that you want. But also importantly they can promote the norm.
16:12
So although I've suggested that mandates don't change they don't change our beliefs they only change our behavior in
time, perhaps they can change our beliefs through processes of norming but I'm not going to drill into that right now.
16:27
So, acceptance in the age of mandates: what does all of this mean for those of us here in the room? I've kind of tried to consider what our lives and works look like before and what they might look like now. And I want to suggest that you know - and when I talk about this us I'm framing those of us in this room as researchers and people working in government, working in you know delivering programs around vaccinations.
16:50
I hope I've got that right in that that's who we are. And so I see that our job used to be one of persuading - well for those of you who are not yet in societies with mandates, this is still your job - sort of to persuade for researchers it's about persuading governments and funding bodies to fund the work we do.
And if and to you know and to actually fund and implement it. So that those in practice or obviously to apply and implement the and evaluate the kind of research-led methods of encouraging people to vaccinate.
So our whole thing was that we show we can show you how to convince people to vaccinate at a community and practice level: this is, this is our value-add to this whole proposition.
17:30
And arguably in societies with mandates that's changed. And maybe it hasn't and I'll get to this, but some of the things we might want to think about is firstly; is our job or could our job now be to evaluate the impact of mandates? And I think that it is. Including of course the negative and unintended consequences on, you know intended and unintended recipients
17:52
And is it to promote tweaks? Or you know, some in this room might say that the ideal would be to appeal them.
Is our job to put attention into access? You know, we conceptualize access and acceptance as different things, but if mandates have been rolled out in haste by countries who are like "Oh rates are falling! I better make it mandatory!"
18:15
have they made sure that they have covered every single access stone before they do that? Because if they haven't then we've got a huge social justice problem. So what, what is our job with regard to access in that in that case?
18:28
but finally and here I'll echo the the words and the spirit of Joe last night, is that you know, no matter what I think the role of us is still to persuade get you know, back to these governments still have to fund acceptance work. It's, it's still and do acceptance work. It is still so crucial.
18:46
Arguably it's even more crucial now on a moral basis. If you are going to make people do something, you know, surely it's worth the investment in trying to get them on board at the same time, right?
18:59
And also of course there's an instrumental rationale that says the same thing if you employ multiple modes of governance, you're likely to be more successful, so it should stay packaged in.
And you know to repeat Joe like we can't stop like this this work can't stop. The risk of course is that once governments have introduced mandates, do they think it has, do they think that the job is done?
The other point to make is that has the content of our work changed?
And here I'm going to get a little bit political science.
But um you know, one of the things we see and we can see in the history of mandatory vaccination in different countries with different diseases in different contexts, that the minute the state starts telling people what to do, then there's a language of libertarianism that is pushed back against that.
19:47
You know, you don't want the state to control me; 'My body, My family, My choice.'
And so in societies where mandates are introduced I'm interested in whether this discourse every emerges and become salient in its own right.
Or is it just a kind of front for the same old beliefs and values that we would understand to underscore vaccine refusal in the first place?
20:12
So is, it is it just the same kind of language and beliefs with a new rhetoric added over the top? Or do we start having a
qualitatively different conversation about state power? And if the latter is true, then does persuasion work actually need to take it up to this level as well?
20:30
And do we have to start having conversations around libertarianism vs communitarianism?
And you know I know most of you in this room won't like this but I'm going to ask the question about whether you know acceptance work has to then start to become an act of legitimizing state power?
20:47
And you know the more palatable version of that is to say: "Well it's it's, the state is doing this. So that the rest of the
community, the community needs this.
20:54
But still this is a this is a conversation that those of us who are just focusing on you kno,w that the kind of more narrow
realm of vaccinations and behavior in that regard. Suddenly this is a bigger and deeper conversation.
21:08
and you know, one place I would suggest of course that that that acceptance work would still and unarguably have a place although may still need to be advocated for is that you know not all states apply mandates
21:23
and generally in this case they're not usually enforced but or enforced you
21:27
know meaningfully but not all vaccines
21:30
necessarily fall under the mandate.
21:30
So in that case firstly there could be some really bad unintended consequences of only priviliging in some and not saying that you suggest the other ones are not important and they could certainly be a place for acceptance work around the so-called not important vaccines.
21:48
But look, I have just touched on you know this issue and my thinking around it.
So the next thing we're going to be doing is hearing from two countries where mandatory vaccination has been introduced and one where it has been I suppose flirted with perhaps considered but avoided.
22:04
And so, but before I move on to introducing our speakers, each of whom will speak for 15 to 20 minutess, it's 15 minutes, Anyway. Whatever. I do also want to acknowledge a conversation I had with Julie Lesk around this so Julie's not here but I have to acknowledge the input that she had into me developing these ideas that I've shared with you today.
22:24
Okay. So our first speaker is going to be Christine Justin who joins us from the French Public Health National Agency. Now I'll have some terrible French: Sunday public - France.
Christine leads the infectious risks Prevention Unit there. Her background is as a physician and she has a prestigious history of roles in the French national health with a strong focus on immunization.
So she is going to tell us all about the big news coming out of France.
