cwick (Chadwick Matlin, deputy editor): Maggie, Anna and Neil, thanks for joining me to talk about the new complexities of the COVID-19 vaccines in the U.S. After months of having only two very similar vaccines available, the FDA has approved a third for emergency use: a one-shot vaccine from Johnson & Johnson. That J&J vaccine has prompted a lot of concern and hand-wringing over how to communicate its differences and still emphasize its life-changing benefits. I’ve gathered you all to talk about what the evidence tells us about the science of the vaccines, the best practices for how to encourage people to get them and how to best understand the motivations of those who would rather pass up an opportunity to get the J&J vaccine.
So, let’s start with a quick summation of the differences. What are the different efficacies of the vaccines, and are those numbers even the right way to think about this?
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maggie (Maggie Koerth, senior science writer): We had a really interesting pre-conversation to this conversation yesterday, and I think it encapsulates some of the trouble with how to talk about this stuff. We were debating whether there should be a graphic showing the efficacies of the different vaccines.
maggie: There’s basically no way to do it without wildly misleading people.
neil (Neil Lewis Jr., professor of communication and social behavior at Cornell University): And that’s complicated by the fact that different people care about different things.
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anna.rothschild: Right! So true.
maggie: And different clinical trials cared about different things, too. And not necessarily what all the people cared about.
cwick: And the trials happened at different times, in different places, with different variants swirling.
neil: Right! The headlines have been about the overall efficacy rate, but those numbers might not mean what people think they mean. If we just look at that number, J&J looks worse than the other two. But we have to be mindful that J&J was tested during a very different time period, so it’s not really fair to compare them head-to-head.
maggie: I know you hate to hear this phrase, Chad, but … it’s complicated.
cwick: I just think journalism is more compelling — and inferior — when we don’t acknowledge how complicated life is. IS THAT SO WRONG?? (Yes.)
maggie: Neil, I’m really curious how you would present these different efficacies to people, given that direct comparison isn’t a great way to look at it. Honestly, it’s a thing I’m struggling with right now. Where do you even start?
neil: We have to talk about the nuances. As you’ve all noted, the trials happened at different times, and the outcomes differ a bit. There’s the goal of preventing symptoms and the goal of preventing severe disease. As far as I understand, all the vaccines are effective for preventing severe disease — so that’s important to talk about in addition to the top-line numbers.
anna.rothschild: For sure. In trials, they all prevented 100 percent of deaths (though, again, that was in clinical trials and not in the population at large. The number of deaths in the placebo groups was also very small).
neil: Right, so from a public health perspective, then, it makes sense to say, “Take any of them!” Keeping people alive and out of the hospital is public health’s top priority, so that’s why the public health message has been to take whatever is available to you.
anna.rothschild: Exactly. I’ve heard from some scientists that our “goal” for these vaccines may change over time. Right now, we want to keep people alive and out of the hospital. Once we’re out of the danger zone, our goals may change. At that point, we may start comparing them a bit more, asking which provide the longest immunity, which block more of the mild symptoms, etc.
cwick: Neil, you specialize in public health communication. Would you have preferred that these more exact numbers had never been made public? That we just had big categories like “extremely effective,” “very effective,” “effective,” “not effective”?
neil: That’s something I think about a lot. On one hand, it’s important to be transparent about the process of vaccine development and how we ended up with these vaccines. On the other hand, there can be a downside to how these numbers are talked about. People are making head-to-head comparisons between these different brands that don’t capture the important nuances. That can create some unhelpful confusion, so that’s something I worry about.
maggie: Personally, I feel a little trapped at this point. Like, we present the numbers and they get (very naturally!) compared in ways that they shouldn’t be. Don’t present the numbers and … it kinda feels like I’m hiding the numbers.
anna.rothschild: Yeah, I don’t know what’s right. Take the flu vaccine. I think that when people get the flu shot and then get the flu, they lose trust in that vaccine. But if they had just heard that the flu vaccine was about 40 percent to 60 percent effective, then they might not even get it in the first place.
neil: Yeah, in some ways people probably know far more about these COVID-19 vaccine statistics than about stats for other vaccines.
maggie: Exactly. I may have had this exact conversation with a family member yesterday.
anna.rothschild: It requires a lot of nuance to get the point across that the flu vaccine minimizes illness and also may prevent worse side effects of the flu, like heart attacks.
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cwick: Let’s talk a bit about what happened last week in Detroit, which I think is a good encapsulation of these tensions and how they play out in the real world. Detroit’s mayor, Mike Duggan, said he had declined 6,200 J&J doses because Detroit residents deserved the “best” vaccine. After an uproar he quickly backtracked, saying he turned them down because the city wasn’t ready to administer the additional doses. And now Duggan has announced a clinic that will administer J&J doses. What does this saga tell us about all the complexities at play?
anna.rothschild: I will admit my first reaction was horror, but Maggie actually helped me roll that back.
maggie: It’s a paradox. These specific vaccines for this specific disease exist on top of America’s already grossly inequitable health-care system, and on top of years of all different kinds of social inequity. In J&J, you have a vaccine that works well and has some benefits that the other vaccines don’t. It doesn’t require a crazy elaborate refrigeration system. People only need one dose. It’s less prone to causing allergic reactions. All good things.
But because our society has a wildly inequitable infrastructure, those things make the J&J vaccine seem like a really good choice for people who don’t have as much access to health-care facilities with crazy deep freezers or people who can’t take off lots of time from work for multiple doses.
Which means you very quickly get to a “vaccine for the poor.”
neil: Maggie just hit the nail on the head — historical and contemporary inequality are going to shape how people think about these things.
maggie: And, of course, poor people have a lot of feelings about that.
neil: When you have top-line numbers that imply one vaccine is worse than the others, well-meaning people will want to know how the different vaccines are going to be distributed. If it seems like the vaccines with higher efficacy rates might go to wealthier and whiter places, whereas the vaccine with the lower number might go mostly to poorer places with more ethnic minorities, then I can understand why that raises some eyebrows. It would look like yet another manifestation of racial and economic inequality.
maggie: Exactly, yes.
neil: If there were an equitable distribution plan — for instance, if every place got relatively similar proportions of all the vaccines — then that might alleviate some of those concerns. But then that could create logistical problems.
anna.rothschild: And we’ve already seen deeply inequitable distribution across the country.
maggie: When I was tweeting about this the other day, several Black people replied and said, “I’ll believe J&J isn’t just a scam that’s getting dumped on us when I start seeing white celebrities and politicians choosing it over Pfizer or Moderna.” Which is not an unreasonable position to take!
neil: Yeah, there’s some benefit in seeing “social proof.” Other people trust the vaccine then, too.
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cwick: The debate about whether to wait for the “best” vaccine also echoes the quandary we’ve been in this whole pandemic, as we’ve searched for the “right” or the “best” way to live amidst our changing circumstances. Part of the trick here — as we were saying earlier with the efficacy numbers — is that the concept of “best” doesn’t really exist. But, understandably, we all want the best for ourselves and our families. And Duggan channeled that in his politics.
anna.rothschild: Right. There are pros and cons to each of the vaccines. At the end of the day, a public health official may think “best” is any strategy that gets us fewer deaths and back to something like normal the fastest. But, as we know, it’s hard to think of the population at large when you’re worried about your family.
maggie: I think you’re right, Chad, that the “best” doesn’t exist. And our attempts to understand things that way often create more confusion than they solve, because the “best” isn’t really something any of the results from these studies can answer. That’s not what they were set up to do. I mean, even when we’re not talking about comparing one vaccine with another … we’re just talking about a vaccine preventing 100 percent of deaths. If you’re trying to say anything about preventing death from COVID-19, you have to look at the deaths from COVID-19 in the placebo group in these trials, and those numbers are very, very small. For the J&J vaccine, seven placebo participants died of COVID-19, but no one from the vaccine group did. The Moderna briefing document says there weren’t any COVID-19-related deaths in either group, so they couldn’t tell you whether it prevented death or not. The same seems to be true of Pfizer.
So, by this metric, it would be accurate to say that none of the vaccinated people died of COVID-19 … and it would be untrue to say that the vaccines prevented COVID-19 deaths 100 percent of the time.
And I bring this up to make the point that any metric you’re using to measure this stuff is gonna come with caveats out the wazoo.
neil: YES, YES, YES to all of this.
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anna.rothschild: Right, all of these numbers are bound to change over time, when more and more people get the vaccines — and also as variants spread and new ones emerge.
maggie: If the metrics are complicated, what does that do to our ability to use the metrics as a way to communicate about these vaccines?
neil: I think the best we can do is to present the metrics with the proper context to understand them and then answer people’s questions about them when they come up.
cwick: So, if the messaging is complicated by the historical and ever-present inequalities in our health-care system, what do we do about it in the here and now? How do we alleviate the inequalities in access to the vaccine to help ensure the public health messages will be successful? Or is that the wrong way of looking at it?
neil: We absolutely have to think about the access issues alongside the messaging. It is important to ensure that the context is ready for people to act on the messages. We need to make sure that people can sign up for vaccines (that has been a struggle), that they can get to their vaccination sites, etc. All these things matter for our ability to achieve broader vaccination goals.
cwick: So, what should public health officials be focusing on, Neil? Bridging the digital divide? Setting up volunteer networks to help with the “last mile” problem?
neil: All of the above. Sign-up systems to get a vaccine have been a struggle to navigate. We need to simplify those so that it is not just people who have lots of time on their hands or who have more tech-savvy family members and friends who can navigate them. We have to think about setting up vaccination sites in places that are easy to access, and operating during hours when a variety of people can get to them. Overall, we have to ask ourselves what the various barriers are getting in people’s way and remove as many of them as possible.
cwick: And presumably that will become even more pressing once there is a surplus of vaccines and elected officials can’t hide the inequalities behind saturated appointment calendars.
maggie: I wanna ask you guys something, because a lot here reminds me of the early discourse around masks, when public health officials were telling people, “Masks won’t help” when what they meant was, “We don’t have proof because it hasn’t been studied very much at all, and also we’re worried about people hoarding N95s and hospitals not having any.”
It seems to me like there has been a little of an “end justifies the means” simplification in public health throughout this pandemic. Is that OK?
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anna.rothschild: I totally get the inclination, but I don’t think public health ever wins by hiding complexity from people. Especially when it comes to vaccines. People are already primed to see conspiracy theories about medical interventions we give to healthy people. And that’s not a modern thing. People have had “anti-vaxx” sentiment for over 200 years (the first vaccine was created in 1796).
neil: Earlier, Anna made a point about talking about our goals, and I think that is important to clarify in all these discussions. The mask debacle was about officials trying to prevent the hoarding of N95s when hospitals needed them. We could have talked about the need for preserving specialty masks (N95) for health-care workers while also talking about what we knew about the effects of other kinds of masks for the general public.
cwick: Maggie, can you say more about how this is similar to masks? I am not sure I follow.
maggie: In both cases, Chad, we’re seeing an oversimplification of what is going on, because the details and nuance feel too messy (to … somebody), and experts are afraid it might be misunderstood as “We don’t know what we’re doing, don’t trust us.” But if you do that and people figure out there’s nuance anyway, it looks like maybe you don’t know what you’re doing and that they shouldn’t trust you.
I think my thesis here is Science Is Hard. And Communicating It Doubly So.
neil: Yeah, and I think this is a broader take-home lesson. This is a complex situation, and we can get ourselves into trouble when we make overly simplified claims.
anna.rothschild: Doing things like this has gotten the vaccine industry in trouble in the past. About 20 years ago, there was a lot of fear of a preservative called thimerosal, which contains mercury. There were no studies showing ANY ill effects from thimerosal, but the government told vaccine-makers to stop including it in certain vaccines for fear that parents would stop vaccinating kids. But that only perpetuated the idea that thimerosal was dangerous. (It was also never in certain childhood vaccines to begin with, but that’s another story.)
cwick: And to Anna’s point, as tempting as it is for us to simplify our public health messaging, that might get us into even more trouble than trusting the audience in the first place.
(Coincidentally, that is also FiveThirtyEight’s whole shtick.)