key: cord-0893127-xydvd415 authors: Sorscher, Steven title: Why it is our responsibility to speak out for a universal vaccination mandate date: 2021-10-11 journal: Cancer DOI: 10.1002/cncr.33950 sha: 43a806c9204cbbd21bc96f46dc99c03c782dc1f1 doc_id: 893127 cord_uid: xydvd415 Patients with cancer are among the most likely to suffer life‐threatening complications should they contract coronavirus disease 2019, yet despite encouragement from their oncologists, many continue to refuse to be vaccinated. On behalf of our patients, I believe that oncologists should now exhort our elected government to fulfill its most fundamental responsibility—protecting Americans from existential threats—by enacting either an emergency executive order or universal vaccination legislation and then by helping the rest of the world to vaccinate without delay. Since early in the coronavirus disease 2019 (COVID-19) crisis, oncologists have had many new experiences in their care for patients with cancer, including the use of telemedicine visits and also the challenge of presenting to our patients the incomplete and evolving data related to the likelihood of more life-threatening complications from COVID-19 should they be infected in comparison with patients not undergoing therapies for their cancer. Roughly 8 months ago, the remarkably effective vaccines became available. Now, it was only a question of convincing our patients to be vaccinated and convincing America and the world that nearly everyone must be vaccinated to end the nightmare. We recognized that this action must be nearly immediate because otherwise the virus would replicate and give rise to more virulent and inevitably resistant variants potentially undaunted by the vaccines. In January, when the vaccine became widely available, I thought convincing patients to be vaccinated would be easy. Also, now that the world had seen the ongoing devastation of COVID-19, nearly everyone would be eager to get their shots. Regarding my patients, I thought, "After all, most of these patients are willing to take drugs to attack their cancers that often carry far more side effects and are far less effective than the vaccines now available to prevent life-threatening complications from COVID-19." If not for their own safety, I was confident that my patients would do their part to help to protect others in the community. To my surprise, I have been unsuccessful in disabusing far too many of my patients of their myriad of excuses for refusing to be vaccinated. I spend hours every day listening to reasons for their recalcitrance and explaining the data and the need for urgency, but for roughly one-third of my patients, they say that their decision is final. The most common reason I have been hearing lately is "I just don't want it." It was anticipated that physicians could convince their patients. I thought that if any group of physicians would be expert at persuading their patients, it would be oncologists. After all, understanding and explaining statistics and lifethreatening disease is what we do every day. Despite health care experts, elected officials, respected media outlets, government agencies, hospitals, admired celebrities, and others encouraging nearly everyone to be vaccinated, not enough Americans are being vaccinated. Shaming the unvaccinated has not worked, and incentivizing with lotteries has not been adequate. For example, in Pennsylvania, unvaccinated health care workers were sent personalized emails that "highlighted the societal good" from being vaccinated, and vaccinations increased by only 3%. Moreover, although the efficacy of lotteries is not yet known, there is concern that lotteries may inflate the public's perception of vaccine risks and also distract from the message to be vaccinated for the community's good rather than personal financial gain. 1, 2 Cancer Month 0, 2021 Although it is possible that piecemeal mandates could elevate the number vaccinated, Dr. John Drake, Director of the Center for the Ecology of Infectious Diseases at the University of Georgia, recently calculated that 93% of the population would need to be fully vaccinated to "contain" the spread of the more transmissible Delta variant, a percentage hardly imaginable even if there is a snowballing effect toward businesses, schools, and some government agencies mandating vaccinations. 2, 3 For some time, I thought that I might be more successful in convincing my patients to be vaccinated if I understood their vaccination hesitancy. Surveys from the Centers for Disease Control and Prevention describe various reasons for vaccine hesitancy, such as safety concerns, wait and see attitudes, and a lack of faith in government agencies. A survey by Carnegie Mellon University and the University of Maryland found that 70% of vaccinehesitant adults worried about potential side effects of COVID-19 vaccines. 4 It seems unlikely that the patchwork of mandates planned by businesses and government agencies for their employees and by colleges for their students will work either. Requiring proof of vaccination to go to the cinema or your favorite restaurant is likely to be another woefully inadequate plan that epitomizes the lethargic and inadequate approaches taken so far, particularly because Americans have already witnessed the horrific suffering and death of their own loved ones and an unfathomable number still refuse vaccination. This is a race against a rapidly spreading virus that is far too capable of giving rise to vaccine-resistant variants for incremental measured employer-mandated approaches to be effective in time. The virus does not recognize local borders or state or national borders. I believe that a universal national mandate is needed now. As advocates for oncology patients, who are among the most vulnerable, I believe that it is our responsibility to urge either an emergency executive order or federal legislation. Physicians are the most credible citizens regarding COVID-19. Enough patients may not trust us, but elected officials, whose most fundamental role remains protecting Americans from existential threats, might listen. Although all physicians carry the responsibility to speak out, oncologists in particular must lead the way because our patients are among the most vulnerable should they contract the virus. The legality of a national mandate is not certain. MaryBeth Musumeci of the Kaiser Family Foundation wrote: "It is unclear whether COVID-19 vaccines can be mandated while under a EUA [emergency use authorization], and courts have not ruled on this issue." 5 However, now COVID-19 vaccinations are fully approved by the Food and Drug Administration. In Scientific American, Gorton wrote that "all courts have recognized the states' authority to mandate fully approved vaccines," and legally, the federal government can require vaccinations "to prevent the transmission of a dangerous infectious disease across state lines." 6 On the other hand, the ethics seem clear. The ethicist and philosopher Julian Savulescu wrote that "mandatory vaccination, mandatory for COVID-19, can be ethically justified if the threat to public health is grave, the confidence in safety and efficacy is high, the expected utility of mandatory vaccination is greater than the alternatives and the penalty or costs for non-compliance are proportionate." 7 In all ways, the current crisis clearly meets Professor Savulescu's criteria for a carefully constructed mandate. As for implementation, the pharmaceutical industry has produced and, with the assistance of private businesses and government agencies, widely distributed the vaccines in this country. In fact, the Kaiser Family Foundation reported that, as of June 2021, the share of Americans who wanted to get vaccinated "as soon as possible" but could not was only 3%. We have the tools to contain the virus: we need only the will of our government to act decisively. 8 While we ponder the legal and ethical questions, the virus is terrorizing the world. Our elected officials must mandate vaccinations and work with the rest of the world to do likewise before there is more suffering and death and before more resistant variants emerge. Martin Luther King wrote that "a man dies when he refuses to take a stand for that which is true." COVID-19 remains a public health crisis that can be stopped. It is the responsibility of physicians and other health care providers to expand our stand, and our focus now must include urging legislation to mandate COVID-19 vaccines in order to protect our patients and communities. No specific funding was disclosed. Covid-19 vaccine lotteries might work for the short-term, but they could ultimately backfire. Forbes Do vaccine incentives actually work How many people do we need to vaccinate against Covid-19? Thanks to Delta, just about everybody. Forbes Vaccine hesitancy: more than a pandemic Key questions about COVID-19 vaccine mandates. KFF Vaccine mandates are lawful, effective, and based on rock-solid science Good reasons to vaccinate: mandatory or payment for risk? Mandate the vaccine, not masks. Vox The author made no disclosures.