Intended for healthcare professionals

Feature Vaccination

Donuts, drugs, booze, and guns: what governments are offering people to take covid-19 vaccines

BMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n1737 (Published 13 July 2021) Cite this as: BMJ 2021;374:n1737

Read our latest coverage of the coronavirus pandemic

  1. Serena Tinari, freelance journalist,
  2. Catherine Riva, freelance journalist
  1. Bern, Switzerland
  1. serena.tinari{at}re-check.ch
  2. catherine.riva{at}re-check.ch

As the race to vaccinate the world accelerates, some countries are using novel methods to persuade those who are less forthcoming. Serena Tinari and Catherine Riva report

In Ohio, you could get a covid-19 vaccine … and the chance to win a million dollars. “Vax a Million,” a state funded public outreach campaign, consisted of a five weekly lottery drawing for those taking their covid-19 shots. For Ohioans aged 12 to 17, there was a draw for five four-year university scholarships.1

Cash, donuts, fishing and hunting licences, entry to museums, zoos, concerts or a sports game: these are just some of the offerings to people if they take a covid-19 jab in the US.2 “Get a shot and have a beer,” teetotaller President Joe Biden had said,3 which New Jersey took literally with its “Shot and a Beer” campaign.4 Others go further: Washington state offers “Joints for Jabs”5 and Michigan, “Pot for Shots.”6 In West Virginia, the “Call to Arms” vaccine initiative will be paid for using federal pandemic relief funds. It promises to the vaccinated cash, trucks, and guns.7

And it’s not just the US. In Canada, children as young as 12 have been offered ice cream for vaccines.8 The Netherlands has one place offering soused herrings.9 In Chang Mai, Thailand, you might win a cow.10 Hong Kong has gold bars and a Tesla on offer.11 In Romania, the Dracula castle has been transformed into a fancy vaccination centre to attract people.12 Some have turned instead to disincentives not to vaccinate (box).

As coronavirus variants dominate the news, and some batches of vaccine approaching expiry dates, health officials appear to be doing whatever it takes to get vaccination levels up, particularly in the face of vaccine hesitancy. But Ana Santos Rutschman, a legal scholar at Saint Louis University School of Law, has serious concerns about the trend, particularly where cash is concerned.

Rutschman argues that paying people “is undesirable against the backdrop of a pandemic marked by the intertwined phenomena of health misinformation and mistrust in public health authorities. Even beyond the context of covid-19, paying for vaccination is a dubious public health policy likely to backfire in terms of (re)building public trust in vaccines.”13

Trust and mistrust

Maya J Goldenberg, a philosopher of medicine who has published a book on the complexity of vaccine hesitancy,14 says incentives fail to address the underlying problem. “Incentive programmes do not target the trust relationship between the public and the providers,” Goldenberg told The BMJ. “They are meant to gently steer the ‘fence sitters’ in favour of the desired behaviour” (a recent Kaiser Family Foundation15 survey found nearly four in 10 adults in the “wait and see” group plan to wait more than a year before getting vaccinated).

Ross D Silverman, a health policy expert at Indiana University, said that incentives “focus on individual awards, rather than, say, offering a benefit should 85% of a community choose to get vaccinated.” He is concerned that they signify the limited success of common good-based public health messaging and are at risk of drawing public resources away from addressing underlying structural barriers in vaccine outreach programmes. “I’d rather government agencies not use incentives like guns, alcohol, and cannabis for these programmes,” he told The BMJ.

Allyson Pollock, who directs Newcastle University’s Centre for Excellence in Regulatory Science, agrees. “These programmes are the antithesis of good public health practice and are grounded in commercial interests, not public health,” she says. “Vaccination policies should be built on information, trust, and consent and not coercion and bribes. The policies of these incentives are adding public health harms as incentives for vaccine uptake.”

In the US in particular, Pollock worries about the lack of universal health insurance and high costs of care. “What are the safeguards for people who suffer adverse health events as a result of vaccination and have no insurance cover?”

Unintended consequences

Ana Santos Rutschman says small tokens like donuts or beer “do not strike me as posing the same type of ethical problems as direct payments” and that raffles and lotteries—being unpredictable and with low odds of winning—are in her view preferable to cash prizes.

But others say incentives of any kind could still selectively pressure people of lower socioeconomic status over others. Goldenberg asked: “What do those who don’t win the lottery get? They are vaccinated (a benefit), but if they feel mistreated because they were compelled to do it (ie, because the unjust system makes college out of reach for many), then there is legitimate moral harm.”

Poorly designed incentives may ultimately backfire. Research conducted by behavioural economist George Loewenstein has shown that people believe a study’s riskiness to be greater when payment is higher.16 In a recent article in the New York Times, Loewenstein and a colleague write: “Humans don’t respond to incentives like rats pressing levers for food; they try to interpret what being offered payment means. In this case, the offer risks implying that the vaccine is not a thing of value.”17

Disincentives

While rewards dominate, some locales have turned to retribution. In the Philippines, President Rodrigo Duterte has stated: “Get vaccinated or I’ll jail you.”18 And while Serbia is offering the vaccinated €25 (£21, $29) (around 1.5 days’ earnings for the average worker),19 its president announced that unvaccinated public sector employees would no longer be eligible for sick pay if they contracted covid-19.20

Various governments and businesses are considering the case for employees—health workers in particular.21 In Moscow, two million people in public-facing jobs have been told they must be vaccinated by the city’s mayor. Businesses will be monitored to make sure they comply, with at least 60% of employees needing a first dose by 15 July or firms risking being fined. In May, Saudi Arabia’s government said employees in the public, private, and non-profit sectors must be vaccinated before they can return to work. And the city of San Francisco has announced a similar requirement for its 35 000 public employees, to take effect once the covid-19 vaccines are approved.22

Footnotes

  • Competing interests: Serena Tinari and Catherine Riva are the co-founders and co-chairs of Re-Check, Investigating and Mapping Health Affairs.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References

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