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Opinion Dollars and doughnuts alone won’t conquer vaccine hesitancy

A lollipop and a sticker at a mobile coronavirus vaccine clinic in Orange, Calif., in April 29. (Jae C. Hong/AP)
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In Maryland, Gov. Larry Hogan (R) has announced a $100 bonus for every state employee who gets vaccinated against covid-19 and keeps the vaccine up to date. Maryland joins a long list of governments, philanthropies and corporations dangling every sort of incentive — literally from dollars to doughnuts (in the form of a free Krispy Kreme glazed) — to entice Americans to take a jab or two for the team. But such incentives are unlikely to move the needle on vaccine hesitancy.

With the medical doctors Anthony S. Fauci and Deborah Birx reduced to cannon fodder in the covid culture war, the psychologists Daniel Kahneman and the late Amos Tversky are now dominating the persuasion effort. Pioneers in the field of behavioral economics, they rank among the most influential thinkers of the late 20th century.

Kahneman won the Nobel Prize in Economic Sciences in 2002; Tversky, his frequent collaborator, died of melanoma in 1996, at age 59, so was prevented from sharing the award. Their great insight might not seem so groundbreaking now, but for economists, it was a humdinger. The professors demonstrated that human beings are not the rational animals envisioned by Aristotle. We’re not computers, Homo economicus, coolly calculating our interests in each action and transaction. We tend to overvalue risk and undervalue reward — except when we err in the other direction. To steer onto the right path, we often require nudging.

For the roughly half of all adult Americans already vaccinated, the incentives were simple. We believed that covid-19 was a genuine communal threat. We recognized the value of vaccination in protecting not only ourselves but also our families, friends and neighbors. We saw the vaccines as the simplest and safest path back toward happier, more liberated lives.

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A significant portion of the remaining population doesn’t see things that way. They judge the rewards of vaccination to be lower and the risks to be higher. Health risks. The risk of inconvenience. Even the risk of the government or Bill Gates secretly slipping a microchip into their arms. For some, $100 and a sugar-glazed doughnut might be enough to reorder their calculations. However, research in the field pioneered by Kahneman and Tversky suggests that nudging our way to public health won’t be so easy.

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For private employers, offering a coronavirus-vaccine bonus can be a legal and logistical minefield. Taxes must be withheld. Protections may be triggered under the Americans with Disabilities Act and the Civil Rights Act. Employees cannot legally be punished for having a vaccine allergy or sincere religious objections to vaccination. Leading employment law firms have been cranking out compliance instructions for months.

Despite those efforts, the incentives might not do much good. Britain’s Wellcome Trust funded a study several years ago on the use of cash incentives to promote voluntary testing for chlamydia, a sexually transmitted disease rampant among college students. Some students were offered gift cards at a popular retail outlet; others were offered tickets in a lottery with a much bigger payout. The gift cards worked better than the lottery — but here’s the catch: Neither worked well. The vast majority of students continued to shun the tests.

Those results were consistent with years of data showing mixed results, at best, in programs offering cash incentives to improve health. “Although success has been seen” in some cases, according to one survey of the field, “some financial incentives have not worked at all well, or even at all.”

No health issue better illustrates the limits of incentives to change behavior than smoking. For more than 50 years, since the surgeon general defined the risks, Americans — 45 percent of whom smoked in the 1960s — have been warned, cajoled and frightened about smoking. The price of tobacco products has skyrocketed. Television and radio advertising has been banned. Companies offer cash and insurers offer discounts to nonsmokers or smokers who quit. But 1 in 7 U.S. adults was still puffing away in 2019, according to the Centers for Disease Control and Prevention.

Employers might be better off spending their token bonus money on steps to make vaccination more accessible, and on efforts to create a corporate culture of participation. As a young person, the first time I bothered to get a flu vaccine was when my employer offered it on the way into the lunchroom. Factory owners post signs indicating how many days their company has gone without an injury on the job; similar signs could track the percentage of vaccine-eligible employees who have taken the jab, perhaps boosting the sense of shared safety. Employers can agree to ease masking and social distancing measures in the workplace once a certain level of vaccination is reached.

This will take patience and creativity. Unfortunately, there is no simple $100 path to vaccine compliance.

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