More Than Nudges Are Needed to End the Pandemic

The only realistic end of the Covid-19 pandemic lies with widespread vaccinations, but a sizable part of the population doesn’t want them. A broad range of public responses is possible.

At one extreme are government mandates. Everyone could be required to be vaccinated or face severe punishments. At the other extreme are what Cass Sunstein and I called “nudges” in the first edition of our 2008 book. As we define the term, nudges gently guide people without requirements or economic incentives. Informing people about the benefits of vaccinations and making it as easy as possible to get a shot are in this category.

Many interventions fall between these two extremes. We might call those pushes and shoves.

Wisely or not, governments around the world so far have generally rejected the idea of a hard, universal requirement to be vaccinated, in spite of many precedents. For example, George Washington inoculated his troops against smallpox. Individual states have long required schoolchildren to be vaccinated for a variety of illnesses.

Earlier in the Covid vaccine campaign, nudges were the appropriate policy tool, because the initial doses mostly went to those who wanted the shots. But at this point, those who remain unvaccinated yet would benefit from shots largely range from skeptics to those who are strongly opposed to vaccinations. That’s why its time to go well beyond nudging.

The case of cigarette smoking provides some useful lessons. When the dangers of smoking were well established, and recognized by the government in a landmark surgeon general’s report in 1964, cigarettes were not banned. The initial steps to protect public health involved education, which the tobacco industry countered with disinformation campaigns.

So society took sterner steps. Federal and state governments raised taxes on cigarettes, the Food and Drug Administration made the warning labels on packages increasingly graphic and new regulations made smoking away from home more and more difficult. Yet even with all these measures, one in seven American adults still smokes. Changing the behavior of millions of people is hard, even over decades.

In the case of Covid vaccinations, society cannot afford to wait decades. Although vaccines are readily available and free for everyone over age 12 in the United States, there are many holdouts. About 40 percent of the adult population has not been fully vaccinated, and about a third has not yet gotten even one dose. It is time to get serious.

Of course, information campaigns must continue to stress the safety and efficacy of the vaccines, but it is important to target the messages at the most hesitant groups. It would help if the F.D.A. gave the vaccines its full approval rather than the current emergency use designation. Full approval for the Pfizer drug may come as soon as Labor Day, but the process for the other vaccines is much further behind.

One way to increase vaccine takeup would be to offer monetary incentives. For example, President Biden has recently advocated paying people $100 to get their shots.

Although this policy is well intended, I believe it is a mistake for a state or a country to offer to pay individuals to get vaccinated. First of all, the amount might be taken to be an indicator of how much — or little — the government thinks getting a jab is worth. Surely the value to society of increased vaccinations is well beyond $100 per person.

Second, it seems increasingly likely that one or more booster shots may be necessary for some populations in the United States to deal with the Delta variant of the coronavirus — and, perhaps, other variants as well. If that happens, we don’t want some people to procrastinate, hoping to get paid. Government-sponsored booster shots are already beginning in Israel and are at various stages of planning in several European countries.

An alternative model is being offered by the National Football League, which has stopped short of requiring players to be vaccinated but is offering plenty of incentives. Unvaccinated players have to be tested every day, must be masked and at a distance from teammates on flights, and must stay in their room until game day. Vaccinated players who test positive and are asymptomatic can return to duty after two negative tests 24 hours apart. But unvaccinated players must undergo a 10-day isolation period.

These incentives followed a long effort to educate the players about the benefits to themselves, their families and fellow players. It is hard to say which aspect of the N.F.L. plan is doing the work, but over 90 percent of the league’s players have received at least one jab. The fact that a team could lose a game because an unvaccinated player can’t play creates a powerful group dynamic.

A focus on teamwork is also featured in the Cleveland-Cliffs steel company’s generous offer to its employees. Vaccinated employees get a bonus depending on how many others at their work site do likewise. The company will pay vaccinated workers $1,500 if 75 percent of employees get the vaccine, and $3,000 if the proportion reaches 85 percent. This focus on group vaccination rates reinforces the message that everybody benefits if more people get jabs.

Many universities and businesses like Walmart, Disney, Google and Uber are requiring employees to be vaccinated before returning to campus or the office. New York City will require vaccinations for indoor restaurants, gyms and other activities. But carrying out such policies is unnecessarily difficult because of the archaic state of vaccination records.

As anyone who has been vaccinated knows, the card you receive to document your shots looks like a handwritten 1950s library card, and is too big to fit in a wallet. It is jarring to use that piece of paper as documentation for vaccines created with 21st-century science.

California and New York State (and many countries) have shown that there is a better way. The basic idea is to turn the information on that card into a digital Covid vaccine record. Specifically, the record contains your name, birth date and vaccination history. That information is captured in a QR code that can be scanned easily. The QR code can be stored on a smartphone or printed.

It is important to stress that New York State and California have made this digital record an option for their residents — they did not require that anyone get it. Furthermore, the information captured by the QR code is merely what is already on that card. No one’s rights or privacy is at stake.

There have been inevitable start-up glitches, but these states have been leading the way. Nevertheless, it’s reasonable to expect the federal government to play at least a facilitating role in making this happen. Many people have gotten shots in two states or in one other than the state in which they live. Without federal coordination, creating reliable electronic documentation across jurisdictions will be a major database management problem.

Being unvaccinated in 2021 is similar to smoking in public, though it is more immediately hazardous. The unvaccinated are endangering themselves and those with whom they come into contact. It would be good public policy if those who refuse to be vaccinated are compelled to spend more time alone.

Richard H. Thaler is a professor of economics at the University of Chicago and the winner of the 2017 Nobel Memorial Prize in Economic Sciences. He and Cass Sunstein are authors of the newly revised “Nudge: The Final Edition,” which was published on Tuesday.