Rationality and Immunization

Commentary

The rational man, said Bertrand Russell, holds his beliefs with a strength that is proportional to the evidence in their favor: to which one might add that he also fears dangers in proportion to their likelihood of their coming to pass.

Unfortunately, on these definitions no rational man has ever existed or ever could exist. Even if it were possible to measure the strength of a man’s beliefs or fears on a valid and reproducible scale, the fact is that none of us either does or can spend his life examining the evidence for all that he believes or fears. At best, we can do so only intermittently and in bursts. We are obliged to take much on trust or according to our prejudices.

No subject now arouses more passion than immunization against epidemic disease, as it has always done. Possibly the most popular and persistent social movement in England during the nineteenth and early twentieth centuries was that against smallpox vaccination, some form of which eventually rid the world altogether of the disease.

Of course, detractors of that achievement might point out that so long as a supply of the virus exists anywhere in the world (as it does), or some mad scientist or evilly-disposed government could engineer the virus, the loss of herd immunity to the disease consequent upon its eradication makes mankind very vulnerable to an unprecedentedly violent recrudescence of it, or even susceptible to political blackmail by those in possession of the virus who threaten to spread it.

But, as Doctor Johnson has one of his characters say in “Rasselas,” “Nothing will ever be attempted, if all possible objections must first be overcome.” Mankind is thus inevitably both the beneficiary and the victim of the Promethean bargain.

The assertion, often made, that the long-term effects of the Pfizer and Moderna vaccines are unknown is therefore correct in the strictest sense but irrelevant. The long-term effects of much of what we do are unknown. Moreover, we often mistake the rational reasons for doing what we do.

For example, millions, probably tens of millions, of people now take medicines without any understanding of the reasons for doing so. They are mentally stuck in the days when doctors prescribed medicines to cure diseases (whether or not they did so) and do their individual patients good.

Thus, when they take drugs to lower their cholesterol or their blood pressure, they think that the drugs are doing them good as individuals: if they didn’t think so, they probably wouldn’t take them. (As it is, about a half of patients prescribed pills to lower blood pressure give them up within a year.)

But in fact, in the great majority of cases, these drugs are not doing them any good as individuals, though if you give them to enough people for long enough, some of them—a minority—will avoid having a heart attack or stroke that they would otherwise have had.

Many people will have to put up with the slight inconvenience of taking daily medicines or with side-effects in order that some may benefit hugely. This is very different from the person with pneumonia who takes antibiotics or the person with hypothyroidism who takes thyroxine.

Sometimes a doctor has to be paternalist. I once had a patient who had a somewhat raised blood pressure and was therefore, statistically, at increased risk of heart attack or stroke. I gave him the best statistical information I could and asked him whether he wanted to be treated.

“I don’t know,” he said. “You’re the doctor.”

I thought his answer eminently sensible. I decided that he should not take the pills, partly because his risk was not very elevated, partly because I thought he might get side-effects and his quality of life impaired, and partly because I didn’t think he would take them properly anyway and did not want him to feel guilty for not doing so. He was happy with my advice.

Immunization is different. The above patient’s decision affected mainly himself, albeit that, since no man is an island, there was a small chance that others would be affected by his decision also.

By contrast, immunization seeks not only to reduce very drastically an individual patient’s chances of contracting a disease, but to interrupt the transmission of the disease and if possible to eliminate it altogether.

This has very nearly been done with polio. Fortunately, it does not require every last person to be immunized: when a sufficiently large proportion of the population has been immunized, the rest benefit as if they had been immunized. Immunization is both a personal and social choice.

The fear of immunization against Covid-19 seems to me exaggerated and irrational. The fact that none of us can be fully rational does not obviate the need for us to try to be as rational as possible.

Here are some figures from the British Medicines and Healthcare products Regulatory Agency (MHRA), the organization in charge of tracing harmful effects of drugs and medical equipment. It has a scheme by which any doctor, nurse or member of the public can report any suspected harmful effect to it.

As of 5 April, 31,622,367 people had received a first dose of vaccine, and 5,496,716 people a second. In all, there were 43,890  reports of side-effects with the Pfizer, and 126,577 with the Astra-Zeneca, vaccine. 11 million people had received the Pfizer vaccine, and 20.6 million the Astra-Zeneca.

The vast majority of the side-effects reported were not serious and, because of the vagaries of reporting, affected for example by publicity, no conclusions about relative frequency can be drawn from these raw figures.

There were 314 deaths within a month of immunisation with the Pfizer vaccine and 521 with the Astra-Zeneca, suspected by someone of having a connection with the immunisation, that is to say one in 35,032 for the Pfizer, and one in 39,539 for the Astra-Zeneca.

However, these figures are meaningless in themselves, because there is no proof of a causative relationship between the vaccine and the death; in any given month a number of people among 31,000,000, especially including the oldest section of the population can be expected to die, on my back-of-the-envelope calculation at least 25,000. So vaccine followed by death within a month cannot possibly be taken as indicating cause and effect.

The one exception appears to be thrombosis (blood clot), particularly, but not exclusively, of the cerebral venous sinus. There were 100 cases reported, with 22 fatalities, that is to say a fatality rate of one in 936,364 doses given.

If we were to take notice of a 1 in 936,364 chance of dying from something, all human activity whatsoever would cease. Even if half the cases were missed, the figure would still be 1 in 468,182. To adapt Dr. Johnson slightly, nothing will ever be attempted, if all possible dangers must first be avoided.

Theodore Dalrymple is a retired doctor. He is contributing editor of the City Journal of New York and the author of 30 books, including “Life at the Bottom.” His latest book is “Embargo and Other Stories.”