A Moral Theory of Vaccination: States, Societies and the Control of Contagion in China and India

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The ongoing Covid-19 pandemic is a stark reminder of the terror that infectious diseases have long struck in the hearts of humans. This fear is driven by the consequences of contagion. Since settled agriculture and the domestication of animals, germs have not only been the single largest cause of human morbidity and mortality, they have triggered economic reversals of fortunes, prompted societal upheavals and decisively shaped the trajectory of world history precipitating the collapse of once-mighty empires. But in as much as these human, social, economic and political tolls, what makes infectious diseases so uniquely terrifying is their mode of transmission – passing and disseminating stealthily via virtually invisible pathogens across even tightly policed political and administrative boundaries. Yet while disease does not respect political boundaries, an individual’s vulnerability to an infectious disease has historically and continues today to depend critically on the political boundaries she has resided within. Polities with similar epidemiological, socioeconomic and demographic conditions have been characterized by strikingly different levels of effectiveness in countering equivalently severe challenges posed by a disease. Why? Beginning with states as key actors in the control of disease, I argue that their ability to do so hinges critically on their relationship to society. Specifically, I propose a typology of state capacity in which public health represents a category of core tasks including taxation, and raising a volunteer army, where (1) a state’s success is contingent on its ability to gain compliance from society, and (2) gaining such compliance is challenging because these tasks constitute collective action problems. The question then is how have states been better able to secure such compliance? I approach this question through a historical analysis of an empirically urgent topic – the uptake of vaccines. The invention of vaccines was a watershed moment in public health and constitutes a landmark in our ability to control infectious disease. Rational actor models would suggest that people would be more willing to accept vaccines if they are provided more information about its (minimal) risks vs benefits. Yet, through history and into the present day, such strategies have been shown to be of limited utility. This is because humans are less than rational. Our cognitive biases are well established. But we are also more than rational. We are moral actors. Beyond narrowly-defined cost-benefit calculations, we are driven by norms, trust, legitimacy, allegiances, and other ideational considerations. I develop such a moral theory of compliance to explain the differential uptake of the world’s first-ever vaccine across China and India.

Discussant: Tanushree Goyal (Oxford and Harvard)