All Vaccines Are Not Created Equal

The J&J vaccine is especially useful for marginalized populations. Did that make it easier to suspend its use? In the wake of regulators’ lifting the suspension of the J&J vaccine (which I wrote about recently), states across the country have quickly resumed giving people the shot.

This is obviously good news, particularly given that the pace of vaccination in the U.S. has been slowing of late. But it also points to the fact that J&J’s shot is not just a bit player in the U.S.’s vaccination campaign. Instead, it’s filling a role that the mRNA vaccines are not, allowing public-health officials to reach underserved populations that otherwise might be hard to vaccinate. And yet this very fact, paradoxically, may have made it easier for regulators to suspend its use for as long as they did.

The J&J vaccine appeals to some people because it’s a conventional vaccine, rather than being a newfangled mRNA vaccine, which some people are wary of (even though the Pfizer and Moderna vaccines appear to be safer than the J&J and AstraZeneca shots). But its real advantage is simpler: it only requires one shot, while the Pfizer and Moderna vaccines require two. That’s appealing to people who are afraid of needles (of whom there are more than you might imagine). But it’s especially useful for another reason: a one-shot vaccine is ideal for vaccinating people who find it difficult to show up at two appointments in the same place over a four-week span.

That’s why the J&J vaccine has been key to efforts to vaccinate homeless people. It’s been widely used to vaccinate people who are being discharged from hospitals, and homebound seniors (since it means full vaccinations only require one visit.) And it’s been a staple of mobile clinics doing outreach in remote rural communities and vaccinating agricultural workers, who often move frequently, and who typically can’t get or afford time off from work to spend hours traveling to get a 2nd shot.

The extended suspension of the J&J vaccine meant that a lot of these people simply didn’t get vaccinated for 10 days or more. Mobile clinics for homeless people and rural workers were canceled, visits to homebound seniors postponed. People who had no trouble coming back in 4 weeks for a 2nd shot got Pfizer or Moderna shots instead. But a lot of people didn’t have that option. As NYC City Council member Mark Levine Tweeted at the time, the J&J vaccine has played a key role in closing the “equity gap” in access to vaccination. The pause widened it.

Now, it’s true that extending the pause only paused J&J vaccinations for less than two weeks. (The initial pause was intended to notify doctors of the risk of post-vaccine clotting and to advise on proper treatment for these clots. But the CDC advisory panel chose to keep it in place for another nine days to give them more time to collect and analyze data.) Nonetheless, it’s useful to ask yourself a question: Would it have been as easy for regulators to extend the suspension of an effective vaccine because of a very small number of reported blood clots, if the people affected by the suspension were well-off urban professionals? I think the answer is clearly no.

Why? Because had this suspension meant that members of the professional and managerial class couldn’t get vaccinated at all for 10 days, there would have been far more pressure on regulators to not to kick the can down the road. But the people who were mostly affected by the J&J suspension — homeless people, homebound seniors, agricultural workers — are some of the most marginalized people in America. The media doesn’t pay attention to them. They have no political pull. So the negative consequences of having them go unvaccinated were easy to downplay.

The counter to this argument, of course, is that we want vaccines to be safe, and we don’t want to skimp on vaccine safety just because a vaccine is being used to reach underserved populations. But as lots of public-health experts have argued, while the initial pause may have been justified, extending the pause represented not an abundance of caution, but an excess of it. It overweighted the potential costs of lifting the suspension, and underweighted the benefits. And it’s plausible that one reason for that is that the people reaping most of the benefits from the J&J vaccine are people who have no influence on congressmen, the media, and regulators. They’re people who are mostly ignored in public discourse, and they mostly got ignored in the debate over the suspension.

Political scientists and economists talk a lot about what’s called “regulatory capture” — the phenomenon of special interests, typically corporate, having far too much influence over regulatory agencies’ decisions. But the opposite phenomenon is true as well — the interests of genuinely marginalized groups often matter too little to regulators, not because of malice or ideological hostility, but simply because those interests are given such little weight in the public conversation. Call it “regulatory invisibility.”

It’s telling, after all, that when President Biden explained why he was not worried about the impact of the pause on vaccinations, he pointed to the fact that there were ample supplies of the Pfizer and Moderna vaccines available. That would have made sense if those vaccines were perfect substitutes for J&J. But we know that for lots of Americans, they weren’t.

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