COVID-19 Measures Are Soft Compared With Tuberculosis Rules

On Sept. 9, U.S. President Joe Biden announced a new policy that would require all businesses with more than 100 employees to ensure their workers were either vaccinated against COVID-19 or submitted to weekly testing, to be enforced by the Occupational Safety and Health Administration. There was, predictably, conservative backlash, from both politicians and right-wing media. Larry Elder, the leading Republican candidate in the California gubernatorial recall election, called the mandate “tyrannical & authoritarian.” Sean Trende of the American Enterprise Institute asked if the policy signaled a “greater shift in American liberalism.” Josh Holmes, a former chief of staff for Sen. Mitch McConnell, declared: “I’m as pro-vax as it gets but this is an outrageous trampling of civil liberties.”

Several state attorneys general threatened legal actions, as did police unions. Although conservatives were particularly hostile toward the mandate, many others also expressed doubt. Overall, the response to mask and vaccine mandates has featured a similar set of questions: Are such restrictions on individuals’ choices a new threat to liberal society?

But very little about these mandates is novel. Liberal societies have long compromised—for good reason—on individual choice when it comes to controlling infectious diseases, from smallpox to cholera. And, in many cases, the restrictions are far more severe than requiring vaccinations. In comparison, the Biden administration has had a relatively gentle touch. Consider what the government does to protect Americans from another infectious disease: tuberculosis, or TB. As a former TB patient, I have personal experience in this domain.

In 2016, I was diagnosed with TB. I was immediately turned over to public health authorities and informed of the many choices that the government would now make for me. I would submit to contact tracing. I would provide information for everyone I was in close contact with over the previous 18 months. Each person—from my professors to my students to my infant niece—would be tested. I would not choose my doctor. I would be quarantined as the government saw fit. I would submit regular X-rays and bloodwork. I would also provide sputum samples, which, they explained, often involved medically induced choking.

While undergoing treatment, my movements would be restricted. Whenever a sputum sample came back positive for the bacteria, I would return to quarantine. While in quarantine, public health workers would sporadically come to my home to ensure I was compliant. Even out of quarantine, I could leave my house, but I couldn’t go far. A trip outside the city required permission. And if permission was granted, it came with conditions. I would need to immediately report to the public health department at my destination, which would take over the supervision of my medication. If I were to deviate from this protocol, I would be taken to court and placed in jail.

The treatment for TB is unforgiving. I would receive a cocktail of antibiotics for six to nine months. I would not administer these antibiotics myself; rather, a government employee would come to my home every day to unwrap the pills and watch me swallow them. I would learn the rationale for such strict measures: Studies have shown that TB patients are frequently noncompliant. This is due in part to the difficulty of the antibiotic treatment. Patients typically experience peripheral neuropathy (pain and numbness from nerve damage), rashes, nausea, and incapacitating fatigue. The antibiotics can cause liver and kidney damage and, in rare cases, colorblindness. Due to drug toxicity, one must eliminate alcohol and certain foods and avoid exposure to the sun. The antibiotics also interact with many other common medications. In my case, I had no choice but to stop taking antacids. After I developed neurological symptoms of serotonin syndrome, I had to stop taking antidepressants.

Having gone through this process, I experience some mild amusement when I hear commentators naively wonder if the Biden administration’s vaccine mandate poses a troubling new problem for liberal society. Many much more intense measures have been in place for decades—they’ve just affected a smaller number of people.

Of course, plenty of unjustifiable measures last for a long time, and considering the value of these restrictions is still valuable. Discussing those limits is a well-established part of the debate within liberal societies. In On Liberty, published in 1859, the English philosopher John Stuart Mill asserts what is now uncontroversial—an individual’s choices are properly subject to regulation when necessary to prevent harm to others: “As soon as any part of a person’s conduct affects prejudicially the interests of others, society has jurisdiction over it, and the question whether the general welfare will or will not be promoted by interfering with it, becomes open to discussion.” Mill’s proposal was clear enough: When someone’s actions threaten harm to others, they may be appropriately subject to state intervention. Liberalism is not anarchy, after all. But defining that harm can be the tricky part.

The delicate balance between maximizing liberty and minimizing harm has long informed U.S. laws, including those pertaining to infectious disease control. In the early 1900s, smallpox infections surged in the state of Massachusetts. Initially, the state encouraged voluntary vaccination, but, when this proved insufficient, the legislature enacted compulsory vaccination. Henning Jacobson, who refused to be vaccinated, was issued a fine. Jacobson sued Massachusetts, arguing the law was “unreasonable, arbitrary, and oppressive.” In 1905, the Supreme Court ruled in favor of the state. The majority’s decision echoed the liberal principles espoused by Mill, arguing, “There are manifold restraints to which every person is necessarily subject for the common good. On any other basis organized society could not exist with safety to its members. Society based on the rule that each one is a law unto himself would soon be confronted with disorder and anarchy.”

Thus, the issue is not whether the state can justifiably interfere with individual liberty—that is obvious—but, rather, what conditions are necessary to justify this interference?

If we assess both my treatment for TB and the Biden administration’s vaccine mandate in terms of their burden, the harm prevented, and the benefit for society, the balance overwhelmingly shows these policies are justifiable.

Consider first the burdens of the policies on individuals. My TB treatment was extremely onerous. Many of my choices were constrained, if not fully out of my hands. My privacy was regularly invaded. My medication had serious side effects. There was also some benefit. Without treatment, I would have likely died. .

The burden of the vaccine mandate, by comparison, is extremely low, verging on trivial. A jab in the arm takes only a few minutes. The side effects are also minimal. Though many people experience no side effects at all, some endure unpleasant flu-like symptoms, including headache, fever, and chills. However, these symptoms resolve over the course of a few days. More serious side effects are exceedingly rare. There is no contact tracing. There is no cessation of other medication, no daily visits from public health workers, and no restrictions on travel. Additionally, like mandatory public school vaccinations for measles and mumps, the proposed COVID-19 mandates do not entail fining or jailing individuals for noncompliance; rather, they restrict individuals’ access to public spaces where they may pose a harm to others. There is also great personal benefit to vaccination. COVID-19 vaccines provide reliable protection from a disease that, even in cases of survival, can cause multiple organ damage and long-term functional impairment.

This personal benefit-to-burden ratio is hard to beat. But everyone in the United States benefits from the government’s treatment of TB. The disease remains in the top 10 leading causes of death internationally and, prior to COVID-19, was the leading cause of global deaths from infectious disease. In 2019, 130 in 100,000 people fell ill with TB worldwide, and 18 in 100,000 died. In the United States, the rate of illness was 2.7 in 100,000, and the rate of death was 0.2 in 100,000. This vast difference in both disease and death rates can be partially attributed to the strictly enforced treatment protocols I know too well. The invasive and traumatizing contact investigation also ensured that those I had infected could be treated before they advanced to necrotic lung disease.

The surveillance of my treatment, and the specific combination of antibiotics, conferred another significant benefit to society: TB patients are frequently noncompliant, such that they refuse to take the full course of treatment. And, even in the case of compliant patients, if an individual errs in self-administering their drug regimen, they risk developing multiple-drug-resistant TB. This form of the disease is more fatal: According to the WHO’s 2020 report, the global treatment success rate for MDR-TB was only 57 percent, compared to 85 percent success for drug-susceptible cases. In addition to a lower success rate, drug-resistant bacteria are so resilient that treatment lasts, on average, at least 18 months and more toxic antibiotics are required to defeat the infection, if it is defeated at all. Many experience neurological side effects, from convulsions to psychosis. Researchers have found that as many as 50 percent of patients will experience hearing loss.

The considerable burden of TB care is balanced by the extreme harm it prevents. What about COVID-19?

The extent of community harm caused by undervaccination is hard to overstate. More than 711,000 Americans have died of COVID-19. Many who have survived will live with life-altering organ damage. The delta variant is particularly contagious, such that, on average, each infected person will infect six others, leading to exponential spread and overwhelming health care systems.

Undervaccination also presents problems beyond infections and deaths. When a hospital system crumbles, the effects are profound and widespread. Cancer treatments are delayed. Patients with broken bones linger untreated in excruciating pain. Organ donations have decreased, and the wait time for lifesaving kidney transplants has grown. When medical resources are strained in this way, every aspect of American life—from being pregnant to driving one’s car—becomes infinitely more dangerous.

So, no, there is nothing new about using the strong arm of public health. The Biden administration’s mandate is in line with the long tradition of vaccine mandates in schools, the military, and other domains of public life. For both political and philosophical reasons, the United States has stayed away from using more intrusive methods—even if, like centralized quarantine, they proved highly effective elsewhere.

These policies are perfectly consistent with principles at the very heart of liberalism: justifying restrictions on people’s choices based on a calculation of individual burden and community harm. Indeed, the COVID-19 vaccines have an especially favorable profile. The burden on individuals is virtually nonexistent. The harm prevented—both to others and to society as a whole—is immeasurable.