Think politics is nasty? Just wait for the battle over the vaccine

As the day after Election Day dawns, the immediate task for Tuesday's victor is likely to be more mundane and less ideological — and guaranteed to displease most Americans.

The issue that is likely to dominate political discussion for some while, even before Jan. 20, is how to handle and distribute new coronavirus treatments. These debates will be all the more pressing because it now appears that winter will bring a big uptick in cases, hospitalizations and, unfortunately, deaths.

There is now growing evidence in favor of the AstraZeneca vaccine, and even some talk of it being available in the United Kingdom as early as November. Should this same vaccine be rush-approved for use in the U.S.?

Note that on vaccine issues, American public opinion does not map neatly along a simple left/right axis. There are plenty of vaccine skeptics (and advocates) on both sides of the political spectrum, so neither Trump nor Biden can expect their usual allies on this issue.

And who should get the vaccine first? The elderly are more vulnerable, but the young are more likely to spread COVID-19. Some recent results suggest it would be better to vaccinate the young first, but that is less politically likely. Again, it is easy to see potential conflicts over this question, cutting across traditional party lines.

An even more complex problem would arise if one good vaccine is available but other, possibly better, vaccines are imminent. Does everyone get the "good enough" vaccine, disrupting the ability to conduct clinical trials to see if the other vaccines are better? How much patience do Americans have, really?

Americans would probably resent having to wait. But if they end up choosing a lesser quality vaccine, over the long run they might be unhappier yet. It is not clear the U.S. public health bureaucracy is up to the task of approving one vaccine and restructuring the other trials (possibly by paying participants more to stay in, or by shifting to other countries for data) so they can continue.

One sensible approach is to give them preemptively to those working on the front lines, such as nurses and doctors. Still, many more Americans will want them. It will be difficult for any administration to say they cannot have the treatment because they are too far advanced in their coronavirus infection. If you feel bad, you may be desperate to try them (and they probably won't hurt you); and even if you feel OK, you may think that it is exactly the right time to take them (soon enough to make a difference, and besides, aren't Americans famous for demanding overtreatment?).

For policymakers this is a Catch-22, and even scientifically literate Americans are unlikely to confront this situation with full rationality. Again, many Americans will walk away unhappy. There is also the prospect that the antibodies will become the province of the very wealthy or the very conscientious. Imagine that you are rich enough or careful enough that you test yourself virtually every day, doing retests to rule out false negatives and false positives. If it turns out you have COVID-19, then you would rush to get your monoclonal antibodies.

Good for you — but that probably won't be most Americans, even if issues of cost and access are taken care of. Unfortunately, the U.S. is not preparing itself for a system in which most people get tested every day. The result is that the split in health outcomes between the conscientious and the non-conscientious will grow wider yet. And again, the winners and losers will not fall into the standard political coalitions.

With the election, most political commentary has been focused on ideological polarization. Soon enough, the biggest conflicts could be over the time-honored issues of life and death.