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What do you do when your population is reluctant to get vaccinated against COVID-19? Over the summer of 2021, the answer from some policymakers in North America and Europe was to run a public lottery. The idea of a lottery for vaccinated citizens originated in Ohio, where a sweepstake aptly named Vax-a-Million gave adults who had received at least one dose the chance to win one of five $1 million dollar prizes. The Vax-a-Million programme quickly caught the attention of other state and national governments struggling with sluggish vaccination rates. By July, several Canadian provinces and more than 10 states in the United States established vaccine lotteries. In Europe, Poland, Romania, and Slovakia launched vaccine lotteries offering vaccinated citizens the chance to win generous cash prizes, as well as participate in draws for electric scooters and hybrid cars. Targeting citizens who remained indifferent to existing public health campaigns—rather than those categorically opposed to vaccination―these lotteries joined a long list of other initiatives employed to sway the unvaccinated, including cash bonuses, free beers, and even joints of marijuana.
There already exists a lively debate about whether vaccine lotteries work. Yet data-driven studies trying to determine their efficacy tell us little about the way citizens perceive and understand vaccine lotteries. In April 2022, I travelled to Slovakia to start an ethnographic exploration of the country’s vaccine lottery, Byť zdravý je výhra (Being Healthy Is a Win). One of my goals was to understand what people thought about the lottery and their health choices being turned into a game, and what reasons they had for participating (or not). The lottery showed up a fundamental gap between policymakers’ perception of citizens as calculative agents, and their own experience of themselves as morally and socially embedded subjects.
(Not) Getting vaccinated in Slovakia
I was vaccinated first. My husband waited to see whether I survived the fevers, and then he went. I watched him from the balcony; it was evening and getting dark, I saw him hesitate, he was looking at the trees, saying goodbye to everything―the little wrens too―and then then finally he went into the building. And I sent my friends and colleagues a message saying he had gone in, and one sent me back a message, “Betka, check he really has got a needle stick”!
Alžbeta, a schoolteacher, lives directly across from a large vaccination hub in the city of Banská Bystrica, Central Slovakia. In May 2021, she and her husband became eligible for vaccination against COVID-19 and booked their appointments with some trepidation. Like many other Slovaks, she had misgivings about the possible short-term and long-term effects of the new vaccines. She worried about the novelty of the mRNA vaccines (Moderna and Pfizer) and fretted about the reported rare (but potentially fatal) side effects of the AstraZeneca vaccine. In the end, however, her fears about the transmissibility and deadliness of the disease won out. She got vaccinated to protect her children and elderly parents, and encouraged her relatives to do the same. Not all of them followed suit: her sister and her elderly mother remain unvaccinated to this day.
The situation in Alžbeta’s family is not unusual. Slovakia is one of Europe’s least vaccinated nations: as of August 2022, just over 50 percent of the Slovak population has received at least two doses against COVID-19. This is despite the fact that vaccines were free and widely available throughout the country, and that vaccination was promoted as offering individual and population-wide protection against severe illness. Vaccine hesitancy in the country has several roots: low levels of public trust, a pre-existing anti-vaccination movement, and high levels of disinformation in the alternative media and online spaces. Surveys show that up to one-third of the population believe in conspiracy theories, including the fear that vaccines are designed to insert nanochips under their skin which allow citizens to be surveilled by the state and corporate actors. But many others, like Alžbeta, simply felt unable to evaluate the safety of the vaccinations. For them, accepting the vaccine was an expression of trust in the medical establishment and the government.
Vaccination is also a matter of solidarity, Tatiana, reminded me. Echoing government recommendations and the medical establishment, she told me that she got vaccinated not only to protect herself, but also to contribute to general population immunity. Tatiana did not share Alžbeta’s fears about the novelty of the vaccines against COVID-19, and she regarded the choice not to get vaccinated as selfish. In fact, her feelings of solidarity had their limits. Like Alžbeta, Tatiana and her husband belong to what is sometimes called the “sandwich generation,” and she had spent the first lockdown working full time as an architect while catering for the needs of her three children, her husband, and her mother-in-law. The fear of contaminating elderly relatives had led her to adopt strict protocols of hygiene and isolation, including disinfecting all the doorhandles in her house to the point they became discolored. After exhausting herself doing care work throughout the pandemic, she felt the reluctance of others to get vaccinated was a slap in the face.
“Then there was a second thing, which I found sick, which was that there was a lot of money involved for very few people.”
Juraj, a retired teacher, chose not to get vaccinated. He was unable―or perhaps unwilling―to give me a clear reason for his choice. Juraj suffers from several chronic health problems and wanted reassurance about the safety of the shots from his doctor before getting vaccinated. Once he received that medical recommendation, he waited to access a batch of the Russian-made vaccine, Sputnik V. Having received Russian-made vaccines as a child growing up in communist Czechoslovakia, Juraj believed his body would better tolerate a Russian-made vaccine. But when it became clear that the Slovak drug regulatory agency would not certify Sputnik V for public use, he decided to forgo vaccination outright. Indeed, Juraj had come to view the entire immunization exercise as part of a greater political game in which vaccines were being weaponized by various government and opposition figures. The vaccine lottery, too, was designed not to encourage the population to protect themselves, but rather to “get rid” of the thousands of doses which had been purchased by the government at great expense.
Byť zdravý je výhra
Juraj was not alone in experiencing government leadership during the pandemic as chaotic, ineffective, and overly politicized. The start of the pandemic in March 2020 coincided with a change of government which put in place a center-right coalition led by the businessman and politician Igor Matovič. While coalition partners frequently disagreed on key public health strategies, the leadership of the opposition party SMER joined far-right political actors in actively agitating against mask mandates and pandemic-related restrictions. Prime Minister Matovič was prone to demonstrative gestures of leadership without the consultation of his coalition partners, including agreement to the delivery of, and payment for, 200,000 doses of the Russian Sputnik V vaccine in March 2021. This move precipitated a political crisis, leading to Matovič’s move to the post of minister of finance, and his replacement as prime minister by Eduard Heger.
Matovič proposed the idea of a Slovak vaccine lottery after his move to the Ministry of Finance. Inspired by similar schemes running in North America, Being Healthy Is a Win ran from August 15 until October 31, 2021. The lottery offered prizes of €100 to €100, 000 to vaccinated citizens who had registered their personal details and vaccination status on the lottery’s website. Draws for the smaller prizes took place live every weekday evening on the public broadcasting channel RTVS 1, with the largest prizes distributed during a special prime-time variety show run every Sunday evening. This show included educational segments in which public health officials and medical personnel were invited to answer questions from members of the public about infection, treatment, and vaccination against COVID-19. According to Matovič, the lottery presented the perfect blend of financial incentives, entertainment, and enlightenment: “A very large number of people are afraid. They have questions that have not been answered. That’s why we decided to help financially motivate people who are hesitant. And at the same time offer them answers to those unanswered questions.”
“I think its ok, I don’t see a problem in motivating people this way,” Alžbeta told me when I asked her about the vaccine lottery. Having had a front-row seat to the spectacle of mass immunization, she thought the campaign had had some effect: “I think it gave vaccination some sort of positive boost, advertised it; suddenly I saw a long line of people, of pensioners in front of the center! It made me happy. Because at the start we all isolated ourselves because of these pensioners.”
Surveys show that up to one-third of the population believe in conspiracy theories, including the fear that vaccines are designed to insert nanochips under their skin.
For others, however, the lottery’s association with Matovič tainted it from the start. As Tatiana remarked: “The Lottery came across as one more of those wonderful schemes that Matovič thought of when he wanted to be the center of attention again…” Yet Tatiana’s reservations about the lottery ran much deeper than her dislike for the former prime minister:
I had problems with it on a number of levels. I really don’t think health should be the subject of a lottery, right? I have a very strong moral attitude to this. I felt like it diminished the value of the vaccine. Then there was a second thing, which I found sick, which was that there was a lot of money involved for very few people. Sure, if they wanted to do, why not do it by saying, “Fine, we’ll give everyone €50”? That would support public health and public finances.
She was not the only one who found the lottery’s coupling of financial incentives and health choices as morally distasteful. Jan, an economist, found the idea of the vaccine lottery itself unproblematic. He had studied the reports and peer-reviewed articles published on other vaccine lotteries from around the world and concluded that a one- or two-round lottery could indeed have an effect on vaccination rates. What bothered him about the version run in Slovakia was not the principle, but the format. The design of the competition was overly complex, ran for too long, and was too expensive. Yet what seemed to bother him the most was the fact it had no charitable element. Like Tatiana, he was not convinced that handing out large sums of money was either a good motivator or a good use of public money:
I would give people the opportunity to donate the money [they won] to charity right away. Whoever wins, can do it on live television. Because that was really strange…. We had this live entertainment program, in the first round. And there was a woman from some hospice or social care service who was selecting the winning tickets. And it [the prize] was €200, 000 at the time. And it was funny, because she said, “You know, €200, 000 is enough for us [to run the place] for two years.” And she was explaining how they struggle financially. If they gave people the chance to donate the money, I would participate right away. It would be fantastic. It would attract many people because it would have a completely different character. Now it was just about getting rich.
Gaming health
Emerging in the wake of the COVID-19 pandemic, vaccine lotteries possess an air of novelty which has made them the target of both academic research and public debate. In the lead-up to the launch of Slovakia’s vaccine lottery Being Healthy Is a Win, critical commentators voiced their skepticism about the effectiveness of financial incentives for vaccination. In the press, academic experts, politicians, and public figures argued about the cost-effectiveness and moral issues of making vaccination the ticket to participation in a public lottery. A minority argued that it was worth it to try any policy―however unorthodox―to save more lives and rescue the economy. The majority suggested that the authorities should instead focus on boosting ideas of collective responsibility amongst citizens through “soft” methods such as outreach and trust building; or “harder” methods such as excluding the unvaccinated from public spaces.
The lottery was met with similar skepticism by my respondents. Some, like Alžbeta, thought that the scheme was justified by its apparent positive effect on local vaccination rates. Others saw the vaccine lottery as an expensive gimmick imported from abroad by an unpopular politician seeking an easy way to boost his approval rates. And many, like Jan and Tatiana, found the idea of offering financial incentives to encourage vaccination morally distasteful. Viewing financial reward as incompatible with the production of social solidarity, they felt that the lottery put a price on the priceless (human health) and privileged financial self-interest instead of cooperation and social consensus. Indeed, they saw the introduction of the vaccine lottery, with its emphasis on entertainment and promises of cash prizes, as an unspoken acknowledgement of the limits of this consensus. For many, the lottery thus became symbolic of the failures of both the government and of Slovak society in the pandemic moment.
While Slovak policymakers would probably resist this characterization of the lottery as evidence of their moral and practical failure, the launch of Being Healthy Is a Win did signal a change in the government’s pandemic management policies. The ludic elements of the scheme ensured that serious public health messages were presented as part of a glitzy game show, cash prizes being dolled out together with medical advice. Rather than addressing the Slovak public as candidates for vaccination in the midst of a global pandemic, it tried to appeal to Slovaks as playful, pleasure-seeking individuals. And yet what underpinned the vaccine lottery was not a belief in the transformative power of play, but rather policymakers’ confidence that the best way to convince apathetic or reluctant citizens to get vaccinated was by appealing to their self-interest. As such, the lottery simply offered an old solution to a new problem: it treated citizens as calculative agents who could be swayed to make decisions about their health by the prospect of an easy win, rather than as morally and socially embedded subjects weathering an economic and public health crisis.