Hacker News Reader

Comment by chimeracoder | Hacker News Reader

This has been a known problem for years. There are three issues at play:

1. Overuse of antibiotics in non-theraputic settings (e.g. agriculture)

2. Lack of interest in developing new classes of antibiotics

3. Insufficient interest in vaccine development

The last one is particularly interesting because a somewhat-effective vaccine[0] for Neisseria gonorrhoeae was discovered several years ago, but GlaxoSmithKline doesn't want to conduct the trials and submit it for approval until they find one that would be more effective and more profitable for them, so in the meantime it can only be used off-label, which means adoption is next to zero, because most physicians and patients don't even know it's an option. It's also only covered by insurance for its on-label use, which makes it difficult and expensive ($300 for the full series) even for people who want to get it.

Although GSK is at least ahead of Pfizer, who owns the patent for a nearly-identical vaccine that is also shown to be comparably effective against gonorrhea, and as far as I can tell has not even bothered to try using that as the basis for developing another.

[0] about 40%, which for comparison is higher than the effectiveness of the flu vaccine for every year in the past decade except one

View on HN

Those are scientific issues, but STD spread is also a by-product of social changes.

The median age of female's first marriage was less than 22 for 100 years and rose to 28 in the last few decades[1]. I would assume this results in a higher number of partners and more opportunities for an STD to spread.

[1]: https://www.census.gov/content/dam/Census/library/visualizat...

Everything I've read about the 19th and early 20th century has lead me to believe that practically everyone was a walking petri dish. Spreading STDs weren't well understood. Lot's of supposedly brilliant artists and writers usually met there end by going raving mad, usually from syphilis. But were just famous enough to have it documented by their friends.

We don't need to lay blame of STDs on the sexual revolution, we were already down bad as a species.

You say "lay blame" as if I'm being critical, when I'm just theorizing.

My non-scientific assumption is that there were less people who chose the lifestyle of "artists and writers". The sexual revolution took the lifestyle mainstream.

Another social change is increase in oral sex. Most people don't use protection while doing oral sex which is also the cause of widespread STDs. Eating ass is a good way to get a bunch of disease causing microbes into your body. I don't know why it's normalized these days, it wasn't the case in the past.

> The median age of female's first marriage was less than 22 for 100 years and rose to 28 in the last few decades[1]. I would assume this results in a higher number of partners and more opportunities for an STD to spread.

This is a common talking point among conservatives, but it's off-base. Not only has the median number of lifetime sexual partners not increased (in fact, it mostly flatlined from the 1960s, and even fell for many demographics after the 1980s), but it's irrelevant to the issue of gonorrhea, because single unmarried women in their 20s are not the main demographic affected by gonorrhea today.

Do you have some links? The surveys I found show the opposite for number of partners. I'm also curious about the demographics.

This article is a little dated but it shows the data very clearly. Subsequent surveys have shown similar results, with Boomers and X out-sexing Millennials (by # of partners) and with some signs indicating Z is on track for even fewer partners...

https://www.washingtonpost.com/news/wonk/wp/2015/05/06/why-m...

I think it's a terrible trend and we should all start having sex with more people.

Pay walled, so I can't see your article. This article references a survey with a fairly small sample size. I found one other article that claimed what you are, but they were stupidly comparing millennials' lifetime average of 8 to boomers lifetime average of 10, even though boomers have been around almost twice as long (millennials would likely track to surpass boomers at the same age). That's why I was curious for more (open) data.

https://www.the-sun.com/lifestyle/4479617/average-number-sex...

This would be a great comment if you cited sources.

Condom use has also declined over the past decade or so.

This is primarily due to HIV (rightfully) no longer being seen as a death sentence, and PrEP being widely available.

I think most folks were actually being quite rational here. When the consequences of unprotected sex were so severe, most people used condoms. Right now, for someone on PrEP and/or the pill, the negative consequences of unprotected sex are primarily infections that can be cleared up with antibiotics or are generally not very serious.

A serious untreatable pathogen may well change people's behaviors again in the future.

It's kind of sad to think that people would rather help create the next catastrophe by relying on treatments that are known to become less effective with use than act responsibly for prevention.

Yes, new HIV infections have gone down since the 80s but have been relatively flat over the past decade or two, with the cumulative rate of infection continuing to rise. Of course IV drug use is another major source.

> It's kind of sad to think that people would rather help create the next catastrophe by relying on treatments that are known to become less effective with use than act responsibly for prevention.

Neither condoms nor PrEP "become less effective with use". Either one is a way of acting responsibly for prevention.

I was referencing the treatments for gonorrhea (antibiotics). Condoms would actually fall in the "act responsibly" category of my comment, as you pointed out.

Why is this women’s fault somehow?

How do you infer that op is blaming women? They merely stated a fact and didn't assign any blame.

I think the OP indirectly does that. They chose to say

“The median age of female's first marriage was less than 22 for 100 years and rose to 28 in the last few decades”

and not

“The median age of male's first marriage was less than 26 for 100 years and rose to 30 in the last few decades”

or the neutral

“The median age of first marriage was more or less stable for 100 years and rose by about 6 years in the last few decades”

How about we judge people for what they say and not what we fantasize they meant to say?

Judging others based on what we feel they really meant to say is a very dangerous course.

They’re being judged by what they actually said. They could have picked a neutral statement but choosing to focus on only half of the people involved was an editorial choice which is reasonable to question.

Well, even if "they both rose about 6 years", they aren't actually the same. I chose the lowest for a reason, since it shows a bigger shift in relative terms. Going from 22-28 is bigger percentage gain than 24-30.

It actually is the more impactful number which was relevant to my original point (people are staying in the dating pool for a longer % of their life)

> It actually is the more impactful number which was relevant to my original point (people are staying in the dating pool for a longer % of their life)

You may have had that point in your mind, but by choosing to only mention the numbers for women, the point you made was “women are staying in the dating pool for a longer % of their life”.

>" median age of female's first marriage "

The mere mention of a statistic involving a gender does not blame that gender. The point of noting the increase in marriage age is to point out that presumably the number of sexual partners increase as well, which can lead to more spread. Presumably women having more sexual partners ALSO means men having more, it takes two to tango and all that.

That said I had initially assumed that the reason for using women specifically was probably that the male median age didn't increase in the same time-frame, but it looks like it's pretty much been in lockstep (https://www.census.gov/content/dam/Census/library/visualizat...) so it's an odd choice to not just mention the median age of marriage instead of women specifically.

I think that phrasing can reasonably be interpreted as critical: it sounds like it’s saying it’s somehow women’s responsibility and that dovetails with the very common cultural trope of assuming that men are irresponsible horndogs who can’t be expected to control ourselves. I don’t know if OP comes from that background but it’s common, especially in strongly religious communities where you have the “Eve tempted Adam into sin” mythos.

That's a statement of fact that is either true or not. It is not a statement of culpability in anyway.

Men are pigs (see that's a fact and an example of a moral judgement), and are almost exclusively to blame for the spread of STDs. Doesn't change the fact changing female sexual norms change sexual network connectivness and therefore how STDs spread

I chose women because it was the younger age and assumed it was more relevant to taking half the population out of the dating pool, which was my main point. All these comments assuming it was some crack at women are wound too tight.

Why do you assume OP was blaming women? Nothing they said implies blame.

Noone passed blame, simply noting the sexual revolution has made STD's more common-place.

All 3 of these are related to optimizing for income. Even the first. They use so much antibiotics due to optimizing for income when it comes to the meat industry.

Speaks to priorities

> 1. Overuse of antibiotics in non-theraputic settings (e.g. agriculture)

How is agricultural use of antibiotic fueling antibiotic-resistant gonorrhea? Are people having sex with animals, picking up STDs from them, and then passing them along to other people? Is there some other common repositiory of gonorrhea that both people and animals are coming into contact with to a degree that it's causing selection for antibiotic resistance?

#2 and #3 seems like obvious places to direct public funds via government, being investments in public goods.

In the USA, this can be done either through executive agencies, or by Congress. Is Congress unaware of the issue, or is there some political jockeying that prevents it? It seems like maybe it's worth redirecting funds from other basic research (medical or otherwise) into this area for at least a few years.

I think there's a few factors that contribute to there not being much political attention on gonorrhea treatment and prevention in the US.

1) Only about 0.2% of the US population contracts gonorrhea annually [0]

2) Many people see gonorrhea as a consequence of risky sex, which then butts up against religious beliefs and the like. The Religious Right would not generally be in favor of anything that makes sex less dangerous, and it would almost certainly become a culture war issue.

3) Until pretty recently, gonorrhea was not that big a deal because we had multiple antibiotics that worked against it. Public perception has not yet caught up with the science, thus there's not that many people clamoring for action.

[0] https://www.statista.com/statistics/626863/rate-of-cases-of-...

I’d use HPV as a cautionary example: there has been a ton of opposition from religious people who more or less explicitly say that they need the fear of cancer to keep their kids from having sex before marriage. The fact that it can spread without sexual contact or that people get cheated on doesn’t enter into the picture, it’s entirely about the motivational power of fear.

As a parent I find that idea abhorrent but it’s certainly not uncommon, which lead to demand for it not to be on vaccination lists and attempts to exclude it from medical coverage.

Most of the signalling on the religious right for the HPV vaccine was explicitly that if you let your daughter take it to protect her from an annoying and harmful cancer, she will become a sexual deviant and a whore.

Yeah, it was just disgusting both for what it said about how they viewed their children and the not inconsiderable number of women who are cheated on by “good Christian men” and find out the hard way.

> #2 and #3 seems like obvious places to direct public funds via government, being investments in public goods. In the USA, this can be done either through executive agencies, or by Congress. Is Congress unaware of the issue, or is there some political jockeying that prevents it? It seems like maybe it's worth redirecting funds from other basic research (medical or otherwise) into this area for at least a few years.

This problem disproportionately affects gay men and sex workers (of any gender/orientation), and the government's track record with public health issues that affect gay men is... pretty bad. The HIV epidemic began in 1981, and the first FDA-approved condom for anal sex didn't appear until 2022.

Heck, there wasn't even an FDA-approved gonorrhea test for gay men until 2019.

Or if you want something more recent, look at how badly the US government botched the Mpox epidemic. The US literally had Jynneos vaccines ready to go, and at multiple points either failed to arrange for the logistics of using them or (in more egregious displays) simply refused to administer them altogether.

The US government's mishandling of Mpox response has been so egregious that unless you were following it closely, you'd think sounds like satire or a conspiracy theory.

https://www.nytimes.com/2022/05/29/opinion/monkeypox-covid-a...

https://www.nytimes.com/2022/07/25/nyregion/nyc-monkeypox-va...

https://www.nytimes.com/2022/08/01/nyregion/monkeypox-vaccin...

You can't use an entirely unapproved drug off-label (with rare and individual exceptions; https://www.fda.gov/news-events/public-health-focus/expanded...).

Off-label use is using an approved drug for a different medical purpose than the one it was approved for.

> You can't use an entirely unapproved drug off-label

I know how drug development works, but thank you.

The vaccine is approved for use against another bacterium in the same genus. It is not approved for use against gonorrhea. That means it can be used off-label.

> I know how drug development works, but thank you.

No reason to get angry, nobody knows you from Adam. If you don't want to be treated like you're an idiot, post to a different website. The whole point of Hacker News comment sections is to see who can pretentiously promote their own alleged genius at the expense of everyone else

$300 doesn't sound like that much to me, if we're talking about the price in the developed world. Did you mean $3000? In the US, $300 sounds like what you might pay as coninsurance on a non-particularly-generous health care plan for treatments for much less harmful diseases - I would have paid for it out of HSA when I was on a high-deductible health plan, since that insurance only starts covering anything besides an annual physical and flu shots if you spend more than $2000 a year.

So you are saying this functional vaccine exists, and has been approved by the FDA for another use, so that it can be used off-label, but that people do not use it because people don't know about it...

...and you don't name the vaccine or provide any specific information about it.

I'm sure you see the irony!

What is this vaccine called, and for what other purpose has it been approved? Do you have a link to a study indicating that it is somewhat affective against Neisseria gonorrhoeae?

> What is this vaccine called, and for what other purpose has it been approved?

The GlaxoSmithKline version is called Bexsero, but Pfizer has the patent on Trumenba, which is functionally the same thing. Both are used against bacterial meningitis serogroup B. Note that this is different from the standard meningitis vaccine required in most public schools and universities. Isomeone says they've been vaccinated against meningitis, they almost certainly are referring to the vaccine for serogroups A, C, Y, and W-135, which is different and not effective against gonorrhea.

There are tons of studies demonstrating the effectiveness of both against gonorrhea - it's almost a running joke that every 3-6 months a new one gets published, prompting a slew of articles expressing surprise and amazement, as if this hasn't happened so many times over the last decade that we've lost track. Pretty much all of them point to the range of 40% real-world effectiveness, which is actually quite good from a public health standpoint.

Knowing about it isn't really the main hurdle, though. Even if you know it exists, it's incredibly difficult logistically to get it, because your insurance company won't pay for it unless you've been provably in the vicinity of a MenB outbreak (which is rare in the US), and pharmacies will order it but generally not administer it, so even if you are fine paying for it yourself and manage to get your doctor to prescribe it to you, you'll end up in a weird logistical catch-22 where you can obtain it from a pharmacy but have to self-administer it (do not do this, unless you are trained) or find a not-so-kosher way to get it administered.

tier 3 on most formularies: https://www.goodrx.com/bexsero/medicare-coverage

Note that insurance will likely only cover it for on-label use.

This is mostly not true unless it is subject to a prior authorization. There are 100's of drugs used off label dispensed from every pharmacy every day. For instance most drugs used in pediatrics aren't approved for anyone under 12.

> This is mostly not true unless it is subject to a prior authorization.

It is true. I used to work in this field and have helped many people navigate this exact issue.

> There are 100's of drugs used off label dispensed from every pharmacy every day.

Vaccines are treated differently than drugs by insurance, often covered by completely different networks under the same brand. Most people don't know this, because there's no reason for them to encounter the difference, because the situation of having to obtain a vaccine that isn't part of the standard schedules from a pharmacy is very uncommon.

Interestingly, in Australia for young children, Bexsero is part of a recommended vaccine schedule (not compulsory). Both my kids have had it!

> Interestingly, in Australia for young children, Bexsero is part of a recommended vaccine schedule (not compulsory). Both my kids have had it!

That's not surprising. New Zealand had a massive outbreak of MenB about ten years ago, resulting in a massive vaccination campaign, which is one of the reasons we actually found out about its effectiveness against gonorrhea in the first place.

Can't a doctor administer it, if you self-pay?

> Can't a doctor administer it, if you self-pay?

A doctor doesn't have the vaccine in their office, because it's not part of their standard schedule. Most won't order it for you (or even be able to), for the same reason.

They can send it to the pharmacy as a prescription, but the pharmacy (depending on both state law and pharmacy policy) often won't administer the vaccine to you, as it's not one of the "standard" ones that pharmacies do (e.g. flu, COVID-19).

If the pharmacy gives it to you, you can bring it to your doctor's office, but most providers won't administer any medicine that they didn't source themselves, because technically they have no way of verifying the provenance.

This isn't hypothetical - I used to work in this field, and I frequently help people navigate the logistics of obtaining this vaccine. It's really not simple, even if you're insured and willing to pay out-of-pocket and have a good relationship with a competent PCP.

"most providers won't administer any medicine that they didn't source themselves, because technically they have no way of verifying the provenance."

Interesting. In Czechia, a doctor will send you to buy a vaccine against tick meningitis into a pharmacy and when you come back, will administer it.

It is up to you as an adult not to mess up.

Googling "Neisseria gonorrhoeae vaccine" turned up... honestly, a lot of papers that're above my educational level. That said, this[1] WHO article from halfway down the results says that "observational studies indicating that vaccines developed for serogroup B Neisseria meningitidis might offer some protection against gonorrhoea, providing promise that gonococcal vaccines are biologically feasible", which I'd suspect is referring to the development that the OP is talking about. Please, feel free to follow up on that article if you have higher scientific literacy than I do. :D

[1]: https://www.who.int/teams/immunization-vaccines-and-biologic...

They may be referring to the meningitis vaccine: https://www.bmj.com/content/377/bmj.o997

This is not paywalled and has more info:

https://www.cidrap.umn.edu/studies-highlight-meningitis-vacc...

> 1. Overuse of antibiotics in non-theraputic settings (e.g. agriculture)

> 2. Lack of interest in developing new classes of antibiotics

> 3. Insufficient interest in vaccine development

you left out

4. Underuse of antibiotics in people so at risk they already have it, and then among those, them who will catch it again within the same social group.

We have subpopulations and particular communities who engage in "way more than their share" of risky sexual behavior, many of whom also use drugs and alcohol liberally, and in the worst cases (like say drug addiction/mental illness) don't generally seek medical care or otherwise take care of themselves.

I think the overuse of antibiotics on cattle has had much less to do with drug resistant human gonorrhea than giving populations humans who have gonorrhea insufficient quantities of inadequate antibiotics, particularly incomplete courses or treatment of cases without followthrough.That creates a perfect informal laboratory for developing strains of drug resistant bugs.

> I think the overuse of antibiotics on cattle has had much less to do with drug resistant human gonorrhea than giving populations humans who have gonorrhea insufficient quantities of inadequate antibiotics, particularly incomplete courses or treatment of cases without followthrough.That creates a perfect informal laboratory for developing strains of drug resistant bugs.

This is provably incorrect. The standard treatment protocol for gonorrhea is a single IM dose. There's no such thing as an "incomplete" treatment for gonorrhea.

> We have subpopulations and particular communities who engage in "way more than their share" of risky sexual behavior, many of whom also use drugs and alcohol liberally, and in the worst cases (like say drug addiction/mental illness) don't generally seek medical care or otherwise take care of themselves.

It's common and perhaps tempting to lump "people who have a lot of sex" together with "people who use drugs and alcohol" and "people who don't seek medical care or take care of themselves", but the data shows that that's not actually the case. Particularly for the subpopulations most affected by gonorrhea, where the data very clearly and unambiguously shows the opposite relationship.

> This is provably incorrect. The standard treatment protocol for gonorrhea is a single IM dose. There's no such thing as an "incomplete" treatment for gonorrhea.

that is no longer true, the standard treatment protocol is multiple doses now, and it's the exact same treatment for chlamydia which is very common, and would lead to the same "spillover" development of resistant strains of both. And even if you have taken the prescribed dose whether it's one or multiple, if you are re-exposing yourself with varying half-lives of the antibiotics in your body, you are conducting experiments.

to most likely develop a resistant strain, you have to have the antibiotic and the infection strains in the same body, it's not random.

> that is no longer true, the standard treatment protocol is multiple doses now, and it's the exact same treatment for chlamydia which is very common

Incorrect. The standard treatment protocol for uncomplicated gonorrhea is a single IM ceftriaxone shot. The standard treatment protocol for chlamydia is a one-week oral doxycycline regimen. They are completely different treatments.

Treatment adherence is an potential issue for the chlamydia course, but not for gonorrhea, because it is administered as a single shot.

> and would lead to the same "spillover" development of resistant strains of both.

On the contrary, the treatment protocols were specifically constructed to avoid this.

> if you are re-exposing yourself with varying half-lives of the antibiotics in your body, you are conducting experiments.

That's technically true, but thankfully not particularly relevant, as most people aren't re-exposing themselves to gonorrhea within a few hours after being treated for it.

>> if you are re-exposing yourself with varying half-lives of the antibiotics in your body, you are conducting experiments.

>That's technically true, but thankfully not particularly relevant, as most people aren't re-exposing themselves to gonorrhea within a few hours after being treated for it.

It doesn't matter what most people do, it only matters what the petri dishes for gain-of-function gonorrhea are doing. Resistant gonorrhea didn't appear quickly, and it didn't appear magically, it appeared after a sufficient number of people had both the pathogen and the antibiotic in their bodies, and the more times the better. We simply need to explain the behavior of those people.

> It doesn't matter what most people do, it only matters what the petri dishes for gain-of-function gonorrhea are doing. We simply need to explain the behavior of those people.

Researchers have been tracking gonorrhea for decades, and they understand very well how resistance develops. Reinfections during treatment is not how. Nor is treatment adherence, because - as I pointed out - you were mistaken about the basic facts of the treatment protocol.

Regardless - between referring to people as "petri dishes" and your other ad hominem comment about me in this thread, it seems you're less interested in understanding the science here than you are in moralizing about other people's behavior. I share the attitude of most public health officials and sexual health professionals, which is that moralizing rhetoric is counterproductive, so I have no interest in engaging in that, and therefore there's no point in discussing further.

"Particularly for the subpopulations most affected by gonorrhea, where the data very clearly and unambiguously shows the opposite relationship."

People who tend to be sober and care about prophylactic care are the most afflicted with gonorrhoea?

> People who tend to be sober and care about prophylactic care are the most afflicted with gonorrhoea?

Thx! this made me laugh, I mean really :)

>It's common and perhaps tempting to lump "people who have a lot of sex" together with "people who use drugs and alcohol" and "people who don't seek medical care or take care of themselves"

Has he ever been out clubbing in NYC or LA or SF bars and nightclubs on any weekend night? and many more nights of the week? do we think there is alcohol and drugs and resulting sex there? Has he ever engaged a series of prostitutes? Do drug addicts need money? Where do they get it, what's an easy unskilled job? Think there's a higher %age of gonorrhea on Tinder or among those dedicated to going out and partying? Are people who've been drinking more likely to have sex or not? Are there hookup apps that result in a much higher hit rate for unprotected sex than Tinder that people who go out and party use?

Would it be this GSK Vaccine that just started a clinical study relatively recently?

https://www.clinicaltrials.gov/ct2/show/NCT05630859

> Would it be this GSK Vaccine that just started a clinical study relatively recently?

That's the vaccine that GSK is developing as a candidate with the hopes that it will be superior (and also more lucrative) than Bexsero (the existing vaccine).

It's not inherently a bad thing that this might be an option, especially if it turns out to be effective, but keep in mind that GSK has been working on this for years, and that Bexsero's effectiveness has been widely known for years before that. So having a candidate that may be approved in 2026 or later is... not very reassuring given the threats of treatment resistance..

Do you have a link to this vaccine data?

Are there different types of gonorrhea, or is it 40% effective against all strains? And how long does the effectiveness last?

> until they find one that would be more effective and more profitable for them

If I’ve learned anything over the past few years, the less effective the vaccine, the more profitable it is.

The most profitable vaccine would be highly effective, but wears off over time.

The mRNA vaccines have an effectiveness of approximately 90%. The inactivated virus vaccines have a "low" effectiveness like approximately 60% (that is not negligible!).

Are the inactivated virus vaccine more profitable than the mRNA vaccines?

Depends on production costs, can make the inactivated virus vaccine easily.

mRNA vaccines were about 95% effective against symptomatic disease, but only against the targeted strain.

The effectiveness of the flu vaccine is kind of odd, but somewhat makes sense since it seems more like a moneymaking machine than something that actually has some worthwhile results(some people will probably jump on this statement). Most places don't even seriously market them for that very reason.

40% is terrible for something like gonorrhea, so unless it becomes much better you're better off being more diligent in your sexual escapades.

> it seems more like a moneymaking machine than something that actually has some worthwhile results

The flu vaccine is absolutely not a moneymaking enterprise (unless you define "money-making" as "spending less money on treating serious flu cases and sequelae", at which point you might as well leverage that same logic to argue against all preventive care).

> 40% is terrible for something like gonorrhea, so unless it becomes much better you're better off being more diligent in your sexual escapades.

This is a common attitude amongst the public, but it is completely at odds with how public health officials operate, because it's incredibly harmful and counterproductive.

Shaming people for sexual activity might feel good and "moral", but not only does it not actually reduce incidence, but it increases the rate of STI transmission.

40% is not perfect, and it's insufficient to merit mass public vaccination, but it's more than adequate for protecting high-risk groups.

> This is a common attitude amongst the public, but it is completely at odds with how public health officials operate, because it's incredibly harmful and counterproductive.

That's an ABSURD statement. Your statement is completely at odds with how public health operates in most countries. I've worked in it both in the US and in Germany, and worked with two more countries' health systems. In Germany at a leadership level, that is actually very close to the layer that decides what gets covered by public health insurance. Most public health insurance only covers older treatments because the new treatments are too risky for them with too little data on successful treatments. Things such as shockwave treatment that performance athletes frequently use or mothers use for their thumb after breastfeeding are completely out of pocket, because not enough longterm studies show statistical significance on the treatment.

I understand that public health officials in the RECENT years(ten years is considered recent in public health or healthcare in general by the way) are trying to completely change the way public health works, because they want more direct control, but it is absolutely not YET how it works.

> public health insurance only covers older treatments because the new treatments are too risky for them with too little data on successful treatments

They’re also more expensive.

I'd rather have a 40% less chance of getting gonorrhea than a 0% less chance.

Its complex but you should try and separate your idea of “shame” from the concept of “consequence”.

People can change behavior to avoid consequence. Shame is a response to violations of morality. They're really quite distinct.

"Its complex but you should try and separate your idea of “shame” from the concept of “consequence”"

Quite a lot of people are lately invested into the opposite, confusing those two, perhaps deliberately so.

For example, any suggestion that it may be unsafe to walk around totally drunk at night will be met with accusations of "blaming the victim", especially if the crime is rape, plus with (unhelpful) suggestions "you men need stop raping, I don't need to alter my behavior" - as if the perps were present in the discussion and inclined to take such suggestions.

Walking around totally drunk is unsafe for everybody, not least because all those self-inflicted injuries, but some people will deliberately try to silence such an idea.

There has been a huge push for annual flu vaccination in the last ~10 years in the USA. It was a favorite target of anti-vax conspiracy theorists long before Covid.

Reply on news.ycombinator.com