We\u2019re going to need a portfolio of strategies to solve it.<\/b>
\nVaccine Refusal Is America\u2019s Last Great Pandemic Challenge One-third of Americans say they might not get the COVID-19 shot. Decisively ending COVID-19 might depend on our ability to understand why. Why wouldn\u2019t someone want a COVID-19 vaccine? Staring at the raw numbers, it doesn\u2019t seem like a hard choice. Thousands of people are dying of COVID-19 every day. Meanwhile, out of the 75,000 people who received a shot in the vaccine trials from Pfizer, Moderna, AstraZeneca, Johnson & Johnson, and Novavax, zero died and none were hospitalized after four weeks. As the United States screams past 500,000 fatalities, the choice between a deadly disease and a shot in the arm might seem like the easiest decision in the world. Or not. One-third of American adults saidthis month that they don\u2019t want the vaccine or are undecided about whether they\u2019ll get one. That figure has declined in some polls. But it remains disconcertingly high among Republicans, young people, and certain minority populations. In pockets of vaccine hesitancy, the coronavirus could continue to spread, kill, mutate, and escape. That puts all of us at risk. Last week, I called several doctors and researchers to ask how we could reverse vaccine hesitancy among the groups in which it was highest. They all told me that my initial question was too simplistic. \u201cVaccine hesitancy\u201d isn\u2019t one thing, they said. It is a constellation of motivations, insecurities, reasonable fears, and less reasonable conspiracy theories. \u201cI call it vaccine dissent,\u201d Kolina Koltai, who studies online conspiracy theories at the University of Washington, told me. \u201cAnd it\u2019s way more complicated than being anti-vaccine. It goes from highly educated parents who are interested in holistic, naturalistic child-rearing to conspiracy theorists who want to abolish vaccines entirely.\u201d \u201cI call it vaccine deliberation,\u201d said Giselle Corbie-Smith, a professor at the University of North Carolina and the director of the UNC Center for Health Equity Research. \u201cFor Black and Brown people, this is a time of watchful waiting. It\u2019s a skepticism of a system that has consistently demonstrated that their health is not a priority.\u201d \u201cIt\u2019s not vaccine hesitancy among American Indians, but rather hesitancy and distrust regarding the entire government,\u201d said Margaret Moss, an associate professor at the University of British Columbia School of Nursing and an enrolled member of the Three Affiliated Tribes of North Dakota. \u201cAfter decades of distrust, on top of centuries of genocide, now they appear and say, \u2018Here, you have to take this!\u2019\u201d Let\u2019s not forget vaccine indifference. Two-thirds of Republicans under 30 without a college degree say that they are \u201cnot concerned at all\u201d about COVID-19 in their area, according to polling from Civiqs. The same percentage of this group says that they won\u2019t take the vaccine, making them the most vaccine-resistant cohort among all of those surveyed. Dissent. Deliberation. Distrust. Indifference. Vaccine hesitancy is not one thing. It\u2019s a portfolio. And we\u2019re going to need a portfolio of strategies to solve it. Kolina Koltai has been studying online disinformation since 2015, with a special focus on anti-vaccine groups on Facebook. \u201cPeople come into the space for a variety of reasons,\u201d she said. \u201cAt first, it was mostly parents, more women than men, and overwhelmingly white, ranging from stay-at-home moms to people with high levels of education who wanted a naturalistic upbringing for their child.\u201d The group didn\u2019t initially have a political lean. But in the past few years, Republican politicians have played more directly to anti-vaccine fears, pulling these groups to the right. Today, resistance among the GOP seems to be the most significant problem for vaccinating the country. Just half of Republicans say that they plan to get the shot, while the share of pro-vaccine Democrats has increased to more than 80 percent. Online denialism and conspiracy theorizing about the COVID-19 vaccine is more complex than previous anti-vaccine skepticism, Koltai said. \u201cCrisis often breeds conspiracies, and the extended nature of this public-health crisis has given conspiratorial people lots of time to build elaborate theories,\u201d she told me. Beyond the more outlandish theories\u2014for example, that Bill Gates is using the shots to inject Americans with his microchips\u2014she said that most online skepticism is more prosaic. People claim that the vaccine trials were rushed and shoddy. They worry about the long-term side effects of a newfangled chemical that monkeys around with our cells. They read news reports of people getting sick after having taken the shots, and become afraid. \u201cYou shouldn\u2019t say that people are idiots for believing false or misleading information, because they\u2019re not idiots,\u201d she said. \u201cThat\u2019s part of what makes this such a hard problem to solve.\u201d In the past few years, social-media companies have banned content that they consider to be harmful misinformation. Pinterest has famously established a zero-tolerance vaccine-misinformation policy, while Facebook has more recently banned claims that the COVID-19 vaccines are dangerous. But vaccine denialism doesn\u2019t need outright disinformation to thrive; it can breed on poor reporting and misleading headlines, which are harder, if not impossible, to ban. On February 5, NBC reported that a Virginia woman died shortly after her vaccination shot. The story went viral, but no link was ever established between the vaccine and her death. Several weeks later, NBC reported that the death was likely unrelated. Is such a story misinformation? The headline was technically true. But it was the sort of technical truth that actively detracts from our understanding of the world. More subtly, many reporters and scientists consistently focus on the worst news about the pandemic, perhaps thinking that they are doing good. They promote stories that claim with certainty that the vaccines won\u2019t contain the new variants (contra most available data) and emphasize that vaccinated people should not return to a normal life. These messages aren\u2019t entirely wrong; they shouldn\u2019t be classified as misinformation that merits social-media expulsion. But anybody who gets their news diet from such doombait will inevitably come to believe that the vaccines are no good\u2014or that it doesn\u2019t even matter whether they get one. \u201cIt\u2019s not just fake information that might strengthen vaccine hesitancy,\u201d Koltai said. \u201cTrue information that is stripped of context could do the same thing.\u201d Aaron Richterman is an infectious-disease specialist in Pennsylvania, where his clinic serves many low-income patients with HIV. Their vaccine skepticism presents itself in several forms: fear of illness, fear of unnatural substances, and even fear of elite conspiracy. \u201cA lot of my patients tell me they\u2019re worried the vaccine will make them sick,\u201d he told me. \u201cThey hear stories about people who took the vaccine and didn\u2019t feel well. Others tell me that vaccines are unnatural and they don\u2019t want to put such chemicals in their body. Then others tell me they\u2019re worried about big companies trying to do something nefarious. I just heard this too today: \u2018There is some bigger plan that is underlying this.\u2019 They ask about the Bill Gates microchip, too.\u201d It\u2019s tempting to treat these more outlandish conspiracy theories with straightforward contempt. But the history of Western medicine is not a fairy tale of moral purity. In fact, several of its chapters are almost as diabolical as a forcibly implanted computer chip. In the U.S., vaccine hesitancy among Black Americans is an enduring phenomenon, in many cases tied to past abuses such as the horrifying Tuskegee syphilis study. In the study, federal officials enrolled 600 Black Alabamans suffering from syphilis in an experiment to examine the disease\u2019s long-term effects, withholding participants\u2019 diagnoses and denying them treatment. \u201cWe talk about Tuskegee, but it\u2019s not just the history of exploitation by the medical field, or the history of unethical research conduct\u201d that taints Black Americans\u2019 trust in the medical system, said Corbie-Smith at UNC. \u201cIt\u2019s their current-day experience with the health-care system, including with this pandemic, which has such a disparate impact on the lives of Black and Brown Americans. People are looking to see how the vaccine rollout is going to treat them with equity.\u201d The early returns haven\u2019t been promising. In Alabama, where the white population is being vaccinated at twice the rate of Black citizens, a community clinic in a low-income neighborhood in Birmingham has yet to receive its first dose. As Sheila Tyson, a commissioner in the county that includes Birmingham, told Bloomberg: \u201cHow do they know we are turning down the vaccine if it is not offered to us?\u201d Even vaccine shots intended for residents of minority neighborhoods have often gone to higher-income people, by scheme or by mistake. In Los Angeles, the government tried to distribute vaccines to hard-hit communities of color by sending out a set of online access codes through leaders in those communities. But the codes got leaked and passed around the city\u2019s higher-income remote workers\u2014most of whom probably had no idea that they were taking spots intended primarily for Black and Latino communities. Thus, a well-meaning program to distribute shots to poor neighborhoods became another example of how knowledge workers tethered all day to their computers have coped throughout the pandemic while low-income hourly workers have suffered. In Raleigh, North Carolina, online enrollment has left behind older Black citizens without access to a home computer or an understanding of the often Byzantine rules required to sign up for an appointment. Community volunteers have stepped in to help seniors navigate the vaccine websites or print the requisite forms and deliver the papers to their front door. \u201cThey\u2019re calling it an Underground Railroad to help older Black citizens get access to the vaccines,\u201d Corbie-Smith told me. \u201cWhen the community narrative is drawing on slavery, I think it\u2019s fair to say that slow vaccination rates among Black citizens is a bigger issue than Oh, my arm is going to be sore.\u201d I heard the same point from several sources: The confusing vaccine-eligibility rules and the unequal distribution of doses were combining to bar some people from the process. \u201cAt my own reservation in North Dakota, I\u2019ve heard that elders drove for hours over ice\u2014we\u2019re talking North Dakota\u2014and were turned away from the nearest clinic,\u201d Moss, the UBC professor, told me. \u201cThey don\u2019t have time to stand in line for 10 hours a day or refresh a web page.\u201d States could give such enrollees a ticket that guarantees a specific slot for future vaccination. But instead, we\u2019re turning people away from a system that requires near-universal participation. Despite these challenges and the long history of minority Americans\u2019 vaccine deliberation, there is some evidence that things are moving in a positive direction. The share of Black and Latino Americans who say that they plan on taking the vaccine has increased from about 40 percent to roughly 60 percent in the past three months. This raises the possibility that one of the most important ways to solve the vaccines\u2019 \u201cdemand problem\u201d is to rapidly solve the \u201csupply problem.\u201d More shots in arms means fewer sick people; fewer sick people means more normalcy and more headlines about normalcy; and more normalcy provides crucial evidence to the undecided that the drug is worth the jab. Vaccine hesitancy is as old as vaccines themselves. The smallpox vaccine faced immediate skepticism in the U.K. when Edward Jenner tried to present his initial experiments to the scientific community and the public in the late 1700s. Around 1900, as authorities tried to contain smallpox, Americans formed anti-vaccination leagues and hid sick children from public-health officials. Their reasons were as manifold as those of today\u2019s vaccine resisters, including fear of the new and unnatural and skepticism about a dubious authority. A bit of distrust was not entirely irrational. Today\u2019s vaccine resistance isn\u2019t entirely irrational, either. And even if it were, it wouldn\u2019t do any good to treat the vaccine-hesitant as if they were crazy. \u201cAs a clinician, I find it\u2019s a mistake to simply tell people what to think,\u201d Richterman, the Pennsylvania infectious-disease specialist, told me. \u201cScreaming \u2018Just take this!\u2019 isn\u2019t effective, because this isn\u2019t about getting others to see my goals. It\u2019s about helping them identify their own goals and how, maybe, getting a vaccine might help achieve them.\u201d This approach is often called \u201cmotivational interviewing.\u201d It works like this: Instead of telling people why you think they should change, you ask them open-ended questions to help them discover their own reasons. If their motivation (e.g., \u201cI want to be healthy\u201d) matches your goal (e.g., \u201cI want you to take this vaccine\u201d), you can guide them toward a plan. \u201cSometimes I flip the question and ask, \u2018What would make you want to get the vaccine? What would convince you to get it?\u2019 That way you urge them to identify the positive things,\u201d Richterman said. \u201cMaybe they\u2019ll say, \u2018I want to help my friend who isn\u2019t well,\u2019 or, \u2018I want to protect my family.\u2019 And then I latch on to that and try to build on that.\u201d These methods don\u2019t exactly proceed at warp speed. It can take time for people to change their mind, if they do so at all. But the approach seems to work better than any other to soften vaccine deliberation. A 2021 study from the University of Pennsylvania found that Black Americans who expressed reluctance toward the COVID-19 vaccine \u201cwere willing to consider\u201d receiving it when trusted health-care providers reflected their concerns and emphasized the safety of the shot. When we disentangle the constituent parts of vaccine hesitancy\u2014conspiracy theorizing, wait-and-see deliberation, frustration, and distrust\u2014it becomes clear that vaccine reluctance will never be solved by one big thing. Better national messaging on how vaccines could change our lives might encourage young people to get the shot, but would do little to change inequities at the community level. Clearer eligibility rules and more equitable distribution could accelerate vaccination in low-income neighborhoods, but might not solve vaccine indifference among young white Republicans. Motivational interviewing might bring along the skeptical, but more information is unlikely to convert the full-blown conspiracists. The multiple-choice question of combatting vaccine resistance has an obvious answer: We need all of the above.<\/p>\n