Vaccine Hesitancy in the Time of COVID

Few issues can bring out differences of opinion—a worldwide pandemic being among them. Over the past two years, Americans have seen friends, families and coworkers divided. We have been bombarded with opinions about everything from mask-wearing to how much toilet paper to keep on hand. We have heard politicians tie medical advice to political views. We have felt concerned for our health and the health of our loved ones, while also feeling exhausted by the continuous stream of information. And we have lost nearly one million American lives to a single virus.

One of the most divisive issues during the COVID-19 pandemic has been the question of whether or not to get vaccinated. For the American public, controversy around the COVID-19 vaccine has touched on a spectrum of underlying factors, such as pre-existing views about vaccines in general, opinions about the trustworthiness of medical and scientific communities, and varying political ideals. Conflict around the vaccine has even divided families: family court judges have seen an increasing number of cases in which parents cannot agree on whether or not to vaccinate their children and turn to the courts for help. For a sense of how this issue has played out on a national scale, we can look to differences in vaccination rates by state. 82.3% of residents are vaccinated in Rhode Island, the state with the highest vaccination rate. In contrast, just 51% of residents are vaccinated in Alabama, the state with the lowest vaccination rate. California falls in between, with 71.9% of residents vaccinated.

Although some Americans are skeptical about vaccines, a brief history provides some compelling reasons to get vaccinated. In the late 19th century, fear of contracting a deadly disease was a daily reality for people everywhere. Smallpox killed three of every 10 people who contracted the disease. Since there was no cure for smallpox, the only option was to allow the disease to run its course. It is estimated that 300 million people were killed by smallpox in the 20th century alone. However, thanks to the smallpox vaccine, the last known case of smallpox was recorded in 1977, and in 1980, the World Health Organization declared that smallpox had been eradicated. At present, there is still no known incidence of smallpox anywhere in the world—a monumental triumph for public health and vaccines. 

Polio struck fear into the hearts of Americans in the mid-20th century and paralyzed 35,000 Americans per year at its peak. After deployment of the polio vaccine, the number of cases in the U.S. fell to zero. However, unlike smallpox, polio still exists in some parts of the world and can be brought into the U.S. by an infected person. The continued existence of polio can be a potent reminder of the importance of vaccines, since the disease is still without a cure. Some other diseases that were once widespread, but have now been largely subdued by the widespread use of vaccines, are measles, pertussis, rubella and diphtheria. 

It is also important to note the importance of herd immunity in large-scale vaccine effectiveness. Herd immunity is achieved when a sufficient majority of a population is immune to a contagious disease, enabling an infection to remain tightly contained, rather than exploding to infect many more individuals and allowing the pathogen to proliferate.

In spite of the transformative effect vaccinations have had on modern society, public uncertainty about vaccines is as old as vaccines themselves. The smallpox vaccine was the first vaccine ever developed, and it was mired in conflict and opposition, despite driving down the incidence of smallpox in the early 20th century. In 1879, the Anti-Vaccination Society of America was formed. They and other similar groups fought against laws requiring individuals to be vaccinated, claiming uncertainty about vaccine safety and efficacy. 

The 20th century had its share of vaccine-related controversy as well. Andrew Wakefield, a former physician and researcher, published a since-retracted paper in the British journal The Lancet in 1998 claiming to have found a causal relationship linking the Measles, Mumps, and Rubella (MMR) vaccine with autism. Although Wakefield’s research methods were found to be fraudulent and his work was widely discredited, rates of MMR vaccination began to drop as parents feared their children could be at risk of developing autism if they received the vaccine. 

A sticking point for some vaccine-hesitant Americans is the National Vaccine Injury Compensation Program (NVICP), which protects pharmaceutical companies from being sued by individuals who believe they have been harmed by a vaccine. The NVICP was created by the U.S. Department of Health and Human Services in 1988. Because of a dramatic increase in vaccine-related lawsuits being brought against pharmaceutical companies in the late 1980s, many pharmaceutical companies stopped manufacturing vaccines. Since the U.S. government has a strong interest in facilitating the vaccination of its citizens, the NVICP was created to protect pharmaceutical companies and encourage them to continue vaccine production. The NVICP also provides compensation for patients who have experienced adverse effects from vaccines. This compensation comes from a fund which all vaccine manufacturers pay into. Some Americans feel the protections given to vaccine manufacturers by the NVICP go too far, suggesting the NVICP disincentivizes vaccine safety by letting pharmaceutical companies off the hook for any harm their vaccines may cause. 

Some racial and ethnic groups have historically been more hesitant to trust the medical community due to a persisting legacy of mistreatment and inequality. Perhaps one of the most powerful examples of this was the Tuskegee Syphilis Study, conducted from 1932 until 1972. Over the course of the study, researchers from the U.S. Public Health Service knowingly withheld syphilis treatment from hundreds of African American men. The resulting mistrust of the American medical community by people of color affects vaccine uptake as well, and during the first month of COVID-19 vaccine availability, 60% of Americans who received the vaccine were white, while just 5% were Black.

Attitudes of vaccine hesitancy in the U.S. have increased on average over time, as indicated by rising incidence of vaccine-preventable diseases. For example, 1,282 cases of measles were reported in 2019, the most since 1992 (CDC, Eureka). In 2019–before COVID-19 was a household name–the World Health Organization listed vaccine hesitancy among the top 10 threats to global health, noting that it “threatens to reverse progress made in tackling vaccine-preventable diseases.” 

While there is a spectrum of public opinions about vaccines, we can organize the attitudes into three broad categories for ease of discussion: Vaccine accepting (those who believe in the effectiveness of vaccines and follow the recommendations of the medical community regarding vaccines), vaccine hesitant (those who have suspicions or reservations about vaccines, and may or may not get vaccinated or have their children vaccinated), and anti-vaccine (those who believe vaccines don’t work or aren’t safe, and refuse vaccines for themselves and their children).  

Many statistical studies have examined demographic factors that align with attitudes towards vaccines, both prior to the beginning of the COVID-19 pandemic. A 2015 study by Johns Hopkins Bloomberg School of Public Health identified several factors shared by vaccine hesitant parents who intentionally delayed their children’s vaccines, including White race, married mothers, higher maternal education and age, English language-speaking, higher household income, and exposure to negative information about vaccines. With regard to the COVID-19 vaccine, 2022 CDC data found that early in the pandemic, Hispanic and Black Americans were less likely than Whites to be vaccinated for COVID-19. However, as the pandemic progressed this trend shifted, with growing numbers of Black Americans now opting to get vaccinated, and a larger fraction of Hispanic Americans currently vaccinated than White Americans. Black and Latinx Americans cited concerns about getting sick with COVID as a primary motivator in deciding to get vaccinated. For Americans who decided against the COVID vaccine, CDC surveys found that contributing factors included concerns about vaccine safety, mistrust of the medical community, perceptions of low risk from disease, and concerns about side effects from the vaccine.

Identifying societal factors, such as education level and political slant, that tend to accompany vaccine hesitant or anti-vax attitudes can be useful, but it can also contribute to the divisiveness we saw play out during so much of the COVID-19 pandemic as it highlights differences between groups. Some researchers are opting instead to explore creative strategies for connecting with members of the public who may be uncertain about receiving the COVID vaccine, or who lack access to a vaccination site. 

Unidos en Salud, or United in Health, is a program dedicated to finding innovative ways to increase COVID-19 vaccine uptake among the Latinx community in San Francisco. Unidos en Salud emphasizes elements like building trust, speaking the same language as their clients, and leveraging the social networks of those they vaccinate to reach out to others about getting vaccinated. 

Maria Contreras, a Community Prevention Care/COVID Program Leader with Unidos en Salud, highlights the importance of individual choice in whether or not to get vaccinated. Contreras says the most important aspect of her work is providing “low barrier access” to healthcare and health information. “When we engage in conversation with community members, we usually start out by letting them know, what does it mean to be vaccinated? What is the vaccine actually protecting you against?” she says. Unidos en Salud takes care to preserve community members’ sense of autonomy and empowerment to make their own decisions about their health. Contreras says they create a space for intimate conversations with community members, and for candid discussions about why they may not want to get vaccinated. And if they don’t want to get vaccinated, she says, “What can we do to make sure we give them the proper information to have a choice? It’s very important to give people that choice, and to help them feel safe about their autonomy as a person.” Central to the philosophy at Unidos en Salud is a focus on respectful communication with all individuals, regardless of their perspective about the vaccine.  Contreras spoke about the danger of talking about vaccine hesitancy in demographic, statistical terms, rather than keeping humanity in the conversation: “Imagine having to hear, ‘These people aren’t educated, and they don’t want to get the vaccine and that’s why they’re sick.’ That rhetoric is very dangerous, because it is attacking a community that we don’t know. We have to be sensitive to serving communities that are outside of our own ethnic and racial groups, and as a country we still have some space to get there.”  

Looking beyond demographic labels to individuals grappling with the vaccination question can be illuminating. Jenifer is a single mom, and has a career in the healthcare nonprofit sector. She credits her attitude of vaccine acceptance to her decades of close work with patients and researchers. “From the research side, I’ve been lucky enough to be in it because that’s what I do with my philanthropy, so I’ve had a little bit more exposure to be able to wrap my head around it,” she says. Jenifer also emphasizes the importance of understanding that science is not a perfect, static thing, but is constantly evolving and growing: “With the COVID vaccine, and then the strains of COVID, [researchers are] trying to keep pace. They’re rolling out information as it’s learned, and questions are being answered. While I see why some might hit pause and be hesitant about the validity of what’s being put out, it may be due to not completely understanding the process from the research side. Scientists aren’t trying to harm, they’re trying to improve. They want to roll it out as fast as they can, but they’re also learning as well.” Jenifer provides a clear picture of how her background has given her a strong positive opinion of the scientific and medical communities, allowing her to feel completely comfortable receiving the vaccine herself and recommending it for her daughter and other family members.

Nick is a father of four and owns a construction company in the East San Francisco Bay Area. He shared his concerns about the COVID vaccine: “I have not always felt this way. When our kids got their scheduled vaccines, I never questioned it. When the COVID vaccine was being developed, I was hopeful that it would end the pandemic. But as more information came out about how rushed the clinical trials were, I started to doubt. When I learned that pharmaceutical companies would not be held liable for any adverse reactions to the vaccines, it brought more doubt.” For the time being, Nick and his wife have decided against getting the COVID vaccine for themselves or their children. Some qualities Nick values in the information sources he trusts are neutrality, curiosity, and skepticism–he prefers listening to podcasts and radio shows that are themselves uncertain about the vaccine, and trying to sort through the information as best they can. He emphasizes that he is always open to having his mind changed by new information, but needs to feel that he has the freedom to decide what’s best for himself and his family. For Nick, the changing and shifting information during the pandemic has made him uncertain whether researchers, doctors, and major news outlets could be trusted to provide truthful information.

Amber is a massage therapist living in New England, and a self-proclaimed anti-vaxxer. For her, the issue of vaccination largely comes down to a desire for freedom of choice, and a strong faith in her ability to manage her own health. With regard to the COVID-19 vaccine, she expresses her skepticism: “To me, it was very obvious that it was being rushed, and there wasn’t really any solid guarantee that it was going to help us.” She also emphasizes that anyone who wants to put their mind at ease by getting a vaccine has every right to do that. “I really do believe that people deserve the choice,” she says. “That’s pretty much the bottom line for me. The reasons I don’t want [the vaccine] and the reasons somebody else does want it don’t matter. It just matters that we get to make our own decision around it, to weigh out our personal pros and cons.” For Amber, personal stories and testimonials of individual experiences are some of the most compelling forms of evidence: “We seem to think that anecdotal evidence isn’t evidence anymore. There are moms who are watching their kids change before their eyes, and you can’t tell that mom [her experience] isn’t real. Moms know, and those kinds of situations matter, and I don’t think people understand how hard it is to report an adverse reaction to any vaccine.” Amber is also concerned about a desire for profits as a driver for vaccines being recommended in such large numbers and she, like Nick, brought up her uneasiness with the lack of liability for pharmaceutical companies. 

It can be easy to focus on differences when considering the issue of vaccination, especially during this pandemic. However, as programs like Unidos en Salud demonstrate, it can be more advantageous to seek out common ground, to genuinely listen to each other, and try to understand the viewpoints and concerns of individuals who may not share our viewpoint on vaccines. Maria Contreras sums up the importance of communicating with kindness in order to open the door to future engagement: “What has really allowed us to open the conversation has been saying things like, ‘Ok, if you don’t want to receive the vaccine, these are some things you can do to take care of yourself and others around you. We’re always here for you to come back, and if you change your mind here’s our phone number, and you can call us if you test positive for COVID.’ It’s very important to open that door.” Getting involved with community-level efforts like Unidos en Salud can provide opportunities for engaging with community members about their health, help develop understanding, and increase tolerance across groups.