For the past four years, the lingering fear of COVID-19 has caused people to stockpile rapid-test-kits in drawers, stay away from large social gatherings, and be overly cautious of strangers who ignore public health guidelines. During the pandemic’s early month’s, public health officials across the world scrambled to gather reliable data, relaying the surplus of information they unearthed to a panicking global population. Efforts between international, federal, and local agencies were slow to become immersive and reliable. In the United States, the pandemic exposed deep levels of mistrust between government and its citizens. One consequence of this mistrust is the ongoing pattern of vaccine hesitancy, which is the delay or refusal to accept vaccination despite the availability of vaccination services (ECDC).

Vaccine hesitancy is a complex issue common throughout the world. Internationally, health officials have struggled to find methods of encouraging their constituents to feel safe and secure in their decision to be vaccinated, not just against COVID-19, but for diseases ranging from measles to polio. According to the CDC, COVID-19 vaccines in the US help your body build an immune response against the virus, essentially arming your body against severe COVID-19 symptoms. The vaccines have been proven to be the most effective method of preventing serious illness, hospitalization, and death. They have also been shown to be incredibly safe, with federal agencies like the CDC and FDA constantly monitoring patient outcomes. On an individual level, vaccines work to protect you. What about on a community level? The ultimate goal of mass vaccination is the phenomenon of herd immunity which benefits your community directly. Herd immunity occurs when a significant portion of the population has protection from a disease because they are vaccinated. This gives those who slipped through the vaccination cracks to be protected from infection, and in general works to stop the chain of transmission of a disease. However, herd immunity requires a high level of vaccination, which is why lowering vaccine hesitancy is so important.

So, if vaccines are safe, and herd immunity sounds pretty good, why is mistrust of the COVID-19 vaccine so high? 

To begin, a global reason for COVID-19 vaccine hesitancy is the general concern about vaccine safety. In Solano CA, researchers asked study participants to describe in detail what safety concerns they had. Participants described how friends and family developed side-effects from the vaccine (Solano Study). For example, some participants said they knew one friend who developed inflammation of the heart (a condition called Myocarditis) and who then supposedly died from the vaccine. Another participant said they knew a friend who got their period for an entire month after receiving the mRNA vaccine. Others described how they knew co-workers who got COVID multiple times after being vaccinated and questioned the reliability of the vaccine to actually protect you. While these stories are likely idle talk, coincidences, or outliers, community experiences are often taken more seriously by community members than the information of an unknown scientist or a distant federal agency that no one’s heard of before. And as previously mentioned, this is a global phenomena. In Mbarara Uganda, researchers found that 47.3% of their study sample had listed vaccine safety as their primary reason for being hesitant to get the vaccine (BMC Study). 

Similarly, many people became even more mistrustful of vaccines because of the legal act of vaccine mandates. For example, in Solano CA, many felt like the promotion of vaccines by the government and popular media was coercive. School mandates, and private business mandates, although marketed as a method of making vaccinated people feel safe, also made unvaccinated people more entrenched in their negative view of vaccines. Dr. Carinne Brody, Associate Professor in Public Health at Touro University, CA, and lead researcher in the aforementioned Solano Study, described how public health officials “were so strong with the mandate that the equal and opposite response was as strong.” She continues, “In public health, we say we’re doing a mandate so it’s very clear what what the next step is for the public’s health and also we’re trying to incentivize it, to reduce barriers, and to increase acceptance…whereas it had the opposite effect for some people or it was like you’re trying so hard, now I feel even more skeptical.” 

This skepticism in Solano can also be traced to the deep legacy of racism in public health in the United States, and the various human rights violations committed by scientists and researchers. Racist infrastructure in the US dating back to Jim Crow makes obtaining traditional health care often more difficult for historically marginalized communities. Public health is also responsible for medical research on communities of color without their consent, which has not only led to poor health outcomes but intergenerational trauma. And, in general, the spirit of public health has often neglected people of color, their voices, opinions, and needs. Many individuals in the Solano Study felt that billboards advertising vaccines, and marketing efforts by public health officials were targeting people of color in a way that was uncomfortable. Dr. Brody gives the example of a third grade class achievement board, “You might give stars on the board for people who are doing well, but by doing that, you’re actually exposing who’s not doing well… So having a billboard that’s so explicitly targeting African-Americans doesn’t do what their [(public health officials)] intention was.”

Other researchers believe that the climate of high political polarization combined with unethical and unchecked social media platforms also pushed vaccine hesitancy. A study conducted by the BMJ found that exposure to counter-vaccine campaigns via social media increased vaccine hesitancy in those exposed. This is likely because social media algorithms work to show people information based on their preconceived beliefs. People who were already vulnerable to believing misinformation were essentially targeted and pushed further towards refusing the vaccine through false information perpetuated online. Furthermore, a study conducted by Taylor and Francis found that the number one factor in determining vaccine hesitancy in the US was political affiliation, and that political affiliation continued to be the driving factor of vaccination rate throughout the pandemic (Taylor and Francis). When looking at the Populist Right political affiliation, which is characterized by being extremely right-winged valuing traditional ‘American’ ideals, anti-immigration policies, and small government, only 51% reported being fully vaccinated, less than any other political typology (Pew Research Center). Surprisingly, this polarization was found not only in the US but in other studies. In a BMC study conducted in Mbarara, Uganda, there was a correlation between Christian nationalism and vaccine hesitancy. Despite these findings, political ideology and religion do not inherently make someone pro or against vaccines. It is more likely that people with low access to pharmacies or community clinics and who have little social media literacy are more willing to trust well-known opportunistic and charismatic individuals, over public health officials they have never heard of before. Regardless, it is clear that public health must shift its strategy to incorporate these vaccine hesitant individuals, instead of pushing them further away. 

While some scientists and policy-makers believe that vaccination should be mandatory, the ethics of forcing someone to take any sort of medicine or drug that they don’t trust, or that they believe will actually harm them, is murky. It is also likely that mandates ostracize people who are vaccine hesitant, rather than reintegrating them into society. Rather than punish people who are vaccine hesitant, public health officials have a responsibility to educate people of the benefits of vaccines, and empower them to get vaccinated on their own accord. 

In the previously mentioned BMC study conducted in Mbarara Uganda, researchers illuminated a promising new community pharmacy-based counseling intervention to lower vaccine hesitancy. Trained counselors were deployed at local pharmacies to use a communication intervention strategy; essentially, counselors talked to people. The method of communication was through short SMS messages, and through bi-weekly telephone calls in which counselors spoke to people about their individual fears about the vaccine. Since most fears were linked to vaccine safety, counselors discussed how vaccines are developed, the amount of people who have been vaccinated and the low risk of any adverse effects. Counselors also explained the benefits of vaccination for preventing hospitalization and death, and even larger community benefits like herd immunity. By effectively communicating with people directly and one-on-one,  this study was able to increase vaccine acceptance by over 25%. A top researcher from this study, Dr. Paul Alele, P.h.D. Associate Professor, Faculty of Medicine at Mbarara University of Science and Technology (MUST), described how a pharmacy-based counseling intervention is successful because “many people go to community pharmacies to fill their prescriptions, and, I think many pharmacies also play the role of treating different people in the community for minor ailments who may not necessarily have to go and see a physician. So, they give counseling for things like that or even for chronic conditions.” Considering that pharmacies in the US play the same role, it is likely that this sort of intervention is translatable across the world. The study in Mbarara was also limited in terms of funding, and in terms of distance, including only those who lived within 1km radius of a pharmacy. With a larger budget, and improved transportation for those who live in isolated areas, this intervention could be even more successful. One can imagine that if this sort of practice was applied earlier in the pandemic what vaccine acceptance would look like and the countless COVID-19 hospitalizations and deaths that could have been prevented. 

In a world of increasing globalization and interconnectedness, a global pandemic like COVID-19 is bound to happen again. While creating vaccines is now easier than ever before, understanding the best methods of giving people the vaccine is crucial. What we have learned in the years after COVID-19’s peak is that vaccine mandates, marketing schemes like billboards, and press releases by distant public health officials were very limited in their success in reducing vaccine hesitancy. Perhaps, the future of public health lies in simply talking to one another and building trust instead of divisiveness. Community pharmacy-based counseling is an excellent method of doing this.