America Is Now in the Hands of the Vaccine-Hesitant

A subset of Americans haven’t yet made up their mind about getting a COVID-19 shot. Whether they turn out in the coming weeks will determine the future of the pandemic.

Multiple close up images of syringes going into arms
Getty / The Atlantic

It’s official: America’s vaccine-supply crunch is over. The U.S. has ordered, optioned, or procured enough doses to immunize every single member of the population more than five times over, and all adults will be eligible for the shots by May 1. In other words, after months of careful rationing and distribution snafus, we’ve finally hit a new phase of the pandemic endgame: vaccines galore.

Next we must confront a more pernicious problem than one of mere logistics: There’s plenty of supply, but what about demand? The worry that significant numbers of Americans might end up refusing a safe, effective, and available COVID-19 vaccine has been salient from the start: Just a few months into the pandemic, pollsters warned that less than half of American adults were sure to take one. But as long as these vaccines were either in development or scarce, this was a hypothetical scenario. Now, at last, our hesitancy will be tested.

The outlook, at the moment, is mixed. Americans’ overall acceptance of the vaccines seems to have increased in recent months, as some of those who said in 2020 that they’d wait and see have now waited, seen, and drifted into yes. When you consider all the polls together, about 60 percent of Americans are apparently planning to be immunized, if they haven’t been already. But the remainder—a roughly even split of refuseniks and the undecided—isn’t shrinking at the rate we might have hoped.

More alarming are reports of a gaping, and growing, partisan divide. A poll this month from NPR, PBS NewsHour, and Marist found that 87 percent of registered Democrats had either received a vaccine or planned to get one, compared with just 56 percent of registered Republicans. Similar spreads—of 25 to 30 points—have shown up in several other surveys too, and the size of the partisan gap appears to have increased by half since the fall. Donald Trump, who has said little on this topic since leaving office, finally appealed to his supporters on Fox News last week: It’s a great and safe vaccine, he said. “I would recommend it, and I would recommend it to a lot of people that don’t want to get it—and a lot of those people voted for me, frankly.”

Yes, let’s be frank: If vaccine acceptance tops out where it is right now, at less than two-thirds of American adults, then the pathway out of this pandemic could stretch and twist into the future. The virus will remain among us, if defanged for many, and harmful outbreaks could emerge as antibody levels fade. If patterns of refusal continue to develop along partisan lines, our outlook will be even worse. Because Republicans and Democrats tend to cluster in different places, even down to the level of neighborhood, a large partisan gap in vaccine uptake would likely lead to hot spots of infection. (When people who refuse a vaccine live near one another, the risk goes up.) But a better outcome also seems well within our reach. Although no one knows how much immunity would be enough to make the disease go away, Anthony Fauci has lately said, “If you want our society to get back to normal, you have to get about 70 to 85 percent of the population vaccinated.”

So the coming months will be dispositive. An undecided segment of Americans—vaccine swing voters, who now make up roughly 20 percent of all adults—have enormous power to determine how this goes. Which way will they break?

A funny fact about vaccines in America is that public attitudes about them rarely change much. For all the Sturm und Drang in recent years about the spread of anti-vaxxer sentiment, and for all the worry about measles coming back, routine childhood-vaccination rates have barely shifted. For more than 20 years now, the proportion of kids younger than 3 who have received a measles-mumps-rubella, or MMR, vaccine has wavered back and forth in a slender band of 91 to 92 percent.

That’s to some extent a product of our pediatric care, and public-school rules: Vaccinating children on the normal schedule remains parents’ path of least resistance, any other motivations notwithstanding. But even when the system isn’t pushing quite so hard, vaccination rates are pretty stable: The number of people who get the flu shot, for example, doesn’t change much from year to year, even as flu strains vary in their virulence. Among elderly Americans, the people most at risk of death from influenza, vaccine coverage landed somewhere between 60 and 70 percent in every single year from 1995 to 2020.

I say that this is a funny fact about vaccines because one can find it equally consoling and alarming. It’s nice to know that the rise of Andrew Wakefield—whose (since retracted) research linking the MMR vaccine to autism spawned a generation of anti-vaccine activists—caused only a tiny divot in measles-vaccination rates in the U.S. It’s less reassuring that all the righteous work that followed—from anti-anti-vaccination groups on social media, from state legislators, and from many others—hasn’t done that much to move the baseline either.

It’s altogether possible—maybe even likely—that Americans’ attitudes toward COVID-19 vaccines are stuck in the same molasses. It’s true that certain periodic polls in recent months have shown a shift toward more acceptance. But polls with longer trails of data, the ones that started before the fall, suggest a different story: They show a dip in vaccine confidence as the election neared, which has since leveled out. Case in point: Gallup had yes at 66 percent in July, which slipped down to 50 percent at the end of September, and then bounced back to 71 percent in January.

That autumn fade makes sense, given what occurred in the lead-up to Election Day. Trump had promised to deliver a vaccine just in time for voting, and said that he was “rushing it” along. As that deadline neared, his administration all but went to war against the “deep state” actors at the FDA, installing hacks and hall monitors along the way. On October 7, in a televised vice-presidential debate, Kamala Harris told the nation, “If the doctors tell us that we should take [the vaccine], I’ll be the first in line … But if Donald Trump tells us that we should take it, I’m not taking it.”

Naturally, Americans’ faith in any future COVID-19 vaccine went into a slide. Public-health experts warned (against the evidence, as they often do) that this loss of confidence would be long-lasting and profound. But the polling shows that it wasn’t. The dangerous “fever of distrust,” as Ezekiel Emanuel described it, didn’t last much longer than the fall foliage: By midwinter, the polling numbers had returned to roughly what they’d been.

The same pattern applies to the partisan split about vaccines. The gap between Trump and Biden voters has widened in the past few months, but it may not be any bigger today than it was last summer. When the Trump administration signaled a willingness to mess with the FDA’s decision making, Democrats panicked most. As the election approached, their vaccine enthusiasm collapsed to the levels seen among Republicans. Gallup had the spread between the two groups at 37 points in July, four in September, and then 40 in January.

All of which is to say that COVID-19-vaccine attitudes right now are not that far off from where they started back in 2020, and any hopeful signs of movement in the past few months could be nothing more than bounce-back from the fall.

Vaccine-acceptance rates are typically stagnant, but that doesn’t mean they’re stuck in place. It’s often said that more people would get their flu shots if they only grasped the toll of the disease. The deaths caused by influenza—tens of thousands in the U.S. every year—are usually invisible, so much so that the risk is misperceived. For COVID-19, though, the cost is counted every day. When it nears a big, round number—10,000, or 100,000, or 200,000, or 400,000, or half a million—front-page headlines follow. This transparency alone might sway the vaccine-hesitant. So too could the thought of returning to a semblance of one’s former life. Get a COVID-19 vaccine, and you can hug your parents: No other vaccination has this perk.

As distribution centers open up to all adults, and more people get their shots, even just the idea of getting immunized could spread through social networks as its own happy contagion, bringing up acceptance rates. “The thing that works best for getting vaccinated is that it gets normalized,” says Maya Goldenberg, a philosopher of science at the University of Guelph, in Ontario, Canada, and the author of a new book, Vaccine Hesitancy: Public Trust, Expertise, and the War on Science. “When vaccination becomes the norm, most people will do it unless they have a really strong inclination not to.”

What might that mean in practice? At the moment, one-fourth of all adults have already gotten at least one dose of their vaccine. Another 35 to 40 percent say they plan to get vaccinated as soon as they can, and about 20 percent are now at maybe. Goldenberg told me that we shouldn’t think of this latter group as being truly undecided. “We know that a lot of people are saying ‘I want to get it, but I don’t want to be first in line.’ Does that count as vaccine-hesitant? I’m inclined to say no.” So even if the nevers never budge, it’s certainly possible that in the next few months, amid the vaccination saturnalia, nearly all the nation’s maybes will come around. In that case, we’ll end up with 80 percent of all adults having their vaccination cards filled out or making their appointments—right in Fauci’s sweet spot for herd immunity.

Of course, another problem should be considered here: It’s one thing to say you want to get vaccinated, and another thing to do it. (SARS-CoV-2 antibodies, as the saying goes, don’t care about your feelings.) Past research shows that the pipeline from vaccine intentions to behavior can be somewhat leaky. Consider our efforts to address the previous pandemic, of the H1N1 swine flu in 2009. Then, as now, Americans varied widely in their estimations of the disease’s severity, and in how much they trusted the vaccine: A Pew Research poll conducted that October found that 64 percent of Democrats were ready to be immunized, compared with 43 percent of Republicans, and overall, half of American adults said that they planned to get the shot. By June 2010, only 27 percent said they’d actually done so. A somewhat milder attrition rate has been identified in small-scale research. Two very modest flu-shot studies, conducted at Rutgers University and among health-care workers in the Netherlands, compared vaccine intentions to behavior and found that about one-quarter of people who say they plan to be immunized fail to follow through. For the sake of argument, if we apply that rate to all the people who now say they’re yes or maybe on the COVID-19 vaccine, and then add the rest to the group of people who have gotten it already, the total coverage would come out to roughly 65 percent.

That projection lands us close to where we’ve been for flu vaccines among the nation’s seniors. That makes a certain amount of sense: Daniel Salmon, the director of the Institute for Vaccine Safety at Johns Hopkins Bloomberg School of Public Health, told me that he’s seen overlapping attitudes toward flu shots and the COVID-19 vaccine, both in surveys and in community meetings. The reasons people give for being wary are the same: They’re worried about adverse effects, he said, and don’t trust the government. Salmon’s team has also found that people are much more likely to say they’ll get the COVID-19 vaccine in 2021 if they’ve had a flu shot in the past.

Flu-shot rates did go up this year, at least a bit: For the 2020–21 season, coverage reached 82 percent for seniors, up by almost seven points from the year before. But even those gently boosted numbers would be dire for the COVID-19 vaccine. “We need 70 to 80 percent of people to be immune, homogeneous throughout the population,” Salmon told me. Kids younger than 16 aren’t eligible for COVID-19 vaccination (at least for now), so that means coverage must be even higher for adults in order for the country to reach that threshold. “I’m worried that we’re going to make a dent in disease transmission,” Salmon said, “but that it won’t be enough.”

Soon we’ll have a surplus of injections, and then a dearth of upper arms. If the maybes don’t turn out en masse—if in the coming months they fail to make their way to yes—there won’t be any simple finish to this crisis. Without their votes for vaccination, a miserable uncertainty will linger. Deaths could reach their next round headline number. The polls are opening across America. It’s time to watch the needle.