The J&J Rescue Mission Starts With a Choice

The reputation of all COVID-19 vaccines hinges on improving perceptions of the Johnson & Johnson shot.

three blurred vaccine vials labeled A, B, and C
The Atlantic / Flavio Coelho / Getty

Had Johnson & Johnson’s COVID-19 vaccine been the first to get the FDA’s green light, it might have been hailed from the get-go for what it actually is: a scientific and technological marvel. It requires just one injection to confer full immunity—a boon for needlephobes and tough-to-reach populations who can’t easily access a second dose. It’s relatively cheap and has forgiving refrigeration requirements, making it a breeze to ship and store. And clinical trials showed that it’s a knockout at guarding against hospitalization and death, and 66 percent effective at preventing moderate to severe cases of COVID-19, even amid the rise of antibody-dodging coronavirus variants. Johnson & Johnson accomplished all this in less than a year, granting the world a safe and effective vaccine crucial to hastening the pandemic’s eventual end.

That’s not how the J&J story played out.

By the time the authorization for the J&J vaccine went through, its mRNA-based counterparts, boasting clinical-trial efficacies of roughly 95 percent, had been in the field for months. Experts cautioned that differences in trial design and timing made the trio of vaccines impossible to accurately compare. But people pitted them against one another all the same, and time and time again, J&J appeared to lose out. The shot was labeled “second class” just as it surged into some of the disadvantaged populations hit hardest by the pandemic, raising discomfiting questions about whether the rich and privileged were hoarding the top-tier vaccines for themselves. Manufacturing snafus that compromised millions of doses quickly added to the ire. Last month’s 10-day hiatus, when the CDC and FDA linked the vaccine to a rare and unusual blood-clotting disorder, dealt the shot yet another blow, spurring a noticeable dip in confidence in the J&J formulation.

As vaccine supply starts to exceed demand in the U.S., researchers and health workers across the country are steeling themselves for what could be a rough rescue mission. A vaccine that’s thought of as “shitty,” experts told me, has little chance at being seen as truly equitable, and some of them worry that J&J’s product has already been snared in that trap.

“I think it’s going to be hard to dig our way out,” Abraar Karan, an internal-medicine physician at Brigham and Women’s Hospital in Boston, told me.

What the J&J shot now faces is a sort of branded vaccine reluctance, largely specific to one company’s product. But the reputation of other vaccines also hinge on this one, experts told me, making rehabilitation key. An important first step, they said, might be giving people the option not to take it at all.

The Johnson & Johnson vaccine is not, experts repeatedly told me, a “worse” vaccine. Among the three options available to Americans—Pfizer-BioNTech, Moderna, and J&J—“the best vaccine you can get is the one you can get in your arm as soon as possible,” Chrissie Juliano, the executive director of the Big Cities Health Coalition, told me.

But J&J’s vaccine is undeniably different, and its portability and convenience have prompted health departments to shuttle it into distinct populations, such as incarcerated individuals and people experiencing homelessness. In practice, this may be contributing to some unintended stratifications. David Lazer, a computer scientist at Northeastern University, told me his team has collected data showing that Black people are almost twice as likely to have received the J&J vaccine than white people, a disparity that doesn’t seem to be accounted for by preferences alone.

The hustle to allocate J&J immediately raised questions about whether America’s “problematic” vaccine was being earmarked for communities who are already distanced from medical resources and disproportionately pummeled by the virus, says Rachel Hardeman, a health-equity expert at the University of Minnesota. That stigma rapidly began to reinforce itself. In early March, Detroit Mayor Mike Duggan rejected a batch of J&J doses, saying that he wished to provide his residents with only “the best” vaccines. One physician told me that she’d received calls from reporters asking her to comment on J&J “being the poor person’s vaccine.” “There’s this undercurrent of tension,” Taison Bell, a critical-care physician at the University of Virginia Health System, told me. Many of the populations described as good J&J candidates “feel, rightfully so, that they receive second-rate care.”

This challenge, even if it has more to do with public perception than the vaccine’s intrinsic quality, can’t be dismissed: If people believe the vaccine is inferior, “that’s just as important as reality when people try to make healthy decisions for themselves,” Bell said.

Rehabilitating the Johnson & Johnson vaccine, experts told me, will require honest acknowledgments of its shortcomings, and validating, not combatting, people’s concerns. The rare blood clots that have been tied to the vaccine are serious, they said, but extraordinarily uncommon—a risk that’s far outweighed by the benefits of immunity.

The pause clearly did shake things up. Willie Bodrick II, a senior pastor of Twelfth Baptist Church in Boston, who’s heavily engaged in vaccine outreach to the city’s Black community, told me that, even before the pause, he had been fielding questions about the J&J shot for weeks. Some people who were unwilling to take a second dose, whether because of work constraints or wariness of side effects, saw the single injection as an ideal option; others “were really worried they would be receiving a subpar vaccine,” he said. Just days before the J&J halt, Bodrick felt he’d made progress. But news of the rare blood clots “resurfaced a hurdle I thought we were doing a good job moving beyond,” he said. Van Yu, a physician at the Center for Urban Community Services in New York City, where he is working to bring J&J vaccines to people experiencing homelessness, told me that, before the pause, many of his patients explicitly requested “the single-shot thing.” Now that J&J is available again, he and his colleagues have noticed that some people are citing the halt as a reason to turn it down.

The risk of clots has persuaded a few people to forgo vaccination entirely. Earl Potts, a 60-year-old IT-security specialist in Maryland, told me that he’s been skeptical of receiving any vaccines for decades. Although constant coaxing from family initially nudged him and his wife, Lori Renee Potts, toward getting J&J “because it was just one shot,” the pause reignited their fear that the vaccine-making process had been rushed. “I need more data; I need more time,” he said.

In many parts of the country, however, a simple message is still encouraging people to roll up their sleeves: Johnson & Johnson’s vaccine is “one of three excellent choices for protection against COVID-19,” as Hardeman puts it. In Columbus, Ohio, the health department’s on-site clinic vaccinates about 130 to 140 people each day, more than a third of whom are still queueing up for the one-and-done shot, Health Commissioner Mysheika Roberts told me. At another large site, where Pfizer and J&J doses are alternated throughout the week, “the J&J days are just as busy.”

Still, the pause prompted Roberts and her team to switch up their outreach tactics. Before the halt, city officials had brought only one brand at a time when inoculating off-site, prioritizing J&J allocations for the residents of homeless shelters and homebound individuals. When the vaccine returned with a warning label, “we thought it was appropriate to offer a choice,” Roberts told me, so no one felt cornered. Porting mRNA vaccines around requires a mobile freezer, which is “tedious to maintain,” she said, but removes a barrier. “Now when we go out to any location, it’s, ‘Which do you want, Pfizer or J&J?’”

This smorgasbord-of-shots strategy, experts told me, could be key to the next stage of the American rollout, especially as vaccine delivery moves past inoculating enthusiasts, and starts pointedly targeting those with reservations. The idea is to meet the unimmunized where they are, both literally and figuratively. And sending different brands of vaccines to different communities isn’t going to work in a culture set on believing one shot is “worse” than the rest. Biased allocation also puts the vaccination campaign as a whole at risk, Bell told me: If something should derail a shot that’s been doing most of the heavy lifting for certain demographics, those populations could be put in a sudden and irreversible bind.

“There should be no community without a choice of vaccines available to it,” Camara Phyllis Jones, a family physician and epidemiologist based in Atlanta, told me. “Giving options is another way of signaling we value people equally.” Sending J&J to places that lack the infrastructure to store and administer Moderna and Pfizer, for instance, might seem easier or more expedient in the short term. But it sidesteps the actual inequities at play, she said. And she doesn’t consider a lack of a freezer a good excuse for snubbing an mRNA vaccine: “Bring a freezer.”

An infrastructure of choice is now supporting the vaccine rollout among people experiencing homelessness in Los Angeles County, where close to 70,000 people are without stable housing. Heidi Behforouz, the medical director of Housing for Health, told me that her team has delivered doses to more than 3,500 people living in shelters or on the streets in the past three months. Most received the Moderna vaccine. The shot is cumbersome to trek into encampments, but with the help of specialized coolers and a vigilant follow-up protocol, “our second-dose return rate is about 93 percent,” she said. (The national average, meanwhile, is about 92 percent.) The team added J&J to its repertoire in early April, just days before the pause, and plans on offering both brands to all of its patients.

Two of Housing for Health’s recent recipients, Candy Acuña Rodriguez and Daniel Gilbert Trujillo, told me they gladly selected the one-and-done shots last Friday, after health workers assuaged their concerns about the pause. “Why would we want to have to go back and take two doses?” Rodriguez told me. “It should be all in one.”

None of these discussions are intended to erase the fact that the J&J vaccine may be well suited to, or preferred by, certain groups of people. Making assumptions about who those individuals are is what imperils a rollout. Roberts, in Columbus, told me that one of her region’s first outreach clinics brought J&J to a predominantly African American church, whose members rallied for the brand because it was familiar to them. “They said, ‘It’s a company we’ve heard of,’” she told me. In Los Angeles, however, Behforouz told me that some Black women regard J&J with reproach, citing concerns that the company had, in prior years, aggressively marketed baby powder to their demographic, even amid accusations of asbestos contamination. “It’s hard to predict which patients will want which vaccines,” Josh Banerjee, a physician working with the Street Medicine Program at USC, told me. As Yu, the New York physician, said: “It’s not like I can take a look at you and just guess.”

A big asterisk still hangs on this discussion. While millions of Americans quibble over their glut of three spectacular shots, residents of other countries are wrapped into a far worse conundrum: a paucity of any vaccines at all. High-income countries have already laid claim to more than half the globe’s available doses. As things stand, the rest of the world doesn’t have the luxury of choice. The U.S. has taken some limited steps in rectifying global disparities, by shipping out doses of the AstraZeneca vaccine (which resembles J&J in formulation but has yet to be cleared by American regulators), and moving toward waiving intellectual-property protections on the vaccines.

After failing to protect people for months, U.S. policies are finally reversing that trend with a successful vaccination campaign. The country now has another opportunity for global leadership: collectively opting back into a lifesaving shot. Choosing a J&J vaccine here doesn’t just benefit the person who receives it; it sends a reverberating message, Karan, of Brigham and Women’s, told me. “It highlights that perhaps this is not a worse vaccine at all.”