Vaccination in America Might Have Only One Tragic Path Forward

COVID-19 vaccination rates have fallen off a cliff. Will it take a deadly summer surge to change things?

An animated line of vaccine shots, with their back handles rising like an upward-sloping graph
Getty; The Atlantic

America’s vaccination rates have fallen off a cliff, and nothing seems to help.

On June 2, President Joe Biden announced a frantic plan to reverse what already seemed to be an awful, exponential slide: At the peak of the country’s vaccine rollout, in mid-April, almost 3.5 million doses were being put into arms every single day, but that number had quickly dropped by half, and then by half again.

Biden’s “month of action” came and went, and nothing really changed; or rather, the situation kept on changing for the worse. Demand for vaccinations shrank in July, as it had in May and June. Even statewide vaccination lotteries, described here and elsewhere as a great idea, turned out to be a flop.

With every passing day, the pace of vaccinations only seems to drag a little closer to the gutter. As of July 12, it had fallen off by half again. The Great Vaccine Decline now appears to be an ugly force of nature. If it continues, further horrors are all but guaranteed to follow. Sadly, those horrors may be the only thing that stops it.

The problem, it’s been said, is that we live in two Americas, riven by both ideology and immunology: In blue America, vaccination rates are standing up just fine; in red America, they’re slouchy and exposed. Indeed, the latest vaccine numbers show that 17 states have now provided at least one dose to more than 60 percent of their population—and every single one of them voted for Biden in the last election. Another 16 states are struggling to reach a rate of 50 percent; all but one of those went for Donald Trump.

But there’s another, better way to think about what’s happening here: If the distribution of vaccines keeps slowing down, it’s not because America is divided but because we’re running out of people who think vaccines will save their lives.

It certainly hasn’t helped the vaccination drive that Fox News and other right-wing outlets are sowing fear about the safety of the COVID-19 shots, and about the efforts to distribute them. Still, the recent wave of right-wing propaganda hasn’t clearly made the problem worse. Going by the numbers that we have so far, Tucker Carlson’s summer monologues aren’t really changing many minds. In fact, enthusiasm for the vaccine has been growing, overall, in both Americas alike. According to the Kaiser Family Foundation, which has been carefully following vaccine attitudes and behaviors since December, almost half of Democrats were saying that they planned to get immunized as soon as possible (if they hadn’t done so already) at the end of 2020; by June, that rate had nearly doubled, to 88 percent. Republicans started from a lower baseline, but they’ve also gotten more accepting: Just like the Democrats, the proportion saying that they wanted the vaccine almost doubled over time, from 28 percent to 54 percent. Party rhetoric notwithstanding, the overall partisan gap in vaccine enthusiasm has been holding steady, at a little more than 30 points, through all of 2021.

Rather than diverging politics, people’s willingness to get vaccinated might best be understood as a function of how they perceive risk. Although there are more noble reasons to be immunized than self-protection, surveys show that they’re not the ones most often cited. Kaiser finds that among those who have gone in for their shots, more than half say the “main reason” was to reduce their personal risk of illness. Meanwhile, among the unvaccinated, one-half assert that COVID-19 case rates are now so low that further vaccinations are unnecessary.

Risk perception is just one of many factors that determine vaccine uptake. You could be terrified of getting COVID-19, for example, and desperate to be immunized, but still find yourself unable to reach a distribution site. A person’s sense of danger could also modulate these other factors, at least for some people: The time and effort that it takes to get vaccinated may matter less to those who worry more.

Risk certainly seems to help explain the other major gap in vaccination rates across the U.S. population, between the gray America of retirees and the green one of Millennials. Some 85 percent of seniors have now been vaccinated, versus 55 percent of young adults—a gaping, 30-point spread that matches up, almost perfectly, with the spread between Democrats (86 percent) and Republicans (52 percent). If these two Americas of old and young are making different choices about vaccines, it can’t be just because they’re watching different cable talk shows, or because they vary in their trust in institutions, or because they disagree about the legal merits of Jacobson v. Massachusetts. No, old people are much more likely than young people to get their COVID-19 shots because old people are much more likely to die from the disease, and they know it. The same pattern holds for uptake of the flu shot every year: Seniors, who are at the greatest risk of influenza, are much more likely to be immunized. (The age gap for the flu shot, like the one for COVID-19 vaccination, is roughly 30 points.)

Since the very start of the pandemic, Republicans and Democrats have differed widely in their sense of the virus’s dangers. From March 2020, the Pew Research Center has been asking American adults whether the coronavirus outbreak represents a “major threat to the health of the U.S. population as a whole”—and from March 2020, Democrats have almost always been about twice as likely to say yes. In May of last year, 82 percent of Democrats agreed that it was a major threat, compared with 43 percent of Republicans. Politicians were working hard, from March 2020, to shape those very perceptions among their constituents, and it worked: The partisan worry gap was in place long before any vaccines were ever tested, and long before the right-wing media started talking up the risks of deadly side effects. It hasn’t budged for months and months and months.

Differences in risk perception are not as clearly linked to other important (and somewhat narrower) vaccination gaps, such the one between Black and white Americans. But looking at the numbers overall, you can see some hints of how these factors might have played into the timing of America’s Great Vaccine Decline. It’s clear enough that vaccinating people drives down the spread of COVID-19: Over a period of about six months, the number of new cases recorded every day in the U.S. has dropped by 95 percent, while the number of Americans who have been fully vaccinated increased a hundredfold. But the effect might also go the other way, with a decline in COVID-19 cases driving down the rate of vaccination. On March 11, Biden announced a huge expansion of the vaccine rollout, and over the next month, the number of doses being given out per day increased by 25 percent. But case rates were increasing too, by about the same amount. Then, around April 12, both trend lines hit a ceiling: From that point on, fewer Americans were getting sick, and fewer were getting vaccinated. By the end of June, both rates had fallen off by more than 80 percent.

A graph of U.S. COVID-19 cases versus vaccination rates from March 2021 to the present

It’s not surprising that demand for vaccination would tend to fall off over time, given that the most enthusiastic people line up first. Once they’ve gotten all their doses, the pace can only slow. But the coincidental timing of the drop in case rates hints that people’s sense of risk could be a factor too. Imagine that you’re not so sure about getting the vaccine yourself, and then you hear that the pandemic is receding. Maybe that makes you somewhat less inclined to take the day off work and find a mobile clinic. Maybe it’s a reason to wait a little longer.

“One of the main problems that vaccination programs face is that they’re effective,” Noel Brewer, a psychologist who studies health behaviors at the University of North Carolina, told me. “And their effectiveness undermines people’s interest in vaccination.”

If our sense of danger—or lack thereof—is behind the Great Vaccine Decline, then maybe there’s a fix. Should we try to make the holdouts more afraid?

Scared Straight programs for vaccines have been tried before, and they haven’t done much good. Studies tend to find that pointing to the dangers of disease will certainly freak some people out—but that feeling is short-lived and doesn’t seem to change behavior. “They found small increases in perceived risk but no increases in vaccine uptake,” Brewer said. “On balance, it’s not going to work.”

It’s also possible that some people who are disinclined to get their COVID-19 shots might not be wrong, per se, in their assessment of their own, relative risk of dying from the disease, even if they’re neglecting the bigger picture. Young people really are hundreds of times less vulnerable than seniors, and Republicans are, on average, a lot more realistic than Democrats about a person’s chances of developing severe disease once they’ve been infected by the coronavirus. (At the same time, they’re much less realistic about COVID-19’s harms in aggregate.) In other words, efforts to scare more young people or Republicans into getting vaccinated could end up encouraging them to be less informed about the facts, at least narrowly construed, instead of more so.

Brewer warns that any form of intervention aimed at people’s “thoughts and feelings” about vaccines isn’t likely to succeed. We know that those thoughts and feelings help determine people’s actions, but that doesn’t mean they can be changed by PSAs or other public-health campaigns. It’s better to focus on behavior, he told me. “We have to help folks take action; we have to help them take time off work; we have to help lower the barriers that are currently preventing them from acting on their good intentions.” It’s important for people’s own doctors to be involved in the process, encouraging and delivering vaccines, Brewer said. Vaccine requirements might make a difference. Full FDA approval for the vaccines could help, too—though how much is debated.

Of course, helping folks take action is just the sort of thing that the White House has been pushing, and it hasn’t done much good. Brewer acknowledged that the effects have been pretty small so far, but he said that doesn’t mean they’re unimportant. Changing people’s health behaviors tends to be slow and difficult work. “When looking at other vaccines, an increase of 2 percent year over year is a big deal,” he told me. Even tiny bumps like these save lives.

But as the Delta variant rips through Arkansas, Florida, Missouri, and the rest of the United States, we may see the vaccination numbers start to rise in tandem. If a drop in cases dampened people’s urge to get vaccinated, then perhaps a surge in cases will do the opposite. If ICUs keep filling up, and COVID-19 deaths increase again, then a growing sense of danger may envelop some among the vaccine-hesitant, nudging them toward action. It’s a pattern that we’ve seen before: In 2019, when measles struck parts of the Pacific Northwest, local rates of measles vaccination tripled in response. The economist Emily Oster has looked at pertussis outbreaks, county by county, going back to 1991, and found that child vaccination rates increased in the years that followed.

The two lines plotted on the chart above, for new COVID-19 cases and vaccine doses, have started to diverge. It will be a somber consolation if they come back together in the weeks ahead. A national month of action did little to arrest the Great Vaccine Decline. Now a national month of pain and suffering is all we have.