The Surprising Key to Combatting Vaccine Refusal

It’s not just one problem—and we’re going to need a portfolio of approaches to solve it.

A tray of vaccines
Apu Gomes / AFP / Getty

Why wouldn’t someone want a COVID-19 vaccine?

Staring at the raw numbers, it doesn’t seem like a hard choice. Thousands of people are dying of COVID-19 every day. Meanwhile, out of the 75,000 people who received a shot in the vaccine trials from Pfizer-BioNTech, Moderna, AstraZeneca, Johnson & Johnson, and Novavax, zero died and none was hospitalized after four weeks. As the United States screams past 500,000 fatalities, the choice between a deadly disease and a shot in the arm might seem like the easiest decision in the world.

Or not. One-third of American adults said this month that they don’t want the vaccine or are undecided about whether they’ll get one. That figure has declined in some polls. But it remains disconcertingly high among Republicans, young people, and certain minority populations. In pockets of vaccine hesitancy, the coronavirus could continue to spread, kill, mutate, and escape. That puts all of us at risk.

Last week, I called several doctors and researchers to ask how we could reverse vaccine hesitancy among the groups in which it was highest. They all told me that my initial question was too simplistic. “Vaccine hesitancy” isn’t one thing, they said. It is a constellation of motivations, insecurities, reasonable fears, and less reasonable conspiracy theories.

“I call it vaccine dissent,” Kolina Koltai, who studies online conspiracy theories at the University of Washington, told me. “And it’s way more complicated than being anti-vaccine. It goes from highly educated parents who are interested in holistic, naturalistic child-rearing to conspiracy theorists who want to abolish vaccines entirely.”

“I call it vaccine deliberation,” said Giselle Corbie-Smith, a professor at the University of North Carolina and the director of the UNC Center for Health Equity Research. “For Black and brown people, this is a time of watchful waiting. It’s a skepticism of a system that has consistently demonstrated that their health is not a priority.”

“It’s not vaccine hesitancy among American Indians, but rather hesitancy and distrust regarding the entire government,” said Margaret Moss, an associate professor at the University of British Columbia School of Nursing and an enrolled member of the Three Affiliated Tribes of North Dakota. “After decades of distrust, on top of centuries of genocide, now they appear and say, ‘Here, you have to take this!’”

Let’s not forget vaccine indifference. Two-thirds of Republicans under 30 without a college degree say that they are “not concerned at all” about COVID-19 in their area, according to polling from Civiqs. The same percentage of this group says that they won’t take the vaccine, making them the most vaccine-resistant cohort among all of those surveyed.

Dissent. Deliberation. Distrust. Indifference. Vaccine hesitancy is not one thing. It’s a portfolio. And we’re going to need a portfolio of strategies to solve it.

Kolina Koltai has been studying online disinformation since 2015, with a special focus on anti-vaccine groups on Facebook. “People come into the space for a variety of reasons,” she said. “At first, it was mostly parents, more women than men, and overwhelmingly white, ranging from stay-at-home moms to people with high levels of education who wanted a naturalistic upbringing for their child.” The group didn’t initially have a political lean. But in the past few years, Republican politicians have played more directly to anti-vaccine fears, pulling these groups to the right.

Today, resistance among the GOP seems to be the most significant problem for vaccinating the country. Just half of Republicans say that they plan to get the shot, while the share of pro-vaccine Democrats has increased to more than 80 percent.

Online denialism and conspiracy theorizing about the COVID-19 vaccine is more complex than previous anti-vaccine skepticism, Koltai said. “Crisis often breeds conspiracies, and the extended nature of this public-health crisis has given conspiratorial people lots of time to build elaborate theories,” she told me. Beyond the more outlandish theories—for example, that Bill Gates is using the shots to inject Americans with his microchips—she said that most online skepticism is more prosaic. People claim that the vaccine trials were rushed and shoddy. They worry about the long-term side effects of a newfangled chemical that monkeys around with our cells. They read news reports of people getting sick after having taken the shots, and become afraid.

“You shouldn’t say that people are idiots for believing false or misleading information, because they’re not idiots,” she said. “That’s part of what makes this such a hard problem to solve.”

In the past few years, social-media companies have banned content that they consider to be harmful misinformation. Pinterest has famously established a zero-tolerance vaccine-misinformation policy, while Facebook has more recently banned claims that the COVID-19 vaccines are dangerous. But vaccine denialism doesn’t need outright disinformation to thrive; it can breed on poor reporting and misleading headlines, which are harder, if not impossible, to ban. On February 5, NBC reported that a Virginia woman died shortly after her vaccination shot. The story went viral, but no link was ever established between the vaccine and her death. Several weeks later, NBC reported that the death was likely unrelated. Is such a story misinformation? The headline was technically true. But it was the sort of technical truth that actively detracts from our understanding of the world.

More subtly, many reporters and scientists consistently focus on the worst news about the pandemic, perhaps thinking that they are doing good. They promote stories that claim with certainty that the vaccines won’t contain the new variants (contra most available data) and emphasize that vaccinated people should not return to a normal life. These messages aren’t entirely wrong; they shouldn’t be classified as misinformation that merits social-media expulsion. But anybody who gets their news diet from such doombait will inevitably come to believe that the vaccines are no good—or that it doesn’t even matter whether they get one. “It’s not just fake information that might strengthen vaccine hesitancy,” Koltai said. “True information that is stripped of context could do the same thing.”

Aaron Richterman is an infectious-disease specialist in Pennsylvania, where his clinic serves many low-income patients with HIV. Their vaccine skepticism presents itself in several forms: fear of illness, fear of unnatural substances, and even fear of elite conspiracy.

“A lot of my patients tell me they’re worried the vaccine will make them sick,” he told me. “They hear stories about people who took the vaccine and didn’t feel well. Others tell me that vaccines are unnatural and they don’t want to put such chemicals in their body. Then others tell me they’re worried about big companies trying to do something nefarious. I just heard this too today: ‘There is some bigger plan that is underlying this.’ They ask about the Bill Gates microchip, too.”

It’s tempting to treat these more outlandish conspiracy theories with straightforward contempt. But the history of Western medicine is not a fairy tale of moral purity. In fact, several of its chapters are almost as diabolical as a forcibly implanted computer chip. In the U.S., vaccine hesitancy among Black Americans is an enduring phenomenon, in many cases tied to past abuses such as the horrifying Tuskegee syphilis study. In the study, federal officials enrolled 600 Black Alabamans suffering from syphilis in an experiment to examine the disease’s long-term effects, withholding participants’ diagnoses and denying them treatment.

“We talk about Tuskegee, but it’s not just the history of exploitation by the medical field, or the history of unethical research conduct” that taints Black Americans’ trust in the medical system, said Corbie-Smith at UNC. “It’s their current-day experience with the health-care system, including with this pandemic, which has such a disparate impact on the lives of Black and brown Americans. People are looking to see how the vaccine rollout is going to treat them with equity.”

The early returns haven’t been promising. In Alabama, where the white population is being vaccinated at twice the rate of Black citizens, a community clinic in a low-income neighborhood in Birmingham has yet to receive its first dose. As Sheila Tyson, a commissioner in the county that includes Birmingham, told Bloomberg: “How do they know we are turning down the vaccine if it is not offered to us?”

Even vaccine shots intended for residents of minority neighborhoods have often gone to higher-income people, by scheme or by mistake. In Los Angeles, the government tried to distribute vaccines to hard-hit communities of color by sending out a set of online access codes through leaders in those communities. But the codes got leaked and passed around the city’s higher-income remote workers—most of whom probably had no idea that they were taking spots intended primarily for Black and Latino communities. Thus, a well-meaning program to distribute shots to poor neighborhoods became another example of how knowledge workers tethered all day to their computers have coped throughout the pandemic while low-income hourly workers have suffered.

In Raleigh, North Carolina, online enrollment has left behind older Black citizens without access to a home computer or an understanding of the often Byzantine rules required to sign up for an appointment. Community volunteers have stepped in to help seniors navigate the vaccine websites or print the requisite forms and deliver the papers to their front door. “They’re calling it an Underground Railroad to help older Black citizens get access to the vaccines,” Corbie-Smith told me. “When the community narrative is drawing on slavery, I think it’s fair to say that slow vaccination rates among Black citizens is a bigger issue than Oh, my arm is going to be sore.”

I heard the same point from several sources: The confusing vaccine-eligibility rules and the unequal distribution of doses were combining to bar some people from the process. “At my own reservation in North Dakota, I’ve heard that elders drove for hours over ice—we’re talking North Dakota—and were turned away from the nearest clinic,” Moss, the UBC professor, told me. “They don’t have time to stand in line for 10 hours a day or refresh a web page.” States could give such enrollees a ticket that guarantees a specific slot for future vaccination. But instead, we’re turning people away from a system that requires near-universal participation.

Despite these challenges and the long history of minority Americans’ vaccine deliberation, there is some evidence that things are moving in a positive direction. The share of Black and Latino Americans who say that they plan on taking the vaccine has increased from about 40 percent to roughly 60 percent in the past three months. This raises the possibility that one of the most important ways to solve the vaccines’ “demand problem” is to rapidly solve the “supply problem.” More shots in arms means fewer sick people; fewer sick people means more normalcy and more headlines about normalcy; and more normalcy provides crucial evidence to the undecided that the drug is worth the jab.

Vaccine hesitancy is as old as vaccines themselves. The smallpox vaccine faced immediate skepticism in the U.K. when Edward Jenner tried to present his initial experiments to the scientific community and the public in the late 1700s. Around 1900, as authorities tried to contain smallpox, Americans formed anti-vaccination leagues and hid sick children from public-health officials. Their reasons were as manifold as those of today’s vaccine resisters, including fear of the new and unnatural and skepticism about a dubious authority. A bit of distrust was not entirely irrational.

Today’s vaccine resistance isn’t entirely irrational, either. And even if it were, it wouldn’t do any good to treat the vaccine-hesitant as if they were crazy. “As a clinician, I find it’s a mistake to simply tell people what to think,” Richterman, the Pennsylvania infectious-disease specialist, told me. “Screaming ‘Just take this!’ isn’t effective, because this isn’t about getting others to see my goals. It’s about helping them identify their own goals and how, maybe, getting a vaccine might help achieve them.”

This approach is often called “motivational interviewing.” It works like this: Instead of telling people why you think they should change, you ask them open-ended questions to help them discover their own reasons. If their motivation (e.g., “I want to be healthy”) matches your goal (e.g., “I want you to take this vaccine”), you can guide them toward a plan.

“Sometimes I flip the question and ask, ‘What would make you want to get the vaccine? What would convince you to get it?’ That way you urge them to identify the positive things,” Richterman said. “Maybe they’ll say, ‘I want to help my friend who isn’t well,’ or, ‘I want to protect my family.’ And then I latch on to that and try to build on that.” These methods don’t exactly proceed at warp speed. It can take time for people to change their mind, if they do so at all. But the approach seems to work better than any other to soften vaccine deliberation. A 2021 study from the University of Pennsylvania found that Black Americans who expressed reluctance toward the COVID-19 vaccine “were willing to consider” receiving it when trusted health-care providers reflected their concerns and emphasized the safety of the shot.

When we disentangle the constituent parts of vaccine hesitancy—conspiracy theorizing, wait-and-see deliberation, frustration, and distrust—it becomes clear that vaccine reluctance will never be solved by one big thing. Better national messaging on how vaccines could change our lives might encourage young people to get the shot, but would do little to change inequities at the community level. Clearer eligibility rules and more equitable distribution could accelerate vaccination in low-income neighborhoods, but might not solve vaccine indifference among young white Republicans. Motivational interviewing might bring along the skeptical, but more information is unlikely to convert the full-blown conspiracists. The multiple-choice question of combatting vaccine resistance has an obvious answer: We need all of the above.