Something very strange has been happening in Missouri: A hospital in the state, Ozarks Healthcare, had to create a “private setting” for patients afraid of being seen getting vaccinated against COVID-19. In a video produced by the hospital, the physician Priscilla Frase says, “Several people come in to get vaccinated who have tried to sort of disguise their appearance and even went so far as to say, ‘Please, please, please don’t let anybody know that I got this vaccine.’” Although they want to protect themselves from the coronavirus and its variants, these patients are desperate to ensure that their vaccine-skeptical friends and family never find out what they have done.
Missouri is suffering one of the worst COVID-19 surges in the country. Some hospitals are rapidly running out of ICU beds. To Americans who rushed to get vaccinated at the earliest opportunity, some Missourians’ desire for secrecy is difficult to understand. It’s also difficult to square with the common narrative that vaccine refusal, at least in conservative areas of the country, is driven by a lack of respect or empathy from liberals along the coasts. “Proponents of the vaccine are unwilling or unable to understand the thinking of vaccine skeptics—or even admit that skeptics may be thinking at all,” lamented a recent article in the conservative National Review. Writers across the political spectrum have urged deference and sympathy toward holdouts’ concerns about vaccine side effects and the botched CDC messaging about masking and airborne transmission early in the pandemic. But these takes can’t explain why holdouts who receive respect, empathy, and information directly from reliable sources remain unmoved—or why some people are afraid to tell their loved ones about being vaccinated.
What is going on here? Sociology suggests that pundits and policy makers have been looking at vaccine refusal all wrong: It’s not an individual problem, but a social one. That’s why individual information outreach and individual incentives—such as Ohio’s Vax-a-Million program, intended to increase vaccine uptake with cash prizes and college scholarships—haven’t worked. Pandemics, by definition, are collective problems. They propagate and kill because people live in communities. As a result, addressing pandemics requires understanding interpersonal dynamics—not just what promotes trust among people, but which behaviors convey status or lead to ostracism.
Shifting from an individual to a relational perspective helps us understand why people are seeking vaccination in disguise. They want to save face within the very specific set of social ties that sociologists call “reference groups”—the neighborhoods, churches, workplaces, and friendship networks that help people obtain the income, information, companionship, mutual aid, and other resources they need to live. The price of access to those resources is conformity to group norms. That’s why nobody strives for the good opinion of everyone; most people primarily seek the approval of people in their own reference groups.
In Missouri and other red states, vaccine refusal on partisan grounds has become a defining marker of community affiliation. Acceptance within some circles is contingent on refusal to cooperate with the Biden administration’s public-health campaign. Getting vaccinated is a betrayal of that group norm, and those who get the shot can legitimately fear losing their job or incurring the wrath of their families and other reference groups.
Sociology solves mysteries like these by zeroing in on problematic relationships, not the decisions that individuals make in isolation. Many of the people refusing safe, effective vaccination amid a deadly pandemic are enmeshed in a very distinctive type of relationship that sociologists have been studying for more than 70 years: the con job. Con artists gain social or financial advantage by convincing their marks to believe highly dubious claims—and to block out all information to the contrary.
COVID-19-related cons have become big business, not just for right-wing media outlets that have gained viewers while purveying vaccine disinformation but also for small-time social-media grifters and enterprising professionals. The New York Times recently profiled Joseph Mercola, a Florida osteopath whom the paper described as “The Most Influential Spreader of Coronavirus Misinformation.” Four years ago, the Federal Trade Commission forced Mercola to pay nearly $3 million in settlements for false advertising claims about indoor tanning beds that he had sold. In February of this year, Mercola told his millions of followers on Facebook that the vaccine would “alter your genetic coding,” and promoted his line of vitamin supplements as an alternative to ward off COVID-19.
To outsiders, the social dynamics of the con appear peculiar and irrational. Those caught up in it can seem self-destructive and, frankly, clueless. But to sociologists, including me, who study fraud, such behaviors obey a predictable logic.
The seminal text in the field—Erving Goffman’s 1952 essay “On Cooling the Mark Out”—observes that all targets of con artists eventually come to understand that they have been defrauded, yet they almost never complain or report the crime to authorities. Why? Because, Goffman argues, admitting that one has been conned is so deeply shameful that marks experience it as a kind of social death. The victim, he writes,
has defined himself as a shrewd man and must face the fact that he is only another easy mark. He has defined himself as possessing a certain set of qualities and then proven to himself that he is miserably lacking in them. This is a process of self-destruction of the self.
Goffman notes that other life events, such as being fired or dumped, can evoke similar feelings of humiliation. But people targeted by con jobs can save their pride by denying the con as long as possible—or claiming they were in on it the whole time. This saves face and cheats social death, but allows the con to continue unchecked, entrapping others. In doing so, marks prioritize their self-image over the common good.
This behavior—which Goffman doesn’t shrink from calling a “moral failure”—is embodied in figures such as the Louisiana man who attained national fame recently with a defiant rant from his ICU bed, refusing to get vaccinated even after a life-threatening bout with COVID-19. After being hospitalized with the disease, or losing loved ones to it, some former vaccine refusers own up to their misjudgment. But not all do.
Framing vaccine refusal in terms of sociological theory isn’t just an intellectual exercise. On the contrary, it can help public-health experts and government officials figure out how to react when marks collide with the reality that COVID-19 is serious, the vaccines work, and not getting vaccinated is dangerous. Goffman points out that con artists employ specialists to “cool” marks down when the deception is finally revealed. A cooler, he writes, “has the job of handling persons caught out on a limb—persons whose expectations and self-conceptions have been built up and then shattered.” Coolers prevent blowback from angry marks—encouraging them to blame themselves, not the con artist. They help marks rebuild their social identity, retain their self-respect, and preserve their affiliations with their reference groups.
In this light, the recent volte-face of many prominent conservatives toward enthusiastic endorsement of vaccination is great news for everyone who wants to see an end to the pandemic. Representative Steve Scalise, a high-ranking House Republican from Louisiana, recently got vaccinated on camera. Sarah Huckabee Sanders, a press secretary in the Trump White House now running for governor of Arkansas, published an op-ed disclosing that she and her family had gotten vaccinated. On Tuesday, Senator Roy Blunt used the Republican leadership’s weekly press conference to urge his constituents in Missouri to get vaccinated—presumably without resorting to disguises.
Some commentators have mocked these efforts—particularly those of Republican Governors Ron DeSantis of Florida and Kay Ivey of Alabama. DeSantis recently declared, “Vaccines are saving lives.” “It’s the unvaccinated folks that are letting us down,” Ivey recently said, adding, “These folks are choosing a horrible lifestyle of self-inflicted pain.” Both had previously taken vocal stands against certain pandemic-mitigation measures; in May, for example, each signed legislation banning organizations in their states from requiring proof of vaccination for employees and customers.
But those who see only hypocrisy and bad faith in these moves misunderstand the social dynamics of the con. Cooling out the marks—which is what all these right-wing efforts to push vaccination represent—works only when the marks perceive the coolers as members in good standing of the same reference groups. Having expressed doubts about COVID-19 vaccination or other pandemic mitigation likely makes Ivey and DeSantis more effective in persuading other conservatives: Their previous positions signify authenticity and in-group loyalty, making them more trustworthy, not less. High-status leaders such as Scalise, Ivey, Blunt, and DeSantis can expand the range of acceptable behavior for other group members through the example of their own actions.
This is reason for optimism: The conservative coolers are finally on the case, and only they have a chance of transforming partisan vaccine refusers into vaccine adopters. Whether these efforts will improve vaccination rates in red states remains to be seen, but it should come as a relief to those weary of being nice to vaccine holdouts. Blue-staters’ approval probably never mattered in the first place.