The Unvaccinated May Not Be Who You Think

It may seem as if every vaccine holdout thinks that Covid is a hoax, but the evidence shows there’s much more to it, NYT Opinion columnist Zeynep Tufekci writes.

By Zeynep Tufekci, Opinion Columnist for The New York Times.

Back when a viral pandemic killing millions around the world was just the plot of a scary movie, the film “Contagion” was lauded for how accurately it depicted the way such an outbreak would occur.

On the science of viral contagion, it was quite sharp, clearly explaining things like R0 (the measure of how widely one infection could spread to others, on average).

Of the human dimension of contagion, it did not prove as prescient. In the movie, fearful nurses walked off the job at the start of the pandemic, which begins to end as soon as vaccines become available, with people lining up eagerly for their turn.

The opposite happened in real life. Despite enormous personal risk, almost all health care workers stayed on the job in the first months of the Covid pandemic. Despite vaccines being widely available since spring in the United States, tens of thousands of people are dying every month because they chose not to be inoculated.

The failure of the United States to vaccinate more people stands out, especially since we had every seeming advantage to get it done. As early as the end of April of this year, when vaccines were in dire short supply globally, almost every adult who wanted to get vaccinated against Covid-19 in the United States could do so, free of charge. By June, about 43 percent of the U.S. population had received two doses while that number was only about 6 percent in Canada and 3 percent in Japan.

Now, just a few months later, these countries, along with 44 others, have surpassed U.S. vaccination rates. And our failure shows: America continues to have among the highest deaths per capita from Covid.

Science’s ability to understand our cells and airways cannot save us if we don’t also understand our society and how we can be led astray.

There is a clear partisan divide over vaccination — Republicans are more likely to tell pollsters that they will not get vaccinated. Some Republican politicians and Fox News hosts have been pumping out anti-vaccine propaganda. The loud, ideological anti-vaxxers exist, and it’s not hard to understand the anger directed at them. All this may make it seem as if almost all the holdouts are conspiracy theorists and anti-science die-hards who think that Covid is a hoax, or that there is nothing we can do to reach more people.

Real-life evidence, what there is, demonstrates that there’s much more to it.

Almost 95 percent of those over 65 in the United States have received at least one dose. This is a remarkable number, given that polling has shown that this age group is prone to online misinformation, is heavily represented among Fox News viewers and is more likely to vote Republican. Clearly, misinformation is not destiny.

Second, reality has refuted dire predictions about how Americans would respond to vaccine mandates. In a poll in September, 72 percent of the unvaccinated said they would quit if forced to be vaccinated for work. There were news articles warning of mass resignations. When large employers, school districts, and hospital systems did finally mandate vaccines, people subject to mandates got vaccinated, overwhelmingly. After United Airlines mandated vaccines, there were only 232 holdouts among 67,000 employees. Among about 10,000 employees in state-operated health care facilities in North Carolina, only 16 were fired for noncompliance.

The remarkable success of vaccine mandates shows it is not firm ideological commitments that have kept everyone from getting vaccinated, and that the stubborn, unpersuadable holdouts may be much smaller than we imagine.

Let’s start with what we do know about the unvaccinated.

There has been strikingly little research on the sociology of the pandemic, even though billions of taxpayer dollars have been spent on vaccines. The assumption that some scientific breakthrough will swoop in to save the day is built too deeply into our national mythology — but as we’ve seen, again and again, it’s not true.

The research and data we do have show that significant portions of the unvaccinated public were confused and concerned, rather than absolutely opposed to vaccines.

Some key research on the unvaccinated comes from the Covid States Project, an academic consortium that managed to scrape together resources for regular polling. It categorizes them as “vaccine-willing” and “vaccine-resistant,” and finds the groups almost equal in numbers among the remaining unvaccinated. (David Lazer, one of the principal investigators of the Covid States Project, told me that the research was done before the mandates, and that the consortium has limited funding, so they can poll only so often.)

Furthermore, its research finds that the unvaccinated, overall, don’t have much trust in institutions and authorities, and even those they trust, they trust less: 71 percent of the vaccinated trust hospitals and doctors “a lot,” for example, while only 39 percent of the unvaccinated do.

Relentless propaganda against public health measures no doubt contributes to erosion of trust. However, that mistrust may also be fueled by the sorry state of health insurance in this country and the deep inequities in health care — at a minimum, this could make people more vulnerable to misinformation. Research on the unvaccinated by KFF from this September showed the most powerful predictor of who remained unvaccinated was not age, politics, race, income or location, but the lack of health insurance.

The Covid States team shared with me more than a thousand comments from unvaccinated people who were surveyed. Scrolling through them, I noticed a lot more fear than certainty. There was the very, very rare “it’s a hoax” and “it’s a gene therapy,” but most of it was a version of: I’m not sure it’s safe. Was it developed too fast? Do we know enough? There was also a lot of fear of side effects, worries about lack of Food and Drug Administration approval and about yet-undiscovered dangers.

Their surveys also show that only about 12 percent of the unvaccinated said they did not think they’d benefit from a vaccine: so, only about 4 percent of the national population.

In law, “dying declarations” are given special considerations because the prospect of death can help remove the motivation to deceive or to bluster. The testimony we’ve seen from unvaccinated people in their last days with Covid, sometimes voiced directly by them from their hospital beds, gets at some of the core truths of vaccine hesitancy. They are pictures of confusion, not conviction.

One woman who documented her final days on TikTok described being uncertain about side effects, being worried about lack of F.D.A. approval, and waiting to go with her family to get the shot — until it was too late.

Or consider Josie and Tom Burko, married parents who died from Covid within days of each other, leaving behind an 8-year-old daughter. They hadn’t taken the pandemic lightly. They were “100 percent pro-vaccination,” a close friend told The Oregonian afterward, but Josie reportedly had a heart murmur and chronic diabetes and worried about an adverse reaction. Tom reportedly had muscular atrophy, and similar worries. Afraid, they had not yet gotten vaccinated.

It’s easy to say that all these people should have been more informed or sought advice from a medical provider, except that many have no health care provider. As of 2015, one quarter of the population in the United States had no primary health care provider to turn to for trusted advice.

Along with the recognition of greater risk, access to regular health care may be an important explanation of why those over 65 are the most-vaccinated demographic in the country. They have Medicare. That might have increased their immunity against the Fox News scare stories.

One reason for low vaccination rates in rural areas may be that they are “health care and media” deserts, as a recent NBC report on the crises put it, with few reliable local news outlets and the “implosion of the rural health care system” — too few hospitals, doctors and nurses.

Plus, let’s face it, interacting with the medical system can be stress-inducing even for many of us with health insurance. Any worry about long-term side effects is worsened by a system in which even a minor illness can produce unpredictable and potentially huge expenses.

Then there is the health system’s long-documented mistreatment of Black people (and other minorities) in this country. Black people are less likely to be given pain medication or even treatment for life-threatening emergencies, for instance. I thought of those statistics while reading the poignant story of a Black physician who could not persuade her mother to get vaccinated because her mother’s previous interactions with the medical system included passing out after screaming in agony when a broken arm got manipulated and X-rayed without sufficient care for her pain.

While the racial gap in vaccination has improved over the last year — nonwhite people were more likely to express caution and a desire to wait and see rather than to be committed anti-vaxxers — it’s still there.

In New York, for example, only 42 percent of African Americans of all ages (and 49 percent among adults) are fully vaccinated — the lowest rate among all demographic groups tracked by the city.

This is another area in which the dominant image of the white, QAnon-spouting, Tucker Carlson-watching conspiracist anti-vaxxer dying to own the libs is so damaging. It can lead us to ignore the problem of racialized health inequities with deep historic roots but also ongoing repercussions, and prevent us from understanding that there are different kinds of vaccine hesitancy, which require different approaches.

Just ask Nicki Minaj.

About a month ago, the rap artist made headlines after tweeting that she was worried about vaccines because she had heard from her cousin that a friend of his had swollen testicles after being vaccinated. (Experts pointed out that, even if this had happened, it was most likely caused by a sexually transmitted disease.) She was justifiably denounced for spreading misinformation.

But something else that Minaj said caught my eye. She wrote that she hadn’t done “enough research” yet, but that people should keep safe “in the meantime” by wearing “the mask with 2 strings that grips your head & face. Not that loose one.”

“Wear a good mask while researching vaccines” is not the sentiment of a denier. She seemed genuinely concerned about Covid, even to the point that she seemed to understand that N95s, the high-quality masks that medical professionals wear, which have the “2 strings that grips your head & face,” were much safer.

Lazer said that the Covid States Project’s research showed that unvaccinated people who nonetheless wore masks were, indeed, more likely to be Black women. In contrast, those who were neither vaccinated nor masked were more likely to be Republicans, and more likely to be rural, less educated and white. (Among the vaccinated, Asian Americans were most likely to be still wearing masks.)

Lazer also highlighted an overlooked group with higher levels of vaccine hesitancy: young mothers. They were hesitant, both for themselves and their children, an alarming development especially if it starts affecting other childhood vaccinations. Similarly, from real-life data, we know that only a little more than one-third of pregnant women are vaccinated, which has led to many tragic stories of babies losing their mothers just as they are being whisked into the neonatal intensive care unit after an emergency cesarean section.

It may well be that some of the unvaccinated are a bit like cats stuck in a tree. They’ve made bad decisions earlier and now may be frozen, part in fear, and unable to admit their initial hesitancy wasn’t a good idea, so they may come back with a version of how they are just doing “more research.”

We know from research into human behavior but also just common sense that in such situations, face-saving can be crucial.

In fact, that’s exactly why the mandates may be working so well. If all the unvaccinated truly believed that vaccines were that dangerous, more of them would have quit. These mandates may be making it possible for those people previously frozen in fear to cross the line, but in a face-saving manner.

Research also shows that many of the unvaccinated have expressed concerns about long-term effects. Consider an information campaign geared toward explaining that unlike many drugs, for which adverse reactions can indeed take a long time to surface, adverse effects of vaccines generally occur within weeks or months, since they work differently, as the immunologist Andrew Croxford explained in The Boston Review. Medical professionals could be dispatched to vaccination clinics, workplaces and stores to get that point across. (Yes, medical professionals are overwhelmed, but the best way to reduce their burden is to vaccinate more people.) This would let some hesitant people feel like they had “done their research,” while interacting with a medical professional — the basis for more trust.

Finally, consider something hidden amid all the other dysfunction that plagues us: fear of needles.

Don’t roll your eyes. Prepandemic research suggests that fear of needles may affect up to 25 percent of adults and may lead up to 16 percent of adults to skip or delay vaccinations. For many, it’s not as simple as “suck it up”: It’s a condition that can lead to panic attacks and even fainting. During the pandemic, a study in Britain found that as many as one in four adults had injection phobia, and that those who did were twice as likely to be vaccine-hesitant. Research by Covid States shows that about 14 percent of the remaining unvaccinated mention fear of needles as a factor.

Countries with far higher rates of vaccination, Canada and Britain, have responded by mobilizing their greatest strength: a national health care system. Cities in Canada held clinics aimed especially at people with such anxiety, which included privacy rooms and other accommodations. Britain’s national health care system offers similar accommodations.

I’ve yet to find a systematic program in the United States addressing this fear. Worse, much of our public communications around the vaccines feature images of people getting jabbed with a needle, even though that can worsen anxiety.

In researching, I was inundated with stories from people who struggled with this fear and were often unable to find help. Some women said they were treated like drug seekers because they asked for a single anti-anxiety pill to get through a shot. (They also said their male family members and friends had an easier time.) It may seem hard to believe that people might risk their lives over seemingly small fears, but that’s exactly how people behave in many situations.

Of course, there are some people who it seems will never be persuaded. One strategy that has been shown to work is to highlight deceptive practices. In campaigns to keep teens from smoking, advertisements pointed out how the tobacco industry manipulated people. For Covid, the unvaccinated could be shown that they have been taken in by people who have misled them even while those people themselves got vaccinated.

Just recently, there was a brief glimpse at how Fox News actually looks behind the camera: Everyone in the office was wearing masks, even as the hosts have often talked about the alleged tyranny of it all. Stars like Tucker Carlson rant against vaccines, even as their network says that more than 90 percent of full-time employees have been vaccinated. Realizing that one may have been conned and manipulated by opportunists who do not practice what they preach may — just may — be the breakthrough for some.

Responding to our societal dysfunctions has been among the greatest challenges of this pandemic, especially since this includes a political and media establishment stirring up resentment and suspicion to hold on to power and attention in an increasingly unresponsive political system.

Anger — and even rage — at all this may be justified, but deploying only anger will not just obscure the steps we can and should try to take, it will play into the hands of those who’d like to reduce all this to a shouting match.

Instead, we need to develop a realistic, informed and deeply pragmatic approach to our shortcomings without ceding ground to the conspiracists, grifters and demagogues, and without overlooking the historic inequities in health care and weaknesses in our public health infrastructure. It’s not all fair, and it is not a Hollywood ending, but it’s how we can move forward.