Escaping Catch-22 - Overcoming Covid Vaccine Hesitancy - BINASSS
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The n e w e ng l a n d j o u r na l of m e dic i n e
Medicine a nd So cie t y
Debra Malina, Ph.D., Editor
Escaping Catch-22 — Overcoming Covid Vaccine Hesitancy
Lisa Rosenbaum, M.D.
On September 8, 2020, AstraZeneca announced reluctant.1 The behavioral obstacles to wide-
that it was pausing its late-phase SARS-CoV-2 spread vaccination are thus as important to
vaccine trial because of a serious adverse event understand as the scientific and logistic hurdles.
in a U.K. participant. The next day, my hair- Accordingly, since September, I have been
dresser, Ms. J., asked me what I thought about talking with people about their perceptions and
the news. I said the halting of the trial to inves- concerns about Covid-19 vaccination. Before the
tigate the adverse event was reassuring — an election, people often mentioned the prospect
example of science doing its job. “What do you that a vaccine would be approved prematurely by
think?” I asked. a desperate Trump administration, but concerns
“There’s no effing way I’m getting a vaccine,” about long-term safety are common, persistent,
she said. and not unfounded. Even though adverse events
Ms. J., who lives in New York City, had tend to occur within the first 6 to 8 weeks after
Covid-19 in April. Though she didn’t require
vaccination, vaccines are typically not approved
hospitalization, the virus incapacitated her for until 2 years of follow-up data have been gath-
weeks, leaving her weak and unable to tolerate ered. In addition, some SARS-CoV-2 vaccines,
solid foods; for months, she continued to be- such as those based on messenger RNA, use new
come dyspneic with exertion. She was terrified technologies for which long-term data are lack-
of getting the virus again and derived little com- ing. We also don’t yet know the durability of
fort from the possibility that she had enduring immunity, the degree to which vaccines prevent
immunity. Yet the prospect of getting a Covid-19 asymptomatic infections, or whether boosters
vaccine was even scarier. Emphasizing the haste will be necessary, especially given the emergence
of vaccine development, the need for long-term of viral variants. In the midst of a pandemic that
safety data, and concern that side effects could is taking thousands of lives daily and devastat-
“make everything worse than it already is,” Ms. J. ing society, many people will find these uncer-
added that most of her friends and relatives were tainties acceptable. But for others, as with many
similarly “really suspicious” of the vaccines. trade-offs in medicine, the magnitude of benefit
And they are not alone. Though many people may have less emotional resonance than the
initially believed a vaccine was the magic bullet possibility, no matter how minimal, of risk.
that would save us from a devastating pandemic
and return our lives to normalcy, we now find More Than Me ss aging
ourselves contemplating simultaneously how to
ethically allocate a limited number of vaccine For those with intent to be vaccinated, interven-
doses to the many people who want them and tions such as default appointments and onsite
how to increase vaccine uptake among those vaccination effectively increase uptake.2,3 Less is
who don’t. Though estimates vary, public health known, however, about how to increase uptake
officials suggest that about 80 to 85% of Ameri- by modifying the beliefs of the hesitant. In one
cans would need to be vaccinated for the country randomized trial targeting parents with children
to achieve herd immunity. Vaccine confidence eligible for the measles–mumps–rubella (MMR)
seems to be rising, but recent polling suggests vaccine, researchers tested various messaging
that about 31% of Americans wish to take a wait- strategies that either corrected misinformation
and-see approach, and about 20% remain quite or had emotional appeal. One strategy refuted
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the claim that vaccines cause autism, while others are not issues that can be addressed by merely
featured pictures of children with the diseases changing the message or giving ‘more’ or ‘better’
the MMR vaccine prevents or a dramatic narra- information.”6 Though the pandemic has cast
tive about an infant who nearly died of measles.4 the dangers of misinformation into stark, soul-
These strategies not only failed to increase crushing relief, the gravity of a falsehood’s con-
intent to vaccinate, but among vaccine skeptics, sequences doesn’t render it more correctable
they actually did the opposite. Graphic pictures with truth.
of a child with measles increased fears of vac- Larson’s own thinking was transformed in
cine-related side effects rather than fear of the 2003, when, while overseeing vaccine strategy
disease itself. And though accurate information and communication at UNICEF, she was called
reduced the misperception that vaccines cause to Nigeria, where a government-led boycott of
autism, intent to vaccinate still decreased among the polio vaccine was under way. There, Larson
the most hesitant parents. Extrapolating these discovered that resistance reflected not specific
findings to a paralyzing pandemic comes with concerns about the vaccine but rather a conver-
countless caveats, foremost among them that vac- gence of broader social factors, including rumors
cination will initially target adults. Nevertheless, that Western vaccines were intended to sterilize
as we embark on far-reaching messaging cam- children; a fear, in the aftermath of 9/11, that
paigns, some humility about our intuitions about the United States was at war with Muslims; and
human behavior is in order. ongoing conflict between the local and central
We do know that the confidence of physi- governments. Quashing the rumors seemed to
cians and public health officials can be instru- matter less than addressing the nexus of ques-
mental in allaying people’s fears.2 One elderly tions, concerns, beliefs, and historical forces
couple I spoke with in October, for instance, that gave rise to them. Though the reasons for
after expressing reservations about a vaccine be- skepticism may vary among communities, Larson’s
ing approved prematurely for strictly political approach to vaccine hesitancy is universally
reasons, concluded, “If Anthony Fauci approves relevant: before you attempt to persuade, try to
it, we will go for it.” This sentiment is consistent understand.
with what we know about vaccine uptake in gen-
eral: the seemingly most effective way to increase The Undecideds
vaccination rates is with clinician recommenda-
tions.2,5 As Robert Jacobson, a Mayo Clinic pedia- Mr. K. is a 56-year-old man who avoids vaccines
trician who studies vaccine hesitancy, pointed out, and decided with his wife not to vaccinate their
since health care workers are among the first children. “People disregard you as a conspiracy
groups to be vaccinated, they will be able to speak theorist,” he told me, “but we put a lot of
to their patients with authority and confidence: thought into making that decision.” Many of
“I got this vaccine, and I want you to have it, too.” Mr. K.’s beliefs were informed by his father-in-law,
As critical as recommendations from trusted a pediatrician who has concerns about the safety
authorities will be, in an environment rife with of vaccines. “He is not a pharma-driven doctor,”
misinformation and distrust of expertise, dis- Mr. K. explained. “He’s not part of the medical
seminating evidence-based information may be establishment.” The problem with that estab-
insufficient to persuade some people. That’s lishment, as Mr. K. sees it, is not just its drug
partly why Heidi Larson, an anthropologist at pushing and profiteering, but its censoring of
the London School of Hygiene and Tropical people who disagree. For instance, in July, when
Medicine whose recent book, Stuck, summarizes social media companies removed a viral video
her decades of research on vaccine hesitancy, of physicians suggesting (misleadingly) that hy-
sees Covid-19 as an opportunity to rethink our droxychloroquine was an effective treatment for
approach to vaccine uptake. Larson, who studies Covid-19, Mr. K. saw a parallel to attempts to
rumors, cautions against the impulse to merely quash antivaccine sentiment. “What is going on
correct misinformation and assume our work is with this country where people can’t make their
complete. Writing before the pandemic, Larson own decisions?” he asked. “I try to find the sci-
observed that “Vaccine reluctance and refusal entists out there who aren’t afraid of losing a
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grant — people who have nothing to lose if they technology that delivers microparticles intrader-
speak the truth.”7,8 mally during vaccination, creating a digital vac-
In both his aversion to mainstream medicine cine record.10 The research, funded by the Gates
and his perception that people questioning medi- Foundation before Covid, aims to address the
cal dogma are censored, Mr. K. highlights a challenge of vaccine record keeping, particularly
Catch-22 of vaccine hesitancy: by challenging in low-resource countries. Although this technol-
untruths, we may inadvertently feed the percep- ogy is not present in any Covid vaccine, Johnson,
tion that the “real” truth is being suppressed. who has been monitoring vaccine sentiment on-
Larson describes in her book the fallout after line throughout the pandemic, cautioned against
pressure from the scientific community resulted dismissing the rumor as mere misinformation.
in removal of the antivaccination film “Vaxxed” “We can hope that Bill Gates won’t eventually
from the Tribeca Film Festival in 2016. The pull- use it to track Covid vaccine behavior, just like
ing of the film confirmed the belief of vaccine we hope our neighbors won’t one day wake up
doubters that physicians and scientists are un- and plow their car into our house,” Johnson said.
willing to engage with any dissent. Moreover, “They could in principle, but it’s highly unrea-
notes Larson, these instances of so-called cen- sonable to think that they would.” If the vaccine
sorship attract people who, while not necessarily hesitant feel that they’ve been unfairly accused
antivaccine, identify with broader rights agendas of spreading misinformation, Johnson explained,
promoting “freedom” and “a fundamental dem- they become further emboldened in their doubts.
ocratic right to choose.”6 Even ideologically disparate groups unify around
Indeed, while people firmly opposed to all such shared skepticism.
vaccines may be relatively few in number, they Johnson’s observations remind us why teach-
wield outsized influence, particularly on social ing the public to “understand science,” the seem-
media, over the undecideds. A recent study of ingly obvious way to mitigate antiscientific sen-
expressions of vaccine-related sentiments by 100 timent, may fall short. Many discussions about
million Facebook users found that antivaccine science denialism conclude with some version of
clusters of people, though less numerous than “We just need to get the public to understand
provaccine clusters, have a more central pres- science.” But evidence suggests otherwise. Sociol-
ence in large networks and interact with more ogist Gordon Gauchat, for instance, in describ-
undecided clusters.9 Provaccine clusters, mean- ing temporal trends in distrust in science, has
while, engage predominantly in smaller networks, shown that at least among conservatives, it’s the
so even though they exert less influence, they most educated subgroup who have become in-
often have the “wrong impression that they are creasingly skeptical.11 One possible explanation
winning.” Provaccine clusters are also disadvan- is that highly educated people are more facile at
taged by the tendency toward “monothematic” finding evidence to support their views or in
messaging, whereas antivaccine pages deploy poking holes in evidence that doesn’t. Accord-
multithemed narratives to broaden their appeal, ingly, in a 2019 essay on the so-called crisis in
touching on safety concerns, alternative medi- truth, in which antivaccine sentiment features
cine, Covid-19 (both causes and cures), and prominently, history-of-science professor Steve
various conspiracy theories. In response to these Shapin makes the surprising argument that there
dangerous disinformation campaigns, social me- isn’t “too little science in public culture,” but
dia companies have intensified efforts to label “too much.”12 That’s partly because people who
falsehoods and eliminate them. But as Neil John- deny climate change or reject vaccines co-opt the
son, a physicist and the study’s first author, ex- language of science to bolster the legitimacy of
plained to me, such efforts can backfire. their views. Their arguments, Shapin writes, are
One of the most widely shared Covid con- often “garnished with the supposed facts, theo-
spiracy theories, for example, is that the vaccines ries, approved methods, and postures of objec-
contain microchips that will be used by elites tivity and disinterestedness associated with gen-
(Bill Gates is often mentioned) or by the govern- uine science.”
ment to track people’s behaviors. People propa- Where do these bleak observations leave us as
gating the rumor often point to a study of a new we seek to raise confidence in Covid vaccines?
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Fr om S tigma to Empathy and wanted Larson to know how well she’d been
cared for by the trial’s clinicians. “The scientists
As the pandemic has sharpened the polarization were doing the right thing,” Larson told me,
over science, disdain for science denialism has “but they weren’t communicating it.”
made it easy to conflate true antiscientific senti- Of course, people who are determined to un-
ment with simple fear of the unknown. In my dermine confidence in vaccines will always find
many conversations about vaccines, what struck ways to spread misinformation. But a much
me most was the shame that often preceded any larger proportion of the population may be will-
expression of doubt. Some people simply refused ing to get vaccinated given the proper reassur-
to talk to me; others, particularly those who ances, and dismissing their concerns often leaves
work in health care, were skittish about being them seeking someone to validate them. I sus-
identifiable. And those who had questions of- pect that’s one reason why correcting misinfor-
ten prefaced them with “I’m not an antivaxxer mation often falls short. Some people, for in-
but . . . .” One common question, for instance, stance, may truly believe that vaccines cause
was whether people who are young and unlikely autism. But for others, this ostensible fear may
to die of Covid should get a vaccine whose long- mask less easily expressed needs such as main-
term side effects are unknown. taining one’s identity, belonging to a group, or
My instinctive response to this sort of ques- simply being heard. And yet respecting these
tion is to emphasize the population benefits of more basic instincts also raises an uncomfort-
vaccination and the reality that some young able question: At what point does empathy sac-
people do die from Covid and that even survivors rifice scientific truth?
may have long-term sequelae we don’t fully un- Or perhaps this is a false dichotomy. One of
derstand. But why not simply acknowledge the my best friends practices in a region where many
legitimacy of the concern? For many of us in the people, including some health care workers and
medical community who are haunted by the con- patients in her practice, are hesitant to get vac-
sequences of science denialism, validating any cinated. Even my friend — whose brilliance and
aspect of vaccine skepticism may feel like rip- rationality I have always admired — has reserva-
ping your mask off in a crowded elevator. But it tions about vaccination, though she knows that
isn’t “antiscience” to admit that we still don’t expressing them is taboo. But I think that it’s
know some things. It’s just truth. only because she understands why people are
Nevertheless, among people who take no sol- scared that she’s effective not just at allaying
ace in rigorous science, more than transparency fears, but at convincing people who don’t know
will be needed to build trust. Larson notes how anyone who’s willing to get vaccinated that what
quick the scientific community is to justify medi- is known about the vaccine is more important
cal recommendations by saying, essentially, “Sci- than what isn’t. Indeed, the staff members who
ence said so.”13 Referring to the pausing of the were initially reluctant to be vaccinated, changed
AstraZeneca trial due to an adverse event, for their minds after speaking with her.
instance, Larson notes how much of the media Although the scientific community’s obliga-
coverage featured scientists noting the “normal- tion will always begin with championing truth,
ity” of pausing a trial to investigate any adverse the pandemic has shown that society’s health
events. To Larson, though, this response lacked also depends on understanding why so many
expressed empathy for the person(s) who experi- people reject it. While some trust scientific ex-
enced an unexpected reaction. “It’s not normal perts, Larson notes that others seek “truth” else-
for the person who was hurt,” she said. In our where — their experiences, perhaps, or “heard
rush to defend the vaccine and the evaluation truths” from their social networks. The pan-
process, the scientific community may fail to demic, then, has reminded Larson why getting
convey how the participant’s symptoms were ad- the public to understand science may be insuf-
dressed, though it’s the latter — more than fidel- ficient.14 Maybe, she suggests, it’s also time for
ity to science — that may be foremost on peo- science to understand the public.
ple’s minds. After speaking on the radio about This article is Part 1 in a two-part series. Next
this oversight, Larson was contacted by a trial week: “No Cure without Care — Soothing Sci-
participant who’d experienced an adverse event ence Skepticism.”
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This article was published on February 12, 2021, at NEJM.org. competition between pro- and anti-vaccination views. Nature
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