by Alice Tillman ’21
When cities across the United States first went into lockdown in mid-March in an effort to curb the COVID-19 pandemic, there was a sense that with enough diligence and perseverance, we could stamp the virus out of our lives. “Flatten the Curve” became a daily mantra to remind us that soon enough we would be rewarded for our sacrifice. Yet, six months, 11 million cases, and 245,000 deaths later, it has become increasingly evident that a vaccine will be our only way out.1 2 The death rate seems to have declined, due in part to advancements in treatment, as well as the fact that the virus seems to be spreading among younger populations. As a result of the economic fallout, unemployment, evictions, and food insecurity are all on the rise. 3 4 Communities of color have been impacted the most, with rates of infection and mortality three to four times higher among African-Americans and Latinos.5 6 7 A fractured and lackluster policy response at the federal, state, and local levels has left us trapped in a perpetual state of outbreak and denial, and in worse shape than we were in the spring. Yet, despite the incredible urgency for a vaccine, many Americans are unsure as to whether they would be willing to get one once it becomes available.
To develop, test, manufacture, and distribute a safe and effective vaccine within the next year is, of course, an enormous undertaking of unprecedented scale. Moderna, Pfizer, and AstraZeneca are all in the process of development, and Pfizer and Moderna have had significant breakthroughs. 8 Under Operation Warp Speed, the U.S government plans to partner with the military, health agencies, and private contractors to manufacture 300 million doses by early 2021. 9 It is worth noting, however, that each person will need to receive two doses of the vaccine. The vaccine must then be accessible and available to everyone, including communities of color, immigrants, people in rural areas, the uninsured, and the under-insured. Vaccines, while safe, are never completely effective.10 The F.D.A has insisted the vaccine has to be at least 50% effective, but experts predict the vaccine will not likely be more than 75% effective. 11 Instead, vaccine efficacy relies heavily on “herd immunity,” or the number of people who need to be immunized against a virus in order to stop community transmission. The herd immunity threshold for COVID-19 remains unknown, but researchers estimate it is somewhere between 55 and 82%. 12 In other words, no one will truly be protected from infection until the vast majority of people receive the vaccine. This kind of massive effort, however, will be futile if enough Americans do not believe that the available vaccine is safe or effective.
A survey released in May by the AP-NORC Center for Public Affairs found that only 49% of Americans were certain they would receive a vaccine for COVID-19 once one was available.13 14 20% responded they would definitely not get one, while 31% reported that they were uncertain. Another poll by Fairleigh Dickinson University found that only 20% of Americans are confident that a vaccine will be both safe and effective, and only 29% reported they would definitely get a vaccine. 15 African-Americans were the most likely to display skepticism about a vaccine, with only 25% reporting they would definitely get a vaccine and 40% reporting they would not.9 For comparison, 37% of Hispanic respondents reported they would definitely be willing to get a vaccine and 23% reported they definitely would not. Among white respondents, 56% reported they definitely would and 16% reported they definitely would not. While Republicans were more likely to report that they do not plan on getting the vaccine than Democrats, there is a strong sense of skepticism among both parties and independents.
Vaccine skepticism took off in the U.S. and Europe after the infamous (and since redacted) 1998 study by Andrew Wakefield which claimed that the MMR vaccine causes autism in children. Coinciding with the growing popularity of the internet, the “anti-vax” movement has grown significantly over the last twenty years. Those who express distrust towards the COVID-19 vaccine, however, do not necessarily represent traditional “anti-vaxxers.” Rather, distrust of the vaccine reflects more of the historical and current mismanagement of public health than fringe conspiracy theorizing. Vaccine hesitancy cannot be explained by the notion that Americans simply don’t perceive COVID-19 to be a threat. Only 19% of Americans believe that coronavirus is not a “major problem” and 81% agree that masks are effective at slowing the spread of the virus.16 Skepticism towards a vaccine is not simply anti-science, but rather reflects a deeper sense of distrust of authority and deteriorating levels of social trust.
Vaccine confidence is closely tied to the political climate, historical memory, and levels of social trust. Confidence, which is defined in the context of vaccine skepticism as “the performance-based aspect of trust in which the competence and the ability of the trusted party is evaluated,” 17 is reflective of an individual’s perceptions about the safety, efficacy, and necessity of a vaccine. Trust is a broader evaluation of the values and motives of providers. In health care settings, confidence and trust are particularly salient because there is a high level of “information asymmetry” between patients and providers. In addition, the stakes are immeasurably high. Patients may risk their health or their lives if trust is misplaced. Social scientists and epidemiologists have divided vaccine confidence into three main components: trust in the product, trust in the provider, and trust in the policy-maker. 18 Researchers have also identified generalized and historic distrust and out-of-program influences as the primary forces that weaken vaccine confidence.
Generalized distrust is greatly exacerbated by heightened political tensions and disapproval of government. For example, a study of European nations found that high levels of trust in government at both the local and national level was negatively correlated with vaccine hesitancy.19 In the United States, it appears that feelings of government incompetence and distrust of political leaders are also driving vaccine skepticism. A survey from the Kaiser Family Foundation this month found that 62% of Americans believe the Food and Drug Administration might cave to political pressure from the Trump Administration and approve a vaccine before it is proven to be safe and effective.20 The same survey found that 39% and 42% of Americans perceive the F.D.A and C.D.C, respectively, as being “too concerned with politics.” Included in a long list of mishaps and blunders, the Trump administration has adamantly dismissed science, downplayed the risk posed by the virus, discouraged testing, and promoted false treatments. Even our various public health institutions, which are supposed to operate as independent agencies, have lost some of their credibility over the last few months. Most recently, in keeping with the Trump administration’s push to reduce testing, the CDC put forth a set of new guidelines which discourage testing of individuals who are asymptomatic. The FDA has been criticized for their emergency-use authorization of hydroxychloroquine, chloroquine, and convalescent plasma.21 The data seem to suggest that many Americans fear the vaccine development process has been compromised by politics. Moving forward, public health agencies should work to better communicate the safety and reliability of the clinical trial process.
Historic distrust is perhaps the most potent barrier to vaccine confidence. The experiences of both individuals and groups with health care providers can play a powerful role in informing one’s confidence and trust in health care systems. In surveys, African-Americans report the highest levels of skepticism towards the COVID-19 vaccine. The exploitation of African-Americans for medical research has a long, dark, and suppressed history in the United States. Among other things, African-Americans were used, without consent, to develop surgical techniques such as HeLa cells, study syphilis, and test radiation. Our public health institutions must take seriously the legitimate concerns from groups who have been systematically discriminated against and abused by the health industry.
It is unsurprising that there is such widespread skepticism toward a vaccine, especially in light of the massive failure on the part of both institutions and leaders to control the spread of the virus. Although vaccine hesitancy may be exacerbated by misinformation, especially online, the reasons driving people’s fears are often rooted in legitimate questions about the competency of those in power. To dismiss those concerns as fringe conspiracies is not only arrogant but dangerous. Instead, public health institutions must consider and begin to address the multiplicity of concerns of the American populace and skepticisms if they wish to successfully combat COVID-19.
13. AP-NORC poll: Half of Americans would get a COVID-19 vaccine
17. Measuring Trust in Vaccination: A systemic review