When the Covid-19 pandemic became a full-fledged crisis in March, public health experts gave a prescription for riding it out: Flatten the curve with social distancing, lockdowns, contact tracing, etc., and then wait for a vaccine. The hope was, and still is, that a mass vaccination campaign can restore the world to normal.

For many reasons, the success of a vaccination campaign is not guaranteed. The vaccine has to be effective, and there needs to be enough of it to put a dent in transmission. Another challenge perhaps overlooked: “What if we get a safe and effective vaccine, and people choose not to get it?” says Matt Motta, a political scientist at Oklahoma State University.

Pervasive vaccine refusal looks like a real possibility. Motta’s research on a hypothetical Covid-19 vaccine, as well as polling from Gallup (and others) this summer, reveal that between a quarter and a third of the American public would be unwilling to be vaccinated against Covid-19. (These surveys generally ask about a hypothetical FDA-approved vaccine and not about one approved under an Emergency Use Authorization before clinical trials have ended.)

The surveys might be actually underselling the problem. “When we look at seasonal influenza vaccination rates, for example, surveys always overestimate the number of people who get it,” Motta says. It’s easier to say you’re going to get a vaccine to a pollster than it is to actually go get one.

The hesitation showing up in these polls is not about a skepticism of all vaccines (although there is some of that, for sure). It’s skepticism about this potential vaccine, created in record time, via the Trump administration’s Operation Warp Speed. Overall, 83 percent of Americans agree that if a vaccine is approved too quickly, they would worry about its safety.

There’s so much about the US response to the pandemic that has been botched. We failed on testing early and then failed to scale it up. We failed on contact tracing, on reopening many of our communities safely. And yet we haven’t screwed up a vaccine campaign yet.

There’s still time to get it right. It requires not just developing a safe vaccine, approved without the taint of a political rush job, but also a vast social science research effort to better understand people’s anxieties about the vaccine, and then help move them toward acceptance.

No approved vaccine exists yet. But every day, pharmaceutical companies are making progress on vaccine trials, and some may release data before the end of this year. That means the window to get it right “is closing,” Emily Brunson, a medical anthropologist at Texas State University, says. “If we don’t, we run the risk of undermining public health in the US — and even more specifically undermining the entire vaccination program.”

US public health may be undermined by the US government itself

Billions have been spent on developing the Covid-19 vaccines. But lacking in the development process is a key ingredient: the public’s trust. There’s a tension here: The White House itself is diminishing the credibility of its own FDA.

On the one hand, public health researchers and experts want to figure out how to convince people who are vaccine hesitant to accept it to put the brakes on the pandemic. On the other, the Trump administration is muddying the waters with actions that lead to — at best — the appearance of a politically compromised FDA, the US agency tasked with approving a vaccine for widespread public use. There’s reasonable confusion: Is operation Warp Speed designed to save the American public or ensure Trump’s reelection?

In August, FDA Commissioner Stephen Hahn cited misleading statistics about the efficacy of using blood plasma to treat severe Covid-19. And now, the Centers for Disease Control and Prevention (CDC) has told hospitals to be prepared to distribute a vaccine by November 1 (close to Election Day). As Vox’s Umair Irfan reports, it’s still unlikely that a vaccine will be authorized for use by then. But even the appearance of political interference could lead to lasting damage to a vaccination campaign. Sketchiness is creeping into these key public health agencies: CNN reports that sudden changes to CDC Covid-19 testing guidelines (which experts strongly oppose), came from “the top down.”

FDA Commissioner Stephen Hahn speaks during a White House press conference on August 23, 2020. Authorities announced an emergency approval of blood plasma from recovered coronavirus patients as a treatment against the disease.
Saul Loeb/AFP via Getty Images

Even Republicans are worried about political influence on the vaccine process. Seventy-two percent of Republicans and 82 percent of Democrats worry the vaccine approval process is being driven more by politics than science, according to a recent STAT and Harris poll.

“This is a scary moment,” Sandra Crouse Quinn, chair the department of family science at the University of Maryland, says. “I worry that any pressure to try to move one of those [vaccine candidates] forward as an electoral strategy, political strategy, while undermining the public’s trust, will damage us for years to come. … The public’s trust in the FDA is really critical here. With every effort the White House makes to pressure FDA on decisions, we further risk the credibility of the agency and the likelihood the public will take this vaccine.”

Vaccine hesitancy is not uniform. Black communities — some of the hardest hit by Covid-19 — are particularly hesitant.

If a vaccine is approved, it will likely be voluntary for people to get. Right now, the polling and research finds that some communities will be more willing to volunteer than others.

Of particular concern is the increased level of hesitancy in Black communities — for many reasons — which have already been disproportionately impacted by the pandemic. Higher vaccine refusal in these communities could lead to continued disproportionate Covid-19 suffering. (That is, if these communities have access to the vaccine in the first place.)

In a May to June survey, Motta and co-authors estimated Black Americans may be about 40 percent more likely to refuse a vaccine than white Americans (their demographically representative survey found 43 percent of Black Americans plan to refuse a vaccine versus around 29 percent of the American public at large). In July, Gallup found 67 percent of white Americans said they’d get an FDA-approved Covid-19 vaccine; 59 percent of non-white Americans said the same.

Zinzi Bailey, a social epidemiologist at the University of Miami, is not surprised by this disparity. “These are historically rooted, long-standing issues,” she says. Black communities have been exploited and harmed by medical researchers, and biases in medicine persist.

“I think a lot of people feel like they’re going to be experimented on,” Bailey says. “Words like ‘warp speed’ are not reassuring in this case.”

In Motta’s survey, he and his colleagues find several reasons why Black Americans could refuse a vaccine. They’re worried about safety and effectiveness. They are also worried about access: that they won’t be able to get or afford a vaccine when it becomes available.

In terms of access, their fears are well grounded. Already during the pandemic, there have been access problems with Black and minority communities, namely testing. In April, Vox’s Aaron Ross Coleman found that the White House’s initiative to partner with retail stores for testing largely left communities of color underserved.

Bailey stresses that the increased hesitancy in Black communities shouldn’t be framed as a deficiency within those communities. Rather, it is a reflection of how our society has treated them. “I think what these [survey] results are indicating is an underlying level of mistrust that is rampant in the country,” she says. “Mistrust is the name of the game right now, which hampers our ability to move forward with public health initiatives.”

President Trump, Dr. Anthony Fauci, and Health and Human Services Secretary Alex Azar speak to reporters after visiting a vaccine research center on March 3, 2020.
Drew Angerer/Getty Images

Again, there are indications that this hesitancy isn’t just about vaccines in general but that there’s added uncertainty about the Covid-19 vaccines in development. “Black community and other minority communities vaccinate their kids for measles, mumps, rubella,” says Justin Stoler, who studies health disparities at the University of Miami. “There are disparities there, but not disparities like we’re seeing with Covid willingness.”

It’s not just Black communities that may be less willing to vaccinate. Women also report greater hesitancy about a vaccine (they are 70 percent more likely to refuse a vaccine than men, according to Motta’s research), as do political conservatives and people living in rural areas. Plus, there’s the long-standing anti-vaccination movement, which will seek to undermine Covid-19 vaccination efforts.

The challenge is that each of these communities may require a different strategy, have different underlying anxieties and fears, and require a slightly different intervention to placate their fears.

We need more vaccine social science research

How do we get ahead of this hesitancy problem? Experts I spoke to say there needs to be widespread, on-the-ground anthropological research in communities to find out what their vaccine concerns are and to test educational campaigns to address those concerns.

“We are, and should be, investing an enormous amount of resources in the research and development of a vaccine,” Crouse Quinn says. “We’ve invested very few, almost no resources, in the social and behavioral science research that will help us understand in real time how the public will respond to a vaccine.”

In August, Brunson headed a working group that published a social science research agenda for a Covid-19 vaccine campaign. “What we’re arguing for is that state and local health departments need to be given the funding,” she says, to go out into communities and figure out what anxieties people have about the vaccine, and the messages and educational materials that might placate those fears.

Research and development into the vaccine technology costs billions. Brunson says the social science component might cost, nationally, around $40 million. But it’s being overlooked. “We’ve been talking with people in the Senate, we’ve been talking with Congress, we’ve been really trying to push this even with nonprofits and nothing has come through yet,” Brunson says. Which is a shame.

“There’s an assumption that if we can develop the vaccine technology, that if we build it, people will come, and we’ll get vaccinated,” she says. “And it’s not true. The social component is as complicated if not even more complicated than developing the vaccine technology.” (Such a suite of on-the-ground social science research has been effective in increasing willingness to vaccinate for Ebola in African countries.)

Motta and his collaborators are independently doing some of this research (which has not yet been published), trying to figure out what sorts of messages might move people toward vaccine acceptance.

“We don’t have a lot of research on how to communicate during a pandemic,” he says. But preliminarily, “we find that if you talk about the personal health risks of Covid, that’s something that seems to resonate.” Messages about how a vaccine could help the economy don’t work, and messages about how the vaccine could help save others are less effective than messages about personal risk. Most importantly, we know what doesn’t work: shaming, and, as Motta says, “telling people ‘you’re wrong and here’s why.’”

There could be a lot of different strategies that work.

“We know that, from my own research that, the more people you believe want you to get a flu vaccine, the more likely you are to take it,” Crouse Quinn says. “We know that if you have a high perceived risk of the disease, you’re more likely to take the vaccine. But if you have a high perceived risk of vaccine side effects, that will depress your willingness.”

It’s complicated to find out the right mix of messaging that works, and for whom. Trump could upend it all. He has a remarkable, well-documented power for taking issues that normally are apolitical, and splitting opinion on them along political lines.

This could happen with a vaccine, leading to a swell of refusal among his political opponents.

“By tying vaccine safety issues to his personal political ambitions, Trump [could make] vaccine safety a partisan issue,” Motta says. “That’s potentially a huge problem, as Democrats are currently much more likely than Republicans to intend to vaccinate. If Democrats start to doubt that a truly effective vaccine was rigorously vetted, we could see even greater compliance problems.”

How many people need to be vaccinated against Covid-19 anyway?

Let’s say there is a safe and effective Covid-19 vaccine, approved without political interference by the FDA. And still, 30 percent or more of Americans refuse to get it. Does that immediately ruin the chances of a vaccination campaign succeeding?

Not necessarily.

Natalie Dean, a biostatistician and vaccine researcher at the University of Florida, explains there are several variables at play that will determine what proportion of the population will need to be vaccinated.

Dean sent along the following chart to explain. At first glance, it’s a little hard to interpret, but it can help us think through the math.

A chart showing how varying levels of vaccine effectiveness (the different colored line), and the effective contagiousness of the disease (the R), affect how many people in a population need to be vaccinated to eliminate the disease. Courtesy of Zach Madewell

What it shows is that varying levels of vaccine effectiveness (the different colored line), and the effective contagiousness of the disease (the R), affect how many people in a population need to be vaccinated to eliminate the disease.

The more potent the vaccine, the fewer people need to be vaccinated. A less potent vaccine (or perhaps one that requires multiple doses to achieve its highest potency), would likely require nearly everyone to be vaccinated.

The good news in this chart is that R is not a fixed number. It changes based on our actions (like wearing masks), and depending on how we use other public health tools to combat the spread of Covid-19.

“If we’re able to bring the effective R down by other means,” Dean says, “by having better contact tracing, or better isolation, or reducing the super spreading events, or having more testing so that we can catch people in their infectious period … all these ways that we can reduce R, then that will also reduce that [vaccine] threshold that we need to hit.”

A vaccine, Dean reminds, “is a potentially valuable tool, but it’s not the only tool.”

A successful Covid-19 vaccine campaign is not lost yet. But the clock is ticking.

“We are in a window of time right now where this can actually be addressed, and be addressed well,” Brunson says. A botched vaccine campaign could undermine public health in the United States. But, a good campaign, she stresses, could lift it up, and “increase faith in public health and belief in vaccination,” she says. “That would really put us as a country, across the board, on a better path.”

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