A Note on Vaccine Hesitancy
In a previous essay for The Guardian, I argued that among those who publicly profess to belief in conspiracies, these purported ‘beliefs’ don’t seem to drive behavior nearly as much as people seem to think. The same holds with ‘fake news’ consumption: it doesn’t seem to inform behaviors in a meaningful way. In general, people seem to misunderstand why people purport to believe in conspiracies, why they share ‘fake news’ stories, etc. These behaviors seem to be less about reporting sincere beliefs than social posturing and community building.
One of the most common questions people asked in response to the article was, ‘what about vaccines?’ It seems as though many people are literally dying from conspiracy theories in this case. Appearances, however, can be deceiving.
As a matter of fact, prominent narratives about vaccine hesitancy seem to misunderstand both who is resistant to public health guidance and also why.
Misleading Narratives
although anti-vaxxers seem to dominate the public discourse and imagination on vaccine hesitancy, in truth, few of the unvaccinated are actually against vaccines per se – neither in general, nor in the particular case of COVID-19. Moreover, the concerns that incline people towards skepticism of authorities are often quite reasonable.
Even among outright anti-vaxxers, behind their eccentric rhetoric lie concerns common to many other vaccine-hesitant Americans – concerns that are hardly ‘crazy.’ Among them:
- Concerns about whether the safety and effectiveness of the vaccine is as high as experts claim
- Concerns about apparent conflicts of interest and perverse incentives among policymakers, experts and ‘Big Pharma’
- Concerns about the lack of transparency from authorities with respect to the uncertainties in their claims, possible downsides of their guidance, dissenting expert opinions, etc.
Critics often get so wrapped up in mocking the apparent absurdity of conspiracy theories that they are blinded to the legitimate concerns that typically undergird them.
The ‘Bill Gates microchip‘ theory, for instance, straightforwardly reflects worries about the safety of the vaccines, paired with concerns about conflicts of interest and perverse incentives among experts, policymakers and pharmaceutical companies. These are concerns they share with many other vaccine-hesitant people who do not wrap their apprehension in a conspiracy theory. Yet rather than recognizing and attempting to speak to the underlying and understandable concerns shared across vaccine-hesitant people, many choose to focus on the more sensational aspects of conspiracy theorists’ narratives in order to paint virtually all vaccine-hesitant people as irrational.
In addition to misrepresentations about why people are vaccine-hesitant, there also seem to be broad mischaracterizations around who the vaccine hesitant are. One common assumption is that vaccine skeptics are overwhelmingly MAGA-whites juiced up on Fox News misinformation. This narrative has some face-validity problems that have not been well-addressed.
Consider, for instance, the reality that only about 10-15% of voting-age Americans watch even 10 minutes of news per day, from CNN, MSNBC or Fox News combined. Most Americans do not even watch an hour of cable news over the course of an entire month. Even the age bracket that consumes the most cable news, Americans aged 55 or older, watch roughly 90 minutes per day from all sources. Expanding to digital platforms doesn’t change the picture much: only about a third of Americans read anything from Fox News platforms at all in a given month – and among those who do consume this content, users spend on average 38 minutes per month (just over one minute per day) engaging with it.
Incidentally, the demographic that is most likely (by far) to watch Fox News, Americans over 55, is also the age bloc where Trump support is strongest. In a world where Fox News consumption and Trump support were among the primary drivers of vaccine hesitancy, one might expect that vaccination rates would be especially low among older Americans – again, they are by far the most intense bloc of Trump supporters, and the primary audience of Fox News. Yet they also happen to be the most vaccinated group in America by far. The CDC estimates that nearly all seniors have received at least one dose of the vaccine, approaching 90 percent are fully vaccinated, and roughly two-thirds are boosted as well. In short, the older one gets, the more likely one becomes to watch Fox News, to support Trump, and also, to be vaccinated.
Another recent study identified Fox News as an outlier in expressed intent to vaccinate — but not for the reason many seem to assume: “Regular Fox viewers were neither more nor less likely than individuals who never view the program to intend to vaccinate against COVID-19” — in contrast with virtually all other media outlets which did have an apparent effect (see p. 21).
Race, Geography, Vaccine Hesitancy
With respect to race and ethnicity, black people have been more hesitant than most other racial and ethnic groups with respect to vaccines in general, and the COVID-19 vaccine in particular. They were less willing to take part in the vaccine clinical trials. They remained significantly more hesitant to pursue vaccines after they were approved. Although uptake has increased substantially among African Americans in recent months, overall vaccination rates continue to trail whites.
Throughout most of the pandemic, Hispanic Americans also trailed significantly behind non-Hispanic whites in with respect to vaccine uptake, although following a significant boom in vaccinations over the summer they are now approaching parity.
Nonetheless, significant pockets of hesitancy remain among minority populations. Media companies love doing stories about MAGA-whites who publicly flouted CDC guidance and then died of COVID-19, or who ended up with a bad case and recanted their views. It is apparently much less satisfying to talk about hesitancy within Orthodox Jewish or Somali communities, or among undocumented migrants, Indigenous Americans, or the many other racial, ethnic and religious minority populations for whom COVID-19 vaccine hesitancy is much more pronounced than among mainstream whites. Yet vaccine hesitancy within minority populations likely helps explain important trends in COVID-19 spread, hospitalizations and deaths:
Blacks, Hispanics and Indigenous Americans have been significantly less likely than whites to pursue vaccination, both with respect to COVID-19 and in general. Insofar as the vaccine reduces the likelihood of COVID-19 infections, protracted hesitancy within a given population would be expected to correlate with increased rates of infection and higher numbers of cumulative cases. And indeed, we do see this: the number of COVID-19 cases per 100,000 has been significantly higher among Black, Hispanic and Indigenous Americans relative to whites. Asian Americans, who have the highest rates of vaccine uptake among all racial and ethnic groups measured, also have the lowest numbers of COVID infections per capita.
Likewise, vaccinations have been shown to provide significant protection against the more serious manifestations of COVID-19. One would expect to see that populations that have had lower levels of vaccination over time would have higher levels of cumulative COVID-19-related hospitalizations and deaths. This, too, is evident in the CDC statistics.
Of course, vaccination rates are only a part of the story here: Black, Indigenous and Hispanic Americans are also far more likely than whites to possess other co-morbidities (such as heart disease, asthma, diabetes or obesity) that are connected to severe manifestations of COVID-19 and particularly adverse outcomes, irrespective of vaccination status. These populations also tend to have less access to quality medical care in the event that they do get sick. However, more cautious vaccine uptake among many ethnic and racial minority populations likely helps explain a large amount of the observed variance in COVID-19 infections, hospitalizations and deaths as well.
We can see this from another angle by breaking things down geographically. Overall, there is not a single state in the union where a majority of the adult population is not fully vaccinated. The state with the absolute lowest vaccination rate is Alabama, where 60 percent of adults have received two doses. Many other southern states also have lower-than-average vaccination rates. As these states are also decisively ‘red,’ it may be tempting to attribute these low vaccination rates to MAGA-aligned whites.
However, most Southern states also have particularly high concentrations of African Americans. Indeed, most black people in the U.S. continue to live in the South. And within these Southern states, black vaccination rates generally trail behind whites, and Hispanic vaccination rates in the South tend to be lower still.
A telling set of maps by Reuters depict the counties with the largest concentrations of African Americans, Hispanics, and COVID-19 related deaths – and how those counties trended in the 2020 election. Scrolling through the visualizations, it is clear that counties in the U.S. with the highest concentrations of COVID-19 related deaths also tended to have especially high levels of Hispanics and/or African Americans. Granted, many of the minority fatalities may have been among blacks and Hispanics who voted Republican – they’ve been growing in number for much of the last decade, and many of the places with high levels of minorities and high levels of COVID also shifted towards the GOP from 2016-2020. But it may also be the case that relatively low vaccination rates (and relatively high COVID-19 mortality rates) in ‘red’ states is disproportionately driven by populations within those states who skew ‘blue.’
This would not be an unusual finding. Much the same pattern holds for the oft-discussed higher divorce rate in red states: it is driven primarily by Democrats and Independents rather than Republicans. But many commit the ‘ecological fallacy’ and assume erroneously that because the state skews Republican overall, the divorces must be driven overwhelmingly by Republicans. In fact, the opposite holds true: Republicans have the lowest rates of divorce, and the highest rates of marriages, and express greater happiness in their marriages, as compared to Independents and Democrats in these states.
Many seem to be succumbing to the ecological fallacy with respect to vaccination rates as well — assuming erroneously that because the states skew ‘red’ the vaccine hesitant must be conservatives. In reality, attempts to blame low vaccination rates in the south on MAGA-aligned whites seems to miss a lot of what’s going on in these states – including factors that unite unvaccinated whites and minorities, both in the South and beyond, and that probably matter much more than partisan affiliation per se.
Missing the Forest
One big problem with many popular explanations is that they focus on factors unique to the U.S., despite the fact that vaccine-hesitancy patterns observed in the U.S. are actually common around the world.
Across societies and cultures, people with relatively low levels of income and education, those who live in more rural communities, those who are racial, ethnic or religious minorities, and young people have been far more hesitant to get the COVID-19 vaccine. In other words, populations that are underrepresented within the elite, and who often have strong and well-founded suspicion of authorities, are most likely to refuse the vaccine. The drivers seem to be structural, not a product of specific beliefs, ideologies, cultures, informational sources, or rhetoric by politicians in any particular country. The pattern holds across contexts, apparently independent of these factors.
Likewise, other major comparative studies have found that, across the world, the single most reliable predictor of COVID-19 transmission rates are the levels of trust citizens hold in their government. This is because populations that have low levels of trust in the authorities are less likely to follow protocols for containing the disease such as masking indoors, quarantining (upon possible exposure to COVID-19 or when displaying symptoms of COVID-19), avoiding crowded gatherings in poorly ventilated spaces, or getting vaccinated. Again, this holds across contexts, independent of the specific rhetoric, policies, or parties that prevail within a given country.
Across the board, then, we would expect to see, and we have seen, people with sociological proximity to elites aggressively and conspicuously adhering to elite guidance and attempting to coerce and cajole others into doing the same. Likewise, we would expect to see, and we have seen, people with high levels of sociological distance from those ‘calling the shots’ demonstrating much higher levels of skepticism of, and resistance to, declarations by authorities. And again, we don’t just see these patterns in America, but throughout the world.
Incidentally, those with high levels of perceived sociological distance from elites, and a perceived lack of power, are also the people most likely to participate in conspiracy theories. As political scientists Joseph Uscinski and Joseph Parent put it, “power asymmetries, both foreign and domestic, are the main drivers behind conspiracy theories; those at the bottom of power hierarchies have a strategic interest in blaming those at the top” for adverse social outcomes. That is, the kind of person who espouses conspiracy theories tends to be the kind of person who would be highly skeptical of, or resistant to, authorities and their advice independent of the conspiracy theory (they tend to be receptive to conspiracy narratives precisely as a result of pre-existing mistrust) – including with respect to vaccination.
The causal power attributed to conspiracy theories for explaining vaccine refusal, therefore, seems to be overstated. It seems like marginalization and alienation from authorities are the primary drivers of both vaccine-hesitancy and conspiracy theories alike. In focusing on conspiracy theories, which are downstream from mistrust, people are missing what’s really going on. Indeed, as discussed at the outset, the kinds of concerns that the conspiracy theories gesture towards are widely shared among other vaccine-hesitant people who do not endorse the conspiracies. Put another way: most skeptics do not seem to be concerned about vaccines because of conspiracy theories. Rather, many adopt conspiracy theories as a means of articulating their pre-existing concerns about the vaccines, and forging community with others who share similar concerns. As I’ve elaborated at length elsewhere, sharing ‘fake news’ likewise seems to be more about social signaling than sincere epistemic claims.
Nonetheless, many choose to focus on conspiracy theories and misinformation as the primary drivers of vaccine refusal in order to paint the vaccine-hesitant as stupid, crazy or brainwashed. Within liberal spaces, a growing chorus has taken to proclaiming that those who are unvaccinated straightforwardly deserve to die of COVID-19. Some go so far as to heap scorn and mockery at the deceased and their families. There are public debates underway about denying medical care to the unvaccinated, and finding other ways to shame, antagonize and punish people who are vaccine-hesitant.
Liberals seem to feel comfortable engaging in the behaviors because they’ve bought into the popular narrative that vaccine refusers are a bunch of ‘privileged’ MAGA-aligned whites. However, the ugliness of these sentiments, their eugenicist and elitist tinge, becomes much more evident when we understand who the vaccine-hesitant actually are. In the U.S., as in virtually all other countries, the unvaccinated are overwhelmingly people who are marginalized, disadvantaged, dispossessed and/ or downwardly mobile from across racial and ethnic lines – including, and especially, those who also happen to be ethnic, racial and/or religious minorities.
These patterns do not just persist across geographical contexts, but historical contexts as well. In the U.S., similar patterns of skepticism and resistance were evident in previous vaccination campaigns (such as in the struggles over the smallpox vaccine).
Parties and Shots
We are now well-equipped to recontextualize some popular talking points about vaccine hesitancy and political affiliation.
Widely-circulated reports note that counties with the highest concentrations of Democratic voters tend to have much lower rates of COVID-19 deaths than those with the highest concentrations of Trump voters. Yet media reporting on this gap systematically fails to observe the massive differences in wealth and healthcare access between heavily Republican and Democratic regions. Counties with huge concentrations of Democratic voters tend to be among the most affluent in the country, with huge concentrations of hospitals and doctors. Meanwhile, areas with the deepest concentrations of Trump voters tend to be among the most economically distressed in the nation, with huge swaths of the population also living in ‘healthcare deserts.’
Consequently, it would seem bizarre to assert that the most relevant difference between the most intensely Democratic and Republican districts with respect to COVID-19 related outcomes is partisan affiliation or ideological leanings. Yet that is precisely what reporters frequently do: pretend as though the main driver of the differences in vaccination rates, cases, and deaths is political beliefs, not the vast and systematic differences in wealth, education, or access to healthcare between these districts.
The Kaiser Family Foundation estimates that 60 percent of those who remain unvaccinated are Republicans. Just taking this figure for granted, we are now in a position to see that political ideology or political partisanship per se probably explain very little of the disparities observed. Contemporary GOP voters are far more likely than Democrats to possess low levels of education and to live in communities that are rural, post-industrial, and in decline. They tend to have far less trust in government than Democratic peers (this is a big part of the reason they identify with the Republican Party in the first place). Moreover, growing shares of GOP voters are lower-income, working class, and/or minorities (racial, ethnic, religious). These factors probably explain much more than partisanship itself.
Sure, the states with relatively low vaccination rates tend to skew ‘red.’ But they also tend to be more rural, and poorer, with radically lower rates of postsecondary education and far lower levels of trust in government. That is, they are precisely the kinds of places, with heavy concentrations of precisely the kinds of people, who have proven to be vaccine resistant in countries around the world. In an alternate reality where Trump, Joe Rogan, and Fox News were not a part of the American cultural landscape, these same populations would likely remain far more vaccine-hesitant than most other Americans — just as similar sub-populations are among the most vaccine-hesitant in virtually every other country in the world.
Indeed, precisely because counties with huge concentrations of Trump voters also tend to have low rates of postsecondary education, we should be extremely skeptical of claims that ideological commitments or political partisanship are driving vaccine hesitancy: those relatively low levels of education tend to be far less ideological, dogmatic or politically partisan as compared to social elites. Hence, the behavior of constituents in these districts is less likely to be driven by partisanship or ideological commitments as compared to constituents in heavily ‘blue’ districts.
Consequently, it would be fallacious to notice the statistical relationship between party affiliation and vaccine hesitancy and simply impute that the former drives the latter. Because of how things have shaken out in the contemporary U.S., party affiliation serves as a single proxy for a range of other factors that shown to drive vaccine hesitancy around the world. Hence we see a strong correlation between party ID and vaccine hesitancy. But of course, the first rule of statistics is that correlation does not prove, or even imply, causation.
It also deserves to be noted that, again just taking the Kaiser Family Foundation estimates at face value, a huge share (4 in 10) of those who remain unvaccinated are not Republicans.
Many on the left are vaccine hesitant because they are also concerned about profit motives, perverse incentives, and possible collusion between government and big pharma. Others who are into things that are ‘natural’ and ‘organic’ view vaccines, especially mRNA vaccines, as unnatural, artificial and potentially harmful.
Healthcare workers also tend to skew overwhelmingly Democrat. Yet large numbers of healthcare workers are also vaccine hesitant, including in liberal bastions like New York City (and actually, across much of the world). Vaccine hesitancy is especially pronounced among health care workers who happen to be racial and ethnic minorities.
Moreover, non-trivial numbers of Americans across party lines (nearly 1 out of every 10 unvaccinated Americans according to U.S. Census Bureau estimates) declined the COVID-19 vaccine not because they failed to ‘trust the science,’ but because they were actually advised by their doctor that they don’t need, or shouldn’t get, the shot. These polling data correlate cleanly with the results of a recent study of primary care physicians which found that roughly 10 percent of PCP’s do not view vaccines as safe, effective or necessary in general — and express even greater skepticism with respect to the COVID-19 vaccines in particular. That is, not only are a number of healthcare workers vaccine-hesitant themselves, they are often responsible for encouraging vaccine refusal in others as well.
All said, attributing vaccine-hesitancy to MAGA-aligned whites, fake news and conspiracy theories may be personally satisfying for many. It may facilitate one’s desire to villainize and dehumanize perceived political or ideological opponents. However, these narratives are not that great for really understanding who remains unvaccinated and why – let alone understanding what can be done to actually mitigate (rather than merely condemn) vaccine-hesitancy.