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The signs are clear: The U.S. vaccine rollout is plateauing.

A remarkable 230 million shots have been given in a few short months, fully vaccinating about 95 million Americans as I write this. The next 100 million shots will be harder.

News reports are chronicling a slowdown in appointments across the nation. The number of daily doses administered is down from the peak of 4.6 million on April 10 to about 3 million today. By now, this historic effort has captured the vaccine-hungry individuals who are eager, well-resourced, technologically savvy, and excited to get vaccinated. But as fewer people sign up to get their shots, a dominant narrative is emerging: It’s because of hesitancy — too many people don’t want to get the vaccine. Some even call this vaccine resistance.

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Those are convenient narratives. But they are false, and can have harmful consequences.

Let’s start here: If you didn’t get your flu shot last year, are you “vaccine hesitant”? If you haven’t been vaccinated yet and aren’t actively seeking an appointment to do that, are you “resisting”? If you skipped your vaccination appointment because the Food and Drug Administration’s pause of the Johnson & Johnson vaccine raised questions you wanted answered first, are you a “vaccine skeptic”?

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Few people would answer any of these questions with “yes,” yet experts and commentators are quick to use hesitancy to explain the recent dip in vaccinations.

We have seen this before: When the Johnson & Johnson vaccine was found in January to be 72% effective in U.S. studies — lower than the Pfizer and Moderna vaccines — many predicted this difference would make people less likely to get the J&J vaccine. It did not. Instead, this vaccine became the go-to for hard-to-reach groups that prefer a one-shot deal.

After the pause was announced for the J&J vaccine, many worried about its possible impact on the intent to vaccinate for all vaccines. This, too, was unfounded. In one new poll, 71% of people said the pause didn’t matter to them, or that it was a good example of rigorous safety monitoring. In another poll, 88% said the pause was the right call.

As daily vaccination rates settle and the country’s progress toward herd immunity slows down, let’s not rush to the same misguided conclusion that this is mostly about lack of vaccine confidence.

Individuals who aren’t seeking a Covid-19 vaccine right now are not necessarily the same people as those who are truly anti-vaccine. Instead of talking up hesitancy, it’s time to talk about what motivates people to get vaccinated and identify the ongoing barriers to vaccination. Here are three ways to do this.

First, retire the term “vaccine hesitancy.” As any crisis communications expert will point out, it’s not a good idea to say things you don’t want people to be thinking. Repeating the term over and over again unwittingly communicates that there may be something to be hesitant about. The more people talk about it, the more it becomes a self-fulfilling prophecy. It’s the same psychology that puts guardrails around using the word suicide, which news media are urged not to put in headlines and to apply with utmost caution.

Second, keep in mind that vaccine confidence is not a fixed mindset. Instead, it describes where someone is in his or her vaccination decision-making at a specific time. Are people who aren’t ready today to get the Covid-19 vaccine skeptics? Or do they just have important questions about the vaccine? Did they check the “no” box in the poll because they knew enough and truly didn’t want the vaccine, or because they didn’t know how and where to get a vaccine, were concerned about health insurance bills, didn’t have time to make an appointment, were worried about missing work, or have had negative encounters with the health care system?

Narratives that assume vaccine hesitance or resistance also assume that vaccines are easily and equally available to all Americans. That just isn’t true.

Third, looking past the behavior of individuals can shed light on the more systemic drivers of what prevents people from getting vaccinated against Covid-19, which include a host of systematic health and information inequalities.

I lead a team at Brown University School of Public Health that is undertaking new research in partnership with the Rockefeller Foundation and community organizations across the U.S. to understand people’s experiences regarding vaccination, public health, and the health care system more generally, rather than just their intentions about this specific vaccine. What we have learned so far from this survey, fielded by HIT Strategies in communities of color in five U.S. cities, is telling: Even though a majority of Black and Latino Americans want to get vaccinated — 72% in this survey — a surprising 63% said they didn’t have enough information about where to get the shot. In addition, more than 20% said they had regularly been treated with disrespect when getting health care in the past, and 20% said they have had trouble finding health care when needed.

Despite these systemic barriers, only 3% of the total sample said that nothing at all would move them to get the Covid-19 vaccine.

Everyone else, even those who said “no” to getting a vaccine now, listed reasons that would motivate them to get a shot, such as “seeing a person I trust get the vaccine” or having “a vaccination site close to my home.”

In fact, “having more information” is the single most important concern expressed by those unsure about the Covid-19 vaccine, according to almost every poll that asks this question. This is true across the political spectrum. Blaming conservative Americans for taking their time or for believing lies, and labeling them as hesitant or resisters only hardens their viewpoints. Instead, the public health community needs to come to grips with what motivates people, and also with the harmful impact of misinformation on Americans who do not have access to quality information.

It’s still a long road to getting most Americans vaccinated against Covid-19. It can be shortened by worrying less about today’s confidence polls and more about persistent barriers to vaccination. The health and public health communities need to continue the hard work of making vaccines ubiquitous and available without complex sign-up procedures — at churches, grocery stores, barber shops, food pantries, and yes, even in bars and restaurants.

People’s questions must be answered and false narratives preempted by flooding online and offline spaces with high-quality information in the languages people speak on the platforms they frequent. Concerted effort is needed to expose misinformation tactics and how they are unleashed to generate confusion, as well as to regulate the platforms that empower them.

For most Americans — and that includes conservatives — who are given the chance to discuss vaccination on their own terms and timelines and for whom vaccination is easy, nearby, and supported by employers, the question shifts from if they will get vaccinated to when and how.

Stefanie Friedhoff is a professor of the practice in health services, policy, and practice as well as strategy director at Brown University School of Public Health.

  • Vaccine hesitancy should be for Covid vaccines with insufficient efficacy (~60%).
    Moderna, CureVac, Biontech and Novavax are superior than Adenovirus based vaccines in both efficacy (>90%) as well as safety. The much higher antibody levels also made them more effective against the variants.

    The rapid rises of variants (India variant has been like a wild fire lately) have to be closely monitored worldwide using genome sequencers by Pacific Bioscience, Invitae as well as Illumina. Other new variants (from Turkey, Indonesia, Nigeria) will soon come up during next 1~3 months.

    Moderna has developed a new version for the S. African variant.
    Biontech and CureVac should develop for the raging India and Brazil variants (killing ~6000 people/day).

    And we need to immediately double viral genome sequencing, and increase to 10 times by the end of the year. mRNA vaccines can then rapidly code for these newly sequenced variants to help keep them in check.

  • You addressed the conservatives but what about the antivaxers who predominantly are on the left political spectrum?

  • Give everybody an honest chance to get vaccinated (by, say, the end of May), and then stop making excuses for those who don’t, and start calling them for what they are: selfish, and treat them accordingly.

    Besides threatening those who would love to get the benefits of vaccinations but can’t, like the immunodepressed, these selfish individuals will be prime contributors to the possible emergence of vaccine-resistant strains.

    • Mike, I actually had Covid in February 2021. Later in March, when I mentioned to my regular MD that I had a vaccination appointment scheduled, he recommended waiting 90 days, because of some professional speculations circulating about more extreme vaccine reactions when a large quantity of active antibodies are present, which I had. I’m waiting until late May, on a doctor’s suggestion. Others may be doing the same thing.

  • It is sad to see thousands die in other parts of the world for lack of availability of the vaccine, while some in the USA do not want to get vaccinated. It is time that the USA starts selling or donating the vaccines to poorer nations.

  • “Having more information”, EH??

    Why not more information about, say, inactivated virus vaccines and Novavax? Somehow, there doesn’t seem to be any discussion about that alternate prospect here.

    Like, anything, even a piece about WHY inactivated virus vaccines just seem to be comming up short nowadays. Nobody even talks about that, nobody even uses such inadequate vaccines as a contextualizing tool in illustrating how brutal a virus this is.

    Or at least offering up a justification about how the unrolling of protein subunit vaccines would serve to undermine confidence in viral vector vaccines. That would be far better than ignoring such a perspective and just letting it be implied.

  • I haven’t been able to even locate where I can get vaccinated for me& husband. I tried to sign up on a website but nobody ever got back with me and it didn’t show me to register both me& my husband. Some places were asking nearly$100. We can’t afford that on our low income budget.

    • The vaccine is available without cost to every American. It sounds like you need help finding the correct website to sign up.

    • Try vaccinefinder.org. Supported by the CDC, it should show you numerous sites to get the vaccine near you. You can choose which vaccine you are looking for to narro your search in case you have a preference. All should be free.

  • how about motivating people by allowing mask mandates to expire once you have your vaccine. i will not get it just to go back and wear the symbol and do nothing. Its a joke. Incentives work. I would go tomorrow if it improved all of our lives.

    • Because it would be, at least at the present, near impossible to stop unvaccinated people who just don’t want to wear masks anymore from taking advantage of it and endangering others in the process. We know how many people are getting vaccinated each day; we start easing mask mandates when we hit the numbers we need to hit to achieve herd immunity. And if you want to get there sooner, do you part by getting vaccinated and encouraging others to as well.

    • https://www.vaccinespotter.org/ is a good resource that lets you know where appointments can be found. Some sites also accept walk in appointments. You should not have to pay anybody for the vaccine. The most that can be done is a pharmacy can ask for your health insurance information to bill them a few dollars. There is no copay and your deductible does not apply. If you don’t have health insurance, they still have to vaccinate you.

    • When we achieve herd immunity and the pandemic soon after abates, our behavior can safely change enormously! That’s the payoff. You can be a part of that change by getting vaccinated (or by recklessly allowing yourself to get infected). Or you can work against developing herd immunity, prolong the pandemic and possibly make it worse than we’ve seen, by not getting vaccinated.
      I’ll second Eric’s mention of vaccinespotter.org. It’s a great website for finding appointments!

  • Very nice summary of the current thinking on both distribution and communication, all in one place.

  • Thanks for a nonjudgmental, thoughtful assessment. I have found that many people who have not gotten the shots are of the belief that when in doubt, do nothing. There are fewer answers as to the long term consequences of these shots than there are for the immediate consequences of C-19. For anyone who realizes their true risk factors (Worldometers currently has a .6% serious/hospitalized rate for cases around the world), they may feel the long-term unknown is a cause for inaction.

    Here is where I think the government and Pharma and big tech have overplayed their hands: people are suspicious of the hard sell. This idea that scientists know for sure that a mass vaccination effort during a pandemic of a new-ish virus with new medical technology is the absolute best approach can easily be put to rest: there is no such evidence to prove it so because this is a first. You cannot tell people that because airplanes almost always get them somewhere safely that this brand new rocket will get them safely to Mars, much less that Mars is the best place to be. The messaging by authorities is just all over the place and assumes that the public is stupid.

    But another thing to consider is that many people feel that they are helping these ongoing phase 3 trials by volunteering to be in the placebo group. After all, if Pfizer and Moderna were to practice proper medical ethics, they would not have unblinded their trials. So many reasons to scratch one’s head these days. I would rather not roll the dice on unproven tech in my body.

    • What’s with the troublemaking fuss about “uproven tech”? There’s all sorts of vaccines out there based on various kinds of well established methods, I don’t see any of you anti vaxxers calling attention to anything from the whole generous menu of “proven technologies”!

      Like the one with the adjuvant, that used to be the favorite focal point of you anti-vaxxers! Nice U-turn.

    • I appreciate that you are articulating what you believe, but this way of thinking is not sensible because there is a false confidence expressed about the potential ill effects from COVID. Alongside the unknown you are referring to in the vaccine, we have no long-term studies on the potential long-term consequences of COVID infection. So there are multiple unknowns, including the unknown of what might happen to you were you to become ill (or become ill again if you already had COVID once). Since it is a new virus and disease the unknowns are immense. But we have an advantage of not going first. The UK and Israel both did huge vaccination drives and we can see the results. If it resulted in a horrendous death toll or some unusually large negative results we would know already. What we know is that the pandemic is horrible and to stop it we need some kind of “herd protection.” The vaccine is the best way available to do this based on what we know today. Please get one the minute you can.

    • JP, you seem to be the only person actually thinking around here, not being naive nor following the mass only because it is the majority -and that gives them some kind of blind trust-. I’m not talking about being right or wrong, because that’s not totally clear for anyone just yet.

      This is like when in middle age you were either a warrior of god or a heretic that must be killed by either a sword or a fire. There were those who would kill others because it was right (according to those speaking from an unquestionable power position), and those who’d be forbidden, banned and ultimately killed because of thinking differently, if they didn’t change their minds to what was right.

      We’ve learned from history that masses obey under fear, and move forward unknowingly benefiting the power of a few others; in that time, it was the church getting all the power and riches…

      Now -almost- no one fears god or the devil, so there are new gods and devils; science and “a deadly virus” and are equally effective. People acts the same, spreading the word, pointing out the wrong and the right thing, like true believers, knowing basically nothing (ask them about the interaction between the RNA of a vaccine and your own DNA at a molecular level and its consequences in the long term, and most of them won’t even know if it’s a real question or if you just made it up… you can say they don’t interact at all, and anyway they’ll just swear you’re wrong if you won’t vaccinate -just yet-).

      Now, it is only logic (and evolutionary) to be thinking and doubting (I see you doubting, not judging or just rejecting right away), and not to be blindly trusting without questioning; it’s a wise thing wanting to know more before taking action.

      There will always be other people envying your intelligence and courage, trying to get into your head by judging you… They’ll keep calling doubters “selfish” and “ignorant”, and saying all kind of new-evangelical words to make you align to their beliefs and get into the right path. They’re just very well dogmatized and, most of all, scared-to-death.
      As small and limited as we are, there’s no one to blame here YET.
      Humans will know what this really is, one day, hopefully not 800 years from now… One would expect we’d have evolved a little by now…

    • The mRNA vaccines in particular are looking like some of the safest, most effective vaccines ever developed–not to mention the simplest in design and mechanism of action–and they represent the fastest, safest route to herd immunity, but nearly half the population is content with slowly if ever returning to normal and giving the virus more of a chance to thrive by evolving more, possibly more dangerous variants. Nearly half the population couldn’t be bothered to wear a mask either. So as a result, we spent trillions of dollars, lost tens of millions of jobs, hundreds of thousands of lives, and gave millions of people new, chronic conditions.

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