Why Aren't More Americans Getting the COVID-19 Vaccine?

The United States’ march toward pre-pandemic normalcy is now a full sprint. More than 45 percent of Americans have received the COVID-19 vaccine so far. The CDC eased its guidance on mask restrictions last week, advising that fully vaccinated people can go without one both indoors and out. Live music is slowly returning; people are going to sporting events, movie theaters, restaurants, and bars with more regularity.

But there’s still at least one major road block in the way: Millions of Americans don’t want to get vaccinated.

Some experts have dubbed the phenomenon “vaccine hesitancy.” Various news organizations have reported on it; one Google search yields countless headlines using the phrase. But Dr. Céline Gounder prefers to use a different term: vaccine confidence.

“Hesitancy has become a stigmatizing term, and it also implies that the reasons people have for not wanting to get vaccinated are somehow not legitimate,” says Gounder, who served on the Biden-Harris Transition COVID-19 Advisory Board. “You have people who have very good reasons, historical reasons as well as present day reasons, not to trust the government [and] not to trust the health system.”

Aside from serving on Biden’s COVID-19 transition team, Gounder is the founder, president, and CEO of Just Human Productions, a nonprofit multimedia organization. She hosts and produces two podcasts: American Diagnosis, a podcast on health and social justice, and Epidemic, a podcast about the COVID-19 pandemic.

Gounder explains there are a variety of reasons for different subgroups to feel unconfident in vaccines. For some, namely communities of color, it’s lack of adequate medical treatment and historical experimentation on Black and brown patients. It’s not uncommon or unreasonable for such patients to wonder whether the government is using them to test a vaccine or treatment given its long history of doing so. But Gounder says they’ve made significant inroads.

“We anticipated this was going to be a challenge. It’s a challenge with every big immunization campaign,” Gounder says. “We started working specifically with communities of color early on, and I think what we’ve seen is that group that’s kind of on the fence has gotten smaller and smaller as more have decided to get vaccinated.”

More recently, Gounder and others have focused their efforts on reaching rural and conservative Americans. Their vaccine apprehension usually stems from a general distrust of government and not wanting to be told what to do. It’s difficult to reach the roughly 20 percent of Americans who, from the beginning, had no interest in vaccination. Gounder admits that’s more of a long term project, but the progress of building vaccine confidence is encouraging so far.

“I feel like we’ve made real progress, especially in that moveable middle of people who are on the fence in the ‘wait-and-see’ group,” she says. “For that other 20 percent, yeah, it’s going to take time. We’ve seen this with other vaccination campaigns.”

Lack of vaccine confidence is nothing new. In fact, it’s existed as long as vaccines have. It doesn’t necessarily take the form of the typical anti-vax sentiments we commonly see discussed or portrayed in media (though that certainly exists, too). One of the most important parts of building vaccine confidence is listening to actual concerns people have about the shot. Someone eager about vaccinations may simply write off someone who’s hesitant as dumb or uncaring. That attitude doesn’t help assuage deeply held beliefs or legitimate fears. It might even entrench them.

Sometimes, the typical strategies simply don’t work. Appealing to a person’s desire to help the greater good might work for many, but not everyone. And while polling may show a stark political difference in vaccine opinions, the shoe is never too far from the other foot.

“It’s important not to discount [peoples’] fears,” Gounder says. “Some Democrats, certainly before the election, expressed that they might not want to get a vaccine developed or approved under the Trump administration. So I think that cuts both ways.”

In terms of bridging that political divide, Gounder explains it’s about finding a balance and figuring out what really sticks. For some it might require explaining that the technology used to create the COVID-19 vaccines has been around for decades. For staunch Trump supporters, it may be reiterating that the vaccine submission for FDA emergency use was delayed until after the election because pharmaceutical companies needed to collect more follow-up data from clinical trials, not to screw over Donald Trump. But given the timeline, it’s easy to see why they might see it as politically driven.

“For that group in particular, I think finding ways to deliver the information as straight up and clean as possible, ideally from doctors and scientists [is important],” Gounder says. “We know that primary care providers are among the most trusted on this front and I think people want to know if this works for me, if it’s safe for me.”

Perhaps nothing is more personal than a firsthand story about how bad COVID-19 can get. Gounder says it’s one of the most effective ways to cut through to people, particularly conservatives. It’s why she had former New Jersey governor Chris Christie share his experience on a recent episode of her podcast. He battled COVID-19 back in October and spent seven days in an ICU with almost no contact with family, wondering whether he’d make it out alive. He also lost family members to the virus. For Christie, that was more than enough reason to get the shot.

“I think that really resonated because it was just human,” Gounder says. “It wasn’t coming from a political place.”

Branding vaccine or general COVID-19 messaging with official government seals isn’t always the best tactic. Gounder says she wishes the initial strategy was more hyper-local with greater investment in community-based organizations, nonprofits, and healthcare providers. It’s easier to trust someone in your own backyard, no matter where you’re from.

“When you have messaging branded with the White House logo or the CDC logo, for people who don’t trust government, who don’t trust public health officials and institutions, that’s not going to get through [to them],” she says.

This is a living prompt, of course. Gounder and other experts are still working out the problem, but they’ve learned a lot in the past several months. They’ve seen what works and what doesn’t and come to better understand how different people view immunization.

It’s an ongoing project, one that requires diligence, clear communication, and, maybe most importantly, time. It’s not easy to cut through deeply held beliefs or historical fears. New factors and context will always pop up. What Gounder and other experts learn now will certainly pay dividends during America’s next major public health crisis. But we’ve still got to get through this one first.