How to vaccinate the anti-vaxxers

It's hard to believe that only three months ago Americans were furious about the slow and inefficient rollout of the COVID-19 vaccines. In three months, we've gone from a mentality of scarcity, with strict eligibility criteria and appointments that are as hard to get as Springsteen tickets, to one of abundance, with vaccine appointments so readily available that unused vaccines are piling up. But it's not because everyone's vaccinated; on the contrary, case rates and death rates are still hovering at the same level as six months ago, and overall vaccination levels are still well-below the threshold for herd immunity that could lead to the end of the pandemic domestically.

Why is our vaccination effort apparently stalling out so close to the finish line? The answer generally given is vaccine refusal. Something like a quarter of those polled say they will not get the vaccine if offered, which would be a high enough rate to significantly slow progress toward herd immunity and the recovery of normal life for everyone.

Blame for such refusal has been cast in all directions: at the FDA for pausing the use of the Johnson & Johnson vaccine, casting doubt on its safety; at the CDC for saying vaccinated people should continue to wear masks and practice social distancing, making vaccination seem pointless; at President Trump for not evangelizing for vaccines that were developed on his watch; and of course at grifters, paranoiacs, and trolls who have spread false stories about horrible side effects supposedly being covered up. And there's a growing sense of foreboding that this combination of influences has birthed a hard-core anti-vax subculture large enough to keep the pandemic going indefinitely.

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But is refusal to get the vaccines really the main obstacle to reaching herd immunity? I'm skeptical. I think the larger problem remains inaccessibility — even now, as a glut of vaccine is building — and that efforts to bring the vaccine closer to people would go a long way towards inoculating most self-described skeptics.

Why do I say that? For one thing, some slackening in the pace of vaccination would be expected if only because the more people get vaccinated, the fewer there are left to vaccinate — and the most eager are inevitably going to go first. We've now given at least one shot to more than 50 percent of the adult population. That's not a crazy point to expect a slowdown, even without positing any significant resistance to getting jabbed.

We've also given at least one shot to over 80 percent of seniors, suggesting that vaccine refusal runs considerably below 25 percent in that demographic. Vulnerability to serious illness and death from COVID-19 rises dramatically with age, and seniors have been eligible for the vaccine for longer than younger people have, so it makes sense that penetration would be much higher in this demographic. But by the same token, seniors are more likely to watch right-wing cable news, and are primary targets for a variety of scams and grifts. If anti-vaccine propaganda is driving extreme skepticism, why wouldn't it affect seniors as much or more than the population at large?

Meanwhile, when you talk to the vaccine-hesitant, as pollster Frank Luntz recently did with a focus group of Republican skeptics (around 40 percent of Republicans are skeptical of the vaccine), it becomes clear that refusal to get the vaccine is driven primarily by weariness and spite, not hard-core conviction. People are tired of being lectured by the authorities and unconvinced that taking the vaccine will improve their lives in any meaningful way. That's a far cry from widespread paranoia about Bill Gates using the vaccine to implant microchips in all the citizenry.

Now consider what we haven't yet done. We haven't brought the vaccine to people's workplaces (unless they work in the health-care sector or in the military). We haven't sent roving vans through urban neighborhoods or out to remote rural areas, bringing the vaccines to people's homes. We haven't made it possible to get the shot as part of a routine visit to the doctor or pharmacy; we still require people to make a specific appointment. And we haven't worked with people with difficult schedules or mobility issues to make sure they can get the shot. While it is definitely easier to get a vaccine now than it was a month ago, to say nothing of three months ago, it still requires determination and some facility with navigating an often confusing system.

And because we're not bringing the vaccine to people, or generally delivering it through channels that are already trusted, we also haven't opened lines of communication that might be helpful for overcoming the hesitancy that clearly does exist. The same people in Luntz's focus group who were sick of hearing from Dr. Fauci might be far less dismissive if a vaccine drive were being held at their local church. That's the kind of thing Israel did to combat vaccine hesitancy in the ultra-Orthodox community — but it hasn't been our approach, at least not yet.

Anecdotes aren't data, but I think the saga that our doorman went through in trying to get himself and his family vaccinated encapsulates how distant and uncommunicative bureaucracy and misinformation can interact to keep someone from getting vaccinated. He spent weeks trying to arrange vaccination dates for himself, his wife, and his elderly mother, without success. All the appointments he was able to get were on days that he had to work, the vaccine center couldn't work to fit his schedule, and his mother wasn't comfortable going without him. Then, when he finally got dates and times that worked, his sister-in-law warned him that she'd heard the vaccines can harm fertility in both men and women, and so he hesitated at the last minute. It was only a conversation with my wife, who is a physician, that convinced him not to worry about that and to make the appointments. Had he had access to the vaccine through a trusted intermediary from the beginning, he would have gotten an appointment much more easily — and would have been able to ask that person the questions that would have allayed his fears.

Our vaccination rollout was set up to reward diligence and attentiveness, and nonetheless more than half of the country has managed to get vaccinated. How many more people would get the shot if, now that there's the real prospect of a glut, we made access cheaper than free, bringing the vaccine as close to people and as easy to get as possible, offering to vaccinate anyone on the spot, and offering free pretzels and beer as a reward? How many young people who don't think vaccination is worth the bother would jump at a $100 cash reward? And how many would be convinced to get a vaccine that they are currently hesitant about if they were hearing about it from people they are already trusted, because they are known — people like family physicians and pastors — who could then easily “close the sale” because the vaccine was available right next door?

When we've done all of those things, if we're still left with a core of people who simply refuse to get vaccinated, and if that group proves large enough to be a real obstacle to herd immunity, then we can worry about what additional strategies are needed to bring them into the fold. Right now, though, there's still a lot of low-hanging fruit to be plucked without resorting to punitive tactics. Instead of blaming people for not doing the right thing, and thereby likely hardening resistance, let's focus on eliminating the obstacles that still remain, bring the vaccine to people, and see if that's enough to get us over the finish line.