“If we do not get up off our knees and stop worshipping scientists and doctors who have too little knowledge and have been given too much power, tomorrow we will not be able to get on a bus, train, or plane; enter a store or sports arena; obtain a driver’s license or passport; file our taxes; or function in society without getting every vaccine that industry creates and the government orders us to get.”
These words were offered by Barbara Loe Fisher, founder of the largest national organization in the US opposed to vaccine requirements in 2019, long before Americans had imagined the Covid-19 outbreak. Speaking at an event organized by “Crazy Mothers,” a group whose stated goals include bringing attention to injuries caused by childhood vaccines and empowering mothers to make informed health care decisions, Fisher’s comments were meant to condemn state laws that require childhood vaccinations for school attendance and recent state efforts to tighten enforcement of those requirements.
At the time, even those skeptical of vaccines might have found Fisher’s remarks paranoid or conspiratorial. Today, as the Covid-19 pandemic ravages the country, infecting more than 4.2 million Americans and killing more than 146,000, plans to develop and test a vaccine as quickly and safely possible are unfolding. Suddenly, her statement might seem more like a premonition to much of the anti-vax community.
As a sociologist who has been studying vaccine refusal for more than a decade, I work to understand parents’ fears of vaccines and how parents come to make health care decisions for their families. Whenever I read news articles where officials tentatively promise a coronavirus vaccine late this year or early next year, I worry about how this messaging will be received by both existing vaccine critics and newcomers.
I understand the desire to calm an anxious public with good news — and, to be clear, many objections about the potential future vaccine are inaccurate and risk undermining a much-needed public health intervention. But in order for a vaccine to be broadly accepted to provide some community-level protection, we must explore the questions and assertions driving skepticism about a Covid-19 vaccine among those who already oppose them as well as those who are still uncertain.
Before we had heard of Covid-19, vaccine refusal was growing across the country. Parents’ reasons for rejecting vaccines vary — some are not convinced that vaccines are necessary or believe their children’s immune systems would be stronger if they contracted an illness and recovered, often citing their families’ lifestyle and good health. Many do not trust that pharmaceutical companies are adequately testing vaccines and don’t believe government agencies are vigilantly regulating them before licensing vaccines and requiring them for school attendance, both of which are unfounded. Parents who distrust vaccines most often argue that vaccines are a personal consumer product and should be chosen by those who believe they are useful, but should never be required.
The vaccine against Covid-19 is currently hypothetical, so many questions about its use are as well. As of now, it appears that young children are unlikely to be an early target of a Covid vaccine since they are the age group least likely to develop the worst symptoms of coronavirus infection or to die. Although arguments of who should be first in line for the vaccine are ongoing, the World Health Organization recommended that adults over age 30 and in high-risk categories and occupations are most likely to be recommended for priority use.
There is also broad disagreement about what portion of the population needs to become immune to infection, either through antibodies derived from recovery from illness or via a vaccine, to slow new infections. Efforts to estimate herd immunity — that is, the point at which a critical mass of the population is immune to infection and can starve the virus of available vulnerable hosts — range dramatically, with models suggesting everything from 80 percent to as little as 20 percent immunity will help to slow infections.
Surveys conducted in May and June by the Pew Research Center and ABC-Washington Post show about 70 percent of American adults are willing to get a vaccine against Covid-19, while the Associated Press-NORC Research puts that figure closer to 50 percent. Skeptical groups range widely. According to all three polls, Republicans were less likely to say they want the vaccine. African Americans were also less likely to want the vaccine and less likely to support experimental interventions (a logical objection given the lengthy history of unethical research in Black communities). Among those who do not want a vaccine, safety concerns were the largest reason, but fear that the government will use concerns about the virus to promote the vaccine and increasingly surveil and control people, which have fueled protests against stay-at-home orders and mask requirements, also plays a part.
There are no clear answers to questions about a vaccine that does not yet exist. Yet many concerns raised by the parent-led movement to refuse existing vaccines are informative for thinking about how a new one will be received. Those who are fundamentally opposed to vaccines will likely not budge. But addressing some of these concerns and narratives below could increase trust in the Covid-19 vaccine among those who are worried but persuadable.
Many Americans do not trust pharmaceutical companies, with trust plummeting during the opioid crisis and remaining low as more news has come out about drugs that are poorly manufactured, contaminated, ineffectual, harmful, or priced out of reach even when medically essential to save lives. While surveys this spring showed some optimism that companies will likely provide solutions to Covid, trust remains low.
This distrust goes hand in hand with anti-vaccine sentiment. Prior to Covid-19, I often heard complaints from those critical of vaccines about the revolving door between Big Pharma and government. Many of these concerns seem confirmed by the creation of Operation Warp Speed (OWS) this May, a White House initiative to accelerate the development, manufacturing, and distribution of Covid-19 vaccines. OWS is headed by Health and Human Services Secretary Alex Azar, a former pharmaceutical executive and lobbyist, and Defense Secretary Mark Esper, a former US Army officer and defense contractor lobbyist. Dr. Moncef Slaoui, a longtime executive at GlaxoSmithKline (GSK) and recent board member at the biotechnology company Moderna, was appointed a chief adviser to OWS — and, despite still owning millions of dollars worth of stocks in companies who received OWS funds, is not required to disclose conflicts of interest because he is a contractor and not a government employee.
There is no reason to believe OWS will not rigorously monitor safety. Yet the leadership and funding of OWS include financial arrangements in which the government and not the companies carry much of the cost of manufacturing, which will begin before trials are completed. This means that the government must be willing to throw away hundreds of thousands of vaccine vials should the trials fail. Critics suggest that the close relationship between pharma and government and the federal government’s significant financial investment in “at-risk manufacturing” could create incentives to interpret data positively, even when concerns may be present.
These issues are being discussed in anti-vax circles. One online discussion in March in response to a video of a radio show by anti-vaccine activist Del Bigtree illustrated perceptions that governments and public health agencies support pharmaceutical companies’ profits instead of good health among its citizens. Commenting on the video, which has been played almost 300,000 times, one viewer replied, “The answer to disease is not better drugs but better health. The problem with better health is that the big Pharma can’t profit from you.” Others replied: “‘For profit’ public health folks should not be directing our economy ON ANY LEVEL.” Another viewer clarified, “Why make the distinction between for profit and non profit? They all follow the agenda.”
One doesn’t need to be a conspiracy theorist to expect financial conflicts of interest should be managed well. The federal government entered into a $2 billion deal this week with two pharmaceutical companies to offer a vaccine at an affordable $40 a person for 50 million Americans, representing a significant investment in the nation’s health. Public leaders should make clearer to consumers that these partnerships represent a public investment in access and affordability, not a naked attempt at personal or corporate enrichment.
In order to move the vaccine to market quickly, companies are running multiple stages of clinical trials “in parallel” rather than sequentially. Researchers usually take months between phases to examine data and make sure they understand the information before proceeding, and trials take years, not months. Instead, Azar claims OWS will “compress and wring out every inefficiency in the process and take away every unused day” to expedite the research process. Federal agencies insist they are committed to safety and “will not cut corners” in licensing decisions. Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, described his goals: “I really want to make sure that we don’t have a vaccine that’s distributed among the American people unless we know it’s safe and we know it is effective. … Not that we think it might be effective, but that we know it’s effective.”
Despite reassurances, there is signs that this rushed pace and inconsistent messaging from the White House about the severity of the outbreak is harming trust in the potential vaccine. As one Twitter post said, “‘Warp speed’ says it all. Project has been rushed and corners are being [cut]. No point producing a vaccine that could be more dangerous than the desease….but tell that to trump. Desperate to find a vaccine for a desease he thinks doesn’t exist. Bizarre.”
Vaccine critics, like those who work in Robert Kennedy’s Children’s Health Defense, an organization that aims to undermine vaccine usage and promote the widely discredited vaccine-autism link, have been quick to criticize this process, explaining how researchers made “the decision — deemed ‘morally questionable’ by some — to sidestep the standard process for vaccine development.”
Vaccine advocates acknowledge the challenge of assuring the public that science can be fast and careful. Bruce Gellin, president of the nonprofit Sabin Vaccine Institute, noted how the name Operation Warp Speed does not inspire confidence in cautious scientific method: “What is a worse name for something that’s supposed to give you trust in a product that you want everybody to take?”
Researchers are working at a record pace to find a vaccine that will work, but they are also describing the importance of maintaining realistic expectations to ensure there are no pressures to sacrifice the scientific process, irrespective of promises made by the White House. Scientists acknowledge their understanding of this novel coronavirus is still evolving, which could affect how recommendations about an eventual vaccine look, and consistently note that even though finding a vaccine against Covid-19 is important, good science nonetheless takes time.
As new information becomes available and recommendations and scientific processes shift, better messaging should make clear that science must work methodically, incrementally, and sometimes slowly to be sure information is correct. This also requires messaging that acknowledges a vaccine may take longer than expected to ensure it is safe and effective.
Outside of the military, the US does not have any existing laws to mandate vaccination for adults. The US has no system of enforcement of an adult vaccine requirement and lacks infrastructure for door-to-door administration of vaccines. There is currently no proposal for state or federal governments to universally mandate Covid-19 vaccination, and the logistics of creating and enforcing such a mandate are hard to imagine within current systems.
Indeed, there are some calls for mandatory vaccination, including from the New York Bar Association, and from some health care providers who cite low usage of the seasonal influenza vaccine as evidence that voluntary use will be inadequate to obtain herd immunity. But recognizing that supply of any new vaccine will likely be inadequate to meet demand in the first year (even if only half of Americans currently say they plan to get it), the government is unlikely to universally require vaccination.
What is more complicated to evaluate is how the private sector could make different choices. As of now, vaccination requirements by employers are rare and targeted — for example, health care workers and trainees in most states face requirements to get a seasonal flu vaccine and provide proof of vaccination against other vaccine-preventable diseases. About 13 percent of child care centers require care providers to get flu shots. Workplaces like Google and Disneyland considered policies after experiencing measles outbreaks but did not implement any. At least one university has already announced that students, staff, and faculty will need to get a vaccine against both influenza and Covid-19 once one becomes available.
But, given the devastating economic impacts of this pandemic, one could imagine corporate policies to require the Covid-19 vaccination as a condition of employment. In the future, claims of a fully vaccinated staff could be effective marketing tools for long-term care facilities, child care centers, or even grocery stores. These hypothetical market-based initiatives to support vaccination build on existing efforts of many businesses, offices, and universities to require masks, temperature checks, and even “assurance testing.” As private entities, they also would not face the same constitutional restrictions, though there would likely be legal exemptions and requirements to protect personal health information.
What if, as Fisher fears, airlines, sports arenas, or stores require evidence of vaccination to enter? Many vaccine skeptics assume this is inevitable. Social media has run rife with misinformation about forced vaccines, and as one recent Twitter post advised, “All I can say is refuse to take the vaccine and prepare for the inability to buy, sell, travel, work. … I’m not compromising my health. I really believe our freedoms will be gone, pdq.”
Admittedly, there is a small number of people who oppose vaccines in all forms and are unlikely to be persuaded that vaccines are ever safe and effective. (There is also evidence that some anti-vaxxers are rethinking their opposition to vaccines as they face new fear of infectious disease.) However, there are a sizable number of people who are not opposed to vaccines but who still currently do not want to use a Covid-19 vaccine. One study found that about 15 percent of people who are at least somewhat supportive of vaccines said that they wouldn’t get this vaccine and 19 percent of people who did not identify as anti-vaxxers said they wouldn’t get it. This group deserves better information that can communicate why this vaccine — and the process that led to its development — deserves their trust.
The coming months will provide an opportunity for policymakers, researchers, and government agencies to provide clear, honest answers to the many questions potential consumers of any forthcoming vaccine may have. Although the Centers for Disease Control and Prevention has worked to support vaccine acceptance, that agency does not appear to be leading OWS, requiring Health and Human Services, the Department of Defense, and the Food and Drug Administration, which will license a vaccine, to work on public trust in new ways.
As health economist Jay Bhattacharya recently told a House Oversight Subcommittee on Economic and Consumer Policy, “the fallout from disinformation falsely linking the measles, mumps, and rubella vaccine to autism, seeding the anti-vaccine movement, is a cautionary tale.” Public health agencies, scientists, and government leaders would be wise to address misinformation with transparency, honesty, and clarity. Our lives may depend on it.
Jennifer Reich is a professor of sociology at the University of Colorado Denver and author of the book Calling the Shots: Why Parents Reject Vaccines.
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