Guest Essay

Opinion

Guest Essay

Behind Low Vaccination Rates Lurks a More Profound Social Weakness

Dec. 3, 2021

By Anita Sreedhar and Anand Gopal

Dr. Sreedhar is a primary-care physician in the Bronx. Mr. Gopal is a journalist and a professor at Arizona State University. The authors research vaccine hesitancy and access around the world.

Robert Steed knew the toll Covid-19 had taken on the South Bronx, where he’d lived most of his life. There were the ambulances that would pull up to the drab brick apartment buildings of St. Mary’s Park Houses, the public housing complex where he’d grown up. There were longtime tenants who’d succumbed to the disease. There were posters pasted near the elevators, urging residents to get vaccinated. But he wouldn’t go near the vaccine.

“I’m not going to listen to what the government says,” he told friends. While he was down South working at a Waffle House, he tested positive for the coronavirus. He decided he’d fight the disease himself; after all, he was only 41, was rail thin and had no underlying conditions. But when his girlfriend didn’t hear from him for a few days in October, his friends said authorities forced their way into his apartment — and discovered his body. The death shook his friends and former neighbors at St. Mary’s Park Houses, but even as they mourned, many had made up their minds: They would not get vaccinated.

About 70 percent of American adults are now fully immunized, but in pockets around the country — from the rural South to predominately Black and brown neighborhoods in large cities — vaccine hesitancy remains a stubborn obstacle to defeating the pandemic. And it’s not just in the United States: In 2019, the World Health Organization declared vaccine hesitancy one of the 10 threats to global health. With persistent vaccine avoidance and unequal access to vaccines, unvaccinated pockets could act as reservoirs for the virus, allowing for the spread of new variants like Omicron.

The world needs to address the root causes of vaccine hesitancy. We can’t go on believing that the issue can be solved simply by flooding skeptical communities with public service announcements or hectoring people to “believe in science.”

One of us is a primary care physician with a degree in public health, working in the Bronx, and the other is a sociologist assisting international institutions to support polio and Covid vaccination in underdeveloped countries (as well as a journalist covering conflict). For the past five years, we’ve conducted surveys and focus groups abroad and interviewed residents of the Bronx to better understand vaccine avoidance. We’ve found that people who reject vaccines are not necessarily less scientifically literate or less well-informed than those who don’t. Instead, hesitancy reflects a transformation of our core beliefs about what we owe one another.

Over the past four decades, governments have slashed budgets and privatized basic services. This has two important consequences for public health. First, people are unlikely to trust institutions that do little for them. And second, public health is no longer viewed as a collective endeavor, based on the principle of social solidarity and mutual obligation. People are conditioned to believe they’re on their own and responsible only for themselves. That means an important source of vaccine hesitancy is the erosion of the idea of a common good.

One of the most striking examples of this transformation is in the United States, where anti-vaccination attitudes have been growing for decades. For Covid-19, commentators have chalked up vaccine distrust to everything from online misinformation campaigns, to our tribal political culture, to a fear of needles. Race has been highlighted in particular: In the early months of the vaccine rollout, white Americans were twice as likely as Black Americans to get vaccinated. Dr. Anthony Fauci pointed to the long shadow of racism on our country’s medical institutions, like the notorious Tuskegee syphilis trials, while others emphasized the negative experiences of African Americans and Latinos in the examination room. These views are not wrong; compared with white Americans, communities of color do experience the American health care system differently. But a closer look at the data reveals a more complicated picture.

Opinion Conversation Questions surrounding the Covid-19 vaccine and its rollout.

• How much should we worry about the Omicron variant?
  Dr. Ashish Jha breaks down 3 things we need to know in order to respond to the new variant’s threat.
• If Covid-19 isn't going away, how do we live with it?
  Katherine Eban writes that a clear-eyed view is required to organize long-term against an endemic virus.
• Why should we vaccinate kids against Covid-19?
  The president of the American Academy of Pediatrics explains how vaccinating kids will protect them (and everyone else).
• Who are the unvaccinated?
  Zeynep Tufekci writes that many preconceptions about unvaccinated people may be wrong, and that could be a good thing.

Since the spring, when most American adults became eligible for Covid vaccines, the racial gap in vaccination rates between Black and white people has been halved. In September, a national survey found that vaccination rates among Black and white Americans were almost identical. Other surveys have determined that a much more significant factor was college attendance: Those without a college degree were the most likely to go unvaccinated.

Education is a reliable predictor of socioeconomic status, and other studies have similarly found a link between income and vaccination. An analysis in June of census tract data in Michigan showed, for example, that vaccination rates in the heavily Black neighborhoods of Saginaw County were below 35 percent, and the rates in nearby poor white areas were not much different. Voters who identify as Democrats are much more likely than voters who identify as Republicans to get vaccinated, but, according to the Michigan data, this gap also disappears when accounting for income and education. It turns out that the real vaccination divide is class.

This is particularly visible at the St. Mary’s Park Houses, where Mr. Steed grew up. Here, amid the peeling walls and broken front door, residents say that New York City’s chronically underfunded housing authority has left them to fend for themselves. When we visited recently to ask about vaccines, the heating system was out despite the November chill. The roof was in disrepair. Some residents had no choice but to occupy unlivable units; gas line interruptions forced tenants to use hot plates. Homeless people have taken shelter in the stairwells and hallways.

Dana Elden, the tenant association president and a friend of Mr. Steed’s, said she’s felt neglected by the city’s public housing authority. When the pandemic hit, she said, residents were forced to dip into funds meant for the property’s upkeep to purchase masks, gloves and hand sanitizer. They’ve leaned on local charities for Covid testing, and even for meals for hungry tenants. “People are thinking, ‘If the government isn’t going to do anything for us,’” said Elden, “‘then why should we participate in vaccines?’”

Americans began thinking about health care decisions this way only recently; during the 1950s polio campaigns, for example, most people saw vaccination as a civic duty. But as the public purse shrunk in the 1980s, politicians insisted that it’s no longer the government’s job to ensure people’s well-being; instead, Americans were to be responsible only for themselves and their own bodies. Entire industries, such as self-help and health foods, have sprung up on the principle that the key to good health lies in individuals making the right choices.

Amanda Santiago, a St. Mary’s Park tenant, told us, “I’m not necessarily anti-vaccine.” But she decided against the shot, she explained, as “a personal choice.” A growing body of research suggests that Ms. Santiago’s views reflect a broader shift in America, across class and race. Without an idea of the common good, health is often discussed using the language of “choice.” At a recent anti-vaccine-mandate demonstration in Brooklyn, some protesters wore Black Lives Matter T-shirts and chanted, “My body, my choice!” When the Brooklyn Nets banned their star guard Kyrie Irving for refusing the vaccine, the Nets’ general manager, Sean Marks, acknowledged, “Kyrie has made a personal choice, and we respect his individual right to choose.”

Of course, there’s a lot of good that comes from viewing health care decisions as personal choices: No one wants to be subjected to procedures against their wishes. But there are problems with reducing public health to a matter of choice. It gives the impression that individuals are wholly responsible for their own health. This is despite growing evidence that health is deeply influenced by factors outside our control; public health experts now talk about the “social determinants of health,” the idea that personal health is never simply just a reflection of individual lifestyle choices, but also the class people are born into, the neighborhood they grew up in and the race they belong to.

Poverty and environmental conditions are closely linked to chronic illnesses such as diabetes and heart disease. The South Bronx has one of the highest death rates from asthma in the country, in part because of dilapidated public housing; it is also one of the least food secure regions in America. But food deserts and squalor are not easy problems to solve — certainly not by individuals or charities — and they require substantial government action. Without such reforms, primary care physicians can approach their patients only through the lens of personal responsibility. Many medical schools teach “motivational interviewing,” so that physicians can coach patients to make better lifestyle choices. This can be helpful, but it fails to address the deeper problem: Being healthy is not cheap. Studies indicate that energy-dense foods with less nutritious value are more affordable, and low-cost diets are linked to obesity and insulin resistance.

Another problem with reducing well-being to personal choice is that this treats health as a commodity. This isn’t surprising, since we shop for doctors and insurance plans the way we do all other goods and services.

Recent research has shed light on this problem. Jennifer Reich, a sociologist at the University of Colorado, Denver, has spent years studying families who refuse to vaccinate their children against diseases like measles. She found that mothers devoted many hours to “researching” vaccines, soaking up parental advice books and quizzing doctors. In other words, they act like savvy consumers. The mothers in Reich’s study maintain that each child is unique, and that they know their child’s needs better than anyone. As a result, they insist that they alone have the expertise to decide what medicines to give their children. When thinking as a consumer, people tend to downplay social obligations in favor of a narrow pursuit of self-interest. As one parent told Reich, “I’m not going to put my child at risk to save another child.”

Such risk-benefit assessments for vaccines are an essential part of parents’ consumer research. For illnesses like measles, outbreaks — until recently — have been so rare that it’s not hard to be convinced that the harm of vaccines outweighs that of the disease. However, we’ve found in our research that for Covid-19, this risk analysis can get turned on its head: Vaccine uptake is so high among wealthy people because Covid is one of the gravest threats they face. In some wealthy Manhattan neighborhoods, for example, vaccination rates run north of 90 percent.

For poorer and working-class people, though, the calculus is different: Covid-19 is only one of multiple grave threats. In the South Bronx, one man who works two jobs shared that he navigates around drug dealers, hostile police and shootings. “I don’t want my kids to see what I’ve seen,” he said. Another man said he lost his job during the pandemic and slipped back into addiction. “Most of my friends are dead or in jail,” he said. Neither one plans to get vaccinated. Their hesitancy is not irrational: When viewed in the context of the other threats they face, Covid no longer seems uniquely scary.

Most of the people we interviewed in the Bronx say they are skeptical of the institutions that claim to serve the poor but in fact have abandoned them. “When you’re in a high tax bracket, the government protects you,” said one man who drives an Amazon truck for a living. “So why wouldn’t you trust a government that protects you?” On the other hand, he and his friends find reason to view the government’s sudden interest in their well-being with suspicion. “They are over here shoving money at us,” a woman told us, referring to a New York City offer to pay a $500 bonus to municipal workers to get vaccinated. “And I’m asking, why are you so eager, when you don’t give us money for anything else?” These views reinforce the work of social scientists who find a link between a lack of trust and inequality. And without trust, there is no mutual obligation, no sense of a common good.

As the emergence of the Omicron variant shows, vaccine mandates in the United States are not enough to solve this problem. Hesitancy is a global phenomenon. While the reasons vary by country, the underlying causes are the same: a deep mistrust in local and international institutions, in a context in which governments worldwide have cut social services.

Research shows that private systems not only tend to produce worse health outcomes than public ones, but privatization creates what public health experts call “segregated care,” which can undermine the feelings of social solidarity that are critical for successful vaccination drives. In one Syrian city, for example, the health care system now consists of one public hospital so underfunded that it is notorious for poor care, a few private hospitals offering high-quality care that are unaffordable to most of the population, and many unlicensed and unregulated private clinics — some even without medical doctors — known to offer misguided health advice. Under such conditions, conspiracy theories can flourish; many of the city’s residents believe Covid vaccines are a foreign plot.

In many developing nations, international aid organizations are stepping in to offer vaccines. These institutions are sometimes more equitable than governments, but they are often oriented to donor priorities, not community needs. In Afghanistan, villagers lack access to most basic health services; some must travel hours to reach a clinic. Cases of childhood malnutrition are widespread and growing. Even though the country has only a few dozen cases of polio yearly, institutions like the W.H.O. spend considerable sums promoting and carrying out polio vaccinations. People in Kandahar speak about polio in ways that are strikingly similar to how residents in the Bronx speak about Covid. “We have starvation and women die in childbirth.” one tribal elder told us, “Why do they care so much about polio? What do they really want?”

Researchers find these sentiments echoed in poor and marginalized communities around the world. Despite the scale of the problem, experts are divided on which interventions might work best. Here, too, the experience of the United States might prove instructive. In America, anti-vaccine movements are as old as vaccines themselves; efforts to immunize people against smallpox prompted bitter opposition in the turn of the last century. But after World War II, these attitudes disappeared. In the 1950s, demand for the polio vaccine often outstripped supply, and by the late 1970s, nearly every state had laws mandating vaccinations for school with hardly any public opposition.

What changed? This was the era of large, ambitious government programs like Medicare and Medicaid. In the mid-’60s, the number of government-funded social programs targeting the poor and communities of color skyrocketed. The anti-measles policy, for example, was an outgrowth of President Lyndon Johnson’s Great Society and War on Poverty initiatives. Government workers from initiatives like Head Start assisted in vaccination campaigns. In some cities, the government sponsored the creation of health councils, made up of community members, which served as intermediaries between health centers and the public. These councils embodied the idea that public health is effective only when community members share in decision making.

The experience of the 1960s suggests that when people feel supported through social programs, they’re more likely to trust institutions and believe they have a stake in society’s health. Only then do the ideas of social solidarity and mutual obligation begin to make sense.

The types of social programs that best promote this way of thinking are universal ones, like Social Security and universal health care. Universal programs inculcate a sense of a common good because everyone is eligible simply by virtue of belonging to a political community. In the international context, when marginalized communities benefit from universal government programs that bring basic services like clean drinking water and primary health care, they are more likely to trust efforts in emergency situations — like when they’re asked to get vaccinated.

If the world is going to beat the pandemic, countries need policies that promote a basic, but increasingly forgotten, idea: that our individual flourishing is bound up in collective well-being.

Anita Sreedhar is a resident specializing in primary care and social medicine residency at Montefiore Medical Center. She has reported from Afghanistan, India and elsewhere. Anand Gopal, a sociologist, is a professor at Arizona State University and a fellow at Type Media. They are co-founders of the Zomia Center, which assists with public health initiatives in conflict zones.