In the U.S., the reservoir of vaccine resistance is large enough to prevent control of the coronavirus pandemic. Since COVID-19 vaccines were first authorized, over half of all U.S. COVID-19 cases — an estimated 23 million new infections — and more than 300,000 deaths have occurred. The Kaiser Family Foundation estimates that just from June through August of this year, 287,000 preventable COVID-19 hospitalizations of unvaccinated adults (out of 530,000 in total) cost over $5.7 billion for the hospital care alone, not to mention the impact of these illnesses on families, communities, and the economy.
Maximizing the immunization of Americans is necessary to stop the pandemic, but so far, our attempts to get the holdouts vaccinated has proven futile. It’s time for a new approach. One focused less on the facts and the benefits of vaccination, and more on tapping into the deeply held values of the resisters.
First, it’s important to look into the vaccine holdout psyche. The most vocal and significant group of stalwart vaccine resisters tends to be geographically concentrated and broadly dispersed around the country, and includes many vulnerable citizens making them a catalytic source of continuing infectious spread. Crucial to understanding (and empathizing with) them is appreciating that for these folks, objecting to immunization has become a moral issue, as well as a value-laden and integral aspect of their being, a reflection of their persona. Their values motivate their emotionally assertive, angry public protests and their dedication to disrupting existing public health infrastructure and government order while feeling patriotic for defending their values. They have a morality-based resistance, rationalized with many explanations including scientific skepticism, faith in natural products and healing, and strongly proclaiming their American constitutional rights and responsibility to protect their own individual freedom and liberty.
Importantly, they do not reject treatments: accepting both scientifically rejected medications such as hydroxychloroquine and ivermectin, and, when infected, accepting monoclonal antibodies, hospitalization, and intensive care. Their perspective has been mobilized and reinforced, but not created, by ongoing support and encouragement from lively parts of traditional and social media, and many admired faith-based and political leaders. Even more importantly, they have persisted in their resistance as COVID-19 has ravaged their communities, neighbors, and families.
Traditional public health education emphasizing the dissemination of scientific knowledge and demonstration of benefit has been useless in changing their behavior, has been rejected, and in some ways, has made matters worse. Understanding this paradox will lead to a more effective approach. The crucial point is: ignorant, aberrant, or selfish behavior is not the issue; self-esteem, values, and pride are. Their public iconoclasm is akin to the enthusiasm of avid sports fans, but self-protective, infused with a core impact on life or death decisions.
Vaccine resistance has become a moral issue embedded in the individual and group’s identity, be it libertarian, new world naturalism, evangelical Christian, or old-fashioned patriotism. These values loom large in a dramatically changing, alienating, and now scary, insecure world. Media influencers and political leaders initially nourished this attitude with an arrogant disdain for the viral threat. Vaccine development was expedited, but standard public health measures such as masking, social distancing, and curtailing school, travel, and business activity were purposely avoided as an excessive imposition of government power and cast in a pejorative light. When vaccines became available they fit into this frame rather than being seen as a lifesaver we were lucky to have created. They see the public health message promoted by white-coated authorities building an intrusive “Granny State,” and also endorsing other activities seen as alien to their values such as abortion, homosexuality, and gun control.
Within this context, vaccine opponents should not be judged as ignorant, irrational, crazy, selfish, or misinformed. Their obstructive attitude defends their personal integrity, their values, and their perceived best interest. For them, vaccine resistance is no longer a mere behavior, but has taken on a deeper significance more like a core value — like love of children or going to church. It is important to appreciate that this tension between their values and the consensus in the broader community creates “cognitive dissonance” — a stressful psychological conflict between strongly felt beliefs and negative feedback and criticism from the larger environment. This tension leads them to resolve their stress by clinging more firmly to their value system and adulating public officials and media that support their passion.
In this regard, public health messaging falls far short. Education has traditionally been directed toward cognitive motivational change and not beliefs and values. In fact, the standard public health approach may be counterproductive, insofar as the information increases cognitive dissonance, and resistors perceive it as a personal assault on one’s very integrity, causing them to cling more tightly to their beliefs and values.
With this in mind, there is a practical, wiser, alternative approach. We have a long tradition of spontaneous community mutual assistance among Americans during natural disasters. Let’s start there and reach out to the resisters on a serious heart-to-heart level. Setting the stage, as the pandemic crisis continues, the White House COVID-19 Task Force should respond in crisis mode with daily primetime briefings, clearly reporting local successes and failures and reviews of new scientific data and treatments. To reach the anti-vax population and target their beliefs, this messaging must be wrapped in patriotic fervor, such as with flags and martial music, and be repetitive.
In the real world, “patriotism” embodies the words of the Supreme Court in 1905 as they endorsed government mandated smallpox vaccination: “Individual liberty is not absolute in the face of ‘the common good,’ and that ‘real liberty for all’ depends on restraining individual exercises of liberty that harm others.” This was also seen in our eager and active, unified national response to the polio epidemic in the 1950s. Today, we need to reach our fellow unvaccinated Americans with this message, using values-based communication that will resonate.
Jeoffry B. Gordon, MD, MPH, is a retired family physician and former community hospital bioethics consultant.