‘There’s a disconnect’: after a rapid rollout why has US vaccine effort stalled?
Yolette Bonnet, 60, the chief executive of a group of community health clinics in underserved neighborhoods across Palm Beach county, Florida, got vaccinated. Perhaps this would be unremarkable, except that she got her shot on Thursday, more than seven months after she was eligible to get the vaccine with ready access as a healthcare provider.
So, what made her change her mind?
“I’m hoping I lead by example,” Bonnet said. She had already had Covid-19, but saw the disease resurgent in her community, sending more people to the hospital including a 12year-old whose parents thought she had a simple pneumonia. The child almost died. “Then, there was the same scenario for another [child], a two-yearold.” Ultimately, said Bonnet, she said she didn’t want to “contribute to the problem”.
Bonnet, who is Black, described her resistance as a mix of hope the pandemic would fade, and skepticism born from the American medical establishment’s history of racism.
Bonnet’s story is just one example of how people in a vast, heterogeneous country are reckoning with the reemergence of the pandemic with the more contagious Delta strain predominantly causing new cases and their own willingness to prevent it using the most powerful tool at humanity’s disposal – the vaccine.
It also reveals the complex, highly personal deliberations behind a stalled vaccination campaign in the US, one that threatens to undermine vaccine efficacy as each new infection provides an opportunity for the development of a new variant.
Bonnet said she was still ambivalent right up until she got her first Pfizer shot, but the encouragement of her two daughters, husband and staff prevailed, and amid fanfare she got the shot. So did 12 of her staff members, who saw their leader’s willingness to get vaccinated as a sign of its safety.
A little more than half a million Americans a day are getting Covid-19 vaccinations, a plateau that began about two weeks ago, just as Delta picked up steam across the south and midwest.
The rate of new Covid-19 cases remains low nationally compared with the peak of winter, and it is unlikely to reach those heights again with nearly half of Americans fully vaccinated. However, forecasters now believe an October peak sickening 60,000 people a day is the most likely future of the pandemic.
“I would hope that … people who perhaps thought Covid would be done, seeing cases come back at the same time that there’s such convenience and accessibility, and so many people who are clearly safe and protected by the vaccine – maybe that will create more buy-in as we go into the fall,” said Sarah E Poe, director of the Malheur county health department in Oregon.
Nevertheless, daily vaccine distribution is far slower than in mid-April, when for a few brief weeks the US was among the fastest vaccine distributors in the world, inoculating more than 3 million people a day.
Calls for nuanced outreach have grown more urgent as Delta, against which vaccines are very effective, has spread rapidly in areas with low vaccination rates, especially in the US south and midwest. Health officials have said repeatedly 98% of people hospitalized are unvaccinated.
Vaccinated people are not evenly spread across the US. As in Malheur, low vaccination communities tend to be low-income, rural, conservative and have more residents of color. In the south, they also tend to be places that historically underinvested in public health.
Across the US, the wealthy and wellresourced are more likely to be vaccinated than the most vulnerable; urban Americans more likely to be vaccinated than rural; those in the north more likely than in the south; and white Americans more likely than Black or Latino. And, perhaps the most popular narrative in a hyper-partisan world, Democrats are more likely to be vaccinated than Republicans. Malheur is conservative, rural and heavily Latino, and 34% of the county’s children live in poverty.
But, as partisan anger over the pandemic spills into the vaccination distribution drive, the nuances inherent in these overlapping identities are often flattened into two broad categories – the vaccinated and the “vaccine hesitant”.
“There’s been a real disconnect from on the ground, in the community,” said Poe. In Malheur, many of the people most resistant to vaccines are also members of groups that have been worst affected by Covid-19.
That two-dimensional narrative has resulted in campaigns mismatched to the people who need to be reached. Often, they urge residents to get vaccinated so they can eschew masks, see friends or “visit grandma”, all incongruous with the experience of people who work in close quarters, live in multi-generational households, may have already had Covid-19 and never “shut down” from their tough, low-paid jobs.
“We have not had much mask-wearing for a long time, many months,” said Poe. “Then seeing all these campaigns that come out and say: you get to take off your masks … That doesn’t land in a place where we’re not wearing masks and staying away from grandma anyway.”
The pace of vaccination has slowed to a crawl in at least 14 states. At the rate vaccinations are now taking place, it will take until summer or fall 2022 to reach 70% of people in states such as Idaho, Montana and North Dakota. The reasons daily vaccination rates began to slip in mid-April are complex and multifaceted, according to polls, analysts and experts on the ground. They range from hesitancy to apathy to partisanship to racism.
Further, the slowdown repeats historical patterns of vaccination in America, going back to poliomyelitis. In 1955, parents weighed the overwhelming benefits of preventing the devastating paralytic disease against the frightening reality of a bad batch of polio vaccines, all against the backdrop of a rise in cases known to follow increasing summer temperatures. Then, as now, children were kept inside for their safety, with varying degrees of success.
“We get pushed into this false duality,” said North Carolina State University and Langdon distinguished marketing professor Stacy Wood. “When people who want others to get vaccinated see the numbers of people who aren’t vaccinated, and they feel anger that the [emergency departments] are filling back up … They tend to flatten that all down into one segment – people who are just refusing to get the vaccine.”
Wood co-authored a recently published editorial in the Journal of the American Medical Association (Jama) Network suggesting that those who have not yet had vaccines should be considered vaccine “apathetic”, rather than strictly hesitant. This group will be persuaded not by expert appeals and data, she argued, but by convenience, emotive reminders and small incentives.
“A lot of vaccine information isn’t common knowledge. Not everyone has access to Google,” said Dr Rhea Boyd, a pediatrician in the Bay Area, in an interview in the Atlantic. “This illustrates pre-existing fault lines in our healthcare system, where resources – including credible information – don’t get to everyone,” said Boyd. “The information gap is driving the vaccination gap. And language that blames ‘the unvaccinated’ misses that critical point.”
It’s not that the misinformation, partisanship, anti-vaccine sentiment and vaccine hesitancy are fictions – they are real and harmful. But they are only a slice of a bigger story. Analysts are now calling for a reexamination of how public health should reach out to a heterogeneous population of unvaccinated people.
“A lot of those reasons for concern are very individualistic,” said Wood. “Maybe they’re pregnant, maybe they have diabetes, maybe they have past negative experiences with medical institutions,” said Wood. “Those are high-involvement decision makers. They are people who haven’t gotten the vaccine but have been thinking about it.”
Similarly, people who actively oppose vaccines are very involved in vaccine decision-making, though their decisions are more likely to be based on misinformation.
“The group we missed in all of that, the more mundane prosaic sort of group, really doesn’t have strong feelings about the vaccine one way or another,” said Wood. “They’re young or healthy or generally don’t get sick, don’t get the flu shot. Or they have other high-priority items. There’s childcare and care for elderly patients and job fluctuations and the latent stress in the air,” said Wood. She posits that this group, those with vaccine “apathy” is “larger than we expect”.
Experts also agree that whatever phrase best suits the suite of reasons people have not – yet – been vaccinated, they are not wholly static. People can be reminded, incentivized and convinced in conversation with family members, friends, colleagues and medical providers.
Bonnet said she watched as a “great many” of her staff were vaccinated after she got the shot, publicly, in her clinic that morning. “Most of them, it’s not because the fear is going away, it’s because of the fact that, as we mentioned, what’s the alternative?” with cases on the rise.
“I was reluctant,” said Bonnet, “But I felt like I had to do something.”