How to reach the unvaccinated
Late last week Michael Brendan Dougherty of National Review stirred up a mix of interest and outrage among journalists by arguing that more understanding should be extended to unvaccinated Americans, whose hesitancy about getting Pfizered or Modernafied often reflects a reasonable uncertainty and wariness after a year of shifting public-health rhetoric, blunders and misleading messaging.
The alternative perspective, judging from responses to his column, regards the great mass of the unvaccinated as victims of deliberately manufactured paranoia, the blame for which can be laid partly on their own partisan self-delusion and partly on wicked actors in the right-wing media complex — from conspiracy theorists flourishing online to vaccine skeptics interviewed by Tucker Carlson to Republican politicians who have pandered to vaccine resistance.
The sheer numbers of unvaccinated Americans — upward of 80 million adults — means that these perspectives can be somewhat reconciled. On the one hand, there is clearly a hard core of vaccine resistance, based around tribal right-wing identity, that’s being nourished by both online conspiracy theories and the bad arguments and arguers that some Fox News hosts and right-wing personalities have elevated.
On the other hand, the ranks of the unvaccinated are much larger than the audience for any vaccine-skeptical information source and far more varied than the stereotype of Trump voters drinking up Qanon-style conspiracies. The vaxxed-unvaxxed divide is widest between Democrats and Republicans, but it’s also an education divide, an age divide, a gender divide, a racial divide, an urban-rural divide, an insured-uninsured divide and more. (My strong impression, based both on vaccine-hesitant people I know personally and anecdotes that show up in reporting, is that it’s a “good experiences with official medicine”-”bad experiences with official medicine” divide as well.)
The Kaiser Family Foundation has polling on vaccination rates that’s helpful for seeing both of these realities. In its survey, you can see the core of conservative resistance: Among Republicans, 23% say they definitely won’t get the vaccine, and among white evangelicals, 22% say they definitely won’t, figures that are higher than for almost any other subgroup in the poll.
But Republicans aren’t simply isolated in their own partisan world. Vaccine hesitancy abounds outside the conservative base, and overall vaccination numbers for Republicans and independents actually look more alike than the numbers for independents and Democrats. (52% of Republicans have had at least one vaccination; for independents, the number is 61%; for Democrats, 86%. Meanwhile, a full 16% of independents are a hard no compared with just 2% of Democrats.)
Likewise, lots of groups are more likely to be hesitant than firmly resistant, but they still have overall vaccination rates close to the rate for Republican constituencies.
Black adults, for instance, have a vaccination rate of 60%, while Hispanics stand at 63%, both close to the white-evangelical rate of 58%.
Looking at the Kaiser data, then, doesn’t yield a picture of a vaccination effort foundering on the rocks of Republican obduracy and paranoia. It yields a picture of an effort that has been incredibly successful among seniors, well-educated liberals and Democratic partisans and yielded diminishing returns for other groups — from racial minorities to rural Americans to the less educated and young and uninsured. The friendliness of certain Fox News shows to vaccine skeptics is a subset of this problem, but not even close to the problem as a whole.
This has implications not just for Twitter blame-laying but for policy as well. Liberals who are convinced that the main problem lies with deluded Qanon moms or intransigent Trumpistas are naturally drawn to punitive solutions: pressure online giants to censor vaccine skepticism to break the spell of misinformation, and find as many ways as possible to mandate vaccinations, to force the intransigent to take their jabs or lose their jobs.
But if the unvaccinated and their motivations are complex and heterogeneous, then these strategies are more fraught. Censoring the internet will have little effect if many of the vaccine-hesitant are disconnected rather than very online or drawing on personal experience rather than antivaxxer memes.
Heavy-handed vaccine mandates, meanwhile, might alienate not just Fox viewers but also part of the political middle. The Kaiser data shows slight majority support for the general idea of employers requiring vaccination, for instance, but 61% oppose their own employer issuing such a requirement, which is probably the more meaningful statistic.
In a polarized landscape with widely distrusted institutions, a more patient approach seems much more civically healthy: a mix of local outreach, public health guidance that consistently promises normalcy as a benefit of vaccination (and doesn’t withdraw it arbitrarily) and actually arguing with skeptics.
But — and here the pro-vaxx alarm is understandable — patience has substantial costs. Combine the large unvaccinated population with the fact that vaccines are saving lives but clearly do not choke off all transmission, and we’re set up for a near-future with repeated outbreaks and fewer, but still far too many, deaths.
Some share of those deaths may be unavoidable. As William Hoenig argued in a much-cited recent Twitter thread, the delta variant is probably a harbinger of a future in which COVID endures as an endemic disease that many people get repeatedly but whose dangers are mitigated by previous immunity, vaccines and booster shots. In that dispensation, some people will inevitably still die of COVID the way some people die of influenza; the hope of “COVID zero” is slipping out of reach.
If that is our future, though, it still matters how we get there. The more people whose first immune experience comes through a vaccine rather than the virus itself, the fewer who will die during the transition to the future status quo.
So is there a way to substantially expand vaccinations in the narrow window of the next six months without going in for heavy-handed, possibly counterproductive interventions? To me the only major idea that seems worth considering is the simplest one: We could start paying people to take a vaccine — not just in lottery tickets but in big fat gobs of cash.
Along with the doubts of medical ethicists, this idea comes freighted with its own political problems, from annoyance or backlash among the already vaccinated to sneers from hardened anti-vaxxers (see, it’s so risky they have to pay people to take it! ).
At the same time it has the virtue of simplicity — one payment, rather than a patchwork of public and private mandates. It doesn’t force anyone to get a shot by threatening their livelihood. There is solid evidence that even $100 payments can move the needle for the vaccine-hesitant. If you paid $1,000 per two-shot regimen — a limited-time offer, good only through October — and 10 million or 20 million people took you up on it, it would be a rounding error in the Biden infrastructure plan, and it would probably pay for itself just in reassurances to a jittery stock market.
As for the ethical doubts, like the fear of exploiting have-nots who take the vaccine just for the money, I don’t see how imposing lockdowns and long-term school closures, with all their disproportionate negative effects on lower-income workers and parents, can pass an ethical test but paying people to get vaccinated does not.
Now we face what is hopefully the final gasp of the pandemic, the bridge to a world where death becomes rare enough that we simply live with the disease. And maybe just a few dollars more, atop all the trillions we’ve spent, could keep more of us alive until we reach the other side.