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Anti-vaxxers aren’t the cause of America’s dropping vaccine rates

This fact is crucial to getting the US’s vaccination campaign back on track.

Liesl Eibschutz, a medical student from Dartmouth University, loads a syringe with the Pfizer Covid-19 vaccine on April 15, 2021, in Los Angeles.
Liesl Eibschutz, a medical student from Dartmouth University, loads a syringe with the Pfizer Covid-19 vaccine on April 15.
Allen J. Schaben/Los Angeles Times/Getty Images

America’s Covid-19 vaccine rollout has dwindled in recent weeks, plummeting from a previous high of nearly 3.4 million doses administered a day, on average, in mid-April to around 2.2 million a day this week.

The best analogy I’ve heard to explain the trend comes from Brown University School of Public Health dean Ashish Jha: Think of what happens when a new iPhone is released.

When a new model comes out, some people are so enthusiastic about it that they’ll line up overnight to get it. Those superfans aren’t the only people who ever buy iPhones, but they cause a rush of initial demand. That’s similar to many Americans who’ve gotten the vaccine so far: They got shots the moment they were eligible, even if, for some, it meant staying on hold on the phone for hours, constantly refreshing clunky, overloaded websites for days, or driving for hours out of their way to get a shot.

Now, with about 57 percent of the adult population having had at least one shot, America has to reach the less enthused — ranging from those who want a vaccine but don’t want to go too out of their way to get one to people who say they don’t want to get a vaccine at all.

The remaining unvaccinated people aren’t all truly hesitant or resistant to getting vaccinated. Think of enthusiasm for a vaccine as a spectrum, with some Americans very excited to get the shot, others not willing at all, and many in between. The US eventually will need to make inroads with the hard noes — but for now, the low-hanging fruit are the people in between. They might readily take the vaccine if it was right in front of them, but can’t call off work to get it or don’t want to have to set aside hours of their day solely to get a shot.

“There’s a tendency to focus on who is hesitant and who doesn’t want to get this vaccine,” Liz Hamel, director of public opinion and survey research at the Kaiser Family Foundation, told me. “But in almost every segment [of the population], there’s a large group of people who really want to get this vaccine or at least somewhat open to getting it.”

This spectrum is clear in the polling. According to the most recent survey in April from the Covid States Project, 52 percent of people were already vaccinated, 11 percent wanted to get the shot as soon as possible, 7 percent said they would do so after at least some people they know did, 12 percent said they would after most people they know did, and 18 percent said they would not get the vaccine. That’s a lot of people among the unvaccinated — nearly 1 in 5 of all respondents — who aren’t exactly enthusiastic about the vaccine, but also don’t fit the mold of the unpersuadable or anti-vaxxers.

And even the more resistant may not be that resistant: In the Kaiser Family Foundation’s surveys, more than 30 percent of the hard noes say they would take a vaccine if it were required.

The vaccine enthusiasm spectrum has also changed over time. In Kaiser’s surveys, the hard noes have remained pretty consistent — around 20 percent of adults. But from January to March, the “wait and see” group shrank, from 31 percent to 17 percent, as they shifted to the “already gotten” and “as soon as possible” categories.

All of this suggests that America’s vaccine goals are very doable. It’s possible to convert people from a “wait and see” attitude to getting vaccinated. And the case for focusing on persuadable people is strong: Based on data from Israel, the US could start to see a steep decline in Covid-19 cases — allowing more things to return to normal safely — once about 60 percent of the population is vaccinated. That’s totally feasible at a national level even if the 1 in 5 Americans who are hard noes remain resistant, although state-by-state variation means that some places will have a harder road than others.

How to get America’s vaccination rates back up

For now, experts say the best path forward is to make it easier to get vaccinated. As access improves, the country can then try incentives, pushing people a bit further to get the shot. If that doesn’t work, then policymakers should consider moving from the carrot to the stick — and eventually, in some cases, perhaps mandating vaccines.

“It’s not just about convincing people with messages or changing their attitudes,” Hamel said, citing her organization’s surveys. “It’s also making sure that the vaccine is available to them, that there are policies in place to make sure they can get it.”

Here’s how each of those steps could work:

1) Improved access to vaccines: There are still a lot of people — likely around 1 in 5 of the unvaccinated, based on the Covid States Project’s survey — who want to get vaccinated as soon as possible. For these people, the concern isn’t so much resistance as it is access.

To date, the bulk of vaccination in America has required an appointment, typically at a place someone would have to go out of her way to get to. Moving forward, the country should make a greater effort to meet people where they are — in all health care settings, including doctor’s offices, and at places of work, worship, and entertainment. Vaccinators could even meet people in their homes, with mobile vaccination vans in underserved neighborhoods or perhaps a DoorDash-like system for vaccinations in people’s houses.

Vaccinators could also do away with appointment requirements and open up walk-in hours, including outside traditional business hours, enabling people with hectic schedules to walk into, say, their local pharmacy or church to get a shot on the spot.

2) More incentives for vaccines: Over the past few weeks, local and state governments have offered new incentives to get a shot, from free beer to $100. Experts say this could work: If the problem for some people is that they don’t want to go out of their way just to get a shot, maybe they’ll be willing to go out of their way if there’s an extra reward, with a recent study supporting the idea. But there’s also a concern this could backfire — people might question why an incentive would be necessary if the vaccines are really so great — so there’s a balancing act to strike in the messaging around such incentives.

3) Vaccine passports and mandates: Once there’s widespread access and incentives in place, areas facing continued resistance to getting a shot could try to push people to get vaccinated with some kind of mandate. This doesn’t have to be a statewide law that applies to everyone, and could take several other forms instead: Restaurants and bars could ask for vaccine passports to get into their venues. Employers could tell people they have to get a vaccine to get back to work. Once kids are eligible, schools could require them to get the vaccine, as they do with shots for other diseases. Based on the Kaiser Family Foundation’s surveys, this could get more than 30 percent of the hard noes to get the vaccine.

Some localities and states will have to act differently, depending on their unvaccinated populations. Particularly in Republican-dominated states, there are more hard noes, largely because they believe the threat of Covid-19 has been exaggerated. Policymakers in these areas should still try to improve access and incentives first — after all, polls show about half of Republicans either have gotten or want to get vaccinated — but they might have to shift to sticks sooner to make a real dent in their unvaccinated population.

All of this should be coupled with extensive messaging campaigns to persuade people to get the shot. What works will vary locally — what succeeds in predominantly Black, Democratic communities won’t necessarily work in predominantly white, Republican areas. A recent study found, for example, that Republicans respond much better to fellow Republicans. Persuasion campaigns will have to respond to these kinds of realities on the ground.

“It’s tricky,” Emily Brunson, a medical anthropologist at Texas State University, told me. “There needs to be a lot more social outreach to people — and I think some real clarification that this is how we get out of this [pandemic and the associated restrictions].” She added, “But there’s not a silver bullet for this.”

If done correctly, America could get back relatively close to normal. Even at current vaccination rates, the country is on its way to fully vaccinate at least 60 percent of its population as early as June or July. But that will rely on keeping the vaccine rollout going at current speeds, which may not be possible if policymakers don’t change things up soon.