Oh, how the tide has turned. Three months ago, COVID was ravaging my homeland, India. The Delta variant was burning through the country like an uncontrolled wildfire. People carted dying relatives town to town, desperately seeking hospital beds or a whiff of oxygen. A cousin in India said, “COVID is not taking lives, just the beds. Lack of oxygen is taking lives.”
I watched India’s suffering unfold and felt guilty for living in one of the world’s most resourceful and scientifically advanced countries. My homeland was floundering, but at least my other homeland — the U.S. — was finally on track.
104 million Americans had been vaccinated. The Pfizer vaccine alleviated the worst outcomes of the B.1.1.7 and B.1351 variants. Adolescents aged 12-15 were gearing up for vaccine eligibility within days, and the CDC was reporting the U.S. could see a sharp decline in COVID cases by July if nationwide vaccinations continued. Health care workers had proper PPE, millions of people were getting vaccinated each week, and infection rates were declining steadily. We could finally see Spring’s light at the end of the year’s tortuous dark tunnel. Our country was in the home stretch.
Now the Delta variant is here and I have to wonder, Who were we kidding? We don’t live in a world where vertical borders prevent airborne particles from crossing time zones. Planes and boats carry viruses from one country to the next like microscopic stowaways. The virus doesn’t abandon ship. It mutates, and adapts, and colonizes.
We had a real chance to strangle this monster, to show the rest of the world how it was done, to help them all in the process. We let that chance slip away. Not everyone and not everywhere, but enough people got complacent. Some waited for herd immunity to carry the load—a number that crept from 60 to 70 to 85 percent, depending on what you read and when you read it—and others just figured it would pass. Now the Delta variant, the same one that tore through India and Great Britain, has twisted out of our flimsy grip and is roaring with laughter.
How did this happen?
Misinformation. Political discord. Vaccine hesitancy. The bottom line is our vaccination rate faltered. The CDC reported that on August 1, 2021, approximately 400,000 Americans received their first COVID dose. While that seems high, it’s less than a quarter of the peak in mid-April. We haven’t maxed out eligible people (only 58.1 percent of eligible people were fully vaccinated as of a week ago). We’re maxing out the number of people who know COVID’s real repercussions are far worse than the vaccine’s feared ones.
The U.S now has the third-highest rate of vaccine skepticism among 15 of the world’s largest economies. Our vaccine surplus is so large the FDA extended Johnson & Johnson’s vaccine expiration dates to avoid throwing out perfectly good doses. Less than a week ago, President Biden announced the U.S. has donated and shipped more than 110 million doses to 60 countries. While I applaud the humanitarian effort, I question the fate of those doses if the 41.9 percent unvaccinated eligible people in our country had wanted them.
It makes me wonder: Why does science take a backseat to unsubstantiated pseudoscientific claims?
Spreaders of vaccine disinformation fill their social media accounts with statements questioning COVID’s existence and purporting unproven treatments (never mind the fact that we wouldn’t need treatments if COVID didn’t exist) with little to no peer-reviewed scientific research to support their anti-vaccine claims. According to Imran Ahmed, CEO of the Center for Countering Digital Hate, twelve people — the “disinformation dozen” — produce 65 percent of the shares of anti-vaccine misinformation on social media platforms.”
Is it easier for some to believe that a science-backed treatment is inherently more dangerous than an unknown herb plucked from a field? Perhaps. But what do they say to the approximately 216 kids hospitalized daily in the U.S. over the past week, particularly in areas where vaccine coverage is low? Bad luck? You weren’t strong enough? What would have made them stronger?
Yes, there are measures underway to increase vaccinations—full FDA approval, social media crackdowns on misinformation, and government, company, military, and college mandates. But let’s be honest, many Americans are fighting these measures, as they will fight future mandates, and the next vaccine.
Only two things can change how non-vaxxers perceive COVID vaccines: education and trust. We need to sincerely hear their reasons, and then gently clarify misinformation—vaccines don’t introduce disease into our bodies. They stimulate our immune systems to obtain immunity without getting the disease. Vaccines don’t alter our DNA. Their safety has been tested. Medicines have potential side effects, but illnesses have definite ones. COVID kills indiscriminately; vaccines don’t.
Trust is harder. How can we help people trust these vaccines? I suppose on a deeper level, it’s more about trusting the people that make the vaccines. Big pharma, for-profit companies—sure, they are the money makers. But behind the scenes, the vaccines are created by men and women who’ve accepted the charge to make this world—not just individuals—safer and healthier. They’ve spent years studying, researching, and testing potential vaccines with dedication and patience, including the mRNA technology in COVID vaccines. Just because the COVID vaccine’s rollout was fast-tracked to combat the pandemic doesn’t mean the scientists cut corners in designing and testing it.
Unfortunately, we don’t have the luxury of slowly educating and gradually building trust. COVID is terrorizing our planet now. The world is shaking its heads at the U.S., wondering what happened. We were supposed to be the leader. This morning, an aunt in a small town in India sent me a WhatsApp message: “I have taken the vaccine … the positivity rate has gone down … I am worried for America … how r u?” I don’t know. America, how are we? It’s not too late to destroy this monster, but if the unvaccinated remain unmoved, it will be soon.
One hesitates to elevate obviously bad arguments, even to point out how bad they are. This is a conundrum that comes up a lot these days, as members of the media measure the utility of reporting on bad faith, disingenuous or simply bizarre claims.
If someone were to insist, for example, that they were not going to get the coronavirus vaccine solely to spite the political left, should that claim be elevated? Can we simply point out how deranged it is to refuse a vaccine that will almost certainly end an international pandemic simply because people with whom you disagree think that maybe this is a good route to end that pandemic? If someone were to write such a thing at some attention-thirsty website, we certainly wouldn’t want to link to it, leaving our own readers having to figure out where it might be found should they choose to do so.
In this case, it’s worth elevating this argument (which, to be clear, is actually floating out there) to point out one of the myriad ways in which the effort to vaccinate as many adults as possible has become interlaced with partisan politics. As the weeks pass and demand for the vaccine has tapered off, the gap between Democratic and Republican interest in being vaccinated seems to be widening — meaning that the end to the pandemic is likely to move that much further into the future.
Consider, for example, the rate of completed vaccinations by county, according to data compiled by CovidActNow. You can see a slight correlation between how a county voted in 2020 — the horizontal axis — and the density of completed vaccinations, shown on the vertical. There’s a greater density of completed vaccinations on the left side of the graph than on the right.
If we shift to the percentage of the population that’s received even one dose of the vaccine, the effect is much more obvious.
This is a relatively recent development. At the beginning of the month, the density of the population that had received only one dose resulted in a graph that looked much like the current density of completed doses.
If we animate those two graphs, the effect is obvious. In the past few weeks, the density of first doses has increased much faster in more-Democratic counties.
If we group the results of the 2020 presidential contest into 20-point buckets, the pattern is again obvious.
It’s not a new observation that Republicans are less willing to get the vaccine; we’ve reported on it repeatedly. What’s relatively new is how that hesitance is showing up in the actual vaccination data.
A Post-ABC News poll released on Monday showed that this response to the vaccine holds even when considering age groups. We’ve known for a while that older Americans, who are more at risk from the virus, have been more likely to seek the vaccine. But even among seniors, Republicans are significantly more hesitant to receive the vaccine than are Democrats.
This is a particularly dangerous example of partisanship. People 65 or older have made up 14 percent of coronavirus infections, according to federal data, but 81 percent of deaths. That’s among those for whom ages are known, a subset (though a large majority) of overall cases. While about 1.8 percent of that overall group has died, the figure for those aged 65 and over is above 10 percent.
As vaccines have been rolled out across the country, you can see how more-heavily-blue counties have a higher density of vaccinations in many states.
This is not a universal truth, of course. Some heavily Republican counties have above-average vaccination rates. (About 40 percent of counties that preferred former president Donald Trump last year are above the average in the CovidActNow data. The rate among Democratic counties is closer to 80 percent.) But it is the case that there is a correlation between how a county voted and how many of its residents have been vaccinated. It is also the case that the gap between red and blue counties is widening.
Given all of that, it probably makes sense to point out that an argument against vaccines based on nothing more than “lol libs will hate this” is an embarrassing argument to make.
In 2018, a short video circulated on WhatsApp claiming that the MMR vaccine was designed by Indian Prime Minister Narendra Modi to stop the population growth of Muslims. Subsequently, hundreds of madrassas across western Uttar Pradesh refused to allow health departments to vaccinate their constituents.
In 2020, a three-minute video claiming that the coronavirus vaccination campaign was secretly a plan by Bill Gates to implant trackable microchips in people was one of the most widely shared pieces of misinformation online. Alongside a torrent of online COVID-19 vaccine falsehoods and conspiracy theories, sources of medical mis- and disinformation are fostering distrust in COVID-19 vaccines, undermining immunization efforts, and demonstrating how poor information is a determinant of health.
Medical misinformation, referring to inaccurate or unverified information that can drive misperceptions about medical practices or treatments, has flooded the infosphere (all types of information available online). Examples can vary from overrepresentations of anecdotes claiming that complications occurred following inoculation to misinterpretations of research findings by well-meaning individuals.
Considering the many ways in which medical misinformation can shape health behaviors, researchers at the Oxford Internet Institute recently suggested that the infosphere should be classified as a social determinant of health (SDOH) (designated alongside general socioeconomic, environmental, and cultural conditions). This classification, they argue, properly accounts for the correlation between exposure to poor quality information and poor health outcomes.
The connection between information quality and health has been especially pronounced during the COVID-19 pandemic. A 2021 study found that amongst those who indicated that they would definitely take a COVID-19 vaccine, exposure to misinformation induced a decline in intent of 6.2% in the U.K. and 6.4% in the U.S. Further, misinformation that appeared to be science-based was found to be especially damaging to vaccination intentions. These findings are particularly concerning considering the fact that during the pandemic, the 147 biggest anti-vaccine accounts on social media (which often purport to be science-based) gained 7.8 million followers in the first half of 2020, an increase of 19%.
During an unprecedented health crisis, medical misinformation within the infosphere is leaving both individuals and communities vulnerable to poor health outcomes. Those who are unvaccinated are at a higher risk of infection and increase the likelihood of community transmission. This places undue burden on those who cannot get vaccinated—due to inequities and/or preexisting conditions—and increases opportunities for variants to continue to mutate into more infectious and/or deadly forms of the virus. Poor quality information within the infosphere is undermining immunization efforts and threatens to prolong the ark of the pandemic.
Leveraging Healthcare Provider Influence in the Battle Against Poor Quality Information
Healthcare providers are uniquely suited to respond to this challenge. Throughout the pandemic, majorities of U.S. adults have identified their doctors and nurses as the most trustworthy sources of information about the coronavirus. In fact, 8 in 10 U.S. adults said that they are very or somewhat likely to turn to a doctor, nurse, or other healthcare provider when deciding whether or not to get a COVID-19 vaccine.
This influence is especially pertinent considering the state of vaccine resistance across the globe. In March 2021, a Kaiser Family Foundation poll found that 37% of U.S. respondents indicated some degree of resistance to vaccination. If that percentage of Americans remain unvaccinated, the country will be short of what is needed to achieve herd immunity (likely 70% or more vaccinated). Similar levels of resistance to vaccination remain high in countries across the globe, such as Lebanon, Serbia, Paraguay, and France.
Although medical misinformation is contributing to high rates of refusal, it is important to note that drivers of vaccine resistance are complex and intersectional. Vaccine distrust or refusal may be rooted in exposure to anti-vaccine rhetoric, racial injustice or medical exploitation in healthcare, fears that vaccine development was rushed, and/or other drivers. For this reason, responses must be tailored to unique individual or communal motivations. For example, experts have pressed the critical need for vaccine distrust within Black communities to be approached not as a shortcoming of community members, but as a failure of health systems to prove themselves as trustworthy.
With regard to resistance rooted in anti-COVID-19 vaccine misinformation, healthcare providers are leveraging their unique influence through novel, grassroots approaches to encourage vaccine uptake. In North Dakota, providers are recording videos and sending out messages to their patients communicating that they have been vaccinated and explaining why it is safe to do the same. On social media, a network of female doctors and scientists across various social media pages, such as Dear Pandemic (82,000 followers) and Your Local Epidemiologist (181,000 followers), are collaborating to answer medical questions, clear up misperceptions about COVID-19 vaccines, and provide communities with accurate information about the virus. Similarly, the #BetweenUsAboutUs online campaign is elevating conversations about vaccines with Black doctors, nurses, and researchers in an effort to increase vaccine confidence in BIPOC communities. This campaign is especially critical considering the fact that BIPOC communities are often the target of anti-vaccine groups in an effort to exploit existing, rational distrust in health systems.
In addition to these timely responses, evidence-based interventions offer promising opportunities for healthcare providers to improve vaccine uptake amongst their patients. For example, there is a growing consensus around the practice of motivational interviewing (MI).
MI is a set of patient-centered communication techniques that aim to enhance a patient’s intrinsic motivation to change health behaviors by tapping into their own arguments for change. The approach is based on empathetic, nonjudgmental patient-provider dialogue. In other words, as opposed to simply telling a patient why they should get vaccinated, a provider will include the patient in a problem-solving process that accounts for their unique motivations and helps them discover their own reasons for getting vaccinated.
When applying MI techniques to a conversation with a patient who is unsure if they should receive a vaccine, providers will use an “evoke-provide-evoke” approach where they will ask patients: 1) what they already know about the vaccine; 2) if the patient would like additional information about the vaccine (if yes, then provide the most up to date information); and 3) how the new information changes how they are thinking or feeling about vaccination. During these conversations, the MI framework encourages providers to ask open-ended questions, practice reflective listening, offer affirmations, elicit pros and cons of change, and summarize conversations, amongst other tools.
Numerous studies show motivational interviewing to be effective in increasing vaccine uptake. For example, one randomized controlled trial found that with parents in maternity wards, vaccine hesitancy fell by 40% after participation in an educational intervention based on MI. Given its demonstrated effectiveness, MI is likely to help reduce vaccine hesitancy during the COVID-19 pandemic.
With infectious disease outbreaks becoming more likely and resistance to various vaccines increasing across the globe, continuing to leverage healthcare providers’ unique influence through grassroots campaigns while honing motivational interviewing skills as a way to combat mis- and disinformation in the infosphere may prove critical to advancing public health now and in the future.