A version of this article first appeared in Emily Oster’s newsletter, ParentData.
Up until now, the problems with the COVID-19 vaccine roll-out have been largely about supply. More people want to be vaccinated (in total) than doses that are available right now. But—slowly—we are starting to see this ease up. And in more and more places, we’re seeing the first hints of softer demand, states opening up vaccines to all age group because demand is waning among older people. My emails, where until recently vaccine questions clustered around when one would be eligible, have subtly shifted to “What do I do, having just realized my parents refuse to be vaccinated?!”
With this looming, I thought it would be useful to talk through issues of vaccine resistance, both from a policy standpoint and in our personal lives.
From a public health perspective, the end-goal of vaccination is often said to be herd immunity. However, it is unclear what the COVID-19 herd immunity level is. In writing this, I asked two experts I really trust and one told me 50 percent and the other 80 to 85 percent. This is a big range! Most estimates I have seen are around 60 to 70 percent but, again, it isn’t clear what this is based on.
Perhaps more importantly, moving from a herd immunity number to a “number need to be vaccinated” is difficult. This translation depends, first, on the vaccine efficacy against illness. If a vaccine is 95 percent effective against any disease then you’d need 63 percemt vaccinated to get to 60 percent immune. If the vaccine is only 80 percent effective, then you’d need 75 percent vaccinated.
But even without knowing all these factors, it seems likely herd immunity would be a challenge in the short run. Twenty percent of the population (kids under 16) are not vaccine eligible yet and there is clearly some pretty staunch vaccine resistance in the US (not to mention low vaccination rates worldwide).
In my view, however, the focus on some (unknown!) herd immunity number should be put aside in favor of a focus on vaccinating as fast as possible. The exact herd immunity number may be of academic interest, but our goal should simply be: more vaccines.
If we want to increase vaccination rates, more supply is the first answer. But encouraging demand is going to be necessary. The most stark fact for me is that 25 percent of the U.S. House of Representatives has not chosen to be vaccinated despite months of eligibility. This is bad.
I’ve found it helpful in thinking about this problem to consider, basically, three broad groups: the vaccine-eager, vaccine-neutral and vaccine-hesitant. This is a simplification! But it might help us think about solutions.
The first group, the vaccine-eager, really want vaccines. Some of this group has already been vaccinated; the already vaccinated group has been disproportionally white and wealthy, almost certainly due to access issues. If you need to be up at 2:30 am refreshing seven websites to get an appointment, that’s going to favor certain groups. This aspect of the roll-out has been unfair. As we look to expansions in supply, we should be mindful of how we use them. Hopefully, such expansions will mean that within a few weeks anyone who really wants a vaccine can get one.
The second group I’m going to call the vaccine-neutral. People who aren’t actively opposed to the vaccine, but aren’t seeking it out, either. I’ve been doing some volunteering at a vaccine clinic, helping people sign up for second doses. When I ask people if they’re happy to have a first dose, some definitely are, but for many others it’s just … fine. They’re not anxious or unhappy to have been vaccinated, it just doesn’t seem that important.
There is a policy temptation (at least among some) to try to convince this group that vaccines are important. This is a nice goal, but it’s probably very hard to do, in part because this group just isn’t thinking about this that much.
I would suggest that, instead, we simply try to make it easy and provide incentives. What would this mean?
First, ease of access: Better sign-up procedure. More pop-up sites. More accessible locations. More use of the one-shot Johnson & Johnson vaccine in places where it may be hard to get people to return for a second dose.
We are going to need to start bringing the vaccine to the people, rather than asking them to find it. Improving access will also start on the path to improving vaccine equity, since we can hopefully target pop-up sites to underserved areas and communities of color.
We should also offer incentives: Give people stuff for being vaccinated. Krispy Kreme says you can get a free donut every day if you’ve been vaccinated. Some of the fun police oppose this on the grounds that donuts are bad for you, but I think it is great. Publix has offered its workers monetary incentives to get vaccinated. At a minimum, employers should give their employees time off for vaccination.
I’m sure I’m missing other creative ideas. Bottom line: make it easy, make it fun(ish). Make an experience that some people are otherwise neutral about net-positive. This is something we can start thinking about now, and should be our next top priority. It should be possible to get this vaccine-neutral group vaccinated, if we do it right.
Then we get to group three: the vaccine-hesitant. (I do not like the term anti-vaxxer; it’s politicized and unnecessarily pejorative.) There was a lot of talk initially about vaccine hesitancy in the Black community, which has historic reasons to distrust vaccines and health care in general. As vaccines have rolled out, though, this seems to have improved (see this article as an example) and there is a hope that addressing issues of access will improve this further. In the most recent data, vaccine resistance lies much more along political lines than anything else.
What can be done? For people who are nervous rather than actively opposed, progress can probably be made by simply waiting and exposing the vast number of safe vaccines which have been administered. Role models may help. This paper shows that Black men are more likely to sign up for preventative care services if matched with a Black doctor; if this extends to COVID vaccination, vaccine promotion efforts like this one are crucial.
The more actively opposed are much harder to convince. We know from childhood vaccine resistance that giving people in these groups information about vaccine safety tends to actually backfire.
In the end, the last mile of vaccines may have to happen with more active encouragement. After a large measles outbreak in 2015, California ultimately achieved high vaccination rates in schools by, basically, mandating them. I’m not suggesting we do this now (in fact, it would be impossible given that the vaccines are approved only under Emergency Use Authorization). But as we look to the long term, it is something we need to consider.
It’s all well and good to write about how we can improve vaccination rates with policy, but what if it is your parents (or sister or uncle or etc.) who doesn’t want to be vaccinated?
(Related questions have come up with caregivers; this is an overlapping but slightly different situation since they’re your employee. Similarly, if the resistant party is your partner and not some more distant family, it’s different. I’m going to focus on the extended family situation here, but you can adapt and apply these ideas to different situations.)
I do not have a magic bullet. This is a hard problem. It is frustrating and annoying. No one can drive us crazier than our own family. Take a deep breath.
I have two thoughts on framing here, which may help.
First: You do not need them to agree with you, you just need them to get the shot. This lesson is in part why I started with the policy discussion. When we think about the vaccine-neutral group above, we should fight our instincts to spend time convincing them that vaccines are great. Who cares? If people get the shot, then they have it.
It may drive you out of your mind that one of your parents thinks the Pfizer mRNA delivery technology is some kind of liberal voodoo, but if they’ll get the Johnson and Johnson vaccine because they trust the company then that is fine. Paradoxically, arguing about the merits can make people dig into their position and make things worse.
Second: You can control the rules for your immediate family, and that’s about it. In the end, if relatives will not be vaccinated, all you can do is set your own boundaries. It’s not dissimilar to how people advise setting them with kids: Take time to decide what your rules are, what you feel safe and comfortable doing, and then be consistent.
Let’s say your parents don’t want to get vaccinated, and they want to see your children. You could decide no visits until the grandparents are vaccinated, period. You could decide on no indoor visits, or no indoor visits until everyone in your family, children included, has gotten the vaccine. You could also decide that if your parents won’t be vaccinated, they need to quarantine, and possibly also test, before a visit where they’ll be inside with you and your kids.
There are infinite possibilities here, and what you decide is going to depend some on your risk tolerance, some on the situation in your location, and some on your relationship with said relatives. You might hold a harder line with a more distant relative, where seeing them isn’t as important. Your rules may be different if you (the adults in the household) are vaccinated. It may also matter if the people in question have had COVID-19; recovered people should still have the vaccine, but previous infection confers some protection.
As with most of my advice about decision-making, I’d suggest you take time with this, make a decision that works for you and then stick to it and move on. Your parents may decide that hugging their grandchildren is more important than their vaccine doubts, or they might not. These boundaries are about hopefully moving your extended family toward vaccination, but they’re mainly about keeping you and your immediate family safe in a way that feels comfortable for you.
The pandemic has provided many moments when control is wrested from us and this may be another. It’s frustrating to feel like there is a solution available and someone isn’t taking it for reasons which seem wrong or crazy to you. But like with everything else, there is value to recognizing what you can control and working on that.