To Persuade the Unvaccinated, Protect the Unvaccinated

“Your refusal has cost all of us,” President Joe Biden said to unvaccinated people last week, as he announced a new COVID-vaccine mandate for all workers at private companies with more than 100 employees. The vaccinated, he said, are angry and frustrated with the nearly 80 million people who still haven’t received a vaccine, and their patience “is wearing thin.”

© Mario Tama / Getty

He’s not wrong about that. For people who understand that widespread vaccination is our best strategy for beating the pandemic, the 25 percent of Americans who still haven’t received a single shot are a barrier to freedom. Their exasperation is warranted.

But bullying the unvaccinated into getting their shots isn’t going to work in the long run.

[Read: America is getting unvaccinated people all wrong]

Yes, vaccine mandates increase vaccination rates. The White House reported 4 million more first doses in August than in July, after Biden announced his first mandate, for federal workers. And the number of shots administered daily jumped 80 percent from mid-July to the end of August. But the way the mandates are being presented is driving a wedge between the vaccinated and the unvaccinated. If the goal is to inoculate enough people to reach herd immunity, this approach may eventually backfire.

“If you get into these scenarios where you start pitting one group against another, you create tension, you create resistance,” says Simon Bacon, a behavioral scientist at Concordia University, in Montreal. “What you really need to do is totally deflate that.”

Bacon is a principal investigator of iCARE, an ongoing international study of attitudes toward COVID-19 public-health policies. In a small, recent survey, only 30 percent of respondents (which included unvaccinated and partially or fully vaccinated people) said that introducing a vaccine passport would make them more likely to get vaccinated. Sixty-three percent said that it would have no impact, and 4 percent said that it would make them less likely to get a shot. These data are preliminary, but they point to the polarizing potential of passports. Like vaccine mandates, vaccine passports can be considered “coercive” methods for increasing vaccination rates. Neither addresses the key reasons people are hesitant. “If you’re worried about safety and efficacy, a vaccine passport or lottery doesn’t affect that,” Bacon told me. This was one concern raised about Israel’s “green pass” vaccine passport, which, after it was rolled out in February, had at best a minimal impact on vaccine uptake. It was discontinued in June.

It’s important to differentiate between the vaccine hesitant, who are on the fence for legitimate reasons, and the vaccine resistant, who flat-out don’t support vaccines. By one estimate, 8 percent of the U.S. population consistently identifies as anti-vaxxers. Bacon said there’s no use trying to persuade them. It’s the former group we should be careful not to push away with divisive policies, because they are key to getting the pandemic under control.

Biden’s latest mandate requires more than 80 million Americans to get vaccinated or show negative COVID-test results at least once a week. Some early evidence (not yet peer reviewed) suggests that vaccine requirements can be counterproductive because they make people feel pressured and may increase existing distrust of public-health initiatives, especially among marginalized groups. The American Public Health Association’s executive director, Georges C. Benjamin, has warned that Biden’s latest mandate might cause Americans to “dig in and bristle at being told what to do.” An overarching principle of public health, said Jennifer Nuzzo, a senior scholar at the Johns Hopkins Center for Health Security, is that people should engage with policies willingly, not because they fear being penalized.

[Juliette Kayyem: Unvaccinated people need to bear the burden]

A recent study of attitudes toward vaccine passports in the United Kingdom and Israel showed that lower willingness to get a shot is associated with feeling that one’s autonomy is being compromised. For some, said the study’s lead author, Talya Porat of Imperial College London, “passports might increase resistance to vaccination or alter the motivation behind their vaccine decisions in ways that might have detrimental long-term consequences.” Even though people might get vaccinated now, they may resist booster shots or vaccines against new coronavirus variants in the future.

None of this is to say that vaccine requirements are a bad idea. Vaccination is by far our best tool for preventing severe illness and death from COVID-19. But vaccine requirements alone won’t beat the pandemic, and the current framing around them needs some work. Calling this a “pandemic of the unvaccinated” stigmatizes the people we need to engage with most.

One tweak would be to highlight the collective benefit of these policies: protecting both the vaccinated and the unvaccinated. That vaccine passports help unvaccinated people is rarely mentioned, Bacon noted. Vaccinated people, though they are unlikely to get very sick or die from COVID-19, can get breakthrough cases and transmit the disease—especially if infected with the Delta variant. Vaccine passports prevent unvaccinated people from being in areas where people are congregating, which reduces their risk of infection and far more serious illness.

“And how disarming is that? That’s not about pitting me against you—far from it. That’s creating a scenario where I’m trying to take care of you,” Bacon said. “This is a safety measure for the unvaccinated.” Importantly, this approach signals respect for, not dismissal of, a person’s choice not to get vaccinated, leaving the door open for conversation and education. Some countries, such as Canada, New Zealand, and Ireland, have vaccination campaigns emphasizing this angle.

Addressing vaccine safety and efficacy remains paramount if we want to reach the unvaccinated. Though education about these topics is not lacking in the United States, calls from figureheads such as Biden, Anthony Fauci, and even the pop star Olivia Rodrigo will only reach so many people. History suggests that we’d be better off taking a personal approach. In the early 20th century, a skilled public-health communicator named C. P. Wertenbaker traveled between smallpox-infected southern towns to talk candidly about vaccine science and safety. Often, what made his visits effective is that respected townsfolk rolled up their sleeves and got the smallpox shot in front of the crowd, says Michael Willrich, a Brandeis University historian and the author of Pox. “On a really successful visit,” he told me, Wertenbaker could “get people to be vaccinated where previously they were very resistant.”

[Chavi Eve Karkowsky: Vaccine refusers risk compassion fatigue]

In the U.S., where vaccination uptake is divided along party lines and confidence in public institutions is declining, the messenger matters. “Those who do not have confidence in the government and media may still be reached by people they trust in their own community,” such as personal physicians, says Katherine Ognyanova, an assistant communications professor at Rutgers University and a co-lead of the COVID States Project, an ongoing multi-university study of social behavior and COVID spread. The project has found that people who do not trust institutions—including the government, the media, and the health-care system—are less likely to get vaccinated and support vaccine requirements, she told me. To his credit, Biden called on family doctors to make personal appeals to their unvaccinated patients in his latest speech.

Often, the people who are vaccine hesitant are our own family, friends, and colleagues. That’s worth remembering, because it reminds us who is at risk if we alienate the unvaccinated. If there’s any chance of persuading them to get a shot—and ample evidence shows that doing so is possible—it’s not going to happen if we only enforce policies that exclude them, foster resentment, and make them feel like their fears and concerns are being dismissed. Compassion, not coercion, is what’s going to get us through this pandemic together.

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