The next Covid-19 vaccine hurdle: Convincing millions of Americans they want the shot

In the coming months, America could reach a point when it has more Covid-19 vaccines than people want.

Between efforts from the federal government and drug companies to step up manufacturing and distribution, the US’s vaccine supply is truly increasing: At least 150 million doses are expected through March — a rate of more than 3 million shots a day, the kind of speed the country needs to reach herd immunity, when enough people are protected against the virus to stop its spread, this summer.

But public health experts are increasingly warning of what may come as America inches closer to the finish line in its vaccine campaign: After the majority of people who want a vaccine get one, there’s a large minority of people who have voiced skepticism in public surveys. And if these people don’t change their minds in the coming months, they could doom any chance the US has of reaching herd immunity.

“There’s going to be a point … where there’s going to be vaccine available, and getting people to take it will be the primary issue,” Emily Brunson, a medical anthropologist at Texas State University, told me.

To reach herd immunity, experts generally estimate that we’ll need to vaccinate at least 70 to 80 percent of the population — though it could be more or less, because we don’t really know for sure with a new virus. Yet according to a recent AP-NORC survey, 32 percent of Americans say they definitely or probably won’t get a Covid-19 vaccine. If that holds and the herd immunity estimates are correct, it would make herd immunity impossible.

Public health experts say there are ways to make people more willing to get vaccinated, but such efforts have to be flexible to match the different concerns about a vaccine different communities and individuals may hold. What might sway skeptical white Republicans who don’t see Covid-19 as a threat won’t necessarily work for Black communities that are distrustful of a medical establishment that has long neglected and even abused them.

Whatever anti-hesitancy campaigns take shape, though, must happen quickly. With every day the coronavirus continues to spread across America, the country sets itself up for hundreds if not thousands more deaths a day — not to mention the constant need for social distancing, a weakened economy, and potentially harsher restrictions on daily life. Each day of uncontrolled spread also brings the risk of new, more dangerous coronavirus variants, as each replication of the virus carries the risk of a mutation that catches on more widely.

Now, the days when hesitancy becomes the top vaccine problem may still be up to months away. But if the pandemic should have taught us anything, it’s that it’s better to be proactive than reactive. It’s not too late to get ahead of this problem before it becomes the next major bottleneck in America’s efforts to end its outbreak.

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The US’s vaccine supply problem is getting better

The past few weeks have brought a lot of genuinely good news on the vaccine front.

The number of shots delivered has increased dramatically, from less than 1 million a day in mid-January to around 1.7 million in mid-February. (Though recent snowstorms likely slowed that down.) As bad as America’s initial rollout was, the US is still ahead of all countries except Israel, Seychelles, the United Arab Emirates, and the United Kingdom in vaccination rates — and it’s improving quickly enough, so far, to sustain that lead.

There have also recently been fewer mishaps at the state level. There were some alarming reports during the first few weeks of the rollout — machines breaking down, staffing issues, doses going unused. These problems still pop up (the US is big, and someone is always causing trouble here), but they seem to be happening less frequently as states and localities get the hang of the process. To this end, states are using much more of their vaccines: While it was rare for a state to report administering more than 60 percent of vaccine doses in January, it’s now pretty common for them to report using more than 80 or 90 percent.

Meanwhile, President Joe Biden’s administration has made some strides to improve both the supply of vaccines sent to states and communication with states on what supplies they can expect. The latter is particularly important because it lets states plan for the doses they’re getting — something they weren’t often able to do in the early stages of the vaccine rollout, as they would find out how many vaccines they were getting as late as the day they got the doses. That might help explain why states have been doing better.

There are still plenty of problems. The current rate of 1.7 million shots a day is still too slow; experts would like the country to get to 2 million or 3 million to get through the bulk of vaccine efforts this summer. While the country seems to be on track to get enough doses to do that next month, the question then becomes whether it has the distribution capacity to actually turn those doses into shots in arms — and the logistical challenges there will be immense.

Still, a world where there are enough vaccines to go around is rapidly approaching. Biden said vaccines will be available to all Americans by the end of July, while Anthony Fauci, the top federal infectious disease expert, took a slightly more optimistic outlook in saying it would be “open season” in late May or early June.

At that point, vaccine hesitancy may make supply less of a problem than demand.

America has a hesitancy problem

The views of one-third of Americans may not always amount to a national crisis, but those views matter a lot when the country needs to do something that requires nearly everybody on board. That’s the case with the Covid-19 vaccination campaign, where 70 or 80 percent — or more — of the country will need to get vaccinated to reach herd immunity. So surveys that show as many as one-third of Americans are skeptical amount to a real public health crisis.

Compounding that is the reality that a Covid-19 vaccine still hasn’t been approved for children — and that might not happen until later this summer or even 2022. Given that kids make up 22 percent of the population, herd immunity probably can’t happen without them. But even if herd immunity only requires the lower estimate of 70 percent of Americans, that still will be impossible if more than 30 percent of adults refuse a vaccine.

Based on public surveys, particularly in-depth ones from the Kaiser Family Foundation, the skeptical report a variety of concerns regarding the Covid-19 vaccine.

A major one is concerns about side effects, particularly long-term health consequences. The Covid-19 vaccines do have side effects, but they’re almost entirely minor — temporary aches, fever, and cold-like symptoms — aside from rare allergic reactions, which require monitoring but are treatable. Still, people worry about the risks.

Some of the skeptics worry that the vaccine approval process, given its record speed, was rushed. But the Covid-19 vaccines still went through the three-phase clinical trial process required by the Food and Drug Administration, testing for safety and efficacy. The vaccines have also been out in the real world for months now, with still no reports of previously unknown and serious effects.

Some people of color also distrust the health care system, based on their experiences with a system that’s often discriminatory and a history of experimentation on Black bodies, such as the Tuskegee study. Surveys show that Latinos and Black people, in particular, are less likely to trust doctors and hospitals in general. That’s likely fed into distrust toward the vaccine, too.

A segment of the population, particularly on the right of the political spectrum, is also skeptical they even need a Covid-19 vaccine. Encouraged by people like former President Donald Trump, they tend to believe the threat of the coronavirus has long been overplayed in the media. Given other potential concerns, for instance about side effects and a rushed process, they question whether they should get a vaccine, believing that Covid-19 isn’t really a threat to them. The reality is it’s a threat to everyone — killing more people under 55 alone than all murders in a typical year — but the perception remains.

Then there are the concerns that fall more in the conspiracy theory camp, whether about certain wealthy people’s involvement in the vaccine process or more traditional (and debunked) anti-vaxxer concerns. But those tend to make up a very small minority of the US public and even Covid-19 vaccine skeptics.

There’s no one-size-fits-all solution

As the list above demonstrates, concerns about vaccines tend to vary and can differ significantly from community to community. Some concerns may not even show up in national surveys at all — they might be too localized to ever appear. This is a critical fact of public health, but it especially applies here: Local problems require local solutions, meaning messaging to combat vaccine hesitancy will have to be tailored differently from community to community.

“There will be similarities, and I think there will be some overlapping issues,” Brunson said. “But there will be local iterations of this that can vary quite widely.”

That doesn’t mean states or federal governments have no role to play. To the contrary, a big federal campaign about the basic facts, particularly the benefits, of the vaccines could be really helpful — and, in fact, experts have repeatedly told me such a campaign should have started months ago. Federal and state governments can also provide support, with money, personnel, guidance, and expertise, that local governments will need to execute on their plans.

The underlying theme of these campaigns, experts say, should be to meet people where they are. That begins with really hearing the community’s concerns, then transparently and honestly walking through why the vaccines’ benefits still dramatically outweigh any downsides. Doing that could require, at some points, acknowledging that people have a point — for example, the US health care system really does have a history of racism — but making the case that the evidence for vaccines is still strong and they’re still worth taking.

The messaging will have to be tested, and what works best will, again, likely differ from place to place and person to person. But experts pointed to several ideas: Campaigns can point to the evidence that the vaccines are very effective, particularly that they, based on the clinical trials, drive Covid-19 deaths down to zero and hospitalizations to almost zero. They can highlight the importance of everyone getting vaccinated to reach herd immunity and, subsequently, protect not just yourself but your friends, family, and community. They can tap into trusted or beloved sources, including doctors but also potentially celebrities.

A more controversial idea is to tell people about the personal benefits of the vaccines. Some of the public health messaging in the US has actually obscured this — telling people that even if they get a vaccine, they won’t be able to go back to their normal, pre-coronavirus lives right away.

Still, some experts argue that the restrained messaging can drive people to ask, “Why bother?” Masking and social distancing should be encouraged until America reaches herd immunity or close to it because we don’t yet know how effective vaccines are in driving down transmission. But people should be trusted with factual information about how vaccines will make certain activities less risky for them and others who get inoculated — and maybe they could safely enjoy some of those activities with their vaccinated friends and family once again.

“People undersell the vaccine,” Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security, told me. “They don’t understand that if you tell people nothing changes when they get a vaccine — which I don’t think is true — then they’re not going to have an incentive to get the vaccine.”

Whatever form a pro-vaccine effort takes, experts are in agreement — and they have been for a long time — that some kind of big anti-hesitancy campaign needs to get going soon. Really, it should have started yesterday or last year. But there’s still time to act before the country gets to the point where supply is outstripping demand.

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