Opinion: We Need To Distinguish Between Vaccine Hesitancy and Anti-Vax
2020 has been a rollercoaster of a year, defined by the Black Lives Matter movement, President Donald J. Trump’s failure to seek reelection, and lest we forget, the pandemic.
What started out as any normal year, very quickly moved to a stream of lockdowns worldwide. The year seemed to drag on forever as, every day, we were collectively overwhelmed with the uncertainty of a virus the world did not seem to understand. 2020 was a year full of ups and downs, lockdowns, masking, hand-washing, and social distancing. However, we ended 2020 with a beacon of hope for millions across the globe — the approval of some COVID-19 vaccines — the light at the end of a really long tunnel. However, with vaccine hesitancy and anti-vax sentiments on the rise, scientists believe we still have an uphill battle ahead of us.
If you would’ve asked me if I would take a COVID-19 vaccine in August 2020, my response would have been a yes, but a hesitant yes nonetheless. Ask me now if I would take a COVID-19 vaccine? Unlike before, my response is a strong, confident yes. This is vaccine hesitancy in real life. I was hesitant because the news portrayed these novel technologies without explaining that 10+ years went into developing the mRNA vaccine platform. Similarly, there was a lot of talk of “record” speed initially, which made me wonder if corners were cut (which I know, they weren’t). And of course, there was the question of there being no long-term safety assessment. We still don’t have long-term safety data, but as far as science goes, vaccines are more likely to have short-term safety issues, than long-term issues — a fact that I understand because the body will simply eliminate anything that is “foreign” to it within weeks.
If you would’ve asked me if I would take a COVID-19 vaccine in August 2019, my response would have been a yes, but a hesitant yes nonetheless. Ask me now if I would take a COVID-19 vaccine? Unlike before, my response is a strong, confident yes. This is vaccine hesitancy in real life.
Contrarily, ask an anti-vaxxer if they would take a vaccine, any vaccine, whether old or new, and they’re most likely going to say no. Subscribing to false conspiracy theories, anti-vax folks would turn down a rigorously tested vaccine every time. While there is some overlap between vaccine hesitancy and anti-vax, I am of the opinion that there is a fine line that we are treading. Unfortunately, anti-vaxxers are gaining more ground amid this pandemic, with related social media groups having grown by almost 7.8 million people since 2019. This severely undermines the efforts of scientists, institutions, and governments worldwide that have been vital in curbing the effects of the pandemic.
Anti-vax, not Vaccine Hesitancy, Is the Real Global Health Concern
In 2019, the World Health Organization (WHO) released a list of the top 10 global health concerns. Within that list was vaccine hesitancy, defined as a “delay in acceptance or refusal of vaccines despite the availability of vaccine services”. If I was asked to critically analyze this definition before 2020 (pre-COVID), I would have found myself simply thinking vaccine hesitancy is indeed a pressing problem.
However, I now believe the WHO or the Centers for Disease Control and Prevention (CDC) should drop the term “vaccine hesitancy” and use “anti-vax” instead, or at the very least, distinguish between the terms, especially in light of the pandemic. The issue with the current definition is that true vaccine hesitancy, a state of doubt or uncertainty but not a complete behavior of rejecting the vaccine, is normal human behavior while being anti-vax, or the outright rejection of all vaccines (including the new COVID-19 vaccines developed), is the real global health concern. This somewhat general definition, which includes a state of doubt and a complete behavior of rejection, has some individuals muddling the terms and inaccurately concluding that vaccine hesitancy and anti-vax are synonyms.
The issue with the definition is that true vaccine hesitancy, a state of doubt or uncertainty but not a complete behavior of rejecting the vaccine, is normal human behavior while being anti-vax, or the outright rejection of all vaccines (including the new COVID-19 vaccines developed), is the real global health concern.
Wikipedia, a commonly used public resource that is considered not rigorous enough within the sciences and academia, defines vaccine hesitancy as follows:
“Vaccine hesitancy, also known as anti-vaccination or anti-vax, is a reluctance or refusal to be vaccinated or to have one's children vaccinated against contagious diseases. People who subscribe to this view are commonly known as "anti-vaxxers". The term encompasses outright refusal to vaccinate, delaying vaccines, accepting vaccines but remaining uncertain about their use, or using certain vaccines but not others.”
This (in my opinion) inaccurate definition is one used by the public at large. Consider that recently in New York City, Bonnie Jacobson, a waitress, was fired because she wished to hold off the COVID-19 vaccination. While she was enthusiastic about the vaccine itself, Jacobson was planning to get pregnant and wanted to know whether the vaccine would affect fertility: “I totally support the vaccine,” she said in an interview with The New York Times. “If it wasn’t for this one thing, I would probably get it.” In fact, as of the time of writing, the WHO still explicitly recommends pregnant women not to use the Moderna vaccine, unless they are “health workers at high risk of exposure and pregnant women with comorbidities placing them in a high-risk group for severe COVID-19.”
Given that a waitress is generally not even considered to be a frontline worker, Jacobson who was taking a wait-and-see approach in the face of a lack of data or conflicting expert recommendations appears to be a textbook definition of vaccine hesitancy but far from being anti-vax. The WHO’s definition of vaccine hesitancy leaves much room for open interpretation and scapegoating.
In light of the pandemic, anti-vax should be clearly delineated with vaccine hesitancy by stating that it begins at the moment when a person consciously decides not to vaccinate based on safety data and information presented to them. Anti-vaxxers simply don’t trust ANY vaccine and straight-up refuse all of them. These are the people that are commonly dubbed “anti-science”, the ones who dismiss facts themselves.
We have all raised questions. This doesn’t make us anti-vaxxers.
I’ve seen and known many people who have asked and answered these questions regarding the COVID-19 vaccines the same way as I have. My brother is a university-educated, scientific-journal-reading, biomedical sciences graduate, and has conducted laboratory research, and fully understands vaccine science. Until recently, he was also experiencing some vaccine hesitancy. Similarly, my friend who is a diabetic pharmacist, working on the frontlines on the COVID-19 wards within the UK’s publicly-funded health care provider, the National Health Service (NHS), had some feelings of hesitance. Another doctor friend also had some reservations about taking the COVID-19 vaccines. Mind you, they have both since received the Pfizer vaccine and are doing very well and still working front-line (a big thank you!). My brother, too, hopes to receive the vaccine soon, but as a young individual with no underlying health conditions, he has a long wait ahead of him. As do I.
Questioning the science behind a newly developed vaccine is a normal reaction, even among the science-minded. These questions do not make us anti-vax. Curiosity to understand vaccines and how they work, as well as questioning certain aspects of vaccine development based on the facts we know is, in my opinion, a part of the scientific inquiry process.
Many people have perfectly valid reasons to mistrust science and vaccines, which, in a lot of cases, comes from a dark history of unethical scientific research and racial neglect. Many people are becoming aware of the dark history behind the Tuskegee Study: researchers not only misled Black volunteers of the purpose of the study (to track what would happen if syphilis was allowed to progress untreated in the body), but never gave sick volunteers syphilis treatment despite penicillin having been perfected over the course of the study, and even allowed them to die without pausing and reviewing the study. I too would be emotionally scarred and mistrust science (and scientists) if that had happened to a member of my family or even someone I know. However, it is worth noting that the Tuskegee study is just one episode in the past; current inequities in income, accessibility, and participation are what drives much of the hesitancy.
Questioning the science behind a newly developed vaccine is a normal reaction, even among the science-minded. These questions do not make us anti-vax. Curiosity to understand vaccines and how they work, as well as questioning certain aspects of vaccine development based on the facts we know is, in my opinion, a part of the scientific inquiry process.
Science involves feeding our curiosity through asking questions, making observations, and drawing reasonable conclusions that are backed by research and data. An underappreciated part of that is understanding who gets to make decisions and discerning whether the methodology or findings makes common sense. Ignoring the deliberative process of peer-reviewed science, to undermine science and research efforts using scare tactics, misinformation and lies— that’s what would be anti-vax.
Why aren’t we outwardly tolerant about vaccine hesitancy?
We need to normalize this hesitancy — it has crossed all our minds. This behavior, where well-meaning people are simply getting clarification regarding the vaccines, is normal. I only have one friend who never questioned it — she was one of the first volunteers for the Oxford/ AstraZeneca vaccine clinical trial in London (a super big thank you, again!). The majority of people I have come across in my social circles, as well as anonymous Redditors and Twitter users, have questioned the safety and efficacy of the COVID-19 vaccines. I have seen a number of people just putting these thoughts and questions (doubts, really) into words on Twitter and getting bombarded with hate comments from pro-vaxxers. When did we become so intolerant to legitimate questioning?
Throughout 2020, a common theme in the world has been to question ourselves — our biases, conscious and unconscious, our thoughts, and the science we read. So why aren’t we extending this to the critical analysis of vaccines?
Throughout 2020, a common theme in the world has been to question ourselves — our biases, conscious and unconscious, our thoughts, and the science we read. So why aren’t we extending this to the critical analysis of vaccines? This is not a political argument, this is a legitimate concern undermining society’s ability to move on from the pandemic. Without mass vaccination to help us gain immunity in a controlled, safe manner, reaching herd immunity would mean letting people catch COVID-19 and hoping for the best — a recipe for disaster. This would induce further repercussions on health and economies worldwide as the pandemic would continue for a longer period of time. Not everybody is enthusiastic about getting shots in their arms, but why can’t we help those who are willing to listen navigate through their concerns so they have some peace of mind?
Anti-Vax, Pro-Vax and the Vaccine Hesitant
Based on my experiences, and the experience of other science communicators I frequently interact with on Twitter, there seems to be a huge political, religious, and scientific divide in vaccine rhetorics. This divide, however, only seems to focus on the pro-vax and anti-vax communities. Members of both these communities are commonly found arguing with one another — one side using hard scientific facts and data, and the other, using misinformed data fueled with emotion. The conversations between these communities are also openly available to view via Reddit, and in some cases, it is not a pretty sight.
Unfortunately, the focus for many conversations remains on the pro-vax and anti-vax groups. The scale of vaccine beliefs is a lot more fluid than the pro-vax and anti-vax rhetoric, with an in-between group that I would personally call the “vaccine-hesitant” group. Pro-vaxxers and scientists need to focus on “righting the wrongs,” so to speak, and encourage vaccine literacy among the vaccine-hesitant folk before they develop their opinions into the unfounded anti-vax territory.
Perhaps, we can take a page out of the book of climate scientists, who have been dealing with one of the most polarized branches of the sciences before the world succumbed to the global pandemic. While terms such as “climate deniers” are being increasingly (and accurately) deployed in mainstream media coverage, an interdisciplinary group at Yale’s Program on Climate Change Communication has developed and refined a model that provides a nuanced approach to how people view climate change. In “Global Warming’s Six Americas”, instead of using binary, catch-all terms, researchers sorted Americans into six groups: Alarmed, Concerned, Cautious, Disengaged, Doubtful, and Dismissive.
In “Global Warming’s Six Americas”, instead of using binary, catch-all terms, researchers sorted Americans into six groups: Alarmed, Concerned, Cautious, Disengaged, Doubtful, and Dismissive.
In the same way, while there are enthusiastic folks who spend hours refreshing their browsers to fight for a vaccination timeslot, there are those interested but taking a cautious approach, or doubtful about the vaccines’ efficacy but still having an open mind. On the other hand, some might just not care or lack access to information about vaccine efficacy (what we call low-information citizens); unfortunately, it is hard to reach those who are downright dismissive of the science, the true anti-vaxxers.
Interestingly, the Yale team could clearly observe that the Dismissive segment has somewhat shrunk over time, while the Alarmed segment has tripled within five years. Climate communicators across the world are increasingly finding ways to break through the information deficit model to speak to their hesitant audiences. This, combined with the increased sombreness of the effects of the climate crisis, has been changing minds. We can apply these findings to COVID-19 communication.
What can we do about vaccine hesitancy?
This is a great question and has worried scientists and medics for years. The pandemic has been difficult for each one of us, and I think what we must do is be tolerant to legitimate questioning. Although it is tempting, we cannot tell someone what to do — no one likes to be nagged or forced into a decision. Instead, we need to understand that people have legitimate concerns about the COVID-19 vaccines, and then feed them the right information in a targeted manner depending on their concerns. This may take a lot of time and a lot more patience, but it works!
We’re witnessing the same change in attitudes towards climate change happening at warp speed (no pun intended) regarding attitudes towards COVID-19 vaccines. While there is indeed a solid bloc that is resistant towards the COVID-19 vaccines, more and more people on the fence, especially racial minorities, are making up their minds to get their shots. This means that effective messaging does make a tangible difference!
My landlady, who is 89 years old, had serious concerns about the vaccine being rushed. With patience, perseverance, understanding, and open discussion over the course of a month, she was happy to receive her Pfizer vaccine in early January, albeit for reasons that the Oxford vaccine is British, she wishes she received that one. Her doubts are understandable, and we shouldn’t punish her (or anyone else) for asking questions to clear her doubts. In fact, thanks to this questioning, COVID-19 vaccine manufacturers have made the vaccine studies so transparent and available to the public.
I believe we need to remind scientists and communicators alike, that the focus of our communication must be towards people who are on the fence that are trying to decipher different messages and make decisions about the vaccines. People who are hesitant have doubts that require answers, and scientists are perfectly placed to provide them with these. To help the cause, I have authored a number of articles on the COVID-19 vaccines (and created a weekly COVID-19 vaccine newsletter) which are available as a resource here.
I’ve done my research, I’ve got my fears allayed, I’ve helped others with their hesitancy too. Question is, will you?
Correction. A previous version of the article incorrectly stated that the author was hesitant to receive the COVID-19 vaccine in August 2019, when it occurred in August 2020. Researchers agree that the first known COVID-19 cases can be traced back to November 2019 in China and work on most COVID-19 vaccines did not begin until early 2020. We regret the error.
