Causes of COVID Vaccine Hesitancy

By Jasper L. Tran

Vaccinated individuals — like Tolstoy’s happy families — are all alike; each unvaccinated individual is hesitant for her own reason.

Prior research conducted in developed countries reveals five main individual-level determinants of pre-COVID vaccine hesitancy (commonly referred to as the 5 C model drivers of vaccine hesitancy): (1) Confidence (trust in vaccine’s effectiveness and safety, vaccine administrators and their motives); (2) Complacency (perceiving infection risks as low and vaccination as unnecessary); (3) Convenience / Constraints (structural or psychological barriers to converting vaccination intentions into vaccine uptake); (4) Risk Calculation (perceiving higher risks related to vaccination than the infection itself); and (5) Collective Responsibility (willingness to vaccinate to protect others through herd immunity).

COVID-19 vaccines see these five hesitancy determinants again, only further exacerbated by waves of misinformation promulgated on social media, including through “bot” accounts, that prey on the concerns and insecurities of an already vulnerable public.

On the one hand, irrational and unreasonable conspiracy theories about COVID-19 and its vaccine abound among the anti-vaxxers — a subgroup of science deniers. These conspiracy theories include:

• Miracle Cures: Former President Donald J. Trump promoted the anti-malarial drugs, hydroxychloroquine and chloroquine, as COVID-19 cures in March 2020.
• Democratic Party Hoax: Former President Trump’s son, Eric Trump, commented on Fox News that COVID-19 will “magically all of a sudden go away and disappear and everybody will be able to reopen” after the 2020 presidential election.
• 5G Technology: 5G technology’s purported negative health impacts predate the COVID-19 pandemic. Rumors suggest that the emergence of the novel coronavirus was somehow related to the rollout of 5G mobile technology, especially in light of the installation of several 5G towers in Wuhan, China.
• Bill Gates’ Surveillance Microchips: This theory wrongly suggests that COVID-19 vaccines contain tracking microchips, which conspiracists link to Gates’ long-standing interest in vaccination as a public health measure.
• Fauci’s Exaggeration: Anthony Fauci’s erroneous claims from early in the pandemic have been used to discredit his later statements; for example, he told Americans in March 2020 that “it will take at least a year to a year in a half to have a vaccine we can use” and that “there’s no reason to be walking around with a mask.”
• Plandemic: The YouTube pseudo-documentaries titled “Plandemic” claim that vaccines are “a money-making enterprise that causes medical harm,” which would result in a loss of free speech and free choice.
• Wuhan Bioweapon: This conspiracy suggests a secret bioweapon facility Wuhan Institute of Virology deliberately or accidentally released COVID-19.
• Population Control: Conspiracists suggest that COVID-19 vaccines might be a population control effort within an intentional population control scheme that is COVID-19.
• Bat Soup: This theory posits that COVID-19 originated from the bats in Wuhan that humans consumed.
• Antisemitic Conspiracies: The COVID-19 pandemic drove anti-Jewish sentiment domestically and in Europe.
• New World Order / Deep State: The secret “new world orders” or “deep state” government allegedly paid for the COVID-19 responses (including those by Fauci and Gates). This conspiracy is often linked to former President Trump’s joke that called the U.S. State Department a “Deep State Department” during a March 2020 coronavirus press briefing.

On the other hand, summer 2020 interviews of Pennsylvanians with an average age of 46 (89% of whom were non-Hispanic blacks) reveal four main non-conspiracy reasons for COVID vaccine hesitancy. Many of the responses sound quite rational and reasonable.

The responses indicate that whether an individual remains hesitant about receiving a COVID-19 vaccine may depend on personal beliefs, informed by a background that is a totality of, for example, race (and its historical past), gender, education, life experience, and information consumption. This individualized background then forms a value system that informs the personal decision-making process as to whether to receive a COVID-19 vaccine. Some examples of key considerations include:

• Vaccine Development Process Was Rushed. One participant responded: “No, I will not be taking a [COVID-19] vaccine” because “they didn’t have enough studies. It takes at least a year and a half, two years or three years for them to complete a study and they did it in four months.” Another responded that the COVID-19 vaccine is “just being made up” because there was “no data” and “no real testing.”
• Safety and Efficacy Concerns. One participant responded that the vaccine “is too new. You don’t really know, and I don’t want to put anything in me even with a 10% chance that I might get [COVID-19] because I have underlying condition, so I don’t know if that’s going to make me sick, they don’t know if you’re going to get [COVID-19], like you know how you could still get the flu even if you get a flu shot.” To alleviate their fears of the unknown, possible side effects, and yet-undiscovered dangers, some participants preferred to wait and see, stating: “Once we’ll see that a year go by and nobody has symptoms or whatever, I mean people will probably be more lenient to get the vaccine, but we would have to see,” as “there’s a lot of questions.”
• Unethical Historical Practices. One participant responded “I’m already against it. I’m paranoid.” She then brought up the past, saying “when I hear that Tuskegee experiment,” for example, “I stay away from that. I wouldn’t get a vaccine.” Another participant brought up the overrepresentation of African Americans in prisons, saying that we can just simply “look in the prisons. You have more people in prisons have gotten this” COVID-19 and the prisoners “are trying to get help. But I see” in prisons “what they used to do with vaccines, try it on prisoners and see how they respond.”
• Mistrust in Government and Healthcare System. One participant commented on the mixed messages from the federal government: “With that guy [President Trump] in the office, I used to look at how he’s been bouncing Doctor Fauci around.” In light of the observable conflict between Trump and Fauci, she shared that “in the black community, everybody is on high alert, very distrusting, because we don’t know what’s going to be perpetrated against us.” To provide an example that is “on another level, you see what’s going on with police brutality and” even when “things have been caught on tape and it’s not being addressed.” It is thus not “so weird in thinking that the vaccines that go to” certain zip codes with high population of people of color “would be tainted.” Accordingly, she concluded that “there’s substance to the paranoia.” Moreover, when asked whether it would make a difference if former President Obama advocated for a COVID-19 vaccine, one participant responded: “I don’t care who advocates for it.” Another said that she would still “have to say no way” because “it will be still under that umbrella of evil.” As one participant succinctly put it, “I think we’ve all lost trust in our health system.”

The late Justice Antonin Scalia, writing for the majority in Bruesewitz v. Wyeth LLC (2011), summed up what vaccination has accomplished in the last 75 years, that “the elimination of communicable diseases through vaccination became ‘one of the greatest achievements’ of public health in the 20th century.” Nevertheless, since the 1970s and 1980s, vaccines have, ironically, “been so effective in preventing infectious diseases that the public became much less alarmed at the threat of those diseases, and much more concerned with the risk of injury from the vaccines themselves,” Scalia writes. This has resulted in vaccines becoming what Scalia calls “victims of their own success,” among which the recently available COVID-19 vaccines evidently bear no exception.

My symposium article, Of Vaccine and Hesitancy, forthcoming in 77 Food & Drug L.J. (2022), from which this essay is adapted, further explores this topic and proposes potential ex ante solutions to the COVID vaccine hesitancy problem.

Jasper L. Tran is a senior associate at Milbank LA. His expertise includes intellectual property law, technology law, and health law. The usual, obligatory disclaimers apply, including views as my own and not necessarily reflective of Milbank or its clients.