Vaccination confers almost total protection to all adults fully vaccinated against the COVID-19 virus. Because over 650,000 persons have died in the United States alone from this pandemic, it becomes vital to fully understand the phenomenon of vaccine refusal. Recent news sources reported that COVID-19 cases are rising in almost every state, resulting in increasing hospitalizations and deaths (“Coronavirus in the US” 2021). The best explanation for this increase is large-scale failure to vaccinate combined with the rapid spread of the highly contagious Delta virus variant.
As of the latest CDC figures on August 21, 2021, only about 51 percent of American adults have received vaccination against the new virus. This statistic is astonishing, because vaccination has been scientifically proven to be effective and safe. Ninety-nine percent of recent American COVID-19 deaths were of unvaccinated persons.
“Vaccination is the number 1 most effective mitigation step to protect families and neighbors,” commented Dr. Sam Page on July 7 about high infection rates in Missouri (Page 2021). Dr. Rochelle Walensky, director of the National Centers for Disease Control and Prevention, said the United States was experiencing “a pandemic of the unvaccinated” (Anthes and Petri 2021). Though it has become clear that even those fully vaccinated can still catch the virus, very few become seriously or fatally ill.
It is a serious mistake to lump men and women who choose not to have vaccine protection into one single category, though news reports often do this. I maintain that American adults who choose not to receive COVID-19 vaccination are quite diverse. Hispanics and African Americans, who are vaccinated at lower rates than whites, in particular may have special reasons, such as poor access to medical care and distrust of the medical establishment. My emphasis here is not on political party or religious affiliation; it is instead focused on psychological reasons.
Cultural majority populations are better understood and have clearer reasons for their reluctance to be vaccinated. I confine my psychological investigation to them. I arbitrarily divide these into three groups: 1. the relatively reasonable hesitant; 2. the somewhat irrational refusers; and 3. the quite irrational avoiders.
Many explanations have been offered for people’s refusal to be vaccinated against COVID-19. But to this doctor author, most of them seem incomplete or unconvincing. A skeptic must regard many current political analyses as superficial and shallow. Before reexamining the most popular reasons provided for vaccine hesitancy, I will offer a summary of vaccination history overall, apart from COVID-19 specifically.
Without doubt, immunization can boast proven worldwide value. It may even be the most spectacular single achievement in public health. But in the United States, anti-vaccination sentiments arose as rapidly as vaccination itself. The first American vaccination against smallpox was criticized as antithetical to God’s will. One enraged citizen bombed the house of pro-vaccination New England Puritan minister Cotton Mather in 1721 (Ault 2021).
Variolation, later known as inoculation, had come to Britain during the early eighteenth century. It immunized persons against smallpox by infecting them with material obtained from skin pustules produced by a mild form of the disease, variola minor. When smallpox later occurred, it was less virulent. The technique had many risks, including death. The Chinese had used the method as early as the year 1000. In the late eighteenth century, Emperor K’ang, who survived smallpox, had his children inoculated in this way. In fact, this method may have originated as early as 200 BCE.
During the eighteenth century, 400,000 Europeans died of smallpox per year. A son of Benjamin Franklin died from it in 1736. Edward Jenner in England had the idea of taking fluid from a cowpox blister and placing it in scratches he made on the skin of a child in 1796. The boy had a brief illness, but when he was later exposed to smallpox, he did not become sick. But Jenner’s inoculation at the time incited opposition based on infection risks, use of animals to cure humans, and doctors profiteering from the discovery. Much later (1958–1977), vaccination with a live vaccinia virus replaced inoculation. Finally, smallpox was almost eliminated from the world. Other live vaccines were developed that protected humans against diphtheria, whooping cough, measles, mumps, rubella, and chickenpox. Spread of polio, pneumo- and meningococcus, hepatitis B, and type B influenza were prevented through these methods.
The COVID-19 vaccines Moderna, Pfizer, and Johnson & Johnson were manufactured during 2020–2021 with unique speed. “Viral vectors” ingredients used a novel fabrication process. The Federal Drug Administration (FDA) gave the vaccines emergency authorization, and they were put into widespread use. In August 2021, the FDA gave full authorization to the Pfizer vaccine, which many cautious persons require to feel safe getting it. (FDA approval of Moderna is expected also.) The FDA is not an infallible arbiter of a drug’s efficacy, and sometimes the agency succumbs to public advocacy or big manufacturing company pressures in their approval process. But its approval is the best proof of scientific veracity that we have. So what motivates vaccine hesitancy in American majority populations? Even former President Donald Trump was finally vaccinated. I first consider the views of the many typical Americans who fear little harm from COVID-19 but much harm from vaccines.
The ‘Relatively Reasonable Hesitant’
An example of a healthy woman who steadfastly has refused to be vaccinated will introduce a few major questions about such reluctance.
Case History #1
Martha is a forty-year-old upper-middle-class college graduate. A teacher who lives in the suburbs, she claims she will not be vaccinated. This is unusual, because American women are more likely by 3:2 odds to choose to be vaccinated than are males, and in American families, health concerns tend to be often assumed by women (possibly accounting for females’ longer life expectancy). Martha has been happily married for ten years to a wealthy business executive who did get the vaccine. The couple has chosen to remain childfree, because they love the freedom to travel and fully enjoy art, music, and culture. (Women without children are slightly less likely to be vaccinated than those with offspring.)
Martha is rather thin and profoundly preoccupied with health. She exercises daily and consumes a natural food diet emphasizing homegrown vegetables and fruits, which help maintain her stable weight. About vaccination, she says, “I don’t want any artificially manufactured, chemical substance put into my body.” Also, she has heard that current vaccines have not yet received full governmental approval, which worries her. She feels safe from the COVID-19 virus anyway, because she usually wears a mask in public, sometimes even with casual friends. She observes distancing precautions and avoids crowds. She endorsed the following adjectives on a scale of concerns about the vaccine: impure, unnatural, unhealthy, unclean, and unknown.
Martha is influenced by the many prominent people frequently appearing in national news media who emphasize the dangers of vaccination. It seems likely that most such reporting has some integrity and is based on some evidence. (An exception with pre-COVID-19 vaccine reports was the 1998 fake case series of Andrew Wakefield and colleagues, who fraudulently associated the MMR vaccine with autism in children [Sathyanarayana and Andrade 2011].) Fox News’ pundits Tucker Carlson and Laura Ingraham, each with millions of viewers, have overemphasized the dangerousness of vaccines and claimed governmental overstep in pushing them. The Biden administration vaccination initiative, Carlson claimed, was a scandal and an attempt to “force people to take medicine they don’t want or need” (Hsu 2021). Why are many susceptible to this view?
Carlson is influenced by right-wing extremists politically. He overemphasizes the dangers of vaccination and its side effects. Robert F. Kennedy Jr., an environmental lawyer with the Kennedy name, is very influential and responsible for half of the anti-vaccine advertising content on Facebook. He was influenced by Andrew Wakefield and has particularly emphasized the medical dangers of vaccination to blacks and Hispanics. Rudolf Steiner, founder of Waldorf Schools, advocated for “anthroposophy,” which postulates a spirit world accessible through clairvoyant insight. Vaccination for him represents “secular civilization’s impoverished substitute for spiritual enlightenment” (R. Barglow and Schaefer 2021).
All of us—no matter how expert or specialized—are influenced by the personal experiences of peers, friends, and others who are similar to us or whom we admire. This author became quite worried about COVID-19 vaccination when it was reported that Gregory Michael, a healthy Miami middle-aged obstetrician, died sixteen days after being vaccinated (Grady and Mazzei 2021). However, a follow-up report—not well publicized—concluded that he had died from a medical disorder unrelated to his vaccination. All of us are persuaded by publicized beliefs of national leaders with impressive credentials. But people in my first category, such as Martha, frequently can be persuaded to change their vaccination stance with more information.
The ‘Somewhat Irrational Refusers’
Medical complications of COVID-19 vaccination are extremely rare; even so, worry about these to the extent of refusing the vaccine is a common rationale. To illustrate, I offer a case history of a man who for many months had refused vaccination. He eventually changed his stance, giving in to the dual pressure from me (his therapist) and from his wife, a scientist. The example also introduces the important potential magical meaning of syringe needles in investigating vaccination hesitancy.
Case History # 2
Eighty-year-old Samuel is a married retired accountant originally from Brazil. He sought psychiatric treatment for anxiety and PTSD symptoms, psychological depression, and bouts of paralyzing anxiety. He also suffered from physical symptoms secondary to trigeminal neuralgia, gastro-paresis with a variety of chronic bowel symptoms, chronic fatigue syndrome, right-hand tremor, and difficulty with walking long distances. He has never suffered from alcohol- or drug-abuse problems. Recently he has been prescribed low-dose Propanolol, Gabapentin, Buspirone, Hydroxyzine, Lyrica, Amphetamine salts, and Oxycodone tablets.
His many physical and psychiatric conditions had made it impossible to maintain his lifelong success as a skilled accountant. He reluctantly received doses of the Pfizer vaccine after extensively researching its benefits and risks. Right away he developed a slight rash at the injection site, small temperature fluctuations, and a worsening of his arm tremor. Two days after the second injection, he could no longer walk and became confined to a wheelchair. He attributed all this to his COVID-19 vaccination.
Reading this case history could convince many cautious, clear-thinking Americans that vaccines indeed have unknown dangers. But serious adverse medical post-vaccination events occur in only about 0.6 percent of patients (compared with 0.5 percent in a placebo group) (Federal Drug Administration 2021). But such extreme concerns about possible vaccine complications account for many instances of vaccine refusal. “What will happen two or three years from now if I’m vaccinated today?” is a frequent worry. But Americans who worry about such long-term effects can sometimes change their minds when presented with contrary evidence.
It did appear that my patient’s ambulation impairment was worsened by the vaccination, but a clear cause-effect explanation could not be determined. The patient and I agreed to continue routine psychological and medication management of his multiple conditions. He agreed to set aside further consideration of the impact of his vaccination. Physical therapy was reinstituted. The “full approval” by the FDA for the Pfizer vaccine (on August 23, 2021), and the absence of severe side effects in the many millions of people who did get vaccinated, can and sometimes does change people’s minds, given enough support and reassurance.
The ‘Quite Irrational Avoiders’
Magical beliefs about needles and/or fluids can often be identified in the third category of vaccination refusers. Americans, mostly males, who have strong views against vaccination in general constitute a far smaller group than do the first two categories. To further consider the meaning of needles, I will return to Case History #2 above.
In his past, the psychiatric patient, Samuel, had a major worry about complications from vaccination, and he did suffer a minor side effect from the injection. But he had previously regularly used acupuncture for help with his medical symptoms. The ostensibly ancient aspect of this treatment, to him, demonstrated the potency of needles. Treatments that have a mysterious power to heal also may be associated with the power to harm. In traditional Chinese medicine, acupuncture has for many centuries “cured” physical symptoms. I maintain that this is a consequence of the placebo power of needles inserted below the skin’s surface. No investigator has as yet located any evidence for the presence of the twelve Tai Ming meridians, which acupuncturists claim will produce benefits when punctured. But both needles and their contents can have much emotional power to influence decisions, more than rational realistic concerns have. (More discussion about needles will follow below.) This patient did not suffer from “fear of needles,” but many persons do.
A different and far more dangerous and irrational opposition to vaccination characterizes the vocal groups of so-called “conspiracy theorists.” One national March 2021 investigation showed that 16 percent of eligible Americans refused vaccination for two reasons: skepticism about the reality of the pandemic and a belief in at least one conspiracy theory (Smarsh 2021). Only a part of this resistance relates to “trypanophobia”—an irrational needle fear or “aichmophobia,” a fear of sharp objects.
Conspiracy thinking typically involves ideas about invisible, secret, mysterious agents introduced into the healthy body. These refusers’ focus is on “unnatural” hidden chemicals in new vaccines that could cause changes in DNA, among other things. Probably, this category of vaccine resister must be considered to be discontinuous with the “somewhat irrational” opposition to vaccination group discussed just above. The 50,000 members of the QAnon movement are the most influential representatives of this category. Their possible psychology serves as the focus for understanding this third category of vaccination resister.
Here the central thesis of QAnon regarding coronavirus vaccines is that they are not targeted toward saving lives but are “bioweapons concocted by an evil secret cabal of corrupt government officials and drug companies” (Timberg and Dwoskin 2021). The supposed leaders of this loose organization also believe Democrats, some celebrities, and evil others have dark hidden goals and practices, including the promotion of child sex trafficking and even the eating of babies.
Who is the typical QAnon believer? Members are predominately middle-class white males who share a devotion to video games, cryptocurrency, and men’s rights. Women such as Marjorie Taylor Greene, who stated a concern for child protection, reflect a minority of conspiracy believers. There is some overlap with right-wing doubt of Big Government, as was shown in the large Conservative Political Action Conference in Texas July 9–11, 2021. Their misogynistic concerns adopt many of former President Trump’s wilder but influential comments, such as the following one made to former Vice President Mike Pence: “You can either go down in history as a patriot or you go down as a pussy” (Chait 2021).
Such a hyper-masculine stance valorizes matter that is hard and solid (male) over substances soft and fluid (female). A kind of phallic pride is involved. The “swampy” and unsolid are to be feared. Not surprisingly, such concerns on the part of men are not new. Study of German history recalls the fears of the German Freikorps soldiers a century ago. In 1914 after World War I, they were preoccupied and hostile to the human body’s slimy substances (Theweleit 1987).
These concerns reached their greatest influence a few years later during the 1918 flu epidemic, just after the war. Then, as today, airborne infections carried menace. Fans of old movies will be reminded of the character General Jack Ripper in the 1964 Stanley Kubrick film Dr. Strangelove. This heroic fictional character launched a nuclear strike on the Soviets to defend the purity of “our precious bodily fluids.”
Can some QAnon members be considered paranoid? They have unfounded fears that they are being or will be persecuted. They are mistrustful, suspicious, and slightly grandiose. Among their concerns is that new vaccines will change their genes by being inserted into their DNA. One variation of this imagined danger is that mind-controlling microchips are inserted through the vaccine for the purpose of total government control.
Such a danger for conspiracy believers seems far more frightening and threatening than the disease itself. The radio show host Alex Jones has websites widely disseminating these views (Homans 2019). To understand such widely disseminated views requires a nonpolitical “depth” psychological examination.
It is useful to empathize with the lived experiences of an ordinary person receiving an injection. The vaccine fluid is fully visible to the patient while confined to the plastic or glass vial. The needle transfers the liquid beneath the patient’s skin into the muscle, where it can no longer be seen and becomes invisible to the naked eye. That which can’t be seen concretely, for some emotionally vulnerable people, may be easily conceptualized as secret, toxic, impure, unsafe, and dangerous. The process can seem emotionally dangerous, particularly to males. As mentioned earlier, males statistically avoid vaccines more than females.
My understanding uses a conception of developmental visual psychology I described half a century ago (P. Barglow and Sadow 1961). What the year-old baby sees, early in life, becomes a way to decide between what is real and likely permanent or unreal and fleeting. Later what is seen allows the older now adult person to decide what is true and what is false. Sight continues to guarantee reality during adulthood. What can’t be seen (viruses or vaccine contents) can seem unreal. And the “soft” liquid substance injected into the arm seems menacing.
Those whose lives habitually are dominated by conspiracy theories are unlikely to change their opposition to vaccination. It is a waste of scarce educational and information resources to try to educate them. National efforts should focus upon only the “relatively reasonable hesitant” and the “somewhat irrational refusers” who might utilize this life-preserving and readily available medical procedure if given enough information and reassurance. A person just needs to be convinced to say “yes” to vaccination once or twice.
References
Anthes, Emily, and Alexandra E. Petri. 2021. CDC director warns of a pandemic of the unvaccinated. New York Times (July 16). Available online at https://www.nytimes.com/2021/07/16/health/covid-delta-cdc-walensky.html.
Ault, Alicia. 2021. History shows Americans have always been wary of vaccines. Smithsonian Magazine (January 26): 1–6.
Barglow, Peter, and Leo Sadow. 1961. Visual perception: Its development and maturation birth to adulthood. Journal of the American Psychoanalytic Association 115: 433–451.
Barglow, Raymond, and Margret Schaefer. 2021. Red alert: Anti-vaccination in the age of COVID-19. Skeptic. Available online at https://www.skeptic.com/reading_room/red-alert-anti-vaccination-in-the-age-of-covid-19/.
Chait, Jonathan. 2021. Trump made the stupidest possible argument on Mike Pence. New York magazine (January 12).
Coronavirus in the US: Latest map and case count. 2021. New York Times (July 19).
Federal Drug Administration. 2021. US, FDA Briefing Document Pfizer-BioNTech Covid-19 Vaccine (March 5).
Grady, Denise, and Patricia Mazzei. 2021. Doctor’s death after covid vaccine is being investigated. New York Times (January 12). Available online at https://www.nytimes.com/2021/01/12/health/covid-vaccine-death.html.
Homans, Charles. 2019. Alex Jones under oath is an antidote to a ‘post-truth’ age. New York Times (April 17). Available online at https://www.nytimes.com/2019/04/17/magazine/watch-alex-jones-called-to-account-over-sandy-hook-under-oath.html.
Hsu, Tiffany. 2021. Despite outbreaks among unvaccinated, Fox News hosts smear shots. New York Times (July 11). Available online at https://www.nytimes.com/2021/07/11/business/media/vaccines-fox-news-hosts.html.
Page, Sam. 2021. Dr. Page’s message; health advisory. Missouri State DPH County hotline. St Louis County Public Health (July 12).
Sathyanarayana, Rao, and Chittaranjan Andrade 2011. The MMR vaccine and autism: Sensation, refutation, retraction, and fraud. Indian Journal of Psychiatry 53(2): 95–96.
Smarsh, Sarah. 2021. What to do with our covid rage. New York Times (August 8): 4. Available online at https://www.nytimes.com/2021/08/07/opinion/sunday/covid-unvaccinated-anger.html.
Theweleit, Klaus. 1987. Male Fantasies, Volumes I and II. Minneapolis, MN: Minnesota University Press.
Timberg, Craig, and Elizabeth Dwoskin. 2021. With Trump gone, QAnon groups focus fury on attacking coronavirus vaccines. Washington Post (March 11). Available online at https://www.washingtonpost.com/technology/2021/03/11/with-trump-gone-qanon-groups-focus-fury-attacking-covid-vaccines/.