Almost all of us know someone—maybe a relative, friend, or coworker—who is unvaccinated. In my case, it’s a local craftsperson whose services I use on a regular basis. “I’m just not comfortable with it. I might get it if I had to travel abroad or something, but I don’t go anywhere.” However, I am quite certain this person goes to the grocery store and other places where they could get infected. Although I’m fully vaccinated, I wear a mask when I’m in this person’s shop.

As I write this in mid-October 2021, only 56 percent of the U.S. population has been vaccinated, and several industrialized countries have overtaken us on this measure. Figure 1 shows a very slight uptick in U.S. vaccinations in the late summer of 2021, but that timing also coincides with the CDC’s approval—just in time for the start of the school year—of the Pfizer-BioNTech vaccine for children aged twelve through seventeen (Centers for Disease Control and Prevention 2021). Also, as I write this—by a margin of more than 140,000 over Brazil—the United States still leads the world in COVID-19 deaths (744,000, or approximately one out of every 445 people) and SARS-CoV-2 infections (45.8 million, or 13.8 percent of the population).

The vaccines for COVID-19 have been widely available in the United States since at least March—many months ago. I am here to tell you that at this point, the people who are unvaccinated are unlikely to get vaccinated. For those of us who value science, evidence, and our health, this seems crazy. I have had countless conversations with friends that begin and end with the statement, “Why don’t these people just get vaccinated?” For a long time, we heard people saying that they would not get vaccinated until the Food and Drug Administration (FDA) gave full approval to the vaccines. At least in the case of the Pfizer-BioNTech vaccine, full FDA approval came on August 23, 2021, and some news organizations claim to have detected an uptick in vaccinations after that date (e.g., Mitropoulos 2021). But as previously mentioned, that timing coincides with the start of the school year and childhood vaccination. At this point, it is clear that many of the people who started out hesitant are no longer hesitating. They are set in their decision not to get the shot. Why?

The psychology of vaccine hesitancy was a topic of research before the SARS-CoV-2 virus appeared, and I am sure health policy researchers are busy working on this topic as we speak. But there are some features of this wave of vaccine rejection that are quite different from earlier vaccine hesitancy movements. Using the hypothetical example of your anonymous uncle, I will offer a few reasonable hypotheses about why he’s not vaccinated at this late date. Finally, I will try to end this column on an upbeat note.

1. Your Uncle Is a Donald Trump Supporter

To the extent that earlier versions of the anti-vaccination movement were politically motivated, they were more likely to come from the left. In recent years, Robert F. Kennedy Jr., a Democrat who has built a reputation as an environmentalist, emerged as a major anti-vaccination spokesperson, promoting the discredited idea that childhood vaccines cause autism. In a rare example of bipartisanship, he has since embraced the largely conservative anti-COVID-19 vaccine movement and, as a result, has been banned from Instagram for spreading false information (Chappell 2021). The previous anti-vaccination movement was not strictly liberal. Recall that candidate Donald Trump alluded to the debunked claims of a vaccination-autism connection in the 2016 campaign (Lerer 2021), but in the case of COVID-19 vaccine rejection, it is now an overwhelmingly Republican phenomenon. (For more complete history of vaccine hesitancy and another perspective on the psychology of it, see Barglow 2021.)

Being a Trump supporter is not really a reason to reject vaccination, but it appears to be one of the strongest predictors of your vaccination status. An NBC poll conducted in late August 2021 looked at the relationship of vaccine status to several demographic variables, including education, age, race, and political party (Todd et al. 2021). The poll found the overall rate of vaccination among U.S. adults was 69 percent, and 13 percent of respondents said they would not get vaccinated under any circumstances. There was substantial variation in vaccination rates. For example, 80 percent of white college graduates were vaccinated, whereas only 60 percent of white non-college graduates were vaccinated.

One of the lowest levels of vaccination in the NBC poll was among respondents who voted for Trump in 2020: 50 percent, as compared to 87 percent among Joe Biden voters. The overall rate of vaccination among Republicans was 55 percent, but even within the Republican voter group, Trump had a substantial effect. Of the variables measured in the NBC poll, the lowest level of vaccination was among “Republicans who support Trump more than [the] party,” with a mere 46 percent vaccinated. Sixty-two percent of “Republicans who support the party more than Trump” reported being vaccinated.

To look at the Trump phenomenon in a different way, I created Figure 2, a plot of the percentage of the population of each of the fifty states that was fully vaccinated on September 20, 2021, as a function of whether the state voted for Biden or Trump in 2020. The results are fairly dramatic, with very little overlap. Although the data hardly need a statistical analysis to make the point, I performed a t-test and found that the results were highly statistically significant: t(48) = 7.84, p < .001, d = 2.22. The mean vaccination rate in Biden states was 59 percent, and 47 percent in Trump states.

Ironically, former President Trump and First Lady Melania Trump were among the first Americans to be vaccinated, but Trump and his supporters have also disparaged all the medical experts who have urged vaccination. As red states became the hotbeds of COVID-19 infections and deaths in the summer of 2021, Trump tried to urge his supporters at a rally to get vaccinated, but he was roundly booed by his own people (Blake 2021). For reasons I will say more about in the next section, it was far too late for Trump to pivot on this issue and hope to sway his supporters.

2. Your Uncle Wants to Avoid Cognitive Dissonance

If you put yourself in the shoes of one of these vaccine rejectors, you can understand why—even in the face of the more virulent Delta variant—they are not going to change their minds now. At the beginning, there was a moment when things might have gone the other way. It might have been different if the nation’s political leaders had come out united in favor of vaccines—perhaps President Trump, President-Elect Joe Biden, and their wives could have been vaccinated together in a live televised event. Perhaps Mike Pence and Kamala Harris could have done public service announcements together. But nothing like that happened. Instead, President Trump was almost never seen wearing a mask, and Republican politicians and conservative media figures cast doubt on the severity of the pandemic and the safety of vaccines (Lerer 2021).

By now, that moment of opportunity is long past. We can only imagine that, in the months since vaccines became widely available, the adults such as your uncle who have not yet been vaccinated have had hundreds of conversations with their friends and families and have heard themselves justify their decisions over and over. Once vaccine rejection became a fixed idea, going against that decision would produce cognitive dissonance—an unpleasant motivational state created when our actions conflict with our stated beliefs or values. When the stakes are low, the conflict is sometimes resolved by changing one’s beliefs or attitudes, but when the beliefs are more central, the solution is often to remain loyal to your beliefs and avoid those actions that would create dissonance. To suddenly get vaccinated now, without other provocation, would be difficult for vaccine rejectors to justify.

In an earlier column, I considered how QAnon believers would handle the resulting cognitive dissonance when their widely held belief that Donald Trump would be reelected did not come true (Vyse 2021). This was an example similar to the famous book When Prophecy Fails, which described the experiences of a religious group that predicted the end of the world on a specific date (Festinger et al. 1956). In that case, when the date of destruction came and went, many people rationalized the prophecy’s failure and became even more faithful members of the religious group. But in the case of vaccine rejection, the action that would cause dissonance—getting vaccinated—is under the individual’s control. Your uncle can avoid the conflict that would result from changing course so late in the pandemic by remaining true to his risky decision.

3. Your Uncle Thinks COVID-19 Isn’t That Serious

A common theme among opponents of mask mandates and lockdowns is that doctors are trying to scare you and COVID-19 isn’t that bad. In fact, President Trump, while still in Walter Reed Medical Center receiving state-of-the-art COVID-19 treatments available to almost no one else, tweeted “Don’t be afraid of COVID. Don’t let it dominate your life” (Kolata and Rabin 2020).

Concern about the pandemic might be greater if the disease were more visible. The great global pandemics of the past were both more deadly and easier to see. The SARS-CoV-2 pandemic is not like previous plagues. Giovanni Boccaccio witnessed the Black Death of Florence in 1348 and described the progress of the disease in The Decameron:

The first sign in both men and women was a swelling in the groin or beneath the armpit, growing sometimes in the shape of a simple apple, sometimes in that of an egg, more or less: a bubo was the name commonly given to such a swelling. Before long this deadly bubo would begin to spread indifferently from these points to crop up all over; the symptoms would develop then into dark or livid patches that many people found appearing on their arms or thighs or elsewhere. (Boccaccio [1351] 2008, 7)

According to Boccaccio, plague victims typically died within three days of beginning to show symptoms. Because the death rate was so great in these earlier periods, bodies piled up in the streets and were carted off by wagons to mass graves. The accompanying painting, showing corpses strewn about a large area, is by Michel Serre (1658–1733), who lived through the plague of 1720.

Even in the Spanish Flu pandemic of 1918, the medical science and healthcare facilities in the United States were far behind what they are today. Temporary mass treatment facilities for both returning World War I soldiers and civilians were much more common. In addition, unlike COVID-19, which has its worst effects on older patients, the Spanish Flu was most deadly for the very old and the very young. Dying children tend to evoke more sympathy and concern than death among the elderly. Although recent headlines touted that U.S. COVID-19 deaths have now surpassed the U.S. deaths from the Spanish Flu, for a variety of reasons—the most obvious being that the U.S. population was one third the size it is now—the 1918 H1N1 flu virus was still more deadly (Kaul 2021).

In contrast, whenever anyone begins to show symptoms or tests positive for the coronavirus, they immediately quarantine themselves and disappear. It occurs to me that the probability of seeing anyone cough in public is now at its lowest point in my lifetime. We all have learned a lot about how to avoid infection, and one result of that knowledge is that we rarely see sick people. Some people who die of COVID-19 do so at home or in nursing facilities, but many people who are seriously ill go to the hospital. At this point, we know that over 90 percent of the people hospitalized with COVID-19 are unvaccinated (Rosenberg et al. 2021). These people don’t trust the medical establishment enough to get vaccinated, but they head to the hospital when they get really sick. Once in the hospital, they are protected by medical privacy laws, and only the healthcare workers see the scope of the problem. In our everyday lives, we see little evidence of sickness, despite living through the largest pandemic in a century. Finally, if I am right that your uncle is a Trump supporter, the media he consumes are not likely to remind him of the ongoing pandemic very often.

If the medical implications of the pandemic were more visible, it would appear more serious, but our modern healthcare practices give your uncle plausible deniability. From his point of view, the most obvious signs of the ongoing pandemic are those annoying masks, lockdowns, and vaccination mandates.

4. Your Uncle Values His Freedom More Than His Health and That of Those around Him

Freedom is one of the most consistent themes stressed by the anti-COVID-19 vaccine movement (Dickey 2021). Even prior to the coronavirus pandemic, research showed the importance of individual rights to vaccine hesitancy. A 2017 study of the moral values favored by vaccine-hesitant parents found they were significantly more concerned about purity and liberty than they were about harm and fairness (Amin et al. 2017). Highly vaccine hesitant parents also showed significantly lower valuing of authority than non-hesitant parents.

If anything, the theme of liberty and freedom of choice has only strengthened in the current debate over the response to the SARS-CoV-2 pandemic. Florida Governor Ron DeSantis, a Republican who is often mentioned as a potential presidential candidate, is one of the most vocal critics of Dr. Anthony Fauci, the nation’s primary authority on COVID-19 policy, and DeSantis often stresses the theme of freedom. However, as the Delta variant of SARS-CoV-2 spread throughout the country in the late summer of 2021, Florida emerged as the leader of a group of largely Republican and relatively unvaccinated states with the highest number of new COVID-19 cases and deaths (Bump 2021).

None of this seems to have deterred the freedom advocates. Even in my solidly blue state of Connecticut where relatively high numbers of people are vaccinated and the infection rate has been low, there is a state-wide advocacy group fighting mask mandates in schools and vaccine mandates in work settings. In a real-world example of what the research shows, the policies advocated by the freedom groups have harmed themselves and others. At this point, the overwhelming majority of people hospitalized with COVID-19 and dying of COVID-19 are unvaccinated (Sullivan 2021).

This is not the first time in American political history that individual rights have come into conflict with public health. Pro-gun advocates frequently cite their Second Amendment individual right to own firearms, but for several decades there has been good evidence that bringing a firearm into your house increases the likelihood of homicide in your home (Vyse 2015). Thanks in part to a very effective gun lobby, many people believe exactly the opposite—that owning a gun makes them safer. The theme of freedom and rejection of government control is strong in both the gun rights and anti-COVID-19 mandate movements, and some politicians have drawn the two issues together. In July 2021, in response to President Biden’s proposal to go door-to-door to offer the COVID-19 vaccine, U.S. Representative Madison Cawthorne (a Republican from North Carolina) said, “They could then go door to door and take your guns. They could go door to door and take your Bibles” (Castronuovo 2021). As the research suggests, many people with a strong commitment to their individual freedoms either deny that their actions cause harm or are willing to accept those harms for themselves and others.

A Mildly Optimistic Ending

At this point, there is one glimmer of hope: mandates. This will not be an easy route for the politicians, employers, and school systems who impose them. There are already protests, legal challenges, and other forms of resistance, but the evidence suggests that mandates work (Koerth 2021). Vaccine mandates have been employed in the United States as far back as the smallpox epidemic of the late nineteenth century (Astor 2021), and for decades they have been routinely applied to school children. In early September, President Biden announced that all companies with over 100 employees would have to require their staff to be vaccinated or provide a negative COVID-19 test at least once a week (Kavi 2021).

If your uncle (aunt, brother, sister, etc.) is forced to choose among losing his job, submitting to testing, or getting vaccinated, he may give in to getting vaccinated. Similarly, parents who want their kids to go to school may have to get them vaccinated—just like in the old days. As I write this, Pfizer/BioNTech has announced that it will soon ask for approval for the use of their COVID-19 vaccine in children aged five to eleven years.

From a psychological point of view, mandates also provide a hedge against cognitive dissonance. The person who responds to a mandate can claim they still maintain the same beliefs and values about vaccines but have submitted in response to an outside force. “I had to do it for work.” The mandate provides an external force that causes less cognitive dissonance than a more independent choice would produce. It is unclear how many more people will get vaccinated as a result of mandates, but mandates appear to be our last best hope.

References

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Astor, Maggie. 2021. Vaccination mandates are an American tradition. So is the backlash. The New York Times (September 9). Available online at https://www.nytimes.com/2021/09/09/us/politics/vaccine-mandates-history.html.

Barglow, Peter. 2021. The psychology of U.S. vaccination hesitancy. Skeptical Inquirer 45(6): 52–56.

Blake, Aaron. 2021. Trump and top ally get booed by the monster Trump’s GOP created. The Washington Post (August 23). Available online at https://www.washingtonpost.com/politics/2021/08/23/trump-booed-gop-vaccines/.

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Dickey, Colin. 2021. We’re talking about vaccines all wrong. The Atlantic (July 30). Available online at https://www.theatlantic.com/ideas/archive/2021/07/freedom-is-the-only-argument-that-might-work-with-vaccine-holdouts/619609/.

Festinger, Leon, Henry W. Riecken, and Stanley Schachter. 1956. When Prophecy Fails. New York, NY: Harper & Row.

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Vyse, Stuart. 2015. Guns: Feeling safe does not equal being safe. Skeptical Inquirer Online (December 16). Available online at /exclusive/guns-feeling-safe-does-not-equal-being-safe/.

———. 2021. When QAnon prophecy fails. Skeptical Inquirer Online (February 15). Available online at /exclusive/when-qanon-prophecy-fails/.