“If we do not get up off our knees and stop worshipping scientists and doctors who have too little knowledge and have been given too much power, tomorrow we will not be able to get on a bus, train, or plane; enter a store or sports arena; obtain a driver’s license or passport; file our taxes; or function in society without getting every vaccine that industry creates and the government orders us to get.” 

These words were offered by Barbara Loe Fisher, founder of the largest national organization in the US opposed to vaccine requirements, in 2019, long before Americans had imagined the Covid-19 outbreak. Speaking at an event organized by “Crazy Mothers,” a group whose stated goals include bringing attention to injuries caused by childhood vaccines and empowering mothers to make informed health care decisions, Fisher’s comments were meant to condemn state laws that require childhood vaccinations for school attendance and recent state efforts to tighten enforcement of those requirements. 

At the time, even those skeptical of vaccines might have found Fisher’s remarks paranoid or conspiratorial. Today, as the Covid-19 pandemic ravages the country, infecting more than 4.2 million Americans and killing more than 146,000, plans to develop and test a vaccine as quickly and safely possible are unfolding. Suddenly, her statement might seem more like a premonition to much of the anti-vax community.

As a sociologist who has been studying vaccine refusal for more than a decade, I work to understand parents’ fears of vaccines and how parents come to make health care decisions for their families. Whenever I read news articles where officials tentatively promise a coronavirus vaccine late this year or early next year, I worry about how this messaging will be received by both existing vaccine critics and newcomers.

I understand the desire to calm an anxious public with good news — and, to be clear, many objections about the potential future vaccine are inaccurate and risk undermining a much-needed public health intervention. But in order for a vaccine to be broadly accepted to provide some community-level protection, we must explore the questions and assertions driving skepticism about a Covid-19 vaccine among those who already oppose them, as well as those who are still uncertain. 

The anti-vax movement was already growing before Covid-19

Before we had heard of Covid-19, vaccine refusal was growing across the country. Parents’ reasons for rejecting vaccines vary — some are not convinced that vaccines are necessary or believe their children’s immune systems would be stronger if they contracted an illness and recovered, often citing their families’ lifestyle and good health. Many do not trust that pharmaceutical companies are adequately testing vaccines and don’t believe government agencies are vigilantly regulating them before licensing vaccines and requiring them for school attendance, both of which are unfounded. Parents who distrust vaccines most often argue that vaccines are a personal consumer product and should be chosen by those who believe they are useful, but should never be required.

The vaccine against Covid-19 is currently hypothetical, so many questions about its use are as well. As of now, it appears that young children are unlikely to be an early target of a Covid-19 vaccine since they are the age group least likely to develop the worst symptoms of coronavirus infection or to die. Although arguments of who should be first in line for the vaccine are ongoing, the World Health Organization recommended that adults over age 30 and in high-risk categories and occupations are most likely to be recommended for priority use. 

There is also broad disagreement about what portion of the population needs to become immune to infection, either through antibodies derived from recovery from illness or via a vaccine, to slow new infections. Efforts to estimate herd immunity — that is, the point at which a critical mass of the population is immune to infection and can starve the virus of available vulnerable hosts — range dramatically, with models suggesting everything from 80 percent to as little as 20 percent immunity will help to slow infections.  

Surveys conducted in May and June by the Pew Research Center and ABC-Washington Post show about 70 percent of American adults are willing to get a vaccine against Covid-19, while the Associated Press-NORC Research puts that figure closer to 50 percent. Skeptical groups range widely. According to all three polls, Republicans were less likely to say they want the vaccine. African Americans were also less likely to want the vaccine and less likely to support experimental interventions (a logical objection given the lengthy history of unethical research in Black communities). Among those who do not want a vaccine, safety concerns were the largest reason, but fears that the government will use concerns about the virus to promote the vaccine and increasingly surveil and control people, which have fueled protests against stay-at-home orders and mask requirements, also plays a part. 

There are no clear answers to questions about a vaccine that does not yet exist. Yet many concerns raised by the parent-led movement to refuse existing vaccines are informative for thinking about how a new one will be received. Those who are fundamentally opposed to vaccines will likely not budge. But addressing some of these concerns and narratives below could increase trust in the Covid-19 vaccine among those who are worried but persuadable.

Fears of collusion between government and Big Pharma

Many Americans do not trust pharmaceutical companies, with trust plummeting during the opioid crisis and remaining low as more news has come out about drugs that are poorly manufactured, contaminated, ineffectual, harmful, or priced out of reach even when medically essential to save lives. While surveys this spring showed some optimism that companies will likely provide solutions to Covid-19, trust remains low. 

This distrust goes hand in hand with anti-vaccine sentiment. Prior to Covid-19, I often heard complaints from those critical of vaccines about the revolving door between Big Pharma and government. Many of these concerns seem confirmed by the creation of Operation Warp Speed (OWS) this May, a White House initiative to accelerate the development, manufacturing, and distribution of Covid-19 vaccines.

OWS is headed by Health and Human Services Secretary Alex Azar, a former pharmaceutical executive and lobbyist, and Defense Secretary Mark Esper, a former US Army officer and defense contractor lobbyist. Dr. Moncef Slaoui, a longtime executive at GlaxoSmithKline (GSK) and recent board member at the biotechnology company Moderna, was appointed a chief adviser to OWS — and, despite still owning millions of dollars worth of stocks in companies who received OWS funds, is not required to disclose conflicts of interest because he is a contractor and not a government employee. 

There is no reason to believe OWS will not rigorously monitor safety. Yet the leadership and funding of OWS include financial arrangements in which the government and not the companies carry much of the cost of manufacturing, which will begin before trials are completed. This means that the government must be willing to throw away hundreds of thousands of vaccine vials should the trials fail. Critics suggest that the close relationship between pharma and government and the federal government’s significant financial investment in “at-risk manufacturing” could create incentives to interpret data positively, even when concerns may be present. 

These issues are being discussed in anti-vax circles. One online discussion in March in response to a video of a radio show by anti-vaccine activist Del Bigtree illustrated perceptions that governments and public health agencies support pharmaceutical companies’ profits instead of good health among citizens. Commenting on the video, which has been played almost 300,000 times, one viewer replied, “The answer to disease is not better drugs but better health. The problem with better health is that the big Pharma can’t profit from you.” Others replied: “‘For profit’ public health folks should not be directing our economy ON ANY LEVEL.” Another viewer added, “Why make the distinction between for profit and non profit? They all follow the agenda.”

One doesn’t need to be a conspiracy theorist to expect financial conflicts of interest should be managed well. The federal government entered into a $2 billion deal this week with two pharmaceutical companies to offer a vaccine at an affordable $40 a person for 50 million Americans, representing a significant investment in the nation’s health. Public leaders should make clearer to consumers that these partnerships represent a public investment in access and affordability, not a naked attempt at personal or corporate enrichment. 

Concerns that vaccines are not rigorously tested

In order to move the vaccine to market quickly, companies are running multiple stages of clinical trials “in parallel” rather than sequentially. Researchers usually take months between phases to examine data and make sure they understand the information before proceeding, and trials take years, not months. Instead, Azar claims OWS will “compress and wring out every inefficiency in the process and take away every unused day” to expedite the research process. Federal agencies insist they are committed to safety and “will not cut corners” in licensing decisions. Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, described his goals: “I really want to make sure that we don’t have a vaccine that’s distributed among the American people unless we know it’s safe and we know it is effective. … Not that we think it might be effective, but that we know it’s effective.”

Despite reassurances, there are signs that this rushed pace and inconsistent messaging from the White House about the severity of the outbreak is harming trust in the potential vaccine. As one Twitter post said, “‘Warp speed’ says it all. Project has been rushed and corners are being [cut]. No point producing a vaccine that could be more dangerous than the desease….but tell that to trump. Desperate to find a vaccine for a desease he thinks doesn’t exist. Bizarre.”

Vaccine critics, like those who work in Robert Kennedy’s Children’s Health Defense, an organization that aims to undermine vaccine usage and promote the widely discredited vaccine-autism link, have been quick to criticize this process, explaining how researchers made “the decision — deemed ‘morally questionable’ by some — to sidestep the standard process for vaccine development.” 

Vaccine advocates acknowledge the challenge of assuring the public that science can be fast and careful. Bruce Gellin, president of the nonprofit Sabin Vaccine Institute, noted how the name Operation Warp Speed does not inspire confidence in a cautious scientific method: “What is a worse name for something that’s supposed to give you trust in a product that you want everybody to take?”

Researchers are working at a record pace to find a vaccine that will work, but they are also describing the importance of maintaining realistic expectations to ensure there are no pressures to sacrifice the scientific process, irrespective of promises made by the White House. Scientists acknowledge their understanding of this novel coronavirus is still evolving, which could affect how recommendations about an eventual vaccine look, and consistently note that even though finding a vaccine against Covid-19 is important, good science nonetheless takes time.

As new information becomes available and recommendations and scientific processes shift, better messaging should make clear that science must work methodically, incrementally, and sometimes slowly to be sure information is correct. This also requires messaging that acknowledges a vaccine may take longer than expected to ensure it is safe and effective. 

Fear of forced vaccination

Outside of the military, the US does not have any existing laws to mandate vaccination for adults. The US has no system of enforcement of an adult vaccine requirement and lacks infrastructure for door-to-door administration of vaccines. There is currently no proposal for state or federal governments to universally mandate Covid-19 vaccination, and the logistics of creating and enforcing such a mandate are hard to imagine within current systems. 

Indeed, there are some calls for mandatory vaccination, including from the New York Bar Association, and from some health care providers who cite low usage of the seasonal influenza vaccine as evidence that voluntary use will be inadequate to obtain herd immunity. But recognizing that supply of any new vaccine will likely be inadequate to meet demand in the first year (even if only half of Americans currently say they plan to get it), the government is unlikely to universally require vaccination. 

What is more complicated to evaluate is how the private sector could make different choices. As of now, vaccination requirements by employers are rare and targeted — for example, health care workers and trainees in most states face requirements to get a seasonal flu vaccine and provide proof of vaccination against other vaccine-preventable diseases. About 13 percent of child care centers require care providers to get flu shots. Workplaces like Google and Disneyland considered policies after experiencing measles outbreaks but did not implement any. At least one university has already announced that students, staff, and faculty will need to get a vaccine against both influenza and Covid-19 once one becomes available. 

But, given the devastating economic impacts of this pandemic, one could imagine corporate policies to require the Covid-19 vaccination as a condition of employment. In the future, claims of a fully vaccinated staff could be effective marketing tools for long-term care facilities, child care centers, or even grocery stores. These hypothetical market-based initiatives to support vaccination build on existing efforts of many businesses, offices, and universities to require masks, temperature checks, and even “assurance testing.” As private entities, they also would not face the same constitutional restrictions, though there would likely be legal exemptions and requirements to protect personal health information. 

What if, as Fisher fears, airlines, sports arenas, or stores require evidence of vaccination to enter? Many vaccine skeptics assume this is inevitable. Social media has run rife with misinformation about forced vaccines, and as one recent Twitter post advised, “All I can say is refuse to take the vaccine and prepare for the inability to buy, sell, travel, work. … I’m not compromising my health. I really believe our freedoms will be gone, pdq.”

Admittedly, there is a small number of people who oppose vaccines in all forms and are unlikely to be persuaded that vaccines are ever safe and effective. (There is also evidence that some anti-vaxxers are rethinking their opposition to vaccines as they face new fear of infectious disease.) However, there are a sizable number of people who are not opposed to vaccines but who still currently do not want to use a Covid-19 vaccine. One study found that about 15 percent of people who are at least somewhat supportive of vaccines said they wouldn’t get this vaccine, and 19 percent of people who did not identify as anti-vaxxers said they wouldn’t get it. This group deserves better information that can communicate why this vaccine — and the process that led to its development — deserves their trust.

The coming months will provide an opportunity for policymakers, researchers, and government agencies to provide clear, honest answers to the many questions potential consumers of any forthcoming vaccine may have. Although the Centers for Disease Control and Prevention has worked to support vaccine acceptance, that agency does not appear to be leading OWS, requiring Health and Human Services, the Department of Defense, and the Food and Drug Administration, which will license a vaccine, to work on public trust in new ways. 

As health economist Jay Bhattacharya recently told a House Oversight Subcommittee on Economic and Consumer Policy, “the fallout from disinformation falsely linking the measles, mumps, and rubella vaccine to autism, seeding the anti-vaccine movement, is a cautionary tale.” Public health agencies, scientists, and government leaders would be wise to address misinformation with transparency, honesty, and clarity. Our lives may depend on it.

Jennifer Reich is a professor of sociology at the University of Colorado Denver and author of the book Calling the Shots: Why Parents Reject Vaccines.

“You know when you pick your child up from preschool and the teacher tells you he had a really good day? I have never had that day.”  

This is how one mother who I’ll call Katie described what it’s like parenting her son, who is now 6 years old. She visited 15 preschools before she found one she thought would work for him, a place where teachers would understand his passion for space but also his difficulties reading social cues or transitioning between activities. She meticulously manages his diet due to his extensive food allergies and eczema. She also rejects vaccines, which she fears could impair his seemingly challenged immune system or worsen his autism spectrum disorder traits.

Katie is just one mother I spoke to while studying parents who reject some or all vaccines for their children. I’m a sociologist who aims to understand how parents make choices for their families and children, and compiled almost a decade of research into my book Calling the Shots: Why Parents Reject Vaccines.

Katie, like many of the mothers I spoke with, agonizes over how to make sure her kids are healthy, happy, and able to succeed in what seems an increasingly dangerous, competitive, and uncertain world.  

Their reasons for rejecting vaccines vary widely. Vaccines, these parents tell me, do not always protect children. Some insist their children’s immune systems would benefit from contracting the illness. Some don’t trust the government agencies that approve vaccines because they are “too close” with pharmaceutical companies. Many believe their healthy lifestyle or prolonged breastfeeding ensures that their children will not experience the worst outcomes of a vaccine-preventable disease.

All insist that each parent must gather her own information and make an informed decision without feeling pressured by expert recommendations. And all insist that whatever happens to their children, they will ultimately be responsible.

Right now, the country is watching the number of measles cases increase each day, hitting a new high of 764 cases across 23 states since it was eradicated from the US in 2000. With 60 new cases in the past week, we can expect the outbreak will continue to spread.

There is no disagreement that vaccine refusal is the cause of outbreaks. More than 70 percent of measles cases this year were in people who had received no vaccines, and in all, 88 percent of cases were associated with under-immunized, close-knit communities. Yet parents’ decisions have effects that can reach far beyond these networks and neighborhoods.

Just this week, actress Jessica Biel appeared with anti-vaccine proponent Robert F. Kennedy Jr. at the California State Assembly to lobby against a bill that limits medical exemptions for vaccines. When a photo of her appearance went viral, Biel posted on Instagram that she was against the bill “not because I don’t believe in vaccinations, but because I believe in giving doctors and the families they treat the ability to decide what’s best for their patients and the ability to provide that treatment.”

It’s easy to question why any parent would choose not to vaccinate, and to look at mothers like Katie with suspicion, confusion, or disgust. As a mother of three vaccinated children and the granddaughter of a woman who lived her life with a limp that resulted from polio, I too wonder this. And while it is easy to dismiss these parents as anti-science, selfish, ignorant, or delusional, the answer is much more complicated.

Parents who don’t vaccinate are prioritizing their children over other people’s children

First, a few points of clarification. Although I spoke with fathers and mothers in my research, it became clear that health care decisions tend to be maternal terrain. Mothers are most likely to take their kids to doctor appointments and make decisions about food and daily care. They also face scrutiny for their children’s behaviors, performances, and abilities, which makes every decision — including whether to vaccinate — feel high-stakes.

Second, there’s a small number of people who will never believe vaccines work and will never be persuaded to accept them, and I spoke to some of them. This is the group we tend to conflate with the entire world of people who don’t vaccinate.

But the larger and more interesting group to discuss is the significant portion of American parents who say they believe in vaccines but just don’t want them for their children — or don’t want all the vaccines that experts insist are safest and most efficacious. As much as 20 to 25 percent of American parents fall into this latter group, and they arguably pose the greatest threat to herd immunity. They are also the most likely to be persuaded as long as we don’t call them ignorant and selfish.

Finally, parents who refuse vaccines are most likely to be white and college-educated, and to have a higher-than-average family income. I believe their decisions are less about how informed they are and more about the culture of what I term individualist parenting — one that insists parents are personally responsible for their own children, but not other children. Individualist parenting has encouraged mothers to trust their own judgment more than that of experts and believe they can manage their way out of disease risk, even as their choices present risk to others.

For the past two decades, we have increasingly prioritized individual behaviors and choices as the key to good health. Experts recommend people count their calories, steps, pounds, or servings of vegetables as a path to disease prevention. When we hear someone is sick, our first question is often, “What did they do, or fail to do, that led to illness?” These questions ignore how the majority of illness is beyond individual control and reduce health promotion to a series of consumption decisions.

For mothers, the pressure to manage their children’s nutrition, body size, learning styles, peer interactions, or physical activity is boundless and reinforced by schools, doctors, peers, and parenting magazines. Beyond health, we see demands that mothers individually manage their children’s lives and optimize opportunities for their success. Choosing schools, traveling soccer teams, or SAT tutors promises to increase some children’s opportunities for success. Yet when parents choose to send their kids to private schools or competitive public schools, they implicitly accept that it is fine that other children don’t have safe or adequately resourced schools — as long as it’s not their own kids. The culture of individualist parenting makes clear: Parents have a duty to exercise choice to the bounds of their resources, even at the expense of others.

We can persuade vaccine-refusing parents by appealing to their sense of community responsibility

Mothers often tell me how hard they work to do “research” about raising their children. They don’t mean systematic research in the way scientists do. Rather, they conduct research the way we all do before making a consumption decision like going to a new restaurant or buying an appliance: They gather information, read advice from experts, talk to friends and family, peruse reviews and comments, weigh risks and benefits, and, in the end, trust their instincts. On a range of topics — from cooking to finding a pediatrician to requesting the best teacher to deciding whether to consent to vaccines — mothers routinely share information and advice to support their efforts to make good decisions for their families.

We know that parents who refuse vaccines tend to cluster and that living near a high number of other unvaccinated people significantly increases risk of infection. After all, most people are more likely to trust those who are like them. It is therefore not surprising that many of the outbreaks we are seeing are in tightly woven ethnic and religious communities with shared values and practices.

Although public health campaigns aim to convince parents to vaccinate because they love their children, the reality is that vaccines work best when used at a population level. In fact, many vaccines provide more protection to others than the child who receives them.

For example, rubella, which is the third component of the measles-mumps-rubella (MMR) vaccine, is a mild disease in childhood but can cause blindness, deafness, mental disabilities, and a range of birth defects in fetuses, or miscarriage, when pregnant women are infected. Measles can kill about one or two of every 1,000 people infected at any age but is most dangerous to infants and adults. The mothers I studied would often weigh each of these facts to decide if and how it would benefit their own children to get vaccinated. They would not consider that those too young, too old, or too immune-compromised to be vaccinated might benefit most from the herd immunity caused by mass vaccination.

I am not suggesting that parents should no longer advocate for their own children or prioritize their family’s values in making choices for their children. Rather, I am suggesting that we should consider how we can begin to reject the logic that we are only responsible for our own children.

Parents’ rejection of vaccine recommendations often emerges from fear of the uncertainties that surround children in a world that feels increasingly risky. I understand and admittedly sometimes even share these anxieties. I also recognize the pressures on parents to anticipate all possible outcomes and aim to control for them.

When thinking about her son’s struggles, Katie, like many mothers, made clear that she feels alone. Feeling unsupported by schools, health care providers, insurance companies, and her extended family, Katie insists she alone must take responsibility for her child and become his advocate.

Like high-quality education, safe drinking water, food inspection, or any number of resources children need to thrive, infectious diseases cannot be controlled with individual hard work, and thus cannot remain a private concern. In the end, we must find ways to protect each other’s children and support everyone’s family. And perhaps then, mothers who don’t think their children need vaccines will consent anyway.

Jennifer Reich is a professor of sociology at the University of Colorado Denver. Her publications include the award-winning books Fixing Families: Parents, Power, and the Child Welfare System and, most recently, Calling the Shots: Why Parents Reject Vaccines.

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