As physicians who practice on opposite ends of the United States and in vastly different communities, we’re watching the national race to vaccinate our fellow Americans with both optimism and alarm.
First, the optimism: To date, over 147 million Americans have received at least one vaccine dose; nearly 100 million people, or close to 30 percent of the U.S. population, are now fully vaccinated. We are now averaging three million vaccinations a day. Our two states, Florida and Michigan, are reaching out to, and vaccinating, residents. And we have witnessed firsthand the public health workers, nurses and fellow physicians who continue to provide compassionate care for very sick people, more than one year into an emotionally and physically exhausting pandemic. Over 580,000 Americans have died due to coronavirus; at least 3,600 of them have been health care workers.
Here’s where the alarm sets in. Even as we accelerate vaccinations, an immovable force stands in the way of achieving community immunity.
Here’s where the alarm sets in. Even as we accelerate vaccinations, an immovable force stands in the way of achieving community immunity: Millions of Americans who are simply saying “No way.”
As of mid-April, both Florida and Michigan were hot spots for the more severe B.1.1.7 Covid-19 variant that originated in the U.K. and that is now the dominant strain nationwide. This variant is also sending younger, previously healthy people into our hospitals. With the coronavirus mutating to become more contagious and possibly more lethal, vaccination is more important than ever.
Yet, vaccine refusal — not reluctance, not “maybe later,” but flat-out rejection — could prevent us from reaching the threshold when epidemiologists say we can safely and responsibly fully reopen all aspects of society. Recent surveys like this one from CNN put that number at around one in four people. In rural, overwhelmingly white places like rural western Michigan, these are the folks who stagger into the Emergency Room, sick and struggling to breathe, yet still tell nurses and doctors that neither Covid-19, masks and vaccines are real.
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As a black cardiologist practicing in multicultural Miami and a white emergency physician in rural, overwhelmingly white Michigan, we’ve encountered vaccine hesitancy for as long as the pandemic has been around. Some of the reluctance came from lack of information, some from lack of trust, especially among under-served populations.
In September 2020, polls showed that half of all Black people and four in 10 Hispanic people wouldn’t get a vaccine, more than other groups. Hospitals, doctors, public health and community groups began reaching out to, and engaging with, Black and Hispanic communities about vaccines.
Black physicians partnered with Black celebrities and faith leaders. Spanish-language PSAs hit the airwaves. In Miami, Black physicians and nurses staffed vaccination clinics at places like Brentwood Pool. In Michigan, Spanish-speaking health professionals set up clinics in the heart of Hispanic communities. Slowly, matriarchs from Black neighborhoods and pastors in Spanish-speaking churches began getting vaccinated and telling people about it. Barber shops and grocery stores announced vaccine clinic locations. The more information Black and brown doctors shared, the more Black and brown people trusted them and began to accept the value of getting vaccinated.
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In the middle of a pandemic that was killing and hospitalizing disproportionately higher rates of them, Black and brown people began to publicly talk about vaccines as a shield that would help keep them safer, stay on the job and protect their families. And they began telling others to get vaccinated. By December, vaccine reluctance among these communities dropped by double-digits. By the end of February 2021, the percentage of Black and Hispanic people refusing to get vaccinated was down to the low 20s. By May, hesitancy wasn’t the main barrier for under-represented communities and vaccinations; things like transportation and schedules were.
But though Black and Hispanic Americans are now increasingly rolling up their sleeves, one group continues to refuse vaccinations: White, evangelical and rural Americans.
We heard one rural Michigan patient call vaccines a form of government control. Another repeated the unfounded claim that Covid-19 was a Chinese bioweapons plot. One patient refused to get vaccinated despite getting Covid-19 twice, a rare reinfection. Rural white people scoffed at vaccines, citing microchips and infertility, or Fox News disinformation slandering health experts for lying about vaccine efficacy data and calling vaccines a tool for social control. We heard patients accuse hospital workers of being highly paid actors maintaining the pandemic charade.
Vaccines have struck conservative Republican leaders with a kind of stubborn anosognosia, an inability to line themselves up with reality.
Former President Donald Trump, who was vaccinated quietly in January, encouraged people to get vaccinated on April 22 — almost 100 days after leaving office. Meanwhile, state Republican leaders like Florida Gov. Ron DeSantis botched vaccination distribution, while continuing to mangle the science. In Michigan, GOP legislative leaders are undermining vaccinations in word and in deed, including holding millions of dollars in federal vaccination funds hostage. The conservative base, however, says it would rather listen to doctors than politicians anyway. If the only information — or misinformation — about the pandemic is from Fox News and OANN, then the antidote is information from a source who understands the science, the medicine and most importantly, the community.
In the case of rural conservative communities, that source would be rural conservative family physicians who go to the same churches, fish the same stretch of river and volunteer every Friday night at local high school football games. These are the doctors who care for every stage of a family’s life. Births, broken arms, deliveries, disease management and deaths. They aren’t just trusted, they’re family —minus the birthright of blood. Most importantly, they know how vaccines and medicine work.
We work with doctors like these, doctors who are just as frustrated as we are with vaccine rejection and pandemic denials, doctors who ask all the time what more we can do to break through.
Here’s an idea: Recruit these rural family doctors to be messengers in communities where vaccine rejection is high. Host small presentations in churches and 4-H meetings, with the doctors listening, answering questions, debunking conspiracies about microchips and slowly, one by one, moving hearts and minds.
These conversations won’t be easy, quick or necessarily successful. A family physician colleague in a small rural town in the middle of Michigan shared a story about talking to a patient, a longtime leader of the Michigan Militia, about vaccinations. Despite his curt dismissiveness, she persisted, she listened, she walked through the cost-benefit analysis of getting the vaccine vs. getting a virus that’s 10 times deadlier than the flu. By the end of the office visit, the militiaman told his family doctor that he would get vaccinated.
Perhaps this may also be the best way to finally reach people like the elderly Michigan couple who showed up with Covid-19 at the emergency department, refusing to get vaccinated because they didn’t think the pandemic is such a big deal. We hope they recovered — and we hope they’ll reconsider getting vaccinated.
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By the summer, we should know how close we are to herd immunity — if we are close.
In the meantime, we have a wily Covid-19 variant that’s more contagious. We’re seeing patients who are younger and vaccinated at only a fraction of the rate of people 65 and older. In coming months, the race to vaccinate America will likely feel more like a slog, where every shot counts and every 4-H conversation matters. One conversation at a time, every physician has an opportunity to change a mind and get us back to normal. If one country doctor can persuade a member of the Michigan Militia to change his mind and get vaccinated, maybe there is hope after all.