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The U.S. Has the Shots It Needs, But Vaccine Doubt Is Prolonging the Pandemic

Skepticism threatens to drag out Covid restrictions.
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By his count, Jonathan Damato has brought at least a dozen people back from the dead. Over 20 years as a New York City paramedic, those are the moments he remembers most. The ones that called him to the job early on and kept him coming back, a year into a pandemic, in one of the world’s worst hot spots. “Clearly, we’re masked up, you know, you’re protected, but you’re exposing yourself to this every single day,” he says.

Damato remembers seeing his first Covid-19 patient, an elderly man whose vitals seemed to defy medical logic. Based on his blood oxygen levels, the man should have been unconscious; instead he was just a little short of breath, chatting and sitting upright. In so many of those early cases, Damato says, it was impossible to know how to respond. He and his colleagues barely understood the disease, hospitals were already overflowing with patients, and the medical crews couldn’t get their hands on enough protective gear. “A lot of the crews got nervous and panicked,” he says.

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Damato outside his home on Staten Island.
Photographer: Matt Genovese for Bloomberg Businessweek

America’s recent vaccine news has been good. More than half of U.S. adults have now received at least one dose of a Covid vaccine. In most states, new cases are down or at least not surging. Medical personnel know how to better treat Covid patients, which has kept hospitalizations and deaths to a fraction of their winter highs. It’s starting to feel as if life might approach something like normal as spring rounds the corner into summer. There’s just one big, honking, horrifying question: Will enough Americans roll up their sleeves to end the pandemic, or will too many skip out on getting the shots?

Throughout the past year, Damato’s biggest concern has been bringing the virus home to his family. He lives and works on Staten Island, New York City’s biggest Republican enclave. He’s married with five kids, and his 4-year-old son, Nico, has a serious heart condition that’s required more than a half-dozen surgeries, making him especially vulnerable to the virus. When Damato comes home, his uniform goes straight from a plastic bag to the wash. In November, as promising trial data suggested it was more and more likely a vaccine might be ready before the end of the year, he wrote a sarcastic Facebook post remarking on other people’s overblown fears about vaccine side effects. He and his wife, a teacher, could see their borough getting hammered by the virus. He was working more overnight shifts than ever, and they were both extremely exhausted from juggling the kids because they were in and out of school. Damato couldn’t wait to get his shot. Then his aunt texted him a response to his Facebook post.

The aunt, a nurse, said she wanted him to consider another point of view. She sent him literature, but Damato says the accompanying video was what really got him. In the video, a man who identifies himself as a coronavirus researcher makes a bunch of claims about problems with the coming vaccines. He says—falsely—that the mRNA vaccines have been rushed to market without proper trials and that drugmakers had covered up safety concerns about how the vaccines might kill people or sterilize them. The video was full of such misinformation and outright lies, and a quick Googling showed Damato that the “researcher” had been associated with conspiracy theories before. But that didn’t matter. The seeds of doubt had been planted. “I felt even if half of his concerns were correct, it was enough to worry about,” Damato says. “There are too many questions.” Earlier this year, when his station was offered the vaccine, he opted out.

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Across much of the U.S., the ranks of people waiting for Covid shots are dwindling.
Photographer: Chip Somodevilla/Getty Images

So did many of his colleagues. The Fire Department of the City of New York says only 47% of its EMTs and paramedics have been vaccinated, and similar reports of health workers opting out have poured in from across the country. About 3 in 10 front-line health-care workers are either planning to skip the vaccine or are on the fence, according to a March poll by the Washington Post and Kaiser Family Foundation. More recent Kaiser polling puts the number for all Americans at 37%. There are especially large pockets of skepticism among Republicans, people of color, and rural residents. And Damato’s story is a common one: Waves of public-health messaging are often less powerful than a single text from a trusted friend or relative.

People like Damato aren’t anti-vaxxers. (The paramedic gets his flu shot every year.) They’re vaccine skeptics, people who don’t quite know what to think, so they figure why not wait and see how the shots work out for others, or they bet on the protection they’ll get from everyone around them being vaccinated. “One of the problems with the framing of the pro and the anti is that it kind of pushes out this middle group that are undecided but are still open,” says Heidi Larson, the director of the Vaccine Confidence Project at the London School of Hygiene & Tropical Medicine. “If they’re not getting a reasonable answer or even feeling like they’re demonized for just asking questions, it hardens them, and they’re more vulnerable to some of the more extreme views.”

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Larson, director of the Vaccine Confidence Project.
Photographer: Jonas Roosens/Getty Images

The bigger problem for everyone, even in a now vaccine-rich country like the U.S., is that there are too many of these fence-sitters to bet on widespread immunity protecting the populace anytime soon. The fewer people who get vaccinated, the longer the pandemic will drag on and the more lives will be lost. America might have the technology and personnel to stamp out the disease, but not necessarily enough trust left in public-health efforts to get it done.

Witness the spike in overall skepticism after six cases of blood clots among roughly 7 million recipients of the Johnson & Johnson vaccine led the U.S. Food and Drug Administration and the Centers for Disease Control and Prevention to recommend a pause in its rollout. For everyone besides the rare clot sufferers, the data is stunningly good news, an extremely small number of adverse events compared with a virus that has killed more than a half-million Americans. But blood clots fit perfectly into the narrative that Covid shots aren’t as safe as the government wants the public to believe. Distrust makes misinformation seem more believable, and the pandemic has primed a whole lot of people to be more skeptical of the public-health establishment. Doubt, like Covid-19, is highly contagious.

For Damato, all it took was a text and a video. “I was so blind,” he says. “I didn’t even look to see the other side, the people who are not getting the vaccination. Like, it wasn’t even a thought in my head, why would I not get the vaccination?” Now, whenever someone asks his opinion on the vaccine, he sends them the video his aunt sent him.

The Covid vaccines approved in the U.S. are highly effective. A study of health-care workers and first responders released at the end of March found that both the Pfizer and Moderna shots prevent 90% of infections after a second dose. These mRNA vaccines also seem to prevent most viral transmission. Based on that data, the feds have said that vaccinated people can feel comfortable hanging out in small groups.

But no vaccine is 100% effective. The mysteries of human biology mean that some vaccinated people will still get sick when exposed to the virus. So far there have been about 7,000 such “breakthrough cases” out of the 94 million or so Americans who’ve been fully vaccinated. Overall demand for vaccines is still high, but a recent Bloomberg analysis found that in some pockets demand is waning long before a larger percentage of the population has been inoculated.

Vaccine skepticism is as old as vaccination. Larson, in London, discovered yellowed 19th century pamphlets opposing mandatory smallpox shots while she was researching her 2020 book, Stuck: How Vaccine Rumors Start—and Why They Don’t Go Away. The sentiments are depressingly familiar, inveighing against impositions on the natural order and freedom of choice. Over the past several decades, however, skepticism in the U.S. has been turbocharged by state governments’ strong hand in mandatory childhood vaccinations and the online disinformation campaigns of fanatical anti-vaxxers. The steady erosion of trust in government and a shared set of facts have lent an added potency to rumors, allegations, and conspiracy theorists’ YouTube videos.

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A Trump supporter holds an anti-vaccine sign while protesting in Washington, D.C., in January.
Photographer: Wein Scott/Bloomberg

In 2000 the World Health Organization declared that the U.S. had rid itself of the measles. Fifteen years later, after a major outbreak at Disneyland in California, it became clear that too many Americans had grown skeptical of mandatory vaccinations and were betting on community immunity to protect their kids. Measles is extremely contagious, so more than 95% of kids in a community need to be vaccinated against the disease to stop it from spreading. An MIT study that surveyed vaccination rates in 43 states found that most of the kids who caught measles at Disney were living in counties with vaccination rates as low as 50%, according to Maimuna Majumder, one of the study’s authors. “It was really eye-opening,” says Majumder, now a health-informatics researcher at Boston Children’s Hospital.

During the pandemic, prominent anti-vaxxers like Robert F. Kennedy Jr., whose nonprofit Children’s Health Defense has been estimated to be responsible for more than half the vaccine misinformation on Facebook, have also benefited greatly from the Trump administration’s disastrous initial response. “Anybody who asks me about vaccines has already lost some faith in the traditional structure of ‘You should trust your doctor, you should trust CDC, you should trust FDA,’ ” Kennedy says. The Center for Countering Digital Hate, or CCDH, says that the roughly 150 leading anti-vaxxer accounts gained more than 10 million social media followers from December 2019 to December 2020, especially on Instagram and YouTube. (Instagram banned Kennedy in February, but he remains on Facebook, and his organization is on Instagram, Facebook, and YouTube.)

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Robert F. Kennedy Jr.
Photographer: Rich Polk/Getty Images

Where Kennedy and other anti-vaxxers have been loud, public-health officials have often been quiet. After Damato’s aunt planted the seeds of doubt, the paramedic went hunting for more information from his employer and says a staff doctor echoed his concerns. (An FDNY spokesperson says the department has provided extensive educational resources on vaccines to its employees). Like many Americans, Damato has been suspicious of surprises that have changed official guidance, whether shifting views on masks or the record-fast vaccine development that Donald Trump promised. “He swore it was going to be ready by a certain time, and everyone said it’ll never be ready by then. Boom. It was ready by the time,” Damato says. “These are medical professionals that you’re supposed to trust, but they can’t even get on the same page, so why should I believe them?”

Even getting the information he was after might not have been enough to convince Damato. He was already disinclined to trust his bosses given their failures to provide proper protective equipment and training earlier in the pandemic—plus some failures before that. Damato was a first responder at the World Trade Center on Sept. 11, 2001, and like many of his colleagues, he has health issues including sleep apnea and chronic sinus problems he says stem from his department’s lack of protective gear back then.

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Damato inside his home.
Photographer: Matt Genovese for Bloomberg Businessweek

Common public-health practice relies on facts as the best counterpoint to lies, but that won’t be enough to talk skeptics into getting jabbed, says Matt Motta, a political science professor at Oklahoma State University at Stillwater. He says public-health officials need to work to win over the public by addressing their specific concerns and by approaching the subject empathetically rather than rolling their eyes. “There’s no one-size-fits-all approach,” he says, “because there’s no one-size-fits-all reason why people accept vaccine-hesitant views.”

Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, has been on a whirlwind public-speaking tour, trying to win over hesitant Black Americans by addressing Black churches and chatting with celebrities including Steph Curry and LL Cool J. “It is not surprising, but extraordinary and interesting, how when you get a trusted member of society, of the community, to come out and start talking about why it’s important to get vaccinated, how people who would otherwise be very hesitant go ahead and say, ‘OK, I’m good with vaccine,’ ” Fauci says.

The number of people who are firmly against vaccines is very small. The number of people in the middle is far larger. Anti-vaxxers and public-health officials such as Fauci are locked in a battle of persuasion with that middle group as the prize. But if the problem is trust, the burden of earning it is on health officials, who haven’t focused much on education about what efficacy rates actually mean, for example, or the nature of the Vaccine Adverse Event Reporting System.

Vaers is a government-run, publicly available database of self-reported potential side effects or other perceived problems. If patterns emerge, the FDA and the CDC investigate, but mostly the reports simply sit online, unverified and un-fact-checked. That is to say, they’re ready-made propaganda for anti-vaxxer fanatics and skeptical followers who might not know that no one is fact-checking them. The internet is full of videos of anti-vaxxers simply reading off lists of injuries reported in Vaers. Groups including Kennedy’s frequently send out fearmongering emails highlighting the rising number of Vaers-reported deaths.

This phenomenon is part of a larger problem of public-health officials and advocates ignoring spurious arguments and real failings in favor of simply soldiering on with their own messages, says Chris Martin, a public-health professor at West Virginia University. The idea is to avoid raising unfounded concerns that might plant the seeds of doubt, Martin says, but that doesn’t account for the bad actors seeding conspiracy theories that use health officials’ silence as Exhibit A. A better course of action, he says, would be to teach physicians, nurses, and public-health advocates how to talk to people about their vaccine skepticism. “We need to train the trainers,” he says.

The U.S. could do worse than to follow the lead of Martin’s home state. West Virginia proved, for a time, to be a remarkable vaccine success story.

On the surface, that result sounds extremely unlikely. West Virginia is Republican and rural, with mountainous terrain that makes vaccine delivery a serious logistical challenge. Many of its residents are also poor, with health conditions that make them especially at risk for severe cases of Covid. And yet, by mid-February, West Virginia had used up more than 100% of the roughly 380,000 vaccine doses it had been allotted, the first state to do so. It was the first to finish vaccinating its nursing homes, by pairing a network of pharmacies with about 200 long-term-care facilities in lieu of the federal plan.

Ayne Amjad, the state’s head doctor, attributed these successes to West Virginia’s reliance on trusted local pharmacies to administer the vaccines rather than big chains. This was word-of-mouth working in vaccination’s favor, she says. People hesitant to get the shots felt comfortable asking questions at the mom and pops: “There was that trust built in with them.” Republican Governor Jim Justice also tapped Clay Marsh, the respected vice president of the West Virginia University health sciences center, as its coronavirus czar. Marsh’s local ties have been credited with helping speed the early rollout.

Now, though, with about 38% of West Virginia’s 1.8 million residents having received at least one dose, the vaccination drive has slowed. In mid-April, with the CDC now ranking West Virginia 47th in percentage of vaccinated residents, Justice said the state’s administration rate had sunk to an “incredibly low” 85%. “We’ve got a problem to really get after it, to educate more and more folks,” Justice said during an April 21 press briefing. “If we don’t, we’re not going to get rid of these masks.” The next step, says Martin, will be to get vaccines into the family doctors’ offices, churches, and schools where unvaccinated people already are.

Polling has shown that as more people get vaccinated, those who still aren’t say they are more open to it. Watching your friends and family get inoculated is a powerful motivator. But as vaccination has opened up to more groups of people, early hopes that skepticism would fade away altogether are dissipating. More pockets of the country like West Virginia are beginning to report they have more shots than demand. Several states are now administering fewer than 75% of the doses they receive, according to the CDC. Federal survey data peg the South and the Upper Midwest as the most hesitant regions. One of the White House’s plans is a celebrity ad campaign in which the likes of Mark Cuban, Eva Longoria, and Kelly Ripa urge young people to get their shots.

Back in New York, Damato keeps spreading the gospel of skepticism among his friends and FDNY colleagues. He says he did encourage his parents to get Covid vaccines, because their age was too significant a risk, but he’s less worried about Nico now that his son’s heart is in much better condition. Although Damato says he hasn’t firmly decided against getting the vaccine himself, he’s unsure what could drive him to say yes at this point. “I’m not going to get it until maybe down the road,” he says. “If I ever do.”