Back in September, my Yale colleagues Jacob Wallace, Paul Goldsmith-Pinkham, and Jason Schwartz published a preprint of a paper called “Excess Death Rates for Republicans and Democrats During the Covid-19 Pandemic.” This trio linked 2017 voter registration in Ohio and Florida with mortality data in those same states from 2018 to 2021 at the individual level. During this period, the excess death rates were 76 percent higher among Republicans than among Democrats. Once vaccines came online for Covid-19, the gap in deaths widened—with excess death rates 153 percent higher among Republicans than among Democrats. The study also showed that these excess deaths were concentrated in counties with low vaccination rates. Other research shows similar partisan divides in acceptance of Covid-19 vaccination and other mitigation measures, as well as mortality during the pandemic.
What is now becoming clear is that this resistance to vaccination is leaching out of the soil of the same partisan divides—and spreading beyond aversion to Covid-19 immunization. Party affiliation is now becoming more and more associated with hesitancy toward immunization against such common childhood diseases such as measles, mumps, rubella, polio and chickenpox. Recent polling by the Kaiser Family Foundation suggests that more than a third of parents—up from less than a quarter in 2019—now oppose school vaccination requirements. Once again, this resistance to vaccination is concentrated among Republicans or those that lean that way; 44 percent of such parents now say they want out of these routine vaccination requirements.
Vaccine hesitancy has been an ongoing problem in the United States for decades—and while routine childhood vaccination rates overall have been historically high here, there have long been pockets of parents refusing vaccination, whose views span the political spectrum from liberals in San Francisco, Marin County, and Vashon Island near Seattle to libertarians and conservatives to religious groups including the Amish in Ohio and Orthodox Jews in Brooklyn. It’s in these same places and among these same communities that we recently, in the years just before Covid, saw outbreaks of childhood scourges like measles.
But as another of my Yale colleagues, Dan Kahan, warns, tagging vaccine hesitancy to any partisan stance risks solidifying such resistance rather than softening it. As people “look to protect their ties to others, individuals face a strong psychic pressure to conform their perceptions of risk to those that distinguish their group from competing ones”—in other words, tribal allegiances get reinforced when people are forced to choose between their sense of belonging and whether to vaccinate their kids. In the context of Covid-19 immunization, this is why in-group endorsement, when a Republican leader offers support for vaccination, is far more successful than having a Democrat make the same case. For similar reasons, President Biden’s repeated insistence through 2021 and ’22 that this was a pandemic of the unvaccinated may have done more harm than good in terms of communication to communities most at risk. It also wasn’t factually accurate; during 2022, the share of vaccinated elderly dying of Covid increased sharply.
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But now we’re seeing measles, chickenpox and polio outbreaks across the country. While it’s tempting to assign the blame to partisan affiliation, that is not the whole story. Though it’s clear that GOP politicians—Florida Governor Ron DeSantis is the poster boy here—have ginned up animosity, fear, and suspicion of vaccines for months now for political gain, and that their appointed judges see going after vaccine mandates as just another way to smash the regulatory state, some of these outbreaks have nothing to do with politics per se. Collapsing everything to a red-versus-blue face-off is far too simplistic. For instance, New York State’s polio outbreak occurred in an orthodox Jewish community where vaccination rates have been low for a long time now. In addition, the Covid-19 pandemic has interrupted routine medical care, including immunization, for many, and some fear exposure to SARS-CoV-2 in health care settings and have avoided doctors’ offices altogether.
So where do we go from here? Focusing on the GOP politicians, anti-vaccine advocates, and their media fellow-travelers is a bit of a dead end—at least in the short term. It’s hard to believe anything will convince the (at-least-once-Covid-vaccinated) DeSantis to give up his anti-vaccination campaign when he and his political career feed on it like Dracula on a night out. And no scientist or journalist or activist is going to get Robert F. Kennedy Jr. to end his long-standing crusade against vaccination of all kinds when his family and friends have struck out despite making repeated appeals over the years.
Yet precisely because vaccine hesitancy is not a new phenomenon, experts have well-documented strategies for this moment at the ready. First, like any good campaign, you need to know your audience. Micro-targeting aimed at fence-sitters—not the smaller number of outright vaccine refusers—is likely to achieve greater gains in immunization uptake. And as Dr. Kimberly Manning, a professor at Emory University School of Medicine, said in an NPR story in 2021 on Covid vaccination (and which applies to childhood immunization as well): Some people are “slow yeses,” and “we just are too impatient to get to the point where we let them get to their yes,” she said. “We’re like the used-car salesman. We’re just trying to close the deal.”
Helping people along with patience and empathy is key; part of that is knowing where people are coming from—which requires cultural sensitivity and knowledge. Jeneen Interlandi from the New York Times editorial board made a plea for this in the context of the New York polio outbreak: stop judging and blaming the Haredi community. Instead, figure out what is driving hesitancy and who the key influencers are among them (in this case, it’s women making health care decisions for families and those with graduate degrees within the community who are already pro-vaccine).
This all speaks to the need to go into communities, work with them, know them, and support those who can help shift opinion, rather than continuing to pursue top-down initiatives in which this local knowledge and power is overlooked. Building trust is vital to overcoming vaccine hesitancy—and if you think about whom you trust with decisions about your life, it’s people you know personally, people you respect—and who you believe have your best interests at heart. This is why family physicians are so important in conversations about vaccination with parents—and why they also need the resources to help them have precisely the conversations that have become more difficult for so many providers during Covid-19.
In the GOP strongholds, where anti-vaccination sentiment against Covid and serious childhood infections is growing, the same principles apply. Not everyone in a Trump-voting county is a vaccine refuser, or even hesitant; seeking out those who support vaccination—and have the trust of their communities—is crucial. Treating all Republicans as a monolith when it comes to vaccine uptake is a fatal mistake. Instead, we’re going to have to craft strategies to meet people where they’re at—in the places that are hardest for people like me to go.
At the same time, we can’t give up on the high-level policy work needed to make it harder to opt out of vaccination or delay immunization, to shore up our data systems to track immunizations across the country, and to target vaccine misinformation and its purveyors. But we need to resist the temptation to fall back on the technocratic policy fix, since a big part of the answer is good old shoe-leather public and community health work. This means building up from the bottom a public health force that’s been decimated and demoralized by this pandemic. Our public health workers are the first line of defense against infectious diseases—and always will be. Public health is local, and happens in and with our communities. Stopping Covid—like stopping measles, polio, and chickenpox—has to start there.
