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No COVID vaccine min
February 23, 2022+Musa al-Gharbi
+Viewpoint Diversity

How Politics Undermines Understanding of Vaccine Hesitancy

Contemporary journalists and social researchers alike tend to be overwhelmingly aligned with the Democratic Party and the ideological “left.” As I explore in my book, they also tend to be drawn from a particular demographic slice of society, hailing from urban (and, to a lesser extent, suburban) areas and from families with above-average levels of financial and cultural capital. They skew disproportionately white as well. This homogeneity in backgrounds and beliefs often limits and corrupts our understanding of the social world, influencing the questions that are asked, the means used to pursue those questions, how data is interpreted and analyzed, how findings are portrayed to others, and how others evaluate and utilize one’s research. Explorations of morally and politically charged phenomena seem especially susceptible to being distorted by the non-representativeness of knowledge-producing institutions themselves.

Vaccine hesitancy is a case in point. Both scholars and journalists often seem to misunderstand or misrepresent both who is resistant to public health guidance and why — often advancing inaccurate and pernicious but politically convenient narratives.

With respect to the “why” question, for instance, although anti-vaxxers seem to dominate the public discourse and imagination on vaccine hesitancy, in truth, few of the unvaccinated are expressly against vaccines per se — neither in general, nor with COVID-19 in particular. Moreover, the concerns that people convey in order to explain their skepticism of authorities are often quite reasonable.

Even among outright anti-vaxxers, behind their eccentric rhetoric lie apprehensions voiced by many other vaccine-hesitant Americans. Among them:

  • Concerns about whether the vaccine is as safe and effective as experts claim
  • Concerns about apparent conflicts of interest and perverse incentives among policymakers, experts, and “Big Pharma”
  • Concerns about the lack of transparency from authorities with respect to the uncertainties in their claims, possible downsides of their guidance, dissenting expert opinions, and so forth

Critics often get so wrapped up in mocking the apparent absurdity of conspiracy theories that they are blinded to the legitimate concerns that typically undergird them.

The Bill Gates microchip theory, for instance, straightforwardly reflects worries about the safety of the vaccines, paired with concerns about conflicts of interest and perverse incentives among experts, policymakers, and pharmaceutical companies. They share unease on these matters with many other vaccine hesitant people who do not wrap their apprehension in a conspiracy theory. Yet rather than recognizing and attempting to speak to the underlying and understandable concerns shared across vaccine hesitant people, many choose to focus on the more sensational aspects of conspiracy theorists’ narratives in order to paint virtually all vaccine-hesitant people as irrational.

In addition to misrepresentations about why people are vaccine hesitant, there also seem to be broad mischaracterizations around who the vaccine hesitant are. One common assumption is that vaccine skeptics are overwhelmingly Make America Great Again (MAGA) whites juiced up on Fox News misinformation. This narrative has some face-validity problems that have not been well addressed.

Consider, for instance, the reality that only about 10-15% of voting-age Americans watch even 10 minutes of news per day, from CNN, MSNBC, or Fox News combined. Most Americans do not even watch an hour of cable news over the course of an entire month. Even the age bracket that consumes the most cable news, Americans aged 55 and older, watches roughly 90 minutes per day from all sources. Expanding to digital platforms doesn’t change the picture much: Only about a third of Americans read anything from Fox News platforms at all in a given month — and among those who do consume this content, users spend on average 38 minutes per month (just over one minute per day) engaging with it.

Incidentally, the demographic that is most likely (by far) to watch Fox News, Americans over 55, is also the age bloc where Trump support is strongest. In a world where Fox News consumption and Trump support were among the primary drivers of vaccine hesitancy, one might expect that vaccination rates would be especially low among older Americans — again, they are by far the most intense bloc of Trump supporters, and the primary audience of Fox News. Yet they also happen to be the most vaccinated group in America by far. The CDC estimates that nearly all seniors have received at least one dose of the vaccine, approaching 90% are fully vaccinated, and roughly two-thirds are boosted as well. In short, the older one gets, the more likely one becomes to watch Fox News, to support Trump, and also, to be vaccinated.

Despite glaring problems like these, a growing chorus has taken to blaming MAGA-aligned whites for continued COVID-19 transmission and COVID-19-related hospitalizations and deaths. As a matter of fact, vaccine-hesitant people tend to be much more heterogenous than many seem to realize – and people seem to miss the factors that actually unite populations prone to vaccine hesitancy.

Race, Geography, Vaccine Hesitancy

With respect to race and ethnicity, Black people have been more hesitant than most other racial and ethnic groups with respect to vaccines in general, and the COVID-19 vaccine in particular. They were less willing to take part in the vaccine clinical trials. They remained significantly more hesitant to pursue COVID-19 vaccines after they were approved. Although uptake has increased substantially among African Americans in recent months, their overall vaccination rates continue to trail those of whites.

Throughout most of the pandemic, Hispanic Americans also trailed significantly behind non-Hispanic whites with respect to vaccine uptake, although following a significant boom in vaccinations over the summer, they are now approaching parity.

Nonetheless, significant pockets of hesitancy remain among minority populations. Media companies love doing stories about MAGA whites who publicly flouted CDC guidance and then died of COVID-19, or who ended up with a bad case and recanted their views. It is apparently much less satisfying to talk about hesitancy within Orthodox Jewish or Somali communities, or among undocumented migrants, Indigenous Americans, or the many other racial, ethnic, and religious minority populations for whom COVID-19 vaccine hesitancy is much more pronounced than among mainstream whites. Yet vaccine hesitancy within minority populations likely helps explain important trends in COVID-19 spread, hospitalizations, and deaths.

Blacks, Hispanics, and Indigenous Americans have been significantly less likely than whites to pursue vaccination, both with respect to COVID-19 and in general. Insofar as the vaccine reduces the likelihood of COVID-19 infections, protracted hesitancy within a given population would be expected to correlate with increased rates of infection and higher numbers of cumulative cases. And indeed, we do see this: the number of COVID-19 cases per 100,000 has been significantly higher among Black, Hispanic, and Indigenous Americans relative to whites. Asian Americans, who have the highest rates of vaccine uptake among all racial and ethnic groups measured, also have the lowest numbers of COVID-19 infections per capita.

Likewise, vaccinations have been shown to provide significant protection against the more serious manifestations of COVID-19. One would expect to see that populations that have had lower levels of vaccination over time would have higher levels of cumulative COVID-19-related hospitalizations and deaths. This, too, is evident in the CDC statistics.

Of course, vaccination rates are only a part of the story here: Black, Indigenous, and Hispanic Americans are also far more likely than whites to possess other comorbidities (such as heart disease, asthma, diabetes, or obesity) that are connected to severe manifestations of COVID-19 and particularly adverse outcomes, irrespective of vaccination status. These populations also tend to have less access to quality medical care in the event that they do get sick. However, more cautious vaccine uptake among many ethnic and racial minority populations likely helps explain a large amount of the observed variance in COVID-19 infections, hospitalizations, and deaths as well.

We can see this from another angle by breaking things down geographically. Overall, there is not a single state in the union where a majority of the adult population is not fully vaccinated. The state with the absolute lowest vaccination rate is Alabama, where 60% of adults have received two doses. Many other Southern states also have lower-than-average vaccination rates. As these states are also decisively “red,” it may be tempting to attribute these low vaccination rates to MAGA-aligned whites.

However, most Southern states also have particularly high concentrations of African Americans. Indeed, most black people in the U.S. continue to live in the South. And within these Southern states, Black vaccination rates generally trail behind those of whites, and Hispanic vaccination rates in the South tend to be lower still.

A telling set of maps by Reuters depicts the counties with the largest concentrations of African Americans, Hispanics, and COVID-19-related deaths — and how those counties trended in the 2020 election. Scrolling through the visualizations, it is clear that counties in the U.S. with the highest concentrations of COVID-19-related deaths also tended to have especially high levels of Hispanic and/or African Americans. Granted, many of the minority fatalities may have been among Blacks and Hispanics who voted Republican — they’ve been growing in number for much of the last decade, and many of the places with high levels of minorities and high levels of COVID-19 also shifted toward the GOP from 2016 to 2020. But it may also be the case that relatively low vaccination rates (and relatively high COVID-19 mortality rates) in “red” states are disproportionately driven by populations within those states who skew “blue.”

Either way, attempts to blame low vaccination rates in the South on MAGA-aligned whites seems to miss a lot of what’s going on in these states, including factors that unite unvaccinated whites and minorities, both in the South and beyond, and that probably matter much more than partisan affiliation per se.

Missing the Forest

One big problem with many popular explanations is that they focus on factors unique to the U.S., despite the fact that vaccine-hesitancy patterns observed in the U.S. are actually common around the world.

Across societies and cultures, people with relatively low levels of income and education; those who live in more rural communities; those who are racial, ethnic, or religious minorities; and young people have been far more hesitant to get the COVID-19 vaccine. In other words, populations that are underrepresented within the elite, and who often have strong and well-founded suspicion of authorities, are most likely to refuse the vaccine. The drivers seem to be structural, not a product of specific beliefs, ideologies, cultures, informational sources, or rhetoric by politicians in any particular country. The pattern holds across contexts, apparently independent of these factors.

Likewise, other major comparative studies have found that one of the most reliable predictors of COVID-19 transmission rates across countries is the level of trust citizens express in their government. This is because populations with low levels of trust in the authorities are less likely to follow protocols for containing the disease, such as masking indoors, quarantining (upon possible exposure to COVID-19 or when displaying symptoms of COVID-19), avoiding crowded gatherings in poorly ventilated spaces, or getting vaccinated. In contexts where trust in the authorities is low, there tends to be less social pressure to conform to expert advice either. Again, these patterns hold across geographical and cultural contexts, independent of the specific rhetoric, policies, or parties that prevail within a given country.

Across the board, then, we would expect to see, and we have seen, people with sociological proximity to elites aggressively and conspicuously adhering to elite guidance and attempting to coerce and cajole others into doing the same. Likewise, we would expect to see, and we have seen, people with high levels of sociological distance from those “calling the shots,” demonstrating much higher levels of skepticism of, and resistance to, declarations by authorities. And again, we don’t just see these patterns in America, but throughout the world.

Incidentally, those with high levels of perceived sociological distance from elites are also the people most likely to participate in conspiracy theories. As political scientists Joseph Uscinski and Joseph Parent put it, “Power asymmetries, both foreign and domestic, are the main drivers behind conspiracy theories; those at the bottom of power hierarchies have a strategic interest in blaming those at the top” for adverse social outcomes. That is, the kind of person who espouses conspiracy theories tends to be the kind of person who would be highly skeptical of, or resistant to, authorities and their advice independent of the conspiracy theory (they tend to be receptive to conspiracy narratives precisely as a result of preexisting mistrust), including with respect to vaccination.

The causal power attributed to conspiracy theories for explaining vaccine refusal, therefore, seems to be overstated. Marginalization and alienation from authorities seem to be the primary drivers of both vaccine hesitancy and conspiracy theories alike. In focusing on conspiracy theories, which are downstream from mistrust, people are missing what’s really going on. Indeed, as discussed at the outset, the kinds of concerns that the conspiracy theories gesture toward are widely shared among other vaccine-hesitant people who do not endorse the conspiracies. Put another way: Most skeptics do not seem to be concerned about vaccines because of conspiracy theories. Rather, many adopt conspiracy theories as a means of articulating their preexisting concerns about the vaccines, and forging community with others who share similar concerns. As I’ve elaborated at length elsewhere, sharing “fake news” likewise seems to be more about social signaling than sincere epistemic claims.

Nonetheless, many choose to focus on conspiracy theories and misinformation as the primary drivers of vaccine refusal in order to paint the vaccine hesitant as stupid, crazy, or brainwashed. Within liberal spaces, a growing chorus has taken to proclaiming that those who are unvaccinated straightforwardly deserve to die of COVID-19. Some go so far as to heap scorn and mockery at the deceased and their families. Public debates are underway about denying medical care to the unvaccinated and finding other ways to shame, antagonize, and punish people who are vaccine hesitant.

Liberals seem to feel comfortable engaging in the behaviors because they’ve bought into the popular narrative that vaccine refusers are a bunch of “privileged” MAGA-aligned whites. However, the ugliness of these sentiments, their eugenicist and elitist tinge, becomes much more evident when we understand who the vaccine hesitant actually are. In the U.S., as in virtually all other countries, the unvaccinated are overwhelmingly people who are marginalized, disadvantaged, dispossessed, and/or downwardly mobile from across racial and ethnic lines — including, and especially, those who also happen to be ethnic, racial, and/or religious minorities.

These patterns do not just persist across geographical contexts, but historical contexts as well. In the U.S., similar patterns of skepticism and resistance were evident in previous vaccination campaigns (such as in the struggles over the smallpox vaccine).

Parties and Shots

We are now well equipped to recontextualize some popular talking points about vaccine hesitancy and political affiliation.

Widely circulated reports note that counties with the highest concentrations of Democratic voters tend to have much lower rates of COVID-19 deaths than those with the highest concentrations of Trump voters. Yet media reporting on this gap systematically fails to observe the massive differences in wealth and healthcare access between heavily Republican and Democratic regions. Counties with huge concentrations of Democratic voters tend to be among the most affluent in the country, with huge concentrations of hospitals and doctors. Meanwhile, areas with the deepest concentrations of Trump voters tend to be among the most economically distressed in the nation, with huge swaths of the population also living in “healthcare deserts.”

Consequently, it would seem bizarre to assert that the most relevant difference between the most intensely Democratic and Republican districts with respect to COVID-19-related outcomes is partisan affiliation or ideological leanings. Yet that is precisely what reporters frequently do: pretend as though the main driver of the differences in vaccination rates, cases, and deaths is political beliefs, not the vast and systematic differences in wealth, education, or access to healthcare between these districts.

The Kaiser Family Foundation estimates that 60% of those who remain unvaccinated are Republicans. Just taking this figure for granted, we are now in a position to see that political ideology or political partisanship per se probably explains very little of the disparities observed. Contemporary GOP voters are far more likely than Democrats to possess low levels of education and to live in communities that are rural, post-industrial, and in decline. They tend to have far less trust in government than Democratic peers (this is a big part of the reason they identify with the Republican Party in the first place). Moreover, growing shares of GOP voters are lower income, working class, and/or minorities (racial, ethnic, religious). These factors probably explain much more than partisanship itself.

Sure, the states with relatively low vaccination rates tend to skew “red.” But they also tend to be more rural, and poorer, with radically lower rates of postsecondary education and far lower levels of trust in government. That is, they are precisely the kinds of places, with heavy concentrations of precisely the kinds of people, who have proven to be vaccine resistant in countries around the world. In an alternate reality where Trump, Joe Rogan, and Fox News were not a part of the American cultural landscape, these same populations would likely remain far more vaccine hesitant than most other Americans -- just as similar subpopulations are among the most vaccine hesitant in virtually every other country in the world.

Indeed, precisely because counties with huge concentrations of Trump voters also tend to have low rates of postsecondary education, we should be extremely skeptical of claims that ideological commitments or political partisanship are driving vaccine hesitancy: Those relatively low levels of education tend to be far less ideological, dogmatic, or politically partisan compared with social elites. Hence, the behavior of constituents in these districts is less likely to be driven by partisanship or ideological commitments compared with constituents in heavily “blue” districts.

Consequently, it would be fallacious to notice the statistical relationship between party affiliation and vaccine hesitancy and simply impute that the former drives the latter. Because of how things have shaken out in the contemporary U.S., party affiliation serves as a single proxy for a range of other factors that have been shown to drive vaccine hesitancy around the world (measuring sociological distance from elites). Hence we see a strong correlation between party ID and vaccine hesitancy. But of course, the first rule of statistics is that correlation does not prove, or even imply, causation. The primary cause of vaccine hesitancy seems to be perceived sociological distance from elites – a distance which gives rise to mistrust. Insofar as the authorities do not seem to share (or even respect) the values, interests, culture and lifestyles of the kinds of people who are vaccine hesitant – and especially if they’ve been burned by elites in the past – mistrust is not particularly mysterious. It is natural.

It also deserves to be noted that, again just taking the Kaiser Family Foundation estimates at face value, a huge share (4 in 10) of those who remain unvaccinated are not Republicans.

Many on the left are vaccine hesitant because they are also concerned about profit motives, perverse incentives, and possible collusion between government and big pharma. Others who are into things that are “natural” and ‘“organic”’ view vaccines, especially mRNA vaccines, as unnatural, artificial, and potentially harmful.

Healthcare workers also tend to skew overwhelmingly Democrat. Yet large numbers of healthcare workers are also vaccine hesitant, including in liberal bastions like New York City (and across much of the world). Vaccine hesitancy is especially pronounced among health care workers who happen to be racial and ethnic minorities.

Moreover, non-trivial numbers of Americans across party lines (nearly 1 out of every 10 unvaccinated Americans, according to U.S. Census Bureau estimates) declined the COVID-19 vaccine not because they failed to “trust the science,” but because they were actually advised by their doctor that they don’t need, or shouldn’t get, the shot. That is, not only are a number of healthcare workers vaccine-hesitant themselves, they are often responsible for encouraging vaccine refusal in others as well.

This is all to say that even many who are sociologically “closer” to decision makers have displayed reticence about the COVID-19 vaccines – indeed, they seem to share many of the same expressed concerns as those who are more “distant.”

All said, attributing vaccine hesitancy to MAGA-aligned whites, “fake news,” and conspiracy theories may be personally satisfying for many. It may facilitate one’s desire to villainize and dehumanize perceived political or ideological opponents. However, these narratives are not that helpful for really understanding who remains unvaccinated and why — let alone understanding what can be done to actually mitigate (rather than merely condemn) vaccine hesitancy.

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