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To end the pandemic, the Covid-19 vaccine must clear one final obstacle

75% of Americans need to be vaccinated. The question is: How do you convince the undecided?

On December 10, a key panel of scientists gathered over video chat to discuss the fate of the United States’ first coronavirus vaccine. After nine painful hours of presentations, a majority,17 of 22 scientists, gave the vaccine the greenlight.

Meanwhile, the American public was coming to a different conclusion.

The vaccine hasn’t completely won the hearts and minds of everyday people. While “early adopters” of the vaccine are eager to get in line and share their positive experiences with the vaccine — both Nancy Pelosi and Mitch McConnell have already done so — we may soon hit a sticking point, William Schaffner tells Inverse. He’s an expert in infectious diseases at Vanderbilt University Medical Center.

Data hints at a blurry forecast. A poll run by the Associated Press and the University of Chicago in December found 47 percent of Americans plan to get a vaccine. Meanwhile, 26 percent had no plans and 27 percent were unsure. Other polls from December paint rosier pictures: A Kaiser Family Foundation poll found that 71 percent of Americans would get a vaccine. A Gallup poll shows that 63 percent of people were willing to get the vaccine.

Pfizer’s coronavirus vaccine may have won the endorsement of the Vaccines and Related Biological Products Committee, a panel of experts that advises the FDA, but the public isn’t so sure.

As the vaccine rollout progresses, the shots will become available to people who weren’t eager to be in the front of the line to begin with, Schaffner says. And for the pandemic to end, we need about 75 percent of the country to get vaccinated, an estimate put forth by Anthony Fauci. This means convincing the undecided to get the shot.

“Even in the medical professions, there are going to be some people who are reluctant, and it will take more persuasion and reassurance to get them vaccinated,” Schaffner says.

Glen Nowak, a former director of the CDC’s Prevention’s National Immunization Program calls those people the “wait and see group.” They’re people who are nervous about a vaccine that was created in less than a year, people skeptical of the role the politics have played in the process since the beginning, and those who, for good reason, have legitimate concerns about the trustworthiness of the U.S. healthcare system.

"In terms of who you would target a campaign toward, it would be the people who are in the wait-and-see group," Nowak tells Inverse. "You have to do consumer research to find out what will persuade them, what are they looking to see to feel confident and comfortable."

These are the people who may decide the pace of the country’s progress towards herd immunity, and the people that scientists, advertisers, and politicians are scrambling to understand to make sure that we’re on schedule to end the pandemic. And what will convince them may look more like a who.

The "moonshot" of 2020

We’ve always had to convince Americans to get vaccinated, explains Jeanine Guidry, director of the Media+Health Lab at Virginia Commonwealth University. Guidry studies health crisis communication and message design.

Public health authorities have to overcome a polarizing presidential election, the rise of anti-vaccine sentiment, a legacy of mistrust, as well as an “infodemic” that rapidly spreads misinformation. False information may even be better at reaching undecided people than experts: A May 2020 study found that anti-vaccine groups are better positioned to reach undecided people online than public health authorities are, for example.

“The hard thing is we're still in the middle of this,” Guidry tells Inverse. “But I think that also gives us the unique opportunity to say, ‘Okay, here we are, we can still change the trajectory to an extent.’”

One of the groups working to influence the trajectory is the Ad Council, a nonprofit and collaboration between major American ad agencies. The Ad Council has been marketing big ideas to the American public since the 1940s when it was formed in the aftermath of the Pearl Harbor attacks.

Today, the Ad Council is best known as the people who created Smokey the Bear, the cuddly representative of the US Forest Service, and the slogan: “Friends Don’t Let Friends Drive Drunk.” The Ad Council has also faced criticism for a post-September 11th campaign called the “Campaign for Freedom” which was criticized as “inappropriate and bordering on propaganda” for the War on Terror by the New York Times.

It’s a huge influence on U.S. marketing. And now, it’s turning its attention to the coronavirus vaccine with a budget of over $50 million.

It’s one of the Ad Council’s “largest communications efforts yet,” Lisa Sherman, the President and CEO of Ad Council tells Inverse. Sherman emphasizes that the campaigns (a spokesperson declined to share the details with Inverse at this stage) will be “guided by science and research.”

“We recognize that there is currently a lack of confidence and credible resources for people to go to for the vaccine, leading to mass hesitation, fear, misinformation, and complacency,” Sherman says.

She calls the coronavirus vaccine campaign “our generation’s moonshot.”

Ad Council began work weeks before the first coronavirus vaccine was given emergency approval. They’re directly in the middle of their research phase and declined to share any of their findings with Inverse just yet.

Unrelated scientific research gives us an idea. Experts tell Inverse there is no one kind of person who is wary of the vaccine, though some demographic groups are warier than others. Ultimately, the fears the vaccine is rushed and the mistrust in the U.S. healthcare system — and the science behind it — are major drivers of skepticism.

The rush problem — Peter M. Sandman is a risk communication consultant based in Brooklyn who advised the CDC on previous public health crises and bioterrorism threats, from smallpox to the 2001 anthrax attacks. The first mistake those charged with marketing a coronavirus mistake can make, he says, is to treat the undecided person like an anti-vaxxer.

“The last thing I would do is frame them as laggards, or as irresponsible or as anti-social or anti-vax,” Sandman tells Inverse. “I would go out of my way to show respect for the people who are hesitant and for their reasons for hesitating.”

Hesitant thinking before getting the jab isn’t always laced with conspiratorial thinking, he explains. It’s natural to be skeptical of a vaccine that was made on public display in record time – despite reassurances that steps weren’t skipped, rather the robust testing required of vaccines happened in parallel this year.

“We're a bit victims of our own success here.”

Before the coronavirus vaccine, the fastest vaccine ever brought to mass market was the measles and mumps vaccine, developed in four years in the early sixties.

“It's the COVID-19 specific hesitancy that that was gonna be the big issue. That is, the sense that it was rushed,” Sandman says.

Developing a coronavirus vaccine in less than a year is a scientific breakthrough moment. But public sentiment suggests, because of this speed, we may be paying a price when it comes to public confidence.

Guidry, of the Media+Health lab, recently published a survey in the American Journal of Infection Control that backs up Sandman’s intuition. Her sample of 788 isn’t a perfect reflection of the country, but she found that fear of a rushed process was a significant barrier to getting the coronavirus vaccine.

“We're a bit victims of our own success here,” she says. “This vaccine was developed super fast.”

The fear of a rushed vaccine even appears to cut across party lines – despite deep divides in how Republicans and Democrats initially felt about it. As of December, Democrats were more likely to get the vaccine according to multiple polls.

President Trump’s comments about a pre-election Covid-19 vaccine proved particularly divisive, David Lazar, a professor of political science and computer science at Northeastern University, tells Inverse.

Senator Lindsey Graham gets the vaccine on 12/19. In October, Graham refused to be Covid-19 tested ahead of his debate with challenger Jamie Harrison.

Lazar found clear partisan differences towards vaccination when he surveyed nearly 20,000 adults in July, months before Pfizer or Moderna revealed any coronavirus vaccine data to the public. At this time, 62 percent of Republicans said they had plans to be vaccinated compared to 75 percent of Democrats. When Lazar checked his data again he saw things swiftly changed for both parties because of the same catalyst: President Trump started to hint that a vaccine might become available by election day, earlier than scientists had told the country to expect.

The idea that a rapid-fire vaccine would arrive even faster was toxic to both parties. A poll from Kaiser Family Foundation in September showed that 54 percent Americans wouldn’t have gotten a coronavirus vaccine if it had come before election day. That included 60 percent of Republicans and 46 percent of Democrats, suggesting that fears of a rush can be even more powerful than partisanship.

“We actually just saw a general drop in vaccine acceptance,” Lazar says.

Lazar added that the farther away we get from the election, the more we might expect trust to rebound. His predictions have proved right.

The vaccines still arrived in 2020, but not before election day. And as trial results arrived showing that Moderna and Pfizer’s vaccines were around 95 percent effective, the amount of people willing to get a vaccine has started to bounce back. After hitting a low of 50 percent in September, the amount of people willing to get the vaccine has spiked to 63 percent, according to a December Gallup poll.

The trust problem — While some mistrust the medical system as a result of their politics, there are others who mistrust it as a result of a legacy of atrocities.

Specifically, Lazar found African American respondents to his survey were the least likely to want a vaccine, a fact he says reflects “current and historic mistreatment of African Americans by the health system.”

Chyke Doubeni is the Director of Equity and Community Engagement at the Mayo Clinic and a professor of medicine and family medicine. The day before he spoke with Inverse, Doubeni did a live Q&A on Minnesota Public Radio explaining how a legacy of medical racism contributes to Black Americans’ hesitancy about getting the vaccine.

In a recent AP poll, 24 percent of Black respondents said they would get the vaccine. Forty percent said they wouldn’t and 37 percent weren’t sure.

“And that’s the poison that got added.”

On the radio, one caller asked Doubeni about the Tuskegee Syphilis Study, an experiment on 600 black men run by the CDC that began in 1932. Health officials claimed to be treating the men for "bad blood", but the men received no treatment. Instead, scientists watched the progression of the unchecked disease. The study, which was supposed to last for 6 months, lasted forty years, during which treatment for syphilis became available. The CDC did not offer it to the men.

“It's a mistrust of the process,” Doubeni tells Inverse.

But he chafes against the idea vaccine hesitancy is purely down to mistrust of the federal government or even the US healthcare system. Doubeni says the perception of rush and the polarizing political battle around the vaccine (and it’s delivery data) exacerbated existing problems.

“It could have been anybody [making the vaccine], but politics got inserted into it. And that’s the poison that got added,” he says.

Doubeni’s approach isn’t about preaching the safety and efficacy of vaccines or even lecturing about the rising case counts around the country. It’s about demonstrating that he is willing to get a vaccine himself, as proof that he believes the vaccine is truly “our best hope.” Doubeni got the vaccine himself as part of a clinical trial for that exact reason: he became a trusted messenger for its safety.

“I can see people around me, beginning to say, ‘Wow, if you did it and are still standing, then, we will do it.’ What I can tell you is that the attitudes are changing,” he says.

One criticism of the idea of a trusted messenger is that the messenger approach alone forces Black people to take on the extra work of overcoming mistrust wrought by the medical system. Scientists writing in the New England Journal of Medicine wrote that clinical trials should also have clear consent forms, ensure trial participants will receive medical care in the trial, and clearly state that Black communities will have fair access to vaccines. Finally, clinical trial organizers have to promise politics are staying out of the development process.

But in the short term, the coronavirus vaccine still needs that trusted messenger, Doubeni argues. He’s become one of them, and the Ad Council is looking for more. Sherman, the CEO of Ad Council, says that she’s aware that it will take more than a recognition of past atrocities to win back the trust that the U.S. healthcare system has squandered. But with limited time, a trusted messenger is the best place to start.

“We’ll be developing culturally relevant content and leveraging trusted voices and influencers in our efforts to engage key audiences,” Sherman says.

Bring in the celebrities

People tend to discount how large a role influencers play in guiding their own decisions. For instance, in Lazar’s August survey, respondents indicated three factors will ultimately dictate whether people get vaccinated: vaccine safety, efficacy, and side effects.

These are huge issues for the “wait-and-see” group, Nowak says. But seeing other people do something – even if it’s a complex medical procedure — signals that someone else finds the vaccine safe. And it’s what can ultimately get people over the finish line.

For example, in 2012, Angelina Jolie got a double mastectomy after learning she carried a gene for breast cancer and wrote about it in The New York Times. The editorial was linked to an additional 4,500 genetic tests for a breast cancer-linked gene among women, and higher rates of screening throughout 2013. Women who identified with Jolie, a 2013 study noted, expressed greater intent to get screened, regardless of their risk, than those who didn’t identify with her. Her influence was immortalized on the cover of Time magazine as “the Angelina effect.”

Meanwhile, in 1956, Elvis Presley was administered the polio vaccine before going on The Ed Sullivan Show. His much-publicized vaccination is credited as what motivated American teenagers to finally get the jab.

To win out, the coronavirus vaccine will need more of the same: more influencers, more powerful stories, and more relatable characters from all different walks of life.

“A ‘one size fits all’ message is not the solution to a challenge as complex as mass vaccine adoption,” Sherman says. The Ad Council, in turn, is pursuing “united trusted messengers” and “micro-influencers” — people who can convince other people to get vaccinated.

“The right-wing conspiracist types may be reassured if they see Trump roll up his sleeve and get vaccinated.”

The White House made a botched attempt at this in October, promising to give mall Santas vaccines early. More recently, three presidents, Barack Obama, Bill Clinton, and George W. Bush, all volunteered to get vaccines publicly.

A wildcard inclusion would be President Trump himself, who Lazar adds, could speak to republicans already mistrustful of the medical system. Forty-two percent of Republicans in the Kaiser Health Poll in December still expressed hesitancy about getting vaccinated.

“People who have low, low trust in the system are the ones who tend to support Trump. That could make Trump all the more important and critical cheerleader for vaccines,” Lazar says.

“The right-wing conspiracist types may be reassured if they see Trump roll up his sleeve and get vaccinated.”

Vice President Mike Pence has already gotten Pfizer’s vaccine on camera, sitting beneath a flag that read: “Safe and Effective.”

Still, Doubeni cautions that politicians have already been too involved in what should be a nonpartisan effort.

“I take the view that maybe we should take these things out of the hands of the politicians,” he says.

Regardless of who they are, influencers and public health authorities have to be on the same page when it comes to the message they are selling. Celebrities, like everyone else, can break either way: at the outset of the pandemic, Woody Harrelson shared a conspiracy theory about “negative effects 5G towers” and Covid-19 at the beginning of the pandemic. Trump, now a cheerleader for the coronavirus vaccine, supported the false idea vaccines cause autism as late as 2014.

“We need to make sure that we present people with the correct information,” Guidry says. If they’re operating with false information, the "Angelina effect" could go horribly awry.

The "final stage" influencer

During a December press conference with New York Governor Andrew Cuomo, Sandra Lindsay, sat in a blue medical chair while photographers clicked away. Lindsay, a critical care nurse and a Black woman, became the first person to get the coronavirus vaccine in the U.S. outside of a clinical trial.

When the vaccinator approached with the Pfizer vaccine in one hand, Lindsay spoke from behind her mask: “Let’s do this.”

Months ago, you might not have called Lindsay an influencer. But now, she’s exactly the person the Covid-19 vaccine needs to get people on the bandwagon.

Sandra Lindsay, a nurse at Long Island Jewish Medical Center, is vaccinated by Dr. Michelle Chester in New York City.Mark Lennihan/Getty Images

“The bandwagon that really matters are local ordinary folks. The people you think of as just like you,” says Sandman. “If people like you are getting vaccinated, you’re going to get vaccinated. And if people like you are waiting, you’re going to wait,” he says.

Making the vaccine cool will take a multi-pronged approach. But the influencers that can truly seal the deal for people — really convince them they’re making the right choice — aren’t celebrities. They’re normal people.

Nowak adds acceptance at the local level is where the quest for herd immunity will truly be won. He calls it “the final stage” of whether a person decides to get the vaccine. And the people who are getting the first shots right now, or were part of the clinical trials, have a key role to play.

If they have adverse reactions, seem mistrustful of the vaccine, or, in some cases, avoid it entirely, it could send ripple effects through the whole country. On the flip side, if things go particularly well, especially in the early stages of vaccine rollout, winning over the rest of America could go smoothly.

After she got her vaccine, Lindsay turned to the doctor on her right and said “I feel great.”

Moments like that made Guidry feel emotional as both a scientist and a civilian. Watching Lindsay's vaccination made her feel like she was living through history; taking the first steps toward a Covid-19 free world where she can feel safe going home.

She studies how to communicate about vaccines, and is watching the first vaccines roll out keenly as an academic. But, with the pandemic spiraling out of control, she’s also not visiting her family for the holidays.

“I saw these healthcare workers who have been on the front lines getting these vaccines and just, the relief and the awe and all the emotions in their faces,” she says.

“I think that is the power of storytelling. It is one of the most powerful things we have in our arsenal.”

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