Headline: Covid-19: Why do some people choose to remain unvaccinated?

According to the statistical data published by the Robert Koch Institute as well as various scientific institutions and professional bodies on the benefit/risk balance of Covid-19 vaccines, there is no doubt that vaccinations significantly benefit people across all population groups. The risk of infection is roughly three times lower for vaccinated people, and the likelihood of suffering serious illness or even death from Covid-19 is about 30 times lower than for unvaccinated people. And while it is true that the new Omicron variant is set to re-shuffle the cards, people who have received a booster vaccination are still substantially better protected than unvaccinated individuals.

So why is it that around 20% of people over the age of 18 are still unvaccinated in Germany? Why have so many people declined to be vaccinated despite the clear statistical evidence of the effectiveness of the available vaccines and the low risk of serious side effects?

Trust is an important piece in this puzzle[1] . One recent survey revealed a gulf between vaccinated and unvaccinated people with regards to their confidence in various institutions: 77 per cent of the vaccinated respondents expressed confidence in the medical profession. Just 45 per cent of the non-vaccinated respondents shared this view. This disparity extends across diverse areas: trust in science (68 versus 38 per cent), in the federal government (28 versus 14 per cent) and, especially, in the Federal Standing Committee on Vaccination (STIKO) (53 versus 15 per cent). Where trust is lacking, people generally resort to one of two courses of action and either (a) pursue a zero-risk strategy, or (b) they seek out alternative sources of information that they are more likely to consider trustworthy.[2]. 

How do these two options play out in the pandemic?

(a) The zero-risk option is favoured by people who feel that they cannot trust either side in this debate: neither the official sources from science and government nor the professional anti-vaccination campaigners, who have attracted a strong following online and off-line. Their reasoning is as follows: If you can’t trust one side or the other, it seems better to do nothing at all than what could turn out to be the wrong thing. What if the vaccine is riskier than the government claims? Wouldn’t it then be better to err on the side of caution? And the other side also seems suspect: they play down the threat posed by the virus and appear to be pursuing their own (possibly political) ends. Viewed from this perspective, it seems more advisable to adopt a strategy that minimizes individual risk: social distancing, testing, and wearing a mask.

We know from other studies that this attitude is widespread among those referred to as “vaccine hesitant”: they have either had bad experiences with vaccinations, feel that vaccinations undermine their bodily integrity, or prefer alternative medical treatments and are generally sceptical of so-called orthodox medicine. At the same time, people from this group distance themselves from the conspiracy stories disseminated on the Internet and understand the importance of preventing contagion.

This group of people who do not wish to expose themselves to the risks they perceive in connection with Covid-19 vaccines includes many who feel “left behind” in the unfolding economic and societal transformations, as the German weekly newspaper DIE ZEIT recently noted.[3] The group consists largely of less educated people who have little interest in politics, feel that their interests are frequently overlooked in society, and generally seek to minimize their involvement with officials of all kinds. They do not feel addressed by public health messaging and have other priorities than getting vaccinated. The actual size of this group is difficult to gauge as its members rarely take part in surveys and often seek to make themselves “invisible” in other ways.

(b) The second option is pursued by people who seek out alternative sources of information to which they attribute credibility rather than the recognized institutions of science and politics. This group is informed by a greater variety of motives and motivations. These sometimes overlap but in many cases this hesitancy is driven by individual concerns. Two sub-groups with different motivations are discernible here:

•    People who were disillusioned with politics and science before the coronavirus crisis: This group includes individuals and groups who feel “betrayed” by the political system, who consider themselves to be victims of globalisation and digitalisation, who feel harried by either a left-wing intellectual elite (if they position themselves on the right of the political spectrum) or by profit-hungry capitalists (if they are on the left of the political spectrum), and who feel that their own achievements and abilities are not sufficiently acknowledged by society[4].

These individuals understand their refusal to be vaccinated as a political signal: “Look! I’m not falling for your propaganda! You don’t care about people like me anyway! My choice is an act of defiance and a demonstration of my independence!” Members of this group are also susceptible to counter-narratives, including often-invoked conspiracy narratives or supposedly scientific studies that question the existence of the virus, the effectiveness of vaccines or dramatize possible side effects. While this group does include some individuals with extreme left beliefs, the majority hold views along the right-wing spectrum. According to the study by the University of Kassel quoted above, 37 per cent of the protesters surveyed are AfD-voters and 12.8 per cent are non-voters.

•    People who are receptive to alternative and often fanciful explanations and who find conspiracy narratives and tales of secret cabals that run the world particularly appealing[5]: Contrary to their depiction in the media, adherents of conspiracy narratives are seldom psychologically conspicuous individuals, paranoiacs, or psychopaths[6].  Their political views often tend towards the fringes of the political spectrum – mostly to the right but occasionally towards the left. Many are stalwart believers in alternative medicines and healing methods. These individuals frequently feel that they are powerless and at the mercy of the events unfolding around them ¬ they quite literally no longer understand the world. Many conspiracy narratives are anything but simple and, in some cases, it can take hours of study before their logic begins to take hold. However, these narratives offer believers three benefits[7]:

•  A sense of cognitive security: Conspiracy narratives offer the reassuring and appealing certainty that complex events can be interpreted clearly and without ambiguity; in the case of science, on the other hand, believers have the impression that public health assessments and guidelines are revised on a weekly basis[8].

•  A sense of self-efficacy: Conspiracy narratives offer relief from and a framework to understand personal setbacks and experiences of disappointment and frustration[9] .

• A sense of social community: These narratives afford believers social recognition and a sense of belonging within a community of like-minded people.

These three benefits have almost global appeal. However, most people, at least when it comes to the issue of vaccination, are sufficiently critical thinkers to distinguish serious explanations and realistic interpretations of events from wishful thinking, esoteric mysticism, and conspiracy narratives[10]. Indeed, most people, at least in Germany, are careful not to fall for fake news or the propaganda of right- or left-wing sycophants. However, it is not always easy to draw a clear line between truth and lies, between visions and illusions and between belief and superstition. Most people find it difficult to distinguish between fact and opinion without drawing on the advice of professional experts. And therein lies the root of the problem: The more negative experiences that a person has with health experts in the fields of politics, science, and civil society, the less trustworthy these experts will seem to them. This translates into an increasing difficulty to understand complex issues and heightens the appeal of conspiracy narratives that convey a clear and self-enhancing message that lends meaning to their lives.

Of course, this brief outline does not cover the entire spectrum of people who do not wish to be vaccinated. There are also those who feel that their freedoms are being curtailed and express their discontent by refusing to be vaccinated, but who do not doubt that the vaccines are effective. And there are those who believe they are invulnerable and assume that they will somehow escape infection or not suffer any serious symptoms (the Trump syndrome), or whose fear of the injection itself is greater than their fear of the consequences of an infection. Finally, there are those who simply haven’t found the time to get vaccinated.

This leads us to the question: What should we do? Should we simply accept that 20% of the eligible population will remain unvaccinated? Should the government introduce a blanket COVID-vaccine mandate? Should we somehow make getting vaccinated more attractive? Should we make it more difficult to opt-out? Or should we improve the messaging around the benefits of vaccination?

The answers to these questions are not simple and what may work for one group will cause others to harden their opposition and may even stir aggression. However, several recommendations can be derived from previous research on vaccine hesitancy which suggests that we should[11]:

• Improve access by establishing walk-in vaccination sites within communities (e.g., at shopping centres, workplaces, sports centres, and recreational facilities)

• Increase the incentives for vaccination so that unvaccinated people clearly understand what they will miss out on if they refuse to be vaccinated

• Offer a selection of vaccines where possible (this makes it easier for the zero-risk group to save face and choose what they consider to be the least problematic vaccine)

• Focus messaging on the importance of solidarity with weaker and more vulnerable members of society. Make it clear that getting vaccinated will help to prevent further loss of life in the future. This will help to persuade those who see themselves as invulnerable and speaks to those unvaccinated people for whom the concept of public health holds positive connotations (it is not a question of restricting individual freedoms, but of safeguarding the well-being of those who are particularly threatened by the virus)

• Secure the active cooperation of public figures from diverse fields who can act as effective ambassadors for the vaccination campaign. It is important to choose people who enjoy a high degree of credibility, especially among target groups that are critical of government and science, but also among those who feel left behind and unheard: People from left-wing or right-wing cultural circles, well-known critics of government policies, athletes and entertainers, proponents of alternative and complementary medicine or representatives from civil society organizations that work with or are active in communities where vaccine hesitancy is high. Considerable progress could be made towards overcoming vaccine hesitancy with a campaign based around the principle: “I don’t believe everything the government says about the coronavirus, but I’ll get vaccinated to save lives!”.

I am sceptical on the issue of a blanket vaccine mandate. This would deepen rather than bridge the divide between those who are vaccinated and those who are not. A different approach must be taken when it comes to professionals who work with people that require special protection, such as the sick, the elderly, children, or people with disabilities. Here, the state cannot only expect solidarity, but must also demand it in the service of the common good. Beyond this, we must try everything we can to persuade people to get vaccinated unless an objectifiable medical reason prevents them from doing so.