The story of the COVID-19 vaccines is a winding one. Never in the world’s history has a vaccine been developed and deemed safe and effective so quickly—in less than 12 months. For many, it felt like a miracle. For others, it brought trepidation. In the United States—where vaccines are widely available—about 23 percent of eligible individuals have chosen to not get a jab. The ongoing controversy around vaccination uptake has left many Americans on opposite sides of a fiery debate which has significant implications for public health.
Robert Aronowitz, Walter H. and Leonore C. Annenberg Professor in the Social Sciences, has extensively researched vaccines related to HPV and Lyme disease and says, “Every vaccine has a unique history. How the public reacts to a vaccine is based on the target condition it’s treating, the concerns and fears that are raised, and the era in which it comes up. No vaccine story is the same.”
We asked Aronowitz, a professor in the Department of History and Socology of Science and co-editor of Three Shots at Prevention: The HPV Vaccine and the Politics of Medicine’s Simple Solutions, his thoughts on how vaccine hesitancy today compares to the past, the politicization of public health, and the power of vaccination mandates.
How does current vaccine hesitancy and controversy look either familiar or different compared to the past?
The resistance to COVID-19 vaccinations is by no means the first instance of vaccine hesitancy. There has been opposition to vaccinations throughout history. For example, the controversies around the MMR vaccine to protect against measles, mumps, and rubella and the erroneous belief that it causes autism is one example. My HPV research looked at, among other points of contention, how the overreach of pharmaceutical companies—in underhanded lobbying of state legislatures, high pricing, and aggressive marketing that created and exploited fear—undermined the trust necessary for many ordinary people to get jabbed.
I would say that the controversy around the COVID-19 vaccines has more of a left-right political quality to the opposition than existed with some of the other vaccines of the past. Certainly, some of the opposition to older vaccines did arise from a feeling that there was overreach of the local, state, and federal government, which is a political point of view. However, the left-right dimension to the COVID skepticism seems more extreme. As a historian, I would say this is about a moment in time and the politics of that moment. Perhaps if we had had better leadership and direction under the Trump administration, this would have played out differently.
There have been some COVID vaccine mandates for healthcare workers, within private corporations, and soon, within the federal government. Are mandates historically a useful tool to increase vaccine uptake?
I’m on sabbatical in California right now and there is a mandate for healthcare workers here to be vaccinated, and compliance is really high. Mandates can work to get people who are on the fence or dragging their feet to get it done.
Based on the research of other experts, I’d mention the effectiveness of leverage points. A good example of this is the vaccinations that children are required to receive to begin schooling. The push for school mandates for childhood vaccinations came about because of the awareness that lots of people were not getting vaccinated because they had substandard access to healthcare, particularly the poor and minorities. There were social and racial inequalities in vaccine uptake, which was threatening herd immunity and the health of children not vaccinated. The basic idea was that by mandating vaccination for entry into school, you could create a powerful leverage point to influence people and put pressure on localities to find ways of providing and paying for vaccines.
Many people choose not to vaccinate because it’s inconvenient to do so, not necessarily because of ideological reasons. Everyone wants their kids in school—it’s a powerful incentive. Every state in the union eventually had school vaccine mandates and that went hand-in-hand with other programs like CHIP, the expansion of Medicaid’s service to children, and programs to subsidize what families pay for vaccinations. The approach was quite effective.
You’ve extensively studied vaccinations for HPV and Lyme Disease. How does your research dovetail with the current COVID landscape?
My research emphasizes that we have to look closely at the particular circumstances in which vaccines are developed, what the target disease is, and the peculiarities of its preexisting controversies. For example, vaccine hesitancy around Lyme disease had little to do with the kind of concerns or politics that surrounded vaccines like the MMR or others of the time, and everything to do with the problematic nature of what Lyme disease is.
There was a preexisting and ongoing fight over whether Lyme disease is a relatively straightforward tick-borne disease that doesn’t usually cause long-term, serious problems even if left untreated, that is relatively easily treated when identified, doesn’t require multiple courses of antibiotics, and only very rarely leads to chronic symptoms. That’s the sort of mainstream expert medical view of the disease, but a lot of other people believe that Lyme disease is much more serious: That it’s not easily treated by oral antibiotics, that it requires multiple courses of intravenous antibiotics, and that it can cause all kinds of symptomatology, including chronic fatigue, weakness, and various other neurological manifestations. This group originally supported a Lyme disease vaccine, but they turned against it when the success of the vaccine seemed to undermine their alternative view of Lyme disease. The very definition of the disease used in the clinical trials was this narrow acute problem version.
Before introducing the vaccine, there was some issues with the immunological criteria to diagnose Lyme disease. Because clinicians use immunological tests to diagnose the disease, there was concern that there would be overlap between people who were vaccinated and people who looked like they had the disease. So, they changed their criteria and some people in the Lyme disease community got really angry about the narrowing of immunological criteria for diagnosis. Additionally, the more lay oppositional view posited a possible immunological mechanism for the chronic symptoms of Lyme disease, basically a kind of autoimmune reaction to the offending spirochete. If you believe that theory, then you worry that a vaccine could cause long-term problems because vaccines work by inducing immunity. As of today, there is no Lyme disease vaccine for humans currently available largely because of this particular context and other factors such as medical ambivalence about a vaccine against a treatable, non-deadly disease in comparison to, say, the often untreatable and potentially deadly consequences of HPV infection, which does have a vaccine. Ultimately, the context and the details surrounding vaccines matter when talking about the vaccine hesitancy that may arise in each case.