Recent research has shed light on this problem. Jennifer Reich, a sociologist at the University of Colorado, Denver, has spent years studying families who refuse to vaccinate their children against diseases like measles. She found that mothers devoted many hours to “researching” vaccines, soaking up parental advice books and quizzing doctors. In other words, they act like savvy consumers. The mothers in Reich’s study maintain that each child is unique, and that they know their child’s needs better than anyone. As a result, they insist that they alone have the expertise to decide what medicines to give their children. When thinking as a consumer, people tend to downplay social obligations in favor of a narrow pursuit of self-interest. As one parent told Reich, “I’m not going to put my child at risk to save another child.”
Such risk-benefit assessments for vaccines are an essential part of parents’ consumer research. For illnesses like measles, outbreaks — until recently — have been so rare that it’s not hard to be convinced that the harm of vaccines outweighs that of the disease. However, we’ve found in our research that for Covid-19, this risk analysis can get turned on its head: Vaccine uptake is so high among wealthy people because Covid is one of the gravest threats they face. In some wealthy Manhattan neighborhoods, for example, vaccination rates run north of 90 percent.
For poorer and working-class people, though, the calculus is different: Covid-19 is only one of multiple grave threats. In the South Bronx, one man who works two jobs shared that he navigates around drug dealers, hostile police and shootings. “I don’t want my kids to see what I’ve seen,” he said. Another man said he lost his job during the pandemic and slipped back into addiction. “Most of my friends are dead or in jail,” he said. Neither one plans to get vaccinated. Their hesitancy is not irrational: When viewed in the context of the other threats they face, Covid no longer seems uniquely scary.
Most of the people we interviewed in the Bronx say they are skeptical of the institutions that claim to serve the poor but in fact have abandoned them. “When you’re in a high tax bracket, the government protects you,” said one man who drives an Amazon truck for a living. “So why wouldn’t you trust a government that protects you?” On the other hand, he and his friends find reason to view the government’s sudden interest in their well-being with suspicion. “They are over here shoving money at us,” a woman told us, referring to a New York City offer to pay a $500 bonus to municipal workers to get vaccinated. “And I’m asking, why are you so eager, when you don’t give us money for anything else?” These views reinforce the work of social scientists who find a link between a lack of trust and inequality. And without trust, there is no mutual obligation, no sense of a common good.
As the emergence of the Omicron variant shows, vaccine mandates in the United States are not enough to solve this problem. Hesitancy is a global phenomenon. While the reasons vary by country, the underlying causes are the same: a deep mistrust in local and international institutions, in a context in which governments worldwide have cut social services.
Research shows that private systems not only tend to produce worse health outcomes than public ones, but privatization creates what public health experts call “segregated care,” which can undermine the feelings of social solidarity that are critical for successful vaccination drives. In one Syrian city, for example, the health care system now consists of one public hospital so underfunded that it is notorious for poor care, a few private hospitals offering high-quality care that are unaffordable to most of the population, and many unlicensed and unregulated private clinics — some even without medical doctors — known to offer misguided health advice. Under such conditions, conspiracy theories can flourish; many of the city’s residents believe Covid vaccines are a foreign plot.
In many developing nations, international aid organizations are stepping in to offer vaccines. These institutions are sometimes more equitable than governments, but they are often oriented to donor priorities, not community needs. In Afghanistan, villagers lack access to most basic health services; some must travel hours to reach a clinic. Cases of childhood malnutrition are widespread and growing. Even though the country has only a few dozen cases of polio yearly, institutions like the W.H.O. spend considerable sums promoting and carrying out polio vaccinations. People in Kandahar speak about polio in ways that are strikingly similar to how residents in the Bronx speak about Covid. “We have starvation and women die in childbirth,” one tribal elder told us. “Why do they care so much about polio? What do they really want?”