The United Kingdom has announced that travellers who have been vaccinated against COVID-19 in the European Union or United States will be exempt from mandatory quarantine upon arrival — but fully vaccinated travellers from Canada will still have to undergo quarantine.
Earlier this month, I pulled a mask out of the bin of hats, scarves, and gloves I keep by the door; strapped it on; and choked. I had inhaled a mouthful of cat hair—several weeks’ worth, left by my gray tabby, Calvin, who has been napping on a nest of face coverings since I largely dispensed with them in May.
I’ve been fully vaccinated for two months. I spent the end of spring weaning myself off of masking indoors, and exchanging, for the first time, visible smiles with neighbors in the lobby of our apartment building. I dined, for the first time in a year and a half, at a restaurant. I attended my first party at another (vaccinated) person’s home since the spring of 2020. I am, after all, now at very low risk of getting seriously sick should SARS-CoV-2 infect me, thanks to Pfizer’s vaccine.
But the pandemic is once again entering a new phase that feels more dangerous and more in flux, even for the people lucky enough to have received their lifesaving shots. A more transmissible variant—one that can discombobulate vaccine-trained antibodies—has flooded the world. It’s wreaking havoc among the uninoculated, a group that still includes almost half of Americans and most of the global population. After a prolonged lull, the pandemic’s outlook is grimmer than it’s been in months. I am, for the foreseeable future, back to wearing masks in indoor public places, and there are four big reasons why.
1. I don’t want to get COVID-19.
Let me be clear: My chances of getting sick are low, very low, especially if I’m thinking about the disease in its worst forms. The vaccines are spectacularly effective at blocking COVID-19, particularly cases that lead to hospitalization or death, even when squaring off with Delta and other antibody-dodging variants. I expect this to hold true for some time: These vaccines were tested primarily for their power to curb deadly illness, and that’s what they’re accomplishing against every version of the coronavirus they face.
But no vaccine is perfect. Some immunized people will end up infected with the virus; a small subset of this group will fall ill, occasionally severely so. The proportion of vaccinated people who catch the coronavirus might tick up in the presence of certain mutations that make the virus less recognizable to vaccinated immune systems, and thus harder to purge. The longer the virus sticks around in the body—the more opportunity it’s given to copy itself and mosey through our tissues—the more likely it is that symptoms will arise as immune defenders rally to fight. (Delta might be extra well equipped to accumulate in airways.) Most post-vaccination infections, or breakthroughs, appear to be asymptomatic or mild, a sign that the vaccines are doing their job. But mild illness still isn’t desirable illness, especially given the threat of long COVID, which reportedly can happen in vaccinated people, though researchers aren’t yet sure how widely.
Masks slash the risks of all these outcomes. Breakthroughs are more common when the immune system faces a ton of inbound virus—when there’s an ongoing outbreak, or when the people around me aren’t immune. A mask reduces my exposure every time I wear one. Some variants, including Delta, might be more transmissible, but they’re still thwarted by physical barriers such as cloth.
I’m not duping myself into thinking that I’ll stave off this virus forever; SARS-CoV-2 is here to stay. But as hospitals in several states once again start to fill up, I’m in no rush to rendezvous with the coronavirus, especially because …
2. I don’t want people around me to get COVID-19.
If I get infected, that affects more than just me. I worry about the strangers I encounter—many of them maskless—whose immune status I don’t know. I worry about the youngest kids in my social network, who aren’t yet eligible for shots, and the elderly and immunocompromised, whose defenses may be weaker than mine. I worry about the people in my community who have been structurally barred from accessing the vaccines, or who are reluctant to take the shots. My risk of getting COVID-19 is low. Theirs is very much not.
The COVID-19 vaccines come with the delightful perk of blocking some asymptomatic infection, but researchers are still figuring out how often vaccinated people can pass on the pathogen. The math gets all the messier with more contagious variants such as Delta. Inbound virus affects me directly, but it can also turn me into a pathogen pit stop, potentially allowing outbound virus to bop into someone with less immunological armor. “Masks protect both us and the people around us,” Krutika Kuppalli, an infectious-disease physician at the Medical University of South Carolina, told me. In the United States, inoculation rates have taken a serious dip. The proportion of vulnerable people is stagnant, yet still too high.
During a pandemic, personal safety can’t be the only consideration, as my colleague Ed Yong has written. The disease we’re dealing with is infectious; the repercussions of our behavior ripple to those around us. Many unvaccinated people belong to populations that have been marginalized by the country’s fractured health-care system. Saddling them with any increased COVID-19 risk, even indirectly, threatens to widen disparities. Going maskless indoors still feels like a gamble, especially because …
3. I trust the vaccines, but I understand their limits.
My pivot back to masks says nothing about my continued confidence in the vaccines and what they’re capable of. But although vaccines are an excellent tool, they are also an imperfect one, and they’ll perform differently depending on the context in which they’re used.
Consider, for example, the effectiveness of sunscreen, another stellar yet flawed preventive. Certain brands, including those with higher SPF, will be better than others at blocking burns and cancer. Mileage may vary even with the same tube of sunscreen, depending on who’s using it (how much melanin is in their skin?), how they’re behaving (are they dipping in and out of the shade, or spending all day soaking up rays?), and local conditions (is it a cloudy day in a wooded park, or a sunny day on a snow-speckled hill?). Vaccines are similar. Breakthroughs are more likely in people with a weakened immune system and those who mingle frequently with the virus; they may happen more often with certain variants.
Asking a vaccine to shoulder the entire burden of protection felt all right a month ago, when case rates were plunging. Now they’re ticking back up. The vaccines don’t feel different, but the conditions they’re working in do. Maybe now’s not the best time to rely on them alone. “That’s putting a lot of pressure on the vaccines,” Jason Kindrachuk, a virologist at the University of Manitoba, told me. The virus has upped the ante, and I feel the urge to match it. When it’s extra sunny out, I’m probably going to reach for sunscreen and a hat, especially because …
4. Wearing an accessory on my head doesn’t feel like a huge cost to me.
Don’t get me wrong. I don’t enjoy wearing a mask, and all else equal, I’d still prefer to keep it off. But for me, it’s not a big sacrifice to make for a bit more security: I’ll mainly be using one indoors when I’m around strangers, a situation in which the risk of spread is high. And I’ll keep checking pandemic conditions like I would a weather forecast—hospitalizations, variants, immunization rates, and the behaviors of people around me—and adjust as needed. The idea is that this state of affairs will be short-lived, until vaccinations climb and the virus retreats again.
I live in New England, where things are relatively calm. I could probably get away with resuming normal life, whatever that is. But the status quo feels tenuous. It will take work to maintain. As Delta dominates the nation and case rates rise, we may already be losing our grip. Kuppalli said that although she’s concerned about our current menagerie of variants, she’s also trying to ensure that more problematic versions of the virus don’t have the opportunity to arise. The stakes in her community are particularly high: In South Carolina, where vaccination rates are relatively low, “it’s a free-for-all,” she said. “When I walk into a supermarket, I’m the only one in a mask. People look at you like you’re crazy.”
Vaccines have sometimes been billed as an option to supplant the nuisance of masks. But making that trade-off at an individual level feels overly simplistic in a population where so many people are neither immune nor covered up. I also didn’t get vaccinated because I wanted to stop masking. I got vaccinated because I wanted to reduce my chances of getting sick with this virus and transmitting it to others. Masking is a complementary means to the same end. My return to it isn’t an indictment of vaccination. It’s an insurance policy. It’s a small price to pay for more protection, especially once I’ve washed the cat hair away.
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Faced with a pandemic that has killed more Americans than all those who perished during World War II, America is a nation divided, split by both politics and the health crisis at hand. We've become two countries, one vaccinated and largely safe, the other unvaccinated and still at great risk.
L.A. will require city employees to provide proof of vaccination against COVID-19 or undergo weekly testing for the virus.
In the United States, this pandemic could’ve been over by now, and certainly would’ve been by Labor Day. If the pace of vaccination through the summer had been anything like the pace in April and May, the country would be nearing herd immunity. With most adults immunized, new and more infectious coronavirus variants would have nowhere to spread. Life could return nearly to normal.
Experts list many reasons for the vaccine slump, but one big reason stands out: vaccine resistance among conservative, evangelical, and rural Americans. Pro-Trump America has decided that vaccine refusal is a statement of identity and a test of loyalty.
In April, people in counties that Joe Biden won in 2020 were two points more likely to be fully vaccinated than people in counties that Donald Trump won: 22.8 percent were fully vaccinated in Biden counties; 20.6 percent were fully vaccinated in Trump counties. By early July, the vaccination gap had widened to almost 12 points: 46.7 percent were fully vaccinated in Biden counties, 35 percent in Trump counties. When pollsters ask about vaccine intentions, they record a 30-point gap: 88 percent of Democrats, but only 54 percent of Republicans, want to be vaccinated as soon as possible. All told, Trump support predicts a state’s vaccine refusal better than average income or education level.
[Read: Vaccination in America might have only one tragic path forward]
To overcome this resistance, some state and local political leaders have offered incentives: free beer, free food, tickets for a $1 million lottery. This strategy is not working, or not working well enough. Part of the trouble is that pro-Trump state legislatures are enacting ever more ambitious protections for people who refuse vaccines. They are forbidding business owners to ask for proof of vaccination from their customers. They are requiring cruise lines, sports stadiums, and bars to serve the unvaccinated. In Montana, they have even forbidden hospitals to require health-care workers to get vaccinated.
Pro-Trump vaccine resistance exacts a harsh cost from pro-Trump loyalists. We read pitiful story after pitiful story of deluded and deceived people getting sick when they did not have to get sick, infecting their loved ones, being intubated, and dying. And as these loyalists harm themselves and expose all of us to unnecessary and preventable risk, publications—including this one—have run articles sympathetically explaining the recalcitrance of the unvaccinated. These tales are 2021’s version of the Trump safaris of 2017, when journalists traveled through the Midwest to seek enlightenment in diners and gas stations.
Reading about the fates of people who refused the vaccine is sorrowful. But as summer camp and travel plans are disrupted—as local authorities reimpose mask mandates that could have been laid aside forever—many in the vaccinated majority must be thinking: Yes, I’m very sorry that so many of the unvaccinated are suffering the consequences of their bad decisions. I’m also very sorry that the responsible rest of us are suffering the consequences of their bad decisions.
As cases uptick again, as people who have done the right thing face the consequences of other people doing the wrong thing, the question occurs: Does Biden’s America have a breaking point? Biden’s America produces 70 percent of the country’s wealth—and then sees that wealth transferred to support Trump’s America. Which is fine; that’s what citizens of one nation do for one another. Something else they do for one another: take rational health-care precautions during a pandemic. That reciprocal part of the bargain is not being upheld.
Biden’s America is home to vaccine holdouts too. But state and local leaders in Biden’s America have spoken clearly and consistently about the urgency of vaccination. The leaders in Trump’s America have talked a double game: Like Florida Governor Ron DeSantis, they urge vaccination one day, then the next they fundraise by attacking public-health officials such as Anthony Fauci. The consequence of DeSantis’s weeks of pandering to COVID-19 denial: More than one-fifth of all new COVID-19 cases in the United States are arising in the state of Florida—24,000 recorded on a single day, July 20.
[David Frum: The rise of Ron DeSantis]
Can governments lawfully require more public-health cooperation from their populations? They regularly do, for other causes. More than a dozen conservative states have legislated drug testing for people who seek cash welfare. It is bizarre that Florida and other states would put such an onus on the poorest people in society—while allowing other people to impose a much more intimate and immediate harm on everybody else. The federal government could use its regulatory and spending powers to encourage vaccination in the same way that Ron DeSantis has used his executive powers to discourage it. The Biden administration could require proof of vaccination to fly or to travel by interstate train or bus. It could mandate that federal contractors demonstrate that their workforces are vaccinated. It could condition federal student loans on proof of vaccination. Those measures might or might not be wise policy: Inducements are usually more effective at changing individual behavior than penalties are. But they would be feasible and legal—and they would spread the message about what people ought to do, in the same way that sanctions against drunk driving, cheating on taxes, and unjust discrimination in the workplace do.
[Read: America is getting unvaccinated people all wrong]
Compassion should always be the first reaction to vaccine hesitation. Maybe some unvaccinated people have trouble getting time off work to deal with side effects, maybe they are disorganized, maybe they are just irrationally anxious. But there’s no getting around the truth that some considerable number of the unvaccinated are also behaving willfully and spitefully. Yes, they have been deceived and manipulated by garbage TV, toxic Facebook content, and craven or crazy politicians. But these are the same people who keep talking about “personal responsibility.” In the end, the unvaccinated person himself or herself has decided to inflict a preventable and unjustifiable harm upon family, friends, neighbors, community, country, and planet.
Will Blue America ever decide it’s had enough of being put medically at risk by people and places whose bills it pays? Check yourself: Have you?
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America’s split with masks turned out to be a brief hiatus. After getting their shots in the spring and early summer, many people figured they could dump their face coverings for good—a sentiment the CDC crystallized in May, when the agency gave fully immunized people its blessing to largely dispense with masking, indoors and out. Yesterday, the agency pivoted back, recommending that even fully vaccinated people wear masks under certain high-risk circumstances, including in public indoor spaces in parts of the country where the virus is surging, Director Rochelle Walensky said in a press briefing. (She specified places where new case numbers exceed 50 per 100,000 people in the past seven days; that currently includes about two-thirds of U.S. counties.) With an ultra-contagious SARS-CoV-2 variant rampaging, face coverings are being called upon to once again supplement the protection offered by vaccines.
The CDC’s decision, which many public-health researchers have been anticipating for weeks, might look like a flip-flop or a fumble, some sort of masking mea culpa. But to me, and the experts I talked with, redonning masks (or simply keeping them on, as many people have) is not some shameful regression to the dark ages of the pre-vaccination era. Nor is it an indictment of the COVID-19 vaccines, which are doing an extraordinary job of curtailing the global burden of disease. Instead, it’s a doubling down on two defenses that we know work, and work well together.
[Read: 4 reasons I’m wearing a mask again.]
Like any dynamic duo, masks and vaccines share a goal—preventing infection, disease, and virus transmission—and they accomplish it in complementary ways. “They should be seen hand in hand, as helping one another,” Abraar Karan, an infectious-disease physician at Stanford University, told me. We now understand this notion better than ever before, and many experts think anyone who wants to reduce their risk of catching and passing the virus should use both, CDC criteria notwithstanding.
Masks, after all, are reemerging in response to the fast-changing conditions around us—offering another layer of protection at a time when we need it most, in much the same way we seek out umbrellas when it rains, sunscreen when it’s sunny, and better security systems when our neighborhood crime rates tick up. “With Delta being such a dominant force, we need to include every layer we can think of,” Akiko Iwasaki, an immunologist at Yale University, told me. The vaccines are excellent. But while so many people remain vulnerable, and the virus continues to shape-shift, shots can’t shoulder the burden of protection alone. Our understanding of masks is evolving; for now, they still have a crucial role to play, as a partner to the shots we'll be depending on long term.
Partnering masks and vaccines is, in many ways, a natural move. If an unmasked, unvaccinated body is like an unprotected bank, vulnerable to burglars, these two tools are akin to the different high-security measures used to prevent a heist. Shots steel the institution from the inside out, papering its walls with most-wanted posters and alerting bank personnel to upswings in local crime. Supersensitive alarms get installed at windows; extra security guards are stationed throughout the building; the local sheriff’s office is put on speed dial. Should thieves try to force their way in, they’ll be recognized as familiar foes and get arrested on the spot, maybe before any real damage can be done.
COVID-19 vaccines have proved themselves ace at deploying these safeguards and preventing symptomatic disease, especially in its most severe forms, even when tangoing with variants. That is the classic vaccination modus operandi: fortifying our defenses so a pathogen has higher hurdles to clear.
But even vaccinated immune systems can be somewhat foiled when local conditions change. A well-armored bank will still be better off than an unsecured one, but could struggle to thwart career criminals—ones who are savvy enough to show up en masse, move fast, and use brutal tactics. And more of those robbers might make it out of the scuffle unscathed and eager to hit up a neighboring bank. Vaccine-prepped immune systems are still mostly clobbering Delta, the SARS-CoV-2 variant that’s now found in 80 percent of the virus samples being sequenced across the nation: People who have gotten all their shots are a lot less likely to experience symptoms, hospitalization, or death, and don’t seem to be responsible for much virus transmission. But Delta also appears to be especially good at accumulating in airways, and seems to eke past some of our immune defenses. These troubling traits might make it easier for the virus to mildly sicken some inoculated individuals, and perhaps spread from them as well. Vaccines are an imperfect shield; variants like Delta find their way through the cracks.
Masks cut down on all of this risk. If vaccines shore up security from the inside, face coverings (which, you know, literally cover your face) erect a sturdy blockade around the bank’s exterior—fences, bars, better locks, and ID checks at an intruder’s typical point of entry. Masks are physical barriers; they’re “great at preventing exposure to large doses of virus” before the invaders even enter the premises, Iwasaki said. And in the same way that it’s easier for security guards to incapacitate just a few crooks busting through the door, “the less virus you need to fight off, the better—I think that’s pretty clear,” Marion Pepper, an immunologist at the University of Washington, told me. Masks, in other words, curb the amount of labor our immune systems are forced to do—in some cases, maybe eliminating the threat entirely. In that way, they accomplish something vaccines can’t: Unlike immune cells, they don’t have to wait until after the virus has broken into the body to act. That’s an especially big asset for people whose bodies are less equipped to respond to vaccines, including the elderly and the immunocompromised, populations the CDC says should mask more vigilantly indoors, regardless of where they live.
[Read: Mask mandates will come and go.]
Masks might be a particularly important pairing for our current vaccines, which are administered in an arm muscle, rather than the nose—SARS-CoV-2’s natural point of entry. The shot’s contents will still effectively school immune cells and molecules all over the body, but they won’t do much to marshal defenders that specialize in guarding the slimy tissues carpeting the airway and gastrointestinal tract. It’s the difference between keeping security guards on retainer in a bank’s back room, and posting agents at the building’s entrance: Defenses will be mounted either way, but fighters who have to scramble from one location to another will probably lose speed and oomph. A barrier that waylays some viral particles, however, might buy these guards time to rush to the fore. Masks reduce the strain on the body, and keep immune cells in a zone where they can comfortably fight.
Our vaccines are very powerful, but their performance was first measured in clinical trials while masking was widespread. Study volunteers were “asked to act as if they were unvaccinated, and keep all other protections in place,” Michal Tal, an immunologist at Stanford, told me. The startlingly low rates of illness among vaccinated volunteers in those studies likely aren’t attributable to the jabs alone. Even against an earlier iteration of the virus, the shots were being supported by an entourage of precautions; mirroring that initial tag-team approach might not be a bad idea.
The combo of masks and vaccines does a number on outbound viruses as well. Unimmunized, unmasked bodies are good stages for pathogens to reproduce unfettered, then hop into a nearby human. Vaccines coach immune cells to vanquish as many viral particles as they can; masks trap any potential escapees inside. “People need to remember we live in very interconnected societies,” Karan said. While vaccinated people might remain mostly safe from serious disease, plenty of the people around them—especially those who remain uninoculated, including young kids—remain at much higher risk. A virus that keeps spreading, even silently, makes the pandemic that much harder to end.
Karan points out that masks are also a great insurance policy. Vaccines still carry uncertainties: Although experts think that COVID-19 shots are reducing all forms of infection and disease, the extent to which they block long COVID remains murky. Researchers also don’t know when vaccine-trained immune cells might start to forget the coronavirus, or when the pathogen might mutate into more evasive forms. If we end up needing boosters or reformulated vaccines, face coverings might keep some people from falling sick while those reinforcements arrive. “I think masks are our lowest hanging fruit to buy us time,” Karan said.
Some people are already criticizing the CDC’s announcement as a baffling U-turn, maybe even a bellwether of worse restrictions to come. Experts told me that’s the wrong way to view the update, which should be considered an improvement over the status quo—a step forward, not a step back. Combining masks and vaccines reaffirms that we know how to protect ourselves against this fast-changing virus, and match the curveballs it throws our way. Taison Bell, a critical-care and infectious-disease physician at UVA Health in Virginia, told me he sees masks as empowering—not some handicap he’s been saddled with. “It doesn’t represent something that restricts my freedom,” he said. “It allows me to enter a space and do what I need to do.”
The shift in guidance is, in a way, crystallizing a new attitude toward masking, one that will probably stick around in some form or another, even after the pandemic comes to an official close. These past 16 months have underscored the power of masks to prevent all manner of pathogens, and stave off some medical conditions; face coverings might become standard practice, socially, seasonally, as people get more in tune with public health. That’s the upside of crisis. It forces us to react, and hopefully react well. It calls on us to adapt, when we realize our circumstances have changed.
Vaccinations warded off severe Covid for most of the workers, who tested positive this month; two required hospitalization.
With Covid-19 cases and hospitalizations now surging again and officials across the US suddenly reimposing restrictions after a summer of semi normalcy, many vaccinated Americans are becoming increasingly angry at those who won't get vaccinated.
Last week, CDC Director Rochelle Walensky said that COVID-19 is “becoming a pandemic of the unvaccinated.” President Joe Biden said much the same shortly after. They are technically correct. Even against the fast-spreading Delta variant, the vaccines remain highly effective, and people who haven’t received them are falling sick far more often than those who have. But their vulnerability to COVID-19 is the only thing that unvaccinated people universally share. They are disparate in almost every way that matters, including why they haven’t yet been vaccinated and what it might take to persuade them. “‘The unvaccinated’ are not a monolith of defectors,” Rhea Boyd, a pediatrician and public-health advocate in the San Francisco Bay Area, tweeted on Saturday.
Boyd has been talking to underserved communities about COVID-19 vaccines since November, before any were even formally authorized. Together with several partner organizations, she co-developed a national campaign called The Conversation, in which Black and Latino health-care workers provide information (and dispel misinformation) about the vaccines. She has spoken virtually to dozens of community groups, including churches and schools, fielding their questions about the shots. I reached out to Boyd because I wanted to know what she has learned through all these encounters about why some people are still unvaccinated and what to do about it.
Our conversation has been edited for length and clarity.
Ed Yong: You recently spoke with people in southern Georgia who had many lingering questions about vaccines. On Twitter, you said, “Every question they asked was legitimate and important.” Tell me more about the event and the questions you were getting.
Rhea Boyd: It was a tele-townhall, and around 5,000 people participated. I would have imagined that people who stayed on would be unvaccinated, but the people who asked questions were a mix. I had one gentleman who was vaccinated with Johnson & Johnson and he asked, “Did I get a safe shot?” We affirmed for him that this far after his vaccination, he’s likely safe, but that opened my eyes. If you’ve heard about that serious side effect and are worried if you’re at risk, you’re probably not encouraging the people around you to be vaccinated.
Yong: That’s fascinating to me. There’s a tendency to assume that all vaccinated people are pro-vaccine and all unvaccinated people are anti-vaccine. But your experience suggests that there’s also vaccine hesitancy among vaccinated people.
[Read: America is now in the hands of the vaccine-hesitant]
Boyd: Yes, and we tend to hear similar questions among people who are unvaccinated. They may also have heard common threads of disinformation, but they’re still asking basic questions. The top one is around side effects, which are one of the main things we talk about when we give informed consent for any procedure. If people aren’t sure about that, it’s no wonder they’re still saying no.
A lot of vaccine information isn’t common knowledge. Not everyone has access to Google. This illustrates preexisting fault lines in our health-care system, where resources—including credible information—don’t get to everyone. The information gap is driving the vaccination gap. And language that blames “the unvaccinated” misses that critical point. Black folks are one of the least vaccinated groups, in part because they have the least access to preventive health-care services.
Yong: I’m glad you raised the issue of access. Everyone age 12 and up is now eligible for vaccines, and President Biden promised that 90 percent of people would have a vaccination site within five miles of their home. I’ve heard many people doubt that vaccine access is still an issue and, by extension, that anyone who is still unvaccinated must be hesitant or resistant. Do you disagree?
Boyd: Availability and access aren’t the same thing. If you have to walk the five miles, you’re going to rethink getting vaccinated, especially if you’re elderly, or you have chronic disease, or the round trip is interfering with other things like work. [Much of] our paid workforce doesn’t have flexibility about hours, or couldn’t take a day off if they wanted to. And if you don’t have paid sick leave to deal with the vaccine or the potential side effects of the second dose, you’ll skip it because feeding your family is more important right now.
Child care is also an enormous issue. If you don’t have someone to watch your children, then what do you do? Many of these things the Biden administration has tried to address. They have programs involving Uber and Lyft. Child-care organizations have signed on to help with vaccine appointments. There are tax breaks for companies that offer paid sick leave. These are incredible, but they may not filter down to your area. We need to think about local interventions to help stretch them.
[Read: The surprising key to combatting vaccine refusal]
Yong: If these barriers to access were all addressed, do you have a sense of the proportion of people who would then get vaccinated?
Boyd: The truth is we don’t know. If you’re not getting vaccinated, we have even less data on you than if you are vaccinated. But we know that these barriers exist for even basic care. How do we make sense of the fact that some people won’t get critical medications, like their diabetes medications? Or that some people forgo necessary medical care even as they experience complications from chronic illness? It’s not that those individuals don’t want basic medical care! It’s that groups face structural barriers to accessing that care, including rural folks, underinsured folks, and Black folks in particular. Those structural barriers are likely at play for vaccinations too. This is a problem for health care more generally. We’ve been willing to move on without people, while leaving them without resources to fend for themselves.
Yong: What about people at the other extreme, who do have easy access but who are vitriolically opposed to vaccines—people who could more reasonably be described as anti-vaxxers?
Boyd: Anti-vaxxers are incredibly vocal, and because of that, they’ve been a disproportionate focus of our vaccine outreach. But I think that they represent a small part of people in this country, and especially in our communities of color, an irrelevant part. In our work, we haven’t given much credence to their bluster. But the rampant disinformation that’s put out by this minority has shaped our public discourse, and has led to this collective vitriol toward the “unvaccinated” as if they are predominantly a group of anti-vaxxers. The people we’re really trying to move are not.
Yong: I’ve never thought of it that way. We’re used to thinking of anti-vaxxers as sowing distrust about vaccines. But you’re arguing that they’ve also successfully sown distrust about unvaccinated people, many of whom are now harder to reach because they’ve been broadly demonized.
Boyd: Yes. The language we use around unvaccinated people comes with a judgment—a condescension that “you’re unvaccinated and it’s your choice at this point.” That attitude is papering Twitter. It’s repeated by our top public-health officials. They’re railing on the unvaccinated as if they’re holding the rest of us back from normalcy. But unvaccinated people aren’t a random group of defectors who are trying to be deviant. They’re not all anti-vaxxers. They’re our kids! Any child under 12 is in that group.
Yong: Okay, but even if extreme cases are a minority, we can’t ignore them. When I reported on the ongoing surge in Missouri, a hospital chief told me that one patient spat in a nurse’s eye because she told him he had COVID-19 and he didn’t believe her. How do you think about folks who have gotten to that point?
[Read: Delta is driving a wedge through Missouri]
Boyd: These very contentious encounters are driven by people really staunchly holding on to something that they are served by in some way. Maybe it’s the source that belief came from, and they need to believe other things that source says. Maybe they want camaraderie or collegiality with people around them, so they can feel that they’re in an in-group. People need to believe that what they believe is true. They feel threatened when challenged about something to which they feel beholden. The best way to address that may not be to actually challenge them one-on-one, but to shift what people around them are talking about. If you hear enough stories in your Facebook feed or from strangers in the store that reinforce the science, it’ll make what you’re saying less reasonable to you. And less useful to you. And once you don’t need to hold on to it, you can let it go.
Yong: Which is why community-based efforts are so important. People who will be swayed by Anthony Fauci are already listening to him. But, for example, public-health professionals I spoke with in Missouri are trying to get pastors, firefighters, and community leaders to act as trusted voices for their own people.
Boyd: Exactly. At the beginning of the pandemic, we drew on data about how physicians of color were trusted messengers for communities of color. But there are so few of us—only 5 percent of our physician workforce is Black. That isn’t enough. But I think we’re too limited in our thinking about who is a trusted messenger. People use informal communication chains: They have side conversations with the grocery-store clerk, or their niece and nephew. People will believe anecdotal health-care information that their family member suggests over the credible info that a health-care professional is giving.
We’ve talked to virtual faith-based groups on Sundays. We’ve talked to barbershops, after-school organizations, and boys’ and girls’ clubs. Some of these groups are small—hundreds of people, or sometimes just 20. People are then much more specific about their concerns without the things they usually have bluster around. I wonder how many people arrogantly respond about vaccinations during more formal conversations, but then come to our events and share something vulnerable in these protected settings where they’re surrounded by their pastor and people they know.
Yong: This has the added benefit of promoting vaccinations among groups of people who are likely to encounter one another. My concern, however, is that this is slow work—and Delta is moving fast. Does it feel like you’re stuck in a war of attrition against misinformation, while time is running out?
[Read: The 3 simple rules that underscore the danger of Delta]
Boyd: It’s true. Now that vaccines aren’t novel, we’ve lost some of that early momentum when people would go to their local Walgreens. Now we have to do the heavy, high-touch work, making sure that we proactively reach out to everyone. And we can only go as fast as people are willing to go.
That’s concerning, and it’s why we need to reimplement mitigation strategies, like indoor masking, in addition to vaccination. That’ll give us the time to do the work. No form of mitigation will block transmission 100 percent, but we have to use them together. When the cavalry arrives, it’s not like all the other soldiers on the field just leave.
Yong: When I talk to people about the vaccination challenge, the main emotions I hear are frustration and despair. So perhaps the most surprising part of this conversation for me is that you sound … hopeful?
Boyd: Yes. I feel enormously hopeful. If I was only going off what I saw online, I’d probably agree that everyone who wasn’t vaccinated is being selfish and difficult. But talking to people like those church groups has changed how I feel completely. Often, I see an entire family on the other side of the screen—kids and grandparents. People come. They come in groups. They’re willing to be vulnerable. They have questions. And their questions are all ones we have answers for. It’s not undoable.
Children under 12, who cannot be vaccinated, can show a negative test to attend. But the Metropolitan Opera and Carnegie Hall plan to bar them for now.
At a county health department near my hometown in rural Arkansas, almost everyone who comes in for a COVID-19 test is congested and short of breath, with a sore throat and muscle aches. They might have the flu, except for the added telltale symptom of this coronavirus: the loss of taste and smell. Many of the patients now are younger than those in previous months; a nurse who works there told me she saw two cases of young children in one day. (The Atlantic agreed not to name the nurse, because, as a state employee, she is not authorized to speak with the media.) Even worse, though, is that almost every potential case she saw was avoidable. Almost none of the eligible adults she tested had had one of the vaccines.
Arkansas has one of the lowest vaccination rates in the United States, and one of the worst case rates for COVID-19. Our neighboring states—especially Missouri—are seeing similar trends. Case counts have been increasing at the highest rates since February, and we have the most new cases per capita in the nation. On Monday, we saw the highest single-day increase in hospitalizations, 79 new patients, of the entire pandemic. Test-positivity rates are also high, suggesting that infections are undercounted. In my county, Van Buren County; in the more rural Searcy County to the north; and in the more densely populated Faulkner County to the south, the daily case totals are, respectively, 119 percent, 142 percent, and 191 percent higher than their averages over the previous two weeks. Because new cases show no sign of slowing down, we likely have more illness ahead. My local Facebook feed has again become a steady stream of families asking for prayers and making announcements for memorial services.
The nurse at the health department told me that she and her co-workers had expected that some people would resist vaccination, but that “seeing that resistance persist despite education, despite outreach” had left her and her colleagues depressed and downtrodden. “Why are they not understanding how this is putting people’s lives in danger?” she asked. Like her, I’ve been haunted by this question. Sixty-two percent of my neighbors remain unvaccinated for complicated, interrelated reasons that map onto existing, bitter divisions. Any solutions, equally complicated, will likely come only after we’ve seen more death.
I had expected some amount of vaccine hesitancy in my hometown, a small place of about 2,500 residents, called Clinton, on the southern edge of the Ozark Mountains, because of the way this pandemic has unfolded from the beginning. Although schools and many restaurants temporarily shut down here, my region is full of people who have been reluctant to wear masks, stay at home, and otherwise adapt to new recommendations from health authorities. Big stores such as Walmart enforced mask wearing, but many smaller establishments didn’t. Many schools went partly remote, but ball games continued. The community seemed split between people who were taking the pandemic seriously and people who thought the disease was a hoax, or no worse than the regular flu.
That split remains today, as unvaccinated people continue to go about their life as if this pandemic never happened, even as the Delta variant’s presence makes the virus as dangerous as ever. Those of us who rushed out to get vaccinated feel personally safe but remain cautious. Persisting in this contradiction can seem like living in the distorted reality of a fun-house mirror, as we watch those least protected from the virus take the most risks, likely ensuring the disease’s continued spread.
My small county has had 24 COVID-19 deaths throughout the pandemic, and statewide that number has passed 6,000 (for comparison, in recent years, flu deaths ranged between 620 and 720). News of these deaths trickled out among friends and family—I found out about a former teacher’s death because of a group email. We haven’t set aside a time to mourn the community’s loss together, and we haven’t had a COVID-19 memorial. Unlike my friends who live in Washington, D.C., and New York City, I never experienced nights filled with the sounds of sirens, and many of my neighbors never saw the death and devastation up close. The virus spread primarily through family networks because people continued to see their families, but rural life can be atomized and isolating. That kept us from feeling the full force of the pandemic’s effects, and also provided a small amount of protection from the disease itself.
Now the virus’s increased ability to spread, hitting just as we’ve reopened, has finally collapsed that rural space. Suddenly, we’re racing against time, trying to get more and more people vaccinated before hospitals become too full and start turning patients away. The strain on health-care facilities is especially worrisome in rural areas, which have few hospitals and ICU beds. Our most serious medical cases are typically sent to Little Rock, and on Saturday, the University of Arkansas for Medical Sciences announced that its hospital, a public facility ranked among the best in the state, was full.
During last year’s relative isolation, more people went online, especially to Facebook, for socialization and information; today, that is where the vaccines’ loudest opponents announce why they’re not getting the shots. People I know seemed concerned about the fact that the vaccine was approved only for emergency use. They also believe that people have died from the vaccines in large numbers, that the vaccines themselves have caused illness, that they’re responsible for the Delta variant, that they’re made with fetal tissue from aborted babies, that they alter your DNA, that they cause infertility, that the government’s eagerness to offer incentives for vaccination is suspicious, and that because the vaccines are new, their use amounts to a government experiment on the citizen population. There is some understandable distrust of the pharmaceutical industry because of the U.S. opioid epidemic, and of the government because of this country’s history with medical racism. Every vaccinated friend of mine who has tried to champion vaccines to the disbelievers said they end up sad, disappointed, and frustrated, caught in circular arguments that rely more on ideology than facts, and in which every piece of evidence is taken as more proof of conspiracy.
More often, the reasons people give for skipping vaccination are less extreme and more personal. Last Tuesday, I met up with Courtney Patrick, my partner’s co-worker at a medical-cannabis facility. She had just received her first dose of the Moderna vaccine. She is 31, and had avoided vaccination until last week because she doesn’t like needles, and because she wasn’t very concerned about contracting COVID-19. “I still have that false sense of ‘I’m young; I’ll be okay,’” she said. She knows that this isn’t exactly true, because the flu made her very sick three years ago. In her previous job, Patrick worked as a veterinary technician (she still rescues turtles in her spare time), preaching to patients that they should get their dogs and cats vaccinated every year. She knows that vaccines work and believes in them. The push she needed to overcome her fear came from her family. Patrick’s grandmother was diagnosed with breast cancer, and will need help with errands—plus, Patrick wants to be able to visit her grandmother without putting her at risk, which she couldn’t do without getting vaccinated. Before that, she said, “it was just low on my list.”
And nothing around her signaled that that should change. The state has been treating the pandemic as though it’s essentially over. Restaurants were allowed to resume operations at full capacity in February, our mask mandate was lifted in March, and the pandemic unemployment-assistance programs ended on June 26. Although the governor, Asa Hutchinson, still gives regular COVID-19 briefings and encourages people to get vaccinated, we lost a sense of urgency just when we needed it most.
In this context, getting vaccinated has meant acting on our own volition. Although every county has a walk-in center for free vaccines, many are open only during business hours on weekdays, and they’re located in population centers. Two of the three biggest clinics in our county are located here in Clinton—it’s the county seat. From the rural outreaches of the county, the trip can be almost an hour each way. In elderly and low-income rural populations, many people are unable to drive or do not have regular access to a working car, and our county hasn’t made a widespread effort to take mobile vaccination sites out to community centers, churches, or firehouses. Deborah Shoenberger Brennan, a retired veterinarian who volunteered with the county’s wellness committee—which was disbanded last year to avoid meeting during the pandemic—thinks we need them. “We veterinarians, we go out into the whole county to, like, 12, 15 different stations … to vaccinate for rabies. I’d like to see our public-health professionals or our doctors or physician assistants do that,” she told me.
Making vaccinations easier might pull in some people who are simply hesitant because of inertia, like Patrick. The Delta variant’s threat is also pulling a few more people in. On Thursday, a pharmacist in Clinton, Marinda Bryan, who has been vaccinating patients since the shots became available, said on a local radio show that she’s now seeing 10 to 15 people coming in every day for their first dose. (On Friday, the state health department reported its largest daily dose total since May 21.) Bryan said many people falsely believe that the vaccines cost money, but more people arrive with medical misinformation. She and her staff have been able to allay their concerns in most cases. At her pharmacy, all customers are reassured that they are free to make their own choices, but are also asked whether they’ve had a COVID-19 vaccine. If they have not, they get a reminder: It’s always available.
Still, how many people will keep resisting, no matter what? If people also resist mask wearing or other public-health mandates, the idea that getting the vaccine is a matter of personal choice takes on a different valence. “Your choice is your choice, but you don’t have the freedom to force your choice on other people,” Shoenberger Brennan said.
For the 33 percent of people in our county who have already been fully vaccinated, living with that tension has been frustrating: Many of us feel that our neighbors are continuing to put others in danger. Breakthrough cases among vaccinated patients are rare—nationally and in the state, more than 99 percent of current deaths are among the unvaccinated—but they’re more common in populations with high numbers of unvaccinated people. Those of us who were vaccinated early have reluctantly begun wearing masks in stores again. “If something doesn’t change, I will never be able to leave the house!” a friend, Lisa Ray, who is a professor at the University of Central Arkansas, told me.
Courtney Patrick thinks more people won’t be moved to get the vaccine until a health problem affects them personally, like her grandmother’s cancer did her. One Arkansas mother named Angela Morris was interviewed by the Little Rock CBS affiliate, THV 11, from Arkansas Children’s Hospital, where her 13-year-old daughter had been on a ventilator because of COVID-19 for 12 days. That day, the children’s hospital had six other pediatric COVID-19 patients, two of them on ventilators. (By Tuesday, the children’s hospital said it had 12 COVID-19 patients.) “I just want people to get their kids their shots. Everybody just needs to get the shot. It’s a much better route than the one we’re in,” Morris told the station.
But I’ve seen other cases in which personal tragedies haven’t changed anyone’s mind. A friend forwarded me a message from a new COVID-19 widow preparing to bury her middle-aged husband. “I truly believe God has had our time planned for a long time before that day comes,” she wrote. “If you are meant to go, you will despite anything you try to prevent it.”
Many white evangelicals had already begun to shun vaccines altogether, and part of their rationale is this sense of predestination. The message of these anti-vaxxers builds on a basic idea: God built your body, and the immunity that nature gave you is better than any medicine. Sometimes, doctors repeat these messages. Bryan, the local pharmacist, told me that two doctors in our hometown are not discouraging their patients from getting the vaccines, but they are also not advocating for them. Some are more blatant in their opposition—Amy Beard, who practices telemedicine and is licensed in the state, has been outspoken about treating COVID-19 patients instead with medication typically used to prevent heartworms in dogs, cows, and goats. On her Facebook page, she called the shots “mutant factories,” in response to comments about the vaccines creating variants. Someone who had recovered from COVID-19 in January asked her about “natural” immunity; Beard responded, “Before Covid, natural immunity was the BEST immunity. And it still is.”
For the nurse at the county health department and other health-care professionals, this strain of resistance began with President Donald Trump and has been the hardest to fight. “I think that this would be a totally different story had it been addressed appropriately in 2020, at the very beginning,” the nurse told me. When Trump and other leaders questioned health professionals and epidemiologists, those uncertainties led more people to feel empowered to question them as well. Individual reasons for avoiding vaccination keep shifting—whatever it takes to stay on that side of the political divide. Meanwhile, the rest of us have to reckon with what it means that so many of our neighbors have been reluctant to act in the public good, and what that augurs for our sense of community, now and whenever this is over.
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