With three highly efficacious vaccines widely available for COVID-19 in the United States (which were developed in record time, breaking the record set by a mumps vaccine in the 1960s), we are beginning to see the light at the end of the COVID-19 pandemic. But the effort to reach herd immunity and reduce the COVID-19 pandemic into a controllable seasonal disease requires vaccinating as many people as possible as quickly as possible. This still presents public health officials with many logistical challenges. The most concerning of these is the relatively high degree of vaccine hesitancy. A recent KFF study shows that approximately 17% of Americans are hesitant about a COVID-19 vaccine and an additional 13–15% of Americans say they will “definitely not” get a COVID-19 vaccine.
While vaccine skepticism has a long history, Maya J. Goldenberg’s new book Vaccine Hesitancy: Public Trust, Expertise, and the War on Science gives us a fresh and timely new perspective on the most recent, and dangerous, cause of vaccine hesitancy: the so-called “War on Science.” Goldenberg argues, insightfully, that this combative language “is both descriptively inaccurate and normatively unhelpful” and that it only furthers “poor public trust” in scientific institutions.
Goldenberg wants to draw her readers’ attention to the important distinction between vaccine hesitancy and refusal: the latter is a behavior, but the former is a “a spectrum from mild to severe uncertainty” of safety, efficacy, or necessity, which might inform behavior. Studying hesitancy, Goldenberg argues, is especially useful for public health research, as it encompasses a much larger population, especially in the global North.
Goldenberg’s monograph examines many of the factors that may “turn the dial for skepticism to confidence in vaccines” as well as the ways in which “failing to communicate effectively . . . can harden vaccine-skeptical views, turning vaccine hesitators into vaccine refusers.” She argues throughout her first four chapters that although “battle-weary vaccine advocates” who must “combat torrents of online misinformation” might want to evoke the language of a “war,” doing so creates an us-versus-them dichotomy that often presents vaccine hesitant as illiterate, irrational, or willfully antiscientific and turns the dial in the “wrong” direction from hesitance to refusal. Rather, Goldenberg argues that public health officials must reframe their rhetoric to restore the public trust in scientific expertise. Goldenberg offers some lessons as to how we might achieve this in her latter two chapters.
In her first chapter, Goldenberg addresses the idea of “The Ignorant Public.” She dispels the idea that the public is easily susceptible to antiscientific misinformation despite decades of public health outreach. The vaccine-hesitant public might not understand “the values underlying scientific consensus,” but to portray the public as ignorant is self-defeating. To prove her point, Goldenberg takes her readers through the classic example of the now-debunked Lancet study by Andrew Wakefield, which claimed that the measles, mumps, and rubella (MMR) vaccine causes autism, and the process through which vaccinologists like Paul Offit disproved this myth. The vaccinologists were so methodical in their dismantling of the study that they believed continued hesitancy could only persist due to ignorance. Goldenberg suggests otherwise: Public dissent often resulted from an individual’s personal sense of risk-management (i.e., concerns about safety or risk of adverse events) rather than an antiscientific position. By refusing to listen to these concerns, by shutting down dissenting views, or, worse, condemning them as ignorant, public health officials instead made the likes of Wakefield into a martyr among the vaccine hesitant populace.
In her second chapter, Goldenberg considers why pro-vaccine messaging often backfires, as Brendan Nyhan et al. observed, and how the media has made the problem even worse. However, Goldenberg rejects the “fatalistic conclusion that vaccine hesitators and refusers cannot be reasoned with.” She suggests that vaccine advocates must bear in mind the complex social psychology of motivated cognition, cultural cognition, and cognitive bias that influence vaccine hesitant parents. “Indirect” interventions, such as self-affirmation, enlisting a diverse set of experts, or “nudging” persuasion are perceived as less threatening by the target audience, and make them “more open to considering new evidence.”
Chapter Three considers “The Death of Expertise” and the rise of a populist culture war on science by “supposedly expert-loathing publics.” Once again, Goldenberg challenges this supposition. Noting that while expertise is often “vigorously challenged,” she suggests that this can be corrected through a “recalibration” of the role of the expert if they present themselves as both “technically competent and responsive to public interest and concern.” Better appreciating the social context of knowledge creation, Goldenberg contends, will restore trust in institutions that create scientific knowledge.
After a fourth chapter on the increasing politicization of science more broadly, Goldenberg spends the last two chapters (Part II) of Vaccine Hesitancy offering suggestions on alternative modes of science communication than the flawed “war on science” rhetoric she is critiquing.
Chapter Five examines how we might restore “Trust and Credibility in Science.” To start, Goldenberg calls for further and more robust research on how to measure trust. Goldenberg spends the bulk of her fifth chapter examining the epistemology of trust and risk: by placing trust in someone or something (like a vaccine) one is inherently exposing themself to a risk. Misplaced trust threatens the integrity of science, so trust must be earned. She reminds her readers that while the public cannot check experts on their empirical accuracy, it can “evaluate the character of the scientific expert or the integrity of the institution they represent.” According to Goldenberg, some of the metrics for evaluating trustworthiness are honesty, competence, conscientiousness, and the capability for self-assessment. Achieving trust, she contends, can take science farther than just scientific consensus alone in allaying public concerns.
Chapter Six returns to the role of “The Scientific Expert as Hero and Maverick.” Expertise exists in “unorthodox” places, like the world of social media, where many vaccine hesitant persons go out of an active distrust of traditional public health media. In these spaces a new breed of “alternative expertise” emerges that can range from challenging questions of power and privilege to active misinformation. In this new realm, scientists must be prepared to confront the unorthodox “mavericks” (like Andrew Wakefield) who represent a “populist counterforce to the power interests that expert elites are thought to represent and reinforce.”
Vaccine Hesitancy concludes with some lessons on “Rebuilding Trust.” Goldenberg once again reiterates the problematic use of a war metaphor and how it can turn the dial from hesitancy toward rejection of vaccination. She further argues that rather than play the blame game, accusing the public of being ignorant, irrational, or antiscientific, instead we (“the courageous defenders of science”) should be cognizant of why a crisis of trust has emerged and what we can do to correct it. Rebuilding trust in the scientific establishment will require actively listening, building bridges into hesitant populations, responding not with condemnation but with awareness of discrimination and patient dissatisfaction, and by appealing to shared values rather than blind trust. None of this can be done amid a “war.”
While Goldenberg’s monograph is not without its flaws – it is at times overly jargony and it assumes too much knowledge of a wide range of existing literature – it is also an extremely timely and relevant book. With a target of upwards of 85% of the population requiring vaccination to achieve herd immunity to end the COVID-19 pandemic, this will require convincing the 17% of the American public who are still “hesitant” to get the vaccine as soon as they can. Goldenberg tells us how we can.
- Maya J. Goldenberg, Vaccine Hesitancy: Public Trust, Expertise, and the War on Science (University of Pittsburgh Press, 2021), 12, xi. ↑
- Goldenberg, Vaccine Hesitancy, 3–4. ↑
- Ibid., 5. ↑
- Ibid., 13. ↑
- Ibid., 22. ↑
- Brendan Nyhan et al., “Effective Messages in Vaccine Promotion: A Randomized Trial,” Pediatrics 133 (April 2014): 835–842. ↑
- Goldenberg, Vaccine Hesitancy, 43. ↑
- Ibid., 53. ↑
- Ibid., 72. ↑
- Ibid., 73. ↑
- Ibid.,124. ↑
- Ibid.,123. ↑
- Ibid., 153. ↑
- Ibid., 168. ↑