Vaccine Hesitancy and the War on Science

Debates over issues like vaccination and climate change are about public trust, not a rejection of expertise

In her outstanding new book, Vaccine Hesitancy: Public Trust, Expertise, and the War on Science — published today, Maya Goldenberg of the University of Guelph documents her intellectual journey. She writes that when she first set forth to write a book about vaccine hesitancy, “I initially assumed that vaccine hesitators were missing some scientific evidence that kept them from embracing the strong scientific consensus on vaccine safety and efficacy.” Instead, the book she actually wrote argues that its not scientific ignorance or denialism at the heart of vaccine hesitancy, but “that vaccine hesitancy is a problem of poor public trust.”

The rewards of Goldenberg’s journey were well worth the trip. Goldenberg argues that there are “two alternative frameworks for understanding vaccine hesitancy and refusal.”

One is encapsulated by the metaphor of a “war on science” which holds that many in the public are ignorant or even anti-science, readily misled and misinformed, in part due to their cognitive biases. From this view, public ignorance is exploited by denialists and other fringe figures who challenge established scientific authorities for money, power or both. The remedy thus is to correct the publics’ misunderstandings and to counter the authority wielded by bad actors.

A second perspective is framed as a “crisis of trust,” which to be addressed requires that “public health agencies and experts must move their ideas and communications beyond false ideals of scientism and work to address vaccine hesitancy by responding to discrimination within their institutions, reforming their susceptibility to industry influence, and appealing to shared values and priorities with public stakeholders.”

Goldenberg fully aligns herself with this latter perspective and forcefully argues that the “war on science” framing is not just wrong, but it actually contributes to undermining public trust. Goldenberg is not the first to offer a critique of the “war on science” framing, but she very well may have written its most devastating and comprehensive critique.

In the book’s first four chapters, Goldenberg summarizes the problems with the notion of a “war on science.” She taps a rich and varied literature in chapters on (misunderstandings of) public understandings of science, cognitive biases, and “antiexpertise and denialism.” She writes, “it is shocking to many vaccine advocates that scientific consensus on vaccines does not settle public concern.” These chapters confront what is — in many areas of science — unchallenged conventional wisdom and thus may prompt strong reactions among those holding the “war on science” perspective. But even so (or maybe especially so) any expert wishing to engage or persuade the public should confront Goldenberg’s arguments, and the large literature that she situates them in.

One great irony of the “war on science” perspective is that it reifies the central importance of evidence-based action, but at the same time rejects the overwhelming evidence that it is ineffective, and can even be pathological by contribution to an unhealthy politicization of science. For instance, Goldenberg cites a recent review that concludes, “no intervention targeting vaccine attitudes has been demonstrated to significantly improve vaccine attitudes or to increase vaccine uptake.”

What does work to increase vaccine uptake? Building trust. Goldenberg cites as an example the “I Immunise” campaign in Western Australia, in 2014, which “notably focused on identity rather than the vaccine facts to improve vaccine perception and behaviors, invoking many of the community’s shared values.” This was exactly the approach taken by Dolly Parton last week in a viral video in which she revised her hit song Jolene to focus on the Covid-19 vaccine, telling people, “Don’t be such a chicken squat. Get out there and get your shot.”

Trust — “having confidence in someone or something” — is complicated. It can be difficult to earn and easy to lose. One key issue that Goldenberg raises with respect to vaccination, but can be applied across science, is the critical importance of engaging to a much greater degree marginalized communities and diversifying the workforce in health and health care. It can easier to build trust among people with shared experiences, backgrounds and values than it is to demand it by virtue of expertise, credentials or authority.

Trust — or more accurately its absence — is starkly illustrated in Pew survey results released last week, which indicated that most black Americans believe themselves to be at much greater risk to Covid-19 than others, but at the same time indicate a greater aversion to Covid-19 vaccination. This seemingly contradictory divergence does not indicate a “war on science” by black Americans, but instead, systematic distrust grounded in a long history of medical racism. As Goldenberg emphasizes, “equity is paramount to making public health impactful.”

With a focus on building trust rather than persuade with science, Goldenberg challenges us to rethink public health campaigns. But more broadly, her book challenges us to reconsider how we think about the many different roles that experts play in democratic systems. I agree with her conclusion: “Enacting change is difficult, but the status quo is a plague.”