Scientists have developed vaccines for Covid-19 in record time. Now how do we convince enough people to take them? To get a better understanding of the roots and causes of "vaccine hesitancy," Sarah spoke with political scientist and Watson Institute Associate Professor Prerna Singh.

In studying the history of mass vaccination, Prerna has come to a troubling conclusion: skepticism (and at times, outright rejection) is an inescapable part of modern vaccination efforts. But by looking at successful vaccination programs of the past, Prerna also explains why this kind of skepticism exists, and what can be done to overcome it.

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SARAH BALDWIN: From the Watson Institute at Brown University, this is Trending Globally. I'm Sarah Baldwin. Finally, we have some good news COVID vaccines are here, and they're highly effective, but there's a catch. Getting them into the arms of enough people to end this pandemic is going to be very difficult. One reason for that is the patchwork way vaccines are being rolled out in communities around the world, but there's another, perhaps even more, vexing reason. Many, many people seem hesitant about taking the vaccine at all. It might be a big enough number that it gets in the way of our ability to reach herd immunity.

While this may seem confusing to people who take all the vaccines their doctors tell them to take, the history of mass vaccination shows that skepticism and rejection are inescapable parts of the process and much more common than you might think. On this episode, the origins of vaccine hesitancy and what we can do now to push back against it. To get answers, I talked with Prerna Singh, associate professor of political science at Watson. We looked at the history of vaccine hesitancy, how it's transformed into the more recent anti-vaxxer movement, and what we can do to overcome it.

This is obviously a pressing topic, speaking as we are from inside a pandemic, but our conversation also brought up some really interesting and more timeless issues about institutional trust, why humans believe what they do, and what it actually takes to change someone's mind. We started by talking about all the different reasons people refuse vaccines. Here's Prerna.

PRERNA SINGH: It varies by group it varies by part of the world, so causes for vaccine hesitancy, for instance, against the polio vaccine in Nigeria, northern Nigeria tends to be quite different from the reasons for Orange County moms in California, where I am right now. But it also varies by vaccine. So the one vaccine that has been particularly resisted and has led to the resurgence of a potentially deadly childhood diseases measles. And so that vaccine, the MMR vaccine, is the one that was especially in the news as the target of anti-vaxxers.

So yes. Trust in government, trust in authorities is a major factor. It's a major factor in the US that is traced to conscious of individualism and gender hesitancy towards the state but also in other parts of the world. Let's not forget that the way that Osama bin Laden was captured was by people impersonating vaccinators delivering the polio vaccine, knocking door to door in Abbottabad. And we know from research that since then, there has been hesitancy and a drop in acceptance of the polio vaccine in those parts of the world. So there is a lot of misinformation. There's a lot of mistrust. There's a lot of rumor. So it's everything that you say and more.

SARAH BALDWIN: I was interested to see that in China, acceptance rates are the highest, and in Russia, they're the lowest. But also, something that you touch on is intriguing to me. You say that human psychology and neuroscience play a role in how we are making decisions about whether or not to take, accept a vaccine. And that facts-- you say facts don't change our minds, which freaks me out a little bit. So can you explain what we can take away from that?

PRERNA SINGH: Yeah. So when I say that facts don't change our mind, that's research that I am referring to. We know this from both neuroscience, but it was our experience with trying to convince people of things like climate change or about the efficacy of vaccines, about the fact that they actually have very few side effects. And a lot of the rumors are based on misinformation, for instance, the MMR vaccine rumor that has really triggered the anti-vaxx movement. To a large extent, it's based on a completely junk science article that the Lancet retracted, which linked the MMR vaccine to autism.

We know that there is no scientific evidence for this. And yet we also know from studies that giving people this information, pretty much just as I laid it out, that there is no link between MMR and autism. Actually, not only does it not overcome vaccine hesitancy, it actually backfires. And so there are a number of studies that have been published in journals like pediatrics, public health communication, science communication journals that shows that giving people more, information, more information about the disease that the vaccine is preventing, or more information about the side effects. Or lack thereof of the vaccine doesn't make them report a higher degree of vaccine acceptance.

And so in this one particular study, Brendan Nyhan was a political scientist and his co-authors. I forget the exact conditions, but they actually found that giving people information on measles and how deadly and dangerous measles can be. Actually, it made them less likely to take up the MMR vaccine because it scared them. And when you get scared, you shut down, and we know this from science communication research about climate change.

It's just giving people facts. It's giving people information, much as we want to think that this information will be what we will process and that will lead to decision making and behavioral change. Unfortunately, we have more and more information and evidence that this is not sufficient. And in fact, sometimes that's actually counterproductive.

SARAH BALDWIN: Well, on a hopeful note, you have identified something that you say could work, which is culturally embedding the vaccine, and you draw this lesson from the past, and you compare how the first ever vaccine was accepted into different but similar port cities in China and India, respectively. So can you talk about that how you think we have something to learn from the past going forward?

PRERNA SINGH: Yes. Vaccine hesitancy is as old as vaccines themselves. And so I the world's first ever vaccine, which was against, at that point, the deadliest human disease, which was smallpox. And it's the only human disease that we've actually managed to eradicate through a global vaccination program. And so the COVID vaccine outreach efforts are significantly influenced by the smallpox eradication campaign because it was the world's most successful.

But in some ways, what worked during this vaccination campaign with the world's first vaccine is this idea of humans as not just rational actors. And so we know from neuroscience that emotions play a really critical role in decision making, and I think that insight about humans as not just information. Processes is at the root of this idea of culture embedding because people have very distinct ideas.

They might be different from ours on what it means to be healthy, what it means to be sick, what a disease is, and how do you overcome a disease. And so in some ways, what my research, which is a historical study, is you send off to cities and to countries.

It basically finds evidence for this insight about human behavior that the most success for vaccination campaigns were not those that necessarily gave people information about the science behind the vaccine or how it worked, but one that actually was embedded in the way that they thought about the body and how it fights disease and how it heals. And so when I talk about culture embedding, what I mean is that the vaccine, both the message and the messenger, don't need to be culturally familiar and accessible to the people to whom the vaccine is being provided.

SARAH BALDWIN: So how did that play out in Canton and in Kolkata?

PRERNA SINGH: So these were two cities that in the early years of the 19th century were very similar epidemiologically. They were hot. They're both tropical-subtropical cities, and they see the arrival of this brand new vaccine invented by Edward Jenner. And that vaccine actually gives rise to the dome vaccine itself. So when we say vaccine, they're referring to variola vaccine, which means vaccine from the cow, which refers to this first vaccine ever against smallpox that I'm studying.

So variola vaccine arrives in these two cities, and it gets surprisingly taken up quite enthusiastically in Canton. And what I find through my archival research is because when the vaccine is promoted, it is promoted as being within traditional Chinese medicine and their understandings of the body and off disease. For instance, in Chinese medicine at that point in time, really southern Chinese medicine in Canton because of a very distinct bodies of, of course, traditional medicine as well, disease was seen-- so smallpox is a childhood disease, and disease was seen as a result of toxins.

But as a child, you haven't really done anything quite evil yet because you're a child. And so smallpox was the result of fecal toxin. This was toxin that you inherited, in a sense, from your parents. And so they embedded this new vaccine very much in this existing idea of a feature of toxin, and so it made sense theoretically to people. But then the actual vaccine itself, a lancet, was a completely new way of intervening into the body up. Until then, Chinese medicine in southern China in Canton, at that time, did not have a system by which an incision was made into the arm by a needle.

So in many ways, this was a completely foreign intervention using a totally new technique. But they very creatively embed this piercing of your skin with a needle to the very familiar traditional healing system of acupuncture. And so this becomes a way to link this very new lancet, this very new vaccine to a very familiar system of healing. And not only do they embed the technique in acupuncture, they embedded in Meridian theory that underlies acupuncture.

And so they tell parents who are the ones usually making the decisions but also the vaccinators that you must vaccinate in certain designated points in the arm. Girls are vaccinated on one arm first, boys on the other. The vaccine is to be injected into certain points in the arm. In some ways, this is all very creative. It's also quite unnecessary. But the thing is that it works to kind of form this culture bridge it so that the vaccine is something that it becomes familiar and is more easily accepted within the existing world view of the local Cantonese in the early to the mid-19th century.

SARAH BALDWIN: And what went wrong with the approach in Kolkata?

PRERNA SINGH: So the difference in Kolkata was that even though the way that it came to both cities was the same, it comes through the English East India Company, and it comes via the British who are very keen to spread this colonial benevolence to their colonies. But the structure of colonialism is quite different in that while the vaccine gets taken up by local motion guilds. And so here's where the messenger becomes important because it's also who's communicating this embedded message.

And in southern China in Canton at this point, the people communicating this message were the local Cantonese, the local traders, and also the local gentry. But in Kolkata at that time, this is the early years of British colonialism. Kolkata is at that point in time, the capital of the British empire, and they have this motive by which this is a British benevolence. At this point in time, they're really learning from Indian and Chinese medical traditions. A large part of colonialism is driven because they want to know about the different hubs and techniques, very effectively, the traditional healers like [INAUDIBLE].

But the vaccine really marks a switch because this is the first thing that caught the West has that the East can learn from, or so they think. And so they're really pushing this vaccine as something brand new, as something that the colonists are bringing in this act of benevolence. And so they have no incentive to try to link this to traditional indigenous systems of healing because, in some ways, they think it dilutes its British benevolence if we try to link this to what immediately gets seen as backward.

These are the natives. They're dirty. They have their systems of healing. They're ineffective, which of course, is not the case, because Jenner-- Edward Jenner, who invented the vaccine, his father is actually a variolator. Variolation is a technique that forms the basis of vaccination. And it comes from China and India, and variolation, they would expose children to a very mild case of smallpox so that they would get this very controlled case, rather than getting this wild epidemic smallpox.

Vaccination is building this traditional indigenous System, but, of course, the British don't want to acknowledge that at all because they want to really emphasize the newness. And so what happens in Kolkata is that this whole emphasis on the newness of the vaccine means that it's presented as something that is not linked to the existing culture healing traditions, but it's something that is a repudiation. It's like a brick, and so what it does is it creates this cognitive dissonance because, now, everything that's familiar and inherited over generations is just kind of shut out from the way that this vaccine is presented.

And more than anything else, smallpox, in traditional systems of healing in India, also interestingly in China, was in as much as it was a deadly disease. It was a visitation from the goddess Sitra, whose temple you still see dotted across the country countryside of India. And so the vaccine begins to be seen as an attack on the goddess. And so the general argument is that it is resisted because it is introduced by British colonists.

And while there's certainly an element of that, what I tried to show is that there are many other interventions that the British colonists introduced that are not necessarily met with the same degree of opposition as the vaccine. What happens in particular with the vaccine is that it begins to be seen as this cultural destruction, and because of that, it's really opposed, and people hide from vaccinators, and the vaccination rates in Kolkata are really far lower than in Canton.

SARAH BALDWIN: Can you give other examples just briefly from around the world of where treatments, even recently, as recently as HIV/AIDS or Ebola, have really been adapted that respect the people and the cultural norms that they are trying to cure or protect.

PRERNA SINGH: So you're right that the HIV/AIDS crisis is a really interesting example because in the initial years inside Africa, which in many ways, became the center of the pandemic, the Sangomas, who were traditional healers, were treated as public enemies by public health institutions from the West, and the idea was that because they were-- people so different. First of all the first port of call, so people were much more likely to go to a Sangoma than come to get tested for HIV/AIDS, partly because of the stigma in a clinic.

And the Sangomas would usually prescribe some forms of indigenous herbal tinctures and medications. Now, in some ways, my research is less about the effectiveness of these traditional remedies. Though, in many cases, they are actually quite important supplements, at least, to the biomedical regimen. But in a very critical move, at some point in time, the public health community realizes that they can really bridge and reach the Sangomas. Now, the Sangomas, because they were integrated and because they were listened to and respected and brought in to the system of testing and dissemination of antiretrovirals, they see patients, but they referred him for testing.

And if you're referred by a Sangoma, you're actually more likely to go get tested. When they come back with their test, where whether or not they're HIV positive, they are down to the Sangoma, who will prescribe her or his herbal remedies but will also actively, in many cases, encourage that patient to also get onto an antiretroviral regimen. And now, there is an increasing recognition that some of the remedies that these Sangomas are prescribing don't in any way counteract antiretrovirals.

I might go so far as to say they probably also help, and having the Sangomas be this really important culturally-embedded messengers is a really important factor in the increased efficiency of the way in which the public health community is treating HIV/AIDS in Southern Africa today.

SARAH BALDWIN: I wonder about in the US how you might suggest tailoring vaccine messaging to hesitant groups? And related to that, how would you describe the vaccine messaging on COVID so far?

PRERNA SINGH: So I think the first thing is that the CDC has really not paid enough attention to questions of messaging. Now, in some ways, so much has gone wrong in the COVID-19 crisis in the US, and so we know right now the crisis is that of provision. It's of access to vaccines. But in all of this, partly because of the train wreck that the pandemic has been, is that there really just hasn't been enough attention how to message and how to communicate the COVID-19 vaccine.

And Dr. Fauci said that April is going to be open season for vaccines. Anyone who wants one in April is going to be able to get a vaccine. But the success of this open season, you're not going to continue his analogy. Whether or not it bears fruit or not is going to really hinge on the way in which the CDC. But not just the CDC, the CDC working in partnership with a range of different organizations and individuals is going to be able to communicate. And right now, it doesn't seem as if the government, the CDC, other public health institutions are really thinking about how they should be reaching out to these very important groups and what they should be saying when they reach out to them.

And so what I would say from my research is that the first thing is you need to know who the vaccine hesitant groups are. They're very distinct groups in different parts of the US. Orange County moms, ultra orthodox Jewish communities in Brooklyn, QAnon folk, these people are all resisting, are reported to be resisting the vaccine. We know from our experience with other vaccines that these are groups that have seen outbreaks of diseases, for which we have vaccines, like measles.

So we know where measles outbreaks have happened. We know where we've fallen below herd immunity from measles. We know from surveys where these groups are spatially concentrated. We need to know why are they resisting, what are Their reasons. We know they don't trust the government, so that means that CDC messaging-- or at least some of them don't-- is likely to be less effective.

We do know, for instance, in some cases, like the ultra orthodox Jewish community in Brooklyn, we know that they trust their rabbis. Now, so we know who it is that we need to meet that alliance with. So we need to reach out to the rabbis. We need to reach out perhaps to a formal QAnon leader who still come on some kind of following. We need to reach out in Orange County to the chiropractors, to the yoga instructors, to the acupuncturists, to the herbalists. Do these people who command this authority, so we cannot do that for all Americans, or really for everyone in the world, that source of authority will be Dr. Fauci, or that it would be President Biden.

We need to know who is it that they think locally are sources of authority. Whether those are religious leaders or their social leaders or whether that's Gwyneth Paltrow in Goop, or we know that a major source of vaccine hesitancy very correctly, given their history, comes from African-American community.

I mean, African-Americans have very good reasons to be hesitant of state public health interventions, given the way that they have been treated in the very recent and continue to be treated in the US. The CDC and other public health institutions need to be thinking, what is creative messaging? And here, I just thought it was really interesting. LeBron James accompanying his grandmother to get her vaccine, that is a really powerful message.

We're just going to have a much more creative and open-minded approach than I think we're accustomed to. And one that moves away-- the vaccine is a great scientific intervention, but it's not going to be accepted if we keep doubting its science.

SARAH BALDWIN: Are you optimistic that the right people will pick up your message and your suggestions and start to tailor their vaccine education accordingly?

PRERNA SINGH: In some ways. it's not difficult. There is a logical set of steps, like a toolkit that we can use to address vaccine hesitancy. Most of my research has been around this question of the world's first ever vaccine, and the world's first ever vaccine was quite enthusiastically accepted in some places and quite vehemently opposed in other cases. I think that based on my research on this question, there is a way in which we can come up with the toolkit.

It would begin by using the data that we have on surveys that report hesitancy to the COVID-19 vaccine, as well as the data that we have on which communities have been resistant to vaccines in the recent past. We need to target those communities that we know both from our research right now and from vaccine hesitancy data into the past, then we need to kind of listen to these communities. We need to get onto the same platforms and the social media outlets that they're listening to and saying, well, why are there existing vaccines? And what do they believe will prevent disease?

SARAH BALDWIN: It's almost like leaning in approach. It's more like, tell me more about why you, in particular, what makes you vaccine hesitant?

PRERNA SINGH: Yes. And so I listen to what it is about vaccines that you have a problem with, but I also listened broadly about your worldview. Number one step in the toolkit is you can not dismiss their concerns out of hand. You cannot be judgmental about it, even if the way that they're talking about health and healing does not fit with your ideas and your scientific data. You still have to listen.

And I think you have to listen more broadly because we have to begin with the assumption that these people do care about their health and the health of their children and the health of their communities and the health of their elders. So if we begin with that, we then have to say, OK, so how did they think they're promoting their own and the health of those they hold dear? And then trying to build alliances with people in this community in which they're embedded.

And also sometimes, meeting them half way, saying OK. You seem to have a concern about this. Perhaps we can provide you. It maybe it can be something creative about where the vaccine is provided that links in with their daily rituals. Maybe they have something about who delivers the vaccine to them. We know it doesn't take very much to learn how to deliver a vaccine. And so perhaps, we need to train people that they trust to deliver the vaccine to them in settings that their more comfortable in.

SARAH BALDWIN: Might not be optimistic, but you're making me optimistic because what you saying makes so much sense. You're basically offering a blueprint for overcoming vaccine hesitancy or, at least, making a very solid attempt at doing that.

PRERNA SINGH: Yeah. I guess the way that I would put it is that I think what needs to change, at some level, is very basic and very profound because it is this move away from our understanding of ourselves as rational actors. Humans are moral, and not just rational neutral information processes. So that shift needs to be profound.

But what actually needs to happen-- your right-- is that we can really quite quickly come up with a toolkit that can address vaccine hesitancy using those insights. Or I agree that, in some ways, the shift-- the shift in our heads needs to be huge, but this shift in the actual things we need to do to convince the vaccine hesitant is not that huge. They're much really optimistic.

SARAH BALDWIN: Prerna, it's been so interesting talking to you about this. Thank you so much for taking the time.

PRERNA SINGH: Oh. Thanks, Sarah. Thanks for having me on.

SARAH BALDWIN: This episode was produced by Dan Richards and Elina Coleman. Our theme music is by Henry Bloomfield, additional music by the Blue Dot Sessions. I'm Sarah Baldwin. If you like us, leave us a rating and review on Apple Podcasts. Or if you have a friend who you think would like the show, tell them about it. We'll be back next week with another episode of Trending Globally. Thanks.