Pushkin from Pushkin Industries. This is Deep Background, the show where we explore the stories behind the stories in the news. I'm Noah Feldman. We've been talking a lot in the last year about the possibilities of herd immunity or community immunity, but it's now overwhelmingly clear that the US population is not going to hit in the foreseeable future a rate that would satisfy the herd immunity standard. And the main reason for that is not distribution of vaccines, but what is called, slightly as a euphemism, vaccine hesitancy. Some studies have shown that as many as one in five Americans say they wouldn't want to take a coronavirus vaccine, and there are some indications from other studies that those numbers are in fact rising rather than decline. Public health officials and governments and indeed all of us therefore need to think about ways to understand and increase public acceptance of the vaccine, provided they believe, as I do, that the vaccine is an important tool in helping us get beyond this pandemic. Today's guest is one of the world's leading researchers on precisely the question of why people hesitate to take vaccines, why they don't want to take vaccines, and what might be done about it. Doctor Haddie Larson is an anthropologist. She's the founding director of the Vaccine Confidence Project, an interdisciplinary research group at the London School of Hygiene and Tropical Medicine. She also headed the Global Immunization Communication Program at UNISEF, and she's the author of a new book, Stuck, How Vaccine Rumors Start and Why they Don't go Away. Doctor Larson will help us understand what are the contributing factors that undermine vaccine confidence and what we might think about doing differently if we want to improve the situation going forward. Heidi, thank you so much for being I want to begin by asking you a sort of top of the line question, which is in your very deep cross cultural comparisons of vaccine hesitancy. Do you think that there are universal or roughly universal causes for vaccine hesitancy or do you think that each culture has its own reasons making it difficult to speak in very broad general terms comparing places. I would say that the common things are issues of liberty and choice, and freedom of choice, the anti government control sentiments, versus liberty. The second one would be nature. Is it natural or it feels like it's against God's plan? But that tension between you know, natural versus technical or chemical is another tension. And I think the third one, as a universal is just safety, safety, safety, safety. And I think the other kind of critical dimension is trust and underlying trust in government and authorities. In quote experts, I know you've emphasized trust very much. You said to the New York Times, we have a trust problem, not a misinformation problem, which is a provocative claim. Could you say more about why you think trust is at the heart of the concerns. I honestly believe that we don't have a misinformation problem as much as a relationship problem. And I say that because if we had a stronger trust relationship between public and science, public and authorities, people cope with some risk if they trust you, there willing to put up with a little risk. If they don't, they're questioning, they're concerned. They start from a position of distrust. So if we can build that underlying relationship and make it more trusting, we'll have a bit more resilience an acceptance of scientific advice. But that's what I mean by the underlying resilience and willingness to take that little risk. May I ask a follow on question there, because it looks to me like there's some tension between the trust analysis and you are three big drivers of vaccine misinformation. So for libertarians, some distrust and authority is kind of constitutive of their worldview that we need to be fundamentally skeptical of aggregations of power and authority. And then with respect to people who think that it's in God's hands, those folks too have a principled reason to be distrustful of human interventions. And so I'm really wondering if the trust problem is overcomable at all, or maybe even shouldn't be overcome from the standpoint of those two kinds of hesitancy objections, the analysis, the sophisticate analysis that you're offering, may suggest almost a kind of impossibility of overcoming some of these things because of a contradiction that exists between the value of trust and then these principal objections to trust. I do believe that there are going to be certain kinds of hesitancy and actually deep refusers that we won't be able to overcome. I think we need to accept that, But what we should as a health and medical community strive to get as many people on board as it were, for the sake of the public sealth. And there will also be people. There are also people who can't take vaccines because of underlying medical conditions. So, for instance, with COVID, we don't need one hundred percent of people vaccinated to get community immunity, as they say, but we do want to get as many as we can. I'm not saying give up, but we will have these deep challenges. Why can't we actually nevertheless do better? I mean, go back to smallpox, one of the great successes of immunizations in global history, right, effective eradication over a long period of time with a lot of coordination, but not so very long ago, right, I mean that process ended in the seventies, if I'm not mistaken. So why was it possible to do that? But it's not quote unquote possible to do this now. I mean, what were the tools and techniques that were used to bring us to smallpox eradication? And why do we seem so stuck in so many places today? We're much more democratic. This is a really important point you're thinking, and I thought about it a lot when I was going with the polio workers door to door in northern Nigeria, in India in some of the most resistant communities, and thinking, you know, these are some of the same communities, particularly in India, which went through the same thing around smallpox. But for the smallpox eradication, there was some police force and pretty coercive measures that would absolutely not be acceptable today, and certainly in the context of the polio eradication initiative, we could not do in some of the states I was in what was done in the previous campaigns. I'm not saying it was all that way, but there were certain types of coercion that isn't just not tolerated today. I'm going to ask a subversive question, and I want to preface it by saying, you know, my day job is that I'm a constitutional law professor. I spend all of my time thinking about, you know, how you could make liberal democracy work alongside the need for government authority. So I take this with you with that background, Maybe we're just doing it wrong. You know, maybe the idea that there should be a democratic right to refuse vaccination is not only a mistake from a practical standpoint, but is generating the kind of hesitancy that you're talking about to a greater degree than it would otherwise exist, in the sense that if you ask people do you want the vaccine or not, you're putting them almost in an existential situation of having to weigh many, many, many different factors ideological personal belief, chance, risk, knowledge, ignorance. Maybe that's just asking too much bunch of people. And maybe if we simply required it universally, there would be there would still be some objections, but maybe people just wouldn't spend as much time dreaming them up and just to finish the thought about why this isn't maybe so crazy. You know, when the US Supreme Court was asked to consider this issue in the early twentieth century, it answered unequivocally, Look, you have lots of liberal rights against the state, but you don't have a right to say, note of vaccines because vaccination is necessary to help everybody, and so you just don't have that as a fundamental constitutional right. And you know what, if it went to the Supreme Court today, they might well reach the same conclusion. So it's not necessary that we say that forced immunization is undemocratic. We could just say forced immunization is consistent with our values because it's necessary to save lives. I absolutely agree with you. I mean, we do have required immunization to go to school, but it's about settings. In my work in the UN, I worked a lot on rights issues, and particularly the Convention on the Rights of the Child, and we often talked about this fine line where rights become responsibilities. You have your individual right until you get to a point where it harms others, and vaccines sit on that cusp. I agree with you that we do need to rethink our whole approach. I think we really need a whole different approach because also we have a lot more vaccines, and I know that, for instance, in France they added a number of additional vaccines required for school in the context of some very serious measles outbreaks in twenty eighteen. I think there were eighty thousand across Europe, and there was outrage in the streets against it, but ultimately a number of the healthcare professionals told colleagues at the Ministry of Health, thank you. It takes the onus off of me as a healthcare provider to have to persuade someone to take I feel like the government is behind me. I'm supporting that, I'm helping implement that, but the onus is not on me to make that persuasive argument. Well, can you say more about the approach that you would advocate, because we don't train physicians or scientists very much in convincing people to take up the pro social, pro health interventions that they invent, right, I mean, scientists are supposed to invent things that make the world better, and physicians are supposed to give treatments that make the world better. But we don't think that their job is to do persuading. So what is the approach that you think would be better for the next time around. Well, I think actually in the current environment, a lot of the medical community, particularly the more senior medical community, is not used to being challenged, is not used to having their authority challenged. And I think we've come to a different point where we have publics that are very different than they were, certainly twenty years ago, much more questioning the world of information at their fingertips, not hesitant to be challenging the authority of their doctors. And what I've seen happen is some doctors actually shut down because they don't want to go there. They don't want to have that argument. So I think what needs to be trained is less of the promotional side and more of the how to have a difficult conversation. But can I just ask, do you think that would work? I mean, in light of the subtle social pressures that you're describing, I don't think. I mean, I'm just thinking of physicians. I know many of them are most impressive people you know that I come into contact with, and they have many, many amazing skills. But I'm not sure that even with you know, a sophisticated training seminar, they would be able to convince people who are truly vaccine hesitant, partly because I'm just not sure what arguments are are gonna work. I mean, you know, you could say, well, gee, you trust me the rest of the time, why don't you trust me this time? And that's the honest answer, right That's the true answer, Like I can't demonstrate to you the truth of the scientific evidence right now, you have to trust me because you trust me the rest of the time. Like that's the actual epistemological answer. But I don't think people be very inclined to believe them when they said that, given what you're describing, Yeah, you know, it's interesting. I agree with you. And I know a number of doctors who have told me that, you know, they've tried all kinds of angles in some situations, and it's just not going to change some people's minds. And they've kind of gotten to a point where they say, I try in many different angles. I talk about vaccinating my own children, I talk about vaccinating myself. They still don't. So there are going to be some people that are difficult to change. But at the end of the day, we still in all of our globally, in surveys and in any kind of trust barometers or whatever, we still see that more than ever, doctors and healthcare providers have more trust than just about any other institution going. So there is a trust there. But I think right now they need more than the doctor. They need somebody else in their social spheres to change their mind. Now. I don't pretend to have any easy answers, but all I would say is, don't give up. If you're a doctor, keep trying. One of the puzzles that strikes me so rich and interesting around vaccine hesitancy is that unlike almost any other situation that we're required to make a decision about our healthcare, which are usually individualized. That is to say, my decision only affect me. In the case of vaccines, there is a free rider dynamic, right If enough other people are vaccinated and I'm not vaccinated, I'm still reducing my odds of getting sick because the prevalence of the disease will decline by whatever percentage of people are are vaccinated. And that makes me wonder, are there any examples that you've come across in your work of situations where lots of people decline a vaccine and then the disease is bad enough that it spreads, it continues to do harm in the community where the people live, and then you get some kind of systematic shift where people say, WHOA, I thought I was going to get away with this, but now I can't get away with it, and so I'm shifting my views and now I'm going to go out there and get a vaccine. Or does the kind of free rider effect is it so powerful that once people have said no, they're probably never going to say yes. Yeah. I think at the end of the day, the free riders, if they think that there's enough going on. They might be opportunistic. But if they see that it's a pretty serious pandemic or whatever, or in the case of measles, pretty serious wave coming back, they could be more open to getting vaccinated. That could be enough to change their mind if we want to leverage that situation. People don't in general, how many people know what percentage of their community is actually getting vaccinated to even know if they can relax. One strategy would be to let people know, like how many people in your community are vaccinate. I don't know if that's a good strategy in a sense, because it might if the community's going going well, it might make more people say, oh, I don't have to get vaccinated. Do you think, Heidi, that it's too late this time around to make sibstential inroads in let's say, the United States and Western Europe against people who are vaccine hesitant. I mean, I understand that this is a fight that's going to be a global fight, and there may be places in the world where vaccines still haven't spread that much at all and where the fight really needs to be concentrated. Or do you think there's still time to make a meaningful difference in this particular round. So, you know, an optimistic view which didn't turn out to be true, was that we would vaccinate enough people fast enough that community immunity or her immunity could be reached and we would not have to worry about the variants that are will inevitably now spread and some of which may eventually evolve to be vaccine resistant. That ship seems to have sailed, at least in the West. Yeah, I think we still need to get as many people as possible vaccinated. I don't think it's too late, and I don't think we should give up, because out of principle, it's really important to get people on board. I'd like to say it's never too late. It's a very dynamic changing environment. I think I remember saying, I think it was in late January we're going to hit a wall in late March April, I said. So it was a bit later than that because at the beginning of the year we are in the thick of a serious second wave. We had recent news of these vaccines being highly effective, more effective than most vaccines, and there was a limited supply, so all of those things would drive people. So we had the willing the eager upfront, wanting to get whatever limited supply, seeing that you know, this is bad, still bad. But as we get more supply, as the willing have been more vaccinated, and as the pandemic appears to be waning, you know, we're starting to hit it more difficult population. So I think we have to change some strategies. And I also don't think we should give up, because it's not just about COVID vaccine. Everything we do around COVID and building confidence around the vaccines it could be foundational moving forward for other vaccines. We'll be right back. How do you. I am fascinated by the role that fear has played on all sides of the COVID pandemic, addits and the various treatments that we've been looking at for it. So it sometimes seems to me that at first, many, many people were afraid of getting COVID, and those folks eventually masked up and engaged in social distancing, and others said, well, look, it's not the end of the world. Statistically, you probably won't die from it and not get it, and so don't be so fear based. And then with the rise of the vaccines, we've seen a shift, and now there are lots of people saying, well, I am afraid of the vaccine more than I am afraid of the possibility of getting COVID. Now, obviously there's a lot of overlap between those people and people who said they weren't afraid of COVID in the first place. But before they were saying we're not afraid of COVID, and now they're saying, we are afraid of a vaccine. Meanwhile, the people who before we're afraid of COVID are now saying that they're not afraid of a vaccine. I don't realize there's not a perfect match, but that does seem to be the case. I mean, I'm genuinely curious. I don't really understand how the economy of fear is working for each group, except to say that each group is afraid of something different. Yeah, and I think it's a risk perception thing too. I mean, there was more fear about the virus back a few months ago, because there was more virus, the mortality rates or higher. It was more fearful. And now as we see that waning a bit, what seemed like a smaller risk, the relative risk has changed in the Meanwhile, too, people didn't have before the information about the rare risk of these the blood clots, for instance, So there's new information in that mix that we didn't have before. We see this even with childhood vaccines. We've got a lot of mothers now who are skeptical about childhood vaccines. They're just doing a very basic risk calculation. They don't see the threat of all these childhood diseases, but ironically, does the vaccines work. Yeah, But to them and their child, it's like the thing that has the risk is the vaccine. And there's also this kind of way that risk plays with our minds in a way, if a mother gives a child the vaccine or gets a child vaccinated and there's a problem, she feels far more regret and responsibility than if a child naturally gets measles, because it's nature. So it's another factor that weighs in there. Yeah, that actually leads me to a question that I imagine you've spent a lot of time thinking about. It. Seems like vaccine hesitancy has some components that are grounded in quote unquote reason, mathematical reason risk assessment that an economist would say is rational to undertake and then some of it consists in beliefs and values, which who's to say exactly which you're right and wrong? And then some inheres in true irrationality, paranoia, fantasies, false claims about the world that are demonstrably false, not just false opinion, but false claims of fact. And I guess what I'm wondering is, I mean, having spent so much of your career thinking about these questions, do you ever think about, like, roughly what percentage is contributing to each You know, how much of vaccine hesitancy is coming from rational calculations, even if they're unconscious rational calculations. How much of it is coming from beliefs and values which aren't really subject to being shown true or false in the same way that facts are. And how much of it is coming from just false beliefs about the world that we might be willing to labels as irrational. I have thought about that. It really depends on the person. But I think that in the broader group of hesitant people around vaccines, I mean, I think we don't give enough credit sometimes to parents, to others who are kind of weighing things they're not just you know, emotional crazy beliefs there are, and and my point of haut anti vaccine, I don't mind the word. The thing I don't like is that it's used so loosely for anyone who doesn't want a vaccine. It's often used to a lot of hesitant parents who aren't at all anti vaccine. They have some you know, they're asking some questions and then they oh, she's just an anti VAXX, and then she becomes it more anti vacs because of that judgment. Although it is vaccine hesitancy then also though in a sense over inclusive, because for some of the people, sure they're hesitating, and the implication of hesitancy is it hints, oh, you can be convinced. But it seems a bit like a euphemism to me to describe people who are saying, oh, hell no, I'm not going anywhere near this vaccine. And there are a lot of people who are saying that they're not hesitant at all, they're just a clear no. I agree. Hesitancy was not a word I chose. This was a word that was decided by the World Health Organization, and I was part of the advisory group to kind of characterize the scope and scale of it, but we weren't able to name it. We were given that framing of it. And I've written some things about the ambiguity of that term. So I fully fully agree with you. What would you choose if you could choose any term? Well, well, I've picked the framing of confidence because also I was thinking of the consumer confidence index, and we have a vaccine confidence index. You can be zero percent confident and you can be one hundred percent confident. But I don't think there's any magic, one one word. Just to try to close with something slightly optimistic, what is your case study that, in your mind is the most optimistic or positive case in which a population which had hesitancy gradually shifted to being less hesitant. If there are I hope some examples of that out there that you've encountered in your research. There's a few of them. I mean the most recent one, for instance, on the COVID work. One of the more successful engagement strategies was through barbers and hairdressers in Maryland. I know in some of my work in India and in Africa, when you started to address other things in the community that people cared about, they were more accepting of the vaccine because they felt like, actually, you're not just here to give me my job and keep moving. Oh, maybe you do care about what I think or my well being. And I think moving forward on COVID, we do need to somehow embed it in COVID recovery more broadly, addressing mental health things, addressing other things. So I think we need to step back from the needle, as it were, and really think about context and never assume what's in the minds of people. They may be telling you they think it's a safety issue, but there may be something else. I think we need to hear out people because in India, I remember one example that I always think about is there was everyone was saying, oh, it's a rumor that's going to sterilize us. They're never going to let go of this rumor. Well, spending some time when some of these villages talking to people and not just a one time survey, but going back and saying, well, what else is bugging you? You know? And it turned out that this community didn't want men coming from Delhi to their village. One they didn't want men vaccinating their children, and two they wanted people who were from the community. So if something happened they could find them. Well, these are pretty reasonable things. Once that changed, somehow, the rumor thing disappeared. So I think trying to understand if is there something else going on here that you know, is more tangible that maybe maybe it's more straightforward than you think, and maybe it's not, maybe it's more complicated. But well, my Barbara, who's been cutting in my hair since I was nine, it is definitely the wisest person that I know. So I like the idea of relying on relying on Barbara's I mean in the Indian case, of course, in many villages in India people were forcibly sterilized, sometimes against their will, sometimes without their knowledge, as recently as the nineteen seventies, so you could sort of understand. That seems to me to fall into the category of very reasonable people to be afraid of that they had a real world experience. What should I be asking you that I'm not asking you, Heidi, Well, I can tell you what I'm most worried about is where we're going with social media. I think we need to find some way to allow for opinion, find a different way to handle the way we're dealing with it, particularly around vaccines. I see us going in a direction of shutting a lot of things down that might backfire. It is something that keeps me up at night because I see some extreme behavior on both sides. This is something I also spend a huge amount of my time working on and listeners of the show. Not that I've advised Facebook on their free expression policy, so I care a lot about this. I thought I heard you hinting that maybe the social media companies are going too far in taking down content that they label as anti vaccination misinformation. And that surprised me to hear you say that, because so many people from the medical establishment are out there pressuring the social media companies to do still more to take down what is described as COVID misinformation, including anti vaccine misinformation. So I did I hear you're right? Yeah, and governments are too. Did I hear you're right there that you think it would be actually a mistake for the social media companies to go too far in shutting down skeptical discourse. I think it's a risk, and I think that it's not just the health authorities who are putting that pressure. It's government. I mean, it's coming from the top. But my Vaccine Confidence Project group here after spending eleven years and continuing to be listening and understand the dynamics of what's going on out there. You can't just flip a switch. You cannot delete doubt. And some of the key strategies right now that are being used by those who want to disrupt are quicker and more clever and nimble than the more promotional positive ones. And we're just either driving at underground or it's going into its embedding and a lot of other networks, and we need I think we need a different strategy. I mean, I think I fully and absolutely agree with taking down things that are overtly harmful, and I do think and fully agree that we need to work on mitigating the amplification of risk that I think is one of the real issues how it spreads. My red flag is that we need a lot more work to understand the dynamics of this space. And I worried that in trying to clean it up, we're pushing it underground, We're pushing it in spaces that we're going to be less able to engage with it, less able to address it, and not able to get cues on where we need to build more resilience, and I think it should be also a challenge to the public health and scientific community that are we not strong enough to stand up to And you can't just take something down with giving a better story, because they're going to find it somewhere else. It's kind of an almost existential task in sorting this out. And I think it's not just about vaccines. It's in other areas, but vaccines, I think, because of the public health implications, is a serious one. And I'd love to talk to you more about this if you're working on it, because yeah, it's really important, very gladly. I mean, you've really described one of the classic free speech arguments, which is that if speech is suppressed too much, it tends to go underground and then it can do greater harm. I mean, one of the early arguments for free speech, being the twentieth century, when Western government started adopting it more actively, was just the one you're making that we need actually the full range of arguments to be made in public in order to achieve some kind of consensus in order for people to have trust in underlying institutions. And now there's of course a lot of skepticism of that view. In the light of the rise of social media, and that view is very much under attack, so I think your voice is extremely important on this subject. I want to thank you for your fascinating work and for taking time out of your incredibly busy crusade, as it were, to understand hesitancy better to speak with us. Thank you so much, doctor Larson. Thanks very nice to meet you. I found my conversation with doctor Heidi Larson genuinely eye opening and more than a little bit disturbing. Not because of for research, which seems to me thoughtful and brilliant. No, what scared me the most was the realization that what we call vaccine hesitancy is almost certainly a necessary feature of our contemporary liberal democratic approach to vaccines. When I asked Heidi, why is it that in the past we were able to get lots of people to take the vaccine and were not, she answered unequivocally that the difference was democracy. Now she was very positive about democracy, but I have to say that her comment really made me think that we don't have to, as a constitutional democracy, necessarily take the view that people can choose whether or not to get vaccines. We could, in principle say that it is a legal obligation, and under current Supreme Court precedent, the government would be empowered if Congress passed a law to say that everybody must get this vaccine. I don't think that's practically going to happen in the world in which we currently live, but it did occur to me that that might actually be desirable, because in a world where ultimately people are given the choice of having vaccines, then the points that Heidi brought up, namely libertarianism of the left and the right, people who think that it's against nature, against God's plan to have vaccines, people who worry about the vaccine's safety, and overall, people who have less trust in the capacities of government or medical authority to do well by them are inevitably, I think, going to substantially undercut the possibility of broadly adopted vaccinations. In other words, by choosing to define liberal democratic rights in the way that we have, we've invited the possibility of much greater harm. That's a cost benefit analysis that I don't think I fully thought through in the right way before this conversation with Heidi. Finally, and significantly, Heidi made a very counterintuitive point which I think is very well worth listening too carefully, and that is that we need to think about whether we might be going too far in some contexts, including in the context of social media at shutting down discourse that undermines vaccine confidence. Her concern is that if we go too far, we will drive vaccine confidence questions underground, and that that will make it harder, not easier, for medical authorities and the government to convince people to take that scenes Throughout the conversation, our theme of power here on Deep Background was absolutely essential. The power of government to make people take vaccines, the power of people's beliefs to lead them to places of uncertainty or questioning, and perhaps most significantly, the power of the medical establishment, limited by its capacity to be trusted. These questions all could not be more pressing at the moment, and I'm grateful to doctor Larson for joining us to explain them so intelligently. Until the next time I speak to you, be careful, be safe, and please be well. Deep Background is brought to you by Pushkin Industries. Our producer is Mola Board, our engineer is Ben Talliday, and our showrunner is Sophie Crane. Mckibbon. Editorial support from noam osband. Theme music by Luis Gara at Pushkin, thanks to Mia Lobell, Julia Barton, Lydia Jeancott, Heather Faine, Carlie Migliori, Maggie Taylor, Eric Sandler, and Jacob Weissberg. You can find me on Twitter at Noah R. Feldman. I also write a column for Bloomberg Opinion, which you can find at bloomberg dot com slash Feldman. To discover Bloomberg's original slate of podcasts, go to Bloomberg dot com slash podcasts, and if you like what you heard today, please write a review or tell a friend. This is deep background

Pushkin from Pushkin Industries. This is Deep Background, the show where we explore the stories behind the stories in the news. I'm Noah Feldman. We've been talking a lot in the last year about the possibilities of herd immunity or community immunity, but it's now overwhelmingly clear that the US population is not going to hit in the foreseeable future a rate that would satisfy the herd immunity standard. And the main reason for that is not distribution of vaccines, but what is called, slightly as a euphemism, vaccine hesitancy. Some studies have shown that as many as one in five Americans say they wouldn't want to take a coronavirus vaccine, and there are some indications from other studies that those numbers are in fact rising rather than decline. Public health officials and governments and indeed all of us therefore need to think about ways to understand and increase public acceptance of the vaccine, provided they believe, as I do, that the vaccine is an important tool in helping us get beyond this pandemic. Today's guest is one of the world's leading researchers on precisely the question of why people hesitate to take vaccines, why they don't want to take vaccines, and what might be done about it. Doctor Haddie Larson is an anthropologist. She's the founding director of the Vaccine Confidence Project, an interdisciplinary research group at the London School of Hygiene and Tropical Medicine. She also headed the Global Immunization Communication Program at UNISEF, and she's the author of a new book, Stuck, How Vaccine Rumors Start and Why they Don't go Away. Doctor Larson will help us understand what are the contributing factors that undermine vaccine confidence and what we might think about doing differently if we want to improve the situation going forward. Heidi, thank you so much for being I want to begin by asking you a sort of top of the line question, which is in your very deep cross cultural comparisons of vaccine hesitancy. Do you think that there are universal or roughly universal causes for vaccine hesitancy or do you think that each culture has its own reasons making it difficult to speak in very broad general terms comparing places. I would say that the common things are issues of liberty and choice, and freedom of choice, the anti government control sentiments, versus liberty. The second one would be nature. Is it natural or it feels like it's against God's plan? But that tension between you know, natural versus technical or chemical is another tension. And I think the third one, as a universal is just safety, safety, safety, safety. And I think the other kind of critical dimension is trust and underlying trust in government and authorities. In quote experts, I know you've emphasized trust very much. You said to the New York Times, we have a trust problem, not a misinformation problem, which is a provocative claim. Could you say more about why you think trust is at the heart of the concerns. I honestly believe that we don't have a misinformation problem as much as a relationship problem. And I say that because if we had a stronger trust relationship between public and science, public and authorities, people cope with some risk if they trust you, there willing to put up with a little risk. If they don't, they're questioning, they're concerned. They start from a position of distrust. So if we can build that underlying relationship and make it more trusting, we'll have a bit more resilience an acceptance of scientific advice. But that's what I mean by the underlying resilience and willingness to take that little risk. May I ask a follow on question there, because it looks to me like there's some tension between the trust analysis and you are three big drivers of vaccine misinformation. So for libertarians, some distrust and authority is kind of constitutive of their worldview that we need to be fundamentally skeptical of aggregations of power and authority. And then with respect to people who think that it's in God's hands, those folks too have a principled reason to be distrustful of human interventions. And so I'm really wondering if the trust problem is overcomable at all, or maybe even shouldn't be overcome from the standpoint of those two kinds of hesitancy objections, the analysis, the sophisticate analysis that you're offering, may suggest almost a kind of impossibility of overcoming some of these things because of a contradiction that exists between the value of trust and then these principal objections to trust. I do believe that there are going to be certain kinds of hesitancy and actually deep refusers that we won't be able to overcome. I think we need to accept that, But what we should as a health and medical community strive to get as many people on board as it were, for the sake of the public sealth. And there will also be people. There are also people who can't take vaccines because of underlying medical conditions. So, for instance, with COVID, we don't need one hundred percent of people vaccinated to get community immunity, as they say, but we do want to get as many as we can. I'm not saying give up, but we will have these deep challenges. Why can't we actually nevertheless do better? I mean, go back to smallpox, one of the great successes of immunizations in global history, right, effective eradication over a long period of time with a lot of coordination, but not so very long ago, right, I mean that process ended in the seventies, if I'm not mistaken. So why was it possible to do that? But it's not quote unquote possible to do this now. I mean, what were the tools and techniques that were used to bring us to smallpox eradication? And why do we seem so stuck in so many places today? We're much more democratic. This is a really important point you're thinking, and I thought about it a lot when I was going with the polio workers door to door in northern Nigeria, in India in some of the most resistant communities, and thinking, you know, these are some of the same communities, particularly in India, which went through the same thing around smallpox. But for the smallpox eradication, there was some police force and pretty coercive measures that would absolutely not be acceptable today, and certainly in the context of the polio eradication initiative, we could not do in some of the states I was in what was done in the previous campaigns. I'm not saying it was all that way, but there were certain types of coercion that isn't just not tolerated today. I'm going to ask a subversive question, and I want to preface it by saying, you know, my day job is that I'm a constitutional law professor. I spend all of my time thinking about, you know, how you could make liberal democracy work alongside the need for government authority. So I take this with you with that background, Maybe we're just doing it wrong. You know, maybe the idea that there should be a democratic right to refuse vaccination is not only a mistake from a practical standpoint, but is generating the kind of hesitancy that you're talking about to a greater degree than it would otherwise exist, in the sense that if you ask people do you want the vaccine or not, you're putting them almost in an existential situation of having to weigh many, many, many different factors ideological personal belief, chance, risk, knowledge, ignorance. Maybe that's just asking too much bunch of people. And maybe if we simply required it universally, there would be there would still be some objections, but maybe people just wouldn't spend as much time dreaming them up and just to finish the thought about why this isn't maybe so crazy. You know, when the US Supreme Court was asked to consider this issue in the early twentieth century, it answered unequivocally, Look, you have lots of liberal rights against the state, but you don't have a right to say, note of vaccines because vaccination is necessary to help everybody, and so you just don't have that as a fundamental constitutional right. And you know what, if it went to the Supreme Court today, they might well reach the same conclusion. So it's not necessary that we say that forced immunization is undemocratic. We could just say forced immunization is consistent with our values because it's necessary to save lives. I absolutely agree with you. I mean, we do have required immunization to go to school, but it's about settings. In my work in the UN, I worked a lot on rights issues, and particularly the Convention on the Rights of the Child, and we often talked about this fine line where rights become responsibilities. You have your individual right until you get to a point where it harms others, and vaccines sit on that cusp. I agree with you that we do need to rethink our whole approach. I think we really need a whole different approach because also we have a lot more vaccines, and I know that, for instance, in France they added a number of additional vaccines required for school in the context of some very serious measles outbreaks in twenty eighteen. I think there were eighty thousand across Europe, and there was outrage in the streets against it, but ultimately a number of the healthcare professionals told colleagues at the Ministry of Health, thank you. It takes the onus off of me as a healthcare provider to have to persuade someone to take I feel like the government is behind me. I'm supporting that, I'm helping implement that, but the onus is not on me to make that persuasive argument. Well, can you say more about the approach that you would advocate, because we don't train physicians or scientists very much in convincing people to take up the pro social, pro health interventions that they invent, right, I mean, scientists are supposed to invent things that make the world better, and physicians are supposed to give treatments that make the world better. But we don't think that their job is to do persuading. So what is the approach that you think would be better for the next time around. Well, I think actually in the current environment, a lot of the medical community, particularly the more senior medical community, is not used to being challenged, is not used to having their authority challenged. And I think we've come to a different point where we have publics that are very different than they were, certainly twenty years ago, much more questioning the world of information at their fingertips, not hesitant to be challenging the authority of their doctors. And what I've seen happen is some doctors actually shut down because they don't want to go there. They don't want to have that argument. So I think what needs to be trained is less of the promotional side and more of the how to have a difficult conversation. But can I just ask, do you think that would work? I mean, in light of the subtle social pressures that you're describing, I don't think. I mean, I'm just thinking of physicians. I know many of them are most impressive people you know that I come into contact with, and they have many, many amazing skills. But I'm not sure that even with you know, a sophisticated training seminar, they would be able to convince people who are truly vaccine hesitant, partly because I'm just not sure what arguments are are gonna work. I mean, you know, you could say, well, gee, you trust me the rest of the time, why don't you trust me this time? And that's the honest answer, right That's the true answer, Like I can't demonstrate to you the truth of the scientific evidence right now, you have to trust me because you trust me the rest of the time. Like that's the actual epistemological answer. But I don't think people be very inclined to believe them when they said that, given what you're describing, Yeah, you know, it's interesting. I agree with you. And I know a number of doctors who have told me that, you know, they've tried all kinds of angles in some situations, and it's just not going to change some people's minds. And they've kind of gotten to a point where they say, I try in many different angles. I talk about vaccinating my own children, I talk about vaccinating myself. They still don't. So there are going to be some people that are difficult to change. But at the end of the day, we still in all of our globally, in surveys and in any kind of trust barometers or whatever, we still see that more than ever, doctors and healthcare providers have more trust than just about any other institution going. So there is a trust there. But I think right now they need more than the doctor. They need somebody else in their social spheres to change their mind. Now. I don't pretend to have any easy answers, but all I would say is, don't give up. If you're a doctor, keep trying. One of the puzzles that strikes me so rich and interesting around vaccine hesitancy is that unlike almost any other situation that we're required to make a decision about our healthcare, which are usually individualized. That is to say, my decision only affect me. In the case of vaccines, there is a free rider dynamic, right If enough other people are vaccinated and I'm not vaccinated, I'm still reducing my odds of getting sick because the prevalence of the disease will decline by whatever percentage of people are are vaccinated. And that makes me wonder, are there any examples that you've come across in your work of situations where lots of people decline a vaccine and then the disease is bad enough that it spreads, it continues to do harm in the community where the people live, and then you get some kind of systematic shift where people say, WHOA, I thought I was going to get away with this, but now I can't get away with it, and so I'm shifting my views and now I'm going to go out there and get a vaccine. Or does the kind of free rider effect is it so powerful that once people have said no, they're probably never going to say yes. Yeah. I think at the end of the day, the free riders, if they think that there's enough going on. They might be opportunistic. But if they see that it's a pretty serious pandemic or whatever, or in the case of measles, pretty serious wave coming back, they could be more open to getting vaccinated. That could be enough to change their mind if we want to leverage that situation. People don't in general, how many people know what percentage of their community is actually getting vaccinated to even know if they can relax. One strategy would be to let people know, like how many people in your community are vaccinate. I don't know if that's a good strategy in a sense, because it might if the community's going going well, it might make more people say, oh, I don't have to get vaccinated. Do you think, Heidi, that it's too late this time around to make sibstential inroads in let's say, the United States and Western Europe against people who are vaccine hesitant. I mean, I understand that this is a fight that's going to be a global fight, and there may be places in the world where vaccines still haven't spread that much at all and where the fight really needs to be concentrated. Or do you think there's still time to make a meaningful difference in this particular round. So, you know, an optimistic view which didn't turn out to be true, was that we would vaccinate enough people fast enough that community immunity or her immunity could be reached and we would not have to worry about the variants that are will inevitably now spread and some of which may eventually evolve to be vaccine resistant. That ship seems to have sailed, at least in the West. Yeah, I think we still need to get as many people as possible vaccinated. I don't think it's too late, and I don't think we should give up, because out of principle, it's really important to get people on board. I'd like to say it's never too late. It's a very dynamic changing environment. I think I remember saying, I think it was in late January we're going to hit a wall in late March April, I said. So it was a bit later than that because at the beginning of the year we are in the thick of a serious second wave. We had recent news of these vaccines being highly effective, more effective than most vaccines, and there was a limited supply, so all of those things would drive people. So we had the willing the eager upfront, wanting to get whatever limited supply, seeing that you know, this is bad, still bad. But as we get more supply, as the willing have been more vaccinated, and as the pandemic appears to be waning, you know, we're starting to hit it more difficult population. So I think we have to change some strategies. And I also don't think we should give up, because it's not just about COVID vaccine. Everything we do around COVID and building confidence around the vaccines it could be foundational moving forward for other vaccines. We'll be right back. How do you. I am fascinated by the role that fear has played on all sides of the COVID pandemic, addits and the various treatments that we've been looking at for it. So it sometimes seems to me that at first, many, many people were afraid of getting COVID, and those folks eventually masked up and engaged in social distancing, and others said, well, look, it's not the end of the world. Statistically, you probably won't die from it and not get it, and so don't be so fear based. And then with the rise of the vaccines, we've seen a shift, and now there are lots of people saying, well, I am afraid of the vaccine more than I am afraid of the possibility of getting COVID. Now, obviously there's a lot of overlap between those people and people who said they weren't afraid of COVID in the first place. But before they were saying we're not afraid of COVID, and now they're saying, we are afraid of a vaccine. Meanwhile, the people who before we're afraid of COVID are now saying that they're not afraid of a vaccine. I don't realize there's not a perfect match, but that does seem to be the case. I mean, I'm genuinely curious. I don't really understand how the economy of fear is working for each group, except to say that each group is afraid of something different. Yeah, and I think it's a risk perception thing too. I mean, there was more fear about the virus back a few months ago, because there was more virus, the mortality rates or higher. It was more fearful. And now as we see that waning a bit, what seemed like a smaller risk, the relative risk has changed in the Meanwhile, too, people didn't have before the information about the rare risk of these the blood clots, for instance, So there's new information in that mix that we didn't have before. We see this even with childhood vaccines. We've got a lot of mothers now who are skeptical about childhood vaccines. They're just doing a very basic risk calculation. They don't see the threat of all these childhood diseases, but ironically, does the vaccines work. Yeah, But to them and their child, it's like the thing that has the risk is the vaccine. And there's also this kind of way that risk plays with our minds in a way, if a mother gives a child the vaccine or gets a child vaccinated and there's a problem, she feels far more regret and responsibility than if a child naturally gets measles, because it's nature. So it's another factor that weighs in there. Yeah, that actually leads me to a question that I imagine you've spent a lot of time thinking about. It. Seems like vaccine hesitancy has some components that are grounded in quote unquote reason, mathematical reason risk assessment that an economist would say is rational to undertake and then some of it consists in beliefs and values, which who's to say exactly which you're right and wrong? And then some inheres in true irrationality, paranoia, fantasies, false claims about the world that are demonstrably false, not just false opinion, but false claims of fact. And I guess what I'm wondering is, I mean, having spent so much of your career thinking about these questions, do you ever think about, like, roughly what percentage is contributing to each You know, how much of vaccine hesitancy is coming from rational calculations, even if they're unconscious rational calculations. How much of it is coming from beliefs and values which aren't really subject to being shown true or false in the same way that facts are. And how much of it is coming from just false beliefs about the world that we might be willing to labels as irrational. I have thought about that. It really depends on the person. But I think that in the broader group of hesitant people around vaccines, I mean, I think we don't give enough credit sometimes to parents, to others who are kind of weighing things they're not just you know, emotional crazy beliefs there are, and and my point of haut anti vaccine, I don't mind the word. The thing I don't like is that it's used so loosely for anyone who doesn't want a vaccine. It's often used to a lot of hesitant parents who aren't at all anti vaccine. They have some you know, they're asking some questions and then they oh, she's just an anti VAXX, and then she becomes it more anti vacs because of that judgment. Although it is vaccine hesitancy then also though in a sense over inclusive, because for some of the people, sure they're hesitating, and the implication of hesitancy is it hints, oh, you can be convinced. But it seems a bit like a euphemism to me to describe people who are saying, oh, hell no, I'm not going anywhere near this vaccine. And there are a lot of people who are saying that they're not hesitant at all, they're just a clear no. I agree. Hesitancy was not a word I chose. This was a word that was decided by the World Health Organization, and I was part of the advisory group to kind of characterize the scope and scale of it, but we weren't able to name it. We were given that framing of it. And I've written some things about the ambiguity of that term. So I fully fully agree with you. What would you choose if you could choose any term? Well, well, I've picked the framing of confidence because also I was thinking of the consumer confidence index, and we have a vaccine confidence index. You can be zero percent confident and you can be one hundred percent confident. But I don't think there's any magic, one one word. Just to try to close with something slightly optimistic, what is your case study that, in your mind is the most optimistic or positive case in which a population which had hesitancy gradually shifted to being less hesitant. If there are I hope some examples of that out there that you've encountered in your research. There's a few of them. I mean the most recent one, for instance, on the COVID work. One of the more successful engagement strategies was through barbers and hairdressers in Maryland. I know in some of my work in India and in Africa, when you started to address other things in the community that people cared about, they were more accepting of the vaccine because they felt like, actually, you're not just here to give me my job and keep moving. Oh, maybe you do care about what I think or my well being. And I think moving forward on COVID, we do need to somehow embed it in COVID recovery more broadly, addressing mental health things, addressing other things. So I think we need to step back from the needle, as it were, and really think about context and never assume what's in the minds of people. They may be telling you they think it's a safety issue, but there may be something else. I think we need to hear out people because in India, I remember one example that I always think about is there was everyone was saying, oh, it's a rumor that's going to sterilize us. They're never going to let go of this rumor. Well, spending some time when some of these villages talking to people and not just a one time survey, but going back and saying, well, what else is bugging you? You know? And it turned out that this community didn't want men coming from Delhi to their village. One they didn't want men vaccinating their children, and two they wanted people who were from the community. So if something happened they could find them. Well, these are pretty reasonable things. Once that changed, somehow, the rumor thing disappeared. So I think trying to understand if is there something else going on here that you know, is more tangible that maybe maybe it's more straightforward than you think, and maybe it's not, maybe it's more complicated. But well, my Barbara, who's been cutting in my hair since I was nine, it is definitely the wisest person that I know. So I like the idea of relying on relying on Barbara's I mean in the Indian case, of course, in many villages in India people were forcibly sterilized, sometimes against their will, sometimes without their knowledge, as recently as the nineteen seventies, so you could sort of understand. That seems to me to fall into the category of very reasonable people to be afraid of that they had a real world experience. What should I be asking you that I'm not asking you, Heidi, Well, I can tell you what I'm most worried about is where we're going with social media. I think we need to find some way to allow for opinion, find a different way to handle the way we're dealing with it, particularly around vaccines. I see us going in a direction of shutting a lot of things down that might backfire. It is something that keeps me up at night because I see some extreme behavior on both sides. This is something I also spend a huge amount of my time working on and listeners of the show. Not that I've advised Facebook on their free expression policy, so I care a lot about this. I thought I heard you hinting that maybe the social media companies are going too far in taking down content that they label as anti vaccination misinformation. And that surprised me to hear you say that, because so many people from the medical establishment are out there pressuring the social media companies to do still more to take down what is described as COVID misinformation, including anti vaccine misinformation. So I did I hear you're right? Yeah, and governments are too. Did I hear you're right there that you think it would be actually a mistake for the social media companies to go too far in shutting down skeptical discourse. I think it's a risk, and I think that it's not just the health authorities who are putting that pressure. It's government. I mean, it's coming from the top. But my Vaccine Confidence Project group here after spending eleven years and continuing to be listening and understand the dynamics of what's going on out there. You can't just flip a switch. You cannot delete doubt. And some of the key strategies right now that are being used by those who want to disrupt are quicker and more clever and nimble than the more promotional positive ones. And we're just either driving at underground or it's going into its embedding and a lot of other networks, and we need I think we need a different strategy. I mean, I think I fully and absolutely agree with taking down things that are overtly harmful, and I do think and fully agree that we need to work on mitigating the amplification of risk that I think is one of the real issues how it spreads. My red flag is that we need a lot more work to understand the dynamics of this space. And I worried that in trying to clean it up, we're pushing it underground, We're pushing it in spaces that we're going to be less able to engage with it, less able to address it, and not able to get cues on where we need to build more resilience, and I think it should be also a challenge to the public health and scientific community that are we not strong enough to stand up to And you can't just take something down with giving a better story, because they're going to find it somewhere else. It's kind of an almost existential task in sorting this out. And I think it's not just about vaccines. It's in other areas, but vaccines, I think, because of the public health implications, is a serious one. And I'd love to talk to you more about this if you're working on it, because yeah, it's really important, very gladly. I mean, you've really described one of the classic free speech arguments, which is that if speech is suppressed too much, it tends to go underground and then it can do greater harm. I mean, one of the early arguments for free speech, being the twentieth century, when Western government started adopting it more actively, was just the one you're making that we need actually the full range of arguments to be made in public in order to achieve some kind of consensus in order for people to have trust in underlying institutions. And now there's of course a lot of skepticism of that view. In the light of the rise of social media, and that view is very much under attack, so I think your voice is extremely important on this subject. I want to thank you for your fascinating work and for taking time out of your incredibly busy crusade, as it were, to understand hesitancy better to speak with us. Thank you so much, doctor Larson. Thanks very nice to meet you. I found my conversation with doctor Heidi Larson genuinely eye opening and more than a little bit disturbing. Not because of for research, which seems to me thoughtful and brilliant. No, what scared me the most was the realization that what we call vaccine hesitancy is almost certainly a necessary feature of our contemporary liberal democratic approach to vaccines. When I asked Heidi, why is it that in the past we were able to get lots of people to take the vaccine and were not, she answered unequivocally that the difference was democracy. Now she was very positive about democracy, but I have to say that her comment really made me think that we don't have to, as a constitutional democracy, necessarily take the view that people can choose whether or not to get vaccines. We could, in principle say that it is a legal obligation, and under current Supreme Court precedent, the government would be empowered if Congress passed a law to say that everybody must get this vaccine. I don't think that's practically going to happen in the world in which we currently live, but it did occur to me that that might actually be desirable, because in a world where ultimately people are given the choice of having vaccines, then the points that Heidi brought up, namely libertarianism of the left and the right, people who think that it's against nature, against God's plan to have vaccines, people who worry about the vaccine's safety, and overall, people who have less trust in the capacities of government or medical authority to do well by them are inevitably, I think, going to substantially undercut the possibility of broadly adopted vaccinations. In other words, by choosing to define liberal democratic rights in the way that we have, we've invited the possibility of much greater harm. That's a cost benefit analysis that I don't think I fully thought through in the right way before this conversation with Heidi. Finally, and significantly, Heidi made a very counterintuitive point which I think is very well worth listening too carefully, and that is that we need to think about whether we might be going too far in some contexts, including in the context of social media at shutting down discourse that undermines vaccine confidence. Her concern is that if we go too far, we will drive vaccine confidence questions underground, and that that will make it harder, not easier, for medical authorities and the government to convince people to take that scenes Throughout the conversation, our theme of power here on Deep Background was absolutely essential. The power of government to make people take vaccines, the power of people's beliefs to lead them to places of uncertainty or questioning, and perhaps most significantly, the power of the medical establishment, limited by its capacity to be trusted. These questions all could not be more pressing at the moment, and I'm grateful to doctor Larson for joining us to explain them so intelligently. Until the next time I speak to you, be careful, be safe, and please be well. Deep Background is brought to you by Pushkin Industries. Our producer is Mola Board, our engineer is Ben Talliday, and our showrunner is Sophie Crane. Mckibbon. Editorial support from noam osband. Theme music by Luis Gara at Pushkin, thanks to Mia Lobell, Julia Barton, Lydia Jeancott, Heather Faine, Carlie Migliori, Maggie Taylor, Eric Sandler, and Jacob Weissberg. You can find me on Twitter at Noah R. Feldman. I also write a column for Bloomberg Opinion, which you can find at bloomberg dot com slash Feldman. To discover Bloomberg's original slate of podcasts, go to Bloomberg dot com slash podcasts, and if you like what you heard today, please write a review or tell a friend. This is deep background