Her question unleashed a torrent of answers. The women said they were frustrated by the government’s aggressive efforts on behalf of a single vaccine when their villages lacked reliable drinking water and electricity. They wondered why no one was knocking down their doors to rout diarrheal diseases, poverty, or starvation. They were infuriated by the condescending attitude of public-health officials toward their vaccine concerns; they were still haunted by a clinical trial for a meningitis drug, conducted by Pfizer, eight years earlier, which had left eleven Nigerian children dead and dozens disabled. Amid America’s “war on terror,” some found it entirely plausible that Western countries might be trying to sterilize Muslim children or infect them with H.I.V. Others were eager to vaccinate their kids but forbidden from doing so by their husbands. Larson found that there was no single explanation for their vaccine hesitancy. Instead, their attitudes were filtered through an intricate mix of rumors, mistrust, history, and facts on the ground.
Larson, a professor at the London School of Hygiene and Tropical Medicine, studies vaccine rumors—how they start, and why some flourish and others wither. Public-health experts often address vaccine hesitancy on an informational basis, by debunking rumors and misinformation. But, in her recent book, “Stuck: How Vaccine Rumors Start—and Why They Don’t Go Away,” Larson argues for a more expansive view of the problem. “We should look at rumors as an eco-system, not unlike a microbiome,” she writes. Tackling misperceptions individually is like eliminating a single microbial strain: when one germ is gone, another will bloom. Instead, the entire ecosystem must be rehabilitated.
In 2010, in London, Larson founded the Vaccine Confidence Project, with the goal of putting these ideas into practice. Its analysts—trained in digital media, political science, artificial intelligence, psychology, statistics, epidemiology, and computer science—monitor news sites and social media in more than a hundred languages, then strategize with local health groups about how to tackle the rumors they find. Larson describes the Vaccine Confidence Project as “investigating the global vaccine weather, while zooming in to local storms.” This year, the project has fielded requests for help from health officials in some fifty countries, including, in the few days before one of our phone calls, Sudan, Somalia, Turkey, and Iran. Her team works in an epidemiological spirit, hoping to contain outbreaks of misinformation swiftly, before they can spread.
Larson has also developed a tool for quantitatively mapping vaccine hesitancy: the Vaccine Confidence Index, a set of validated questions concise enough to reach vast populations. In 2015, she posed the questions to sixty-six thousand people in sixty-seven countries—the first time a rigorous survey of vaccine attitudes had been conducted at that scale. Larson’s results took many public-health experts by surprise. The lowest levels of vaccine confidence were found in countries with the highest education levels and the best health-care systems; seven of the ten most vaccine-hesitant countries were within the European Union. (France ranked first.) Global-health efforts tend to focus on poorer countries such as Nigeria, but the results suggested that the ability of vaccines to end pandemics might also be weak in wealthier countries—the same nations that export public-health expertise to the developing world.
Larson, who is sixty-four, has a calming, meditative demeanor that masks a restless intellect. Willowy, with no-nonsense straight hair, she has spent the coronavirus pandemic tracking vaccine attitudes from the home in North London she shares with her husband, the Belgian microbiologist Peter Piot, who helped discover and contain Ebola. Larson and Piot share a vast repository of global-health experience; in March, 2020, they shared the coronavirus. She experienced mild symptoms, but Piot fell seriously ill.
Over a video call this spring, Larson told me that the covid vaccination effort “should remind everybody that you cannot have scientific advances and great global-health plans” without taking vaccine confidence into account. Five months into the vaccination effort, the share of the U.S. population who’ve received at least one dose of the vaccine has barely exceeded fifty per cent. After reaching a peak of more than four million doses per day in mid-April, the daily number of doses has been falling off, slipping under a million per day in June. Herd immunity through vaccination seems increasingly unlikely. But Larson is already thinking ahead to the next pandemic. Future outbreaks may well be deadlier and more contagious than covid-19. What good will our high-tech vaccines be if not enough people will take them?
Larson was born in 1957, and grew up in Boston. Her father was an Anglican priest, and her mother was a professor of German. The doors of home and church were unbolted and heavily trafficked, the church as likely to host Passover Seders as N.A.A.C.P. meetings. As a child, Larson spent hours in the basement darkroom with her father, who taught filmmaking and communications in addition to working as a priest; in the nineteen-sixties, those pursuits converged in the civil-rights movement, which he documented on film. The day after Martin Luther King, Jr., was assassinated, Larson’s father headed to Memphis with his camera. Larson, who was eleven at the time, remembers him warning her and her younger brother that he might end up in prison, but for a good cause. “I grew up understanding the power of belief,” she told me.
At Harvard, Larson started as a biomedical-engineering major, then switched to studying sociology and photography. For her senior thesis, she photographed children with Down syndrome who’d been mainstreamed into the public schools. After graduation, she spent a fellowship year in Israel, studying how Jewish and Arab children played together, then made a similar study among Muslim and Hindu children in India; later, as a graduate student in anthropology at the University of California, Berkeley, she worked with a Punjabi community in England that was predominantly Sikh, but changing under the influence of Muslim immigrants from Pakistan. Other researchers had warned her that it would be hard to gain the trust of people in such vulnerable communities; her solution, she recalled, was just to “be interested.”
One morning during her time at Berkeley, as she was driving down a coastal highway in the fog, her Volkswagen hatchback flipped over a cliff and into the Pacific Ocean. The car slammed roof first into the water, sinking until only its rear wheels broke the surface; Larson was trapped upside down in the car. Two elementary-school kids cutting through the redwoods on their way to school managed to contact rescuers, who pulled her from the car, unconscious, after forty-five minutes. Larson survived the crash with only a case of hypothermia and a ticket for driving with an out-of-state license. Her father had always stressed the importance of listening to those who are overlooked, and her rescue by children reinforced that lesson. “I’ve learned to pay close attention to people on their own terms,” she said.
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In 1990, fresh out of grad school, Larson took a job at Apple Computer, studying how the presence of computers affected students and teachers in a series of Los Angeles classrooms. Later, she moved to Xerox parc, where she observed office workers adjusting to new technologies, such as fax machines. Among other things, Xerox hoped to install a printer on every desk, but Larson found that workers preferred walking to the printing room. “It reminded me of women going to the well in Nepal,” she said—it was a detour with a social function. Xerox wanted to know how workers at an international company related to fax machines, and unicef, in New York, had recently splurged for two. Larson spent a year studying faxes in the organization, then took a job there and was sent to Fiji.
For six years, Larson worked to help South Pacific countries improve children’s welfare. Attending to people on their own terms turned out to be critical. Once, she obtained an audience with the King of Tonga, who preferred to hold forth about his slimming regimen. (He’d previously held the Guinness World Record for world’s heaviest monarch.) Larson talked with him about his cycling and his penchant for coconuts; the king eventually signed on to the United Nations Convention on the Rights of the Child.
It was impossible to ignore how H.I.V. was ripping through Asia. There was no vaccine or effective treatment. Although Larson had jettisoned pre-med as an undergrad, anthropology turned out to be the right specialty for the crisis. “The social, cultural, and human dimensions—that was all we had,” she said. She moved to Geneva to join the World Health Organization, focussing on the factors that shape behavior around infectious diseases. She crisscrossed the globe for the next two years, leading workshops, meeting government officials, collaborating with local health teams, and observing communities that were getting it right. Her mother, however, had died of ovarian cancer. Larson herself had contracted a host of illnesses—dengue fever, hepatitis E, amoebiasis, giardiasis, eosinophilic meningitis, and cerebral malaria—and wanted to move closer to her father. She returned to New York to work with unicef’s newly formed Gavi Alliance, in 2002.
The Nigerian vaccine boycott, which started two years into Larson’s tenure with Gavi, brought her face to face with an unsettling aspect of global health: even the most strenuously wrought achievements—ones that required years of painstaking logistical, financial, and diplomatic effort—could be gutted by the mere puff of rumor. The local strain of polio ultimately spread to twenty countries, as far afield as Yemen, Saudi Arabia, and Indonesia. Fifteen hundred children were paralyzed; it cost a half-billion dollars to contain the outbreak. The lesson, for Larson, was that global vaccination efforts would never succeed without a detailed understanding of rumor and a rigorous process for creating trust.
In 2016, Larson helped develop a tabletop pandemic communications exercise sponsored by the Johns Hopkins Center for Health Security. The exercise was based around the idea of a fictional coronavirus pandemic in the year 2025. The notional virus originated in Southeast Asia, but was first diagnosed in Minnesota among returning missionaries; it became known as spars, or St. Paul Acute Respiratory Syndrome. Holiday travel accelerated its spread, launching a global pandemic.
In the exercise, the response to the fictional pandemic was tripped up by government agencies offering conflicting information, national and local leaders sending mixed messages, and scientists struggling to explain shifting data. Citizens, many of whom already distrusted government and Big Pharma, were disoriented by the fragmented media landscape, social-media provocateurs, and malevolent actors for whom confusion offered political or financial gain. “I predict that the next major outbreak . . . will not be due to a lack of preventive technologies,” Larson wrote, in Nature, the following year. “Instead, emotional contagion, digitally enabled, could erode trust in vaccines so much as to render them moot.”
The W.H.O. estimates that vaccines save between four and five million lives every year. No other intervention except sanitation saves lives on this scale. And yet vaccines are singularly controversial, inspiring resistance not seen for other preventive public-health measures, such as mammograms or colonoscopies. In “Stuck,” Larson describes mass vaccination as “one of the biggest worldwide social experiments in collectivism and cooperation” in history. It unnerves people, she told me, because of the involvement of the state. “People don’t like being counted,” she said. “They wonder what the government—or the W.H.O., or Bill Gates—is doing with all these numbers.” During the course of 2020, with the help of the polling firm ORB International, Larson’s team surveyed thirteen thousand four hundred and twenty-six people in thirty-two countries about their governments’ handling of the pandemic and the upcoming covid vaccines. They found that trust in government was the strongest predictor of willingness to be immunized.
A successful vaccination effort, Larson explains, requires the public to trust the scientists who create the vaccine, the companies that manufacture it, the health-care workers who inject it, and the governments that oversee the process. “That trust chain is a far more important lever of acceptance than any piece of information,” she writes. The chain is made more fragile by “the feeling of being disenfranchised and not heard.”
In Nigeria, the polio boycott lasted eleven months. To end it, the country had to restore the trust chain. Community health workers, along with global-health experts like Larson, went door to door, village to village, talking with citizens. The Nigerian government invited prominent Muslim leaders to be part of a committee to reassess the safety of the vaccine. Larson met with government officials and appeared on state television to answer questions. Samples of the vaccine were sent abroad to be re-analyzed; they went, among other places, to Indonesia, a country that would not be seen as harboring anti-Muslim sentiment. Traditional chiefs and Muslim leaders from other African countries travelled to Nigeria for roundtable discussions. Meanwhile, wells were drilled in communities that lacked drinking water. The polio vaccinations were bundled into mobile “health camps” that brought a full range of primary-care medical services to villages in addition to the vaccines.
Polio vaccination remains challenging in Nigeria. Boko Haram continues to sabotage the effort; it assassinated nine polio vaccinators in 2013. Nevertheless, in August, 2020, while the world was busy battling the coronavirus, Nigeria was declared free of wild polio.
In science, trust depends on data, and progress is incremental and hard-won. Years of rigorous mRNA-vaccine research undergirded the seemingly overnight success of the first covid vaccines. “Scientists were probably thinking, ‘This will be so great! People will definitely want it!,’ ” the chemist Derek Lowe, who writes the popular drug-discovery blog In the Pipeline, told me. Researchers and health experts were proud of the vaccines; perhaps it was inevitable, Lowe said, that they would be dumbfounded by how many people didn’t find the vaccine safety and efficacy data intrinsically compelling. “We put so much work into this amazing research, and then we’re stunned when people don’t want it,” he said.
As a primary-care physician, I find that my days are saturated with discussion of the covid vaccines. Shortly after speaking with Lowe, I had a conversation with a patient of mine. He’s an overweight smoker from an Eastern European country who has diabetes, emphysema, and little interest in the covid vaccine. I tried to conjure my inner Larson, asking about his concerns and empathizing, all the while envisioning his scarred alveoli flailing on a ventilator. After a dozen rounds of discussion, our interpreter finally broke in. “The patient wishes to inform you that he will never take this vaccine,” she said, not unkindly. It was hard not to be stunned.
Not long afterward, another patient told me that she wouldn’t be taking the vaccine: it was made from bats, she said, and contained placenta and bits of rats. I gently clarified that, although the coronavirus had jumped from bats to humans, the vaccine itself wasn’t made from bats, rats, or placenta. Later, as I relayed this conversation to Larson, I realized that I’d fallen into the trap of debunking. Larson told me that she would have handled the conversation differently: “I would have said, ‘That’s fascinating! I’ve never heard anything like that before.’ ” She would’ve enthusiastically invited my patient to elaborate. In “Stuck,” she argues that “listening to rumors and the stories behind them” is crucial for rebuilding trust.
When Larson sits on global-health committees, she said, she sees herself as “helping channel what is going on in peoples’ lives and minds and feelings” to a medical community that is “increasingly alienated” from the citizens it heals. In the era of social media, many people have come to value personal experiences and opinions over data-driven science. This “speaks to a near reversal of the Age of Enlightenment,” she writes, in her book. “Three hundred years ago, science was championed as freedom from religious dogma. Today science has become the new dogma.” She cringes at the hectoring style of some public-health edicts, which are framed as “because the science says so.” For the general public, she said, “it isn’t just about science—it’s also about values.” Health experts often speak of the need to improve public understanding of science. “That’s not what it’s about,” she told me. “We need science understanding the public.”
Larson told me that she had been impressed by the work of the Black Coalition Against covid-19, a group of health professionals based in Washington, D.C., and directed me to its Web site. The site doesn’t lecture visitors about personal responsibility or bombard them with data and links to vaccine-appointment hubs. Instead, it centers on a video titled “A Love Letter to the Black Community,” which showcases Black health-care workers and researchers involved in fighting the coronavirus. “We have locked arms in an initiative to place the health and safety of our community at the heart of the national conversation about covid-19,” a narrator says. The video acknowledges that the medical system needs to earn the trust of Black Americans; only then does it address masks, social distancing, and vaccination. In the site’s menu, a tab for “Remembrance” is adjacent to the one for “Vaccines,” putting community grief on an equal footing with vaccine education.
How we handle vaccination and public-health measures in this pandemic will set the stage for the next one. “We should not forget that we are making people’s future history now,” Larson said. “Are people going to remember that they were treated respectfully and engaged?” I asked Larson how she would structure the vaccine response for the next pandemic. “Make sure that the vaccine effort is embedded in the over-all pandemic effort, not a stand-alone measure,” she said. The head of the vaccine effort should be appointed on Day One, even before the research starts. Vaccines “always seem so far in the future,” she said, but planning and communications need to start immediately. Public-outreach efforts for the covid vaccine under the Trump Administration didn’t kick into gear until mid-December of 2020, when the first doses were already being delivered to health-care workers. Earlier outreach in September—as part of a larger endeavor to “defeat despair” regarding covid-19—collapsed amid credible accusations that they were thinly veiled efforts to bolster Trump’s reëlection campaign.
From the beginning, Larson said, national leaders should explain that vaccine development is “an evolving story,” and help the public acclimate to the inevitable scientific shifts. Her vaccine team would include not just vaccine and public-health experts but people who work in global health and diplomacy, to anticipate the need for international coördination. Communicators with expertise in explaining risk and ambiguity would be essential team members, Larson said; so would tech-savvy young people, not unlike the analysts at the Vaccine Confidence Project, who could monitor online rumors and vaccine discourse. Larson would also convene a board of trusted public figures—she hesitates to call them “influencers”—who could serve as vaccine emissaries. She imagines a dozen or so well-known individuals from the worlds of music, television, sports, and religion, as well as from underrepresented communities. They would be regularly briefed by the pandemic-response team and also have the opportunity to ask questions, perhaps on television or a social-media live stream. The approach would also extend to businesses, schools, service agencies, and nonprofits. “We need high-level cohesion,” Larson said.
The idea that our health-care success might hinge on the future equivalents of Morgan Freeman, Rick Warren, Taylor Swift, and LeBron James—plus the odd TikToker and video-game streamer—can feel unsettling. For Larson, it’s simply another link in the trust chain. She added that her hypothetical vaccine-response team would draw up contingency plans that would not be “dependent on higher-level leadership.” States, she argued, should be more explicitly prepared to handle pandemic response and vaccination strategy, should there be another President unable or unwilling to lead.
In an e-mail not long ago, Larson told me that the Vaccine Confidence Project will be broadening its ambit, becoming simply the Confidence Project. “We are increasingly looking at vaccines as a window into a broader mix of experiences and emotions,” she wrote. For many of our most critical societal issues—climate change, civil peace, national security, democracy—trust is the only currency we have. The project’s expanded goal, Larson explained, will be to understand how trust is created, eroded, and hopefully rebuilt.
My conversations with Larson unfolded over the course of the U.S. vaccine rollout, which unfurled in tense parallel with the country’s devastating second covid-19 surge. The rollout débuted in December, with health-care workers taking giddy vaccine selfies and then devolved into the rugby-style appointment derby for the general public. Vaccine supply and eligibility expanded, and by June—the AstraZeneca and Johnson & Johnson dramas notwithstanding—nearly all of the willing had been jabbed. We were now beached on the stubborn sandbar of the vaccine holdouts.
I found the prospect of convincing the rest of my patients daunting. Even while garnering inspiration from Larson, I sometimes felt uneasy. Listening to a slog of pseudoscience and conspiracy theory can be exhausting, even angering, given all the risks my colleagues have taken this year. I do want to listen, but deep down I wonder if I might not actually be listening; I might simply be trying to make my patient feel heard so that I can get on with the business of safeguarding her health. That condescension, even if well-meaning, corrodes the chain of trust.
Recently, a patient told me that he would absolutely not take the vaccine, because someone from back home had dropped dead immediately upon receiving it. I started to launch into my usual encouragement, explaining how the risks of the disease vastly outweigh the risks of the vaccine. Then I realized that his story was far more compelling than mine. We could return to the vaccine facts later. I wanted to hear his story. I was interested.
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