1. Why do you think people are so much less likely to get COVID boosters than flu shots even though there are still more people dying from COVID than from flu – and how much of this might be because people think the pandemic is over or because people think that COVID shots don’t work or that boosters are unnecessary? What’s going on here?
The main thing going on here, I think, is that COVID shots are controversial and polarizing, whereas flu shots (for the most part) are not.
The decision to get or not get a flu shot is made calmly. The questions in people’s minds are pretty straightforward:
- How likely do I think I am to catch the flu?
- If I catch it, how bad might it be? Can I accept a hellish week? Might it be worse than that? Might it kill me?
- How much good do I think the annual flu shot will do?
- What are the downsides of getting a flu shot? How inconvenient is it? Can I accept being under the weather for a day or two?
- What if anything has changed since my last flu shot? Is there any reason to rethink, or should I just keep getting it every fall?
Most people don’t “know” the medical and statistical answers to these questions. But they have intuitions about the answers, based largely on their past experience and what they’ve learned about consensus expert opinion. Those intuitions guide them to a calm yes-or-no decision.
Pretty much the same questions apply to getting a COVID booster. And once again, most people don’t “know” the answers. But unlike with flu shots, for COVID boosters many people have a sense that the experts don’t entirely know the answers either. Plus, the experts seem to disagree about the answers, even as both sides confidently insist they’re right and the other side is spewing misinformation. So people’s intuitions about whether or not to get a COVID shot may be very tentative. Or if their intuitions are firm, they’re likely to be grounded less in evidence than in allegiance to one side or the other.
And then there are the COVID questions that simply don’t come up for flu shots:
- The COVID vaccine is new. It was developed in a hurry and the government authorized it as an emergency measure. Is it really as safe as they say?
- Some scientists say the COVID vaccine might be dangerous for some people. Others say or imply that it’s completely safe. How can I tell who’s wrong? Or who’s lying?
- Some scientists say a COVID booster is unnecessary for healthy people who have already been infected or vaccinated or both. Others say it’s essential for everybody who’s eligible. How can I tell who’s wrong? Or who’s lying?
- Some people say COVID shots are an outgrowth of the same leftwing authoritarianism that brought us lockdowns and mask mandates. Should conservatives avoid getting boosted as a matter of principle? (Talk about self-defeating!)
- Nearly everyone agrees the worst of the COVID pandemic is over, at least for now. So why are public health agencies still insisting on yet another booster? When can we get back to normal?
Annual flu shots and COVID boosters are recommended most strongly for elderly and high-risk people. Most such people know that flu is an annual risk, especially for them. They’re not worried about a flu pandemic, and they don’t need a pandemic to think flu is worth protecting themselves against every year. They’re used to getting an annual flu shot, and don’t see any reason why this year would be different.
It’s not a newly developed vaccine made in a hurry using a new technology. They aren’t hearing a lot of expert disagreement or nonexpert rumors about the vaccine, or about the disease. The messaging they hear every year is pretty consistent. Flu is old news, and they know the drill.
By contrast, they’ve heard a lot of highly uncertain and rapidly changing information about COVID and COVID vaccines. Many agencies and experts have sounded confident – arguably often overconfident, given that they have changed their minds or been wrong a lot. And some people who claim they’re experts too are on the other side. They often sound just as overconfident about their radically different opinions – opinions the mainstream majority has worked hard to suppress.
Despite all that, most elderly and high-risk people eagerly got vaccinated against COVID in 2021. Better a controversial vaccine than a deadly disease, they figured. But the disease seems a lot less deadly now, while the vaccine is no less controversial. So getting yet another booster is a tougher call.
At age 78, I get every COVID booster I’m entitled to get. I’m a risk communication expert, immersed for decades in the emerging infectious diseases world. I can take in all the uncertainty and changing information – communicated by officials who have often sounded overconfident and sometimes been untrustworthy – and still decide to keep rolling up my sleeve. But I really understand why some elderly and high-risk people who are quite comfortable with their annual flu shot might be more leery about the COVID vaccine. I think they’re making a mistake not to keep getting boosted, but I sympathize with their doubts and worries.
It’s worth noting that the American public health establishment is more enthusiastic about universal annual flu vaccination than comparable agencies in most peer countries. As a result, far more Americans than people in most other countries have successfully been taught that annual flu shots are a must. From an international perspective, “Why do so many Americans get a flu shot every year?” is as reasonable and perplexing a question as “Why are so many Americans not getting their COVID boosters?”
2. Why do you think COVID is killing almost twice as many people as flu – and how much of this is because of differences in how we can prevent or treat these viruses versus other factors?
I pass. This isn’t my field.
3. What would you say to people who don’t want COVID shots to try to convince them of this – and how would you explain things differently if they generally resist all vaccines, versus if they have had previous COVID shots but not boosters, or if they are coming in for a flu shot but don’t want a COVID shot?
When the CDC’s Advisory Committee on Immunization Practices was considering whether to recommend that nearly every American get another COVID booster, some committee members argued that the evidence wasn’t all that strong for boosting healthy young adults. There was discussion of maybe recommending boosters only for the elderly and people whose other illnesses made them high-risk if they caught COVID.
The decision went the other way in large part because the committee was worried about high-risk people who don’t know they’re high-risk or who don’t like considering themselves high-risk. CDC might well have wished it could say something like this: “We recommend COVID boosters for everyone who’s at least six months old. But we really, really, really recommend COVID boosters for certain people whose risk is much higher. Here’s who they are….”
It’s debatable whether high-risk people are likelier to take a precaution if it’s recommended for everybody or if it’s recommended specifically for them. There’s evidence on both sides. I’m in the latter camp. Especially now that we see how many high-risk people have shrugged off the universal recommendation, I think it’s past time to focus more on targeted recommendations.
Targeting aside, there’s a huge literature on how to convince people to get vaccinated, and an even huger literature on how to convince people to take precautions in general. Much depends on how reluctant they are. For the least reluctant, all it sometimes takes is a tacit pro-vax assumption by a respected source. Imagine if every doctor routinely said to every patient, “You’re due for another COVID shot. While you’re here, let’s get that out of the way.”
Convincing the most reluctant people, of course, is mostly a lost cause. It pays to talk to them only if there’s an audience of less reluctant people watching to see how respectfully or disdainfully you treat them.
In the vast middle ground, many how-to-convince recommendations have been floated, some with considerable research validation. If I had to point to one key conclusion among many, it would be this: Don’t tell people they’re stupid, or even unwise, to have reservations. (And yes, frame their reluctance as a set of reservations, not as an obstinate or irrational or irreversible determination to go unboosted.) Assume their reservations are grounded in something. Then to the extent that you can, follow this admittedly time-consuming protocol:
- Ask them to tell you what’s bothering them about the COVID booster – not in a perfunctory way, but with genuine curiosity. Ask follow-up questions that show not just that you’re listening, but that you respect what you’re hearing, even that you’re learning some things you didn’t know (if you are). Let them dominate the conversation and determine its flow. Wait to respond until they’re truly done venting; wait, in fact, until they insist that they’re done and solicit your response.
- Then echo what they told you. Show you really heard. But since maybe you didn’t hear everything right, make your echo tentative: “Let me see if I understand what you’re telling me. I’m hearing that you have three main reservations about getting a booster today….” Don’t try to respond until they confirm that you’ve truly understood what they told you.
- Then ask if they’re interested in your response. If they’re not, let it go. You’ve launched a dialogue and accomplished all you can accomplish today. If they want a response, on the other hand, start with the things they said that you can honestly agree with, the things you think they’re right about. They may be wrong about the science, for example, but right about ways the experts have sometimes sounded contemptuous or overconfident or untrustworthy.
- Then add some points to what they said – not disagreements, but not entirely agreements either. They’re “Yes ands” – things you want them to know that you think they’ll probably find interesting rather than objectionable. Part of why you were listening so hard at Step 1 is to decide which “Yes ands” are likely to be worth attempting.
- Then ask if they’re okay if you express disagreement with some of what they said. If permission is granted, go ahead and tell them some things you disagree with. Frame these points as just your opinions. Do explain what your opinions are grounded in: experience, research, med school, your more general sense of what most of the real experts believe, whatever. But try not to pull rank; keep the dialogue a respectful exchange of opinions, not you “correcting” their ignorant misimpressions.
Obviously, this protocol works best one-on-one, but it also works in groups if you give it the time it needs. It’s what I used to teach clients to do in hostile public meetings.
Addressing people’s reservations about COVID boosters is much harder if you’re in a hurry, or if you’re trying to “reach out” to an audience via monologue in a one-way medium like a pamphlet or a website or a publicity campaign. But even there, it is possible to respond respectfully to the real concerns on people’s minds.
This approach is pretty much the opposite of the very common and very disrespectful “Myths versus Truths” approach to selling vaccination. All too often FAQs, for example, are not the real concerns on people’s minds. If your FAQs genuinely address the questions people frequently ask, and if your responses are respectful, you might actually change some opinions.
4. Is the pandemic over? And how much do you think people’s perceptions about the pandemic being done might influence the resistance to COVID booster shots?
I’d love to think that the pandemic isn’t over! Because if it is over, then COVID seasons like the one right now may be the new normal. That would be a new normal with COVID worse than the annual flu season … plus the annual flu season itself – and thus a new normal much worse than the world used to be. And that’s not even taking into account the uncertainties and unknowns about long COVID.
I hope COVID epidemic waves will become smaller and milder over time, until COVID eventually settles into a cyclical or seasonal disease much less severe than the annual flu. We’ll know in hindsight that the pandemic is over when we see that it has become fairly stable and predictable. If we’re lucky it will weaken first, then stabilize into a less burdensome new normal.
But of course I find it nearly impossible to say that to most people. “I hope the pandemic isn’t over” would sound to most people like I must be a sociopath or a Big Pharma grifter.
The vast majority of the U.S. public has rightly noticed that COVID is way less deadly than it was in 2020–21. People are rightly relaxing out of an emergency posture into, yes, a new normal. Of course some people are relaxing too much; I think failing to get a COVID booster if you’re elderly or otherwise high-risk is relaxing too much. Other people are relaxing too little, still refusing to eat at restaurants and still making their kids wear masks.
All people mean when they say the pandemic is over is that the emergency is over, at least for now. The times are a lot less bad than they were – which means, among other things, that COVID boosters have become a lower priority for healthy young people. They’re right about all that. But I still hope the pandemic isn’t over; I hope it weakens much more before it ends.
Copyright © 2024 by Peter M. Sandman
