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Vaccine Hesitancy: Public Trust, Expertise, and the War on Science
The public has voiced concern over the adverse effects of vaccines from the moment Dr. Edward Jenner introduced the first smallpox vaccine in 1796. The controversy over childhood immunization intensified in 1998, when Dr. Andrew Wakefield linked the MMR vaccine to autism. Although Wakefield’s findings were later discredited and retracted, and medical and scientific evidence suggests routine immunizations have significantly reduced life-threatening conditions like measles, whooping cough, and polio, vaccine refusal and vaccine-preventable outbreaks are on the rise. This book explores vaccine hesitancy and refusal among parents in the industrialized North. Although biomedical, public health, and popular science literature has focused on a scientifically ignorant public, the real problem, Maya J. Goldenberg argues, lies not in misunderstanding, but in mistrust. Public confidence in scientific institutions and government bodies has been shaken by fraud, research scandals, and misconduct. Her book reveals how vaccine studies sponsored by the pharmaceutical industry, compelling rhetorics from the anti-vaccine movement, and the spread of populist knowledge on social media have all contributed to a public mistrust of the scientific consensus. Importantly, it also emphasizes how historical and current discrimination in health care against marginalized communities continues to shape public perception of institutional trustworthiness. Goldenberg ultimately reframes vaccine hesitancy as a crisis of public trust rather than a war on science, arguing that having good scientific support of vaccine efficacy and safety is not enough. In a fraught communications landscape, Vaccine Hesitancy advocates for trust-building measures that focus on relationships, transparency, and justice.
264 pages, Hardcover
Published March 1, 2021
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November 9, 2023Teaching this book next semester in my seminar on Public Trust in Science.
March 11, 2023
Goldenberg's "Vaccine Hesitancy" offers an important - if optimistic - corrective to dominant ways of thinking about why people hesitate and/or refuse when it comes to vaccination. At the heart of Goldenberg's project is the notion that vaccine hesitancy is born out of a "crisis of trust" in science (p. 168), and that it's only through the efforts of scientists to repair this broken trust that we will be able to make progress towards vaccine acceptance.
Goldenberg begins by arguing that there are three common, but incorrect, narratives that explain why vaccine hesitancy occurs. The first is a basic "deficit model" formulation, wherein the public is science ignorant, and if only they had more information, all would be well. A second is an appeal to "stubborn minds," wherein cognitive biases - and, more likely, various forms of motivated reasoning driven by identity, ideology, and affiliation, a la Dan Kahan - explains vaccine failures. A third is the "death of expertise," which harkens back to the deference of the first: if only people had more unquestioning trust for scientific experts, they'd get vaccinated. Goldenberg argues that these are all unsatisfactory and inaccurate accounts of where vaccine hesitancy actually comes from.
Goldenberg then turns to trust, arguing that historical injustices and financial conflicts of interest of big pharma sew a massive distrust, which is then amplified by social media (p. 139). A number of other factors are alluded to (e.g., lived experiences of your family physician not listening to you, for instance, as well as important epistemic/ontological mismatches between understandings of what adverse outcomes matter, see p. 31), though it's the above two (historical injustices and big pharma) that are identified as the primary drivers of distrust. Once this distrust is present, "mavericks" like Andrew Wakefield are able to affirm these experiences of distrust and, in doing so, gain significant followings based on the fact that they take distrust seriously.
For Goldenberg, scientists have a duty to solve this. She offers a series of prescriptions that are simultaneously quite logical (improving the quality of patient experiences in healthcare settings, switching from individualistic messaging to emphasizing the public in public health), and also somewhat unsatisfying (such as the potential value of, but need to be careful with, vaccine mandates). The latter fall a little flat both because of the vast learning that occurred since Goldenberg wrote these recommendations six weeks into the COVID pandemic, but also because it largely seems like these are "damned if you do, damned if you don't" kinds of recommendations (e.g., while being thoughtful about mandates is certainly important, as we've seen during COVID, every single possible implementation is going to foster distrust in some way).
That, I think, is one of my two critiques with this analysis: that it treats distrust as the product of the failure of scientists to live up to their role, rather than a more complex phenomenon that includes the very pathways Goldenberg spends the first half debunking. In 2023, for example, it's hard to look at the 'trucker anti-mandate convoy' in Canada and explain it on the basis of only good-faith actors with genuine distrust and not, say, massive foreign financing, incredibly motivated reasoning, the fact that vaccines became a convenient proxy for attempting to enact a January 6th-style insurrection in downtown Ottawa, etc. (It's also hard to find her claim that "Today, vaccine-skeptical communities are epistemically and politically progressive... because they take women's concerns and actions seriously" on p. 158 very believable in the context of the last three years of vaccine discourse.) To be clear, I think that distrust certainly played a massive role in this... but it's a complex distrust that is, in part, fostered through the genuine injustices that Goldenberg identifies... and also the fact that it turns out some people find it really fun to fly "fuck trudeau" flags while getting paid for it.
Put another way, when contesting the notion that expertise is dead, Goldenberg says "I argue that the publics do /not/ think they know better. Rather, they are not buying what the experts are selling" (p. 75). And yes, the latter is unequivocally true. But, so is the former. Again, the hindsight of the last three years of an ongoing global pandemic is perhaps unfair, but it is clear that many critics of COVID policy indeed do explicitly argue that they know better.
In other words, I agree strongly with Goldenberg that scientists ought to do much more to live up to their duties. But, at the same time, we also need an analysis of the system that acknowledges that many of the 'science decisions' that generate significant distrust (e.g., mandates) don't actually really involve any scientists at all, or if so, an incredibly small number of chosen agents. And, we need an analysis that takes seriously the politics, power, and economics of it all.
The second critique is not unrelated: it seems odd to me to set up "the stubborn mind" as mutually exclusive with the "crisis of trust" analysis. Again, I grant full agreement with Goldenberg that a crisis of trust is at the heart of many of these problems. But, this distrust isn't simply a passive, dependent variable. Rather, it /does/ influence how people interpret evidence, who they see as being credible sources, and their willingness to be open to building trust in different parties. Indeed, Goldenberg's "maverick" theory ends up circling back to this. Wakefield is a rallying figure precisely because he is affectively perceived as "on the side of" those who distrust the system. This is, indeed, a crisis of trust... but this is also the kind of mechanism that Kahan and others argue for in the "stubborn mind" thesis. If we accept the attraction Goldenberg's 'mavericks,' we accept that people's judgements are coming prior to their encounters with factual information and expertise, which is the stubborn mind thesis.
With all that said, I still consider this book to be an essential read and important corrective. While my review is, in essence, a 'third wave' style critique, calling for us to avoid pushing the pendulum too far the opposite way... Goldenberg is right, I think, that most people are deeply entrenched in the first three narratives alone. As such, the project is valuable and insightful - we just need to land somewhere in the middle, acknowledging and embracing the complexity of it all, and the fact that likely /many/ different explanatory stories (trust, yes, but also motivated reasoning, and also dozens of other theories) offer a partial picture of the overall phenomenon.
Goldenberg begins by arguing that there are three common, but incorrect, narratives that explain why vaccine hesitancy occurs. The first is a basic "deficit model" formulation, wherein the public is science ignorant, and if only they had more information, all would be well. A second is an appeal to "stubborn minds," wherein cognitive biases - and, more likely, various forms of motivated reasoning driven by identity, ideology, and affiliation, a la Dan Kahan - explains vaccine failures. A third is the "death of expertise," which harkens back to the deference of the first: if only people had more unquestioning trust for scientific experts, they'd get vaccinated. Goldenberg argues that these are all unsatisfactory and inaccurate accounts of where vaccine hesitancy actually comes from.
Goldenberg then turns to trust, arguing that historical injustices and financial conflicts of interest of big pharma sew a massive distrust, which is then amplified by social media (p. 139). A number of other factors are alluded to (e.g., lived experiences of your family physician not listening to you, for instance, as well as important epistemic/ontological mismatches between understandings of what adverse outcomes matter, see p. 31), though it's the above two (historical injustices and big pharma) that are identified as the primary drivers of distrust. Once this distrust is present, "mavericks" like Andrew Wakefield are able to affirm these experiences of distrust and, in doing so, gain significant followings based on the fact that they take distrust seriously.
For Goldenberg, scientists have a duty to solve this. She offers a series of prescriptions that are simultaneously quite logical (improving the quality of patient experiences in healthcare settings, switching from individualistic messaging to emphasizing the public in public health), and also somewhat unsatisfying (such as the potential value of, but need to be careful with, vaccine mandates). The latter fall a little flat both because of the vast learning that occurred since Goldenberg wrote these recommendations six weeks into the COVID pandemic, but also because it largely seems like these are "damned if you do, damned if you don't" kinds of recommendations (e.g., while being thoughtful about mandates is certainly important, as we've seen during COVID, every single possible implementation is going to foster distrust in some way).
That, I think, is one of my two critiques with this analysis: that it treats distrust as the product of the failure of scientists to live up to their role, rather than a more complex phenomenon that includes the very pathways Goldenberg spends the first half debunking. In 2023, for example, it's hard to look at the 'trucker anti-mandate convoy' in Canada and explain it on the basis of only good-faith actors with genuine distrust and not, say, massive foreign financing, incredibly motivated reasoning, the fact that vaccines became a convenient proxy for attempting to enact a January 6th-style insurrection in downtown Ottawa, etc. (It's also hard to find her claim that "Today, vaccine-skeptical communities are epistemically and politically progressive... because they take women's concerns and actions seriously" on p. 158 very believable in the context of the last three years of vaccine discourse.) To be clear, I think that distrust certainly played a massive role in this... but it's a complex distrust that is, in part, fostered through the genuine injustices that Goldenberg identifies... and also the fact that it turns out some people find it really fun to fly "fuck trudeau" flags while getting paid for it.
Put another way, when contesting the notion that expertise is dead, Goldenberg says "I argue that the publics do /not/ think they know better. Rather, they are not buying what the experts are selling" (p. 75). And yes, the latter is unequivocally true. But, so is the former. Again, the hindsight of the last three years of an ongoing global pandemic is perhaps unfair, but it is clear that many critics of COVID policy indeed do explicitly argue that they know better.
In other words, I agree strongly with Goldenberg that scientists ought to do much more to live up to their duties. But, at the same time, we also need an analysis of the system that acknowledges that many of the 'science decisions' that generate significant distrust (e.g., mandates) don't actually really involve any scientists at all, or if so, an incredibly small number of chosen agents. And, we need an analysis that takes seriously the politics, power, and economics of it all.
The second critique is not unrelated: it seems odd to me to set up "the stubborn mind" as mutually exclusive with the "crisis of trust" analysis. Again, I grant full agreement with Goldenberg that a crisis of trust is at the heart of many of these problems. But, this distrust isn't simply a passive, dependent variable. Rather, it /does/ influence how people interpret evidence, who they see as being credible sources, and their willingness to be open to building trust in different parties. Indeed, Goldenberg's "maverick" theory ends up circling back to this. Wakefield is a rallying figure precisely because he is affectively perceived as "on the side of" those who distrust the system. This is, indeed, a crisis of trust... but this is also the kind of mechanism that Kahan and others argue for in the "stubborn mind" thesis. If we accept the attraction Goldenberg's 'mavericks,' we accept that people's judgements are coming prior to their encounters with factual information and expertise, which is the stubborn mind thesis.
With all that said, I still consider this book to be an essential read and important corrective. While my review is, in essence, a 'third wave' style critique, calling for us to avoid pushing the pendulum too far the opposite way... Goldenberg is right, I think, that most people are deeply entrenched in the first three narratives alone. As such, the project is valuable and insightful - we just need to land somewhere in the middle, acknowledging and embracing the complexity of it all, and the fact that likely /many/ different explanatory stories (trust, yes, but also motivated reasoning, and also dozens of other theories) offer a partial picture of the overall phenomenon.
July 15, 2023
An innovative and seminal look, at the underlying reasons for vaccine hesitancy. Goldenberg gives an objective and balanced view on a difficult subject, and I hope her research will inform future vaccine guidance and policy
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December 14, 2023read for school
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