As coronavirus cases rise across the United States, the fight against the pandemic is focused on an estimated 93 million people who are eligible for shots but have chosen not to get them. These are the Americans who are most vulnerable to serious illness from the highly contagious delta variant and most likely to carry the virus, spreading it further.
It turns out, though, that this is not a single set of Americans, but in many ways two.
In one group are those who say they are adamant in their refusal of the coronavirus vaccines; they include a mix of people but tend to be disproportionately white, rural, evangelical Christian and politically conservative, surveys show.
In the other are those who say they are open to getting a shot but have been putting it off or want to wait and see before making a decision; they are a broad range of people but tend to be a more diverse and urban group, including many younger people, Black and Latino Americans, and Democrats.
With cases surging and hospitalizations rising, health officials are making progress in inoculating this second group, who surveys suggest account for less than half of all unvaccinated adults in the United States.
The problem is, the same surveys show that the group firmly opposed to the vaccines outnumbers those willing to be swayed. And unless the nation finds a way to persuade the unwavering, escaping the virus’s grip will be a long way off because they make up as much as 20% of the adult population.
Interviews this past week with dozens of people in 17 states presented a portrait of the unvaccinated in the United States, people driven by a wide mix of sometimes overlapping fears, conspiracy theories, concern about safety and generalized skepticism of powerful institutions tied to the vaccines, including the pharmaceutical industry and the federal government.
Myrna Patterson, 85, a Democrat from Rochester, New York, who works at a hospital, said she could not shake her worry that the vaccines were produced too quickly. “Is it really worth me taking it?” Patterson said. “How do they know that it will kill the virus and if it’s really good for humans to be taking this vaccine?”
Hannah Reid, 30, a mother of four and a certified sommelier in Oregon who is an unaffiliated voter, said she had long been apprehensive about vaccines; her young children get many but not all pediatric shots. She said her Christian faith has also made her comfortable with not yet getting a COVID-19 shot, which she thinks is too new, the conversation around it too noisy and bombastic.
Alex Garcia, 25, who is not tied to any political party and works in landscaping in Texas, said he believed he was too young and healthy to need a vaccine. “My immune system could fight it,” Garcia said. He said he did not worry about infecting his unvaccinated 86-year-old grandmother, either.
About 30% of the adult population in the United States has yet to receive a shot, and about 58% of those ages 12-17 have yet to receive a shot.
Part of the challenge is that the unvaccinated live in communities dotted throughout the United States, in both lightly and densely populated counties. Although some states like Missouri and Arkansas have significantly lagged behind the nation in vaccination rates, unvaccinated Americans are, to varying degrees, everywhere.
In Cook County, Illinois, which includes Chicago, 51% of residents are fully vaccinated. Los Angeles County is barely higher, at 53%. In Wake County, North Carolina, part of the liberal, high-tech Research Triangle area, the vaccination rate is 55%.
The rate of vaccinations across the country has slowed significantly since April, but there are signs in recent days of a new rise in shots being distributed, with upticks in vaccinations particularly in states like Arkansas, Louisiana and Missouri, where cases have grown.
As of Friday, about 652,000 doses, on average, were being given each day, according to data from the Centers for Disease Control and Prevention; that was up from recent weeks, when the country hovered just above 500,000 shots a day. Nationwide, about 97% of people hospitalized with COVID-19 are unvaccinated, federal data shows.
How many people eventually decide to get shots could help determine the course of the virus and severity of illnesses across the country, so efforts to convince the unvaccinated — both the group that is waiting and watching and the vehemently opposed — have gained steam with advertising campaigns, incentives and new mandates. Some experts have estimated that 90% or more of the total population — adults and children — would need to be fully vaccinated for the country to reach a possibly elusive herd immunity threshold of protection against the coronavirus.
So far excluded from the debate over vaccination are 48 million unvaccinated children younger than 12, who are too young to be eligible for a shot until at least fall. They make up 15% of the total population in the United States. Once they are eligible, it is uncertain how many will get shots; even some vaccinated parents are hesitant to inoculate their children, surveys show.
Doctors say they are working to convince reluctant Americans, sometimes in long conversations that unravel falsehoods about vaccines.
Dr. Laolu Fayanju, a family medicine doctor in Ohio, has encountered patients on both ends of the spectrum: those who are insistent in their refusal to be vaccinated and others who agree to a shot after he painstakingly lays out facts.
Never did he expect that so many Americans would still be resisting a shot this many months into the vaccination effort.
“I vacillate between anguish and anger,” Fayanju said. “We live in an era of unprecedented scientific breakthroughs and expertise. But we’re also stymied by the forces of misinformation that undermine the true knowledge that is out there.”
In the first weeks of the nation’s vaccination effort, health officials could not distribute shots quickly enough to millions who rushed for them, beginning with health care employees, essential workers and older Americans, who were particularly at risk of dying from the coronavirus, which has killed more than 600,000 people across the country.
Over time, the people choosing vaccines shifted markedly, according to CDC data, which captures race and ethnicity for about 60% of vaccine recipients.
White people, who were vaccinated at a higher rate than Black and Hispanic people earlier this year, make up a larger share of the vaccinated population than the overall population, but that share has been shrinking.
The daily vaccination rate per capita among Asian Americans started out comparable to that among white people, then accelerated when availability opened to all age groups, and now slightly surpasses white people. Black and Hispanic people were being vaccinated at a lower per capita rate than other groups at the beginning, but since April, the vaccination rate for Hispanic people began to rise above other groups.
Asian Americans, Pacific Islanders, Native Americans and Alaskan Natives, who make up a smaller proportion of the overall population, have surpassed other groups in total percentage vaccinated but still include large numbers of unvaccinated people.
Figuring out exactly who is not vaccinated is more complicated; federal authorities have mainly tracked the people getting shots, not those who have not gotten them. But several surveys of adults — from the Kaiser Family Foundation, AP-NORC, Morning Consult, Civis Analytics, the Ad Council and the Census Bureau — together present a sense of the range of who the unvaccinated are, an essential set of data as health officials seek to convince reluctant Americans.
About 10% of American adults have made it clear in interviews, discussions with family members and conversations with survey researchers that under certain circumstances, they are open to being convinced to get a vaccine.
With the help of a friend who is a nurse, Lakeshia Drew, 41, of Kansas City, Missouri, has been on her own journey for weeks. Drew, who voted for President Joe Biden but is unaffiliated with a political party, said she was learning all she could about the risks that the coronavirus carries and how a vaccine could protect her from getting critically ill.
As the delta variant has spiked case numbers in her area, she has decided that her family will need to get vaccinated before receiving every last answer to its questions.
“It’s gone from, ‘We aren’t getting it,’ to, ‘OK, if I get more information, I’m going to get it,” she said of the shot. “I would rather get it than to bury any one of my children or to have them bury me.”
Drew and other people in the so-called wait-and-see group tend to be younger and harbor more concerns about the safety of the vaccines. They may be worried that the vaccines are too new, or about what friends have told them about side effects.
In one Kaiser survey, 44% said they would be more likely to get a vaccine once it is fully approved by the Food and Drug Administration. Currently, the three coronavirus vaccines being offered in the United States have only been granted an emergency use authorization, a step short of full approval.
“It’s kind of like the known versus the unknown for some of those people,” said Mollyann Brodie, an executive vice president at the Kaiser Family Foundation, who runs the group’s survey research. “Fear is a hard thing to overcome, and there has been a lot of fearmongering with relation to the vaccine, and there is a lot of stuff that isn’t known about it.”
Some adults younger than 50, in particular, suggest that the risk of an unknown vaccine feels greater than the uncertainty of its benefits.
Don Driscoll, 38, who is from Pittsburgh and calls himself a socially liberal Republican, said he has opted for now against vaccination because of safety concerns.
“I don’t think there’s a conspiracy. I don’t think Bill Gates is shooting microchips into my veins,” he said. “I don’t think the Democrats want to kill half the population. I am just not an early adopter of anything, really.”
Some people who have yet to get vaccinated say they have encountered obstacles to obtaining shots, are worried about hidden costs or are waiting until they can get a shot from someone they trust. But the share of unvaccinated Americans who are held up because of issues of convenience is shrinking, survey research shows.
For some Latino immigrants, fear of immigration authorities has been a roadblock.
For instance, grassroots organizers recently hosted a vaccine clinic at a supermarket in Merced, a city in California’s fertile Central Valley that draws farmworkers from Mexico. But some residents say they were turned away by the health care workers administering the vaccines because they did not have government-issued IDs — although officials have said that only proof of age should be required.
“For the undocumented, their fears are not the vaccine but the record-keeping that goes along with it,” said Dr. Richard Pan, a pediatrician and Democratic state senator in California who has gone into neighborhoods to knock on doors and urge people to get inoculated.
A substantial share of the wait-and-see group — more than 40% in the Kaiser survey — says it would be motivated by vaccine mandates.
But San Francisco became one of the first cities to impose a vaccine mandate for its nearly 35,000 city workers and immediately encountered resistance from labor unions and other organizations.
“I don’t believe in mandates of any kind,” said Sherman Tillman, president of the San Francisco Black Firefighters Association, who described himself as a conservative Democrat. “I don’t believe that governments should force our workers to do anything about their bodies and health. I think it’s an individual choice.”
Other people who have skipped vaccinations so far but said they might be persuaded said they planned to rely on advice from their own doctors — whenever their next checkup might be.
Candice Nelson, a personal assistant in Spartanburg, South Carolina, has suffered medical challenges before. She is a cancer survivor who endured chemotherapy. And she had COVID-19 several months ago, spending three days in a hospital to recover.
Yet she is in no hurry to receive a vaccine — until she can discuss it with the doctor who treated her cancer at their next appointment. Her employer has asked her to be vaccinated and is pressuring her for an answer.
“I’ll go with what my doctor says,” she said, adding that she would also be responsive to a requirement at her job.
The CDC recommends vaccines even for people who have been infected with the virus. Some evidence suggests a prior infection offers less protection than a vaccine, particularly against variants like delta.
For Troy Maturin, from Abbeville, Louisiana, the rapid spread of the delta variant through his state does not make him more interested in getting the vaccine. To the contrary: He takes it as further evidence, he said, that the vaccines are a government plot.
“They’d have to Taser me, drag me out and give it to me while I’m unaware of it,” Maturin, a 50-year-old auto parts salesman who described himself as conservative, said at the suggestion of a mandate.
Maturin belongs to the group of unvaccinated Americans who are unlikely to say they could be persuaded with improved convenience or even requirements. They are far less concerned about getting seriously ill with COVID-19 and much more likely to say they do not trust the government or the pharmaceutical companies that have developed the shots. They are not opposed to all vaccinations, but very few of them get annual flu shots.
Several studies have suggested that a Republican Party affiliation is among the best predictors of membership in this group. But the demographics of the group also overlap with key Republican constituencies. People who say they will never get a COVID-19 vaccine are disproportionately likely to be white and to live in rural areas. They are overrepresented in the South and the Midwest.
Pete Sims, 82, recalls ducking mandatory vaccines during his time in the Air Force in the late 1950s.
Servicemen would periodically line up, hold out a vaccination card, get it stamped and when their turn came, hold out their arms.
Moments before the injection, Sims always managed to take a bathroom break. He said he would emerge after his turn had passed.
Now he lives in Houston and identifies as more of a libertarian than a Republican, though he voted for Donald Trump in November. But Sims was emphatic that his politics have not shaped his nearly lifelong antipathy to vaccines.
“It has to do with my civil rights,” he said. “The United States government’s main job is to protect me from foreign and domestic enemies. Not my health. I’m in charge of my health.”
Angelique White, 28, a hairstylist in Romulus, Michigan, is firm in her decision not to be vaccinated, despite pressure from her boyfriend to get the shot. White, who is a Jehovah’s Witness and does not vote, had several cousins who died from COVID-19. But she believes that years ago, when she and her twin sister became violently ill, they were reacting to a flu shot. They never got another vaccine.
“I wear my mask, I sanitize my hands and do it like that,” White said. “I think I’ll be fine.”
She has not spoken with her doctor or pastor about the vaccines. There is no need, she said; her mind is made up, and she has moved on.
This article originally appeared in The New York Times.