Faced with an uncontrolled pandemic that has thoroughly disrupted the societies that preceded and enabled it, there is little chance of escape without recourse to inoculation. Despite the UK government’s litany of mistakes and corruption scandals in handling the crisis, the vaccination programme has so far been a success, mostly because it was handled by the public-sector NHS, who know what they’re doing. But there remains a serious obstacle to this strategy: so-called ‘vaccine hesitancy’ – the voluntary refusal or distrust of vaccination.

Data from the UK’s Office for National Statistics show that overall Covid-19 vaccine hesitancy for the first months of 2021 was around 8%, falling very slowly. A recent study of US adults found that vaccine hesitancy, although slowly decreasing, remained around 22%. A study of working-age adults in France found the number declaring outright refusal of any vaccine to be as high as 27% overall.

How should a society respond to this tendency towards vaccine hesitancy? One thing is for certain: those who simply respond by insisting on ‘the facts’ and ‘but, science’ may be accurate in terms the information they hold, but there are several other factors that they fundamentally misunderstand. However much we may want near-universal inoculation so that we can get on with building our post-pandemic societies, scientific arrogance and positivism will not get us there. We need to make sure that vaccine hesitancy is properly understood.

We are not individualised automatons making rational choices about or own individual self-interest. There is a social, cultural and even political character to the way we make decisions in relation to everything in the world that we cannot independently verify with our own senses, including vaccines and other medicine, and while science can give us a working vaccine, it cannot always help us understand social, cultural, and political issues.

All the studies of vaccine hesitancy show substantial variations amongst national populations. In the data from the UK, there is considerable variation along the lines of age and ethnicity, for example. As many as 17% of younger people (aged 16-29) are more hesitant to take a Covid vaccine—more than double the rate of the overall population—and as many as 44% of people identifying themselves as Black or Black British report reluctance. In the US study, this hesitancy varied widely among professions, with just 8% of those in life and social sciences hesitant to receive a Covid-19 vaccine, while as many as 46% of those in construction/industry ‘answered that they probably or definitely would not choose to get vaccinated if offered a vaccine to prevent COVID-19 today.’ In the French study, vaccine hesitancy decreased as education increased, and was worse with vaccines made outside the EU/USA or with lower efficacy rates.

There are undoubtedly numerous reasons for these variations, and I will leave their examination to a sociologist or anthropologist who will do it properly: whatever else their careful analysis might tell us, we should be mindful that vaccine hesitancy is not one simple phenomenon with one straightforward cause. But these varied levels do not change the fact that in a population of millions of people, even a hesitancy rate around 8% is a serious problem. So without generalising, or justifying vaccine hesitancy, it is worth exploring further.

As a starting point, consider that moment common to all vaccination – the actual act of inoculation. Perhaps it is helpful to acknowledge that besides many other factors, vaccines are afforded an elevated level of attention, if not controversy, because in some way they function as a sort of leap of faith. Is it really so surprising that a mysterious liquid, produced by large, distant corporations and administered by governments, being literally injected through the skin and into the body, functions as a threshold at which people reflect on their trust of the network of institutions and power that have come together to make that moment of inoculation happen?

We are happy to eat processed foods without knowing (or usually caring) what ingredients they contain, or use any number of verifiably harmful or carcinogenic products, from refined sugar to the toothpaste you use to mitigate the effects of that sugar. But an injection directly into the body of something we cannot see, hear, taste, or smell by a person we do not know is very much a moment of vulnerability that can be easily cast in the imagination as a sort of metaphor for power and its potential abuse. In this way, it’s like conspiracy beliefs about 5G or the water in our taps – potentially an invisible malevolence. But particularly given its manner of introduction into the body, that injection represents an enormous act of trust between the recipient and the forces that its creators and administrators represent, not because there is anything wrong with the science went into making that vaccine, but because of the lack of independent sensory verification, the highly asymmetrical power relations involved, and context of distrust that often forms the background for our dealings with that power.

Distrust need not always have exactly the same origin for it to manifest in some of the same ways, including an aversion to vaccination. Women who are worried about their fertility despite no evidence to suggest the vaccine affects it, people of colour distrustful of a system that has let them down, failed to take their safety into account, and discriminated against them and their ancestors for centuries, and inward-facing ‘self-protective’ religious groups that avoid vaccines and other medicines may all be quite different, but they share a sense that ‘the system’ is not there for them and will not put their safety and health above all else.

This is not a sentiment that can be ignored. Put this together with your standard garden-variety anti-vaxxer conspiracy theorist, and the common denominator is clear: an abundance of suspicion. In the narrow context of escaping a once-in-a-century pandemic that has killed millions of people using vaccines that have received more funding and research interest than virtually any medical product for decades, that distrust may be misdirected, but in a broader social and historical context it is hard not to acknowledge it as understandable.

In fact, there are a number of reasons why trust in the institutions of power (or those associated with them) may be damaged or entirely absent. Indeed, the society that, until about mid-February 2020, we considered normal—the one to which some people are mindlessly trying to return to as quickly as possible—was one in which suspicion and the conditions that produce it were as intrinsic as the sugar in a cake.

First, power was and remains viewed as corrupt because it often is. This does not mean that all the institutions of democracy are crooked and out to get us; rather, it is a basic acknowledgement that our institutions of power are rife with scandals, exposés, and broken promises. From the MPs’ expenses scandal to the financial crash to the current government giving Covid contracts to their neighbours and friends, along with countless other examples, the continual potential for ‘yet another’ scandal to break is a constant part of our relationship to power. This tendency is perhaps as old as power itself, but to carry on insisting that we live in a democracy while a cosy and fundamentally corrupt relationship between governments and the private sectors suggests otherwise is extremely damaging to any faith we might have placed in those institutions that nominally are supposed to represent us.

Second, but relatedly, Britain and the US in particular remain societies built largely according to market principles—competition, exchange, inflation, greed—and the pandemic has done little to change this. Both literally and figuratively, people have been increasingly encouraged to quantify and individualise everything, to always see what the maximum is they can get for the minimum effort, and to take the most for themselves where possible.

This is not to say that everybody behaves this way – far from it. It is more that beneath everything, we recognise that there is a tacit expectation that others may well try to take advantage; to fuck us over; to ‘sow where they have not reaped’. We anticipate the possibility for dishonesty and greed, even when we and the people we are dealing with may be entirely honest. The original free-marketeers of the 1930s and ’40s supposed an actor governed by basic morals. The neoliberals of the ’70s and ’80s dispensed with this unceremoniously, and greed became good. Now it is the lens through which we interpret each other and the institutions of our society.

Third is the question of communications by the powerful. In the first half of the twentieth century, propaganda was fairly overt: wartime generations were told to ‘keep mum’ and ‘dig for victory’ with colourful posters. Over time these types of overt communications lost their efficacy. Propaganda had to be disguised, and what we saw and heard carefully controlled, which is broadly the development of modern PR under figures such as Edward Bernays. Once again, is it any wonder that people might suspect that they are being lied to, or that statistics are being massaged to make a specific case, even where this is not in fact happening? Not everything is a lie, but until five minutes before the pandemic, everything was a potential lie. Then came a relatively sudden and extreme public health crisis and it became crucial that we really believe what our institutions tell us. This could not undo fifty years of organised mendacity, both from the state and corporations.

Last comes the fact that, while many nefarious claims about individual vaccines may have been debunked, there have been enough instances of major pharmaceutical companies producing products that harmed us—from thalidomide to the opioid crisis—for a distrust of vaccination, and a huge swathe of other health misinformation, to be sustained. In my book After the Fact: The Truth About Fake News, I argue that misinformation does not come from nowhere – it often arises in response to alienation, to corruption, and to legitimate fears. We live in a world that is awash with toxins, pollution, microplastics, and side-effects. These are not good reasons to avoid or refuse a vaccine, but they do reveal yet another reason why people are hesitant about trusting what is on offer. We may laugh at Gwyneth Paltrow’s wacky alternative health treatments and sneer at homeopathy, but the reality is that the world of alternative health is huge, and much of it shades into a lot of other far more nefarious beliefs. The noted right-wing conspiracist David Icke, for example, has reportedly been into alternative health for years, and the pandemic has only brought these areas into closer alignment.

Despite all of this, there is still no rational justification for avoiding vaccines, or failing to vaccinate your children, without real and material evidence of potential harm. But for us to reduce vaccine hesitancy, we need to help those who are hesitant to feel heard. Even if their understanding is wrong, their caution is understandable. Between Covid, long Covid, and the issues outlined above, the more cautious choice in this case is to take the vaccine, but this will only become clear once we have addressed some of the underlying causes of suspicion. Make our democracy more democratic, our Department for Health and Social Care more focused on public health, and our pharmaceutical companies less greedy, and you might find vaccine hesitancy falls with time.