Where NICU nurse Donna Schmidt worked, the earsplitting shrill of alarm bells was only sometimes drowned out by the tears of patients sobbing for help. Since June 2020, Schmidt has been fighting on the frontlines of the pandemic, but her biggest battle started on August 26th—when New York State implemented its COVID-19 vaccine mandate.
Schmidt, the founder of New Yorkers Against Medical Mandates, is unvaccinated and proud. In her fifties, she looks like an oddly intense substitute art teacher with her messy bun tucked behind a tribal-patterned headband. As a self-proclaimed “not-a-crazy-conspiracy-theorist,” Schmidt told me, “they can kill me before they make me get vaccinated.”
So, what does she think about shame and other strategies to get her tribe vaccinated? “Medical rape,” said Schmidt.
From the perspective of my tribe—coastal, college-educated, and long-since vaccinated—refusing the COVID-19 vaccine during a pandemic that has killed millions seems not only irrational but also deserving of stigma. At least, that was my unquestioned assumption back in July when I hadn’t met or talked to a single unvaccinated person. To be fair, I was hardly seeking them out. But that began to change after hearing Alabama Governor Kay Ivey exasperatedly proclaim, “it’s time to start blaming the unvaccinated folks.”
To get the unvaccinated vaccinated and bring an end to this pandemic, public health officials and political leaders have tried everything from free beer and doughnuts to million-dollar lotteries. But still, over 25% of adult Americans haven’t gotten their shots. With New Jersey Governor Phil Murphy calling the unvaccinated the “ultimate knuckleheads,” rare bipartisanship underlies certain irritation and perhaps a pseudo-strategy to get the unvaccinated vaccinated.
Stigma.
Like many Americans, I share Governor Ivey and Murphy’s frustrations, but their baldness rattled me. I thought the shaming would be more subtle. (Maybe disapproving glares, lips twisted in disgust, and head shakes not of anger but disappointment.) Politicians and public health leaders instead seem to be endorsing outright stigma. But, no one seems to know whether deploying stigma against the unvaccinated will actually work. Is it a viable public health strategy or just a valve for letting off puffs of condescending steam?
For better and worse, public health and social stigma have long been intertwined. When things go wrong, questions of responsibility and blame naturally occupy the public’s imagination, whether the threat is syphilis, HIV, or smoking. For syphilis and HIV, stigma drove the sick underground, proving disastrous for infection control. But for smoking, stigma seemed to help, with smoking rates dropping by about 70% since the Surgeon General’s landmark 1965 report.
In February 2022, after vaccine supply has outstripped demand for months and over half the world has been vaccinated, many people will tell you that being vaccinated is no longer a question of safety and access. They might see stigma as a reasonable way to roundhouse kick the recalcitrant few into their senses. Intentionally or not, we “vaccinated elite” seem to be sprinting down the path of stigmatizing the unvaccinated. But we owe it to ourselves to ask what stigma means in the age of COVID-19. Stigma might represent a potent public health tool against the rampage of the Omicron variant. Or it might do the exact opposite, entrenching the unvaccinated in their beliefs and estranging them further from public health. In a pandemic rife with missteps and political polarization, stigma is more than just this abstract moral quandary.
It’s a matter of life and death.
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How would you define stigma?
You probably have some sense, but it’s notoriously hard to put those feelings into words. When thrown around in conversation, stigma usually just means negative attitudes. But Canadian sociologist Erving Goffman thought it was more complicated. In 1963, he defined stigma as a state of being “reduced in our minds from a whole and usual person to a tainted and discounted one.” Goffman’s foundational theory inspired a cottage industry of researchers and sparked a blaze of stigma research, spattering its embers into the wind.
And some of this smoke billowed toward Bruce Link and Jo Phelan, then professors at Columbia, who sought to address critiques that stigma was “too vaguely defined and individually focused.” Link and Phelan deconstructed stigma into six inseparable stages: labeling, stereotyping, separating us and them, status loss, discrimination, and power. They portrayed stigma as all or nothing: each of these overlapping components had to be interwoven for true stigmatization to emerge.
I’d done my research on Goffman and Link & Phelan before I asked Scott Burris, Director of Temple University’s Center for Public Health Law Research, about stigma against the unvaccinated. Burris sports a neatly trimmed goatee and narrow glasses stretched wide across his shiny bald head. After I pitched my first softball question “What role should stigma play to get the unvaccinated vaccinated,” I thought Burris would hit me a homer.
Instead, I got, “The problem is I don’t think it is a stigmatized condition.”
As a “diehard traditionalist,” Burris believes that negative attitudes toward people unvaccinated for COVID-19 don’t meet the definition of stigma. I pushed back. We, the vaccinated elite, label them as “anti-vaxx,” we stereotype them as ignorant Trumpies, we separate us and them in the workplace. They encounter status loss by losing their jobs and face discrimination with refused services. People in power blame them.
“You’ve used all the elements, but I don’t think you used them with their actual meaning,” said Burris, clearly disappointed in my rejoinder. Burris argued that stigma broke down with “power and status loss” since the anti-vaxx movement had become a means of claiming status, not losing it. He also pointed out that, even though they championed their “oppressed” statuses, Texas Governor Greg Abbott and Florida Governor Ron DeSantis were powerful people licensing their social status to communities of anti-vaxxers.
I had automatically assumed there must be a stigma against the unvaccinated, but maybe Burris was right. For HIV and syphilis, the power and status loss were unmistakable. You’d be hard-pressed to find an HIV apologist or an advocate who was syphilitic and proud. But for being unvaccinated for COVID-19, it feels like they’re everywhere.
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The stench of rotting coffee must have been a welcome distraction from the noxious fish entrails and bloated animal carcasses on the banks of the Delaware River. In what was the driest, hottest summer anyone in Philadelphia could remember, farmers were collapsing in their fields from heatstroke. Prancing streams became stagnant marshes, buzzing with swarms of hungry mosquitoes.
Yellow Fever hung in the air.
Not far from the marshes, politicization of the 1793 Yellow Fever Epidemic cut through Philadelphia, the nation’s capital then. Hamiltonians swore that yellow fever had been imported from the French Caribbean while Jeffersonians blamed miasma, or bad air, from the city’s filth. Political divisions over the French Revolution—did it represent anarchy or heroism—loomed large in those explanations. As antagonism grew and identities transformed into political parties, the epidemic was exploited for political gain, with Federalists inciting xenophobia against French refugees and Democratic-Republicans assailing large cities as unhealthy.
It wasn’t just the disease’s origins they contested; they fought over the treatment too—bark and wine, or bloodletting. As University of Michigan historian Martin Pernick describes, physicians’ treatments were often identical, but Federalists transformed this nonpartisan issue into a political battleground “by simply declaring long enough and loud enough that bark and wine was the Federalist cure.” So, bloodletting proponent Benjamin Rush lamented how many Democratic-Republicans “have been forced to expiate our sacrifices in the cause of liberty by suffering every species of slander and persecution.”
The 1793 Yellow Fever Epidemic suggests there’s nothing new when it comes to politicizing an infectious disease, no matter the cost to trust and institutional integrity. Like the coronavirus, yellow fever is an ostensibly nonpolitical pathogen. Yet, through embedded partisan controversy and imposed political significance, it was embroiled into identity politics, leaking even into the mundaneness of infection control. A polarized media featured relentless broadsides to shame and humiliate the other side, with language of “liberty,” “sacrifice,” and “persecution” exploited to score political points. In both the Yellow Fever Epidemic and the COVID-19 pandemic, battle lines are drawn in blood, and both sides are armed to the teeth with power and status. So, stigma, with all its dependence on social consensus, may just be impossible.
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But it feels too simplistic to dismiss stigma against the unvaccinated because it’s not a national endeavor; maybe we need to understand stigma more contextually within our local contexts. As Harvard anthropologist Arthur Kleinman argues in What Really Matters, we all live in local worlds, encompassing our friends, our neighborhoods, our news, our jobs. And we seek them out because they conform with our moral priorities. In these local worlds, there are things that really matter and define who we are. What really matters in one community—think public health and institutional trust—may not be what really matters in another—think autonomy and individualism.
Rabbi Michoel Green and I, for instance, come from two very different local worlds. I figured out that stumper when, on Facebook, he lambasted the “eugenics bioweapon” that is the vaccine (or the “C0\/ID \/a¿¿ine” as he calls it). Overhearing shreds of my conversation with Rabbi Green, you might think we were discussing slavery, apartheid, or the Holocaust. In fact, Rabbi Green did briefly touch on the Holocaust but only to suggest the magnitude of what he called “the most widespread, most egregious human rights abuse in history,” something “straight out of the Nazi’s playbook.”
That egregious abuse? Stigma against the unvaccinated.
“What do people stereotype the unvaccinated as?” I asked.
“Selfish, recalcitrant, rebellious? I’ll tell you the truth; I’m not the right person to ask,” Rabbi Green demurred, scratching his unkempt, free-ranging beard. He confessed that he didn’t really see stigma in his local world of Central Massachusetts where people are very “tolerant and understanding.” But, in this Digital Era, anti-vaccine stereotypes spread through news broadcasts, social media, and other virtual local worlds. So, Rabbi Green still railed against the ubiquity of stigma and how it promised to incite a grassroots revolution against the vaccinated elite.
Schmidt was similarly emphatic on the pervasiveness of stigma, even more so for healthcare workers who are expected to do everything in their power to protect the communities they serve.
“But people have been called in repeatedly to their manager’s office and sat down. It’s like the walk of shame, you know? The stickers on the badges that are larger than life that say that you’re vaccinated. And if you don’t have it, you can’t eat in the break room or take your mask off at any time. You have to be completely ostracized,” Schmidt said, gesticulating so wildly that her computer began convulsing. “And listen, the facts don’t bear this stuff out.”
“Do you have any anecdotes or suffered any status loss because of stigma?” I asked, genuinely curious—and perhaps hoping to disprove Burris.
After speaking in generalities about how some people looked at her like she was evil, Schmidt finally said, “You know, it’s, it’s, it’s just, it’s hard to put into words how many different stories there have been.” Sparse on personal details, Schmidt primarily cited stories about those in her 25,000-member Facebook group.
“I’m fortunate to be in the least discriminatory environment here in healthcare in New York,” said Schmidt. She could point to plenty of examples of stigma, but in her local world of Long Island, New York, she seemed relatively immunized against it.
On social media and beyond, not so much. To describe her conflicting experiences, Schmidt likened stigma to a “stripe of honor.” Far from making her feel alone, stigma provided Schmidt a powerful community of people who feed off one another, a support group of comfort and camaraderie unlike any other she had ever been in. But, turning so scarlet that I nearly reminded her to take a breath, Schmidt also described the suffering she bears, indirectly comparing stigma to crucifixion with allusion to Isaiah 53:5 (“And by His stripes, we are healed”). Stigma blazes through some of Schmidt’s overlapping local worlds yet not others.
But would Schmidt have gotten vaccinated if stigma burned through them all?
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When Professor Allan Brandt and I flipped through his collection of smoking ads, Big Tobacco’s creativity impressed me. Brandt is the author of The Cigarette Century, as well as a historian of science at Harvard University. We were sitting in his fourth-floor office, surrounded by towering shelves overflowing with books, journals, and, of course, tobacco ads. There was one ad where an attractive secretary claims she took a 30-day test to know that “Camels are the mildest, best-tasting cigarette I ever smoked!” In another R.J. Reynolds ad, a businesswoman describes that “the smell of cigarette smoke annoys me. But not nearly as much as the government telling me what to do.”
Smoking represents one of the most interesting case studies in stigma because conventional wisdom holds that the anti-smoking campaign actually worked. In fact, smoking rates decreased from 43% in 1965 to 14% in 2018. If you temporarily set aside the question of whether there is a stigma against being unvaccinated, you can begin to answer the big question: should stigma even be used to get Americans vaccinated?
Many people will argue that, whether or not stigma works as a public health strategy, it is barbaric, inhumane, and morally unjustifiable. Even academics more supportive of stigma’s utility waffled when I asked them whether stigma would get the unvaccinated vaccinated. “It’s a politically fraught question if stigma can work here,” admitted one psychologist. Stigma might work, but nobody was willing to say that it would.
So why did stigma work in the anti-smoking campaign? For one, smoking was portrayed as a voluntary health risk, so those who didn’t quit were portrayed as illiterate, primal, and selfish. This stereotyping intensified as the public learned that smoking didn’t just harm the smoker but also those around them. Public spaces became smoke-free, and smokers were pushed off to the sides to practice their craft in private. These stereotypes, harms to others, and sense of exclusion were all critical to the stigma campaign against smoking—and may be key for the unvaccinated as well.
Over the past few months, the White House has responded to stalling vaccination rates by stepping up a stigma campaign against unvaccinated Americans. The unvaccinated are going to cause “a winter of severe illness and death,” President Biden recently warned, “for themselves, their families, and the hospitals they’ll soon overwhelm.” The president’s COVID czar Jeff Zients similarly moralized vaccination by distinguishing between those who did “the right thing” and those who selfishly didn’t. It’s a morbid, stark shift in messaging, reportedly driven by top health officials hoping to single out the unvaccinated and emphasize the exigency of the moment.
And the smoking case study suggests that stigma can work. The philosophical question to confront then is what outcome might overcome our moral quandaries against stigma. If stigma led to 1% of the unvaccinated getting vaccinated, should we endorse it? Maybe not. How about 50%? How about 99%? Maybe yes.
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But drawing an arbitrary line where stigma is justified or not misses the point. Public health leaders and politicians shouldn’t resort to stigma because it accepts grave long-term costs—forever alienating a segment of the population—for obscure short-term gains—getting some more people vaccinated. According to Heidi Larson, a University of London anthropologist and Director of the Vaccine Confidence Project, the pandemic is a once-in-a-lifetime opportunity to give people distrustful of scientific and governmental institutions a new memory. (Only 39% of people who are unvaccinated trust doctors and hospitals a lot, compared to 71% of the vaccinated.) But, if this moment to reach the unvaccinated is squandered in stigmatization, suppression, and betrayal, those negative memories will forever stick with unvaccinated Americans and torpedo future public health outreach. It’s already affecting routine childhood vaccines for polio and measles. In Tennessee, the state Department of Health stopped all pediatric vaccine outreach after COVID vaccine backlash.
Now imagine a future pandemic worse than COVID-19 where we’ve lost 25% of the population from the start. Reflexively resorting to stigma may be an awfully high price to pay.
“Othering people as unvaccinated sounds like a late 19th-century statement that the problem in urban areas is unwashed, underclass immigrants,” said Brandt. “You’re not going to ever change their behavior that way.” Sure, smoking rates decreased, but stigma wasn’t the active agent, he emphasized. People make decisions based on what really matters. Take a father with two young daughters who quits smoking. “There are too many good reasons beyond shame,” said Brandt.
Speaking to Rabbi Green and Schmidt was eye-opening, not because they were so stuck in hyperbole but because they were sympathetic, charismatic, and articulate. In heartbreaking detail, Schmidt described being raised by a single mother, spending freezing nights huddled together on the couch. She emphasized her family’s long history of military service and the importance of “fighting for protecting constitutional and civil rights.” After caring for COVID-19 patients, Schmidt told me how she doused herself with bleach so that she didn’t kill her immunocompromised husband and leave her children fatherless.
In a similar way, Rabbi Green wore a bright smile across his face and cracked jokes throughout the interview (“I realized the libertarians were right all along!”) while citing Patrick Henry, John Dalberg-Acton, and Alexis De Tocqueville. He expressed genuine concern that my article wouldn’t be accepted anywhere if I was “too objective” and wished me luck in getting it published. And at the end of our interview, he extended an invitation to assist anyone in writing their own religious exemption, no matter their faith. “A lot of people have sincere religious beliefs; they just don’t know how to articulate them,” said Rabbi Green.
At times, I found them deeply troubling, and at others, I found them kind and really quite thoughtful. What was clear was that they truly believed in the conspiracies they peddled. It’s easy to dismiss them as crazy, but it felt more like they were caught in webs of misinformation than anything else. How can we reach Donna Schmidt? How can we reach Rabbi Green?
Stigma isn’t the answer.
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So, what is the answer?
Brian Hooker, professor of biology at a California institution he asked me not to name, thinks we need to better understand the unvaccinated. (He is also a Director of the Children’s Health Defense, an innocuous name for a vaccine misinformation group.) Hooker, whose rounded head and silver whiskers are reminiscent of a walrus wearing glasses, wouldn’t tell me if he was vaccinated (“you probably can guess my vaccination status”) but emphasized the importance of personal messages and frank conversations. “That to me is going to go much, much further than blaming the pandemic on the unvaccinated,” he said.
And I can’t help but agree. Only by taking the time to learn from people who are unvaccinated could I appreciate what really mattered to them—autonomy, safety, freedom of speech—and not dismiss their values out of hand. Having these honest one-on-one conversations allowed me to better understand their sincerely held fears and what each of them would need to get vaccinated. Schmidt needs unsuppressed data to be sure that being vaccinated is “the best thing for an individual and society.” Rabbi Green needs respect, not persecution, so the facts about vaccine efficacy can speak for themselves. Others I spoke to want the chance to rebuild trust in external authorities. There’s no doubt that some of these needs are more reasonable than others. But, by emphasizing stigma, politicians and public health leaders never take productive steps to determine what would get the final quarter of Americans vaccinated, what off-ramp could be built around their beliefs without invalidating their identities.
Learning more about what it means to be unvaccinated and providing the corresponding support might offer a window for concerted progress. For smoking, racial minorities, the poor, and other marginalized groups had the worst success quitting. Who is the most likely to quit? “Those with the best support,” Brandt said.
And who is the least likely to be vaccinated? According to the Kaiser Family Foundation, it’s not Republicans, young adults, nor White Evangelical Christians. It’s the disadvantaged, namely people without health insurance. Maybe the way to get people vaccinated is support, not stigma.
“People are, more than ever, on pins and needles. Everybody’s fragile right now. People are tired. And you can’t just flip a switch overnight,” Larson said. There’s no quick fix. Bill Gates calls himself an “impatient optimist,” but Larson thinks about it differently.
“Sometimes you can get things done quicker if you’re patient. And that’s the irony of it all.”
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To get the remaining 25% vaccinated, politicians and public health leaders should shift away from absolutist, mutually exclusive strategies and embrace the diversity of responses this crisis demands. Vaccine mandates have a role to play, as do nuanced one-on-one conversations, as do all sorts of public health measures that emphasize dignity and respect. But in whatever we choose to do, we must be vigilant about and actively avoid the potential for stigma.
It’s easy to feel pessimistic about our chances of success. After all, we’ve seemingly tried everything, and still more than 30 million American adults haven’t got a single shot. So, I asked Larson what message she would prioritize if she oversaw the vaccination effort.
“Hope, protection, and the future,” she said.
Bolivia labels their vaccines “dosis de esperanza,” meaning doses of hope, to reframe vaccination behind unity and promise. Similarly, a World Economic Forum report found that vaccine messaging that emphasizes protection triggers the most positive, engaging conversations. But, most importantly, public health leaders can emphasize the future of what’s to come if society bands together now. Airlines don’t talk about their cramped seats or the soggy cardboard they claim is food. They talk about the diamond beach, shimmering in a warm golden glow.
Larson said, “We need to get people focused on the destination.”
