In spring 2021, in a nation battered by a devastating pandemic, the prognosis was suddenly upbeat: Science had delivered a miracle. Not just one, but several effective vaccines against the novel coronavirus SARS-CoV-2 were produced, tested and approved in record time. Vaccinations, history has shown, save lives. They can make lockdowns, masks, physical distancing and other pandemic response measures unnecessary. Within days of availability, Americans started lining up to get vaccinated and move forward. 

A year later, this optimism has vanished. Millions of Americans got vaccinated and boosted, but too many did not. The United States, a nation that had access to the most vaccine doses the earliest, quickly fell behind other Western democracies in vaccination rates. Meanwhile, the virus mutated into more contagious forms, leading to new surges of cases, hospitalizations and deaths.  

In year one of the Covid-19 pandemic, thousands of Americans died every day from a novel disease that scientists knew little about and healthcare workers had few tools to treat or prevent. 

In year two of the pandemic, thousands of Americans still died every day — from what by then had become largely preventable complications from Covid-19 — in one of the richest nations in the world, despite unprecedented federal, state, city and community efforts to inoculate people against it. 

At least 318,000 Covid-19 deaths could have been prevented between January 1, 2021 and April 30, 2022, according to modeling research by our team at Brown University in collaboration with Microsoft AI for Health and collaborators at the Brigham & Women’s Hospital and the Harvard T.H. Chan School of Public Health. The number of vaccine-preventable deaths keeps climbing, because at this point in the pandemic, severe illness and death from the disease are predominantly affecting unvaccinated and undervaccinated Americans. 

It is a tragedy beyond what many thought possible in the United States (U.S.), a nation that scores highly on pandemic preparedness and global security indexes. 

The U.S. vaccination rollout is at once a remarkable public health success and a striking public health failure. It reveals challenges far beyond vaccinations, and urges investigation into why current models for delivering and building confidence in life-saving public health measures are failing to reach and protect all Americans equally.  

In his March 2022 State of the Union address, President Joe Biden vowed, “We will never give up on vaccinating more Americans.” The reality, however, is that this is an uphill battle: Daily vaccinations have stalled, and with each new booster, fewer people are eager to get shots. While incentives offered by community clinics and mandates once made a difference, the number of people seeking vaccines, whether it is their first or fourth, has sharply declined. Health workers, community workers and volunteers tasked with vaccinating the remaining 58 million Americans over 5 years old who haven’t received a single shot, and millions more who are not up to date on their Covid-19 vaccines, are overworked, underappreciated and underfunded. With the depletion of federal funding and congressional reluctance to renew funding, vaccination efforts may be even worse off during the next surge.

At this critical junction, the nation is torn between those who want to focus on individual risks and choices, and those highlighting systemic barriers and asking for systemic change. Within a year, vaccinations have become about ideologies, politics, inequalities and misinformation – and about who advances and who is left behind.

In our work at the Brown University School of Public Health, we focus on how complex, intersecting factors —  behavioral and social drivers, information needs and structural factors —  come together to shape people’s decision making about vaccinations. Alongside other researchers in this space, we find that unvaccinated Americans are not a monolith, but instead diverse individuals with unique histories, identities and lived experiences — and more remain open to vaccination than public discourse may suggest, even among those who say they will not get the shot.  

Taking a closer look at unvaccinated Americans, we find concerns about Covid-19 vaccines among people of all races and ethnicities, faith groups, education and income levels, political leanings and affinity groups — but not the same concerns. We find people who have lost trust in government and public health authorities, people who no longer have any trusted messengers or never had them, and people for whom Covid-19 is just one of many health threats and by far not the worst. Some have more questions, some ask for more time for this important decision, some feel alienated, some are being misled, some don’t believe that Covid-19 is real.  

Meeting the unvaccinated where they are reveals how response efforts have overfocused on an inadequate “vaccine hesitancy” framework that places the onus of motivation and of accessing the vaccine on the individual. Instead, we need to  understand and invest significantly in vaccine demand. A vaccine demand framework inherently acknowledges and addresses institutional and structural failures and responsibilities alongside individual-level drivers of vaccination. 

The struggle to generate vaccine demand is not unique to the U.S., and will increasingly challenge vaccine efforts around the world as countries try to reach beyond those who are eager to be vaccinated. Recently, John Nkengasong, director of the Africa Centres for Disease Control and Prevention, ordered vaccine donations for the continent paused because challenges with logistics and vaccine confidence are preventing people from accessing Covid-19 vaccines before they expire.  At the same time, political will to invest in global vaccination is in decline. 

In a world with dramatically increased capacities to develop, manufacture and distribute vaccines, pandemic resilience will increasingly depend on the ability of governments, experts, institutions and community leaders to build and maintain vaccine demand. 

Working to improve health equity, meet the massive information needs of diverse communities, and build trust in the process and in government institutions are key to strategies that will empower people to embrace vaccines and other public health measures as the life-saving tools they can be.