A tale of two Covid Americas: can the US unite behind a pandemic strategy?

In Mississippi and Massachusetts, two pharmacists working in very different parts of America have seen a sharp drop in demand for Covid-19 vaccines in recent months. Their best guesses for why they’ve seen such slowdowns diverge considerably.

Saad Dinno, co-owner and pharmacist at four drugstores in the suburbs of Boston, wagers that most people in his community are up to date on their vaccinations. As he speaks from Acton Pharmacy, in the Massachusetts town of the same name, his bet is a fairly safe one – 95% of the people in this county have had at least one shot, according to the Centers for Disease Control and Prevention (CDC).

Bob Lomenick, the owner of G&M Pharmacy in the northern Mississippi college town of Oxford, where just 60% of people in the county have received a single shot, offers a different explanation.

“We still have lots of people, even today, who just refuse to get the vaccine,” said Lomenick. “I don’t get into controversial discussions with them, all the evidence proves they [vaccines] are effective. I got all of mine and my family got all of theirs.”

The Boston suburbs where Dinno practices are awash in blue Democratic voters, with few surrounding areas voting for Joe Biden in the 2020 presidential election by margins smaller than 50%. Meanwhile, precincts in Oxford split closely between Donald Trump and Biden, but voters in many surrounding districts broke for Trump by a margin of 74% or more, a detailed map of both precincts showed.

With US health authorities braced for another potential Covid-19 wave, likely to be fueled by the subvariant of Omicron known as BA.2, the country is still deeply divided over its approach to its pandemic future – even as restrictions have been relaxed across all states.

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Since scientists recorded the first case of the Sars-CoV-2 virus in the US just over two years ago, politicization has been a hallmark of the American pandemic experience.

Despite being worlds apart, the pharmacists both said they had to convince customers to take vaccines, but Lomenick said he encountered far more widespread resistance. Neither Dinno nor Lomenick wanted to talk politics, but the dividing lines are clear, and in Acton and Oxford, they mirror national trends.

Republicans are far behind Democrats counterparts in vaccine uptake. As of January, just 63% of Republicans have had at least one shot, compared to 91% of Democrats, according to a Kaiser Family Foundation (KFF) vaccine tracking poll.

“If you look at the patterns of under-vaccination, you can see how they track with the political environment,” said Joshua Sharfstein, vice-dean for public health practice and community engagement at Johns Hopkins University and the previous secretary of the Maryland department of health.

The division has often been pitched as one of science against politics, masks against liberty and mandates against freedom. But deeply held political beliefs are only part of the story.

The split is fed by America’s polarized news media. Republicans tend to trust Fox News above most other news outlets, and became more alienated from mainstream sources between 2014 and 2020, a Pew Research study found. That meant right- and left-leaning Americans have often received wildly different messages about Covid-19.

In turn, Fox News’ opinion-heavy coverage has left its audience with more misconceptions about Covid-19. A separate poll by KFF found people who cite Fox as their most trusted pandemic news source are three times more likely than an NPR listener to hold misconceptions about Covid-19.

States also diverged wildly in their handling of Covid-19. What the pandemic divide showed – in “real time”, according to one population health researcher – is the expanding role state governments’ play in their residents’ health, as well as the health effects of deprivation in a country where life expectancy is increasingly determined by where a person lives.

There are just a few things on which all parties agree. Primarily, everyone wants the pandemic to be over. In January, similar shares of Republicans, Democrats and independents said they were “frustrated”, “tired” and “angry” in a KFF poll. By February, the majorities of all three parties, notably including the strongest support from Democrats (69%), said they believe the worst of the Covid-19 pandemic is “behind us”.

And yet Covid-19 could become one more disease Americans in red states tolerate at disproportionately high rates.

Health disparities have plagued a large swath of the country for decades. Around 1980, life expectancy gains in the US began to slow in comparison with other wealthy nations. By the 1990s, life expectancy for people living in a large swath of southern states also started to diverge from western and north-east counterparts.

The populations facing the greatest risks from Covid-19 gradually shifted over the last two years, from cities along the eastern seaboard to a large swath of south-eastern states stretching from West Virginia to east Texas, according to the National Institute of Environmental Health Science Covid-19 pandemic vulnerability index.

The same vast region is well known to population health researchers has having among the nation’s high rates of chronic diseases, risky health behaviors, lack of healthcare access and poverty.

“Although the divergence in state health trajectories might reflect changes in demographic and socioeconomic characteristics, a more likely potential explanation is the growing polarization of public policies across states,” said a recent editorial in the Journal of the American Medical Association by Dr Steven Woolf, a population health scientist at Virginia Commonwealth University.

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States that resisted pandemic control measures, such as Florida and Georgia, experienced excess deaths up to four times during than pandemic higher than north-eastern states, such as New York and Massachusetts, which sought to vigorously control the spread of Covid-19 including through vaccines. Excess deaths are considered the most accurate way to count the true toll of the pandemic, because the figure includes direct and indirect deaths above a normally steady annual average.

Florida’s surgeon general recently declared the state would “recommend against” vaccinating healthy children. Experts in infectious disease and vaccine hesitancy described the announcement as “irresponsible”, “inappropriate” and “dangerous”, even as Florida’s governor, Ron DeSantis, continued to attack pandemic prevention measures as a cornerstone of anti-“woke” rhetoric.

And, as rhetoric and policy filters down to everyday people, it has left healthcare workers like Sandy Reding, who works in conservative (and socially vulnerable) Bakersfield, California, in a bind.

“Oftentimes, in the more conservative areas … folks don’t take [Covid] as seriously,” said Reding, who is also a member of National Nurses United. Like nearly all healthcare providers, her patients have presented her with, at times, unshakeable misconceptions about Covid-19. “It is very frustrating as a healthcare worker, because you feel very disrespected when you’re going to work every day.”

Anecdotal evidence and voting data appear to support Sharfstein’s conclusions, points he made with co-authors in a commentary piece in the Lancet last year.

“In this country, people get their news from different sources, and there’s a bubble that has a very erroneous and confused narrative about vaccines,” said Sharfstein. “That has driven a lot of misunderstanding about their value with tragic consequences.” Conservative, anti-vaccine sentiment is “probably the largest” factor driving down vaccination rates right now, he said.

In July 2021, right-leaning legislatures attacked the powers of public health authorities with the backing of big money donors. In August, Donald Trump was booed when he recommended vaccines at a rally of supporters. By October 2021, five conservative radio hosts died from Covid-19, often after deriding vaccines. By February 2022, one Republican commentator who promoted vaccines said he had received “death threats”.

Sharfstein and his co-authors argued public health outreach efforts needed to do more to “diversify” the people delivering vaccine information (including more conservatives), combat misinformation and engage behavioral scientists on the issue.

The solution to bringing the country together on its pandemic future is “reducing the forces driving people apart, and creating opportunities for people to see their similarities and common interests,” said Sharfstein.

However, in a country divided by media, politics, geography and inequality, this is a tall order. Researchers who focus on disparities in health, such as Dr Randy Wykoff, dean of East Tennessee State University College of Public health and recent co-editor of the book Appalachian Health, argues political ideology alone does not account for lower vaccination rates.

“It’s important, at least as a starting point, to acknowledge they may be related, but may not be causal,” said Wykoff. “The same factors that drive many rural Americans to be Republican voters oriented toward Donald Trump are the same factors that result in health disparities.”

Urban areas also suffer from health disparities, especially among Black and Latino communities, a majority of whom tend to vote Democratic. In those cases, many of the same forces detrimental to health are at play – poverty, environmental degradation, lack of access to healthcare and indeed vaccine hesitancy.

However, researchers view those patterns as distinct, and closely linked to abuses by the medical system – not state leadership or personal political ideology. About 80% Black Americans have received at least one vaccine dose, according to the Kaiser Family Foundation vaccine tracking poll, roughly in line with the national average.

Despite apparent barriers, some political scientists find hope vaccines will have a better chance of reaching people across ideological divides than visible tools to combat the pandemic, such as masks.

In 2021, when mask mandates were the focus of pandemic politics, assistant professor of public policy at the University of Chicago Austin Wright analyzed how partisanship affected mask-wearing.

He found partisanship accounted for more than one-third of the difference in mask utilization across Democratic and Republican counties.

“In data, the first thing you look at – without doing anything fancy to disentangle correlation and causation [is] – ‘Do you see a consistent pattern?’ The answer was yes.”

Wright and his co-authors added a huge number of variables to their analysis – race, measures of economic inequality and healthcare access, many of the same metrics studied by Wykoff and Sharfstein. These variables reduced, but did not eliminate, the the effect of partisanship.

However, this effect is notably weaker with vaccines, for two key reasons. First, partisanship is strongly correlated to race. Many Black and Latino Americans received vaccines later than white Americans. Second, and perhaps more fundamentally, Wright suspects vaccines are a less potent marker of political identity.

“You have quite a few people who end up getting the vaccine who do not wear masks,” said Wright.

To truly reach across the divide, Wright suspects the US has bigger fish to fry than simply adjusting who delivers public health messages.

“There are bigger structural problems for why there are these gaps,” said Wright, explaining how partisanship is tied up in the same issues of inequality that make it difficult to disentangle whether conservative ideology causes or aggravates low vaccination rates. “Frankly, messaging is not going to bridge those gaps.”