The global effort to develop and distribute COVID-19 vaccines has progressed despite myriad challenges. Yet the final step—shots in arms—meets resistance among some that can’t easily be overcome by science and supply chains.

Vaccine hesitancy—a reluctance or refusal to be immunized—could represent nearly 30% of Americans and even more in Europe. That reluctance is due to longstanding mistrust in technical, health and government institutions, and challenges efforts to achieve herd immunity and ultimately return some semblance of normalcy, according to University of Michigan researchers.

“Contrary to popular belief, not all vaccine hesitancy is the same. Nor is it simply the result of ignorance or antipathy towards science,” the researchers write in the study, “In Communities We Trust: Institutional Failures and Sustained Solutions for Vaccine Hesitancy.”

“Communities question whether their governments, and scientific, technological and medical institutions, really represent their needs and priorities. Long legacies of mistreatment of marginalized communities further fuels this mistrust.”

The study by the Ford School of Public Policy’s Science, Technology, and Public Policy Program found two main causes of public mistrust: limitations and failures in scientific and technical institutions, and institutionalized mistreatment of marginalized communities.

The first cause includes bureaucratic cultures that minimize problems or exclude community knowledge or expertise, such as what happened during the Flint water crisis. The second encompasses structural racism and has taken many forms, such as preventing patients from obtaining access to adequate health care, subjecting people to experiments without proper consent or pay, or developing treatments or technologies without keeping in mind the needs of historically disadvantaged communities.

Government failures and misdeeds further foster alienation and distrust, which make those affected more likely to believe misinformation. That’s only exacerbated by media fragmentation and ideological silos of social media.

Many public health officials link infectious disease outbreaks to falling rates of vaccinations for childhood diseases, and the study cites the example of a widely debunked study purporting to forge a connection between the measles, mumps and rubella vaccine and autism in young children. Similarly false information about COVID is spreading around the globe.

In short, they say, people might be hesitant to take a COVID vaccine because they ” feel that they have been controlled, and that their needs and perspectives have been ignored for decades.”

To be sure, researchers add, there is plenty of present-day fuel to the fire: Black people die of COVID at a higher rate than whites but disparities in testing access make it impossible to know exactly how many. There also has been a disparity in vaccine access, with more available vaccine appointments in whiter, wealthier neighborhoods and scheduling systems that require access to the internet and favor those with cars and flexible schedules. More broadly, wealthy countries have hoarded vaccines and won’t share until they have vaccinated their entire population, the researchers said.

“Given these institutional failures at all levels, we might be surprised that rates of COVID-19 vaccine hesitancy are not even higher,” the researchers write.

So what can be done?

For starters, researchers say, scientific and government institutions must acknowledge their own failures of communication, regulation and oversight. The study offers several recommendations, including interventions focused on building community trust, increasing research and educational funding, and improving accountability and oversight within institutions. And they offer model examples of how other domains have implemented such ideas.

All the while, these institutions should encourage and facilitate honest communication about scientific limitations and uncertainties. They should commit to being transparent about the risks of the vaccine and acknowledge what they don’t know. Contrary to conventional wisdom this actually increases experts’ credibility, the researchers say.

“At its root, vaccine hesitancy is a problem of public mistrust in institutions. For decades, our public health, medical, and science and technology policy institutions have ignored and even mistreated our most marginalized communities, and these communities are now understandably skeptical of this intense focus on their vaccination,” said Shobita Parthasarathy, director of the Science, Technology, and Public Policy Program.

“In order to address these feelings of mistrust and alienation, in this pandemic and for future public health and policy initiatives, these institutions need to take the needs and priorities of these communities seriously and make systemic change accordingly. This must be a long-term project.”

The study is part of STPP’s Technology Assessment Project, which seeks to anticipate the social, ethical and equity dimensions of emerging technologies and offer solutions by looking at similar historical cases.The vaccine hesitancy study, for example, looked at previous public health campaigns and science and technology policy crises to understand how institutional mistrust might appear in the case of COVID and how it might be resolved.

The research team also included STPP Program Manager Molly Kleinman and three graduate students.