In last week’s Healthiest Goldfish, I discussed how our individualist bias can stop us from seeing the full picture of what matters most for health. Today, I would like to talk a bit about how our positional bias can do the same. I do so as part of a series of columns leading up to the November 1 release of my new book, The Contagion Next Time, which aims to help us look past our biases to see the true causes of health during the pandemic, so we can prevent the next one.  

Positional bias is, broadly speaking, when our vision of health is blinkered by our socioeconomic status—when we cannot see past the confines of our own immediate circumstances, to recognize the true drivers of health. I recently wrote about a form of positional bias when I touched on the suburban impulses that helped shape attitudes towards COVID policies, as stricter lockdowns were more widely embraced by the populations most able to easily navigate them.

For today, I will use a different example, that of vaccine hesitancy and the challenge of understanding it. As I write this, the US is currently undergoing the delta wave of COVID-19. What is distinct about this wave is that nearly all COVID deaths are among the unvaccinated. While the vaccinated can still be infected—although this is rare—we have seen a dramatic decoupling of infection rates from death rates. This speaks to the effectiveness of vaccines and the danger posed by vaccine refusal. On April 19, 2021, the date by which President Biden said all adult Americans would be eligible for the COVID-19 vaccine, there were 567,314 total COVID deaths in the US. On October 15, there were 742,008 total deaths. While the 174,694 deaths which occurred between these two dates cannot be laid entirely at the feet of vaccine hesitancy, it is undeniable that mistrust of vaccines informed the conditions that made these deaths likelier.

Cleary, vaccine hesitancy is a problem, one which has done much to prolong the pandemic. It speaks to how creating a healthier world is not just about developing leading-edge treatment, but also about engaging with the context in which our efforts to treat disease unfold. The emergence of vaccines suggested hope for a quick end to the pandemic. This was in, many ways, an example of positional bias at work, as our common collective tendency to view health solely through the lens of medicine helped distort the reality of the pandemic’s likely trajectory. We in public health know that the development of effective treatment is often just a first step toward addressing a disease. The other steps involve addressing the complex circumstances surrounding the emergence of the disease and getting treatment to the populations in need. This can be a complicated, drawn-out process. It is, for example, the case that we currently possess highly effective drugs for treating and preventing HIV. Yet the disease remains a challenge around the world largely due to the socioeconomic contexts in which it still has a foothold, and the challenge these contexts pose to efforts to treat the disease. With COVID, we are seeing a similar emergence of context as a complicating factor in delivering treatment, a context which intersects with vaccine hesitancy.

Now, many of us in public health have difficulty understanding vaccine hesitancy. Because our strong pro-vaccine attitudes tend to be informed by an understanding of data, we perhaps ascribe hesitancy to a lack of information on the part of skeptical populations. Or maybe we think it is simple willfulness, informed by the politicization of the vaccine and of COVID in general. What may be harder for us to understand, much less accept, is the possibility that these attitudes may be informed by anything like a mistrust of authority which is based on some degree of truth. Our positional bias, which causes us to see this issue through the lens of our particular place in life, can make a more nuanced view of vaccine hesitancy elusive indeed. 

If we can look beyond this bias, we can see how vaccine hesitancy is often rooted in distrust of institutions more broadly, a distrust which long predated the pandemic, and which may be, in some respects, justified. It is not difficult to see how this perspective evolved over the years, nor why it is attractive to many. In the last two decades alone, there have been many examples of institutional failureincompetence, and outright deceit. From falsehoods told by political actors to build the case for war, to the failure of many of society’s elites to fully grapple with the central socioeconomic shifts of our time, to the selective use of misinformation by some in positions of political or institutional power, there is no shortage of reasons to be suspicious of those who seem to speak from on high.

Such suspicion can indeed be healthy in small doses, when it is tempered with the understanding that occasional institutional failure does not mean that institutions do not also do vital, effective work supporting the common good. When healthy skepticism of institutions grows into a wholesale dismissal of these entities, that is a key blind spot, one that can undermine health. We have seen this during COVID-19, as distrust of institutions has informed vaccine hesitancy, helping to prolong the pandemic and cause much preventable sickness and death.

Understanding this mistrust of institutions requires us to first check our positional bias. We in public health tend to be deeply invested in institutions, and many of us work in the very academic and governmental spaces that are so widely distrusted among the populations we serve. Yet if we are to serve them effectively, it is necessary that we try to understand their thinking about issues that are core to health.

How can we be mindful of positional bias, so that we can avoid the problems it can cause? We can start by assuming, always, that we have this bias, taking for granted our propensity to see issues only partially, our perspectives clouded by our distinct socioeconomic perspective. This means being wary of conclusions that are too neat, too suggestive of a world without the shades of grey we know characterize so much of life. Next, we can seek out the perspectives of those with whom we disagree, those who may occupy a place in society entirely different than our own. In the spirit of Hegelian dialectic, we can look for the truth in the generative conflict of opposing ideas. This requires us to be on the watch for when we are vulnerable to echo chambers, and to remain in pursuit of the opposing views which can help us sharpen our thinking (See prior thoughts on the importance of viewpoint diversity). Finally, we may do well to cultivate the capacity to change our minds when data or the force of opposing arguments seem to warrant it. This does not always mean completely reversing ourselves on major issues; more often, it can mean simply modifying our position, adjusting it to be more in line with data. In taking these steps, we can guard against blind spots informed by positional bias, towards the goal of advancing a conversation which is more responsive to reality, more engaged with different perspectives, and less prone to the errors that can be costly for health.


  • Sandro Galea is Dean and Robert A. Knox Professor at the Boston University School of Public Health. He has been named an "epidemiology innovator" by Time and one of the "World's Most Influential Scientific Minds" by Thomson Reuters. A native of Malta, he has served as a field physician for Doctors Without Borders and held academic positions at Columbia University, University of Michigan, and the New York Academy of Medicine. His new book, The Contagion Next Time, was published in fall 2021, and is available to order here:

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