America’s health care workers have lived through unspeakable trauma over the last year, putting their lives and those of their families at great risk as they fight a novel viral outbreak. Covid-19 has claimed more than 450,000 American lives, including almost 3,000 health care personnel.

The development of effective vaccines was always going to be a key turning point in controlling the pandemic and bringing back something resembling normalcy. That has been most true for front-line health care workers, who are among those most vulnerable due to their proximity to infected patients.

A vaccinated health care workforce can continue manning the front lines in the battle against the pandemic, and be ambassadors for a broader vaccination effort.

But the campaign to immunise health care professionals has hit a snag as a notable number of front-line workers decline the vaccine. According to the Centers for Disease Control and Prevention, just 38% of nursing home workers participated in the federally run vaccination campaign for residents and employees of the facilities during its first month. Although those numbers likely have risen in the weeks since, and that tally doesn’t include workers who received a vaccine outside of their workplaces, they illustrate the problem.

A Morning Consult survey conducted in the first week of January found that 23% of health care workers said they would never accept the vaccine. Among unvaccinated employees, 38% said they feared long-term side effects. Health care workers appear somewhat more sceptical compared to the general public. A Henry J. Kaiser Family Foundation survey last month found that 13% of Americans said they will never get vaccinated against Covid-19.

But surveys are also showing consistently increasing acceptance of the vaccines since they actually became available, and more than 27 million Americans have gotten at least one dose, so hesitancy may be fading.

Given how much they stand to gain from a safe vaccine, the fact that many health care workers are reluctant may seem surprising to laypeople. Many assume the reticence is an outgrowth of the “anti-vax” movement or a sign that the vaccines aren’t safe. But the reasons health care workers have declined are complicated and disparate.

Christina Allen, a nurse practitioner from Hyattsville, Maryland, was initially hesitant to get a vaccine because of unanswered questions about the vaccines and the inequities in their distribution, especially in Black and brown communities. Still, she got her first dose of the Pfizer/BioNTech vaccine on Jan. 13.

“I knew I would get the vaccine eventually. I never had a distrust in the science behind vaccinations and I understand how impactful vaccinations have been in advancing public health and eradicating some of the most deadly viruses and diseases in history,” Allen said. “Because this is a new and novel virus, there’s so much we still don’t know, and so I think that that also created a slight hesitancy for me.”

Allen feels good about her choice to get the shot, though: “I want to protect myself, and not only myself, but my community and my patients as much as possible. And I feel like I did the right thing ― it wasn’t an easy decision ― because I feel like I’ve given myself and others that much more protection.”

Experts and representatives of health care workers and health care employers are quick to emphasize that these hesitant workers aren’t fools, conspiracy theorists or anti-vaxxers. In many ways, their worries grew from the peculiar circumstances of the coronavirus pandemic.

Some health care workers have developed deep mistrust of their employers and government leaders during the pandemic, after months of fighting for basic needs like masks and other personal protective equipment. They have watched the government bungle so many aspects of the Covid-19 response that when those same authority figures tell them to get vaccinated first, essentially to be guinea pigs for new vaccines, their messages aren’t always well-received.

“Folks are caring through a really challenging crisis and are sort of at a breaking point, and we need to understand that and invest in this workforce,” Matthew Yarnell, president of Harrisburg-based Service Employees International Union Healthcare Pennsylvania, said during a conference last month sponsored by the Kaiser Family Foundation. “We feel like there are some very critical steps that need to happen to build trust for a workforce that’s feeling very distrustful of their government, of their employers.”

Some health care employers have used financial incentives to encourage workers to participate in the vaccination campaign. Others have mandated vaccinations, but such dictates from their bosses could deepen workers’ mistrust, not improve matters, Yarnell said.

The speed with which the vaccines have been developed and approved also gives some health care workers pause. Even the name of then-President Donald Trump’s vaccine development program, Operation Warp Speed, was a turnoff. (President Joe Biden has scrapped that name.)

“A trend we saw in our survey was that people were really concerned about the fast-track development timeline of the vaccine, how quickly it was going, Operation Warp Speed, all of these kinds of subliminal messages about, ‘This is fast. This was put together quickly,’” said Adva Gadoth, an epidemiologist at the University of California, Los Angeles who is conducting an ongoing study of UCLA hospital employees about their experiences during the pandemic. Though these concerns are unfounded, she said, health care workers aren’t getting the message clearly enough.

“Something public health needs to do a better job of is communicating that to the public and reassuring them that all these checkpoints are in place,” Gadoth said.

There are concerns about side effects, too, especially among women who are or may become pregnant, because the science is unclear about how the vaccines may affect pregnancies.

“They’re concerned that because they’re the first ones to go, something might pop up that wasn’t discovered before, and that they’re going to be the ones saddled with it,” Gadoth said.

In addition, health care professionals are susceptible to rampant false information about the vaccines just like anyone else, especially those workers who haven’t had the kind of advanced medical and scientific training physicians and senior nurses have. The health care workforce comprises a large and varied number of jobs, including home health and nursing home aides, hospital orderlies, cleaning staff, security personnel and more, and many of those jobs require no more education than a high school diploma.

Vaccine hesitancy “does not mean that our staff are dumb or aren’t making good decisions or anything like that,” said Mark Parkinson, CEO of the American Health Care Association, a Washington, DC-based industry group for nursing home operators.

“It’s just that there’s been a lot of misinformation out there. There are rampant rumours spreading on social media that the vaccine can cause fertility problems, which has caused concerns among many of the young women who work in our facilities,” Parkinson said during the Kaiser Family Foundation event.

There are special concerns for Black and brown health care workers, who are disproportionately represented in health care sectors like home health care and nursing homes and who have good reasons to view the medical establishment and the government warily. Members of these communities can point to evidence in the form of historical crimes against Black people, like the infamous, decadeslong Tuskegee experiments on Black men with syphilis, along with chronic disparities in access to medical care and poorer health outcomes compared to white people.

“If you don’t believe that’s real and has a real effect, this experience has shown that that is still out there,” Parkinson said.

Many factors guided Allen’s decision to get vaccinated, including her own health, her responsibility to her patients and her responsibility to her community at large. “I wanted to give myself time to reflect and just have more conversations with my colleagues and my peers,” she said.

Making her decision also meant grappling with the fact that the pandemic has hit Black and brown communities the hardest, and they are getting vaccinated at lower rates than other segments of society. Especially with limited supplies of vaccines, Allen worried she was stepping ahead of someone who might need the protection more than she does.

“As a woman of colour, especially a Black woman, when you make certain decisions about your health and your health care, there are certain things that you take into consideration that maybe others don’t,” she said.