Given the devastation wrought by the COVID-19 pandemic, many are asking why people would be hesitant to be vaccinated against it. That’s the question that bounces around the skulls of countless physicians, public health experts, journalists, politicians, and others. But before trying to answer the question, it might be reasonable to ask why people do, or fail to do, other things that negatively affect their health.

Why does a patient with diabetes come to the emergency department with a blood sugar over 500, having failed to take insulin for 2 weeks? Why does the patient with lung disease continue to smoke two packs per day despite struggling to breathe around the clock? What prompts the elderly patient with abdominal pain to sign out and go home to be with her dog? And for heaven’s sake, why do young people take that first hit of heroin or methamphetamine?

The easy, heartless answer is to say that these people are just stupid. Stupid people don’t take their insulin, and they keep smoking. Ignorant, uneducated people refuse medical care. Unwise, unscientific young people start using drugs.

And yet, having practiced medicine for 28 years, I can say that none of the above patients would be more likely to follow my suggestions if I told them their decisions were “stupid.”

Human decisions are far more complex, nuanced, and personal than most of us realize. So, revisiting the above scenarios, it’s possible that the patient with diabetes couldn’t afford insulin. It could be that the smoker has few joys in life, and nicotine is one of them. As so often the case, the owner of the dog has no family or friends, and her dog is her closest companion. Finally, the person using drugs may be anesthetizing a life of terrible abuse, or may come from a home where drugs were always in the background. Are their decisions concerning? They certainly are. But they are comprehensible. We needn’t agree with a choice to understand it.

Still, in light of a deadly pandemic, why would people eschew a vaccination that might be life-saving for them or those around them? As before, the easy answer is: “because they are simply ignorant or don’t care if they hurt other people.” This argument is inadequate and unproductive. Let me suggest some alternative reasons why people might not want the vaccine.

Even as “follow the science” is a common mantra, science is often quite hard to understand. Few people understand the incredible complexities of virology, immunology, or epidemiology. Despite my own education, the intricacies of human biology and medical science still can seem a bit much to me too.

An understanding of science is not innate. Furthermore, reading and posting news clips about science with which one simply agrees is not the same as “following the science.” Many people with 4-year college degrees have only a passing grasp of science at best. Likewise, high school science classes are often relatively basic. As such, our general population-wide comprehension of science makes it very difficult to explain the research that might alleviate anxieties among the unvaccinated. Any practicing physician knows how difficult this is when trying to explain a disease process, a procedure, or the results of imaging or labs to a patient.

Another commonly cited reason for vaccine hesitation is that the COVID-19 vaccine was developed and launched much more quickly than typical vaccines and most pharmaceuticals. While those who express this are often viewed with some scorn, the fact is that for years we have been told by academics in medicine that we should view pharmaceutical companies with suspicion, and that they are often dishonest in their research. It may be that some of the vaccine-hesitant are only doing what they have been told to do … until now.

Those in rural America, particularly those in the throes of the ongoing opioid crisis, might have more personal reasons to distrust Big Pharma. After all, OxyContin was sold to them as a less addictive way to manage chronic pain. And yet, the death and devastation left in the wake of the opioid crisis has been truly apocalyptic.

Many lower-income individuals are distrustful of government in general, and not without cause. Poor citizens in the U.S. (and around the world) suffered terribly during the lockdowns advocated by public health professionals and government. Unable to work from home, they lost jobs, businesses, and homes as their children suffered from compromised educations, depression, and anxiety. Rates of overdose and interpersonal violence have risen significantly from the agony of the lockdowns and endless restrictions.

It was easy for those with money, or who could work from home, to tell others to stay home, order food, and watch Netflix. Those without money, both urban and rural, remain unimpressed by the sort of pseudo-scientific guidance, wrapped in politics, that nearly wrecked them. As such, their concerns about vaccine guidance might seem a little more reasonable, feeling distrustful as they certainly have reason to be.

Vaccine hesitation is certainly amplified by social media, which constantly churns out half-truths and untruths, readily shared with the click of a button. The classic example is that the vaccine implants some sort of chip in the body that allows humans to be tracked. False information abounds.

On the other hand, ideas initially treated as crazed rants turn out to have some value. For instance, there is now growing support for the idea that COVID-19 originated in a lab. The switch in this viewpoint, as formerly recalcitrant experts have hesitantly come to embrace a once reviled viewpoint, is also a source of confusion and distrust for the masses.

While problematic, no one should be surprised by the effect of social media on this debate, or on the way it has become increasingly toxic. In fact, social media is used by movements and advocates of every stripe, and not always in an honest way.

It can be very hard to know whom to trust; even more so as legacy media and Big Tech increasingly seem to apply censorship that is sharply partisan in their treatment of the pandemic. In addition, the algorithms of social media intentionally drive anxiety and division in an already divided populace in pursuit of clicks and advertising dollars.

In summary, it’s not all that surprising that many people still have not gotten the COVID-19 vaccine. After treating COVID-19 patients for many months, I finally got the vaccine this past winter. I am a rural, Southern, evangelical Christian, and I have actively encouraged patients, friends, and family to be vaccinated. Unlike the general narrative, I have been met with very little pushback on the idea of vaccination. Obviously, that is anecdotal. But it is relevant.

Along with many physicians, I believe that the science of the vaccine is good and the benefit is great. While we are early in the process, and should be attentive to (and honest about) potential problems, I believe that the COVID-19 vaccination effort was one of the great scientific and governmental triumphs of the last century.

However, I work with real human beings and with their very real doubts and fears. I urge everyone to try and understand the vaccine hesitant and talk to them. Treat them as potential allies rather than enemies. Try to learn from them and apply that information to future situations. But do not, under any circumstance, treat them as simpletons or dismiss their concerns out of hand.

We change the minds of our patients, and our loved ones, with compassion and kindness. We only alienate them with disdain. And this is nowhere more true than in the issue of COVID-19 vaccine hesitation.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of the Practice Test and Life in Emergistan. This article originally appeared in MedPage Today.

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