Internationally, vaccines have become a foreign-policy tool. Some countries are receiving vaccines from China, Russia and the US through preferential commercial access, outright donations or strings-attached arrangements (“vaccine diplomacy”). These countries may struggle to convince their citizens that the vaccines they get are the best available and were obtained freely, instead of second-best options accepted under duress or in desperation. Complicating the political economy of vaccines further is the unfair global intellectual property regime that has led many people to distrust the products of “greedy” highly profitable pharmaceutical companies.
Fourth, confidence could be low because people perceive that governments or companies cut corners to develop, approve and manufacture Covid-19 vaccines so quickly. Public-health officials and the media may not have offered explanations for how science, economics and politics enabled such speed without compromising quality or safety. The are many logical reasons behind the success: Because Covid-19 affected rich countries (unlike other infectious diseases such as malaria or tuberculosis, which mainly affect poor countries), much more money and political will were channelled into its research. Also, there are more capable scientists than ever before, boosting the global capacity for knowledge exchange (including sharing of viral genetic material) and collaboration built on decades of extensive research into coronaviruses and mRNA vaccines. The basic science research into coronaviruses and vaccines already took place precisely in preparation for a pandemic such as Covid-19.
It was also much easier to enlist volunteers for vaccine testing. Pfizer, Moderna and Johnson & Johnson recruited a total of 117,000 subjects over six months for three separate global trials. Compare that with the three trials for the one Ebola vaccine that involved only 12,000 subjects from 2015 to 2017. Fierce competition among pharmaceutical companies delivered several safe and effective vaccines in a short time.
Finally, governments guaranteed purchases of Covid-19 vaccines through a tool called advanced market commitments, which gave the pharmaceutical companies the confidence to invest more money into research and manufacturing capacity. The speed should be regarded more as an indication of the robustness of a global collaborative scientific process and the presence of adequate incentives and political will.
There are other systemic reasons for vaccine hesitancy:
- Vaccines are victims of their own success. Because people do not see smallpox, polio and measles today, they forget that vaccines prevented all those diseases. Populations, therefore, are less cognizant of the value of vaccines because they are not as aware as before of the role they played in mitigating, indeed eliminating, the risk of death and long-term effects from certain diseases.
- People in countries that were successful in fighting Covid-19 (such as Thailand and Vietnam) or have highly trusted and accessible medical services (such as Japan and South Korea) may have become too confident in their healthcare systems, prompting them to decline getting vaccinated. Citizens spared the brunt of the pandemic may believe that their hospitals will save them if they ever get infected.
- Declining science-literacy levels may have led to a poor understanding of vaccines and the science behind them. Consider how the average PISA scores for science subjects in Organisation for Economic Co-operation and Development (OECD) countries declined between 2012-2018, regressing to 2006 levels. As a practical matter, people without scientific literacy may not understand the basic risk-benefit assessments of getting inoculated.
- The effects of vaccines are invisible, leaving people unable to appreciate their value. Vaccines prevent diseases, instead of dramatically reducing pain or killing cancers. If they succeed, while the number of infections may go down eventually, at first there may be no clear sign of their effectiveness. Some may interpret this as the failure of vaccines and therefore decline to get vaccinated.
Pragmatic, holistic and sustainable
Given this wide range of powerful tectonic forces that may drive vaccine hesitancy, governments must significantly enhance their efforts to bolster vaccine confidence. To do this, governments must deploy political will and skill alongside science and facts.
There are three overarching strategies to achieve confidence in vaccination programs. First, governments must adopt a suite of solutions as there is no single remedy to hesitancy. Second, governments must take an all-of-society approach because they do not possess all the required skills, capacity and trusting relationships to increase people’s willingness to get their shots. Third, these efforts must be continuous over the long term because vaccine confidence is a moving goalpost, with ever-changing circumstances and levels of trust. In short, vaccine confidence efforts must be pragmatic, holistic and sustainable.
Understanding the vaccine-confidence continuum is crucial for developing a full suite of solutions to hesitancy. Those actively demanding Covid-19 vaccines stand at one end, while those actively hostile to them are at the other. People can be divided into three groups along that spectrum, each requiring different approaches:
- Those who understand and accept vaccines – This group needs continual health education, encouragement and perhaps policies to allow them to become “vaccine ambassadors”.
- Those who are genuinely hesitant and want more information – This group needs more non-judgmental and targeted health education to address their specific questions and doubts.
- Those who are anti-vaccine, anti-science, or impossible to convince – Although a minority, this group is highly vocal. The Centre for Countering Digital Hate recently calculated that 65 percent of anti-vaccine content on Facebook and Twitter originates from only 12 people. If education and persuasion fail, countries may need to impose penalties (such as social media bans, fines or prison sentences) on certain types of anti-vaxxer activities as they may be direct threats to public health.
This neat landscape is complicated by numerous factors contributing to vaccine hesitancy that vary across countries, age groups, education and income levels, and political and religious beliefs. Education to strengthen vaccine confidence must, therefore, be nuanced and targeted to specific types of doubters, while focusing on four main areas:
- the science behind vaccines and how they work,
- the process of selecting, approving and procuring the vaccines,
- vaccine safety and efficacy compared to the risks of Covid-19, and
- the coincidence of adverse events with “background rates of diseases” (for example, a heart attack after immunization may be entirely due to natural causes and not to a vaccine).
When delivering vaccine education, governments must operate on several organizing principles. First, information must be extremely easy to understand and delivered repeatedly. Second, the messenger is as important as the message, which is why trusted figures such as teachers or religious leaders are helpful. Three, governments must treat their citizens as adults with dignity and agency, instead of being judgmental or paternalistic.
But education alone is not enough, no matter how nuanced, targeted or sustainable. Governments must deploy solutions to the other issues described earlier, including the following any or all of these strategies:
- ensuring the transparency of all vaccine data and partnering with communications experts to deliver press statements and describe clinical trial results in layman’s terms,
- establishing media standards for accurate vaccine reporting (such as the guidelines set by the International Federation of Journalists), with reasonable penalties for non-compliance,
- dealing with adverse events in thoughtful and compassionate ways, including the management of vaccine liability and compensation schemes that are necessary but could send the wrong signals,
- enlisting trusted or admired public figures (including famous athletes, popular entertainers, religious leaders and social-media influencers) as role models, and
- appropriately using behavioral psychology and economics to persuade citizens to get vaccinated.