Since the COVID-19 pandemic has upended our lives, there is eager anticipation for a vaccine that will allow us to get back to “normal.” But it is important to recall that many people still harbor doubts about vaccines. Just last year, the World Health Organization listed “vaccine hesitancy” — the reluctance or outright refusal to use effective vaccines despite their availability — among the major threats to global health in 2019.

The pandemic has already changed some minds. Many who were previously opposed to vaccinations have softened their stance. However, misinformation from anti-vax groups continues to be far-reaching and influential. Why are anti-vax claims influential despite the immediate threat of the pandemic? What, if anything, can be done to lower the number of people hesitant to use effective vaccines?

A brief historical background: vaccines have played a major role in radically reducing the mortality rates of polio, rabies, typhoid, and plague, among many others. For these reasons, the Centers for Disease Control and Prevention (CDC) credit vaccinations as being among the great public health initiatives of the twentieth century.

If a sufficient rate of immunization is reached and maintained — about 95 percent of the population, for certain diseases — vaccines bring about herd immunity. This limits the spread of infectious diseases, ensuring the protection of vaccinated persons and those who do not develop immunity after vaccination or remain vulnerable due to underlying medical conditions.

Discussions before the pandemic focused on an increasing number of parents being hesitant to vaccinate their children. Reduced immunization rates compromised herd immunity, in some cases leading to needless deaths. For example, in 2018 an outbreak of measles resulted in 140,000 deaths. The number of measles cases increased three-fold the following year. The varying character of vaccine acceptance is discussed in a graph created by Robert Chen, previously head of vaccine safety at the CDC, and Beth Hibbs, from the National Immunization program. When a terrifying disease becomes widespread, like polio in the 1950s in the United States, a vaccine represents an immediate solution to stopping its spread. When followed by a successful mass immunization program, the prevalence of the disease is drastically reduced.

But success can breed complacency. When an infectious disease is no longer perceived to be an ominous threat, the urgency motivating vaccination dissipates. Public attention can then turn to other concerns, real or perceived, such as side effects from vaccination. If public fears of a specific vaccine become widespread, a disease like the measles may reappear, with lethal results. And so the cycle begins again, according to Chen and Hibbs.

Paul Offit, the co-inventor of the rotavirus vaccine, claims that the cyclical character of vaccine acceptance represents “the natural evolution of a vaccination program.” The urgency surrounding a vaccine declines over time. Herd immunity is taken for granted. And this becomes fertile ground for doubts about the safety of immunizations to spread, in which case some bio-medical experts argue that vaccines can become a “victim of their own success.”

The cyclical model explains how the urgency to vaccinate has returned with the threat of the pandemic, and why some may have softened their opposition to vaccines more generally.

But it does not explain why sections of the public remain uncomfortable with a COVID-19 vaccine even if it were affordable and available, or how in some cases the pandemic has managed to bolster the opposition to vaccines.

The cyclical model uses “knowledge gaps” or “trust deficits” to explain the motives of those who remain vehemently opposed to vaccines in the USA, Australia, Germany, and Canada, among many other countries. We have also seen an influx of dangerous conspiracy theories: for example, the idea that Bill Gates engineered the coronavirus or that the COVID-19 pandemic is a mass conspiracy aimed at promoting vaccines.

Some anti-vax agitation has focused on profit motives pushing for the faster development of a vaccine. In some countries, like Slovenia, efforts are underway to force the parliament to discuss ending mandatory vaccinations, even in the case of COVID-19. Similarly, Polish president Andrzej Duda tapped into anti-vax sentiment against mandatory vaccinations to win a tightly contested election campaign.

But the lack of trust in scientific expertise does not rest on the public’s shortcomings alone. It also feeds off research controversies (such as the “Tuskegee syphilis experiment”) that continue to linger in the memory of certain communities, and the increased role of commercial interests in bio-medical research.

Moreover, a lack of trust in science does not imply a trust deficit in society as a whole. This overlooks the fact that people continue to trust, but in a different way. We see this evidenced by the increasing interest in alternative and complementary medicine alongside non-scientifically based nutritional regimes couched in “holistic” notions of well-being. Vaccine hesitancy needs to be situated within this broader horizon of distrust between bio-medical expertise and sections of the public.

In a study published in 2008, anthropologists Melissa Leach and James Fairhead argued that anxieties underlying vaccine hesitancy are better understood as demands or expectations that are not being adequately met. In the case of a COVID-19 vaccine, this means that public concerns should be understood as misgivings calling for an appropriate response. It is reasonable to worry that the safety of a COVID-19 vaccine might be compromised by the fast pace of vaccine development, just as it is not irrational to suspect that big pharmaceutical companies stand to profit from large-scale immunization programs. Mandatory rules of any kind inevitably place limits on the freedom of individuals to choose how to live. These concerns are not strictly bio-medical and cannot be adequately met by public health outreach that limit themselves to scientific evidence demonstrating the effectiveness of a vaccine.

At the same time, devastating effects of COVID-19 have not been shared equally. Poor people living in tight quarters and older people in nursing homes die at far higher rates than other segments of the population. Poorly paid “essential” workers face a higher risk of getting sick. For many people, the pandemic isn’t simply an infectious disease, it threatens their ability to earn a living, it’s a reminder of the precariousness of their social status, and a source of profound anxiety, potentially leading to depression and drug abuse.

When governments privilege expert concerns over public distresses in the name of “evidence-based policy”, some understandably make a direct association between science and the inequities and injustices in society that the pandemic makes obvious. This leads to a suspicion that expert recommendations like social-distancing or quarantining are unconcerned with the overall well-being of the public — a suspicion that spills over into how a COVID-19 vaccine is perceived.

The anxieties underlying vaccine hesitancy are two-sided. On the one side, there is ignorance; on the other, there are warranted fears that the those in power may not be interested in the well-being of all equally. To address these fears, public health efforts need to avoid stigmatizing those parts of the population that have to be persuaded to vaccinate if we are to limit the spread of the coronavirus. This cannot happen if public health officials only concern themselves with successfully delivering a vaccine and do not confront the broader issue of improving the strained expert-public relationship.

As Emily Harrison and Julia Wu note, vaccine technology cannot achieve this alone: it also requires the simultaneous reimagining of the physical and intellectual infrastructure of public health initiatives. What this reimagining entails remains unclear. Figuring this out is crucial, especially if we hope to avoid failing back into a cycle of vaccine acceptance followed by a lack of public confidence in vaccines.

We are currently experiencing a surge of optimism surrounding vaccines. However, this optimism is fragile and sustaining it depends upon how we deal with those who remain hesitant to vaccinate. The unprecedented global collaboration and technical innovation required to develop a COVID-19 vaccine is a tremendous social achievement. But this ground-breaking accomplishment will go for naught, so long as doubts regarding the vaccine are at the forefront of public concern.

A vaccine can protect us from an infectious disease. It cannot, however, provide immunity from the multiple personal, socio-cultural, and economic problems that inevitably surface during a pandemic — problems that invariably influence how a COVID-19 vaccine will be perceived.

Perhaps a pandemic is required not just for the public to recognize the value of vaccination programs, but for medical experts to accept the importance of gaining public trust as well.

Tarun Jose Kattumana is a PhD student of philosophy at KU Leuven in Belgium.

From the author: I am very grateful for comments and suggestions from Aristel Srkbic, Firat Haciahmetoglu, Rikus van Eeden, Karthik Harinath, Tanuja Viswanath, Tanvi Gupta, Vibhor Jain, Sharanya Deepak, Robert Alvarez, Elke Mahieu, Emanuele Caminada, Karthikeya Jain, Narayanan Gopalkrishnan, Urska Fele, Krishna Nair, and Philip Kupferschmidt, and for the help of the Public Seminar editorial staff in preparing this essay.

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