As the world is confronted with the phenomenon of people who insist on their rights not to be vaccinated, several questions are being raised: Who are they? What are their reasons? Why their resistance to what the science is saying? How to achieve national and global solidarity?
This blog is being written when the Delta variant among others is leading to an upsurge in the incidence of the coronavirus, globally. According to the latest CDC projections, the US is poised to achieve the single worse week with 200,000 COVID cases per day, leading Dr. Saju Mathew, National Institutes of Health (NIH) Director, to pronounce that “the Unvaccinated are sitting ducks”. In the Caribbean, The Hon. Gaston Browne, Prime Minister of Antigua and Barbuda, Chair of the Caribbean Community, speaking at the Inauguration of the new CARICOM Secretary General, Dr. Carla Barnett of Belize, said that in many of CARICOM member states, the percentage of the population that has been vaccinated remains unacceptably low. The latest figures from the Caribbean Public Health Agency (CARPHA) suggests 23 percent. In addition, inequitable access to vaccines has been further complicated by pervasive vaccine hesitancy.
GOFAD combed the literature for empirical research on vaccine hesitaters that would help in the response to the who, what, why and how raised above. The most enlightening analysis was a interview by Ed Yong, a staff science writer in an article America Is Getting Unvaccinated People All Wrong in The Atlantic July 22, 2021 with Dr. Rhea Boyd, a pediatrician and public-health advocate. https://www.theatlantic.com/health/archive/2021/07/unvaccinated-different-anti-vax/619523/
The conclusion to be drawn is that ‘the unvaccinated’ are not a monolith: “they’re not all anti-vaxxers, and treating them as such is making things worse.” They are a diverse group with many reasons for avoiding vaccination. Some are concerned that COVID-19 vaccines aren’t safe or that potential side effects aren’t worth the risk of taking them. Others think the risk of getting COVID themselves is low; so, why bother?. Still others have a resistance to government intervention and see taking the vaccine as capitulation to government overreach and a bane to personal freedoms. Othersare skeptical of taking vaccines that have not been officially certified by WHO. A small number are simply opposed to all vaccines. What is more, public opinion about vaccination include varied and deep-seated beliefs. These are a result of the tension between divergent cultural viewpoints and value systems. Several key cultural perspectives stem from individual rights and public health stances toward vaccination, various religious standpoints and vaccine objections, and suspicion and mistrust of vaccines among different global cultures and communities.
Protecting Individual Liberties vs Safeguarding Public Health
Two studies advance the need to understand the difference between the individual and public health stances. Helen Riess argues for building empathy in health care, requiring public health officials to recognize and respect diverse social and cultural perspectives toward immunization policies, and help support their success and acceptance.
https:greatergood.berkeley.edu/article/item/building_empathy_in_healthcare. Many countries for example require citizens to receive certain immunizations such as those required for children to enter school. Historically there have been controversies over the efficacy, safety and morality of these mandatory vaccinations stemming from these two divergent goals.
Another perspective is presented in Hendi Larson’s recent book, Stuck: Why Vaccine Rumors Start and Why They Won’t Go Away. She advises that a more understanding view around vaccine hesitancy is to approach people with respect and dignity, even if you disagree with them. Her main conclusion is to build empathy in health care requiring good public health policies to balance both individual rights and community needs. These are best illustrated by religious objections to vaccines and suspicions and mistrust of vaccines and even political leaders who advocate for their use. Religious objections are based generally on the ethical dilemmas associated with using human tissue cells to create vaccines, and beliefs that the body is sacred, should not receive certain chemicals or blood or tissues from animals. They believe it should be healed by God , prayer or natural means. However in most recent statement Pope Paul captures a different spirit when he states that “vaccination is a simple but profound way of promoting the common good and caring for each other. It is an act of love“ https://www.today.com/health/pope-francis-urges-people-get-vaccinated-calling-it-act-love-t228635
At the same time, suspicion and apprehension about vaccination are best understood in a social and historical context of inequality and mistrust. For example, the legacy of racism in medicine and the Tuskegee Syphilis Study, a clinical trial conducted with African Americans who were denied appropriate treatment opportunities, are key factors underlying African Americans’ distrust of medical and public health interventions, including vaccination. https://www.cdc.gov/tuskegee/index.html
How to get the Vaccine Hesitant to change their Minds : Nudge not Sludge
The question, how to resolve this public health dilemma is not straightforward. In a fascinatingly engaging book by Professor Richard Thaler (University of Chicago), 2017 Nobel prize in Economics and Professor Cass Sunstein (Harvard University) entitled Nudge: Improving Decisions About Heath, Wealth, and Happiness (reviewed by GOAD May 25, 2019) they make the essential point that most human beings do not make decisions in the way that is often characterized in elementary economic text books. In a follow up publication, Nudge - Final Version release August 3, 2021 they provide some interesting recommendations for policy makers intent on combating the coronavirus to “nudge for good” with well-designed warnings using the power of social norms. This approach they argue will blunt the “sludge” (barriers, fake news etc.) by “choice architects” that sponsor the cause of antivaxxers out of self-interest or even malicious intent. Reject mask mandates and social distancing despite scientific evidence of their absolute necessity are the most obvious examples. https://bookshop.org/books/nudge-the-final-edition/9780143137009
When anti-vaxxers sow distrust about vaccines they successfully sow distrust about unvaccinated people as a whole. This is the reason why it is necessary to ensure that credible and consistent scientific information reaches everyone since what is becoming more evident is that the information gap is driving the vaccination gap. The language of policy makers that blames the unvaccinated is sludge because it misses the critical point that structural barriers maybe a major reason. So for example, Black people in the USA are one of the least vaccinated groups, in part because they have the least access to preventive health-care services. On a global scale the comparison is "vaccine apartheid" between the developed and the developing countries.
Yet those who are unvaccinated should not be made a protected class nor should governments be nudged into giving their personal choice the same anti-discrimination status as race, gender and religion. Instead the emphasis should be to nudgerather than mandate people toward an intervention that maintains freedom of choice and steers them in a particular direction.
There is so much more to Nudge Final Version to be explored further (in another blog). However the lessons learned are that nudges targeting vaccine hesitation should aim to:
In the final analysis for nudges to achieve their objectives they must be compatible with human dignity. They should make people feel safer, better and agree that they have individual rights but also obligations to their communities, nations, and regions to bring an end to the pandemic. There will however always be those "beyond nudging". Imposing sanctions may yet be the only alternative. Above all nudges must be aimed to achieve global solidarity in recognizing that this worldwide pandemic will further disrupt the lives of the most vulnerable, and countries will see a rise in extreme poverty and malnutrition, shattering all hope of attaining the Sustainable Development Goals.
Edward and Auriol Greene Directors, GOFAD.