Vaccine Confidence in the Time of COVID-19

"It is possible that this COVID-19 crisis may ignite a collective memory of long human struggles against infectious disease. But will re-experiencing the force of an epidemic alone be sufficient to solve the problem of vaccine hesitancy?"

Drawing on historical and epidemiological analyses, this essay critiques contemporary approaches to addressing vaccine hesitancy and articulates a notion of vaccine confidence as a broader way of conceptualising the problem and how to respond to it. In the context of the vaccine optimism pervading discourse around the COVID-19 epidemic, the authors suggest that a re-envisioning of the culture of public health would be necessary - toward one that attends to constructs of care and solidarity and extends beyond narrow biological and technical considerations.

Vaccine hesitancy has been traced to factors such as misinformation spread on social media and lack of trust of public health agencies, among others. In response, medical and public health authorities often frame lack of scientific information among the public as the culprit. Medical societies call for coalitions with technology companies to ensure user access to scientifically valid information on vaccines; the World Health Organization (WHO) Vaccine Safety Net initiative aims to address public questions and provide up-to-date scientific evidence; and outreach efforts to vulnerable communities prioritise "informing" skeptical parents. Yet, such measures - as well as legal approaches to require vaccination for school attendance - do not seem to be working.

The authors argue that "these modes of thinking about the problem still fall within too narrow and too clinically-oriented of an idea about health, disease, and how complex the human responses to them truly are....[V]accine confidence - a wider trust in the directives of those advising or requiring pre-emptive actions - is not the same as an agreement to be vaccinated against a particular and immanently frightening disease." To support this line of argument, they reflect on 4 interrelated points; in short:

1. For reasons the authors outline, a broad vision of public health has eroded - in part with the complicity of medical and public health authorities - leaving us with vaccinations as a "technical, objective solution to the problem of prevention and population health."
2. Vaccine hesitancy is not new: "Dissent has long been observed among communities who do not feel represented by authorities dispensing the vaccine or a sense of belonging to the broader public in whose interest they are asked to participate."
3. "When it comes to vaccine hesitancy, what matters most varies across time and communities." There are myriad reasons why people may resist vaccination; for some, the decision can even come down to the ideology or aesthetic identity of the person doing the messaging.
4. The public health community has been "programmed with a mindset in which the essential ethical dilemma of public health is a tension between autonomy and state power." An alternative to a "logic of choice" is a "logic of care", in which "the failure of states to provide not only the biomedical but also the economic and social resources that would allow citizen lives to be equitably protected from health catastrophe...would be cast not as a form of government that respected 'autonomy' or 'the rights of individuals to choose,' but as abject neglect."

This analysis leads the authors to suggest that public confidence in vaccination programmes depends on comprehensive community work at social, political, and moral levels, as well as the biological one. Studies of Ebola vaccine responses, malaria vaccine trials, polio eradication efforts, and human papillomavirus (HPV) vaccine scale-up have highlighted the importance of "how much common value we have collectively constructed as a society that includes communities, individuals, and the state."

The authors conclude that, "however quickly the public rushes for a vaccine in this particular outbreak, and however successful this one-off vaccine may be, a broader confidence in vaccines after the charted epidemic passes will likely depend on widespread public trust that cooperation with preventive health directives will not equal catastrophe....This likely means a re-imagination of cultures of public health, in which the ideal of social solidarity is granted enough power to infuse and shift our guiding ethical constructs" - not only in word, but in deed.

Some of the questions they leave the reader with to spark reflection include: "Will our accounts fixate on the salvation that comes from a successful vaccine, if that vaccine does ever come, or will they focus our gaze on the unnecessary loss of life that came before and continued in quietly persisting social, economic, and biomedical tragedies after the epidemic officially concluded? Will we let these stories guide our policy actions? This narrative work needs to happen now..."