When Maya Goldenberg started research for her forthcoming book on vaccine hesitancy—the term for delaying or outright refusing to get oneself or one’s kids inoculated—she started by looking into measles, mumps and rubella.
These viral diseases were dangerous, sometimes deadly. Fortunately, there is a single vaccine against all three, studied over decades and backed by scientific consensus that it is both safe and efficacious. Goldenberg wondered why some parents—in the face of this overwhelming validation—still wouldn’t get their kids vaccinated. “I went in with the expectation that there was some sort of gap in the scientific evidence,” says the University of Guelph philosophy professor, “that people just needed to hear X and then they’d come on board.”
But as she delved deeper into the psychology and history of vaccines, she found evidence wasn’t really the issue. “The acceptance of vaccines is not about your relationship to science,” she says. “It has a lot to do with your relationship to social and government structures.”
While some anti-vaccination advocates bring up arguments that appear to have basis in science, Goldenberg says, their claims are really acting as a placeholder for cultural and social anxieties around the process; that is, the organizations and government structures that manufacture, approve and market vaccines.
That growing sense of suspicion could have profound implications for what many—Goldenberg included—see as the one development that could pull the world from the all-encompassing crisis caused by the current pandemic. She was putting the finishing touches on her book, Vaccine Hesitancy: Public Trust, Expertise, and the War on Science, when the novel coronavirus started to spread, killing more than 570,000 people worldwide and crippling the global economy. In Canada, within weeks of social distancing measures taking hold, the sense of fear and frustration was visible on streets and in legislatures across the country, where people demanded the reopening of stores, parks and businesses. Says Goldenberg: “The vaccine is our ticket out of the lockdown.”
But punching that ticket could be a greater challenge than governments and vaccine-makers anticipate. Some of the same protesters at anti-lockdown rallies are using those events to raise their voices against vaccines, presaging resistance against a future COVID-19 inoculation. If history and recent surveys are any guide, one in six Canadians, and one in four Americans, will balk, and their hesitation will take a number of forms. Some will flatly refuse; others will hold off, waiting to see what happens when the rest of society gets it first.
Plenty will think of themselves as too busy to line up, or fear potential side effects, or figure they’ve survived this long without the vaccine so they should be fine. And the seeds of doubt will be easy for avowed anti-vaxxers to plant. “It’s a new virus. It’s a new vaccine. It’s being pushed to market quickly,” Goldenberg says.
Yet returning to the “old normal”—a life without mass casualties; where people fill up hockey arenas and travel around the world on crowded planes without constant testing and monitoring—will require that enough people get vaccinated to develop a herd immunity. If the slow, careful and long-term science behind the measles, mumps and rubella vaccine doesn’t get a buy-in from everyone, it’s hard to believe a COVID-19 vaccine will be widely embraced at first. “There will be a lot of fear around it, that is for certain.”
Health experts have long warned it will likely be more than a year before a vaccine is ready, still longer before everyone on earth has access to one. It will instantly become the most valued resource on the planet, as governments clamour to get enough for their own citizens. But it would all be for naught if authorities are unable to convince people to take it when the time comes.
To develop herd immunity from COVID-19, over 80 per cent of the global population may need to get vaccinated, noted Bill Gates in a recent interview with BBC Radio, citing estimates from some epidemiologists (though the exact percentage to prevent outbreaks of the virus is still unknown). The Microsoft co-founder has committed billions of dollars to vaccination programs over his lifetime through the charitable foundation he runs with his wife, Melinda—including substantial funding for a COVID-19 vaccine. But inoculating four out of five people is no easy target.
“There is a general anti-science, anti-authority, anti-vaccine feeling among some people in this country—an alarmingly large percentage of people, relatively speaking,” warned Anthony Fauci, director of the U.S. National Institute of Allergy and Infectious Diseases, in an interview with CNN.
During the swine flu pandemic of 2009, fewer than 40 per cent of people in Canada, the U.S. and the United Kingdom went to get the vaccine or intended to get it, according to Steven Taylor in his 2019 book The Psychology of Pandemics: Preparing for the Next Global Outbreak of Infectious Disease. In Switzerland, it was fewer than 20 per cent. At one Swiss hospital, only half of health-care workers got vaccinated. “The 2009 influenza pandemic turned out to be a mild influenza, which may have influenced people’s vaccination adherence,” says Taylor in an interview.
But while COVID-19 is far deadlier, only 47 per cent of Canadians said they “definitely” intend to get a COVID-19 vaccine, according to an early July survey by the public opinion firm Research Co. Fully 15 per cent of respondents said they wouldn’t or likely wouldn’t. Another 11 per cent said they weren’t sure.
Approximately 20 per cent of parents consider themselves vaccine hesitant, according to a 2016 survey from the Canadian Immunization Research Network. The World Health Organization (WHO), meanwhile, named vaccine hesitancy among its top 10 threats to global health.
And Taylor is worried by signs he’s seen on Canadians’ Facebook pages of what he calls a “rise of anti-vax [posts] specifically targeting COVID-19”—in many cases recycled theories from previous health crises. “It’s a riff on the new world order—that there’s a shadowy organization intent on world domination.”
There are already plenty of debunked narratives floating around social media, including the outlandish tale that COVID-19 was created as a plot by Bill Gates to get everyone microchipped. And yet, a Yahoo News/YouGov survey in May found half of Americans whose primary TV news source is Fox News believed this to be true; another 25 per cent said they weren’t sure.
“We keep informing people with scientific facts, trying to address misconceptions through statistics and data, but people are much more moved by narrative and stories,” says Eve Dubé, a medical anthropologist at Université Laval in Quebec and former member of a WHO working group on vaccine hesitancy. “I think public health needs to have good stories.”
Here’s one. A century ago, Charles Hastings was a rarity: a doctor renowned beyond Canada’s medical community. As Toronto’s medical health officer, he ordered the city’s milk and cream supply to be pasteurized, which was credited with helping reduce the tuberculosis rate to the lowest of any major city in North America or the U.K. He made changes to the city’s sewage treatment system, helping rid its water supply of 95 per cent of disease-producing bacteria. And when Hastings led Toronto through the 1918 Spanish influenza, his recommendations to close schools and theatres—and to practise physical distancing by walking to work instead of using streetcars—helped keep the fatality count to under 2,000 in a city of a half-million, an enviable stat amid a pandemic that would kill anywhere between 50 and 100 million people worldwide.
“It seems as if we were now only at the dawn of the health age, when people are waking up to the fact that every nation has been spending millions on the cure and the attempt to cure diseases that should never have occurred with proper administrative and preventive measures,” Hastings told Maclean’s in a 1915 article, titled: “Saving lives on wholesale plan: How Toronto has been made the healthiest of large cities.”
So when a mild smallpox outbreak occurred in the fall of 1919 among schoolchildren, Hastings’ answer was easy: there was a smallpox vaccine proven to be effective. Here’s where the success story goes slightly awry. Using his powers under the province’s Vaccination Act of 1914, Hastings ordered all schoolchildren to be vaccinated. It did not go over well.
City council was split on mandatory vaccination. Despite Hastings’ proven track record, a group of British-Canadian First World War veterans living in the city’s east end formed a Toronto chapter of the Anti-Vaccination and Medical Liberty League. At one rally, protesters held a sign claiming that the idea of compulsory vaccination was German-born, “because Germany had been one of the first countries to require compulsory vaccination for everybody—especially their army,” says Heather MacDougall, a medical historian at the University of Waterloo. It was an idea that resonated in the aftermath of the Great War.
“I think these guys were reacting to four years of being told what to do, figuring they had fought the war for liberty and freedom of expression,” MacDougall adds.“They weren’t going to be pushed around by a civic administration over something they perceived might harm their children.”
Hastings, for his part, considered the anti-vaxxers to be “ignoramuses,” according to a newspaper report of the day. Eleven people in the city died of smallpox in the coming months, but the outbreak ended after more than 200,000 were vaccinated. What didn’t end: controversy over vaccines.
There are more than 150 vaccine candidates for COVID-19, and only a handful are likely to make it to the finish line and be approved for use in humans. Despite signs of widespread uncertainty, surveys suggest a majority of Canadians would approve of mandatory vaccination for COVID-19 if a vaccine were proven safe and effective. (Their definitions of safe, of course, likely vary.) Studies show making it mandatory tends to increase uptake, Taylor adds, “but it can also increase resistance with people digging in their heels about not being controlled.”
Already, experts are recommending politicians and health authorities talk about the importance of getting the vaccine—even if it’s more than a year away. But Taylor warns leaders to be careful what they say. “You need to be honest and transparent, but on the other hand, you don’t want to offer false hope or announce things prematurely. We saw that with Trump and hydroxychloroquine”—the anti-malaria drug the U.S. president touted as a possible COVID-19 cure, despite a dearth of scientific evidence to support his claim.
While health authorities can still address long-standing problems like conspiracy theories, there is debate about the best ways to go about it. Dubé, for one, doesn’t believe in “myth busting”—at least not when it entails public health campaigns emphasizing the myth in big bold letters. “If you say ‘vaccines don’t cause autism,’ and then list the reasons why, people forget the explanation because it’s dry and boring,” says the Laval professor. “But they do recall the link between vaccines and autism.” Better, she says, to simply emphasize the facts about a vaccine’s safety and importance, and leave out the myths.
For people who won’t get vaccinated because they doubt the virus is a danger to them personally, Taylor suggests appealing to altruism. In the U.S., that might mean framing vaccination as the patriotic thing to do. In Canada, it could mean urging people to get vaccinated for the sake of their communities. “You’re asking people to do it voluntarily, not for themselves, but their elderly next-door neighbour,” says Dubé. Alternatively, if personal finances are a motivating factor, health officials might focus on the cost of not getting vaccinated—like missing out on paycheques due to illness or quarantine.
Back in Guelph, Ont., Goldenberg added a letter to the reader at the beginning of her book, noting that the volume went to production mid-pandemic and that COVID-19 will be a global test case for public trust in health authorities and government. “We trust vaccines to the extent that we trust the governing bodies that create and distribute them,” she says in an interview. “That’ll be more true with this pandemic.”