By Ryan Andrew (BA Philosophy, Politics And Economics)
We are well on our way to finding a Covid-19 vaccine1, and governments are reaching that point where they must consider how to dish out treatment. It is uncertain whether a compulsory policy would improve immediate vaccine uptake, but the problem is also ethical. Addressing 160 years of anti-vaccine movements2 may prove the hardest part. We will ask why good policy communication is key to overcoming this issue.
Historical Opposition to Vaccines; The Power of Information
The 1853 Vaccination Act was the first of its kind in the UK, making the smallpox vaccination compulsory for all new-borns. Failure to comply would land you a hefty fine, or even imprisonment3. The Act was met by widespread opposition, both from academics and the general public. Many were sceptical of science and fearful of losing their freedoms4. Needless to say, the Act was later revoked5, but the anti-vaccine movement continues to this day.
The arguments pitted back then have only gotten more sophisticated. Various lobbies argue against the safety and effectiveness of vaccination, or insist they violate civil rights or religious beliefs6. These movements have been able to influence public perceptions7, and in both the short and long-term, reduce the number of people becoming vaccinated8. “Vaccine scares” play a large part in this story, causing resurgences in epidemics previously beaten. The biggest examples include the Pertussis Controversy and the Wakefield Scandal.
Before being discredited, the 1974 study linking the Pertussis vaccine to neurological problems caused British vaccine coverage to fall from 77% to 33% by 19779. The news, exacerbated by anti-vaccine lobbyists, lead Pertussis, AKA whooping Cough, to spread rapidly across populations again10. For almost twenty years, cases in countries where immunisation was discontinued rose up to 100 times higher than those still vaccinating11.
Andrew Wakefield’s 1998 study met a similar fate. It suggested the Mumps, Measles and Rubella (MMR) vaccine caused autism12. Parents soon began to construe the risk of MMR as outweighing the benefits, partly because the media characterised Wakefield as a whistle-blower and partly due to the low incidence of MMR at the time. By 2003-4, only 79.9% of children under two had been MMR vaccinated in the UK13. In 2018, Measles outbreaks had reached 41,000 cases in Europe, a new record14 directly attributed to the Wakefield study, which was later retracted.
This growing scepticism is not just limited to Europe. Lower vaccination rates allowed the incidence of communicable disease to rise in the USA for the first time in a century15. The speed and reach of new media across Western societies has allowed these misleading narratives to pervade public perception like never before.
Along with “vaccine scares”, very real cases of medical negligence, such as the Thalidomide scandal17 have justifiably affected public perceptions. It has been harder for governments to square with these events, and whilst they are far and few in-between, their role in the anti-vaccine movement has been long-lasting and dire.
The Government’s Problem; Free-Vaxin’
If the UK’s public compliance to social distancing rules during the Covid-19 pandemic is anything to go by18 then we can expect vaccine uptake to be quite high. But the problem is not convincing those who want the vaccine. It is convincing those hesitant or opposed.
There exists a minimum number of people who must be vaccinated to prevent an outbreak of disease in an epidemic. This is known as herd immunity19. Authorities who wish to achieve herd immunity will set up vaccination on a wide scale.
This makes vaccinations a public good, as individual benefits from mass-vaccination are non-rivalrous and non-excludable. One problem associated with public goods is the free-rider problem. As not everyone needs to be vaccinated to achieve herd immunity, individuals can free-ride by avoiding or refusing a vaccine when offered to them20. Parents have been found more likely to forgo vaccinating their own children—free-riding—when they gain knowledge that their children’s’ friends have already been vaccinated21.
If historical opposition to vaccines has shown anything, it is that trust is fragile, yet instrumental to uptake in vaccine welfare programmes; Low amounts of trust in the medical system will increase the amount of those forgoing the jab. This is important. Top epidemiologists at Johns Hopkins believe that 70% to 90% of us will need protection to achieve herd immunity22.
If vaccination rates fall too low because there are too many free-riders, we risk vaccinations being ineffective at achieving herd immunity. In other words, we wouldn’t sufficiently slow down the rate of spread of the virus, that precious R number23 showing the average number of casualties that a single infected person will pass Covid-19 on to.
What Whitehall Can Do; What Whitehall Should Do
One idea spreading around has been to make the Covid-19 vaccine compulsory.
Whilst compulsory vaccinations are currently not legally feasible, things can change. One study finds that, generally, preference for a policy of mandatory vaccinations increases when the current vaccination rate is low and the risk of infection high24. As Covid-19 is very much at the forefront of our minds, it seems we may be more lenient to a mandatory policy. Now would be the time for Whitehall leaders to implement one. But how would they enforce it? Perhaps we can learn from other countries.
‘No jab, No school’ and ‘No jab, No Pay’ policies, among others, have been tried and tested to enforce vaccine uptake, with varying results. Evidence of increasing vaccination rates in Australia25, California26, France27 and Italy28 have shown the effectiveness of these mandatory policies. Notably, each country differs in their approach29.
For example, Australia has used financial incentives since 1998 to ensure children stay up to date with the National Immunisation Plan. Those not adhering to the plan risk their Family Tax Benefit and Child Care Subsidy being reduced by as much as $15,000 a year. Only very strictly controlled medical exemptions are possible for some, and whilst this has helped to incentivise vaccinations for large swathes of lower-income earners, wealthier households remain relatively unaffected30.
Meanwhile, families in Italy risk getting fines along with school exclusions for refusal to receive their vaccines. Whilst these sanctions in reality are rarely enforced31, they have seen a noticeable increase in immunisation for vaccines across the board; measles coverage, for example, rose from 87.3% in 2016 to 91.8% in 2017 for children under two32.
Despite these encouraging case studies, the effectiveness of mandatory policies is less clear when considering the big picture. An EU funded study33 found no obvious relationship between mandatory vaccination policy and vaccination coverage in European countries.
Additionally, the majority of countries with over 95% MMR coverage, including Portugal and Sweden, do not enforce any mandatory vaccine policy. They instead have substantially high “vaccine confidence” among their populations, along with minimal barriers to access healthcare34. One European Journal of Public Health study even found that compulsory vaccinations might reduce the acceptance of future vaccines, especially for the vaccine hesitant35. For those on the fence about vaccines, perhaps the best way to bring them to the right side is not through coercive means after all.
Addressing vaccine hesitancy has become a focal point of vaccine policy discussions36. One concept this cohort of researchers have pinpointed37 as vital in vaccine decisions, is trust. Shaping the public’s perception of government into a competent, objective, fair, consistent, sincere and faithful source of vaccine wisdom should be the direction of all their efforts if they can ever hope at achieving herd immunity.
The need for government to listen to and monitor public opinion is key, and the evidence shows it. A communication campaign ran by the Ministry of Health in Israel to mitigate a Polio crisis in 2013 was made successful, only because it was able to convey the right level of information about risk to an otherwise resistant group of protestors38.
Instances like this have shown that policy communication needs to be relevant to those it intends to affect39. Knowing exactly why certain groups might be hesitant or opposed to vaccines is crucial to convey the right message along the right channels40. Understanding historical opposition is a good start. Any response that improves trust must also come hand in hand with the ability to distribute vaccinations, raising logistical problems41.
A growing crowd of behavioural economists would suggest that reducing barriers to vaccination may nudge those people misbehaving in the right direction. Interventions as simple as text message reminders telling patients the cost of missed appointments can significantly increase attendance to vaccine appointments42. The power of meaningful relationships between healthcare workers and patients may also save us a lot of policy trickery43.
Take it or Leave it
Experts are seeing a paradigm shift. ‘Communications is increasingly embedded throughout the policy cycle’ and ‘policymakers want to govern in partnership with citizens’44. The vaccine debate has come to the forefront because of Covid-19, but it forms only a part of national discussions about the grey zone between freedom and safety.
Libertarians have constantly struggled to reason with policies that would allow compulsory vaccinations45, and governments scramble to find a response that ultimately balances lives with economies. But In the wake of all this evidence, it seems obvious that 160 years of medical history could not be remedied in one fell swoop.
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