What’s Really Behind Global Vaccine Hesitancy

A Pinocchio figure with a vaccine syringe for a nose
Getty; The Atlantic

Countries with low vaccination rates are suffering from more than just inequity.

In the public-health world, the rise of Omicron prompted a great, big “I told you so.” Since the new variant was detected in South Africa, advocacy groups, the WHO, and global-health experts have said the new variant was a predictable consequence of vaccine inequity. Rich countries are hoarding vaccine doses, they said, leaving much of the developing world under-vaccinated. But in reality, countries with low vaccination rates are suffering from more than just inequity.

South Africa, the country where the variant was first reported, did receive vaccines far too late, partly because wealthy countries did not donate enough doses and pharmaceutical companies refused to share their technology. At one point, South Africa had to export doses of the Johnson & Johnson vaccine that it had manufactured in-country in order to comply with a contract it had signed with the company. The COVID-19 vaccines must be kept cold, and because not everywhere in South Africa has reliable roads and refrigeration, the country has struggled to store and transport vaccine doses to far-flung areas.

Today, though, South Africa has about 150 days’ worth of vaccine supply. It’s now facing the same problem that’s bedeviling countries the world over: Lots of people don’t want to get their shots. South Africa recently paused deliveries of the J&J and Pfizer vaccines because it has more stock than it can use. “We have plenty [of] vaccine and capacity but hesitancy is a challenge,” Nicholas Crisp, the deputy director-general of the country’s health department, told Bloombergrecently.

The South African experience is an example of how anti-vaccine sentiment has become a global phenomenon at precisely the worst time. Nearly a quarter of Russians, 18 percent of Americans, and about 10 percent of Germans, Canadians, and French are “unwilling” to get vaccinated, according to a November Morning Consult poll of 15 countries. South Africa wasn’t part of the Morning Consult sample, but a study from this past summer found that it had a high level of vaccine hesitancy when compared globally. It falls roughly in the middle of African countries in terms of vaccine hesitancy: About a third of South Africans have been vaccinated, a higher percentage than most other African countries, but 22 percent of South Africans weren’t willing to accept a COVID-19 vaccine, according to a study from this past spring, compared with just 4 percent of people in Ethiopia and 38 percent of people in the Democratic Republic of the Congo. Malawi and South Sudan recently destroyed thousands of vaccine doses because the countries weren’t going to be able to administer them before they expired.

The U.S. should not blame South Africa—or any other nation—for vaccine hesitancy, or stop sending vaccines to places that need them. Vaccine access is crucial. But vaccine hesitancy is an urgent problem, and a global one. New variants can emerge wherever populations remain unvaccinated. (Indeed, it’s possible that Omicron emerged elsewhere and was merely detected in South Africa, which has an advanced genomic-sequencing operation.) “If we had had everybody immunized in the world who is over the age of 18 with at least one dose of COVID vaccine, Omicron might not have happened,” Noni MacDonald, a vaccinologist at Dalhousie University in Nova Scotia, told me. Some surveys suggest that vaccine hesitancy is actually higher in rich countries than in poor ones, so the virus is just as likely to evolve into some dreadful new form in an unvaccinated American’s body as in a Congolese or Russian person’s.

Read: Inside the mind of an anti-vaxxer

If policy makers want to limit the damage that Omicron and future variants do, they’ll have to better understand why people reject vaccines. Something as complex as vaccine hesitancy is bound to have many causes, but research suggests that one fundamental instinct drives it: A lack of trust. Getting people to overcome their hesitancy will require restoring their trust in science, their leaders, and, quite possibly, one another. The crisis of vaccine hesitancy and the crisis of cratering trust in institutions are one and the same.

The world over, people feel lied to, unheard, and pushed aside. They no longer have any faith in their leaders. They’re lashing out against their governments and health officials, in some cases by rejecting the COVID-19 vaccine.

Populism, a political expression of this mistrust, is correlated with vaccine hesitancy. In a 2019 study, Jonathan Kennedy, a sociologist at Queen Mary University of London, found a significant association between the percentage of people who voted for populist parties within a country and the percent who believe vaccines are not important or effective. Past research has similarly found that populists around the world are more likely to believe in conspiracy theories about issues such as vaccination and global warming. “Vaccine hesitancy and political populism are driven by similar dynamics: a profound distrust in elites and experts,” Kennedy writes. In politics, populism manifests as supporting parties and figures outside the mainstream, like Donald Trump or UKIP. But populism can be expressed differently in other spheres. “In public health, there’s this growing distrust and anger towards doctors, also towards pharmaceutical companies. Medical populism is skepticism that’s uninformed,” Kennedy told me.

Medical literature reveals a strong connection between vaccine hesitancy and distrust of pharmaceutical companies, government officials, and health-care workers, even among health-care workers themselves. Studies and polls from various countries over the past two years show that people who are reluctant to get a COVID-19 vaccine are more likely to vote for politically extreme parties and to distrust the government, and to cite their distrust as a reason for not getting the shot. In a recent German poll, half of the unvaccinated respondents had voted for the far-right populist party, Alternative für Deutschland, in the recent election. Anti-vaccine sentiments are also most common in the populist areas of Austria, France, and Italy.

In South Africa, vaccine hesitancy is higher among white South Africans than among Blacks, though whites are more likely to have been vaccinated, possibly because of better access, an August survey found. Some white South Africans mistrust the country’s government, which is led by politicians from the Black majority. South Africans circulate American anti-vaccine material on WhatsApp and Facebook, including videos by Tucker Carlson and memes about Tony Fauci, says Eve Fairbanks, a Johannesburg-based journalist at work on The Inheritors, a book about South AfricaA group representing the Afrikaans-speaking white minority, AfriForum, recently came out against vaccine mandates. “I feel like there’s a little bit of a posturing and a sort of feeling of being marginalized among white South Africans,” Fairbanks said. “One of the biggest losses that white South Africans suffered after the end of racial segregation was not material, but it was status.” Among Black South Africans, skepticism toward doctors might arise from the fact that pro-apartheid arguments were often rooted in wrong, but supposedly “scientific,” beliefs about differences between races.

Though many factors contributed to the erosion of trust in government and science, Kennedy highlighted one in particular: As the postwar narrative of optimism and progress failed to pan out for some people, they became suspicious and angry. “There’s large amounts of the population that haven’t benefited economically from globalization,” he said. “There’s lots of people who feel increasingly disenfranchised by politics; they feel like mainstream politicians are aloof and aren’t interested in them.” Populism and anti-vax sentiment, then, “seems to be a kind of rejection of this narrative of civilizational progress … It’s kind of like a scream of helplessness.”

Perhaps no country better exemplifies the role of trust in vaccine uptake than Russia, one of the most vaccine-hesitant countries on Earth. Despite the fact that its vaccine, Sputnik V, was one of the first developed, only 40 percent of Russians have been vaccinated. Russian anti-vaxxers are numerous and includeopposition activists, Communists, and some Orthodox figures.

Russia, and Eastern Europe in general, has an extremely low level of trust in institutions: One in three Eastern Europeans doesn’t trust the health-care system, compared to one in five residents of the European Union on average. Romania and Bulgaria have also vaccinated only small fractions of their populations, despite an abundance of vaccines, in part because trust in health care is much lower in these formerly communist countries. “One of the legacies of the Soviet health-care system is the high level of bureaucracy,” says Elizabeth King, a professor of health behavior at the University of Michigan who has studied Russia. “The multilevels of bureaucracy also work to erode trust in the medical-care system, including vaccination efforts.”

Russia also spreads vaccine hesitancy beyond its borders with the help of government-funded news sites and trolls. Russian state news agencies have “gleefully amplified every complication and casualty from vaccines produced by BioNTech-Pfizer, Moderna, and AstraZeneca and gloated over every development hiccup. Meanwhile, the Russian foreign broadcaster RT has been feeding Western audiences anti-vaxxer conspiracy theories, comparing lockdowns and other restrictions to the Nazi occupation and apartheid,” the Russian journalist Alexey Kovalev wrote in Foreign Policy. Russian trolls have, for years, posted anti-vaccine content to social media, hoping to sow division in the U.S. During the pandemic, Russia Today’s German-language channels have promoted skeptical views of vaccines, masks, and lockdowns. At one point, the Russian government used fake news sites to undermine trust in the Pfizer vaccine, The Wall Street Journal reported.

Russia-specific factors contribute to this distrust in vaccines: Russia has a tradition of folk medicine, perhaps allowing skeptical Russians to believe that there are alternatives to vaccination. Sputnik V was released quickly and with little public data, making it hard to trust, and Russian President Vladimir Putin’s government has issued conflicting and confusing statements about the true scope of the pandemic. After centuries of government mistreatment, fatalism pervades Russia, and some Russians have come to the conclusion that it doesn’t matter whether they get COVID or not. Judy Twigg, a global-health professor at Virginia Commonwealth University who focuses on Russia, told me she hears arguments from Russians like, “This is just another in a long series of ongoing catastrophes affecting our country,” or “What’s going to happen is going to happen, and everything is always terrible.” More and more, people outside Russia seem to feel the same way about their own countries.

Restoring trust in institutions will be hard. The simplest step governments can take immediately is making it easier to get the vaccine and to learn about it. Developing countries haven’t, for the most part, had the money to invest in flashy pro-vaccine ad campaigns. “How easy I make it for you to get information about the vaccines that’s of good quality, and how easy I make it for you to be able to access that vaccine, makes a huge difference on vaccine acceptance,” MacDonald said.

Though some low-income countries might have adequate doses right now, being forced to wait for doses while the rest of the world swam in them might have increased vaccine skepticism. “If you can’t have what you should have, sometimes you rationalize it by saying you don’t need it,” says Saad Omer, director of the Yale Institute for Global Health.

But mostly, restoring trust in medicine and vaccines comes down to the extremely boring and extremely necessary task of properly funding public health, even when there’s not a pandemic raging. African countries have struggled to vaccinate willing people with the doses they have, because clinics are few and the health workforce is strapped. Sometimes even political populism can be overcome if the public-health system is strong: Brazil, where trust in the public-health Sistema Único de Saúde is high, has an excellent immunization track record despite having a populist leader. Brazilians trust the SUS with their lives, so they trust it for their shots.

All Rights Reserved for Olga Khazan 

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