Author: Wilmot James, December 14 2017 - Cynthia Gorney wrote in National Geographic in November about the phenomenon of "vaccine hesitancy". She cites the example of Pakistan, where polio vaccinators were turned away or attacked on the basis of rumours that were, on the one hand, false (it was not true vaccines were a western plot against Islam) and, on the other, true (the Central Intelligence Agency had indeed used vaccinators to search for Osama bin Laden).
She cites a further example where, in parts of India, a measles-congenital rubella syndrome vaccination campaign, one of the world's largest targeting 35-million children, ran into trouble after anonymous posts on social media falsely claimed the vaccines were dangerous or targeted the children of religious minorities. Many people believed the erroneous posts, at the cost to their children's health and lives.
This is not the first or last time misinformation has been a barrier to effective public health intervention. During the Ebola outbreak, citizens of Liberia, Sierra Leone and Guinea, some more than others, discounted the health authorities' warnings because they thought they were a ruse to attract more aid, which would end up in the pockets of corrupt politicians.
Sometimes leaders perversely contradict compelling public health messages. During his rape trial of December 2006, for which he was acquitted, President Jacob Zuma admitted to having had unprotected sex with his accuser, who he knew to be HIV positive, but said he took a shower afterwards to cut the risk of contracting HIV, a profoundly irresponsible statement.
The difference today is the proliferation of unfiltered antiscience misinformation that traffics over social media platforms globally at a time when the Global Alliance for Vaccines and Immunisation (Gavi), a multibillion-dollar public-private collaboration started in 2000 by the Bill and Melinda Gates Foundation, is fighting hard to get old and especially new vaccines into the public health sectors of developing countries.
The barrier that rumour-mongering presents to vaccine delivery logistics is so serious that the world's premier pandemic preparedness assessment body, the inelegantly named Joint External Evaluation, or JEE Alliance, initiated by the Global Health Security Agenda in collaboration with the World Health Organisation (WHO), ranks "dynamic listening and rumour-management" as one of the most important risks governments must get under control.
The JEE assessment document talks about health risk communication as "real-time exchange of information, advice and opinion between experts and officials or people who face a threat or hazard" and providing citizens with the hard facts "to take informed decisions to mitigate the effects of the threat" using a "mix of communication and engagement strategies".
Effective public messaging requires taking into account community-specific social, religious, cultural, political and economic needs. Effective engagement with communities means building resilience and holding exercises and simulations with citizens. Dynamic listening and effective rumour management are about the continual monitoring of all social media platforms during a crisis so there is an early understanding of what affected communities need.
The assessment scores for managing rumours were deeply troubling. Of the 51 JEE/WHO country mission reports examined, 15 countries, mostly African, have no dynamic listening and rumour-management system, 21 have average systems that require significant improvement and five countries do well but should not lower their guard. Pakistan, mentioned earlier, struggles with disabling rumours and unsurprisingly failed the JEE test outright.
Fixing the vaccine hesitancy problem is of the greatest importance. More than 800,000 children die every year from a common organism, pneumococcal bacterium, which lives without causing any problems in people with healthy immune systems. But in poor countries among undernourished children, the bacteria cause pneumonia or meningitis or blood disease and kill them. There is a vaccine available but the challenge is to get it into the public healthcare systems of developing countries, and fast.
The first step towards this end was taken by the Gates Foundation when it put $750m into Gavi, which uses its financial muscle to negotiate and, backed up with subsidies, drive the vaccine price downwards for countries that apply for it.
Gavi started out by making and discounting established vaccines for tetanus and hepatitis B but soon poured [US]$500m a year into the pneumococcal vaccine PCV when it became available in 2010. A more recent vaccine manufactured by GlaxoSmithKline is for rotavirus, the leading cause of diarrhoea, which kills hundreds of thousands of children in sub-Saharan Africa and South Asia annually.
There are more vaccines in the pipeline, but there are challenges ahead as the subsidies cannot be sustained forever.
However, there is no question that Gavi is a game-changer. To add further value there must be a second step, which is to get the vaccines (and other medical measures) to where they are needed, at the point of care.
This is often easier said than done. In some countries, the public healthcare system is so dysfunctional, it is a serious mistake to use it as a distribution platform. A recent alternative is the use of drones to deliver medicines, and the robotics company Zipline has agreements with Rwanda and Tanzania to do just that, but it takes a rare leadership that embraces innovation to seize the opportunity.
The JEE Alliance assesses a country’s ability to get medical measures to where they are needed in an emergency. This serves as a good proxy for routine logistical and distribution capacity. Analysis of the results shows that 12 countries had no systems for getting medicines where they should go in an emergency, 12 had a weak system, 12 performed moderately, six did well and a further eight did very well indeed.
It is significant that a country such as Bangladesh did moderately well. This is because the health authorities enlisted the help of popular singers, athletes and imams - in other words, those with credibility and moral authority - to praise the benefits of inoculation on television and radio. Gorney tells the story of how "the health authorities and Islamic leaders together came up with a plan for mosque milking" where encouragement to vaccinate "trumpets from thousands of minarets, like calls to prayer".
The philanthropic community could do well by investing in research to better understand and intervene to boost vaccine take-up. Bangladesh provides a model of public service community engagement involving leaders who have moral authority, standing and credibility. But what to do about social media, where there is no curatorship over content and rumours thrive without restriction, remains a challenge.
Getting vaccines to those most vulnerable matters. Vaccines are one of medicine's greatest success stories. Measles was killing more than 2-million people a year worldwide in the 1980s but by 2015, the death statistics dropped to 134,200. Polio has been wiped out in all but three countries. With its attractive package, Gavi stimulates commercial vaccine discovery and development on scale. Barriers to take-up can be removed with understanding, innovation, investments in communication and, most of all, ethical leadership.
Image credit: Illustration by Karen Moolman
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