The Dangers of Vaccine Over-Confidence

There are many lessons to be drawn from 18 months of the pandemic. They will undoubtedly be the subject of conflicting analyses for months and years to come. Discussion of the prevalence of vaccine hesitancy among groups distinguished by age, ethnicity, political affiliation, or some other characteristic will continue. But are we also seeing the emergence of something new? Something we might call "vaccine over-confidence"?

Vaccinologists worked wonders in developing safe and effective vaccines with unprecedented speed. Vaccines are playing a vital role in controlling the pandemic. Some of them are more than 90 percent effective, though only after two doses and three or four weeks. Has a tendency emerged for people who are partially protected (say immediately after the first dose) to feel over-confident and behave in ways they would previously have avoided? That remains to be seen.

But what about the collective level, that of public health? From almost the start of the pandemic, a constantly reiterated message was that "when there’s a vaccine, life will return to normal." Eighteen months later, there is little sign of the promised return of normal life for most people. For me, the faith in vaccines expressed in that early public messaging raises two intriguing questions: Where does it come from? What does it do?

Vaccines were once of limited importance.

In the second half of the 20th century, public health became more and more reliant on vaccination. In the 1920s and '30s, when tuberculosis was a major concern of public health, it was scarcely in evidence[i]. Views as to the value of using the BCG vaccine to protect communities differed sharply. While some countries (including France and Sweden) used it widely, in other countries (including the U.S. and the UK), physicians were skeptical, and the vaccine was scarcely used.

By the late 1940s, tuberculosis had become an even greater problem, especially in the war-ravaged countries of Central and Eastern Europe (such as Poland), among millions of displaced refugees, and in many tropical countries (including Brazil and India). New BCG vaccination programs were launched. In newly independent India, mass BCG vaccination provoked considerable resistance. The country’s public health experts knew full-well that tuberculosis was a disease of poverty. They saw vaccination as a "technological fix," valuable because the country was not yet equipped to tackle the poor housing, sanitation, diet, and working conditions in which the disease flourished.

The emergence of the current reliance on vaccines.

The 1960s and 1970s saw the successful introduction of new and effective vaccines against measles and polio. The global eradication of smallpox was justifiably celebrated. Public health became increasingly dependent on vaccination.

In parallel, the rapidly growing vaccines market was becoming an important source of growth for the pharmaceutical industry, which set about developing and promoting one new vaccine after another. Gradually and unobtrusively, what had been a means was becoming an end in itself. Vaccine coverage, rather than any measure of (child) health, became the key global health metric. Our current "faith" in vaccines, underpinning the now-dominant vaccine narrative, was being crafted.

What does the current vaccine narrative do?

What does this dominant vaccine narrative do? It offers hope, for sure. But in early 2020, it also overwhelmed any concern with the issues that would not be solved by the successful development of a vaccine. There was virtually no interest in thinking through problems such as shortages, rich country monopolization, or liability in case of vaccine-related injury. These problems are still with us.

In the 1940s, Indian public health experts saw vaccination as diverting attention from the underlying causes of the country’s tuberculosis problem. Does something like this hold for the COVID-19 pandemic? What is the underlying cause of the pandemic? The virus? The location (whether laboratory or market selling wild animals) which facilitated its "jump" from a wild animal host to humans? Or should we go along with the biologists and ecologists who blame economic activities (logging, mining, farming, road building) that displace wild animals from their natural habitats, driving them into contact with humans? The underlying cause of the present pandemic, and potentially of pandemics yet to come, is then the destruction of these animals’ forest habitats[ii].

No one can anticipate when or where a new pandemic will emerge or what kind of virus will be involved. Vaccine development is scarcely feasible. Does that rule out any kind of preparation? By no means. The impact of COVID-19 has been highly unequal, both in terms of the seriousness of infection for individuals and in terms of rates of infection impacting communities.

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Individuals differ widely in how likely they are to become infected and how serious a SARS-CoV-2 infection is likely to be. Not only age and underlying health conditions, such as obesity and diabetes, but also gender and ethnicity play a role. There are differences between communities as well. The impact is particularly serious where people are crowded together: in refugee camps, for example, or prisons, or districts of industrial cities in which poor people breathe polluted air.

The political will to tackle any of these factors may be scarcely greater than in 1940s India. When the time comes, we will turn to the vaccinologists once again. But though of vital importance, a vaccine can only ever be part of the solution. If the objective is to be public health rather than simply vaccine coverage, then the focus of attention and investment in preparing for future pandemics must be public health infrastructure. The difficulty is not only that such a shift of focus requires political will. It also requires us to think around our current faith in vaccines.