Could You Have Been Vaccine Hesitant in 2006?

The pandemic, the virus, the vaccine

How the Covid-19 pandemic started, where and how the virus found its way to a human host, is disputed even now. On the other hand, the nature of the virus, its genetic structure, was soon established. It proved to be a coronavirus, similar to others that normally inhabit wild animals, especially bats. What also became clear, though not in the same way, and not to everyone, is that recovery from the pandemic—psychological and social as well as physical—would depend on widespread deployment of a safe and effective vaccine. Virologists and immunologists around the world immediately set to work.

Reluctance to be vaccinated

By the end of 2020, the first vaccines had been licensed in the US, the UK, and Western Europe. Roll-out began. But despite nearly 2 million deaths by that time, surveys were uncovering widespread reluctance to be vaccinated. There is a lot to say about the reasons respondents gave for their doubts or likely refusal. But here I want to focus on how the public health profession tries to make sense of such doubts and refusals.

The concept of ‘vaccine hesitancy’

The term ‘vaccine hesitancy’ is widely used. In 2006, I chose that date because it’s when the FDA first approved Merck’s Gardasil, the concept didn’t really exist. In 2012, a World Health Organization advisory group set out to clarify and define it. Its report was published in 2014. “Vaccine hesitancy refers to delay in acceptance or refusal of vaccines despite availability of vaccine services. Vaccine hesitancy is complex and context-specific, varying across time, place, and vaccines. It is influenced by factors such as complacency, convenience, and confidence.” It had to be distinguished from low resource contexts in which vaccine services are unavailable, or inaccessible to many families. This categorical distinction is problematic: but that’s for another occasion.

Vaccine hesitancy is used to refer to a heterogeneous set of behaviors. Parents who vaccinate selectively, others who delay certain vaccines, and others who keep to the schedule but remain unsure they did the right thing, are all labelled vaccine-hesitant. But whatever ambiguities it conceals, ‘vaccine hesitancy’ is the subject of more and more scientific publications.

Here’s my question. Before 2014 or thereabouts, lacking such a term, how did public health experts talk about these things? How did the need for such a concept arise?

Pro-vax or anti-vax

Concern at the growing visibility of anti-vaccination groups on the internet emerged around 1980. Why then? That too will have to wait for another occasion. The rise of these groups seemed to be reflected in declining vaccination rates, giving reason for concern. From that time until quite recently this was the single explanation of what was going on. Parents who failed to vaccinate their child, fully and according to the approved schedule had been led astray by the misinformation they found on the internet. The content of anti-vaccination websites was scrutinized in study after study. How could their message best be countered?

Attributing everything to the activities of groups promoting junk science was congenial to the public health profession. First, it pointed to an identifiable culprit. Anti-vaccination groups are an enemy that can be outmaneuvered. Since they mainly exist online, steps could be taken to ensure that search engines put official pro-vaccine sites first. Second, it avoided the need for any self-questioning. There was no need to ask whether resistance to vaccination might not reflect problems in the way vaccination programs worked, let alone more fundamental social processes or cleavages.

Difficult to accept that it isn’t so black-and-white

When social scientists actually talked to parents it gradually became clear that this explanation simply didn’t hold up. Something much more complicated, and for public health unwelcome, was going on. The internet was not the sole and generally not the most important source of influence on parents’ thinking about vaccination. Many parents found deciding about the vaccination of their child complex and difficult.

In 2014, the writer Eula Biss described how she began to think about vaccination during her pregnancy. She explained how her world, that of educated middle-class professionals, was riddled with doubts, anxieties, and mistrust. Deciding whether or not to vaccinate a child was an anxious and uncertain process. There was nothing specifically American about this. Studies in various parts of the world were showing something comparable. Many parents, especially educated middle-class parents, were no longer willing to take vaccination recommendations on trust. Doubts were widespread, even among the majority of parents who did still accept all the recommended vaccines at the recommended times. This is what came to be known as ‘vaccine hesitancy.'

It’s now acknowledged as a major problem for public health. But how to deal with it? Inexpertly handled hesitancy could tip over into vaccine refusal. What’s more, it can’t be properly analyzed, let alone tackled by measuring, mapping, and informing—the tools of epidemiology. These will shed little light on a phenomenon through which a multitude of anxieties, disaffections, and injustices are being refracted.