Fearing the Cure

Public health officials are frightened that such interference is already hindering support not just for a COVID-19 vaccine, but also for vaccines in general. A comprehensive poll performed in September showed that only 51 percent of Americans would be willing to get a vaccine, down from 72 percent in May. A similar drop in confidence has occurred in the United Kingdom, especially amongst young people.

In May, the Centers for Disease Control and Prevention reported that among children aged five months in Michigan (using the state as a proxy for the country), up-to-date status for all recommended vaccinations had declined from around two-thirds of children from over the previous three years to under half.

These declines could leave children vulnerable to diseases such as the measles because if vaccination coverage for this highly infectious disease drops below around 90 percent, outbreaks can occur. The World Health Organization and Unicef report similar global declines.

There has been a substantial drop worldwide in the number of children completing the three vaccine doses against diphtheria, tetanus, and pertussis, the first time in almost three decades that there has been any reduction in coverage at all.

Most of this decline will have been the result of the lockdowns, as well as fear of contracting COVID-19, keeping families away from health service providers. But this is all the more reason why trust in vaccination needs to be enhanced, not undermined.

In the last few days in order to restore that trust, the Food and Drug Administration has resisted Trump’s efforts to block release of stricter rules governing the emergency authorization of a COVID-19 vaccine. These include a requirement that companies producing vaccines gather data on at least 50 percent of subjects in their clinical trial for two months following a second dose of the vaccine (if the vaccine requires two doses).

This latter development automatically pushes an emergency authorization application for even the earliest likely candidate vaccine, from the firms Pfizer and BioNTech, back to mid-November — as that will be the earliest time they will have been able to gather such data — and, crucially, after the election. Hopefully this will be sufficient to turn the tide on vaccine trust.

Harris was absolutely right to denounce Trump’s meddling, but it would have been preferable for Harris to say that Trump must halt his partisan interference in vaccine development so that there will not be a loss of confidence in vaccines at the height of a global pandemic.

Instead, she gave a gift to anti-vaccination campaigners everywhere, and, in effect, told anyone hesitant about any vaccines that their fears are warranted. She said would happily take a vaccine recommended by Anthony Fauci, the head of the National Institute of Allergy and Infectious Diseases, but not one developed by Trump.

Immediately online, anti-vaxx activists were cheering her comments, or asking why is it okay for her not to trust Trump, but not okay for them to trust Big Pharma with respect to other vaccines. As Australian anti-vaxx campaigner Toby Rogers tweeted, “Harris believes she has a right to refuse a vaccine because she doesn’t like the current president. Parents should have the same right of refusal for their kids.”

The interference by Trump, prior to his election explicitly anti-vaccination himself, plainly makes him the primary villain here — along with Vladimir Putin — but Harris has not helped the pro-vaccine cause. Perhaps worst of all would be if Harris has unwittingly helped turn vaccination into a partisan issue akin to the mask debate, but inverted, where mask-wearing Democrats refuse to be vaccinated, while mask-refusenik Republicans demonstrate their partisan commitment by being first in line to get a Trump jab.

And this is where we are even prior to rollout of vaccination, for which governments have generally not explained well to citizens — especially how even a vaccine demonstrated and widely trusted to be safe and effective may not be a silver bullet that allows us to “return to normal.”

They have not really gotten across the message that the first vaccines may not provide complete immunity, and how even existing vaccines are not binaries but provide a sliding scale of protection. And few vaccines provide lifelong protection from a single dose. Some vaccine candidates require additional doses — perhaps over multiple years.

The Emotional Contagion

It is also increasingly clear that COVID-19 reinfection, while rare, does occur. The first case of reinfection in the United States was confirmed this week, a twenty-five-year-old Nevada man with no known history of immune disorders, and whose second infection was more severe, requiring hospitalization with oxygen support.

As of the time of writing, four other cases of reinfection have been confirmed in Belgium, Ecuador, Hong Kong, and the Netherlands. Reinfection cases mean it will be ineffective to attempt to achieve herd immunity acquired by natural infection. We do not yet know what this means for achieving herd immunity via vaccination.

So even in a world where trust in vaccination were not an issue, the situation would still be extremely messy.

But it’s already such a mess. Vaccines are one of the greatest advances in the history of our species, yet we are at great risk of losing the protection they offer at the moment of our greatest need.

This appalling situation is more or less what the London School of Hygiene and Tropical Medicine’s Heidi Larson predicted two years ago: A politically degenerate and digitally enabled “emotional contagion” that destroys trust in vaccines will be what results in our failure to halt the spread of the next outbreak.

While the pandemic she had in mind when writing a caustic commentary published online in the journal Nature on the deluge of anti-vaccination misinformation was a highly deadly influenza on the scale of the 1918 Spanish Flu, not a coronavirus, her prophecy appears to be coming true.

She is the head of the Vaccine Confidence Project (VCP), an international team of epidemiologists, statisticians, anthropologists, and political scientists that monitors public attitudes toward vaccines around the world. This week in the Lancet medical journal, the project published the first truly global estimate tracking levels of support for vaccination, an assessment based on interviews of more than 284,000 people across 149 countries from 2015 to 2019.

The results are not heartening. Though there has been a modest uptick in confidence in vaccines in Europe and North America over the period investigated, it’s an uptick from startlingly low levels, particularly in some EU states such as France and the Netherlands.

In France, just 9 percent of people believed vaccines to be safe in 2015 — tied with Japan for the lowest rate in the world that year — and four years later, that had jumped up to a still-appalling smidge under 30 percent. The Netherlands was around 30 percent last year, up from 20 percent in 2015. South Korea has also seen a significant drop in confidence as a result of online anti-vaxx campaigning by ANAKI — the Korean abbreviation of “raising children without medication.”

The developed countries with the highest levels of trust in vaccines are places like Australia (72% strongly agree that they are safe in 2019), Canada (67%), and Finland (66%). But before you go off thinking: “Oh there they are again, those insufferable Scando-Antipodean-Canuck goody-two-shoes that top the international league tables of just about everything, from math scores to life expectancy to people who have reached adulthood without cavities,” these vaccine confidence rates are far below rates seen in much of the Global South. The three countries with the largest proportion of the population believing vaccines to be safe as of 2019 are Uganda (87%), Bangladesh (85%), and Liberia (83%).

In fact, not a single developed nation sits in the top ten, the top twenty or even the top thirty. The highest ranking wealthier state, Australia, clocks in at thirty-third place. We can see clearly from a map produced by the researchers that the safety of vaccines is questioned most strongly in the Global North, particularly in Japan and Europe.

The orange and yellow colors show lower numbers of people who agree that vaccines are safe, while the light and darker blue shades indicate higher numbers of people who believe this to be true.

Clinicians and researchers say the reason for this is straightforward: in the developed world, most of the common infectious diseases that have ravaged human society throughout history had all but been defeated by the twentieth-century marvels of vaccines, antibiotics, and modern sanitation and hygiene.

The memory of what it was like to live in constant fear of infectious disease has, until the COVID-19 pandemic, been almost entirely lost in the West outside of those communities affected by HIV/AIDS. Most people are unaware that they prevent two-three million deaths each year. We have forgotten what a wonder vaccines are.

Meanwhile in the developing world, with the exception of global efforts to eradicate smallpox (and soon, hopefully, polio), many such diseases never really went away. In these countries, people often line up for hours to get their jabs because they are all too familiar with the horror of infectious disease.

Of course, this is the overall trend. Human affairs are never clear cut. There is great variation in levels of confidence and resistance in the West, and there are developing states that have seen substantial declines in confidence. The paper in Lancet describes how while the EU as a whole suffers from particularly low vaccine confidence, public trust in vaccine safety has turned a corner in recent years, enjoying a modest uptick in the UK, Finland, Ireland, France, and Italy, albeit up from very low levels in the latter two countries.

This is particularly good news out of Italy, as the hard-right Lega and the left-right-green mélange of the Five Star Movement, both recently in coalition government together, had made anti-vaccination a signature issue. As Jacobin’s Europe editor, David Broder, has reported, the country’s “no vax” movement produced a six-fold rise in the number of individuals with measles in 2017, rising to 2,718 cases, and resulted in twelve deaths.

Though the news from most of Europe is good, Poland meanwhile has experienced a sharp drop in confidence over the period surveyed — the result of a local highly organized anti-vaccine movement.

And in places with higher levels of political instability or religious extremism such as Afghanistan, Indonesia, Nigeria, and Pakistan, there has been a small increase in the numbers of those strongly disagreeing that vaccines are safe, again albeit up from a very low level.

A polio eradication initiative in Nigeria has been defeated due to attacks from terrorists in Boko Haram targeting and killing polio workers, disrupting the polio immunization campaign, and vandalizing or destroying clinics.

Indonesia has experienced one of the steepest declines in public trust anywhere over the 2015–19 period, likely the result of a fatwa issued by Muslim leaders. It claimed that the vaccine contained ingredients derived from pigs and so was haram, a misinformation campaign exacerbated by local healers pushing “natural alternatives” to vaccines, much like alternative medicine hucksters in the West.

In the Philippines, confidence in the safety of vaccines has sharply dropped from 2015 to 2019 as a result of a very real issue with a vaccine for dengue fever, Dengvaxia, which is produced by French pharmaceutical firm Sanofi Pasteur.

Dengue fever has an unusual profile in that a first infection typically does not kill, but a second infection by a different type of dengue is made much worse because the immune system’s response to the first infection actually aggravates the reaction to the second. Some dengue specialists warned at the time that this particular vaccine might have a similar effect on any children who had never had a first infection in that any subsequent exposure to the virus in the wild would act as this “second infection,” amplifying rather than preventing the disease.

So the vaccination program was suspended in 2017, and later restarted once protocols had been established ensuring that it was only given to children who have already been exposed to the disease. As dengue is widespread in the Philippines, most children were not at risk of such complications, but the public relations damage from the premature implementation of an otherwise safe vaccine had already been done.

Trust plummeted not only in the Dengvaxia vaccine, but in vaccines in general. This has been a disaster in the country, which had managed to achieve a reduction in child mortality of two-thirds over the course of twenty-five years thanks to a series of government immunization campaigns. What is locally called the Dengvaxia Mess has been messy indeed, with vaccination rates nosediving against all diseases.

The progress of the last two and a half decades has essentially been reversed and the nation experienced a crisis of infectious disease, not just of dengue, resulting in over 1,400 deaths from dengue as of November, but also diphtheria (47 deaths), measles (560 deaths), and polio. The latter outcome is particularly tragic as the Philippines had otherwise been polio-free since 2000. The Dengvaxia Mess, whether the result of a mistake or negligence, directly caused a reported six hundred deaths. But the drop in trust in vaccines resulted in far greater mortality.

Combatting Hysteria the Right Way

The Vaccine Confidence Project concludes that the reasons for the drop in confidence in vaccination comes from a combination of the rapid and global spread of misinformation online, “a general distrust in government and scientific elites,” and the exploitation of these two phenomena by some groups for financial or political gain.

The VCP survey does offer some hope however about how to turn this around. The researchers found that most people, regardless of location, do not necessarily reject the importance of vaccines even if they question their safety.

“The public seem to generally understand the value of vaccines,” says Clarissa Simas, one of the researchers involved in the study, “but the scientific and public health community needs to do much better at building public trust in the safety of vaccination, particularly with the hope of a COVID-19 vaccine.”

In addition, the determinants most associated with vaccine uptake were trust in health-care workers over non-medical sources of health advice such as from family or friends, higher levels of science education, and sex — women are more likely than men to report having their children vaccinated.

What this suggests is that scientific and medical literacy campaigns and improved communications strategies by public health organizations should work to produce some improvement in vaccination rates.

This seems to be backed up by the improvements seen in regions in Europe where high-profile vaccine awareness campaigns have achieved modest improvements. The researchers give the examples of how both Denmark and Ireland turned around declining human papillomavirus vaccination (HPV) uptake rates through smart campaigns combatting misinformation online.

But such campaigns need to be funded at the appropriate levels. Larson laments there has been no shortage of strategic plans to improve vaccine communication infrastructure from the United States’ Department of Health and Human Services as far back as 1999, its National Vaccine Advisory Committee in 2011, and the WHO in 2012. “Unfortunately, these plans were never fully funded or implemented.”

The WHO is preparing to launch yet another such effort, the Global Vaccine Safety Blueprint 2.0, that covers not just vaccine communications but also issues surrounding governance, surveillance, and how to deal with fragile states and emergencies such as COVID or Ebola. This is yet another reason why it is essential that the United States end its financial and diplomatic war on the global health body. Without American support, this effort is not likely to do much better than previous efforts.

But even with improved scientific literacy and vaccine awareness campaigns, the underlying problem of lack of trust in scientific and political elites remains unresolved.

This question, which is ultimately one of political economy, is obviously something that scientists understandably feel uncomfortable making any pronouncements about. However, if we do not tackle it, even the most well-funded vaccine comms campaign will fail.

The most immediate concern is the spread of vaccine misinformation through social media, and also by legacy media. Fear, outrage, and partisanship are superior drivers of user activity for companies like Facebook, and, in a vicious cycle, the algorithm will deliver up anything similar to that which enjoys greater engagement.

This is what allows a, well, pandemic of COVID-19 falsehoods such as those found in Plandemic, an anti-vaxx conspiracy theory video claiming the pandemic is a ploy to coerce mass vaccinations to spread faster and more widely than accurate public health guidance, which tends to provoke little emotional response.

Yet it would be wrong to only consider social media. Following the collapse of print advertising revenues, legacy newspapers and magazines are similarly driven by emotional headline and content packaging, which drives the greatest number of clicks.

Understaffed and abjectly paid newsrooms are required to pump out content as fast as possible with insufficient time to go into much depth or find additional sources to confirm their findings, while the bullpen’s historical complement of copy editors, specialist editors, and fact-checkers has been gutted. The Berlin Wall between opinion and news, which was never particularly inviolable to begin with, has now tumbled.

Censorship or even “flagging” of fake news on social media will not work because it runs up against the profit-maximization incentive built into any enterprise in a market. Moreover, much of the current flurry of crackdowns on misinformation by social media firms are efforts to ward off state regulation.

Censorship, in any case, is counterproductive because the goal is to win people away from vaccine hesitancy rather than to drive it underground. Anti-trust break up of the social media giants is no solution either, for the emotional hijacking driven by the profit motive is there whether performed by one giant Face-amaz-oogle, or a dozen medium-sized ones.

Instead, the response in the immediate term will have to be regulation, although decommodification of the sector should be the long-term goal. Alongside this, levies placed upon the media giants and telecommunication firms could recycle revenues back to journalists and their publications to revive the institution of journalism.

But even fixing the media landscape, a colossal task in itself, is insufficient, and the breakdown of journalism is only a symptom of a wider malaise.

The Italian case is illustrative here. Broder in his Jacobin essay on the situation there describes a battle between virologist Roberto Burioni, who has become a household name for his work promoting vaccination, and the anti-vaxx pseudoscience promoted by the former coalition government of the hard-right Lega and the Five Star Movement (M5S), a party that is hard to place on the left-right spectrum but mashes together left-populist anti-globalization rhetoric, localist green politics, and anti-immigrant sentiment.

It is hard to disagree with Burioni’s advocacy for evidence-based policy and defense of science. But any endorsement of Burioni’s battle against the death of expertise has to come with a qualification.

Broder describes how Burioni insists “science is not a democracy” and that “only ‘those who have studied these matters’ should speak on issues of life and death.” One can interpret these statements as saying that decisions on vaccination should be removed from democratic debate. M5S voters certainly do.

Broder writes that such statements are symptomatic of the political center’s contempt for ordinary people as functional illiterates. Akin to how Hillary Clinton dismissed Trump voters in the deindustrialized heartland of America as a “basket of deplorables,” and centrist opponents of the UK exit from the European Union derided Brexit voters (in particular from impoverished former Labour-voting heartlands) as elderly mouth-breathing racists whom they wish would just die already, former centrist prime minister Matteo Renzi and his associates regularly sneer at M5S voters as undereducated and lazy.

One does not have to agree with these voters, or for that matter with vaccine skeptics, to recognize that dismissing one’s opponents as too stupid to make decisions only feeds greater resentment.

But one should certainly be able to sympathize with how these voters feel let down by centrist governance led by experts, with policy area after policy area removed from sovereign accountability via trade agreements and treaties whose closed-door tribunals overrule domestic legislation that protects workers or the environment, and central banks (especially in Europe) that remove monetary policy from the realm of democratic debate while enforcing privatization and wage cuts.

Such austerity may not have been performed by scientific experts but they were certainly imposed by self-styled financial experts. While working in Brussels during the Eurozone crisis, I remember a senior European Commission official telling me that there was no way voters should be able to decide even fiscal policy, as they were too stupid to know what was best for them, and would constantly vote themselves into greater and greater debt if the experts did not make such decisions instead.

And how well have these experts that rule us faired in their predictions anyway? It really is no wonder that there has been a loss of faith in expertise after the 2008 economic crisis, the Eurozone debacle, and the accompanying soaring inequality across the West.

Reconciling Expertise and Democracy

There is a pearl-clutching response in the political center — and sometimes on the Left as well — to the global rise over the last decade of what is sloppily called populism, that doubles down on this post-democratic, technocratic rule by experts. They feel that the people have voted the wrong way, and so these nostalgists for “Before Trump” advocate or work to achieve a recourse to unelected bodies such as courts, civil servants, and, in the case of Trump, even the so-called deep state of the military or intelligence services, to do the right thing and block what the people have voted for.

Science can only tell us what is, not what ought to be. Science only describes the world. Burioni is correct about science not being democratic insofar as we do not vote on what the facts are, on what is. But we do not live in science. We live in democracy. And in any democracy, it is up to the voters to decide what ought to be.

Now, given a democratically decided course of action of what ought to be, science can absolutely assist us in telling us how best to get there. If we decide democratically that we want to build a bridge, engineers can tell us how to do so. This is why expertise is essential! But engineering does not tell us we must build a bridge. There is no objectively, scientifically “correct” set of policies outside of democratic debate.

Thinking otherwise is pure scientism, the belief that science is the best or only way to determine our values, and what we should do. Ironically, scientism works extremely well to undermine trust in expertise because it places experts in the role of a ruler who, like an absolute monarch, can never be kicked out of office.

Put another way, scientistic technocracy undermines popular sovereignty. And any time there is an absolute ruler extinguishing popular sovereignty, eventually there will be a revolt against them. But where any democrat wishes to be rid entirely of a monarch, we do not wish an end to expertise.

We only want the experts to know their place as advisors to the true sovereign: us. In the absence of any articulation of a defense of the expert as advisor to the voters and the voters’ representatives, there will only be a desire to overthrow the expert as ruler. Thus expansion of democratic rule, whose purpose is self-government, not “correct” government, is the only solution here.

And understanding democracy as the salve to the irritation of vaccine hesitancy leads us to a comprehension of why there is mistrust of pharmaceutical firms in the first place.

Most anti-vaxx campaigners, and even those who are not opposed to vaccines per se but are just hesitant about their safety, will in the first instance point to the depravity of “Big Pharma.” They will say that these corporations are corrupt, only out to make money for their shareholders, and that their lobbyists have bought our political leaders. The system is rigged.

They are not wrong as far as the wickedness of these firms goes. Ben Goldacre is a British medical doctor and author who has written widely about how the pharmaceutical industry finances clinical trials where negative data is not disclosed, never published, and often plans and even ghostwrites purportedly independent scientific papers about their drugs on behalf of academics. Goldacre believes that the pharmaceutical system is utterly broken and even a “murderous disaster.”

These are the same firms that are lobbying diplomats to prevent affordable access in the developing world to existing drugs that work against COVID-19, and that have hiked the price of hundreds of existing drugs used in the treatment of COVID-19, from steroids to sedatives. When Gilead’s Remdesivir antiviral proved to be extremely powerful against the disease, the company goosed the price by 33 percent. It is no wonder that so many people have contempt for these vampires.

But instead of fighting for the decommodification of pharmaceutical science, for taking these companies out of the private sector and turning them into agencies for the public good like the fire service, the response of far too many is to embrace the pseudoscience of alternative medicine, from naturopathy and homeopathy to acupuncture and chiropractic.

They forget that the quacks that provide these “services” — taking advantage of the lack of medical and scientific understanding of their marks to sell them purported remedies that have in fact consistently failed the battery of scientific tests — are no less profit-driven than Big Pharma.

Goldacre may be a campaigner against Big Pharma for its unethical, profit-driven distortion of medical science, but he is no less a critic of the snake-oil salesmen of the alternative medicine industry — much of which, it turns out, is actually owned by the same large pharmaceutical corporations that produce conventional medicine.

This makes sense: if a pharmaceutical giant will fiddle the data on a conventional drug that they know doesn’t work, why would they suddenly have qualms about selling an alternative remedy that they also know doesn’t work? As Goldacre puts it: “Big Pharma being shit doesn’t mean that magic beans cures cancer.”

And this is where we on the Left — or at least parts of the academic left — have to admit to our own shameful role in undermining trust in vaccines, and by extension trust in all conventional medicine and medical experts.

There is a flavor of left academic influenced by poststructuralist interpretations of philosophers of science such as Thomas Kuhn and Paul Feyerabend that argues that scientific theories are merely social constructs, that science is Eurocentric ideology, that “Western” medicine is ineluctably the product of structures of oppression, and that there are “other ways of knowing.”

Those who defend science, and hence “Western” medicine, are benighted fools drinking from the well of naïve positivism (the materialist philosophical position that no true facts about the world can be ascertained other than through the senses as interpreted by reason).

Since the 1980s, this anti-realist “philosophy” has escaped the academy and has infected much wider swathes of society. It is not uncommon to hear an anti-vaxx activist campaigner assert a vulgarized version of the poststructuralist notion: “Science doesn’t know everything.” Which of course on the face of it is true, as Irish comedian Dara Ó Briain, who also happens to be a trained theoretical physicist, concedes, while famously adding: “otherwise, it’d stop. But just because science doesn’t know everything doesn’t mean you can fill in the gaps with whatever fairy tale most appeals to you.”

The Scientific Revolution is called so precisely because the revolution in the mind that it represents was a recognition for the first time in human history that an authority should not be believed by dint of it being an authority, because human understanding of the world is inevitably incomplete and biased.

Science is the attempt we make to try to correct that bias and carry out the infinite, incompleteable process of completing our understanding. However, because scientists are themselves humans, this bias correction mechanism will itself always be biased. But the solution to this ineluctable bias is not abandonment of attempting bias-correction, but to always work to do it better.

Thus Big Pharma’s dirty deeds are not yet further proof that science and medicine are indeed social constructs, but rather that the commodification of pharmaceutical research distorts the science it performs. So the solution to the problem of Big Pharma is not alternative medicine and rejection of the marvel that is vaccination, but to remove the cause of that distortion of science. Remove pharmaceutical research, development, and production from the market.

We are engaged in a complex war on multiple fronts here: against anti-vaxx and alternative medicine pseudoscience; against those in our own ranks who would abet such mumbo-jumbo; against sneering centrist post-democratic technocracy; against neoliberal underfunding of vaccine public health strategies; against the profit-motivated exploitation of behavioral science by social media; against the collapse of the institution of journalism; and, above all, against Pharma’s market-driven distortion of science.

There is no one simple solution to the problem, but we cannot let up on any one of these fronts, not just to escape from the COVID-19 nightmare, but to avoid even worse should a much deadlier plague emerge, as it likely will one day.