Vaccine Inequity Is Nothing New, but New Approaches Are Needed

We recently experienced a fifty-year high in the occurrence of pertussis (whooping cough) in the United States. And before we had even heard of SARS-CoV-2, the US had already come within a hair’s breadth of losing its measles elimination designation—because of sustained outbreaks in this country.

People do not realize how fragile our control of vaccine preventable diseases is because that control is based on maintaining high levels of vaccine coverage.

These close calls are not just about what we might call the anti-vax movement.

Beyond individual decisions, there are tremendous challenges with the development and distribution of vaccines globally. About 50 largely poor countries are effectively shut out of the global vaccine marketplace. Haiti, for example, still hadn’t administered a single COVID vaccine as of last summer when richer countries already had a surplus on hand.

The public does need clear, transparent information about health matters, so they can make informed decisions. But simply increasing the volume of information has diminishing returns.

The clear inequities across countries and within countries—in who has access to information about vaccines and who has access to vaccinations—has always been one of the biggest challenges to successfully deploying vaccine programs to prevent disease and protect human lives.

We have a unique opportunity, as we live through this global pandemic, to get much better at equitably providing vaccine doses to communities around the world and in improving how we develop communications around vaccination programs.

The COVID pandemic has highlighted vaccine inequity in a way perhaps not otherwise possible. More people than ever before, from researchers to policymakers to community leaders, are thinking about vaccines in the context of their potential for improving population health.

Vaccine Distribution and Access

Across academia, a true commitment to interdisciplinary collaboration has generally been lacking. We all saw the promise of a COVID vaccine move rapidly from development of the vaccine itself to manufacturing to large-scale distribution and then local delivery to clinics and other community settings.

And we saw many places where those connections need to improve.

The term vaccine decision-making more fully captures the process of weighing information, personal experience, preexisting perceptions, and other important considerations

Scholarly research needs to get better at two things right now. The first is integrating a broader range of relevant and different topical expertise in addressing complex public health problems. The second is translating that research into practice.

Too often the importance of the second step is simply not considered by academics, which lessens or even negates the potential impact of research on public health programs and practice.

Communicating about Health Interventions

Public health practitioners can also take lessons from the current pandemic. Too often health professionals think more information alone can solve public health problems.

The public does need clear, transparent information about health matters, so they can make informed decisions. But simply increasing the volume of information has diminishing returns.

Other factors—like when and by whom information is shared, and one’s personal experiences—can be more important than volume.

I prefer the term vaccine decision-making to vaccine hesitancy because I believe many people who choose not to receive a vaccine are making, for them, an informed choice based on the information—which may be incorrect—they have at hand. That information may have come primarily from the internet, a friend, their doctor, or other sources.

The term vaccine decision-making more fully captures the process of weighing information, personal experience, preexisting perceptions, and other important considerations—all of which contribute to whether a person chooses to be vaccinated.

From a global perspective, a variety of cultural and political realities drive the reasons behind a person’s vaccine decision-making. Within a country, attitudes about vaccines are affected by socioeconomic status, gender, religion, race and ethnicity, and other factors that can change from one region or even neighborhood to another.

Given these divergent attitudes, we need to develop health communications that are culturally appropriate and community-engaged, because who’s giving the message can be just as important as the content of the message.

Trusted community leaders often are able to share a message about health promotion and disease prevention with far more impact than communications from regional or national governments. Government officials might struggle with distrust of the messenger, especially in minority populations that have experienced systematic racism, discrimination, and oppression from those same government entities.

Opportunities Abound

Ironically, vaccination programs have become a victim of their own success. Few people today—including most doctors—have seen infections of measles, polio, or diphtheria. These terrible diseases have largely been eliminated regionally or even globally through coordinated multinational vaccine distribution and community vaccination programs.

But the lack of personal experience with these diseases had led many to perceive the risk of acquiring them as low, even without vaccination. This has contributed in turn to rising levels of vaccine hesitancy and the resurgence of measles and pertussis in the US.

The fact remains that, as vaccine coverage increases, human communities will experience less disease. It is that simple.

As of February 2022, over 400 million COVID cases—including nearly 6 million deaths worldwide—have led to incalculable costs and profound disruptions to the lives of people, societies, and countries.

I remain confident, however, that vaccines will allow us to prevail over this pandemic, just as they have done historically. We have seen remarkable improvements in public health over the last century, in large part because vaccines have continued to help prevent disease and promote health in communities everywhere around the globe.

About the Author

Matthew L. Boulton is senior associate dean for Global Public Health and professor of Epidemiology at the School of Public Health and professor of Internal Medicine at Michigan Medicine. At the School of Public Health, Boulton is also director of the Office of Global Public Health and is the Pearl L. Kendrick Collegiate Professor of Global Public Health. He founded the school’s Office of Public Health Practice and was director of the Preventive Medicine Residency for 20 years. He is the current editor-in-chief of the American Journal of Preventive Medicine and, prior to joining the University of Michigan, spent 16 years in public health practice, including as the governor’s chief medical executive and state epidemiologist. Boulton’s research interests are in global health, infectious disease epidemiology, childhood vaccinations and vaccine preventable diseases, preventive medicine, and the health workforce.