Culture of Vaccine Acceptability or Resistance
The Curious Case of Chile’s COVID-19 Vaccine Rollout a Great Example and Anthropology’s Role in Increasing Vaccination
Introduction
In their article, Castillo and colleagues have described the curious case of Chile’s COVID-19 vaccine rollout, which is interesting in several ways [1]. Despite the escalation of COVID-19 infection and resulting deaths, Chile has also been successful in vaccinating a significant part of its population in a short period of time. The authors then explore various answers based on current and historical factors that have made what they call “Chilean [vaccination] paradigm” successful, hence, to be followed by other countries who are lagging in terms of mass COVID-19 vaccination.
This analysis draws on the framework of implementation science, in which they view several stakeholders and factors responsible for the rapid and extensive vaccination rollout. They have appropriately illuminated “the role played by the government and the academia in securing vaccines through a pragmatic approach; the capacity built at [the] local level…the coordination between the health system and local authorities; and a favorable vaccine culture, developed through the implementation of the National Immunization Program.” Here I would like to emphasize on “favorable vaccine culture” because this is a particularly crucial factor, which often receives less or no attention in the making of vaccination programs; and because this is so related to my theoretical understanding and expertise. Let me revisit the concept of culture from an anthropological perspective and then explicate the culture of vaccine acceptability.
On Culture—A Brief Note
One can simply say that culture is a way of life. Yet, the concept of culture is what an early anthropologist Edward B. Tylor “complex whole”. It is an extremely complicated phenomenon as talking about culture means discussing all those abstract and nonabstract forms of norms, values, and traditions that humans consult to live their lives. The role of culture starts even before the conception of an embryo and continues after physical death. Alfred Krobber and Clyde Kluckhohn—two eminent American Anthropologists—defined it that “ Culture consists of patterns, explicit and implicit, of and for behavior acquired and transmitted by symbols, constituting the distinctive achievements of human groups, including their embodiments in artifacts; the essential core of culture consists of traditional (i.e. historically derived and selected) ideas and especially their attached values; culture systems may, on the one hand, be considered as products of action, and on the other as conditioning elements of further action." [2]. In this definition, they have significantly emphasized on the “traditional” ideas, which to them are “the essential core of culture” that are the results as well as drivers of human actions. Culture then becomes “the shared knowledge and schemes…for perceiving, interpreting, expressing, and responding to the social realities around” human beings [3].
Culture of vaccine acceptability or resistance
From the above-mentioned brief note on culture, one can view vaccination as a “social reality” that contains various meanings results of a shared knowledge given by various stakeholders such as laypeople, government bodies, medical doctors, and global actors. Based on the specific shared knowledge that can be local, national, or global (or may have some other scale), a vaccine either can be accepted, suspected, and/or rejected. There can be the availability, accessibility, and affordability of the vaccine that are incredibly strong factors to be considered, but then it can be the acceptability or resistance of people. Complex enough, these factors are highly interrelated and interdependent. Behind such interpretations and meanings that stakeholders attach to a vaccine, there are always historical factors that play a crucial role to construct a “culture of vaccine acceptability” or a “culture of vaccine resistance”.
As Castillo and colleagues [1] appropriately revisit the “vaccine culture” that contains “the existence of public trust and awareness of the benefits of vaccines” which [o]f course, this culture was not developed overnight.” Becoming a “leader” in the region, the country was successful to eradicate smallpox in 1950, and polio in 1975 under the National Immunization Program (PNI by its Spanish acronym), established in 1978 [1]. That culture of vaccine acceptability has led to a significant influenza vaccine coverage, i.e., 80% and 90% in the last five years and 99% during 2020. This culture seems in contrast to several countries where the culture of vaccine resistance is high as people question the vaccine.
This phenomenon prevails in Pakistan where many people suspect vaccination. Right from the beginning, the Expanded Programme of Immunization (EPI) of Pakistan—that was launched in 1978—did not receive much trust of people [4]. Various competing narratives, e.g., rumors and conspiracy theories, affected it and contributed to vaccine refusal and resentment [5]. That means “vaccine culture” contains a public mistrust, which is a result of an ongoing interplay between historical, sociocultural, economic, and political contexts.
Prior to 2011, there were rumors that “hidden interests” lay behind vaccination, such as it is “Western plot” to sterilize Muslim women [6]. However, such rumors became a “reality” in 2011, when media reported a “fake” vaccination campaign led by American Central Intelligence Agency (CIA) in Pakistan’s Abbottabad city for locating Osama-bin-Ladin. It considerably contributed to the culture of vaccine resistance that already had the influence of another critical event: the previous British colonization. Analogous to many previously colonized countries, there are narratives regarding the lootmar (lit. looting) of Gora (white people). After this 2011-critical event that was termed by some as a “vaccination suicide,” the vaccinators were assaulted and killed [4]. Such historical developments and happenings became part of a shared knowledge that influences vaccine uptake.
Currently, when the pandemic still continues and its various variants have been reported in many countries, including in Pakistan in July 2022, there is a great need to pay attention to the vaccine culture that what factors make people accept or reject a vaccine. A low-income country like Pakistan can learn great lessons from Chile that is also a low-income country but has shown great vaccine uptake rate generally and the COVID-19 vaccine particularly. Pakistan needs greater efforts to cover its wider population, keeping in view the current COVID-19 vaccine percentage, that in December 2021 was around 41%: around 29% of people with two dozes and 12% with the first doze [7]. And by the mid of July 2022, the percentage of fully vaccinated population is around 58%. To understand how the culture of vaccine acceptability or resistance is developed, countries with low vaccine rates need to engage (medical) anthropologists who are well-positioned and can work as great experts. They are the one who thoroughly study culture— “the complex whole”. In the following section, I reflect upon this aspect.
What Can Anthropology Offer for Vaccination?
Anthropological accounts would be significantly useful for stakeholders such as policymakers and implementors. Since anthropological studies and analyses dig deeper to reveal invisible factors shaping vaccine refusal and resentment, findings can exhibit the qualitative aspects of vaccination, especially the social tensions surrounding it. For instance, in public health, significant attention has been directed to vaccine hesitancy [8-12], yet with a different angle and focus. Thus, anthropology can enormously add to the “vaccine hesitancy continuum” developed by the WHO’s Strategic Advisory Group of Experts (SAGE) on vaccination [9]. In this model, McDonald claims that “complacency, convenience, and confidence” create vaccine hesitancy (italics in original) (2015:4163). Yet this is not always the case, as in some countries such as Pakistan, people not only refuse vaccination but are also deeply resentful of vaccination programs, believing such programs to be part of larger geopolitical forces acting against them—a topic not covered in the studies listed above [4, 5, 13].
Thus, anthropological scholarship offers a critical and necessary perspective to search underneath this continuum of accepting and refusing vaccine—or accepting or refusing some vaccines but not others. The discipline can inquire and demonstrate how one parent’s vaccine refusal can impact decision making at the global level and how global level decisions, such as the fake vaccination campaign in Pakistan, can spur anti-vaccination movements. Anthropological accounts of vaccinations can reveal the impacts of socio-cultural, economic, and political particularities concerning the acceptance and rejection of a vaccine. Just as Lock and Kaufert [14] find “local biologies” at play in the case of menopause, there are what I call local sociologies, anthropologies, geographies, and economies at play in vaccination. For instance, there could be a significant difference between a Pakistani body and an Italian body. In the former country, as previously noted, malnourishment and stunting of children are significant problems [4, 15]. This difference puts Pakistani children at a significant risk compared to Italian or Usonian children for vaccine reactions and for contracting infectious diseases. Therefore, vaccine refusal and vaccination itself can have vastly different consequences in these three countries.
In this regard, anthropology has a meaningful and indispensable perspective to contribute to global health, including vaccination. Panter-Brick and Eggerman [16] have showcased four central characteristics of medical anthropology— critically reflective, cross-cultural, people-centered, and transdisciplinary—to study the interrelationships between health and society. Keeping in view these four characteristics, (i) vaccination appears to be an excellent critical entry point to study sociocultural viewpoints, lived experiences, and contested social worlds by studying and interpreting vaccination programs from conception, implementation, and strategies to approaches. (ii) Since vaccination receives multiple local and global understandings, it is an intriguing entry point to conduct cross-cultural inquiries, e.g., comparing societies and countries by using the concepts of local biologies, anthropologies, sociologies, geographies and economies. (iii) Demonstrating local perceptions, concerns, and particularities to be incorporated into vaccination programs, vaccination offers a platform to record people-centered views of the world in the form of their lived experiences, their structural vulnerabilities, and their social agency (or lack thereof). (iv) Vaccination is a great endeavor to design multidisciplinary research agendas to study and analyze “the nexus of cultures, societies, biologies, and health” [see 16]. Anthropological studies of vaccination can present conversations on the body, mind, person, community, environment, prevention, and therapy: e.g., devising a joint project that engages epidemiologists, public health specialists and medical anthropologists to study and improve vaccination in a given society simultaneously).
Conclusion
The curious case of Chilean vaccine rollout has revealed several crucial factors that are responsible for its success despite the country’s critical state in terms of resources and pandemic effects. Along with many factors, Castillo and colleagues [1] have explicated what they call “vaccine culture” that was developed over time and made the country a “leader” in the region to eliminate smallpox and polio. This culture has been playing a significant role in vaccine acceptability. Although culture is a “complex whole,” it is humans’ doing that shapes our actions. Thus, it is important to value the understanding of the factors contributing to a specific culture. Under discussion is the culture of vaccine acceptability or vaccine resistance. In Chile, the culture of vaccine acceptability prevails that is the result of various factors, especially historical elements. Likewise, in Pakistan lies a culture of vaccine resistance developed by several factors, including historical ones, such as British colonization or a decade-old “critical event” of a “fake vaccination” drive in the country. For grasping such necessary understanding, countries who are lagging in the domain of vaccination need to engage (medical) anthropologists as they are culturologists. I believe that anthropologists can aid greatly in that endeavor by sharing their findings with public health vaccination program designers and helping them develop locally effective vaccine education. This kind of culturally informed education has enormous potential to increase vaccine uptake and thereby to decrease people’s suffering from preventable infectious diseases.
Acknowledgement
This paper has been published Under a Creative Commons. The full citation is here: Ali, Inayat. "Culture of vaccine acceptability or resistance: The curious case of Chile’s COVID-19 vaccine rollout and anthropology’s role in increasing vaccination uptake." Vaccine: X 13 (2023): 100272. Moreover, a few pictures have been added, which are not in the original article.
References
[1] Castillo C, Villalobos Dintrans P, Maddaleno M. The successful COVID-19 vaccine rollout in Chile: Factors and challenges. Vaccine: X. 2021;9:100114.
[2] Kroeber AL, Kluckhohn C. Culture: a critical review of concepts and definitions. Papers Peabody Museum of Archaeology & Ethnology, Harvard University. 1952;47:viii, 223.
[3] Lederach JP. Preparing for peace: Conflict transformation across cultures. Syracuse, NY: Syracuse University Press; 1996.
[4] Ali I. Constructing and Negotiating Measles: The Case of Sindh Province of Pakistan. Vienna, Austria: University of Vienna; 2020.
[5] Ali I. The COVID-19 Pandemic: Making Sense of Rumor and Fear. Med Anthropol. 2020;39:376-9.
[6] Ali I, Sadique S, Ali S. COVID-19 and Vaccination Campaigns as “Western Plots” in Pakistan: Government Policies,(Geo-) politics, Local Perceptions, and Beliefs. Frontiers in Sociology. 2021;6:82.
[7] Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, et al. Coronavirus (COVID-19) Vaccinations. 24 December 2021 ed. England and Wallace 2021.
[8] Schuster M, Eskola J, Duclos P. Review of vaccine hesitancy: Rationale, remit and methods. Vaccine. 2015;33:4157-60.
[9] MacDonald NE. Vaccine hesitancy: Definition, scope and determinants. Vaccine. 2015;33:4161-4.
[10] Roberts JR, Thompson D, Rogacki B, Hale JJ, Jacobson RM, Opel DJ, et al. Vaccine hesitancy among parents of adolescents and its association with vaccine uptake. Vaccine. 2015;33:1748-55.
[11] Karafillakis E, Dinca I, Apfel F, Cecconi S, Wurz A, Takacs J, et al. Vaccine hesitancy among healthcare workers in Europe: A qualitative study. Vaccine. 2016;34:5013-20.
[12] McClure CC, Cataldi JR, O’Leary ST. Vaccine hesitancy: where we are and where we are going. Clinical therapeutics. 2017;39:1550-62.
[13] Feldman-Savelsberg P, Ndonko FT, Yang S. How rumor begets rumor: Collective memory, ethnic conflict, and reproductive rumors in Cameroon. In: Fine GA, Campion-Vincent V, Heath C, editors. Rumor Mills. London and New York: Routledge; 2017. p. 141-58.
[14] Lock M, Kaufert P. Menopause, local biologies, and cultures of aging. American Journal of Human Biology. 2001;13:494-504.
[15] Ali I, Ali S. Why may COVID-19 overwhelm low-income countries like Pakistan? Disaster Medicine and Public Health Preparedness. 2020.
[16] Panter-Brick C, Eggerman M. The field of medical anthropology. Social Science & Medicine. 2018;196:233-9.
Very Informative write-up