By Katherine Hawley

“Coronavirus Vaccine Bottle” by Jernej Furman. Used under: https://creativecommons.org/licenses/by/2.0/. 

Quelling the COVID-19 pandemic will require governments and peoples to work together, motivated by more than mere fear of legal sanction. Whilst lockdown measures have been given legal force in many countries, these would be unenforceable in the face of widespread civil disobedience. Restrictions on shops and restaurants need the cooperation of business owners, and it’s impossible for the police to systematically monitor who we mingle with in our own homes, or indeed whether we’re really washing our hands for the full twenty seconds. Test-and-trace systems need individuals to come forward for testing when appropriate, and to be honest about their social contacts. And even as we wait anxiously for a vaccine to become available, we should not expect this to be imposed on any individual without their consent.

Without public trust, such things fall apart. We need to trust that our governments and healthcare institutions are imposing lockdown measures for good reason, that our engagement with test-and-trace will genuinely help to suppress the spread of disease, that vaccines will be safe enough, effective enough and distributed fairly enough. Yet public trust in government is fragile. In the UK, for example, it dropped after Prime Minister Boris Johnson’s aide Dominic Cummings got away with a flagrant breach of lockdown rules. Actions like this which squander public trust are dangerous, since nothing can be done without it.

The importance of trust goes beyond institutions. Very many of our actions make sense only if our neighbours do them too. If I am especially vulnerable to the virus, I will avoid public places out of sheer self-interest. But someone who judges that her own risk is low has little motive to stay at home if her peers are crowding into bars; her restraint will make no discernible difference to the overall spread of disease. Likewise, co-operating with a test-and-trace system, especially if it means losing wages because of self-isolation, is worthwhile only if others are also co-operating.

And whilst we often think of vaccines benefiting the vaccinated, first-generation COVID-19 vaccinations may be as little as 50% effective in preventing illness. (For comparison, measles vaccines are 97% effective.) But the scientific hope is that even a so-so vaccine will move us collectively closer to the fabled herd immunity, reducing opportunities for the virus to flow around our community. This will help protect people who have not yet been vaccinated, or for whom the vaccine is ineffective. But only if there is good take-up. So if I do not trust the bulk of my fellow-citizens to get vaccinated, then there is no point my getting vaccinated for the greater good; instead, it’s just a matter of calculating my personal risk-versus-reward.

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Trust and Vaccination

Are we ready to accept vaccination? ‘Vaccine hesitancy’ has often been elided with the ‘anti-vaxxer’ movement, attributed to misinformation at best and conspiracy theories at worst. Institutional efforts to promote vaccination pre-Covid have targeted a perceived information shortfall, assuming that hesitation is primarily due to misunderstandings about the relative risks and benefits of various vaccinations. But as philosopher Maya J. Goldenberg argues (2015, 2021), this approach ignores the importance of public trust, trust which has quite understandably been shaken by missteps, poor corporate behaviour, and exploitation or neglect of disadvantaged peoples within healthcare systems. (Grasswick 2010 explores these challenges for trust in science beyond vaccinations).

Challenges to public trust are heightened for any potential coronavirus vaccine. On the one hand, we are all desperate for some magic bullet to restore our pre-Covid freedoms. On the other hand, we are told that candidate vaccines are being developed at unnerving speed, whilst even minor problems in the trial process make front-page news. We’ve heard Trump insisting that a vaccine will be available before the US elections, and we’ve read of Putin mysteriously approving vaccines many months before they are expected outside of Russia. Even the most public-spirited of democratic leaders has much to gain from the success of a vaccine. It’s easy to see why many people worldwide are currently reluctant to commit to getting vaccinated, though advance polls are not a reliable guide to eventual behaviour.

Trust in a putative vaccine may be especially hard to achieve for some communities. People from a wide range of Black and other non-white backgrounds have been harder hit by COVID in the US, UK and some other Western countries, and these disparities have been widely discussed in the media.

How might this experience affect decisions about whether to accept vaccination, for members of those hard-hit communities? Trust involves confidence along various dimensions, including expectations of both competence and good intentions. Many government failings during the pandemic have reeked of incompetence: in the UK, the most striking examples are the early inability to procure enough PPE (personal protective equipment) for health and social care workers, and the ongoing disaster of the privately-‘run’ test-and-trace ‘system’, which so far has been too slow, too limited, and too centralised. Black, Asian and minority ethnic people are disproportionately represented both in healthcare work, and in urban areas which could most benefit from effective testing and tracing.

“Trust involves confidence along various dimensions, including expectations of both competence and good intentions.”

These concerns spill over to undermine confidence in governmental good intentions. In principle, lack of competence in buying millions of face-masks does not entail inability to license a safe and effective vaccine. These are two very different challenges. But if we suspect that incompetence is boosted by neglect of the differential impact of Covid on disadvantaged groups, then it makes sense to fear similar neglect when it comes to vaccines. After all, it would not be surprising if the risks and protectiveness of any available vaccine differed depending on race, sex, age, or current health: can we expect the government to pay special attention to these differences? This is not primarily a question of individual politicians’ or scientists’ intentions, but rather a question about the orientation of institutional priorities.

Worries like this can be pejoratively framed as ‘conspiracy theorising’, especially if we confuse the idea of institutional or systemic racism with the claim that evil individuals are plotting together to oppress minorities. But in reality experience of the pandemic so far – and lifelong experience of interactions with government or healthcare systems – can provide some of us with quite reasonable grounds for distrust in whatever vaccine may be offered. This is not tinfoil-hat territory.

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What next?

So if a safe-enough, effective-enough vaccine does indeed become available, what actions will help promote the trust required to accept it, especially amongst groups who have been at the sharp end of the pandemic so far? Demonstrating competence will involve communicating clearly about safety and effectiveness for vulnerable groups, not just for the population on average. Such nuanced clarity will also help to demonstrate good intentions, rather than neglect. As ever, effective communication will involve dialogue not dictats, listening attentively to members of disadvantaged groups rather than just broadcasting medical information.

Government decisions about prioritising vaccinations will also demonstrate (in)competence and intentions, for better or for worse. Early supplies will be limited, so who should be offered vaccinations first, and who will have to wait? An open, consultative approach to setting priorities here will be important for showing trustworthiness, even if we cannot all be satisfied by the eventual policy.

“People who feel that their communities have already made too many sacrifices for the greater good may reasonably bridle at being asked to step up once again, unless it is plain that their own families, neighbours, and broader communities are amongst the primary beneficiaries of their action.”

Finally, it will help if we can all grasp how even a partially-effective vaccine can benefit the community as a whole. We need to appreciate altruistic as well as self-interested reasons to participate, and to see that we can benefit from other people’s vaccinations. Trust in our fellow-citizens is important here, alongside trust in institutions. But which fellow-citizens, or indeed resident non-citizens? People who feel that their communities have already made too many sacrifices for the greater good may reasonably bridle at being asked to step up once again, unless it is plain that their own families, neighbours, and broader communities are amongst the primary beneficiaries of their action.

These complexities create significant challenges for government communications strategies. But the challenges must be met head-on, for without public trust and public cooperation there can be no effective vaccination campaign, and no emerging from our collective crisis.

References

Goldenberg, Maya J. (2016): ‘Public Misunderstanding of Science? Reframing the Problem of Vaccine Hesitancy’, Perspectives on Science 24.5: 552-81.

Goldenberg, Maya J. (2021): Vaccine Hesitancy: Public Trust, Expertise, and the War on Science, University of Pittsburgh Press.

Grasswick, Heidi (2010): ‘Scientific and Lay Communities: Earning Epistemic Trust Through Knowledge Sharing’, Synthese 177: 387-409.