Following COVID, institutions will need to earn back trust: Heidi Larson

Professor Heidi Larson has become the world’s go-to expert on vaccine confidence.

Larson is the founding director of the Vaccine Confidence Project and Professor of Anthropology & Risk at the London School of Hygiene & Tropical Medicine, and Clinical Professor of Health Metrics Science at the University of Washington.

Over the past year, she has fielded requests for advice on COVID-19 vaccine rollouts and other vaccine-related questions from dozens of governments. Professor Larson, who is also the author of STUCK: How Vaccine Rumors Start – and Why They Don’t Go Away, researches not only vaccine rumors, but has also developed the Vaccine Confidence Index, a tool for quantitatively mapping levels of vaccine confidence globally.

With the COVID vaccine rollouts well under way in some countries, but severely lagging in others, we spoke with Professor Larson about reaching those who are less confident and hesitating to get their shot. We also discussed lessons for public health officials from previous mass vaccination campaigns and building back trust in elected and health leaders in the wake of the pandemic.

Exemplars News: With all eyes on the COVID-19 vaccine rollout, what would you say are the biggest challenges to reaching those who remain vaccine-hesitant or anti-vaccination?

Professor Larson: One of our big challenges now is how we maintain the confidence we have in places where there is no vaccine. We have a mix of issues. [In the West] we now have an abundance of vaccine, yet some people are still hesitant. We also have situations in places like Africa and India where there's not enough vaccines and you have a mix of people who are keen and those who are hesitant and getting even more suspicious. These gaps create very vulnerable spaces for people to make up their own narratives about why they aren't getting the vaccine and some might just say, "Well, by the time the vaccine comes, I'm not going to need it anymore, so I don't have to worry.” We need to build confidence where we can and try to marry that to where the vaccines are, but also try to engage those who don't have vaccines immediately available – we don't want to lose them.

I also think more and more we need to situate vaccine confidence building in the context of overall COVID recovery while also addressing some of the other health needs that have been neglected during COVID. We see again and again how much underlying confidence in the system is a lever of confidence in vaccines. If we focus on relationship building rather than just getting people vaccinated, it will not only help improve confidence in the system more broadly and help us recover from COVID, but we'll hopefully be in a better place in building vaccine confidence and uptake.

Exemplars News: In regard to the COVID vaccine rollout, are there any important lessons from previous vaccination campaigns, such as HPV and polio, that may be applicable?

Professor Larson: I think there are some great examples from COVID vaccine experience already. One of the really moving things I've seen is the trust building that's going on in the U.S. in the Black community. It's just been remarkable how Black doctors have come together and engaged in communities – from barbers to community leaders – and really shifted the landscape in very moving ways. It also dispelled some assumptions that people didn't really want the vaccines. They found out that in a number of cases, actually, people didn't have a problem with the vaccine, they just weren't getting the right information about where to get it and how. I think that one of the big learnings is ‘don't make any assumptions about what's in the minds and hearts of people, you need to find out.’

I think from polio vaccination campaigns we've learned a lot, particularly in recent years where we’ve been in the last mile of the eradication effort, facing the most difficult and entrenched beliefs and distrust. In some of the most difficult places, the thing that made a big difference was embedding the polio vaccine in the context of other needs in communities where they didn't feel like polio was their biggest problem anymore, that kids weren't dying of it, that they barely saw it anymore. ‘Why do you keep coming back with the same vaccine when our children are dying of measles, not polio? Where are the measles vaccines? You don't come to our door with that. You saw the dirty water, you walked through it to come to this house, where's the clean water?’ I think by being responsive to the felt needs of communities was a huge lesson with polio. When that did happen, when it was made part of a message that we do care about other things besides just this polio vaccine, it shifted the relationship and improved uptake of the vaccine.

In the case of HPV, one of my favorite examples is from Denmark. There have been several countries where there is resistance to the HPV vaccine. It's a mix of fear, while some have anxieties about it promoting promiscuity. There's a whole range of perceptions and issues, but in Denmark, there were a lot of anxieties about safety issues to the extent that the government asked the European Medicines Agency to re-review the safety profile of the vaccine because they were getting so many complaints. It was reviewed, and it came out that all was fine and that they should go ahead with the program. In the meanwhile, the health authorities brought in a group of teenage girls of HPV-vaccinating age to co-create a social media strategy to reach their peers. I think that kind of co-creation is something that’s really important. Health authorities will do appointment reminders on text messages, which is already a leap, but in terms of genuine engagement and going into that messy, emotional opinion space, which many think is too toxic to engage, there are ways to do it.

Exemplars News: Following COVID, how do we ensure trust not just in vaccines themselves, but also in the policymakers, experts and institutions responsible for their rollouts?

Professor Larson: I think we need these institutions themselves to think about how they can become more trustworthy, because there's a lot of finger-wagging at the public that they need to know more, learn more about science, and they need to trust more. Well, we need to give them a good reason. I think that cycles back to this point of hearing them out for what their felt needs and concerns are, which already sends a signal and will be a trust builder when they feel like they're being heard and that the policymakers are listening to them. Populist leaders and movements are very much appealing to this hunger in the population for being heard and not being dictated to by science and authority. I think one of the reasons these populist movements have gotten so much traction is they are listening to people.

Exemplars News: Have you found the drivers of vaccine hesitancy to be different in different regions and cultures?

Professor Larson: There are differences among cultures and regions. I think sometimes we group people or make assumptions that, ‘Oh, X culture thinks this way,’ when in fact there's huge diversity within these cultures. We've even seen this in our Vaccine Confidence Index, which has four key domains that we investigate. One is confidence in the importance of vaccines, confidence in the safety, in the effectiveness, and whether it is compatible with religious beliefs. What we see is that people from the same religious group across different settings can have very different answers and very different concerns. It often has to do with the political context of the religious group. There's a layering of issues that I think we sometimes forget in trying to get formulaic, '’Well, this culture thinks this way, and we have to be respectful of this culture or this religion,’ when that same religion or that same culture in different political settings is different.

Exemplars News: Most vaccine development takes place in the Global North. Is that problematic in terms of vaccine hesitancy in the Global South and how might we address that?

Professor Larson: There is a divide, but I think that speaks to the reality that we need to diversify and build vaccine development and manufacturing capacity in all regions. This is especially important given the political behavior we've been exposed to during COVID which, in too many cases, favored nationalism over global equity. I think one of the silver linings, as it were, from COVID is that a lot of local, national, and regional leaders and stakeholders in Africa have really stood up, come together, mobilized investment, and are committed to strengthening African ownership and African-led pandemic responses— including vaccine production— moving forward. I know the EU has given some funding and the U.S. has made commitments to building capacity, and not just factories, but training and tech transfer, safety mechanisms and all the rest. It's a project, it has many layers, and I think that's been good, but it's not just about the capacity. Look at India – one of the biggest vaccine suppliers and producers in the world – and they still didn't have enough. For people who think that free IPO is going to fix this problem, you can have free IPO, but if you have no training, no capacity, it misses the point.

This interview with Professor Larson has been edited for length and clarity.