Vaccinations, political will, and the importance of using anecdata for good
Dr. Walter Orenstein, the former director of the United States' National Immunization Program, discusses the 'massive' challenge of getting vaccines out of vials and into arms – and how sharing personal stories could bolster the scientific case for COVID vaccines
When the world set out to battle smallpox, measles, and polio, the public health community benefited from a reliable common denominator: access to vaccines. We've not had the same fortune with COVID. Although it's not the first time we've fought a pandemic, the enormous challenges we’re facing with the novel coronavirus are, in many ways, novel.
For the first time in history, we're in a race to vaccinate 100 percent of the world’s population as close to "all at once" as has ever been attempted. It’s a tough contest, one that includes slowing the spread of the virus, flattening surge curves, and running from – or perhaps towards – new variants that are now pushing this pandemic into the start of its third year.
One of my favorite sayings has always been "Vaccines don't save lives, vaccination saves lives." That’s because no matter what the clinical trials show, vaccines that remain in the vial are zero percent effective at combating disease. And, as we’re witnessing, getting vaccines out of vials and into arms has become a massive challenge, one we're far from meeting effectively.
Much of my career has been spent on the eradication of diseases, particularly smallpox and polio. And while both those diseases were pervasive, we had three major advantages in fighting them. First, vaccines were already available. Second, it was much easier to get the number of doses we needed, when we needed them. And third, we were aided by swells of political momentum.
When I was director of the U.S. Immunization Program, my former colleague Dr. Roger Bernier was fond of saying that “the P in public health is for politics and the importance of getting political will.” And he was right. Political will helps us get resources for staff and laboratories. It helps us fund analyses and vaccine development efforts. And, of course, it helps us deliver those shots.
However, despite the fact that pandemics having no political persuasion, a lack of political will has hindered our efforts to fight COVID. Since March 2020, we have seen – and continue to see – COVID being made into a political issue when it should have only ever been seen as a reason to come together on a global scale. SARS-CoV-2 originated in one country but made its way to every country due to the simple fact that we are a global community. And there is no solving the pandemic if we do not think globally and work cooperatively around the world.
But how do you create the political goodwill needed to solve a crisis like this one when the world is so polarized? How do you ensure that vaccinations take place in environments that have been overrun by vaccine hesitancy?
We live in a world where politics divides us. We also live in a world that lacks scientific literacy and misunderstands the scientific process. Anchoring bias can lead us to adhere to the very first opinion we hear regarding any given topic. All of this has been far too evident during COVID. After the pandemic emerged, some people felt confused and betrayed when official guidance was naturally adjusted as new evidence and data emerged. Meanwhile, some people cherry picked data to feed their own narratives and agendas. They began embracing and spreading falsehoods and competing narratives that led to "solutions" completely unsuited to addressing COVID.
When people are unwilling to take a vaccine proven to save lives and instead turn to horse deworming pills with no scientific evidence to support their effectiveness, we’ve let ourselves be guided by that which is not fact. Alan Hinman, who for many years was my boss at the US Centers for Disease Control and Prevention, used to say ruefully that "anecdata will always triumph real data," which is somewhat understandable since human beings are storytellers. We often believe the things we hear. And, worse, we tend to place ourselves at the center of our own echo chamber, precisely so our beliefs can be reinforced.
But what if we used anecdata – which is information or evidence based on personal experience or observation rather than systematic research or analysis – to illustrate real data, and harnessed it to inform our scientific literacy for the common good?
I will never forget when I first became director of the U.S. Immunization Program in 1988, and I was summoned to Israel, which was having a polio outbreak at the time. Israel had switched from the Sabin polio vaccine to the Salk polio vaccine a few years earlier. Children who had been vaccinated with the Salk vaccine were still getting infected and transmitting the wild poliovirus to others, even though they did not get paralytic polio, which led to the outbreak. I left Israel thinking we needed to continue the Sabin oral polio vaccine in the US. The Sabin vaccine consisted of live weakened polioviruses. While the Sabin and Salk vaccines were highly effective in preventing polio paralysis, the Sabin vaccine was more effective at preventing transmission if someone got infected because the Sabin vaccine induced higher levels of intestinal immunity. While the Sabin Vaccine had very rare adverse effects – during the 90s, about 8 to 10 people a year in the U.S. were paralyzed from the vaccine – its benefits far outweighed its risks. The risks seemed very small, about 1 in every 2-3 million doses of the Sabin Vaccine used. In contrast, the benefits of the Sabin vaccine seemed super high. There had been no polio epidemics in the US since 1979.
But the risks were not just small numbers. That became apparent in the mid1990s when, at a meeting of the Advisory Committee on Immunization Practices ACIP), those 8 to 10 people went from being data in a printed table, to anecdata. They came before the CDC, horribly crippled, to prove that we should invest in a potentially safer alternative. Overnight, we went from supporting the sole use of the oral Sabin vaccine to supporting use of the inactivated (killed poliovirus) Salk vaccine, which could not cause polio. This was because those numbers were real people. That's an example of an anecdote that, in essence, changed public policy for the better.
Anecdata is powerful – and has a tendency to stick. In the United States, the COVID vaccines were developed in record times, with researchers working night and day to conduct trials faster than ever before. That was the story. But after the effort was named Operation Warp Speed, perhaps to drum up pride and enthusiasm, many ended up believing the vaccines were unsafe because they had been developed so quickly.
But anecdata can also help us deliver the right message about data, especially when we use the right messengers and channels. In the case of COVID, our research should not only have included how to develop vaccines but also how to ensure their acceptance and uptake. By investing in understanding people’s attitudes, we could have learned what might have helped change their minds. Investing in those who are trusted to deliver important messages is also essential.
I was seven years old when the polio vaccine became available and I was not very happy about having to take it. But I will always remember my mother saying to me: "Better you should cry than I should cry." It was her form of anecdata, delivered to a young boy in clear, compelling and, ultimately, convincing manner. In many ways, it’s what we’re missing today. Shunning anecdata won’t help us end COVID. Fighting it – and even using it for good – just might.
Dr. Walter Orenstein is the former director of the United States' National Immunization Program and the former Assistant Surgeon General of the United States Public Health Service. He co-authored the textbook "Vaccines" along with Paul Offit and Stanley A. Plotkin and is currently a professor of infectious diseases at Emory University. He also served as Deputy Director of Immunization Programs at the Bill and Melinda Gates Foundation between 2008 and 2011.