Attributing Public Ignorance in Vaccination Narratives

"A concentration on 'ignorant public' narratives thus allows governments to avoid direct accountability for vaccination challenges, and in turn, this deflection of responsibility facilitates a dismissal or denial of the broader socio-political problems that vaccine hesitancy makes visible."

How we frame problems inspires different kinds of actions. The issue of vaccine hesitancy, a growing policy concern across the world, has sparked sensational media headlines that have at times emphasised the irrationality of vaccination-related fears and described those refusing vaccines as ignorant. This study explores how the "ignorant public" narrative frame reduces public concerns about vaccines to a lack of knowledge and, in the process, obscures deeper causes of mistrust and deflects attention away from structural challenges impacting vaccine uptake.

The article begins by setting out the conceptual framework. As noted here, the "knowledge deficit model", when applied to vaccine hesitancy, suggests that the lack of (scientific) knowledge is the problem, with the remedy being increased scientific literacy (e.g., via information and education) to improve public trust. However, this model and the corrective approaches associated with it have been repeatedly critiqued by social scientists and historians who suggest that, for example, framing rumours as mere misunderstandings neglects contextual complexity and the deeper causes of mistrust. Even if it is not possible to identify a particular source and one intention alone in institutions' attribution of ignorance to vaccine-hesitant publics, the authors nonetheless see value in asking what the consequences of the discourses are.

To that end, they investigate the use of an "ignorant public" frame in three vignettes from Sierra Leone, Uganda, and India. The data collection was part of a wider project, AViD, which provides anthropological perspectives on vaccine deployment outbreaks, using geographical case studies. These examples are based on ethnographic fieldwork and media analysis carried out before, during, and after outbreaks of diseases afflicting both humans and animals.

Brief excerpts from each of the vignettes include:

• Sierra Leone: "Ignorance" and vaccination challenges in the Ebola aftermath - "...Field staff tasked with outreach and 'sensitisation' reported difficult encounters, but the reasons for vaccine refusals or delays were strikingly unknown and remained that way. Therefore, ignorance served as a 'catch all' explanation to characterise these encounters....[In contrast, a deeper...] analysis of vaccination challenges would require interventions that engage directly with the structural dimensions of mistrust in vaccination efforts, including confronting fraught relations between service providers and rural communities, rather than simply providing more information about the uses and safety of vaccines. In this sense, the 'demand side' issues require paying attention to similarly larger health system challenges as the 'supply side' issues that tended to be kept separate from the hesitancy question. This makes it financially, logistically, and politically more challenging, in practice, for public officials to engage with challenges to the narrative about ignorant publics....Inadvertently, marginalisation is reinforced by perpetuating the framing of rural publics as uneducated..."
• Uganda: Attitudes to disease control in livestock farming - "...the perception of an ignorant public - specifically, subsistence pig farmers in rural Uganda - has had a detrimental effect on uptake of, and attitudes towards, response efforts to control notifiable infectious diseases such as African Swine Fever (ASF) in pigs....To the Ministry of Health, this was understood as a problem of ignorance, as farmers did not acknowledge their role in the transmission of disease and so were viewed as lacking in knowledge. However, rather than being ignorant, farmers felt that the government was being inconsiderate in their methods. Governments were culling their animals without adequate compensation or sustainable solutions to loss of livelihood, without acknowledging farmer methods of managing disease, and farmers were unsure of government intentions and had reduced confidence in the ability to respond to outbreaks..."
• India: Measles and rubella vaccines and minority publics - "...the 'demand side' has gained attention, with slow vaccine acceptance rooted in ignorant anti-vaccine beliefs being blamed for poor vaccine coverage....However, a longer history of public interaction with health policy, including vaccination can also be traced, for which a diverse collection of religious, social, political, and cultural beliefs deeply impacts upon vaccine attitudes and uptake. Most prominent was the Pulse Polio campaign, launched in 1995...[T]he media and popular depiction of Muslims were as irresponsible, selfish, and 'anti-national', causing continued polio clusters that threatened the wider population....A state-sponsored mass measles-rubella (MR) vaccination drive ran from 2017 to 2018 and is the focus of this vignette....[T]he 'Muslim opposition' to the MR vaccination was identified in news reports early on. The characterisation of opposition was based on a portrayal of age-old prejudices which deemed immunisation as un-Islamic....Lower vaccine coverage among religious minorities is frequently presented as a threat to the immunity of the nation-state, which pits the minority groups against nationalist ideals....Therefore, the government's most negative reference to the vaccinating public was directed to those who spread misinformation or disinformation and the ignorance of those who believed them in the Muslim minority..."

Using these examples, the authors assess how official explanations for low vaccination coverage reproduced by officials and the media contrast with the possibility for more complex socio-political issues underpinning vaccination challenges. Drawing on science communication and development studies, they argue that when institutions tasked with strengthening vaccine uptake see public ignorance as the key problem, this can obscure other problems, such as competing interests and experiences, and also minority group treatment. As a result, public governance is rationalised by assigning the ignorance label to certain public groups that stand in contrast to scientific and government expertise, and so accountability for low vaccine uptake is transferred onto the public. In short, the rhetoric of portraying people as ignorant in refusing vaccination is more palatable to governments and the media than addressing the complex, less controllable entity of public concerns that often becomes aggravated - but also deprioritised - during outbreaks.

The authors suggest that, in order to improve vaccination uptake at a national and international level, there must be more meaningful engagement with public opinion, community experiences, and the complex challenges to immunisation coverage. They outline three steps for policymakers to avoid oversimplistic framing:

1. In analysing vaccine hesitancy, avoid a focus on demand for vaccination and instead address the ways in which supply also influences hesitancy.
2. Conduct formative social science research before, during, and after outbreaks to build a more complex and detailed picture of vaccinating publics and their perspectives.
3. Integrate public engagement into all vaccine deployment programmes in order to understand, build trust, and develop ongoing dialogue - not only information provision.

The authors conclude that "the frame of an 'ignorant public' must be challenged to understand and address the complex intersecting factors which influence health decision-making....As we confront a global vaccination challenge to address COVID-19, these lessons will be paramount in addressing inequity in access to vaccination and understanding of why publics may not vaccinate."