Build Trust, Not Jails, To Improve Immunization

By Ify Aniebo

News that Uganda’s President Yoweri Museveni signed a law that will put parents in jail who fail to vaccinate their children has sent ripples through the immunization community. The law also requires that children must have up-to-date immunization cards to attend school.

Uganda is not alone. Other governments have taken similar approaches against parents who reject vaccination. Australia declared that parents would lose their welfare payments, while France and Belgium declared that parents could face jail time.

However, the coercive Ugandan law is extreme and begs the question: Could the law increase the mistrust of vaccines in Uganda and other African countries? And, if so, could this seemingly bold step derail immunization programs?

The advent of vaccines has ensured that millions of people are protected from preventable diseases. The evidence in favor of vaccination as a safe and effective public health strategy is overwhelming. However, gains in vaccination are threatened by a surge of anti-vaccine groups around the world, including on the African continent.

The roots of suspicion of medical and public health interventions can be traced back to the Tuskegee syphilis study, a clinical trial conducted between 1932 and 1972. In the trial, African Americans were treated like lab rats; they were misinformed about their rights as study participants and were denied necessary treatment. This infamous study contributed to the rise of anti-vaccine groups in America.

Illegal experimentation has occurred in Africa as well. In 1996, Pfizer sent a team to Kano, Nigeria, during a meningitis epidemic to test the efficacy of its new antibiotic, trovafloxacin (Trovan). They conducted an open-label trial involving 200 children—half were given ceftriaxone, the gold standard treatment for meningitis, while the other half were given the experimental drug. When it was evident that one child’s condition was not improving, she was not taken off the experimental drug. Five children who were given trovafloxacin died, along with another six who were given ceftriaxone. In 2001,30 Nigerian families sued Pfizer in a New York federal court, but the case ended in an out-of-court settlement in 2009.

While some of the fear of vaccination in Kano stems from this experience with the U.S. pharmaceutical giant, it has been compounded by the repetition of misdeed and minor retribution with other major drug companies.

Additionally, the distrust of government is almost as bad as that of the pharmaceutical industry throughout Africa. Governments have not always passed policies that have been beneficial to their people. The current health, social, and economic indicators of the majority of African countries are proof of decades of bad decision-making and policies. Given this history, would coercive immunization laws work?

People fear what they do not understand. In Africa, scientists and governments need to demystify vaccines through increased transparency and effective public communication. The controversy over the efficacy, safety, and morality of compulsory immunization stems from the tension between two divergent goals: protecting individual liberties and safeguarding the public’s health. Good public health policies balance both. Therefore, governments must recognize local politics and the diverse social and cultural perspectives concerning immunization policies in order to support the success and acceptance of vaccinations.

Local governments should also establish research ethics committees that work alongside local medical associations to build trust. Immunization campaign programs should be participatory, involving state and local governments, traditional political and religious leaders, and citizens. It is also critical that campaigns are in languages that local populations understand.

Campaigns should involve community health workers as well, as they play a fundamental role at the grass roots level in remote communities by providing care and encouraging healthy behavior. Community health workers could help build and maintain public trust in vaccines.

Finally, pharmaceutical companies should partner with governments to continue public education. In order to address vaccine refusal, they should listen to public concern and discuss the risks associated with non-vaccination.

The Nigerian polio eradication campaign focused on health communication and engaged community leaders who advocated for the protection of children. The eradication of polio exemplifies the efficacy of innovative, community-led campaigns. A similar approach for vaccinations would be more beneficial than passing coercive laws.

We can achieve high vaccination rates in Africa—but it needs be by building trust and not through force.



Ify Aniebo is an Aspen New Voices fellow and a Ph.D. candidate at Oxford University where she is conducting research on malaria. Follow her on Twitter @ifyaniebo.

[Photo courtesy of the PATH global health]

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