Hesitancy

Acts of public defiance towards public health efforts have been observed throughout history. In colonial Africa, public health teams seeking to eradicate sleeping sickness by extracting lymph fluid from the neck of suspected patients were consciously avoided. People would flee to escape the mobile public health disease eradication teams, or persuade traditional physicians to remove their lymph nodes so that they would not be subjected to the dreaded needles.

Smallpox immunization campaigns in the late 18th century in the United States were met with bitter opposition. In a seminal case of resistance to state vaccine mandates, in 1905 Henning Jacobson appealed to the US Supreme Court having refused the smallpox immunization for himself and his son claiming bad reactions to earlier vaccinations. The Supreme Court ruled in favor of the Cambridge Massachusetts Board of Public Health, granting states the authority to mandate vaccination if deemed necessary for public health or public safety. Immunization could not be physically forced and fines for refusal were imposed.

In northern Nigeria in 2004, a campaign to eradicate polio was abandoned temporarily due to widespread rumors that the vaccine was a western plot aimed at sterilizing Muslim women and infecting children with HIV. In Pakistan, Taliban leaders refused entrance of polio vaccination teams in protest against US drone strikes. In Afghanistan, where villagers lack access to basic health services and cases of childhood malnutrition and maternal deaths are widespread, expensive polio vaccination campaigns to contain a dozen annual cases are inconsistent with community needs.

In my own work in Lesotho in 2010, I observed the active resistance to the scale-up of medical male circumcision services for HIV prevention, with references made both to national health data that suggested the procedures’ ineffectiveness and the lack of involvement of local healers and community leaders.

In Central Africa, members of Ebola outbreak control teams were physically attacked by local residents. During the 2014 Ebola crisis, health workers (both foreign and local) were challenged, driven out of villages, and even killed.

In the United States, resistance to childhood vaccinations contributed to the “Disneyland” measles outbreak in 2014, which spread nationally. Similar outbreaks have occurred in Canada, countries in Europe, Asia, and Oceana.

While hesitancy varies by situation and context, there are instructive similarities. As Dr. Anita Sreedhar and Anand Gopal, researchers of vaccine hesitancy and access note, when people feel supported through social programs, they are more likely to trust institutions they believe have a stake in society’s wellbeing. Opposition to public health efforts highlight inequities in social services and public infrastructure. And, they reveal the continued disregard of public health practitioners to address inequities in program design and delivery.