What can the infrastructure sector learn from the history of public attitudes to vaccination in a pandemic?

Perspectives with Bruce Hugman from the World Health Organisation’s Uppsala Monitoring Centre (UMC) – an independent centre for patient safety and scientific research

In a pattern close to that of major public health programmes, the infrastructure sector delivers major projects supported by government policy with the aim of addressing societal issues, protecting a population’s wellbeing and achieving progress against global challenges while balancing impacts, all within a political context. To achieve these aims, regulatory, planning, legal, safety and communications risks need to be addressed before this becomes a reality.

©Bruce Hugman         

I am not writing as a representative of WHO or Uppsala Monitoring Centre UMC), but have worked for both for the past 25 years as a communications expert and teacher. WHO plays a major, active role in strategy, guidance and field-work in all aspects of global health; UMC focuses exclusively on patient safety and, among other things, collects data on the adverse reactions patients have to their treatments. The UMC database contains over 20 million reports of adverse reactions gathered worldwide over 40 years since the WHO Programme began. Those represent only a tiny percentage of all adverse reactions experienced by patients.

My job has been to help put communications on the medical and scientific map and to promote the case that failures in communications often underlie problems and failures of all kinds. Our concerns range from the encounter between patient and doctor, all the way through to drug development, national regulation and global public health policy. Effective communications promote health and save lives, everywhere.

This article mentions empathy, among much else. Lest you think this is some woolly, armchair concept, I want to make the case for it now. Empathy is the ability to think and feel like someone else, to see the world from their perspective, for however brief a period. It is not ‘putting yourself in some else’s shoes’, it is experiencing life as someone else would experience it in their shoes. It is not sympathy or concern or compassion; it is a strenuous intellectual and imaginative effort to move utterly outside one’s own reality and into the reality of another. It is achieved by research, engagement, by profound listening and patience. If there were more empathy of this quality in the world, there would be a great deal less strife and alienation, in families and institutions, in politics and economics, and in infrastructure and healthcare.

So, with that background, let’s begin; I hope you will enjoy this short cross-sectoral journey.

From medieval cathedrals to Victorian railways, from the Adirondacks Northway to the 30-metre telescope on Mauna Kea in Hawaii, from dams to bridges, from windfarms to HS2, even foreign embassies in Tower Hamlets and golf courses in Aberdeenshire, great infrastructure and engineering projects have always provoked a measure of opposition, sometimes extreme.

From the first modern vaccination, of an 8 year-old boy with live cowpox by Edward Jenner in 1796, until the present day, vaccination has also provoked opposition, sometimes extreme. Hostility to projects is one of several influential, common features of infrastructure and health that I hope you will find illuminating to explore with me.

This text appeared in the synopsis for the webinar:

‘The infrastructure sector delivers major projects supported by government policy with the aim of addressing societal issues, protecting a population’s wellbeing and achieving progress against global challenges while balancing impacts, all within a political context. To achieve these aims, regulatory, planning, legal, safety and communications risks need to be addressed before this becomes a reality.’

These very words describe equally accurately the enterprise of public health, where ‘projects’ are focused on delivering healthcare programmes or services of one kind or another within a comparably complex context of demands and risks.

Effective risk management and programme integrity in vaccination are matters of life and death: over the centuries, hundreds of millions of people died from smallpox, even through the 20^th century until it was declared eradicated through vaccination in 1980; overall, the life-saving capacity of vaccination is stunning: WHO reports that immunization currently prevents 2-3 million deaths every year from diseases like diphtheria, tetanus, whooping cough, influenza and measles, as well as millions of hospitalisations.

When things go wrong in vaccination programmes, when risks are not anticipated or well managed, people become infected or die from direct or indirect effects:

• scores of health workers distributing polio vaccine have been killed on the Pakistan-Afghanistan border
• a boycott of polio vaccination in northern Nigeria led to re-emergece of the disease
• problems with the dengue vaccination programme in the Philippines led to a loss of faith in vaccination in general
• in Europe and the US loss of confidence in the measles, mumps and rubella (MMR) vaccine led to outbreaks of measles and the death of children
• ebola projects were recently being stymied in DRC because of rumours of foreign plots and threats to health
• substantial numbers of people in the West indicate refusal or likely reluctance in relation to a Covid-19 vaccine.

What can we learn about risk management from these compelling and troubling facts?

The complexity of public perception:

There are a few fundamental truths about public perception and opinion about infrastructure projects, vaccination or any issue in society that we all need to keep in mind:

• Heterogeneity within society and within individuals
• Everyone assesses risk differently and inconsistently
• Opinions and perceptions are driven less by facts and reason than by emotion and political, religious and other affiliations (for example, denial of climate change and the politicization of mask-wearing in the US)
• Patterns of opinion and perception tend to cluster together, especially under the influence of social media; such clusters are powerful determinants of loyalties and opinion
• Confirmation bias, that is the tendency of every one of us to rally round those who share and confirm our opinions and to dismiss or re-interpret opinions or facts that challenge our views (we all do it, however clever we think we are)
• Fundamentalists, especially at the hostile end of the spectrum, are usually small in number but effective in making themselves heard.

Perception and opinion are strongly influenced by variables that we must factor into our planning and communications by accurately identifying and targeting them:

• The degree of trust in the entity or company making the proposition in health or infrastructure
• The degree of audience engagement with or alienation from the current proposition and/or previous comparable historical events
• The degree of felt inclusion or exclusion within society as a whole (for example, President Trump’s base embraces many who have felt excluded from dominant US society; many people in parts of the UK feel left behind from the prosperity of the nation; BAME citizens are often severely disadvantaged in their communities)
• Multiple socio-economic, demographic, ethnic, gender and other issues and poverty
• The immediacy of the risk or threat, its novelty and dreadfulness
• Risks related to children
• Conservatism, that is the urge to resist change, especially in the midst of uncertainty
• The seeding of doubt (this is what the tobacco companies did for decades after the lung cancer facts were established beyond question; what China is trying to do about the source of Covid-19; and a major tactic of climate change deniers)
• Vivid, emotionally-charged stories (real or imaginary medical injuries or deaths; infrastructure disasters of one sort or another)
• Group allegiance; political, religious, identity and other affiliations (especially through social media)
• Scientific, technical and statistical illiteracy
• The views of influencers and celebrities for good and ill
• Media reporting of variable integrity and quality

There is a small, but highly vocal group of fundamentalist anti-vaccination campaigners across the world who embrace a variety of beliefs: religion, hostility to science and scientific medicine, belief in natural remedies, distrust of governments and the pharmaceutical industry, doubts about efficacy and safety. Between them and vaccine supporters are large numbers of people who maintain a degree of agnosticism, sometimes known as ‘vaccine hesitancy’, who may be amenable to persuasion one way or the other, especially by those who pay them serious attention. We should pay a great deal of attention to this large intermediate, undecided group and never assume that the loudest voices represent the majority.

Although vaccination rates in the UK are generally quite good, maybe a third of the British population say they are either uncertain or very unlikely to agree to be vaccinated against COVID-19, and this includes some health professionals. Herd immunity is at risk if the threshold of (probably) 70-80% coverage is not reached.

If we look at some of these issues in relation to preparations for rolling out a Covid-19 vaccine (or any other project in public health or infrastructure), there are some very clear pointers to action in risk management measures:

• Trust and engagement are essential: built over time through meaningful engagement with audiences, transparency, reputation and a track record of positive achievement
  • In terms of individual decisions, for example, people are particularly amenable to the advice of their own doctors or local leaders whom they know and trust; beyond that, other channels are much less predictable, though informal ones tend to be more influential than official ones
• Recognition that trust cannot be established simply by centralized, top-down communications, though inspired leadership can have beneficial effects
• Building trust on the basis of respectful attention to feelings and opinion, by listening, by empathy and authentic, targeted, calibrated responses in people’s preferred language; listening to everyone, not just the loudest voices
• Engaging trusted intermediaries, such as celebrities, religious and community leaders in messaging (the NHS is planning such a campaign for Covid-19; Birmingham is engaging ‘Covid Champions’ to promote the case; ex-presidents in the US are volunteering to be televised when they are vaccinated)
• Understanding that trust cannot be established overnight by strangers.

With vaccination, the perceived risk may not be the distant risk of sickness or death from an infectious disease (as a species, we are very poor at envisaging distant risks), but from the immediate insertion of needles into infants. Babies and adults are, after all, healthy when they get vaccinated. Covid-19 aside, in the West, we live in an era when the ravages of infectious diseases have not been seen at first hand by most people. As a result, exaggerated immediate risks or very rare adverse effects, or other fears, become more potent influencers than the diseases themselves. Once this conviction is established, it retains its potency even in the face of a pandemic and the daily evidence of sickness and death. Fake news promotes disinformation about all aspects of reality, including the existence of the virus itself.

There has been a decline in trust in politicians and experts; there is widespread cynicism about corporate standards and the motive for profit; and there are common beliefs about corruption and cronyism in national affairs There are well attested examples of both. Big, remote, powerful entities, like governments, public health systems and corporations can provoke suspicion or hostility just because they are big, remote and powerful – and because they sometimes do terrible things. This perception and its effects are risks that must be managed.

People have long memories for problems and failures: in infrastructure projects, disruption and delays, cost-overruns, aesthetic challenges, fires, collapses, and so on, rare though they are. The revelations of the Grenfell enquiry are currently doing inestimable damage to the reputation of the building industry. Similarly damaging in health are medicines safety and other scandals (like thalidomide, Vioxx, Valproate, vaginal mesh, benzodiazapenes, opioid painkillers, the 1976 US flu vaccine debacle), as well as abuse and incompetence in hospitals and care homes; rare though these are too, they stick in the public’s mind and shape opinion.

If you add the chaotic mismanagement of the pandemic and the appalling communications in the UK, US and other places; what some see as the risks of the unholy and dangerous rush to find and approve a novel vaccine for a new disease; questions about the competence of the government and the health service to operate track and trace and to cope with the huge logistical complexity of mass vaccination, it is not surprising that many people are anxious.  I’m anxious. The coming together of multiple past memories and present doubts is a powerful recipe for loss of public confidence. It needs research, acknowledgement and active and highly skilled management.

Political and official blindness and deafness

Responses to the anti-vax movement have often been naïve and counterproductive. A belief that anti-vaxxers are ignorant and stupid has influenced the tone of communications (‘total nonsense’ said the PM dismissively on 11 November), in spite of the fact that many leading lights are intelligent and well educated, some of them qualified doctors and scientists. They are wrong, but they are not stupid. Cascading safety data and generalized assertions of benefit entirely miss the target.

Much the same issues apply to opponents of infrastructure projects: some may be malicious or ideological, but the majority are likely to be honest, conscientious citizens acting on the best information they have and on what they regard as the best interests of themselves and the community. Their arguments and feelings have to be taken as seriously as their actions and negotiated and managed, face-to-face.  We need to know how far any hostile group is representative of their communities.

The vivid video of a distressed mother who claims her child’s autism or neurological damage or death was caused by the vaccination she trustingly agreed to cannot be rebutted by any amount of data, nor by the essential (but counterintuitive) truth that temporal association does not equal causation.

The truth is that short term, mild side effects of vaccination (inflammation of injection site, slight fever or headache, for example) are common, while serious reactions (usually allergic) are vanishingly rare (one or two per million doses). (On the first day of the Covid vaccine roll-out there were two reported adverse reactions, probably allergic, from which the individuals recovered quickly. The regulator has since offered guidance that anyone with a history of allergic reactions to food, medicines or other substances should not be vaccinated.) It is the case that rare side effects do not usually become known until very large numbers of people (hundreds of thousands) have been vaccinated or have taken a new drug over a long period of time (months or years), so there is always some measure of uncertainty, something we manage very badly as a society, always seeking a black or white answer. Serious side effects may be very rare, but anxious parents don’t necessarily believe that and they worry that it will be their baby that’s the one who suffers.

Communications

There is a considerable risk of disconnect between centralised, top-down planning and communications and the reality on the ground. Politicians, officials and corporate executives, engineers and scientists, can be blind to the complex reality of their audiences and to ways of developing the kinds of communications that might reach and engage them. Good communications are as complex as bridge-building, and a single person or department rarely has the ability to do both well.

There is always a risk of failure if there is not a serious, on-the-ground commitment to early research and listening. One of the tragedies of the current crisis is that both the US and the UK had very sophisticated pandemic preparedness plans and teams that were defunded or abandoned as recently as 2019. It is too easy to neglect investment in planning for risks that seem remote.

Although an infrastructure project may go ahead in the face of opposition, no company wants to carry a negative reputational legacy once it is completed. Avoiding or mitigating that risk, and building reputational strength for future projects, may depend crucially on the company’s insight and understanding of the objections and on the quality of the process of face-to-face engagement and communication through every stage. One complexity, of course, is that objections to a project may be ideological or political that the company cannot hope to resolve. However, the degree of empathy, the extent of willingness to listen, to negotiate, to make concessions, to manage problems, and to admit mistakes, will have a huge impact on public perception of any project and on future projects too (this is also true in healthcare). Nevertheless, we have to accept that there will be some, usually a small minority of objectors, sometimes a larger number, who will never be won over to supporting some infrastructure projects or to consenting to vaccination.

Societies have become more individualized, more fragmented, more tribalized and partisan in recent years. There are goodness and generosity, but preoccupation with self is rampant. Alienation and inequality have increased; deference to experts and authority figures have declined; social media and the internet have fundamentally changed the way people define themselves, cultivate their opinions and assess facts and information; fake news, conspiracy theories and disinformation have erupted everywhere.  We need to be aware of these destabilizing trends and their implications for us; we have no choice but to be energetically engaged hour by hour in monitoring and participating in multiple channels, especially social media. This requires clever, busy, agile staff.

The argument for vaccination relies on two equally important objectives: protection of the self or children from infection and disease; and the phenomenon known as ‘herd immunity’, the protection of society at large from the spread of infection and the sickness and death of others. Sadly, the possibility of exposing other people to potentially fatal infection does not seem a sufficient motivator to get vaccinated for a percentage of the population.

No medicine or medical procedure is risk free; every pill you take has the potential to harm you (every year millions of patients worldwide are harmed by their medicines) and, rarely, to kill you (this is true even of penicillin, for example). The ethical purpose of shared decision making with patients is that they understand the benefits of potential treatments and their risks. Accepting any treatment at all means accepting some measure of risk; the calculation will be different for every individual.

A similar computation of benefit and risk happens in the public’s assessment of infrastructure projects and there will be a similar range of varying opinion about the extent of benefit and the extent of risks and losses. Any doctor or drug manufacturer who says ‘This drug is safe’ is, at best, making a misleading and unjustifiable assertion, at worst lying. Any contractor who says ‘This project is without negative impact’ is in much the same ethically dubious category.  Both players risk, in due course, exposure as irresponsible and untrustworthy and being added to a blacklist for the future. We need to remember also that almost all projects have unintended and unforeseen consequences. Covid, for example, has led to a huge backlog in cancer treatment in the West, and, in developing countries, to diversion of scarce resources, away, for example, from treatment of HIV/AIDS; the mental health of young people has been deeply damaged; in the bizarre category of unexpected harm, 398 people in the UK have died after ingestion of hand-sanitiser since January this year. Planning has to be radically imaginative to anticipate and take account of these kinds of consequential risks.

In relation to an infrastructure project, people may need to be encouraged to make the difficult benefit-risk assessment that the benefits to the common good outweigh the risks or losses to me, the individual citizen, exactly as we might hope to persuade a reluctant parent to vaccinate their child. Big ticket projects may draw attention to local deficiencies and intensify this conflict.

We must assume that a mother whose child dies of measles after she has refused to have them vaccinated, would feel substantial measures of grief and regret. That may be one of the stories we should exploit in promoting vaccination.

I mention this because I think that grief may be a powerful emotion that exercises some infrastructure project opponents: the loss of woodland or a much loved tree; the loss of parts of a familiar landscape; displacement from home; the disruption or destruction of daily routines; the impact on wildlife; all some kind of version of death. These are all unique, profound sensations which are rather more amenable to therapy than the blandishments of public relations. If I am right in this speculation, then it has implications for the way we deal with opposition in the early stages, throughout the project and in the aftermath of completion. This is just one more of the influential and complex existential risks that has to be recognized and managed.

Conclusion

My concluding key points to this rich and fascinating set of problems, relevant for infrastructure and public health, are:

• Communications in advance of major projects or programmes, and throughout, require sensitive and intense on-the-ground, face-to-face research about the multiple variables of public attitudes, loyalties, values and beliefs (standard consultation and online or postal surveys fall far short)
• The profound influence of memory, contemporary culture and social media on public opinion must be recognized and managed, principally by engagement that is rapid, empathetic, respectful and finely calibrated; ‘rapid’ means next to instantaneous
• Public assessments of benefit, risk and loss must be factored into the arguments for any proposition, including admission that not all benefits may be realized or universal, not all benefits may be perceived as outweighing the losses, and not all losses can be ameliorated
• In our communications we must seek to be trusted, through transparency, empathy, consistency, honesty, accuracy, genuineness, speed; even if in the end we are unable to reconcile all parties, we do not want to be remembered as heavy-handed, distant, neglectful, arrogant, for such an assessment would deeply damage our future prospects and those of the industry or of public health as a whole.

These principles may result in:

• Reduction of hostility and lessening of obstacles
• Facilitation of engagement and negotiation
• Persuasion and conversion of some opponents and alignment of the undecided
• A reduction in lasting antagonism, bitterness and resentment
• The enhancement of reputation
• More people looking favourably on projects and more people getting vaccinated

Before I finish, let me just reflect briefly on the extraordinary event of this week: the first vaccination of a UK citizen against Covid-19. This rapid, scientific triumph is built on years of slow, anonymous, painstaking foundational research. The story of coronavirus and the vaccine have now been told to us by a multitude of experts and scientists. Even with some distracting interventions by politicians, there has been a continuous narrative in which we have been able to locate ourselves and through which we have been able to make judgements and envisage the future.

There has rarely been much of a narrative for infrastructure’s great projects, or for its little ones. We never hear about the years of thinking, designing, planning, and imaginative risk-taking that the geniuses of the industry routinely deploy; nor do we hear an authentic voice of the industry as a whole or of the contractor on our doorstep. The British don’t respond well to having rules or changes imposed on them or having what they see as their rights damaged or taken away. Mandatory vaccination would provoke opposition even among some vaccine supporters and would cascade fuel on the fire of opponents’ protests. Infrastructure and public health, both having such massive impact of the lives of the nation, must tell a good story which touches people’s hearts and minds and makes them glad to travel with them.

About Bruce Hugman

Bruce Hugman

 

Bruce has written extensively on healthcare communication, particularly in patient safety, risk communication and crisis management; he has published a dozen or so books (law, sociology, criminal justice, literary criticism, biography) and multiple articles in professional journals and chapters in edited collections. He teaches and lectures in many parts of the world. He has taught English and social studies in schools and universities; worked in criminal justice as a probation officer; held senior communications posts in the public transport sector; and ran his own communications company in the UK for ten years. He lived in Chiang Rai, Thailand for eighteen years, now settled in Oxford.

 

He has recently spoken and presented on the contemporary threats to science and evidence and on the corrosive threats of fake news. His principal books in the field of healthcare are Expecting the Worst (a crisis management manual for healthcare) and Healthcare Communication, a textbook for all sectors of the field.