No Man (Or Country) Is An Island

A reflection on autonomy and solidarity

The science of decision-making is fascinating. Economics posits that individuals are 'rational actors' - meaning they make decisions based on a rational thought (prioritizing where their utility is maximized). This process is based on the assumption of a measurable and objective logic. But I think that in reality, the logic process of individuals is actually quite...squishy. Rather than being objective, the lenses, the philosophies, and experiences that influence the way people look at the world in turn affects their 'logic.'

As a result, behaviour change programmes often aim to affect the decision-making of individuals by influencing this 'logic.' This could be through more passive information campaigns or more active design 'nudges' (such as the iconic example of choice architecture being used in school cafeterias where placement of various foods influenced the consumption of different items). An important component of these behaviour change interventions is behaviour change communication. This is communication that aims to affect the knowledge, attitudes, beliefs, or norms of individuals or societies and we see it all over public health interventions and more. And in the case of public health, part of this may involve sharing new or relevant scientific findings or information to large populations.

But unfortunately, what scientific communication often lacks (as is the nature of any mass communication) is the ability to have an actual conversation, to spark discourse and truly reciprocal exchange. As a result, we end up with this one loud blow horn as thousands of murmurs and side chatter build up while that initial message disperses. (I want to say up front that I do not intend for this post, or anything I share really, to fall into that same trap of one-sided communication. I would love to have a conversation). We see and talk about the failings of scientific communication over and over again - and especially throughout the COVID-19 pandemic. From misleading guidelines to the misrepresentation of non-peer reviewed findings on treatment options combined with the novel and evolving nature of the problem, it has not always been easy (and often not possible) to communicate one objective truth.

Right now, there is an abundance of research trying to understand the perceptions of the COVID-19 vaccine in populations around the world - their reasons for acceptance, refusal, indifference. And while I find that work really interesting (biased by my time as a researcher with the Vaccine Confidence Project), the purpose of this post is not to address those factors or reasons or to sway anyone to do anything. Any decision-making process, especially one involving risks, comes down to determining whether the benefits outweigh the harm. From my own perspective, it is very likely and even understandable that an individual faced with the choice of whether or not to get a vaccine will choose not to because the individual perceived benefit may not outweigh the perceived risk. But in times of global crisis, this leaves out an integral piece of the equation to be considered -- the societal or communal benefit.

When we talk about vaccination as a response to a disease outbreak it's important that we (the 'science communicators' which in the case of an emergency is not only scientists and health professionals but also politicians and the media) frame it and reiterate its use as a public health intervention. In this way, getting a vaccine is not the same as getting (or refusing) treatment for a chronic disease. I think one of the closest examples to an epidemic vaccination programme would be the use of maternal vaccinations (specifically pertussis and tetanus in high income countries where these diseases are not as common). These vaccines (Tdap) have become standard of care in most countries, as a recommendation from the World Health Organization. Yet, maternal vaccination decision-making is not necessarily the same as adults getting their annual flu shot or even parents deciding whether or not to get their schoolchildren the MMR vaccine. This is because when a pregnant woman considers vaccinations, she is also taking into account the effect on another individual - her baby. She may be concerned about potential risks or side effects for herself, but also for her baby. But the same goes for the benefits or protection offered by the vaccine. When we think about getting a vaccine as a response to a disease outbreak, we also consider the effects on the people around us.

A non-health related example of individual choices with further reaching consequences is voting. Voter turnout rates in the United States are infamously low. Many have tried to understand or explain this behaviour and have even presented models to capture it. The calculus of voting theory suggests:

V = pB + D > C

A person is likely to vote when the probability of their vote literally swaying the results times the benefit of voting (or of one candidate winning over the other) plus the goodwill feeling of completing your civic duty is greater than the cost

Understandably, very few people probably expect their vote to be the deciding vote. But there's this 'mob mentality' we risk falling into - if we all felt like our vote didn't matter, then none of us would vote because we expect there to be plenty of other people voting. And yet, when all those votes amass, when all those individual pieces come together, that's when we see a change in outcome that affects a community or a country. Vaccination interventions are the same. The more people who are vaccinated, the fewer opportunities there are for rampant disease transmission, and that affects the entire population. In this way, an individual's choice does not then reflect an individualized risk. Our actions affect not only ourselves but those that we come into contact with in our communities. It's the same reason we respect traffic laws and have regulations against drunk driving. Our behaviours on the road, while they may be an individual choice, these actions have consequences far beyond the individual. We may be autonomous, but no man is an island.

For this same reason, equitable allocation of vaccines around the world is vital to any pandemic response. Though we may be separated by oceans, our world is so globalized that the challenges (in this case, variants) facing one community may quickly become a very real threat elsewhere. While several countries hoard vaccine supplies, high income countries have vaccinated over 50% of their populations and low and middle-income countries (LMICs) have only been able to vaccinate 1-15%. Global health experts around the world fear that recent announcements regarding booster shots will only further encourage and entrench the deep disparities in vaccine distribution that we already see. There are certainly other barriers to be considered regarding vaccination rollout in a number of LMICs, such as infrastructure - but none of this matters if they are not able to even access or procure these supplies.

This is not a new or surprising challenge. We saw similar patterns play out around avian influenza in the 2000s, characterized by a particularly memorable showdown between Indonesia and the global community (or perhaps it's only memorable to me because my global health hero David Heymann had us essentially role play this incident in our Globalisation & Health class two years ago). Annual flu shots are informed and designed with the input of various strains of influenza. This variable 'influenza cocktail' and the rapidly mutating nature of influenza viruses is why some years the flu shot is a little less on the nose. In 2007, when concern of a potentially pandemic-inducing strain of influenza was brewing, Indonesia refused to share their samples of their viral strains citing the fact that even though they contributed these viral strains they were unable to access any of the vaccines produced because they had already been claimed (paid for) by larger, richer countries. This sent shockwaves throughout the global health community, initiating some important negotiations at the World Health Assembly regarding material sharing and vaccine access, and has become a case study for global health diplomacy and multilateral agreements. Unfortunately, the last 18 months have shown us that in times of crisis, it is very easy for countries to fall back on the 'modus operandi' of nationalism and self-preservation. However, in the case of this global crisis it is important to remember that even 'self-preservation' is not possible when such inequity exists because it further perpetuates the threat.

Last year, I wrote about my reflections on how some described COVID-19 as an 'equalizer.' I referred to some of the calls for solidarity, "we're all in this together." It often feels like this has become an anthem for so many as we deal with challenges of working from home, COVID-19 fatigue, exhaustion, and mental health challenges we may never have expected. Well, now is the time to put our money where our mouths are (maybe literally?), to be in this together, to encourage not only national but also global solidarity.