What History Can Teach Us About Vaccine Hesitancy

Andrew Carnegie Fellow Prerna Singh is working to develop a moral theory of popular compliance with public health interventions

By Carnegie Corporation of New York October 19, 2021

Andrew Carnegie Fellows

Prerna Singh

Prerna Singh, a 2018 Andrew Carnegie Fellow, is Mahatma Gandhi Associate Professor of Political Science and International Studies with appointments in the School of Public Health and the Department of Sociology at Brown University. She is the author of How Solidarity Works for Welfare: Subnationalism and Social Development in India and the forthcoming Corporation-supported “Moral Vaccination: The Control of Contagion in China and India.”

An award-winning writer on human development, public health, ethnicity, and nationalism, Singh has been awarded fellowships by the American Academy of Berlin, the Center for Advanced Study of Behavioral Sciences at Stanford University, and the Social Science Research Council, among others, and she has shared her research in more than a hundred talks delivered in 20 countries around the world.

Her Carnegie-supported book develops a moral theory of popular compliance with public health interventions, such as vaccination, through a comparison of China and India from the turn of the 19th into the 20th century. In the Q&A below, Singh explains how she came to study the societal impact of pandemics, and what history can teach us about vaccine hesitancy and communication around contagion.

How did you come to study pandemics?

The study of pandemics represents a continuation of my interest in two main research areas: human development and state-society relations.

In my first book, How Solidarity Works for Welfare, I sought to understand variation in education and health policy. In my new Carnegie-supported book, I focus on the challenge to well-being posed by infectious diseases. Since settled agriculture and the domestication of animals, germs have not only been the single largest cause of human morbidity and mortality, they have also decisively shaped the trajectory of world history, precipitating the collapse of mighty empires, triggering economic reversals of fortunes, and prompting societal upheavals.

While the 20th century was marked by unprecedented medical advances in research and treatments, we continue to confront a serious threat from a host of deadly diseases. The COVID-19 pandemic is only the starkest reminder of this vulnerability.

In addition to their challenge to human welfare, a second reason I focus on pandemics is because infectious diseases provide a critical, if relatively underutilized, analytical prism through which I can examine a topic at the core of my research: the relationship between states and societies.

Historically, the control of disease has been an important driving force for the development of states. Charles Tilly famously argued that wars make states. And yet, historians have shown that in as much as military conflict, it has been war against an often more deadly foe than an enemy army — disease — that historically prompted the extension of the state into previously autonomous societal realms and encouraged the development of state institutions.

On the one hand, pandemics prompted the development of institutions of control, notably civilian law enforcement agencies like police; customs, migration, and intelligence services for the surveillance of people and goods; and implementation of quarantine and separation — often forced — of victims and families. Pandemics led to the establishment and strengthening of health bureaucracies, including city health boards, that marked the exertion of unprecedented state power over societal actors like the church. City boards overruled the clergy in prohibiting festivals, processions, and gatherings. On the other hand, contagion also encouraged the development of institutions of care, such as poor laws, and relief for the needy.

The control of disease, and healthcare in general, has gradually gone from being recognized as something within a state’s jurisdiction, to a key responsibility of a state toward its people.

However, state attempts to control disease have historically been deeply fraught processes. This is because to a much greater extent than other state tasks, a state’s capacity to control disease rests critically on its ability to gain compliance from society.

In my Carnegie-supported book, tentatively titled “Moral Vaccination: The Control of Contagion in China and India," I focus on the control of contagion to develop a typology of state capacities based on the degree to which they are contingent on popular compliance. In such a typology, the control of infectious diseases belongs to a set of tasks, such as collecting taxes and raising an army, and unlike other tasks (i.e. the formulation of macroeconomic policy, the building of infrastructure, and the dispensation of justice), the capacity of a state to realize its aims hinges critically on its ability to elicit compliance from society.

States’ strategies to ensure such compliance range on a spectrum from coercion to cooperation. In their attempts to control disease, states have frequently relied on various forms of coercion. Following Foucault, generations of scholars have analyzed state interventions in public health as constituting “bio-power,” a particularly pernicious type of control over their people. Yet, in addition to raising ethical questions about the curtailing of individual liberties, coercion is both a materially and politically costly strategy. Coercive state interventions against disease, ranging from quarantines to compulsory vaccination laws, have provoked popular discontent, conflict, and even violence, threatening the legitimacy and stability of states. There is also much research questioning the efficacy of such coercive policies in attaining their stated goal of controlling disease.

In my book, I argue that variations in the effectiveness of the control of disease rest critically on differences in the nature and extent of popular cooperation with health interventions. What are the factors that encourage or deter such societal compliance? Why have some polities been able to better gain the support of residents? As we continue to confront the most serious public health emergency of our times, these are questions that are as empirically urgent as they are theoretically salient, lying at the very core of the subfield of comparative politics.

How did your Andrew Carnegie fellowship provide support for the work that you are doing today?

My Carnegie-supported book explores the factors that encourage and discourage societal compliance with public health interventions by following the trajectory of the vaccine against smallpox. This vaccine was a landmark. It was the world’s first vaccine. Discovered by Edward Jenner in Britain in 1796, the achievement was itself built on the technique of developing smallpox immunity through variolation that was well-established in China and India by this time. The global dissemination of this vaccine — which gave rise to the term “vaccine” itself — eradicated smallpox, the oldest and deadliest of human afflictions, and the only human disease to have been eradicated to date.

This vaccine was simultaneously carried to the shores of China and India a few years after Jenner’s discovery by the East India Company. From there, it was met with varied receptions. I compare these differences in popular responses to the smallpox vaccine in China and India from the time of its arrival at the turn of the 19th century to the eventual eradication of smallpox in both countries in the mid-20th century. This comparative historical analysis has required intensive archival research across libraries, archives, and institutes in China, India, the United Kingdom, Switzerland, and the United States. The Carnegie fellowship has been invaluable in providing me the leave and resources to be able to carry out this research.

How do some of your findings apply to COVID-19? What should we be paying more attention to in the current crisis?

The development of the COVID-19 vaccine is a remarkable achievement. Anyone in the U.S. who wants a COVID-19 vaccine can now get one. But it’s also clear that millions do not want one. We cannot attain the herd immunity required to overcome the COVID-19 pandemic without overcoming vaccine hesitancy.

Disinclination for the COVID-19 vaccine is, on the one hand, part of a recent global turn away from vaccines. Such vaccine hesitancy has led to a resurgence of potentially deadly diseases such as measles, and is identified by the WHO as one of the gravest threats to public health today. On the other hand, opposition to vaccines is as old as vaccines themselves. This is why my research holds valuable lessons for countering hesitancy to the COVID-19 vaccine, and in broader terms.

The main insight from my research is that vaccines are more likely to be accepted when they are communicated by a trusted institution and linked to established beliefs, norms, and values.

Key to the ready uptake of the Jennerian vaccine in China, for example, was its endorsement by the local gentry, an institution with a long legacy of trust and authority. And because the vaccine was creatively linked to the principles and practices of traditional Chinese medicine. Notably, the incision into the arm by the vaccination lancet was linked to the familiar needling technique of acupuncture. Vaccination manuals used ornate illustrations in traditional drawing styles to show vaccinators how to make incisions to move the “vaccine Qi” along acupuncture meridians that corresponded with smallpox. The customary cooling diet (smallpox was seen as a “heat disease”) was maintained, and traditional herbal formulas were prescribed to accompany the vaccine.

In contrast, the vaccine was met with a far cooler association in 19th-century India where it was neither embedded in credible channels of communication, nor in traditional medical knowledge and customs. At the time — and even to this day —diseases were commonly associated with deities. In 19th-century India, a very important reason for the rejection of the vaccine was that it was an affront to the goddess of smallpox, Shitala. Interestingly, medical historians note that in the cases that Jenner’s vaccine was accepted, it was often “desecularized” and accompanied by rituals: an auspicious day was chosen, the vaccination was accompanied by incantations to Shitala, and patients adopted the traditional smallpox diet of cooling foods. Fast forward more than a century, to the 1970s, when culturally astute CDC epidemiologists like Larry Brilliant used a repertoire of creative strategies including posters, puppets, visits to temples, and participation in religious fairs to frame the WHO’s smallpox eradication campaign as a propitiation of Shitala.

My work suggests a move away from the dominant scientistic model of vaccine communication. Vaccine hesitancy, by this model, is due to a lack of information. Therefore, the path to overcoming it should be paved with communication around the workings, efficacy, and safety of vaccines. Yet we know that facts don’t change our minds. Studies show that providing people more information about vaccines is not only ineffective, it can backfire.

My book suggests a move away from humans as rational actors who process information in neutral, Bayesian ways, and maximize narrowly defined interests. Instead, it begins with a view of humans as moral actors, who process information in biased, motivated ways that are in line with established norms and worldviews, and are embedded within, and moved by, relationships of trust, legitimacy, and authority.