Marcella Alsan is a professor of public policy at Harvard Kennedy School. She is also a medical doctor and health economist who studies infectious disease, global health policy, and health inequality. With her policy and clinical experience, Alsan is well positioned to reflect on the ways leaders can most effectively quell the ongoing public health crisis. When it comes to tackling COVID-19, Alsan emphasizes the importance of accessible health care, messaging that takes into account the concerns of a diverse array of people, and the delicate balance between data and privacy.
We spoke to her about her recommendations for a successful COVID-19 immunization campaign.
Q: What are the challenges to containing the coronavirus pandemic? And what bright spots do you see?
Public health crises predictably give rise to a defeatist chorus: Let COVID-19 spread, we can’t contain it; expanding access to HIV treatment will increase drug resistance; insecticide-treated bednets will be used by poor households as fishing nets; the less educated won’t trust, or can’t be trusted with, the latest breakthrough technology; and so on.
Fortunately, history offers powerful examples of scientists, clinicians, activists and policymakers who recognized that responding to a communicable disease requires shared awareness that the fate of others—and particularly those less privileged who bear the brunt of infection—affects us all. The recent rise in the share of COVID-19 deaths among white Americans, particularly in counties that voted for Donald Trump, is a grim reminder that we are interconnected.
Lessons from successful historical public health interventions, coupled with present-day research aimed at communicating effectively to marginalized groups, provide crucial guidance for the current crisis.
“A COVID-19 vaccine can be much more than just a tool to stop disease.”
Q: What are these lessons?
I see four primary guidelines that can aid our response.
First, accessible, high quality health care supply can induce greater demand. Partners in Health (PIH), a nonprofit dedicated to health care delivery in the most challenging conditions, has demonstrated this point time and time again in developing countries. In dilapidated clinics where sick individuals were reluctant to seek care, PIH increased demand by improving the reliability and quality of the supply. They ensured that staff were present, medications were stocked, and individuals were treated with dignity. History demonstrates the importance of accessibility. My research on The 1985 Turkish immunization campaign, for example, found that health workers successfully distributed almost 30 million vaccines in less than three months, increasing measles immunization rates from 37 percent to 83 percent nationwide. The campaign aimed to have vaccination sites within a 10- to 15-minute walk of each household. Trusted community spaces such as schools and mosques were used for dispensation. These efforts were complemented by messaging from religious and political leaders.
Which leads to the second lesson: Who delivers the message on vaccination matters. There are legitimate reasons for people to mistrust authority. Black Americans have endured a long legacy of medical exploitation that provides an empirical basis for trepidation. Minority communities are over-surveilled. The economic pain rural communities have endured is too often ignored. All this adds up to an important reality: Who says what to whom matters. According to a recent Kaiser survey, 42 percent of Republicans and 35 percent of Black Americans are probably or definitely not willing to get a COVID-19 vaccine. The same survey revealed that 78 percent of Republicans would trust President Trump as a source of COVID-19 vaccine information, whereas just 12 percent of Black Americans do. Previous research has shown, particularly for Black men, that having a race-concordant physician is important when trying to increase the take-up of preventive care. The diversity of our country should be reflected in the diversity of vaccine messengers, be they celebrities, athletes, religious figures, or community leaders. The televised vaccination of Sandra Lindsay, the first person to receive the Pfizer vaccine in the United States and a Black health care provider, is an outstanding example of such messaging.
The third lesson is that how messages are framed matters. The best shot health officials have at a successful message is to listen first. What are the concerns with the vaccine? What are the honest facts we can provide to allay them? The Biden administration should convene listening sessions to gather the concerns of different groups and respond to those concerns. Set realistic expectations on vaccines now, reinforce that a vaccine is not a magic bullet—masks will be needed for the foreseeable future. Prepare the population for potential reactions and be frank about unknowns. Many of the same people most worried about the safety of the vaccine are also worried about their rent, paychecks, food, and their children’s education. It could be helpful to frame vaccine benefits in economic gains as opposed to health benefits for oneself or for grandma. Community members who have been vaccinated, including home health aides and those with pre-existing conditions, may be the best ambassadors for others in their neighborhood.
And the final lesson: Shine a light into data darkness. Implore analysts from social media companies to provide real-time information on emerging conspiracy theories. Add a rapid response system in the White House/HHS/CDC to coordinate on debunking myths and preventing them from reaching a critical mass. Overhaul surveillance for vaccine side effects at the federal level. While contact tracing apps might work for some who trust the government, the notion of being tracked by an authority might be anathema to others. Try a hotline or text to a number that anyone can access at any time to report problems with the roll out or the vaccine. Examples of successful coronavirus jingles in other countries could help cement a toll-free number in people’s heads. Community health workers and organizations can also help monitor vaccination access, hesitancy, and reactions. Data on vaccination must be disaggregated so Americans from every background can be reassured that the technology works well for people they identify with most.
Q: It sounds like these lessons go beyond responding to an illness but reflect how we should operate as a well-functioning society. Is that the case?
That’s right. Governments at every level can take steps that will ensure a successful COVID-19 vaccination campaign. A COVID-19 vaccine can be much more than just a tool to stop disease. How we distribute the vaccine—listening and responding to constituents’ concerns, strengthening surveillance systems to respond to rumors and adverse reactions, expressing humility regarding the limits of our knowledge base alongside a commitment to improving it—matters. A well-executed, national immunization campaign not only prevents COVID-19 disease, but also serves as a salve to heal our divided nation.