WEBVTT 00:00:00.000 --> 00:00:03.388 align:middle line:90% [MUSIC PLAYING] 00:00:03.388 --> 00:00:07.732 align:middle line:90% 00:00:07.732 --> 00:00:09.190 align:middle line:84% SVEA CLOSSER: One of the challenges 00:00:09.190 --> 00:00:13.660 align:middle line:84% that polio eradication has faced is that it's become politicized 00:00:13.660 --> 00:00:16.400 align:middle line:90% and mistrusted in many areas. 00:00:16.400 --> 00:00:18.920 align:middle line:84% And to get at the reasons for this, 00:00:18.920 --> 00:00:22.900 align:middle line:84% we want to go through a few examples with you from the DRC 00:00:22.900 --> 00:00:27.130 align:middle line:84% and from Nigeria to understand why people might refuse 00:00:27.130 --> 00:00:28.840 align:middle line:84% vaccines and to sort of peel back 00:00:28.840 --> 00:00:33.740 align:middle line:84% the layers that go into people's mistrust of vaccine. 00:00:33.740 --> 00:00:36.710 align:middle line:84% So to do that we're going to start with a tool 00:00:36.710 --> 00:00:40.550 align:middle line:84% that UNICEF has promoted within polio eradication that's 00:00:40.550 --> 00:00:43.710 align:middle line:84% called the root cause identification tool. 00:00:43.710 --> 00:00:45.720 align:middle line:84% So let's walk through this for a minute. 00:00:45.720 --> 00:00:47.220 align:middle line:84% And if you could take notes on it, 00:00:47.220 --> 00:00:49.872 align:middle line:84% I'm going to have you use it in these examples that come up. 00:00:49.872 --> 00:00:51.830 align:middle line:84% You don't have to write down all of these boxes 00:00:51.830 --> 00:00:54.770 align:middle line:84% because as you can see, many of them repeat themselves. 00:00:54.770 --> 00:00:57.410 align:middle line:84% It's actually simpler than this graph makes it look. 00:00:57.410 --> 00:01:01.200 align:middle line:84% So the first step is to identify the problem. 00:01:01.200 --> 00:01:04.310 align:middle line:84% So first thing you're going to do with these examples 00:01:04.310 --> 00:01:07.140 align:middle line:84% is you're going to identify what is the problem. 00:01:07.140 --> 00:01:10.640 align:middle line:84% So the example that UNICEF gives here is 70% of the community 00:01:10.640 --> 00:01:12.800 align:middle line:84% thinks that giving the oral polio vaccine 00:01:12.800 --> 00:01:14.210 align:middle line:90% is a somewhat good idea. 00:01:14.210 --> 00:01:16.950 align:middle line:84% That's not quite as enthusiastic as you'd want. 00:01:16.950 --> 00:01:19.310 align:middle line:90% So then you say, why? 00:01:19.310 --> 00:01:21.030 align:middle line:90% What's causing this problem? 00:01:21.030 --> 00:01:23.240 align:middle line:84% So you look for the cause of that problem. 00:01:23.240 --> 00:01:25.460 align:middle line:84% The example here would be 80% of the community 00:01:25.460 --> 00:01:26.990 align:middle line:90% is not concerned about polio. 00:01:26.990 --> 00:01:28.002 align:middle line:90% Then you ask why again. 00:01:28.002 --> 00:01:29.960 align:middle line:84% You're sort of acting like a two-year-old here. 00:01:29.960 --> 00:01:31.490 align:middle line:84% Every time you come up with an answer, you're saying, 00:01:31.490 --> 00:01:32.970 align:middle line:90% why is that the case? 00:01:32.970 --> 00:01:34.080 align:middle line:90% Why is that the case? 00:01:34.080 --> 00:01:35.240 align:middle line:90% You keep going. 00:01:35.240 --> 00:01:38.660 align:middle line:84% Why is 80% of the community not concerned about polio? 00:01:38.660 --> 00:01:41.690 align:middle line:84% The answer that UNICEF gives is that, oh, 70% of the community 00:01:41.690 --> 00:01:43.700 align:middle line:84% believes that the symptoms are curable. 00:01:43.700 --> 00:01:45.360 align:middle line:90% Why do they believe that? 00:01:45.360 --> 00:01:47.450 align:middle line:84% So you're going back another step. 00:01:47.450 --> 00:01:51.145 align:middle line:84% In this example, UNICEF is saying that, oh, in this case, 00:01:51.145 --> 00:01:52.520 align:middle line:84% traditional healers are a trusted 00:01:52.520 --> 00:01:56.570 align:middle line:84% source of medical information and say that medicine is only 00:01:56.570 --> 00:01:57.990 align:middle line:90% for curative purposes. 00:01:57.990 --> 00:01:59.460 align:middle line:90% So that might be one example. 00:01:59.460 --> 00:02:02.030 align:middle line:84% So what I want you to do in examples coming up 00:02:02.030 --> 00:02:04.482 align:middle line:84% is go through this root cause identification. 00:02:04.482 --> 00:02:06.440 align:middle line:84% You can think of it as the two-year-old method. 00:02:06.440 --> 00:02:09.320 align:middle line:84% For everything that you come up with, ask why. 00:02:09.320 --> 00:02:10.512 align:middle line:90% What is the cause of that? 00:02:10.512 --> 00:02:12.470 align:middle line:84% See if you can get deeper into some of the root 00:02:12.470 --> 00:02:14.250 align:middle line:90% causes of what's going on. 00:02:14.250 --> 00:02:16.460 align:middle line:84% Because if we don't address the root causes, 00:02:16.460 --> 00:02:19.790 align:middle line:84% we won't be able to solve the problems. 00:02:19.790 --> 00:02:21.670 align:middle line:84% Here's a quote from a parent, and I 00:02:21.670 --> 00:02:24.370 align:middle line:84% want you to think about what are maybe some of the root causes 00:02:24.370 --> 00:02:25.630 align:middle line:90% at work here. 00:02:25.630 --> 00:02:27.460 align:middle line:84% "I refused the vaccine because of God. 00:02:27.460 --> 00:02:29.657 align:middle line:84% In the Bible, Matthew speaks of King Herod. 00:02:29.657 --> 00:02:31.990 align:middle line:84% He had learned that a baby king was born in the country, 00:02:31.990 --> 00:02:33.460 align:middle line:90% and he went to the hospital. 00:02:33.460 --> 00:02:36.390 align:middle line:84% He went there to kill all children aged zero to five. 00:02:36.390 --> 00:02:39.280 align:middle line:90% Matthew's Epistle, 1:1 to 50. 00:02:39.280 --> 00:02:41.110 align:middle line:84% At the time we saw polio in the hospital, 00:02:41.110 --> 00:02:42.670 align:middle line:84% we also saw the polio vaccine that 00:02:42.670 --> 00:02:44.750 align:middle line:90% was distributed free of charge. 00:02:44.750 --> 00:02:47.710 align:middle line:84% The vaccine is also for children from zero to five years old. 00:02:47.710 --> 00:02:49.545 align:middle line:90% How can one explain that?" 00:02:49.545 --> 00:02:50.920 align:middle line:84% So what I would like you to do is 00:02:50.920 --> 00:02:53.950 align:middle line:84% think about what are some of the root causes at work 00:02:53.950 --> 00:02:56.410 align:middle line:90% behind this parent's concerns. 00:02:56.410 --> 00:02:59.140 align:middle line:84% So take a minute and see how deep you might be able to go. 00:02:59.140 --> 00:03:01.990 align:middle line:84% It's a little challenging if you don't know the DRC well, 00:03:01.990 --> 00:03:05.050 align:middle line:84% but thinking about maybe some similar examples 00:03:05.050 --> 00:03:06.850 align:middle line:84% you may know from your own experience. 00:03:06.850 --> 00:03:09.082 align:middle line:84% Try to get some of those root causes. 00:03:09.082 --> 00:03:11.290 align:middle line:84% And you can pause the video to do this if you'd like, 00:03:11.290 --> 00:03:13.498 align:middle line:84% and then when you're ready to look at the next slide, 00:03:13.498 --> 00:03:15.750 align:middle line:90% you can restart. 00:03:15.750 --> 00:03:17.490 align:middle line:84% So here's some more from the same parent 00:03:17.490 --> 00:03:20.370 align:middle line:84% which may help you get a little deeper into some root causes. 00:03:20.370 --> 00:03:21.990 align:middle line:84% "In 1880, when the church arrived, 00:03:21.990 --> 00:03:24.240 align:middle line:84% we were told to stop our natural medicine practices 00:03:24.240 --> 00:03:25.140 align:middle line:90% and bleeding. 00:03:25.140 --> 00:03:27.600 align:middle line:84% Whites told us, 'Stop using drugs to protect yourself. 00:03:27.600 --> 00:03:30.900 align:middle line:84% Stop protecting yourself.' The only true healer is God, 00:03:30.900 --> 00:03:33.298 align:middle line:84% so we eliminated our ways of doing things. 00:03:33.298 --> 00:03:35.340 align:middle line:84% And after that, the white man came back and said, 00:03:35.340 --> 00:03:37.920 align:middle line:84% 'Come on, this time I'll give you medicine to protect you.'" 00:03:37.920 --> 00:03:39.750 align:middle line:84% So does this quote add any layers 00:03:39.750 --> 00:03:41.367 align:middle line:90% to the root causes you had? 00:03:41.367 --> 00:03:43.200 align:middle line:84% You can pause the video again and see if you 00:03:43.200 --> 00:03:45.210 align:middle line:90% can add some more root causes. 00:03:45.210 --> 00:03:48.570 align:middle line:84% So if I were doing this exercise, one thing I would say 00:03:48.570 --> 00:03:53.580 align:middle line:84% is that refusals are complicated and they're historically deep. 00:03:53.580 --> 00:03:56.400 align:middle line:84% So in this example, it's easy to chalk this up as something 00:03:56.400 --> 00:03:57.360 align:middle line:90% like, oh religion. 00:03:57.360 --> 00:03:59.490 align:middle line:84% This person is religious, so they're refusing. 00:03:59.490 --> 00:04:01.320 align:middle line:90% But that's a little too simple. 00:04:01.320 --> 00:04:03.420 align:middle line:84% This is about the history of colonialism. 00:04:03.420 --> 00:04:05.170 align:middle line:90% It's also about current events. 00:04:05.170 --> 00:04:07.440 align:middle line:84% It's probably about politics, the relationships 00:04:07.440 --> 00:04:09.990 align:middle line:84% between this parent and local political leaders. 00:04:09.990 --> 00:04:12.810 align:middle line:84% So all of these multi-layered levels 00:04:12.810 --> 00:04:16.500 align:middle line:84% are feeding into this person's distrust of polio vaccine. 00:04:16.500 --> 00:04:18.104 align:middle line:84% So simply having messaging about, 00:04:18.104 --> 00:04:20.220 align:middle line:84% oh, polio vaccine is good for your kid, 00:04:20.220 --> 00:04:23.430 align:middle line:84% isn't likely to get at some of these really complex layers. 00:04:23.430 --> 00:04:27.150 align:middle line:84% And ideas about foreign intervention in particular 00:04:27.150 --> 00:04:31.580 align:middle line:84% often feed into vaccine hesitancy. 00:04:31.580 --> 00:04:34.400 align:middle line:84% So here's another example that I want to do the root causes 00:04:34.400 --> 00:04:35.990 align:middle line:90% analysis with. 00:04:35.990 --> 00:04:38.840 align:middle line:84% This one's from Nigeria, and it's a religious leader. 00:04:38.840 --> 00:04:42.350 align:middle line:84% So this religious leader says, "In 2000 and 2001, 00:04:42.350 --> 00:04:45.112 align:middle line:84% when we shared our fears and concerns about the possibility 00:04:45.112 --> 00:04:47.570 align:middle line:84% that the vaccine might contain substances that could render 00:04:47.570 --> 00:04:49.790 align:middle line:84% populations infertile, we were told 00:04:49.790 --> 00:04:51.860 align:middle line:84% that the drugs were WHO-certified, and were 00:04:51.860 --> 00:04:54.560 align:middle line:84% manufactured in the best manufacturing environment, 00:04:54.560 --> 00:04:57.410 align:middle line:84% and the vaccine did not contain any other ingredients. 00:04:57.410 --> 00:05:00.580 align:middle line:84% We wanted concrete evidence but we only had words. 00:05:00.580 --> 00:05:03.080 align:middle line:84% The fears of my people are not the same as those of Zimbabwe 00:05:03.080 --> 00:05:05.622 align:middle line:84% where people thought the vaccine would turn people into pigs. 00:05:05.622 --> 00:05:07.910 align:middle line:84% Our fears are more about medical issues. 00:05:07.910 --> 00:05:09.330 align:middle line:90% But what are you looking for? 00:05:09.330 --> 00:05:10.880 align:middle line:90% What is WHO looking for? 00:05:10.880 --> 00:05:12.620 align:middle line:90% What is UNICEF looking for? 00:05:12.620 --> 00:05:14.270 align:middle line:90% Why this relentlessness? 00:05:14.270 --> 00:05:17.810 align:middle line:84% How much money is spent in Nigeria to stop 109 cases? 00:05:17.810 --> 00:05:21.260 align:middle line:84% How many children die from measles, malaria, diarrhea?" 00:05:21.260 --> 00:05:23.930 align:middle line:84% So as we did before, if you want to take a minute 00:05:23.930 --> 00:05:25.910 align:middle line:84% and pause the video and see if you 00:05:25.910 --> 00:05:28.460 align:middle line:84% can get to root causes of why this religious leader is 00:05:28.460 --> 00:05:30.890 align:middle line:90% concerned about polio vaccine. 00:05:30.890 --> 00:05:32.570 align:middle line:84% So some answers I might have here 00:05:32.570 --> 00:05:36.300 align:middle line:84% is that there's some distrust in international organizations, 00:05:36.300 --> 00:05:38.390 align:middle line:84% particularly in their focus on polio. 00:05:38.390 --> 00:05:40.460 align:middle line:84% I mean he's saying how much money is spent 00:05:40.460 --> 00:05:43.200 align:middle line:90% in Nigeria to stop 109 cases. 00:05:43.200 --> 00:05:46.070 align:middle line:84% That's how many cases of polio there had been in Nigeria. 00:05:46.070 --> 00:05:48.350 align:middle line:84% He's comparing that to burden of disease 00:05:48.350 --> 00:05:51.740 align:middle line:84% from other diseases, which are far, far greater, 00:05:51.740 --> 00:05:54.950 align:middle line:84% and asking why there's so much focus on one disease. 00:05:54.950 --> 00:05:57.140 align:middle line:90% That's making him nervous. 00:05:57.140 --> 00:06:00.208 align:middle line:84% There's some deeper root causes beneath that as well. 00:06:00.208 --> 00:06:02.750 align:middle line:84% As a side note, I'm not actually sure that people in Zimbabwe 00:06:02.750 --> 00:06:05.630 align:middle line:84% thought the vaccine would turn people in the pigs. 00:06:05.630 --> 00:06:10.160 align:middle line:84% But the idea is that he's making the point that his fears are 00:06:10.160 --> 00:06:11.300 align:middle line:90% not irrational. 00:06:11.300 --> 00:06:12.530 align:middle line:90% He really wants evidence. 00:06:12.530 --> 00:06:15.140 align:middle line:84% He wants data, and he doesn't understand 00:06:15.140 --> 00:06:19.640 align:middle line:84% why WHO and UNICEF are making the choices they're making. 00:06:19.640 --> 00:06:22.900 align:middle line:84% So let's look at some more from the same religious leader, 00:06:22.900 --> 00:06:26.230 align:middle line:84% see if it helps us more with root causes of his concern. 00:06:26.230 --> 00:06:28.150 align:middle line:84% "When you've come to vaccinate the population, 00:06:28.150 --> 00:06:31.660 align:middle line:84% you tell us that you've reached 60, 70, or 100,000 people, 00:06:31.660 --> 00:06:33.828 align:middle line:84% but all children in the state are vaccinated. 00:06:33.828 --> 00:06:36.370 align:middle line:84% Then you come back the next day and say there was a new case, 00:06:36.370 --> 00:06:38.560 align:middle line:84% and you have to re-vaccinate the whole state. 00:06:38.560 --> 00:06:41.410 align:middle line:84% What does this mean about the effectiveness of the vaccine? 00:06:41.410 --> 00:06:42.630 align:middle line:90% Nobody knows what's going on. 00:06:42.630 --> 00:06:43.150 align:middle line:90% You come. 00:06:43.150 --> 00:06:43.870 align:middle line:90% You vaccinate. 00:06:43.870 --> 00:06:45.787 align:middle line:84% You collect money, and the following year, you 00:06:45.787 --> 00:06:48.050 align:middle line:84% come back to vaccinate the same children." 00:06:48.050 --> 00:06:50.025 align:middle line:84% So take a minute and see if you can get deeper 00:06:50.025 --> 00:06:51.400 align:middle line:84% into some of the root causes that 00:06:51.400 --> 00:06:55.547 align:middle line:84% might be going on behind this religious leader's concerns. 00:06:55.547 --> 00:06:57.880 align:middle line:84% What I take from this quote is that the religious leader 00:06:57.880 --> 00:07:00.790 align:middle line:84% is really asking for more information, that there's 00:07:00.790 --> 00:07:03.450 align:middle line:84% a distrust of international organizations 00:07:03.450 --> 00:07:07.030 align:middle line:84% that's, again, in the Nigerian context, 00:07:07.030 --> 00:07:10.960 align:middle line:84% quite well founded given historical experience 00:07:10.960 --> 00:07:15.220 align:middle line:84% with foreign intervention and some vaccine trials 00:07:15.220 --> 00:07:16.900 align:middle line:84% actually that happened in Nigeria. 00:07:16.900 --> 00:07:19.960 align:middle line:84% It's not unreasonable for people to be concerned. 00:07:19.960 --> 00:07:21.910 align:middle line:84% And in this case, the religious leader 00:07:21.910 --> 00:07:25.870 align:middle line:84% is concerned about this issue of these positive messages that 00:07:25.870 --> 00:07:29.080 align:middle line:84% are getting put out by polio eradication about how well it's 00:07:29.080 --> 00:07:31.780 align:middle line:84% going, how many children are getting vaccinated. 00:07:31.780 --> 00:07:34.330 align:middle line:84% And then when polio isn't eradicated, 00:07:34.330 --> 00:07:36.610 align:middle line:84% this religious leader is getting more concerned 00:07:36.610 --> 00:07:37.990 align:middle line:90% and less trustful. 00:07:37.990 --> 00:07:41.230 align:middle line:84% So this, in part, goes back to some of the issues 00:07:41.230 --> 00:07:46.843 align:middle line:84% around addressing fatigue and distrust in endemic contexts 00:07:46.843 --> 00:07:48.010 align:middle line:90% that we talked about before. 00:07:48.010 --> 00:07:51.190 align:middle line:84% Nigeria, of course, has been polio endemic for a long time. 00:07:51.190 --> 00:07:54.280 align:middle line:84% It certainly was at the time this quote was taken. 00:07:54.280 --> 00:07:59.170 align:middle line:84% But thinking about not just people's ideas about polio, 00:07:59.170 --> 00:08:02.362 align:middle line:84% but also people's ideas about international organizations 00:08:02.362 --> 00:08:03.820 align:middle line:84% and the fact that they may not have 00:08:03.820 --> 00:08:07.450 align:middle line:84% been told the entire story about how complex this is 00:08:07.450 --> 00:08:08.800 align:middle line:90% and how difficult it is. 00:08:08.800 --> 00:08:15.330 align:middle line:84% And that may have led to some really understandable concerns. 00:08:15.330 --> 00:08:17.610 align:middle line:84% So here's what a community health worker in Nigeria 00:08:17.610 --> 00:08:19.710 align:middle line:90% had to say about these issues. 00:08:19.710 --> 00:08:21.360 align:middle line:84% Quote, "The members of the communities 00:08:21.360 --> 00:08:23.370 align:middle line:84% always complain about the constant visits 00:08:23.370 --> 00:08:26.495 align:middle line:84% to house to house, mainly only on the polio activities. 00:08:26.495 --> 00:08:27.870 align:middle line:84% Sincerely speaking, the public is 00:08:27.870 --> 00:08:30.480 align:middle line:84% so suspicious about the campaign on polio. 00:08:30.480 --> 00:08:33.403 align:middle line:84% People need malaria tablets more than polio vaccine. 00:08:33.403 --> 00:08:35.820 align:middle line:84% Some people complain that when fuel prices were increased, 00:08:35.820 --> 00:08:37.799 align:middle line:84% nothing was done to console the poor. 00:08:37.799 --> 00:08:39.804 align:middle line:84% But when polio was rejected by the poor, 00:08:39.804 --> 00:08:41.429 align:middle line:84% the government and the community elders 00:08:41.429 --> 00:08:43.950 align:middle line:84% were used to persuade people to accept it. 00:08:43.950 --> 00:08:46.020 align:middle line:84% If boreholes and other essential amenities 00:08:46.020 --> 00:08:48.120 align:middle line:84% should be provided to these communities, 00:08:48.120 --> 00:08:50.560 align:middle line:84% the polio vaccine would be more acceptable." 00:08:50.560 --> 00:08:52.380 align:middle line:84% So here you have a community health worker 00:08:52.380 --> 00:08:54.700 align:middle line:84% making the argument that when there's 00:08:54.700 --> 00:08:59.285 align:middle line:84% this focus just on polio and not on other issues, 00:08:59.285 --> 00:09:00.660 align:middle line:84% this is something that inherently 00:09:00.660 --> 00:09:01.800 align:middle line:90% makes people nervous. 00:09:01.800 --> 00:09:03.877 align:middle line:84% They wonder, what's going on when 00:09:03.877 --> 00:09:05.460 align:middle line:84% these international organizations that 00:09:05.460 --> 00:09:08.340 align:middle line:84% don't seem to care about our kids for any other disease 00:09:08.340 --> 00:09:10.890 align:middle line:84% seem to care so much just about this one disease. 00:09:10.890 --> 00:09:13.410 align:middle line:84% And people start to wonder if, oh, maybe there's 00:09:13.410 --> 00:09:15.240 align:middle line:90% some ulterior motive here. 00:09:15.240 --> 00:09:17.730 align:middle line:84% Or maybe this is not exactly what it seems. 00:09:17.730 --> 00:09:19.350 align:middle line:84% And it's, of course, not the majority 00:09:19.350 --> 00:09:20.970 align:middle line:90% of parents that feel this way. 00:09:20.970 --> 00:09:22.860 align:middle line:84% But if enough are a little bit nervous 00:09:22.860 --> 00:09:24.590 align:middle line:84% that they start to refuse vaccine, 00:09:24.590 --> 00:09:27.390 align:middle line:84% that can get in the way of eliminating the disease 00:09:27.390 --> 00:09:31.710 align:middle line:84% and leads to more and more campaigns, which unfortunately, 00:09:31.710 --> 00:09:34.260 align:middle line:84% can reinforce those sorts of concerns. 00:09:34.260 --> 00:09:38.755 align:middle line:84% So this brings us back to the opening of the section that 00:09:38.755 --> 00:09:40.380 align:middle line:84% actually understanding the relationship 00:09:40.380 --> 00:09:43.050 align:middle line:84% between vertical programs and broader health systems 00:09:43.050 --> 00:09:46.410 align:middle line:84% can be really, really critical for understanding vaccine 00:09:46.410 --> 00:09:50.280 align:middle line:84% refusals when you're looking at eradication programs 00:09:50.280 --> 00:09:51.580 align:middle line:90% in particular. 00:09:51.580 --> 00:09:55.560 align:middle line:84% So thinking about ways to provide broad health services 00:09:55.560 --> 00:09:58.500 align:middle line:84% to people can actually be really important in allaying 00:09:58.500 --> 00:10:02.890 align:middle line:84% some of their fears around a specific vaccine. 00:10:02.890 --> 00:10:04.720 align:middle line:90% So here are some takeaways. 00:10:04.720 --> 00:10:07.318 align:middle line:84% Vaccine refusals are not just about misinformation. 00:10:07.318 --> 00:10:08.110 align:middle line:90% Sometimes they are. 00:10:08.110 --> 00:10:10.180 align:middle line:84% Those are very simple to correct. 00:10:10.180 --> 00:10:11.652 align:middle line:90% People are just misinformed. 00:10:11.652 --> 00:10:13.360 align:middle line:84% You can give them the correct information 00:10:13.360 --> 00:10:15.130 align:middle line:84% and then they will accept vaccine. 00:10:15.130 --> 00:10:19.430 align:middle line:84% In many, many cases, reality is much more complex than that. 00:10:19.430 --> 00:10:21.310 align:middle line:84% So just telling people the right information 00:10:21.310 --> 00:10:22.870 align:middle line:84% or getting mad at them because they don't believe 00:10:22.870 --> 00:10:24.745 align:middle line:84% the right information is not going to get you 00:10:24.745 --> 00:10:25.840 align:middle line:90% where you want to be. 00:10:25.840 --> 00:10:28.680 align:middle line:84% Vaccine refusals are also about more than local culture. 00:10:28.680 --> 00:10:33.592 align:middle line:84% Of course, people's local cultural networks and norms 00:10:33.592 --> 00:10:35.800 align:middle line:84% are going to affect the way they think about and talk 00:10:35.800 --> 00:10:39.640 align:middle line:84% about vaccination, but that's not the whole story. 00:10:39.640 --> 00:10:41.990 align:middle line:84% Vaccine refusals are very complex. 00:10:41.990 --> 00:10:44.140 align:middle line:84% They're political and they're historical. 00:10:44.140 --> 00:10:47.010 align:middle line:84% They have to do with people's power relationships, 00:10:47.010 --> 00:10:49.770 align:middle line:84% who they've historically had good relationships with, 00:10:49.770 --> 00:10:51.970 align:middle line:84% who they have reason to mistrust, 00:10:51.970 --> 00:10:54.430 align:middle line:84% and who's approaching them with a given vaccine. 00:10:54.430 --> 00:10:57.040 align:middle line:84% They also have to do with trust in the health system, which 00:10:57.040 --> 00:10:59.470 align:middle line:84% in turn, has to do with the quality of the health system. 00:10:59.470 --> 00:11:01.480 align:middle line:84% If a health system is very poor quality, 00:11:01.480 --> 00:11:05.030 align:middle line:84% people naturally aren't going to trust it as much. 00:11:05.030 --> 00:11:07.420 align:middle line:84% So the point is addressing vaccine refusals 00:11:07.420 --> 00:11:10.960 align:middle line:84% is very complex, and programs addressing vaccine refusals 00:11:10.960 --> 00:11:13.600 align:middle line:84% have to be extremely sophisticated to deal 00:11:13.600 --> 00:11:15.820 align:middle line:84% with these interrelated and complex reasons 00:11:15.820 --> 00:11:19.510 align:middle line:84% that people may be hesitant about vaccines. 00:11:19.510 --> 00:11:22.030 align:middle line:84% I want to take a moment here and talk 00:11:22.030 --> 00:11:26.140 align:middle line:84% about the role of religious language in framing refusals. 00:11:26.140 --> 00:11:29.260 align:middle line:84% So many people refusing vaccine may use religious language 00:11:29.260 --> 00:11:32.110 align:middle line:84% to do so, as we saw in the case of DRC. 00:11:32.110 --> 00:11:34.990 align:middle line:84% In South Asia, people in polio's last strongholds 00:11:34.990 --> 00:11:38.200 align:middle line:84% happen to be Muslim and many of them frame their refusals 00:11:38.200 --> 00:11:39.760 align:middle line:90% in Islamic terms. 00:11:39.760 --> 00:11:42.700 align:middle line:84% But being Muslim in and of itself doesn't drive refusal. 00:11:42.700 --> 00:11:46.360 align:middle line:84% The vast majority of Muslims globally accept polio vaccine, 00:11:46.360 --> 00:11:49.060 align:middle line:84% and most major Muslim religious leaders worldwide 00:11:49.060 --> 00:11:51.130 align:middle line:90% support polio vaccination. 00:11:51.130 --> 00:11:53.800 align:middle line:84% As this image shows, polio vaccination 00:11:53.800 --> 00:11:55.510 align:middle line:84% may actually be required for people 00:11:55.510 --> 00:11:58.480 align:middle line:84% from polio endemic countries when they go on the Hajj. 00:11:58.480 --> 00:12:02.810 align:middle line:84% But Islamic discourses do shape how refusals are talked about, 00:12:02.810 --> 00:12:04.870 align:middle line:84% and it's important to understand how people 00:12:04.870 --> 00:12:08.230 align:middle line:84% are thinking about and talking about vaccine hesitancy 00:12:08.230 --> 00:12:10.370 align:middle line:84% if you're trying to communicate with them. 00:12:10.370 --> 00:12:12.970 align:middle line:84% Many people who distrust polio vaccine 00:12:12.970 --> 00:12:16.150 align:middle line:84% draw on ideas about Islam as a potential alternative 00:12:16.150 --> 00:12:18.460 align:middle line:84% paradigm to Western domination when 00:12:18.460 --> 00:12:21.280 align:middle line:84% they talk about their resistance to vaccination. 00:12:21.280 --> 00:12:25.030 align:middle line:84% So is the issue about religion or about Islam? 00:12:25.030 --> 00:12:26.680 align:middle line:84% Sure, in the sense that that frame 00:12:26.680 --> 00:12:28.540 align:middle line:84% is very meaningful to people who might 00:12:28.540 --> 00:12:31.060 align:middle line:84% distrust the people providing polio vaccine. 00:12:31.060 --> 00:12:32.500 align:middle line:84% And a good communications program 00:12:32.500 --> 00:12:34.880 align:middle line:90% has to take that into account. 00:12:34.880 --> 00:12:36.850 align:middle line:84% But it's also not about religion in the sense 00:12:36.850 --> 00:12:39.550 align:middle line:84% that religious belief is not a sufficient explanation 00:12:39.550 --> 00:12:42.400 align:middle line:84% when it comes to designing a good communication program 00:12:42.400 --> 00:12:44.950 align:middle line:84% since it may disregard some root causes. 00:12:44.950 --> 00:12:47.380 align:middle line:84% So it's important to be careful here. 00:12:47.380 --> 00:12:49.990 align:middle line:84% Framing vaccine refusal as a Muslim problem 00:12:49.990 --> 00:12:53.140 align:middle line:84% can cause further alienation and further communications 00:12:53.140 --> 00:12:56.230 align:middle line:84% breakdowns if the full range of root causes of refusal 00:12:56.230 --> 00:12:57.950 align:middle line:90% are not considered. 00:12:57.950 --> 00:13:02.060 align:middle line:84% So in the case of polio, it's also global policy decisions. 00:13:02.060 --> 00:13:04.240 align:middle line:84% In fact, funding for the polio program 00:13:04.240 --> 00:13:07.630 align:middle line:84% itself has paradoxically contributed to some vaccine 00:13:07.630 --> 00:13:09.238 align:middle line:90% hesitancy in some places. 00:13:09.238 --> 00:13:10.780 align:middle line:84% In certain ways, the program has been 00:13:10.780 --> 00:13:12.970 align:middle line:84% a victim of its own success because it's 00:13:12.970 --> 00:13:15.970 align:middle line:84% been so good at mobilizing funds, 00:13:15.970 --> 00:13:18.920 align:middle line:84% because it's been so good at getting governments on board, 00:13:18.920 --> 00:13:21.400 align:middle line:84% because it's been so good at reaching every single child 00:13:21.400 --> 00:13:22.810 align:middle line:90% with polio vaccine. 00:13:22.810 --> 00:13:25.667 align:middle line:84% This has actually led to some concerns and parents who 00:13:25.667 --> 00:13:28.000 align:middle line:84% haven't gotten any other services saying, wait a minute, 00:13:28.000 --> 00:13:30.160 align:middle line:84% why am I only getting polio services 00:13:30.160 --> 00:13:33.010 align:middle line:90% and not these other services? 00:13:33.010 --> 00:13:35.460 align:middle line:84% So this image of a house in Bihar, India 00:13:35.460 --> 00:13:38.310 align:middle line:84% shows just how many campaigns there may be. 00:13:38.310 --> 00:13:39.990 align:middle line:84% The side of this house is blanketed 00:13:39.990 --> 00:13:41.490 align:middle line:90% in polio team markings. 00:13:41.490 --> 00:13:44.850 align:middle line:84% So each of these markings here was from a different campaign 00:13:44.850 --> 00:13:47.790 align:middle line:84% when polio team came by in March. 00:13:47.790 --> 00:13:50.180 align:middle line:84% They'd come by and vaccinated kids. 00:13:50.180 --> 00:13:53.310 align:middle line:84% And when you have these really well-funded, 00:13:53.310 --> 00:13:55.740 align:middle line:84% frequent polio campaigns, if that's 00:13:55.740 --> 00:13:58.000 align:middle line:84% paired with a health system that provides little, 00:13:58.000 --> 00:14:00.180 align:middle line:84% if any of what people need, it's a dynamic 00:14:00.180 --> 00:14:01.830 align:middle line:90% that will drive distrust. 00:14:01.830 --> 00:14:03.900 align:middle line:84% The situation can be suspicious to people. 00:14:03.900 --> 00:14:06.620 align:middle line:84% Why are polio vaccines being delivered to our doorstep 00:14:06.620 --> 00:14:08.370 align:middle line:84% when the medicines we need are chronically 00:14:08.370 --> 00:14:10.130 align:middle line:90% unavailable at the health post. 00:14:10.130 --> 00:14:12.420 align:middle line:84% A health worker in Nigeria explained quote, 00:14:12.420 --> 00:14:15.760 align:middle line:84% "People say they're a misplaced priority." 00:14:15.760 --> 00:14:17.920 align:middle line:84% A contributing factor to the disconnect 00:14:17.920 --> 00:14:19.960 align:middle line:84% is the relative lack of availability 00:14:19.960 --> 00:14:22.780 align:middle line:84% of international aid funds and international pressure 00:14:22.780 --> 00:14:25.090 align:middle line:84% for basic health service provision. 00:14:25.090 --> 00:14:27.490 align:middle line:84% So thinking about primary health care and the importance 00:14:27.490 --> 00:14:30.640 align:middle line:84% of wide-ranging basic health services 00:14:30.640 --> 00:14:33.580 align:middle line:90% that provide what people need. 00:14:33.580 --> 00:14:36.400 align:middle line:84% So these images are of crumbling health infrastructure in two 00:14:36.400 --> 00:14:38.320 align:middle line:90% areas that are polio endemic. 00:14:38.320 --> 00:14:41.470 align:middle line:84% And both of these places have had long, ongoing polio 00:14:41.470 --> 00:14:42.590 align:middle line:90% campaigns. 00:14:42.590 --> 00:14:45.880 align:middle line:84% So despite rhetoric about the need to improve health systems, 00:14:45.880 --> 00:14:48.790 align:middle line:84% most global health donors are currently focusing largely 00:14:48.790 --> 00:14:51.130 align:middle line:84% on disease-specific interventions rather than 00:14:51.130 --> 00:14:53.500 align:middle line:84% integrated support for health systems. 00:14:53.500 --> 00:14:56.860 align:middle line:84% And paradoxically, this can undermine public trust 00:14:56.860 --> 00:15:00.610 align:middle line:84% in those vertical interventions as well. 00:15:00.610 --> 00:15:04.020 align:middle line:84% So this creates a challenge for a communications program. 00:15:04.020 --> 00:15:06.120 align:middle line:84% As a communications program, can you 00:15:06.120 --> 00:15:07.620 align:middle line:84% address this root cause having to do 00:15:07.620 --> 00:15:09.160 align:middle line:90% with international funding? 00:15:09.160 --> 00:15:11.710 align:middle line:84% And I don't have an answer to this question, 00:15:11.710 --> 00:15:14.460 align:middle line:84% but I think it's a huge one and an important one, 00:15:14.460 --> 00:15:17.280 align:middle line:84% and one that those of us who work in this space 00:15:17.280 --> 00:15:21.740 align:middle line:84% need to be thinking about and working towards addressing. 00:15:21.740 --> 00:15:23.770 align:middle line:84% So we have one more example here of how 00:15:23.770 --> 00:15:26.310 align:middle line:90% this dynamic may play out. 00:15:26.310 --> 00:15:29.230 align:middle line:84% And this is something called demand refusals. 00:15:29.230 --> 00:15:30.910 align:middle line:84% So many local communities have become 00:15:30.910 --> 00:15:34.720 align:middle line:84% quite sophisticated about the polio eradication initiative 00:15:34.720 --> 00:15:36.710 align:middle line:90% and the politics around it. 00:15:36.710 --> 00:15:39.040 align:middle line:84% So in Pakistan, some communities have 00:15:39.040 --> 00:15:41.470 align:middle line:84% started rejecting polio vaccine, which 00:15:41.470 --> 00:15:43.900 align:middle line:84% they know that international agencies and their government 00:15:43.900 --> 00:15:46.570 align:middle line:84% want them to accept, as a way of drawing attention 00:15:46.570 --> 00:15:47.750 align:middle line:90% to other needs. 00:15:47.750 --> 00:15:49.360 align:middle line:84% So this is an interesting situation 00:15:49.360 --> 00:15:50.860 align:middle line:84% where they're not actually concerned 00:15:50.860 --> 00:15:52.412 align:middle line:90% about the polio vaccine itself. 00:15:52.412 --> 00:15:53.620 align:middle line:90% They're not worried about it. 00:15:53.620 --> 00:15:56.220 align:middle line:84% They are confident that it prevents polio, 00:15:56.220 --> 00:15:58.480 align:middle line:84% but because they have so many other needs, 00:15:58.480 --> 00:16:00.770 align:middle line:84% as a way of drawing attention to those needs, 00:16:00.770 --> 00:16:03.490 align:middle line:84% they've been refusing polio vaccine. 00:16:03.490 --> 00:16:07.420 align:middle line:84% So one example is the situation in Bannu 00:16:07.420 --> 00:16:10.150 align:middle line:84% which is an area on the Pakistan side of the Pakistan, 00:16:10.150 --> 00:16:15.130 align:middle line:84% Afghanistan border, and which had 23 cases of polio in 2019. 00:16:15.130 --> 00:16:17.890 align:middle line:84% So the Bannu Chamber of Commerce and Industry 00:16:17.890 --> 00:16:20.230 align:middle line:84% actually organized business leaders and people 00:16:20.230 --> 00:16:24.040 align:middle line:84% across the city to boycott the polio campaign. 00:16:24.040 --> 00:16:26.350 align:middle line:84% This resulted in thousands of refusals. 00:16:26.350 --> 00:16:29.980 align:middle line:84% And in this case, the demands of the Chamber of Commerce 00:16:29.980 --> 00:16:32.060 align:middle line:84% were actually a reduction in taxes. 00:16:32.060 --> 00:16:34.450 align:middle line:84% So here's what the independent monitoring 00:16:34.450 --> 00:16:36.760 align:middle line:84% board for polio eradication had to say about it. 00:16:36.760 --> 00:16:38.708 align:middle line:84% They say, the spokesman for the Chamber 00:16:38.708 --> 00:16:40.750 align:middle line:84% of Commerce and Industry said it was the only way 00:16:40.750 --> 00:16:42.352 align:middle line:90% to get the government to listen. 00:16:42.352 --> 00:16:44.560 align:middle line:84% He also said he has no doubts about the effectiveness 00:16:44.560 --> 00:16:47.740 align:middle line:84% of the vaccine, is aware of the dangers of creating 00:16:47.740 --> 00:16:50.920 align:middle line:84% a gap in herd immunity that the full coverage of the vaccine 00:16:50.920 --> 00:16:53.500 align:middle line:84% offers, but that he and members of his community 00:16:53.500 --> 00:16:55.940 align:middle line:90% felt they had no choice. 00:16:55.940 --> 00:16:59.230 align:middle line:84% So this is one example of a number of demand refusals. 00:16:59.230 --> 00:17:02.530 align:middle line:84% Other ones have been communities demanding electricity, 00:17:02.530 --> 00:17:04.353 align:middle line:90% sanitation, other issues. 00:17:04.353 --> 00:17:05.770 align:middle line:84% And the issue here is that there's 00:17:05.770 --> 00:17:08.740 align:middle line:84% so much government and international focus on polio, 00:17:08.740 --> 00:17:10.780 align:middle line:84% and so little government and international focus 00:17:10.780 --> 00:17:13.839 align:middle line:84% on these other issues, that communities have been refusing 00:17:13.839 --> 00:17:16.464 align:middle line:84% polio vaccine as a way of trying to leverage 00:17:16.464 --> 00:17:18.339 align:middle line:84% support for these other issues that they feel 00:17:18.339 --> 00:17:19.427 align:middle line:90% are more important. 00:17:19.427 --> 00:17:21.760 align:middle line:84% And again, this is a question I don't have an answer to, 00:17:21.760 --> 00:17:24.470 align:middle line:84% but for you to think about what would you do in this situation. 00:17:24.470 --> 00:17:26.470 align:middle line:84% If you were a polio communicator, 00:17:26.470 --> 00:17:28.888 align:middle line:84% how would you try to address some of these challenges? 00:17:28.888 --> 00:17:30.430 align:middle line:84% And again, this is going to take more 00:17:30.430 --> 00:17:32.110 align:middle line:90% than a mass media campaign. 00:17:32.110 --> 00:17:35.890 align:middle line:84% It's about listening to people and their needs, 00:17:35.890 --> 00:17:37.690 align:middle line:84% building trust over the long term, 00:17:37.690 --> 00:17:40.070 align:middle line:84% and thinking about health services broadly. 00:17:40.070 --> 00:17:42.310 align:middle line:84% So the takeaway here is that relentless focus 00:17:42.310 --> 00:17:44.350 align:middle line:84% on a single disease can end up becoming 00:17:44.350 --> 00:17:47.170 align:middle line:84% problematic for the vertical program itself 00:17:47.170 --> 00:17:48.668 align:middle line:90% in the case of polio. 00:17:48.668 --> 00:17:50.710 align:middle line:84% And this is not to say that vertical programs are 00:17:50.710 --> 00:17:52.630 align:middle line:90% inherently problematic. 00:17:52.630 --> 00:17:54.820 align:middle line:84% In areas where polio eradication activities have 00:17:54.820 --> 00:17:56.680 align:middle line:84% been less intense, these sorts of issues 00:17:56.680 --> 00:17:58.480 align:middle line:90% generally have not arisen. 00:17:58.480 --> 00:18:00.310 align:middle line:84% But a mismatch between the emphasis 00:18:00.310 --> 00:18:05.320 align:middle line:84% on polio vaccination and other services can drive distrust. 00:18:05.320 --> 00:18:07.930 align:middle line:84% So I've got a couple of questions for you 00:18:07.930 --> 00:18:09.760 align:middle line:84% to sort of ponder, and we'll discuss what's 00:18:09.760 --> 00:18:11.265 align:middle line:90% been tried in the next section. 00:18:11.265 --> 00:18:12.640 align:middle line:84% But these are some things for you 00:18:12.640 --> 00:18:14.660 align:middle line:90% to think about in the meantime. 00:18:14.660 --> 00:18:16.600 align:middle line:84% What kind of health communication strategies 00:18:16.600 --> 00:18:19.300 align:middle line:84% might work in a context where people are dissatisfied 00:18:19.300 --> 00:18:23.050 align:middle line:84% with priorities and the way that services are being provided? 00:18:23.050 --> 00:18:24.850 align:middle line:84% And second, what could polio staff 00:18:24.850 --> 00:18:27.370 align:middle line:84% do when dissatisfaction with their projects 00:18:27.370 --> 00:18:29.920 align:middle line:84% stems from issues beyond the polio program? 00:18:29.920 --> 00:18:33.570 align:middle line:90% [MUSIC PLAYING] 00:18:33.570 --> 00:18:37.000 align:middle line:90%