n less than a year of the Covid-19 pandemic, we had our first vaccines. It was unprecedented and encouraging that several vaccines were available so quickly for use against a new disease. Those devising global and national Covid-19 control policies were euphoric. “Soon, the pandemic will be over; the world could go back to business as usual,” said one. However, I disagreed with this flawed estimate. In January 2021, I sought to dampen such expectations by writing that: “Vaccines are part of our arsenal, but never think you can ride out this pandemic just on them.” The reason was that, while working on previous immunisation strategies, including for polio, we had learnt that even after the production of an effective vaccine, there will be so complex issues to solve. The problems include procurement, transport, maintenance of cold chains and actual injection. In the Covid-19 case, more than seven billion people had to get the shot in the arm. Each of these steps needed significant time. That was why my next sentence was: “Think about public health to safeguard our survival in the long run.” We knew that the rich countries would horde vaccines, which were expensive. Some of the vaccines needed storage at very low temperatures. Our turn was going to come late; we had to ensure that we could still protect our population.

Once modern vaccines were rolled out (thanks to the World Health Organisation and the United Nations programmes) we too got some. Later, China started providing another type of vaccine to Pakistan. There were a lot of myths doing the rounds and much propaganda against vaccines. The situation was so bad that the WHO called it an info-demic (a pandemic of wrong information). Some people were especially worried about the new vaccines as a lot of false information was circulating. I remember that when I got vaccinated, the district health office, Islamabad, tweeted my photo to encourage others to follow suit.

Vaccine refusal is not a new phenomenon. It has been around since the advent of vaccines. I think there is only one instance of a vaccine being given universally and successfully. As a result, smallpox was eradicated from the world. The second success story could have been polio, if it were not for us and Afghanistan. All other countries have stopped polio transmission in their populations. As a result of the failure of polio eradication programme in Pakistan, the local audience is familiar with the vaccine refusal phenomenon. A nice word for it is vaccine hesitancy.

In Pakistan, vaccine hesitancy has been blamed mostly on an illiterate people and the fundamentalist section of the society. But we saw in the Covid-19 days that it’s not just the illiterate who refuse vaccines. Some of the well educated people at the top of the socioeconomic ladder too refused vaccines for various reasons. It was not just religious fundamentalism either. Those refusing vaccination included liberals. Some of the highly educated and liberal people in the West have sometimes been responsible for measles outbreaks in children because they refuse to get their children vaccinated.

But how many of these people are really against vaccines? Whose failure is it to convince them that vaccines are important for their children? Some of my colleagues working in the immunisation sector might not agree with me, but as a public health professional I know that it’s our own failure. We saw colossal failures in risk communication strategies as privileged people like us were making health advisories while sitting in the capitals, without any idea of the real-life challenges faced by common people. That is why I hardly ever blamed the public for non-compliance with health advisories as those were not issued after consultation with the communities. The measures were never adequately explained to them; the governments just asked for compliance. Many people did not follow the advice and we blamed them for the harm.

That is also the real story behind the large numbers of cases of vaccine hesitancy or refusal. Yes, there will always be a hard-core section that will refuse vaccines, even medicines. But we don’t need 100 percent uptake of vaccines to make a population safe. The strategy should be to vaccinate more people, especially some who have earlier refused vaccines. Some will say that is “easy said than done.”

We need better communicators in public health. We need people who can engage with communities and develop a bond of trust with them. We need the best risk communicators deployed at the field level. We also need to hire the best for field deployments and pay them better. In the polio eradication programme our front soldiers, many of whom have sacrificed their lives for vaccinating children, are paid so little that it is plain shameful. The pay gap between those in the field and those in the capital is horrendously large. Our population needs to receive a complete package of disease prevention and basic treatment options. Local people should feel that the person trying to vaccinate their child is doing it because he wants the best for their child and is not doing it to complete his quota. This could be easily done by converging polio and children’s routine vaccination programmes.

In the absence of all of the above, it’s not surprising that in repeated vaccination drives, missed children are missed again. We have never tried to sit the reluctant parents down at the community level. Yes, there is and will always be some vaccine hesitancy, but we should not add to those numbers those that are due to our failure to communicate better, develop trust and programme deficiencies. If we do our work properly and do not act in a patronsing manner, we could control the diseases even with small pockets of those refusing the vaccines. Vaccine hesitancy is real, but its scale is often over-reported.

The writer is an adjunct professor of epidemiology at the University of Nebraska, USA, and chief executive officer of Global Health Strategists and Implementers, a consulting firm in Islamabad. He has worked at the Stanford University, University of Washington and London School Hygiene and Tropical Medicine and with the US Centre for Disease Control and Prevention.