Immunization: A Social Pact for Collective Health

Editorial

Vaccination is the most effective and economical way of preventing diseases and can be understood as a social pact for collective health [1]. We understand “Pact” as an agreement, and the term “Social”, a very broad word, indicates something of greater interest. Thus, in order for it to have the expected effect, immunization must take place on a massive scale, capable of bringing about the so-called “herd immunization”, whereby vaccinated individuals protect themselves and non-immunized individuals, leading to the control and even complete elimination of the circulation of the infectious agent [2].

In Brazil, the Unified Health System (SUS) guarantees the population free access to all the vaccines recommended by the World Health Organization (WHO). The SUS is the largest public health system in the world, serving more than 190 million people every year, fully and free of charge. The Organic Health Law, Law 8080 of September 19, 1990, which regulates health actions and services throughout the national territory, states in Article 2 that “health is a fundamental right of the human being, and the State must provide the indispensable conditions for its full exercise” [3]. The National Vaccination Calendar in Brazil, offered by the SUS, corresponds to the set of vaccines considered to be of priority interest to the country’s public health. It currently consists of 19 vaccines recommended for the population, from birth to old age, and distributed free of charge at public vaccination centers.

The National Immunization Program (PNI) of the SUS was created in 1973 with the aim of social inclusion in terms of immunization. Within this context, the campaigns aimed at engaging the population in immunization against poliomyelitis (infantile paralysis), which has been mandatory in Brazil since 1975, initially addressed fear, guilt and the exclusive responsibility of parents. Over time, the campaigns began to appeal to individual and collective responsibility in guaranteeing the vaccine for children, defended as an act of love, as well as a child’s right. To further popularize the vaccine, the PNI opted to use a doll called “Zé Gotinha”, created in 1986 by artist Darlan Rosa. With a national competition to choose the doll’s name, a great deal of mobilization and effective participation by society around the topic of vaccination was promoted. Thus, “Zé Gotinha” became synonymous with vaccines and a reference point for the population [4].

In addition, the establishment of National Vaccination Day, which has had a major epidemiological impact, and the promotion of well-organized campaigns have contributed to the acceptance of preventive practices and strengthened the image of local health services among the population. In this way, the SUS has become a benchmark in vaccination, offering one of the most complete free vaccination schedules in the world.

However, in recent years, vaccination rates in Brazil have returned to alarming levels, comparable to the 1980s. The debate on vaccine hesitancy (reluctance, indecision, or refusal to vaccinate) has grown worldwide, making it a central issue for immunization programs [5]. The drop in vaccination rates in Brazil, although caused by multiple factors, has the misinformation of the population as one of its main components [6]. The movement against compulsory vaccination has been strengthened for reasons ranging from religious reasons to the belief that vaccines are unsafe to criticism of the financial interests of the medical- pharmaceutical complex [7].

The World Health Organization (WHO) recommends polio vaccination coverage of at least 95% of the child population. According to data from the Ministry of Health, the population’s vaccination coverage has been plummeting, since in 2019, the rate was 73% of citizens immunized, in 2020, 67% and 2021, less than 59%. In 2022, 84% of municipalities were classified as “high risk” and “very high risk” for the return of polio. According to PAHO, despite the Americas being the first region in the world to eliminate polio in 1994, national immunization programs have suffered numerous losses in the last decade, as the risk of disease outbreaks in the Americas reaches its highest level in 30 years due to the drop in vaccination coverage. In this sense, diseases that had previously been eradicated or controlled, such as measles, have reappeared, and in 2018, the World Health Organization recorded the highest number of measles in the world since 2006, even causing Brazil to lose the Measles Elimination Certificate awarded by the Pan American Health Organization (PAHO) [8].

The mandatory vaccination of children and school attendance for families to access government cash transfer programs in Brazil was a strategy to guarantee this social pact for health. However, the Bolsonaro government (2019-2022), infected by scientific denialism, abolished this requirement, as well as fostering distrust of vaccination, especially in the midst of the Covid-19 pandemic. According to the former President of the Republic, during the Covid-19 pandemic, infection with SARS-Cov-2 was compared to a “little flu”, and he also stated that “Will some people die? They will, I’m sorry. That’s life”; and publicly taking a stand against making the vaccine compulsory, to the point of saying that “If you become an alligator, that’s your problem” [9], referring to the possible side effects of the immunizer. Even the famous Zé Gotinha, a strong symbol of immunization, was slow to appear in government vaccination campaigns against Covid-19 [10]. In this sense, we can see that the social pact that involves immunization becomes very weak when the government itself sabotages it. Whether it’s sowing disinformation about vaccines, motivating vaccine hesitancy, eliminating strategies that have historically been successful or reducing and jeopardizing funding.

It is important to consider that the lay population’s trust in specialized systems or expert systems, those systems of technical excellence or professional competence that organize the material and social environments is based on pragmatic elements of faith, based on the experience that such systems generally work as they are expected to. For this reason, the public authorities and their public health agencies must function like lanterns in the dark, in the midst of health crises [11].

In 2023, the Brazilian Ministry of Health is seeking to rebuild the full relationship with scientific societies and the dialog with states and municipalities in an inter-federative logic in decision-making to achieve the goal of 90% vaccination coverage in all groups. To this end, the agency launched the National Movement for Vaccination, which carries the message “Vaccine is life. Vaccine is for everyone”, as a priority action to rebuild the Unified Health System (SUS), confidence in vaccines and the country’s vaccination culture. In response, the Childhood Health Observatory (Fiocruz) identified a recovery in vaccination coverage for children under two in Brazil [12].

An important step towards resume Brazil’s historically high vaccination rates is by informing the population about the benefits of vaccination and training health professionals to take on the role of disseminating truthful, scientifically backed information on the subject, as an ethical and professional commitment to society.