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Effects of Social Stratification on Global Vaccination Rates - by Allen D Archer

Allen D Archer

Social Problems (SOC-220-LO1)

Porscha Orndorf

April 7, 2020

Abstract

This paper’s primary focus is to investigate the effects of social stratification on global access to quality preventive healthcare, primarily vaccinations. This paper explains vaccinations and their importance globally followed by a compilation of research articles from around the world that pertain to vaccination rates, methods, and obstacles. These research articles are analyzed and compared to assess the effectiveness of different methods and practices of vaccinating citizens in different regions of the world. From this research and analysis, patterns of lowered vaccination rates among lower socioeconomic regions becomes apparent and this paper takes a closer look at some of the underlying factors that contribute to this unfortunate reality. After identifying some of the primary barriers to equal vaccination for all people, this paper assesses measures that are currently being taken by global health organizations to rectify this problem. Possible solutions to low vaccination rates are formulated and presented with the focus being on preventative healthcare and life saving vaccinations being established as a basic human right for all people in accordance with the United Nations Developmental Sustainability Goals.

Introduction

Wealthy countries have access to endless vaccines, yet some citizens choose not to take advantage, while other countries around the world lack access to basic immunization and preventive healthcare. Until this global problem is addressed with an adequate level of urgency, hundreds of thousands of people will continue to die needless deaths from vaccine preventable disease. In the book Deadliest Enemy by Dr. Michael Osterholm and Mark Olshaker (2017) it is stated that, “The return on investment in global health is tremendous, and the biggest bang for the buck comes from vaccines. Vaccines are among the most successful and cost-effective health investments in history. – Seth Berkley, MD” (p. 80). The following research paper outlines some of the hurdles that currently stand in the way of providing immunization to all and attempts to propose ways to achieve success moving forward.


Central Argument

The third Sustainable Development Goal of the United Nations is to ensure healthy lives and promote well-being for all people at all ages (Health, n.d.). The primary barrier to this goal is that globally, socioeconomic status overshadows access to quality healthcare and immunization against communicable disease. Preventative healthcare and life saving vaccinations must be a basic human right for all people if there is hope of achieving the healthcare goals set by the United Nations. Vaccinations must be made readily available for all people and the general knowledge and understanding surrounding vaccinations must be improved. In line with this, the United Nations published a list of targets that must be met to achieve this goal. One of these targets is to “Achieve universal health coverage, including financial risk protection, access to quality essential healthcare services, and access to safe, effective, quality and affordable essential medicines and vaccines for all” (n.d.). Another target states that there must be, “Support for the research and development of vaccines and medicines for the communicable and noncommunicable diseases that primarily affect developing countries” (n.d.).


Vaccinations

Vaccine is a term used to classify a type of solution that is administered for the purpose of helping the immune system develop antibodies to protect against infectious diseases. These solutions consist of small doses of diseases that the immune system can combat and build a resistance to before interacting with the diseases in mass in everyday life. Some vaccinations consist of a disease that has been killed while others may contain a live disease that has been weakened prior to introduction into the body. Some may not contain disease at all and instead simply contain proteins or toxins that are unique to specific diseases. After the immune system has interacted and combatted the “invasion” it will remember the characteristics of the disease and build an immunity to that disease. This method of building immunity is referred to as adaptive immunity (Tortora, 2019).


The original vaccination was created by a man named Edward Jenner in 1796 in response to the Smallpox pandemic. At this time, it was well known that if someone was infected with smallpox and was able to survive the sickness, they would be immune to the disease for the remainder of their life. Also, Jenner was informed of a growing theory that milkmaids were contracting cowpox and surviving this disease at much higher rates than that of smallpox and the milkmaids were also developing immunity to smallpox. So, working off this theory, Jenner began a process of inoculating healthy people with cowpox acquired from open lesions on an infected milkmaid named Sarah Nelms. The newly infected person would then get sick for a few days but survive the sickness with relative ease. Jenner would then attempt to infect the person again, with smallpox this time, and there would be no second sickness. Therefore, he concluded that surviving a minor cowpox sickness would build immunity to both cowpox and smallpox. After documenting these findings and submitting them for publication, which were initially rejected, he published a book in 1798 explaining how he had discovered the solution that would lead to the eradication of the smallpox disease globally. The Latin word for cow is vacca, and cowpox is vaccinia. So, Jenner decided to call this new procedure vaccination (Riedel, 2005).


Since Jenner’s discovery, vaccinations are credited as one of the greatest scientific discoveries in human history. Vaccinations are relatively simple and cost effective to make and have saved millions of lives every year since their invention. There is no single medical procedure or preventive measure that has had as great an impact on human civilization than the introduction of widespread vaccination. Chirico (2019) states the following:


Vaccines may have saved more lives and added more quality life years across the globe than antibiotics. There are vaccines available for about 25 diseases, many of which are potentially deadly. From 2000 to 2015, the measles vaccine alone saved 17.1 million lives, but progress toward new vaccines and increased vaccination stagnated from 2010 to 2015 (WHO 2015a). One in five children still do not receive necessary immunizations. Vaccination efforts must increase to include everyone and expand to include more emergent diseases. (p. Chapter 4)

Even armed with the knowledge that vaccines save millions of lives globally each year, not everyone has access to vaccination. There is a principle known as herd immunity that is critically important in eradicating disease from communities around the world. Herd immunity protects the population within a community who are vulnerable to communicable diseases or are unable to receive vaccines for several potential reasons such as a compromised immune system, allergies to certain vaccines, or other health reasons. To gain herd immunity and protect the vulnerable in a community, a very high percentage of the community must be vaccinated so that, when a communicable disease is introduced, there are not enough susceptible people for the disease to be able to gain a foothold and spread. Limiting the possibility of spreading effectively kills the disease and save lives. The necessary immunization rates to insure herd immunity against measles, for instance, is 94% (Helft, 2014). Measles is also a very highly contagious virus that has the potential to infect eighteen people for every one person who has the disease (Helft, 2014). So, if herd immunity is not prevalent, this disease can spread remarkably quickly and devastate an entire community. The concept of global herd immunity is what has led to the elimination of diseases like polio and tetanus. Although these diseases still exist, they are unable to infect people due to immunity.


Cost of Vaccinations

When looking at overall cost of vaccinations, it is important to understand that there are different vaccination requirements for different regions of the world depending on exposure to disease and likelihood of transmission. According to an article published in the American Journal of Public Health, “The cost of vaccine purchase in the year 2020 following recommendation of 7 additional vaccines is estimated to be $1,225 per child (95% confidence interval = $891, $1559)” (Davis, 2002, p. 1982). This cost may initially seem high. However, when compared to the potential cost of non-vaccination, these costs are very minimal. It is also important to note that the price listed above are based on vaccinations purchased in the private sector and are inherently more costly that the price of vaccinations that are administered by public organizations.


According to a study by Tembo et al (2019) that looked at the cost effectiveness of the oral vaccination for cholera in Zambia, “The mean cost per administered vaccine was US $1.72… Costs per life year saved ranged from US $18,515 – US $27,976” (p. 1). This is an example of a single vaccine in one region of the world. Extrapolate this example over the range of vaccinations and the entire world and this translates to billions of dollars saved. According to an infographic produced by the United Nations titled Good Health and Well-Being: Why it Matters pertaining to the third sustainability goal, “Spending $1 billion in immunization coverage can save 1 million children’s lives each year” (n.d.). From an economic standpoint alone vaccination makes sense.


Low Vaccination Regions

In a research article by Kumar Arun et al. (2016), a study was conducted in a rural area of Gharaunda, Karnal, in India that looked at immunization coverage and dropout rates of vaccines among 60 children between 0-15 months. This study acknowledges 15% of the 60 children surveyed lacked complete immunization. The lowest coverage (83.33%) was observed for vitamin A vaccine immunization. Some of the reasons listed for dropout were the mother being unaware, travelling, and the medications not being available. Ironically, the leading cause of dropout was child sickness. The leading causes of dropout acknowledged in this study are all preventable. For instance, the mother being unaware of the vaccination schedule is a poor reason for a child to miss routine vaccinations and is indicative of poor community education by healthcare providers or a lack of qualified health workers in the area.


Similarly, another research article by Cashman et al (2016) looked at the vaccination gap between the Aboriginal people of Australia and other Australian citizens. The background section of this research article opens with the following statement “The socio-economic disadvantage of Aboriginal and Torres Strait Islander peoples in Australia is evidenced by the gap in measurable social, economic, and health indicators between Aboriginal and Torres Strait Islander peoples and the rest of the Australian population” (p.1). The remainder of the article discusses the tactics used by the Australian people to close the immunization gap. This included the hiring of Aboriginal people by Australian healthcare organizations to contact other Aboriginal families prior to their immunization dates and explain the rationale behind receiving these immunizations and making sure they were aware of their appointments. It was determined that this tactic was highly effective in improving vaccination rates. So much so that the research concludes that, “By the end of the study period in 2014, immunization coverage in Aboriginal infants had surpassed that of non-Indigenous infants by 0.8 %” (p.1).


From this study, it can be inferred that having a healthcare system that is made up of healthcare workers that reflect the population they serve is an effective way of ensuring that all people are being accounted for. Implementing the employment and education of diverse cultural populations in global and local healthcare organizations is a fundamental step to increasing the likelihood of success in global immunization.


Another study conducted in China in 2010 by Z. Ji et al. (2014) found that only 23.5% of the children studied had vaccine-induced immunity to Hepatitis B virus (HBV) in Wuwei City, Northwest China. Even though there is effective vaccine, HBV and illness related to HBV are some of the leading causes of death in China. Efforts were made in the early 2000s to offset this epidemic with little lasting success. It is stated in the discussion section of this article:


After routine implementation of the HBV immunization program in 2002 the primary obstacle to overcome was vaccine administration to children of lower socioeconomic levels, which hampered the efficacy of the vaccination program in infants since some parents did not precisely follow the immunization schedules, especially at younger ages due to low socio-economic status and residence in remote areas that limited access to health and educational services. (p. 9)

This study clearly demonstrates the fact that simply having a vaccination is not enough to stop an epidemic. It must be distributed to an entire population before it can be truly effective. The conclusion of this study acknowledges that significant improvement is needed in the Chinese immunization strategy, with a primary focus on rural migrant workers.


Pakistan also has very low vaccination rates that range between 59-73% and Pakistani health organizations have made efforts to combat these low rates with little success. A study was conducted in 2008 that investigated the factors that drive these low vaccination rates. This study stated that “Low parental, specifically maternal literacy and knowledge regarding vaccines and immunization schedule, poor socioeconomic status, and residence in rural areas are associated with low immunization coverage” (Owais et al., 2011, p. 2). Therefore, the researchers assessed the effects of a simple educational intervention designed for low-literate populations. It was concluded that this educational intervention improved vaccination completion rates by a massive 39%.


In all these studies about low vaccination rates that were reviewed, low socioeconomic status was the common theme. Along with low socioeconomic status came under-representation in the regional healthcare systems, lowered education rates, lowered access to vaccinations, and an overall decreased quality of preventive medical care. This is problematic because it reflects a pattern of neglect among those tasked with protecting citizens. From government officials to healthcare workers and everyday citizens who are not in poverty, everyone must acknowledge this crisis and take necessary steps to combat unnecessary illness and death.


High Vaccination Regions

Alternatively, there are regions of the world that have lower socioeconomic status and have still been able to achieve acceptable vaccination rates. For instance, a study conducted by Yuan et al. (2012) examines how a rural area in Honduras can maintain very high vaccination rates for all citizens in the area. Many factors have aided this successful vaccination program.


The article states:


Based on our analyses, the current system appears to have had a positive impact on the frequently cited barriers to immunization in rural settings, including parent forgetfulness and convenience of time/place for vaccinations [4]. Community health workers and other staff in Intibucá have noted these barriers and included programs such as education on vaccine importance. Vaccine delivery rates are also included in the monthly evaluation of health centers and staff by the health department”. (p. 5)

The results of this study show that when the proper resources are allocated and public health is prioritized, vaccination can be achieved for all eligible citizens. Through education and community outreach a very rural region maintains vaccination rates that some urban, industrialized nations are not able to maintain.

Another study was conducted in the United States by Ransom et al. (2012) that assesses factors that affect vaccination rates. Specifically, they address the structure, resources, and community engagement of 17 local health departments over 10 states to identify why vaccination rates vary widely across the nation. It was determined by this study that six key factors emerged that affect a local health departments ability to be effective in vaccinating the population it serves. Of these six factors, resources, community engagement, and understanding of the community are three that played a major role in the success of vaccination rates across the country. There is clear correlation between successful vaccination and the health departments that were able to effectively represent their community and allocate resources to engage the people that they serve.


In this study, “Limited cultural competency and cultural humility of staff; limited local health department infrastructure for supporting focus on staff development and growth in cultural humility and cultural competency; limited activities focused on health equity” (Ransom, 2012, p. 434) are listed as some of the challenges associated with some local health departments perspectives on their community. Many of these can be addressed through education and hiring from within the community that is being served.


Another method that has proven effective in increasing vaccination rates in certain regions is the implementation of legislation that requires vaccination in order to participate in federally funded programs. In Australia, for instance, there is a growing anti-vax movement that jeopardizes the health of people who are not in rural areas or lower socioeconomic classes. The anti-vax movement is a global group whose members opt out of regularly scheduled and accessible vaccinations due to ill-placed fears surrounding the vaccinations themselves and perpetuated by the continued spread of information that has been repeatedly proven false.


In Australia, the rise in communicable disease outbreaks and the influence of the anti-vax movement in recent years led the Australian government to act and impose new regulations on vaccination to help keep the unnecessary mortality rate down. These new regulations are referred to as “No Jab, No Pay” and, according to an article by the Australian Department of Health titled Why get Immunized (2020), “Children must meet the immunisation requirements for Family Tax Benefit (FTB) Part A and Child Care Subsidy (CCS). To meet the immunisation requirements, children up to 19 years of age need to be up to date with their immunisations, on an approved catch-up schedule or have an approved exemption”. Meaning that if citizens do not vaccinate their children, they will not be eligible for Australia’s federal childcare benefits and can be turned away from enrolling children in any childcare services. Along with the implementation of these requirements, Australia has also made all vaccinations free to citizens so that, regardless of socioeconomic status, everyone can access the required vaccinations.


Possible Governance Solutions

Through the analysis of all these studies, there is a consistently glaring correlation between lower socioeconomic status and lower vaccination rates globally. Lower socioeconomic status is often accompanied by unequal representation in local healthcare systems and this plays a major role in decreased vaccination rates as well. While a disease outbreak often starts in an isolated area, often an area of lower socioeconomic status, outbreaks of a deadly communicable disease quickly becomes a global problem. Therefore, to combat future global problems, the United Nations must be given more power and funding to first identify all the regions globally that have below acceptable vaccination rates. From there, the next step is to ensure proper resources are allocated to improving access. This includes providing vaccinations for free or reduced cost and making schedules for vaccinations easily understandable by both the providers and the patients.


However, beyond simply supplying vaccinations, hiring and educating local healthcare personnel who represent the communities they serve is a critical factor that will require an extensive, long term education plan for young people in rural and underrepresented areas of the world. Like the study of the Australian Aboriginal people suggests, one of the most effective way to achieve successful infiltration into a society is to educate from within rather than try to introduce outsiders who lack cultural understanding. The benefits of access to quality education are summarized well by Chirico (2019) in Chapter 5 Expanding Horizons Through Lifelong Learning:


Education is essential for the development of the individual and the society. The benefits of education to individuals, their families, communities, and societies are indisputable. The whole world benefits. For individuals, education improves their personal health and that of their families. A person with just a primary education is much less likely to contract HIV. Just six years of schooling improves rates of prenatal care, assisted childbirth, postnatal care, and immunization. (p. Chapter 5)

To achieve this, core nations like the United States must partner with global organizations like the United Nations and the World Health Organization to assist in providing affordable and accessible educational pathways into medicine, nursing, and public health for citizens of underserved populations. Without this critical step, it is unlikely that long-term understanding and health education will be able to take root in these rural and lower socioeconomic areas.


Once the United Nations, along with other global health organizations, have identified all regions who fall below the required vaccination guidelines they must formulate realistic goals to eradicate many of the deadly communicable diseases that persist today despite the existence of effective vaccinations. From a financial standpoint, the goal of eradication will garner buy in from core nations because eradication saves billions of dollars in treatment and prevention costs long term. Along with these goals, legislation must be put in place that allocates the power to enforce and prioritize these goals. Like the current climate change crisis, without legislative action there is nothing forcing the improvement of global preventive healthcare. In the section titled Fighting Poverty and Inequality, Chirico (2019) summarizes this well by stating:


Programs and policies to spur development and combat inequality and poverty at the same time must build an infrastructure for inclusive and sustainable growth. In many respects, these activities are governance activities because they determine the direction the society takes, and the opportunities afforded to people in the society. Efforts of national governments, international governmental and non-governmental organizations, and the private sector must be coordinated to tackle these problems. (p. Chapter 2)

Action must be taken globally to improve healthcare on a local level. Socioeconomic status should not overshadow access to quality healthcare and immunization against communicable disease. Preventative healthcare and life saving vaccinations must be a basic human right for all people if there is hope of achieving the United Nations third sustainable development goal.

References

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