One of the important messages in the “Wellcome Global Monitor: How does the world feel about science and health?” report is that the seemingly objective, “evidence-based” field of science lives in a messy world of emotions, trust and distrust, politics, and religion that may or may not align with what science shows. It is, after all, an objective discipline living in a subjective world.

The Wellcome investigation, which covers 144 countries, and sought the views of over 140,000 individuals, brings a new lens on how globally diverse these sentiments really are.

A special chapter on vaccines brings a more tangible lens on how trust matters in science and health. Vaccines—a scientifically proven, life-saving intervention is mediated by trust and distrust, and the findings in Japan were particularly telling around both trust in vaccines, as well as in the institutions and individuals that deliver them. 

The Monitor found that among the “Big 5” (China, US, Japan, Russia and the EU), which together are home to over 70% of all researchers in the world, Japan had the lowest level (11%) of “high trust” in scientists. The UK had the highest level at 35%. Japan is also among the most sceptical nations in the world around the impact of science and technology on their local jobs, with only 26% feeling it will improve job opportunities, and 36% believing it will actually decrease the number of available jobs in the country.

When it comes to trust in the national government in Japan, only 4% report that they have “a lot” of trust in government, 47% “some,” 30% “not much” and 11% “not at all.” Public trust in journalists seems to be higher than trust in government, with 19% having “a lot” of trust in journalists, 67% having “some,” 5% not much, and only 1% report “not at all.” 

As with most countries, trust in doctors and nurses rank the highest from the public’s view. In Japan, 26% report a lot of trust in doctors and nurses, 67% “some” trust, 5% “not much” and no one responded “not at all.” While that is good news for the patient-doctor relationship, what the Japan story tells us is that even when confidence in healthcare providers is high there can still be confidence issues related to other influential actors.  

Although many of the Japanese respondents agreed with the statement “vaccines are important”—23% “strongly” agreed and 43% “somewhat” agreed—confidence was much lower when it came to vaccine safety. The Global Monitor found that only 9% of the Japanese respondents strongly agreed that vaccines are safe and 25% somewhat agreed.  

The current situation around the HPV vaccination in Japan—where the government suspended their proactive recommendation of the vaccine nearly seven years ago—is a poignant example of the tangible impacts broken trust on health outcomes

In April 2013, HPV vaccination was introduced into the national immunisation programme, with an enthusiastic 70% uptake. Two months later, the government suspended its “proactive” recommendation of the vaccine, faced with a number of complaints by mothers that their daughters had pain and difficult moving following vaccination. Soon after the suspension was announced, the media sensationalized the negative personal stories. As the Global Monitor reported, the public trusts journalists more than the government, and with the widely reported news media, the public anxiety only heightened. 

Vaccine acceptance rates have plummeted from over 70% to 0.03%, partly due to the negative public voices and media amplification, but largely due to the governments’ unwillingness to stand by the science, despite efforts by health professional associations to overturn the suspension. 

In 2016, the Japan Expert Council on Promotion of Vaccination, representing the voices of 17 Japanese academic health and medical societies involved in immunization, issued a statement appealing to the government to reverse the suspension and resume proactive recommendation of the vaccine based on the investigations and advice of the global scientific community.^1,2 Nothing happened.

Now, nearly seven year after the suspension, the proactive recommendation of the HPV vaccine in Japan remains in limbo, as does the public’s confidence. Adding to the uncertainty and anxiety provoked by this suspension, the government says that although they are not able to proactively recommend the vaccine, the vaccine is still in the programme and available to those who demand it. The problem is few are demanding it. Recent research revealed that the 2013 suspension and its dramatic impact on vaccine uptake is expected to result in approximately 25,000 additional cervical cancer cases and over 5,000 cervical cancer deaths.³ Additionally, there were already increasing rates of cervical cancer among 15-39 year-old women in Japan – a 4.4% annual increase between 1994 and 2011 –  and low uptake of cervical cancer screening, making proactive recommendation of HPV vaccination more important than ever.³  

What the Wellcome Global Monitor tells us is that high level trust in doctors is important, but it is not enough. Trust in government and the policies they create is essential, along with the government’s own trust in science to inform their policy decisions. 

Japan is not the only country to have faced similar reactions following HPV vaccination, but Japan is the only country to go against scientific consensus and WHO advice discouraging the suspension. Denmark, Ireland and Colombia⁴ faced similar situations, but the governments stood by the science.⁵ In Denmark, the health officials invited young girls of HPV vaccination age to help co-create a social media campaign for their peers to rebuild confidence and demand for the vaccine. And, It worked.

Japan should consider such actions, as trust building is urgently needed at multiple levels and will be paramount for their public’s health.

Heidi J Larson, Professor of Anthropology, risk and decision science, London School of Hygiene & Tropical Medicine, UK.

Competing interests: None declared. 

 

1. Iwata S, Okada K, Kawana K. Expert Council on Promotion of V. Consensus statement from 17 relevant Japanese academic societies on the promotion of the human papillomavirus vaccine. Vaccine 2017; 35:2291–2.
2.  Saitoh A, Okabe N. Progress and challenges for the Japanese immunization program: Beyond the ‘‘vaccine gap.”  Vaccine 2018; 36:4582–4588.
3. Motoki, S. Mizushima, M. Taguri, K. Takahashi, R. Asano, H. Kato, et al., Increasing trends in cervical cancer mortality among young Japanese women below the age of 50 years: an analysis using the Kanagawa population-based Cancer Registry, 1975–2012, Cancer Epidemiol. 39 (2015) 700–706.
4. Simas C, et al. HPV vaccine confidence and cases of mass psychogenic illness following immunization in Carmen de Bolivar, Colombia. Hum Vaccin Immunother. 2019;15(1):163-166. doi: 10.1080/21645515.2018.1511667.
5. Larson H J. The world must accept that the HPV vaccine is safe. Nature. 2015 Dec 3;528(7580):9.