CAIRN-INT.INFO : International Edition

1 Even before the COVID-19 health crisis revealed a strong anti-vaccine sentiment in France, signs of an oppositional tendency had appeared, with roots in several controversies beginning in the 1990s. These involved the vaccines for hepatitis B, human papillomavirus, and rotavirus, as well as the aluminum adjuvants present in some vaccines, and generated doubt about the safety of certain vaccines. Above all, however, such controversies were testament to an anti-government sentiment, which returned to the fore during the contentious handling of the swine flu (H1N1) pandemic in 2009–2010. This was a tipping point that marked the widespread establishment of vaccine mistrust in France. The proportion of the French population declaring themselves to be against vaccination rose from 8.5 percent and 9.6 percent in 2000 and 2005 respectively to 38 percent in 2010 (Gautier, Jauffret-Roustide, and Jestin 2008; Peretti-Watel et al. 2013). This dramatic shift is particularly pronounced at the two extremes of the spectrum: the percentage of people strongly in favor of vaccination decreased significantly (43.6 percent in 2000 versus 15 percent in 2010), while the percentage of people strongly opposed to vaccination rose sharply (2.7 percent in 2000 versus 19 percent in 2010).

2 The negative associations that had surrounded anti-pandemic vaccination in 2009–2010 worsened as the COVID-19 crisis took hold, as shown by the “vaccine compliance” section of the CoviPrev survey, organized by the French Public Health Agency to monitor developments in citizen behavior in the context of the pandemic. [1] Launched in 2020, the survey found that a significant proportion of the population—between 39 and 60 percent of respondents, depending on the survey period—“certainly didn’t” or “probably didn’t” intend to get vaccinated against COVID-19. Although to a large extent vaccine mistrust during the two pandemic periods in question (2009–2010 and 2020) can be explained by fears of possible side effects from vaccines developed rapidly in a health-crisis context, other factors point to more deeply anchored representations among the French regarding this preventive health tool. The CoviPrev survey clearly traces a change in vaccination intentions according to the period: levels of mistrust peak in December 2020, coinciding with the launch of the national vaccination campaign, indicating distrust of the government and its handling of the pandemic.

3 Beyond the French panorama, vaccine skepticism is a major international trend that threatens population health. Since the 2010s, the resurgence in measles epidemics in the West linked to insufficient vaccine coverage has been accompanied by increasing media focus on “anti-vax” movements. Political and health actors are all too aware of the implications of vaccine skepticism; indeed, in 2019, the World Health Organization (WHO) placed vaccine hesitancy on its list of the ten greatest threats to global health. The study of vaccination behavior by researchers from the human and social sciences has grown steadily since the 1990s, such that this area has become a field of investigation in its own right over the last ten years, thanks also to the leadership provided by the Vaccine Confidence Project. Partly financed by the WHO, this program detects public concerns about vaccines via computer surveillance, and also receives funding from the Bill and Melinda Gates Foundation, as part of this philanthropic organization’s ambitions to influence and guide global health programs. It is headed by the American anthropologist, Heidi Larson.

Map 1

COVID-19 vaccine coverage as at August 18, 2021

Map 1

COVID-19 vaccine coverage as at August 18, 2021

4 Classic notions of vaccine refusal or acceptance have more recently been joined by the concept of vaccine hesitancy, developed in 2014 by specialists from the WHO’s Strategic Advisory Group of Experts (SAGE) on immunization, a body also partly funded by the Gates Foundation. It defines vaccine hesitancy as “delay in acceptance or refusal of vaccines despite availability of vaccination services” (WHO 2014, 8). The committee of experts led by Heidi Larson stresses that between pro- and anti-vaxxers lies a continuum of people who are undecided, and who must be taken into account when developing national or international vaccine strategies.

5 Vaccine mistrust is political, in that it is informed by the relationship between a population and its political institutions and leaders. This article will address the concept of vaccine resistance rather than that of vaccine hesitancy (Guimier 2016). Vaccine resistance is the result of militant, reasoned choices taking shape in collective configurations. Unlike hesitation, resistance involves reasoning based on common values that enables identification with a group, and, in its most developed form, the sharing of arguments and tactics with other sympathizers. We use the notion of resistance to refer to the permanent power games that are played between a government and its subjects, paving the way for a broader reflection on phenomena of domination and resistance in political planning, and—for the purposes of this article—in vaccine policy.

Historical tensions around mandatory vaccination

6 Anti-vaccine movements have existed for as long as vaccination itself, in particular in response to its institutionalization. In France, organized opposition began in the last quarter of the nineteenth century, when the idea of compulsory vaccination was first discussed in parliament. In 1879 a Belgian doctor, Hubert Boëns, set up the first French anti-vaccination league, the Ligue universelle des antivaccinateurs (Universal Anti-vaccine League), which organized four conventions in various European cities over the years to 1885. Opposition to vaccines in these cities predated and was more active than that in France, which had made vaccination mandatory later than its neighbors.

7 Indeed, Bavaria had made vaccination compulsory as early as 1807, followed by Sweden in 1816, England in 1853, and Italy in 1859 (Porter and Porter 1988, 233). Principally composed of doctors, in 1880 Boëns’s League managed to block a draft bill to make smallpox vaccination compulsory upon pain of prosecution and penalties (Skomska-Godefroy 1996, 424). A similar proposal had been put forward more than a decade earlier in 1868 by Amédée Monteils, a doctor and member of Parliament. However, after twenty years of Bonapartism (1848–1870), public feeling was not ready to accept such a perceived attack on individual freedoms; indeed, as a nation, France considered itself more advanced in this matter than its neighbors who employed authoritarian coercion. Thus, Monteils’s project was rejected on the basis of an objection introduced by Senator Conneau, also a medical doctor, who posited a comparison with England “which everybody holds to be a model of individual freedoms,” yet where, according to him, “a father is subject to the most vexatious of obligations: that of having his child undergo a procedure that he may believe to be harmful or dangerous to the health of that which he holds most dear in the world.” [2],[3] Moreover, he continued, “In an age such as ours, […] could we really proclaim a law that would nullify the most cherished and sacred freedom, that of a father to decide on matters of health and education for his child as he sees fit?” [4]

8 In parallel with these paternalistic representations anchored in contemporary discourse, resistance was also manifested by private doctors, the profession with greatest representation in the Chamber of Deputies and the Senate, who generally resented state interference in their professional affairs. Indeed, records from discussions at the Academy of Medicine over the 1880 draft bill on compulsory vaccination show that these recalcitrant doctors’ concern was not so much inoculation itself as the implications for the medical profession. Guilds having been banned under the constitutional monarchy by the Le Chapelier law of June 14, 1791, physicians were in search of legitimacy. “It is not yet a question of our citizen’s freedoms being surrendered to the arbitrariness of law,” Doctor Jules Guérin openly states, “but rather the freedom of the doctor to willingly and rightfully guarantee that of his client […] mandatory vaccination would therefore be an attack on professional freedoms, and a source of perpetual conflict between the right of the physician and the arbitrariness of the law.” [5] These debates clearly form part of broader concerns around the safeguarding of interests in the medical profession, since the first doctors’ union was also created at this time (1881). The pugnacity of this union led to the law of November 30, 1892, which restructured the medical profession and officially recognized doctors’ unions.

9 These changes “symbolized the new prestige of medicine” (Léonard 1978, 64), whose nascent representation required the defense of both the powers acquired by the profession and its identity. Characterized by the independence of physicians from the state, this identity notably took shape in opposition to changes in Germany at the time, where Otto von Bismarck, chancellor from 1871 to 1890, was establishing a compulsory social health insurance system (1883), requiring all industrial workers to pay into local health insurance funds. [6] Whether a health system was organized around private practice (as in France) or by establishing a public health-care model whereby doctors became state employees (as in Sweden or Germany), was an issue that greatly impacted the social standing of the profession. The social positioning associated with private practice was more likely to facilitate doctors’ entry into politics and, consequently, the medical profession’s influence within parliament—a fact that weighed in the French delay in making vaccination mandatory. After several years of heated debate, parliament finally voted in favor of mandatory smallpox vaccination on February 15, 1902, enshrining the concept of public health in law for the first time.

10 In 2018, it was easy to see how tensions surrounding mandatory vaccination persisted, when the list of compulsory vaccines was extended from three to eleven to address the insufficient vaccine coverage resulting from vaccine skepticism. This major reform of French vaccine policy [7] provoked numerous protests from individuals and associations defending “vaccine freedom” on social networks or at rallies. A number of prominent media and political figures galvanized the protesters by calling for “resistance” against state directives perceived as intrusive and even illegitimate. Among these influential figures we find representatives of the ideological foundations of anti-vaccine activism, laid down between 1950 and 1970: Henri Joyeux, a doctor; Michèle Rivasi, a member of the European Parliament and of the French green party, Europe Écologie Les Verts (EELV); Nicolas Dupont-Aignan, president of the nationalist Debout la France party; and Christine Boutin, former president of the Christian Democratic Party. Their shared school of thought presents the vaccine refusal struggle as a vector of utopia: preserving the integrity of the body—both at the individual and community level—against the poison of vaccination in the name of personal freedom.

The ideological roots of vaccine resistance in France

11 The contemporary anti-vax movement can trace its roots back to the early 1950s, launched by actors from the organic agriculture sector whose political affiliations are not as evident as they may seem. This is important as the political agenda of those promoting an anti-vaccine stance underpins the alliances, strategies, and reach of the movement among the population.

12 In 1954, Marcel Lemaire created the Ligue nationale pour la liberté des vaccinations (LNPLV) (National League for Vaccination Freedom) [8] from the merger of the Association des parents des victimes des vaccinations (Association of Relatives of Victims of Vaccinations), the natural living journal La vie claire (later to become a commercial pioneer of organic food), and the Santé et Liberté (Health and Freedom) league. The LNPLV opposes what it refers to as “Pasteurian dogma” and counts among its ranks the homeopath who developed oscillococcinum®. This last detail is significant, since—owing to their marginalization by the conventional medical profession and other sectors of society, who view them as charlatans—homeopathic practitioners have had to seek support elsewhere. The anti-vaccine community was quick to welcome them into the flock, eager to take advantage of the opportunities presented by their professional activity and influence over patients.

13 Prior to co-founding the LNPLV, La vie claire magazine disseminated a naturalist and vegan philosophy alongside a conservative and nationalist morality, denigrating the welfare state, materialism, and the erosion of the family and religion, as well as opposing abortion and contraception via a discourse that drew on a mythologized past. In two particularly instructive issues of the magazine, sociologist Christine César (2003) and researcher Arouna Ouédraogo (1998) expound the interconnections between the journal’s principal actors and the philosophy of pioneers of the organic agriculture and vegan food movement. Described as “the most influential European prophets of healthy eating and naturist vegetarianism” (Ouédraogo 1998), three actors played a key role in the ideological construction of the anti-vaccine movement: Austrian philosopher Rudolf Steiner, originator of the biodynamic theory that underlies organic farming and founder of the anthroposophical movement, regularly singled out for its sectarian aspects; Swiss doctor Maximilian Bircher-Benner, of muesli cereal fame; and French doctor Paul Carton. The latter was a fervent admirer of the nationalist Charles Maurras and of his L’Action française newspaper, which reflected his own “contained indignation at modern society.” [9]

14 It is easy to identify the common values at the origins of this intertwining of nationalism, organic agriculture, and vegetarianism: Christianity, purity, and sanctity of nature, which these thinkers set in opposition to the “transformed, foreign, artificial, impure” (Ouédraogo 1998). Christine César analyses the discourse appearing in La vie claire to demonstrate how this pillar of organic farming in France shifted away from extreme-right ideologies and toward a left-wing environmentalist position from the 1970–1980s. This evolution was driven by the labeling of organic products (1981) and ensuing normalization of this kind of agriculture, and its commercial orientation following the rejection of consumerism advocated by the libertarian movements of 1968, the emergence of political ecology, and the dissemination of New Age theories.

15 This detour through the network of connections linking the LNPLV, La vie claire, and the philosophy of the pioneers of organic food shows how anti-vaccine ideology infiltrated far-right movements before entering left and far-left environmentalist movements from the 1970s onward.

The COVID-19 crisis: A window of opportunity for rallying vaccine skeptics to the world of conspiracy theories

16 The pandemic sparked protests driven by various issues and demands (COVID-skeptic, anti-lockdown, anti-mask, anti-vaccine etc.), but all were united in rejecting government health measures. It should be noted that numerous oversights and errors in communication—with grave consequences—added fuel to these opposition movements.

17 A shortage of masks during the first wave of the pandemic, which notably left health-care workers with insufficient levels of protection against infection, and comments made in March 2020 by various members of the government (including spokesperson Sibeth Ndiaye, Health Minister Olivier Véran, and Prime Minister Édouard Philippe) questioning the utility of mask-wearing, prompted outrage among the population. The flames were then fanned by multiple factors: the inadequacy of resources allocated to public hospitals, both preceding and during the health crisis; Health Minister Agnès Buzyn’s flippancy in declaring, on January 24, 2020, that “the risk of the virus spreading among the population [was] very low” (she was forced to resign a month later); and the presidential couple’s visit to the theater, encouraging citizens to go out despite the pandemic, with the president himself declaring on March 6, 2020 that “life goes on. Except for those who are clinically vulnerable, there is no reason for us to stop going out,” just eleven days before the start of the first French lockdown. The list of blunders and strategic mistakes committed by political decision-makers over the handling of the health crisis is extensive and will not be detailed here; rather, the examples provided are intended to illustrate how these elements discredited political words and actions, fueling the wider distrust that was observed throughout the pandemic.

18 Of all the French movements to mobilize against the handling of the health crisis, the Réinfo Covid collective is the most widely known in the public sphere, thanks to its use of media platforms and organized demonstrations. Bringing together doctors, health-care workers, academics, and citizens, the movement was launched in October 2020 via the creation of a website presenting a selection of pseudo-scientific articles (featuring methodological bias and cherry-picking) [10] in support of the collective’s anti-vaccine, anti-mask, COVID-skeptic, and anti-lockdown theories. It was founded by Louis Fouché, an anesthetist and resuscitation specialist at Hôpital de la Conception, a public hospital in Marseille. Fouché made a name for himself during the COVID-19 pandemic thanks to his anti-restrictions stance, speaking at conferences and on YouTube, as well as in the more sensationalist media (such as CNews, Sud Radio) and on far-right platforms (Radio Courtoisie), and those with a penchant for conspiracy theories (FranceSoir). Having become an influential figure in the world of conspiracy theories via the health crisis, he labels himself a collapsonaut and expounds the collapse of civilization in a videoconference entitled “Propaganda, mass manipulation,” made with the conspiracy theorist and film-maker, Hayssam Hoballah. [11] Fouché’s popularity with a certain audience is largely explained by his construction of a discourse that is “reassuring” compared with that of other dissident doctors, aimed at minimizing the severity of the virus and delegitimizing the restrictive measures imposed by the government.

19 The concept of “re-information” used by Fouché’s Réinfo Covid collective is inspired by the far-right conspiracy movements that emerged on the internet in the first decade of the 2000s seeking to establish an alternative to the discourse of the mainstream media. Réinfo Covid’s credo is “civil disobedience,” as indicated in an email sent by the collective and relayed by the LNPLV to its members on May 5, 2021:

20

Fellow members of the resistance, in the face of the global dictatorship that is establishing itself on the back of this health crisis, we must take urgent, large-scale National Action […]. We propose to form a federation involving all Social Actors who are determined to oppose these liberticidal measures. The clock is ticking, they have our children in the sights of their syringes […]. Given that both the summer break and the execution of these sentences are imminent, we have decided upon May 15 as the date for launching our National Call for civil disobedience. This Call advocates the sustained, mass rejection of all measures imposed by the health dictatorship […]. If we all disobey together in an organized and synchronized fashion, victory shall be ours!

21 The collective’s desire for political destabilization is made clear in this message, which was accompanied by an Excel spreadsheet listing potential “allies” who could help mobilize public opinion “against the injection agenda.” This list was organized by category (“artists,” “free news media,” “medical,” “citizen reporters,” etc.), and featured the names of around 150 individuals or collectives associated with the anti-system and reactionary network which has developed over the course of the health crisis. [12] Réinfo Covid stepped up its strategy of influence in 2021 by sponsoring several candidates running as “independents” in regional elections for Provence-Alpes-Côte d’Azur (PACA), Brittany, and Pays de la Loire.

The anti-vaccine network driving an increasingly blatant politicization

22 In recent years, populist movements have realized that they can exploit anti-vaccine sentiment to achieve political destabilization. It would appear however that this strategy only works as long as its proponents remain in opposition, as evidenced by the U-turns of vaccine skeptics when they win power (such as US president, Donald Trump, or Italy’s Five Star Movement). The exercise of power makes it necessary to assume certain responsibilities regarding public health. In France, the president of the National Rally, Marine Le Pen, clearly understood the need to adopt a less seditious posture on the issue of vaccines in the run-up to the 2022 presidential election. At the other end of the political spectrum, Yannick Jadot (of the EELV)’s support for compulsory vaccination against COVID-19 came as a surprise, given that other figures from his environmentalist party—Michèle Rivasi, for example—have tended to oppose it. These internal divisions between figures in the EELV show how the issue of vaccination has become a key electoral issue.

23 Some ten years previously, during the swine flu (H1N1) pandemic of 2009–2010, conspiracy theory culture established itself as a new vehicle of global vaccine skepticism. The pandemic coincided with the democratization of the Internet, giving people greater online influence via social networks, platforms, blogs, and web-tv channels, which became new repositories and broadcasters of fake news regarding vaccines. The impact was thus far greater than at the time of the aforementioned Leagues, whose publications reached only a limited audience. In the years since the swine flu pandemic, the anti-vaccine cause has gradually been swallowed up by conspiracy culture, mainly in relation to far-right ideologies.

24 The uncertainties prompted by the COVID-19 health crisis, the very reactive development of the vaccines, and the emergence of health measures perceived as restrictive (wearing masks, lockdowns, etc.) all created fertile terrain for the struggle for individual freedoms, enabling the self-proclaimed actors of the “reinfosphere” to swell their ranks by making claims that fly in the face of scientific data and the recommendations of public health institutions. This shift to the far right, increasingly socially acceptable, is not limited to France. In the US, the Capitol riots of January 6, 2021—described as the result of a social-political polarization representing a direct threat to democracy—show that conspiracy movements do not just have influence online, but can destabilize politics in a very real way.

25 On Capitol Hill that day, among the crowd formed mainly of far-right groups and galvanized by the slogan “Stop the steal” were prominent anti-vaccine conspiracists. They included the producer Del Matthew Bigtree, president of the Informed Consent Action Network, one of the most influential anti-vaccine movements in the United States; producer Mikki Willis, known for directing and distributing the documentary series Plandemic, which argues that the COVID-19 pandemic is the result of a global conspiracy; and Ty and Charlene Bollinger, the activist couple behind the The Truth About Cancer website, which promotes alternative medicine and publishes anti-vaccine theories.

26 In February 2021, a survey conducted by researchers from Monmouth University (New Jersey) shed some light on the common political agenda of the North American conspiracy movements that had joined forces during the Capitol riots, bolstered by the anti-vaccine contingent. [13] It revealed that one in four people surveyed would avoid getting the COVID-19 vaccine if they could, but above all that participants’ political persuasions were far more indicative of their intent to get vaccinated or not than other determinants, such as demographic data. Thus, the study showed that Democrats expressed the keenest desire to get vaccinated as soon as possible (72 percent when respondents who intended to get vaccinated are added to those who had already received the vaccine at the time of the survey), followed by independents (51 percent), with Republicans showing the least inclination to get vaccinated (39 percent). The results of the survey evidence far greater reticence among Republicans, 42 percent of whom stated that they would avoid getting the vaccine if they could, as opposed to 10 percent of Democrats.

27 The reach of conspiracy culture and its extensive web of fake news regarding vaccines goes well beyond social networks. However, the theories it advances can only take hold if they encounter a receptive audience, something which is determined by factors such as political persuasion, personal trajectory, and social background—all of which are closely linked to geographical space.

The geographical character of vaccine resistance: The case of Southeast France

28 On September 23, 2020, the Health Minister Olivier Véran announced the closure of bars and restaurants in areas with high rates of the virus, which had been put on “maximum alert” (namely, Guadeloupe and the metropolitan district of Aix-Marseille), prompting a wave of indignation among politicians in Marseille and the PACA region more broadly. The mayor of Marseille, Michèle Rubirola (EELV), and the president of the PACA region, Renaud Muselier (Les Républicains), strongly opposed the decision, rekindling tensions between Marseille and the capital and playing on identity markers familiar to Marseille’s population owing to their use in collective representations. The region’s rebellious image was reinforced during the first months of the pandemic in France as a result of extensive media coverage of the infectious disease specialist, Didier Raoult (at Marseille’s Méditerranée Infection Foundation), and his promotion of a treatment against COVID-19 based on hydroxychloroquine and azithromycin. Despite a lack of scientific evidence regarding the effectiveness of this treatment, Didier Raoult became a local icon for his anti-system views, which only intensified in the face of hostility from most of the medical world. Thus, in Marseille and Southeast France more broadly, the historic climate of suspicion with respect to institutions appeared to harden over the course of the health crisis.

29 Mapping of vaccination coverage—in particular for the hepatitis B vaccine, which was the subject of a major controversy in France in the mid-1990s, and the measles, mumps, and rubella (MMR) vaccine—reveals a North/South divide, with the South trailing behind. This divide persists despite the improvement in immunization rates nationwide following an increase in the number of mandatory infant vaccinations on January 1, 2018. This territorial correlation with higher levels of vaccine refusal or delay also holds true for the COVID-19 vaccine, and can be explained by an intricate network of determinants contributing to local climates of distrust with regard to the central authorities.

Map 2

Immunization coverage against measles, mumps, and rubella (MMR) in France

Map 2

Immunization coverage against measles, mumps, and rubella (MMR) in France

Map 3

Immunization coverage against hepatitis B in France

Map 3

Immunization coverage against hepatitis B in France

30 The influence of GPs is a primary determinant, inextricably linked to vaccine behaviors in the wider population. Studies carried out by the French National Institution for Health Education and Illness Prevention (now Santé publique France (French Public Health Agency)) show that practitioners based in the Southeast, and to a lesser extent those in the Southwest, tend to have a more negative opinion on vaccination than their counterparts in the north of France, a phenomenon that is particularly marked for the hepatitis B vaccine (Gautier, Jestin, and Beck, 2013, 100). This greater propensity to skepticism influences their practices and attitudes, making them less likely to adhere to the immunization schedule than their colleagues in northern France (Collange et al. 2015). In view of the special bonds of trust that are forged between doctors and patients, it is impossible to separate this more marked skepticism among doctors practicing in the Southeast from the local vaccination coverage rates.

31 The region’s physical distance from central government in Paris and its inhabitants’ sense of belonging to a local community with a strong cultural identity—as is the case with Marseille or in the Cevennes, for example—play an important role in the indifference or distrust felt toward institutions perceived as distant. We should also not overlook the fact that the electoral profile of the Southeast reveals that voting is principally divided between the extreme right (National Rally) and the greens (EELV)—two political currents with long-standing ties to the anti-vaccine movement and its ideological universe, as we have seen. This detour through the geographical vagaries of vaccine resistance in France should not, however, detract from the fact that, despite its marked geographical distribution, this remains a nationwide issue.

France: The global epicenter of vaccine skepticism?

32 In 2019, the American polling organization, Gallup, presented the findings of an unprecedentedly large study conducted for the British medical NGO, Wellcome, [14] involving 140,000 people in 144 countries. The survey investigated people’s views on health and science, and the results made quite a splash in France: one in three French respondents did not agree with the statement “vaccines are safe”—the highest proportion worldwide according to the study. Almost 20 percent of French respondents also disagreed with the statement “vaccines are effective,” ranking second after Liberia for this question, and 10 percent disagreed with the phrase “vaccines are important for children,” ranking third after Armenia and Austria.

33 Yet the results of this survey were hardly surprising: since 2010, measles epidemics have reappeared in France (and other European countries) owing to insufficient vaccine coverage. By way of contrast, 97 percent of those surveyed in Bangladesh declared that they had confidence in the safety and effectiveness of vaccines. Bangladesh continued to experience cases of polio until its official eradication from the country in March 2014. The discrepancy between these two countries can be explained by what vaccinologists refer to as the “vaccine paradox,” namely that populations that are familiar with the burden of diseases for which vaccines exist are more aware of the benefits of immunization on public health than inhabitants of developed countries where these diseases no longer or rarely circulate.

34 Gallup’s survey for the NGO Wellcome also revealed that 73 percent of respondents claimed they had more confidence in health professionals (doctors and nurses) than in any other source of advice on health matters (including people from their family circle or religious leaders), which is important for understanding the relationship populations have to vaccines. We must therefore investigate the role and influence of health professionals if we are to make sense of a country’s relationship with vaccinations.

The right to administer vaccines at the heart of power relations among health professionals

35 In France, aside from the geographical determinants discussed previously, it would appear that the doctors who least adhere to recommendations regarding vaccination generally practice alternative or complementary forms of medicine (acupuncture, homeopathy), tend to be older (over 60) and, when they have children, to give them relatively few vaccines (Collange et al. 2015), showing their professional and personal behaviors to be coherent, as well as testifying to the strength of their convictions. The doctors most favorable to vaccination tend to be female, belong to a network, carry out a high volume of procedures (more than fifteen per day), practice in Sector 1 (i.e., applying the base rate charge for consultations as established by the Social Security authority), see a higher proportion of patients in the context of universal health-care coverage, and work in a group practice (Jestin, Fonteneau, Lévy-Bruhl, and Gautier 2011, 90).

36 If we expand the field to include other health-care professionals, we can see different viewpoints emerge from immunization data concerning seasonal flu: in 2019, the average rate of immunization coverage in health facilities was 35 percent, with those working in medical professions taking up vaccination at a higher rate than paramedic workers (67 percent of doctors and 48 percent of midwives versus 36 percent of nurses and 21 percent of nursing assistants). [15] In residential care homes for the elderly, the average rate of immunization is even lower, at 32 percent, distributed thus: 75 percent of doctors, 43 percent of nurses, 27 percent of nursing assistants, and 34 percent for other paramedic staff.

37 The at-times dissident attitudes shown by health-care and medico-social professionals regarding vaccination resurfaced with the COVID-19 vaccine campaign. Although data is rather lacking to date, in March 2021—i.e., three months after the launch of the national vaccination campaign—only one-third of health-care workers (doctors, nurses, midwives, home help) were vaccinated, despite being prioritized owing to their risk of exposure to the virus. The same situation was observed in residential care homes, where, at the same time, around 37 percent of care workers were vaccinated, according to the French Public Health Agency.

38 Health-care workers were responsible for almost 40 percent of nosocomial SARS-CoV-2 infections between January 1 and February 14, 2021. Faced with these findings, in March 2021 the Health Minister Olivier Véran urged caregivers to get vaccinated, refusing to rule out the possibility that the National Advisory Committee on Ethics (CCNE) could be asked to pronounce on the legitimacy of making vaccination compulsory for care workers. The CCNE had nevertheless warned against such a measure in December 2020, considering it to be a “last resort.” Unsurprisingly, the government’s stance provoked an outcry from various unions representing both doctors (the Confederation of French Medical Trade Unions) and nurses (the National Union of Nursing Professionals). Despite this pushback, on July 12, 2021, President Macron finally announced that vaccination against COVID-19 for health and medico-social workers was indeed to become compulsory, with the introduction of sanctions from September 15.

39 In addition to the reservations of some health-care workers with regard to the seasonal flu and hepatitis B vaccines, it is necessary to consider the timing of the campaign to vaccinate this sector, which coincided—in early February 2021—with the controversy surrounding the AstraZeneca vaccine, leading to its temporary suspension over concerns about its safety.

40 Moreover, we should note the inverse relationship that exists between vaccine resistance and professional status, with doctors being less resistant than midwives, midwives less so than nurses, and nurses less so than nursing assistants. These stances are related to factors such as differences in income, the highly subordinate nature of less qualified roles in the medical profession, and whether or not the professional in question has the right to administer vaccines, with doctors in private practice (GPs and pediatricians in particular) having a near-complete monopoly on this procedure. The nursing profession was particularly vociferous during the controversy surrounding the hepatitis B vaccine in the 1990s, and to this day remains the sector most skeptical of this compulsory professional vaccination. The issue has also served as a vehicle for the expression of their discontent regarding dynamics of subordination within the medical profession.

41 Yet nurses outnumber doctors, and their territorial network is far denser than that of GPs, such that to widen their remit regarding vaccination would make vaccines more widely accessible, especially in areas insufficiently served by doctors. [16] Training nurses to participate in vaccination programs would enhance their role and encourage an evolution in current representations of the profession, whose functions are currently seen as subordinate to those of doctors.

42 In 2016, the “Touraine law” proposed endowing pharmacists with the capacity to vaccinate but failed to pass, having met with strong resistance from medical trade unions, who called several strikes in 2014–2015 in protest against various aspects of the new health law. They were joined by the nursing profession, which was particularly opposed to giving pharmacists the right to carry out vaccinations. In countries such as Canada, the US, Ireland, Portugal, and the UK, vaccines are commonly administered in pharmacies following medical prescription and/or local protocols. In France, the 2017 Social Security Financing Act ultimately facilitated trialing of pharmacist-administered seasonal flu vaccines in several regions—a pilot scheme that was then rolled out across the entire country by the 2019 Social Security Financing Act. However, pharmacists are limited to providing the seasonal flu vaccine, and even then only to a certain segment of the population.

43 Tensions between attempts to extend or monopolize professional competences point to the corporate fragmentation of the medical world, which sometimes stands in the way of reforms to the health system in France. Conflicting relationships between doctors and competing health professions are not a recent phenomenon, as Aquilino Morelle observes: by the nineteenth century, the Sisters of Charity, pharmacists, health officers, and foreign doctors were already engaged in professional conflict (Morelle 1996, 358). The work of sociologist Eliot Freidson is particularly enlightening on how the political, and later social, recognition of doctors’ monopoly on care is the result of a historical fight for power waged by the profession to secure and preserve their professional autonomy, as well as the way in which this power entails domination over the paramedical professions (Freidson 1984).

44 The COVID-19 health crisis made it possible to finally restart the debate around extending vaccination capabilities. Faced with the need to maximize mobilization of medically qualified personnel to speed up the vaccination process, the government issued a decree expanding the list of health professionals authorized to administer the COVID-19 vaccine in the context of the state of emergency. Nurses, midwives, and pharmacists would be officially authorized to vaccinate under certain conditions, although private doctors remained at the forefront of the vaccination campaign.

45 This monopoly and the power it confers on the profession is open to abuse, as revealed by a press article published in April 2021 [17] about the differences between the fee-for-service payments (€30.40 per vaccination on weekdays and €44.60 on weekends) and flat-rate payments (€420 for four hours of vaccination on weekdays and €460 on weekends) established by the national health service to encourage doctors to mobilize in COVID-19 vaccination centers. Media coverage of the fees received by doctors who volunteered to work in vaccination centers under the fee-for-service payment option revealed that some doctors were earning as much as €9,000 per day. The ensuing public outcry led to the cancellation of these fee-for-service payments in mid-April 2021. The scandal was all the greater since these doctors were only present in the vaccination centers to carry out a pre-vaccine consultation; the vaccines themselves were administered by nurses paid half as much (€220 per half-day during the week and €240 for weekends and public holidays). The episode established a link between vaccination and economic gain, thus reinforcing negative representations of vaccination among population groups already inclined to think that vaccines are first and foremost commercial products rather than public health tools.

Health-care system architecture shaping representations of public health

46 A survey of 5,114 people conducted in the UK in the fall of 2020 (Freeman et al. 2020) indicates that while almost 72 percent of respondents declared themselves ready to get vaccinated against COVID-19, 12 percent of the sample were very hesitant. At the same time in France, only 53 percent of participants in the CoviPrev survey said that they would “definitely” or “probably” get vaccinated. Why such a gap between two neighboring countries? Let us begin with an observation: over the course of the COVID-19 vaccination campaign, the UK did things rather differently.

47 In early 2021, media coverage of a suspected link between the AstraZeneca vaccination and increased risk of blood clots led some fifteen European countries including Germany, France, and Italy to ban this vaccine from their national market. Predictably, this measure was followed by a fall in vaccine uptake in the countries concerned. The British government set itself apart from its European and even US counterparts in choosing not to ban the vaccine but rather to mobilize its National Health Service (NHS), updating guidelines to recommend that people under the age of 30 or those with a predisposition to blood clots be given other available vaccines (Moderna or Pfizer-BioNTech). Despite significant UK media coverage of the controversy over the AstraZeneca vaccine, public confidence remained high (Comerford et al. 2021). This can be attributed to particularly effective public communication, but also to the fact that this vaccine was developed by researchers from the University of Oxford, with production entrusted by the British government to the British-Swedish company AstraZeneca. It is therefore possible that a sense of national pride may have influenced the British public’s perception, particularly in the context of Brexit stirring up nationalist sentiment and pushing the government to flex its muscles in the face of the European authorities. Contrary to the aforementioned partisan attitudes seen in France and the US, it would appear that mistrust of the European authorities, particularly among the populist right in Britain, acted in favor of vaccination. National pride clearly did not have the same effect in the US, even though the Pfizer-BioNTech and Moderna vaccines were products of US businesses.

48 The UK also distinguished itself from other countries, including France, in terms of organizational efficiency, made possible by its NHS, an ultra-centralized health system. Whereas France’s vaccine campaign suffered significant logistic and organizational delays, in the UK the entire campaign was organized via an NHS-managed website that centralized appointments. The centralization of health records also enabled health authorities to be proactive in contacting people eligible for vaccination—a winning strategy according to data from the beginning of June 2021, which show that 35 percent of the population was fully vaccinated by this point (putting the UK in eighteenth place globally) compared to only 15 percent in France (in fifty-third place).

49 The UK has not always escaped problems with vaccine resistance, however. In 1998, the Wakefield case generated great controversy around the MMR vaccine, after surgeon Andrew Wakefield fraudulently claimed in his study (Wakefield et al. 1998) that it could cause autism. This prompted a decline in vaccine coverage and resulting upsurge in cases of measles from the late 1990s to the 2010s. Memories of this episode, which in 2019 led the WHO to strip the UK of its measles elimination status, may also have contributed to the government’s decisive participation in vaccination strategy during the health crisis.

50 Close examination of the systemic causes that partly explain the differences in public opinion between the UK and France regarding vaccination during the pandemic reveals the critical role of health-care system architecture. The UK has a Beveridge (or “universalist”) model, named after the British economist Lord Beveridge (1879–1963), who, in 1942, set out three major principles: universal social protection, managed solely by the state, and providing uniform benefits. With the creation of the NHS in 1948 by the Labour Party, the British government became the first to provide free, tax-funded health-care to its entire population. As a national institution, the NHS is globally unparalleled: with over 1.5 million employees, it is Britain’s largest employer and the fifth largest in the world, after the US Department of Defense, the Chinese People’s Liberation Army, American retail chain Walmart, and the McDonald’s group.

51 The French health-care system, on the other hand, is organized around a Bismarck (or “corporate”), insurance-based model, originally established by the German Chancellor, Otto von Bismarck (1815–1898). Fearing the rise of the socialist party, Bismarck ordered the dissolution of the trade unions in 1880, but sought to improve living conditions for the proletariat by institutionalizing social welfare, making insurance payments obligatory for workers from 1883. This model is mainly financed via compulsory insurance payments collected through people’s salaries and is characterized by its decentralization. While in the French system, doctors’ salaries are not all paid from one source and fee-per-service predominates, British GPs are paid by the state according to the number of patients registered in their practices, and must fulfill public health objectives.

52 The fact that the French system does not engage GPs in public health objectives may go some way toward explaining the difference in attitude toward vaccination versus the UK: in France, GPs are driven more by an individual conception of health than any shared community vision, with the patient-doctor consultation held in special regard. Moreover, the dependence of British doctors vis-à-vis the health authorities discourages them from expressing distrust of vaccines, as this could jeopardize their employment, whereas French GPs are completely free to speak out on the subject without fear of losing their jobs. The French and British health systems are, however, in agreement on one point: namely, their predominantly liberal ideology, which translates into an emphasis on individual responsibility for health in political discourses. Nevertheless, national particularities such as the population’s strong attachment to the NHS and an emphasis on prevention policies have shaped a long-established culture of public health in British society. Conversely, the specificity of the French vaccine system, based essentially on health care in private practice, has made it impossible to unite health-care professionals and the population at large around matters of prevention, which may partially explain the strength of vaccine skepticism in France.

Conclusion

53 The appearance of the word “vaccine-skeptic” in the media was delayed by the context of vaccine scarcity in which the French vaccination campaign launched, with repercussions for vaccine behaviors. The successive waves of infection also played an important role in refusal or acceptance of the vaccine, with personal experience of COVID-19 or infection among family members undoubtedly contributing to a change of heart among those who had previously been hesitant to receive the vaccine. Nevertheless, there remains a minority of people who, despite the Public Health Agency’s efforts, cannot be persuaded that the vaccine is effective and/or safe.

54 Vaccination beliefs bring the personal and social spheres into close contact. Fluctuations in vaccine resistance are closely tied to social, health, cultural, and political contexts. In this study, we have focused on the systemic elements that influence vaccination practices and representations among the population: health-care system architecture and the role of health-care professionals in matters of vaccination provide a partial explanation for the specificities of vaccine resistance in France. Policymakers face a significant challenge, and not only in terms of public health.

55 It is becoming increasingly clear that vaccination is now an electoral issue in its own right. Moreover, actors from the world of conspiracy theories also influence public opinion, having gradually pervaded anti-vaccine discourse since the swine flu (H1N1) pandemic, and achieving far-reaching influence in the COVID-19 health crisis. These increasingly polarized debates contribute to significant fractures in the societies concerned and give rise to new geopolitical challenges.

Notes

  • [1]
    French Public Health Agency, “CoviPrev : une enquête pour suivre l’évolution des comportements et de la santé mentale pendant l’épidémie de Covid-19,” last updated June 9, 2022, https://www.santepubliquefrance.fr/etudes-et-enquetes/coviprev-une-enquete-pour-suivre-l-evolution-des-comportements-et-de-la-sante-mentale-pendant-l-epidemie-de-covid-19.
  • [2]
    In italics in the source text.
  • [3]
    Translator’s note: Unless otherwise stated, all translations of cited foreign language material in this article are our own.
  • [4]
    “Vaccination et revaccination obligatoire : séance du 12 avril,” in the Bulletin de l’Académie nationale de médecine 10, no. 15 (2nd series) (1881): 468–469.
  • [5]
    “Vaccination et revaccination obligatoire : séance du 12 avril,” in the Bulletin de l’Académie nationale de médecine 10, no. 15 (2nd series) (1881): 448.
  • [6]
    See P. Hassenteufel, Les médecins face à l’État. Une comparaison européenne (Paris: Presses de Sciences Po, 1997).
  • [7]
    Mandatory vaccination in France dates from the public health law of 1902, which concerned only smallpox. The list of mandatory vaccines gradually expanded to include diphtheria in 1938, tetanus in 1940, the Bacillus Calmette-Guérin (BCG) vaccine against tuberculosis in 1949, and the polio vaccine in 1964. The smallpox vaccine was removed from the list of obligatory vaccinations in 1979 and the BCG vaccine in 2007.
  • [8]
    Lemaire’s association was originally called the Ligue nationale contre les vaccinations obligatoires (National League against Compulsory Vaccination). It was renamed the Ligue nationale pour la liberté des vaccinations (LNPLV) (National League for Vaccination Freedom) in 1969.
  • [9]
    Paul Carton 1936, cited in Ouédraogo 1998, 59–76.
  • [10]
    Cherry-picking is a data analysis strategy in which data supporting a particular point of view are presented while any contradictory data are ignored.
  • [11]
    See remarks by Louis Fouché in a videoconference with Hayssam Hoballah (the latter styles himself as a “wellness coach,” “holistic health” practitioner, and “Living food” enthusiast) in “Entrenôtre #9 with Louis Fouché,” March 6, 2021. YouTube video, 3:34, https://www.youtube.com/watch?v=qs0uvlD-hGQ.
  • [12]
    This list includes the journalists Pascal Praud (CNews), Charlotte d’Ornellas (Valeurs actuelles), Eric Zemmour (Le Figaro, CNews), and André Bercoff (LCI, SudRadio), as well as actors and media from the world of conspiracy theories such as ufologist (UFO specialist) Silvano Trotta, the identitarian web-TV channel TV Libertés, the Profession Gendarme website (which notably published opinion columns by members of the military calling for sedition in the spring of 2021), and the revisionist pseudoscience magazine Nexus; on the medical side, the list includes Didier Raoult (director of the Méditerranée Infection Foundation), Christian Perronne (head of the infectious diseases department at the Garches hospital), and Alexandra Henrion-Caude (geneticist, former research director at the French National Institute of Health and Medical Research (Inserm))—all specialists who have made a name for themselves by taking a controversial stance during the health crisis. Political figures appear too, including Xavier Lemoine (mayor of Montfermeil, Christian Democratic Party), Robert Ménard (mayor of Béziers, independent populist), Nicolas Dupont-Aignan (president of Debout la France), and Florian Philippot (president of the Les Patriotes movement).
  • [13]
    “National: 1 in 4 Say “No Thanks” to Vaccine. Partisanship more than demographics drives willingness,” Monmouth University Polling Institute, February 3, 2021, https://www.monmouth.edu/polling-institute/reports/monmouthpoll_us_020321/.
  • [14]
    Gallup, “How does the world feel about science and health?” Wellcome Global Monitor – First Wave Findings (2019), https://cms.wellcome.org/sites/default/files/wellcome-global-monitor-2018.pdf.
  • [15]
    French Public Health Agency, “Couverture vaccinale antigrippale chez les professionnels de santé,” Bulletin de santé publique, October 2019.
  • [16]
    In 2018, France had 102,466 general practitioners, 8,205 pediatricians, and 6,995 public and occupational health doctors to vaccinate its 67 million inhabitants. Meanwhile, 22,812 midwives have limited vaccination prerogatives and 700,988 nurses are authorized to administer the influenza vaccine on medical prescription, following strict protocols.
  • [17]
    “Des toubibs bien soignés pour piquer,” Le Canard enchaîné, April 1, 2021.
English

For the past ten years or so, international studies have regularly identified France as the epicenter of vaccine skepticism. Public debates around the French national vaccine campaign to counter the COVID-19 pandemic have confirmed the unique relationship that Pasteur’s nation has with vaccines, or more precisely with vaccine policy. This article describes the historical foundations of this French singularity, its networks of influence, and its systemic causes, as well as providing insights into geographical variations within the country.

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Lucie Guimier
Geographer specialized in public health and associate researcher at the IFG Lab (University Paris 8).
This is the latest publication of the author on cairn.
Uploaded on Cairn-int.info on 23/08/2022
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