Low COVID-19 vaccination rates in Bulgaria

There hasn't been a shortage of vaccines in Bulgaria, but only around 30% of the population are vaccinated, in a country which already had the lowest life expectancy in the EU. Professor Antoniya Dimova joins Gavin and Jessamy to talk about the pandemic in Bulgaria, how misinformation shaped the public health response during COVID-19, and where Bulgaria goes from here.

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Gavin: Hello, welcome to the Lancet voice. I'm your host Gavin Cleaver, and I'm joined by Jessamy Bagnall, executive editor at The Lancet. Welcome Jessamy. 

Jessamy: It's great to be here with you, Gavin. 

Gavin: We're talking today about COVID 19 vaccination rates in Bulgaria, which are strikingly low when compared to the rest of Europe, despite good vaccine availability.

As of August 4th, 2022, while the majority of countries in Europe have administered over 200 vaccine doses per 100 people, Bulgaria has administered just 65 doses per 100 people, 22 less than the nearest country, Romania. Jessamine and I wanted to find out, what's behind Bulgaria's low vaccination rates?

How has the pandemic played out in Bulgaria? And how can this be addressed going forward? For this, we spoke to Professor Antonia Dimova, Dean of the Faculty of Public Health at the Medical University of Varna in Bulgaria.

Antonia Dimova, you're the Dean of the Faculty of Public Health at the Medical University of Varna in Bulgaria. Thanks so much for joining us to discuss. Progress of the COVID 19 pandemic in Bulgaria, vaccination rates, that sort of thing. It's a really fascinating topic and one that's been kind of picked up in the UK media a few times, which is why I guess it came to my attention.

Before we talk more generally about Bulgaria and COVID 19, what's your experience of the COVID 19 pandemic been like in Bulgaria? 

Antoniya: Thank you for the invitation. Instructive and enlightening, I would say. First, because the pandemic showed us which are the weaker parts of the healthcare system in Bulgaria and the deficits in health policy process.

Unfortunately, at a very high price. Second, because we learned a lot or we should learn a lot, what needs to be done to strengthen the system in the future. And third, I think it provided a sound ground to attract society attention to public health and to rise health and healthcare is a real priority in Bulgaria and all kinds of public policies.

Personally, my scientific interest outweighed the fear of uncertainty for the future. 

Gavin: Is there anything kind of specific to public health in Bulgaria that's kind of important to think about when we think about COVID 19 and how the pandemic's gone? 

Antoniya: The pandemic has had a dramatic influence on life expectancy, which was anyway the lowest in EU before.

before the pandemic and due to the COVID 19 pandemic, the drop between 2019 and 2020 was twice as larger as the level for the EU as a whole. Another issue is the high mortality rate in general and specifically for, from cardiovascular diseases. And the pandemic made the situation worse. Bulgaria has the highest mortality rate from COVID 19 and excess mortality, which was more than double.

that the reported COVID 19 deaths during the second wave in 2020. The number of COVID 19 deaths in 2021 has more than three times higher compared to a year earlier. Another factors, behavioral and environmental risk factors are also important and together with health system factors contributed to these poor health outcomes.

In regard to health system factors, the shortage of nurses, the lack of integration in the system, the heavy reliance. Of the health system on out-of-pocket payments and health spending skewed heavily to inpatient care and pharmaceuticals, determined, ineffective, and inefficient healthcare provision.

Our latest report on financial protection in Bulgaria, published by the WHO Barcelona office provides strong evidence. on the very weak financial protection and that there are significant gaps in all three dimensions of health coverage. So there are many public health issues that the pandemic has exposed and accelerated.

Gavin: One of the reasons I think for discussing COVID 19 in Bulgaria is that in Western European countries, generally we saw quite a high. vaccination uptake. Quite a few Western European countries had an uptake around 70, 80%, but in Bulgaria, it was much lower, wasn't it? Around the mid thirties, I think. So what do you think is some of the, some of the reasons that Bulgaria had such a low COVID 19 vaccination rate?

Antoniya: Yes, indeed. Currently. Only 30% of Bulgarians are fully vaccinated against covid. And this percentage varies from 21 to 43 among districts and less than 20 12% have booster dose. I think absolutely this is really a very low rate rate which can be due to a variety of reasons. I think the main of which is the absence of an effective communication campaign addressing not only positives of vaccinations for public health and society in general, but also explaining to people the process of the new vaccines development and all kinds of issues regarding their safety.

The spread of information regarding COVID 19 vaccines was not led by the health authorities, but was rather left on stochastic factors. 

Gavin: So before the COVID 19 pandemic and before, you know, the back and forth and the misinformation about the COVID 19 vaccine, how accepting was Bulgaria generally of public health measures?

Antoniya: In general, citizens in Bulgaria support public health measures, which are well articulated by the politicians. Unfortunately, there are cases in which, despite the majority of people support particular health policy, it fails because of strong, strong opposition from some stakeholders. I can give you an example.

Some years ago, there was an attempt to introduce tax on foods and drinks, which contains salt, sugar. trans fatty acids and et cetera, both a certain quantity. Despite this measure was fully supported not only by health professionals and academia, but also by the bigger part of the society, it failed because some industry representatives strongly and loudly opposed.

And they were finally supported by the ministers of finance and economy which are stronger ministers than ministers of health, for example. 

Jessamy: Yeah, I think it's super interesting about this sort of the, the misinformation aspects and, and vaccine uptake, because we've seen similar trends across Europe, really.

I mean, what do you think are some of the policies that were used? in other countries to increase vaccine uptake that that might have been applicable to Bulgaria or where were the sort of missed opportunities? 

Antoniya: I think missed opportunities to communicate on time effectively what What are the positives of vaccination and the process of development of the new vaccines against COVID?

Because what really frustrated people is that there were not enough information or not appropriate information about safety. 

Jessamy: I mean, Bulgaria also has quite a unique makeup in terms of its population, in terms of, you know, different minorities and there's There's obviously a huge historical context there, you know, to what extent was Were some of the issues around marginalized communities or, you know, people that didn't feel engaged in the sort of main process or may not historically or previously even be having regular contact with health systems?

Antoniya: I think People just don't trust in government very much and in Bulgaria particularly what hampered the vaccination process most were contradictory messages which different health and non health experts were giving using all kinds of official and social media. Those of the experts who questioned the COVID 19 vaccines were the same who earlier criticized measures against COVID and in general the approach of setting restrictions.

And because many people liked their messages more than measures, I think they influenced public opinion for vaccination more, unfortunately, in a negative way. 

Jessamy: That's interesting. So is the public health community in the scientific community then very polarized and divided at the moment? And, and, and is there, is that starting to heal or do you still see those sort of lines between these different factions of the community, you know, very sharply?

Antoniya: I wouldn't say that the scientific community is so divided, but there were other health experts or experts physicians who, who, who, who had on a different position and they influenced the public opinion a lot because they were very loud and active and stating their position. 

Jessamy: Because we've seen similar things in other countries, but then often there's a, you know, there's a counterbalance which is a, a group of healthcare experts or public health clinicians that also try and have an equally, you know, loud voice.

You know, we saw that, that kind of division between the Great Barrington and the John Snow Memorandum. You know, people very much sort of staking out their, their ground. Did that not happen then in Bulgaria in terms of the public health community, scientific community that were, you know, reading the science in terms of vaccines are safe, public health measures, you know, non pharmaceutical interventions are appropriate.

Was that, were their voices not, not as loud and could they have been louder? 

Antoniya: I think they could be louder, but I think they could also approach people on much more understandable for the people way. So the approach to communicate with people and to share scientific information to, to get this information understandable.

to, to people. Here I see deficits. 

Jessamy: That's interesting. I mean, in terms of your views on what this means for health more generally within Bulgaria and how people, you know, interact with the health system, how people interact with healthcare workers, has it been purely negative or are there any positives from COVID 19?

Do you see a way forward that will, that can possibly You know, try and use this experience to, to, to sort of drive for change. 

Antoniya: Absolutely. I, I, I think one of the biggest problem in Bulgaria is that there is lack of integration in provision of healthcare. We count a lot on hospital care and we saw from the other countries experience that Attracting general practitioners and other outpatient providers Earlier at earlier stage.

It's a better approach. This is something we Didn't do 

Jessamy: and is there is there any desire to have some sort of public inquiry or you know? Is there a scholarly? scientific process to evaluate what's happened over COVID 19 and to try and draw those lessons out more formally? Is there something like that in the works or is that something that's not, not, not about to happen?

Antoniya: I think many people are involved in studying scientifically. What is going on in, in Bulgaria regarding to its response to, to the crisis. I and my colleagues particularly involved in the HSPM network on, of the European Observatory on Health Systems. And we were involved in monitoring the process and the country response since the beginning.

I think so we. We did at national level and at international level as well, many analysis and comparative papers. 

Gavin: I wanted to ask as well, do you think in Europe as we kind of move further and further away from the shock of the first two years of the COVID 19 pandemic do you think in Bulgaria there's a chance that people will kind of come to accept the COVID vaccines over time?

Do you think the debate could become slightly less toxic than it currently is? 

Antoniya: I hope so. There was severe debate from the beginning when the vaccines were introduced till the moment when green certificate to access public places close public places and work was removed. And then this debate stilled.

So I think that now it's. good moment to to start another campaign so to make people get vaccinated, more people to get vaccinated. 

Gavin: Is there anything that you've learned that I guess you think you feel like you kind of didn't know before from, from going into the pandemic, you know, what, what lessons do you think you'll take away from this in relation to public health?

Antoniya: Many things. I'm interested in the policy process. I found out how many deficits in policy process we have. And generally, a maturity of health politicians and their inability to communicate in a proper way with the community. They almost left this health policy process to other forces. Like economic debate was much stronger.

Then health issues were discussed. 

Gavin: You've talked quite a lot about government communications. There was quite a lot of political instability in Bulgaria, wasn't there, during the pandemic? And do you think that played into it at all? 

Antoniya: I think it also was, one of the contributing factors. We are not performing very well.

And now we are still again in such political instability. 

Gavin: So I guess finally then looking forward, what do you think of the prospects for kind of tackling COVID 19? You know, we're we're not the pandemic different. Different Omicron mutations seem to keep coming back. As we speak, BA5 is is all over the US and the UK and various other countries as well, of course.

So do you, can you see major changes going forward or is it kind of a frustrating situation at the moment? 

Antoniya: I expect less compulsory or restrictive measures because I think both politicians and citizens are not willing to apply or to bear such I think rather the ministry of health will count, count on more successful campaigns, promoting vaccination and other measures.

On 14 of July. This year, the national plan for dealing with the pandemic was updated by the Council of Ministers and in it envisages very restrictive measures such as closure of schools only during epidemic peak in the spread of COVID 19. The healthcare system is overloaded, and this is almost entire such restrictive measures that this plan, national plan envisage, and these measures are going to be applied at regional level.

Now compulsory mask wearing was introduced. In few days ago in hospitals, pharmaceuticals and social care centers in most of the districts because of the spread of COVID 19 is increasing right now in Bulgaria. 

Gavin: Well Professor Antonia Dimova, thanks so much for, for joining us on the podcast to to discuss COVID 19 in Bulgaria.

It's a really kind of interesting and nuanced picture and Best of luck, I guess, for proper communication of COVID 19 policies in the future.

Jessamy: Gavin, I really enjoyed our interview. Why were you particularly interested by this story and by this part of the world? 

Gavin: You know, I read a lot generally about politics and COVID. I think with the Western European nations, we were seeing a relatively lockstep vaccination rates. You know what I mean?

They all ended up around the kind of 70, 80 percent rate of vaccine acceptance. But then just sneaking into the headlines now and again was the difference in in Eastern European figures. And I found that really interesting, you know, especially as some of these. nations are members of the EU. They're quite financially linked.

They are, you know, by all intents and purposes, at least middle income, if not high income countries. And so it, it really made me wonder. And then one of the reasons I ended up emailing professor Demova to talk about this was to try and unpack some of the reasons that these countries had such poor vaccination rates.

And I've got, you know, a good example is that the out of European nations, the five least vaccinated against COVID 19 countries as of August the 4th are Croatia, Serbia, Russia, Romania, and Bulgaria. So all kind of Balkan, Eastern European, partially former Yugoslavian nations. So I think it's really interesting to, to dip into the reasons behind that.

I think a lot of it for me, as Preston over talked about, is about trust in government, trust in messaging that comes from authorities, that sort of thing. I don't think I can fully explain it, but I think as I've said before, Jessamy, I think there's probably a podcast in every single country in the world as to how they dealt with the COVID 19 pandemic.

I think there's different decisions taken by different governments in a situation that was unfolding so fast that no one could truly get a handle on it, and we still don't have a handle on it. So I just think it's, it's, it's really interesting to look at. A European country that differs so heavily in vaccination rates from from the Western European countries that we so often talk about and so dominate the media over here in Western Europe.

Jessamy: Yeah, a podcast and more. I mean, I guess it's, it's important not to sort of just generalize some of those countries and sort of put them together because they've got so such a sort of very different demographics, different politics, different, different places. But. What were some of your kind of take home messages from our conversation?

Or what were some of the insights that you found particularly interesting? 

Gavin: You're right, you're right that we shouldn't generalise. So what I'm going to do is I'll stick to Romania and Bulgaria two nations that are next to each other and have the lowest vaccination rate. Yeah. So I think It was really interesting in the media coverage how much the media narrative on low vaccination rates in Romania and Bulgaria relied on the kind of wild spread of misinformation in those countries, which I don't, I, you know, I think misinformation is incredibly important in terms of people's vaccine acceptance.

I didn't think it could explain the full picture, but then we spoke to Professor Demova, and so much of what she talked about was about public health messaging and the misinformation that filled the gap where public health messaging should have been. But actually, I think if anything, I now consider misinformation to be a more important driver, or at least the lack of a coherent public, we should probably say the lack of a coherent public health Message on these topics to be a more important driver in these situations, but I think when we say something like in these situations, you know, this is unprecedented and in recent human history, at least in our experience when we talk about public health messaging before where we're talking about campaigns that are targeted at specific, you know specific groups, I think, and this obviously dominated it.

the everyone's kind of like thoughts kind of dissemination of information for a full two years basically across across the world. So when we talk about public health messaging in this sphere, we talk about something that actually needed to kind of dominate that space. And people often talk about the vacuum that that gets filled by misinformation.

And so, yeah, I think what I'd take away from, from our chat was that that vacuum is a very important place. That public health messaging, coherent public health messaging has to dominate. 

Jessamy: Yeah, it's interesting because, you know, we've spoken before about that brilliant book which I read called The Constitution of Knowledge, A Defense of Truth by Jonathan Rauch.

And in that he sort of, I don't know whether I pronounced his name right, probably not. But in that he comes up with this phrase of epistemic helplessness. That, you know, we live in a world where there's so much information and so much misinformation that many people, you know, are unable to tell the difference between the two.

And I don't think that that's unique to, you know, Romania or Bulgaria. It's It's everywhere. But it, it is interesting how that story has played out in different parts of the world and, and what have been the drivers and what have been the, the barriers and what have been the implications and changes.

Gavin: Yeah. So in that interview with Professor Dimova, we did allude to the instability in the Bulgarian governments, you know, which kind of leads to a lack of coherent messaging. But it really is an, you know, an incredible amount of instability. There were protests raging against the government from June 2020 all the way through to April 2021 around the world as well, not just in Bulgaria, but at various Bulgarian embassies.

Until the government finally ended in April, 2021. Then there was a caretaker administration. Then there was a coalition, which collapsed in June this year. And now currently there's another caretaker. There has been a complete lack of stability in the Bulgarian government. Now, obviously. You'd need someone you need someone more involved in the situation than me to draw the direct parallels between that government instability and the lack of messaging and then relate that to the very low COVID 19 vaccination rates in Bulgaria.

But I guess going in to the conversation, I didn't consider that to be something as important as I now consider it to, to be, if that makes sense. And I 

Jessamy: mean, from your point of view, you know, coming at it from a sort of political philosophy point of view, what are the types of analysis or pieces of work that need to be done to, to really kind of get to the bottom of what's been going on so that we can learn from it and understand what what needs to happen differently in the future?

Because we also spoke about that during our interview, but Yeah. Yeah. I think we were coming at it from quite a medical point of view, which perhaps isn't the right way to come at it from. 

Gavin: I think probably the word that we didn't talk about when we talk about instability is trust, trust in authority, trust in institutions, trust in figures in the public life.

Do you know what I mean? And I think that maybe we didn't realize how important that level of trust in government was going into this pandemic, you know, politics. can be quite a, in more normal times, politics can be quite a background function. And so you can get away with quite a lot in politics without having a particular trust in government because a lot of what happens in politics doesn't really affect people on a day to day.

But when you have a situation like we had around the world where governments are asking you not to leave your homes, which is a very, very direct effect on an individual, then that trust, I think, becomes heavily magnified. And so, you know, I can, I can go to work. I can get on with what I usually do with a deep level of distrust in the government in normal times, but in a pandemic, I have that level of distrust in the government.

It then becomes a very different and more difficult situation. You know what I mean? But actually, actually, my perception of trust in the government hasn't changed. It's just that now. that level of trust has become something more of an investment in how I feel about, about the day to day functioning of a government.

Jessamy: Yeah, that's interesting, isn't it? And so does that just mean that we have to focus more on trust? I mean, we, we obviously published that, you know, large study about trust in governments and how, and, and sort of what that looked like globally in terms of. how people dealt with COVID 19. Is it just that we need to focus more on it, or should we be thinking about it in a different way?

Do we have measures of trust? We often sort of, we, we, we often you know, proxy it with, with corruption or, you know, with other aspects. Is, is that the right thing? 

Gavin: I think corruption tends to be a pretty good proxy. There was also a lot of corruption in the Bulgarian government at at the time.

It was the worst ranked country for corruption by the NGO Transparency International when the pandemic kicked off. So that could be a good kind of correlate, I suppose. Of of trust people's perceptions of corruption within a government, but I'm afraid I'm not up to date enough with my political science readings to provide you any particular models.

Maybe that's something I can work on for future episodes. Yeah, come on, 

Jessamy: Kevin. I mean, you've got to do better on this. 

Gavin: I know, I know. I can't just pull these models, can't just pull these models out of my house, apparently. 

Antoniya: But, 

Gavin: I think these are all very kind of like vital things to talk about when we, when we talk about government and like I said, it's in times like this, governments become far more involved in people's day to day lives and that's really when trust and perception and perceptions become more important.

Yeah, I think, I think trust is something that definitely needs to be a feature of, of governments going forward and we're looking at it as well going into this winter, obviously with the energy prices crisis around Europe, that there will need to be a lot more state intervention again. The 2008 recession was probably one of the biggest levels of state intervention.

In, in recent times since, you know, since the second world war, but we could be looking at almost kind of back to back on precedented levels of state intervention and emergency situations with the pandemic into the energy price crisis, given that the state seems to be destined to be more heavily involved in people's day to day lives for the foreseeable, and it has been for the last two years, I would imagine that Trust is something that's going to feature quite heavily in political campaigning over the coming years.

But then, you know, you look at some governments and you, you wonder if the damage has already been, has already been done in terms of, you know, I think there's a lot of politics at the moment where trust is just completely out the window and people are campaigning in the vacuum that's, that's left without the trust.

very much an element of they're all the same. And I think that element of they're all the same, there's no politicians you can trust has been present in politics for, you know, since time immemorial. But I think the, the levels of indifference towards whether or not you can trust politicians. since the pandemic are reaching quite serious levels.

What do you think? 

Jessamy: Yeah, I think that's right. And I guess I also feel that we've got this whole, you know, we've got many other factors that are compounding this issue at the moment. You know, we've got the sort of the climate crisis and a, and a transition to hopefully more green energy, but also an energy crisis.

And yes, of course, I mean, 

Gavin: you're right. We've absolutely got to mention the climate crisis as one of those, as one of those factors. 

Jessamy: Exactly. And so when you have those other factors coming in, which are so destabilizing, it feels very precarious from my point of view, because we're starting at a very low and weak place where we've had these things exposed to us over the pandemic.

And we're now we're not even post pandemic, but we're in a You know, a phase. Which is toward the end of the pandemic with these other huge sort of global things that are issues that are that are compounding any of those vulnerabilities, but though even individually, those large complex issues that are compounding them on their own are hugely destabilizing forces like the lack of energy, like people not being able to pay, you know, for food or for their energy bills or to be able to have energy, you know, are we going to have to you know, only have energy for three days of the week, or whatever, like we did in the 70s.

That, those kind of things have huge political ramifications, and so it feels like a, a precarious and dangerous place to be at the moment as we go into this winter. 

Gavin: It very much does. About the only thing I have left by this point is reading the Wikipedia page on declinism, and looking, looking at times in the past when people have also decided that all of these crises are finally going to overwhelm us and have been wrong.

And that's really all I have left by this point. I don't have any predictions. I don't have any predictions left. I don't see what's going to happen. We'll you know, we'll figure it out. We'll muddle through. 

Jessamy: We'll keep talking about it. 

Gavin: Yeah, we'll keep talking about it. Exactly. And I think we'll keep looking into different countries as well, because it's I think it's very illustrative to talk to people from from the countries that have been there.

You know, I opened the interview with Professor Demova with the question, how has the pandemic been for you? And I think that's such a kind of, that question is so important to ask because one person's experience in a country during the pandemic is completely individual. And it's very difficult, you know, we've tried a little bit of speculation.

It's very difficult for us to sit here and talk about Bulgaria having experienced a pandemic in the UK. So I think going around and talking to people who've lived through this pandemic in individual countries is really important. We did it briefly with with Japan as well. And last year.

So I think there are a lot more stories to tell in this area. 

Jessamy: Yeah, I think that's right. And if listeners want to reach out and let us know any particular countries or regions that they think have had some interesting stories, then we'd love to investigate that more, wouldn't we? 

Gavin: Yeah, absolutely. That would be, that would be absolutely fantastic.

If you can think of any countries that have had some really interesting, fascinating experiences during the COVID 19 pandemic, then do let us know because that's something that I would absolutely love to spend hours Googling. Genuinely, I would. I don't mean that to sound sarcastic. That's the sort of thing I really enjoy.

So yeah, absolutely.

That's it for this episode of The Lancet Voice. If you want to carry on the conversation, you can find Jessemy and I on Twitter, on our handles, at Gavin Cleaver and at jessemybagginal. You can subscribe to The Lancet Voice if you're not already. wherever you usually get your podcasts. And if you're a specialist in a particular field, why not check out our In Conversation With series of podcasts tied to each of the Lancet specialty journals, where we look in depth at one new article per month.

Thanks so much for listening, and we'll see you again next time.