Vaccine xxx (xxxx) xxx

Contents lists available at ScienceDirect

Vaccine
journal homepage: www.elsevier.com/locate/vaccine

Fear, mistrust, and vaccine hesitancy: Narratives of the dengue vaccine

controversy in the Philippines
Vincen Gregory Yu a,b,⇑, Gideon Lasco a,b,c, Clarissa C. David a
a
School of Government, Ateneo de Manila University, Quezon City, Philippines
b
Development Studies Program, Ateneo de Manila University, Quezon City, Philippines
c
Department of Anthropology, University of the Philippines Diliman, Quezon City, Philippines

a r t i c l e i n f o a b s t r a c t

Article history: This article applies a qualitative approach to the 2017 dengue vaccine controversy involving Sanofi
Received 23 March 2021 Pasteur’s Dengvaxia to understand vaccine hesitancy and related anxieties in contemporary
Received in revised form 14 July 2021 Philippines. Through a multisited project that investigated the health aspirations and lived experiences
Accepted 19 July 2021
of low- and middle-income Filipinos across urban and rural Philippines, this article distills the perspec-
Available online xxxx
tives of both ordinary community members and health workers in local and national capacities regarding
the controversy—and how it altered their perceptions toward vaccines, health care, and government. Our
Keywords:
study reveals widespread mistrust and fear in the communities toward both the state and health insti-
Vaccines
Vaccine hesitancy
tutions following the controversy, with frontline health workers bearing the brunt of the communities’
Local vaccination culture apprehensions, and the media partly responsible in fomenting these fears. Given the repetitive nature
Dengue vaccine of health and vaccine controversies, this article suggests the importance of responsible journalism,
Crisis communications well-calibrated crisis communications, and a people-centered health paradigm that involves exploring
Philippines local contexts of vaccine hesitancy and mining people’s lived experiences in tackling present and future
health crises—especially now in the advent of COVID-19 vaccinations.
Ó 2021 Elsevier Ltd. All rights reserved.

1. Introduction
In 2016, the Philippines became the first Asian country to
launch a mass immunization campaign against dengue fever, using
the novel Sanofi Pasteur vaccine Dengvaxia. The program unfolded
at a transitional time in Philippine politics: It was approved and
begun during the term of the late President Benigno Aquino III,
pilot-tested in three regions during the weeks surrounding the
2016 national elections, and continued by the new administration
of President Rodrigo Duterte [33]. It was also incorporated into the
school-based immunization program run by the Philippine Depart-
ment of Health (DOH) and Department of Education, which had
started in 2013 with the free rollout of measles, rubella, tetanus,
and diphtheria vaccines among select primary and secondary
school levels nationwide [43]. During the latter half of the year,
the dengue vaccination campaign would encounter some contro-
versy—suspended briefly over an expert panel’s call for more ‘‘par-
⇑ Corresponding author at: Ateneo Policy Center, School of Government, Ateneo
de Manila University, Pacifico Ortiz Hall, Fr. Arrupe Road, Social Development
Complex, Katipunan Ave., Loyola Heights, Quezon City 1108, Philippines.
E-mail addresses: vincengregoryyu@gmail.com (V.G. Yu), pdlasco@up.edu.ph (G.
Lasco).
allel studies on the safety and efficacy of the vaccine,” and
subjected to congressional hearings over allegations of corruption
on the approval and procurement process carried out by the previ-
ous administration—but would nonetheless be re-approved and
even expanded to other parts of the country [33].
In December 2017, almost two years since the program
started—and with over 800,000 Filipino schoolchildren already
inoculated with at least one dose of the vaccine—Sanofi announced
that Dengvaxia may in fact be unsafe for certain populations [45].
The program immediately became a cause célèbre in the Philip-
pines. Within days of the announcement, reports of vaccinated
children who had either died or fallen seriously ill from dengue
became the focus of print, broadcast, and online media. The
Duterte administration launched criminal investigations against
top-ranking politicians and DOH officials who had initiated the
immunization program, with most of them belonging to the oppo-
sition or preceding administration, while the Public Attorney’s
Office (PAO) performed its own highly publicized inquiry involving
televised autopsies and interviews with bereaved families [33].
These investigations, both on the clinical and political aspects of
the program, persisted in the succeeding months and received con-
stant media coverage; at one point, a group of experts from the
Philippine General Hospital, the national government referral

https://doi.org/10.1016/j.vaccine.2021.07.051
0264-410X/Ó 2021 Elsevier Ltd. All rights reserved.

Please cite this article as: V.G. Yu, G. Lasco and C.C. David, Fear, mistrust, and vaccine hesitancy: Narratives of the dengue vaccine controversy in the Philip-
pines, Vaccine, https://doi.org/10.1016/j.vaccine.2021.07.051
V.G. Yu, G. Lasco and C.C. David
center, even had to publicly ask the Justice Department to inter-
vene against the PAO’s sensationalized handling of the events [4].
The Dengvaxia controversy has since been analyzed extensively,
primarily from the lenses of clinical research, public health and
epidemiology, and communications [2,8,14,23,25,27,44]. One
acknowledged consequence has been its impact on vaccination
rates in the Philippines: A year after Sanofi’s announcement, the
country experienced a measles outbreak that claimed over 500
lives—a phenomenon largely attributed even by the DOH itself to
increased vaccine hesitancy that resulted in part from the contro-
versy [2,23,36]. However, these analyses have been chiefly expert-
driven appraisals—and collectively stress a great omission in the
relevant literature, which is the absence of voices from the field.
Just how exactly did ordinary people in the communities experi-
ence the controversy—and how did the controversy affect their
lives? More importantly, how did it alter their perceptions toward
health care in general and vaccination in particular? Four years
since, these questions resound with even greater urgency as the
Philippines grapples with yet another large-scale health and vacci-
nation crisis. Like many parts of the world, vaccine mistrust and
hesitancy have emerged as major obstacles to stomping the
COVID-19 pandemic in the Philippines. Survey results from March
2021 showed that 60 percent of Filipinos were unwilling to be vac-
cinated against the viral disease [30]—a number that decreased to a
still-considerable 33 percent in May of the same year, as the coun-
try entered its third month of immunizations [47].
In this article, we employ a qualitative approach to understand-
ing vaccine hesitancy and related anxieties in contemporary Philip-
pines using the dengue vaccine controversy as a foundational point
of reflection. To date, only Ezra M. Valido et al. [57] have interro-
gated the said controversy from a predominantly anthropologic
lens, in their work with urban-poor settlers in Quezon City, Philip-
pines. While following their example, our article expands this
interrogation of ‘‘local vaccination culture” [48] by utilizing the
narratives of ordinary citizens, health workers, and government
officials across urban and rural Philippines to craft an immediate
picture of the controversy and its consequential aftermath, and
propose recommendations for future responses to similar health
crises.
It must be noted that the Philippines is no stranger to issues
surrounding vaccines. Historical records tell of active resistance
against smallpox vaccination during the nation’s early years as
an American colony [1]. Closer to the present, in the mid-1990s,
widely publicized allegations that tetanus vaccines were abortifa-
cient supposedly led to a drop in coverage rates among mothers
and newborns, according to an anecdotal account by the medical
anthropologist Michael Tan [52]. And while the dengue vaccine
controversy could have indeed worsened vaccine confidence in
the country, data from the World Health Organization and United
Nations Children’s Emergency Fund actually already demonstrated
persistent downtrends in the Philippines’ national immunization
coverage in at least the last two decades, especially for measles
and DTP or diptheria-tetanus-pertussis vaccines [58]. This cer-
tainty, then, of vaccine-related crises and controversies arising
time and again only underscores the importance and relevance of
studying—and learning from—such crises. In parsing the past and
elucidating citizens’ lived experiences, we hope to provide a more
cohesive and people-centered understanding of what makes a vac-
cination crisis—and better ways of moving forward.
2. Methods
From November 2018 to May 2019, we embarked on a multi-
sited qualitative project to articulate the health-related aspirations
and experiences of low- and middle-income Filipinos. This project
2
Vaccine xxx (xxxx) xxx
was an offshoot of an earlier, nationwide study (for which third
author was an investigator) that found poor health care to be a sig-
nificant barrier for many Filipinos in achieving their goals in life;
and more significantly, that the less affluent are often driven into
debt, if not further poverty, by catastrophic health events [60]. Like
the original study, our new project was grounded on the spirit of
equity: To obtain a more realistic picture of the everyday lives of
ordinary Filipinos, our sampling and recruitment processes
emphasized representation of the poor and the middle class that
comprise majority of the country’s population.
We conducted 30 focus group discussions (FGDs) with 250 par-
ticipants, as well as 33 key informant interviews (KIIs) with 37
individuals, across 10 sites in the Philippines. In selecting our par-
ticipants and field sites, we employed maximum variation sam-
pling, a type of purposive sampling method that aims to capture
as many population contexts as possible. For our study, this meant
accounting for variations in geography, given the archipelagic nat-
ure of the Philippines and regional differences in terms of lived
experience (e.g. rural versus urban settlements, mountainous/in-
land versus coastal communities), as well as variations in occupa-
tional sectors to which the poor and middle class frequently
belong. Tables 1 and 2 describe in numerical detail these geograph-
ical and occupational variations, respectively. Meanwhile, the KIIs
covered the spectrum of ‘health workers’, which we defined
broadly as anyone working or involved in the health sector, from
elected and appointed government officials, public and private
practitioners, to biomedically trained village health workers and
traditional or indigenous healers (see Table 3). For ease of access,
we eventually selected study sites where our team already had
prior contacts.
Our FGDs adhered to a three-part structure, beginning with an
articulation of personal health-related goals, followed by a con-
frontation of the barriers to achieving those goals, and concluding
with a discussion of our participants as members of the health care
system. Throughout these discussions, we encouraged our partici-
pants to relate their experiences with health workers and the sys-
tem itself in various settings. The KIIs, on the other hand, usually
zeroed in on the interviewee’s area of expertise vis-à-vis the coun-
try’s current health situation. The FGD and KII questionnaires are
included in this article as supplementary material.
The discussions, lasting 30–90 min, were conducted in either
English or Filipino, depending on participant preference, and took
place in secure community venues (e.g. village conference halls,
hotel function rooms, personal offices), though some KIIs occurred
in coffee shops or similar public places at the interviewees’ request.
Local facilitators from the same communities handled FGD recruit-
ment, venue arrangement, and some KII referrals, but only the
research team and participants were present during the discus-
sions. Informed consent was obtained prior to participation and
iteratively throughout the sessions. Audio recordings were then
transcribed, with participant anonymity prioritized through
Table 1
Distribution of field sites and FGDs according to urbanity.1
Site classification Number of sites Number of FGDs
Highly urbanized cities (HUC)2 4 11
Non-HUC 2 7
Rural municipalities 4 12
1
Based on the definition of ‘urbanity’ (versus rurality) adopted by the National
Statistical Coordination Board in 2003. See https://psa.gov.ph/article/adoption-
operational-definition-urban-areas-philippines.
2
Based on the definition of ‘highly urbanized city’ according to the Philippine
Statistics Authority. See http://202.78.94.78/index.php/ddibrowser/64/export/?-
format=pdf&generate=yes.
V.G. Yu, G. Lasco and C.C. David Vaccine xxx (xxxx) xxx

Table 2 Table 4
Distribution of FGDs according to occupational sector. Summary of key findings.

Sector Total Description/ examples Perspectives from the community Perspectives from the health sector
FGDs
1. Mistrust and fear of vaccines 1. An observable rise in vaccine
Health workers 4 Physicians, nurses, and other allied medical resulting from direct community hesitancy
workers in public or private settings experiences or from media
Government 4 Public school teachers, local government coverage of the controversy
workers employees 2. Mistrust of other government 2. The media as partly responsible for
Formal workers 2 Young urban professionals, business process health programs (i.e. besides aggravating people’s fears and
outsourcing (BPO) agents vaccinations) hesitancy toward vaccines
Urban poor 3 Residents of poor communities in urban areas 3. Mistrust of and anger toward 3. Health workers on the receiving
Local migrants 2 Inter-island and inland migrants authority, including the end of hostile behavior in the
Farmers/ farming 3 Rice, high-value crops, upland, lowland government, DOH, and health communities
communities workers
Fisherfolk 1 Coastal and inland fisherfolk 4. Moral division: the belief that 4. Low workplace morale within
(Families of) 2 Overseas Filipino workers or their family ordinary citizens should be DOH, as employees experienced
overseas members responsible for how they consume discrimination and worried about the
workers health-related information and be institution’s credibility
Disaster survivors 1 Natural or man-made crises held partly accountable for the
Youth 4 Students, out-of-school youth, workers controversy
Persons with 1 Including caregivers 5. An urban–rural divide: Less 5. An urban–rural divide: Less
disabilities apprehension and vaccine apprehension and vaccine hesitancy
Other groups 3 Parents of children below 7 years old (1) hesitancy observed in rural and observed in rural and far-flung
Caregivers of the sick or elderly (2) far-flung communities communities
6. The measles outbreak as a turning 6. The measles outbreak as a turning
point (i.e. returned people’s trust point (i.e. returned people’s trust in
Table 3 in vaccines) vaccines)
Distribution of FGDs and KIIs with health workers. 7. The rise of conspiracy theories
regarding the dengue vaccination
Health worker classification FGD KII program
Department of Health officials (current or former) 6
Department of Health Central Office personnel 2
Government health officers (city, municipal, or provincial level) 6 of our participants who had previously allowed their children to be
Local chief executives (e.g. city mayors, councilors, village 8
captains)
vaccinated through the school-administered programs or at village
Hospital administrators 3 health centers admitted to now refusing any form of vaccination
Resident doctors 1 for their children. A few said they still allowed their children to
Medical association heads 1 be vaccinated, but only with what they referred to as ‘‘trusted” vac-
Medical school heads 2
cines, or those already included in the DOH’s yearly immunization
Medical students 1
Health advocates/ nongovernment organization heads 5 program.
Health finance/ insurance sector 1 However, while some participants were indeed parents of chil-
Traditional/ folk healers 1 dren who had been inoculated with Dengvaxia or belonged to com-
Total 4 33 munities covered by the vaccine’s pilot implementation, many
were actually neither. Instead, these participants ascribed their
removal of identifying information. Only our team had access to apprehensions toward vaccines to what they learned about the
transcripts, consent forms, and information sheets. controversy from internet searches, TV news reports, and social
We used NVivo 11 to analyze the FGD and KII transcripts media—the same three answers that constituted majority of the
through two rounds of coding. Throughout analysis, our team— responses when we first inquired about our participants’ usual
coming from the fields of anthropology, mass communications, sources of health information. Commonly, these participants
and public health—constantly consulted each other to address would express their fears as precipitated by ‘‘what we saw on
potentially subjective readings. During the first round of coding, TV” or ‘‘what we read on Facebook.”
we determined 14 major themes, ranging from health financing
and health service delivery to the politics of health and, relevantly 3.1.2. Mistrust of other government health programs
for this paper, vaccines and the Dengvaxia controversy, which we The controversy’s impact was not only confined to vaccine con-
then parsed into subthemes through another round of coding. This fidence; people also lost trust in other DOH programs coursed
article now distills those specific findings into two major perspec- through schools and local health centers. In two separate FGDs
tives—that of ordinary community members; and that of health with public-school teachers—one in a major seaport, the other in
workers in village centers, hospitals, and local and national govern- a rural coastal municipality—our informants shared how parents
ment capacities—all of which are summarized in Table 4. The were suddenly pulling their kids out even from long-running,
quotes presented are either in the original English or translated annual programs such as ferrous sulfate supplementation and
from Filipino. Ethics clearance was obtained from Ateneo de Man- worm treatment. In fact, the perception that a health program
ila University Research Ethics Committee (approval no. AdMUREC- was government-sponsored appeared to be foundational in peo-
18-016). ple’s narratives of mistrust and apprehension toward vaccines
and related products. Schoolteachers in that FGD at a major sea-
3. Results port, for example, shared how some parents actually opted to
pay for the services of private doctors rather than allow their chil-
3.1. Perspectives from the community dren to participate in the free immunizations in schools. Even
among these teachers, who were at the forefront of administering
3.1.1. Mistrust and fear of vaccines these yearly programs, we observed similar feelings of mistrust: ‘‘I
When the dengue vaccine controversy broke out, the predomi- myself forbade my kid from joining anything involving injections,”
nant community reaction was one of fear and apprehension. Many to quote one informant. In another FGD from that same seaport,
3
V.G. Yu, G. Lasco and C.C. David
one mother said she refused to let her child receive worm treat-
ment in school—and would just buy over-the-counter purgatives
in local pharmacies ‘‘to be safe.”
3.1.3. Mistrust of authority
These feelings of mistrust and apprehension toward vaccines
and public health programs coexisted with a range of negative sen-
timents toward government and authority figures. Some infor-
mants felt the government had failed to prioritize the welfare of
citizens, with one participant from an urban poor settlement say-
ing, ‘‘How could the government have found it in themselves to
inject those children with Dengvaxia—when they weren’t sup-
posed to?” That the Philippine government was just as clueless
as the rest of the world with regards to the dangers of Dengvaxia
for the dengue-naïve—until Sanofi released its reevaluation—
mostly went unrecognized in the communities we interviewed.
For many of our participants, the controversy was the Philippine
government’s fault, as in this excerpt from that same FGD:
The government didn’t tell us that Dengvaxia was only for those
who haven’t had dengue. How were we ordinary citizens sup-
posed to know that? That’s what the government failed to tell
us. Even during the orientations prior to inoculation, they said
nothing.
Among the schoolteachers we interviewed, some felt the
authorities had turned them into scapegoats:
[Dengvaxia vaccination] should have been solely the job of the
health centers. Schools should not have been involved. But
teachers became the ‘face’ of the program. When the contro-
versy erupted, it put us teachers in a dubious light. The parents
came for us. It was our names they were calling out over the
radio.
There were also those who directly blamed the DOH, as in this
excerpt from another FGD in an urban poor community: ‘‘It was
like [the DOH] rushed things. Suddenly my son needed to be
injected. Then we found out they hadn’t even studied the vaccine
thoroughly. Now I fear for my son’s life [if ever he gets dengue].”
Others, as in the following quote from that same FGD, expressed
disillusionment toward medical authorities: ‘‘They said to always
trust the doctors. But who allowed Dengvaxia to be injected to chil-
dren? Doctors. The DOH.”
3.1.4. Rise of conspiracy theories
Some participants had their own theories regarding the contro-
versy. In one FGD among schoolteachers, one participant said,
‘‘Maybe [the authorities] used our children as test subjects for
Dengvaxia.” In an FGD in an urban poor community that was part
of the vaccine’s pilot implementation, some wondered if the gov-
ernment had intentionally ‘‘tested” Dengvaxia on poor people
because they were ‘‘convenient” subjects. Others from that same
settlement, as in this quote, were suspicious even of foreign gov-
ernments: ‘‘Do you think these [new vaccines] were for free? These
foreigners probably said, ‘Can you please try our new product [on
your people],’ and whom do you think they paid to do that? Our
government.”
3.1.5. A moral divide: Belief in personal responsibility
It should be noted, however, that not all participants blamed
the authorities for the controversy. There were those who believed
that ordinary citizens should and could have been more proactive,
especially since the controversy concerned their health. In an
FGD in an urban poor settlement in Quezon City, some believed
the families of children who had been injected with Dengvaxia
4
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had only themselves to blame: ‘‘They heard the vaccine would be
given for free, and they immediately signed their children up for
it without thinking of possible consequences.” One participant con-
cluded, to the agreement of others:
People should also hold themselves accountable. The govern-
ment did not force any of those children to be injected with
Dengvaxia. The parents all had to sign a waiver allowing their
children to be injected. And when those children died, people
immediately blamed the government.
Another participant from the same FGD echoed similar
sentiments:
We shouldn’t just believe everything the authorities tell us. We
should strive to find things out on our own. It’s very easy to look
things up on the internet. Those who don’t use the internet can
just ask their children to do it for them.
3.1.6. An urban-rural divide
Curiously, relative to the urban communities, our FGDs in rural
communities yielded a more variable experience at the height of
and after the dengue vaccine controversy—and on the whole, less
apprehension toward the fallout. An exchange among local
migrants to a coastal community in Eastern Philippines, for exam-
ple, revealed more favorable sentiments toward vaccination:
Interviewer: Did you hear about Dengvaxia [the vaccine
controversy]?
All: Yes.
Interviewer: How did you feel back then?
Participant 1: Afraid. My children are still young.
Participant 2: Good thing Dengvaxia didn’t reach our town.
Interviewer: So after [the controversy] happened, you still
allowed your children to participate [in school vaccinations]?
Participants 1 and 2: Yes.
In another seaside settlement in Central Philippines, the FGD
participants agreed that even after the controversy, it was still
‘‘rare” for parents to refuse immunization for their children by gov-
ernment health workers, regarding the dengue vaccine controversy
as something that only occurred in urban parts of the country ‘‘like
Manila.”
Though the more anxious sentiments toward vaccines were also
informed primarily by media consumption—‘‘We were scared by
the investigations on TV, all those dead children,” said one parent;
‘‘[the controversy] was always on the news,” said another—our
participants in rural areas were largely less apprehensive toward
pertinent health matters. One even said ‘‘those children did not
really die from Dengvaxia; it was just smear tactics against the
government.” And in another FGD from the aforementioned Cen-
tral Philippine community, all the participants eventually recog-
nized that ‘‘it really is better to be vaccinated.”
3.1.7. The measles outbreak as a turning point
In the end, regardless of an area’s urbanity, the resulting
measles outbreak of late 2018 became the major turning point
for many of our participants when it came to vaccine trust and con-
fidence. In multiple FGDs—as in the one excerpted below, with
female residents of an urban poor settlement in Manila—our par-
ticipants related how even hearing news of the outbreak was
enough to send them and their neighbors to the health centers to
have their children vaccinated immediately:
Participant 1: Because of Dengvaxia, people were really afraid
to be vaccinated, but not anymore.
V.G. Yu, G. Lasco and C.C. David
Participant 2: Now they’re afraid of measles.
Participant 3: If not for the measles outbreak, they wouldn’t
have let themselves be vaccinated ever again.
3.2. Perspectives from the health sector
3.2.1. Observable rise in vaccine hesitancy
Our conversations with health workers across the country
reflected the community narratives of fear and apprehension
toward vaccines and health programs. Anecdotally, community
health workers said the drastic decline in participation in health
programs was conspicuous, with people objecting verbally to
‘‘everything that had to do with injections,” from annual flu shots
to pneumococcal vaccination for the elderly. According to one rural
health officer, ‘‘parents would just say yes or nod in agreement
during orientations, but come vaccination time, their children
would show up with unsigned parental consent forms.”
Official statistics mirrored the flagging confidence in
government-administered vaccinations. In a rural Eastern Philip-
pine town, the lone public health nurse shared how immunization
coverage rates on the whole dropped from 95 percent to 65 per-
cent in the aftermath of the dengue vaccine controversy. A similar
drop in percentage was observed in a major Central Philippine city,
according to anecdotal information relayed by the city councilor
who chaired the health committee. Though multiple participants
in separate discussions did qualify that immunization coverage
rates were already dwindling even before the dengue vaccine con-
troversy for a variety of reasons—for instance, some parents in
remote settlements not reached by door-to-door vaccinations said
the transportation cost to the health center was already pro-
hibitive—these interviewees also contended that the controversy
worsened those numbers unequivocally.
3.2.2. The role of the media in the controversy
Our discussants from the health and government sectors uni-
formly suggested the role of media in worsening the effects of
the controversy and the resulting measles outbreak, especially in
places that were not part of Dengvaxia’s pilot implementation. In
the words of a municipal health officer in an Eastern Philippine
island, people ‘‘became afraid [of vaccines] because of what they
saw and heard on TV,” like ‘‘the prosecution cases and televised
autopsies of the dead children.” And because of broadcast media’s
relentless coverage of the controversy, to quote a rural village
nurse, even people from remote towns became apprehensive not
only of Dengvaxia, but also of other, long-running government
health programs.
3.2.3. Hostility toward health workers
In extreme cases, health workers who ran such programs on the
ground found themselves on the receiving end of hostile behavior.
‘‘People shut their doors at us in an effort to shoo us away,” said
several participants in an FGD among rural village health workers.
A high-ranking DOH official said his staff got cursed at and called
names: ‘‘‘Leave us alone, you animals,’ some people shouted at
them.” And as a city health officer from Central Philippines related:
‘‘The nurses and midwives involved in door-to-door vaccination
under my office even received threats. Protective of their grand-
children, some grandfathers chased my staff away with machetes.”
3.2.4. Low workplace morale within DOH
Within the DOH, our participants shared how workplace morale
inevitably plummeted following the controversy: A top-ranking
informant noted how, after the controversy erupted, employees
were suddenly getting the legal team to review their work more
frequently, as if they ‘‘had lost confidence in what they were
doing.” Moreover, our interviewees shared how the controversy
5
Vaccine xxx (xxxx) xxx
hounded them even beyond the workplace. ‘‘People in the commu-
nities refused all of our programs because they linked everything
related to DOH with Dengvaxia,” one FGD participant said. Another
shared how, for a time, working under the DOH meant you were
‘‘marked” in the communities: ‘‘People identified you as part of
DOH. It didn’t matter if the bureau you worked at had nothing to
do with vaccines. They would say, ‘You’re from DOH? How’s Deng-
vaxia?’” ‘‘I would try to answer their questions and defend the
effectivity of vaccines,” another interviewee said, ‘‘but it’s use-
less—people already believed their preconceptions and truths
based on gossip, social media, and news reports.”
DOH employees also voiced their anger at how the controversy
had affected them. Some high-ranking officials pinned it on the
‘‘incompetence” of their predecessors, while others felt current
officials were complicit in what they alleged to be the railroaded
procurement of Dengvaxia. But regardless of who should be
blamed, our informants uniformly expressed concern for the insti-
tution’s credibility as a whole, and how the situation would affect
future programs, especially with the upcoming implementation of
universal health care in the country.
3.2.5. An urban-rural divide
Interestingly, our conversations with health workers also mir-
rored the earlier observation that rural and far-flung communities
had less apprehensive reactions toward vaccines and health pro-
grams in the aftermath of the controversy. One municipal officer
summarized the observation as such: ‘‘The less-affected a commu-
nity was, the easier to appease the residents with regards to vac-
cine hesitancy.” In an FGD with rural health workers from a
coastal settlement, the participants shared how, despite the same
initial misconceptions and fears toward vaccines and health pro-
grams abounding in the communities, it was also not difficult to
get residents to believe again in the science—through simple mea-
sures such as regular village-hall meetings and door-to-door infor-
mation campaigns.
3.2.6. The measles outbreak as a turning point
Finally, mirroring as well another earlier observation, health
workers also noted how the measles outbreak was inadvertently
instrumental in bumping the flagging vaccination rates up. A
senior DOH official said national rates of the country’s annual
immunization campaign plunged to 36 percent one year after the
controversy broke—but shot back up to 93 percent only three
months after the measles outbreak struck. In fact, village health
workers even described ordinary citizens as ‘‘desperate” and ‘‘beg-
ging” to be vaccinated. In an Eastern Philippine town, health work-
ers said some parents begged to have their five-year-olds
vaccinated against measles even though national guidelines at
the time only targeted six- to fifteen-year-old children for emer-
gency inoculation. In West-central Philippines, a rural health offi-
cer shared how, after the measles outbreak, teenagers whose
parents never finished or even began formal education ended up
being the ones insisting to be included in the town’s human papil-
lomavirus (HPV) vaccination campaign. Still, people in the commu-
nities continued to maintain a certain degree of wariness toward
vaccines: As the aforementioned health officer related, even in
the midst of the measles outbreak, there were numerous instances
when parents would verbally specify their intent to have their chil-
dren inoculated with the measles vaccine—‘‘but not Dengvaxia.”
4. Discussion
4.1. Mistrust, sensationalization, and moral division
The dengue vaccine controversy in the Philippines can be con-
sidered the first of its kind only insofar as the specific implicated
V.G. Yu, G. Lasco and C.C. David
entity (i.e. Dengvaxia) is concerned. Else, it falls squarely in the glo-
bal continuum of vaccination crises arising from multidimensional
public mistrust. The controversy may be foremost a manifestation
of people’s fear toward a novel piece of technology, but in examin-
ing the controversy’s narrative architecture, we find elements that
overlap and resonate with similar historical events, showing how
such fear is informed by and bleeds into a host of interconnected
factors.
Most prominently, the anger toward and distrust at government
articulated by our participants, coupled with their sentiments that
the government had failed to prioritize their welfare, have count-
less, contemporary parallels—from Ukranian measles and rubella
campaigns marred by post-Soviet anxieties [3]; HPV vaccinations
in Romania that were perceived as mere ploys by the government
to further violate and subjugate female bodies [40]; to racialized
perceptions of flu immunizations in the United States, where
state-led vaccinations have been deemed untrustworthy solely
because they were state-led [17]. Even poor Filipino’s suspicions
that they were being used as ‘test subjects’ for Dengvaxia echoed
the case of HIV vaccination trials in impoverished communities
in South Africa [53].
Importantly, the mistrust at government that sprung from the
dengue vaccine controversy could only have been worsened by
the fact that the campaign was already politicized from the outset,
taking place in a decisive election year and questioned over its
supposedly inequitable implementation well before it began [16].
Furthermore, it reflected Gideon Lasco and Heidi J. Larson’s [26]
(p. 341) observation that immunization campaigns are all too
easily politicized; that the vaccination program unfolded as it
did— under the polarizing climate of Duterte’s Philippines and with
unforeseen associations to fatal outcomes—could have only
amplified the ‘‘populist refrain of a corrupt establishment”—and
aggravated the people’s apprehensions.
Separately, our study observed public mistrust in health
institutions, as evidenced especially by the narratives of frontline
health workers who bore the brunt of the people’s frustrations
and occasional hostility—narratives that approximate, for example,
health workers’ experiences with polio vaccinations in modern-
day Pakistan [21]. These narratives also underscored how, despite
decades of work in promoting trust in scientific fact, our health
institutions remain all too easily vulnerable to sociopolitical shocks
like vaccine controversies, which erode not only the literal health
of involved communities, but also the morale and psychological
constitution of health workers.
Crucially, our participants’ narratives showed how mass media
played a detrimental role in sensationalizing the controversy—and
(inadvertently) abetting public mistrust—in their consuming
coverage of the controversy’s more headline-grabbing aspects. This
echoed the findings of similar qualitative work in the Philippines
where participants also cited media reportage of the controversy
as fueling their vaccine-related apprehensions [34,57]. Moreover,
that the deaths of several children vaccinated with Dengvaxia
became a narrative anchor of the controversy—consequently fuel-
ing parents’ fears of having their children vaccinated—illustrated
Pieter Streefland et al.’s [48] (p. 1711) point that vaccination refu-
sal becomes conflated with larger societal conflict—in this case, the
people’s unidirectional conflict with an untrustworthy state—once
it ‘‘is associated in the collective imagination with a child’s death.”
Additionally, rumor and word-of-mouth contributed to propagat-
ing mis- and disinformation during the course of the controversy,
even spawning conspiracy theories, reminiscent of such cases as
that of Cameroon in 1990, where schoolchildren ‘‘leapt from win-
dows” to evade tetanus vaccinators who had been rumored to be
implementing a sterilization program [11] (p. 159).
6
Vaccine xxx (xxxx) xxx
Finally, our study shed light on a moral dimension to the con-
troversy, showing how a health crisis can affect the social fabric
of community. In particular, we glimpsed the moral divides among
the urban poor, in the way some of them insisted on a certain
degree of individual responsibility in accounting for the contro-
versy’ effects in the communities—demonstrating how moral poli-
tics [22] also informed the controversy in certain pockets of
society.
4.2. Implications for present and future vaccination crises
Inarguably, the dengue vaccine controversy has been thrust to
the core of the Philippines’ institutional memory [28]. As such,
any consideration of the controversy must be hinged on treating
it as a pivotal learning experience for the country, not only in terms
of vaccination, but also in the wider arena of public health.
One thing the controversy highlighted is the importance of cri-
sis and risk communication especially in matters of science and
health [8]—and in the ensuing melee of competing voices from var-
ious state and non-state parties, the constant, pressing need for
coherent and trustworthy, expert-led messaging [27]. This is par-
ticularly relevant—and challenging—to the contemporary Philip-
pine context on two overlapping grounds. First, far from a
monolingual and mono-cultural country, the Philippines consists
of more than 2,000 inhabited islands and close to 200 established
linguistic cultures. Like many developing nations, its settlements
range from megalopolises that double as technological and educa-
tional hubs, to far-flung and/or impoverished communities with
limited access to human and material resources, and implicitly,
to ‘science’ as understood by academic and affluent circles. As such,
on a baseline level, crisis and risk communicators already have to
navigate these geographic and linguistic disparities, while also
having to consider how their message may be received differently,
if at all, as it reaches various ‘micro-cultures’ with their own local
epistemologies and understanding of scientific matters [37]. This
picture, however, becomes more complicated when situated in
the Philippines as it exists at present: a country where populist
politics have taken a stronghold, rendering science and general
intellectual expertise more susceptible to distortion, if not outright
rejection [7,25]; and where state-funded propaganda machinery
have played a major role in ‘weaponizing’ the truth and shaping
debates on important issues [39], enabling ‘infodemics’ [10] and
fake news to thrive with little resistance. Thus, tailoring interven-
tions to ensure consistent and effective scientific communication
from the experts to the general public would now necessitate a
preliminary recognition of how the political environment, com-
bined with existing social disparities, can warp such communica-
tion in the first place.
At the same time, journalists across print, broadcast, and online
media must be cognizant of their capability to influence public per-
ception, especially in matters of science with which the layperson
may not be entirely familiar—and must therefore be more deliber-
ate in shaping their reportage, lest they end up only exacerbating
people’s fears and anxieties, as our study and many other accounts
worldwide have demonstrated [15,32]. Lasco and Larson [26] have
pointed out the role of virtual media as mediators of vaccination
misinformation, while Maryke S. Steffens et al. [49] have outlined
how virtual media can be utilized precisely to counter such
misinformation. In the Philippine context, virtual media acquires
an added layer of significance in its potential to propagate (mis)in-
formation, given the country’s heavy reliance on online sources—in
place of traditional platforms—for news consumption [35].
Although no scholarly work has yet to correlate directly people’s
consumption habits during the Dengvaxia controversy with the
V.G. Yu, G. Lasco and C.C. David
increased rates of vaccine hesitancy in the aftermath, Manuel Day-
rit et al. [8] graphically demonstrated the surge in online media
coverage of the controversy to arrive at that very conclusion
implicitly, while Valido et al. [57] reached the same through their
qualitative discussions in Quezon City. That said, our study also
joins the call of existing scholarship [8,37,56] in highlighting the
still-sizable responsibility of traditional media (i.e. broadcast and
print) in molding discussions and propagating (mis)information,
especially, as in the case of the Philippines, in less urbanized com-
munities where such media sources remain the dominant modes of
knowledge acquisition as regards health and vaccination [9].
Most importantly, our study reiterates Streefland et al.’s [48]
assertion that any navigation of vaccine hesitancy and vaccination
crises—more so now in the ‘‘post-truth” age [38]—cannot be
divorced from an understanding of local vaccination culture. This
culture consists of a foundational aspect, such as ‘‘prevailing beliefs
about disease aetiology, ideas about the potency and efficacy of
modern medicine, and views on the need for preventive health mea-
sures,” and an experiential aspect, or the ‘‘shared notions [that]
emerge when [people] exchange accounts of their vaccination expe-
riences”—and is further informed by external forces ranging from
technology, mass media, religion, and politics on a ‘‘regional,
national or even global” scale [48] (p. 1707). In other words, getting
to the heart of why people accept or reject vaccines should entail ‘‘a
sensitivity to differences in local experiences and vaccination set-
tings” [48] (p. 1707) and approaching the subject with an awareness
of the subtle contextual variabilities characterizing a particular sec-
tor’s vaccine-related worries [18]. As the global literature reveals,
these variable approaches can include accounting for differences
even in native politics, as illustrated by the polio vaccination boy-
cotts in Nigeria [19]; deviations in cultural norms and daily societal
circumstances across regional and population sectors, as with the
European HPV vaccination campaigns [20]; even personal convic-
tions, as in people’s sense of belonging that the sociocultural anthro-
pologist Elisa J. Sobo [46] uncovered in a US-based study; or how, as
in the case of Cameroon, nations’ histories, their encounters with
and lingering wounds from colonial forces, can breed future mis-
trust in the state—and state-led health programs [11].
Under the COVID-19 pandemic, we have already seen such
variabilities at work in the Philippines, centering mostly on
China-made Sinovac vaccines that have comprised majority of
the country’s supply since immunizations began in March 2021.
A survey conducted in the weeks leading up to the start of vaccina-
tions showed that only 22 percent of Filipinos who were willing to
be vaccinated would pick Sinovac if they had the option to choose a
brand (the majority of respondents named the American Pfizer
vaccines as their preference) [30]. Around the same time, an inter-
nal survey at the Philippine General Hospital, where vaccinations
would commence ceremonially, showed that only 12 percent of
hospital personnel were willing to be inoculated with Sinovac
[6]. We can intuit several reasons that could have produced these
numbers during that specific point in time. One is the seeming lack
of transparency regarding independent, refereed data: At that time,
the Philippine Food and Drug Administration approved Sinovac for
emergency use based only on interim reports from clinical trials
abroad, which showed relatively lower efficacy rates compared
to other brands with published Phase 3 trial results—a fact that
was not lost upon dissenting sectors of the local health community
[31,51,55]. This could have fed into the impression that the country
was ‘‘settling” for a second-tier (i.e. less efficacious) product, espe-
cially considering earlier reports that detailed how the government
had apparently mismanaged—and altogether missed out on—a
potential shipment of 10 million Pfizer doses for as early as January
[13]. Beyond scientific data, however, revelations of fraudulence
both within and outside government could have also tarnished
the reputation of the Chinese vaccines, from the discovery of a
7
Vaccine xxx (xxxx) xxx
‘‘black market” of such vaccines flourishing within the country’s
overseas Chinese worker community since the previous year [5],
to the state’s admission in December 2020 that members of Cabi-
net and the presidential security detail had already been inocu-
lated with smuggled doses from China [42,50]. All this unfolded
against the backdrop of the Philippines’ continuing territorial dis-
pute with China in the West Philippine Sea—an issue toward which
the Duterte government has repeatedly and uncharacteristically
sided against its own country [41], to the dissatisfaction of most
ordinary people [54]. Taken together, these circumstances and
resulting perceptions could thus potentially explain the culture
of ‘‘sinophobia” [29] that arose at the time the country began vac-
cinating against COVID-19.
Indeed, be it in vaccination programs or in other public health
campaigns, only through a rigorous understanding of people’s
context-specific fears and apprehensions can we eventually come
‘‘to comprehend the prevailing gradations of acceptance” [48]
(p. 1715).
5. Conclusion
Our study has several limitations. The archipelagic geography of
the Philippines suggests the need to further explore the experiences
of people in other areas of the country, despite the relative breadth
of our sampled sites. Similarly, it also excludes the sentiments of
other sectors, given our focus on a limited number of representative
low- and middle-income populations. More precisely, our conclu-
sions do not account for how the sentiments of our participants
might have shifted parallel to the progress of current events.
Nevertheless, this article provides a snapshot of a particular
temporal fraction of Philippine history, in which a single contro-
versy spawned and magnified in the mindsets of people mistrust
toward vaccines, health institutions, and the state. Writing about
the Philippine experience of the severe acute respiratory syndrome
(SARS) outbreak of 2003, Lasco notes a gap in the literature on con-
temporary public health crises in the country—and highlights the
importance of documenting such events as epidemics, given that
their repetitive nature renders them ‘‘amenable to anticipation
and policy formulations” [24] (p. 361). The same, then, can easily
be said of vaccination crises—and the seemingly inextinguishable
issue of vaccine hesitancy.
Fortunately, the aftermath of the dengue vaccine controversy
provided a glimpse of a more optimistic future. The qualitative
data we presented earlier on the perceived influence of the measles
outbreak of 2018–2019 in ameliorating vaccine confidence in the
Philippines suggests that people may actually be more fickle
toward vaccines and public health programs—in spite of preexist-
ing controversy—and more encouragingly, that such a contro-
versy’s impact may be more labile and amenable to repair than
previously thought. How a country bounces back from such a crisis
now depends on, among other factors, well-calibrated crisis com-
munications, responsible journalism, and a genuinely people-
centered public health paradigm that puts a premium on contextu-
alized health interventions.
Declaration of Competing Interest
The authors declare that they have no known competing finan-
cial interests or personal relationships that could have appeared
to influence the work reported in this paper.
Acknowledgment
The authors would like to acknowledge Jenna Mae Atun, Jeriesa
Osorio, and Ivyrose S. Baysic for their contributions to this study.
V.G. Yu, G. Lasco and C.C. David
Funding
This work was supported by the Department of Science and
Technology–Philippine Council for Health Research and Develop-
ment. All authors attest they meet the ICMJE criteria for
authorship.
Appendix A. Supplementary material
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.vaccine.2021.07.051.
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