Romania’s Covid-19 related vaccination campaign was successfull at first. But then ‘vaccine skepticism’ began to spread everywhere. Rather than identifying ‘information, education, and communication’ as the cause of this, we need to unpack the country’s social fractures and hollowed-out welfare state, social science researcher and health care expert Sabina Stan claims in her contribution to the text series “Black Box East.”
To the memory of Marian. His death and that of thousands others that occurred after September 2021, when Romania, were it to reach other European countries’ higher vaccination rate, could have offered to its citizens a higher protection against the lethal effects of the coronavirus.
In the early morning of October 23, 2021, Marian (not his real name), a local postman in a picturesque sub-Carpathian village in Romania, died in a hospital emergency unit. His family had called the ambulance the previous night but it wasn’t until noon of the next day that they managed to have him admitted and hooked to oxygen supply at the nearby town’s hospital. Marian was happily married and had an adult child. He was only 50 and his death occurred less than 24 hours since the first call to the ambulance. The hospital recorded among the causes of his death Covid-19. His two sisters, who accompanied him to the hospital, confirmed that X-rays showed that his lungs had been dramatically affected prior to his death. His brothers, however, kept their skeptical stance to all things related to Covid-19: according to them, Marian rather died of his many long-existent illnesses, including diabetes and cardio-vascular diseases.
Marian’s brothers’ stance towards Covid-19 reflects a largely spread skepticism towards the pandemic among the Romanian population. This skepticism goes beyond embracing conspiracy theories to include milder, but deeply-rooted distrusts. As a neighbor of Marian, and many others, would say ‘I don’t say that the Covid [pandemic] doesn’t exist, but the numbers are pumped up. People went to hospital and died of other illnesses, but they [the hospitals and the government] declare they have died of Covid.’ Pecuniary motives were invoked as a reason for hospitals inflating the number of Covid-19 deaths, and officially-acknowledged discrepancies in the numbers reported by different institutions for justifying one’s skeptical stance.
The (ir-)rationality of skepticism
This skepticism extends not only to Covid-19 death rates but also to the appropriateness of Covid-19 vaccines. At the time of Marian’s death neither him, nor the other members of his nuclear and extended families were vaccinated against Covid-19. Neither were just below two thirds of Romania’s population, which had a vaccination rate almost half the EU average – the second worst in the EU after Bulgaria. This was despite the fact that medical professionals were already deploring that over 90% of Covid-19 deaths in Romania’s hospitals were among un-vaccinated people.
Leading medical figures and politicians attributed vaccine skepticism to a lack of ‘information, education, communication’ (the new public health’s ‘IEC’ approach!), which is allegedly rampant among less educated, rural and older Romanians. The vice-chairman of the Romanian Society of Anaesthesia and Intensive Care explained the low uptake of vaccination as being the result of ‘national blindness, caused by the lack of education, by the lack of civilisation.’ Public commentators contrasted this ‘lack of education and understanding’ on behalf of the population with the success of the government’s vaccination campaign in ‘efficiently managing to make vaccination easily accessible.’
And, apparently, this was the case. In spring 2021, the country’s vaccination record was among the top in the EU. While Romania, like other European countries, started its vaccination campaign in the beginning of 2021 with a rationed vaccination schedule in response to supply bottlenecks, increased stocks led the country fully liberalizing vaccination by May of the same year. After that, any adult Romanian (and after June 2021, any child above 12) could pre-book an appointment or just walk in a vaccination center; they also had a choice of which of the four available vaccines to avail of. The Romanian vaccination platform announced that, in addition to usual vaccination centers, they organized ‘drive-through’ centers in major cities, as well as mobile vaccination caravans for ‘those with a limited access to vaccination.’ In the same spirit, in May 2021 Romania’s leading medical school in Bucharest organized a vaccine marathon over a whole week-end. Faced with such an open, patient-choice-oriented system, skepticism towards vaccination seemed even more irrational.
Political interference, defective access to healthcare
Critics highlighted, however, that the lack of ‘information, education, and communication’ among Romania’s vaccine skeptics was due not only to the reviled influence of social media and boulevard television stations, but also to how communication unfolded during the vaccination campaign. Certainly, neither the militarization of everyday life during the first wave, nor the continued intrusion of politicians in the vaccination campaign helped to build trust in the government and its approach to the pandemic. A stark illustration of the latter is President Iohannis’s declaration in June 2021: ‘the [vaccination] campaign was a success, practically we stopped the pandemic. The fact that we have so few cases [explains why] we do not have any more a very high interest for vaccination.’
It is no surprise then that low vaccination uptake continued through the summer (when only 8% of the population got the jab), thus making the President’s declaration a self-fulfilling prophecy.
More critically, the vaccination campaign had in fact far from managed to truly make vaccines accessible to everybody, most notably among the rural population. Inoculation has been mainly offered in vaccination centers, which have been predominantly located in urban areas, despite almost half of the country’s population still living in rural communes. In contrast, family doctors, a potentially important avenue for rural population’s access to vaccination, were allowed to take part in the campaign only after May 2021. Most family doctors deemed the vaccination contracts offered by the National Health Fund insufficient, and by the end of September 2021, only 38% among them had signed one. Even so, the family doctor avenue would not have been available to the over 300 communes (or 12% of the total) which lack one on their territory, and would have been insufficient for the 1414 communes (or 53%) with deficient coverage by family doctors.
Long-lasting structural problems
Here, the vaccination campaign hit the wall of Romania’s long-lasting structural problems, including not only its depleted health care system but also, more generally, its dwindling public services and diminishing population. According to senior researcher Remus Anghel, the map of Romania’s areas of low vaccine uptake matched that of areas most affected by out-migration. For Romania’s aged and impoverished rural population, the lack of support from children departed to work abroad in Europe only added to curtailed public transport infrastructure and low rates of use of personal vehicles among the barriers to access vaccination. As a result, by the beginning of October 2021, proportionately half as many people living in rural areas were vaccinated as compared to those living in Romania’s cities (16% as compared to 33%).
What is even more baffling, though, is that the map of infection rates during the fourth wave of the pandemic did not match the distribution of non-vaccinated population. Instead, high infection rates overlap with the north-west – south-east corridor of post-socialist economic development. Certainly, this is due to the higher mobility and contact frequency in busy urban areas, especially in a context of relaxation of anti-Covid restrictions during summer 2021, and a timid reintroduction of restrictions since September 2021. Of course, these factors are multiplied by low vaccination rates. Though higher than in rural communes, they are still very low by European standards.
The low vaccine uptake in urban areas, where access to vaccination centers is far easier, is also because, even among the urban population and ‘educated’ groups, vaccine hesitancy has been significant. Among those who were supposed to ‘educate’ the Romanian population, notably because they are themselves ‘educated’ and in a position to influence public opinion (i.e. as public service professionals, public intellectuals or politicians) a significant part were not up to the call. For a long time now, Romanian right-wing politicians and public intellectuals have played the card of the opposition between the ‘educated’ classes (i.e. those who, like themselves, captured the cultural and symbolic capital given by third-level education) and the non-educated ones among Romania’s dwindling manufacturing and agricultural workers.
A fractured society
According to the writer and journalist Vasile Ernu, they portrayed the latter as un-civilised, unclean, lacking knowledge and judgement to make adequate electoral choices, and lacking a strong work ethic which would have allowed them to stop being ‘dependent’ on social transfers. But Covid-19 made visible that the ‘education’ which had become the currency of social distinction after 1990 has not been offering anymore an effective shield against skepticism among professionals and the political class – if it ever did. This is true also among Romania’s ‘diaspora,’ which in the last decade has likewise been praised for its better knowledge by right wing parties and politicians in search of a sympathetic electorate. Startlingly, at the last parliamentary elections in December 2020, Romania’s diaspora voted in a worrying proportion with a far-right nationalist party; in turn, its vaccination rates have sometimes reached less than half of that of the general population in their host countries.
Tellingly, those in the diaspora who refused vaccination are not only among the bulk of those engaged in low-skilled low-waged jobs, but also among the relatively fewer, but better-paid ‘educated’ professionals. The first have encountered numerous barriers to access their host countries’ health services even before the pandemic; lower language skills may have also played an important role in their not benefiting from these countries’ vaccination campaigns. The diaspora’s professionals, however, encountered no such barriers; moreover, even if a minority among Romania’s more than three million out-migrants, their hesitancy is more significant given the symbolic power of their ideas and practices. Like in Romania, educated professionals’ vaccine hesitancy matters more and became striking with its now lethal consequences.
Reviving the vaccination campaign
At the start of September 2021 when the fourth wave of the pandemic was already in sight, Romanian medical authorities announced that their renewed efforts to revive the vaccination campaign focused on two main measures: a vaccination lottery and meal vouchers for those who got the vaccine. Not surprisingly, these measures did not manage to make the vaccine significantly more accessible to the population or to significantly counter vaccine hesitancy in the country: if in May, 34% of people declared they were willing to get the vaccine, by end of September 2021 only 16% were so.
By beginning of October, Romania was registering a 14-day incidence rate of over 1.000 new infection cases per 100.000 population, and a 14-day death rate of over 240 deaths per 1 ml population; in the second part of the month the latter went even over 300. During that month, the Covid-19 death toll went on several occasions over 500 per day. By comparison, Italy’s Covid-19 14-day death rate reached 182 at the height of its debacle at the end of March 2020. By the beginning of October all Intensive Care Units (ICU) in Romania were working over capacity, and by the end of the month doctors working in Covid-19 units reported having to select patients who would avail of ICU treatment, and the first Covid-19 patients were transported for care abroad.
Since Marian’s death, a few more villagers from his commune died of Covid-19. They were old and had very many illnesses to bear. But their time would not have come were it not for the conjunction between Corona infection and lack of vaccination. More than 13.000 Romanians died of Covid-19 since the start of September 2021. This led in September 2021 to an excess mortality of 30% compared to the same month in 2019; excess mortality in October 2021 has seemingly been even higher. By the beginning of September 2021, Romania could have had, like other European countries, most of his population vaccinated against Covid-19. Most of the fourth pandemic wave deaths could have therefore been avoided.
The uneven distribution of avoidable deaths
Among those who died of Covid-19, the vast majority had been afflicted by many other illnesses – so-called co-morbidities – in addition to the virus. Co-morbidities follow, however, social class division: they are higher among less educated, lower paid, rural, and vulnerable populations. If a significant proportion among both the latter and among Romania’s ‘educated’ class embraced vaccine hesitancy, the unnecessary deaths to which it led during the fourth wave are far from being equally distributed.
Indeed, those who bear the brunt of this hecatomb are mostly among Romania’s dispossessed and silent majority rather than among its more protected and vocal ‘educated’ strata. Moreover, 85% of Covid-19 deaths during the fourth wave have been of people above 60 years old. With an aging population afflicted by numerous co-morbidities and poor access to health care, during the Covid-19 pandemic Romania’s villages have been depopulating even faster than these factors and strong outmigration would have warranted.
Marian’s sisters got the jab while he was fighting for his life in the hospital. Quite a few among their neighbors got the vaccine at the local pop-up center organized by their commune’s mayor at the beginning of November 2021. His brothers continue to refuse vaccination, even if, one day after Marian’s death, the Romanian government introduced restrictions for those without a Covid-19 certificate. In the last few weeks, more people have followed Marian’s sisters in getting the vaccine, and willingness to do so raised again to 37% of the population. However, most of the increase in vaccine uptake is in the cities. As most developed cities in Romania are managing to shorten the gap to average European vaccination rates, the gap between them and rural communes is widening ever more.
One of the many ways in which vaccine hesitancy could be countered is to show that, contrary to conspiracy theory claims, vaccination is not a way to pump the profits of big pharmaceutical corporations. To do that, left wing forces in Romania need to join other socially progressive parties and movements in Europe and campaign for Romanians to sign the No Profit on Pandemic European Citizens’ Initiative. While less than a thousand Romanians have signed it, there is still some time (namely, before its closure in August next year) to reach the needed threshold for the country, that is, 23.265.
Note from the editors: This article is a contribution to the Berliner Gazette’s “Black Box East” text series. The German version is available here. You can find more texts, artworks, and video talks on the English-language “Black Box East” website. Have a look here: https://blackboxeast.berlinergazette.de