While Switzerland struggles to vaccinate, Portugal is already finished

No other country is more vaccinated than Portugal, but the reasons why are complex. AFP

Nowhere are more people vaccinated against Covid-19 than in Portugal, where 98% of over 25-year-olds have had both doses. Switzerland, with an overall rate of 72%, is well behind the field in Europe. What are the Portuguese doing differently?

The Swiss government launched a vaccination blitz this week, hoping to put new life into the Covid-19 vaccination campaign. In Portugal, meanwhile, the task force in charge of vaccinations was already in the process of winding down by the end of September. Their mission was complete: only 2% of Portuguese men and women over the age of 25 have not been fully jabbed, and even among 12 to 24-year-olds the rate is over 85%. Switzerland has an overall rate of just 72% of over-25-year-olds (figures from early November) and is a European laggard. Why?

Social and health psychologist Urte Scholz says the low rate in Switzerland cannot be explained simply in terms of those who have openly declared their opposition to the vaccinations. There are more such people in Switzerland than in Portugal, where there are hardly any anti-vaxxers – but, Scholz says, they do not constitute the majority of those still unvaccinated.

“We should certainly not dismiss the unvaccinated simply as conspiracy theorists,” says the University of Zurich professor. Rather, the majority of them are better described as reluctant: once the overall rate reached 50% and anyone who had wanted to be vaccinated from the start had done so, the curve flattened out rapidly. Scholz concludes that “the doubts and concerns of many people were not taken into account early enough.”

Trust in the system, and painful memories

Before a vaccine against coronavirus had even become available, reservations were strong, including in Portugal, where they were in fact even stronger than in other countries. This was a finding of health economist Pedro Pita Barros, who has been regularly monitoring the concerns, attitudes and vaccine willingness of Portuguese people since April 2020 as part of the European Covid Survey (ECOS). The number of hesitant people in all countries studied before vaccines were available was higher than afterwards. “But nowhere did the curve drop so sharply as in Portugal,” says Pita Barros, a professor at the Nova School of Business & Economics in Lisbon.

Percentage of fully vaccinated people in the total population, as of mid-October 2021. swissinfo.ch

“The Portuguese have a high degree of confidence in their national health system,” says anthropologist Cristiana Bastos, a health and epidemics researcher at the Institute for Social Sciences at the University of Lisbon. “This also extends to the national vaccination commission and what it recommends.” As well as the standing national vaccination commission, Portugal’s directorate-general for health created an extra body exclusively concerned with Covid-19 a year ago. When the available vaccines were given the green light, the Portuguese population had hardly any reason left not to get vaccinated as soon as possible.

The public system has its weak points too of course, Bastos admits, such as waiting times for scheduled operations. “Yet primary health care works very well.”

That has to do with how health care is organised in Portugal: each person is assigned to one of a local health centres (Centro de Saúde), and there to a particular physician and nurse. This is the first response level whenever flu strikes, menstruation periods are missed – or vaccinations are needed. “This kind of personalised care over a period of many years creates trust and can deal with feelings of uncertainty at an early stage,” says Válter Fonseca, a physician who chairs the national Covid-19 vaccination commission.

The favourable attitude to vaccinations in Portugal may also have to do with the fact that memories of the ravages of polio and measles are more vivid in the public mind than in Switzerland. While the number of polio cases in the Alpine nation dropped markedly in the mid-1950s, the disease was a big concern for Portuguese into the 1970s, Pita Barros points out.

The success of the Portuguese vaccination campaign is also due, however, to efficient planning and logistics. After the task force got off to a rather rocky start under the leadership of health expert Francisco Ramos, Vice-Admiral Henrique Gouveia e Melo took over in February. “His clear and direct approach put the campaign quickly on the right road,” Pita Barros says of the former submarine commander. The task force appealed to the population to get vaccinated, one age group after another, and people who didn’t register for an appointment got an automatic SMS reminder later on with a proposed date.

Swiss bureaucracy

“Though federalism brings many benefits in normal times, in a crisis it just works too slowly,” says Suzanne Suggs about the situation in Switzerland. The expert on communication and public health is a member of the Federal Covid-19 taskforce, the scientfic body advising the government on the pandemic. “You need to be able to make decisions quickly and from the centre,” she says. Yet in the past months, the federal government was always careful to avoid stepping on the toes of the cantons.

For Suggs, however, political structures are not the only explanation of Switzerland’s faltering vaccination rate. “People here too often have to take the initiative themselves to find information on Covid-19 vaccination, instead of such information being sent directly to them,” says Suggs, a professor at the University of Lugano. “It’s extraordinary how many Swiss, even younger Swiss, are inadequately informed.”

Easy access is the key factor in such a situation: this means not only uncomplicated registration procedures, accessible vaccination locations and convenient blocks of time for appointments – but also, that the doubts and questions of the population are heard at an early stage, and that the population is actively provided with answers. “Fake news reaches people more easily than solid information about vaccination,” agrees health psychologist Scholz.

“In Switzerland people seem to have inhibitions about being perceived as someone who explicitly campaigns for Covid-19 vaccination,” she says.

That is true to a certain extent of the federal government’s messaging itself, says Suggs. The fact that getting vaccinated was purely voluntary couldn’t be emphasised too much in the past months, but “the fact that vaccination is a matter of social responsibility and solidarity has not been emphasised enough at all.” Many official messages about vaccination have not amounted to much more than an announcement that the vaccine was available.

Social and health psychologist Scholz also sees a lack of clear models and communicators in the vaccination campaign in this country. It could have been footballers on the national team (an attempt that failed badly), but also the president of the local cultural society, the village clergyman or the trainer of the local sports team. For those who don’t necessarily inform themselves about the progress of the pandemic via newspapers or TV news, such advocates could have played an important role, Scholz believes.

“Elvis once restored the reputation of polio vaccination single-handedly when he appeared before the cameras to be vaccinated himself,” she says.

Catching up with the hesitators

The government’s vaccination blitz should certainly get things moving again, the two researchers believe. Mobile vaccination locations and in-person or telephone counselling are the right way to remove obstacles for those undecided.

The recently-approved vaccine from Johnson&Johnson could also help. “The lack of trust in the previous mRNA vaccines is for many people the main reason for hesitancy,” says Scholz. The new vaccine is not just based on another approach, but it only has to be taken once. Last but not least, the obligation to show a certificate, and charging a fee for corona tests, should have some effect. “To be sure, positive incentives would be socially more acceptable”, says Scholz. “But the latest measures will nudge more people towards vaccination.”

Translated from German by Terence Macnamee