Written by: Peter LaBelle

A glance at world COVID vaccination rates reveals a curious pattern. As one would expect, the percentage of a given country which has been vaccinated largely correlates with its wealth, with the highest percentages of the population vaccinated in Europe, North America, and parts of East Asia; reasonably high levels of vaccination in the middle-income nations; and low levels in Africa, parts of the Middle East and central Asia. A notable exception is visible, however, in Eastern Europe, where low vaccination rates prevail despite relatively higher incomes. Romania, Ukraine, and Bulgaria come in at 38.6%, 27.8%, and 26.4% fully vaccinated respectively, well below the world rate of 42.7%. Citizens of Bulgaria, a member of the European Union, are vaccinated at a similar rate to those of Tajikistan, even though Bulgaria is over 14 times wealthier in terms of GDP per capita. So what explains this discrepancy?

In Romania and Bulgaria, it is not a problem with supply. The European Union has, despite some hiccups in its approval policies (for instance, the European Commission was initially unprepared for negotiating with vaccine manufacturers), negotiated for the delivery of 4.2 billion doses of vaccine from manufacturers and has already distributed over a billion of them to member states. In all, 77.4% of adults in EU countries have been fully vaccinated.

The key issue in eastern Europe appears to be lack of trust in institutions, a trait which has been associated with vaccine skepticism in other regions and has a particularly tenacious grip in the region for historical, cultural, and political reasons. Bulgaria has been mired in political turmoil for the past year, which appears resolved only after a third election in 2021. Political chaos had the direct effect of destabilizing the government to such a degree that the Ministry of Health had only $6,000 budgeted toward promoting its vaccination campaign. The years of corrupt governance which preceded these elections are responsible for a large part of Bulgarians’ distrust of institutions. Evidence is provided by the fact that vaccine hesitancy in Bulgaria predates the current crisis: an EU study in 2018 determined that Bulgarians were least confident in vaccine safety out of all EU member states. When the COVID-19 pandemic arrived, it had little impact on the country at first, which made the government’s quarantine and shutdown requirements seem unnecessary. Then, after restrictions were lifted, a severe wave of the disease in winter 2020 completely swamped the ill-prepared Bulgarian health system, leaving many inclined to mistrust its medical expertise. To make matters worse, this distrust extends to the medical professionals themselves, only 22.5% of whom are vaccinated. Some Bulgarian health officials blame this on historical trends dating back to the Communist era, which cut the Bulgarian medical establishment off from the world and led to a culture of skepticism towards innovation.

Similar conditions are present in Romania, where vaccinations got off to a strong start but have since lagged well behind the EU average. Romania has a history of vaccine hesitancy: in the past it has been the epicenter of serious measles outbreaks due to low levels of childhood vaccination. Like Bulgaria, Romania has long suffered from corrupt governance, which has eroded public trust in institutions and likely contributes to the distrust of vaccines. In 2000, the World bank found that 44% of Romanians believed “all or most” officials to be corrupt, and 42% of households had felt the need to give a bribe during the last year. A large series of protests took place between 2017 and 2019, demanding an end to corruption. Though they resulted in the resignation and prosecution of several government officials, corruption still haunts the Romanian government. This year, a global ranking of corruption placed Romania dead last for corruption in the EU – tied with Hungary and Bulgaria.

Corruption is endemic in eastern Europe more generally; in Ukraine, another vaccine laggard, voters’ frustration with corruption was a significant factor in the election of President Volodymyr Zelensky in 2019. When trust in government is lacking, other institutions pick up the slack: in Romania, 55% of adults say they are “highly religious”; in Montenegro, religious leaders are trusted by 60% of people, and the government by only 41%. Religious leaders in eastern Europe, as elsewhere, have often contributed to vaccine hesitancy: of the three major religious groups in Montenegro, only the leader of the Muslim community encouraged vaccination. Conservative Orthodox church officials from Romania to Georgia have resisted calls to alter church practices in the era of Covid-19, claiming that the holiness of communion wine will stop disease. These feelings have extremely deep roots (the details of the communion ritual were a contributor in the Great Schism of 1054), and are thus extremely difficult to influence even in countries where there is greater public trust. In Italy, for example, churches largely closed during the height of the pandemic, but not without complaints from many church leaders.         The implications of all this are worrying: while improved public outreach may help convince some, a large fraction of eastern Europeans will remain skeptical of any claim coming from mainstream political sources. In the short run, governments must provide additional funding for public health and pro-vaccine outreach. But the longer-term problem is more difficult, and more crucial. As long as citizens perceive their government to be corrupt, opaque, and under the control of a powerful few, corruption will hamper public health efforts, just as it has undermined political security and economic growth. And as the appearance of new variants like Omicron suggests, areas with large unvaccinated populations risk serving as breeding grounds for newer, more threatening Covid variants — a problem with global significance.