Determinants of Public Health Decision-Making in Japan: The Case of the Hpv Vaccine

Abstract

Vaccines are one of the greatest triumphs in medicine. They have also, however, been accompanied by an equally long history of vaccine hesitancy. One of the recent instances is the hpv vaccine, probably the most important vaccine against cancer to date. Despite huge successes worldwide, there is a significant antivaccine movement, and this has been particularly virulent in Japan, where the government issued a nationwide suspension of its vaccine recommendation. This thesis explores the political and institutional factors that contributed to this decision, and beyond that, whether this decision to suspend should have been made. To date, no previous study has been conducted on this topic. The widely accepted literature claims that decision-makers abide by rational choice or poliheuristic theories. This thesis argues, however, that the Japanese government officials make immunization-program decisions based on broader institutional features of the state, and not on the value of the vaccine, to the detriment of public health. Government officials face incentives that result in vaccine suspensions when there is ambiguous legal liability, immense political pressure, short executive time horizons, and a risk-averse culture, Focusing primarily on government official–anti-vaccine “victim” relations regarding immunization programs, this thesis develops a model investigating the incentives facing these two key stakeholders. Government officials face the prospect of imprisonment, harassment, and other significant professional and reputation sanctions should they continue an immunization program. On the other hand, anti-vaccine “victims” can pursue political and legal action against government officials to receive compensation. In this context, anti-vaccine “victims” pose a threat to government officials, incentivizing officials to suspend immunizations in order to avoid any individual responsibility. Quantitative analysis using cross-country data of adverse reaction rates finds that Japan indeed did not have an abnormally high number of adverse reactions compared to other countries and was likely acting based on legal threats and political pressure. An implication of this study suggests that policymakers should seek to take into account these determinants in order to increase the independence of public health decision-making. This thesis points out four recommendations for the Japanese government in dealing with immunization programs. First, remove existing threats of legal liability by implementing a no-fault compensation system and amending vaccination laws. Second, create an independent adverse events review committee to facilitate a justifiable and swift investigation progress. Third, establish a public relations office and surveillance system to improve public health communication to diffuse political pressure before it escalates out of control. Lastly, increase the executive time horizons in order to allow government officials to take ownership of the success or failure of immunization programs.