Abstract
In the face of declining vaccine uptake, public health advocates and decision makers have emphasised the value of vaccination, expressing it in medical and technical terms and metrics, such as in the number of lives saved. This narrow and monolithic understanding of value conceals how different actors value and assess the importance of vaccination – for example, its scientific, economic, ethical, social or personal value. To capture the scientific and political deadlock we observe in vaccination governance, we understand insufficient vaccine uptake as a paradigmatic example of a ‘wicked problem’ – socially complex and resistant to solutions due to differing stakeholder perspectives on what the problem is. We propose a new methodology for the study of wicked problems, labelled policy valuography, and illustrate its novelty by discussing three vignettes from our ongoing research on vaccination against human papillomavirus (HPV), COVID-19 and mpox. Such a methodology entails studying valuation practices to understand how different actors assign value to vaccination, particularly in moments of problematisation. From our perspective, value is not given, nor can it be reduced to quantifiable terms. Instead, value is the result of coordination between different actors and their respective valuations when, over time and in interaction with one another, they become aligned to a considerable extent. This new methodology will be relevant for the study of other wicked problems, too, including those associated with the global climate crisis. In addition, it can contribute to politically sustainable immunisation strategies both for existing and emerging vaccines.
Introduction
Vaccines are one of the most effective forms of public health intervention. Yet vaccine hesitancy is a persistent concern worldwide (Neumann-Böhme et al, 2020). In seeking to address this policy problem, policy makers and public health advocates emphasise the value of vaccination, and appeal to a seemingly universal sense of what makes vaccines valuable to society at large. What is more, this presumed value is then often expressed in narrow and metrical terms, such as the number of lives saved, the number of vaccines administered, life years gained or percentage of the population vaccinated. For example, the value of pandemic measures, including vaccination, was most often explained in terms of their function for decreasing hospitalisation rates. These unduly narrow tropes mark health policy at the level of states, supranational (European Union [EU]) and global (World Health Organization [WHO]) authorities, as well as other global health actors (Adams, 2016; Reubi, 2018). We argue that this appeal to a supposedly intrinsic and unequivocal value is misled, and that the nature of vaccination governance relies on the complex and contingent coordination of different notions of value that actors hold and practise.
Unpacking this complexity is urgent as we find ourselves in a political and scientific deadlock: policy discourse and social science research rest on a binary distinction between pro- and anti-vaccination sentiments and either reduce vaccine hesitancy to a matter of ignorance or attribute them to medical populism (Lasco and Curato, 2019). Research on pro-vaccine activism is, however, emerging slowly (Gottlieb, 2013; Attwell and Freeman, 2015; Vanderslott, 2019). Analyses of individual decision making regarding vaccination have become more nuanced, too (Zimmermann et al, 2023). Moreover, public health experts are beginning to understand that assessing, let alone calculating, the value of vaccines is a value-laden practice in itself and may escape quantification (Schwartz and Mahmoud, 2016). Instead, as expert communities increasingly recognise, vaccines can be valued in multiple ways, such as in technical, societal, personal and allocative terms (Drummond et al, 2007; Henshall and Schuller, 2013; Schwartz and Mahmoud, 2016; Hutubessy et al, 2021; Calabrò et al, 2022). As practitioners become aware that the value of vaccination may be multiple, it is now of importance for us as social scientists to be able to account for this diversity.
In this article, we devise what we call a multi-sited policy valuography (borrowing from Dussauge et al, 2015) that helps policy scholars account for the diversity of valuation practices across societal actor groups and the coordination practices that serve to bring these into some degree of alignment. Moving beyond the current focus on either public attitudes towards vaccination or the unequivocal focus on the clinical benefits of vaccination, we seek to make observable what makes vaccination valuable, to whom, and based on what value repertoires. We are not concerned with measuring or determining the ‘real’ value of vaccination (compare Datta et al, 2021) – whether in medico-scientific, economic or ethical terms. Instead, we seek, first, to develop a methodology that allows us to open up the very notion of value regarding vaccines and to account for the diversity of value understandings throughout society. Second, we demonstrate the usefulness of this approach with three vignettes that build on past and ongoing research projects.
This article forms part of a larger study conceptually inspired by valuation studies and critical policy studies. Empirically, we draw on extensive research on vaccination governance. Here, we often struggled with capturing vaccination attitudes either in terms of societal values such as solidarity, or individual values such as trust or self-interest (Zimmermann et al, 2023). To extract ourselves from this deadlock, we take a step back from sociological concerns with values (for example, Parsons et al, 1964) as more or less static characteristics. Instead, we consider that value is not given but is the result of coordination (Dewey, 1939; Neyland and Simakova, 2015; Stark, 2017) between actor groups who shape matters of concern (Latour, 2004) and, importantly, relay to one another what is important – particularly in situations of acute uncertainty. Consider, for instance, the rapid development of pandemic vaccines and efforts to design (and fund) safe vaccines that would be made available worldwide.
This approach is particularly useful when it comes to wicked problems (Rittel and Webber, 1973; Conradie, 2020) that are socially complex and resistant to solutions due to differing stakeholder perspectives on what the problem is to begin with. Wicked problems are marked by scientific uncertainty, values are at stake, and competing problem definitions emerge. Vaccination governance presents such an area of problematicity: different groups, such as parents, scientists, medical professionals, members of the industry, and policy makers differ not only in their ontological perspectives on what kind of challenge, if any, declining vaccine uptake presents for vaccination governance. What is more, they differ in their understanding of the value of vaccination to begin with. Accordingly, we contend that the wickedness and ‘problematicity’ (Turnbull and Hoppe, 2019) of vaccination governance results from conflicting valuations, rather than fundamental conflicts of values. This perspective entails moving away from the current behaviouralist paradigm of vaccine-related research. More specifically, this approach stands in stark contrast to dominant approaches that equate differences in the perception of vaccination and its governance with differences in seemingly fixed values that social scientists have focused on (Hitlin and Piliavin, 2004). Finally, this research adds to an emerging body of scholarship that seeks to understand the role of scientific experts and their intricate relationship to political decision makers in times of crisis (Aagaard et al, 2024)
Moving towards a broader governance approach, in this article, we mobilise three vignettes – vaccination against human papillomavirus (HPV), SARS-CoV-2 and mpox (formerly ‘monkeypox’). In these vignettes, we review secondary literature, grey literature (such as policy documents) and scientific literature (such as those reporting on clinical studies of vaccines) to showcase the different ways in which these vaccines become valued (see Table 1 for a summary). These materials were collected and archived between 2012 and 2023 in the context three major research projects. For this article, we screened these manually for relevance – understood here as explicit valuations of the individual vaccines, such as in appeals to the importance of a particular vaccine for a particular target group or their potential for societal impact. Based on this exploratory analysis, we conclude by emphasising the need to investigate empirically how different valuations – be it economic, ethical, social or individual – come to matter in vaccination governance. We first lay out our object of concern – wicked problems in vaccination governance. We then discuss the three vignettes around the introduction of three individual vaccines. In these episodes, or moments of problematisation (Foucault, 1998; Bacchi, 2012) the value of vaccination became open to reinterpretation. The three cases – all of which were introduced as new vaccines and (initially) for particular target groups only – thus lend themselves well for what we label a policy valuography.
Comparing valuations in three vignettes
| Vaccine | Value principle | Prominent actors and spokespersons | Expression of value |
|---|---|---|---|
| HPV | • Cost-effectiveness (long-term) • Efficacy and effectiveness (individual) • Enabling a shift from cure to prevention • Reducing transmission of HPV • Potential to harm trust in screening programmes • Potential to harm public perception of vaccines |
• Gynaecologists • Health economists • Political decision makers • Industry actors • Civil society (for example, US) |
• Number of women’s lives saved • Reduction in mortality rates (cervical cancer) • In expanding vaccination offers to all genders: potential to reduce other HPV-related cancers (in men who have sex with men) • Disability-adjusted life years |
| Mpox | • Containing the epidemic/reducing transmission • Safety of existing vaccines • Destigmatisation in vaccination campaigns/risk of stigmatisation • Equity/access |
• Epidemiologists • Public health experts (WHO) • Activists/civil society |
• Social acceptance measured in uptake in at-risk groups • Safety and effectiveness of existing vaccines • Uptake of ring vaccination • Observed reduction/increase in infection rates and mortality rates |
| COVID-19 | • Safety and efficacy • Containing the pandemic (short-term) • Containing economic cost of illness • Ease of manufacturing and distribution • Potential to achieve herd immunity • Protecting vulnerable groups |
• Economists • Behavioural scientists • Medical professionals • Scientists • General public |
• Social acceptance: measured in number of basic vaccines received (excluding booster shots) • Prevention of infection measured in mathematical models • Reduction of mortality and hospitalisation rates • Reducing burden on intensive care units • Time spent on safety and efficacy studies |
Background
Vaccination as a wicked problem: from values to valuation
The concept of wicked problems emerged in the early 1970s among planners and has become a widely cited concept in political science. Concerned with emerging problems in urban planning and social policy at the time, Rittel and Webber (1973) invoked a distinction between, on the one hand, significant social problems – especially ‘wicked’ problems characterised by differences in values and actor perspectives – and, on the other hand, technical problems (also labelled as ‘tame’ or ‘benign’ problems) that could be addressed by relying on existing forms of knowledge such as engineering. The concept of wicked problems and its underlying distinction has received much critical attention (Peters, 2017) and further development in empirical research (Levin et al, 2012; Dodge and Metze, 2017; Waltner-Toews, 2017).
We are calling them ‘wicked’ not because these properties are themselves ethically deplorable. We use the term ‘wicked’ in a meaning akin to that of ‘malignant’ (in contrast to ‘benign’) or ‘vicious’ (like a circle) or ‘tricky’ (like a leprechaun) or ‘aggressive’ (like a lion, in contrast to the docility of a lamb) (Rittel and Webber, 1973: 160).
In the field of public administration, wicked problems are understood to consist of three constitutional elements: non-resolvability, involvement of multiple actors and the difficulty of problem definition (Danken et al, 2016). These are also characteristic of several problems related to vaccination governance: governance affects and involves a multitude of actors, ranging from scientists, industry actors and decision makers to the parents of infants. What is more, specific problems – for example, low vaccine uptake, supply issues, scientific literacy and trust in vaccination – are defined and perceived of in different ways: for instance, parents do not necessarily understand low vaccine uptake as a problem, but it constitutes an issue for decision makers and industry alike. These actor groups understand this issue of vaccine uptake or, as we propose, value the issue at hand in different ways, be it ethical, social or economic.
While the elements included in definitions of wicked problems help capture the nature of many contemporary policy problems, Termeer et al (2019) point to risks associated with the overuse or misuse of the term wicked policy problem, not least because the apparent distinction between political and scientific problems proposed by Rittel and Webber, as Turnbull and Hoppe (2019) suggest, is somewhat problematic. To mitigate this, Noordegraaf et al (2019) call for an analysis of how actors themselves experience and act upon perceived problems, as these practices co-shape definitions of what the problem is to begin with. Wicked problems can then be considered as always in-the-making and open to contestation in their very meaning. We echo and respond to these calls for further analytical development by moving away from a static notion of values towards an understanding of valuing as practice (Dewey, 1939; Heuts and Mol, 2013).
Notwithstanding this critique and the different connotations of the term, it is evident that the wickedness of contemporary policy problems has challenged state-led governance and has shaped what has been termed network governance (Hajer and Wagenaar, 2003). Network governance denotes the need for coordinated forms of governing that is no longer solely led by states but by complex actor constellations involving a multiplicity of public and private actors. As a result of these networked forms of governance, a multiplicity of (at times irreconcilable) valuation practices shape governance, including economic, ethical, social and individual value repertoires. Valuation practices differ along several dimensions: industry players as well as policy makers rely on more established and institutionalised valuation practices, such as health technology assessment (Beck et al, 2022), estimations of vaccination coverage required to maintain a stable economy (Bloom, 2015) or market forecasting. Such economic valuations have played an important role in the emergence of ‘immunization economics’ (WHO, 2004), not least for stakeholders such as donor agencies and the WHO, which pointedly has set up a unit for ‘Value of Vaccines, Modeling and Economics’. In this context, global health actors such as the WHO will additionally value the success and effectiveness of vaccination in terms of equal access and distribution (Hutubessy et al, 2021).
Scientists and regulators, on the other hand, will draw on technical and scientific repertoires in valuing individual vaccines. Conversely, parents of infants will draw on more intuitive (Ten Kate et al, 2021) and less institutionalised practices that defy traditional measurement in terms of fixed values (Cataldi et al, 2019): they will, for instance, consider the well-being of their child, yet this value can be construed in different ways. For some, avoiding possible side effects arising from childhood vaccines will take priority. The value repertoire they draw on then also differs in its temporal dimension and seems more immediate than those of industry actors and policy makers as the latter focus on making the future of public and individual health. In efforts to make the future calculable, these actor groups design and use devices (for example, to estimate expected return on investment, likely vaccine uptake, disability-adjusted life years gained or the infamous R number that gained unprecedented political currency during the COVID-19 pandemic; compare Miller, 2022). These calculative devices have gained particular prominence in the management of the COVID-19 pandemic (Rhodes and Lancaster, 2022) as ‘a means in the process of attributing value to something’ and acting as ‘the filters of sorting out – and thus defining – what counts as valuable’ (Hauge, 2019: 57).
As we posited, these differences in value repertoires (economic, political, personal, social, ethical and so on) means that stakeholders are not only unable to come to a joint solution but that they do not agree on what the problem is to begin with. This essentially contested nature of the problem (Gallie, 1955) means that wicked problems – such as vaccine hesitancy – escape finite definition but are subject to coordination that renders them temporarily stable on the policy agenda. To account for both multiplicity and temporary alignment of value perspectives, we must therefore open up the very notion of value, to move away from any fixed notion of what makes vaccines valuable and to whom. We next lay out a new approach by drawing on valuation studies, and then explore the methodological advantages of such an approach by introducing three vignettes.
How to study valuations and governance: a focus on practices
Values have been an important part of the social scientific toolbox, but the use of the term varies considerably. It is most often associated with a set of beliefs and norms that shape human action (Botterill and Fenna, 2019). The concept of values has informed understandings of politics, too, such as in Lasswell’s contention that the ‘policy-science approach not only puts the emphasis upon basic problems and complex models, but also calls for a very considerable clarification of the value goals involved in policy’ (Lasswell, 2003 [1951]: 95). With the arrival of the argumentative turn (Fischer and Forester, 1993) and the interpretive turn (Yanow, 2000), values also became a relevant epistemological category: value(s) were no longer distinct from policy, nor from the very activity of policy analysis itself: policy analysis was to become accepted as a value-driven activity in and of itself. Yet overall, political scientists have mainly captured values as norms that actors hold, as opposed to something actors do, as the verb ‘valuing’ denotes.
Values have recently re-emerged as an object of analysis in interpretive research – a shift that may reflect the realisation that terms such as discourse, narrative or practice are no longer able to capture the wicked nature of many political controversies. In their call for an interrogation of values in policy analysis, Botterill and Fenna (2019: 2) put the question of values centre stage: ‘Decision makers are confronted with conflicting value positions, and enough of each value needs to be visible in the outcome to generate acceptance of the decision’. While important, this insight largely takes value as something given, rather than exploring how one and the same value, such as safety, may be assessed differently in a specific situation. In other words, the meaning of value hinges on the site and practices in which it is articulated and the repertoires informing the ascription of value. Recognising this multiplicity (Mol, 2002) is key to moving away from a monolithic framing of the value of vaccination.
Inspired by and critically engaging with the work of Boltanski and Thévenot (2006), valuation scholars advocate an approach that places emphasis on value as a verb (Dewey, 1939) investigating how actors assign worth to social and physical phenomena (Fourcade, 2011; Heuts and Mol, 2013; Sharon, 2017; Lee and Helgesson, 2019). Dussauge et al (2015) term this approach ‘valuography’. Valuation studies have investigated both valuation practices (‘giving worth or value’) and evaluative practices (‘assessing how an entity attains a certain type of worth’) even if these remain conflated both in theory and actual practice (Lamont, 2012). In this perspective, actors draw on different ‘registers of valuing’ (Heuts and Mol, 2013) or ‘evaluative principles’ (Stark, 2009) – and they do so in spatially localised and temporarily marked moments of problematisation (Stark, 2017). Valuations then take place in attentive critical moments, they do not have a fixed outcome, and they can vary substantially not only across organisational contexts, but country-specific cultural repertoires that shape legal practices (Fourcade, 2011).
As already mentioned, in the present case, parents may value vaccination in terms of protecting their child, but also as taking up time from their workday. Industry practices may establish the estimated worth of vaccination for a particular market, while policy makers evaluate its effectiveness in reducing disease burden and increasing societal productivity. For the pharmaceutical industry, these tools have sometimes been called pharmacoeconomics (Gregson et al, 2005). Scientific researchers will probably value vaccines in terms of efficacy in the human body, but they may also be driven by value principles such as ‘doing good’ (Aviles, 2018; Darling et al, 2022). The shape these practices take reflects different principles of valuation (what is important to whom on what basis, what rationale, what ordering of priorities). These practices form part of a ‘regime of valuation’ (Fochler et al, 2016) specific to health governance (Datta Burton et al, 2021) and produces a networked governance regime that brings together disparate actors. At the same time, such a perspective allows for accounting for political valuation practices, too: for industry actors, valuing vaccines in terms of likely profit is constitutive of their very raison d’être, but keeping their calculative techniques somewhat opaque is strategic, too. Similarly, populist politicians may devalue the science behind vaccines and thus leverage the uncertainty of the value of vaccines for their own political gain.
The central argument is then that the meaning of value is not to be found in the object that is being referred to, nor in the actors articulating it, but that it emerges from the practices in which this object is being referred to or valued. As mentioned earlier, this focus on practices speaks to calls by scholars of wicked policy problems to include the perspectives and experiences of actors in discussions of wickedness and ‘problematicity’ (Noordegraaf et al, 2019; Turnbull and Hoppe, 2019). This means that rather than insisting on the intrinsic value of vaccination as a monolithic construct resting on metrics, we must explore what makes it valuable and desirable (or not) to different social actors, and what specific mode of valuation we find in relevant sites. This helps expand the somewhat conventional way of thinking about vaccination governance challenges: these are not conflicts between stable preferences (values), but disagreements about what the issue is or what Latour labels ‘matters of concern’ (Latour, 2004), and about the appropriate way of assessing that issue. These are core questions of governance, even more so in wicked policy problems (Rittel and Webber, 1973).
how the setting is set up as an assemblage whether this be in the stagings, equipment, and protocols of public situations such as the courtroom, the concert hall, or the wine tasting or in the specialised tools, devices and materials of the less public assemblages such as the laboratory, the architectural studio, or the perfume counter. (Stark, 2017: 390)
Moreover, studying valuation entails examining ‘how it takes place in discrete moments of time when evaluative attention is particularly acute’ (Stark, 2017: 390). Such moments of problematisation (Castel, 1994; Foucault, 1998), in the present case, may occur with the development of new vaccines that challenge established public understandings of what vaccines are meant to do: for instance, the development of the vaccine against HPV invoked a link between sexual activity, infection and cancer. Another example would be the recognition of the COVID-19 pandemic and the necessity to develop vaccination programmes with a global outreach to ensure not only vaccine equity, but also the full impact of the vaccine in times of an economic and political crisis.
We next present a preview of what such an analysis could look like: we discuss three vignettes based on secondary, scientific and grey literature. Rather than presenting original empirical research, these vignettes are meant to showcase the novelty of a policy valuographic approach. The first two vaccines – those against HPV and COVID-19 formed part of earlier research projects whereas the vaccine against mpox forms part of an ongoing project examining stakeholder views and experiences. Ethical approval was obtained from the ethics committee at the University of Vienna (Ref. no. 00936). For the purpose of this article, we updated and reconsidered our reviews of the state of the art as well as policy documents with respect to more or less explicit valuations of the individual vaccines, such as appeals to their particular importance for target groups or the weighing of their costs against benefits. The vignettes draw on in-depth empirical knowledge of these three episodes which we report on more systematically elsewhere (compare Paul, 2016; Paul et al, 2018, 2022).
Vignettes: valuing vaccination in moments of problematisation
The vaccine against human papillomavirus
Vaccination against the sexually transmitted HPV, a necessary agent for the development of cervical cancer, has triggered much debate. In the late 1990s, medical research concluded that infection with specific strains of HPV could cause cervical cancer. In 2006 and 2007, respectively, two vaccines (Gardasil and Cervarix) were approved by the United States Food and Drug Administration and the European Medicines Agency. These were designed to immunise girls and women against several strains of HPV, targeting specifically those that cause cervical cancer and, in the case of Gardasil, those that cause genital warts.
Medical scientists announced the vaccine as the ‘first vaccine against cancer’ (Gericke, 2008), thus problematising established cervical cancer screening programmes and opening up a new discourse for valuing vaccination against other, established public health mechanisms. Critical observers commented on the vaccine as an uncertain and costly tool that might either sexualise children at an early age or medicalise women unnecessarily who might benefit more from improved Pap smear–based screening programmes. Governing HPV vaccination was thus a challenge of balancing scientific value repertoires against economic ones in cost–effectiveness analysis, typically framed in metrical terms such as disability-adjusted life years and its potential to lower cancer mortality rates among women. But these value principles were in tension with or perhaps incommensurable with ethical and political value repertoires that entered the debate and are less prone to quantification: immunising young children and adults against the sexually transmitted, carcinogenic virus became controversial across countries (Wailoo et al, 2010; Charles, 2022) and representative of the ‘pharmaceuticalization of sexual risk’, much like the associations of gay sex with HIV/AIDS in the 1980s (Mamo and Epstein, 2014). The fact that HPV could cause other cancers, such as anal cancer and cancers of the neck and throat in men, was sidelined. The possibility to prevent cancer for all genders was thus not a value against which the vaccine was assessed either scientifically or politically (if we can consider these as separate valuation practices at all).
For the medical community, the vaccine therefore presented a double-edged sword: the HPV vaccine seemed appealing to gynaecologists and decision makers invested in reducing, if not preventing, cervical cancer. Yet it also brought about a potential to problematise established Pap-based screening programmes, as their design – and hence the financial interests for healthcare providers – was called into question. Decision makers faced the political risk of reducing the effectiveness and trust in what they considered to be a historical opportunity to improve women’s health. This means that the vaccine was also valued in terms of the risk it presented to established public health policy and immunisation infrastructures in place at the time. Notably this value was more difficult to quantify as it is not only contingent on national policy design but also on deep-rooted notions of what it means to intervene in women’s health.
Despite the global nature of pharmaceutical investments, economic valuations of the HPV vaccine differed across countries. Health technology assessments varied in terms of their valuations, even if economic value registers – referring to cost-effectiveness – proved dominant (Maldonado Castañeda, 2018). As Maldonado Castañeda (2017) points out along with many valuation scholars (Kjellberg and Mallard, 2013; Geiger et al, 2015), pricing plays an important part in invoking the presumed value of a particular vaccine, such as that against HPV, which was one of the most expensive vaccines on the market when it was introduced (Kim, 2011). Notably, the price of the vaccine, which is typically negotiated behind closed doors, was a key element of the public debate on HPV vaccination, not least because the vaccine offer was limited to a particular age group only and offered out-of-pocket to other, older groups (Paul, 2016).
Overall, the HPV vaccination debate and our observations of decision making (including dis/investments in national immunisation programmes) points to the relevance of three interrelated value repertoires that reach beyond the technical value repertoire of safety and efficacy: first, decision makers need to minimise the political risks associated with vaccines. In the case of HPV, this included conflicts with healthcare providers who sought to hold on to the Pap smear as the ‘right tool for the job’ of safeguarding women’s health (Casper and Clarke, 1998) but also the general public and their perception of vaccination governance. As evidenced in sociological scholarship, resistance against HPV vaccination cannot be reduced to hesitancy as such but must be seen in context of its gendered character (Casper and Carpenter, 2008) and parents’ desire to protect their daughters against an industry they distrusted, certainly in postcolonial contexts (Charles, 2022). Second, decision makers considered the economic cost and value of HPV vaccination for all genders, while also valuing the social and symbolic value of ‘saving women’s lives’ against the limited individual effectiveness. As we shall see later, these value dilemmas have shaped other vaccine governance instances, too, and are best understood as conflicting valuations, rather than values as such. The consensus reached here – that HPV vaccines are valuable as public health tools and should be offered to certain segments of the population – is then an effect of valuations and alignment, but at best only temporary and subject to contestation. It contains multiplicity and what Mol (2002) calls ‘coherence-in-tension’: the value of vaccination is not one, it is not subject to ‘discovery’ – but it is invoked and temporarily stabilised in different sets of valuation practices.
Overall, this episode – and the renewed problematisation of screening programmes – shows how different concerns can become linked in valuations of vaccines. Moments of problematisations can, moreover, produce alliances between seemingly divergent sets of actors, such as industry actors and civil society pleading for the HPV vaccine for all genders – a plea that has led to enhanced access to HPV vaccination.
The vaccines against SARS-CoV-2
What makes for a good vaccine against SARS-CoV-2? What value do current vaccines hold and for whom? These questions have marked the COVID-19 pandemic in substantial ways. The notion that ‘the best vaccine is the one that you can get’ became a common wisdom among those eager to be vaccinated once vaccines were being rolled out. Yet what made for a good vaccine differed across contexts, actor groups and socio-demographic subgroups (Tafuri et al, 2022). For many, a good vaccine would have to be ‘tested thoroughly’, with time being perceived of as constitutive of evidence of vaccine efficacy and safety (Harrison et al, 2022). The seemingly rapid development and approval timeline of COVID-19 vaccines has often been set in relation to imagined ‘typical’ timelines and thus seemed unacceptably fast to many (Paul et al, 2022). Beyond time, vaccine development in the public interest and the societal value of COVID-19 vaccines and equal access to them is often set against the economic value of vaccines for the pharmaceutical industry (Towse et al, 2021). Distrust in institutions, including decision makers and vaccine manufacturers are central in parental rejection of vaccination for their children (Attwell and Smith, 2017). These reservations have also shaped acceptance of the COVID-19 vaccine, with value principles such as protecting one’s child being expressed in different ways: for some, this entails vaccinating against a disease, for others, this value is expressed by protecting one’s child against possible side effects.
Good vaccines, in a widely shared public perception, are voluntary, rather than delivered outside of a vaccine mandate (Attwell and Navin, 2022). This indicates that valuations of vaccines are at once valuations of their governance. Likewise, frequent appeals to the need for more data regarding safety and effectiveness points to this effect. Once roll-out campaigns pointed to rare adverse effects of some vaccines (for example, myocarditis in toddlers and men; rare occurrence of blood-clotting conditions in younger women), it also became clear that while the safety of vaccines had been prioritised as a value in vaccine development (compare Haddad, 2019: 65–8 for a more general trend), more specific value principles, such as the need to differentiate degrees of safety and suitability for different genders, had been remarkably absent in vaccine development (Harman et al, 2021). Set against the background of our other two vignettes, HPV and mpox vaccination, this neglect speaks to a wider trend of excluding women from medical research (Merone et al, 2022).
For decision makers, beyond safety and efficacy, ease of manufacturing and convenience emerged as important value principles. For instance, cold chain requirements for mRNA vaccines were widely discussed as inconvenient for rural areas and small-scale vaccination centres. The value of vaccines is thus also inseparable from their uses, including administration, delivery and the trust invested in it. While convenience formed an important value principle, this was notably limited to the Global North and not discussed in conjunction with vaccine equity in low- and middle-income countries. Moreover, while equity became a matter of concern early on in the pandemic, it notably played little role at the national level, where vaccine wastage remains poorly documented, and in the way of more equal distribution (Lazarus et al, 2022). This once again points to a central effect in how vaccination is valued: what constitutes a good vaccine is tightly linked with the ways in which it is delivered locally and regionally (for example, in EU countries, which had jointly procured COVID-19 vaccines), and the value aspect of global distribution receives little consideration. Next to scientific value principles of safety and effectiveness, the political value of vaccination is thus a dominant principle around vaccination governance in and beyond the COVID-19 pandemic. This value is predominantly expressed in clinical terms and metrics such as coverage rates and reduced hospitalisation rates, thus sidelining expressions of emotional value and feelings. Overall, the moment of problematisation brought about by the COVID-19 pandemic shows that valuations of vaccines are inextricably linked to valuations of their governance.
(Post-)endemic vaccination strategies: the case of mpox
Mpox is a known pathogen and was described as early as in the 1970s in Central and West Africa (Gonsalves et al, 2022). Mpox attracted global attention when a new outbreak was declared a Public Health Emergency of International Concern by the WHO in July 2022 (Nuzzo et al, 2022), though this was reversed in May 2023 with unclear implications for future pandemic preparedness (Wenham, 2023). Despite the endemic nature of mpox in Africa in the past decades, neither public nor industry actors had invested in clinical trials on treatments and vaccines up until the 2022 global outbreak and decision makers were now faced with shortages in vaccine supply and testing kits. In contrast to the already mentioned vaccines targeting HPV, mpox had not received much attention from decision makers, industry and activists alike: the pathogen seemed confined to Africa.
The 2022 mpox pandemic affecting other continents such as North America and Europe, however, spurred new research and development of tests and improved smallpox vaccines that could cross-protect against mpox with fewer side effects, particularly for communities affected by co-morbidity with HIV (Chakraborty et al, 2022). Yet their clinical and scientific value, as commentators point out (Harris, 2022), hinges upon efforts towards equitable distribution of knowledge and technologies. This line of argumentation shows that scientific valuations are now more tightly interlinked with ethical modes of valuation – probably as a result of the ongoing pandemic and the evident failure to introduce testing and vaccines in an equitable fashion (Ennab et al, 2022; Lazarus et al, 2022). This tension was exacerbated by the unequal and stigmatising ways in which data on infection rates were reported, with disproportionate attention paid to sub-Saharan Africa. Reflecting the value principles of fairness, destigmatisation and a decidedly global approach, the WHO announced in June 2022 that it would no longer report mpox cases and mortalities separately for endemic and non-endemic countries (Kozlov, 2022).
Moreover, in the 2022 outbreak, men who have sex with men (MSM) seemed to be particularly affected in the Global North. Public health actors have drawn on different value repertoires in their decision making on the vaccine, with the epidemiological value principle of containment through ring vaccination being most prominently pushed for by the WHO. This means that the vaccine is ideally given within four days of an exposure and to close contacts of an infected person. At the same time, this principle does not always smoothly align with the value principle of destigmatisation (Banjar and Alaqeel, 2023), as the former entailed identifying sexual contacts and identities. These conflicting valuations – clinical and social impact weighed against the risk of stigmatisation are somewhat reminiscent of those surrounding the HPV vaccine discussed earlier. In the case of HPV vaccination, the seemingly technical value principle of prevention stood in similar tension to the ethical mode of valuing the HPV vaccine in its ability to treat all genders equally and to avoid what commentators have referred to as the ‘pharmaceuticalization of sexual risk’ (Mamo and Epstein, 2014). Gonsalves et al (2022), moreover, identify important parallels between the perception of mpox and that of HIV in the 1980s: at that time Haitians were blamed for allegedly bringing the virus into the US, and MSM and heroin users were the focus of stigma and discrimination.
Yet there are several important differences in the value repertoires that shaped HPV and mpox vaccination, respectively. A first difference concerns the value of embracing medico-scientific innovation: mpox vaccination strategies relied on more established knowledge regarding the vaccine, even if this knowledge was limited to a small community of researchers concerned with smallpox. This meant that scientific research appeared less innovative than that regarding HPV but also, as a result, less controversial. While the introduction of HPV vaccinations featured frequent appeals to its potential to revolutionise women’s cancer prevention, such references to innovation as a value principle were less pronounced with the mpox strategy using pre-existing vaccines against smallpox. Second, and by the same token, the mpox vaccination strategy was less prone to suspicion regarding the role of the industry (see Charles, 2022 on HPV vaccination in Barbados) even if concerns over limited efficacy and the need to mitigate side effects featured prominently in scientific commentaries (Kupferschmidt, 2022).
A third difference concerns the role of stigma and sexuality: the HPV prevention campaigns of the early 2000s focused heavily on (heteronormative) sexuality, thus foreclosing effective access to vaccination for MSM (Mamo and Epstein, 2014). Conversely, mpox vaccination strategies feature explicit efforts to reduce stigma for MSM – while also trying to achieve effective access for at-risk groups. For instance, our ongoing research indicates that, when designing the mpox vaccination campaign, decision makers weighed the value of protecting privacy against that of optimising access in a large-scale vaccination facility that required identification and registration for the sake of data collection (the latter having become a value in and of itself with the COVID-19 pandemic, it appears). In addition, they valued the mpox vaccine in terms of its logistics: compared to HPV and COVID-19 respectively, it was not only cost-efficient but also reasonably easy to store and administer. This shows that the ways in which we value clinical aspects of vaccination are tightly interlinked with how we conceptualise their social and political value and their ethical dimension with respect to, for instance, risks of stigmatisation. Table 1 provides a summary of how the three vaccines under consideration here have been valued, by whom and in what ways.
What does it mean to conduct policy valuographies?
We contend that the wickedness and ‘problematicity’ (Turnbull and Hoppe, 2019) of vaccination governance issues result from conflicting valuations, rather than fundamental conflicts of values. While we find that, with many vaccines, there is apparent consensus on their value for society at large, conflicting valuations are never fully resolved and there remains what Mol (2002) refers to as coherence-in-tension. The diversity of terms in which vaccines become valued reflects a need to accommodate valuation practices in policy analysis: different actors value vaccines in different ways, be it scientific, ethical or economic terms. The relative dominance of one or several competing value principles at any point in time is an effect of the relative dominance of the pertinent spokespersons, as our vignettes sketched out. Overall, this means that vaccination governance should not be reduced to conflicting values, but different valuations, while leaving room for accounting for power asymmetries that are consequential in making some valuations more influential than others. Likewise, the political, symbolic or financial gains that actors stand to gain from these valuations should be carefully scrutinised.
A policy valuography should explore these different perspectives and the relative dominance of some spokespersons over others with ethnographic sensibility (Prainsack and Wahlberg, 2013; Simmons and Smith, 2017): qualitative methodologies may be most suitable for exploring, for instance, the vaccine-related valuation practices of parents of infants. Such studies could focus on how and why they prioritise some vaccines over others, on what is of value to them (for example, reducing side effects), and how and based on what values they assess different sources (information provided by credentialled experts or lay expertise shared by peers in social media, for instance). Systematic literature reviews or policy document analysis (such as annual reports of national immunisation programmes) will be more apt for examining other aspects. For instance, a historical policy valuography could address the emergence and role of immunisation economics, its calculative techniques (such as cost–benefit analysis), and how these are used in political decision making.
For valuations in the pharmaceutical industry, archival sources (such as company profiles filed with the Securities and Exchange Commission in the United States) may be most easily accessible and can reveal in what ways industry actors consider their business risky or valuable, and for whom. Studying value repertoires in vaccine research and development (compare Aviles, 2018) might entail biographical interviews with basic scientists regarding their choices and priorities (for example, valuing publications over patents) and a triangulation of this data with an examination of the political economic context in which these value repertoires become established, such as increasingly competitive innovation ecosystems and the relative dominance of the pharmaceutical industry, given their near-monopoly in funding clinical trials for vaccines. Finally, an analysis of public debate – broadly understood to include journalists, bloggers and social media users – may require quantitative content analysis (compare Paul et al, 2024). Combining these methods is perhaps unorthodox in policy analysis, but their premise is not: the aim to make visible the diversity of practices of valuation and thereby exposing their contingency.
Conclusion
This article forms part of a larger project in which we aim to understand how different groups of actors assign value to vaccination and how, in turn, these valuations both reflect and produce particular forms of governance. This article proposes setting up a suitable methodology to address this question and conceptualises vaccine uptake as a wicked problem. We want to move away from technical and expert notions of value as they tend to occur in discussion of healthcare and biomedicine. In our perspective, value is not given, nor can it be reduced to quantifiable terms. Bringing together policy studies and science and technology studies (STS), we make three core points. First, we conceptualise value as the result of coordination between different actors and their respective valuations when, over time and interaction with one another in vaccination governance, these come to align to a considerable extent. When alignment of value principles and actors happens, the wickedness of vaccination becomes less visible. Second, in moments of problematisation, these become receptive to contestation and renegotiation. This contingency becomes visible, for example, in discussions of the scientific rigour, economic value, or societal benefit of vaccines and how we can best assess these for the sake of policy making. We illustrate these points by drawing on past and ongoing research and prevent three vignettes to this effect: the vaccine against HPV that targets a sexually transmitted virus, vaccination against COVID-19 and the vaccine against mpox.
Our third, and overall methodological argument is that, rather than insisting on the intrinsic value of vaccination as a monolithic construct captured in metrics, we must explore what makes vaccination and individual vaccines valuable and desirable (or not) to different social actors, and what specific mode of valuation we find in relevant sites. For STS scholars, the interlinkages between how we value scientific knowledge on the one hand and how we perceive of the individual, social and collective value of technologies – vaccines in the present case – is, of course, not surprising. Moreover, the COVID-19 pandemic has made clear that effective and ‘good’ vaccination governance cannot just be captured in terms of metrics – vaccination rates, number of lives saved and so on. Instead, vaccines are only as good as the public perceives their governance to be, that is, the regulation of collective and actor specific interests, rather than just safety, efficacy and effectiveness.
A new approach is needed to address the scientific and political impasse we currently face in vaccination governance. This requires us, first, to investigate how different groups of actors ascribe value (economic, social, political, scientific and so on) to vaccination and its governance in contemporary democracies. Second, and more specifically, such an approach must consider the different sites on which valuation practices can be observed: policy programmes, primary care, industry, scientific research, and platforms for public debate such as social media or newspapers. In each of these, actors will draw on different repertoires of valuation and different (e)valuative principles will become dominant while other value principles (such as equitable access in the case of the COVID-19 vaccine) become sidelined. To sum up, the meaning of value hinges on the site and practices in which it is articulated and the repertoires informing the ascription of value.
Third, there is a temporal and sequential element in our multi-sited policy valuography. This means that we need to investigate empirically how different valuations – be they economic, ethical or individual – come to matter in vaccination governance and practice throughout the life cycles of vaccines, ranging from research and development to assessments of their economic value for society at large (Hutubessy et al, 2021; IFPMA, 2024).
This article provides several avenues for future research. Research at the intersection of critical policy studies and STS may investigate how valuations of vaccination – or other objects of governance in the context of wicked policy problems – reflect, produce or contest forms of governance. Beyond specific technologies, societal infrastructures could be subjected to such an analysis: for example, how contemporary societies deal with waste and what constitute ‘good enough’ infrastructures for doing so could benefit from such an analysis. Finally, wicked problems that require broad coalitions of actors – such as antibiotic resistance (Zaman et al, 2024) – could be subjected to the kind of analysis we propose here to unpack different problem definitions and the current deadlock faced by global health institutions.
In proposing what we have called a multi-sited policy valuography, we hope to promote an understanding of the role of valuations in policy and governance more generally. This necessitates a symmetrical approach, one that considers the multiplicity of actors that engage in the discursive negotiation around wicked problems. Concretely, social research must look at devaluation as much as we look at valuation: in the case of vaccination, this would entail an examination of both sceptical and positive stances towards vaccines. For after all – and here lies both the value of policy valuographies and their challenge to more established methods to understand wicked problems – it is through these valuation practices that actors are connected in jointly governing the range of wicked problems contemporary societies are facing.
Funding
This research was funded in whole or in part by the Austrian Science Fund (FWF) [Grant doi: 10.55776/Y1433].
Acknowledgements
I would like to thank Dmitrii Zhikharevich for his invaluable feedback on earlier versions of this article. I am also grateful to the whole VALUE VACC team, particularly Anna Pichelstorfer for her contributions in the early stages of this research project.
Research ethics statement
Ethical approval was gained from the ethics committee at the University of Vienna (Ref. no. 00936).
Conflict of interest
The author declares that there is no conflict of interest.
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