Consequences of the Anti-vaccination Movement in Croatia Before and During the COVID-19 Pandemic

Nenad Jarić Dauenhauer

In the COVID-19 pandemic, with 15,675 deaths by 9 April 2022, Croatia ranked eighth in the world in terms of deaths per million inhabitants.

However, some research has shown that the actual death toll from a pandemic is usually significantly higher than officially reported. They are reflected in excess mortality, which, among other things, includes people, who have died because they have not been able to receive adequate health care due to overloaded health systems or because of the fear of visiting hospitals due to the possibility of infection. According to the data provided by the health services in Croatia, a surplus of 21,250 deaths was recorded from 20 April 2020 to 27 February 2022. According to this criterion, Croatia ranked tenth in the world.[1]

The question is how this came about since at the very beginning of the pandemic in the first wave, Croatia was among the best countries in the world with the lowest number of deaths per million inhabitants thanks to very strict control measures.

There are many answers, the most important of which are certain misjudged moves by the authorities, citizens' distrust of the authorities, relativization of the severity of COVID-19 even among a number of scientists, who are perceived as medical authorities, and the anti-vaccination propaganda.

Anti-vaccination Movement Downplaying the Importance of Vaccination

Vaccination resistance has existed as long as vaccination itself. Despite the success of major vaccination campaigns around the world that suppressed or even eradicated many infectious diseases such as polio, measles, and smallpox, new generations began to forget and relativize their dangers. A narrative began to emerge according to which infectious diseases had disappeared mainly due to a higher standard of living and better nutrition and hygiene, rather than vaccination. The promoters of this idea persistently refuse to accept the opinion of medical mainstream experts that vaccination is one of the greatest successes of modern medicine, thanks to which life expectancy has almost doubled from 40 years in the early twentieth century to about 80 today. Instead, they persistently relativize the severity of infectious diseases and the importance of vaccines, and on the other hand, oversize the side effects of vaccines.

A strong push for the modern anti-vaccination movement came from Andrew Jeremy Wakefield, a discredited British doctor, who was expelled from the medical register for his involvement in fraud with a study published in The Lancet in 1998, falsely claiming there was a link between autism and the MMR vaccine for measles, mumps, and rubella. Investigations revealed that the study was faked and that Wakefield was linked to lawyers, who intended to use his research for lawsuits seeking huge settlements for children with autism.[2]

Despite being discredited, or perhaps precisely because of it, Wakefield became something of a hero of the anti-vaccination movement in America. Moreover, he accumulated enormous wealth through the anti-vaccination propaganda.

Anti-vaccinationism in Croatia Before the Pandemic

Anti-vaccinationism has a relatively long history in Croatia. The country had inherited the system of compulsory vaccination of children against numerous infectious diseases from socialist times. With the disintegration of Yugoslavia, opposition to mandatory vaccination began, often citing examples of Western countries that did not have similar programs. Croatian vaccine opponents relied heavily on Wakefield's propaganda and the American anti-vaccination movement. One of the main popularisers of anti-vaccination in Croatia, the internist Lidija Gajski, published a book in 2009 titled Drugs or a story about deception, in which she criticized the so-called ‘wild marriage’ of medicine with the pharmaceutical industry in the service of profit.

Her right hand in the anti-vaccination movement, the chemist Valerije Vrček, wrote in the book review:

The author unsparingly calls out those doctors, pharmacists, scientists, politicians, and journalists who are involved in the systematic transformation of medicine into the market and institutional violence against human health. Many of the actors and collaborators involved in the project to transform medicine into a health industry will easily identify themselves in the book; of course, not by name, but by their work and 'results of their work'.[3]

Published in 2009, the book was apparently well-received by the public, as it was the year, in which the World Health Organization (WHO) warned of the seriousness of the swine flu pandemic. Unfortunately, a great deal of the public saw the warning by the WHO as a kind of conspiracy designed to bring great profit for the pharmaceutical industry and everyone associated with it by selling vaccines against a disease that was not more severe than the usual seasonal flu.

Sadly, public television, the media, and at one point even the official gazette of the Croatian Medical Chamber (Liječničke novine), also contributed to the anti-vaccination movement in Croatia.

For example, in 2011, Liječničke novine published an article titled “Vaccination - salvation from infectious diseases or unnecessary risk”,[4] in which Lidija Gajski stated that the role of vaccines in the control of infectious diseases was minimal and that vaccination is one of the procedures with the least scientific basis. In the text, the Croatian internist presented a whole series of meaningless arguments against vaccines, including that the epidemiology of the diseases we are vaccinated against coincides with the epidemiology of those against which there is no mass vaccination. Even those readers superficially familiar with infectious diseases will understand that the incidence of diseases associated with poor hygiene, malnutrition, and poverty, such as hepatitis A, is declining even without vaccination. However, diseases transmitted by droplets, aerogenously and sexually, do not decrease without vaccination.

In the last few decades, in her numerous appearances and interviews, Gajski has continued persistently to challenge the effectiveness of conventional medicine, which she claims is linked to the pharmaceutical industry and private capital.

In an interview in 2011, asked whether we can at all believe in the effectiveness of drugs since they are tested by the pharmaceutical industry that makes money from selling them, Gajski answered:

This is the biggest problem, not only in medicine but also in modern science in general, which has been largely privatized. Applied science today is increasingly funded by the private sector for its own needs. Research is mostly done by drug manufacturers themselves and this research has proven to be biased. The chances that a privately funded preparation will prove to be safe, cost-effective, and effective are 4-5 times higher if the research is paid for with private money. It is difficult to rely on such data because it is unreliable. Doctors themselves are not aware of the real state of affairs, because data on drugs also come to them exclusively through the channel of the drug industry, which has its own interest, so it presents the same drugs in a much better light: exaggerates their benefits and reduces real harm.[5]

On the other hand, in her public appearances, Gajski often promotes alternative and folk medicine as effective, cheap, and less harmful than conventional medicine. She believes the problem is that doctors in the healthcare system are not sufficiently versed in the secrets of alternative medicine.

“We, the doctors, are very narrowly educated about it and know very little about what is offered outside the institutional health system. But in folk medicine there are certainly several procedures that are effective, simple, cheap, and less harmful than what official medicine offers us", claimed Gajski in the same interview trying to create the impression that natural is usually better than artificial.

A significant contribution to anti-vaccination movement in Croatia was also made by biochemist Lucija Tomljenović, co-author of the book Vaccination Policy and the U.K. Government: The Untold Truth, which criticizes vaccination. Her research https://www.cbc.ca/news/canada/british-columbia/ubc-autsism-vaccine-paper-retraction-chris-shaw-1.4351855, in which she claimed that vaccines contain aluminium that causes autism, was published in the journal Inorganic Biochemistry and then retracted after serious criticism from experts. According to Retraction Watch,[6] the pseudo-scientific article she wrote as a co-author was jointly withdrawn by both the authors and the editors of the journal. Unfortunately, her anti-vaccination theses were promoted even by the Croatian national television HTV,[7] which has also hosted Lidija Gajski on several occasions.

Several other individuals, perceived by the uninformed public as medical authorities, contributed to strengthening the atmosphere of distrust towards vaccines.

One of them is Srečko Sladoljev, a biologist. who became famous thanks to his fight against the closure of the state Immunological Institute.[8] Many promoters of the so-called alternative medicine, such as proponents of quasi-medical remedies, such as the 'Miracle Mineral Solution', certain populist politicians, especially members of the party Živi zid, and some pop stars, such as the famous singer Tony Cetinski, also joined the ranks of the anti-vaccination movement.[9]

In June 2019, amid the measles epidemic in Croatia, a protest was held in Split against mandatory vaccination, in which Andrew Wakefield participated. The gathering was organized by the Croatian Association of Parents and Activists, and led by Alma Demirović, a doctor who claims that her child contracted alopecia after vaccination.[10]

At the symposium Vaccination 2015,[11] attended by myself and the executive editor of the news portal Index.hr, Neven Barković, several health professionals expressed their concern over the decline of vaccination coverage in Croatia, and especially over the participation of some doctors in it. The practice has shown that some family doctors have helped parents to postpone the mandatory vaccination of their children or even to avoid it, even though they would be fined for it. The leading Croatian epidemiologist Bernard Kaić has repeatedly pointed out that irresponsible doctors, supporters of the anti-vaccination movement, should have their licenses revoked, unfortunately without success.

Together anti-vaccinationists managed to achieve for the level of the measles vaccination in some parts of Croatia, especially in the southern parts of the country, to fall below 50 percent. This has resulted in repeated outbreaks of measles, mainly in kindergartens and schools.

At the European conference on vaccination held in Luxembourg in 2016, participants from all over Europe, including two representatives from Croatia (I was one of them), warned that vaccination against measles in some parts of Europe, including Croatia, Bosnia and Herzegovina, and Slovenia currently does not meet the minimum standards necessary to achieve collective immunity. As Robb Butler, Vaccination and Preventable Diseases Program Manager at the WHO in Europe pointed out in an interview for Index.hr,[12] vaccination coverage in some countries is not high enough to prevent the re-emergence of diseases that had already been controlled. Butler said:

Vaccination levels must remain high at the sub-national level as well. We often see that they are sufficient at the national level - about 95 or even 97 percent. But when we look at variations at the subnational level, we see that they range from 80 to 99 percent. If we are aware of gaps, and we know that there are anthroposophical communities, among migrants and asylum seekers, and we also know that residents of the Bible Belt in the Netherlands oppose vaccination, etc., in these cases, we need to improve education in those communities. We knowexactly which communities these are. They are hard to convince, but they are not hard to contact. We can identify them, and the WHO has certain tools to access such communities. Many countries have not tried it yet. That requires political determination. To achieve 95 percent vaccination coverage in the general population, as necessary for collective immunity (when it comes to measles), we should ensure that through education future generations become resistant to unfounded rumours about vaccination safety issues, to myths that have been developed. We could do the same thing we did in the 1960s with car seat belts.

Government Errors in Pandemic Management

Anti-vaccinationists played a very detrimental role in the COVID-19 pandemic, though not in the very beginning.

In the first wave, following the spreading of information about the dramatic consequences of the COVID-19 epidemic in China, and especially in northern Italy, which was hit particularly hard by the spread of the virus in healthcare institutions, the Croatian government responded by introducing very harsh control measures, including a strict lockdown and restriction of movement. Thanks to such measures, only 255 people died in Croatia from COVID-19 till 22 September 2020. Moreover, the excess mortality in the same period was negative: 1.099 fewer people died than a year earlier. As expected, the strict control measures reduced the spread of other infectious diseases such as influenza, but also the number of traffic victims, accidents at work, and the like.

However, not surprisingly either, the strict measures had severe economic consequences, especially in Croatia as a country of service industry and tourism. The authorities therefore significantly eased all measures during the warmer season of the year in order to attract tourists and reduce damage to the economy. As Croatia seemed like a low-risk country due to the successful fight against the pandemic in the first wave, it was relatively attractive to foreign tourists. Nevertheless, according to the Central Bureau of Statistics,[13] Croatia recorded a decline in the number of tourist arrivals of about 64 percent, and of about 55 percent in overnight stays compared to the pre-pandemic year 2019. It was a strong blow to the Croatian economy, in which tourism accounts for about 18 percent of the total GDP.

Thanks to strict measures and the consequent low number of deaths after that relatively calm summer, during which the virus spread somewhat more slowly and mainly among the younger and healthy population that came into contact with tourists, the Croatian population did not experience COVID-19 in such a serious way as others in other European countries did that had not introduced such strict measures or had not introduced them in time. This may have negatively affected the interest in vaccinations once the vaccines finally arrived.

Numerous statements and moves by certain people in power, who relativized the severity of COVID-19, significantly contributed to hesitance towards vaccination. The vaccine efficacy was also relativized, while various sources, from conspiracy theorists and sensationalist media to some self-proclaimed authorities, highlighted non-existent vaccine side-effects or overemphasized existing ones.

The Croatian authorities, meanwhile, made a series of missteps and omissions that undermined the citizens' confidence in their management of the pandemic. They eased the measures in a whole series of cases, where it suited their cause, even though there was no scientific justification for such an approach. The pre-election campaign, for example, and the elections, various political rallies and commemorations, church processions, and similar events were occasions when the measures did not apply. In addition, many individuals in high positions in politics and the healthcare system had been caught personally breaching strict measures. That way, a message was sent to the people that what is valid for them is not necessarily valid for people in positions of power; what applies to restaurants or gyms does not necessarily apply to election headquarters or church premises.

For example, Alemka Markotić, a member of the official COVID-19 combat team that issued a ban for all public gatherings attended by more than 25 people in one place, herself attended a mass in front of the Zagreb Cathedral in February 2021 where about 100 people gathered. Before Easter 2020, Croatian Prime Minister Andrej Plenković spoke about the easing of some measures and the opening of markets, which encouraged people to be less careful or even careless during the holidays. In early April authorities also allowed a religious procession to be held on the island of Hvar. Certain measures were also canceled to enable the holding of the parliamentary elections in early July 2020 and local elections in May 2021.[14]

Easing Measures for Tourism

A sweeping cancellation of measures followed before the start of the tourist season: on 3 May all confining measures were eased: playgrounds, shops, hairdressers, etc. reopened; and on 9 May the borders reopened, so Croatian citizens could leave the country and foreigners could enter it; the 14-day house quarantine for those entering Croatia was no longer required.

Despite the concessions during the tourist season, however, Croatia did not fare badly until August 2020. According to the European Center for Disease Prevention and Control (ECDC), Croatia still had a lower rate of new cases per 100,000 people at that time than Sweden and even Finland, which introduced similarly stringent measures in the first wave.

Unfortunately, by the beginning of August, the number of new cases in Croatia began to rise significantly again.

Delayed Introduction of Stricter Measures

Croatian pandemic statistics deteriorated significantly in November 2020 because the necessary measures were reintroduced too late, after they had been cancelled for the tourist season.

Unfortunately, even members of the government’s Scientific Council contributed to the delay in the introduction of serious measures. For example, the molecular biologist Gordan Lauc relativized the severity of COVID-19 and the importance of upholding control measures and promoted instead a false strategy of gaining herd immunity by contracting the disease – an approach propagated by the libertarian think tank from Great Barrington.[15] Since he was a member of the government’s Scientific Council, the media paid great attention to his pseudoscientific arguments. Lauc often argued that control measures such as a lockdown or vaccination passes are not only ineffective but also counterproductive.

At the beginning of December 2020, 26 scientists and doctors, led by the scientist Ivan Đikić, professor at Goethe University in Frankfurt, wrote an open letter,[16] in which they pointed out their deep concern about the spread of the coronavirus in the new wave in Croatia. In the appeal, they listed their recommendations for combating the epidemic in Croatia. Five signatories of this appeal, who were members of the Scientific Council, were expelled from it.[17] Later, that decision was revoked, however, and presented as a misunderstanding.

Together with the entrepreneur Nenad Bakić, with whom he also has business connections, Gordan Lauc launched the web page Pandemic Realism,[18] where he relativized the danger of the COVID-19 pandemic and promoted the acquisition of collective immunity through contracting the illness.

Đikić, on the other hand, warned on several occasions that some members of the Scientific Council, including Lauc, did not report that they were in a potential conflict of interest, among other things because there was a possibility that they could make profit from COVID-19 tests.

At the end of July 2021, the Croatian Medical Chamber asked Prime Minister Andrej Plenković to dismiss Lauc as member of the government’s Scientific Council. The Croatian Medical Chamber's Commission for Public Health submitted a request to the chamber’s Honorary Court to initiate disciplinary proceedings against Dr. Lidija Gajski for harming the reputation of the medical profession and violating the provisions of the Code of Medical Ethics and Deontology.

Lauc was finally expelled from the Scientific Council, after he began openly criticizing vaccines on social networks and in the media, downplaying the importance of high vaccination coverage and opposing some control measures such as covid passes introduced by the government.[19]

Croatian President Zoran Milanovic also contributed significantly to the problem, relativizing the seriousness of COVID-19 with his statements. Among other things, he compared it to tooth caries and also said the pandemic would end when the world stopped talking about it.

When the vaccines finally arrived in early 2021, the interest in vaccination seemed to be high. Some government officials and dignitaries rushed to get themselves or their family members vaccinated by queue jumping. Such morally questionable moves were criticized in the media, but at least they sent the message that vaccination is a good thing.

Unfortunately, in July 2021, it became evident that interest in vaccination among Croatian nurses was quite low.[20]Although they were among the first in Croatia to get the opportunity to get vaccinated, almost half of them did not take it. This information resonated badly with the Croatian public, especially because some of the nurses explained their hesitation by claiming that the vaccine had not been tested enough. Fortunately, the percentage of doctors, who did not get vaccinated, was significantly lower – about 20 percent.

Confidence in vaccines was also significantly shaken by claims of certain well-known scientists, such as geneticist Tomislav Domazet Lošo, professor at the Faculty of Medicine at the Croatian Catholic University and employee of the Ruđer Bošković Institute, who said that vaccinating with mRNA vaccines is dangerous molecular tattooing. He stated:

My message is very short; I am here to defend the scientific truth. I have been working with mRNA molecules all my life. I know very well that they can be embedded in the genome and that mRNA vaccines are very dangerous gene therapy and can cause tumours and change the genome of our children.[21]

The Ruđer Bošković Institute, where Lošo also works, condemned his inappropriate statements,[22] but that did not have much of an impact on people opposed to vaccination, because many of them perceived him as a whistle-blower and a hero.

In October 2021, Lauc linked the excess mortality in Croatia to vaccination, to which the Croatian Association of Hospital Doctors (HUBOL) reacted vehemently. "Only a malicious and heartless ignoramus can link the vaccine to excess mortality, deliberately seeking to increase the incidence and mortality of COVID-19 disease," HUBOL warned, asking the government how long it would tolerate Lauc in the Scientific Council.[23]

Finally, on 10 November 2021, after Lauc called his followers on his Facebook page to stage protests against COVID passes and compared the government to Socialist President Tito, Prime Minister Plenković announced that cooperation with him in the Scientific Council was no longer possible.[24]

During the pandemic, numerous protests against control measures and vaccinations were held in major cities across Croatia. One quite big event, attended by protesters who converged by busses from all over the country, took place in Zagreb on 20 November 2021, at the height of the fourth wave at a time when about 20 people were dying every day from COVID-19, which is a lot for a country with less than four million inhabitants. The gathering of about 10,000 protesters brought together a diverse range of people, dominated by alternatives and members and supporters of right-wing and populist parties.

For all the reasons mentioned, vaccination coverage in Croatia has remained very low. According to Our World in Dataon 14 April 2022, only 55 percent of the population has been fully vaccinated, and another 1.76 percent have been partially vaccinated. For comparison, in Denmark, which ended in 90th place in the world by the number of COVID-19 deaths, with 1,033 deaths per million people (three times less than Croatia), as many as 83 percent of the population was fully vaccinated on the same date. Unfortunately, about 10 people still died daily from COVID-19 in Croatia in April 2022.