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How Will Bulgaria Vaccinate A Skeptical Public When It Can't Even Convince Its Doctors To Get The Shot?

A doctor examines a patient at the Covid-19 unit of a hospital in Kjustendil, Bulgaria, where coronavirus infection rates have been soaring in recent weeks.

SOFIA -- "I've never asked my patients to get those shots," the doctor said. "There are people who don't know what aspirin is and have survived. The only real deal going on now is scaring people, through media and other information sources."

A general practitioner who spoke on condition of anonymity works with Bulgarian national teams and Olympic athletes in several sports, including soccer, wrestling, and karate. He told RFE/RL's Bulgarian Service last month that he is unvaccinated because "there's no proof that's been created by empirical method that [such] a virus...exists."

He is just one of many Bulgarian health-care professionals who have refused to get vaccinated. The cumulative vaccine uptake among Bulgarian health-care workers is just 25.5 percent, the lowest among EU member states and a small fraction of the bloc-wide average of 85 percent, according to the European Center for Disease Prevention and Control. Around half of a narrower category of "medical personnel" has been fully vaccinated, according to the Bulgarian Health Ministry, and numbers are higher still among some specific groups, including doctors and medics.

In the United States, by comparison, around 75 percent of medical professionals have been fully vaccinated, versus 60 percent among the U.S. population as a whole.

The anonymous doctor who spoke to RFE/RL's Bulgarian Service claimed, without any evidence, that "a ban on autopsies of people who died of COVID" exists and suggested that while "other deadly viruses can be diagnosed...with COVID you don't have that." Coronavirus skeptics often argue that patients whose deaths are officially attributed to COVID-19 are actually dying of other causes.

The country's overall vaccination rate remains under 25 percent -- the worst in the EU and particularly moribund when compared to comparably sized Portugal at over 90 percent. The low rate is particularly troubling amid a new massive surge in COVID-19 cases that is crowding hospitals and inflicting the world's third-worst death rate on this EU nation of around 7 million people. COVID-19 has been responsible for 25,000 deaths so far in Bulgaria.

'A Huge Threat'

Late last week, half a dozen leaders of Bulgarian medical associations and a patients' group gathered alongside Health Minister Stoycho Katsarov to present a united front against COVID-19.

Masked and with hands clasped one day after a record daily death toll of 310, they urged all Bulgarians to get vaccinated as soon as they can. "We are all facing a huge threat, and joint action is needed," said Katsarov, whose caretaker government launched a "green pass" on October 21 to restrict access to most indoor activities to the fully vaccinated, the freshly tested, or the recently recovered from the coronavirus. Workers in the health-care sector also must have the "green pass."

Bulgarian Health Minister Stoycho Katsarov (fourth from left) and the heads of professional medical groups present a united front against COVID-19 on November 2.
Bulgarian Health Minister Stoycho Katsarov (fourth from left) and the heads of professional medical groups present a united front against COVID-19 on November 2.

Brief upticks in vaccinations among the general public that preceded the summer holidays and then accompanied the introduction of the green pass appear to have waned quickly.

"Bulgaria has failed with vaccines," Stanimir Hasardjiev, who heads the Bulgarian National Patients' Organization and sits on the board of the European Patients' Forum (EPF), said at the meeting with Katsarov.

He expressed hope that vaccine-hesitant Bulgarians understand that "there are no conspiracies," and added, "For God's sake, brothers, get vaccinated."

But as wanly as average Bulgarians have responded to such calls to get their shots, perhaps Katsarov and Hasardjiev should have directed their appeals to the representatives of doctors, nurses, dentists, and other medical professionals standing beside them.

Aleksandur Naidenov, a doctor of dental medicine who also teaches biology at a private STEM school in Sofia, blames Bulgaria's low vaccination rates broadly and in the health-care sector on a "low health culture," along with a distrust of authorities and a media circus around the vaccine debate.

A man holds his daughter as he receives a second dose of a vaccine against COVID-19 in the Bulgarian village of Krushovitsa last month.
A man holds his daughter as he receives a second dose of a vaccine against COVID-19 in the Bulgarian village of Krushovitsa last month.

He also thinks Bulgarian doctors' stubborn resistance to embrace innovations like the COVID-19 vaccines is among the legacies of bad habits forged in the Eastern Bloc, including a failure to keep current on scientific trends.

"Most of them are not against vaccines, but they just don't understand vaccines," he said.

Naidenov has become a vocal pro-vaxxer on social media, and he told RFE/RL that he frequently confronts vaccine skeptics among his medical peers by citing the science and providing links.

He said their responses frequently include some version of "But I don't trust the data."

"They don't trust authorities at all in Bulgaria, but not only Bulgarian authorities," Naidenov said. "They don't trust the World Health Organization, they don't trust the CDC (Centers for Disease Control and Prevention) in the U.S.A., they don't trust anything. But then I ask them, 'You treat patients, but you didn't discover how to treat them yourself -- you read protocols from the WHO or from other scientific papers, right?'"

"'So why do you trust them about how to treat your patients with different diseases, but you don't tell them about COVID and the vaccine?' And then they just stop arguing with me."

'Chaotic, Confusing' Information Campaign

There have been complications in the vaccine rollout in Bulgaria for sure, including an early lack of availability because a politically unpopular government in Sofia was slow to act and because Western pharmaceutical companies overpromised on their deliveries.

The sluggish vaccine take-up is also being blamed on the public's failure to recognize the risks of COVID-19 and the benefits of inoculation, particularly among Bulgaria's aged and undereducated population.

A small line of people forms to receive a vaccine against COVID-19 in the Bulgarian village of Krushovitsa.
A small line of people forms to receive a vaccine against COVID-19 in the Bulgarian village of Krushovitsa.

But vaccine skepticism in Bulgaria was significant well before the new coronavirus came along with its seemingly countless, debunked conspiracy theories. A report published by the European Commission in 2018 on the "state of vaccine confidence" concluded that among all EU countries, Bulgarians were the "least likely to agree that vaccines are safe."

That suggests the need for a robust public-awareness campaign and reliable medical advice to combat public apprehension once detailed clinical studies and regulatory approval suggested the new vaccines were safe and effective.

"All the way back when the pandemic started, and later when the vaccines started coming, the information campaign of the Health Ministry was very chaotic, confusing, and the information given created much more fear than trust in the vaccine," the vice president of Bulgaria's National Association of General Practitioners, Dr. Hristo Dimitrov, told RFE/RL. "What we are seeing now is the fruit of that."

Bulgarian vaccine skeptic Dr. Atanas Mangarov (file photo)
Bulgarian vaccine skeptic Dr. Atanas Mangarov (file photo)

Instead, Bulgarians quickly acquired a taste for prominent medical professionals like Dr. Atanas Mangarov, a Sofia-based pediatrician and infectious-disease specialist who became a beacon for anti-vaxxers.

Mangarov is widely quoted in Bulgarian media and has millions of followers on TikTok, Instagram, and YouTube, where he cites his own refusal to get vaccinated and shares stories about vaccine setbacks and opposition to vaccine mandates.

He spurns the kind of immunity that comes with vaccination in favor of natural immunity through infection, which he says is the only guarantee against new coronavirus variants.

Some European states, including Greece, Hungary, and France, already require health-care and home-care workers to be vaccinated.

Some others that already have high vaccination rates, such as the United Kingdom, have hinted at plans soon to require health-care workers to be vaccinated.

But many other governments have avoided such mandates.

Doctors' representative Dimitrov insisted that there are "very, very few" doubters among medical specialists who oppose the COVID-19 vaccine. He said the notion that general practitioners "somehow sabotage the vaccination campaign is fundamentally wrong."

"What makes the whole situation seem worse is that those doctors who are doubtful are 'louder' and their voices seem to resonate more in the media and in turn with the citizens," Dimitrov said.

He echoed other critics who cited the late start and slow pace of Bulgaria's national vaccination campaign. In fact, Dimitrov argued that the seemingly low rate of vaccination among medical professionals was a result of their high rate of infection.

"If you take away the small percentage of anti-vaxxers -- maybe not 'anti-vaxxers' but 'vaccine doubters' -- it's a fact that a huge percentage of medical personnel have suffered from COVID, sometimes more than once," he said. "So they fall in the category of people who are [still waiting] to be vaccinated, because they have antibodies."

Decline In Life Expectancy

But, as of November 5, official statistics showed 4,424 confirmed COVID-19 cases among Bulgarian doctors, 5,409 among nurses, 3,149 among paramedics, and 3,180 among "other medical staff," out of a total of 16,162 cases.

That leaves tens of thousands of doctors, nurses, and other medical professionals and caregivers unaccounted-for -- spelling potential trouble as officials enforce the "green pass" requirements on the health-care sector.

The Bulgarian Medical Association puts the number of registered medical doctors in the country at nearly 33,000, and claimed that more than half of the country's doctors and medics had been fully vaccinated by late July.

A Bulgarian anti-vaxxer attends a protest against the country's "green pass" on November 2.
A Bulgarian anti-vaxxer attends a protest against the country's "green pass" on November 2.

Bulgaria got off lightly in the spring of 2020, when Italy and Western Europe became the "epicenter" of new coronavirus infections.

But it has since faced three major COVID-19 surges that have waylaid its aging population and overstretched an already creaking health-care system, the most recent peaking at nearly 5,000 daily infections in late October.

The results are among the EU's highest infection and death rates over the past month, as Europe once again becomes a COVID-19 epicenter.

The effects on life expectancy are already being felt. Newly published research comparing mortality data among 37 upper-middle and higher-income countries showed Bulgaria has suffered the third-worst decline in average life expectancy, after Russia and the United States, since the pandemic began.

Bulgarian men are dying nearly two years earlier and women 1.37 years earlier, on average, according to the study in the British Medical Association's BMJ journal on November 5.

Written and reported by Andy Heil in Prague with reporting by RFE/RL Bulgarian Service correspondent Nikolay Lavchiev in Sofia
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    Nikolay Lavchiev

    Nikolay Lavchiev is a correspondent for RFE/RL's Bulgarian Service. 

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    Andy Heil

    Andy Heil is a Prague-based senior correspondent covering central and southeastern Europe and the North Caucasus, and occasionally science and the environment. Before joining RFE/RL in 2001, he was a longtime reporter and editor of business, economic, and political news in Central Europe, including for the Prague Business Journal, Reuters, Oxford Analytica, and Acquisitions Monthly, and a freelance contributor to the Christian Science Monitor, Respekt, and Tyden.