Citra Lestari – Indonesia has around than 1 million TB cases annually and clinical trials of vaccine candidate M72/AS01E have been underway since last year. The final trials, funded by the Bill and Melinda Gates Foundation, start soon in Indonesia. They will also be conducted in South Africa, Kenya, Zambia and Malawi.
But a meeting in Jakarta between President Prabowo Subianto and Microsoft founder and philanthropist Bill Gates on 7 May 2025 has sparked huge controversy, mainly on social media. Conspiracy theories abound that Gates is only seeking to profit from the vaccine production, with the Indonesian people being used as guinea pigs. Former health minister Siti Fadilah Supari is among those amplifying the conspiratorial narrative.
The Indonesian Ministry of Health was quick to respond to the uproar by providing scientific explanations about the safety of the program. Experts, including leading researchers involved in the vaccine trials, doctors and epidemiologists, have joined the government in their effort to quash public concern about the vaccine trials.
Indonesia has a TB problem
It is not hard to understand the government's position – the stakes are very high. Indonesia currently ranks second in the world for TB cases, reporting 1.1 million TB cases and 130,000 TB-related deaths in 2023, according to the 2024 World Health Organisation (WHO) Global TB report. The current TB vaccine being used in Indonesia – the Bacilius Calmette-Guerin (BCG) – was developed in 1920s and is only effective for babies and children.
In fact, WHO has stated that a new TB Vaccine is urgently needed globally, and the M72/AS01E vaccine could be the first approved in more than 100 years.
The plan to conduct clinical trials in Indonesia was hatched last year following the success of the first and second phases of the vaccine's trials. Indonesia is expected to benefit as it means the final development of the vaccine's efficacy will incorporate Indonesians' genetic characteristics. In addition, Indonesia will have the opportunity to co-lead the development of the vaccine, with the University of Indonesia and the University of Padjajaran. Indonesia's Bio Farma is then expected to produce the vaccine domestically.
All this means there is no question that the government will continue with the trials regardless of public concerns about the vaccine's safety. But it cannot afford to ignore prevailing public scepticism over the safety and efficacy of the clinical trials. What is at stake is not just the trials and the potential economic benefits for Indonesia of producing the vaccine, but the success of the domestic vaccination drive once M72/AS01E approved, and thus the health of the nation.
Understanding risk perception
Unfortunately, public distrust of the vaccine trials remains high. Some people have expressed fears about the program citing their experiences during the COVID-19 pandemic when military personnel and security officials (Satpol PP) were deployed to help the government boost vaccination rates. Others have accused the government of "selling off" its people to a foreign billionaire for economic gain.
But the government cannot simply dismiss their conspiratorial and pseudo-scientific concerns. If they are not addressed they could affect not just TB prevention but also uptake of other vaccinations in Indonesia. More broadly, they could threaten a huge range of disease prevention efforts across the country.
It is important to note that public concerns about vaccines often have little to do with lack of scientific understanding. We tend to perceive risk perception as a personal judgment that is shaped only by individual's cognitive and affective assessment. But scholars have argued that risk perception does not come in a vacuum. There are underlying conditions – social, political and economic barriers or pressures – that inform their judgements.
Consider marginalised groups, for example. Low-income people and those living with HIV are often blamed for spreading TB in Indonesia and are therefore labelled "high-risk communities". They are likely to have different concerns about the vaccine trials compared to most others, fearing, for example, that they will be singled out by the health authorities as "guinea pigs". Past experiences with vaccination programs, which have sometimes involved military and Satpol PP personnel, may contribute to their perception of vaccination programmes and explain why many low -income people and those living with HIV oppose vaccination.
The problem is that the government's risk communication strategy does not address these underlying social and cultural factors. It focuses narrowly on scientific arguments.
Empowering risk communication
Correcting or debating those opposed to the TB vaccine clinical trials with scientific arguments is clearly not enough; it can even be counterproductive. The government instead needs to understand why people believe in conspiracy theories and pseudoscience. Only when the underlying causes of concern – which might seem irrational but could have rational drivers – are understood can risk perceptions and behaviours be changed.
One approach suggested by risk communication scholars is to use risk communication for empowerment. This approach involves meaningful listening to acknowledge people's fears and understand the structural barriers that contribute to their decision making. This is because their perception of risk may provide solutions to the problem.
The empowering risk communication approach suggests that people can only make informed decisions about a risk when they are empowered. To make a sound decision, people need not only access to information or an ability to comprehend the information, but also spaces to voice their concerns and be actively listened to.
This is not rocket science, and it is hardly new, but it must be done. With the planned clinical trials of the TB vaccine expected to take about four years, Indonesia must change its risk communication strategy to ensure the success of the vaccination drive. This approach clearly requires political commitment from the government, but more importantly, it requires humility on the part of government officials, doctors and public health experts. It is time for them to listen to the vaccine sceptics and engage with them.