Belgium’s COVID-19 Comeback Is a Model for the World

Jos Hermans, 96, the first person to receive a Pfizer COVID-19 vaccine in Belgium, gives a thumbs-up in front of journalists at a rest home in Puurs, Belgium, on Dec. 28, 2020. DIRK WAEM/POOL/AFP via Getty Images

Belgium was Europe’s poster child for government dysfunction in handling the pandemic.

But since the end of this June, a completely different picture has emerged. Suddenly, Belgium was posting one of the EU’s highest vaccination rates. Along with most other EU countries, it has now soared past the United States, Britain, and Israel—the early stars in the vaccination race—when it comes to the share of the population that has received its doses. And unlike those early leaders, Belgium’s vaccination campaign does not appear to be flatlining. At this pace, Belgium will be one of the first countries in the world to reach herd immunity.

This is the story of Europe’s most dramatic turnaround—from the disastrous response of a non-functioning government in the early stages of the crisis to recent vaccine leadership in Europe and beyond. Most importantly, it’s a comeback that offers key lessons for the United States and other countries now struggling to keep up their vaccination campaigns.

In April, there was another false start. Through an app called QVAX, anyone in Belgium was supposed to be able to sign up for a vaccination wait list. If anyone with a regular vaccine appointment did not show up, the wait list would kick into action and offer that place to someone else. But so many people tried to sign up that merely putting your name down took more than 10 hours. Many saw it as a sign the government was failing yet again.

But even as the stream of bad news continued, the tide had already started to turn. When almost all of Europe temporarily stopped administering AstraZeneca shots in March based on early reports of an exceedingly rare lethal side effect, Belgium did not budge. (In early April, it did pause distribution of the AstraZeneca vaccine to those under age 56, citing an ability to choose other vaccines without hampering distribution.) One of Belgium’s most famous virologists, Marc Van Ranst, even went on CNN to defend the AstraZeneca jab. And when vaccine availability finally started increasing in April and May, Belgium started to rise up the European ranks of vaccination rates. Where previously it had been lagging behind countries such as Germany, Italy, and France, it began to surpass them one by one.

To Belgian Prime Minister Alexander De Croo and his scientific advisor, Sam Proesmans, the comeback was no surprise. “We took a step backward first to take two steps forward later,” De Croo told me when I spoke to him for this article.

It did not help that the new government only took office on Oct. 1, 2020. “By that time, countries like Germany had been planning for the vaccination campaign for months,” Proesmans said. “We knew we would have to play catch up.”

From left: Adnane Lamarti, COVID-19 commissioner Pedro Facon, and Bilel El Majnaoui prepare for a youth anti-virus campaign presentation in Brussels on March 9. VIRGINIE LEFOUR/BELGA MAG/AFP via Getty Images

Next, the newly instated task force had to decide on the logistics of the campaign. In the early planning stages, the group foresaw 100 to 300 major vaccination centers to serve the country of 11.5 million, Proesmans said. Going for a high number of centers would mean better access for more people, but a smaller number of mass vaccination centers would be more efficient in terms of distribution. In the end, the government opted for efficiency, installing 150 large centers. That some of these massive centers, like the one in my hometown Lier, would at first be almost empty was a price it was willing to pay.

While the vaccination centers offered benefits of scale, another decision was made early on to create a system of fair vaccination priorities. Age would not be the only determiner for who would get the jab first: Underlying medical conditions that led to disproportionate numbers of hospitalizations and deaths would also be taken into consideration. To identify these priority patients individually, the federal task force used a database made by general practitioners, who are often neighborhood or family doctors who know their patients, and their patients’ underlying diseases, personally. The responsibility of updating the files in the central database lay with the local doctors, which added to their workload and took time. But it let the Belgian authorities create a fair list of priority patients.

There was also the QVAX reserve list. The idea was a creative one, developed with Seaters, a ticketing start-up based in Brussels and New York. For years, the Seaters team had been developing software and databases for last-minute ticket sales to sporting events and concerts. Before the pandemic, the company’s founders had developed their product after noticing even sold-out games had many open seats, often because ticket holders did not have an easy way to resell their seats. But with business almost at a standstill during the pandemic, they found a different use for their platform; from a process perspective, re-assigning unused vaccination spots was identical to re-selling stadium tickets. They repurposed their technology, and the QVAX app was born.

Belgians, not used to their government innovating, were initially wary of the app. In 2020, a COVID-19 tracking app had taken months to build and proved almost useless. But knowing they’d otherwise wait in line for months, Belgians signed up on QVAX anyway. In the first few weeks, when there were few spare vaccine doses available, only a few thousand people were called up. But as vaccine deliveries accelerated, more people started to benefit from the system. More than 310,000 Belgians—about 3 percent of the population—have now gotten their shots this way, Seaters CEO Jean-Sébastien Gosuin told me. That may not seem like a lot, but in a mass vaccination drive every percentage point counts.

There were other small wins, which together added up to Belgium gaining an edge over most other vaccinating countries. The decision not to pause AstraZeneca vaccinations, even for a few days, was one of them. “We followed a rational, science-based approach,” Proesmans said of the decision, “not an emotional one.”

That stance translated into taking a numbers approach to the dilemma of halting or continuing vaccinations. Halting the vaccine to wait for new advice from the European Medical Agency would have prevented 0.1 deaths per day due to thrombosis (blood clotting), the country’s biostatistical office calculated. But doing so would also have led to about 65 new ICU cases and 40 likely deaths due to COVID-19 per day. So the country took the opposite route from many of its neighbors, including Germany and France.

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As soon as medical guidelines allowed, Belgium proceeded to other quick wins in vaccinating a lot of people fast: It squeezed six doses of Pfizer vaccine out of each vial officially containing five and stretched the time between doses for each of the two-shot vaccines to their medically prescribed maximum: five weeks for Pfizer, six for Moderna, and 12 for AstraZeneca instead of the three, four, and four, respectively, that the companies prescribed as the minimum. Since the first shot already provides significant protection, it was a way to save the most possible lives in the fastest way. Other countries, such as Britain and Germany—but not the United States—followed a similar strategy.

As vaccine deliveries started to increase in frequency and volume, Belgium found itself racing from the bottom to nearly the top of the European vaccination charts. Around June 17, it surpassed the United States, which had gotten off to a flying start with its vaccination campaign last winter. And by Aug. 12, almost 72 percent of the Belgian population had received at least one shot of vaccine, with 65 percent fully vaccinated. (The only EU countries ahead of Belgium on the first metric were Denmark, Malta, Portugal, and Spain, and only Malta was ahead on the second.) It’s hard to believe that this is the same country that just a few months earlier was quite literally the sick man of Europe.

Members of a COVID-19 team speak to people at a weekly market during a pilot program for on-the-spot vaccinations in Brussels on May 6. ERIC LALMAND/Belga/AFP via Getty Images

De Croo, buoyed by his country’s recent successes, thinks that passing an 80 percent vaccination rate won’t be a problem. “I don’t think we’ll stumble on that hurdle,” he told me.

Proesmans was even more certain. “We’ll easily surpass that hurdle,” he said. “In fact, we’ll pass straight by it.”

But to get there, it will take more than the government’s conviction. Vaccine hesitancy has proven to be the biggest hurdle in reaching herd immunity around the world. Israel, for example, was the envy of the world with its impressive pace of vaccination but has now stalled around 65 percent. Britain was Europe’s vaccination star but has confronted a slowdown in the campaign due to logistical difficulties reaching the rest of the population. The most worrying slowdown may well be in the United States, which is seeing a surge in cases, hospitalizations, and deaths among the unvaccinated. U.S. officials are finding it hard to hit vaccination targets despite offering cash and other incentives for vaccination.

So far, though, the signs for Belgium are positive. In Flanders, where a majority of Belgians live, only 1.7 percent of those offered a vaccine explicitly declined it, with an additional 8 percent not showing up to their appointments. In part, these low numbers may be attributable to the bandwagon effect: People who were skeptical about vaccines change their minds after seeing friends and family get their shots without complaining.

But the high uptake of vaccinations is also the result of a policy of carrots and sticks. The carrot is that since this spring, the government has made relaxing lockdown restrictions contingent on vaccination rates, rather than case numbers or hospitalization rates.

Connecting opening up the country with a positive, proactive indicator is a better motivation for the population, De Croo said. “The faster we vaccinate and the faster you as an individual sign up, the faster we can open up the country again,” he said. “People like that.”

The stick lies in the restrictions that remain for those who refuse the vaccine: They cannot take a plane or go to mass events without a negative COVID-19 test or proof of vaccination. It turns out to be a powerful motivator especially for young people, who weren’t against vaccinations per se—they just initially hadn’t seen any concrete benefits for themselves.

I could see this on display in my own family. My father, a retired virology professor, recently sent my mother, my two siblings, and me the recording of a presentation he had given at our local vaccination center. Speaking to 16-, 17-, and 18-year-olds as part of a youth vaccination drive, my father talked in simple terms about the benefits of vaccines and the latest science on them. It followed presentations he had given to general practitioners and volunteers a few months ago. It reminded me of the power of speaking to people in the community directly—rather than through the press and social media, my natural habitat. And clearly, the personal approach has worked.

If Belgium succeeds in spite of its tragic, deadly first pandemic year, it will also be a good result for those who believe in international solidarity. Belgium, a global center of vaccine production, has kept doses flowing out of the country throughout the entire pandemic, without imposing restrictions. Both Pfizer and AstraZeneca relied on Belgian facilities to produce a substantial part of their global supply. By April, the Pfizer factory in Puurs, Belgium, for example, had already exported more than 300 million doses to 80 countries, while delivering only 2 million doses to Belgium itself. But even as the country faced vaccine shortages and delays, Belgian leadership never considered putting a brake on exports.

“We never got tempted,” De Croo told me. “We’re a vaccine powerhouse and we’re proud of it. In fact, we fought hard to maintain the free flow of goods.”

In the end, Belgium’s comeback in the fight against COVID-19 is a success story—first of all for the Belgian people, who went from being intensely at risk to being among the most well protected in Europe. It’s a victory, of course, for the new government, and the organizers of the vaccination drive. And it provides a welcome pat on the back for all the local community organizers, policymakers, and volunteers whose frontline work and efforts in the shadows are now paying off.

But the Belgian tale also holds an encouraging lesson for other countries and communities around the world that may still be struggling with vaccine supplies and logistics, or hitting a ceiling in their fight against the pandemic. The lesson? When combatting COVID-19, it’s never too late to stage a comeback.