Vaccines. Diseases. Measles. Big Pharma. Anti-vaxxers. Medical Industrial Complex. Individual rights. Herd immunity. Selfishness. Stupidity. Toxins. Chemicals. Autism. Encephalitis. Mercury. Thimerosal. Febrile seizures. Science. Anti-science. Pseudo-science. Alternative. Natural. Money-grubbing. Lying. Evil.
My Facebook feed has been blowing up with posts and memes related to vaccination. The topic cycles through the news and social media regularly and is prominent at the moment in the wake of the recent/current measles outbreak originating at Disneyland in California. People are angry. People are defensive. People are offensive.
Over the past several decades, vaccines have prevented millions of deaths. They are effective. There is no question about this. Current vaccines are exceedingly safe. There is no question about this.
Vaccines are not 100% effective. We need a high communal vaccination rate (generally 95% or more) to ensure “herd immunity,” which stops widespread epidemics and protects those who cannot, for medical reasons, be vaccinated, and those for whom the vaccine did not generate adequate immunity. Vaccines are not 100% risk-free, although the risk of a serious reaction is extremely small (for example, about a one-in-a-million chance of an anaphylactic allergic reaction to the Measles/Mumps/Rubella vaccine). Many vaccines have minor side effects, such as soreness at the injection site or a mild fever (the fever actually is a sign that your body is mounting an immune response to the immunization). The diseases the vaccines protect against have significant rates of severe complications (encephalitis – an inflammation of the brain which frequently leads to permanent damage, pneumonia (the most common measles-related cause of death), paralysis, sterility, blindness, deafness, death, etc., depending on the specific disease).
The scientific and medical establishment is in overwhelming agreement that everyone who can be immunized should receive all recommended vaccinations. The benefits far outweigh the risks. The vast majority of people in this country follow these recommendations.
And yet we have pockets of people loudly protesting vaccines.
And some people listening to these loud protests and quietly forgoing immunizations for their children.
And this is a problem.
From the community health and welfare standpoint, this is a problem because there are enough people forgoing immunizations to impair our herd immunity. Those who are most vulnerable (people undergoing chemotherapy, people on immunosuppressive medications, babies too young to be immunized, people with immune deficiencies, people who are too frail or ill for their bodies’ immune responses to function properly, etc.) are at risk. And because the vaccines are not 100% effective, even those healthy folks who are fully immunized are at higher risk because of the decrease in herd immunity. So clumps of folks refusing to immunize will affect other people, not just their own families.
And because we are human, even if the herd immunity issue were not in play (although it most definitely is), many who understand the science and the importance of immunizing and the benefits versus the risks to the individual (putting aside, for the moment, the community as a whole) would still be frustrated by the failure of groups of people to vaccinate their children. Because even if (again, ignoring the public health risk for the sake of this argument) we could say to ourselves, “if they don’t want to immunize themselves that’s their problem – they can suffer from and potentially die from preventable diseases if they so choose,” (which I personally have a hard time saying), we still care about the welfare of their children.
And there’s the rub.
Because that is also what motivates the vociferousness of some of the people who loudly oppose vaccines. Not all of them, but some of them.
And understanding motivation is essential to understanding and communicating with people.
What doesn’t motivate people is calling them stupid.
At this time, I will not speak to the few people within the official medical establishment (M.D.s and D.O.s) who speak against, discourage, or otherwise buck the positions of the American Medical Association, American Osteopathic Association, Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), American Academy of Pediatrics, American College of Physicians, etc. My opinion and analysis of these people will be a topic for another day.
I will also not speak at this time to people who have not undergone the rigors of scientific medical training who hold themselves out to the public to be healthcare practitioners and give advice contrary to scientific medical consensus. This will also be a topic for another day.
What I will speak to right now is the vaccine resistance (and vigorous promotion of this resistance) that is found within small proportions of the general population.
The people I am speaking about certainly love their children. They are motivated to protect their children. They are motivated to protect other people’s children. They are motivated by fear. Deep fear.
I understand fear. And I understand fear of vaccines.
Most of our immunizations are done by injection. A needle is stuck into us (or our child) as the vaccine is injected into our muscle. It hurts.
We have evolved to resist being stuck and injected – we reflexively try to avoid bees and wasps. That resistance for most of us is easily overcome with our intellectual understanding of immunization, but we are definitely actively resisting a natural impulse when we allow ourselves to be injected. Sometimes fears can be too strong to overcome with our own intellectualizing and we need a little help.
Frequently, young children will cry when given injections. It’s awful to see your child in pain. Yes, that pain is to protect him from something that would cause much greater discomfort and could cause grave harm or even death, but the injection pain is right here, right now, and real, while that disease potential is not right in our face and we don’t frequently see the awful diseases that we once used to (due mainly to vaccination).
A child will frequently be fussy after vaccinations – her leg or arm hurts where she was poked. She may have a fever for a couple days. She may sleep poorly while she feels icky. And a parent feels awful, because the parent gave permission to someone to do this to her. This ickiness of vaccination is right in front of the parent, while the disease being inoculated against is not in front of the parent.
Although severe vaccine side effects are exceedingly rare, a parent may still worry about the potential.
We look for confirmation. We look for validation. We look for reassurance. We take it where we get it.
While most of us are able to intellectualize and rationalize the extreme benefit of vaccination, some of us have more difficulty overcoming the fears. When we’re having difficulty, the reactions of others can make all the difference in the world.
Who listens to our fears with empathy? Who rolls their eyes? Who sighs with exasperation? Who ridicules our fears? Who explains and educates? Who gives us time?
Although correlation does not imply causation, our tendency is to infer causation from correlation. We are suggestible. Although large scale data gives us significantly more information than a few anecdotes, we tend to remember and hang on to stories. When we are given some information we know to be correct, we are more inclined to believe accompanying information from the same source, whether or not that accompanying information is valid.
These tendencies, coupled with who is responding to a person’s fears (and how they are responding), will influence whether someone who is afraid will go in one direction or the other.
There was a recent study that looked at information intervention to see how it affected parental attitudes on the MMR vaccine. For this study, parents were given a questionnaire which included questions on how likely they were to have their future children vaccinated with the MMR vaccine, whether they thought certain vaccines caused autism, and how likely they thought it was that someone would suffer serious side effects from the MMR vaccine. They were then randomly assigned to five groups. One group received information (from the CDC) explaining the lack of evidence that the MMR vaccine causes autism. The second group received text from the official Vaccine Information Sheets explaining the dangers of the diseases against which the MMR vaccine protects. The third group received pictures of children with measles, mumps, or rubella. The fourth group received a dramatic story (from the CDC) about an infant who almost died from measles. The fifth group was the control group – they received no vaccine information intervention materials, but were instead given reading on the costs and benefits of bird feeding. The parents were then given a second questionnaire which included the three specific questions mentioned above.
The results of this study showed that none of the interventions increased a parent’s likelihood of having a future child immunized with the MMR vaccine. The autism-vaccine corrective information did decrease the respondents’ beliefs that there was a link between vaccines and autism, but it also decreased the respondents’ future likelihood to vaccinate (mostly in the group of parents who originally held the least favorable view of vaccines). The dramatic story of the infant with measles increased the perception that the MMR vaccine has serious side effects. The pictures of ill children increased the parents’ likelihood of saying that some vaccines cause autism.
I don’t find the above results surprising, nor do I find them particularly discouraging, although headlines in response to its publication were generally along the lines of “You Can’t Change an Anti-vaxxer’s Mind” (that one was from the Mother Jones blog). The above study looked at four different “spot” information interventions. It did not look at comprehensive education, communication techniques, nor empathy of information providers – it simply provided limited, unifocal written materials. It is not fair to say, from the results of this study, that people scared of immunization cannot be reached.
If I had been a parent in this study given a story to read of a sick child, or had been given alarming pictures of children with measles, mumps, and rubella, I might then go to my computer and do a quick search on those diseases. While doing so, I would very likely come across websites promulgating false information about dangers of the MMR vaccine or quoting the (fully discredited) study linking the MMR vaccine to autism. I also might have thought, “Why are they trying to scare me about these diseases? Maybe they think they need to scare me because the vaccine is dangerous.” I wasn’t given information on the safety of the vaccines. I wasn’t told details about potential side effects. I wasn’t given an opportunity to ask questions.
Communication is critical. Comprehensive communication is critical. Empathy is critical.
The costs would likely be prohibitive, but it would be nice to set up a study (with the same questions looked at in the above study) where people with negative attitudes towards immunization were identified, where they were randomized to an intervention group where a doctor listened to their fears, addressed their concerns, quantified the risks and benefits of vaccination versus the diseases themselves, provided trustworthy further sources, and explained which sources were not scientifically trustworthy and why, all while maintaining an empathetic demeanor; a group where the above was done in an arrogant/ridiculing manner; and a control group where a doctor discussed the benefits of wearing a bicycle helmet. How might people respond then?
The anti-immunization community (both physical and internet) provides empathy. They tend to be comprehensive in their information (albeit false). They define the enemy (enemies). They pull people into their fold, making them feel a part of a valued and cared-for community.
Calling people names will not pull people back from a group that’s making them feel welcome and supported.
Again, the majority in this country understands the science behind immunizations, trusts the medical and science establishments, and immunizes their children against dangerous communicable diseases. People who are wary of immunizations are not trusting the overwhelming consensus of physicians. If they are already pulling away in some thoughts from the medical world, why would anyone think that insulting them would help pull them back?
A piecemeal approach of a written form here, a scary story there, or some random disease photo is also not likely to pull anyone back, nor is an internet meme with a snarky comment or comparison.
Memes make points or sum up arguments with a picture and just a few words, frequently with an element of humor. I frequently appreciate the humor and the analogies made when the memes are pro-vaccine. But when I look at those of the anti-vaccination type, it hammers home just how lacking a meme is. It may pack punch, but it lacks depth. It lacks nuance. It lacks explanation that addresses questions or concerns.
This is not to say that the memes are useless. They generally serve to support/confirm/validate what people on one side or the other already understand or believe. They also, by serving as an indicator of what someone posting the meme thinks, contribute to defining norms. So it is helpful for Facebook to have a preponderance of pro-vaccine posts, since it helps cement immunization as the acceptable/preferable thing to do, and it is possible to do this with humor, with analogies, and with respect. It is helpful for people to respond to/refute anti-vaccine posts in a respectful, empathetic, honest, respectful, non-condescending manner.
Here is my official, as-a-doctor stance on vaccination:
Vaccines save lives. Vaccines are not perfect, but the ones that we have now have been proven overall safe and effective. We’ve come a long way since the first documented attempts to immunize. Variolation for smallpox – rubbing material from smallpox sores into people’s skin to induce a cutaneous case of the disease which was milder than the normal variant and conferred immunity to the more severe infection – has evidence of being performed in China 1000 (yes, one thousand) years ago, and was practiced in Asia, Africa and Europe from the 1600s through the 1700s (see historyofvaccines.org). Our vaccines and their manufacturing process have been refined and improved remarkably over the past two centuries. All of our present-day science overwhelmingly indicates that the benefits of our current vaccines vastly outweigh the risks. This does not mean that the risks of vaccination are zero, but they are ever so much lower than the risks of not vaccinating.
Choosing not to vaccinate has risks not only to those who refuse to vaccinate but to others in the community as well. Doctors and medical researchers read studies, discuss findings, analyze quality of research, and continually ask questions to direct further lines of inquiry. As new information becomes available and as better methods evolve, we update recommendations and practices accordingly. All of our best available current information leads me to recommend immunization.
Immunize yourselves. Immunize your kids. And if you still have concerns or questions about vaccines, ask them of your physician. If you feel you are not being answered respectfully by your doctor, calmly and respectfully point this out, and ask again.
If you are a doctor and there seem to be multiple patients in your practice with similar vaccine concerns, hold a few group talks to openly address the concerns and share your knowledge with multiple people at once. Make a video addressing common concerns, make it comprehensive, include analogies, show appreciation for concerns as you discuss them, and put it on your website. No matter how exasperated you may be with the whole anti-vaccination issue, show empathy, kindness, and compassion to those with fears. Teach your patients, and don’t chase them away with outward manifestations of your frustrations.
Let’s live beyond the memes.