Lies spread through social media have helped demonise one of the safest and most effective interventions in the history of medicine. So how can we vaccinate against the disease of conspiracy theories and fake news? Tim Tonkin reports
‘The world and its peoples have won freedom from smallpox… collective actions have freed mankind of this ancient scourge and, in so doing, have demonstrated how nations working together in a common cause may further human progress.’
These triumphant words formed the WHO’s (World Health Organisation) 1980 declaration proclaiming the eradication of smallpox – a virus responsible for the deaths of hundreds of millions of people throughout history, following a 20-year global public-health campaign.
During the last two centuries, vaccination has proved itself as one of the most cost-effective methods for disease prevention. According to WHO it now helps to prevent up to three million deaths a year around the world.
Yet, much like the fall of the Berlin Wall was once prematurely cited as the permanent triumph of liberal democracy over totalitarianism, the end of smallpox did not spell the end of scepticism and opposition to vaccination.
Hesitant to accept
The phenomenon of ‘vaccine hesitancy’ is defined by WHO as the ‘delay in acceptance or refusal of vaccines’ despite the availability of such services. Those who stoke such sentiments are commonly described as ‘anti-vaxxers’.
As such, WHO has listed vaccine hesitancy alongside antimicrobial resistance and climate change as one of the top 10 global health threats of 2019, warning that such beliefs have contributed to a 30 per cent increase in measles cases globally.
The Wellcome Trust’s Global Health Monitor for 2018 meanwhile found that while 79 per cent of people globally strongly or somewhat agreed that vaccines are safe, 7 per cent strongly or somewhat disagreed, with 11 per cent indifferent and 3 per cent unsure.
The trust also identified that scepticism in vaccination has been creeping upwards in recent years in developed and developing countries. In France, for example, one in three people disagree that vaccines are safe.
Not coincidentally perhaps, France has recently seen a 462 per cent increase in the number of measles cases, rising from 518 in 2017 to 2,913 last year.
It is not a new phenomenon. Discredited research by Andrew Wakefield, falsely linking the MMR vaccine to autism, was associated with a fall in take-up of that vaccine after its publication in 1998. But while the years that followed saw a gradual recovery in public trust, the huge proliferation of anti-vaxxer activity on social media in recent years has led to a renewed, sustained, and stronger threat to public health.
Speaking at the Nuffield Trust summit in March, NHS England chief executive Simon Stevens read out a message, apparently posted by another parent to a WhatsApp group for his children’s school, to illustrate the type of anti-vax rhetoric he himself had encountered.
‘My kids aren’t vulnerable, and I think loading up on vaccines blocks their system from fighting disease as it should do,’ he paraphrased.
Mr Stevens went on to label anti-vaxxers as another part of the ‘fake news movement’ that appeared to be gaining traction.
Figures published by NHS Digital on childhood vaccination rates in England for 2017-18 showed a decline in coverage for three-quarters of the 12 vaccines routinely provided, compared to 2016-17.
MMR vaccine coverage in children aged one stood at 91.2 per cent in 2017-18 – the lowest rate since 2011-12 and well below the 95 per cent recommended for conferring herd immunity.
Health and social care secretary Matt Hancock has publicly stated his growing concern with the spread of anti-vaccination messages online, to the extent that he has more than once raised the idea of compulsory vaccination, while qualifying that such a move is not something he wants or feels is yet necessary.
‘I have called in the social media companies… to require that they do more to take down lies that are promoted on social media about the impact of vaccination,’ he said in April. ‘Vaccination is safe and is very, very important for everybody’s health.’
The significance of social media in amplifying false concerns has become apparent to David Turner (pictured below), a GP in Hertfordshire.
While the number of patients expressing concerns seemed to have peaked following the Wakefield case, and then were falling away, he says they have been reignited in recent years.
<img src=”http://www.bma.org.uk/~/asset/4/39137.ashx?format=8″10000″ alt=”Issue 12 The Doctor” />
‘I would say that [anti-vax ideas] are creeping up again. It had gone away but it’s come back again with people using things like Twitter and Facebook where damaging messages are being spread.
‘A lot of people ask for separate vaccines rather than the combined MMR, which is not something we do on the NHS. They might then decide to go via a private clinic, which can lead to a delay and put children at risk during the interim period.’
He says that, while there is no specific training on how to handle a discussion on vaccines with a hesitant patient, having good general communication skills and judgement often makes all the difference in addressing concerns.
‘I think it’s really first of all about finding out where a patient has been getting their information from and why they believe it,’ he says.
‘If you just dismiss their beliefs out of hand then you’re not going to get very far in persuading them. It’s about listening to them and then gently challenging those ideas by giving them the facts.’
Dr Turner says that explaining the importance of herd immunity and the fact that not being vaccinated could put others as well as oneself at risk, is also a persuasive approach.
He adds, however, that trying to talk round those trenchantly opposed to vaccination is generally a pointless exercise.
Certainly, a cursory glance at anti-vax online groups and message boards quickly reveals that there is no such thing as a casual or part-time anti-vaxxer. Discussion threads reveal that many contributors have invested considerable amounts of time in accumulating vast amounts of information to buttress their positions.
This information ranges from genuine yet highly selective facts cherry-picked from scientific papers, to blatant pseudo-scientific falsehoods, around the science of vaccination and the supposed consequences.
Bizarre echo chamber
Anecdotes shared by parents on one public group give some insight into the views and attitudes that can propagate within an online echo chamber.
One contributor cites how their son was ‘vaccine injured and had autism’ adding that thanks to treatment he was ‘cured’ of the latter.
Another said that the MMR vaccine had led to her son developing Type 1 diabetes, while another parent expressed concerns about the risk of her child being exposed to ‘viral shedding’ from vaccinated children.
It also seems that if you believe one conspiracy theory, you may well believe them all. Many of the anti-vaxxers online also express views about the veracity of the moon landings, for example.
US president Donald Trump, a proponent of the absurd and offensive notion that his predecessor Barack Obama had lied about his place of birth, was also once an anti-vaxxer.
In March 2014, he tweeted: ‘Healthy young child goes to doctor, gets pumped with massive shot of many vaccines, doesn’t feel good and changes – AUTISM. Many such cases!’
He has since, apparently, changed his view, urging parents to get their children vaccinated amid a serious measles outbreak.
Heidi Larson (pictured below) is director of the Vaccine Confidence Project at the London School of Hygiene and Tropical Medicine, having previously headed up UNICEF’s global immunisation communication.
She says that while vaccine questioning and alternative beliefs are not in themselves new, the role of the internet has been a game changer.
‘In my view the waves of anti-vaccine sentiment have been a tipping-point phenomenon in the sense that we’ve primarily had a lot of these other infrastructure and access [to vaccination services] issues but this is on top of all those other issues,’ she says.
<img src=”http://www.bma.org.uk/~/asset/4/39135.ashx?format=8″10000″ alt=”Issue 12 The Doctor” />
‘The questioning of vaccines is not new but in the context of social media it is amplified quite a bit.
‘We do see from our 67-country study into vaccine hesitancy that Europe featured as the most sceptical region in the world [and] the countries that we picked up as being the most sceptical absolutely correlated with the worst measles outbreaks that were seen a couple of years after [the study].
‘We can’t pretend that it’s not having an impact.’
Professor Larson is keen to stress that declining vaccination rates cannot solely be explained by online anti-vaccine material, pointing to other factors such as underfunding and lack of access to public health services.
She adds that while efforts to do more to tackle false information online is important, the medical establishment also needs to up its own game in how it communicates with – and listens to – the public about vaccination.
‘The problem is the tendency that we push out, as a medical and public health community, the information that we think is important, but it’s not necessarily what people are asking and that disconnect has really been a problem.
‘The reality is that some of the questions that the public are asking are not the sort of things that doctors and healthcare professionals will necessarily have at their fingertips.
‘I don’t say that with any criticism of the doctors. The public is coming up with questions that are well beyond any medical curriculum, really probing on things like ingredients in vaccines.
‘We do need a more proactive effort to contain the negative information but also to be in that same social media space with better and more accessible information that is responding to people’s questions.’
Public health cuts
Other doctors agree that the proliferation of conspiracy theories about vaccines is not the only reason for falling take-up rates.
BMA public health committee chair Peter English (pictured below) points to the ‘huge cutbacks’ in health-visitor services, meaning parents receive fewer reminders about vaccination and less follow-up when they miss appointments.
A report published by the CD Howe Institute in Canada identifies factors such as parents who face difficulty in getting time off to enable their children to attend health centres and a general sense of complacency as being significant factors.
Some would argue that you reach a point with public health arguments where you can have all the reasoned discussions in the world but it’s still not enough, and that’s where the law comes in. The compulsory wearing of seatbelts is often cited.
<img src=”http://www.bma.org.uk/~/asset/4/30209.ashx?format=8″10000″ alt=”Peter English, Chair of Public health medicine committee 2018″ />
But there are two considerations as soon as something is legally mandated or banned – unintended consequences, and whether society is willing to follow through on enforcing the law.
Dr English says: ‘The problem is, would it improve uptake or not? Are we seriously going to arrest people or force children to be vaccinated against their parents’ wishes? I can’t see that being feasible.
‘There’s a serious concern that if you made it compulsory, people who would otherwise have had their children vaccinated won’t do so because they don’t like being told that they must.’
In the absence of compulsion, then, this is a battle of information. It’s a battle that doctors took to the high-tech giants at the BMA annual representative meeting in June. They urged the BMA to lobby the Government to compel social-media corporations to prevent the dispersal of false or misleading information on the effects of vaccination.
Midlands foundation doctor 2 Rebecca Acres was one of those who spoke in favour of taking action. She said her own mother had struggled with whether to get her vaccinated because of the information she was hearing about the false links made between MMR and autism.
‘Since then, my extended family have experienced a diagnosis of autism in a relative vaccinated with separate measles, mumps and rubella vaccinations at high profit to a private service,’ Dr Acres said.
‘That relative is a brilliant, bright person integral to our family lives and their autism is not worse than the risk of death from measles.’
She added: ‘I hold Andrew Wakefield, and those anti-vaxxers who have turned him into some kind of tragic hero, personally responsible for significant harm to young people like me, my family and the students and youth in my church community.’
Almost 40 years on from the global eradication of smallpox, the next big victory: the eradication of polio is tantalisingly close, with the virus now endemic to only three countries. And yet what should be remembered as an era of successfully tackling terrible diseases may be as much remembered for one
of needless setbacks.
Pseudo-science, fake news and conspiracy theories are diseases in themselves. If only there was a simple vaccination to prevent them. It will be a battle that every doctor will need to fight.
Anupam Ghose, a physician by training, was diagnosed with Type 2 Diabetes Mellitus (T2DM) in 2017. After the diagnosis of T2DM, he followed a low carbohydrate high fat diet and reversed his T2DM within a year. Now he has one main goal in life and that is to make people understand that the conventional method of treating T2DM is not beneficial. Type 2 diabetes is reversible and the best way to reverse T2DM is through diet and lifestyle modifications. He now decided to help people with type 2 diabetes by offering online coaching to reverse their diabetes.