Vaccine refusal

Vaccine refusal is one of the most difficult health problems of our age. In the Democratic Republic of the Congo a terrible Ebola epidemic is raging -and has just had its first case in the major city of Goma- despite the existence of an effective vaccine. There have been outbreaks of violence directed against public health workers, which have made fighting the outbreak infinitely more difficult. But these workers are not alone. In Pakistan and Afghanistan polio cases are rising, and public health workers have faced threats, stigma and violence as well. Polio is appearing in tests in neighboring countries now, from southwestern China to Iran. While it’s easy to portray the people in these countries who refuse vaccination as being ignorant or uneducated, the truth is that in the United States, Canada and Europe we have a similar problem with vaccine refusal. As I discussed in another post, there was recently an outbreak of measles near Portland, Oregon, which was driven by low-vaccination rates.

There are many factors driving these fears of vaccines and public health measures. But one common element is conspiracy theories, which have been a recent focus of my research in public health. With Zika, people adopted conspiracy theories that discouraged them from putting screens in windows, abstaining form sex after infection, and implementing mosquito control efforts. In Indonesia, these sentiments were one of the factors that briefly led the country to stop cooperating with the World Health Organization by sharing viral samples that could help prepare pre-pandemic vaccines against avian influenza. During the 2009 H1N1 outbreak some right wing pundits  in the United States used conspiracy theories to stigmatize Mexicans, while some people in Latin America argued that the virus had been created in a lab in the United States.

While I cannot prove this, I believe that the same factors that are driving the rise of populism and nationalism globally are also feeding anti-vaccine beliefs: a mistrust of authorities, disdain for education, and a sense that the system is fundamentally broken or rigged. In particular, it betrays a trust in elites, which is a broad term that is even used to describe the doctors, teachers and government employees who may serve the public. It also betrays a breakdown in social unity, so that the idea that one cabal of people would seek to do terrible things -such as injecting harmful vaccines into a particular group for financial benefit- appears plausible. Conspiracy theories flourish in times characterized by high levels of political division and mistrust, as my colleague and I discussed the context of Argentina.  What is heartbreaking about these conspiracy theories is that they show that even having vaccines is not enough to stop an outbreak, as the DRC’s ongoing experience with Ebola demonstrates.

In this context, I strongly recommend a podcast episode titled “Adverse Events: Vaccines and the Media.” This particular episode is part of a podcast series called “Going Viral: the Mother of all Pandemics,” by Mark Honigsbaum and Hannah Mawdsley. In general the podcast examines the 1918 influenza pandemic in an insightful and critical manner. But this particular episode convenes a panel to look at the role that the media -and social media- has played in shaping how people view vaccines. The panelists talk about vaccine refusal from Japan to Ireland, and how the experience with discredited doctor Andrew Wakefield in the UK has shaped media coverage of vaccines. The panelists also discuss difficult questions, such as whether there is a moral panic about vaccine refusers now, so that journalists are hesitant to discuss real issues with vaccines.  If you enjoy the episode, you might want also to read Mark’s book, Pandemic Century, which looks at SARS, Zika, influenza and other threats. One of the book’s points is that human behavior has always impacted outbreaks.

I will finish with a personal story. About five years ago I went on a wonderful vaccination to Nova Scotia. I watched Shakespeare in the park, hiked trails, kayaked and ate lobster with family. Not too long after I returned home my wife pointed at my leg and said “what is that? You need to go see a doctor.” My thigh had a bulls eye rash, which had a large red blotch in the middle, surrounded by another circular rash. Since my regular doctor was out, by chance I saw a doctor who had practiced in a rural area of a midwestern state (Wisconsin?), where Lyme disease was common. She took one look at the rash and said that she would do a Lyme test, but that she was staring me on antibiotics now. In her experience, there were a significant number of false negatives with the test. My rash looked so similar to all the others that she had seen with Lyme that she would prescribe antibiotics even if the test results were negative. I finished the antibiotics (perhaps a ten day course) and never had any symptoms. But when the test results came back they were negative. Later when I saw my family doctor he said that since the test was negative he would not have given me the antibiotics if he had seen me that day. In his view, the rash didn’t match Lyme clearly enough to make a diagnosis on that basis alone. To this day I don’t know if I ever had Lyme disease.

Years later I happened across an article in a magazine called Vox that pointed out that we have a vaccine for Lyme in dogs but not in people. This fact, the article suggested, was not because it was more difficult to design a vaccine for people, but rather because it was more difficult to persuade people to take a vaccine. SmithKline Beecham created a vaccine that the FDA approved in 1998. But the drug maker pulled it from the market after some people reported joint pain, even though there was never solid scientific evidence that the vaccine was flawed. As Brian Resnick pointed out in this essay, the vaccine came out during the height of popular fears of vaccines.

Since the vaccine became unavailable, how many people have been needlessly infected with Lyme. How much anxiety and fear have parents and loved ones suffered after someone is infected? And how many kids have been told not to play in the woods or go off the path? Although I teach (online) for Portland State University, I live in Massachusetts. Here there are places (Martha’s Vineyard and Nantucket Island, for example) where the rate of Lyme is so high that everyone knows someone who has had it. And so many people for whom Lyme has had life-changing effects. This includes those people for whom the outdoors will never again be a place that they can enjoy spending time. Why did the story of the people whose lives been deeply impacted by Lyme matter less for the vaccine’s success than the small number of people who reported side-effects from the vaccine? There is no understanding this fact without considering peoples’ perception of risk, which is why I think that this podcast episode “Adverse Events” is so interesting.

There are risks to vaccines, and sometimes it can be difficult to judge if apparent side effects are real. Still, vaccine refusal isn’t driven by the science around these risks. While we have developed new tools to address old threats, it has become far more difficult to use them. Let us hope that we make as much progress in understanding the social issues around disease as we do of the biology, before the next outbreak appears.

Shawn Smallman, 2019

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