Image: Medicine for injection from Marco Verch's Flickr Photostream

Communicating Public Health in a Changing Landscape

Some of you may already be aware of the latest Netflix documentary Behind the Curve. It focuses on a group of conspiracy theorists who persist in believing that the earth is flat. The film has attracted a lot of positive reviews and some critics have made the link between this group of people, in denial of scientific consensus, with those who are part of the Anti-Vaxx community. The issue of vaccination is currently a hot topic with childhood diseases such as measles on the rise again. Indeed, it is perhaps no coincidence that during #worldimmunizationweek (traditionally the last week of April), US President Donald Trump, somewhat surprisingly, announced to reporters outside the White House that:

The vaccinations are so important. This is really going around now,”. “They have to get their shots.”

The reason it is surprising is that Trump has repeatedly spread misinformation about links between MMR and autism. Trump’s statement comes in the wake of news that America faces its highest incidence of measles in 25 years and maybe just months away from losing its ‘measles free’ status (thus becoming the only country apart from Venezuela that has not eliminated measles in North and South America). In this context, his apparent reversal of position was unexpected and welcome.

The issue of vaccinations is complex and complicated. There is shame and opprobrium from all sides for those identified as different or other. Disturbing stories of anti-semitism have been uncovered in areas of New York where there are large numbers of the ultra-Orthodox Jewish community who are blamed for not vaccinating their children. The situation is not perhaps as clear cut as we might assume. These processes, of what we might describe as vaccine ‘hesitancy’, are not that unusual. Certainly, amongst orthodox Jewish mothers I interviewed for a London based study there was some anxiety associated with immunisation. Although relatively insulated from media influence, there was no doubt that word of mouth was a potent source of rumours about vaccination dangers. Being part of a tight-knit global community also led to a sense of relative safety in relation to tuberculosis. In other words, low uptake of different immunizations appeared to arise from enhanced feelings of both safety and danger. Apparently, in some neighbourhoods of New York there is rising resentment because of the perception that Jewish people are directly to blame for measles outbreaks.

Erica Wingate was working at a clothing store in town this week when a male customer, with the black hat and sidelocks typically worn by ultra-Orthodox Jews, started coughing. Another shopper standing next to him suddenly dropped the item she had been holding and clutched her child. “She was buying something, and she just threw it down,” Ms. Wingate recalled. “She said, ‘Let’s go, let’s go! Jews don’t have shots!’”

The World Health Organisation has warned that the anti-vaccine movement is one of the worst health threats facing humanity and that reluctance or refusal to immunise “threatens to reverse progress” made in tackling preventable diseases. This raises the question of how have we got here? It is worth considering what has changed since Andrew Wakefield’s study linking MMR to autism was published in the Lancet in February 1998. This paper was subsequently retracted, with Wakefield being struck off the medical register ‘for offences relating to dishonesty and failing to act in the best interests of vulnerable child patient’. How have we arrived at the point where the Head of NHS in England warns of a growing public health time bomb in relation to vaccinations?

The growth of the so-called ‘Anti-Vaxx movement’ cannot be ignored. High profile celebrities are part of the community including actors Jim Carey and Alicia Silverstone. These celebrities often base their views on being pro-choice or cite their personal experience of children who were ‘never the same again’ following vaccination. Jenny McCarthy, whose son is autistic, has been vocal about her opposition to MMR for years though, she has recently toned down her stance to what she describes as a ‘pro safe vaccination’ perspective:

I don’t think it was just the MMR shot that caused any kind of trigger with autism. I think it was a compilation of so many shots to a kid that obviously had some autoimmune disorders. So I would say maybe a couple of months, a month or so after the MMR, I started to notice some physical ailments such as constipation, rashes, eczema. That was like the first little sign. And then the train just kind of descended from there.

The current crisis speaks to wider debates about differences in lay and scientific perceptions of risk, ethics in public health and issues around public trust in science. It also raises important questions about science and risk communication in the media. Social media has helped build platforms for these views. Larry Cook is a key anti-vaccine campaigner who uses closed Facebook groups to fuel fear through emotive advertisements targeted at mothers. Through these types of processes, doctors who advocate vaccination become the subject of orchestrated personal and professional harassment, through the posting of online negative reviews of their services and repeated and highly personal attacks. In this context, the Anti-Vaxx movement is often linked to far right and so-called ‘populist movements’, via claimed concerns about scientific expertise.

Twenty years ago traditional media were being criticized for giving Wakefield a platform to air his views which challenged the scientific consensus and were found to be baseless. Currently, we have a perfect storm of public concern about ‘fake news’, coupled with a purported decline in trust of institutions, a rise in the popularity and widespread use of social media and mistrust in ‘Big Pharma’. It is in this context that conspiracy theories abound and are distributed easily and quickly.

So, what should public health professionals be doing? Well, there needs to be fresh thinking around how health messages are communicated.  This is not just about immunization misinformation but also about the plethora of fake science stories which circulate on social media. Debunking these is only part of the issue. Many Anti-Vaxx websites are dominated by themes of safety and effectiveness, alternative medicine, civil liberties, conspiracy theories and morality. As such, it seems that education alone is insufficient. To challenge those who oppose vaccination is to look at engaging with alternative explanatory models of health and indeed with world views which include distrust of expertise.

We do not need to redress a science ‘deficit’. Rather we need to become involved in ideas of civil liberties and individual empowerment.  At a time where we are promoting personalised medicine and individual patient choice, we would be advised to think also about how these ideas might have unintended consequences which could undermine important concepts of herd immunity and community protection.  In the era of new media and so-called ‘anti-elitist’ movements, public health campaigns will need to be agile in terms of the responsibilities and benefits of immunization and invent novel ways of communicating.