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What Do We Really Know About Social Resistance to Vaccines?

Sara Gorman explores some of the factors behind anti-vaccination movements. 

Image credit: RIBI Image Library at Flickr
Image credit: RIBI Image Library at Flickr

Last year, polio eradication efforts were severely compromised by a rash of killings by militants in Pakistan and Nigeria. Between December 2012 and January 2013, at least 16 polio workers were killed in Pakistan. In early February, more bad news arrived: 9 health workers were murdered in northern Nigeria while working on the polio eradication campaign.

Potential explanations and suggestions for future action poured out following the attacks. Some people thought the CIA’s actions years earlier in the Bin Laden assassination laid the groundwork for Pakistani suspicion of Western vaccination campaigns. By employing a Pakistani doctor to gain entry into what was thought to be the Bin Laden compound by feigning a vaccination program, the agency perhaps stirred local suspicion of the real motives behind Western-based vaccination campaigns. Of course, the resistance to polio vaccination is also largely political, especially in countries like Pakistan, where polio workers have been seen as “soft targets” for anti-Western terrorism. Some people believe that the murders are connected to beliefs that the vaccination campaign is really an effort to sterilize Muslim children. In response to these allegations, some are suggesting better education, outreach, and communications about the devastating effects of polio and the real benefits and risks involved in vaccination.

These killings should be stimulating an essential set of questions about our knowledge of vaccine resistance: what do we really know about social resistance to vaccines? How much do we know about the demographics of vaccine resistance, and how well do we truly understand fear of vaccines, a fear so overpowering that it has motivated murder? How much does social resistance to vaccination vary across cultures? In other words, are Muslim fears that foreign vaccination programs are designed to sterilize Muslim children that different from U.S. parents’ conviction that the government has been poisoning children with vaccines for decades and is intentionally covering it up?

A few, but not many, studies have been done to begin to understand the demographics, spread, and circumstances behind various anti-vaccination movements or instances of vaccine non-compliance. One study published in PLOS One in September 2012 examined fear and resistance to the polio eradication program in Aligarh, India in 2009. The study found that vaccine fear and resistance were borne from a kind of fatigue and suspicion that stemmed from confusion about changing vaccination strategies. When the polio eradication program shifted from a strategy of vaccinating a few times per year to a strategy of a more aggressive short-term vaccination campaign involving shots once per month, families were left confused and suspicious about the efficacy of the vaccine in the absence of explanation by officials. The result was what the authors call “vaccine fatigue,” suggesting that lack of proper explanation of all the details in a vaccine program, including the frequency of administration of shots, may contribute to suspicion and fear of vaccines. A 2007 study published in PLOS Medicine investigated the polio vaccine boycott situation in Nigeria. The author of this article insists that social resistance to vaccines be placed in the wider political and social context of health services in northern Nigeria. Controls on population growth in the region since the 1980s led to suspicion of vaccine programs in particular, which were believed to be a method of checking on the number of children in each family. Similarly, aggressive vaccination campaigns are particularly eyebrow-raising in a region where healthcare is generally difficult to attain. As the author notes, free door-to-door healthcare in northern Nigeria is as bizarre as a stranger going door to door handing out $100 bills in America. In the end, the study urges widespread public awareness campaigns about the benefits of vaccination and sensitivity to local politics to help avoid future boycotts.

A few similar studies following disease outbreaks in the absence of vaccination in pockets of the U.S. have revealed the general demographic of the anti-vaccine movement: middle-to-high-income whites who favor natural, organic foods and remedies. A few other studies have taken a close look at anti-vaccination websites to try and gain a better understanding of how anti-vaccination materials are formulated and how they spread.

The truth is, we have relatively little data about the demographics and nature of anti-vaccination thought and the mechanisms of its spread. But we do know that anti-vaccination sentiments have a very long history, at least in developed nations such as the U.S. and England. A common belief is that smallpox elimination in the U.S. represents a case of unique cooperation between a terrified public and an even-handed, responsible public administration. But resistance to smallpox vaccination was potent, probably much stronger than today’s American anti-vaccination movement. In fact, vaccination against smallpox in those days was often a risky business, with little government control over quality and safety. Compulsory vaccination was seen as potentially dangerous and certainly a threat to civil liberties. Antivaccination leagues in 1900 performed very similar actions to antivaccination activists in 2013: they challenged compulsory vaccination laws and staged boycotts. They even rioted and hid sick children from vaccination authorities.

What can we learn from this long history of antivaccination sentiments and what do we still need to discover about today’s antivaccination movements, active all over the world? We can probably learn something from certain “golden ages” in vaccine history. When were people particularly cooperative, and what circumstances helped to produce this acceptance? Perhaps looking back to the types of messages and outreach that public health officials provided in times of low vaccine resistance might give us some ideas about how to offer a more effective PR message about vaccines today. Perhaps most importantly, we need to know more about how vaccine resistance movements operate. What exactly are the demographics behind these movements? What methods do they use to spread information? Are anti-vaccine believers clustered in certain geographical areas or social networks? How can we best distribute pro-vaccine messages to target the right people? These are all essential questions if we are to successfully encourage widespread uptake of this crucial public health tool. At present, the medical and public health communities often resort to pedantic educational campaigns and exhortation in the face of vaccine skepticism. But berating anti-vaccine adherents has not proven useful. Rather, we need to understand the roots and motivations of misguided health-related ideas in order to design effective counter efforts.

  1. Couple of important points are completely missing from your review. My guess, due to pre-conceptions that are not necessarily true. Bad for science.
    1) Not all anti-vaccination movements are the same. You properly analyzed one fraction – religious and cultural worry of the unknown, mixed with low education level. However, when you stumbled on another group that does not match your world view – you stopped short of the obvious conclusion staring you in the face: mid-to-high income whites in highly developed nation… Highly educated population very interested in their well-being with access, funds and understanding of the issue… Obviously, those people saw credible disadvantage of vaccination… Repeated: highly educated, highly interested in well-being.
    2) Disparity between medical community risk management viewpoint and goals and someone else with different risk estimates and very different goals. Widespread vaccination no matter what is public centered risk minimizer. “Good of the many more important than good of the few”. Well educated family raised on American individualism goals may see it differently – minimizing needles risk for them particularly. “Right of one individual is more important than benefit to the group”. Viewpoint that gave us such things as freedom of speech. I’d claim that such viewpoint is the real humanity. We are not ants or the bees. We are not collective. Benefit to society that brought us where we are now comes from INDIVIDUAL risk assessments and INDIVIDUAL choices. Different for each. Some will be right, some wrong but never in unison. Wrong collective decision – dead collective. Wrong individual choices – Darwinian selection in natural process, but species continuing as there are some who chose differently. That is the “secret” of human advance.
    Finally, what can be wrong with vaccination? Those well to do families may state greater risk of few severe possible but rare side effects vs. disease that can be treated fine. I see enthusiasm for vaccination run amok, similarly to happy DDT spraying or overuse of antibiotics (giving us severe problems). Because immediate public policy of killing bugs or washing every child hand every hour in the school seemed right. Sometimes vaccination is needless – I work at the large university, exposed to daily confined contact with hundreds as well as frequent air travel abroad, high flu exposure. Instead of “external” immune improvement by vaccination I chose to improve my own immune system function. Up to that point I have had regular flu and colds … since 2002 (almost 12 years!) when I raised my vitamin D levels to over 60 ng/ml , despite regular high exposure (and regularly flu/cold affected spouse) – 0 (zero) colds or flu despite intentional non-vaccination. Works for me, individual. Hence, over long term it will work for humanity.
    My advice would be – vaccinate against as few as possible most severe threats. For rest – let your own immune system take and learn the fight, you’ll be better off. For medical community – respect individual choice, do not be bully. It is never right to be a bully.

  2. Both the Salk and Sabin vaccines against Polio were embraced because there were visible reminders of the deadlyseriousness of this disease . My Mom always remembered the young gymnast who lived down the block playing with all the neighbors kids and her older son and then this young girl got sick, paralyzed, and dead in just a few days. They used to close public swimming pools in the summer when there was an outbreak. Fear drove the acceptance then and it appears that fear of vaccine safety is driving the anti-vaxer movement now. They just don’t see examples of the really bad effects the childhood disease can have. The fear has an emotional basis and so must be fought with an emotional campaign describing the kids who are permanently disabled or stories of those who dies because they were not vaccinated or worse being vaccinated and who lived in a high unvaccinated area and whose immune system just couldn’t cope with the multple insults.

  3. Why do you ask about social resistance to vaccines? Do one ever ask about social resistance to drugs?

    My point is that vaccines, like drugs, are very different from each other: they use different types of antigens, adjuvants, production processes. They are alive, or not. They may contain many unidentified, extraneous molecules, or not.

    The cost/benefit/risk ratio is very different from one vaccine to the next. Populations and individuals benefit a lot, or not at all, from different vaccines.

    Some vaccines clearly prevent disease, while others (like HPV vaccines Gardasil and Cervarix) have only been shown to affect surrogate markers.

    As a physician, my job is to choose the most effective and least risky and expensive solutions for my individual patients. I have little interest in protecting my patients against surrogate markers; my preference is to prevent disease.

    Therefore I choose certain vaccines in certain circumstances. Flu vaccine rarely, and HPV vaccine not at all. My choices are scientific, not social.

    Why are you calling this social resistance? Why are thoughtful medical consumers and practitioners being tagged as anti-science, when in fact we may be more familiar with the vaccine literature, and more scientific, than our detractors?

  4. The primary roots and motivation I have seen are these:

    Formerly trusting provax individual gets some vaccines (for self or child) followed by a serious vaccine reaction. This reaction is called a “coincidence” by doctors and govt agencies. The parent/individual is unable to find good support and treatment from mainstream medicine. The parent/individual loses confidence in the vaccine program.

  5. I think of you look at the history of vaccine development and testing by both Western governments and pharmaceutical companies, you may understand the root of distrust. It is certainly not without merit or a product of hysteria – and the more the PR supposedly representing the scientific community fail to acknowledge ethical missteps (which include even using prisoners in Guatemala as human guinea pigs and as well as US prisoners – clearly some lives are more disposable than others), then the distrust and resistance will grow. We also cannot sweep criticisms of over or abuse of vaccination in the young children under the rug just because they are excellent sources of funding. Vaccines, like antibiotics, are powerful medical arsenals but there is a lack of wisdom in their application. Perhaps they should be reserved for life and death situations and not for chicken pox because immune education and following the natural course of immunity is important. We are just realizing the adverse effect of excessive sterility on the immune system. Women’s immune systems are twice as strong as men’s when it comes to producing antibodies – but we don’t tailor vaccine doses by what one’s body can handle. The adverse side effects could be dramatically reduced if there was sound experimentation to see changes in the immune repertoire, immune resiliency cross-reactivity with inert antigens, susceptibility to autoimmune and allergic responses over the course of time following vaccination. Is there any association with the increasing number of childhood vaccines and the epidemic rise in immune disorders and allergies – when I was a kid, not too long ago, we could take peanuts to school. Now they are banned because of the threat of anaphylactic shock to a legume we have cultivated through generations. It is important that both sides keep an open-mind on the issue, but I feel one should have autonomy over one’s body and what is injected into it. Conflict of interest statement: I am an immunologist with a doctorate in Experimental Medicine specializing in innate immunity.

  6. The author does not need to “declare” conflicts of interests to be conflicted. The conflicts are not necessarily direct nor financial. All of the institutions to which she owes her “education” are funded in part by, and their curricula created by pharmaceutical interests. As such, her entire education has been received within a paradigm of which she is probably not even consciously aware. Having said that, the blinders which limit her world view are blindingly obvious.

    Firstly, there is a built in assumption that the primary issue in vaccine resistance is “demographic”. It is not. It is not based on money, education or location. If anything, it is based on ability to critically evaluate varying sources of information including HMDS’s and vaccine package inserts and personal experiences. In the case of India, it is based on parent’s own experiences of vaccine injuries and deaths. Before the polio eradication campaign in India, there were an average of 8,000 paralytic polio cases per year. Last year there were 46,000 cases of what has now been called nonpolio acute flaccid paralysis cases. These cases are not called “polio” because they only occur in the vaccinated and are not being caused by wild polio, but rather the vaccine strain. It is clinically the same as paralytic polio except it is more severe with a much higher mortality rate. On top of that, the Indian Government recently found that vaccine trials were being held by leading pharma companies without abiding by Indian laws for trial safety and informed consent.

    So simply put, we have a country which has a much higher rate of paralysis and death from a clinically identical disease after vaccination as compared to before and a track record of corporate greed overshadowing local laws and morality. This is not a case of “demographic resistance”. This is a case of people waking up to what is in plain sight but ignored by corporate trained and/or financed cheerleaders who are trained to see every “positive” outcome of vaccination as proof of efficacy and safety, and every “negative” outcome as mere coincidence. I suggest the author, as well as anyone who claims to be “science based” start applying the true scientific method and search for the reality instead of trying to prove dogma through flawed research methods and corruption of objective scientific principles.

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