Psychology of the Anti-vaccine Movement
The most common of all follies is to believe passionately in the palpably not true. It is the chief occupation of mankind.
—H. L. Mencken
Although it is disconcerting to believe, studies show that there is no reproducibly effective approach to the vaccine discussion with anti-vaccine patients, at least not that we’ve found so far. Particularly, attempts at education and correction of misinformation about vaccines rarely cause people opposed to immunization to change their minds and can actually cause their doubts to become more entrenched.1,2,3 As tempting as it is to do, it turns out that throwing numbers and percentages at people may not be the most useful approach. This is not to suggest that education about vaccines isn’t important, however. It is vital for medical providers to be able to easily discuss the facts, data, and science behind vaccines. Anti-vaccine people have often done hours of “research” to support their concerns, and, if we don’t have the knowledge to speak to those concerns, we will lose their confidence and only fuel their belief that they are more educated on the subject of vaccines than we are (see chapters 9, 10, and 11 for detailed discussions about anti-vaccine concerns and their data-driven counterarguments). Likewise, if we don’t acknowledge the very rare, but real, potential adverse effects of vaccines, we will lose patients’ trust, and they may be less inclined to believe that we have their best interest, or that of their children, at heart.
The statistics about vaccines and vaccine-preventable disease are impressive to us as scientists and medical professionals, but some of our patients will more naturally gravitate to the “lies, damned lies, and statistics” view of such data. Science hasn’t always given us correct information (for example, the now-corrected assertion that all fats are bad for you), and patients may not fully trust that these data or numbers should be believed or that they are applicable to their family’s lives. As medical providers, we are often working against an inherent mistrust of the medical system as well as invisible enemies (family, friends, Facebook groups, Twitter campaigns) who play on the fears of our patients, particularly the fears of parents. So, what can we do to change people’s views?
When we think about the anti-vaccine movement, a certain picture comes to mind. It conjures up images of hostile people shouting at their public representatives, individuals wielding signs at rallies that accuse doctors of being in bed with Big Pharma, and making claims that vaccines cause everything from seizures to multiple sclerosis to cancers and worse. We may recall uncomfortable
encounters we have had with patients who absolutely refuse to hear our recommendations about vaccines and our explanations of safety and effectiveness. We may feel insulted and frustrated by people who seemingly don’t trust our years of education and self-sacrifice to help and to heal. For a small minority of people, these images may be correct. However they are by no means representative of what all anti-vaccine people are like. We have a tendency to think of people who refuse vaccines as a homogenous group, but it turns out, as with everything else in life, there is a spectrum.
encounters we have had with patients who absolutely refuse to hear our recommendations about vaccines and our explanations of safety and effectiveness. We may feel insulted and frustrated by people who seemingly don’t trust our years of education and self-sacrifice to help and to heal. For a small minority of people, these images may be correct. However they are by no means representative of what all anti-vaccine people are like. We have a tendency to think of people who refuse vaccines as a homogenous group, but it turns out, as with everything else in life, there is a spectrum.
I would argue that we have found no one effective approach to the vaccine discussion with our anti-vaccine patients, because there is no one type of vaccine-resistant person. They are not a singleminded group. They are a group with varying concerns and motivations. Understanding those motivations and understanding the different belief systems at play in the anti-vaccine movement are vital to helping scientists and medical providers bridge the divide between reason and emotion that is so central to their line of thinking.
This chapter will look at the fascinating work that is currently underway examining the psychology of the anti-vaccine movement, trying to better understand what drives it. We will look at studies that try to find commonalities in belief, for example, by evaluating the socioeconomic break-down of the anti-vaccine community and looking for patterns in the political leanings of the group’s members. We will look at the field of social psychology, exploring cognitive bias and errors in logic and how they allow us to perpetuate and support beliefs that fit our preexisting views on a subject.4 This very important research is, I believe, where we will find our most helpful guidance in tailoring our message. Then perhaps, going forward, our investigations into strategies for dealing with anti-vaccine sentiment will take the varying subgroups of belief into account. As we are learning, a one-size-fits-all approach to the vaccine discussion is not working.
ANTI-VACCINE VERSUS VACCINE-HESITANT
First, it is important to recognize the difference between a truly anti-vaccine patient and the merely vaccine-hesitant patient. The anti-vaccine patient is part of a vocal minority, those angry individuals that we initially envision, who organize and lobby and bring literature to their appointments to try to educate us about vaccines. These folks are so entrenched in their way of thinking that we are hardly going to be able to hold a civil conversation, let alone change their minds about vaccines. They are operating from a place, not of reason, but of emotion and paranoia. Attempting to convince them of a more reasoned way of thinking is only going to increase anger and frustration on both sides.
Not engaging in debate with anti-vaccine patients is easier said than done, particularly when it comes to the ill-informed decisions they make on behalf of their children, who are the innocent bystanders in the vaccine discussion. I’m not suggesting that we should discontinue offering vaccines to people who adamantly refuse. On the contrary, we should continue to offer vaccines to anti-vaccine patients even though they may have declined in the past, to show that we care about their health and well-being. There is always hope that something will change their minds. Moreover, with continued emphasis on the importance of immunization, particularly during well-child visits, we may provide further education to their children who will hopefully grow up knowing the value of vaccines and will eventually make their own more-reasoned, pro-vaccine decisions as adults.
The people on whom we should focus more attention are those that would be better classified as vaccine-hesitant or vaccine-questioning. These people are not conspiracy theorists. They don’t think all doctors are shills. They generally trust our expertise
and motivations. Some may have merely seen too many scary anti-vaccine claims come across their Facebook or Twitter feeds. Others may have been a part of parent groups where doing everything “naturally” to avoid “toxins” is promoted. Still others are afraid of frightening diagnoses, such as cancers and autoimmune diseases, that the anti-vaccine movement claims vaccines cause. Moreover, many merely need additional information to fill in gaps in their understanding of vaccines that will allow them to feel more confident in their decisions. These are patients who have had grains of doubt and fear introduced into their minds, but they are generally eager to find reassurance and confidence in the counsel of their trusted medical provider. Working with our vaccine-hesitant patients is where we will find our greatest successes.
and motivations. Some may have merely seen too many scary anti-vaccine claims come across their Facebook or Twitter feeds. Others may have been a part of parent groups where doing everything “naturally” to avoid “toxins” is promoted. Still others are afraid of frightening diagnoses, such as cancers and autoimmune diseases, that the anti-vaccine movement claims vaccines cause. Moreover, many merely need additional information to fill in gaps in their understanding of vaccines that will allow them to feel more confident in their decisions. These are patients who have had grains of doubt and fear introduced into their minds, but they are generally eager to find reassurance and confidence in the counsel of their trusted medical provider. Working with our vaccine-hesitant patients is where we will find our greatest successes.
THE SOCIOECONOMIC AND POLITICAL BREAKDOWN
So, who are these vaccine-hesitant individuals? Studies looking at this question have found that people who use philosophical exemptions from vaccination are more likely to be white, college educated, married, and with a higher family income. Unvaccinated nonwhites from lower-income groups are more likely to be so due to limited access to health care services or limited financial resources.5 Unfortunately, it is also this population who would potentially see the greatest adverse impact should they or their child suffer from a vaccine-preventable disease. With a lack of job flexibility and security and the financial resources to support days to weeks off of work, potentially dealing with complications of illness that may require expensive medical visits, treatments, or hospitalizations, lower-income individuals and families have the most to lose. Reminders, flu clinics, and community outreach for vaccines, approaches that will decrease the cost and increase the convenience of getting immunized, may prove more effective in reaching our unvaccinated or under-vaccinated lower-income patients. Whereas, addressing vaccines with our middle- to upper-middle-class vaccine-hesitant patient population may require a more intensive and individualized focus.
These days, in the battle to lay blame at the feet of one group or another, it is also tempting to look for political affiliations that may be common to the nonvaccinating or vaccine-hesitant community. It turns out, however, that general anti-vaccine sentiment is not purely a conservative or liberal issue. It is more an issue of people with very strongly held beliefs, on both sides of the political spectrum. Charles McCoy, Assistant Professor of Sociology, SUNY Plattsburgh, has studied the political leanings of parents who refuse vaccination for their children, trying to understand any common motivations or concerns. Prior research on the topic of political affiliation and views on vaccination has been conflicting. However, McCoy’s evaluation of recent surveys by the PEW Research Center shows that the more staunchly conservative or staunchly liberal someone is, the more likely they are to believe that vaccines are unsafe. In looking at the political divide regarding vaccination mandates, however, it is more often the conservatives who feel that vaccination should be primarily under the purview of parents and not mandated by the government. McCoy’s research found that, as a group, conser-vatives are “twice as likely as moderates to think that [vaccination] should be a parent’s choice” compared with liberals who “are 43.5% less likely” than moderates to think it should be a parent’s choice.6 Though we don’t often delve into the political views of our patients unless they are voluntarily offered up, McCoy’s research does give us interesting food for thought, regarding how we may approach the vaccine discussion differently, depending on the leanings of our patients. For example, it may be a greater motivator to
conservatives to hear about how not achieving herd immunity can limit the freedoms of those children and adults who would desire to participate in their community without being at risk for serious illness and disease.
conservatives to hear about how not achieving herd immunity can limit the freedoms of those children and adults who would desire to participate in their community without being at risk for serious illness and disease.
FALLACY AND THE ANTI-VACCINE MINDSET
Understanding the ways that errors in logic can impact our decision-making is important as we try to develop approaches to vaccine-hesitant patients that will bring them to a greater level of confidence in vaccines. As human beings, we have an innate tendency to want to draw connections between events in our lives. These connections satisfy an emotional need for reason and purpose. They also represent an adaptive measure that helps us learn from our mistakes and protects us from making them again in the future. For example, if I grab the hot handle of a pot on the stove and burn my hand, then I will think twice before reaching to pick up something hot again in the future. This logical association is protective. However, some of our associations represent faults in logic that have the potential, as in the case of erroneous thinking about vaccines, to put us at risk. These errors in logic are called fallacies and we often see them at work in arguments used by the anti-vaccine community (Box 3.1). For the purposes of this book, we will examine a few of the most common.
A prime example is the fallacy in thinking that allows people to continue to draw a connection between the measles, mumps, and rubella (MMR) vaccination and autism, despite a large body of work showing no causal relationship. In this instance, we know that autism begins to show more overt signs and symptoms around the same age that the MMR vaccine series is administered (age 12 months to 4-6 years). Drawing the false conclusion that there is a causal relationship between the two because one event is followed by the other in time is a classic example of the Post Hoc, Ergo Propter Hoc Fallacy (Latin for “after this, therefore because of this”).7 We are, by nature, uncomfortable not knowing the reason behind events in our lives, particularly highly impactful events, such as when one of our children develops autism. “We can’t tell you why your child developed autism” doesn’t sit well with parents. We feel more settled with an erroneous explanation than with no explanation at all.
Some of the fallacies that are employed by the anti-vaccine movement could actually be used to our advantage. For example, the Appeal to Authority Fallacy happens when a statement is thought to be true just because someone in authority said it was true. We’ve seen this in the case of celebrities and politicians, such as Jenny McCarthy and Robert F. Kennedy, Jr, who claim, for example, that vaccinations cause autism or that the aluminum adjuvant in vaccines causes autoimmune disease.7 Perhaps, if we can
engage equally well-known individuals to speak publicly in support of vaccines and the science behind their safety and efficacy, we can gather more questioning people to the pro-vaccine side.
engage equally well-known individuals to speak publicly in support of vaccines and the science behind their safety and efficacy, we can gather more questioning people to the pro-vaccine side.
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