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Measles: low uptake blamed on “incredulity and hostility” towards doctors

BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l1932 (Published 26 April 2019) Cite this as: BMJ 2019;365:l1932

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Rebuilding trust in immunisation is key to tackling vaccine hesitancy

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Re: Measles: low uptake blamed on “incredulity and hostility” towards doctors

I agree with John Stone that we should have a “tolerant discussion of evidence” about the effectiveness, safety and importance of vaccines[1]. As far as understand, however, the jury is in and the evidence overwhelmingly supports the position that the benefits of vaccines far outweigh the risks. This is true if we look at vaccines in general: they have vastly reduced the prevalence of once common and devastating diseases and it is estimated that they save 2-3 million lives every year[2]. It is also true for the much maligned MMR vaccine: a recently published study that looked at 650,000 children in Denmark concluded there is no evidence of a link between MMR and autism[3], while it is estimated that measles vaccination has saved over 21 million lives this century[4].

It is important to acknowledge the context in which these discussions take place. In an ideal world, parents would read the evidence and make an informed decision to vaccinate their children based on the facts. In reality, we appear to live in what has been referred to as a “post-truth” era, where “objective facts are less influential in shaping public opinion than appeals to emotion and personal belief”[5]. This is borne out by recent studies. For example, Eurobarometer recently published a report in which 48% of the 27,000 people interviewed believed the statement that “vaccines can often produce serious side-effects” to be true[6]. At 54%, the figure was higher still in the UK.

It is perhaps not surprising that there is a strong correlation between populism and vaccine hesitancy. Countries such as France, Greece and Italy, in which populist political parties received a high proportion of votes in the 2014 European Parliament Elections, also have the highest levels of vaccine hesitancy in Western European[7]. Similarly, President Donald Trump has tweeted about the connection between MMR and autism[8]. This association can be explained by the fact that support for populist politicians and vaccine hesitancy are driven by similar feelings: distrust and animosity towards elites and experts.

All this raises the question of how public health authorities should respond to vaccine hesitancy. In the current context it seems unlikely that raising awareness of the benefits of vaccinations will, on its own, increase uptake. Therefore, JK Anand’s suggestion that we simply discuss vaccines with the public will probably not be enough to markedly increase coverage[9]. In such a situation, mandatory vaccinations might be the best option, as the state has a responsibility to safeguard those who have most to gain from herd immunity – e.g., children who have not been vaccinated because they are too young or because they are undergoing chemotherapy – from the consequences of individuals’ decisions not to vaccinate their children.

However, as John Stone notes, legislation making vaccinations mandatory is not unproblematic[1]. One major concern is that it plays into the hands of populist politicians[10]. This is what happened in Italy, where the decision by the former Democratic Party-led government to fine parents who sent unvaccinated children to school became an important issue in the 2018 elections[11]. The law was seized upon by the Five Star Movement and League and presented as an intrusion on parents’ freedom to decide what is right for their children. Interestingly, the law was successful at increasing coverage and, since being in government, the Five Star Movement and League have not repealed it.

Populists politicians’ reasons for objecting to mandatory vaccinations focus on freedom of choice[10-11], but they misunderstand the issue at hand. There is an argument to say that freedom of choice extends to the freedom to make wrong decisions about one’s health – although this is questionable. However, the decision to not vaccinate your children does not impact one’s own health, but that of your children and other people’s children. Indeed, research from the US shows that levels of vaccine preventable diseases are higher in areas where more parents opt out of vaccinating their children[12].

It should be noted that the state intervenes in many areas of life in order to stop individuals acting in ways that harm their children and other people. Ha-Joon Chang points out that in the 19th century economic liberals in the UK opposed legislation that outlawed child labour because they saw it as unnecessary state intervention[13]. In the 21st century child labour is widely seen as reprehensible. Similarly, we are not allowed drive drunk or over the speed limit because it puts us and other people in danger, and smoking is prohibited in many public spaces because it exposes non-smokers to the harmful effects of cigarettes. Few people would now argue that this legislation is unreasonable. Interestingly, one particularly prominent opponent of smoking regulation is Nigel Farage, who argues that it is symptomatic of the interfering big state[11].

Of course, as Allan Cunningham and Elizabeth Hart point out, we need be sceptical regarding the role of pharmaceutical companies, which are driven by the desire to make money rather than improve people’s health[14-15]. We must also be vigilant regarding how pharmaceutical companies use money to influence governments, researchers, and a variety of other influential actors. What is more, medical science is not infallible and Allan Cunningham and Noel Thomas note that there are questions that need to be addressed about specific vaccines[14,16]. Nevertheless, none of these points should be allowed to blur the headline message: the benefits of vaccines far outweigh the risks. The objections raised by Cunningham, Hart and Thomas do not suggest that this paradigm or research tradition should be replaced.

We should not overlook the fact that the so-called antivaxxer movement is an assault on medical science. As Marvin Harris points out, science is remarkable because it is the only way of knowing “in the entire course of human history and prehistory” that “has encouraged its practitioners to doubt their own premises and to systematically expose their own conclusions to the hostile scrutiny of non-believers”[17]. Certainly medical science does not always live up to this ideal and when it does not then it is important that concerned observers hold it to account. Having said that, we should not lose sight of the fact that medical science in general and vaccines in particular have brought enormous benefits to human kind.

REFERENCES
1. Stone, J. 2019. Rebuilding trust in immunisation is key to tackling vaccine hesitancy. https://www.bmj.com/content/365/bmj.l1932/rr-5
2. World Health Organization. 2018. 10 facts on immunization. http://www.who.int/features/factfiles/immunization/en/
3. Hviid, A., Hansen, J.V., Frisch, M. and Melbye, M., 2019. Measles, Mumps, Rubella Vaccination and Autism: A Nationwide Cohort Study. Annals of internal medicine.
4. WHO. 2018. Measles cases spike globally due to gaps in vaccination coverage. https://www.who.int/news-room/detail/29-11-2018-measles-cases-spike-glob...
5. Oxford Living Dictionaries. undated. Post-truth. https://en.oxforddictionaries.com/definition/post-truth
6. European Commission. 2019. Europeans' attitudes towards vaccination. Special Eurobarometer 488. https://g8fip1kplyr33r3krz5b97d1-wpengine.netdna-ssl.com/wp-content/uplo...
7. Kennedy, J., 2019. Populist politics and vaccine hesitancy in Western Europe: an analysis of national-level data. European Journal of Public Health.
8. Sun L. Trump’s vaccine views are at odds with those of most Americans, study says (2017). https://www.washingtonpost.com/news/to-your-health/wp/2017/02/02/trumps-...
9. Anand, JK. 2019. Re: Measles: low uptake blamed on “incredulity and hostility” towards doctors. https://www.bmj.com/content/365/bmj.l1932/rr
10. Kennedy, J. and Michailidou, D. 2017. Divergent policy responses to increasing vaccine scepticism in southern Europe. The Lancet Infectious Diseases 17(9), p.900
11. Kennedy, J. 2019. How populists spread vaccine fear. https://www.politico.eu/article/how-populists-spread-vaccine-fear/.
12. Salmon, D.A., Haber, M., Gangarosa, E.J., Phillips, L., Smith, N.J. and Chen, R.T., 1999. Health consequences of religious and philosophical exemptions from immunization laws: individual and societal risk of measles. Jama, 282(1), pp.47-53.
13. Chang, H.J., 2002. Kicking away the ladder: development strategy in historical perspective. Anthem Press.
14. Cunningham, AS. 2019. Incredulity and hostility: measles, AFM, bullying and mandates. https://www.bmj.com/content/365/bmj.l1932/rr-3
15. Hart, E. 2019. Re: Measles: low uptake blamed on “incredulity and hostility” towards doctors. https://www.bmj.com/content/365/bmj.l1932/rr6
16. Thomas, N. 2019. Re: Measles: low uptake blamed on “incredulity and hostility” towards doctors. https://www.bmj.com/content/365/bmj.l1932/rr-1
17. Harris, Marvin. 2001. Cultural Materialism: The Struggle for a Science of Culture. New York: Random House.

Competing interests: No competing interests

17 May 2019
Jonathan J Kennedy
Lecturer in Global Public Health
Barts and the London School of Medicine and Dentistry, Queen Mary University of London
Yvonne Carter Building, 58 Turner Street, London, E1 2AB