Intended for healthcare professionals

Feature Essay

New power versus old: to beat antivaccination campaigners we need to learn from them—an essay by Kathryn Perera, Henry Timms, and Jeremy Heimans

BMJ 2019; 367 doi: (Published 21 November 2019) Cite this as: BMJ 2019;367:l6447
  1. Kathryn Perera, director1,
  2. Henry Timms, senior adviser2,
  3. Jeremy Heimans, cofounder and chief executive2
  1. 1NHS Horizons, Coventry CV1 2WT, UK
  2. 2Purpose, New York, USA
  1. Correspondence to: Kathryn Perera kathryn.perera{at}

Healthcare professionals have grown up in “old power” institutions, but only by understanding how “new power” works can we respond effectively to the antivaccination narratives spread on social media, surmise Kathryn Perera, Henry Timms, and Jeremy Heimans

Shanelle Cartwright is a 20 year old mother of two young children and a social media influencer. Her personal account on Instagram has 7000 followers. Tens of thousands more people have interacted with the “healthy lifestyle” messages she promotes in blogs and online interviews.

The wife of a prominent rugby league player, Cartwright uses her global profile to share antivaccination stories. Some take the form of “informational pieces” and some cite, for instance, the books of Suzanne Humphries, a US nephrologist and prominent voice in the antivaccination community.

Others are deeply personal. They invite Cartwright’s virtual community to learn about her parenting philosophy, accompanied by photos of her young family. In a recent series of posts, Cartwright explained her decision not to vaccinate her children, citing her own experiences of developing “allergies and autoimmune disorders” as a result of vaccination, leading to a “(sloooow) process of healing.”

One of Cartwright’s most shared posts states that she would rather home school her children than succumb to clinical and governmental pressure to vaccinate them.

Restrictions on content

Facebook, which owns Instagram, recently introduced tougher rules for users sharing antivaccination content. As a result, Cartwright and other influencers like her have seen their accounts restricted. Yet such case-by-case restrictions do little to stem the surge of self organising networks that drive the rapid spread of antivaccination messages around the world.

The motivations of these communities vary widely. Some are driven by a suspicion of science and concerns about personal liberty—“I know what’s best for my child.” Others focus on “clean living”—emphasising homeopathic remedies over vaccination. Still others feed into wider conspiracy narratives—“governments ‘hide’ information that we believe to be facts.”

As content is shared, it is adapted and amplified for and by different groups. When one platform applies restrictions, the content simply migrates to other online platforms or transfers to semi-closed spaces, such as WhatsApp groups.

The impact is significant. Of course, access to vaccination is also critical,1 but this year, the World Health Organization listed “vaccine hesitancy” as one of its top 10 threats to global health.2 The rapid, self organised spread of antivaccination content both provides fuel for those promoting antivaccination sentiment and creates the conditions in which vaccine hesitancy is a growing public health concern.

Unlike in previous decades, this spread has no geographical limits. The global reach of communication networks enables pockets of vaccine hesitancy (and consequent lower vaccination rates) to emerge in geographically disparate spaces. An alarming resurgence of deadly measles outbreaks in countries where the vaccine is readily available has prompted WHO to call for “urgent action.”3 This resurgence includes the UK, which has lost its measles-free status (keeping company with three other European countries: Albania, the Czech Republic, and Greece).

The question is, what can be done to combat this spread?

The real story behind the success of Shanelle Cartwright and influencers like her is not social media in itself. It’s about the way ideas spread and how technology enables that to happen at pace. It’s about how communities of all kinds can build and “metastasise” rapidly, and the power that puts in the hands of people like Cartwright. In order to respond effectively with the “urgent action” that WHO demands, we need to recognise the shift in power that defines our times.

We all sense that power is shifting in the world. We see startup businesses flipping incumbents on their heads. We see surges of political power bringing unexpected figures into office. We see the institutions we once relied on faltering and falling. A complex transformation is underway, one driven by a growing tension between two distinct forces—old power and new power.

Old and new power

Old power works like a currency. It is held by few. Once gained, it is jealously guarded, and powerful people have a substantial store of it to spend. It is closed, inaccessible, and leader driven. It downloads, and it captures.

New power operates differently, like a current. It is made by many. It is open, participatory, and peer driven. It uploads, and it distributes. Like water or electricity, it’s most forceful when it surges. New power is exploited not by hoarding but by channelling.

Voices like that of Cartwright have impact because they have worked out how to use new power effectively and at speed. While opposition to vaccination has existed for as long as vaccination itself, what we now see is an unprecedented ability to organise power around that counter narrative. Its most influential figures have none of the expertise or professionalism of the old power world but they have all the efficiency of spreading their message in a new power way.

The challenge for many health professionals is that they have grown up—and shaped their careers—inside a system that takes the opposite approach to that of Cartwright and her allies. In the health and care world, power is still closely held. You are what you can hoard up. Expertise is downloaded from on high. The enduring stereotype of the doctor with his or her illegible prescriptions, insulated by arcane language, knowing what’s best for his or her patients, touches on a truth: most of the institutions in health and care were built on old power models and mindsets.

We see this old power approach playing out in how mainstream sources of health advice have sought to rebut antivaccination claims. Most either serve as information repositories or emphasise the evidence rebutting antivaccination claims. Neither of these approaches gets to the emotional core of antivaccination attitudes. Indeed, as leading provaccination voices such as Heidi Larson, director of the Vaccine Confidence Project, have stressed, simply throwing more information at the problem can lead people who are vaccine hesitant to become entrenched, as their underlying concerns are not being acknowledged.4

To beat the antivaccine campaigners, first we need to learn from them. Whether you’re a clinician working to promote vaccinations locally, a public health practitioner, or an interested citizen, here are three key steps for getting started.

Lesson 1: create context, not content

New power communities that work offer real agency to the participants. They create a context for people to do so much more than consume.

Andrew Wakefield, the British former doctor and researcher who gave birth to the modern antivaccination movement with fraudulent and discredited research (since withdrawn by the Lancet and renounced by most of its co-authors)5 has fuelled the rise of more than 100 community led Facebook groups. Each of these groups independently sustains, strengthens, and personalises the antivaccination message. This isn’t a message he “controls”: in fact, it is all the more resonant because he doesn’t. We need to see many equivalents of this type of self organised, distributed network on the provaccination side. A depersonalised leaflet in the GP waiting room can’t compete with this kind of distributed, infinitely customisable messaging.

Lesson 2: don’t bring a fact to a narrative fight

Experts and health professionals can arm themselves with white papers, peer reviewed studies, and symposia; but if these are our only weapons, we will only ever get so far. In an era in which experts are increasingly distrusted, the “we know best” mindset is counterproductive.

Those wishing to encourage vaccination need to identify and amplify the stories that emerge from the real lives and lived experiences of people in their communities (to start, they need to listen for them). It is no coincidence that the most effective climate advocacy in the world right now comes from the improvisations and stories of a 16 year old girl rather than the strategic plans of a generations old institution.

Lesson 3: not old power v new power; old power + new power

The point is not that old power is “bad” and new power is “good.” Our world desperately needs expertise, professionalism, and institutions to thrive. But while our mainstream institutions cautiously dip their toes into the water of new power public engagement, antivaccination sentiment that is spread peer to peer through new power networks continues to grow in scale, confidence, and influence. To date, the provaccination approach has failed to promote its narrative in a way that both resonates and spreads. This is especially important given the recent progress antivaccination forces have made in mastering old power techniques such as traditional lobbying efforts. Antivaccination campaigners are realising the potency of combining their new power with old.

It is easy to despair at, criticise, and wish away the antivaccination movement. But this movement’s success is based on tactics and thinking that can and should be deployed against it. This will require courage from health and care leaders, new mindsets from public health leaders and clinicians, and cross system experimentation. We propose that the right prescription for the health and care world is a daily dose of new power.


Kathryn Perera is the director of NHS Horizons, a specialist team focused on supporting the implementation of large scale change across health and care. NHS Horizons uses social movement and campaigning approaches to accelerate the pace of change in priority areas of the NHS Long Term Plan.

Kathryn started incorporating “new power” concepts into her work while co-presenting the virtual School for Change Agents (, the most widely used free online course in the NHS.

Henry Timms and Jeremy Heimans are coauthors of the New York Times bestseller New Power: How Power Works in Our Hyperconnected World—and How to Make It Work for You (2018). They write regularly on how today’s modern grassroots movements take hold and spread.


  • Provenance and peer review: Commissioned; externally peer reviewed.

  • Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.


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