Changing hearts and minds
BMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6601 (Published 21 November 2019) Cite this as: BMJ 2019;367:l6601
All rapid responses
Like Dr Cunningham who has written responses on the subject, I am for immunisation, when indicated. Passive immunisation, active immunisation.
It is a matter for dismay that “vaccination” is regarded by the WHO as something must be done. Please, Dr Loder, can you accept that:
Vaccines are drugs.
All drugs have indications and contraindications. .
All drugs have side-effects. Some early. Some late.
Reporting, recording, collation , of the side-effects is inadequate.
Some members of the public take the word of the WHO as the gospel.
Some wish to have facts, refuse the mantra, “vaccination is good for all”.
Unless you point out fallacies in the above, I for one will continue to believe that patients should be given full facts, and told when the doctor does not have full facts.
Competing interests: No competing interests
Dear Dr Loder,
The trouble is people perceive real ethical and scientific failures in the vaccine project [1]. For instance, today I saw a new article on Hippocratic Post by Christopher Exley, "Aluminium Adjuvants in Vaccines: Missing Information" [2]. This is a grave issue and until the vaccine lobby can address it and other matters of safety, without simply trying to stifle both professional and lay critics, there can be no progress in changing hearts and minds.
[1] Elizabeth Loder, 'Changing hearts and minds',
BMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6601 (Published 21 November 2019)
[2] Professor Chris Exley, 'Aluminium Adjuvants in Vaccines: Missing Information', 2nd December 2019, The Hippocratic Post.
Competing interests: AgeofAutism.com, an on-line daily journal, concerns itself with the potential environmental sources for the proliferation of autism, neurological impairment, immune dysfunction and chronic disease. I receive no payment as UK Editor
"Don't bring a fact to a narrative fight", Elizabeth Loder [1] paraphrases the article by Perera, Timms and Heimans [2], in quite a different spirit from Fiona Godlee's Editor's Choice last year, "A tale of two vaccines" [3], and in the week of the Irish court coming to a settlement over Aoife Bennett's narcolepsy/Pandemrix case [4]: Pandemrix and narcolepsy being the subject of Godlee's article. I am not entirely surprised that public relations advice might be to avoid facts (if that is what is being said) but might one suggest if the object is to win trust this is a very bad idea.
We need, on the contrary, to abandon the narrative of vaccine infallibility and start facing reality (which as ever is likely to be messy). Dare one say it, the battle for trust might ultimately be more essential for the medical profession and the public good than the battle for compliance.
[1] Elizabeth Loder, 'Changing hearts and minds', BMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6601 (Published 21 November 2019)
[2] '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: https://doi.org/10.1136/bmj.l6447 (Published 21 November 2019)
[3] Fiona Godlee, 'A tale of two vaccines', BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4152 (Published 04 October 2018)
Cite this as: BMJ 2018;363:k4152
[4] Clare Dyer, 'Case settled of Irish student who developed narcolepsy after swine flu vaccine',
BMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6658 (Published 22 November 2019)
Competing interests: AgeofAutism.com, an on-line daily journal, concerns itself with the potential environmental sources for the proliferation of autism, neurological impairment, immune dysfunction and chronic disease. I receive no payment as UK Editor
Small changes in your diet*
make BIG changes in your health.
Small changes in your habits*
make BIG changes in your health.
Small changes in your health
make BIG changes in your life.
*Avoid addictions like sweets, chocolate, cola, caffeine, alcohol, tobacco, and drugs.
Competing interests: No competing interests
The Ponseti method for clubfoot management is an example of many things; the advantages of immigration, the spread of good ideas through the Internet, the advantages of simple treatments. It is decidedly not an example of reverse innovation. The method was developed and used in the United States and spread rapidly through the developed world around the turn-of-the-century. It was introduced to the developing world by surgeons who either visited or chose to practice in other parts of the globe such as Pirani and Lavy. This process was quite clearly documented in the references quoted by Skopec and his co-authors, particularly the maps in Shabtai et al 10.5312/wjo.v5.i5.585
The distinction is important because false assertion, particularly when reiterated in an editorial, as by Loder, is the germ for the development of false ideas and beliefs such as the anti-vaccine movement.
It would be better perhaps to study how Ponseti spread in the United States and Europe because it was an example of the strategies recommended by Perera and colleagues in their essay on resisting anti-vaxxers. Families on the East Coast of the United States, who were only being offered extensive surgery for their infants, found and promoted Ponseti's method largely through self-supporting groups and the Internet. The same thing happened in the UK where, around 2001/2, parents would ask if I was using the Ponseti method. If I hadn’t been they would surely have looked elsewhere.
Competing interests: No competing interests
Re: Changing hearts and minds
Dear Editor
We agree with Hunter that patients’ demands and expectations can drive the diffusion of innovations (1). He makes the point clearly that in the case of the Ponseti technique, widespread adoption can be driven in part by patients demanding access to this cost-effective, safe, non-invasive technique which is as effective as the costly, invasive surgical option (1). It illustrates that clinical practice can be changed for the better when patients are enabled to articulate that demand. In the case of the Ponseti technique, we think it is interesting that, in the UK, to some extent it has taken patients to drive that change, despite the long-standing experience and evidence from contexts where it has been used extensively (2–4). Perhaps it has required this effort because the techniques and innovations from these contexts are not taken seriously enough. Previous studies have demonstrated that research from low-income countries is discounted, and significantly so, by English clinicians and there is a dramatic North-South divide in research consumption at a global level (5,6).
Hunter argues that in the case of the Ponseti technique, it is debatable as to whether or not it can be accurately attributed to be a low-income country innovation (1). Again, we agree, and in our Analysis, we highlight the challenge of defining some innovations as Reverse Innovations and note that the Ponseti technique is a case in point given that it began in the US, was scaled as de facto treatment in many sub-Saharan countries, before then scaling also in high-income countries (2,3,7). If Zedwitz’s typology is to be followed, then this would be called a Spill-back innovation or Developing Country Spill-over innovation, both types of Reverse Innovation (8). The classification depends on how one defines where the innovation was ideated and then developed and where the primary and then secondary markets were. Codifying the spread of some innovations is a challenge. For example, how do you ascertain where an idea first begins? Ponseti didn’t invent Plaster of Paris, but he did find a new application for it. We would think to some extent that it is a semantic issue other than for the fact that attributing innovations such as the Ponseti technique as a Reverse Innovation elicits such strong reactions. Hunter draws parallels between the attribution of the Ponseti technique to low-income countries and the ‘false ideas and beliefs such as of the anti-vaccine movement.’ This is to suggest that acknowledging the ingenuity and innovativeness of low-income countries is a dangerous myth that can put peoples’ lives at stake. That, in itself, is a dangerous myth.
1. Re: Changing hearts and minds | The BMJ [Internet]. [cited 2019 Dec 10]. Available from: https://www.bmj.com/content/367/bmj.l6601/rr
2. Tindall AJ, Steinlechner CWB, Lavy CBD, Mannion S, Mkandawire N. Results of manipulation of idiopathic clubfoot deformity in Malawi by orthopaedic clinical officers using the Ponseti method: a realistic alternative for the developing world? J Pediatr Orthop. 2005 Oct;25(5):627–9.
3. Pirani S, Naddumba E, Mathias R, Konde-Lule J, Penny JN, Beyeza T, et al. Towards Effective Ponseti Clubfoot Care: The Uganda Sustainable Clubfoot Care Project. Clin Orthop [Internet]. 2009 May [cited 2019 Aug 13];467(5):1154–63. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2664445/
4. Shabtai L, Specht SC, Herzenberg JE. Worldwide spread of the Ponseti method for clubfoot. World J Orthop [Internet]. 2014 Nov 18 [cited 2019 Aug 13];5(5):585–90. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4133465/
5. Harris M, Marti J, Watt H, Bhatti Y, Macinko J, Darzi AW. Explicit Bias Toward High-Income-Country Research: A Randomized, Blinded, Crossover Experiment Of English Clinicians. Health Aff (Millwood) [Internet]. 2017 Nov [cited 2018 Jul 3];36(11):1997–2004. Available from: http://www.healthaffairs.org/doi/10.1377/hlthaff.2017.0773
6. Pan RK, Kaski K, Fortunato S. World citation and collaboration networks: uncovering the role of geography in science. Sci Rep [Internet]. 2012 Dec [cited 2018 Jul 2];2(1). Available from: http://www.nature.com/articles/srep00902
7. Skopec M, Issa H, Harris M. Delivering cost effective healthcare through reverse innovation. BMJ [Internet]. 2019 Nov 14 [cited 2019 Nov 22];l6205. Available from: http://www.bmj.com/lookup/doi/10.1136/bmj.l6205
8. von Zedtwitz M, Corsi S, Søberg PV, Frega R. A Typology of Reverse Innovation: A Typology of Reverse Innovation. J Prod Innov Manag [Internet]. 2015 Jan [cited 2018 Jul 26];32(1):12–28. Available from: http://doi.wiley.com/10.1111/jpim.12181
Competing interests: No competing interests