What do we really know about social resistance to vaccines?

Post originally published here

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 inPLOS 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 inPLOS 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 1900performed 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.

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