Skepticism and doubt are both necessary -- they plant seeds in our minds that may blossom into paradigm shifts needed for the evolution of our society. There is a fine line, however, between a healthy 'dose' of skepticism and misguided fear -- the latter of which is simply anxiety. Anxiety that is based on untrue information or irrational presumptions, as anyone with anxiety can attest to, can be unpleasant to say the least.
When these fears are scaled up to affect larger communities, they can be disastrous. The 18th century philosopher Michel de Montaigne once remarked "there is no passion so contagious as that of fear." A statement that Edward Jenner, after discovering the smallpox vaccine a few decades later, may have agreed with. Indeed, fear and anxiety can themselves be contagious; the casualties as it applies to healthcare can be paramount. Nowhere is this more true than with the measles outbreak. Unfortunately the approach to addressing these fears has been largely misguided as well.
As of this this writing, the virus has challenged the immune systems of 18 Canadians in Ontario alone, over 150 Americans, and has led to a recent death of a child in Europe. This doesn't even include the countless other children and families around the world who simply cannot access the vaccine. Indeed, the "secondary outbreak" of fear around vaccines, has not been approached effectively.
To be clear, this isn't another article about why parents should vaccinate their children. For the record, I believe, or rather know, they should. My training, which specifically focused on vaccines, covered hundreds of studies and debates that quelled even the strongest skeptics in the class. The value of vaccination has already been reiterated by others much wiser than me: parents of vulnerable children, physicians, politicians, disease control centres, and even journalists.
Instead, my intention is to shed light on the sliver of opportunity inherent in the outbreak -- the seed of a possible paradigm shift -- that many vaccine advocates (particularly physicians) keep missing. The idea that vaccine hesitant parents are merely selfish, ignorant, uneducated, or simply over-exercising their libertarian freedoms to 'choose' (at the risk of the utilitarian 'herd') is a myopic one to put it simply. We know this because the epidemic is progressing despite the best efforts of vaccinate advocates.
We know that these fears are not new historically -- since the discovery of vaccines, skeptics have existed. They are far-reaching geographically as well -- Nigeria had a well publicized issue with polio vaccine in 2003 and more recently Kenya has been fraught with mistrust around the tetanus immunization campaigns.
However, the current measles outbreak has provided an innovative opportunity for physicians (along with support from others) to better engage parents in a way that just might make a difference. I will elaborate on this "how" in another piece. Before that, we need to establish a few things that are different today compared to even 10 years ago, when doctors may have exercised a greater sphere of influence over their patients' healthcare decision-making. This is particularly evident with children and their parents, and may explain why the antiquated messaging around vaccines, while they may have worked a decade ago, is not a sound strategy today.
First, up to three out of four parents will seek healthcare advice, management or curative therapies based outside of the conventional medical system. These therapies can be chosen by the parent or recommended by anyone from a naturopath to a chiropractor to a pharmacist to a homeopath -- creating a "shared patient" of sorts. What this means is that the 'sphere of influence' that doctors might have enjoyed in the past may be less extensive today, and their recommendations may be debated by other more non-conventional providers. As many of these other providers operate from an entirely different framework (i.e. not the biomedical model), recommendations may be inherently incommensurable.
Second, the vast majority of parents will consult the Internet for health information. This might, for better or worse, be the first place a parent may go to read about a child's symptom. As Dr.Freedhoff aptly warns, the world wide web can be the "Wild Wild West" of health information -- its difficult to distinguish evidence-based sources from opinion, and often the latter is written in a way that appears like the former. The existence of myriad blogs around parenting also overlaps with this and means that physician advice can be further diluted -- possibly by "non-expert" sources or very vocal bloggers (including celebrities) that may choose to disseminate opinion-based information under the guise of 'scientifically valid' information.
Third, our friends' opinions around health matter - more so today than even 10 years ago. Indeed "ingroup" bias is common. For parents, social networks both online and offline provide support, comfort, and very often advice for the periods when they are not receiving real-time, in-person advice from their doctor. Parents who belong to a social network that values or does not value a specific medical or public health recommendation (using vaccination as an example) are more likely adopt the predominant view. We have most recently seen this around cancer treatment perceptions in a small First Nations community. Clearly, community is crucial; belonging is a human need, and those whose views around vaccination might have been 'on the fence' might be more likely to opt-out if they frequently interact with other parents who themselves opt-out.
Last, education level is irrelevant. This is why traditional messaging by physicians in the media might not in and of itself lead to behaviour change. It doesn't really matter whether the parent is highly educated (and by 'educated' I mean formal education) or not. Whether concerns are over the (scientifically invalid) autism risk or the belief that vaccine components are 'toxic' (i.e. more damaging to the child's system than the disease) we have seen time and time again that there may even be an inverse relationship between education level and likelihood of vaccination.
What's more relevant is a parent's ability to evaluate risk -- a component of both negativity bias (i.e. if an adverse event is described in the media or a blog) and probability bias (i.e. the probability of contracting measles while unvaccinated compared to the probability of a vaccine-related adverse event). As with anxiety symptoms, the inability to rationally evaluate risk has little to do with inherent knowledge. Therein lies the poignancy of fear and the potency of skepticism, as alluded centuries ago by de Montaigne.
So, I've discussed a lot of barriers -- because it is unquestionably an uphill battle, one that is both divisive and frustrating for everyone involved. Yet peeking between those walls are glimmers of opportunity, and the seed of a paradigm shift - including ways in which the medical community can exercise its due diligence and advocate effectively. This rests in establishing that it is not "what" physicians (or the press, or politicians, or public health officials) say around vaccinations, but "how," they say it, "when" the message is communicated, and with "whom" they involve -- I will share my thoughts around this in Part 2.
Alright that's enough for my first "jab" (sorry I couldn't resist!) at the vaccine advocacy issue -- the "me in measles" if you will. If it's anything like the measles vaccine, hopefully this has been about 85 per cent as effective as a one-shot deal to convince you that we need a new approach. Regardless, next I'll propose the second and last shot -- a solution to these barriers and the crucial role that physicians (and many others, including yourself, the reader) can play right now if we really want to confront the epidemic specifically and perceptions around vaccinations in general.
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