Holistic and conventional medicine must collaborate to find a solution
The rate of measles infections reached a sixteen-year high in Australia last year, mainly due to travellers catching measles overseas and passing it on to unvaccinated children after coming home. We are in danger of diseases that had been eliminated from Australia making a comeback due to a rapid increase in parents failing to have their children vaccinated.
The term ‘vaccine hesitancy’ (VH) implies hesitancy in relation to vaccination, but some people are not hesitant but decisive in refusing vaccination, and some are hesitant about a specific vaccine, not vaccination as such. But the term is used to indicate this entire field of behaviours.
Since the Christian Scientists confirmed that they do not have a conscientious objection to vaccination, there is now no basis for objection on religious grounds. There remain, however, a range of reasons behind failure to access available vaccination programs, and different responses by the community are required in each case. The Abbott government’s policy to send a ‘price signal’ by withdrawing welfare payments will work for a minority of VHers but will alienate and harden the resistance of an expanding section.
Education and socioeconomic status have proven to be poor predictors of VH and the usual empirical-demographic and public-education approaches to public health challenges have proved problematic. Policy makers do not know what to do to improve the uptake of vaccination.
Researchers using Ulrich Beck and Anthony Giddens’ ideas of ‘reflexive modernity’ and ‘risk society’ measure responses to vaccination along two axes. The horizontal axis measures the extent to which the subject has embraced risk culture, in which the world is full of unpredictable sources of danger, and ‘healthism’, in which the subject takes active responsibility for managing their own health. The vertical axis measures the subject’s disposition to trust the entire system of expert culture and established power and authority.
On the left of the horizontal axis are people unaware of the severity of diseases like measles, smallpox and rubella because they have never had any personal experience of them. On the right are people who take an active interest in their own health and that of their children, seek out information and are strongly committed to whatever views they arrive at, positive or negative.
Positioning on this axis is questionably deemed to reflect a personality trait. Characteristic of modernity is the shift towards individual responsibility. People no longer ascribe their good fortune or their poverty to the political-economic system or expect governments and authorities to look after them. Governments actively promote ideologies of self-reliance and discredit collective action, such as by trade unions.
Distrust of public officials is as old as civilisation, but in the past people did tend to accept the word of experts. But the rational scepticism that has been the province of science for 400 years has now been turned back onto science itself, and everyone thinks they are qualified to form a scientific opinion. No one believes advertisements, and neither do they believe the claims of scientists and public-health officials.
At the top of the vertical axis are those who still believe that the doctor will keep you healthy and that scientists understand nature.
At the bottom of the vertical access are those who presume that genetically modified food is dangerous to world health, that the government is probably lying, that scientists are motivated by prospects for promotion and that vaccination programs are some kind of ruse.
The combination of the two axes produces four archetypes, which can be mapped on a ‘compass’:
- Passive conformism In the NW quadrant are people who take no interest in vaccination issues, believing vaccination to be either unimportant or all taken care of. Unaware of the danger of diseases like rubella and smallpox or their part in eliminating them, they forget to attend clinics for top-ups and ignore news about infectious diseases. But when told that this is what they have to do, they will not suspect any ulterior motive or doubt what their doctor tells them, and they will try to comply. These people may respond to ‘price signals’.
- Enlightened conformism In the NE quadrant are people who follow the advice of their doctors and health authorities, closely read the instructions on the packets, check that the local school is doing the right thing and actively support public vaccination programs. These people do not need threats.
- Passive hesitancy In the SW quadrant are people who make no effort to inform themselves about vaccination issues, but neither do they believe what the government or their GP says. They only trust information from their friends and neighbours.
- Rationalised hesitancy In the SE quadrant is the group that is truly a product of our times: they take responsibility for their own health, meticulously controlling their diet and avoiding manufactured food. They take an active interest in issues such as contamination of crops and water sources and they inform themselves about vaccination issues. However, they do not regard the federal government, far less Pfizer or Roche, as a source of reliable information and they believe that university research is subject to corporate influence. Because this group make their judgements based on evidence, they may refuse one vaccine while accepting another. It is this cohort that is of particular interest, both because it is the quadrant that is growing and because it is most resistant to public health measures such as Abbott’s ‘price signal’.
‘Herd immunity’ relies on the number of unvaccinated people remaining below a critical percentage. So long as the percentage of vulnerable people is less than the critical level, an infection will eventually die out; beyond that level, transmission continues indefinitely. So vaccination is not a question of personal choice but of public safety, like a fire ban enforced during summer. At the same time, rational scepticism is an entirely responsible orientation: there are ample precedents for irresponsible marketing of health products and unforeseen consequences of innovative medical practices. There is no formula or universal criterion by which to judge the safety and efficacy of vaccination that does not rely on trust.
In the early 1970s, the whooping-cough vaccine was producing some unpleasant but harmless side effects. In 1977, The Lancet published an article suggesting that the risks of the vaccine outweighed its benefits and media reporting led to the coverage rate falling from about 75 per cent to 40 per cent. Controversy raged in the medical press until 1981 and confidence gradually recovered, coverage reaching 90 per cent by 1992. During this period there were no active anti-vaccination groups, but these had appeared by the 1990s.
In 1998, The Lancet published a paper claiming that the MMR vaccine—a combination of measles, mumps and rubella vaccines—caused autism and colitis. The claim was completely fraudulent, but The Lancet only fully retracted the paper in 2010. Epidemiological research ruled out the association, but the claim was reported in the international media, and the belief that MMR vaccination can cause autism persists to this day. MMR vaccination rates in the United Kingdom dropped from 92 per cent in 1996 to 84 per cent in 2002, and as low as 61 per cent in parts of London, and has still not recovered to the 1996 level. The incidence of mumps was thirty-seven times higher than 1996 levels in 2006, in 2008 measles was once again declared endemic in the United Kingdom, and there were consequent outbreaks in other countries.
In December 2009, Council of Europe parliamentarian and epidemiologist Wolfgang Wodarg presented a recommendation to the Council of Europe entitled ‘Faked Pandemics: A Threat to Public Health’, claiming that the WHO had overreacted to the threat of the N1H1 virus. After months of debate, the Council of Europe passed a motion decrying the WHO’s public reaction to H1N1. Subsequent experience tended to confirm that the Council of Europe had been correct; scientists judged that a pandemic had not developed, there were questions over the efficacy and safety of the H1N1 vaccine, and the threat was not serious enough to warrant mass vaccination, which carries its own risks. The anti-vaccination voice proved to be the most worthy of trust.
Decisions on vaccination cannot sensibly be understood as individual decisions. The Council of Europe and The Lancet are not simply ‘sources of information’ on which an individual can draw. An individual is or is not a participant in a discourse prior to the reception of an argument framed within that discourse, and they will accept or reject the argument accordingly. A decision on whom to trust cannot be made from outside a discourse; it is always made within a discourse.
In Australia, the average vaccination rate at five years old is 91.5 per cent. This leaves 75,000 children vulnerable, 15,000 of them registering a conscientious objection. The three postcodes with the lowest vaccination rates for five year olds are:
2481 Byron Bay, New South Wales north coast: 66.7 per cent
2483 Brunswick Heads, New South Wales north coast: 70.2 per cent
2000 Sydney central business district: 72.1 per cent
These areas are well known to have significant population sections that can be described as well educated, favouring ‘alternative’ lifestyles and distrustful of authorities, thus squarely fitting the profile of ‘rationalised hesitancy’. Areas with the highest numbers of children registering a conscientious objection have the same demographic.
The highest rates of vaccination are in Far North Queensland. In Indigenous communities, rural areas and working-class suburbs, the five-year-old vaccination rate is nowhere under 90 per cent. So it is clear that the problem with vaccination levels is with the ‘rationalised hesitancy’ of the SE quadrant.
In the United Kingdom, one could say that the public’s loss of confidence in the whooping-cough vaccine was a rational reflection of the state of scientific knowledge in the 1970s. But, whereas authorities could restore confidence in a vaccine in 1992, a few years later they proved unable to do so.
Modernity has fostered certain social attitudes that colour public health problems in a distinctive way, but the strong localisation of vaccination refusal suggests that the problem is not one of personality types, but that individual responses to modernity are socially constructed.
Research has shown that being critical of vaccination is correlated with a preference for natural childbirth and the use of alternative therapies such as acupuncture, homeopathy and naturopathy. This, combined with a correlation with living in the ‘lifestyle’ areas or the inner cities of the major capitals, confirms that VH is part of a wider attitude to health.
Giddens and Beck give us a plausible picture of the social changes that have fostered distrust of experts and individual ‘entrepreneurship’, but if anti-vaccination views are taken to passively reflect the conditions of modernity, how can we change this situation? These social conditions will continue, and so presumably will the attitudes characteristic of these conditions. The ‘life politics’ of ‘reflexive modernity’ are not a spontaneous response to modern social conditions but a product of projects that have arisen from modern conditions and produced modernity as we know it.
None of the archetypes represented in the VH compass represent satisfactory stances, including the ‘balanced position’ at the centre point. The WHO, The Lancet, the Council of Europe and so on are also subjects that could be mapped on the compass. Isn’t this reducing the problem to an objective process in which ‘reflexive modernity’ simply reproduces itself? If we are going to characterise subjects according to dimensions, is it believable that there are only two dimensions? For example, isn’t trust specific to who is trusted: religious leaders, passers-by, neighbours, scientists, pharmaceutical companies, the media, politicians? And is ‘entrepreneurship’ really so thoroughly individualised, or do people still seek to control the events affecting their lives collectively with others, if not governments? In any case, one and the same person would occupy different positions on the Compass in relation to particular vaccines.
As valuable as the insights of ‘reflexive modernity’ may be, we are still left with an individual making rational decisions against a background of given social conditions and we have no clue as to how to deal with rationalised hesitancy. Asking such people to ‘listen to reason’ has not worked so far.
Rather than taking the rational hesitancy of a section of the population as an individual response to social conditions, we need to know how parents acquire their views and how the population’s trust in scientific and medical establishments was lost to know if and how that trust can be restored.
Stuart Blume has studied how parents form their attitudes to vaccines and has examined the contribution the medical profession has made to loss of trust in it. Earlier health activism such as the Women’s Health Movement and the HIV/AIDS movement makes it clear that relations between the medical establishment and the population have been actively produced and are not a passive, individual reflection of social conditions.
Blume says that anti-vaccination movements arose in the nineteenth century, when compulsory mass-vaccination programs were introduced in Europe and America. These movements were generally led by the promoters of alternative therapies whose projects were threatened by mass immunisation, and they found allies in both the working class and the middle class because of the compulsory aspect of the programs. Compulsory vaccination was a challenge to the workers’ movement, whose project was independence from state regulation, welfare and philanthropy, and to the liberal middle class, whose project was the extension of personal liberty. Without a history of the impact of mass vaccination, the procedure did look risky, and there were plenty of adverse outcomes to fuel antipathy to vaccination.
However, with the progress of medicine and the success of public health measures overall, the rhetoric of the snake-oil salesmen sounded less convincing and adverse outcomes declined. The anti-vaccination movement disappeared in the first decade of the twentieth century and science-based medicine and mass vaccination were generally accepted until the 1980s.
However, because of this hegemony, the medical establishment suffered from a measure of hubris and, from the 1960s, critics of medical science began to appear. These included the critical psychology movement, which began among psychology students, and other critical trends within psychology; the natural-childbirth movement, which emerged within medicine; the Women’s Health Movement in the 1970s, which involved both medical professionals and patients demanding women have a say in how they were treated; and the HIV/AIDS movement in the 1980s. The AIDS activists objected to terminally ill people being given placebos in clinical trials. They demonstrated that research could be far more effective if people with AIDS were included as collaborators rather than objects of research, and that gay men, drug users and prostitutes were better placed to design and implement public health programs than public authorities. The medical institutions were dragged kicking and screaming into collaboration with their clients.
A rising tide of voices objected to the abuse of research subjects, the marketing of drugs that later proved to be toxic, the corruption of GPs and researchers by companies, and dangerous and unethical research practices by the military. Modern conditions contributed positively to the formation of these opposition projects, but scientific and medical institutions failed to rein in their hubris before these voices were raised. Among the critical voices were a number of anti-vaccination groups, which first appeared in the 1980s, after the decline of the ‘new social movements’ and in the wake of the AIDS controversy and the whooping-cough scare.
According to Blume, these anti-vaccination groups are predominantly self-help groups of people who have become anti-vaccinationist as a result of adverse experiences with vaccination. Their message is promoted online and is easily accessible for anyone who goes looking for it. According to Blume, only 2 per cent of parents consult the internet in making their vaccination decision, and only a proportion of these would even read an anti-vaccination website, let alone trust it. Only a minuscule proportion of the population would have direct contact with an anti-vaccination group, so the existence of such groups is insufficient to explain the extent of vaccine hesitancy—it is not the product of scaremongering by anti-vaccinationists.
The most dramatic collapses in the perceived safety of specific vaccines have occurred in direct response to doubts raised within medical research itself. But parents did not get this information by reading The Lancet; they received it mainly through conversations with friends, family and neighbours. A survey showed that 75 per cent of parents who had made a decision on vaccination had had at least one discussion on its advisability with the relevant health professional and 85 per cent had read the literature provided, but 16 per cent felt that they needed more information. For the majority it was the information they received from trusted peers that was most decisive in forming their opinion. Moreover, the proportion of parents who distrust information from health authorities is growing. This group is strongly correlated with people using ‘alternative’ therapies. However, Blume finds that active criticism of vaccination by advocates of alternative therapies is insufficient to explain the decline in vaccination rates, although such views are finding increasing sympathy in the population at large.
So why are increasing numbers of people open to arguments that the medical establishment should not be trusted and ready to accept advice that contradicts the scientific consensus? One bad experience sows the seeds of doubt, but this would not be enough for a parent to reject the advice of their doctor. Given that the public views of vaccine sceptics and alternative therapists are not sufficient to explain the extent of vaccine hesitancy and its growth, it seems that it is when parents consult their trusted friends, neighbours and family that doubts are consolidated.
Blume claims that the best predictor of vaccine hesitancy is ‘a general commitment to holistic ideas about health (and to natural childbirth and breastfeeding) and the importance of lifestyle and environment for a child’s well-being’.
Information about vaccination from the media, friends and neighbours, alternative-health practitioners and health professionals will be framed by this pre-existing view. Most influential in developing this ‘holistic’ view of medical issues are friends and neighbours, not professionals of any kind. Local vaccination cultures form because it is through friends-and-neighbours networks that antivaccinationism is propagated, as an incidental part of interest in ‘holistic medicine’.
Science is a hegemonic ideal: the wackiest strand of alternative medicine still lays claim to science, even if without basis. In itself, a holistic health movement ought not to be a danger to public health. But because it arose as a critique of institutionalised scientific medicine, holistic medicine is saddled with a fatal contradiction, in that it excludes the only party capable of producing a genuinely holistic theory of well-being: scientific medicine.
Like the HIV/AIDS movement, the holistic-medicine movement is being treated as an irrational pariah. But then as now, the medical establishment needs to enter into a collaborative relationship with its critics.
Nowadays, people want to make decisions about their health and that of their children ‘for themselves’. Such decisions are possible only by weighing up conflicting sources of information according to trust. The sources themselves—whether neighbours or professionals—and the assessment of those sources are constructed through participation in collaborative projects and, generally speaking, one trusts a collaborator before someone with whom one has never collaborated. The only collaborative relationships many people have are with family, neighbours, friends and colleagues. The brochures provided by the health system supporting vaccination make no pretence at helping you make your own decision. They are transparently aimed at persuading you to comply.
The medical establishment is part of the problem and the holistic health movement is part of the solution. Only when these two projects collaborate can scientific medicine become genuinely holistic and the holistic health movement become genuinely scientific. Science is, in essence, holistic and collaborative. But science also relies on trust; it needs to be able to trust its sources. Medical experts have to be engaged and drawn into collaboration. The departmentalisation of all the relevant institutions militates against a holistic approach, but medicine is in essence holistic. In collaboration with non-experts who insist on taking the idea of holistic medicine seriously, these structural problems can be overcome. By participating in the necessary transformation of the health system, the holistic health movement would itself be transformed.
Vaccine hesitancy arising from distrust of institutionalised medicine is a serious problem. If this distrust continues to grow, we will eventually learn our lessons in the wake of a global pandemic. Health authorities must take the holistic health movement seriously and engage it in finding practical solutions in collaboration with the medical profession. Such collaboration was the outcome of both the Women’s Health Movement and the HIV/AIDS movement. ‘Representatives’ of the holistic health movement are not easily identifiable, but people who may be influential in localities where there is an antivaccination culture could be engaged in formal deliberative dialogue—not to persuade, but to explore solutions.