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To the Editor: Dr Wolfe and colleagues¹ found that most claims made by antivaccination Web sites are not supported by scientific evidence. My colleagues and I recently reported similar findings.² In attempting to respond to such vaccination concerns, however, it is less important to know what people believe than why they subscribe to such views.

For many people, the decision not to vaccinate is merely one manifestation of wider philosophies that embrace individualism, New Age lifestyles and ideas, or an antiauthoritarian stance. Refutations based on fact alone fail to address the core appeals that attract people to antivaccination sentiment in the first place.³ For those who are wary of vaccines, a compelling case must appeal to the values central to these philosophies. Likewise, any analysis of antivaccination discourse must go beyond explicit claims and look into the deeper levels at which such opposition originates.

This has implications for physicians who counsel parents who are suspicious of vaccines. A response that is tailored to the particular philosophical framework from which vaccine fears originate is more likely to succeed than a generic argument based only on "the facts." For example, a parent objecting on the basis of an intuitive perception of vaccination as a cruel or unloving act may be acting out of a New Age value system in which intuitive emotional responses are considered superior to analysis and reason. Another may have a perception of self-interest or incomplete disclosure on the part of government and medical authorities that may be a manifestation of a wider distrust of authority pervading their worldview.

It is only by looking behind the rhetoric to the philosophical basis of vaccine refusal that strategies for an effective response can be formulated.

 
Peter Davies, BMedSci
Department of Public Health and Community Medicine
University of Sydney
Sydney, Australia
 
 

1. Wolfe RM, Sharp LK, Lipsky MS. Content and design attributes of antivaccination Web sites. JAMA. 2002;287:3245-3248. ABSTRACT  |  FULL TEXT  |  PDF  |  MEDLINE

2. Davies P, Chapman S, Leask J. Antivaccination activists on the World Wide Web. Arch Dis Child. 2002;87:22-25. MEDLINE

3. Leask J, Chapman S, Hawe P. Facts are not enough. BMJ. 2000;321:109. MEDLINE
 

 

To the Editor: Organized opposition to vaccination has existed for more than 2 centuries. The content found in modern antivaccination Web sites, as reported by Dr Wolfe and colleagues,¹ is similar in its emotions but differs in its arguments from early charges against the procedure. The "society of antivaccinationists" was founded in 1798, the same year that Jenner published An Inquiry Into the Causes and Effects of the Variolae Vaccinae. At that time vaccination was considered an inappropriate meddling in the work of God. One critic claimed that "Smallpox is a visitation from God and originates in man, but cowpox is produced by presumptuous, impious men. The former Heaven ordained, the latter is perhaps a daring and profane violation of our holy order."²

When Dr Benjamin Waterhouse first introduced Jenner's vaccination technique to the United States in 1800, he was concerned that negative public sentiment could derail its acceptance. For help he turned to Thomas Jefferson, then president of the United States. After studying the data, Jefferson threw his prestige and support behind the program. He became a legitimate vaccine expert, learning both its clinical and technical subtleties. From the White House he directed the vaccination program in the South and, according to Waterhouse, was responsible for introducing the procedure throughout most of the middle and southern states. In this he set the standard for a political leader in public health.^{3, 4}

Jefferson was not afraid to embrace the science of vaccination and in the process open himself to the criticisms with which it was associated. According to Jefferson the key to confronting any misinformation is education. He believed that the majority of citizens would make wise decisions when they were appropriately educated and informed. "Enlighten the people generally, and tyranny and oppressions of the body and mind will vanish like evil spirits at the dawn of day," he wrote in 1816.⁵ Finally, it is worth remembering that sound political leadership has been an important ingredient in successful vaccination programs. The story of Jefferson reminds physicians and scientists to engage their political leaders when vaccination controversies surface. They can be the most effective catalysts for public education, itself the most effective tool in this debate.

 
David M. Abbey, MD, MS
University of Colorado Health Science Center
Poudre Valley Hospital
Ft Collins
 
 

1. Wolfe RM, Sharp LK, Lipsky MD. Content and design attributes of antivacccination Web sites. JAMA. 2002;287:3245-3248. ABSTRACT  |  FULL TEXT  |  PDF  |  MEDLINE

2. Haggard HW. Devils, Drugs, and Doctors. New York, NY: Harper & Brothers; 1929: 231.

3. Blake JB. Benjamin Waterhouse and the Introduction of Vaccination: A Reappraisal. Philadelphia: University of Pennsylvania Press; 1957.

4. Martin HA. Jefferson as a vaccinator. N C Med J. 1881;1:1-34.

5. Jefferson T. Letter to P. S. DuPont de Nemours, 24 April 1816. In: Peterson MD, ed. Thomas Jefferson: Writings. New York, NY: Library of America; 1984.
 

 

To the Editor: Dr Wolfe and colleagues¹ claimed that the 22 Web sites they studied were chosen on the basis of containing "content specifically opposing vaccination for human infants or children." In fact few, if any, sites express such an opinion. These sites promote informed choice, for the most part, as would be apparent if the article had listed the 22 Web sites.²

While the sites warn of various risks of vaccination and present anecdotal evidence, the same could be said of most of the provaccination sites. What really distinguishes the so-called antivaccination sites is that they do not endorse the official vaccine recommendations. The availability of alternate sources of information and viewpoints is good thing, not a bad thing.

 
Roger Schlafly, PhD
Santa Cruz, Calif
 
 

1. Wolfe RM, Sharp LK, Lipsky MS. Content and design attributes of antivaccination Web sites. JAMA. 2002;287:3245-3248. ABSTRACT  |  FULL TEXT  |  PDF  |  MEDLINE

2. Information on Vaccines and Immunization. Available at: http://www.schlafly.net/vac. Accessibility verified August 27, 2002.
 

 

To the Editor: Dr Wolfe and colleagues¹ do not cite my study of antivaccination Web sites,² which was quite similar to theirs and published nearly 2 years earlier.

 
Laeth Nasir, MBBS
Department of Family Medicine
University of Nebraska Medical Center
Omaha
 
 

1. Wolfe RM, Sharp LK, Lipsky MS. Content and design attributes of antivaccination Web sites. JAMA. 2002;287:3245-3248. ABSTRACT  |  FULL TEXT  |  PDF  |  MEDLINE

2. Nasir L. Reconnoitering the antivaccination Web sites: news from the front. J Fam Pract. 2000;49:731-733. MEDLINE
 

 

In Reply: Dr Davies addresses the issue of the motivation of those choosing not to vaccinate and how to communicate with them. This is a complex topic, and was beyond the scope of our study. Halperin¹ outlined 5 categories of parents concerned about vaccine risk, from "uninformed but educable" to "committed and missionary," the latter on a campaign to persuade others of the evils of vaccines. Our experience agrees with Halperin that little is usually accomplished by trying to persuade those who perceive vaccines as being entirely evil; however, many parents will respond to listening and empathy. Very often misinformation can be corrected, and even very resistant parents will respond to being allowed some small degree of control, such as delaying some vaccinations by a few months. Some excellent resources about communicating about vaccine safety issues are available from the Canadian Immunization Awareness Program (http://www.immunize.cpha.ca/english/resourc2.htm#providers) and the Immunization Action Coalition (http://www.immunize.org/genr.d/vaxsafe.htm).

Dr Abbey makes the important point that antivaccination activities began immediately after Jenner first publicized his work with vaccination. However, it is worth noting that the appeal of reason and education and the support of political leaders are not universally appreciated or effective. The "antivaccination" sites we studied express a range of attitudes and viewpoints, but the majority express strong mistrust in some or all vaccines and those governmental agencies promoting them. Sometimes such mistrust can become the norm: for example, during the recent crisis of trust over the measles-mumps-rubella (MMR) vaccine in the United Kingdom, an opinion poll showed that only 20% said they would "trust a lot" advice from politicians and officials, 47% said they would trust it "a little," and 30% said they would disregard it altogether.² Many traced this loss of trust to the British government's mishandling of the epidemic of bovine spongiform encephalopathy ("mad cow" disease),³ in which a failure to acknowledge and respect the public's concerns, and an overly aggressive attempt to reassure the public, actually backfired.⁴ Calming a worried public is often more a matter of attitude than substance, and attempts at education must be preceded by a genuine acknowledgement of and respect for the feelings and concerns of the audience.

Dr Schlafly argues for informed choice and availability of different viewpoints. We concur, and do not believe that our article disputed this point. Recently, a representative of the US Centers for Disease Control and Prevention recommended using the expression "vaccine safety activists" rather than "antivaccinationists" or "antivaccinators" (K.M. Sheedy, PhD, oral communication, April 2002), and we believe this will foster a healthier dialogue among individuals with different viewpoints on this issue.

Finally, we apologize to Dr Nasir. Earlier versions of our article referenced his research,⁵ which we did not read until we had almost completed our study. Space limitations forced us to eliminate a large amount of text, but we feel that omitting his reference was an oversight.