anti-vaccine activists, web 2.0, and the postmodern paradigm – an overview of tactics and tropes...

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Vaccine 30 (2012) 3778–3789 Contents lists available at SciVerse ScienceDirect Vaccine j ourna l ho me pag e: Anti-vaccine activists, Web 2.0, and the postmodern paradigm – An overview of tactics and tropes used online by the anti-vaccination movement Anna Kata McMaster University, Psychiatry and Behavioural Neurosciences, 555 Sanatorium Road Hamilton, Ontario, Canada L9C 1C4 a r t i c l e i n f o Article history: Received 26 May 2011 Received in revised form 25 September 2011 Accepted 30 November 2011 Available online 13 December 2011 Keywords: Anti-vaccination Health communication Internet Postmodernism Vaccines Web 2.0 a b s t r a c t Websites opposing vaccination are prevalent on the Internet. Web 2.0, defined by interaction and user- generated content, has become ubiquitous. Furthermore, a new postmodern paradigm of healthcare has emerged, where power has shifted from doctors to patients, the legitimacy of science is questioned, and expertise is redefined. Together this has created an environment where anti-vaccine activists are able to effectively spread their messages. Evidence shows that individuals turn to the Internet for vaccination advice, and suggests such sources can impact vaccination decisions therefore it is likely that anti- vaccine websites can influence whether people vaccinate themselves or their children. This overview examines the types of rhetoric individuals may encounter online in order to better understand why the anti-vaccination movement can be convincing, despite lacking scientific support for their claims. Tactics and tropes commonly used to argue against vaccination are described. This includes actions such as skew- ing science, shifting hypotheses, censoring dissent, and attacking critics; also discussed are frequently made claims such as not being “anti-vaccine” but “pro-safe vaccines”, that vaccines are toxic or unnatural, and more. Recognizing disingenuous claims made by the anti-vaccination movement is essential in order to critically evaluate the information and misinformation encountered online. © 2011 Elsevier Ltd. All rights reserved. 1. Introduction Vaccinations are a significant public health achievement, con- tributing to dramatic declines in morbidity and mortality from vaccine-preventable diseases [1]. However, by reading certain web- sites, one might be persuaded to think the opposite that vaccines are actually ineffective, useless, or even dangerous. These are merely some of the arguments posed by the anti-vaccination move- ment, an amorphous group holding diverse views that nevertheless shares one core commonality: an opposition to vaccines. The pop- ularity and pervasiveness of the Internet today has facilitated the transmission of such beliefs. Many people search online for health information, and the information found impacts patient decision-making; it is therefore essential to understand what is shared online. This paper pro- vides an overview of how the new generation of the Internet (Web 2.0) and its emphasis on user-generated content has combined with characteristics of the current postmodern medical paradigm, creating a new environment for sharing health information. The anti-vaccination movement has taken advantage of this milieu to disseminate its messages. Strategies the movement employs, Tel.: +1 905 387 3141. E-mail addresses: [email protected], [email protected] found on various anti-vaccine websites, are then described; this includes various tactics the movement engages in (e.g. misrep- resenting science, shifting hypotheses, censorship, attacking their critics), as well as commonly argued tropes (e.g. that they are “pro- safe vaccines”, that vaccine advocates are “shills”, that vaccines are unnatural, etc.). Such narratives may be compelling, and help anti-vaccination protests persist despite a lack of scientific sup- port. Identifying and analyzing these tactics and tropes is not only an important exercise in critically evaluating medical advice found online, but also a necessary step in ensuring individuals searching online are not misinformed. 2. Web 2.0, health communication, and the postmodern medical paradigm Though the exact definition of the term “Web 2.0” is debated, its meaning is generally derived from comparison against the first gen- eration of the Internet Web 1.0 [2]. The main difference between the two is the amount of interaction and user-generated content; whereas Web 1.0 content was controlled by the provider, Web 2.0 allows users to create information. Anybody can contribute con- tent via blogging, photo-sharing, video-uploading, and more. The creation and sharing of user-generated content is supported by applications known as social media (e.g. YouTube, Blogger, Face- book, Twitter, etc.). 0264-410X/$ see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.vaccine.2011.11.112

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  • Vaccine 30 (2012) 3778 3789

    Contents lists available at SciVerse ScienceDirect


    j ourna l ho me pag e: www.elsev ier .com

    Anti-va odtactics ina

    Anna KatMcMaster Univ tario, C

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    Keywords:Anti-vaccinatiHealth commuInternetPostmodernismVaccinesWeb 2.0

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    and more. Recognizing disingenuous claims made by the anti-vaccination movement is essential in orderto critically evaluate the information and misinformation encountered online.

    2011 Elsevier Ltd. All rights reserved.

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    ions are a signicant public health achievement, con- dramatic declines in morbidity and mortality fromventable diseases [1]. However, by reading certain web-ight be persuaded to think the opposite that vaccines

    ineffective, useless, or even dangerous. These aree of the arguments posed by the anti-vaccination move-orphous group holding diverse views that nevertheless

    core commonality: an opposition to vaccines. The pop-pervasiveness of the Internet today has facilitated then of such beliefs.eople search online for health information, and the

    found impacts patient decision-making; it is therefore understand what is shared online. This paper pro-rview of how the new generation of the Internet (Web

    emphasis on user-generated content has combinedteristics of the current postmodern medical paradigm,ew environment for sharing health information. The

    ation movement has taken advantage of this milieuate its messages. Strategies the movement employs,

    5 387 3141.resses: [email protected], [email protected]

    found on various anti-vaccine websites, are then described; thisincludes various tactics the movement engages in (e.g. misrep-resenting science, shifting hypotheses, censorship, attacking theircritics), as well as commonly argued tropes (e.g. that they are pro-safe vaccines, that vaccine advocates are shills, that vaccinesare unnatural, etc.). Such narratives may be compelling, and helpanti-vaccination protests persist despite a lack of scientic sup-port. Identifying and analyzing these tactics and tropes is not onlyan important exercise in critically evaluating medical advice foundonline, but also a necessary step in ensuring individuals searchingonline are not misinformed.

    2. Web 2.0, health communication, and the postmodernmedical paradigm

    Though the exact denition of the term Web 2.0 is debated, itsmeaning is generally derived from comparison against the rst gen-eration of the Internet Web 1.0 [2]. The main difference betweenthe two is the amount of interaction and user-generated content;whereas Web 1.0 content was controlled by the provider, Web 2.0allows users to create information. Anybody can contribute con-tent via blogging, photo-sharing, video-uploading, and more. Thecreation and sharing of user-generated content is supported byapplications known as social media (e.g. YouTube, Blogger, Face-book, Twitter, etc.).

    see front matter 2011 Elsevier Ltd. All rights reserved.vaccine.2011.11.112ccine activists, Web 2.0, and the postmand tropes used online by the anti-vacc


    ersity, Psychiatry and Behavioural Neurosciences, 555 Sanatorium Road Hamilton, On

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    2011ovember 2011e 13 December 2011


    a b s t r a c t

    Websites opposing vaccination are prgenerated content, has become ubiquemerged, where power has shifted froexpertise is redened. Together this heffectively spread their messages. Evadvice, and suggests such sources cavaccine websites can inuence whetexamines the types of rhetoric individanti-vaccination movement can be coand tropes commonly used to argue aging science, shifting hypotheses, censmade claims such as not being anti-v/ locate /vacc ine

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    nt on the Internet. Web 2.0, dened by interaction and user-. Furthermore, a new postmodern paradigm of healthcare hasctors to patients, the legitimacy of science is questioned, andated an environment where anti-vaccine activists are able toe shows that individuals turn to the Internet for vaccinationpact vaccination decisions therefore it is likely that anti-eople vaccinate themselves or their children. This overviewmay encounter online in order to better understand why theing, despite lacking scientic support for their claims. Tactics

    vaccination are described. This includes actions such as skew- dissent, and attacking critics; also discussed are frequently but pro-safe vaccines, that vaccines are toxic or unnatural,

  • A. Kata / Vaccine 30 (2012) 3778 3789 3779

    Web 2.0 facilitates health communication users can engageand educate others by sharing medical histories, treatment suc-cesses and failures, or experienced side-effects [3]. Several salientthemes have been identied when using the Internet in thisway: the intors in theemergence ing and cohealthcare ical paradigmedical paremphasis oover benebeen a tranphysician between pactively engpreviously access to thfrom doctothemselvesinformationhigher statuteristics of notion of exsystems [1legitimacy oto hold momodern soc

    Using Wempowermnities butInternet alsfringe me9/11 Truthact with likfall into a tthat can foobeliefs, whe[14]. Web truth [15]; each portraern charactbut rather 2.0 places ccrusaders, cmessages fin public fotheir meritknowledge encounterin[18]. This iswhere self-the notion tequally valibecomes jugroups havbining themto effective

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    Eighty ponline [21].care for lov

    available show 16% of seekers searched online for vaccination infor-mation, and of this group, 70% say what they found inuenced theirtreatment decisions [22]. Surveys indicate the Internet now rivalsphysicians as the leading source of health advice [3].

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    ility, studthercy ofe safcreased participation of patients as active contribu-ir own care, and their subsequent empowerment; theof online communities and social networking; the shar-llaboration of knowledge; and the personalization of[4,5]. These characteristics relate to the current med-m, which is one of postmodernism. The postmodernadigm has developed new priorities for healthcare: ann values as well as evidence; preoccupation with risksts; and the rise of the informed patient [6]. There hassition from the white coat ethos of the traditionalto the current environment of shared decision-makingatients and professionals [7]. Web 2.0 lets patientsage in their own care. While medical knowledge wasbound to textbooks and journals, the Internet allowse school of lay medicine [8], shifting the locus of powerrs as sole directors of a patients care to the patients. Patients are depicted as consumers with access to

    diversity, their choices no longer restricted by thes allocated to experts [9]. In fact, postmodern charac-

    disillusionment and suspicion towards science and thepertise have contributed to decreased trust in expert0]. The postmodern medical paradigm questions thef science and authority, stressing the need for patients

    re power [11]. Indeed, it can be argued that in a post-iety, everybody is an expert [12].eb 2.0 for health collaboration has benets patientent, consumer reviews and advice, supportive commu-

    has drawbacks as well. The connective power of theo brings together those previously considered on thembers of marginalized groups (e.g. Holocaust deniers,ers, AIDS deniers) can easily and uncritically inter-e-minded individuals online [13]. There it is easy torap of self-referencing and mutually reinforcing linksl users into believing there are many who share theirn in reality it may only be a small, committed group2.0 has furthered postmodern ideals by atteningthe innite personalized truths presented online areyed as legitimate. This is supported by the postmod-eristic of relativism that there are no objective facts,multiple meanings and ways of knowing [6]. Webarefully scrutinized evidence next to the opinions ofritics, and conspiracy theorists, potentially weakeningrom qualied experts [16]. New theories are debatedrums before the scientic community can examine

    s [17]. That ofcials speak with special authority oris a concept now rejected by laypeople, as readersg expertise may believe themselves to then be experts

    demonstrated by anti-vaccinationism on the Internet,proclaimed experts tout conicting messages; withhat multiple truths based on different worldviews ared, evidence-based advice from qualied vaccine expertsst another opinion among many [17,19]. Anti-vaccinee harnessed postmodern ideologies [20], and by com-

    with Web 2.0 and social media technologies, are ablely spread their messages.

    uence of the Internet on vaccination decisions

    ercent of Internet users search for health information Those most likely to do so are adults providing unpaided ones, such as children. The most recent statistics

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    Anoaccuravaccinanti-vaccine messages being more widespread andd on the Internet than in other media forms [23], theearch on this topic is not particularly large. A groupnalyzed anti-vaccination websites for features such asims, design attributes, rhetorical appeals, and reasoning333]. Common assertions found online included: thatuse illness; they are ineffective; they are part of a medi-ceutical/government conspiracy; and that mainstream

    incorrect or corrupt. Misinformation was widespread, of inaccuracies or outright deception.

    has recently shifted to social media. An analysis ofmunization videos [34] found that 32% opposed vac-d that these had higher ratings and more views than

    videos; 45% of negative videos conveyed informa-icting reference standards. A YouTube analysis specicunization [35] found that 25.3% of videos portrayed

    negatively. An analysis of MySpace blogs on HPV immu-] found that 43% were negative; these blogs referenced

    tical organizations and disseminated inaccurate data. Anadian Internet users tracked the sharing of inuenzaormation on social media networks such as Facebook,Tube, and Digg [37]. Of the top search results during thed, each which had been shared and viewed thousands% contained anti-vaccination sentiments.

    currently no direct evidence on the precise inuencecine messages; online exposure linked to real-world

    yet anecdotal [38,39]. However, there is evidencemedia forms impact vaccination decisions. A Welshd vaccine uptake was signicantly lower in the dis-rea of a newspaper that ran a campaign against theumpsrubella [MMR] vaccine, compared with uptake

    rest of the country [40]. A Swedish study of parentsned or abstained from vaccinating their children foundurce of information for over 80% of respondents was

    [41]. An international study found that countries withation media campaigns had signicantly higher rates

    compared to nations with fewer such reports, which higher vaccination levels [42].ase-control studies of exempted and fully vaccinated3,44], common reasons parents gave for not vaccinat-d: fears vaccines might cause harm or overload thestem; believing their child was not at risk for the dis-at the disease was not dangerous; that it was betterimmunity naturally rather than from vaccines; or thats might not work. These are all popular assertions onation websites. In both studies, parents of exemptedre more likely to have searched the Internet for infor-

    n were parents of vaccinated children. Their perceptionion sources was revealing exempting parents reported

    ofcial sources (e.g. healthcare professionals, healthts, government agencies) but were more likely to rateccination organization Dissatised Parents Togethergood/excellent source than were vaccinating parents., the good/excellent ratings for the National Vaccine

    Centre [NVIC] were higher from vaccinating parents C is merely the new, more neutral name of DPT. Not onlyemonstrate problems people may have gauging sourcebut similar parental responses towards not vaccinatingies suggests a pervasiveness of anti-vaccine ideas.

    study examined how effectively users assessed the Internet-based medical information, using the termsety and vaccine danger in search engines [45]; 59% of

  • 3780 A. Kata / Vaccine 30 (2012) 3778 3789

    student participants thought retrieved sites were accurate on thewhole, although 55% of the sites were actually inaccurate on thewhole, as dened by the study (i.e. sites were not evidence-based,and argued vaccines were inherently dangerous). The majority ofparticipantsabout vacciwebsite forrisks and dcompared tstudy viewintentions ttranslated inations tha

    Vaccine tion. In-depto vaccinatiing them towould turn and when e93% respona general secination, Mterms returSuch sites mation on Another serwho fully vawere more lquently mesource credtheir physicothers weresided. This not only inleast 1 vaccveys wheresay doctors[51].

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    Anti-vaccan be trachange sincday anti-vaairing of a [54], prompcines, inundlawsuits (mUS Congrewhile compThe documthe organiztions of par1998 paper

    suggested that MMR vaccine was linked to autism, intensemedia coverage spread the story worldwide. It was during thiswave of anti-vaccine sentiment that books [58] and popularmedia outlets [59] linking vaccines to various ills followed and

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    over (53%) left the exercise with signicant misconceptionsnes. Research has found that viewing an anti-vaccine

    merely 510 min increased perceptions of vaccinationecreased perceptions of the risks of vaccine omission,o visiting a control site [46]. More importantly, in thising the anti-vaccine website signicantly decreasedo vaccinate, which persisted ve months later thisnto parents having their children receive fewer vacci-n recommended [47].decision-makers may be overwhelmed with informa-th parental interviews [48] found even those favourableon were confused by the debate and data provided, lead-

    second-guess their choices. When asked where theyfor further education, 70% of parents would look online,xplicitly asked whether they would use the Internet,ded afrmatively. Almost all (93%) said they would usearch engine, and easily produced search terms (e.g. vac-MR vaccine) when entered into search engines, thesened anti-vaccination websites in the rst page of results.are most accessible to users looking for basic infor-vaccines, and who therefore may be easily persuaded.ies of focus groups [49] found that compared to thoseccinated, parents struggling with vaccination decisionsikely to use a wider variety of resources they more fre-ntioned using the Internet, and had difculty assessingibility. Only parents of fully vaccinated children trustedians, pharmaceutical companies, or the government;

    distrustful and felt data provided to them was one-distrust of legitimate information sources is reected

    vaccination rates 11.5% of parents have refused atine their doctor recommended [50] but also in sur-

    the majority of parents (71%) of unvaccinated children are not inuential in shaping their vaccination decisions

    is multitude of factors the convenience of searching, the misinformation present online, the inuence others have had on vaccination rates, difculties assessingibility, the effect mere minutes of viewing a negative

    on risk perception, and the lack of trust in authoritiesred together, it seems inferable that anti-vaccine infor-

    websites and other social media sources would impact decisions in some way. Despite no direct data on pre-nuential the movement is, the potential for persuasionresent, but also is an explicit goal.

    ne anti-vaccination community

    cine sentiments are not a new phenomenon. Theyced back to the origins of vaccinology, with littlee [52,53]. Pinpointing the beginning of the modern-ccination movement may depend on ones age. The1982 television documentary, DPT: Vaccine Rouletteted thousands of parents to withhold pertussis vac-ated pharmaceutical companies with personal-injuryany then stopped producing vaccines), and led the

    ss to pass a law protecting vaccine manufacturersensating those allegedly harmed by vaccines [55,56].entary was also the impetus for the creation ofation Dissatised Parents Together. Newer genera-ents may be more familiar with Andrew Wakeelds

    [57]. After Wakeeld held a press conference and

    receivethe staJenny Live, Gmomm[14] (eexpervaccincompokeeperonline

    Copstrate includautismRescueerationNewspable min majcine InAwarework [for thebiased[69], wprofessuch ato not(e.g. diantiretsectionare incdefunc1.5 mithe meral nehave ndoctorand Jimplatforther prautisming) into othadvice

    Theyet all[20,23relay asome orylines i.e. acThe trmake rebuttasites (prior wvaccinthe scohere, aevolvensiderable attention; perhaps most inuential waswer harnessed with the release of a book by actorrthy [60]. Through various appearances on Larry KingMorning America, and Oprah, where she touted hernstinct and degree from the University of Googleples of postmodern relativism and self-proclaimed), McCarthy became a celebrity spokesperson againstnd pushed the issue into the mainstream. A key

    of her narrative was bypassing the traditional gate- medical knowledge by searching for information

    anti-vaccination websites exist online, and demon-derable diversity. Some sites foster an activist identity,afeMinds [61] (which promotes the hypothesis that

    novel form of mercury poisoning [62]), Generation] (Jenny McCarthys Autism Organization), and Gen-cues blog site, Age of Autism [64] (the Daily Web

    of the Autism Epidemic). They have had consider- inuence, even taking out full-page advertisements

    newspapers [65]. The American-based National Vac-ation Center [66], the Canadian-based Vaccination RiskNetwork [67], and the Australian Vaccination Net-ortray themselves as neutral watchdog organizations

    spective countries, but in reality dispense informationnst vaccines. Some sites may appear unsophisticated

    other promote similar allegations but with a morel appearance [70]. Prominent natural health sites,,, and tend

    spread irresponsible health information in generalraging chemotherapy or radiation for cancer treatment,als for HIV, and insulin for diabetes), but also have largeth dubious information on vaccines [7173]. Some sitesbly popular, the website for a now-gazine often disparaging of vaccination [74], receives

    unique visitors per month and has been ranked asctive online community for parents [75]. Even gen-and blogging websites, such as the Hufngton Post,rous entries on vaccines [76], where articles written byside-by-side with celebrity posts by Jenny McCarthyrey. All of these websites use various social mediasuch as Facebook and Twitter, allowing users to fur-te and share information. If McCarthy tweets aboutaccines [7779], over 450,000 followers (as of this writ-tly receive her comments and can forward them onome users even use Twitter to ask her for medical82].ebsites are but a sampling of the many in cyberspace,ain arguments that previous anti-vaccination studieshave discussed. The common errors and myths theybunked elsewhere [8388]. This overview focuses on

    tactics and tropes used to further such anti-vaccine sto- tactics described are the movements ways of operatings they undertake to spread their messages (see Table 1).

    are commonly recurring themes and motifs used to arguments i.e. oft-repeated mottos, phrases, andsted as they are typically phrased on anti-vaccinationable 2). The tactics and tropes were derived fromon quantifying and analyzing broader themes on anti-

    websites [20], although discussion of them was beyondf that paper. They are elaborated upon and added togh this list is by no means exhaustive and will no doubt

    time. The aim of this overview is not to quantify the use

  • A. Kata / Vaccine 30 (2012) 3778 3789 3781

    Table 1Tactics used by the anti-vaccination movement (i.e. actions undertaken to spread their messages).

    Tactics Description

    Skewing the science: Denigrating and rejecting science that fails tosupport anti-vaccine positions; endorsingpoorly-conducted studies that promoteanti-vaccine agendas.

    Shifting hypotheses: Continually proposing new theories for vaccinescausing harm; moving targets when evidence failsto support such ideas.

    Censorship: Suppressing dissenting opinions; shutting downcritics.

    Attacking the opposition: Attacking critics, via both personal insults andling legal actions.

    of these tactics and tropes, but to exemplify what they are and howtheir spread is facilitated by Web 2.0 and the postmodern paradigm.

    Works critiquing the anti-vaccine movement are often accusedof being propaganda [8991]; those on the other side of the issueaccuse anti-vaccine activists of propaganda as well [92,93]. Theintent here is not to enter that fray. Rather, the purpose is to increaseawareness of common anti-vaccine techniques. It is also impor-tant to note that the criticisms levied here are not meant to belittleindividuals with good-faith questions about vaccines, or those wor-ried or swayed by what they nd online it is easy to succumb toaws in reasoning, for cognitive or motivational/social reasons (e.g.difculty detecting biases, a desire for order, false impressions ofsocial support [26]). The tactics and tropes discussed take advan-tage of such reasoning aws; indeed, some of the tropes listed areactually logical fallacies. It is an important exercise in critical think-ing to be able to identify the misleading arguments that engage

    audiences through emotional appeals, anecdotes, or fallacious rea-soning, rather than through evidence. An awareness of these issuesis needed to help audiences recognize and evaluate the informationand misinformation they encounter.

    4.1. The anti-vaccination movements tactics

    4.1.1. Skewing the scienceThe anti-vaccination movement often denigrates scientic stud-

    ies (and the scientic method in general), while simultaneouslycraving scientic legitimacy for their theories that vaccines areharmful. Science is praised when appearing to bolster their posi-tion such as on the Fourteen Studies website [94], which ranksstudies supporting and discrediting the vaccineautism hypothe-sis. The ranking system is biased against pro-vaccine studies forexample, the Conict of Interest criterion reads, We considered a

    Table 2Tropes used by the anti-vaccination movement (i.e. oft-repeated mottos, phrases, and rebuttals).

    Tropes Description

    Im not anti-vaccine, Im pro-safe vaccines: Denying one opposes vaccination, instead claimingthey are for safer vaccines and further research.

    Vaccines are toxic!: Listing potentially toxic vaccine ingredients whileproviding disingenuous explanations of their dangers(a.k.a. the toxin gambit).

    Vaccines should be 100% safe: Because absolute safety cannot be promised, is the

    You cant pr vaccinto harove th

    Vaccines did improactors

    Vaccines are somenaturaher th

    Choosing be cinati outcoine si

    Galileo was e namimplyilly ga

    Science was instanidenc

    So many pe

    Skeptics bel

    Youre in th

    I dont belie

    Im an expervaccinationove vaccines are safe: Demanding

    do not lead having to pr

    nt save us: Attributing decades to fsanitation).

    unnatural: Designatingoption (e.g. diseases rat

    tween diseases and vaccine injuries: Framing vacundesirableserious vacc

    persecuted too: Invoking thorthodoxy, will eventuagambit).

    wrong before: Citing priorscientic everror.ople cant all be wrong: Implying anti-vacpeople support su

    ieve. . .: Ascribing false moare then easily att

    e pocket of Big Pharma: Claiming those suare hired by pharmpharma shill gam

    ve in coincidences: Rejecting that heacoincidentally aft

    t on my own child: Redening experttheir own childrediscounted.refore awed and dangerous.e advocates demonstrate vaccines

    m, rather than anti-vaccine activistsey do.vements in health over recent

    other than vaccines (e.g. better

    thing natural to be the betterlly acquiring immunity froman from vaccination).on choices as restricted betweenmes (e.g. catching a disease versusde-effects).es of those persecuted by scienticng ideas facing close-mindednessin acceptance (a.k.a. the Galileo

    ces of scientic errors to imply thee supporting vaccination is also incine claims are true because manych ideas.tives to vaccine supporters, whichacked.pporting vaccines do so because theyaceutical companies (a.k.a. the

    bit).lth problems can occurer vaccination.ise, where parents are the experts onn while medical authorities are

  • 3782 A. Kata / Vaccine 30 (2012) 3778 3789

    scientist employed by a vaccine maker or a study sponsored by avaccine maker to have the highest degree of conict, with a publichealth organization (like the CDC) to be the second-worst. [95] Agood study listed is by David and Mark Geier [96], a father-sonteam involtional Revieand staffedand a lawyStudies doewhile, the received thMMR contrivaccineauing it are ra[103,104].

    The movin the formnated versuwill show u e.g. the etics of recr[107] makobstacles aerly conducto the wro(President oexamining [108]; it waand neurodstudys metabout ideolfacilitated binformationtivism and various way

    4.1.2. ShiftiScienti

    cines are hcontinuallyto nd a cculprit thenmercury poafter remov[115,116]. W[117121], izations forover from Cbeing disch[123]. Whebecame alution Prograa childs confor mitocho

    The vaccvaccines ththen speciand then v[128]. BroadVaccines tthe idea besons and Too Soon, at too younit has fully these new

    examined scientically; when they were studied, the theorieswere not supported [133]. The targets established by anti-vaccineactivists are continually being redrawn in order for their key mes-sages to endure in the face of contradictory evidence.

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    verostednd oaby [ved in questionable practices [97100]. The Institu-w Board overseeing the Geiers studies was created

    by themselves, their family members and associates,er working on vaccine injury suits [101] Fourteens not acknowledge these conicts of interest. Mean-pro-vaccine study scoring highest (5 out of 40) onlye ranking because it appears to actually show thatbutes to higher autism rates [102]. Studies refuting thetism hypothesis are rated poorly while those support-ted highly, despite repeated critiques of that research

    ement constantly demands more research namely of randomised controlled trials comparing vacci-s unvaccinated children [105,106], expecting resultsnvaccinated children to be healthier. Various obstaclesthics of leaving children unvaccinated, or the logis-uiting enough subjects to sufciently power a studye conducting such a study virtually impossible. These

    re not mentioned when making such demands. Prop-ted work on the issue that already exists, yet comesng conclusion, is rejected. For instance, Sallie Bernardf SafeMinds) provided input on the design of a study

    thimerosal exposure and neuropsychological outcomess only when results indicated no link between vaccinesevelopment that she resigned and began criticizing thehods [109,110]. These are indications that the issue isogy rather than science. The democratization of datay Web 2.0 may allow for greater access to scientic, but when combined with postmodern notions of rela-questioning expertise, research can be reinterpreted ins to support specic ideologies.

    ng hypothesesc studies have repeatedly refuted allegations that vac-armful, forcing the anti-vaccination movement to

    propose new theories. When various studies failedonnection between MMR and autism [111114], the

    became thimerosal and autism was rebranded asisoning [62]. Proponents of this theory predicted thating thimerosal from vaccines, autism rates would drophen this decrease did not occur by 2006, and then 2007

    the target date was pushed back to 2011 [122]. Rational- the decrease not occurring included: mercury oatinghinese coal smoke, being released by forest res, or

    arged when cremating individuals with mercury llingsn the mercury hypothesis oundered, the new culpritminum [124,125]. When the Vaccine Injury Compensa-m settled a case where vaccines may have exacerbateddition, autism was again rebranded as a misdiagnosisndrial disorders [126,127].ineautism hypothesis has repeatedly shrunk rst

    emselves were a major cause of the autism epidemic,c vaccine components led to autism misdiagnoses,accines exacerbated the condition only in rare casesening the scope of vaccine protests again, Green Our

    hen became the movements rallying cry [129,130] ing that vaccines would be safer after removing poi-toxins contained within. Another motto is Too Many,the notion that children receive too many vaccinesg an age, overwhelming their immune system beforematured [131,132]. Web 2.0 facilitated the debate oftheories in public forums before their merits could be

    4.1.3. The

    those cions. Tunder safe encounterejectenity vathousapolicy this focuss isdecisioadvocavaccindue topoweract as erepeat

    Mocine adof the vaccinother wco-fourects tallegedpharmthe unregardred [1to ceashis pro

    4.1.4. Ant

    ics. Aftshe wadley su[56,14co-fouand jouWallaclies. [threatepaid Anpurpos

    Somsonal wprostit[145]. ment [After jofor autand mwas rebeyondblog pOft, adead brshipi-vaccination movement is extremely disparaging ofizing them, to the point of censoring dissenting opin-e of Autism blog often refuses to post critical commentsuise of comment moderation or the need to have anment to talk within this prompted the creation ofgs, such as Silenced by Age of Autism [134,135], wheremments are posted. hosts a commu-tion forum with thousands of threads and hundreds ofof individual posts by parents. The vaccination forums: We would like all members to understand thatis not an anti-vax forum but rather is a forum to dis-

    and concerns so that parents can make an informede are not, however, interested in hosting discussions

    for mandatory vaccination. [136] Posts opposing anti- views or supporting vaccines are removed, apparentlynda-focused behaviour [137]. While the connectiveeb 2.0 has created supportive communities, these maychambers, where one point of view is unquestioninglyd reinforced while critiques are expunged.derhanded methods have also been used to silence vac-ates. For example, Orac is the pseudonymous authorectful Insolence blog, which often censures the anti-

    movement. A misspelling of the domain name of hisite,, was bought by JB Handley,

    of Generation Rescue [138] [139]. Posts at Age of Autism alsoc has pharmaceutical ties, as his university receivedtical company funding [140]; one commenter posteditys address, which was bombarded with complaintse supposed conict of interest in attempts to have him

    More recently, another public health blogger was forced social media activities when a critic complained aboutcine opinions to his employer [142].

    king the oppositioncine activists have led legal actions against their crit-e blogger wrote about a familys vaccine lawsuit [143],poenaed [144] despite no involvement in the case. Han-r. Paul Oft, author of books critical of the movementr a particular passage he wrote [146]. Barbara Loe Fisher,

    of the National Vaccine Information Center, sued Oftist Amy Wallace for libel over a comment Oft made inired magazine article [147] specically, She [Fisher]The British publishers of Ofts latest book [56] were

    with a libel suit over a sentence suggesting a lawyer Wakeeld to conduct his infamous study for litigation

    49].ti-vaccine activists attack their detractors in more per-. Dr. Oft is often called a biostitute (i.e. a bioscience

    or Dr. Proft [150]; he has even received death threats publication of her article on the anti-vaccination move-, Wallace endured various misogynistic slurs [151,152].list Trine Tsouderos articles on biomedical treatmentsere published [153155], her writings were criticized

    s impugned [156159]. After Seth Mnookins book [14]d, his journalistic integrity was assailed [160]. Movingbal attacks, for Thanksgiving 2009 the Age of Autism

    a Photoshopped image showing Wallace, Tsouderos,ther vaccine advocates sitting down to a dinner of a161]. Rather than debating the merits of the evidence,

  • A. Kata / Vaccine 30 (2012) 3778 3789 3783

    the anti-vaccination movement tries to win through intimidation.Web 2.0 makes it easy for their protests to be heard.

    4.2. Common anti-vaccination tropes

    4.2.1. Im nA comm

    instead is fanti-vaccinaway from [91,164] studied [16to safe vacctic, and sadue to the emaking thissent and dmisinform r

    4.2.2. VaccMany w

    (e.g. ether, aviruses, andgambit. Wexplanationare frequensure, not acit mentionebody (e.g. fothrough acton the toxitors, offerinvaccines adapplicants avaccines thlator [174] but the resufrom a one-on chronic,dangerous [

    4.2.3. VaccAnti-vac

    perfect, it issafe, some sous websitemeant to inthey cannonothing canissue, in thadiseases thpation with

    4.2.4. You This acc

    cines do nohaving to presearch prthere is alsoautism andcausing theclusive ansculprit. Thiknowing soing someth

    have been no studies conducted with the specic conditions anti-vaccination groups ask for [180], this lack of knowledge meansvaccines are not safe. Lists of questions to ask vaccine proponents[181] are circulated with the intention of stumping them, with the

    ty to

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    fromes wsing ed. trodd.

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    So ertinthatot anti-vaccine, Im pro-safe vaccineson evasion is denying one opposes vaccination, butor safer vaccines [162,163]. Some oppose the label ofe, complaining it is pejorative and deects attentionlegitimate questions and gaps in scientic knowledgefor instance, claims that vaccines are not adequately5,166]. This is difcult to argue against, for who objectsines or further research? Yet calls for a balanced, scien-fe approach to vaccination [167] tend to be misleading,rroneous and distorted information coming from those

    assertion [168]. Such websites promote informed con-oing research before vaccinating, but tend to subtlyeaders with worrisome and unsupported claims.

    ines are toxic!ebsites list toxic ingredients supposedly in vaccinesnti-freeze, formaldehyde, aborted fetal tissues, animal

    foreign DNA [169,170]). This is known as the toxinhile some ingredients listed are technically present,s of their dangers are often disingenuous. Their riskstly emphasised in terms of larger or prolonged expo-knowledging that the dose makes the poison. Nor isd that some substances occur naturally in the humanrmaldehyde [171]), or accumulate in greater amountss such as breastfeeding (e.g. aluminum [172]). Variantsn gambit include Vaccine Challenges issued to doc-g cash rewards in exchange for injection with infantjusted for adult weight, to prove they are safe; with noccepted, challengers claim that doctors do not trust theey administer [173]. Also, a Vaccine Ingredients Calcu-shows exposure to various ingredients via vaccination,lts are deceptive for instance, comparing aluminum

    time vaccine dose to the daily estimated safe dose based long-term exposure, making the vaccine dose appear175].

    ines should be 100% safecine activists may claim that because vaccination is not

    therefore awed yet even if vaccines were perfectlytill would not vaccinate [176]. A document on numer-s is the Physicians Warranty of Vaccine Safety [177],timidate doctors by asking them to promise somethingt namely, absolute safety. This ignores the fact that

    ever be 100% safe; it also ignores the complexity of thet vaccines are safer than allowing vulnerability to the

    ey prevent. This exemplies the postmodern preoccu- risks over benets.

    cant prove vaccines are safeusation demands vaccine advocates demonstrate vac-t lead to harm [178], rather than anti-vaccine activistsrove they do. Claims such as There is no denitiveoving a link between vaccines and autism or ADD, but

    no denitive research ruling it out or Those who say ADD are not linked to vaccines do not know what is

    epidemics [179] imply that because there is no con-wer to certain problems, vaccines remain a plausibles involves arguing based on a lack of evidence notmething is true is taken as proof it is false, or not know-ing is false is proof it is true. Likewise, because there


    4.2.5. Rat

    healthfactors[182]. deathsvaccindecreaexplaincine inomitte

    4.2.6. Thi

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    4.2.7. Vac

    dichotthe susibilityprevenchooseMcCarand Ifor the Such frvaccin

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    weiss, orthodare crimaveris consthat ideventu

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    [194], answer taken as evidence against vaccination.

    ines didnt save ushan acknowledge the role vaccines played in improving

    recent decades, those gains are instead attributed to as cleaner water, better sanitation, and less crowding

    claim is usually accompanied by graphs [183] showing vaccine-preventable diseases were declining before

    ere introduced. That mortality rates would have beendue to improving medical and supportive care is notGraphs showing decreasing disease incidence after vac-uction would be evidence of their efcacy, and are

    ines are unnaturalignates something natural as being inherently goodile what is unnatural is bad or wrong. Vaccines arend therefore bad [184]. Acquiring immunity from dis-tural and therefore the better approach [185], such ashickenpox parties [186]. This logic overlooks higheratural infection while xating on comparably minuteaccination. Alternative approaches may be seen as morean vaccination [187]; such options may be couched inealth freedom [188].

    osing between diseases and vaccine injuriesion may be portrayed in terms of misleadings e.g. the unlikelihood of catching a disease versusedly greater likelihood of a vaccine injury, or the pos-vaccine side-effects more serious than the diseasesOne blogger claims that vaccination is Making parentseen chronic and infectious disease [189], while Jennyas declared that It shouldnt be polio versus autismask a parent of an autistic child if they want the measlesm, we will stand in line for the f***ing measles. [190]g restricts the possible outcomes when others exist (e.g.

    without side-effects).

    leo was persecuted toos the Galileo gambit, names such as Galileo, Semmel-rnicus, or other great minds attacked by the scienticof their time are invoked by those whose argumentsd [191,192]. This is related to the concept of the braveoctor whose work ies in the face of the status quo andd heresy against the establishment. The implication isurrently facing close-mindedness and persecution willbe accepted as truth.

    nce was wrong befores where science erred or was slow to acknowledge thesomething proclaimed to be safe (e.g. Vioxx, Thalido-garettes [179,193]) are cited. The implication is thatprevious errors, the science supporting vaccination isr; this overlooks the self-correcting nature of the scien-. This is related to the declaration that science doesnt

    answers or the appeal to another way of knowing,alleged that science is not the only source of truth aodern assertion [20].

    many people cant all be wrongg that many children have been harmed by vaccines

    many people do not vaccinate [195], or that many

  • 3784 A. Kata / Vaccine 30 (2012) 3778 3789

    doctors question vaccination [196], does not make such claims true.For example, petitions signed by medical professionals opposed tovaccines [197] are held up as evidence against vaccination, despitesignatories being in the minority among practitioners. The con-stant repetifool readersshared by m

    4.2.11. SkeFalse mo

    labelled as cines are saALL people there is NOgiven [198dence. [19positions anwhich are t

    4.2.12. YouColloqui

    who defendmaceutical is continuarotavirus vaprolic propublished acompany tirather than

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    occur after At the indivtions occurvaccine blamthat the incschedule ovrates of au[205,206]. Tteria or incnot prove c

    4.2.14. ImGenuine

    vaccinationCentral to ton their owresearch anredening eities who athe late antibased on heof Health [2in immunolpatients aftspecial insiwhen they

    5. Conclus

    The techcunning, fotionable rhevaccine sa

    medical paradigm. Calls to do your own research before vacci-nating dovetail with the postmodern characteristics of patientempowerment and shared decision-making, where individualsplay a more involved role in their healthcare. The Internet pro-

    asy ition

    for thaner wo seevinc

    mays tros charoposed b

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    Whant, y nestmoscienr option of this and other tropes on various websites can into thinking anti-vaccination opinions expressed areany.

    ptics believe. . .tives are often ascribed to vaccine supporters, who areskeptics for example, Skeptics believe that ALL vac-fe and effective (even if theyve never been tested), thatshould be vaccinated, even against their will, and that

    LIMIT to the number of vaccines a person can be safely] or You believe everything about Autism is a coinci-9] These straw men not only misrepresent pro-vaccined ignore the original issues, but also create easy targetshen attacked instead.

    re in the pocket of Big Pharmaally called the pharma shill gambit, this alleges those

    vaccines do so because they are hired to promote phar-products for devious purposes or prot [200]. Dr. Oftlly discounted because Merck bought the rights to hisccine, making him a shill, the vaccine industrys mostpagandist. [201] After Amy Wallaces article, Wired

    follow-up in response to allegations of pharmaceuticales [202]. This forces the accused to defend themselves,

    arguing the evidence.

    nt believe in coincidencesment rejects that health problems may coincidentally

    vaccination without having been caused by the vaccine.idual level, this involves anecdotes about negative reac-ring in children near the time of vaccination, with the

    ed [203,204]. At the population level, the argument isreasing number of vaccines added to the immunizationer recent years has led to simultaneously increasingtism (i.e. an autism epidemic) and other illnesseshis disregards factors such as changing diagnostic cri-reased autism awareness [207]. That correlation doesausation is ignored, or even ridiculed [208].

    an expert on my own child authorities on vaccines are denigrated for supporting

    and belittled as not having appropriate expertise [209].his issue is parents considering themselves the expertsn children [210], claiming they have done their ownd again demonstrating the postmodern characteristic ofxpertise. Alternatively, appeals may be made to author-re not experts on the particular subject e.g. touting-vaccine spokesperson Bernadine Healy as an authorityr former position as Director of the National Institutes11], doctors criticizing vaccination despite no trainingogy [212], or doctors noticing certain reactions in theirer vaccinating or not vaccinating, implying they haveght into the issue [213,214]. Authorities are invokedsupport the desired opinion.


    niques used by the anti-vaccination movement arer not only are their protests camouaged in unobjec-toric such as informed consent, health freedom, andfety, they take advantage of the current postmodern

    vides eredenallowsrather anothcult tbe conmentsvariouvariourisky p2.0 is utainty,

    Whinclud[30,21social aids abdetermpaignsand coanti-vainstancfound extentof emomany tems, alone wals cho[223].

    Thapenducoveraular mmovemmovem[228] dF. Kennremovcorreccoverathe jouare affparticuinvestiAndrewthese rers andstatemmunityrolled

    Sucwith teasy tathis hamedia.importis likelthe potative, anotheaccess to online health information, and through the of expertise and notion of relativism, postmodernismthat information to be interpreted in various ways

    an interpretation being wrong, it can be reframed asay of knowing. With this paradigm in place, it is not dif-

    how Internet users attending Google University mayed by what they might nd. Some anti-vaccine argu-

    at rst seem reasonable and to hold a grain of truth; thepes encountered, particularly when repeated throughnnels, may make vaccinating seem like an extremelysition. Rather than creating informed patients, Weby the anti-vaccination movement to spread fear, uncer-doubt, thereby creating misinformed patients.lutions exist to quell these fears? Some proposalsmunizing against misinformation through educationsing emotional appeals [216,217], or even harnessinga in return such as by creating web-based decisionvaccination [218], using real-time Internet tracking topublic attitudes [37], or launching social media cam-,220]. While it is important to attempt such efforts

    t the misinformation that exists, it is doubtful that theation movement can ever be completely quashed. Forotional narratives about vaccine side-effects have beenrease risk perception and uptake intention to a greater

    statistical information [221], demonstrating the powerl appeals and anecdotes over educational efforts. Withle desperate for answers, invested in their belief sys-istrustful of authorities, it is unlikely that the factsver sway the truly committed [20,222]. Some individu-o disregard the evidence, and are essentially denialists

    not to say there is no reason for optimism, for theis now swinging in the other direction. Whereas prioras supportive and largely unquestioning [163,224], pop-

    outlets have begun to lambaste the anti-vaccination Various articles [147,225227] have condemned theand its representatives; a PBS Frontline documentaryt portray the movement in a positive light; and RobertJr.s error-laden article on vaccines and thimerosal wasom, after acknowledging that keeping even aersion posted was a disservice to the public [229]. Such

    distinct from past reporting in that it largely ignoredistic mantra of balance, where both sides of the issue

    equal time and respect, thus equating the positions. A large blow to the movements credibility was dealt bye journalist Brian Deer, whose series of articles exposedakeelds research as fraudulent [230232]. However,ations did not appear to matter to Wakeelds follow-thers who distrust vaccines, as evidenced by numerous

    of support [233235]; Handley even said, To our com-drew Wakeeld is Nelson Mandela and Jesus Christto one. Hes a symbol of how all of us feel. [236]tatement is a reminder that nding common groundwho question, fear, or crusade against vaccines is noheir arguments are constantly shifting and evolving en furthered by the uidity of the Internet and socialile acknowledging and correcting awed arguments isan approach that moves beyond providing the factseded. With the anti-vaccination movement embracingdern paradigm, which inherently questions an authori-ce-based approach, facts may be reinterpreted as justinion. This issue is as much about the cultural context

  • A. Kata / Vaccine 30 (2012) 3778 3789 3785

    surrounding healthcare, perceptions of risk, and trust in expertise,as it is about vaccines themselves. For these reasons it is possiblethe minds of deeply invested anti-vaccine activists may never bechanged; therefore it is for both the laypersons with genuine ques-tions or wowho work tof persuasiotactics andgenuous arindividualsencounter ochoices can


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