Childhood immunisation rates have featured in the news lately and for obvious reasons.
Cover rates are declining and there has been a resurgence of measles in particular. In England, the MMR cover rate of children by their second birthday, which improved after the MMR- Autism scares of the late 1990s/ early 2000s, seems to have peaked at a fairly unimpressive 93% of 2-year olds in 2014 and now appears to be on a downward slide.
For a while, the UK achieved measles elimination in 2016, clearly not unconnected with achieving a 95% cover rate (the WHO recommendation) in five-year olds. But latest figures show only 87.5% of five-year-olds in England have had the MMR jab and more than half a million children in the UK went unvaccinated against measles between 2010 and 2017 leading Simon Stevens to warn of a “public health timebomb”.
There were 913 cases of measles in England between January and October last year – compared with 259 in the whole of the previous year. And it’s a worldwide problem – some 112,000 cases of measles globally were reported between January and March this year compared to just 28,000 during the same period last year.
Much of the discussion has referred to that enticing notion of “herd immunity”.
The concept of herd immunity is well established. This graphic simulation shows the spread of disease in 10 different cover rate scenarios aligned to actual examples of US Counties and demonstrates how increasing cover reduces the rate of transmission to a point where the population is, for all intents and purposes, safe. Which is essential as not every child can be immunised (the immuno-suppressed, those who experience serious reactions) and depend on herd immunity to protect them.
I am old enough to have actually had measles and mumps and to know what a vile experience that can be. They are not things I would wish on any child especially when they can be easily avoided with the simple means we now have available. So, I share some of the great frustration being expressed about the “deviants” within the herd who fight against vaccination.
But the term “herd” troubles me – a herd of what you might well ask?
Implicit in the term is an expectation of compliance, of uniform behaviour, doing the right thing as a group for survival. You can imagine the soft, authoritative voice-over of David Attenborough commenting on the quirks in the herd that seem to be inexplicably sending it to its own self-destruction.
Herding is never easy and those of us in the health system may be fine ones to talk when it comes to group action. It must have been a good twenty years ago that I first heard the term “like herding cats” used in a health context. It was in relation to getting GPs to do things differently but since then I have heard it used to describe the outlook across the range of clinical tribes.
If we can’t get the herd to behave what can we do? For a start, we can certainly vent our feelings as Matt Hancock did when he told the Times “Those who have promoted the anti-vaccination myth are morally reprehensible, deeply irresponsible and have blood on their hands.” We can invoke the science argument as he did on the Today programme on Radio 4 – “Those people who campaign against vaccination are campaigning against science. The science is settled.” We can rail against the social media behemoths who facilitate the transmission of some of the utter nonsense that influences some parents – Hancock has proposed new legislation to force social media companies to remove content promoting false information about vaccines – a study has found that Facebook’s 2016 fake news ban led to a 75% drop in erroneous anti-vaccination messages.
We can also be draconian with individuals. Speaking in a Commons debate, Labour MP Paul Sweeney called for failure to immunise a child to become a criminal offence.
Matt Hancock has said he is prepared to consider making immunisation a mandatory requirement for school entry. We have not had mandatory immunisation in the UK since the 1853 Vaccination Act to enforce the giving of cowpox (to prevent smallpox) to a suspecting and resistant population. Out of 27 EU states, 15 have no mandatory vaccines. Italy has 10 compulsory vaccines. France is preparing legislation. People refer to the US example – but the US experience with cover rates is nothing to aspire to. In reality, only three states require vaccinations for children to attend kindergarten without any nonmedical exceptions, most states excuse parents if they have religious objections and other states will accept objections even if they are not on religious grounds. As Gary Finnegan (see his paper here) has noted there is no one-size-fits-all approach – some countries with mandatory imms have high uptake, others (eg Finland) achieve this through other means.
All these reactions show that we have heard what some of the herd are saying. I am not sure we have really listened. And that is not to say that the content of what vaccination-deniers are saying is worthy of listening to or has any scientific or other merit. I am not suggesting “pandering” to the objections. But people speak and behave in a context. And that context is not one that just affects immunisation – you can see its implications across a wide range of things. There are bonkers bubbles right across the internet. Occupiers of them tend to stay within and reinforce one another and are not easily penetrated by reason. Go all guns blazing on one and who knows what will blow up instead. The context deserves listening to and understanding.
So, what are the ingredients of this context that might also have an effect on other interactions with healthcare? I would argue that these can permeate many of our own attitudes and suggest that then fears of vax-deniers, regardless of any crazy notions they may have, may not always be that far removed from the thinking of “more reasonable” people.
Researchers who have looked inside the anti-vaxxer echo chamber have found high levels of distrust towards the government and medical industry, a shared sense of paranoia and conspiracy, and common stories about big government and big business versus individual faith and belief. Well, I can relate some of this without thinking an MMR jab would instantly put my child at the extreme end of the autistic spectrum.
As we see the unravelling of the opioids scandal, the denial of readily available medication through perverse pricing and the persistent manipulation of research findings by the pharmaceutical industry, who is rushing to believe anything that Big Pharma has to say? Then there is the UK contaminated blood scandal and the history of missing documentation that leaves a worrying taste in the mouth of government and industry incompetence and collusion. That’s before we think of the current day-to-day management of the country stultifying in the stagnation of the Brexit fiasco, with a Government one would be hesitant to entrust a whelk store to, yet alone a £100bn system. And after thirty years in the health business, I am afraid to say I can never assume that the multiple divisions in the medical and clinical world automatically have my interest at heart as they pursue their own agenda. Add to that the seemingly daily publication of new findings allegedly proving one thing or another about food, exercise, behaviours (many of which attack things we hitherto have enjoyed and not obviously suffered from) and leaving complete confusion about what is actually best to do (interestingly, concurrent to the recent uproar of vaccination denial has been a discussion about the dogmatism and inflexibility of breast-feeding advice). Facebook may well pull together a confusing plentitude of semi-coherent threads but so does reading serious pieces in the mainstream media and even academic journals – if you can get behind the pay wall.
This is a serious situation but let’s get things in perspective and not make it more intractable than it already is. There may be costs to panicking which will turn out to be detrimental. Just focusing on vaccinations and doing some of the draconian things suggested may satisfy us that we are doing something but may in fact simply reinforce positions – banning kids from school will create a new raft of home educators of the very children you would want to keep in mainstream influence.
Perhaps we need to tone down some of the rhetoric lest it becomes another story of doom amongst all the other doom stories we face. How does the doom of measles really compare with the doom of climate change? These various dooms are threatening to present some sort of doom overload which could well have the opposite effect to anything intended. If it is all so terrible, why not just give up now?
I think getting to grips with some of the context is, in the long-term, more important and cannot be detached from some of the existential threats which we face. Elfy Scott , an Australian journalist, argues that we all understand what it means to be scared in 2019, and “while we’re sure as hell not required to respect pseudoscience, we should at the very least be able to understand how the fear can make a person’s belief system so awry”. Belief in pseudoscience and conspiracy theories is propelled by external pressures of fear, confusion and disempowerment. Scott emphasises the existential, epistemic and social reasons that appear to drive people to conspiratorial belief, asking why we are shocked that these untruths are thriving in a seemingly chaotic post-truth world where loneliness has become a major health concern? When we feel so fundamentally disenfranchised Scott says “it’s comforting to concoct a fictional universe that systemically denies you the right cards. It gives you something to fight against and makes you self-deterministic”.
We see these forces at work in Trumpism, other populist movements and they have been cited in much discussion around Brexit. US white supremacist and far-right sites are “hitching a ride on anti-vaxxers’ natural suspicion of authority and mistrust of big pharma” and in Italy, the populist Five Star Movement has seized on parental resistance to a compulsory vaccination
Underpinning all our relationships with health, social care and society as a whole, are some fundamental 21st Century issues with major ramifications beyond a simple childhood jab. A list for starters is set out below. They are interlinked. These fundamentals are much harder to deal with, of course, than issuing edicts and blanket bans. There are no easy answers, no Daily Mail or Secretary of State soundbites. They have been and will be recurring themes in my writing. They are things to work towards – sometimes in small manageable shifts. Things certainly won’t change overnight. They are part of a long-haul struggle of adaptation to, and moulding of, the new world we are facing. Together they could help to encourage a greater positiveness which could start to address some of society’s underlying fears:
- Enfranchising the disenfranchised, empowering the disempowered. This needs to be at the heart of service planning and service delivery and starts in the face to face interactions in the surgery. A lot is talked about this, but we continue to avoid this. I see opportunities for this missed on a daily basis as CCGs plough ahead with Primary Care Networks without any real engagement on the ground. This links with the next point.
- Developing a meaningful, responsive and responsible 21st century concept of the common good and community. In our identity-defined, individualist world this will be a challenge. Just telling people that getting their children immunised is a social responsibility (a duty of the herd) is unlikely to be particularly successful. I started discussing the role of the community and its wider political implications in my last blog. Linking back to vaccination, actually some public health commentators already refer to herd immunity as “community immunity” – it’s a bit of a mouthful but maybe to switch to that term away from the herd idea would be a good start.
- Re-establish the position of clinical and other expertise and to think more self-critically why this has fallen from grace. Don’t just blame Google. We have to find ways of working with the media to re-establish the notion of expertise and the value of the study and hard work that supports it. Not helped of course by faceless technology and apps. Rediscovering the importance of expertise comes out of enfranchising and empowering rather than counter to it. Yes, it may be possible with some humility and time (although arguably not in an 8-minute GP appointment). This may start with a more effective interaction between health services and schools and will be linked to attempts to develop a sustainable future workforce.
- Enhancing the role of the scientific base by providing visible independence in the way it is presented with the media not rushing to publish and talk up the latest tiny piece in a complex jig saw of ongoing discovery and challenge as if it provided the only answer. It means persuading some of the broadcasting media not to cravenly give equal weight to opposing views in their paranoia about bias regardless of technical merit. Making the scientific evidence readily available and accessible is the responsibility of all and that certainly must mean removing pay walls especially on publicly funded research for which there can be no justification. All clinical researchers and paper-writers should be demanding open access.
- Having a more sophisticated approach to education – The Royal Society for Public Health suggested more factual information and better education about the benefits of vaccinations could be key but that must surely depend on how it is presented and communicated (see below). One randomised control trial in Colorado found that parents who were given rich information about the benefits of vaccines before their baby was born were more likely to have them immunised.
- Communicating with more understanding – as Elfy Scott (above) has pointed out, a great deal of science communication has become smug, prodding and has lost its sense of empathy. She argues we have become too satisfied with pinning the nonsense on some bizarrely flourishing individual idiocy but sneering (as I, myself, may have slipped into early on in this piece) only serves to enforce an “us and them” worldview. This applies also to any necessary public health advertising and propaganda as well as the way in which clinical workers work or co-create with citizens. Information about vaccination often focuses on the harm that not immunising children can do and its unfairness to other people. Such messages are unlikely to connect with people who are suspicious of vaccinations because they don’t speak to their values. They are much more likely to notice messages which play up themes of purity and liberty.