When I came to the United States for medical training after going to medical school in Pakistan, there were certain diseases I was sure I would never see surface here again. Measles was on top of that list. Even though Pakistan is one of only three countries where a vaccine-preventable disease like polio is endemic, measles is very uncommon, especially in high-income countries. Yet today, measles outbreaks are popping up in America — from Orthodox Jewish communities in New York City to Washington state, where a state of emergency has just been declared as officials scramble to keep the outbreak from spreading. Countries across Europe, too, are witnessing the reemergence of a disease that should have been eradicated with vaccination.
Measles is a highly infectious viral infection that can lead to fevers, a rash, and a flu-like illness, and can sometimes cause inflammation in the lungs or the brain. The vaccination developed in the 1960s almost eliminated measles from the face of this planet. But rumors and conspiracies about the supposed side effects of the vaccine have led some parents to prevent their children from getting inoculated, leading to its resurgence in parts of the country.
What allows these anti-vaccine rumors to spread? One cause that has likely contributed to this crisis is the epidemic of medical misinformation about vaccines and other evidence-based medical advances enabled and spread through the internet. A recent report suggests that half of parents of young children have been exposed on social media to fake news about vaccination, including ominous advertising on Facebook suggesting their children may die from the supposed toxicity of vaccines. Medical misinformation is so widespread that the World Health Organization has recently declared vaccine resistance one of the top 10 threats to global health in 2019.
In Clark County, Washington, 50 cases have been confirmed and 11 more are suspected in an outbreak that’s still ongoing. In the same state, groups like Informed Choice Washington have built online communities around vaccine skepticism. Officials believe groups like these are a reason for the spread of measles: “These outbreaks are due to the anti-vaccine movement,” Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, told CBSN AM.
Clark County Council Chair Eileen Quiring echoed Fauci recently in the Columbian: “In the 25 years that I’ve known about immunizations and the controversy over it, there are things on the web and there are organizations that say that vaccinations cause autism and that’s why some parents are reluctant to have their children vaccinated.”
Trust for institutions is decaying. That includes medicine.
For much of recent human history, physicians have enjoyed immense trust from those they were responsible for caring for. Yet recent years have seen some of that trust decay, in parallel with a decline in trust in other institutions like the government and the media. Increasingly, as consumers of health care have gained more autonomy, the traditional relationship skewed to favor the power of doctors in decision-making has been shaken up. While many patients continue to trust their doctors, others are seeking a second opinion on the internet.
There are many features of our health system stacked against providing patients easy access to reliable health information. Trying to see a doctor can be time-consuming, expensive, and inconvenient, and one can receive information that might be hard to understand. This helps make the internet an attractive source of information for many patients, with sites like WebMD and UpToDate offering advice information that is convenient, intelligible, timely, nonjudgmental, and mostly for free. Yet for all its strengths, the internet can lead people down wormholes of inaccurate medical information and conspiracy theories.
And there are many features about vaccines that make them a vulnerable target for misinformation.
The most important reason misinformation about vaccines is so prevalent is ironically because of how effective they are. Growing up in Pakistan, I frequently saw children with polio, and my parents would use that to ensure I got every vaccine I was eligible for. Yet because of the effectiveness of vaccine campaigns in countries such as the United States, vaccine-preventable diseases such as measles, mumps, rubella, smallpox, diphtheria, pertussis, and polio had largely been relegated to the history books.
Nowadays, almost everyone either receives or sees other people receive vaccinations, yet they rarely ever witness the diseases they are so good at averting. And because of a kind of cognitive bias called availability bias, we may attach outsize significance to what we see around us rather than looking critically at the full picture.
This availability bias is so potent, it even affects those who should be most resistant to misinformation: physicians. A 2013 study found that recent medical graduates, who are much less likely to have taken care of patients with vaccine-preventable diseases, are more suspicious of the effectiveness of vaccines than older graduates.
Prevention is the holy grail of medical advances, given that it promises to treat disease before it even rears its head. Yet I believe that, ironically, preventive medical advances are the ones most likely to be the targets of medical misinformation campaigns.
This is reflected by the fact that the other major target of medical misinformers has been medications that prevent heart disease particularly statins. Statin medications that lower cholesterol and lower the risk of heart disease are probably the most well-studied medications of all time and are also one of the safest available. Yet, similar to vaccines, a tsunami of fake medical news exaggerating the risks of statins has proliferated on the internet.
Preventive therapies treat illnesses that a patient will never witness
Why? If they are effective, preventive therapies treat events that a person will never witness. So a patient who takes a statin might never experience the heart attack it prevented but might experience side effects, or simply the inconvenience of taking a medication sometimes with no perceived benefit. This is unlike treatments that are therapeutic for symptoms or obvious physical manifestations of diseases after they have developed. For example, while many patients may overstate the risks of statins, the benefits of treatments such as coronary stents, which are used to increase blood flow in blocked or narrowed arteries supplying the heart to manage heart attacks and chest pain, are frequently inflated.
Outbreaks of measles in the US, largely driven by refusal of a critical mass of parents in a community to have their children vaccinated, could be a result of this phenomenon. Rumors and fears that have taken hold of largely well-educated, concerned, and well-meaning parents, connected through online networks, are fueling the anti-vaxxer movement.
Yet perhaps the answer to this modern disease that appears to have landed straight out of a Black Mirror episode might also lie in the online networks that have helped foment this in the first place. A team of scientists successfully predicted the measles outbreak at Disney World in 2014 using machine learning to analyze social media posts and search engine behaviors two years in advance.
The most effective known strategies to prevent the emergence of vaccine-preventable diseases is quite simple and has been implemented by states such as West Virginia, Mississippi, and more recently California — make vaccination mandatory unless there is a strictly medical contraindication to vaccination. Others argue that physicians and other health care staff should be trained using social media to debunk misinformation and effectively engage with the public about medical matters.
“Taking on the misinformation campaign about vaccines has become more complex now that research is demonstrating that a large amount of the social media posts represent state-sponsored cyberwarfare, particularly from Russia,” said Robert Califf, a former commissioner of the Food and Drug Administration who now leads the Forge, Duke University’s center for health data science. The center is now mounting an effort to understand and address misinformation on the internet.
Yet it will take more than one university to address this issue. “If our tax-exempt institutions intend to find the truth and disseminate it, misinformation on the internet may be the issue of our times that demands top priority,” he said, adding, “We must join together to come up with effective methods to provide people with truthful, reliable, and actionable information about their health.”
To me, most of these suggested approaches target the symptom and not the underlying malady. To win the information war, we need to earn back people’s trust.
In my work as a cardiologist, this means taking time to help educate patients about how best to take care of their heart and to provide context to the risks and benefits of common cardiac medications like statins. One reason physicians have lost patients’ trust is because changes in health care have forced them to spend more time with computers and electronic health records than with patients at the bedside. We need more doctors and nurses offline, interacting with concerned people in the clinic and hospital as well as in communities and homes, sharing stories rather than simply regurgitating facts.
Painting anti-vaxxers as a hysterical, unhinged horde only intensifies distrust and sharpens divisions. Such tactics have left our politics in shambles, and could very well turn the ongoing public health crisis into a full-blown catastrophe.
Haider Warraich is a cardiologist at Duke University Medical Center and the author of the forthcoming State of the Heart: Exploring the History, Science, and Future of Cardiac Disease.
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