Tuesday, October 23, 2012

On the Vaccine-preventable Disease Outbreak Narrative

Articles like this one that appeared in Parade a few weeks ago, "Why so Many Parents Are Delaying or Skipping Vaccines,"not only hit my radar because I follow its author, Seth Mnookin, on Twitter and he tweets like 7 times an hour. Not that I'm complaining--I feel certain at most times that I know everything going on in vaccination just by following him.

I continue to be surprised and intrigued by the number of articles that appear--in the popular media as well as scientific journals--that claim to have answers to vaccine controversy. Yet, not only do these articles rarely provide any actionable answers (other than encouraging people to vaccinate), but they also tend to report mostly by re-hashing a standard narrative about vaccine refusal, complete with cast of good guys and bad guys and what happens when even a few parents refuse to vaccinate:

Bad guys:
  • Andrew Wakefield (whose 1998 argument that MMR vaccination caused rising rates of autism is characterized as the impetus for today's vaccine controversy) 
  • Vaccine success (diseases now seem so rare that parents aren't afraid of them and skip vaccinations)
  • Parents in affluent, well-educated areas who are overly concerned with environmental issues and child development (so, focused on the wrong things, they refuse vaccines to avoid environmental contaminants and instead put their kids--and others--at risk for disease; they also worry about autism and think it is related to vaccines, thanks to Andrew Wakefield [above])
Good guys: 
  • Vaccines (of course. They have greatly reduced measles and polio worldwide and have eradicated small pox)
  • Herd immunity (which protects everyone--vaccinated and unvaccinated--from contagious disease)
  • Health officials, researchers, and doctors (who, try and try as they might, cannot out-persuade Jenny McCarthy)
Parents stop fearing diseases because they have become rare. A segment of parents fears vaccines instead because their resources afford them the time and education to over-research vaccine safety and indulge their personal political whims. Parents delay vaccines. Disease comes to a community, circulates to unvaccinated children, but then vaccinated and immune-compromised children become sick as well. Doctors don't recognize the diseases the children present with because they are so uncommon now. Children die or become very ill. Non-vaccinating parents learn that diseases are serious and that they should vaccinate. Vaccinating parents learn that parents who don't vaccinate their children don't realize that their decisions put others at risk.

I don't disagree with this narrative so much as I am perplexed by its over use. Paul Offit's Deadly Choices begins with a similar story, and Mnookin's book is peppered with similar stories throughout. And even when the full narrative isn't present, the good guys and bad guys are almost always the same. 

What is it about this set-up that is so compelling as a story for why vaccines are necessary? 

After all, the case of the pertussis outbreak in Floyd County, Virginia, which Mnookin mentions off-hand but doesn't delve into here (but does here), offers an excellent example of a vaccine-preventable disease outbreak that didn't happen that way. 

Floyd County is not an incredibly affluent area, and the people in that community clustered at a local, private "alternative" school largely shared values that made them avoid vaccination, so this was not an isolated segment of this community that avoided vaccination--the community was essentially made up of non-vaccinators. The disease ended up spreading to about 30 people and engaged a nearly immediate response from the health department, so there was no widespread confusion about what disease people had, causing surprised doctors and delayed diagnosis. Finally, all of those who contracted pertussis were unvaccinated, so the vaccinated child with a rare disorder that made her susceptible to disease was not present. And there were no fatalities. 

Other than perhaps the ideologies behind not vaccinating (it is unclear if environmental or backlash against the government or something else is why those parents did not vaccinate), this story differs at every turn from the story Mnookin relates here, which has a predictable, convenient narrative arc that has to end with an unvaccinated child getting sick. Not to say that that isn't a serious ramification of vaccine refusal or that it is necessarily incorrect much of the time.

But just as the case of Floyd County demonstrates, it isn't the case all of the time, making it possible that the telling and re-telling of this narrative is serving some other purpose, to reify the dangers of non-vaccination among vaccinating and non-vaccinating parents alike, creating a possible counter-narrative to vaccine safety arguments. After all, the vaccine choice that vaccine skeptics advocate isn't really possible in an environment where everyone is truly at risk, demonstrating the larger rhetorical purpose for the telling and re-telling of this narrative.

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