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.

Thursday, October 04, 2012

The Hazy World of Vaccine Messaging

After almost 3 years now of complete absorption into issues related to vaccination, it's no surprise that I continue to be fascinated and dumbfounded by the complexity of the rhetorical situation that occurs when a doctor must convince a new parent (or even an old one) that vaccines are the right course of action for protecting a child. The issue has been researched and studied and battled for hundreds of years, and as much as vaccines may be an "answer" to the scourge of small pox, polio, and measles, no "answer" has yet emerged that guarantees that vaccines will be accepted by the people they are intended to protect. I'm fascinated and in some ways encouraged that, in this case, a scientific discovery comes along quicker than a rhetorical one.

On Twitter (my new, sole connection to the outside world since I started writing my dissertation) today another piece of yet more confusing information about vaccine messaging rolled across my feed. This article in Scientific American reports on a study published in Health Psychology about the role that pro-vaccine messages play in convincing parents of vaccine efficacy and safety. 

The article states, in what seems like a completely counter-intuitive conclusion, that after participants were told to "imagine parenting an 8-month-old" (maybe a problematic scenario; I'd have to read the study to understand this, but couldn't they just have gotten participants who actually were parents of 8-month-olds?) and were told about a serious disease that the doctor wanted the parent to vaccinate against: "Those who were told there was no evidence for risk [from the vaccine] reported greater concern about vaccination and less intention to vaccinate their child than those who read the moderate messaging. The effect intensified when the messaging came from a perceived untrustworthy source, like a pharma company."

The conclusion the article draws is that a harder sell for the vaccine might produce the opposite effect, and so therefore a softer sell may be more effective. 

I have two thoughts: first, I have a lot of questions about the population/participants here, and I really wish I had time to find this study and give it a closer look. To imagine you're the parent of a baby, and then to imagine being told about a disease, and then to imagine how you might react to different ways of "selling" the vaccine constitutes a lot of imaginative leaps. I don't want to extrapolate too much on that without reading the full study, but I am really curious why they didn't ask actual parents of 8-month-olds. I also wonder whether they had a doctor, pediatrician, or a researcher present this scenario. Here, I'm thinking ethos: did the person seem concerned, did the person seem like an advocate for children, or did he/she seem disinterested? That could have played a role in how the "parent" interacted with the person delivering the information relative to disease perception and need for vaccination. 

Second, I don't think this is about hard/soft sells. I think the believability, in this case, has to be tied to trust in some way. Does anyone really think that any medical treatment comes with absolutely no risk? We are so engrossed in a culture and scientific reality now that knows about and accepts side effects as an expected part of any treatment, that it would strike me as suspect if someone told me that there were no risks rather than just some risks. 

In my Literature, Medicine, and Culture class a few weeks ago, we looked at commercials for Ambien, one from 2000 or 2001 and another from 2012. The list of side effects in the 2012 commercial takes up more airtime than the actual description of what the drug is supposed to help, and the list ranges from mild side-effects to ridiculous things (that have by now been well-publicized) like hallucinations and sleep walking. 

This expectation of risk may not stop us from being surprised or annoyed when we take a medication and it makes us sick in ways we weren't anticipating, but at the outset, I think I would feel lied to if a doctor told me there was absolutely no risk as a result from treatment, and that is particularly true with parents and vaccines. Even people who are pro-vaccine know that there are risks associated with the vaccination, even though they are rare when severe. 

So, again, I don't think this has to do with the "hardness" or "softness" of the information as presented. My sense is that it has more to do with believability, trust, and the logos at work here. If the participant feels liked to or deceived by being told that the vaccine carries no risks, then that person may be less likely to trust the related recommendation. But, if the speaker acknowledges the side effects and risks, then the appeal matches the expectation of risk, and the person feels leveled with, spoken to honestly. 

The inherent persuasiveness trust, even if risks are involved, may be more convincing than the imaginary notion of a risk-free world, or even a risk-free treatment.