In April 2011, the worst measles outbreak to hit North America in a decade ignited at a Quebec high school. It likely started when a staff member at L’école Marie-Rivier in Drummondville, a rural town 100 kilometres east of Montreal, picked up the virus on her way back from the Caribbean, waiting for her luggage at the airport amid thousands of travellers returning from spring break. She had been back on the job for three days before going to the emergency room with a high fever and the telltale rash that starts around the face and creeps downward. Measles spreads mainly from person to person but also travels on droplets in the air, making it highly contagious—particularly in the swarming halls of a school. For most people, measles is like a lingering itchy flu, but others can suffer from pneumonia or, less commonly, swelling in the brain. In developed countries, it is fatal in one to two cases out of 1,000. Doctors quickly isolated the staff member in intensive care, and a public health official notified the principal.
It was an unexpected phone call. National immunization campaigns against measles, mumps, and rubella (combined as the MMR shot) in the 1990s had pretty well eradicated the virus; Canada saw its last bout of endemic measles in 1998. And though Marie-Rivier’s principal had been infected as a kid, his students probably had no concept of the illness until it circulated through their classrooms, felling friends and teachers, and spilling into a few surrounding regions. When the outbreak’s last diagnosis was recorded eight months later, 776 people had become sick—11 percent seriously enough to require hospitalization.
Health officials were baffled. How could measles make such a comeback in a country with generally high immunization rates? Going by the theory of herd immunity, widespread adherence should act as a kind of firewall against the disease, protecting even the vulnerable and the unvaccinated fringe. The national immunization coverage goal for measles is 95 percent, placing it among the more aggressive public health objectives because the virus is so contagious. According to the Public Health Agency of Canada, this rate for MMR vaccination—and for all recommended childhood shots—is largely on target. Undetectable in those large national surveys, however, are small pockets of people with lower immunization rates. At Marie-Rivier, only 85 percent of students were fully vaccinated against measles (the rest had not been inoculated or their immunity had waned).
The outbreak underscores the delicate nature of herd immunity. “People think of measles in terms of a historic interest,” says Scott Halperin, director of the Canadian Center for Vaccinology, in Halifax. “The population gets complacent. But when you stop immunizing, the diseases are right there.” Earlier this year, some 100 cases of measles were reported in BC’s Fraser Valley, where just 88 percent of two-year-olds have been inoculated; southern Alberta, Saskatchewan, and southwestern Ontario also reported minor outbreaks. The cases in BC and Alberta were mainly linked to individuals who had visited religious communities in the Netherlands that have traditionally low immunization rates; those in Saskatchewan and Ontario were associated with travel to the Philippines, which has been experiencing a large outbreak for more than a year. In the United States, 592 cases had been documented as of August 29, the highest number since endemic measles was declared eliminated in 2000. Meanwhile, other antiquated, largely eradicated illnesses—such as whooping cough, mumps, and rubella—have reappeared in the last several years in North America, Europe, and parts of Asia.
In light of these resurgences, health organizations and governments around the world have begun to address what they see as the growing issue of vaccine hesitancy. Whereas under-immunization once occurred largely in low-income and immigrant communities, a consequence of access and educational challenges, it is now a conscious phenomenon made in the context of affluence and fear. The group that has attracted the most attention from researchers—and drawn the most fire from doctors and the public—is the overprotective, well-intentioned parents who decline or delay their children’s shots because they believe that vaccines do more harm than good. Anti-vaccinators, as they’re called, blame excessive immunization for autism and other proliferating chronic conditions; compelling personal accounts spread via social media and blogs. Underlying the emotional tenor is often a deep distrust of medical science and studies that affirm vaccine safety.
Medical skepticism is not new, nor is the quiet disregard with which many doctors tend to treat the cynics. But whereas patients who waive heart medication or chemotherapy in favour of herbs or homeopathy invite purely individual consequences, people who refuse vaccines potentially affect us all. “We need to find out what is animating these concerns,” says Mark Largent, a science and medicine historian at Michigan State University who has written extensively on vaccine fear. “We need to find ways to engage what actually worries parents.”
Ananda More’s daughter, Maayan, is in the kitchen holding court, as five-year-olds do. She has her mother’s olive skin and dark wavy hair, and a flair for the dramatic. While twirling in circles, she bashes her forehead with the toy binoculars dangling from her neck. She bursts into tears and buries her face in her mom’s chest. More, a slight woman with a gentle manner, swiftly administers homeopathic arnica (derived from a type of sunflower) for the pain and swelling, and some chocolate (raw, sugar-free) to soothe the spirits.
More, thirty-eight, is co-owner of Riverdale Homeopathy in Toronto. When Maayan was born, More and her husband, a manufacturing engineer, decided to opt out of Ontario’s recommended immunizations schedule. By now, Maayan should have received annual flu shots plus fourteen other vaccinations: Two doses of MMR, one with added varicella (for chicken pox). Four doses of DTaP-IPV-Hib (for diphtheria; tetanus; pertussis; polio; and Haemophilus influenzae type b, a bacterium that causes meningitis). Three doses of pneumococcal conjugate (for pneumonia and infection of the blood). Two doses of rotavirus (for a diarrhea-causing virus). One for meningococcal conjugate C (for various other meningitis-causing bacteria). And a second dose of varicella. “It doesn’t seem natural to be putting this stuff in our bodies and messing up the immune system before it’s developed,” More says. “And then there are the heavy metals and other adjuvants that go right into the bloodstream—what are the long-term effects? We don’t know.”
Choosing not to vaccinate Maayan is in keeping with the family’s larger mission to live naturally. They eat as much organic and non–genetically modified food as their budget allows. Maayan’s toothpaste is fluoride-free. They use eco-cleaning products, their toiletries are free of sodium laureth sulphates, and they purify their tap water with a reverse-osmosis filter and buy meat from two local organic farms. Medications are used sparingly, if at all. Maayan has never taken an antibiotic, and More has given her Tylenol just twice for fever (she still feels guilty about it). She treats most of her daughter’s illnesses with homeopathic remedies, including a Cuban remedy for Dengue fever when they visited the country two years ago.
These choices fit into a broader cultural obsession with perceived healthfulness, especially among younger educated urbanites keen to avoid those vague, omnipresent toxins thought to build up in our systems and cause harm. They believe that one can stave off illness through personal vigilance, a fixation that can be heightened in the context of modern parenting, which comes with new expectations—and anxieties—about keeping a child protected and pure. The possible strictures are almost limitless: no plastic toys, no refined sugar, limited screen time, and—for some—no vaccines.
In Manitoba, Ontario, and New Brunswick, where public schools require proof of some vaccinations, parents can request an exemption for “reasons of conscience,” wording that suggests deep-seated, almost moral underpinnings. Low immunization rates are particularly common in Waldorf schools, the trail-blazing alternative educational model founded in 1919 by Rudolf Steiner, an Austrian philosopher who famously promoted unstructured play, but also, more obscurely, the importance of illness. He believed that toughing out sickness and infection without medication ultimately built up a child’s spiritual foundation.
For modern anti-vaccinators, diseases such as chicken pox and measles “train the immune system,” More explains. “If we don’t allow it to respond to illness, then it’s not going to be reactive and responsive.” This belief in the benefits of naturally occurring infection and the dangers of artificially suppressing it dates back to the moment the path first forked.
In the late 1700s, an English doctor named Edward Jenner became intrigued by the long-held belief that anyone who caught cowpox from their bovine charges appeared uniquely resistant to smallpox—a gruesome illness, characterized by oozing pustules, that had killed hundreds of thousands of Europeans during that century alone. Suspecting that the immunity had something to do with the relatively mild cowpox virus, which milkmaids routinely contracted from infected udders, he implanted the pus he had collected from a woman’s cowpox blister into the arm of an eight-year-old boy. When the boy was then exposed to smallpox, he remained infection free. Jenner repeated the results with twenty-three other subjects (including his own eleven-month-old son) and published his findings in 1798, paving the way for what would become the basic tenet of inoculation: the stimulation of immune response against a disease using its weaker form.
By 1801, thousands of Europeans had been jabbed with Jenner’s inoculation, with uneven and sometimes fatal results. Some strains caused scores of people to develop tetanus; others caused serious reactions or infected subjects with the very disease they were meant to prevent. Still, Jenner’s rudimentary vaccine was a monumental medical advancement for the time, and its use by soldiers during the Franco-Prussian and American Civil Wars earned it a powerful legitimacy.
Five decades after Jenner’s discovery, Britain passed the first mandatory vaccination law in 1840. Thirty-one years later, inspectors were authorized to confiscate the possessions of resisters, and the public revolted. Middle-class writers and thinkers had already formed the Anti-Vaccination League, arguing that immunization shouldn’t be coerced, and by the end of the century members had successfully fought for conscientious objector legislation. Immunization rates plummeted, dropping to 50 percent coverage in 1914 from 80 percent coverage in 1898.
It was easy enough to believe that vaccines were a money-making sham imposed by the same torturous barbarians who inflicted bloodletting, mercury treatments, and other largely useless and destructive purgative therapies typical of the time. These were also the early days of the first alternative therapies, such as botanical medicines, steam baths, hypnotism, and homeopathy, which all promised gentler methods that didn’t require losing bodily fluids or teeth. Historically, public uptake of unorthodox therapies has been a reaction to the missteps or failings of conventional medicine. Conversely, interest in alternative remedies has quieted during periods of striking medical achievement.
By the end of the nineteenth century, Louis Pasteur’s germ theory of disease had illuminated the role of bacteria and viruses in illness; sanitation had improved, and antibiotics would soon revolutionize medicine. In this golden era, doctors enjoyed new credibility and life expectancy climbed. By 1947, when smallpox unexpectedly reappeared in New York, citizens lined up for the vaccine, even though—like all vaccines past and present—it still wasn’t unfailingly safe. There had been several related deaths in the city due to encephalitis, and some 100 people reported severe reactions, but this caused not even a murmur. Immunization had become the gospel of public health.
This reverence went unchallenged for decades, until, in 1982, an NBC affiliate station aired a chilling documentary by Washington reporter Lea Thompson called DPT: Vaccine Roulette. It featured disturbing images of convulsing or spaced-out babies, all with neurological damage that their parents blamed on the diphtheria-pertussis-tetanus shot. After the broadcast, outraged mothers and fathers who recognized these symptoms in their kids found each other and formed an association to lobby for safer vaccines. (It’s still active today as the National Vaccine Information Center.)
The resulting media attention forced an investigation into the safety of the pertussis portion of DPT, which is more commonly called the DTP vaccine. It turned out that multiple trials dating back to the 1940s had recorded rare cases of encephalitis and seizures, thought to be caused by toxins in the vaccine’s pertussis bacteria. But because DTP was cheap to make and proved so effective against an infection that had killed up to 3,000 American children a year, it remained in widespread use. In 1994, the Institute of Medicine, an independent health panel, concluded there was an association between the whole-cell vaccine and brain damage, and a safer acellular version (DTaP) was introduced in the US and Canada shortly thereafter.
The DTP scandal provoked what would become a persistent tug-of-war between parents and health regulators, and between individual rights and public health. It had been decades, after all, since whooping cough and measles had struck as deadly epidemics, and the neo-liberal leaning of the time promoted a new, widespread individualism. From a parent’s point of view, no child—certainly not theirs—should have to risk serious side effects for the greater good. And now there was proof that vaccines could cause harm, contrary to doctors’ most fervent assurances.
As a child, More had received all her scheduled shots and “was fed antibiotics with every cold and flu,” she says disparagingly. Later, as a young tourist heading off into jungles and teeming cities, she had dutifully taken her malaria pills and travel vaccinations. Then she experienced a bad reaction to a routine rabies shot, in preparation for a trip to Central America, when she was twenty-one. Admitted to hospital, weak and dehydrated, she asked the doctor if the shot could be to blame. “Nobody would admit that it could possibly be the vaccine,” she recalls. What struck her was the physician’s obstinate attitude that the vaccine was somehow infallible—a zealous faith that anti-vaccinators say is common among health professionals (not unlike the fanaticism that health professionals see in anti-vaccine lobbyists).
On an extended trip through India in 2002, More encountered homeopathy, which she used to treat everything from a herniated disc to a gastrointestinal bug. Like vaccination, homeopathic remedies work on the principle of like cures like, priming the body to prevent or cure illness using the offending substance. Because these ingredients are diluted to the point where no or very few active molecules remain, critics consider such treatments, at best, a very effective placebo.
On a later trip, More volunteered at a homeopathic hospital in Bombay, where the breadth of conditions treated there—even many cancers—surprised her. “The only thing they will not treat right away with homeopathy is a heart attack,” she says. About a year later, she enrolled at the Ontario College of Homeopathic Medicine in Toronto. Though she claims she is not anti-medicine—“homeopathy can’t heal a broken bone”—she believes the alternative discipline does a better job of treating chronic conditions and their underlying causes.
One of today’s most vexing chronic conditions is autism spectrum disorder, a catch-all term for an array of developmental deficits. Its hallmarks are impaired social interaction, communication difficulties, and fixation on specific objects or behaviours. An autistic child can be frustratingly beyond reach, even to loved ones. Little is known about how best to treat autism, or even what causes it. What researchers do know is that diagnoses are rising sharply: one in sixty-eight kids in 2014 compared with one in 150 in 2000, according to the Centers for Disease Control and Prevention, in Atlanta. This increase has fuelled a raging public advocacy movement and wide-ranging speculation about the condition’s origins, including random genetic mutation; older parents; and, most evocatively, vaccines.
If there were ever a ringleader for the vaccine-blamers, it would be Jenny McCarthy, the mouthy actor and Playboy playmate whose son was diagnosed with autism around the time he had his inoculations. In 2008, she published a book about her son’s illness and railed on any talk show that would have her about “vaccine toxins,” such as antifreeze, ether, and mercury. “Please stop poisoning our kids!” she pleaded to the CDC in a 2010 interview.
The first to point the finger at vaccines was UK gastroenterologist Andrew Wakefield, in his now infamous 1998 study published in The Lancet. After examining stool samples and spinal fluid from twelve kids, many of them autistic, he linked the MMR shot to a rising incidence of autism. But the study was small and poorly designed, and six years after its publication a British journalist discovered Wakefield had been paid by a legal-aid group representing the families of his young participants. The Institute of Medicine publicly denounced the article as well as any association between autism and immunization, citing a review of several large population studies. Shortly afterward, the Cochrane Collaboration, another independent non-governmental health organization, reached the same conclusion; the UK’s National Health Service, the CDC, and PHAC, among others, followed this stance.
But the UK’s MMR immunization rates had already taken a hit, falling from 92 percent in 1996 to 73 percent in 2008, and as low as 60 percent in some areas of London. (Rates have since started to climb.) In the US, anti-vaccine and autism activist groups glommed on to Wakefield’s study and advertised his findings in a joint press release, which the media propagated. It was a public relations nightmare; in 1999, the Food and Drug Administration went so far as to recommend removing thimerosal, a mercury-based preservative, from most US-licensed vaccines to quell public fear—even though there was no evidence linking thimerosal to autism. (In Canada, influenza and some hepatitis B vaccines contain thimerosal, but most do not.)
“The timing of the onset of autism symptoms is very similar to the timing of childhood vaccines, while the increase of the number of autism diagnoses corresponds roughly with the increase of the number of vaccines we now give,” says Michigan State’s Largent, who published Vaccine: The Debate in Modern America in 2012. It’s hard to say whether autism is more prevalent because of earlier diagnoses that include a broader category of symptoms, or if some external pollutant or combination of circumstances is triggering the disorder in genetically predisposed kids. Immunization arose as a tidy and timely explanation, a much-needed punching bag for weary parents without much recourse.
Even for parents of healthy children, the threat of autism seems to have activated latent fears around immunization. “Health care officials get very frustrated when they demonstrate beyond a shadow of a doubt that in fact vaccines don’t cause autism, and parents don’t suddenly say, Oh, okay, give my kid the vaccine,” says Largent. But research has shown that, especially when it comes to the anti-vaccine camp, facts have little resonance.
Before Health Canada approves a vaccine for market, it must pass a rigorous battery of preclinical and clinical safety studies, the latter often conducted by academic institutions, such as the Canadian Center for Vaccinology, which have strict publication agreements barring manufacturers from hiding unfavourable data. But a vaccine’s real test is when it’s put on the market, where the truly rare reactions are detectable. “We can’t test every vaccine or vaccine combination on every child,” says Largent. “We can only have a high level of confidence that it’s safe, then start using it and watch to see if there are problems.”
Canada has two levels of immunization safety monitoring. One is passive, in which reactions can be reported to PHAC, while the other is an active surveillance program that is run out of a dozen pediatric hospitals across the country. Researchers pore over hospital forms looking for possible vaccine-related admissions. In the US, the CDC reports that one in 3,000 children will have febrile seizures after an MMR shot; one in 16,000 will develop a dangerously high fever following DTaP; and one in a million might fall into a coma or suffer permanent brain damage. In Canada, the situation is similar. “We don’t find much,” confirms Scott Halperin, of the CCV. “We’re actively looking for events that are severe enough to cause children to be admitted into the hospital. That should be reassuring to the public.”
But More, for one, is not convinced. She believes that vaccine clinical trials are likely rushed or flawed, while severe reactions are probably under-reported. In her practice, she sees plenty of kids on the autism spectrum and those suffering from autoimmune disorders (allergies, ear infections, asthma), which some people think may also be caused by vaccine toxins. This intimate exposure to the human toll of illness triumphs over cold statistics every time.
During our interview in her cramped office at Riverdale Homeopathy, More pulls up an online video she had come across that morning. It had been posted by the mother of a baby girl in Australia; she had received a round of routine vaccinations at eighteen months, and then her face swelled up like a grape and she went blind—the results of a rare allergic reaction to certain drugs called Stevens-Johnson syndrome. More cries softly as we look at the slide show of the squinting, severely blistered infant—set to the song “True Colors” by Cyndi Lauper—and it is hard not to be swept up.
The Internet has become an effective tool for feeding these fears. A German study published in the Journal of Health Psychology in 2010 found that ten minutes spent on a vaccine-critical website was enough to heighten viewers’ perceptions of risk and “significantly decreased the intentions to vaccinate.” Sophisticated “vaccine awareness” sites with benign names, such as the National Vaccine Information Center and Vaccination News, report the ingredients and possible side effects of every licensed vaccine, offer first-person accounts by parents whose children developed autism or suffered brain damage, and even shed light on the shadowy side of the pharmaceutical industry.
Earlier this year, Russell Saunders, an American pediatrician who writes under this pseudonym for the Daily Beast, weighed in with an opinion piece called “Vaccinate Your Kids—Or Get Out of My Office.” It’s fairly measured as rants go, and he throws some deft hardballs. For example, if parents won’t accept the science on vaccine safety, then when can he ever employ medical evidence to explain his treatment decisions? On a personal note, he questions what such parents must think of him as a doctor, and even as a human being. “For immunization to be as malign as their detractors claim,” he writes, “my colleagues and I would have to be staggeringly incompetent, negligent or malicious to keep administering them.” Similar sentiments might explain why in a survey of American pediatricians published in 2005, 39 percent of the 302 respondents said they would stop seeing families who refused all vaccines, while 28 percent would drop parents who refused any such shots.
Lately, however, professional groups including the Canadian Paediatric Society and the College of Family Physicians of Canada have started urging their members to reconsider the practice of ditching patients, which undermines any opportunity for education. “I think a lot of people feel their doctors don’t listen to them or take them seriously,” confirms More. “We have this culture of supposed informed consent, but when a doctor tells you they’re not going to see you as a patient unless you vaccinate your kid, that’s pretty swaying.”
Steven Moss, a pediatrician in Toronto, hears vaccine concerns or questions almost every day. He takes a less judgmental approach, and is quick to assure me that the vast majority of parents are on board with immunization. Answering basic questions about whether vaccines contain thimerosal or cause autism are straightforward and effective, he says. But it’s the more adamant resisters who require sound, non-judgmental treatment: “You can tell them about herd immunity, but these parents don’t care about that; their focus is on their individual child. So we have to approach it as a question of how the vaccine is going to benefit their child, not society.” Moss has a forthright, chummy sort of conversational style, and he’s become adept at steering the subtle dynamics of the doctor-patient exchange in a way that respects, rather than condescends to, the patient. For example, instead of pouncing on them with facts and numbers, he requests that vaccine-wary parents book a follow-up appointment to discuss their decision: “I find that deflates the argumentative relationship and encourages the therapeutic relationship—they don’t feel like they were hounded.” He also advocates addressing the various vaccines separately, since not all are as controversial as MMR, as well as being sensitive to variation among parents; some might be fine with inoculations against polio, for example, but don’t feel the risk of rotavirus infection is enough to justify yet another shot.
The diversity and nuance of parental concern has become a primary focus of vaccine-hesitancy research. A World Health Organization working group assembled in 2012 has identified three overarching categories, described as the three Cs: people who are complacent about infectious diseases (but generally agreeable to vaccines); people who are motivated by convenience (also generally compliant immunizers); and those with little or no confidence in vaccines or their providers, like More.
Here at home, PHAC is working on a coordinated, countrywide approach to vaccine anxiety, which also entails teasing out degrees of hesitancy and establishing appropriate recommendations. The “Canadian Immunization Guide” offers advice to health care providers with vaccine-hesitant patients. But mandatory immunization legislation seems unlikely. “I think it’s better when people actually understand what they’re doing and why, without us having to tell them they ought to do it,” says Noni MacDonald, a pediatric infectious disease specialist in Halifax who sits on the WHO working group. It’s an acknowledgement not only of past mistakes, but also of the new understanding of vaccine skepticism’s intensely personal, entrenched nature.
MacDonald’s own research points to the role of heuristics, a behavioural-science term denoting a reflexive type of decision-making involving cognitive shortcuts. Maybe the parents have read too many stories about vaccine-damaged kids or know someone whose child reacted badly—imagery that becomes a strong emotional anchor, like the video More watched of the blinded child. Or maybe they don’t often get sick and are overconfident in their health. “The anti-vaccine people really, really, really believe what they believe, even if the evidence is contrary,” MacDonald says. “And once people’s beliefs are shaped, it’s difficult to change them.”
When I ask More’s young daughter if she knows what chicken pox is, she says yes, “but I don’t want to explain it because talking about it will make me scared I’m going to get it.” More reassures her that it’s not so bad. For most children, chicken pox and measles are mild, inconvenient illnesses that, to her mind, don’t warrant vaccination and its potential long-term effects. She admits these viruses can be more serious for children who are unwell or immunocompromised, but doesn’t necessarily agree with the concept of herd immunity. She believes homeopathic stand-ins will protect Maayan against a number of infectious diseases, which she considers to be more serious threats—including Lyme disease, polio, and meningitis.
Nosodes, as these homeopathic products are called, are made from the highly diluted diseased tissue, bacteria, or virus against which they’re meant to protect. More cites several reports out of Cuba, Brazil, and India showing high success rates preventing certain locally prevalent diseases—though these studies have not been published in peer-reviewed journals.
Among many mainstream medical professionals, nosodes might as well be magic beans, and the fact that Health Canada regulates them while also promoting vaccination is a dangerous contradiction. In 2012, after a group of scientists and doctors called on Health Canada to deregister more than eighty nosodes that its Natural Health Products Directorate had approved, the department instead mandated that labels explicitly state that nosodes are not meant to be vaccine alternatives. Lobbyists felt it was a feeble concession that would do little to discredit bogus treatments that might lure people away from proven ones. But in an open letter to the Toronto Star last fall, the NHPD director general defended the organization’s position, stating that “Health Canada respects diversity and recognizes that a growing number of Canadians choose natural health products to maintain and improve their health.”
It seems the most productive approach to the vaccine-hesitant is neither to ignore them nor bully them, but to respect their freedom to choose from treatment options in a collaborative environment, as is the case in India. In Canada, it took months for More to find a family physician who was willing to take her on despite her daughter’s vaccination status. “My doctor is not a naturopath or homeopath, but I feel she truly believes in informed consent,” she says. “She lets me deal with my ailments on my own, and provides support when I need it.”
In her own practice, More aims to offer the same open-minded support when faced with vaccine questions. “I provide parents with all the information on homeoprophylaxis,” she says. “But I also tell them to talk to their family doctor to get the other side. I may think there are a lot of problems with vaccination, but I’m not in a place to make that decision for someone else. People have to feel comfortable with how they’re raising their children.”
This appeared in the November 2014 issue.