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Why Do Affluent, Well-Educated People Refuse Vaccines?

A small, surprising demographic is worried about vaccines. But don’t panic about it, because that’s actually counterproductive.

Dr. Scott Goldstein (facing) examines newborn Jacob Gasinsky as parents Dmitry and Julia Gasinsky look on at Northwestern Children's Practice on Friday, Jun. 24, 2011, in Chicago. Beginning June 1st, the pediatric center implemented a policy to treat only children immunized according the schedule of the American Academy of Pediatrics.   Photo: Shauna Bittle/Chicago Tribune

During the off-season, the Bears signed Jay Cutler to a lucrative deal. How have things gone since for the quarterback Chicago loves to be wary of?

When directly asked whether she was opposed to vaccines during an appearance on the Fox Business Network program, The Independents, [Kristin] Cavallari said, “we don’t vaccinate.” The reason? “I’ve read too many books about autism and the studies,” she said.

[snip]

Cavallari, pregnant with the Cutler’s second son, went on to explain, “Well, there is a pediatric group called Homestead, Homestead or Homefirst, now I have pregnancy brain I got them confused — they’ve never vaccinated any of their children, and they haven’t had one case of autism. And now one in 88 boys is autistic, which is a really scary statistic.”

Oh. Hopefully he won’t miss any games to pertussis this year.

It would be easy to dismiss the Cutler/Cavallari household as a pair of boneheaded celebrities, were it not more indicative of a more interesting trend: the remarkable persistence of anti-vaccine sentiment among the well-off and/or well-educated. Take, for instance, this post-mortem of a measles outbreak in San Diego:

During the 1980s and 1990s, undervaccination in the United States was primarily unintentional, associated with diminished access to health care, and was frequently observed among inner-city ethnic or racial minorities, inner-city families living in poverty, and children whose mothers had limited education. Outbreaks attributable to vaccine refusal tended to be observed among religious groups with objections to vaccination (eg, Christian Scientists and the Amish). In contrast, reluctance to vaccinate in the San Diego outbreak was associated with health beliefs, particularly among well-educated, upper- and middle-income segments of the population, similar to those seen in measles outbreak patterns elsewhere in 2008.

Or this 2004 study, which sampled 152,000 children:

Undervaccinated children tended to be black, to have a younger mother who was not married and did not have a college degree, to live in a household near the poverty level, and to live in a central city. Unvaccinated children tended to be white, to have a mother who was married and had a college degree, to live in a household with an annual income exceeding 75,000 dollars, and to have parents who expressed concerns regarding the safety of vaccines and indicated that medical doctors have little influence over vaccination decisions for their children.

To put things in perspective, though, that latter study found a mere 795 unvaccinated children, and Dan Kahan of Yale’s Cultural Cognition Project, who has done some fascinating work on vaccine acceptance, suggests that trust in vaccines remains high and that associations with specific political ideologies is overblown. Nor is the CDC panicking, with a caveat:

During 2013, nearly two thirds of the cases came from three outbreaks. In these outbreaks, transmission occurred after introduction of measles into communities with pockets of persons unvaccinated because of philosophical or religious beliefs. This allowed for spread to occur, mainly in households and community gatherings, before public health interventions could be implemented. Despite progress in global measles control and elimination, measles importations are likely to continue posing risks of measles outbreaks in unvaccinated communities.

In short, vaccine refusal is an isolated issue; nationwide, vaccination rates remain above 90 percent. But it’s precisely the geographical isolation of unvaccinated children that puts herd immunity, the principle of vaccination, at stake. So it’s worth thinking about what causes people to not vaccinate, and in particular why people with a lot of resources, both financial and informational, choose not to. The best clue I’ve seen comes from a study led by Daniel Salmon of the Institute for Vaccine Safety at Johns Hopkins. In particular, a look at the sources parents trust:

Parents whose children have been exempted from vaccinations have, unsurprisingly, less trust in a long list of authorities, from health care professionals to the CDC. There are four notable exceptions: alternative health care professionals, parents/friends, the internet, and Dissatisfied Parents Together, one of the most established anti-vaccination organizations (DPT, get it?).

Social networks (actual ones) seem to be incredibly important in forming opposition to vaccines, either in whole or in part: “in this study, parents who didn’t follow CDC guidelines were more likely to have extensive ‘source networks’ that included books, blogs, websites, and magazine articles to which they turned for vaccine-realted information.”

Resisting vaccination isn’t a matter of laziness; it’s actually time-consuming and expensive. This Los Angeles magazine profile of Jay Gordon, a prominent L.A. pediatrician who falls into the “too many, too soon” camp, is a good example. He doesn’t take insurance, recommends unusually intensive attachment-parenting practices and diets, and serves a wealthy clientele: “while his philosophy has helped make him popular, one of the things parents seem to like most about him is his willingness to heed their wishes, almost as if they knew what was best. In one respect that’s not surprising. The sorts of parents he deals with—such as Danny DeVito and Rhea Perlman—are people accustomed to being in control.”

When Seth Mnookin began his definitive book The Panic Virus on the anti-vaccine movement, he was inspired to do so by encountering the beliefs among “our peers… they lived in college towns like Ann Arbor and Austin or sophisticated urban centers like Boston and Brooklyn; they drove Priuses and shopped at Whole Foods. They tended to be self-satisfied, found it difficult to conceive of a world in which their voices were not heard, and took pride in being intellectually curious, thoughtful, and rational.”

It’s not a group that has too little information, but one that’s responding to a flood of information made possible in the digital age, and with considerable resources to devote to it. Dalton Conley, who teaches sociology and medicine at NYU, offers a fascinating glimpse into what he calls “parentology”:

So, where tradition fails us (after all, what does the Bible have to say about kids and cell phones?) we can and should resort to the scientific method. Hypothesis formation, trial, error, and revision. That is, we should experiment on our own kids.

[snip]

Like with patient-driven medicine, in which informed patients advocate to their doctor rather than just passively receiving information, I predict that American parents and their children will increasingly shun authorities — even good old Dr. Spock — and instead interpret and generate the scientific evidence for themselves.

Of course, Conley is an academic, with experience in both social science and medicine; even among the well-educated, he’s unusually familiar with parsing academic work. Not everyone has his background, and figuring out who and what to trust at a point in your life where you are awash in advice is difficult.

How should worried doctors respond? Kahan suggests with science, but not in the way that you think: “Emphatic assertions that a technology poses no danger can actually enhance its perceived riskiness. In addition, people tend to contribute voluntarily to public goods—such as herd immunity—when they believe that others are doing so but refrain when they perceive widespread free-riding. Thus, misleadingly implying that increasing numbers of parents are fearfully refusing vaccination could create exactly such fear and resistance.” (Kahan’s tested perceptions of vaccine coverage, and found that people underestimate it, substantially.)

In short, panicking about the “panic” could backfire, one panic virus boosting another.

 

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