On Measles, Vaccination, Social Media Activism, and How to Win Back Our Role as Our Patients’ Best Advocates

Abstract

Once declared transmission free in the United States less than 20 years ago, measles and other vaccine-preventable diseases have made a spectacular comeback. Waning public support for childhood immunization and subsequent recent outbreaks of vaccine-preventable diseases have been spawned by several technological and social factors, including the erosion of the provider-patient relationship, the emergence of internet-based patient resources and social media sites, and the rise of online healthcare activism. New tools are needed for physicians and healthcare providers to reverse this trend and regain our role as our patients’ best advocates.

measles, vaccination, social media, communication, medical activism

For more than 20 years, I have practiced as an infectious diseases specialist. I strive hard to promote the goal of infection prevention. Some years ago, as I was coming home from work, my next-door neighbor stopped me in my driveway. She had just had a baby a few weeks earlier, and said, “I’ve been reading a lot online and talking with my girlfriends. Do you know all of those vaccines that newborns are supposed to get?” I nodded. She added, “Do you really think I should get them for my son—with all of the side effects?”

Back then, I’d always assumed that the benefits of childhood vaccination were well known. Unfortunately, I’ve had this same discussion with patients and parents too many times ever since. Individuals who once expressed an openness to listen to their physicians but now have a preconceived bias against childhood vaccines.

They share stories from acquaintances and online testimonials of vaccine adverse effects and exude a healthy skepticism about their physician’s recommendations. For many years, clinicians tolerated some pushback about vaccinations, rationalizing that well-intentioned persons had simply become victims of online misinformation.

Over time, however, more and more families began to “opt out,” citing personal or religious objections. At first, the effects were negligible, and public health authorities, physician groups, school systems, and the media took little notice. But all parties were relying on an unpredictable factor: herd immunity [1].

First described in 1923 during a rubeola (measles) outbreak [2], “herd immunity” or “community protection” signifies that if a sufficient proportion of susceptible persons are vaccinated, new infections would decrease or even be eliminated, because the remaining unvaccinated community (including not only those refusing vaccination but also persons in whom vaccination is medically contraindicated) would be too small to permit effective transmission. Herd immunity has limitations, however. Although the fraction varies by transmissible pathogen (Table 1), there is a critical threshold [3] (for measles, a vaccination rate of about 95% [4]) below which the vaccinated community is unable to protect the unvaccinated.

Table 1.

Select Vaccine-preventable Diseases and Their Herd Immunity Thresholds^a

Disease	Herd Immunity Threshold, %
Measles	93–95
Mumps	75–86
Rubella	83–85
Polio	80–86
Smallpox	80–85
Diphtheria	85

^aAdapted from Centers for Disease Control and Prevention [3] and [4].

WAKEFIELD AND THE REEMERGENCE OF THE ANTIVACCINATION MOVEMENT

After British researcher Andrew Wakefield’s long-since-discredited 1998 scientific article linking measles-mumps-rubella vaccination with childhood autism, UK vaccination rates dropped precipitously, and the antivaccination movement, whose origins began a century earlier in Britain, became reinvigorated [5]. Even so, due to a much more effective US childhood vaccination program, measles was eliminated from our country in 2000. For the next 16 years, facilitated by the United Nations, the federal government and American philanthropy, worldwide measles cases declined by nearly 80% through 2016 [6]. In the middle of the last decade, however, international cases began to surge owing to poverty, access issues, cracks in the public health infrastructure, international travel, and reduced vaccination rates.

When combined with declining US rates and waning herd immunity, it was only a matter of time before an imported case of measles resulted in a large outbreak. For many, the 2014–2015 Disneyland Park measles outbreak [7] in California was a wake-up call. The outbreak, sourced to an overseas case, sickened 147 persons in 6 US states, Mexico, and Canada. Since then, multiple outbreaks have occurred in the United States, including a 75-case outbreak in a Minnesota Somali-American community in 2017 [8] and the recent 2019 outbreak of more than 500 episodes of measles among Orthodox Jewish communities in the New York area, originally sourced to Israel [9]. This outbreak, as well as others in the Pacific Northwest [10] and across 28 states, resulted in at least 1095 cases of measles as of 27 June 2019, the largest number of US cases since 1992 [11].

SOCIAL MEDIA AND THE RISE OF THE INTERNET

The last 20 years have also been marked by the simultaneous emergence of another potent factor: The rise of the internet. The availability of online medical information since the late 1990s has gradually altered the provider-patient relationship. Whereas providers were once solely in charge of healthcare decision making, patients with online access to medical knowledge began to feel emboldened to take more control. At the same time, the rise of online social media permitted like-minded lay people to share online health-related opinions and to engage in social activism. Unlike with scientific medical journals, the absence of any online peer-review standards led to the dissemination of false and misleading medical information to a sometimes-unwitting public.

The growth of Facebook, Instagram, Pinterest, and other sites soon created an online echo chamber [12]. Antivaccination groups could now spread misinformation to a wide social media audience [13]. Although many participants were legitimately seeking accurate information, for others, the dissemination of “fake news” about vaccination may have helped to forward a political or financial agenda. Many antivaccination Web sites now intersperse their vaccine-related misinformation with ads for medical supplements and vitamins [14]. Others wish to continue to sow distrust about institutions for political purposes, and set their sites on the Centers for Disease Control and Prevention, the pharmaceutical industry, government regulators, the media, and even physicians [5]. Evidence exists of the weaponization of antivaccination messages by Twitter bots and Russian trolls to spread discord, erode public confidence, and amplify the vaccine debate [15]. Meanwhile, many social media platforms have been slow to acknowledge responsibility. In my recent informal search [16] for the term “#vaccinations” on Instagram, antivaccination posts outnumbered provaccine posts by more than 9 to 1.

REGAINING OUR VOICE

I lament the subtle ways that healthcare providers have relinquished their role as counselors and educators to our patients. We sometimes sit in the background while patients consult with social media resources, online forums, media pundits and virtual support groups. Our busy practices pressure us to provide information only when asked, confine our engagement with patients to medical appointments, and ignore the information they are receiving online.

It is time again for healthcare providers to step out of the shadows and regain our voice. But we need to be smart and sensible in our approach, and open to engaging our patients in the modern ways of smartphones and Twitter. I have identified five approaches to regaining our role in guiding patients to make sound decisions about their healthcare.

Adapting our Medical Communicators to a Mass Media Culture

There are so many well-trained, bright, and articulate physician scientists in our discipline, but no real coordinated effort to craft some of them into savvy media figures (such as Neil Degrasse Tyson or Bill Nye) who can engage and influence the public in the same way that musicians and celebrities do. These individuals may also serve as role models for future generations of social media-capable clinicians.

Developing Social Media Influencers for Medicine

Almost 90% of older adults (aged 50 years or older) have used social media to find and share health information [17], yet, the medical community is being handily outmaneuvered on issues such as vaccines and childhood disease outbreaks by meme-posting social media activists. Major medical organizations have placed very low priority in developing their social media presence. For instance, the American Medical Association has scarcely more than 5000 followers on Instagram [18], while “Vaccinesuncovered,” an Instagram antivaccination account, has more than 46 000. The Instagram account of the Centers for Disease Control and Prevention, with 162 000 followers, is easily outnumbered by that of Gritty, the mascot of the Philadelphia Flyers (with 184 000 followers) and even more so by the National Rifle Association (with 1.1 million).

When the social media presence of the one of the largest sectors of the economy is being soundly outdone by homespun activists, National Hockey League mascots, and the gun lobby, it is clear that we are trailing in one of the main ways people acquire medical information. To counter social media misinformation, we need to develop or enlist “social media influencers” for medicine in the same ways that corporations and other groups promote their celebrities, products, and services so successfully.

Becoming More Effective At Broadcast and Social Media Communication in Our Practices

Individual providers can do more to engage patients within their practice and in their communities with the use of the media. Communicating on healthcare topics via a practice Facebook page, starting a twitter feed, posting or sharing accurate health-related information to a professional Instagram account, and volunteering medical interviews to local broadcast and print media can all improve our footprint as medically trained “influencers” and can bolster respect for our practices as well.

Improving and Enhancing Patient Access to Providers

For many lay people, the internet is as easily accessible as a few keystrokes. Even if it is less reliable or credible, they crave the convenience it provides. If given the opportunity, however, most would choose their own medical professional over all other resources. There is much more that healthcare providers can do to make themselves much more accessible for simple questions, brief phone consultations, and other informal interactions, both online (via nonsecure and secure resources) and offline.

Understanding Our “Adversary”

The medical community need not look at medical activist groups from an adversarial standpoint. Instead, finding areas of common ground (eg, increasing pediatric access to care, reducing patient discomfort with vaccine administration, and streamlining vaccine schedules when possible), acknowledging their concerns, and making sure they feel heard in a respectable manor can increase understanding between professional groups and medically informed lay people.

CONCLUSIONS

The medical community is facing unprecedented challenges in confronting new outbreaks of preventable diseases once considered vanquished in previous eras. At the core of the reluctance to participate in vaccination programs among some persons is a seeming distrust in established institutions in favor of social media and online information resources. The provider-patient relationship is a critical component in restoring the public’s confidence of the importance of childhood vaccinations and other preventative healthcare. Our understanding of the underpinnings behind societal attitudes about immunization as well as our willingness to try new approaches is also essential to influencing the public debate over this issue.

Even in cases where the most extreme activists remain unpersuaded, most people are open to vaccination when (1) there is a significant enough perceived risk and (2) they understand that the small risk of adverse effects is greatly outweighed by the vaccine’s benefits. If the medical community has not communicated the clear benefits of vaccination, the failure is ours, and we should acknowledge our shortcomings and correct them. In our quest to engage and motivate the public and reverse the trend of escalating outbreaks, we may at last be able to enlist an unexpected (though unwelcome) ally. Measles, eliminated in the United States in 2000, is now making a spectacular comeback. The threat to our elimination status—and our patients—now appears graver than ever. Fortunately, there is evidence that communities across the country [19] are reconsidering previously lax vaccination exemptions. In the long saga of childhood diseases, only the return of measles itself may be able to compel the skeptical to acknowledge the true reality and clear dangers of an unvaccinated world.

Note

Potential conflicts of interest. Author certifies no potential conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.