Jonathan M. Berman is one of the founders of the March for Science movement and Assistant Professor in the Department of Basic Sciences at NYITCOM–Arkansas. In Anti-vaxxers: How to Challenge a Misinformed Movement, he examines anti-vaxx arguments from the nineteenth century to today, proposing a strategy that recognises the role of emotion and community.

Your book shows that a rise in vaccination doubt doesn’t necessarily lead to low uptake. But aren’t these doubts still a cause for concern?

I believe they are. While doubt doesn’t always coincide with refusal of vaccines, there are “enclaves” of low vaccine uptake, as well as entire countries where uptake has dropped low enough to allow for outbreaks. It’s likely that vaccine hesitancy has slowed the elimination of polio, and has allowed for outbreaks of measles and whooping cough in the past. It will have very real consequences if a significant number of people refuse a future SARS-CoV-2 vaccine for Covid-19.

You describe three strategies to counter anti-vaccination sentiment: ‘reactive’, ‘information-deficit’ and ‘community-based.’ Which works best?

There has been significant use of the information deficit strategy, and it has been studied and found to be largely ineffective. Science denial is a different beast than ignorance. If someone doesn’t know how to do calculus, then you can teach it to them and there’s a flow of information from expert to non-expert. Vaccine hesitancy sometimes comes from ignorance, but sometimes comes from denial. In the latter case deniers aren’t “ignorant.” They’ve often spent significant time reading anti-vaccine websites, and even (selected) scientific papers. The trouble is that they’ve gone to seek out information that supports views they arrived at for other reasons.

If someone has a visceral disgust at the idea of “polluting their body” with “chemicals,” just telling them that the components in vaccines have been shown to be safe probably won’t be very convincing. Likewise if they have been convinced of a conspiracy theory that vaccines are being used by outsiders to sterilise their community, one of those outsiders telling them that isn’t true likely won’t convince them.

In 2017 there was a measles outbreak in Minnesota primarily in the Somali-American community. Public health officials worked with religious leaders to talk with people about vaccination and its importance, and vaccine coverage recovered to a very high rate. People tend to make decisions for emotional reasons and then then justify them with scientific-sounding arguments. Simply addressing the science doesn’t address those underlying reasons.

So a community-based strategy is most effective. How might this work in UK, in regards to Covid-19 vaccination?

I suspect that many will be motivated to seek out vaccination simply to be able to return to work, or move about in the world again. People respond well to seeing what their peers values are and how they behave. Everyone expects scientists and physicians to be in favour of vaccination, so convincing people to vaccinate will benefit from illustrating the importance of vaccination to and in the communities that people belong to. Not just lab-coat wearing scientists, but also regular people.

What are the financial and political motivations driving anti-vaccination advocates today?

One of the most prominent early anti-vaxxers was a “hydropath,” and many current ones are naturopaths, homeopaths, or chiropractors. Right now science has a monopoly on the treatment of disease, and the existence of “alternative medicine” careers depends on spreading doubt about science-based medicine. Likewise the supplement industry benefits from doubts being sown about actual medicine. The US Vaccine Adverse Event Reporting system receives a significant percentage of its reports from lawyers seeking settlements, and in the 1980s, several vaccine manufacturers were nearly sued out of the business. There are even lawyers who specialise in “vaccine injury.” There’s also a cottage industry of speakers and personalities who gain income from book sales and public appearances.

The World Health Organisation has warned of a “dramatic resurgence” of measles in Europe. More than half of cases are in Ukraine. Why is this, and what can we learn from the outbreak?

Ukraine is an exception to vaccine doubt not coinciding with significant drops in vaccination. There was a significant drop in vaccination rates from about 95 per cent of eligible children in 2008 to about 31 per cent in 2016. Since then there have been significant improvements. In 2017, 93 per cent of 1-year-olds were vaccinated on time.

Probably two things contributed most directly. There was a drop in confidence when a 17-year-old boy died of unrelated causes shortly after a measles vaccine. The immunisation program was suspended temporarily and public confidence was lost. Mid-decade political turmoil in Ukraine led to shortages as well, which made obtaining vaccines quite difficult as well.

What we learn from these outbreaks is the same lesson we learn again and again: when immunisation rates drop infectious diseases return.

You reference the philosopher of science Karl Popper, who compared conspiracy belief to theistic religious belief. In what ways does anti-vaccination sentiment behave like a ‘religion’?

I think that both involve holding strong beliefs arrived at for reasons more to do with human psychology and emotional drives than with rational examination of evidence. The humanistic response to anti-vaxxers (and religious believers) needs to be a compassionate one. I don’t have any goal of converting religious believers away from their strongly held beliefs, only preventing those beliefs from infringing on the rights of those who believe differently. Anti-vaccine beliefs are a little bit different because they can lead to disease outbreaks.

What kind of effect might religious objections to vaccinations have on tackling the pandemic globally?

Currently there are over 100 vaccine candidates at various stages of development that use a few different kinds of technology. One of the ways of growing virus for attenuated or inactivated virus vaccines is to grow it in cultured human cells. A couple of the best suited cells lines, HEK-293 or MRC-5, for example, were originally derived from tissue from aborted foetuses – although of course no abortion was ever performed for the purpose of producing a cell line. Cell lines are often grown with products derived from cow serum that might also produce religious objections, or use porcine gelatin as a stabilising agent. These might be seen as interfering with restrictions in various religions.

With regard to Catholicism, the pontifical academy for life issued a statement that using vaccines produced in human cells lines was acceptable if no alternative was available. Hindu, Muslim and Jewish leaders have generally, with very few exceptions, had similar findings. That being said, the views of individual religious people don’t always align with their leadership, and not all leadership agree with one another. All of that is to say that I believe that it may be a challenge, but not an insurmountable one.

The aim of ‘Anti-Vaxxers’ is to increase awareness of a strain of thought that stretches back to the nineteenth century, and also to debunk some of its core un-scientific claims. However, you say you’re not confident that the book will change the mind of anti-vaxxers themselves.

The target audience are those interested in arriving at a deeper understanding of anti-vaxxers. It's probably a mistake to come to the book with the expectation to find a list “10 things to say that will change an anti-vaxxer’s mind on twitter.” I don’t think that’s possible. That being said, one of the recurring themes in stories of people who left the anti-vaccine movement is coming across convincing sources, such as Paul Offit’s books. I would hope that some people would come across this book prior to going down the anti-vaccine rabbit hole, and that it might help some back out.