By Erin K. Costello
Over the past couple weeks I have been asked in media interviews for my opinion on what actions should be taken to combat the spread and harm from the anti-vaccine community on-line as well as off-line. Though I try, this is not a question I can properly answer in a 15 second window. I have thought about how to stop anti-vaccine zealots from time to time these past two years, though I haven’t done much reading on the issue or explored many options. Due to media attention from current measles outbreaks, this subject has been popular and often discussed. This is a list of those suggestions made by myself, but mostly colleagues, that I believe hold the best possibility of being implemented, as well as the most potential for some success. Luckily I am not limited in time and length here in this blog so get ready for a whole lot of opinion.
To begin with, I think the anti-vaccine problem is one that could benefit from both preventative actions and reactionary actions. Preventative actions to hopefully prevent any future spread of such ignorance, and reactionary actions to deal with the damage that has already been done. Because of this, I broke them down accordingly. Let’s start with preventative.
Preventative Measures Through Legislation
In terms of preventing outbreaks caused by those who have already been indoctrinated into refusing vaccinations,, what we can do is simply pass legislation limiting the types of vaccine exemptions available. Preferably, this would be done at the state level. Available vaccine exemptions currently vary among the 50 states. There are three different types of vaccine exemptions available to parents; medical exemptions, religious exemptions, and philosophical exemptions. Philosophical exemptions have been available for parents who simply don’t agree with the concept of vaccinating against diseases. Religious exemptions have been allowed for the very few faiths/parishes that believe vaccinating goes against their belief system. Medical exemptions are required for some children and some adults who are allergic to ingredients in a vaccine, or are immunocompromised, or have other health related issues that cause vaccinations to be too high of a risk for a person.
It is very important to state right away that no state will ever remove the medical exemption option for it’s citizens. Many anti-vaccine talking bobble-heads like to create fear and anger by claiming medical exemptions are also being taken away, THIS IS NOT AT ALL TRUE. No state has even considered doing this, nor could they. So when we talk about removing exemptions, we are never talking about removing medical exemptions.
Vaccinations are required for children to attend public school, many private schools, most day cares, participate in sports, attend summer camp, and they are now even required to participate in some homeschooling co-ops. Even if all states allowed only medical exemptions, parents would still have a choice to opt out of vaccinations for any reason. However, their kids would not be allowed to attend school or participate in the privileges listed above, as well as a few others.
According to the NCIV, 47 states allow for religious exemptions. The three that do not allow such exemptions are West Virginia, Mississippi, and California. Philosophical exemptions are allowed in 17 states. As I explained above, all 50 states allow for medical exemptions. However, these exemptions are now being exploited both by parents who have philosophical objections to vaccinations but cannot obtain this type of exemption from their state, and by doctors who realize some parents will pay outrageous prices to obtain a physicians signature on the application form. This has especially been true in California ever since the state passed SB277, which removed the option for religious exemptions in 2015. As a result, some states have considered, or have introduced legislation requiring multiple physicians to sign off on medical exemptions.
In response to the recent measles outbreaks several states have introduced legislation to remove religious exemptions, as well as philosophical exemptions in those states that still allow them. The passing of such legislation is what will make the biggest difference in preventing or lessening such outbreaks. However, if passing these bills is not possible, there is another option. Though not quite as effective as removing all non-medical exemptions, adding extra requirements for parents applying for non-medical exemptions can surprisingly decrease submissions for these exemptions. For example, Oregon has had an educational requirement for non-medical exemptions in place since 2013. This requirement can be met in one of two ways; parents can either talk to a health care provider to obtain a signature after they are explained the risks of not vaccinating; or parents can watch an interactive online educational video and then print out a form that parents can then fill out. Though both options have the best intentions, the online video is most often the chosen route by parents. Last year Oregon received more that 31,500 submissions for non-medical exemptions, almost 30,000 of them came from the parents who opted for the online video and do-it-yourself form. Less than 2,000 submissions chose to speak to a health care provider. When parents have an option to avoid discussing their decision with a qualified health care professional, they will almost always decide to avoid this talk. Anti-vaccine parents are noticeably afraid of confrontation concerning their choice. They routinely state how they dread the possibility of being questioned about their vaccine beliefs, and judged for their beliefs in the posts they make on social media. Most of these parents will even lie to emergency room medical personnel regarding their child’s vaccination status, while seeking their expertise to treat their emergent child, because of this fear and dread. According to a study, in Washington State, after they passed similar legislation in 2011, overall non-medical exemptions fell by about 40% as a result.
Preventative Measures Through Community Action
A few months ago I happened to notice in an AV group that a member posting was from a town about 2 miles from me. She was bragging about how she obtained a medical exemption for her child and instructing others on what to write to convince the state you object for religious reasons. The town she lives in has one elementary school, and one school for both middle and high school grades. Her child was under 10 years old so I concluded he went to the elementary school. I then wrote out an e-mail to the school principal as well as the district superintendent, attached screen shots of the posts and comments she made regarding her lying for a religious exemption as well as exposing her real reasons for wanting to refuse her child’s vaccinations, and pressed send on each e-mail. I never heard back from either person, though, I didn’t really expect to. I don’t live in the town or district. And even though the information I sent to them is their business, what they do as a result of learning this information is not my business.
The other day I read a news article about a group who goes by “Concerned Moms of Wisconsin.” The article explains how this group of moms passed out letters in their neighborhood alerting those in the area that there was an anti-vaccine advocate living among them. I applaud the Wisconsin women for what they did. They did this quite respectfully in my opinion. The letter wasn’t to shame the anti-vaccine family, but to warn the community in case members needed to take precautions due to having a newborn or being immunocompromised.
If I talked about my e-mail or the letters in Wisconsin a few years ago, most people would be shocked and find these actions way too extreme. I probably would have agreed. However, they aren’t viewed this way any longer by many people. That being said, I do not think most of the country is at a point where these types of actions are needed. Or I should say, not YET. However, there are some pockets of the US where such letters should be written today. Imagine if the Northwest communities hit with a measles outbreak had been notified ahead of time. There are communities all throughout the US that have similar low vaccination rates to those in Oregon when they were hit by the measles outbreak. Oregon’s outbreak was predicted as far back as 4 years ago in a PBS documentary called The Vaccine War. Maybe if members of the communities were alerted to the dangers and risks facing their neighborhoods through community outreach programs more people would have acted and sought vaccinations for themselves and their families. Maybe some of those who refused vaccinations would have had second thoughts as well. Informing your neighbors of the risks to their health and that of their loved ones caused by low herd immunity is something we have a right to do, and arguably a responsibility to do.
Preventing Future Anti-Vaccine Advocates
The most difficult lesson for me to learn over these past two years the extreme unlikelihood of ever being able to reason with vaccine deniers. I think most colleagues of mine, especially those who have dealt with the anti-vaccine community for a decade or longer on social media, would agree that these on-line fights are not displayed for those already lost to the beliefs of anti-vaccine rhetoric. It is for those who have not yet fully committed to the science of vaccines, or the pseudoscience of denying vaccinations. The point of all this public debate on all these social media posts is to influence the thoughts, mood, and feelings for those watching because they are quietly wondering what to think in terms of vaccines and anti-vaccine tenets By influencing which way these spectators sway we can create a favorable zeitgeist.
One way to prevent future advocates from forming is by speaking out regarding the real dangers and consequences they have caused. If you read the claims from the anti-vaccine community regarding their experience with “vaccine injury,” you will realize they have this story telling down to a science, even though science is almost completely left out or skewed in their claims. What they have excelled at though is telling stories that provoke strong emotions from a disturbing amount of readers. It also helps that they can lie very well. Some of the more tragic “stories” will often allegedly involve a cousin’s child, or “my best friend from high school’s brother’s best friend’s child…” making most anecdotal claims impossible to verify, as well as making their inability to provide additional information almost excusable. It’s interesting to see how many anti-vaccine mouth pieces can tell these types of stories with intense vivid detail on what happened after vaccinations, when it happened, how the events of the injury played out day by day, and how everyone was and is so divested as a result, but then prove unable to even provide a last name or a location for the family affected.
It would help if we could invoke the same emotions in people by speaking out. However, it’s more difficult for pro-vaccine stores to match their anecdotes. The stories of those injured by the anti-vaccine movement on our side often consist of the tragedy of a baby or young child dying from pertussis, the flu, SIDS, etc… or of children suffering due to contracting a vaccine preventable disease and having to be hospitalized for a time due to extreme sickness. Telling such stories is hard enough on its own. Then, what those who do end up speaking out soon learn, is that doing so makes you a target for dozens even hundreds of anti-vaccine cult members. These heartless individuals will seek you out on social media and say the most horrific things in a comment or message. My colleagues and I have an idea on how to avoid this harassment for these families, though it is still in the process of being worked out and discussed. Hopefully within a week or so it will be complete and we ]will post about it on our own respective pages and other platforms What I can say is, for families affected by the loss of a child due to low herd immunity, families affected due to low herd immunity by having to experience their child becoming ill, as well as those parents who lost a child in a way not related to vaccines or the lack thereof but experienced anti-vaccine attacks anyways, this would provide a way for them to tell their stories, voice their grief, seek support, or anything else they wish to get out of it, in a way that shields them from future attacks by providing them anonymity.
Dorit Rubinstein Reiss, a law professor at UC Hastings College of Law in California, wrote and published a law review in 2014 that explored arguments supporting the ability for parents to hold anti-vaccine parents legally liable and financially liable when their unvaccinated child infects their child. In a recent pod cast on Lawyer 2 Lawyer with Craig Williams, Professor Reiss broke part of this down for listeners. She explains how in most states a person cannot be held liable for results due to that person, a bystander, choosing “inaction” in response to something they witness, since we have no legal duty to act. This argument mostly applies to those who don’t take action while suddenly finding themselves witnessing a crime or accident. However, not vaccinating your child isn’t simply an inaction. You aren’t simply choosing not to act in a brief moment. You are choosing to refuse your child many vaccinations over the course of their childhood, and you are choosing to refuse vaccinations every single day that you allow them to remain unvaccinated. It can be argued that the refusal to vaccinate is in fact taking an action. This act to refuse vaccinations can cause harm to other children, as well as cost other families money in missed wages, medical bills, or worst case scenario funeral expenses. Professor Reiss brings up another point that never even crossed my mind, what if your child doesn’t infect other children, but instead becomes the infected child? As a parent you have a duty to your child to protect them. If you purposely refuse medical protection for them, and this results in the child suffering through pain and disease, or causes a permanent disability that will require some extent of lifetime medical care or attention, shouldn’t the parent be held liable for this since it was their actions that resulted in such negligence? I don’t know the answer to these questions, nor am I qualified in a legal sense to suggest answers, but the fact that Professor Reiss authored this law review already makes the argument a worthy one. Reading the review then solidifies the need for this discussion.
Can Anti-Vaccination Lies Be Considered "A Clear & [present] Imminent Danger?"
Though the first amendment protects our freedom of speech, this does not mean we are allowed to say anything we want without the possibility of legal consequence, Most of us have heard this explained using the example of knowingly and falsely yelling “FIRE!” in a crowded theater. This is an example of when speech is not protected since your lie is likely to cause mass public panic which is then likely to result in bodily harm to members of the public inside the theater, and could even cause a death or two. Another explanation to describe when speech is not protected is when it presents a clear and [present] imminent danger. The precedent for determining when speech becomes a clear and [present] imminent danger has a long history with many arguments and Supreme Court rulings that have evolved over time. Such rulings as; Patterson v. Colorado in 1907, Schenck v. United States in 1919, Abrams v. United States in 1919, and Gitlow v. New York in 1925. In the 1927 Supreme Court case, Whitney v. California, the ruling concluded that there was a need for greater protections for speech and suggested “present danger” was not restrictive enough wording and suggested changing it to “Imminent danger.”
The ruling I find most interesting for the argument against certain examples of anti-vaccination rhetoric comes from a 1951 ruling in the case of Dennis v. United States. The ruling is explained as followed:
"Chief Judge Learned Hand....interpreted the [clear and present danger] phrase as follows: 'In each case [courts] must ask whether the gravity of the "evil", dissented by its improbability, justifies such invasions of free speech as is necessary to avoid danger.' We adopt this statement as the rule. As articulated by Chief Judge Hand, it is as succinct and inclusive as any other we might devise at this time. It takes into consideration those factors which we deem relevant and relates their significance. More we cannot expect from words."
I can’t help but to tread lightly when discussing the possibility of removing first amendment protections from anti-vaccine misinformation and lies. I value our right to legally protected free speech more than any other Bill of Rights. I realize I am not an expert in law, however, I strongly believe there are certain situations where it is very much like lying and yelling “FIRE” in a crowded theater, as well as causing a clear and imminent danger. To begin with, I would never suggest that all anti-vaccine speech by all anti-vaccination advocates should be considered unprotected speech. It isn’t the speech itself or on its own that I believe is the issue. It is when the speech is spoken by known anti-vaccination figures, public figures with a large following and audience, and when they say such speech in or on a public forum. The type of speech in these examples becomes the issue when they intentionally ignore established proof that their speech is largely lies and misinformation and then choose to say the speech anyways. When the result of these such actions cause so much panic and fear in parents that they make the poor decision to leave their children unprotected thus increasing the risk of disease throughout communities, creates these problems we are just beginning to see unfold with recent disease outbreaks. If it can fit the criteria provided in previous Supreme Court rulings that established legal precedent, then it is time to address and explore this as possible speech violations.
For an example, just this past January Larry Cook from Stop Mandatory Vaccination posted in his Facebook group a link to his recent Go Fund Me campaign (Go Fund Me has since removed campaign. I have posted our screen shots of his posts below this paragraph) asking for donations to boost Facebook posts of his so he can target parents in Oregon and Washington State. He wanted people to give him money so he could purposely target the very communities that were already the most affected and most vulnerable to the outbreak of measles, so he could convince even more of these parents to refuse vaccinations, thus attempting to spread the measles outbreak (an outbreak that could already be argued that he played a part in help creating), as well as increase the likelihood for future outbreaks from measles as well as outbreaks from other vaccine preventable diseases. It wasn’t as if he were telling this to a group of friends in the privacy of his home, or while attending a party with friends and family. He was on a global public platform, talking to his 150,000 group members and his 125,000 page followers, not to mention any audience reading this on his website or on the Go Fund Me site, knowing and hoping it would cause even more public panic and possibly line his pockets. A colleague of mine once said, “The internet has given us many things….a platform for the village idiot isn’t one of the better things.” Though true, I can live with the village idiot having a platform. Sadly though not everyone can survive harmful and greedy liars knowingly spreading information that is false and causes panic and harm to many people while they are in search of a nothing more than a great payday. Many anti-vaccine figures do this, though Larry Cook and Kate Tietje are arguably two of the worst.
Reactionary Measures We Would Love To See From Medical Personnel
I’m talking to all of you in the medical field, and all agencies that specialize in medicine, health, and other sciences. Though we ordinary people haven’t proven to be masochistic enough to endure medical school, residency, and being called an idiot by anti-vaccine parents while paying off student loans for decades, we have been and are essential to fighting this threat. However, we just aren’t enough. I realize health care professionals must maintain a reasonable amount of professionalism while working with their patients or otherwise representing their place of business. That being said, I do not believe the properness of medical professionalism in other situations has done you many favors when dealing with these “woke” and “informed” people. We also need more of you more engaged in this debate on social media, and in certain venues off-line. You see, we don’t have the education that physicians, nurses, or scientists posses. The best most of us can do is cite from the sources that are written by those with the education. As effective as this can be at times, it hasn’t been enough. Its time for us to ask for the help we need.
I know many of you have spoken out at times, or wrote articles, have tried to discuss vaccines with patients, etc…. And it isn’t right to ask this of any of you, you shouldn’t have to spend your spare time trying to explain vaccine safety and efficacy to adults in the civilized world of 2019. However, if you find yourself doing just that, or find yourselves getting sucked into a vaccine debate on-line, we need you to take the gloves off and argue more from a personal level than a professional level. Of course I am not suggesting anyone should be mean, insulting, or hateful in any way. But taking a stance that, “Enough is enough,” showing how angry you are about the harm this is causing, and dropping the concern for professionalism as you fight back in such situations could be what this fight needs. I say this because I have witnessed this approach on social media, albeit only a handful of times, but those few times it appeared to have some success in certain ways. By making it clear that these professionals have had enough of this shit I noticed some anti-vaccine members gave up Facebook fighting sooner than normal, and moved on from the post and the page more quickly that usual. I noticed in their arguments how their confidence had waned when faced with someone who knew they were full of shit as well as could easily explain this, and displayed this with zero disregard for their feelings. I have included a few examples of that I mean here below;
--Kids Pediatrics Plus in Pittsburgh, PA experienced anti-vaccine hate first hand after an August, 2017 video post that explained the benefits of the HPV vaccine. As Chad Harmann, the communications director for the practice, discusses this type of behavior, he very correctly states "They're coordinating attacks and sending the troops." We have seen dozens of these types of posts. They are a form of battle recruitment. Harmann goes on to say, "When pediatric practices are being...terrorized into silence, it's going to create a void in the discource," Hermann continued, "and we all know who's going to fill that: the anti-vax folks." Harmann and Dr. Todd Wolynn, a physician in the practice, speak at conferences, encouraging doctors to not avoid social media and to not back down against such attacks. One suggestion they made is to call in reinforcements. Having a network of vaccine advocates coming to your aid can drown out much of the anti-vaccine narrative and even discourage them from continuing the argument. Basically, if they feel they cannot control the narrative and are not successfully pushing their agenda, they will retreat. One by one they begin to feel defeated and just stop commenting.
--The Night The Anti-Vax Came Knocking
On October 17, 2018, ZDoggMD, aka Dr. Zubin Damania, interviewed Dr. Paul Offit for his website and Facebook audience. During the interview though, a couple of anti-vaccine protestors trespassed on private property, in the dark nonetheless showing what creeps they are, just so they could harass and confront Dr. Paul Offit and ZDoggMD. They brought signs with them, banged on the window, and yelled things at the two men. The creepy voyeurs outside the studio ended up recording their actions as they attempted to approach the two well respected physicians for…….you know, I honestly don’t know why they wanted this confrontation…..but they then uploaded the video to Facebook for fellow anti-vaccination cult members to enjoy their pathetic attempt at making contact. This then led to a bunch of anti-vaccine lunatics heading to ZDoggMD’s Facebook page to “educate” Dr. Damania and his followers on the error of their ways. As usual, this post that was under attack by anti-vaccine supporters ended up revealing how angry, threatening, aggressive, and hateful they often become. This then led to one of the most inspirational, correct, and long anticipated videos I have ever seen on Facebook; ZDoggMD’s October 22, 2018, video titled “I’ve changed my mind about anti-vaxxers” followed by the hashtag “enoughisenough.” In this video DDoggMD holds very little back in describing anti-vaccine supporters in all their evil, how we will never change their minds, and that we cannot continue to give them a platform to tell lies and place lives at risk. I’m oversimplifying what ZDoggMD says in this video. It’s only about 6 minutes long. I highly suggest you watch this video. I just watched it again now for the purpose of this blog post and I think I love the video even more than after first viewing it months ago.. Everything he says is emphatically correct. I held a totally different opinion on how to deal with anti-vaccine advocates about 2 years ago when I first began fallowing their actions online. I firmly believed they should be given the time and reasoned with. It took less than a year for me to shed that naivety and realize it’s a detrimental waste of time.
--Dr. Dino William Ramzi, from Patient Direct Care, is my favorite. Though ZDoggMD is a very close second, this man here is my hero. His attitude and refusal to put up with anymore of this nonsense is what we need to see more of from health care professionals.
In early January 2019 Dr. Ramzi and his medical practice Facebook page, Direct Patient Care, came under attack by anti-vaccine abusers after one anti-vaccine supporter in particular posted screen shots of Dr. Ramzi’s comment and business page in an anti-vaccine support group to encourage other members to join her in harassing the good Doctor. Her reasoning for doing this? Dr Ramzi made a comment, a general comment not one directed at her but a general comment, that vaccine refusal should warrant a visit by CPS. I’m adding two screen shots at the end of this paragraph to accurately represent Dr. Ramzi’s approach to anti-vaccination bullies and liars. Some highlights are, "It's time the same people fight back against the delusional promoters of misinformation who are harming our entire community. And no, it's not rude to call people out for putting our communities at risk for easily preventable diseases." And on the other image he calls them "blowhards." Many of the posts showing this harassment and Dr. Ramzi’s reaction to the harassment have since been deleted or are unable to be viewed since he was forced to turn off reviews for a while due to them attacking his review section. However, some of the posts are viewable on his profile and they show how Dr. Ramzi ran fresh out of……I’ll go with “concern”……for the feelings or claims of the anti-vaccine community, and holds very little back. He isn’t threatening, hateful, or in any way attacking them, but he understands how we have to be honest and call them out for what they are, "Delusional promoters of misinformation who are harming our communities."
In February of 2019 a pediatric practice from Rochester, NY posted an image to their Facebook page that showed their staff proudly wearing matching shirts that said, “Vaccines Cause Adults.” Naturally the existence of such an image no where near any anti-vaccine related group, page, or zealot was unacceptable by the anti-vaccination community and they had to ,again, assemble the battalion to go fight a battle in honor of their butt-hurt. The practice held their own with replying here and there to provide accurate vaccine information, but they mostly denied the anti-vaccine members the satisfaction of having grabbed the clinic’s attention.
Here’s the thing though about this post, posting this image alone was pretty brave, but what impressed me the most was that Legacy Pediatrics did not apologize for the image or post, did not remove the image, and continued to post along with their vaccine convictions. Each of their comments showed the clinic to be completely unfazed by the attacks and abuse from the vaccine deniers. Almost every medical group or professional page I have seen come under attack by anti-vaccine advocates for a post supporting vaccinations has caved right into their terroristic demands. Some have even apologized! Yeah, that’s correct! Some have actually apologized to anti-vaccination terrorists for having offended them by posting factual information about vaccinations that, naturally, ended up exposing the lies told by the anti-vaccine community. Legacy Pediatrics was not and is not one of those practices though. The post and image is still up to this day and they even posted a couple media links on their page regarding this ordeal, which I am choosing to believe is an extra “fuck you” to anti-vaccine advocates. These are 7 of some of the most bad-ass women in upstate NY.
**If anyone is interested in purchasing one of these shirts made by Crazy Dog Shirts you can find them here.
Though I am not an expert on human behavior, nor am I qualified to be listened to as some voice of authority on such matters, I have spent much of the past two years watching the behaviors, their reactions, and their movements on-line. Many of my colleagues have been doing this for much longer than I have, and have witnessed more than I have. The only idea in this post that I can claim full ownership of is the one regarding the first amendment. All other ideas have been discussed among many of us dozens of times throughout our combined efforts. This is why I am able to put confidence in these suggestions. I trust them and respect the work they have done and continue to do. Many of those I’m referring to aren’t much different from than I am in regard to educational expertise in such areas, or lack thereof rather. However, I will listen to their suggestions on how to handle vaccine deniers and the risks they post before I listened to anyone else. You just cannot gain their insight without having their experience and their passion.
Whatever we, both as a collective and an individual, decide to do in response to this growing threat, should be implemented sooner than later. The anti-vaccine community, though still small when compared to the population, is growing and spreading at an unnerving rate. The measles outbreaks, both in the US and around the world, are just the beginning. These outbreaks will become worse. They will become larger. They will become more widespread. And this is just the measles threatening us at the moment. There will be outbreaks of other diseases. These could easily turn into large scale epidemics when combined with the unavoidable effects of global warming in the future. This is likely the worst time in human history for the anti-vaccine movement to reach a critical mass. I am immensely concerned and afraid of what the health of communities, and especially the health of our children could look like in just as little as 5 years from now. Something needs to be done and done now. To steal ZDoggMD’s hashtag…. #EnoughisaEnougjh.
What's The Harm?