I have tried to convince you that data shows that vaccines work, and that maintaining a whole-population vaccine coverage shield protects us all. It follows that those who actively oppose vaccination – anti-vaxxers – are in fact sabotaging the public health programs that are designed to protect their own children…and yours. So, why would people do that? What are the reasons for declining vaccination coverage in this modern day and age? Answers to those questions range from somewhat reasonable to completely irrational. In this article I’m going to try to deal with the somewhat reasonable ones. In a third segment, I will deal with serious misinformation and conspiracy theories. 

Let’s start by acknowledging that the Covid pandemic has made things worse. It isn’t the only cause for declining vaccine coverage, but it has acted as accelerant or a catalyst – turning little brush fires into bigger ones.

 The first reason for falling global coverage is supply side interruptions. Wars and political turmoil, natural disasters and economic issues can all impact weakly supported vaccination programs in developing low and lower middle-income countries. Throw in the Covid pandemic, and the availability of vaccinations gets hit in two ways. First, the vaccine itself is either unavailable or more expensive because of the generalized supply chain disruption that we are familiar with. And second, vaccination program priorities got disrupted – when administering Covid vaccines was a public health imperative, some other vaccination clinics may have gotten delayed or deleted. And it is in the poor regions of the world that the vaccine coverage decline is most apparent. WHO says “global figures, however, hide significant disparity between countries of different income strata, with low-income countries lagging behind.”

            There is a kind of an echo effect from those supply side disruptions. As the US Centre for Disease Control (CDC) explains, “The COVID-19 pandemic affected immunization programs worldwide and resulted in millions of children missing vaccine doses and substantial increases in the numbers of zero-dose and incompletely vaccinated children. As these children age out of the usual target age range for their country’s routine immunization program, they might experience limited opportunities for catch-up vaccination unless countries adopt catch-up vaccination schedules and strategies for older children.”  

So, there are reasons, especially in poorer countries, why vaccines were unavailable. The remedy is obvious. Rich countries need to step up to support both the routine and catch-up vaccination programs in those countries that need help. And for those who object to spending tax dollars on damn foreigners, I will remind you that germs know no national boundaries. When we help Mozambique achieve a herd-immunity level of vaccination coverage, we are helping ourselves.

The rest of the reasons for not receiving vaccinations are all what might be termed demand side issues. They are why, in countries with strong and readily available vaccination programs, kids are still missing the boat.

Demand side reasons one and two are interlinked– it’s just damn inconvenient and it’s not really important.  An article in The Economist says “But parents rarely opt out of all vaccines. Many are overwhelmed by the large number of vaccines now required for young children, so they choose to limit or delay the jabs…Paul Offit, a doctor at Children’s Hospital of Philadelphia, notes that most of (the parents) have never seen the 14 diseases for which the government recommends vaccination. “In the end,” says Dr Offit, “people don’t get vaccinated because they don’t fear these diseases.” In other words, vaccines are a victim of their own success.”

Alright, I can sympathize with that…a little. I remember, as a kid, seeing people in the community who were wearing braces and using mobility assist devices because of the long-term ravages of polio. So, it’s easy for me to believe in the importance of polio vaccine. I remember when my mother set up what amounted to a hospital ward in the living room when a half dozen or more of our (large) family all came down with mumps at the same time, and having witnessed that, (and remembering how it felt!) I wouldn’t lightly dismiss the mumps vaccine either. Part of our family history is the death of my grandmother in the influenza epidemic of 1918 so in the back of my mind, the flu is more than just a random autumnal annoyance. I suppose that it’s harder for millennials or Gen X or Gen Z or whatever to appreciate the benefit from vaccines when they’ve never witnessed the downside. 

But I only sympathize a little. When your baby is born you will have been inundated with information from the medical system. You may not have a family doctor or a paediatrician, (and I agree you should have one), but even if you lack those supports, the information about vaccine schedules is readily available. In less than five minutes I found three sources of that information online. So, you know what you need to do. Do your job as a parent. Don’t tell me that you need to see the bogey-man before you can be scared of the bogey-man. That line of argument basically posits that the decision to vaccinate your child is primarily an emotional one – you must be motivated by fear or you can’t be motivated at all. But you don’t need emotion here. Cold hard logic and a look at the data will tell you that vaccines work and that they will protect your child from disease. That’s really all you need to know. 

It’s inconvenient for you? Of course it is, but so is taking your kid to the dentist, and you manage that ok. Is preventing a toothache more important to you than ensuring your child doesn’t die in an outbreak of measles or diphtheria?

That discussion leads somewhat logically to the next reason for people ignoring the good advice they are being given and that is that people are losing their faith in their institutions. They don’t trust what they’re being told. A Gallup poll in the US shows about 5% decline in trust across almost all of the “institutions” in the poll between 2021 and 2023. Those institutions are really groupings – police, military, newspapers, television news etc. There are some interesting divisions in the poll. Small business is greatly trusted; big business is almost universally distrusted. The police are trusted, but the justice system is not. Newspapers are trusted by 18%; television news by 14% of those polled. Surprise, surprise, Congress gets an 8% confidence rating south of the border. 

A survey of 30 OECD (richer) countries shows about 41.4% of people trust their government. Canada is almost a mirror of the OECD picture at 44.7%. A survey in 2023 conducted by Statistics Canada provides a breakdown of factors affecting trust in institutions and media. We report higher levels of trust for the police, the justice system, schools, the media and Parliament, and we appear to be generally more confident in institutions than the Americans. There are a number of linkages and I’m going to try to summarize them. If you’re poor, in ill health, and young, you are likely to distrust major institutions. If you’re old, financially secure and healthy, you likely have high level of trust in the major institutions. The correlations with financial and personal health aren’t surprising – why would anyone for whom the good life is but a dream, trust institutions that don’t seem to be working for them? But the correlation with age is interesting. 

The age-related decline in confidence in institutions is concerning in the context of this essay because it is reflected in the confidence in vaccinations. A 2023 study on vaccine coverage and confidence by Rachel Eagen and others is available on the National Library of Medicine in the US. The abstract hits on the problem in the very first sentences – “Decliningtrends in vaccine confidence come at a time when routine immunization coverage for children has slumped to a decades-long low. With some of the largest losses in confidence experienced among young adults, this is a concerning trend with the potential for long-term implications.

Survey questions in 27 countries (not including Canada) asked two questions about the MMR vaccine. First, is it safe, and second, is it important? In almost all countries, younger people rated vaccines lower on both counts than older people did. And in most countries, the youth group showed declining confidence between 2018 and 2022 whereas older people were more likely to have remained the same or even increased their belief in vaccines. The article notes that “Declining confidence among younger age groups is a significant cause for concern as they are the next cohort of parents making decisions around childhood vaccination.”

The pandemic has evidently contributed to this declining vaccine confidence trend. The authors report that “there is evidence to suggest that they may have triggered psychological reactance – or backlash – among specific socio-demographic groups, including in younger people. Concerns about state control have also featured strongly, ranging from those around vaccine passports and mandates and the corresponding electronic infrastructure that has been built to rumors around vaccination and depopulation”. 

Statistics Canada points out one possible reason for why younger people are more likely to distrust what they hear. “Exposure to online misinformation, and preferred media sources may affect levels of trust. In general, young Canadians are more likely to get most of their news or information from online sources, resulting in a possible higher exposure to misinformation. Social media was the most common outlet for young people aged 15 to 24, with 62% getting their news or information this way, while Canadians aged 65 years and older were more likely to rely on traditional sources such as television (64%). 

Two years ago, I wrote a blog essay entitled “Information sources in the Age of Trump. It points directly at this issue – that people need to choose their preferred media sources very carefully. If you’re believing what you read on the internet without doing some serious verification work on your own, you are being led down the garden path.

I believe that sources like Health Canada, Public Health Ontario and the American Center for Disease Control (CDC) are reliable sources, but I know that those who distrust institutions won’t agree. They would accuse me of drinking the Kool-Aid offered up by my malicious and conniving government. I would tell them this – that large bureaucracies are imperfect, but absolutely immune from conspiracy. Everyone who has ever worked in a large organization, especially a government organization, knows that decisions are made by you and me. By ordinary people. “The government” isn’t an evil genius hiding in the shadows. It’s your neighbour, and the hockey mom, and your uncle Dennis. Errors get made and inefficiencies happen, but the notion that 11000+ people working for Health Canada could be directed to sustain a conspiracy is frankly ludicrous. So, I’ll believe and trust organizations like Health Canada. If you don’t want to, that’s fine, but do yourself a favour. Do your best to read some peer reviewed scientific articles, or articles from trusted sources like the Economist or the BBC. Anything you read at random on the ‘net could be gold… but it is more likely to be garbage.  

The one ray of sunshine in this picture is that a Pew Research study of trust and confidence as a function of age reveals that the young (18 to 29) are slightly more likely to trust scientists, university professors and journalists than are older groups. And that’s good – if you trust scientists, go and do the work to find out what the real scientific consensus is.

There’s a kind of a progression in the reasons for declining vaccines. We’ve talked about people who don’t think it’s important. And people who think it’s inconvenient, and people who don’t believe in the institutions that are telling them what they should do. The next group is people who fear the possible side effects of vaccinations. 

These fears are real and not lightly dismissed. The MMR vaccine has a number of common side effects including faint red rash, fever, cold symptoms and the like. A story like “my Johnny got the measles vaccine and he was feverish for three days” might be enough to stop the listener from having her child vaccinated. And the MMR vaccine also has some more serious side effects. Febrile (fever induced) convulsions, which “stop without treatment and don’t cause other health problems”, occur in 1 of 3000 children vaccinated. Low platelet counts causing bruising or bleeding may occur (1 of 20000 to 30000) and in something less that 1 in 1,000,000, severe allergic reactions might occur.  

The DTaP vaccine is similar – common side effects are soreness, low grade fever etc., but according to WebMD, “Although it’s rare, you could have a severe allergic reaction after any type of vaccine. But the chances of this are less than one in a million doses.”

The logical argument is that risk of febrile convulsions in one of 3000 children vaccinated is a better bet than risk of death in one of 3000 unvaccinated kids who catch measles. Some might argue that avoiding the vaccine eliminates that one in a million risk of severe and life-threatening allergic reaction, and since almost everyone else is vaccinated, my child really doesn’t need it, does she? But there are two problems with that argument. The first is that the failure to participate in the vaccination program weakens that shield that protects us all. Perhaps a selfish person won’t care about that. But they should care about the second problem which is that this is a well-connected world, and we have no way to prevent accidental contact with a virus-spewing traveller. So, your odds are better if your kid is vaccinated. Full stop.

  If I’m debating vaccines with a person who says that vaccines make kids sick, my response is “Yes, that’s true. Bad things could happen if you do get your kid vaccinated. But bad things can also happen if you don’t get your kid vaccinated. Our best scientific assessment is that the risk of seriously negative outcomes for your child is lowest if you follow the recommended vaccination schedules.” 

So that takes us past ignorance, distrust, lack of focus and rational but misplaced fears. And that brings us to people who object to vaccination on the grounds that it’s against their religion. 

I don’t understand. Has the “revealed word of God” been given to any major religious group since 1900? Could the Bible or the Koran possibly have been written in anticipation of inoculations? No, they weren’t. However, the reasons cited in a public health research article aren’t about a specific prohibition in the fundamental religious document. They cite dietary rules because the vaccine might contain minute amounts of pork-based material. They cite concerns about fetal cell technology. They’re concerned that the HPV virus for teenage girls might lead to promiscuity. Finally, there’s the argument that reliance on vaccines shows a disappointing lack of faith in God. We don’t need vaccines, because God will look after us. 

I have absolutely no tolerance for those objections. When we hear those pathetic excuses, we are not hearing the word of God. We are hearing the rule of some power-hungry authoritarian church leader. None of the religious groups that oppose vaccination are unanimous on their reasons for prohibition. Some Jewish groups oppose vaccinations; others welcome them. The same is true for Muslims and Catholics etc. So, the “rule” that people follow came from one or more individual human beings who made an interpretation, and imposed it as church policy. If God has an opinion on the matter I would expect it to be consistent at least across one chosen religious group. But it’s not. Either God is a terrible communicator who has failed to make his message clear to these diverse religious groups, or there really is no revealed truth on the matter. I vote for the latter.

I have written before about my belief in the need for a secular government. I respect everyone’s right to believe in whatever religious doctrine takes your fancy, but public policy decisions shouldn’t be based on religion. If you think they should, then you have to tell me which religion is the one to follow, and how does that respect adherents of other religions? And let’s face it, vaccination programs are public policy decisions. Perhaps religious leaders should put a little faith in science as a demonstration of God’s caring and stop inventing reasons to be difficult.

Assuming that you’re trying to reason with an anti-vaxxer who falls into one of these categories, I would tell you that your best argument isn’t contained in this essay. It lies in the previous one. And that argument is simply the overwhelming data about the eradication of childhood diseases following the introduction of vaccines. The arguments I’ve given here are responses to specific objections and concerns, but the hammer is “the data doesn’t lie – vaccines save lives.”

The reason I’m trying to provide you with arguments to use is that the argument matters. An article by Benoit and Mauldin published in the peer reviewed journal BMC Public Health says “Surveys from the American Academy of Pediatrics found that the rate of parents who refused one or more recommended vaccines increased from 9.1% in 2006 to a staggering 16.7% in 2013.” That’s one in six families being under-vaccinated, and that means we’re lowering our collective guard too much. In 2019, prior to the pandemic, the World health Organization named vaccination hesitancy as one of the top ten threats to global health. Top ten! It has undoubtedly gotten worse following the pandemic. So, if you get a chance to argue with an anti-vaxxer, don’t back away. It’s an important topic, so have that tough conversation. It’s all we can do.

Next time we’ll deal with some of the more whack-a-doodle reasons not to get vaccinated. 

I welcome your comments.

Dennis