When Vancouver parents clash with their doctor over whether to vaccinate a child, they are often referred to B.C. Children's Hospital pediatrician Jane Finlay.
To ensure they consider at least some injections, Finlay wields tactics not always associated with medical experts: humour, validation and compromise. She recently worked with a family to deliver most of an infant's six-month shots at a slower pace, finishing close to her first birthday. Now the parents want to delay the measles-mumps-rubella vaccine, because they think their daughter's immune system will be stronger after the flu season is over.
"These are beliefs," Finlay says, adding that while she can't acknowledge them as true, she must work with them in the interest of the child.
Medical professionals are increasingly engaging in these kinds of negotiations around health issues that breed conspiracy theories, from vaccines to weight-loss tricks, alternative multiple-sclerosis treatments and cancer cures.
Empowered by the Internet and spooked by controversies involving medical errors, patients have become their own best advocates. While doctors emphasize it's important for people to be active participants in their own health, they are also vexed by how seeds of doubt planted by online naysayers can overrule firmly established scientific truths.
The stakes are high. In the case of vaccinations, deadly, preventable diseases such as whooping cough and measles are making a comeback due to sliding rates of vaccinations in some pockets of the country. Last month, British Columbia's Fraser Valley region reported about a dozen cases of measles, a disease that had all but been eradicated. An outbreak in Quebec last year saw more than 700 cases. Measles is fatal in about onein 4,000 cases.
Confronting patients with data hasn't worked yet. So instead, progressive doctors are now turning to behavioural scientists and medical anthropologist for ideas on how to help patients sort fact from myth. It can be quite a challenge when your foes are a person's strong social networks and Dr. Google.
Noni MacDonald, a professor of pediatrics at Dalhousie University in Halifax says one study has shown that spending five to 10 minutes on an anti-vaccine website can influence a parent to opt out. She and others are calling for more regulation of seemingly neutral immunization websites that push anti-vaccine messages. She applauds a case involving an Australian site, the Australian Vaccine Network, which has been forced by government regulators to run a consumer-warning banner saying it has been found to have a misleading name.
MacDonald says this kind of information can confirm deep-seated suspicions.
"We all like to think we make our decisions based on incredible evidence and we weigh it out. Well, we don't. A lot of our decisions are based on our beliefs at the unconscious and subconscious level," she says.
Those beliefs, she says, are shaped by what we remember and stories that stick – such as those from celebrity anti-vaccine activist Jenny McCarthy, who has claimed her son became autistic because of a vaccination, a theory that has been soundly disproven.
In turn, these stories can be reinforced by friends and family chiming in, according to new research. Emily Brunson, an anthropologist at Texas State University, is studying the mechanisms behind parental decision-making around vaccines. In the past 50 years, she says, the number of people who simply follow their doctor's orders has shrunk.
In a study to be published in the journal Vaccine, she found that those who are uncertain about whether to opt in or out of vaccinations seek information from their social networks or the Internet. Regardless of the number of people involved, if more than 25 per cent of a parent's social circle recommended not conforming to the vaccination schedule, "the parent was going to opt out in one way or another."
Another group of parents she identified was more influenced by their own research, even paying to print out articles from online academic journals. They tended to be the highest socioeconomic group with the most education and they also tended to be the most likely to opt out of some element of vaccination. "There's the idea that you have to be risk-aware – you're supposed to an informed consumer of medical issues. You're supposed to be savvy, knowledgeable and question."
Often, this group will be satisfied with a modified schedule or dropping shots seen as less crucial, such as the hepatitis B shot usually done in Canada at two months of age.
Finlay says this is exactly the kind of compromise she'll make with parents in the hopes that other vaccines will be accepted as the child ages. "Hep B is not the hill I'm going to die on for a low-risk infant," she says. "It can be given later."
In a paper they released with the Canadian Paediatric Society in May on how to work with vaccine-hesitant parents, Finlay and MacDonald say pediatricians should use a non-confrontational tone, hear parents out and not assume all parents have the same concerns. To combat McCarthy-style stories, they should share compelling stories of children damaged or killed by vaccine-preventable diseases – a suggestion that borrows from psychological work on "automatic mental associations," with the goal of changing those subconscious beliefs.
They tell pediatricians to resist the urge to "fire" a family from their practice over vaccinations. "Every health encounter is an opportunity to discuss vaccination," they write.
As for learning from anthropology, they also advise pediatricians to validate why a parent has a concern and not to be judgmental.
Finlay says she's learned that there's no one demographic of parents who are wary of vaccines. "I have pre-judged the lovely hippie-yoga family who live in Kitsilano, for their child not to be vaccinated, and they are," she admits. "You can't typecast people." She adds that in Vancouver, girls from wealthier families are less likely than girls from families of average or lower means to have received the HPV vaccine.
And Brunson says it's helpful to remember that most parents aren't evangelical abstainers.
"Some people are definitely conspiracy theorists and you can find crazy stuff online, I know I have, but for most of the parents it's not that. They're doing what they feel is honestly the best thing for their child."