The vaccine “debate” is the art of not talking about what we are talking about

Culture spills into politics the way leaking oil blankets an ocean: tenaciously and indiscriminately. So it was in Texas this week, where the state’s primary elections turned into a battleground for the anti-vaccine movement, which has been campaigning over the past few months for their endorsed candidates.

The anti-vaccine group Texans for Vaccine Choice has been asserting itself in local politics for a few years now. In 2015, the group successfully lobbied against a repeal of vaccine exemptions for non-medical reasons. And since then, they have kept up the pressure on state lawmakers, culminating in Texas’s passage of a law forbidding doctors from vaccinating children in temporary foster care. But in this week’s elections the politicking was more personal as the group canvassed to unseat incumbent state representative Sarah Davis. What did Davis do to deserve this ire? She unsuccessfully proposed an exception for the HPV vaccine in the aforementioned foster care law.

Andrew Wakefield, who 20 years ago released a fraudulent study linking vaccines to autism, and who has since become a living martyr of the anti-vaccine movement, was quoted as saying he saw this election as an “an extremely important time” to advance his agenda. In Texas, where Wakefield now lives, he said “there are clearly a number of candidates running with this platform front and center—vaccine choice, medical freedom.”

I think it’s important not to wade too deeply into the “medical choice” rhetoric dominating the Texas anti-vax movement. The vaccine “debate” is the art of not talking about what we are talking about. In political science, there is the concept of the “dog whistle.” When Donald Trump says he wants to “build a wall,” for example, some interpret it as a call for a brick and mortar border wall. Others hear an anti-immigrant rallying cry or ignoble racist demagoguery. Vaccines are similarly dog whistle medicine. The appealing call for choosing one’s own medical care is political subterfuge, a way to open the door to conspiratorial digressions.

When doctors respond to “medical choice” activists by emphasising the need for herd immunity, they miss the political point. Even though the vast majority of Americans vaccinate, a small oppositional movement has successfully influenced this intervention’s emotional geography. Every conversation, even between those who support vaccination, is now an anti-vaccine conversation. Doesn’t every doctor’s chest tighten when they hear the word “vaccine” in a media report? Imagine how confused and apprehensive the average patient must feel.

Given the 20th anniversary of the Wakefield paper and the influence anti-vaxxers are wielding in politics, we hear a lot about Wakefield’s turn of the century anti-vaccine boom. But if Andrew Wakefield did not exist, he would need to be invented. The anti-vaccine movement is as old as vaccines themselves. America’s founding fathers even waded into the vaccine controversy. In ebbs and flows, hesitation has sadly always tarnished these miraculous little jabs.

More than a historical flashpoint, the anti-vaccine movement is part of an entrenched alternative medicine worldview. In trying to make sense of this wide ranging sociopolitical belief system, I have argued that alternative medicine can be viewed as a reactionary movement, driven by distrust and revulsion of the modern medical world. No matter how much I learn about it, however, the soul of alternative medicine feels ethereal, with seemingly impossible to reconcile political, cultural, and psychological characteristics. It is challenging to move forward when this movement feels deliberately erratic in the issues and arguments it advocates.

In the face of such a cultural movement, where does that leave the medical establishment? Do we continue knocking down anti-vaccine talking points? Some now argue that we need a Newtonian response to anti-vaxxers—an equal and opposite political movement. While a logical dissection of anti-vax misinformation is tedious, a passionate political campaign, complete with slogans and spokespeople, is compelling. If some people are “anti-vaxxers,” we can create even more ardent “vaxxers”—no longer simply people who vaccinate.

I don’t know if I’m ready for cynical tribalism, where a public health victory is defined not by informed action but by accruing the most fanatics. Nor do I look forward to more alt-med political proxy wars, like the one that just took place in Texas. But if doctors are in this for the long haul, we should decide whether to combat the tool or the ideology, for each strategy has its risks. For those of us raised on a diet of journal club and medical conference debates, combatting the “tool” of fallacious argument seems like the dignified, scientific approach. But the belly rumbles at the prospect of a self-righteous cultural and political fight.

Ultimately, we can’t develop any effective strategy until we learn to hear the ultrasonic tones emanating from alternative medicine. While sometimes just out of a doctor’s earshot, they are nevertheless captivating to many. We may find common ground. While not reactionary, doctors are now reacting to the unsustainable financial burden patients shoulder and the potential for conflicts of interest to disrupt patient trust. We can build alliances through these shared goals.

It could be said that the pro-vaccine camp “won” the Texas primaries this March. Susanna Dokupil, who was backed by Texans for Vaccine Choice, trailed incumbent Sarah Davis in their primary. Nico LaHood, an incumbent district attorney, who once said “vaccines can and do cause autism,” was ousted in his election. But we shouldn’t oversimplify the convolutions of cultural politics. The races turned on many issues, not just vaccines.

Still, it’s worth listening to the anti-vax dog whistles coming from Texas. They’re telling us that now is the time to prevent medicine from deteriorating into the bitter polarity of politics.

Benjamin Mazer is a resident pathologist at Yale New Haven Hospital. His views are his own and do not represent those of his employer or other organisations. Twitter @BenMazer

Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None