Abstract
Ahead of a Covid-19 vaccine becoming widely available, two leading thinkers go head-to-head to debate the moral implications of allowing fake news to flourish versus censoring it
Despite the remarkable public health benefits of vaccines, a significant proportion of the population views them with hostility and suspicion. These feelings are largely driven by unsubstantiated concerns that governments, pharmaceutical companies and public health authorities are hiding evidence of vaccines’ dangerous side-effects.
Low vaccine confidence is not a new issue, but it has received a great deal of attention over the last few months because it threatens to undermine future efforts to end the Covid-19 pandemic. According to the Pew Center, almost half of Americans would “probably not” or “definitely not” get the Covid-19 vaccine if and when one becomes available. While the figures are not as high in the UK, they are still alarming: in a study conducted by King’s College London of attitudes to having a possible Covid-19 vaccine, 10% answered “I would not” and 19% “Don’t know”.
Social media has transformed the way that people communicate and access information. As a recent article in The Lancet pointed out, social media offers “an unprecedented opportunity to amplify and spread anti-vaccination messages”. Half of British parents with children under five have seen negative messages about vaccines on social media, according to the Royal Society for Public Health. The current pandemic poses an existential threat to the world as we know it. We must consider every available option to increase confidence in vaccines – and this includes prohibiting misinformation on social media.
I will begin with the flawed basis of censorship. Calls to censor misinformation rest on a hypodermic model of influence where information is “injected” into the passive mind of an individual who then acts in response. Yet studies consistently find that people are influenced to vaccinate by how they think and feel. They are particularly influenced by the people and institutions in their lives; and practical issues, such as vaccine availability and convenient and culturally appropriate services. Parents who actively refuse vaccines describe beliefs, experiences with healthcare and parenting practices as pivotal to their decisions.
Social media is a mode of communication but we lack evidence that the misinformation alone is influential enough to cause a population impact on vaccination coverage, though this is often claimed. Global vaccination coverage has increased, not declined, over the past 20 years and since social media has become widely used. A recent global survey found just six out of 149 countries had a significant increase in the percentage of respondents strongly disagreeing that vaccines were safe, with the largest increases in Azerbaijan, Serbia and Pakistan. Perceptions of safety, or of the effectiveness or importance of vaccines, were weakly associated with uptake. For Covid-19, a recent study showed intentions to vaccinate at a country level were strongly influenced by trust in government.
Vaccines are based on sound science. The process for achieving high vaccination uptake should also be based on sound evidence.
CREDIT: Matthew Hasteley
In high-income countries, there is evidence that vaccine uptake has fallen in response to fears about safety. For example, the percentage of children receiving the MMR vaccine in the UK and the USA is lower now than in 1998, when Andrew Wakefield published his fraudulent research linking MMR with autism.
It should be noted that authors of the global survey that Professor Leask cites pointed out that the marked falls in vaccine confidence in South Korea and Malaysia were caused by “online mobilisation against vaccines”. The same study stated that misinformation about the HPV vaccine that began in Japan spread throughout the world via “online media and social media networks”.
Attitudes to vaccines can be conceptualised as a spectrum. At one end are people who accept that vaccines are safe and effective.
At the other extreme are the non-believers – so-called anti-vaxxers. It is unlikely that misinformation would affect either group’s deeply entrenched convictions. This is not the case for the “fence-sitters” located in the middle of the spectrum who are unsure about the risks and benefits of vaccination.
It is true that the relationship between social media misinformation and attitudes to vaccines is not well understood by researchers. This doesn’t mean that no such link exists. Advertisers paid Facebook almost $70 billion in 2019 precisely because social media has the power to shape our mood, beliefs and behaviour – although systemic absorption strikes me as a more apt medical metaphor for how this happens than hypodermic injection.
Censorship will also backfire. A core appeal of anti-vaccination claims has long been the cover-up of negative information for conspiratorial purposes. To censor plays into this narrative and risks attracting a broader coalition of voices who reject attempts by powerful actors to control what people see. In doing so, censorship will give anti-vaccination activists and their misinformation more, not less, attention.
The process of censorship is also prone to error. Censors must find a reasonable dividing line between truth and falsehood in a complex field. Insufficiently-qualified censors may place thresholds for censorship too high, shutting down expression of genuine concerns. With vaccines to prevent Covid-19, public hesitancy is not a pathology but a reasonable and predictable pattern when vaccines are new and final trial data is yet to be reported.
Robust vaccination programmes are secure enough to withstand some dissent. These programmes are characterised by solid primary care, co-ordinated systems and sustained funding. They offer people convenient and welcoming services. They train health professionals to be knowledgeable, skilled and confident to answer questions. Robust programmes have strong safety monitoring and adverse-events response systems. They prioritise transparent communication, trust and engagement with diverse populations. Misinformation loves a vacuum, but robust programmes fill early information gaps with open and frequent communication.
Dr Kennedy argues that safety fears caused the recent decline in the UK’s childhood vaccination coverage. However, expert analysis concluded that reorganisation of health services, changed migration patterns and a reduction in vaccination reminder systems were the most likely causes. Significantly, there was a four-percentage point decrease in the proportion of parents seeing anything that might persuade them not to vaccinate.
Misinformation generates a lot of heat and noise. But we should not be distracted or dismayed: we can trust the audiences and respond with nuance, confidence and calmness.
Another recent study showed that people with lower numeracy skills were more likely to believe coronavirus-related misinformation. On its own, this is a cause for concern because it demonstrates that these people and their families are harmed by these untruths. But it also creates a problem for the whole of society because it can undermine the herd immunity that protects people who have not been or cannot be vaccinated, including newborn babies and children undergoing chemotherapy. The 6.4% of the population who refuse vaccines after viewing online misinformation could be the difference between herd immunity or not.
It is interesting to consider who produces this misinformation and why. An article published in the American Journal of Public Health demonstrated that the same Russian Twitter bots and trolls that interfered with the 2016 US election on the side of Donald Trump also spread misinformation about vaccines. The authors concluded that the issue of vaccine safety was being “weaponised” by a hostile power that wanted to create social discord.
Even from a liberal perspective, there is a clear case for banning vaccine misinformation. While those who peddle untruths often defend their right to do so by invoking individual freedom, more nuanced liberals such as John Stuart Mill argue that exercising our personal freedom should not harm other people. Just like violence and hate speech, vaccine misinformation falls foul of Mill’s Harm Principle. In a society that aspires to protect its members – especially those who are vulnerable – we must restrict the propagation of harmful misinformation.
A decision to limit rights to freedom of expression also needs strong support. Censorship must be done with great care, as it can cover-up both misinformation and truth. Countries using censorship as a tool of political oppression increasingly cite the need to control misinformation, implementing “fake news laws” where the bycatch can include legitimate journalism. A recent Unesco report cautioned against rapidly moving to curtailing disinformation without appropriate debate, transparency and scrutiny.
This challenging environment calls for balanced, proportionate strategies that do not erode human rights. Rather than reactively moderating content, the focus should be on keeping vaccine programmes resilient: meeting demand for information with early credible information; monitoring the sharing of misinformation to see what is salient; addressing actual information needs (not assumed ones); and managing hesitancy well in healthcare situations. Countries need to support public interest journalism. Young people – the parents of tomorrow – should have sufficient digital literacy to critically view content.
While bots may account for 9%-15% of all Twitter accounts, few people follow them. This means that their vaccine-critical content is almost never seen, as our recent study found; between 2017 and 2019 in the USA, a typical Twitter user potentially saw 757 vaccine-related posts, of which 27 were critical of vaccination and less than 0.5% originated from bots.
The greatest enemies of vaccination are poverty, disadvantage, failed health systems and neglectful governments. People require opportunities and capabilities to vaccinate and this does not always happen.
Through preventing certain infectious diseases, vaccines aim to improve the wellbeing of individuals, communities and societies. The process by which vaccination is supported should not compete with this ultimate aim.