Silencing the virus? Government communication and MMR vaccination campaigns – the Australian case

Mandatory immunisation

In theory, one must first define a problem to find then its solution. In practice, however, solutions sometimes precede and frame the problem. The trend of ever more governments making the MMR vaccination compulsory illustrates the reflex of putting the solution before the problem. Stricter legislation through litigating, penalising and limiting access to various resources seems to many politicians to be the quickest, one-fits-all and best serving the common good solution. In 2020, the voices clamouring for and against mandating of the (still in development) Covid19 vaccine, essentially replicate the arguments of the 2019 MMR debates (Knaus, 2020; Sanchez Hidalgo, 2020).

But what difference mandated immunisation could make? An answer, at least a partial one is aim of this study. Early evidence is inconclusive. An EU-funded ASSET Project could not confirm any relationship between mandatory vaccination and rates of childhood immunization in Europe (ASSET Reports, 2015). In Australia, Italy and France immunization coverage has slightly risen with the introduction of mandates (Drew, 2019). Yet Portugal and Sweden can boast vaccination rates over 95% without mandating (Suárez and Villarreal, 2019).

Over the past five years, Australia, France and Italy introduced quasi-mandatory measles immunisation by restricting access to school for children who have not received the recommended by the health authority vaccination, including MMR. Germany, along France, Italy, the UK and US, used to be the stronghold of libertarian thinking, preferring informed parenting decisions to coercive vaccination measures. But not when the crisis struck. In November 2019, the Bundestag urgently passed a law that will fine parents (starting in March 2020) up to €2500 if children are not inoculated. Now, when I write this paper, it is not clear whether a ban from Kindergarten and school will also follow. Such implementation is flagged as ‘likely’ (Connolly, 2019).

Even one of the last standing bastions of ‘consumer rights’, ‘vaccine safety’ and ‘vaccine choice’ in public health started shaking when the UK Health Secretary, Matt Hancock, said ahead of the elections in December 2019 that the government was ‘looking very seriously’ at making vaccinations mandatory for state school pupils. ‘I don’t want to have to reach the point of compulsory vaccination, but I will rule nothing out’ (Mohdin, 2019). Early on, he had angered liberal ‘free thinkers’, including some in his own party, by telling the Times that ‘those who have promoted the anti-vaccination myth are morally reprehensible, deeply irresponsible and have blood on their hands’ (Mostrous and Stoneman, 2019).

That was enough, and in an apparent rebuke of the Health Secretary, a spokesman for the conservative Prime Minister, Boris Johnson, declared that ‘We’re not at the stage of refusing admission. Our priority is on increasing vaccination numbers’. Instead, the alternative plans included making it easier for parents to make GP appointments for vaccinations and keeping better records of children who have not been vaccinated (Walker, 2019). Such uncertainty in the recent German and UK vaccination policies are not by accident, although perhaps not entirely deliberate either. I will later discuss similar ambiguity in the position of the Australian government. But here it makes more sense to think that making threats of denying access to education for kids – unjust collective punishment by any measure – without making such threats reality, may serve as a casual warning to parents of which effect politicians are no doubt aware.

Vaccine hesitancy

There is an important – and underlying for this paper – difference between ‘vaccine hesitancy’ and ‘vaccine refusal’. The World Health Organisation (WHO) defines vaccine hesitancy as a ‘delay in acceptance or refusal of vaccines despite availability of vaccination services’ (MacDonald, 2015). The WHO Strategic Advisory Group of Experts (SAGE) on Immunisation suggests that attitudes to vaccine should be conceptualised as ‘a continuum, ranging from total acceptance to complete refusal’ and that ‘vaccine hesitant individuals are a heterogenous group in the middle of the continuum’ (WHO, 2014: 8). Accepters (vaccine confident) and rejecters (vaccine refusers) should be regarded as belonging to this continuum, occupying its opposite ends. Following that terminology, an Australian research team calls the vaccine hesitant individuals fence sitters who are ‘characterised by uncertainty and lack of confidence in vaccines, but who may still support vaccination in some respect’. They are not analogous to vaccine accepters who ‘strongly endorse vaccine practices’. Neither are they identical with the refusers (antivaxxers) – ‘a small yet vocal group . . .’ who oppose the use of vaccine in all forms (Rossen et al., 2019: 24).

Vaccine hesitancy and coverage (an informal term) are inversely related. The higher the vaccine hesitancy – the closer it is to potential vaccine refusal – the lower the vaccine coverage, although the former may be only one – among Western countries perhaps the one – factor that impacts coverage. There may be other, more material and less attitudinal obstacles such as a prohibitive cost of vaccine or limited access to immunisation. In other words, there are unintentional hurdles to coverage, which may stop parents from immunising their children although they do not reject to doing it (Yaqub et al., 2014).

This paper is concerned with government communication and its main target – the vaccine hesitant individuals, the fence sitters, who in the middle of the continuum constitute a group smaller than the accepters but larger than the antivaxxers. This is the strategically important group to win – the sitters, which pro-vaccination campaigners must and can pull out from the fence. As I will argue, their agenda of concern with the health of their children and risks of the vaccine should not be confused with the political agenda of the antivaxxers, which by addressing vaccine also has other things in mind. Parenting concern and health ideology influence each other but are not identical. The vaccine-confidant parents have embraced the worldview of objective science and trustworthiness of its agents. This slants their parenting concern towards the risks for their children from failing to vaccinate them.

The ideology – or ideologies – of the antivaxxers, who are in general well educated and well-off people, has roots in various religious, libertine and New Age spiritual traditions (Wolfe and Sharp, 2002; Wolfe et al., 2002). They do not directly reject science but rather mistrust its ‘hijacking’ by self-interested agents such as politicians, bureaucrats and some experts. In the self-image of the antivaxxers, they are scientifically more knowledgeable and critically minded than the ‘unaware’ and ‘gullible’ vaccine-confidant parents. Thus, their parenting concern is focussed on the ‘unknown’ or ‘undisclosed’ risks of some vaccines for their children (Hobson-West, 2007).

The fence sitters – the vaccine hesitant parents – are perhaps a bit but not a lot affected by those opposing ideologies. The agenda of their rather un-political concern as parents is still prevailing over their ideological beliefs as citizens. Their political agenda – whatever it is – is weak, but their parental anxiety is high.

But if winning the vaccine-hesitant parents is the real problem, the question is what highway to take in that journey. Is it possible to keep the argument un-political? Or is it not better to find a more adequate translation between parental worry and political motivation, because, in the end, there are no such things like policy-free solutions of public health issues?

Stigma, voice and silence

A public relations theory of government public health campaign cannot go around the category of stigma and process of stigmatising, in which both the pro-vaccination workers and antivaxx activists are involved. Goffman (1990) defines stigma as a set of discrediting characteristics to someone’s identity, which can be of a person or a group. The advantage of his definition is that he is a sociologist and sees the process of stigma not as an individual act but as a complex discursive event. Stigmatising takes place not when a new word or a new collocation is introduced but when a whole language is changed. The stigma ‘should be seen that a language of relationships, not attributes’ (p. 2).

In the mainstream media, the name of the person who started it all in 1998 with his infamous publication in Lancet (later retracted) about the link between the measles vaccination and autism, Wakefield (1998), goes by default together with adjectives such as ‘discredited’ and ‘disgraced’ (scientist, expert). This is an example of stigma through colocation. Minister Hancock gives another example of negative branding. (Branding is the origin and literal meaning of stigma, the sign ancient Greeks burnt into the body of a slave, criminal or traitor.) As cited above, he put together – or did not clearly differentiate from each other – vaccine hesitant parents and anti-vaccination activists and branded them as ‘morally reprehensible, deeply irresponsible and [with] blood in their hands’. Stigmatising, in that regard, is the opposite of ‘normalising’. A stigma brands the others as morally and noticeably inferior. Those in power need the stigma not to help the stigmatised, not to improve their moral, and not to change them into ‘normal’ people and return them to us, but to parade them as a living example and deterrence to the others in the first place. Stigma silences by visibility.

Goffman’s term, however, only allows passive and static strategies for the stigmatises – mostly of camouflage. They mimic the dominant group either by imitating (raising it a bit too high) its voice of wisdom, or by making their own discredited Self more invisible. Examples: hiding unemployment (Siebert, 1997) or masking sexual orientation (Lovaas, 2003). But research also unveils an opposite, resistant and transformative feature of stigma (Smith, 2007, 2011). Passively and tactically, one can adapt to a dominant discourse; but actively and strategically, one can try to change it – weakening it (by deliberate overuse, for example), imposing their own language, and, finally asserting their dominance (Lakoff, 2004; Lakoff and Johnson, 2008). Both for the dominant and dominated, stigma may have unexpected and unintended consequences.

Stigma is an ambitious strategy. It may demoralise the victims or spoil them for a fight. For example, one can undermine the stigma by doing the opposite of what it enforces – by becoming instead of silent and visible – vocal and invisible. Cultural (mis-) appropriation does exactly that – adopting dominant ‘cultural codes’ (Eyerman and Jamison, 1991) to achieve something different from their origin or genesis (Aldredge et al., 2009; Rogers, 2006). It is true that stigmatised groups do not have the cognitive power to define their own identity imposed on them by primary definers, but they do have the axiological power to subvert it by tweaking the value of who they are – from negative to positive. ‘So you say, we, skinheads, are fascists. OK, you, smart alecks, we are fascists. And this is good’. Changing the value sign is one of the strategies of how resource-weak fringes may transform into core movements (Dimitrov, 2015).

Bruno Latour’s actor-network theory (ATN)

When we search for the effects rather than meanings in a vaccination campaign, Latour’s (1996) actor-network theory (ANT) may lend us a hand. There are two main reasons for that. First, Latour attempts an ontological and epistemological synthesis of social and natural science, in which he offers a material understanding of an actor – beyond the hermeneutic and idealistic definition of (co-) producer of meaning (Dilthey, 2010 (1939); Weber, 2002 (1922)). According to Latour (1996), ‘anything that does modify a state of affairs by making a difference is an actor’ (p. 71). And second, he developed and applied his theory of the material constitution of the social in the field of epidemiology and immunology. In The Pasteurisation of France, he dissects the combinations and alignments of social forces that made the immunisation of the population in France possible on a grand scale. For Latour (1988), both the virus and the vaccine perform as actors, who, if virtually silent themselves, by sheer impact recruit and rally influential speakers on their behalf.

Latour’s ANT overcomes Cartesian dichotomies and move from the search for meanings to the search for effects. Such understanding is easily applicable in public relations campaigns. Practitioners are aware of the difference between (media) output as a means and (public) outcome as an end. Although publicity effects may be a goal, they are more often a means to achieving other, more material effects such as higher attendance, increased sales or taking action (Hon and Grunig, 1999; Xavier et al., 2005). As collective intermediaries between groups, institutions and languages, public relations practitioners and units are not only interpersonal mediators. Beyond that, at the societal level, they are historical, institutional and cultural intermediaries. They belong to promotional industries, which help keeping the fragmented and fragile global society stay intact (Aronczyk et al., 2017; Davis, 2013).

The benefit from ANT is that it critically widens the understanding of communication as historical and societal (above and below interpersonal) agency beyond the narrow horizon of interpretative interaction. It focusses on material (action, communication) outcomes instead of symbolic (expressive, hermeneutic) outputs (Umanski, 2019).

ATN and public relations

Only few researchers have adopted ANT in the field of public relations. Somerville (1999) accepts Latour’s theory as an ‘amodern’ meta-theoretical and methodological alternative to the ‘modern’ post-Kantian thinking in organisational theory, which works with oppositions such as ‘subject/object’ and ‘self/others’. In contrast, ATN regards the human subject as simply another actor in a network. The interconnectedness of the heterogeneous elements in a network triggers the process of ‘translation’. The latter means that actors and forces within networks ‘will try to redefine the meaning of other actors, ‘speak’ on their behalf, and enrol (manipulate or force) the other actors into positions with them. When an actor’s strategy is successful, and it has organised other actors for its own benefit it can be said to have translated them’ (p. 41). ATN disputes a whole set of presuppositions within organisational and public relations theories. Its methodological allure is that it has the potential to identify new actors which have previously been ignored in strategic communication scenarios.

Luoma-aho and Paloviita (2010) use ANT it to widen the stakeholder theory to include non-human influences, which may reveal new, unexpected stakeholders into the complex corporate world. Schölzel and Nothhaft (2016) discuss the relevance of the ANT in public relations theory in their case study of the PhD-plagiarism of a German minister and the ‘swarm’ of his anonymous ‘plagiarism hunters’. They appeal for a new understanding of publics as actor-networks. They suggest looking not only into the ‘objective’ facts but rather into the agency of facts – including the artefacts, which often act seemingly disconnected from persons’ intentions. After a two-weeks of controversy, the minister resigned. Decisive, however, were not the established ‘matters of plagiarism’ but the ‘matters of concern’ – that is the dynamic relations between hybrid elements such as the role of the ‘swarm’, the reactions of the minister, the growth of a wiki investigating the case, and so on. The authors conclude that, in lieu with Latour, ‘we need to systematically take into account as PR-scholars [. . .] that the fabrication of facts (or of non-factual claims, alternatively) as facts (i.e. in discourse) very rarely, if ever, can be undertaken by one single actor. It almost always is ‘a collective process’’ (p. 58).

Verhoeven (2018) also calls for the reconceptualization of the public relations practitioners as participants in the construction of actor-networks. If public relations is best defined within in the organisations-publics network, a better understanding of the role of the non-human in forming human alliances would only strengthen the formations for which they work.

The virus as an agent

Of special value here is the paper of Aylesworth-Spink (2017) about the failures of public relations during the swine flu outbreak in Canada. Latour’s theory explains how networks consist of heterogeneous actors – human and nonhuman. What matters is not so much the actors – people, organisations, or objects – but rather their actions and effects. ‘Entities that do things’ were, for example, the government, the media, the parents, the organisations, the virus and the vaccine. Such network relations of ‘doing’ highlight that an actor is ‘any element that bends space around itself, makes other elements dependent upon itself and translates their will into language of its own’ (Callon and Latour, 1981: 286).

In 2009, during the influenza outbreak, the Canadian government took the mass media for granted by assigning them the role of mere messenger for the health authority. It presupposed that the interests of the sender (government) and translator (media) were the in the same direction because most of the population was genuinely concerned about the virus. It replaced the vernacular use of ‘swine flu’ with the scientific label of ‘H1N1’, fetishizing the virus as laboratory-certified and brand-novel external agent in the rhetoric of ‘germ theory’. It pitched measures affecting a simplified interaction between microorganism and host. The human voices assigned to the invisible and silent virus its own social life and somewhat mystical, ghostly features (Aylesworth-Spink, 2017: 6).

What happened in 2009 with the campaign against H1N1 in Canada, partly repeated what had already taken place there in 2003 with the fight against the Severe Acute Respiratory Syndrome (SARS). As soon as the government rallied the media, alliances of interested parties started assembling, fragmenting and realigning. Pursuing their interest, the mass media pushed the moral panic button, overblew the SARS danger, exaggerated the risk, and questioned the competence of the public health authorities to manage the crises. Looking for sources corroborating their stories, they largely employed historians, who delighted in making parallels with pandemic disasters in the past (Feldberg, 2006). In result, the virus not only increased the mistrust in the government but also pushed the myth of dangerous others and sponsored the fear, intolerance and hatred in the society (Muzzatti, 2005). The risk communication exercise went awry, and an unwarranted perception of the high risk of SARS materially impacted on the economy (Smith, 2006).

Back in 2009, the Canadian government visualised H1N1 as an actor with distinctive behaviour to tangibly localise it in the social order and coordinate its siege with other allies. Visualising made the virus remarkable. Its strength only grew as its self-appointed speakers weakened. Instead an object, the microorganism became a mediator with its own agency and autonomy, connecting and realigning various stakeholders. Again, the imagined strength of its movement questioned the management and effectiveness of the vaccination campaign. The media helped the virus and vaccine to mutually adjust their roles. If the vaccine is scientifically tested and effective beyond any doubt, reasoned many users, why do we not wait to see how it goes – and whether people around get sick. If they do, we will immediately get the shot. Thus, not the virus but the vaccine was identified as the greater risk.

Officials weakened themselves as actors when they inserted themselves into the news collection process and undervalued the media’s free will. These leaders saw the media as a natural part of society at their disposal during a needy time. On the contrary, journalists begin from a place of power and expand their size by gathering experts. As the media allied with other actors, this expansion shaped and strengthened the pandemic narrative (Aylesworth-Spink, 2017: 9).

Again, the public health officials failed to recognise that the media were not mere instruments but powerful actors – peculiar translators and independent mediators. And this is the strength of Latour’s ATN. An association is strong when threatening one actor means threatening others or, positively, when benefiting one actor is also benefiting others (Latour, 1987). For that reason, the new association of the government with the media in the Canada’s swine flu campaign grew not stronger but weaker.

The virus and vaccine are network entities, which can act as agents and cause effects. Groups also make representations against them or on behalf of them. Some give the virus and vaccine a voice, and some try to silence them. In October 2020, the former US President Obama ridiculed the complaints of the incumbent President Donald Trump about the media giving the coronavirus crisis, so to say, a higher rating than his efforts to solve it with the famous ‘He’s jealous of Covid’s media coverage’ (Greve et al., 2020). This was not only a good soundbite by an apt metaphor. It was true in a more profound and material way. Trump and the virus were competitors. The strategy of dismissing, silencing the virus – and by analogy of the then still undeveloped vaccine – was inconsequential, even counterproductive. Downplaying its invisible presence was not diminishing but only increasing its real effect.

Natural history of a vaccine-preventable disease

Following Latour, I consider virus and vaccine two agents, which mutually contribute to the creation, composition, and realignment of coalitions of support or resistance. Trough the circumstances they create, they both become prominent through their speakers. Depending on the phase in the natural history of a vaccine-preventable disease, the ‘voice’ of the virus or the ‘voice’ of the vaccine alternately gets upper hand (Chen and Hibbs, 1998; Ołpiński, 2012). At the same time, the other ‘voice’ (which is ascribed, different from material agency) gets silenced.

When analysing a case of immunisation-preventable disease – be it the Canadian or the Australian one in the following pages – the phase of its natural history is important. And the natural history of such disease – as any history – is not foreign to irony. In calm times of relatively healthy communities, the virus loses visibility – it goes, so to say, undercover, and lets the vaccine take centre stage. Vaccine then falls into the trap of the limelight. As cases of infection become rarer, the number of people with first-hand experience of the seriousness of the diseases diminishes. The vaccine becomes victim of its own success (Janko, 2012). ‘When the disease isn’t around’, says Helen Bedford, a children’s health specialist at Great Ormond Street Institute of Child Health, London, ‘half the equation has been removed — all the risk is focused on the vaccine’ (Drew, 2019: 59).

In the phase of relative vaccination success in the natural cycle, the virus still acts – but in stealth. Then people take their time to have a long look at the only visible agent around – the vaccine. Ironically, some start recognising it as the virus – or the remains of it. Some parents – and political agendas can catalyse it from aside – start seeing in it more risks than benefits, more real danger than one from a hypothetical virus. Because of that, fighting a virus during the best phase when health services are closer to its eradication is not easier than in times of crisis. Mandating immunisation at this moment may appear the golden bullet, which can hit all targets. But how to persuade the public in the safety of the vaccine and credibility of its providers, when there is no sense of urgency and everything else in life reminds the people of the inadequacy of the public health services?

Communicative distance

What is the nature of relations between a pro-vaccination government campaign and the various actors – such as parents, media, scientists, health services, citizen groups and political movements – in the strategic alliance? A prominent theory in public relations puts relationships – organisations-publics relationships (OPRs) – front and centre (Ledingham and Brunig, 2001; Ledingham, 2006). Public relations, in that approach, is a management function, which goal is to establish and maintain mutually beneficial relationships between organisations and publics. Five dimensions of those relationship make their strength empirically measurable: trust, openness, involvement, commitment and investment (Ledingham, 2003). An assumption of the theory is that it observes the inter-personal relationships through the prism of the organisation-customers relations. The authors are aware of the methodological problem here, especially when it comes to the identification and measurement of other kinds of relationships such as between the government and its publics, when the values of democracy and citizenship are involved (Ledingham, 2001).

Still, is it possible to understand, for example, government communication as political communication (democracy, competition, activism) and as public health communication (services, citizens as customers with rights)? How about the commodification of government services, including the application of public relations techniques developed in the commercial sector? Where is the place of sceptical or agonist publics? Are, for example, anti-government activists with low trust in the health services or in official science per definition anti-democratic? It becomes obvious that in a democratic society, there is no linear continuum of trust-mistrust, which can meaningfully measure government-publics relations. For example, government mistrust by a public can alone reflect neither the democratic quality of the government nor of the public. Not only in relation to a government, postulating positive relationships as the golden standard between organisations and their publics may be the shortest way to paternalist and authoritarian doctrines (Waymer, 2013). Publics, due to their historical troubles with a government, may desire not to be in any close relationship with it. Greater closeness may only intensify and seal the harm and injustice between two entities unequal in power. Relationship is an exclusive, more personal and, in a way, more unguarded relation. Only more distant relations are inclusive – inclusion, not exclusion defines the democratic public sphere.

(Hess, 2000) introduces the term of ‘communicative distance’ to locate publics, who in non-voluntary relationships are happy not with closeness but with the non-violation of the distance from a power, which they historically do not trust. Waymer (2013) adopts this concept to problematise and further develop the OPRs paradigm in public relations, when he analyses lukewarm and unyielding reactions to the US Government’s official apology, administered by President Clinton, to the African-American survivors of the Tuskegee medical experiment in Alabama. For decades scientists observed untreated syphilis among uneducated Black men, keeping them at the same time unaware of their condition and already available methods to treat it. In his study, Waymer suggest further research about why distance is not more or less social (normal) than closeness, how publics create and regulate distances, and, finally, how public relations should factor in strategies of effective communication without violating such norms of distancing (p. 329).

Notes about the method

This section offers a case study of the MMR and HPV campaign by the Labor government in Australia in 2012 and 2013. I also discuss of the next period of conservative governments (from 2013 to the present), which have introduced more coercive and less communicative means of achieving higher vaccinations coverage. I compare the results and offer some conclusions.

Case studies allow us to draw on previous models and experiences, learn lessons from both success and failure, and articulate solutions that have a broader relevance and may be applied in various situations (Patti, 2003; Yin, 2003). The type of this case is of the limits and potential of government health communication. I critically examine the decisions of the Health Minister, Tanya Plibersek, and her communicators when to act and when not – or, more precisely, when to recourse to stigma and when not to as well as when to act by speaking and when to act by remaining silent.

For this purpose, I did document analysis of government sources. I have also conducted in-depth interviews (Legard et al., 2003) with two communicators who worked for the MMR campaign of the Minister for Health in 2012–2013. Caroline Turnour was then Senior Adviser for Plibersek’s office ¹ . And Paul Perry was her Director of Communications ² . They were not only insiders but also instrumental for that campaign. The interviews gave me valuable knowledge about the planning process, including research, dilemmas, ongoing decision making, objectives, strategies, implementation, and. I will cite them using their initials: C. T. and P. P.

Lack of access or refusal?

In 2012–2013, the communication team of the Australian Labor Minister of Health, Tanya Plibersek, decided to mount an MMR campaign by choosing a path unlike the Canadian one. Indeed, the situation was different from that in Canada. The natural cycle of measles in Australia was in the phase of further stabilisation, not of epidemic crisis. The immunisation rate for five-year old children in the country was satisfactory – 91.5%, albeit with measles still a concern (AIWH, 2014). The immunisation rate had been gradually climbing, but the herd immunity threshold of 95% was still some points away. This was the lull when the virus becomes invisible and the vaccine – its problematic safety, irrefutable risks and mistrusted providers – increasingly attracts public attention as the leading actor to deal with.

There were some pockets in the country, where the share of immunised children was notably lower – even below 70%. Two groups of the population defied the overall uptrend. The first included some Aboriginal communities in Western and South Australia as well as the Northern territories. In general, the Aboriginal and Torres-straight people had an immunisation rate by 5%–6% lower than the average of the population. In general, the causes for that were no different than those for the worse health situation and life expectancy of the Aboriginal people in Australia. The leading negative factor is access to health with both demand and supply issues.

The second group had a very dissimilar profile. It is safe to say that those are affluential, white and well (although not the highest) educated people with libertarian and anti-authoritarian views. In Australia they are rather on the left than on the right, but otherwise, they are of various political hues. Religious beliefs also were a certain, although not dominant factor (Trentini et al., 2019; Ward et al., 2012). Statistical areas with lowest immunisation rates were, for example, Inner Sydney (NSW), North Sydney-Mossman (NSW) and the hinterland of the Sunshine Coast (Queensland). But the most striking low (between 66% and 70%) was registered in the area of Richmond Valley-Costal (NSW). Those are the communities around the famous – or notorious – Byron Bay, where old hippy and new age sub-cultures mix with ‘sea-change’ and well-to-do intellectuals. They include postcodes such as Broken Head and Byron Bay (2481), Brunswick Heads and Ocean Shores (2483), and seventeen others around them (NHPA, 2014).

It is plausible to speculate that for the first group – for some but not all Aboriginal communities in Australia – access to vaccine as an element of access to public health was the main, albeit not only reason for not vaccinating their children. And it is also safe to say that the second group of well-off libertarians produced a disproportionally larger minority of active refusers, although its majority still consisted of vaccine-confidant and vaccine-hesitant parents.

Code appropriation

The Australian Vaccination-risks Network Inc. (AVN), previously known as The Australian Vaccine-sceptics Network Inc., the most organised anti-vaccination pressure group, has its headquarters in the same NSW area – in Bangalow, a few kilometres from Byron Bay. The online group was established in 1994 by an American, Meryl Dorey, who moved to Australia and had claimed that her son, when he was a child, was badly affected by DPT (diphtheria, pertussis and tetanus) and MMR (Vines and Faunce, 2012). The strength of the network, depending on who counts, has been between 2000 and 3500 members (Hansen, 2014; Watt, 2009). The group has been heavily criticised by doctors, experts and health authorities as ‘misleading, inaccurate and deceptive’ (Health Care Complaints Commission (HCCC), 2010). All former governments and most civil society organisations in Australia had called for zero tolerance against AVN. There had been various actions against it – from a petition to deport Meryl Dorey (Change.org, 2013) to a government decision to strip AVN from its charitable status – that is, to ban the organisation to raise funds (Stewart, 2010). Such jolts do not seem to have decreased the otherwise limited influence of the group. Administering stigma is often a step too far.

A string of events is also noteworthy. In 2012, the NSW Office of Fair Trading ordered the pressure group to change their name or de-register (Burns, 2012). AVN then made such name change two times. In 2014, it first scrapped from its name ‘-sceptics,’ which had so much affronted the government. And in 2018, it settled on ‘Vaccination-risks’ instead. AVN declared that it had not been comfortable with the world ‘sceptics’ anyway because it was associating it too close with the Australian Sceptics – an unrelated group, which represents the international chain of Scientific Scepticism. As many other anti-vaccination groups, AVN positions itself not as anti-science. On the contrary, it insists that it is closer to science than those who mindlessly let their children immunise. Thus, its mission is to scrutinise sloppy laboratory methods and standards, vested bio-technological and multi-national interests, and corrupt health authorities, who align in a powerful cabal that compromises the safety of vaccines (Tasha, 2018). In other words, the legislatively enforced rechristening of the organisation made its mark even sharper and more persuasive. AVN managed to appropriate the cultural code of the government (Merry, 1998; Rao and Giorgi, 2006) and use it back its own argument against its vaccination logic and policies.

‘Apolitical’ politics

Each phase in the natural cycle requires different communication strategies. In 2012–2013, the challenge before Minister Tanya Plibersek was – also with a view to the Canadian experience – about how to walk the tightrope between persuading more hesitant parents in the safety of MMR and, at the same time, not to overblow its power – not to push them towards the refusers. In contrast to Canada, there was no illusion around the tabloid and mostly right-wing media as a mouthpiece of government communication. The media is always after conflict – possibly with the government. The opposition is always after conflict – necessarily with the government. Now, how to involve diverging political and commercial interests without alienating pivotal actors? And how not to take the bait of sought adversity – how not to embolden the dissenting groups with a disproportionately strong response?

The Department’s silent mantra was: ‘We are not going to be in conflict with you’ (C.T.). Prioritising health was the right choice to tame the conservative opposition, which main concern had been the fight the government’s policy of Emission trading scheme, which it dubbed ‘carbon tax’ – an ideological label that tainted the carbon emissions trade as a hidden tax. ‘Carbon tax’ was a confrontational – and successful, as it proved later – discursive strategy, which used the neoliberal presupposition of ‘tax is bad’ against an otherwise sound real-policy (Dimitrov, 2014). Pro-vaccination, however, enjoyed a bi-partisan support, which let the opposition no other choice but to silently align with the government. Here Labor momentarily won with the apparent more consensual and ‘apolitical’ positioning in ‘health’ – although health and vaccine are, of course, political trough and trough ³ (Blume, 2006; Epstein, 1995; Hobson-West, 2007).

At this phase of the natural history of the virus – especially of measles – the media were not going to make much trouble either. Because vaccination was a shared value in the Australian political public sphere, the legacy media were rather tempted to criticise the failure of the government to vaccinate rather than the campaign itself. Even influential digital media, such as MamaMia (www.mamamia.com.au), which feeds on informed cultural gossip and conflict, would question Minister Plibersek whether she had not missed to immunise her own children rather than directly attack her policy (Plibresek, 2012). For a scoop one would assail the government for double standards rather than bad faith. And the antivaccination pages such as those of the AVN, had a limited, albeit ardent fellowship.

A dog whistler by proxy

Another move by the government was to distribute to the media internal information about the vaccination inequalities between the statistical geographic areas in Australia. For that purpose, the Minister asked the National Health Performance Authority, which collects the vaccination statistics, to add to its bi-annual report all local information, including of the smallest areas – the postal codes. The artful design of the report, usually a bland administrative sheet, was also a lucky strike. Clear and colourful figures allowed a layperson to look for certain geographic places, compare them and see the picture as a whole – including, the ‘winners’ un blue and the ‘losers’ in red (NHPA, 2012). The government sent it to the news outlets even before officially publishing it. The media liked it; the contrasts between the post codes stroke a cord with them. The shared facts were newsworthy. What is more, they allowed chasing moral narratives – from sensitive to scandalous, depending on who the pundit was.

The Daily Telegraph of Murdoch’s News Limited Ltd. is the largest newspaper circulation in Australia. It got not only involved but it also wanted to run a campaign about it. On one hand, it did not sympathise with the Labor government – only a year later it would lead the most vicious election campaign against it (Dimitrov, 2014). On the other, it had recognised that campaigning on a value shared by almost all Australians would increase its sale. There was an ideological reason as well. The tabloid saw the Byron Bay type of people as ‘elitist lefties’ – which, of course, is a violent simplification of the local demographics – who were the perfect enemy, against which it could energise its populist and rather conservative base. It started a campaign, called ‘No Jab, No Play’, which required a ban of unvaccinated children from childcare centres and withdrawing childcare rebates and family benefits from their parents (Hansen, 2013; Leask and Willaby, 2013). Other media followed suit, although in a less agitated, finger-pointing manner.

Plibersek watched the development with mixed feeling. She was happy with the value of vaccination as the frame of the media campaign. But she did not agree with the #NoJabNoPlay demands and shrill, aggressive tone of the Daily Telegraph. The strong value element was tempting. Politicians prefer to campaign on values shared by everyone. The value of community safety and herd immunity were such strong values. But values are not policies. Her communication team were watching and thinking:

The Daily Telegraph were very much onto values. . .The vast majority of Australians would hold the same values. It is a great campaign to run if you are to sell news, to engage readers and to create moral outrage. But it’s not actually a great campaign to run if you want to increase vaccination rates. By being morally outraged you’re actually inflaming and giving oxygen to a group whose profile you don’t want to increase (C.T.) So they’re talking to their base but, giving greater attention to that issue, they’re actually advantaging the people they don’t agree with. That is the moral conundrum. (P.P.).

Advertising the vaccination campaign, the government stayed in the background and let the media step forward and exploit the pros and contras of the value debate. The bully pulpit was not the business of the executive. Daily Telegraph, however, had taken this position. The government, however, needed to stay focused on what it could do best, which in many ways is also what no one else could do. It needed to carry on its less visible but closer to parents policies and measures. What were they like?

We want to encourage people to be vaccinated and we will do as many public policy things as we can to get all those people who are not vaccinated just because they are too busy, or they haven’t had the opportunity to get to the doctor, encourage them to do that, but not, you know, demonise people which was what Daily Telegraph was trying to do. . .It would have been very easy to jump on [its] campaign, but that is not the role of the Health Minister. The Minister’s role and leadership is to promote best policies and promote the best considered debate (C.T.)

As long as a broad alliance of media and agencies, led by Daily Telegraph, was after the Byron Bay vaccine refusers, the government was left, so to say, ‘off the hook’. This helped it concentrate on its work on the ground.

Silence as not engaging the antivaxxers

The Health Minister evaluated the anti-vaccination activists as relatively week and wanted to see them staying so. He who targets is also targeted. Nowadays, one targets many, and many target one. Nowadays, strategies are not primal but responses to other strategies. Agendas try to highjack agendas. Thus, even more often silence is the right response to voice. Strategic silence is the answer to being strategically targeted, especially when this would strengthen someone else’s agenda and weaken your agenda (Dimitrov, 2018: 163–170).

Thus, the psychology of government communication:

You don’t want to be talking to the community action group down the road, because whoever you’re talking to, you’re going to be essentially brought down or brought up to their level. That is part of the decision who you engage with in an debate, and also whether people are pushing an agenda that you don’t want to be pushed and they don’t have enough currency in the current media world or they’re not getting enough of attention. If you are a serious player and you engage with them, you raise them up. So why would you want to raise up someone who does not agree with your position? That is a strategic question that doesn’t necessarily have to have a moral component. It is just about a strategic decision what our agenda is. We are pushing our agenda and we don’t want your agenda cutting us out’ (C.T.).

Not to give them the conflict, the government preferred strategic silence. Silence as the opposite of engagement with the anti-vaccination activists – neither acting as Daily Telegraph ‘who run against those guys and painted them in the most radical sort of way’ nor by giving them a place at the table, where ‘the more you give voice to the small minority, the more they will actually influence and take people from the majority’ (P.P.).

HPV for boys – how much above the line?

The introduction of the vaccine against human papilloma virus (HPV) for boys was another interesting subcase of the campaign. Previously, only girls were vaccinated because the main possible harm from HPV – otherwise a relative harmless sexually transmitted disease – was warts that may lead to cervical cancer in women. Hence girls had been its main beneficiary. But there were two main reasons to put it also to boys. First, in a limited number of cases of HPV boys may get anal and throat cancer if they have anal sex in the future. And second, girls would indirectly become even greater beneficiaries, because they would not get the disease from immunised boys (Stanley, 2014).

The big question was how to sell it to parents of boys who get vaccinated before they are sexually mature. How to persuade parents who have never entertained the possibility of their boys having anal sex in the future? There was an intensive internal debate in the Department of Health with strong and conflicting opinions about the message and media strategies. Which message would tell it all without saying much? Which medium would give it the right format and tone? How to custom tailor the messages for various groups of parents? For example, how much money to spend to advertise above the line, so that everyone can appreciate the universal benefits of HPV for both genders? How much detail to leave to the GPs and health workers for their more personal or confidential conversations with parents? What should be done first – setting up a favourable public opinion or getting the process to work through school nurses and public health units? It was a stark dilemma:

‘And we can either promote the benefits to a small proportion of boys who will potentially go on to practice anal sex or we were sort of saying, let’s promote it as universal because of the [scope of] community we were talking to’ (C.T.). The term we [finally] used was ‘Cancers that boys can get’. The view of the Department was that we did not need a multi-million advertising campaign, that we could remain silent and let out some parts of the debate. We launched it. Tanya did a press conference, and we got good national media. We used the systems that are in place just to get it out there so that we just could get on with it’ (P.P.) ‘Indeed it was almost universally accepted. It was also Ian Fraser, the clinician who initially developed the original vaccine. We were saying that it was an Australian success story. And it was framed by the media as equity – finally boys had access to the vaccine’ (C.T.)

Discursive silence

The Australian Department of Health had also contributed to the battle of languages.

One of the things the minister was very keen on was that in the past these people who refused to have their children vaccinated were called ‘conscientious objectors’. And we changed the name to ‘vaccine refusers’ in all Government documents because the Minister was very clear that she didn’t want to be about a conscientious sort of moral decision but just about ‘refusing’ (C.T.)

Indeed, ‘conscientious objectors’ has gained currency since the very beginning of the anti-vaccination protests. Even since Edward Jenner had success in preventing smallpox, coined the word ‘vaccine’ and promoted the first vaccination campaign in 1796, anti-vaccination movements emerged in the UK, waxing and wining but never disappearing. And one of the first arguments against vaccine was the libertarian one, which today is as often used as in the past – the argument against the ‘infringement on traditional civil liberties’ in the name of public health. Vaccination acts from 1840 and 1853 in the UK made vaccination compulsory. But in 1898, due to the pressure of the Antivaccination League, the vaccination law was amended to allow parents to reject vaccination, based on conscience (Wolfe and Sharp, 2002). That way ‘conscientious objectors’ was codified and legislated. Other complaints against the vaccines have varied from conspiracy theories and dictatorship accusations to more complex spiritual and philosophical convictions – from libertinism and environment, to holism and religion. In leu with the British tradition, the Australian law had contained the ‘conscientious objectors’ exception until the fall of Labor government. In 2015, the conservative government of Malcolm Turnbull introduced the ‘No Jab, No Pay’ clause, which has brought the campaign of Murdoch’s Daily Telegraph to a successful end (Yang and Studdert, 2017). Another irony of history: it took a liberal government to take out a liberal amendment ⁴ .

What were the reasons for Labor changing ‘conscientious objectors’ to ‘vaccine refusers’? They were in the in the knowledge of discourse as strategic resource (Fairclough, 1992; Hardy et al., 2000). First, as the Minister wanted, ‘vaccine refusers’ removed the moral element from ‘conscientious objectors’. The stigma of ‘conscientious objectors’ has faded over time, including for the Labor supporters. Although coined in the British liberal tradition of the 19^th century, history has partly altered its meaning. Especially since the Vietnam War and the social movements in the 70s and 80s, the phrase has gained a pacifist, human rights and, yes, somewhat leftish accent.

‘Vaccine refusers’ was closer to personal traits, which can be easily stigmatised. It was an ideologic move by the Minister to de-ideologize its meaning – to redress it from left and moral to neutral and physical. Physical, because ‘refuser’ neutralises a moral intent and transforms it into an internalised and constant attribute – ‘refusers’ always refuse, no matter what. The word frames them as stubborn, obstinate, nihilist – with no rhyme or reason. What is wrong is the person, not the situation. He refuses by default; today it happens to be vaccination, tomorrow – something else. I do not even exclude an allusion of ‘refuser’ to another kindred noun, ‘refuse’, which synonyms are ‘debris’, ‘rubbish’, ‘trash’, ‘waste’ and ‘dregs’.

Curiously, the conservative government after Labor quickly restored ‘conscientious objectors’ – also working with the states to remove the legal exception altogether (Beard et al., 2017). I see two opposite reasons for that. On the one hand, as conservative and mostly monarchist, the Turnbull (after him Tony Abbott) Government wanted to cancel the Labor legacy and preserve the colonial British tradition, including such archaic codes. On the other, they were happy with the new leftish – negative for them – sound of the word; the louder the better. Ideology is contrapuntal – not logical.

The social media gap

A missing link in the communication of the Labor and successive conservative governments in Australia was the lack of an unit with social media specialists who would employ popular platforms such as YouTube, Facebook and Twitter for the purposes of their pro-vaccination policies. From the interviews, I know more about the reasons in the Labor campaign. In short, they were based on the belief that government is not a good social media influencer. Apart from a few tweets raising the profile of the Health Minister, the communicators regarded the social media useless for their goals. First, the Health Ministry lacked those resources at that time. Second, and more importantly for the campaigners, the mainstream media such as national radio and TV stations still looked enormous. The social media were brushed aside as a small proportion of the mediascape. The official view was that they facilitated elitist bubbles, which were not transforming but only reinforcing the same opinions and prejudices – ‘Can you believe these people are saying this?’ – in closed circles of people talking only to each other. In that regard, the Minister and her communicators were critical of the Press Gallery in Canberra, which was paying too much attention to the social media.

I mean it can be skewed though because if all you do is listen to people, trolls and other people on social media, then you would get a skewed idea of what the public actually believes because it’s only a small majority of the people who are engaging in that commentary, whereas the vast majority of people may have a different point of view, so you have to be very careful if you are monitoring and listening to what’s going on in social media to actually recognise that there might be a silent majority who are not speaking. (C.T.)

Minister Plibresek was more comfortable with the format of the legacy media but not of the social media, where instead of journalists with polite questions, everyone and from everywhere could troll her for whatever reason. Like tabloids, social media were regarded as exaggerating and polarising tools per definition. They seemed prone to negative campaigning, especially against a mistrusted government. For example, the social media were considered a natural domain for antivaxxers. Technology was confused with attitude. There was no way of establishing a balance and reasonable dialogue between pro-vaccination campaigners and antivaxx activists when the social media was considered a haven of freedom and resistance, unyielding to government censorship. Such views made the strategy of tackling the vaccine refusers indirectly – by proxies in the media and by experts in communication with parents – even more plausible.

‘No jab, no play’ and ‘no jab, no pay’

Since 2013 until present (2020), Australia has had three consecutive conservative governments. From January 2016, responding to the Murdoch’s News Limited campaign, the Australian federation started withdrawing three government payments for families with unvaccinated children – the Child Care Benefit, the Child Care Rebate and (from 2018) the Family Tax Benefit Part A – implementing its ‘No Jab, No Pay’ legislation. In 2017, a couple of states – education in Australia is state-based – also mandated the ‘No Jab, No Play’ policy. Unvaccinated children were banned from pre-school (kindergarten) admission (Finnegan, 2017). Those legislations had instantly increased the number of vaccinated children by a small quantity. It did, however, not caused a bigger change in the long run.

From 2007 to 2015 – a period both of conservative and Labor governments – the immunisation rate of the five-year olds in Australia increased from 79.4% (Bogle, 2019) to 92.2% ⁵ (NHPA, 2016) – that is by whooping 13.8% or, in average, by 2% per year. After the new conservative government of Turnbull introduced mandatory vaccination, the immunisation rate increased from 92.2% in 2015 to 93.5% in 2017 (AIHW, 2018), or by 0.65% per year. The trend had gone up but not much.

The most recent study by the National Centre for Immunisation Research and Surveillance and the University of Sydney analysed the catch-up vaccinations of children (Davey, 2020). Children receive the MMR vaccinated twice – first at the age of two and three and, then (the second dose of the catch-up), when they are aged five to under seven. The researchers examined baseline data from the years before the ‘No Jab, No Pay’ policy was introduced. Then they compared it with data from the same age group during the first two years of the policy to December 2017, including data from children aged seven to under 10 and young people aged 10 to under 20.

The findings were mixed. The proportion of children aged five to less than seven years who received catch-up MMR vaccine in fact decreased from 13.6% before the legislation to 12.9% after it was introduced. Yet 17.6% of the group of the incompletely vaccinated adolescents aged 10 to less than 20 years received catch-up MMR during the first two years of the new legislation. This increased the overall coverage for this age group from 86.6% to 89.0%. The finding in this age group also show that mandating economic pressure on families has had greater effect ‘in the lowest socioeconomic status areas than in the highest socioeconomic status areas (29.1% vs 7.6%), and also for Indigenous than for non-Indigenous Australians (35.8% vs 17.1%)’.

In other words, the monetary sanctions managed to promote some catch-up vaccination, but mostly among the socially disadvantaged. Those groups, though, are characteristically not vaccine refusers. More likely, they have issues of access or language barriers. Withholding family and childcare tax benefits would affects them even more. As the director of the research centre, Frank Beard, stated, ‘It was always thought by experts that the policy might have little impact on vaccine refusers. This study certainly provides evidence to support that’.

But how about the vaccine hesitant parents, the group of major concern in this paper? Julie Leask, from the University of Sydney – the most prominent scholar on vaccination policies in Australia – confirms that what was seen here – as well as previously in other cases – is that the policy simply served as a prompt for people already happy to vaccinate their children but did not work on those who actively rejected vaccines. ‘That caused people to dig down more, and we saw that coming through in this study with parents continuing not to vaccinate despite the policy, and in fact it suggests some who were on the fence said, ‘That’s it, if they force me I won’t do it at all’’ (Davey, 2020).

Alignments of interests rather than knowledge

Governments are under pressure to reverse the downtrends in MMR vaccine coverage and increase the number of immunised children. This task is not unpolitical but rather meta-political. In accord with the Latour’s ANT, the success of a government campaign depends not on how much power the government has, but on the serial performances by the members of the diverse – and sometimes unlikely – network, which is supposed – but not guaranteed – to back the campaign. It all depends on the interests of each link in the chain and on its ability to translate its own project as ‘the picture as a whole’. The chain is made of active actors, not passive patients. The network transforms rather than transmits the ‘token’ passed by the government. No one has power in principle, not even the government, which tries to rally a pliable coalition; power emerges as consequence in practice. Success depends on momentary performative alignments of interests rather than knowledge (Latour, 1984).

Both the Labour government and successive conservative governments were democratic ones; no one wanted to force vaccination on everyone. In Australia, there is a general constitutional and human rights consensus on that issue. When in 2020 the PM Scot Morrison was caught in saying that he would expect that the still undeveloped Covid-19 vaccine ‘to be as mandatory as you can possibly make’, there was a strong backlash by concerned leading experts on vaccine hesitancy and refusal. They feared that such a discussion was dangerous and could drive some Australians away, given the vaccine was not yet proven effective and safe. This link in the chain fired warning shots. Morrison quickly walked his comments on potential coronavirus vaccine back. ‘It is not going to be compulsory to have the vaccine, OK? It’s not compulsory. There are no compulsory vaccines in Australia’ (Knaus, 2020). It was the swift performance and translation of the interests of expert groups such as doctors and scientists – not of the government – which the PM embraced to correct his message and reformulate his agenda.

Labor did not mandate economic sanctions because it did not need new research to figure that they would punish part of its constituency. The conservative government did not have such concerns. It campaigned and legislated on broadly shared values, which prioritised law an order for the middle class to economic (family benefits) and cultural (access to school) punishment for the socially weak. The group, which would really suffer – the socially disadvantaged – were not their staple constituency. With the other one, the affluent refusers – but also fence sitters – monetary sanctions did not work. They only provoked their stronger resistance against the conservative policy. But the conservatives – like The Daily Telegraph – did not mind or were even happy to have the ‘conscientious objectors’ as their public enemy, because this only galvanised their base.

Indirect communication

The Labour media campaign respected the communicative distance between government and vaccine hesitant parents – in contrast to its refusal to communicate with the vaccine refusers. (Its problem was to figure the borderline between both groups.) The strategy of distance was implemented through various tactics. Such was letting the public shaming to the Murdoch’s press as a proxy dog whistler. Others did the stigmatising; the government pulled back as an invisible sponsor. This was by the Latour’s book: ‘When you simply have power – in potential – nothing happens and you are powerless; when you exert power – in actu – others are performing the action and not you’ (Latour, 1984: 264–265). Lack of dialogue in the media, however, is always a risk. Not engaging with the vaccine refusers – especially in the social media – ultimately means ignoring, not addressing the concerns and critique of many parents who still sit on the fence.

A further tactic was the ‘unpolitical’ argument of broadly scheduled personal meetings between parents and medical experts. The political opposition was also ‘tamed’ by the emphasis on the ‘unpolitical’ narrative of public health. This was tactical for both sides. The real reason, however, was that in matters of vaccination there was such a large alignment of group interesses that bi-partisan support was a forgone conclusion. The culprits – the antivaxxers and their publics – were singled out and extracted out of politics, out of science and out of the public health services. This translation was incorrect but served well the temporary interests of the government.

Another tactic was that Labour preserved the policy that the conservative governments would later remove – the rejector’s exemption, which requires from parents to have a signed note from their doctor or nurse (Davey, 2020). As long as this right and procedure still existed, there was an important avenue for health care providers to engage with those who refused vaccine. The exception offered an opportunity for some vaccine hesitant parents to move back closer to the vaccine confident parents. The ‘No Jab, No Pay’ and ‘No Jab, No Lay’ policies, on the contrary, caused anger among many fence sitters towards having their choices removed. They rather moved some vaccine hesitant parents closer to the vaccine refusers.

Health workers as influencers

Portraying antivaxx activists as organised opponents – as ideological and political movements – may be tempting and convenient because it ‘unites public health professionals under a banner of reasons’ (Blume, 2006: 628). It may also mobilise potential partners. It may divert attention from disruptive critique of problematic vaccination practices. But it could also assign more symbolic power and visibility to an otherwise unremarkable opponent. It could legitimise it by a disproportionate ‘due response’. In short, it could have opposite effects.

Health workers – experts, doctors and nurses – build entity in the pro-vaccination alliance, which collaboration governments in Australia have taken for granted. The common cultural code of belief in science aligns them with scholars, but also partly with the vaccine hesitant parents. To recollect again – 48% of the Europeans, for example, believe that vaccines are not entirely safe (Jennings, 2019a). The Australian governments knew how they could use them offline. ‘Getting the process going’ is less dramatic than media scare and imposed mandate. Small practical improvements could earn big results. Flexible services, for example, that make appointments easier may significantly increase the immunization uptake. Simply sending reminders – especially for the second MMR jab, when parents tend not to have as much contact with health workers, is one of the best-proven strategies (Drew, 2019).

The professional argument of the health workers, however, has been more nuanced and complex than that of the government. Research shows that in most European countries a significant share of doctors does not believe in the safety of MMR. For example, in the Czech Republic only two-thirds and in Slovakia three-quarters of doctors say the measles vaccine is safe. Research also finds that parents have more trust in health visitors (trained nurses who visit home very young children or chronically ill people) than family doctors who are more distant providers. Yet research also cautions that home visitors are more sceptical about the vaccine safety than the GPs (Brownlie and Howson, 2006; Poltorak et al., 2005). Another complication is that austerity measures in many well-off countries have reduced the number of health visitors over the last decade (Jennings, 2019b).

Medical experts, but especially doctors and nurses, feel constrained in the double bind of vertical government communication and hierarchical discipline of their self-protecting professional guilds (Tomeny et al., 2017). Reputation, licence, insurance, membership, job security and good pay come into play. Parents trust the medics selectively, differentiating between personal-professional and role-institutional relations. The health workers know that and, often, to bargain trust, they give an undefined or ambiguous advice. Intuitively, they probably do the right thing. Not scaring or pushing parents is very important. A too strong message like mandating MMR can trigger the opposite results (Dubé et al., 2015; Nyhan et al., 2014). This explains why so few of them have taken the path of digital content producers. Because, if they speak out frankly, they may be misinterpreted and stigmatised by the state and their own guild as fence sitters, if not antivaxxers. Doctors and nurses may have the highest authority and impact to vaccine hesitant parents in interpersonal, offline settings. But their online influence on those parents remains negligible (Tafuri et al., 2014; Zimmerman et al., 2005).

Online presence of doctors and nurses

What could be done for the alignment of parents and health providers online? It is about new skills but also new incentives. Medical students in Sweden, for example, have only 40 minutes training in vaccination and immunology (Jennings, 2019b). And established professionals are seldom prepared to discuss with parents’ current vaccine concerns, including rumours and insinuations in the social media (Kata, 2010; Odone et al., 2015; Tafuri et al., 2014). To be informed, they do not need to be active bloggers. Any Department of Health can easily organise routine social listening of the media and a regular newsletter that keeps the GPs and health workers abreast of what medical Internet keywords and hot topics dominate the parents’ search right now. Such reports do not even need to debunk myths and suggest answers. It would be enough to remove the surprise and a plus to fact-check the claims and explain the interests behind wrong assertations. ‘The practice of medicine is increasingly a branch of informatics’ (Peters, 2015: 3). Medical competence is no longer possible without a transborder system of communication – from personal cards to immunisation registries – something the EU has not built yet (Wheaton, 2019).

But before all, and lieu with the ANT, governments must recognise the interests of the health workers, which agency is blocked online. They cannot meet parents where they spent most of their time for information. For example, health workers and doctors need training in horizontal communication, which is different from the paternalist agent-patient model in their practice (Dubé et al., 2015). Recent research has found that there is nothing wrong with more firm, presumptive discussion styles by health supervision visitors, which can be more effective in improving vaccine acceptance (Opel et al., 2013). In person, they can be more assertive, even blunt with their clients. In contrast, the online audiences consist mostly of searching and interactive strangers. To influence them, one needs to spend time and effort – one needs to engage through dialogue and conversation. And this is something extra – something for which health workers are neither asked for nor paid in their current occupation.

The problem is not that the pro-vaccination bloggers are weaker or less represented in the social media. In Australia, there are vigorous pro-vaccination Facebook and Twitter pages such as Refutations to the anti-vaccine memes (@RtAVM), which have many followers and produce memes that go viral. The problem is that they mostly close a vicious cycle of ‘us versus them’, of mirroring techniques of ‘mockers and stalkers’ that are often ‘highly combative, using personal and identity-based insults’ (Green, 2017). Although such pages work as rallying cries for many pro-vaccination parents, they lack the empathy and culture of deliberative reasoning (Madden et al., 2012). In such sparing between antivaxxers and pro-vaccination activists, the vaccine hesitant parents are often lost.

Institutionally tolerated, supported and trained workers can fill that gap of calm, informative and argumentative discussion of the risks and benefits of vaccination. They may be stimulated to construct websites that tap into the well-developed resources of the WHO Vaccine Safety Net and become one of its influential members (WHO, 2020). Health departments may also use the experience of the foreign affairs departments in public diplomacy (Ross, 2002; Signitzer and Coombs, 1992)? As with the diplomats, why not make the careers of health specialists – their promotion and extra income – contingent on their online presence measured by traffic and engagement with parents?

Why do they not tender Internet social enterprises to do pro-vaccination education, for which government – for reasons discussed above – is not good at? One possible model is that of social benefit bonds – known also as impact bonds (SVA, 2019), successfully experimented by the New South Wales government in areas such as foster care and prisoner recidivism. Businesses are invited to invest and fund non-profit organisations, who are more efficient than the government as social and educational service providers? The saved money is paid back as dividends to the businesses, which hold the bonds. In the current – and perhaps staying for long time – situation of low, even negative interest rates, businesses in NSW managed to cash in up to 7% per year interest from that initiative (NSW Government, 2019).

Concerns of parents

It is time to ask the question about parents as agents. Is the desired transition of some from vaccine hesitancy to vaccine confidence purely an effect of representations by other actors such as government, media, health workers and scientists to them? Is their role so passive – only to listen and choose? Or do parental groups deal with the virus and vaccine in a more independent and pro-active way, fully capable of finding and selecting the information they need? Some hypothetical assumptions are possible.

An advantage of the Labour’s government policy was that it managed to separate the fence sitters from the antivaxxers and not to aggravate (politicise) them by ascribing to the former the ideological motives of the latter. As research in other countries confirms, the project of the vaccine hesitant parents – fragmented and contradictive as it was – was advancing individual and rather consumer concerns about the statistical risks of the health services. The antivaxxers were a minority of activists. There was no significant political or ideological movement of vaccine refusers in Australia. Krijnen (2004) observes it in a similar context,

. . . contrary to popular and scientific presumptions, a (selectively) anti-immunisation stance is not based on previously held beliefs or ideologies, but is moulded by and shaped through personal experience, observations of side effects (whether first-hand or second-hand), negative advice, a personal interest in the subject, and the motivation to read the available literature.

Labour’s government was right to be anxious not to politicise vaccine hesitant parents by accusing them of being a political movement. This was obvious in the discursive shift form ‘conscientious objectors’ to ‘vaccine refusers’. Labour wanted to reframe the motives of the most active of the vaccine hesitant parents as individual, obstinate or metaphysical instead of ideological, political or moral. One of the reasons of the Health Minister’s not to talk to the activists was not to endorse them negatively – not to elevate them to the level of political equals – of influencers versus influencers, of movement versus movement.

Yet no government in Australia was ready to accept vaccination as health service, in which there are transactions between equals – administrators reformed as providers and patients empowered as clients. Especially after the social movements in the 70ies and 80ies – a libertarian and anti-authoritarian culture of individual rights has permeated Western societies.

Its effects on the health services are chequered. For example, there are still doctors in the USA, who refuse to serve parents who do not vaccinate their children – with the blessing of the American Association of Pediatrics (Haelle, 2016). Such attitudes are out of sync with the public health standards not only for purely human reasons but also because those parents are also, to a degree, clients of the public health services with their rights of informed choice and individualised provision (Evans et al., 2001). And those rights are in apparent clash with the practice described above.

Common code of science as a chance

The participation of the citizens in the construction of science – in how scientific democratic governance and how democratic the science should be (Davies and Horst, 2016; Woolley et al., 2016) – was not a topic in the government communication about vaccination. When, for example, the Australian Department of Health excluded the anti-vaccination activists from any form of dialogue in public, it applied an extreme version of the Enlightenment model of governance. The argumentation of that model is based on the following presumption. Activists are laypeople, not scientists – although a third of the members of AVN were medical professionals (Hansen, 2014). There is no laypeople science, including no laypeople biomedicine, which innovates public health with new vaccines.

According to the Enlightenment model, the only scientific citizens are the scientists themselves. As Latour argues, such argumentation reveals a historical process, in which the grip of the government on science has grown stronger and the grip of society on science has grown weaker. In Europe – but also in Australia – this is associated with the raise of the national state ⁶ (Latour, 2012: 258). It also determines the direction of communication: While government communicates with the citizens directly, science communicates with them indirectly – including through the government. And vice versa: the state speaks for the public to science (Shapin, 1990: 1004). This is a model of communication, in which government is the exclusive mediator that represents science to publics and publics to science. One voice linking two silences.

Contrary to the Minister Plibersek’s conviction that science gets health out of politics, historical evidence speaks against this hypothesis such as in the cases of chlorin, thalidomide or asbestos (Blume, 2006: 638). State-sponsored forays of science into society, campaigns such as that of MMR do not put an end to politics. Science – applied and escalated – only enlarges politics further (Latour, 1988).

There are common values, common cultural codes, which can be used as a frame of more deliberative approaches towards, what Hobson-West (2007) calls, vaccine critical groups, which construct vaccine risk as unknown and non-random:

Vaccine Critical groups may well represent a challenge to vaccination policy but express conformity with, and provide an articulation of, broader cultural attitudes. This line of argument is, I suggest, more fruitful for research than attempting to offer further consideration or clarification of supposed differences between lay and expert understandings of risk (p. 211).

Because both pro-vaccination and antivaxx campaigners had appropriated the same cultural code – the discourse of science, the Australia governments were framing the debate based on the Enlightenment model. Highlighted was not who was for and against science (truthfulness) but rather about who was representing science and who not (legitimacy). This was excluding a large group of parents, who were actively reading and trying to come to terms with the risks and side effects of the vaccine. For example, laypeople activists on both sides were broadly using the scientific rhetoric and, at the same time, questioning and criticising certain scientific luminaries and organisations (Johnson et al., 2020). All Australian governments in the last decade either did not see that paradox or pretended not to see it, sticking to the privilege of (almost) solely representing scientific expertise.