The 5 Stages of Anti-Vax Angst: A guide

Last week the Biden administration was criticized for making some harsh statements about those who refuse to be vaccinated. “For the unvaccinated, we are looking at a winter of severe illness and death — for themselves, their families and the hospitals they'll soon overwhelm. But there's good news: If you're vaccinated and you have your booster shot, you're protected from severe illness and death,” said Biden.

That statement came in for much criticism on social media, especially by those who took the statement out of context. “You’re not going to convince anyone to get vaccinated with such harsh language,” some scientists complained.

Well, true. But as someone who’s been fighting the anti-vaxxers for years, I recognized the Biden team’s statements as Stage 3 of what I’m calling the Five Stages of Anti-Vax Angst. I understand their frustration, because I’ve been there myself. Let’s go through these stages, shall we?

Stage 1: Disbelief. I first encountered the anti-vax movement, in the early 2000s, when I was leading a research project on sequencing the flu virus (here’s one of our papers), and a reporter asked me, quite seriously, if the flu vaccine could cause autism. Huh? I thought. “Well no,” I reassured him, “where’d you get that idea?” I soon traced the source of his concern back to a now-notorious Lancet paper by Andrew Wakefield, which turned out to be fraudulent and was eventually retracted.

Surely, I thought, the solution is simply to educate people better, and to explain that vaccines are the single greatest medical advance in the history of medicine. With better education, the anti-vax movement will quickly fade.

In Stage 1, vaccine advocates simply can’t believe that significant numbers of people believe stuff about vaccines that simply isn’t true. Alas, though, they do.

Stage 2: Frustration. Unfortunately, merely writing articles explaining the benefits of vaccines is not nearly enough. Officialdom (government agencies like the CDC and NIH) constantly issues statements about the benefits and safety of vaccines, such as this CDC website. Scientists and physicians have written hundreds of articles and countless books explaining how beneficial vaccines are, to no avail. For example, renowned vaccine expert Paul Offit wrote an outstanding book warning of the dangers posed by the anti-vaccine movement, called “Deadly Choices: How the Anti-Vaccine Movement Threatens Us All.” That book appeared all the way back in 2010, and yet look where we are now.

Just a year after Offit’s book, journalist Seth Mnookin published “The Panic Virus,” an excellent exposé of the fraud behind Wakefield’s original paper, and on how the anti-vax movement has been aided (often unwittingly) by popular media personalities.

What these books and others reveal is that the anti-vaccine movement is loud, committed, and (unfortunately) highly influential. For every article or book written by a clear-headed vaccine advocate (and there are many!), there are multiple articles and books promoting wildly inaccurate claims that vaccines cause harm. Trying to refute these claims is like playing whack-a-mole.

Scientific bloggers have learned that no amount of patient explanation can get through to some people, and the anti-vaxxers just won’t quit. Eventually, some of them move on to Stage 3.

Stage 3: Anger. This is where the Biden administration finds itself. After months or years of explaining, pleading, and even begging people to get vaccinated, the crazy, irrational, and often angry opposition of anti-vaxxers (or the “vaccine hesitant,” to use a kinder term) can be just too much.

Some people take a long time to reach this stage. Dr. Anthony Fauci, director of NIH’s infectious disease institute (NIAID), has been the public face of the government effort to get people vaccinated for all of the past year. He’s been subjected to inexcusable vitriol, including death threats towards him and his family, and he continues to try to convince people that vaccines are safe and effective. It’s a tough and thankless job. Dr. Peter Hotez, a vaccine expert at Baylor College of Medicine, has been tirelessly explaining the benefits of vaccines throughout the pandemic, and he too has been subjected to awful, hateful attacks. (Dr. Hotez also wrote a highly personal book a few years ago, explaining why vaccines didn’t cause his daughter’s autism.)

Neither Dr. Fauci nor Dr. Hotez has reached Stage 3, but I wouldn’t blame them if they did. Some public-health experts have, though, and one can see why: after trying for months to get people to do something that reduces their own risk of deadly disease, only to meet defiance, one might say “I’m done. You all can just go ahead and get sick.”

Or, as the FDA’s Twitter account responded in exasperation a few months ago, to the never-ending insistence that ivermectin, can cure Covid-19: “You are not a horse. You are not a cow. Seriously, y'all. Stop it.” (Ivermectin is a de-worming agent for horses. It does not work against any virus, including the one that causes Covid-19.)

The comments on Twitter can be far, far harsher. So when Biden warned that the unvaccinated “are looking at a winter of severe illness and death,” I can’t blame him. After all, he’s right.

Stage 4. Persistence. For those who get past Stage 3 (or skip it entirely), there’s a realization that even though some anti-vaxxers are simply beyond reasoning with (I’m looking at you, Robert F. Kennedy Jr. and Joseph Mercola), that doesn’t mean we can’t fight back. We have to recognize that misinformation is out there, and that some people will continue to spread it no matter what we might say. But there are strategies that work to convince others to get vaccinated, and we have to keep trying. That’s persistence.

For example, a study early this year showed that just a dozen people were responsible for a large majority of the vaccine misinformation across most of social media, including Facebook, Twitter, YouTube, and Instagram. I and others have called for social media companies to de-platform these harmful individuals, which could go a long way towards slowing down anti-vax propaganda. Let’s keep trying.

Another strategy, illustrated by Paul Offit’s 2010 book, is to reveal how anti-vaxxers often profit from their misinformation. Some anti-vaxxers have gotten wealthy selling supplements and “alternative” medicines, promoting them with bogus claims that the supplements can substitute for vaccines. If we raise awareness that these quacks are profiting from the spread of misinformation, that can help raise skepticism about their claims. Getting someone to ask questions themselves–to think critically, in other words–is often the best way to get them to reject the arguments of anti-vaxxers.

And even though I might seem critical of the efforts by government agencies to educate the public, I still think they should do it. Indeed, they should do far more than they are doing: in addition to providing facts about vaccine safety and effectiveness, the CDC and NIH could work harder to directly counter the myths and misinformation that are constantly circulating.

I’ve been blogging about the anti-vax movement since 2008, even before I started writing for Forbes in 2010 (see here and here, for example). I’ve long ago lost count of how many articles I’ve written, trying to point out the harm caused by anti-vaccine misinformation, and I’ll keep trying. So I’d say I’m still in Stage 4.

Stage 5. Surrender. In the face of stubborn opposition, and sometimes virulent and personal attacks, some people eventually just give up. It’s easier, of course, to stop fighting people who just don’t want your help, and I can’t blame anyone who does. When I call this stage “surrender,” I don’t mean to suggest that pro-vaccination and pro-science advocates ever accept the wildly misinformed views of the anti-vaccine movement. Of course not. It’s just that some people decide they can no longer spend time on what seems an endless battle.

I’m not advocating that we should ever give up. We can’t, because infectious diseases don’t care if we stop vaccinating ourselves.

So those are the 5 stages of anti-vax angst, as experienced by countless medical and scientific professionals who are fighting misinformation.

And here we are, in the midst of another huge peak in Covid-19 infections, with a significant portion of the U.S.–and of other countries as well–refusing to get vaccinated. The unvaccinated may indeed be facing a “winter of severe illness and death,” even though no one wants that. I don’t blame anyone for pointing out what is very likely to happen. And if the winter ahead is indeed bad, then I place much of the blame on a small number of very loud voices, such as the Disinformation Dozen, who irresponsibly continue to promote harmful untruths about vaccines.

Vaccines are the single greatest public health advance in the history of medicine. Vaccines have eliminated smallpox from the planet, nearly eliminated polio, and made many other previously-feared childhood illnesses a thing of the past. We can do the same to Covid-19, if everyone will just get vaccinated.

RNA vaccines have arrived. Let's starting making them for influenza, right now.

The race to end the Covid-19 pandemic will be won by vaccines. We now have at least four approved vaccines, and the first two–the fastest to be developed and approved–were both RNA vaccines, a new technology that has never before been used on a large scale.

As I’ve written before, these RNA vaccines are a scientific triumph. Both the Moderna vaccine and the Pfizer/BioNTech vaccine are 95% effective against the virus. Both were developed in a matter of days–days!–after the genome sequence of the Covid-19 virus, SARS-CoV-2, was first revealed.

Now that we know that RNA vaccines work, what’s stopping us from designing and deploying this technology for many other infections that we don’t yet have under control? Simply put: nothing. We just need to have the will to do it, and it will happen. By which I mean, we need the government to pay for it.

Once Covid-19 fades, as it will, we’ll still have to deal with influenza, which sweeps through the population every year, often mutating significantly from the previous year. That’s why we need a new flu vaccine every year: the flu itself mutates to escape the protection we have from last year’s vaccine.

(Aside: we’re in the midst of the mildest flu season in decades, perhaps ever, thanks to the Covid-19 restrictions. The CDC reports fewer than 100 confirmed cases of influenza in the entire country, at a time when we’d usually be seeing thousands of cases per week.)

RNA vaccines are remarkably easy to design, and they’re much cheaper than conventional vaccines too. We should be thinking about making them for a raft of illnesses now: not just flu, but malaria, HIV, and others. But let’s start with the flu.

We already know that we need a new flu vaccine every year, so here’s a not-so-radical proposal: let’s create an RNA vaccine for the flu, right now, paid for by the government. It’s almost certain to work, and it will likely work far better than the current vaccine. Here’s why.

For the current flu vaccines, we create a new vaccine every year based on what’s currently circulating among humans. For the Northern hemisphere, we choose the vaccine strain right around now (late January or early February), because it takes 6 months to prepare the vaccine for the following fall.

The flu vaccine production uses a crude, decades-old process. After choosing a vaccine strain, the manufacturers (GlaxoSmithKline is one) isolate the virus and then inject it into chicken eggs, where they let it grow for 4-5 days. The virus is then extracted from the eggs, killed, and stuck into a syringe. That’s basically it. (This is why people who have egg allergies are sometimes warned not to get the flu vaccine.)

There are loads of problems with this process. First, it often turns out (and this is not widely known) that the first choice for a vaccine strain doesn’t grow well in eggs. In those years, the manufacturers move on to a second, third, or fourth choice, until they find one that grows in chicken eggs. These inferior choices, in turn, lead to vaccines that are less effective at conferring immunity.

Second, the process requires huge, messy chicken farms, which means it is slow and costly. Third, even though the virus is a killed virus, there’s always a small chance that some live virus will survive and infect people.

RNA vaccines, in contrast, can be manufactured precisely to match the virus that you wish to target. There’s no need to grow it in chicken eggs. And it’s far cheaper to make. In addition, you only need a fragment of a virus to make the vaccine, so there’s zero chance that anyone can ever be infected from the vaccine. And we know exactly what to target on the influenza virus: the hemagluttinin and neuraminadase proteins that cover the surface of the virus.

If RNA vaccines are so good, one could argue, why not allow the free market to produce them? Because it just won’t happen: the flu vaccine is not very profitable, and getting an entirely new vaccine approved is very expensive. Private companies just aren’t going to do it; on the contrary, several past flu vaccine manufacturers dropped out of the business because it just wasn’t profitable.

(Interesting story: about 15 years ago, I attended a talk by Anthony Fauci about influenza. At the time, I was leading a large-scale effort to sequence thousands of influenza viruses, a project that continues to this day and that is run by Dr. Fauci’s institute, NIAID. At the end of his talk, I asked Dr. Fauci why the NIH itself couldn’t sponsor flu vaccine development. He answered that it just wasn’t done that way–that NIH handled the basic research, but left vaccine development to industry. Well, Covid-19 has changed all that.)

We don’t have to create a new government-run facility to make the vaccines in order for this to work. Instead, we can do exactly what we did for Covid-19: pre-purchase a large supply of RNA-based flu vaccines, and provide generous funding to pay for the vaccine development and testing. Then companies like Moderna and Pfizer will have proper incentives to use their technology on influenza.

The health benefits of new, better vaccines are far too important to leave this to private companies, who are motivated more by profits than by an interest in public health. Let’s use the scientific success of RNA vaccines to change the way vaccine development works in a big way. We can save untold numbers of lives if we do.

The newest member of the coronavirus task force is giving out terrible advice

Why shouldn’t we trust the advice of an M.D. from Stanford University? Because he’s unqualified, that’s why.

As everyone with a pulse knows, the U.S. has handled the coronavirus pandemic very, very badly. Tragically, over 220,000 people have died, and our rate of deaths per capita is higher than any other country in the world.

The Trump administration established a coronavirus task force back in the spring, supposedly led by VP Mike Pence. For a long time, the task force included Dr. Anthony Fauci, a world-renowned expert on viruses who is also the Director of the NIH’s infectious disease institute, where he has worked for 40 years. Despite the frequently erroneous and misleading statements by President Trump, Dr. Fauci consistently gave the public advice that was both scientifically and medically accurate. He never promised that the virus would simply disappear, and he urged everyone to wear masks and avoid unnecessary contact with others. He also warned against re-opening businesses too quickly.

Trump didn’t like that, so he pushed Fauci to the sidelines in favor of someone whose advice matched what he wanted to hear.

Enter Scott Atlas. Atlas is a Fellow at the right-wing Hoover Institute at Stanford University, where he studies health care policy. He’s also an M.D., a radiologist who specializes in MRIs. Notably, he has no special expertise on viruses, vaccines, or epidemiology.

Atlas has pushed for schools to reopen and for college sports to resume, against the advice of public health experts. Just last week, he tweeted that masks don’t work, a claim that was so outrageous and dangerous that Twitter took it down. (To be precise, Atlas’s tweet was “Masks work? NO”.) Another coronavirus task force member, Dr. Deborah Birx, said she felt “relief” that Atlas’s tweet was removed.

Perhaps Atlas is so convinced of his own brilliance–after all, Stanford is one of the world’s top universities, and he wason the faculty there–that he thinks he’s an expert on everything. But a good scientist would pay attention to the recommendations of others who are clearly more qualified, and Atlas has not done that. For example, he has argued, against the evidence of experts, that “low-risk groups getting the infection is not a problem” (wrong–they can spread the infection to high-risk groups) and that only people with symptoms should get tested (very bad idea, given that many people are asymptomatic).

Alarmed at the harm that Atlas’s advice has been causing, a group of more than 70 of his Stanford colleagues, including world-renowned experts in infectious diseases, epidemiology, and health policy, published an open letter decrying Atlas’s bad science. Their statement read, in part:

“... we have both a moral and an ethical responsibility to call attention to the falsehoods and misrepresentations of science recently fostered by Dr. Scott Atlas, a former Stanford Medical School colleague. Many of his opinions and statements run counter to established science and, by doing so, undermine public-health authorities and the credible science that guides effective public health policy.”

Atlas responded by threatening to sue his Stanford colleagues over their letter, and in response to that, an even larger group of Stanford professors released a statement saying they wouldn’t be intimidated. The second letter, with over 100 signatories, stated:

“We believe that his [Atlas’s] statements and the advice he has been giving fosters misunderstandings of established science and risks undermining critical public health efforts.”

My bottom line: Atlas is a bad scientist, apparently far more interested in power and influence than in public health. I’m not commenting on his skills as a radiologist, which are irrelevant here. (He might be an outstanding radiologist.) However, he’s providing advice to the U.S. government that contradicts the advice of scientists who are far more qualified than he is, and when they pointed that out, rather than buttressing his arguments with data, he threatened to sue. That is not the behavior of a good scientist.

To those who think that this disagreement means there are two sides to the issue, I urge you to think again. Science and medicine are highly specialized. Just as you wouldn’t want a virologist to read your MRI scan, you wouldn’t want a radiologist (Atlas) to decide on the best way to treat the Covid-19 virus. So when a radiologist (Atlas) disagrees with a virologist (Fauci) over a virus, guess who’s most likely to be right?

It’s unfortunate that the current administration has chosen to heed the advice of someone who tells them what they want to hear, rather than someone who truly has the qualifications to advise them.