Published in Social Medicine, Vol. 7, No. 2, May 2013, pp. 90-97
"Caught in the vaccination wars" describes responses to a draft of this article.
Ideally, public health debates are conducted civilly and focus on the evidence and the public good. In practice, many debates deviate markedly from this approach, for example with personal denigration of opponents. To help assess methods used in public health debates, a classificatory system of ideal types is introduced, with the categories of deliberative democracy, marketplace of ideas, marketplace of abusive comment, dominant orthodoxy, authoritarianism, and totalitarianism. To illustrate how methods can be fitted into these ideal types, instances of opposition to the Australian Vaccination Network are examined. Being able to identify the types of methods used in particular debates provides public health advocates with opportunities to reflect on the impact of different methods deployed and how they relate to public participation and free speech.
The ideal of rational scientific debate is one in which evidence is clearly and fairly presented and then subjected to careful scrutiny. In practice, scientists can be highly passionate in support of their preferred views and be scathing about the motivations and character of opponents [1]. However, debates conducted between scientists are usually decorous in public forums, for example in scientific journals and conferences. Open personal criticisms of other scientists are not common and often seen as improper.
Public health debates add extra dimensions to the challenge of maintaining civility. Such debates are conducted both in the pages of professional journals and in the mass media as well as other public forums including public meetings and blogs, with many citizens joining in. Public health debates over contentious topics such as abortion, contraception, cancer therapies, smoking, and fluoridation can be punctuated with personal abuse and claims about conspiracy and vested interests.
Is there a limit to aggressive behaviour in public debates? Is there a responsibility for credible figures to protect and foster fair and honest debating? These questions are highlighted by developments in the debate over vaccination in Australia involving diverse techniques used against a citizens' group. This example raises the question of appropriate limits to action on behalf of what is considered to be a worthy cause.
In the next section I propose a set of categories for assessing methods used in health debates, based on ideal types. The vaccination debate is then used to illustrate how this framework can be used. First I outline the main issues in the vaccination debate and the usual way the debate is conducted. Then I turn to opposition to the Australian Vaccination Network, highlighting some novel techniques used against participants in the vaccination controversy. In the final section, I suggest some implications for public health professionals who subscribe to ideals of free speech, and offer suggestions for countering intolerance.
How should the methods used in health debates be understood? It would be possible to compare them to norms in different arenas, including scientific journals, the mass media and the legal system. Here, I propose a set of debate categories - in the form of ideal types - against which actual debates can be benchmarked. These categories can be used to assess the acceptability of different tactics.
Sherry Arnstein in a classic paper described a 'ladder of participation" with each successive rung of the ladder denoting a higher level of citizen participation in social decision making [2]. The ideal types here - listed from the most participatory and deliberative to the least - start with significant participation but then descend below Arnstein's lowest rung to situations in which participation is actively discouraged.
Note that, in sociology, ideal types refer to categories that are conceptually clarified down to basic elements, and hence not expected to be realised in practice. Ideal types are not necessarily ideal in the sense of desirable [3].
Deliberative democracy describes a process in which decisions are made by groups of citizens who have been briefed by diverse experts and then carefully discuss the issues together to make an informed choice. Examples of deliberative practice include consensus conferences, citizens' juries and deliberative polls. In these forums, groups of citizens are presented with information about all sides of an issue and are able to question experts and advocates and to discuss policy options with each other under the guidance of neutral facilitators. Such methods have been used on topics such as genetic engineering and nanotechnology [4]. Deliberative democracy is closest to embodying the ideal speech situation advocated by Jürgen Habermas [5].
A marketplace of ideas is an arena allowing public debate in which all views can be freely expressed. The marketplace allows views to be scrutinised, challenged, revised and judged, ideally with the result that the best view becomes widely accepted. The mass media enable a marketplace of ideas, but with constraints including editorial control and the influence of advertisers. Social media provide a different sort of marketplace in which there are fewer limitations on the expression of views.
A marketplace of ideas works best when there are no strong vested interests. In the health area, this applies to topics that are debated least, for example first aid treatments. One of the shortcomings of idea marketplaces is that debate may proceed primarily by slogans and superficial opinions, without much deliberation.
Another problem is that powerful groups can skew a marketplace of ideas [6,7]. The classic example is the debate over the health effects of smoking from about 1950 to 1990, during which time for-and-against arguments were presented in public and scientific forums. The tobacco industry was the key powerful group that distorted the debate by suppressing findings, touting results from scientists it funded, defending legal actions, and advertising [8].
A marketplace of abusive comments refers to a debate in which different viewpoints are presented in public and sometimes professional arenas, accompanied by verbal attacks on individuals and groups that can be described as personal abuse, defamation or hate speech. For example, someone commenting on an issue might be called ignorant, a dupe, unqualified, a fool, corrupt or fraudulent. In this sort of marketplace, individuals, including both professionals and citizens, are free to speak out but are at risk of being personally denigrated. Abusive comments can be made by partisans on one or both sides of an issue. The debate over climate change, for example, has involved considerable abusive comment [9].
Abusive comments discourage participation in debates. A person witnessing this sort of behaviour may be wary of contributing to the debate because of the risk of becoming a target.
Dominant orthodoxy occurs when the view held by nearly all expert authorities on an issue is backed up by powerful groups - typically governments, large corporations or the medical profession - with a vested interest in the dominant position. In the face of a dominant orthodoxy, it is extremely difficult for professionals with contrary positions to sustain a career [10,11]. Examples of viewpoints marginalised by the dominant medical orthodoxy are homoeopathy, the view that HIV is not involved in AIDS, and faith healing.
Questioning of the dominant orthodox position is possible, but it is treated as heresy rather than merely dissent [12]. However, unlike authoritarian systems, challengers are allowed to exist on the margins, just not within professional circles.
Authoritarianism is a system in which rulers impose a viewpoint and use a range of measures, potentially including force, to suppress alternative viewpoints. The classic example is Lysenkoism in the Soviet Union under Stalin, in which Darwinism was suppressed [13].
Authoritarianism in public debates is most obvious when the political system is autocratic, though rulers in such systems may or may not have any interest in suppressing debate on a given topic. Authoritarianism in health debates is also possible as a result of mass action, which can occur, for example, as a result of fascist movements. When authoritarianism prevails, any dissent is vulnerable to attack, whether from scientists, government employees or citizens.
Under systems of totalitarianism, even private speech is under threat through ubiquitous secret police, surveillance or thought control, as in Orwell's 1984 . Furthermore, totalitarian systems sometimes aim to control people's thoughts. Totalitarian systems usually target political or religious beliefs rather than scientific matters.
Table 1 shows how these six systems can be defined using five criteria dealing with thought, public speech, professional speech, verbal attacks, and critical analysis. For example, without free public speech, anyone is potentially subject to attack for challenging the dominant viewpoint, whereas with a dominant orthodoxy, members of the public can debate the issue without reprisals but professionals such as doctors and scientists are at risk if they dissent.
Some entire debates can be characterised as fitting one of the six ideal types, such as Lysenkoism as authoritarianism. In practice, though, most debates are complex, with different facets fitting into different types. This is a limitation when it comes to characterising an entire debate, but useful for categorising particular methods within a debate. For example, a method such as a citizens' jury fits the model of deliberative democracy; attacks on dissenting scientists - in the absence of attacks on dissenting citizens - fits the model of dominant orthodoxy.
The framework summarised in Table 1 serves several functions. It is a reminder that debates may be carried out using a variety of methods, some of which restrict or discourage participation. It offers a hierarchy of methods, suggesting that deliberative ones are most desirable and totalitarian ones least desirable. And it offers a conceptual toolkit for assessing actual debates. To show how this assessment process can be carried out, I look at debates over vaccination.
Ideal type |
Criteria |
Free thought inhibited |
Public speech suppressed |
Professional speech suppressed |
Public participation discouraged |
Critical analysis inhibited |
Deliberative democracy |
||||||
Marketplace of ideas |
yes |
|||||
Marketplace of abusive comment |
yes |
yes |
||||
Dominant orthodoxy |
yes |
maybe |
yes |
|||
Authoritarianism |
yes |
yes |
yes |
yes |
||
Totalitarianism |
yes |
yes |
yes |
yes |
yes |
|
The central argument for vaccination is that it reduces the incidence of infectious disease and consequent disability and mortality [14,15]. Critics have raised a number of objections to particular vaccines and to vaccination in general [16,17].
Critics question the benefits of vaccination by noting the decline in mortality rates for many diseases long before vaccines were introduced. Proponents cite studies showing the benefits.
Critics point to risks from vaccination, especially adverse reactions by individuals, including disability and death. Critics claim that rises in some types of disease, such as auto-immune diseases, may be linked to vaccination. Proponents say that adverse reactions are rare, anecdotal and, to the extent they exist, much less significant than the consequences of full-blown disease.
Critics argue for the right of individuals to decide whether to be vaccinated and whether their children should be vaccinated, using the rhetoric of individual choice. Proponents point to the benefits of herd immunity: when a sufficiently large proportion of the population is immunised, infections have difficulty being transmitted, so the entire community - both vaccinated and unvaccinated individuals - benefits from a reduced burden of disease. Proponents thus argue on the basis of collective welfare.
The overwhelming majority of doctors and scientists support vaccination in general, though they may differ about specific vaccines and about how to promote vaccination. In the face of this orthodoxy are what can be called 'vaccine-critical" groups, whose members typically support choice and question the standard views about benefits and risks [18]. Most members of vaccine-critical groups are citizens without specialist training or formal roles relating to vaccination; a small number of doctors and scientists are critical of vaccination.
The vaccination debate has been prolonged and extremely bitter, for a number of reasons. One is that children's health is involved, with each side claiming that the other's stance harms children. Another reason is that deeply held values are involved, notably differences between individual rights (choice) and collective benefits (herd immunity).
Much of the debate involves disagreements about scientific claims, for example the existence and prevalence of adverse reactions. But, as in many other scientific controversies, scientific findings seldom lead to closure of the issue [19]. In part this is because some issues are unresolved: for example, scientists disagree about explanations for the apparent increase in autism spectrum disorders. This leaves open the possibility that vaccines may be implicated, even without strong evidence.
Proponents and critics differ over the burden of proof. Proponents say the scientific evidence is overwhelming and hence critics must provide strong findings to show otherwise. Critics say proponents have not resolved all doubts and put the onus of proof on proponents to answer every possible objection.
So far I have described the vaccination debate as a matter of evidence, logic and values. However, the way the debate has been waged also involves the exercise of power. Proponents have obtained the endorsement of government authorities to adopt vaccination as a standard procedure: medical authorities recommend vaccines at certain ages and circumstances and are able to promote their recommendations, for example through policies at hospitals and schools. In some countries, vaccination is semi-compulsory, for example with objectors having to obtain exemptions to permit their children to attend school.
How should the vaccination debate be characterised? So far as the public is concerned, there is very little deliberation: citizens are seldom involved in formal processes for formulation or assessment of vaccination policies. Much of the debate fits into the model of a marketplace of ideas, with stories for and against vaccination presented in the mass media, public meetings, newsletters, blogs and other social media. In some places, the debate has been vehement, with each side accusing the other of being ill-informed, endangering children's health, unethical and dangerous. These are characteristic of a marketplace of abusive comment.
To characterise an entire debate as fitting one of the ideal types runs the risk of ignoring specific behaviours. To illustrate how a more fine-grained assessment can proceed, I turn to a specific campaign in the Australian vaccination debate.
The Australian Vaccination Network (AVN) is a citizens' group that describes itself as pro-choice. It produces a magazine, Living Wisdom, with thousands of subscribers, and hosts a large website [20]. Meryl Dorey, the AVN's spokesperson and most visible figure, has a blog, gives talks and is regularly interviewed by the media.
In 2009, an online group called Stop the Australian Vaccination Network (SAVN) was created. Like the AVN, it is a citizens' rather than a professional group. Its main presence is a Facebook page with several thousand friends, which provides a window into the thinking and tactics of many of the AVN's opponents [21].
SAVN's main page includes a very active 'wall" with dozens of contributions each day, numerous 'discussions" and a number of photos and videos. As with most Facebook pages, a small number of contributors make the majority of comments. Only some members reveal details about their identity.
SAVN's main page has had some discussion about vaccination, plus a host of related topics, but the dominant theme is the AVN, mostly how wrong or silly it is and, to a lesser extent, how to attack it. SAVN's explicit goal is to put the AVN out of business.
Here I describe several examples of SAVN's commentary and related activities, as well as actions by others opposing the AVN. My aim is not a full description of either the AVN or its opponents, but rather to illustrate some of the methods used in a particular campaign in the vaccination debate and how they can be related to the ideal types. Note that because both the AVN and its opponents are citizens' groups, the ideal type of dominant orthodoxy is not involved in this conflict. It is important to remember that SAVN's methods are not necessarily used or endorsed by other Australian supporters of vaccination.
Some AVN members have responded to SAVN, including with what can be classified as abusive comment. I focus on actions by opponents of the AVN not because the AVN is faultless - it is not - but because the opponents' methods are more diverse and thus useful for illustrating connections with ideal types.
The tone of SAVN's Facebook page was set by its profile, which until April 2011 stated [22]:
Name: Stop the Australian Vaccination Network
Category: Organizations - Advocacy Organizations
Description: The Australian Vaccination Network propagates misinformation, telling parents they should not vaccinate their children against such killer diseases as measles, mumps, rubella, whooping cough and polio.
They believe that vaccines are part of a global conspiracy to implant mind control chips into every man, woman and child and that the 'illuminati" plan a mass cull of humans.
They use the line that 'vaccines cause injury" as a cover for their conspiracy theory.
They lie to their members and the general public and after the death of a 4 week old child from whooping cough their members allegedly sent a barrage of hate mail to the child's grieving parents.
The dangerous rhetoric and lies of the AVN must be stopped. They must be held responsible for their campaign of misinformation.
SAVN provided little evidence that members of the AVN believe in a 'global conspiracy to implant mind control chips," nor indeed that any single AVN member believes this. The claim served to position the AVN as beyond the bounds of reasonable belief, namely to equate scepticism about vaccination with delusion. SAVN's profile readily fits into the marketplace of abusive comment. (Since May 2011, SAVN's profile has contained a more circumscribed reference to AVN conspiracy beliefs.)
One of the activities of SAVN members is to produce images that make fun of the AVN. One striking example is a sketched face, in the style of the mask for 'V" in the film 'V for Vendetta" but with the tongue hanging down, with the words 'W for windowlickers" [23]. The word 'windowlickers" refers to people with intellectual disabilities who let their tongues hang out and who lick windows, especially the windows of a bus in which they travel. There is commentary following the image, in part stimulated by one contributor, Olivia Dale, asking 'Why attack someone with silly pictures?" Among the following comments, Lance Penna replied 'Because its [sic] fucking funny. And mocking the ridiculousness of their Profile pic" [the picture on the AVN's Facebook profile page]. Nathan Woodrow commented, inter alia, 'This is just a puerile but worthy comment on the stupid that is the AVN." Carol Calderwood said, among other things, 'We enjoy humour to break the monotony of lies that is excreted from the Twilight Zone. In case you're unaware, our goal here is to stop the Australian (anti) Vaccination Network - to completely put them out of business as they are a danger to public health." Rohan James Gaiswinkler commented 'Olivia, I think this is our coping mechanism for the landfill quantities of batshit crazy that comes out of antivaccinationism. It's enough to make one despair for the human condition."
These comments, which are extracts from just one of hundreds of discussion threads on SAVN's page, give a feeling for the tone of quite a bit of the SAVN commentary, suggesting contempt for the AVN and no support for the right of the AVN to present its viewpoints. This commentary fits into the marketplace of abusive comment.
Much of the SAVN commentary is directed specifically at Meryl Dorey, the AVN's spokesperson, and much of it is abusive. SAVN's page includes photos of Dorey as part of graphics portraying her in unfavourable ways. There is also a separate webpage called 'Stop Meryl Dorey" [24].
Opponents of the AVN have made dozens of formal complaints about the AVN to agencies that regulate professional practice or incorporated organisations in the Australian state of New South Wales, including the Health Care Complaints Commission, the Department of Fair Trading and the Office of Liquor, Gaming and Racing. These complaints can be interpreted as a form of harassment. They are similar in form and impact to legal actions that deter free speech, called Strategic Lawsuits Against Public Participation and more widely known as SLAPPs [25].
Even when the complaints are not sustained, they may require much work by the AVN to respond and thereby divert the organisation from its main orientation to vaccination issues, as well as serving as a method of intimidation, given that the viability of the AVN could be at stake. Accordingly, these can be called Strategic Complaints Against Public Participation or SCAPPs [26]. Making complaints about the AVN to government agencies is an attempt to leverage the power of the state to shut down the AVN. Because their aim is to silence a citizens' group, they fit into the ideal type of authoritarianism.
A different pro-vaccination website, VAIS (Vaccination Awareness and Information Service), separate from SAVN, put up a 'Hall of Shame" listing the names and contact details for businesses advertising in the AVN's magazine Living Wisdom. Some of these businesses were then contacted by pro-vaccination activists in a way that was experienced as harassment. The Hall of Shame serves as a form of intimidation, deterring some businesses from advertising in Living Wisdom or being otherwise associated with the AVN. The issue of Living Wisdom published in 2011 contained no new advertising - only a few pre-paid ads - because Dorey, the editor, did not want to expose businesses to unwelcome communications. The hall of shame fits into the ideal type of authoritarianism.
Dorey and some others associated with the AVN - for example who have posted comments on the AVN's website - have received pornographic images through the post or email. One image, involving sex and violence, would be refused classification under Australia's scheme for rating visual images: it is illegal to send such images. No one in SAVN has taken responsibility or endorsed the sending of these images. However, it could be argued that the attitudes expressed by SAVN contributors against Dorey and the AVN have created a hostile atmosphere that encourages some individuals to send gross images and make personal threats. Sending pornographic images fits into the ideal type of authoritarianism.
Debates over health-related matters are often extremely bitter. Usually, though, more attention is given to the content - the facts, which position is correct, and policy implications - than to the way a debate is carried out. Yet the methods used are important. Heavy-handed and abusive techniques can discourage participation and distort outcomes, affecting health policies and practices.
Because there is no standard way of assessing methods deployed in debates, a classification system is proposed here based on a series of ideal types of debate. By examining an actual debate - namely the public debate over vaccination and specifically opposition to an Australian citizens' group critical of vaccination - one immediate conclusion is that different modes of engagement are readily found within an actual debate. The ideal types are useful for assessing different methods used and pointing to characteristic styles used by particular players.
Science, as a model form of truth-seeking, is based on rational assessment of evidence. Health policy disputes can only partly follow the science model because they also involve differences in values. Furthermore, it can be argued that citizens can and should be involved in decision-making about matters that affect them. From this perspective, deliberative modes of engagement should be a goal. The question then arises: what can be done to shift debates towards more participatory, respectful modes of engagement?
Those who care about fair debate and greater participation can themselves promote methods in the deliberative democracy mould, for example citizens' juries and calm and rational presentation of information and arguments in various media. They can also refrain from more manipulative and aggressive techniques. However, in highly charged and polarised debates such as vaccination, setting a good example may have only a limited impact. The next question is, what should be done about those who engage in personal abuse and who attempt to silence opponents? A first step is to expose and criticise these sorts of methods, especially when used by those on one's own side. Another option is to intervene in debates to support the right of all to be heard. Yet another is to provide skills to actual and potential participants in debates, so they can identify and counter aggressive techniques.
Just to mention these options is to indicate the scale of the enterprise to move public health debates in a more participatory and deliberative direction. Much more attention, theoretical and practical, needs to focused on how debates are carried out.
For feedback on drafts, I thank Bokhtiar Ahmed, Paula Arvela, Anu Bissoonauth-Bedford, Trent Brown, Rae Campbell, Lyn Carson, Kevin Dew, Meryl Dorey, Don Eldridge, Paul Gallagher, Peter Gibson, Michael Matteson, Anne Melano, Majken Sørensen, Peter Tierney and Rowena Ward. None of them necessarily agrees with the views expressed in this paper.
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[The image and subsequent commentary are available here.]
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