Oddly, I’ll never forget the moment I learned about the anti-vaccine movement. It was right after Andrew Wakefield unleashed his fraud on the world and right before I went to medical school when a friend told me that vaccines cause autism. I’d scarcely given vaccines a moment’s thought before, but I was skeptical of this claim. During medical school and residency, I thought about vaccines only occasionally. They didn’t come up too often in the day-to-day care of patients with neurological or psychiatric illness.

However, I became fascinated by the anti-vaccine movement shortly after residency when a doctor I trained with, Dr. Kelly Brogan, morphed into one of the country’s most outspoken anti-vaccine doctors. I’ve been closely following the anti-vaccine movement ever since. My primary interest wasn’t in vaccines per se, but rather the cognitive flaws and logical fallacies that led smart people to reject medicine’s greatest achievement. I never felt that vaccine-preventable diseases were too much of a threat to my children – they and those around them have been vaccinated – but rather I feared the science-denial and conspiracies that underlined the anti-vaccine movement. As I said before the pandemic,

The biggest danger to my kids isn’t the measles, but the thought process that leads people to reject the vaccine in the first place.

Over the ensuing decade, I observed something interesting about the anti-vaccine movement. When I first encountered it, anti-vaccine influencers could gain attention by claiming vaccines caused autism. That was once cool and edgy. After a few years, however, this bogus claim was merely the price of entry into Anti-Vaxx World. Since there was nothing to be gained by merely saying vaccines caused autism, in order to gain attention, anti-vaccine influencers like Dr. Brogan were forced to blame vaccines for all manners of maladies, such as the “epidemic” of SIDS (even though SIDS rates have decreased markedly). Other anti-vaccine doctors compared vaccines to rape, and RFK Jr. compared vaccinations to the Holocaust. Attacking pediatricians became commonplace.

Meanwhile, vaccine-preventable diseases were spoken of in glowing terms. In her essay, “Vaccination: Your Body. Your Baby. Their Flu” Dr. Brogan said:

This better way embraces periodic sickness as part of comprehensive wellness. The only way to truly protect ourselves and our infants is through natural immunity bolstered by wild-type exposure in the community. Once you have a particular flu strain, when it comes around again, you will be uniquely protected, and you will pass on this protection to your newborn. There is no replacement for this.

Simply saying vaccines cause autism just doesn’t cut it for anti-vaccine influencer in 2022 the way it did in 2000. In order to get continue to get clicks and customers, anti-vaccine doctors had to continually escalate their rhetoric and above all, never stop being controversial.

This is not to say that people like Dr. Brogan are insincere in her beliefs. However, while she may be a leader of the anti-vaccine movement, she’s also a follower of her followers. They won’t let her say certain things. For example, in 2020, a study of nearly 1.7 million women found the HPV vaccine’s efficacy was especially high if girls were vaccinated before the age of 17, which led to an almost 90% drop in cervical cancer over the 11 years of the study.

There’s no way Dr. Brogan could even contemplate sharing this information with her followers. There are many obvious truths she cannot share without destroying her brand. She’s trapped, and it’s sad that she put herself in this position.

As Dr. David Gorski said, everything old is new again. Everything that happened before the pandemic regarding vaccines is repeating itself. Sometime last year, I noticed a similar escalation amongst the contrarian doctors I’ve discussed here previously. Doctors who had superficially valid concerns about vaccinating children against COVID in early 2021 are now overtly anti-vaccine for children. A doctor who once said semi-positive things about the pediatric COVID vaccine – “No one arguing against first dose” – is today calling for the dissolution of the American Academy of Pediatrics.

Many doctors have seen their audience grow substantially over the pandemic. They’ve been on podcasts and have made a large number of YouTube videos. Some write for Substack, a nice source of revenue. Others have access to influential politicians. Most have large social media presences, where their followers extol their courage and independence. In order to get continue to get clicks, attention, and occasionally customers, they had to escalate their rhetoric. It’s all very familiar.

Yet, contrarian doctors too are trapped. Like Dr. Brogan, there’s information about vaccines they simply cannot share. Nearly 20,000 children were involved in the pediatric randomized-controlled trials of the COVID vaccines, which have since shown to be very effective in limiting severe disease in children. For example, a recent article from The New England Journal of Medicine titled “Effects of Vaccination and Previous Infection on Omicron Infections in Children” reported that nearly all hospitalized children were unvaccinated as were all 7 children who died. There are now many such studies.

Table 1: Studies of the pediatric COVID vaccine. Some doctors cannot share them.

Olson
In hospitalized adolescents, “179 COVID-19 case-patients, six (3%) were vaccinated and 173 (97%) were unvaccinated. Overall, 77 (43%) case-patients were admitted to an intensive care unit, and 29 (16%) critically ill case-patients received life support during hospitalization, including invasive mechanical ventilation, vasoactive infusions, or extracorporeal membrane oxygenation; two of these 29 critically ill patients (7%) died. All 77 case-patients admitted to the intensive care unit, all 29 critically ill case-patients, and both deaths occurred among unvaccinated case-patients.”
Delahoy
“Hospitalization rates were 10 times higher among unvaccinated than among fully vaccinated adolescents.”
Wanga
“Among 272 vaccine-eligible (aged 12–17 years) patients hospitalized for COVID-19, one was fully vaccinated.”
Lutrick
Vaccine effectiveness “…was 92% against SARS-CoV-2 infections irrespective of symptom status.”
Zambrano
“Among critically ill MIS-C case-patients requiring life support, all were unvaccinated…97/102 children with MIS-C were unvaccinated. None of the 5 vaccinated MIS-C patients required respiratory or cardiovascular life support (invasive mechanical ventilation, vasoactive infusions, or ECMO) compared to 38/97 unvaccinated MIS-C patients.”
Levy
“In 33 adolescents with MIS-C eligible for vaccination…0 had been fully vaccinated, 7 had received 1 dose.”
Olson
“Of the case patients, 180 (40%) were admitted to the ICU, and 127 (29%) required life support; only 2 patients in the ICU had been fully vaccinated. The overall effectiveness of the BNT162b2 vaccine against hospitalization for Covid-19 was 94%. The effectiveness was 98% against ICU admission and 98% against Covid-19 resulting in the receipt of life support. All 7 deaths occurred in patients who were unvaccinated.”
Nygaard
“We identified 51 MIS-C cases among unvaccinated individuals and one in a fully vaccinated adolescent.”
Chang
“Reports of MIS-C after COVID-19 vaccination occurred in only 1 per million individuals aged 12–20 years who received one or more doses of a COVID-19 vaccine.”
Fleming-Dutra
Estimated booster dose effectiveness in adolescents 2 to 6.5 weeks after the booster was 71.1%.
Yousaf
“The overall reporting rate for MIS-C after vaccination 1·0 case per million individuals receiving one or more doses in this age group.”
Tan
Vaccine effectiveness against hospitalization was 83% in children ages 5-11.
Marks
“A higher proportion of unvaccinated adolescents (70.3%) than fully vaccinated adolescents (40.8%) had COVID-19 as a primary reason for admission. A significantly higher proportion of unvaccinated adolescents were admitted to the ICU (30.3%) than were those who were vaccinated (15.5%).”
Price
Vaccine effectiveness against hospitalization was 68% in children ages 5-11
Lin
Vaccine effectiveness against hospitalization was 88% in children ages 5-11, though this waned to 76% after several months. 7 children died, all unvaccinated.
Messiah
“Additional increased risk for persistent COVID symptoms >12 weeks included severe symptoms with initial infection, not being vaccinated and having unhealthy weight”
Cohen-Stavi
This observational study of effectiveness of the BNT162b2 vaccine among children 5 to 11 years of age showed a vaccine effectiveness of 51% against documented SARS-CoV-2 infection and 48% against symptomatic Covid-19 at 7 to 21 days after the second dose.
Klein
Overall, 2-dose vaccine-effectiveness against COVID-19–associated hospitalization was 73%–94%.
Shi
During the period of Omicron predominance (December 19, 2021–February 28, 2022), COVID-19–associated hospitalization rates in children aged 5–11 years were approximately twice as high among unvaccinated as among vaccinated children. Non-Hispanic Black children represented the largest group of unvaccinated children. Thirty percent of hospitalized children had no underlying medical conditions, and 19% were admitted to an intensive care unit.

Like Dr. Brogan, some contrarian doctors literally cannot share these studies. It would be too off-brand and their followers would abandon them. These studies cast the vaccine in an accurate, positive light. Think about how sad it is that some doctors have put themselves in this position. I have no trouble sharing information on vaccine-myocarditis. However, were these doctors to tell their audience something unexpected, advising them to vaccinate their children against COVID, for example, they’d shatter their carefully curated reputation. They’d be alone.

I recently learned the term for this phenomenon: audience capture, which is defined as “…a self-reinforcing feedback loop that involves telling one’s audience what they want to hear and getting rewarded for it”. In a fascinating article, titled “The Perils of Audience Capture How Influencers Become Brainwashed by Their Audiences“, Gurwinder Bhogal warned of its perils:

Audience capture is an irresistible force in the world of influencing, because it’s not just a conscious process but also an unconscious one… It involves the gradual and unwitting replacement of a person’s identity with one custom-made for the audience.
[…]
When influencers are analyzing audience feedback, they often find that their more outlandish behavior receives the most attention and approval, which leads them to recalibrate their personalities according to far more extreme social cues than those they’d receive in real life. In doing this they exaggerate the more idiosyncratic facets of their personalities, becoming crude caricatures of themselves.

The caricature quickly becomes the influencer’s distinct brand, and all subsequent attempts by the influencer to remain on-brand and fulfill audience expectations require them to act like the caricature. As the caricature becomes more familiar than the person, both to the audience and to the influencer, it comes to be regarded by both as the only honest expression of the influencer, so that any deviation from it soon looks and feels inauthentic. At that point the persona has eclipsed the person, and the audience has captured the influencer.

I think this perfectly describes what I’ve observed before the pandemic with anti-vaxxers like Dr. Brogan and during the pandemic with contrarian doctors, several of whom I once admired as defenders of evidence-based medicine. However, they’ve since become trapped by their followers. After 2.5 years of minimizing COVID and discouraging pediatric vaccination, they’ve cornered themselves into positions they knew to be quackery prior to the pandemic. Echoing Dr. Brogan and anti-vaccine tropes about measles and HPV, they write pro-virus articles titled “The Triumph of Natural Immunity” and argue that it’s “natural and healthy” when children get sick with COVID.

Their social media followers are – slightly – worse. Last week one doctor claimed on Twitter that the new boosters had been only tested in 8 mice, though results of a study from 900 volunteers were released in a company press release the next day. Here are some sample comments from his Twitter thread:

  • CRIMINAL
  • Scott Gottlieb owns 200,000 shares of Pfizer. When Pfizer hits $64 share he will become a billionaire. Trust science
  • Do pediatricians not care? What’s going on here?
  • Of course. #TheScience dictates someone somewhere needs a new summer home. Trust the Science.
  • It’s DANGEROUS !
  • The AAP is pro vaccine and “gender affirming” surgery. Whatever makes them more money is what they support.
  • Clinical trial data that can be cherry picked before presenting to the FDA board is hardly valuable at all. Its not really a secret, but just not well known. SciAm did an article about this problem a decade ago and that was long before operation warp speed.

There are hundreds of such comments on some doctors’ social media feeds every day. In contrast, those who correct misinformation get blocked. Their fans often lavish them with praise, telling them they are “fearless” for challenging the orthodoxy. And you can see how some doctors get cornered by their followers and are forced to adopt more extreme positions. The cardinal rule is to never stop being “heterodox”, no matter what. This is how doctors end up praising viruses.

Young doctors take heed. Be careful not to develop a brand and cultivate followers you must continually impress – instead of leading your followers, you might become their follower. Mr. Bhogal ended his essay with a warning to would-be influencers and social media celebrities.

This is the ultimate trapdoor in the hall of fame; to become a prisoner of one’s own persona. The desire for recognition in an increasingly atomized world lures us to be who strangers wish us to be. And with personal development so arduous and lonely, there is ease and comfort in crowdsourcing your identity. But amid such temptations, it’s worth remembering that when you become who your audience expects at the expense of who you are, the affection you receive is not intended for you but for the character you’re playing, a character you’ll eventually tire of. And so be warned: being someone often means being fake, and if you chase the approval of others, you may, in the end, lose the approval of yourself.

I agree with Mr. Bhogal, having the wrong audience is worse than having no audience.

Author

  • Dr. Jonathan Howard is a neurologist and psychiatrist based in New York City who has been interested in vaccines since long before COVID-19.

Posted by Jonathan Howard

Dr. Jonathan Howard is a neurologist and psychiatrist based in New York City who has been interested in vaccines since long before COVID-19.