Get your facts first, and then you can distort them as much as you please.

—Mark Twain

There is an educational approach to becoming a doctor. It involves learning massive amounts of basic science, followed by massive amounts of pathophysiology, which barely prepares you for the clinical years of the last half of medical school and subsequent residency, with the massive knowledge dump you will have to absorb. Much of the information is given by experts in the field, usually MDs or PhDs (or both), who lecture formally and informally. Being considered an expert in infectious disease (ID) at a teaching hospital, I now spend hours a day yammering on about infections to anyone who will listen, students in all the medical fields who rotate through our hospitals. I value the facts I have learned in my field and respect those who have worked to provide me with the information. I greatly value facts and the people who provide them.

Most of the information I get in medicine is from those in the field. It is rare for people to write about aspects of medicine that I will take seriously. Yes, there are a lot of people who write on the web about medicine, but given what it takes to achieve even a solid knowledge in medicine, much less develop expertise, I usually can’t take them too seriously. Call me arrogant, but if you want to be a legitimate source of information there are dues that have to be paid.

The world of anti-vaccination discourse is small. There are few physicians who take an interest in the topic. Most doctors are too busy to care and it is like worrying about defending fresh water and clean air. I would wager that to most physicians outside the world of pediatrics, the benefit of vaccines is rarely given a thought.

The anti-vaccinationists are an equally small group of people, at last the ones that bother to write on the topic. Sometimes they seem inordinately loud, but that is only because they end up on Oprah.

I often feel that the two sides inhabit different worlds with different approaches to reality. I live in a world dominated by facts derived from the sciences. The facts always change, or better words may be evolve or refined, with time. But facts matter to me. There is a world of facts derived from observation of the natural world and in the end my opinion on a topic medicine does not matter. It is what the facts indicate that should determine my opinions, not the other way around. Facts can be tricky things, especially in medicine, with nuance and subtlety that makes the facts less clear cut than one would like, especially compared to a hard science like physics or chemistry.

Facts often do not seem to matter to anti-vaccine proponents and other CAM practitioners to the same degree that they do to me. For example, given the preponderance of information about the worthlessness of homeopathy I cannot see how anyone would ‘practice’ homeopathy. Or acupuncture. Or chiropractic. Or virtually any CAM discussed on this blog.

I have spent half of my life accumulating facts to understand the best way to practice medicine and, as best I can tell these facts, do not matter much to the CAM practitioners or anti-vaccinationists.

And I don’t get it. Why do the CAM practitioners and anti-vaccine proponents not pay attention to the facts. It is, as I have said, like we live in two separate cultures. I have spent some time in other countries whose customs are different from mine: Japan, France, Minnesota. Before visiting those foreign lands I would read texts by anthropologists and historians on what to expect and how their culture differed from mine. I would never have survived my three years in Minneapolis if not for “Lake Woebegon.” But who better to understand a foreign culture than an anthropologist. What I need is anthropologist to help understand why the facts do not matter.

Ask and you will receive. I serendipitously came across two articles. The first is by Leonard Pitts in my local paper.The other is “A Post-modern Pandora’s box: Anti-vaccination misinformation on the internet” by Anna Kata, an anthropologist from Canada. There are other studies on the beliefs of the anti-vaccinationists, but they are from the perspective of doctors and have underlying belief that if you get the right information to people they will make the right decision. Doctors believe, in the end, in rational discourse.Others do not.

The Internet plays a large role in disseminating anti-vaccination information. This paper builds upon previous research by analyzing the arguments proffered on anti-vaccination websites, determining the extent of misinformation present, and examining discourses used to support vaccine objections. Arguments around the themes of safety and effectiveness, alternative medicine, civil liberties, conspiracy theories, and morality were found on the majority of websites analyzed; misinformation was also prevalent. The most commonly proposed method of combating this misinformation is through better education, although this has proven ineffective. Education does not consider the discourses supporting vaccine rejection, such as those involving alternative explanatory models of health, interpretation strikes me that this argument is for a freedom without responsibility for the consequences of parental responsibility, and distrust of expertise. Anti-vaccination protestors make post-modern arguments that reject biomedical and scientific “facts” in favour of their own interpretations. Pro-vaccination advocates who focus on correcting misinformation reduce the controversy to merely an “educational” problem; rather, these post-modern discourses must be acknowledged in order to begin a dialogue.

Note she puts facts in quotes.

What the author did was Google for websites that opposed childhood vaccinations for any reason and she ended up with 9 sites, including the whale,,, and Why so few? Evidently those seeking health information on the net rarely look past the first 10 search results, so she tried to mirror the results of the average internet user searching for information. She then analyzed the sites for content relating to Safety and Effectiveness, Alternative Medicine, Civil Liberties and Conspiracy Theories/Search for Truth as well as design attributes of the web sites, emotive appeals and content. Interestingly, a search using the terms “immunization OR immunization” failed to find any anti-vaccine sites; anti-vaccinationists do not use the term as “they tend not to believe that vaccine confer immunity.”

The findings will be no surprise to those who frequent anti-vaccine sites, or alt med sites in general.

What 100% of the sites had in common was the assertion that vaccines are dangerous because they contain poisons or cause a variety of illnesses. It was noted that on the sites “pertinent information was not elaborated upon” and gave examples of the amount of ‘toxins’ being too small to cause disease and that the ether in vaccine is the chemical not the anesthetic not being mentioned on the anti-vaccination sites.

Also common were statements concerning the lack of vaccine immunogenicity, the lack of vaccine efficacy in decreasing childhood diseases (credited to diet, hygiene, etc) and a trivialization of vaccine preventable diseases, failing to mention the past and present morbidity and mortality of the diseases.

What these sitesdemonstrateis a disregard for facts, which at one time were considered the final arbitrator of reality. If facts do not matter, and can be ignored arbitrarily, then the conversation between the reality based approach to medicine and the alt med practitioners is impossible.

She notes that most sites endorsed the use of alternative medicines and often argued against germ theory.

Anti-vaccination website tended to reject scientific, clinical and epidemiologic studies demonstrating the safety and efficacy of vaccines. Pro-vaccinations studies were criticized as unreliable, conducted by those with vested interests in vaccination.

Again. Facts ignored or dismissed.

Three quarters of the sites cited the infringement of civil liberties by requiring vaccination. It strikes me that this argument is for a freedom without responsibility for the consequences. It is an argument for which I have some sympathy, but only as long as those who wish to exercise their freedom not be vaccinated are always at least 30 miles away for me and mine or agree to take all the financial responsibilities for the medical care of anyone they inadvertently infect. My problem with the civil liberty approach comes from having to take care of for free and my hospital treat for free people in the trauma ICU who preferred the freedom of not wearing seat belts and helmets in defiance of the man and ended up with multiple, very expensive, traumas. But we are all biased by our experience.

“The conspiracy theory theme was present on every website analyzed”. Someone, usually doctors or big pharma, is covering up of the TRUTH they don’t want us to know (but is somehow widely available) about the sordid truth that vaccination production and promotion is being motivated by solely profit.

Those who speak out against vaccination were considered martyrs to the cause, such as Dr Andrew Wakefield. I cannot wrap my head around the fact that after all the information that has been released about the conduct in his Lancet paper that people would resort to insisting that the man is out to get him rather than the fact that his study was unethical and the data falsified. I hate to risk invoking Godwins law, but I am reading the Fall of Berlin at the moment, and one of the many striking aspects of the madness of the Eastern front is how, as the Soviet’s were shelling Berlin and the Soviet troops were entering the city, there were still those who still thought and acted like a German victory was possible. I have also seen patients who deny remarkable pathology and present with advanced cancer or AIDS. The ability for people to deny even the most compelling evidence is beyond my feeble intellect to comprehend. I can only shake my head in wonder.

Religious ideology was the least represented reason against vaccination on the sites, although the morality of growing vaccines in aborted fetus or experimenting on children was mentioned, it was only mentioned in about a third of sites.

Not unsurprisingly, misinformation and falsehoods were found on every site. “88% made claims unsupported by evidence” and personal testimonials of the harm alleged to caused by vaccines were also common.

Only the Wikipedia was free of taint.

The open nature (of the Wikipedia) appears to have acted as form of peer-review, keeping the page current, unbiased and properly referenced. There appears to be no self-criticism within the anti-vaccination community; this was demonstrated by most of the analyzed website.

Free and open debate is least practiced by those who rage against the oppression of the man. That should have been an Alanis lyric; she would have had less criticism for a lack of understanding of ironic. Again the pattern: a disinterest in facts as well as no interest in having factual errors corrected. The attitude evidently being ‘if I want your opinion, I’ll give it to you.’

Interestingly, 25% identified themselves as non-partisan, non-profit or a public education group, giving the impression impartiality, but all linked to other anti-vaccination sites while only half linked to pro-vaccination sites.

If you spend time in the anti-vaccination world, or alt-med world, none of the above will come as any surprise. To my mind what was an interesting conclusion of the author.

A proponent of vaccination would likely wish to counter with “correct” information; indeed, the most commonly proposed intervention to combat vaccine misinformation is education…With acknowledging falsehoods is important, the assumptions behind educational methods must be examined. Assuming additional information will influence vaccination decisions reduces the issue to one in which the two sides are separated only by a gap in information.

She further points out that educational attempts only anger those who are corrected (AoA anyone?) and that historically education has not altered the opinion of those who have been against vaccination, whose essential messages have changed little since the 18th century, despite the massive increase in biomedical information to correct vaccine misinformation.

It is not the facts that inform the rejection of vaccines (or, more broadly, modern medicine) but “belief in alternative models of health, promotion of parental authority and responsibility and suspicions of expertise.”

It is not the facts that guide opinion, but opinion that determines the facts. She uses the relationship opinion = evidence + values, and as the former approaches zero, the latter predominates.

She also points out how the trend in medicine to patient autonomy and informed choice has had the inadvertent effect of medical consumers extending that autonomy to public health issues and rejecting the premise of vaccines for the overall societal good, noting that “parents may reject epidemiological and population-level risk arguments for vaccinations, for such statistics do not take into account specific experiences, ideologies, and health histories.”

It is both the triumph of medicine that so much benefit can be gained by ignoring specific experiences, ideologies, and health histories, and is medicines current bane. I know that the data suggests the more we treat all patients the same, the better the outcomes, but no one wants to be another cog in the medical industrial complex.

I am motivated by the facts, and have a trust in the long term validity of the results of medical research. Ideas wax and wane, but most people in the field are doing good work and are not dishonest. They are good people trying to do good work. Dr. Wakefield is an aberration. However, to the anti-vaccination crowd, not only is Dr. Wakefield a source of truth, the rest of the results of biomedical research are suspect. It is the post-modern questioning of the legitimacy of authority and science, and neither is valued nor trusted. In my world, both are valued and trusted.

So where does that leave science based medicine? I am not certain. I value facts, medical and scientific authority, always with the understanding of its somewhat fluid nature. The ‘other side’ does not value facts or the weight of expert opinion, especially when it contradicts their opinion. Those who promote anti-vaccination or homeopathy or the numerous non-reality based therapies live in a different world than I, and we do not share a common common view.

What is the proper dialog or is such a dialog even possible? I suppose the best I can do is plant a seed of doubt here or serve as a source of information for someone who is not committed to the ideas of scams. Maybe Fordor’s needs to have a new guide.

Posted by Mark Crislip

Mark Crislip, MD has been a practicing Infectious Disease specialist in Portland, Oregon, since 1990. He is a founder and  the President of the Society for Science-Based Medicine where he blogs under the name sbmsdictator. He has been voted a US News and World Report best US doctor, best ID doctor in Portland Magazine multiple times, has multiple teaching awards and, most importantly,  the ‘Attending Most Likely To Tell It Like It Is’ by the medical residents at his hospital. His growing multi-media empire can be found at