Introduction
The implementation of vaccinations against once prolific diseases such as measles, mumps, pertussis, and chicken pox, has long been heralded as one of the most important medical success stories in modern history. Illnesses that once viciously swept through countries, killing hundreds of thousands of children and costing millions in medical bills for society, have been stymied by this most ingenious form of prevention. In the years between 1994 and 2013, vaccination programs in the United States have prevented 322 million illnesses, 21 million hospitalizations, and $295 billion in direct costs of medical treatment, not to mention $1.38 trillion in societal costs (Whitney et al. 2014). However, vaccination rates in certain areas of the United States and other developed countries have begun to drop, leading to the revival of some diseases which had previously been labeled as eradicated, such as measles and pertussis.
Cases of measles at Disneyland, in Ohio, and in France in the last decade have shown just how quickly diseases can return without strict adherence to the vaccination guidelines suggested by medical professionals and researchers. So why are people choosing to opt out of vaccinating their children? The issue is made complicated by the wide range of reasons which parents use to explain their decision. A study in Switzerland cited reasons varying from fears of what they are injecting into their children and the possible side effects, to not feeling that they have been provided with sufficient information to make a responsible choice for their child (Fadda et al. 2015). One unifying theme that research has recently begun to identify, however, is the patients' subscription to complementary or alternative medicine (CAM) practices. CAM includes massage therapy, naturopathy, acupuncture, and chiropractic practice (Complementary and Alternative Medicine in the United States 16). What aspects of CAM practices affect rates of vaccination? If this correlation can be shown to be valid, how can conventional medical practitioners bridge this gap? The fundamental, cultural distrust between CAM and conventional medical communities leads patients to feel divided between their care providers, making them more likely to opt out of vaccination due to confusion. To prevent the decline in vaccination rates from continuing to drop, conventional physicians must cooperate with their patient's CAM providers and allow for a more integrative and comprehensive approach to medicine.
This paper will begin by exploring the background on vaccine importance and effectiveness and investigate current events sources and biological research to show how and why we know vaccination rates are falling in developed countries. Second, data collected by researchers in the field of pediatric medicine, as well as popular opinion research will be used to support the claim that there is a correlation between use of CAM and the anti-vaccination movement. Third, medical and sociocultural research on CAM practices and ethics will be examined to deduce what aspects of CAM can be attributed to patients' attitudes towards vaccination. Finally, suggestions for how this issue could be ameliorated will be presented.
Background
Vaccination Efficacy and Importance
To understand why lowered vaccination rates are detrimental to society, one must understand the fundamental basis for how these medical marvels work. Many people belonging to the anti-vaccination movement lack a basic understanding of how inoculation works, ranting that doctors are attempting to inject the world's children with disease. Of course, this is the elementary way in which vaccines work–small injections of modified diseases must be injected into the human body so that the immune system can be taught how to respond to that foreign invader. This small introduction allows the body to build up a recognition of the threatening disease in case the human should ever encounter it again in the real world (Sadava 860). The next time the pathogen and the person meet, her immune system's antibodies will know just how to respond.
Not only do vaccinations protect the individual, they also establish within a community the phenomenon of "herd immunity." This means that when a certain percentage of individuals are inoculated, the whole population can be protected from the threat of that illness, most importantly, those who are physically unable to be vaccinated, like the elderly and very young, or those with immune deficiencies. To achieve this percentage level of protection, a certain threshold value must be met based on the voracity of the disease. Researchers mathematically determine the basic reproduction number (R0) for a disease, which provides the data on which to build a recommendation of what percentage of a population needs to be vaccinated for the herd immunity to be effective (PBS Herd Immunity). Usually, these R0s require an extremely high rate of vaccination to reach the threshold immunity– somewhere in the 80th or 90th percentiles. So, although not much more than 10% of people may opt out of vaccinating, even this small proportion can vastly reduce the quality of the herd immunity the medical community is trying to uphold, which is why it is so essential to find a solution for dropping vaccination rates.
The scientific community cannot deny the fact that injecting a child with foreign substances is a scary prospect, and, indeed, there are many instances where vaccines have triggered severe reactions in recipients– these are issues that researchers are constantly trying to resolve. For example, a NOVA documentary, Calling the Shots, discusses a case in which an oral polio vaccine tragically caused paralysis in a young patient. After the father's advocacy for a change in the vaccination, however, this drug was pushed off the market, and replaced by a safer, injectable version. Instances like these show that while there can be serious side effects to vaccines, it is important to understand that rejecting vaccines altogether will not protect the general public from harm in any way. Change must be affected through research and dialogue.
In any case, however, the overwhelmingly positive contribution to global society that vaccinations have made is unprecedented. They have eradicated many diseases in developed and third world countries, they save trillions of dollars in healthcare cost to governments and citizens, and, most importantly, they save millions of lives every year (Two Decades of Vaccination Success). To continue this important work, it is of the utmost importance that the medical community determine the root of the anti-vaccination movement's success and come up with a way to slow its growth.
Anti-Vaccination Sentiment and Prevalence
In order to understand the anti-vaccination movement, one must identify those areas in which preventable diseases have recently had large outbreaks, and root out the underlying causes. In the NOVA documentary "Calling the Shots", doctors express their shock at encountering cases of measles, a disease believed to be long eradicated, in the heart of New York City. In 2010, around 9000 cases of pertussis were reported in California, 89 % of which were under the age at which they could be vaccinated for the disease (Diekema 391). Infants under the age of six months rely on herd immunity against pertussis, and at this time in California vaccination rates were clearly not high enough to provide this protection. Diekema also reports that despite an overall vaccination level which appears satisfactory, some areas in the United States which cannot be labelled economically challenged, such as San Juan County in Washington (San Juan County Profile), have much lower vaccination rates than the rest of the country, corresponding to more outbreaks of diseases like pertussis (Diekema 392). These cases exhibit that preventable diseases are not re-emerging in impoverished, uneducated areas, but rather wealthy communities where parents are making a conscious decision to not vaccinate their children. Large outbreaks of measles and pertussis across the United States in isolated regions emphasize this pattern.
A study done in Switzerland interviewed dozens of families, attempting to solve the mystery behind why smart, well-to-do families across the world are choosing to not get their kids vaccinated. The participants were asked to explain why they were choosing a different timeline for vaccinating their children or choosing not at all– what caused their hesitations or distrusts? Responses ranged from the fear of unnatural chemicals and their side effects, to believing that a government's decision not to enforce the mandatory title of a vaccine made it unnecessary or unsafe, to not feeling educated enough about the subject to decide either way (Fadda 4). These results show the complexity in determining a way to categorize what an anti-vaccinator believes and directly approach that issue. In another study attempting to understand the population opting out of vaccines, Browne et al. in Australia conducted a number of personality tests on their subjects to help them determine any sort of correlation between personality and belief with anti-vaccine sentiment. They also performed questionnaires regarding whether the subjects had utilized any complementary or alternative medicine in the last year. This data led them to the conclusion that the strongest influencer of whether a person was against vaccination was their general preference for alternative medicine or their spiritual orientation (10). These conclusions and their implications will be examined more closely throughout the entirety of this paper, as they provide a method for the medical community to identify those who may opt out of vaccines, allowing steps to be made towards reversing the trends in vaccination rates.
Complementary and Alternative Medicine as an Indicator for Anti-Vaccination Sentiment
Complementary and alternative medicine are those practices and products which are either used alongside or in lieu of conventional medicine. Nowak et al. divide CAM into five categories: "alternative medicine systems, biologically based practices, manipulative and body-based therapies, mind-body interventions, and energy therapies" (362). The most common of the CAM modalities are chiropractic, naturopathic, homeopathic, acupuncture, and massage. With increasing research promoting the correlation between CAM treatments and anti-vaccine beliefs, as well as reduced-likelihood of pediatric inoculation, it is necessary to understand the trends in popularity of CAM in recent years and what attitudes CAM providers have towards vaccination. By examining the prevalence of CAM in developed countries, the medical community can predict future patients' outlook on conventional treatments, particularly in regards to vaccination. In this way, a plan for how best to interact with and treat CAM users can be devised.
Trends in CAM usage
In recent decades CAM usage has increased dramatically, and today over 40% of American adults claim to have used some form of complementary or alternative medicine. The World Health Organization has recognized this increase in demand for CAM and states that its inclusion into medical treatment could be largely beneficial to worldwide health care access (Nowak et al 362). Though pediatric use of CAM is much lower than adult, increases in this area have been detected as well, with percentages in the U.S. rising from 2% in 1996 to around 6% in 2002, particularly in chiropractic and naturopathy practices (Downey et al 923). However, because parents are generally the decision-makers of whether to opt out of vaccines or not, parental usage of CAM is thought to be an important indicator for whether a child will receive his vaccinations or not. MacLennan et al. found that between the years of 1993 and 2000 usage of nearly every form of CAM had increased. It was also found that usage was more common among females, the educated, the employed, and people below the age of fifty. Furthermore, the study emphasized the increased economic cost to society that the surge in CAM popularity brings with it (171).
Studies have shown that education level is one of the strongest predictors of whether a person will be inclined to use CAM methods, with college undergraduates making up the largest proportion of participants in the United States (Nowak et al. 363). When taken in relation to the anti-vaccination movement, this intellectual preference for CAM can help to explain why a more educated population of higher socio-economic class is opting out of vaccinations. If use of alternative medicine can be labelled a predictor for opting out of vaccinations, and primarily educated people are taking part in this type of treatment, then it follows that this population would be more likely to have lowered levels of inoculation. These educated individuals have begun to turn to alternative medicine primarily in search of solutions for health problems that conventional medicine cannot, or has not, provided them with. Typically, this relates to chronic pain or dire medical diagnoses for which there is no cure, or the treatment is considered highly toxic (Ernst 91). CAM users, which researchers have found to be highly health conscious, seem to be looking for treatment methods with almost no adverse effects, as well as a more autonomous platform for maintaining their family's health.
Evidence relating CAM usage and vaccination rates
As more outbreaks of preventable disease occur around the world in the developed countries where CAM is gaining popularity, the correlation between the CAM and vaccination is difficult to ignore. Many researchers have attempted to link the two, by looking at records of vaccination and medical bills to see where patients were treated, or by interviewing CAM users about their opinions on vaccination. These studies are an integral part of understanding why vaccination rates are faltering in some areas of countries like the United States and Australia, so that steps can be taken towards stopping the spread of diseases like measles and pertussis.
Research done by Professor Matthew Browne and his collaborators, which correlated personality traits such as spirituality, creativity, and openness to new experiences with a patient's attitudes towards inoculation, shows just how strong of a predictor use of CAM can be for those who will have negative ideas about vaccination. This study concluded that preference for CAM was the biggest indicator for negative vaccination attitudes, followed by spirituality and openness. A study done by medical researcher Lois Downey and her colleagues, elaborates on this conclusion by compiling a large base of statistics from Washington state medical records about whether children met the vaccination requirements laid out by the healthcare effectiveness data and information set (HEDIS)– meaning four shots were received between the child's first and second year of life. Downey at al. also examined the relationship between pediatric CAM use and outbreaks which could have been prevented by the four vaccines proposed by HEDIS because research shows that exemption from school immunization requirements correlates to increased outbreaks of preventable disease. Though only a small subset of the patients on record used CAM treatments (3%), Downey found that not only children who had seen some form of a CAM provider themselves, but also those who had had family members receive CAM treatment were much less likely to have received the four vaccinations. Likewise, acquisition of preventable disease was quite low, but those who had received CAM treatment experienced these illnesses at higher rates than those who used conventional care.
These results are important because they give statistical significance to the correlation between the increase in popularity of CAM practices and outbreaks of preventable disease. Particularly because a large sample set was used in Downey's research (11,144 children), this data is instructive in that it bridges the hypotheses that CAM users are less likely to vaccinate, and those that do not vaccinate will be more likely to acquire a preventable illness. Furthermore, Browne's success in discovering a category of personalities who were more likely to feel anti-vaccination sentiment contributes to the conventional community's ability to predict who will stray from vaccination recommendation, in general. Of course, these conclusions do not reflect the reality of the entire world, nor do they apply to every individual who may fit these descriptions, and more research should be done to further illustrate this point, but results such as these provide the medical community with an area on which to focus their efforts for increasing vaccination program adherence.
Why do CAM users opt out of vaccination?
Correlations between CAM use and aversion to vaccination use can be widely found within scientific literature, but the reasons for why this relationship is found are not as clear. As explained before, the primary group of people seeking CAM treatment are those who are well-educated and employed, often seeking more natural methods for treating persistent or dire medical issues. But how does this relate to vaccine sentiment? The answer cannot be found in differences between scientific evidence gathered by the CAM community compared to research that has been done by the conventional community. Science resolutely upholds the efficacy and importance of vaccinations. CAM users, in general, are not being swayed by scientific facts, but rather by the influence that their CAM practitioner may have on them, or the beliefs that go along with alternative medicine.
CAM practitioners' attitudes towards vaccination
Though international CAM associations have no official stance on the immunization issue, there is considerable evidence that the CAM community is anti-vaccine. While associations such as the American Chiropractic Association or the International Chiropractors Association do not actively advise against getting vaccinated, they do stress the importance of the patient's right to choose, as well as the risks involved with inoculation (Downey et al. 923). Individual practitioners have been surveyed on their beliefs towards vaccinations, with responses varying between fields, but with particularly negative feedback from chiropractic, homeopathic, and naturopathic providers. Only a small percentage of these people, around 9 %, claimed to actively discourage their patients from receiving vaccinations, while the majority made no recommendation at all (Ernst 92). However, many held alarming beliefs surrounding the risks and importance of vaccinations were held by a large population of CAM providers, for example, that vaccines actually caused disease rather than preventing it, that side effects such as autism were possible, or that the government and public health agencies involved with vaccination programs should not be trusted (Browne 2). Obviously, the exposure to clients of these ideas could be extremely detrimental to that individual's perception of vaccinations. If CAM patients frequently receive this type of negative information from their CAM specialist, or other alternative medicine resources such brochures, websites, or conferences, it would clearly follow that these people would be more concerned about the dangers of vaccinations than someone who only sees a conventional physician, therefore making it more likely that they would opt out of vaccinations for their families.
CAM values that affect patients' and practitioners' views on inoculation
The general attitude of the complementary and alternative medicine community towards vaccination is not wholly surprising – there are many values associated with CAM that are in contrast with those of mainstream medicine. The most prominent of these is simply the extreme focus on natural and pure forms of treatment. Much of alternative medicine has to do with finding something in nature and using it to treat an ailment, dealing with different types of energies within the body, or taking a pathogen and purifying it to its elements and administering this as the anti-drug for an illness (Ernst 91). CAM practices are intended to keep the body pure of any toxins and functioning as naturally as possible. Not surprisingly, this contributes to the CAM community's distrust of vaccinations because it is hard to know what the effects of putting something containing foreign viruses, chemicals, and minerals into a body might be.
Besides the contrasting forms of treatment used by these differing genres of health care, the approach with which practitioners in the opposing fields treat their patients is often very different. Typically, CAM treatments are highly individualized to the patient, based on certain characteristics, ailments, and symptoms, whereas a conventional doctor may prescribe the same medicine or dosage to many different patients. Furthermore, the success of a treatment or procedure is thought to be dependent on certain qualities and strengths of the particular healer. While this is not so different from conventional medicine, it does encourage increased respect and trust from a patient if the CAM treatments have been effective. Alternative medicine effectiveness is also believed to rely heavily on the bond between the practitioner and the patient (Institute of Medicine 110). An especially close relationship between patient and physician would greatly increase the odds that the patient would trust their CAM provider for advice about vaccinations, and believe whatever information they were guided to. This could be damaging to vaccination perception if the CAM provider held doubts about the safety and necessity of the conventional vaccines, as many do.
In general, complementary and alternative medicine is grounded in a much more spiritual view of the human body. Practitioners are not seen as scientists trying to cure one single health problem, but rather as a guide to a more comprehensive healing for the patient, involving the body, mind, spirit, and energy. CAM providers are devoted to helping their patients find autonomy in their health care and strongly advocate for the patient's right to choose, especially with issues like vaccination (Nowak et al. 369). For reasons such as these, it is not hard to understand why many people are interested in partaking in forms of alternative medicine, especially highly spiritual people, those who value all-natural lifestyles, and those who feel strongly about their independence in all aspects of life. At the same time, these CAM qualities are often clearly in contrast to conventional medicine as a whole, because it so often adheres to rigid guidelines, policies, and treatments, not to mention the government and big pharmaceutical companies are intimately related with conventional medical care, and many independently-minded people are suspicious of this. For all of these reasons, certain groups of people are attracted to alternative medicine, and are therefore more at risk for being anti-vaccination.
Lack of communication between CAM and conventional medicine communities
Because alternative and conventional medicine systems are generally accepted to be very different, and often in conflict, there has been little exchange of ideas, information, and policy between the two medical sectors. In medical school, students are instructed a very minimal amount about alternative practices, for they are viewed as ineffective and inefficient in comparison to conventional methods. This widens the gap between what the two genres know and understand about one another's treatments, making it difficult for physicians in the future to collaborate well with patients receiving alternative care outside their own practice. Conventional physicians who have not been educated in the various types, practices, and beliefs of alternative medicine may not feel comfortable advising or discussing usage of such treatments with their patients, which could reduce their credibility and trustworthiness in the eyes of their patient. Additionally, there is no policy requiring that patients report to their conventional care giver that they have been partaking in CAM treatments, or vice versa (Institute of Medicine 180). Without this information being given, the treatments of the two practitioners may be in opposition to one another, reducing the effectiveness. Also, if a patient is receiving contrasting information about issues such as vaccination, it could create confusion which would cause a delay in a parent's decision to vaccinate their child or not.
Conclusion
The evidence that usage of complementary and alternative medicine is correlated to lowered uptake of vaccinations is substantial. Data from around the world supports this theory by examining the philosophical beliefs and records of participation in CAM of patients, and comparing these factors to their vaccination records. When the basic tenets of alternative medicine are investigated, it is clear that the focus on the natural and spiritual healing of patients would make vaccination counterintuitive to both practitioners and users of this form of medicine. So, if the popularity of alternative medicine continues to rise as it has in the last few decades, conventional medical professionals must look closely at their relationship with alternative medicine and determine how it could be changed to prevent more decreases in vaccination levels across the globe. Browne et al. assert that the minds of those who partake in CAM therapies, which have little to no empirical evidence to suggest that they are effective, are "unlikely to change by appeals to reasoning or evidence alone" (2). Instead conventional physicians will have to change how they interact and communicate with the CAM community, so that more effective and responsible care can be achieved, especially in regards to vaccination.
One of the primary ways in which this could be achieved if through the introduction of some CAM principles into the medical school curriculum. As medical professionals, it is essential that these students learn everything that their patients could encounter. With the growing prevalence of CAM in developed countries, it is likely that more and more patients will partake in these therapies. By getting an educated overview of the genres of CAM, their risks and benefits, and an outside perspective on conventional medicine, conventional doctors would be much better equipped to instruct their patients on how best to integrate CAM into their health regimen, if at all. Doctors who are sympathetic to alternative medicine practices and beliefs will be more likely to come across as trustworthy and respectful when dealing with patients who are interested in CAM, reducing the likelihood that they will alienate these patients who do not conform to the typical protocols or treatments.
Another important change to make in order to boost cooperation between the two types of medicine is to set guidelines for reporting systems, so that doctors will be more fully aware of the care and advice given by alternative practitioners, and vice versa. When no communication is fostered between the two providers, the patient is more at risk for feeling divided between allegiances to them, which reduces their bond with one provider, and strengthens their attachment to the other – likely the CAM practitioner, for reasons laid out before. Requiring the patient to explain what treatments and information they have been given by their CAM doctor, would provide the conventional physician with the opportunity to express their own opinions more fully and to answer any questions that the patient may have had after receiving CAM.
Alternative medicine, in itself, is not a dangerous thing – in fact, it can be highly beneficial to many ailing patients seeking a new way to treat pain or illness. However, because of its correlation to lowered vaccination rates, CAM usage should be known as a likely predictor for families who will opt out of vaccination, potentially putting herd immunity levels at risk. By improving their knowledge of the complementary and alternative medical field's beliefs, practices, and shortcomings, the conventional medical community would be much more equipped to fight back against this surge of anti-vaccine sentiment.
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