"I am a pro-vaccine doctor. I am also a pro-information doctor." So says Robert Sears in his preface to The Vaccine Book: Making the Right Decision for Your Child, a best-seller billed on Amazon.com as a "fair, impartial, fact-based resource."
The average reader might never guess that Sears, a pediatrician in Dana Point, California, is actually an intensely controversial figure in the mainstream medical community. For parents who worry that vaccines might be harmful, he offers alternative vaccination schedules that omit or delay certain shots. Sears argues that this is the best way to get through to hesitant parents, who may otherwise fail to get their children vaccinated at all.
But many of his fellow doctors accuse Sears of downplaying the dangers of infectious disease and misrepresenting the evidence from studies that have shown vaccines to be safe and effective. The Vaccine Book is "peppered with misleading innuendo and factual errors," wrote Rahul Parikh, a doctor in Walnut Creek, California, in a 2010 article for Salon, describing the book at "a nightmare for pediatricians like me."
Sears' vaccine schedules, according to his critics, put children at risk by extending the period during which they are susceptible to infectious disease. "I think it's wholly irresponsible," Paul Offit, director of the Vaccine Education Center at the Children's Hospital of Philadelphia, told BuzzFeed News.
But Sears' schedule enrages the mainstream for a more abstract reason too. It implicitly validates a dangerous idea: that vaccines are something to worry about. "It's not just that he fails to educate parents who are afraid of vaccines," Offit added. "He stokes those fears and says you can avoid those problems by using his schedule."
Offit has been an energetic and passionate advocate for vaccination for years, often taking flak from the anti-vaxxers for his troubles. I share his reading of the scientific evidence, and I have big problems with the way that evidence is portrayed in The Vaccine Book. But as Offit responded to my query about Sears, and his tone became increasingly strident, I couldn't help but wince. I understand why concerned parents would be drawn to Sears — known as Dr. Bob to his 41,000 fans on Facebook — and find Offit, well, off-putting.
This isn't just about personal styles of communication. The contrast between Sears and Offit exposes a wider problem for the scientific establishment, and one that social scientists have been shouting about for years. It's not enough just to be right. You need to think about how to sell the truth. If Offit and his allies paid as much attention to the science of communication as they do to the science of vaccines, it would be good news for public health.
The problem is that people’s opinions are influenced by a host of factors, including their personal experiences, social circles, religious beliefs, and political views.
Working out how to frame messages grounded in science so they hit home is hard, and the best approach varies from topic to topic. But the clear message from research on communication strategies is that lecturing people with the scientific facts will not, by itself, change their minds. It's a strategy doomed to fail.
Few parents are hardcore anti-vaxxers, and most don't accept celebrities' advice on vaccine safety. They just want what's best for their kids. They yearn for credible expert opinions, and they want their concerns and questions to be addressed with respect, not dismissed.
Sears has positioned his book to appeal to that audience. Its cover identifies the author as "Robert W. Sears, MD, FAAP," stressing his medical credentials. Inside, friendly Dr. Bob lays out his take on the scientific evidence in what seems an even-handed way. He makes frequent references to parents' worries, and recounts his own experiences from pediatric practice.
The Vaccine Book also sits within a circle of trust created by the Sears family business. Dr. Bob's father, William Sears (aka Dr. Bill), is perhaps America's best known pediatrician, the author of more than 30 books on parenting. On his popular website, askdrsears.com, he dispenses advice on parenting and health with his wife, Martha, a registered nurse, and his three physician sons — Dr. Bob, Dr. Peter, and Dr. Jim.
From the preface to Dr. Bob's closing message, The Vaccine Book appears safe and welcoming. "I hope I've answered all your questions," Sears signs off. "Your children are precious, and you have the right to make informed medical decisions for them. I wish you the best."
Sears is frequently wrong about the science, as many have noted. (Offit's criticisms of Sears are analyzed here.) But unless you've had professional training in interpreting scientific studies, it's hard to tell a flawed account of the science from the real deal. Sears' book seems perfectly reasonable. And that explains its appeal.
Contrast Sears' reassuring words with some of Offit's recent comments, such as this radio interview with Democracy Now! broadcast earlier this month. He came on the air immediately after Mary Holland of New York University, a legal scholar who attributes her son's autism to the MMR (measles, mumps, and rubella) vaccine. Offit could not contain his exasperation with what he'd just heard.
"You know, what is upsetting to me about this — and I honestly think the last 10 minutes of your program set a new record for consecutive statements that were incorrect — is that when you do the science, when you do these excellent, retrospective, huge studies that answer the question, that people don't believe them," Offit said.
Calling Holland a "conspiracy theorist," he went on: "I think that it is not important to have a debate about the science with someone who clearly doesn't know the science. I'm sorry, Ms. Holland misrepresented the science again and again and again."
I understand Offit's frustration. And he's right: Careful research has conclusively debunked the idea that the MMR vaccine causes autism. The 1998 study that claimed a link, setting off the scare over vaccines and autism, has been retracted by the journal that published it.
But Offit's reaction provides a classic example of how scientists can get into trouble when they find themselves in the rough-and-tumble of public debate. The reason some people reject the scientific consensus, they assume, is a lack of knowledge. So if you simply educate the public, then opposition will melt away. When it doesn't, scientists like Offit are prone to dismiss those who don't accept the evidence in a shrill, self-defeating way.
The assumption that knowledge is what matters is called the "deficit model" of science communication. The irony, given scientists' conviction that they are promoting an evidence-based view of the world, is that rigorous surveys have found little support for the idea that more knowledge leads to greater trust in science and for scientists — especially on controversial topics like climate change or the safety of genetically modified food.
Perversely, people who know more about science and are more numerate actually disagree more strongly over whether climate change is a serious problem, depending on their political views. Here, attitudes drive people's interpretation of the scientific evidence, rather than evidence driving attitudes.
Once false beliefs have taken hold, they are hard to shift through factual corrections alone.
Vaccines are no exception, as Brendan Nyhan, a political scientist at Dartmouth College in New Hampshire, found in a study published in March last year. Nyhan and his colleagues divided nearly 1,800 parents into groups and presented each with different information, based on material provided on the web by the Centers for Disease Control and Prevention (CDC), the federal agency responsible for the official recommendations on vaccination.
In an online survey, one group was shown text explaining the lack of evidence that the MMR vaccine causes autism, while a second got an explanation of the dangers of the diseases that the vaccine prevents. Two more groups were shown photos of children with measles, mumps, and rubella, or were presented with a dramatic true story from the CDC website about an infant who almost died of measles. The final control group received no information at all.
None of the messages had the desired effect on the parents' intent to vaccinate, and some were counterproductive. The images of sick children actually increased belief in a link between vaccines and autism, and the story about the child who nearly died heightened concerns about vaccine side effects.
"Throwing facts and science at people is ineffective," Nyhan told BuzzFeed News. "It doesn't change people's minds and it can make the problem worse."
I asked Offit what he thought of Nyhan's study. "I just think he's wrong," Offit told me, arguing that studies like Nyhan's can't account for the persuasive powers of a caring and passionate doctor. "I think we're pretty compelling," he said.
Maybe so, but it's strange to hear someone who urges parents to heed scientific evidence putting more faith in his own personal experience than the results of a controlled experiment.
I also worry that reactions from the pro-vaccine camp to the current measles outbreak could prove as counter-productive as some of the messages Nyhan put to the test. Parents who blame the non-vaccinating minority for putting children at risk are angry. That helps explain why lawmakers in California are trying to remove the state's "personal belief" exemption from school-mandated vaccinations, and enthusiasm for ideas like making non-vaccinating parents pay a "no-vax tax."
The danger is that some people who previously were unsure what they thought will see such moves as overreaching, and be pushed into the arms of the anti-vaxxers.
"When you turn issues into us-versus-them conflicts, some proportion of people decides they identify with the 'them,'" Dietram Scheufele, a specialist in science communication at the University of Wisconsin-Madison, told BuzzFeed News. That's even more likely if the debate becomes politically polarized.
Let's not lose perspective: The vast majority of parents support the medical consensus on vaccination. Imagine where we'd be if more than 90% of people not only accepted the evidence that human activities are warming our planet, but also agreed on what should be done about it.
On issues like climate change, a healthy majority of public opinion is enough to carry the argument. But vaccination is different, because it only takes a minority of refuseniks to undermine the "herd immunity" on which protection for everyone — including those who can't be vaccinated for medical reasons — depends.
So much for what doesn’t work. What does? The embarrassing truth, for vaccination, is that there’s little evidence to draw upon.
Doctors are used to being trusted figures whose advice is rarely questioned. So until recently, scant attention was paid to how to overcome problems like vaccine refusal. "We're really relying on anecdote and not data," Douglas Opel, a pediatrician at the University of Washington in Seattle, told BuzzFeed News. "Part of my work has been to try and fill that gap."
Opel set up video cameras in 16 doctors' offices and recorded their conversations about vaccination with more than 100 parents. The most important thing, Opel's team found, was how the subject was raised: Parents were more likely to vaccinate if the talk began with something like "Well, we have to do some shots," than if their doctor started by asking them what they wanted to do.
Finding that parents are more likely to get their kids vaccinated if it's obvious that their doctor views getting the shots as imperative is hardly rocket science. Still, Opel's work shows that it's possible to convey this conviction subtly yet effectively, without confrontation. It was just clear from start of the conversation that the most persuasive doctors had no personal doubts that their advice was sound.
But it's just one study, and by the time parents get to their pediatrician's office, the seeds of doubt may already be sown. That's why Saad Omer, a vaccine researcher at Emory University in Atlanta, is beginning to investigate how to communicate about vaccines to women when they visit their doctors during pregnancy. His approach includes providing doctors with suggested talking points, and an iPad app that pregnant women can view while they sit in the waiting room.
It will take several years to find out if Omer's prescription has the desired effect of convincing hesitant parents to vaccinate their kids — and more studies will be needed to give doctors a range of tried-and-tested options that help get the message across.
Until the results are in, here's some advice to anyone who cares about getting more kids vaccinated: Spend less time railing against Dr. Bob's equivocal "pro-vaccine" stance, and refrain from beating up on those who heed his advice. Instead, let's ask why some parents find his message more convincing than what the real experts have to say.
Peter Aldhous is a Science Reporter for BuzzFeed News and is based in San Francisco.
Contact Peter Aldhous at firstname.lastname@example.org.
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