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Tuesday, February 16, 2016

Cover Sheet & Handout for Legislators in Olympia!

Is There Actually A Vaccination Problem in WA?

HB 2009 seeks to eliminate our existing right to take a philosophical exemption to vaccine requirements for school entry.  This discards our right to Informed Consent by threatening the education of our children in order to force vaccine compliance. 

In an emergency, we want our public health bodies to take necessary action. 
We are not currently facing a public health crisis that would warrant such legislation.

(1) Every disease that can be effectively controlled with a vaccine is being effectively controlled with a vaccine. Larger outbreaks of disease come from vaccine failure, not vaccine refusal.
(2) Deceptive statistics are being used to suggest large numbers of parents are refusing all vaccines. This is false. Most children who have a vaccine exemption have skipped or deferred a single vaccine, not all of them.
(3) Diseases which are NOT vaccine-preventable are far more dangerous for the immuno-compromised than those we can vaccinate against. 

The right to Informed Consent and the right to a Free and Appropriate Public Education each stand independently. Rights are not interchangeable. Requiring anyone to choose between any rights sets a dangerous precedent.

We are not facing an emergency that justifies interfering with access to public education.  Such legislation sets a dangerous precedent that makes sense only in the midst of a public health disaster on the scale of the 1918 influenza epidemics. We are not currently in such a disaster, nor are we likely to be in one. Voluntary vaccination is working.

Is HB 2009 warranted or appropriate for Washington State? No. 

Medical Paradigms Matter

Medical paradigms are the basic models that shape how we think about medical questions.    Having a correct paradigm can drive major advances. Having an incorrect paradigm can blind us to mistakes, even serious ones. A dramatic example of this phenomenon can be seen in the history of cholera.

Cholera is a disease that causes death by dehydration, often within 24 hours. In the 1850’s, cholera ravaged London. No one knew what caused it, only that people were dying by the thousands. There were many theories as to the exact cause of cholera, but many of them centered on a single paradigm: miasma. In this paradigm, disease is caused by foul odors.  

Edwin Chadwick, now considered the father of public health, advocated tirelessly for government to take responsibility for public infrastructure to protect the health of society. He wanted to clean the air and rid the city of cholera. So he dumped all the human waste of the city into the Thames river, which also served as the city’s main water supply.

Cholera is waterborne. It is estimated that 15,000 people died.

John Snow was an anesthesiologist and Henry Whitehead was a minister. These two “outsiders” began to explore the issue with fresh eyes - and they presented strong evidence that cholera was waterborne. Now we revere them. But at the time, the establishment disregarded their evidence, calling them idiots and amateurs. As it turns out, they were entirely correct.

Edwin Chadwick was also correct. Government has a moral obligation to support public health, which is why we honor him. He was dedicated to the common good. But his first strategies to support that common good were disastrous, because his premise was flawed. 

Today, we face a similar paradigm problem around the social science of vaccine medicine. The unquestioned paradigm of most vaccine education is that people fall along a continuum from very pro-vaccine to very anti-vaccine, and that people can be moved along this continuum in a predictable way through a combination of education and force. Almost all of our current public health communication is based on this “Continuum Paradigm”. There’s only one problem: it’s not true. 

There have been very few social science studies done on vaccine decision-making, but none of them support the continuum paradigm. Two of these studies are at the back of this packet for your consideration. 

Acting on a false paradigm causes unpredictable results at best.  Sometimes, it costs lives.

The Simplifer/Delegator/Questioner Paradigm

The S/D/Q paradigm is quite different from the Continuum paradigm. Instead of focusing on what people decide, the S/D/Q paradigm focuses on how people decide. The S/D/Q paradigm has not yet been directly tested in clinical trials. However, it does match the data from existing studies about vaccine attitudes. The S/D/Q paradigm has also been implemented with great success on Vashon Island as a way to reduce hostility and improve communication.

The S/D/Q paradigm states that for any given area of health care, an individual will choose one of three strategies:

Simplify:  Create a simple rule about this type of medical care, usually pro or con.

Delegate:  Find a trustworthy authority figure and follow instructions.

Question:  Collect data from a variety of perspectives and take personal responsibility for decisions based on that data.

When discussing vaccines, each of these strategies offers something vital to the larger society.

(1)  Simplifiers, whether pro or con, offer vital protections to society. 
  1. Anti-vaccine Simplifiers raise awareness about vaccine problems. Our first drug safety law, the Biologics Act of 1902, was passed after anti-vaccine Simplifiers raised awareness about a contaminated vaccine batch that killed a number of children.  
  2. Pro-vaccine Simplifiers support everyone’s access to vaccine medicine. The Vaccines for Children program exists because pro-vaccine Simplifiers made sure it got passed and funded.

(2)  Vaccine Delegators reflect the decisions of other people, magnifying the effects enough so that statistically significant conclusions can be drawn.

(3)  Vaccine Questioners promote the best possible use of science by continually asking questions. This allows discoveries that can improve our use of vaccine medicine, and protects us against rigid assumptions.

What is changing (and what is not)?

Many people have observed an apparent trend of increasing vaccine exemption rates and concluded with some alarm that anti-vaccine sentiment is on the rise. This is incorrect and based on both the false Continuum paradigm and deceptive statistics.

There is no increase in anti-vaccine Simplifiers. This is the group that is called anti-vaccine extremists in the old, inaccurate Continuum paradigm. They generally call themselves anti-vaxxers.  This group has held stable at less than 3% of the population for more than 100 years.

There is a large shift from Delegators to Questioners. This shift is not just found in vaccine medicine. We have seen this shift in every area of health care over the last 50 years or so.  There are many reasons for this shift, including general skepticism of authority, changes in the practice of medicine, and the increasing availability of information via the internet.
There is also a huge shift in how we define vaccine exemption. Consider, if you will, a six year old child who is fully vaccinated against rotavirus, diphtheria, tetanus, pertussis, measles, mumps, rubella, polio, chickenpox, Hib, pneumococcus, and hepatitis A. This child even just had his annual flu shot.  Most people would consider this child vaccinated. But according to many statistics, this child is classified as “unvaccinated” because his parents chose to defer the Hepatitis B vaccine until adolescence.

This bizarre definition of “unvaccinated” also means the rate of “unvaccinated” kids will rise every time a new vaccine is introduced. Most kids with vaccine exemptions are vaccinated.  

This gets even more absurd when people start making hysterical claims that the unvaccinated kids are going to bring back polio. In fact, vaccination rates for polio are high. In other words, skipping the chickenpox vaccine will not bring back polio. 

For that matter, nearly the entire adult population would be considered “unvaccinated” if held to the same standards as schoolchildren! Are you “unvaccinated” by these standards?

Contrary to recent hysteria, the measles/mumps/rubella (MMR) vaccine also continues to be a very popular vaccine. Measles is one of the most contagious diseases on earth. If Disneyland had more liberal refund policies, it is possible that the contagious individual would have stayed home and saved us all a lot of time, money, and stress. Regardless, this highly contagious virus was introduced into the best possible environment for transmission, followed by many of the exposed individuals getting on airplanes and flying all over the world. Despite this perfect storm of exposure, less than 200 people got measles. This is what herd immunity looks like.

Delegators & Questioners Need Different Messaging

The false Continuum Paradigm leads to many serious errors when communicating about vaccines. The three different styles respond very differently to information. Using the wrong approach is a waste of resources at best and counterproductive at worst.

Simplifiers can and should be disregarded for the purposes of public health messaging. There aren’t enough of them to alter the patterns of disease transmission and they are not going to change their passionate beliefs because of any public health campaign.

Delegators are swayed by appeals to authority. Large amounts of data tend to make them uncomfortable and overwhelmed.

Questioners dislike and distrust appeals to authority. They prefer large amounts of data, including complex data and ambiguous data.

Certain characteristics in the overall population tend to lead to better health outcomes: more education, higher incomes, and more involvement in health care. However, these same characteristics also produce a population that has a relatively high percentage of Questioners.  Current public health messaging is not meeting the needs of this demographic.  Instead, the focus has been on trying to make Questioners act and think like Delegators.  This approach will not work.
Rather than fearing an independent thinking and highly-educated population, we need to capitalize on it. It is time to develop new communication strategies that will meet the needs of both Questioners and Delegators. 

Visual model of the S/D/Q paradigm

Vaccines Simplifiers make up a small portion of the population. More than 90% of the population are either Delegators or Questioners.The ratio of vaccine Delegators to vaccine Questioners will vary based on demographic factors like income, education, and access to health care. The same factors that produce better health outcomes also produce more Questioners.

attach moving pie chart here

Scientific Studies refute the Continuum paradigm

In 2013, a study was done with the objective “to test the effectiveness of messages designed to reduce vaccine misperceptions and increase vaccination rates for measles-mumps-rubella (MMR).” The results were that, “None of the interventions increased parental intent to vaccinate a future child.” The conclusions of the article were that, “Current public health communications about vaccines may not be effective. For some parents, they may actually increase misperceptions or reduce vaccination intention. Attempts to increase concerns about communicable diseases or correct false claims about vaccines may be especially likely to be counterproductive. More study of pro-vaccine messaging is needed.” Full text of the study may be found at

Interestingly enough, this effect is not limited to the United States. A similar study done in the UK had similar results, concluding that “Pro-vaccine messages may be counterproductive among vaccine-hesitant parents.” Full text of the study can be found at

Many similar studies exist. Any time we study the social science of vaccine attitudes, the results are not consistent with the continuum paradigm. By all the standards of science, the continuum paradigm is false. Continuing to build public policy on a false paradigm is unlikely to succeed.

The results of these studies are perfectly explained by the S/D/Q paradigm. While that does not necessarily mean that the S/D/Q paradigm is correct, it does indicate that the S/D/Q paradigm is worthy of further exploration and research. For more information on the S/D/Q
paradigm, please email us at or visit our blog: 

Overall summary
Medical paradigms matter. Taking action based on a false paradigm is risky and can cause unintended consequences. We have growing evidence that the continuum paradigm is false.

Voluntary vaccines continue to be popular. Removing the option of the philosophical exemption infringes on Informed Consent. This is a form coercion that is both unnecessary and may have the paradoxical result of reducing both the popularity of vaccines and confidence in vaccines.  

There is no current health crisis. Every disease that can be effectively controlled with a vaccine is being effectively controlled with a vaccine. Small outbreaks, such as the Disneyland measles outbreak, are to be expected in high-density situations. Large outbreaks, such as the pertussis outbreaks, are the result of vaccine failure, not vaccine refusal. 

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Welcome to the conversation. Knowledge changes. People respond best when this truism is kept in mind. In community, March & Karen