Notes

Three broad strategies have been used to sway people from anti-vaccine beliefs. I refer to these as reactive, information-deficit, and community-based strategies. (Location 161)

When anti-vaccine activists cite scientific articles or use the language of evidence, typically they are aiming to justify beliefs that are held for non-evidence-based reasons. Addressing an argument without addressing the underlying emotional reasons for a belief is unlikely to be effective. (Location 165)

Community-based strategies, which I believe to be most effective, are strategies based on showing those with doubts that others in their community are vaccinating their children; that their peers in their mosque, synagogue, church, or temple who are also good parents have vaccinated their children; and that vaccination is an expectation of any good parent. (Location 173)

Those seeking more details on these claims can look to additional resources, such as Paul Offit’s books or Seth Mnookin’s The Panic Virus. (Location 178)

The best predictors of vaccine coverage were not membership in anti-vaccine groups but access to medical care as determined by private insurance coverage, race, and socioeconomic status. (Location 223)

The way that vaccines are introduced—as well as the cultural competency of those introducing them—to communities plays a very important role in preventing vaccine hesitancy. (Location 254)

Ukraine stands as an outlier, with both high vaccine doubt and a drop in vaccination rates for polio, measles, mumps, and rubella to around 50 percent. This drop preceded a measles outbreak. In Ukraine, vaccination is required prior to school attendance. However, it was often easier to obtain a fake certificate than to obtain a vaccination due to hospitals running low on free vaccines. This forced parents to face paying high costs at pharmacies. More than half of the more than forty thousand cases of measles in Europe in 2018 were in Ukraine. (Location 287)

Some Texas schools have vaccine-exemption rates as high as 40 percent. If a measles infection spread in this population, the risk would be not just to children with nonmedical vaccine exemptions but especially to immunocompromised children; the unvaccinated children’s infant siblings, who are far more vulnerable to hospitalization and death due to measles infection; the elderly; and those with acquired immunodeficiencies, such as those undergoing treatment for cancer and those with AIDS. (Location 309)

Immune function in the body has two “branches”: the innate and adaptive immune systems. Often both work together to fight an infection. The innate immune system responds generally to invasion and to bacteria, viruses, and parasites and does not need to be pre-exposed to a disease. The adaptive immune system recognizes particular bacteria, viruses, and parasites and generates an active response to their presence. (Location 438)

When enough of the population is protected from the disease, the incidence of the disease drops to the point where those who are vulnerable in the population are never exposed to it. Because infectious diseases survive by moving from one person to the next, if the disease cannot find a new host, it cannot continue. No one other than the initial patient (and perhaps one person with whom there is a chance encounter) becomes sick. Reaching this critical threshold in a population protects those who cannot receive a vaccine, which is why health officials often target vaccination rates to exceed herd-immunity thresholds. Once this threshold number exceeded, ongoing transmission of a disease can be ended. (Location 464)

The life expectancy at birth in England in 1750 was approximately thirty-five years. This low life expectancy was exacerbated by what is today an unthinkable infant-mortality rate. So-called puerperal fever, a postchildbirth infection often spread by physicians, took many lives, and preeclampsia, hemorrhage, and cephalopelvic disproportion were not understood, or well treated, making birth a significant risk for the mother, as well as the child. A life without major infectious illness was a luxurious rarity. (Location 485)

There has not been a case of smallpox since the 1970s, and the only known samples exist in secure government research labs in the United States and Russia. The disease was declared eliminated on May 8, 1980. Diseases such as whooping cough and measles are now so rare as to be considered remarkable, and millions of dollars are spent every year researching ways to combat diseases such as malaria and HIV. (Location 509)

The genetic material of a virus tells the cell which proteins to make to produce more viruses and is duplicated into every individual viral particle produced by an infected cell. These duplications are often imperfect and introduce errors into the viruses produced by that cell; these errors are known as mutations. (Location 599)

Gibbs and other anti-vaccine activists did not make scientific objections because they had approached the question with an open mind, and through scientific inquiry, they had decided that vaccination was ineffective. They started with a complex network of personal reasons for objecting to vaccination and approached the science as a source of prestige that could be borrowed for their arguments. From this viewpoint no experiment can be well enough designed, no controls adequate, and no evidence convincing. (Location 846)

Starting in 2008, this lowered standard of evidence came into play in several cases in subsequent years, allowing compensation for a variety of ailments with no biologically plausible link to vaccination, such as chronic fatigue syndrome, fibromyalgia, and multiple sclerosis. (Location 1261)

Legal rulings have no bearing on scientific and medical truth. Like scientists, legal professionals are interested in finding the truth (well, at least sometimes). However, the means that the legal profession uses to arrive at decisions are different from those used in science. In a legal ruling, a decision must be reached. In scientific inquiry, the starting point of every investigation, “I don’t know,” is the default epistemological standpoint, and most common endpoint for an investigation. There are not specific rules that scientists must follow to the letter while evaluating evidence; however, there are heuristics and scientific virtues that scientists follow and apply when conducting, evaluating, and peer reviewing evidence. Results published in the scientific literature are not considered to be final but may at any time be reconsidered in the light of additional evidence, conflicting experiments, or new discoveries. (Location 1270)

So: (US) court cases are not evidence of harm of vaccines.

These claims have followed roughly two parallel tracks, which have often become conflated. The first centers around a scientific paper that claimed the combined MMR vaccine used in England resulted in a kind of “regressive autism.” The second centers around the idea that thimerosal, a preservative that was used in vaccines starting in the 1930s, and largely ending in the 2000s was causing autism symptoms through a kind of heavy-metal poisoning. Both of these claims have since proven to be false. (Location 1452)

Wakefield did not declare his conflict—that he had been paid, in effect, to draw a link between the MMR vaccine and autism in order to justify legal proceedings. This clear conflict of interest was not disclosed to the public or to coauthors of the manuscript. The editor who had approved the article stated that had he known about the conflict, he would not have approved publication. (Location 1587)

The diagnosis of autism increased from 1988 to 1999, by seven times, but the vaccination rate had remained relatively stable at about 95 percent. (Location 1626)

The quantity and quality of this scientific body of work is impossible to ignore in an honest inquiry conducted by someone with scientific training. Did the media cover the findings of the scientists studying these questions as breathlessly and with as much excitement as it did Wakefield’s? It did not. (Location 1644)

Many news outlets attempted to provide ”balance” when discussing vaccination; however, although balance is a journalistic virtue when reporting on disputes, adding balance to a scientific question often elevates an extreme minority position, such as Wakefield’s, to a disproportionate position of false equivalence. This is frequently called false balance. (Location 1649)

Humans are also apt to see studies that find health risks as more trustworthy than those that show low or no risk. As a result, news is biased toward reporting negative stories, those that portray institutions or individuals as villains, and those that present opportunities for the media to serve its role as a watchdog. This can in turn lead to greater availability of information suggesting risk, which may in turn increase a person’s perception of the likelihood of a dangerous event taking place. (Location 1704)

many of the specific claims made in the paper began to fall apart. Many of the children documented in the paper had been diagnosed not with regressive autism but with Asperger’s syndrome, or with nothing at all. Some of the children, who had been believed to be “previously normal,” had previously documented developmental delays or abnormalities. Deer showed that all the children in the study in some way had their case histories altered or misrepresented to fit the paper’s narrative. (Location 1734)

He had received payment to produce plausibility in the scientific literature to help a lawsuit move forward and to market his own alternative measles vaccine. He hid this when conducting the study, violated ethics rules in examining the children, and misrepresented their patient histories and diagnoses. (Location 1750)

In 2009 the authors of the article “Denialism: What Is It, and How Should Scientists Respond?” sought to define science denial as constituted by five features that are shared in part or in total by denial. The first is relying on conspiracy theories to explain a scientific consensus. The second is using fake experts—people who pretend to have specific expertise but whose views go against established knowledge; together with this is attempting to discredit established experts. The third is cherry-picking data, or selecting only isolated papers that go against the dominant consensus. The fourth is demanding that science deliver impossible results, by being always perfect, or testing impossible questions. The fifth is using faulty logic. Vaxxed meets all of these criteria. (Location 1939)

If anything, Hooker’s paper demonstrates the scientific weakness of Wakefield’s hypothesis, due to the degree of statistical manipulation needed to massage a small effect from the data. (Location 1979)

Medical records taken in the first year of life indicated that Hooker’s son had documented developmental delays before vaccination. So Hooker’s statement in Vaxxed that vaccination triggered his son’s loss of verbal ability wasn’t true. Much like the CDC-whistleblower story, with a modicum of fact checking, Hooker’s story falls apart. (Location 2038)

One component of the apparent increase has to do with racial disparities in screening and diagnosis. Non-Hispanic white children are far more likely to be diagnosed with ASD than are black or Hispanic children. As time went on, these children started to “catch up” with their white counterparts. (Location 2050)

Similarly, placing better screening programs in place for the flu or childhood cancers would result in increased diagnosis rates that do not factually represent an increased prevalence. (Location 2057)

The phenomenon of Nobel Prize winners endorsing various crank ideas is so common that it has received a name: “Nobel Disease.” Over the years, Nobel Prize winners have supported or endorsed psychic mediums, Nazi racial theories, beliefs in ESP and paranormal phenomena, evolution denial, vitamin C megadosing, “quantum consciousness,” cold fusion, global warming denial, alien abduction, a holographic talking raccoon, AIDS denial, and homeopathy. All of this goes to show that brilliance in one area does not mean credibility in all areas. (Location 2122)

the safety profile of aluminum has been well established over decades of testing. Furthermore, there is already environmental exposure to some amounts of aluminum without ill effect. There is a small amount of aluminum present in breast milk, and infant formulas contain significant amounts of aluminum. Indeed the amount of aluminum in a liter of formula is comparable to the amount present in a dose of vaccine. (Location 2200)

The transcript shows that the majority of participants thought that the evidence was very weak, and no discussion of how to cover it up occurred. Indeed, it was clear that Kennedy mined the transcript of the meeting for quotes to make it sound like the opposite of what had actually occurred had occurred. Indeed the article even claimed that the Institute of Medicine had been paid by the CDC to cover up a thimerosal-autism link but did not present true evidence to support that claim. (Location 2427)

Thimerosal makes use of a property of heavy metals causing them to react with certain amino acids of bacterial proteins in a way that kills bacteria. The same principle allows certain metal tools, spoons, instruments, and brass doorknobs to self-sanitize by killing bacteria. These antibacterial effects are advantageous because they allow a single vial of vaccine to be used for multiple inoculations. (Location 2444)

Most human exposure to mercury comes from the consumption of fish, followed by dental amalgam, and occupational exposures. (Location 2451)

Regardless, despite no evidence of harm, the FDA recommended removal of thimerosal and started working with vaccine manufacturers to reduce levels or find alternatives. As work continued to safely reduce levels, research continued to study the question of harm. In 2001 a literature review showed no evidence of harm outside of rare acute hypersensitivity. (Location 2482)

Another looked at the rates of autism diagnosis in Sweden and Denmark, where thimerosal was eliminated from vaccines in the early 1990s, and found no link. At the time, many in the anti-vaccine movement were attributing a rise in autism diagnoses to the presence of thimerosal in vaccines; however, the rise in autism diagnosis occurred regardless of thimerosal’s presence. (Location 2491)

Despite the astounding amount of evidence suggesting the absence of such a link, anti-vaccine activists, such as Kennedy, have continued to criticize vaccines as containing thimerosal or “toxins.” (Location 2500)

Outside of mathematics, science does not prove or disprove, it only lends evidence for or against propositions. Proving a negative, that something does not cause any kind of harm, is especially difficult. (Location 2514)

Finally, the challenge is a reversal of the burden of proof. The burden to prove a scientific claim always rests on the person making that claim. All who have tried to show thimerosal as causing autism have failed. (Location 2526)

After many studies and systematic reviews, scientists have found no evidence that homeopathic treatments work. In addition, the proposed mechanisms of how it might work are totally implausible. Those reporting positive effects from homeopathy are mostly likely experiencing a placebo effect. (Location 2654)

However, there is no evidence to suggest that probiotics can prevent infections by any of the diseases that are prevented by vaccination, and there likely isn’t an additional benefit to taking probiotics when a person is not expecting to begin a course of antibiotics. (Location 2667)

A vitamin is an organic molecule, that an organism needs for its normal function, but which it cannot synthesize. Essential amino acids and fatty acids are excluded from being considered to be vitamins. (Location 2671)

For the most part, excessive vitamins are simply excreted as urine; however, there are some negative side effects associated with doses of vitamins A, D, and B6 in doses well in excess of a normal diet. Nevertheless various companies still market vitamins for various purposes they have not been shown to be effective for, such as preventing or treating the common cold. (Location 2684)

The picture this research paints is that patients seek alternative medicine not to avoid real medicine but to expand their portfolio of options and to have greater control of their own medical care. (Location 2713)

Merely seeking additional options doesn’t mesh well with what we’ve seen of the anti-vaccine movement so far. While someone seeking acupuncture for back pain may not deny that pain medication and back exercises are effective treatments, the anti-vaccine movement clearly does reject real treatment. The overlap between those who deny the safety of vaccines and those seeking alternative medicine warrants additional study. (Location 2733)

While some of the symptoms sometimes associated with ASD can be ameliorated with speech therapies, augmented communication, and individual education plans, cures marketed for autism are universally not science based. Such “cures” can victimize people with autism by exposing them to risky treatments, poisonous drinks, or expensive and ineffective treatments. (Location 2933)

Social media make use of direct person-to-person communication, absent centralized gatekeepers that previous means of communication had. (Location 3151)

On the social-media platform Twitter, fake-news stories propagate “farther, faster, deeper and more broadly” than true stories. (Location 3167)

A large fraction of websites presented by search engines can be anti-vaccine, and there is a high probability that someone seeking information on vaccines will encounter anti-vaccine websites; as of 2008 over half of the search results returned for “vaccine safety” and “vaccine danger” were inaccurate. About one-quarter of these websites aspire to claims of authority by imitating those of official organizations or by citing dubious literature, and many frame vaccination as a “debate” occurring within the medical community and offer “unbiased” information. (Location 3177)

By looking at the spread of anti-fluoridation misinformation, researchers concluded that social relationships may be more important for spreading misinformation than is the scientific content of such information. This finding is consistent with culturally competent means of addressing vaccine hesitancy as being most effective. Rather than evaluating the truth of claims, we evaluate the trustworthiness of sources based on our relationship to those sources. (Location 3265)

Cultural cognition is a hypothesis that may help explain some of this disparity. This hypothesis states (in summary) that we assess risks not based on accumulated facts and knowledge but, rather, in line with our cultural preconceptions and biases. For example, in a 2012 study, it was shown that those with the highest scientific literacy and technical-reasoning ability were likely to be most polarized on the issue of climate change. This finding suggests that inadequate knowledge of science is a secondary factor to this kind of scientific risk determination. (Location 3277)

Biased assimilation refers to the tendency of those who hold strong opinions on complex issues to examine empirical evidence in a way that is biased toward confirming their prior beliefs and to more critically evaluate evidence that challenges those beliefs. (Location 3283)

As human beings we have difficulty assessing our own level of knowledge and competence. This has been termed the Dunning-Kruger effect. The psychologists David Dunning and Justin Kruger conducted four studies in which participants were presented with tasks that required knowledge in humor, logical reasoning, or English grammar, and compared the participants’ self-assessment of their abilities to their actual scores. In each case, participant’s scores diverged most from their self-assessment among those with the lowest scores. Conversely, those with the highest scores tended to underestimate their abilities. Several explanations have been offered for this effect, including a lack of metacognitive ability among the incompetent; the inability to make accurate “social comparisons”; a tendency to compare one’s own ability to that of others; and the simple possibility that the less you know, the less likely you are to know how little you know. (Location 3298)

Vaccine advocates engaging in online discussion may presume bad faith, where none exists, on the part of the vaccine hesitant. (Location 3322)

Holly’s experience is typical of social-media interactions surrounding vaccines. Neither party was willing to give an inch, and neither party did. (Location 3345)

That doesn’t mean that social media needs to be abandoned as a means of communication. Facebook has an available audience several orders of magnitude larger than that of traditional means of scientific communication. Hundreds of millions of tweets are posted daily, and hundreds of millions of people use social-media platforms. Like it or not, these platforms have become the de facto means by which most nonscientists receive and access information about scientific discoveries. Internet communication can even lead to positive outcomes. Use of the internet increases positive attitudes about science overall, and access to science blogs can help address knowledge gaps across social classes. (Location 3350)

Since at least the early 2000s, attempts have been made to correct the record online by providing factual resources to counter anti-vaccine information. These work on an information-deficit model of science communication. The information-deficit model suggests that people with negative attitudes on scientific topics are simply lacking adequate information and that the provision of enough information will change the polarity of their attitude. However, the correlation between science knowledge and attitudes toward science and technologies (such as vaccination) is positive but weak. (Location 3363)

When people become committed to courses of action, they rarely rationally reevaluate their commitments to action at each step and rarely step back when confronted by a mistake. Graduate students, having invested six years in obtaining an advanced degree, will often continue seeking a faculty job, even though the odds of getting a tenure-track faculty job decrease every year. Stockholders may continue to buy shares even after their price has fallen several times. Couples may persist in romantic relationships well after the “spark” is gone. A nation may double down on its commitment to a losing war so that its soldiers cannot be said to have “died in vain.” Business executives are more likely to allocate money to a failing division when they themselves made the initial investment in that division. (Location 3554)

Being surrounded by those with anti-vaccine views, they may be exposed to more anti-vaccine arguments over time and thus develop a mental model of vaccination that is based largely on arguments against vaccination that they have been exposed to through their group membership. Thus, over time their views become more solidified. (Location 3583)

A significant challenge to views on vaccination in some Muslim-majority countries came in 2011, when it came to light that Dr. Shakil Afridi had aided US intelligence agencies in tracking down Osama bin Laden by leading a HepB-vaccination campaign that collected DNA. (Location 3653)

These incidents aside, the majority of Muslim scholars support vaccination, and the majority of Muslims have no problem with immunization. Worldwide, religious leaders have been critical aids to vaccination efforts and the efforts to eliminate smallpox and polio. (Location 3677)

There were early concerns among Jewish scholars that vaccination may not be kosher (adhering to specific Jewish dietary laws); however, a number of rabbis and scholars have written opinions stating that vaccination is allowable or even a mitzvah, or religious duty. (Location 3680)

In 1985 an outbreak of measles occurred at Christian Science–affiliated Principia College, where approximately 113 of its 712 students were affected, including three deaths. (Location 3711)

Additionally, there have been outbreaks of polio and diphtheria associated with Christian Science communities in the past. This group permits vaccination when required by law but does not believe it to be necessary. (Location 3716)

These cases of seeking religious exemption for vaccination are largely a smokescreen that allows anti-vaccine activists to bypass normal vaccination requirements for children to attend schools or daycares. Rather than a true expression of religious faith, the use of religious vaccine exemptions is often an exploitation of the privileged status of religious faith in society. (Location 3750)

Indeed, at the start of 2019, more than one thousand drugs saw increases in price averaging well over inflation. The often standard explanation that these increases reflect the cost of research ring hollow because many drugs were researched decades ago, and research costs are small compared to the money spent on marketing of drugs. (Location 3923)

Many believe that there is a fundamental conflict between the motivations of corporations to make a profit and the needs of patients to receive safe and effective medications. (Location 3945)

By contrast to the regulation of drugs and biologics, the regulation of products marketed as dietary supplements is extremely permissive. The Dietary Supplement Health and Education Act (DSHEA) of 1994 effectively exempts manufacturers of these substances from the need to demonstrate safety or efficacy. (Location 3960)

Between 2004 and 2012, half of the FDA-mandated recalls in the United States were supplements. Often these recalls were for supplements’ containing unlabeled active pharmaceutical products—meaning that the supplements were deemed unsafe because they might actually do something. However, I have been unable to find either complaints among anti-vaccine activists about the closeness of “Big Supplement” to legislators, about Big Supplement’s safety issues and skirting of the laws, and about the secrecy of manufacturing processes by Big Supplement, or complaints about the ineffectiveness of nearly all supplements at solving the problems they are marketed as solving. Before the DSHEA legislation, the dietary-supplement industry was estimated to be about $4 billion per year. It is now predicted to surpass $200 billion per year by 2024. (Location 3965)

Although it’s tempting to dismiss such conspiracies outright because conspiracy theorists tend to be wrong about everything, there have historically been actual conspiracies. So it is worthwhile both to address why people believe in conspiracy theories, even after the absence of confirmatory evidence becomes overwhelming, and to examine the evidence put forward for those conspiracy theories in particular. (Location 3978)

In The Paranoid Style in American Politics, Richard Hofstadter suggested that those with conspiracy beliefs are prone to collect evidence, not to determine the truth, but to protect themselves from it. (Location 4015)

To a conspiracist, these side effects, or the occasional failure of a treatment to work, provide evidence that confirms what they already knew, that Big Pharma is a sinister entity, manipulating the government, and spreading disease. (Location 4019)

The market forces that drive pharmaceutical companies don’t always favor the production of drugs that consumers need. Research into new antibiotics has slowed to a near stall because of the high cost of bringing new drugs to market, and the low economic returns on antibiotics that are only prescribed for short courses. Likewise vaccines, which are often inexpensive, yield comparatively little profit for pharmaceutical companies. Out of nearly $1 trillion in annual revenues, only about $20 billion are revenues from vaccines, likely the net profit from these vaccines is much less when costs of production, research, taxes, and so forth are taken into account. These profits, are small compared to the potential profits from sales of drugs to treat someone hospitalized for a preventable disease. (Location 4024)

Drug studies funded by manufacturers and published in proceedings of symposia are far more likely to show a positive result for the drug of interest than are publicly funded studies (98 percent vs. 79 percent). However, although there is less likelihood that pharmaceutical companies will publish a negative result, the results of individual studies are less likely to show bias. (Location 4037)

A trial should select a control treatment for which the outcome is uncertain, rather than one that is not comparable. This means that a new drug should be compared to the current standard drug on the market and not to a placebo. (Location 4044)

The conspiracy model usually has Big Pharma deliberately falsifying studies in order to sell products. The truth is far more mundane. Although the profit motive produces biases, those biases don’t much affect the results of individual studies. Moreover, often the initial development of drugs and vaccines are publicly funded through research grants from the National Institutes of Health. The perverse incentives created by the profit motive of the pharmaceutical industry are overridden by sound science and adequate regulation. (Location 4050)

Once again a comparison to the unregulated supplement industry is apt. If the pharmaceutical industry operated the same way that the dietary supplement industry does, Cui bono? would be a more appropriate question. Though dietary supplements do have important health uses, such as folate during pregnancy, these are a tiny fraction of the dietary supplements marketed, the majority of which are not based on evidence. Many contain substances other than those on the label, which are sometimes toxic. All in the name of profit. The industry surrounding supplements is exactly what anti-vaccine advocates fear about vaccines: unregulated, unsafe, and ineffective. By comparison, the testing required to bring a vaccine to market ensures a high likelihood of safety and efficacy. (Location 4054)

The success rate for treatments that make it to the clinical-trial phase are very low, only a little more than 10 percent. Many times more are tested or examined in labs, but the evidence is never sufficient to move them to the stage of clinical trials. (Location 4105)

Since 1997, an average of $1.4 billion was spent each year on vaccine research and development, 46 percent from vaccine sales, 36 percent from taxes, and 18 percent from risk capital. (Location 4109)

The year 2018 saw a 30 percent increase in measles cases worldwide, from nineteen cases per million to twenty-five cases per million, attributed by health professionals to the effects of the anti-vaccine movement. That same year also saw over one hundred thousand measles-related deaths worldwide. (Location 4237)

Nyan and colleagues found that the use of a dramatic narrative about a sick child who was not vaccinated, or images of children suffering from vaccine-preventable illness, actually decreased the desire of parents to vaccinate their children. Textual information from the CDC showing that there was no vaccine-autism link reduced misconception about that proposed link but did not increase intent to vaccinate. This suggests that inventions focused on correcting misconceptions about vaccines, raising concerns about communicable diseases, or simply filling an information deficit may be ineffective. (Location 4421)

These results suggest two broadly defined methods as being effective in increasing intent to vaccinate: providing factual information about vaccines and providing community- and identity-centered messaging about vaccines. (Location 4448)

A reactive strategy can be prone to what’s known as the backfire effect, which occurs when someone with a prior set of beliefs is exposed to new, contradictory information. Something funny happens: they become more set in their original belief, or at least they hold on to their favored but erroneous views. For example, those who were predisposed to support the US invasion of Iraq became more confident in their position after being corrected about their mistaken belief that Iraq had possessed weapons of mass destruction. (Location 4456)

Engaging directly in reactive corrections on the internet also quickly runs into the problem of the so-called Gish Gallop. The Gish Gallop is named for the creationist Duane Gish, who was known for producing a series of weak arguments and false statements in rapid succession. When opponents responded, they would be left unable to address every point because it can take longer to refute every point than was allotted for rebuttal. (Location 4468)

Moreover, the most tempting form of activism, debating anti-vaccine activists online, one on one, is in her view ineffective and only leads to pro-vaccine activists burning themselves out. Debating anti-vaccine activists forces them to articulate their view and, in doing so, makes them more entrenched in it. Better, in Russin’s view, is to publicly be a good parent and model for others that good parenting includes vaccinating one’s own children. (Location 4547)

These topics suggested that anti-vaccine activists view vaccination as a kind of institutional oppression and use Facebook to express moral outrage at the conspiracy of media and powerful interests that perpetuate vaccination. (Location 4635)

Rather than being low-information parents, these are parents who are, if anything, less selective in choosing the sources they get information from. Rather than using information arrived at through the scientific method, they have also incorporated information from websites, alternative health practitioners, and religious leaders. (Location 4671)

biased assimilation, the credibility heuristic, selective perception, the Dunning-Kruger effect, and backfire effects. (Location 4706)

Dr. Smith was operating from an information-deficit model. She believed that Jim and Jenny simply didn’t have enough information. However, Jim and Jenny have more than enough information. It’s just bad information. The bad information came from people whom Jim and Jenny trusted, friends and family. The good information came from an authority figure. (Location 4745)