So, do you want to talk about which vaccines we recommend for you?

A conversation that is increasingly cringeworthy.

I’m reading fellow Philadelphian Dr.

Paul Offit

’s series here on Substack called A Dangerous Time for America’s Children. In part one he describes how anti-vaccine organizations like ICAN (Informed Consent Action Network) have seen substantial financial growth during the Covid-19 pandemic, and have used their increased resources to mount legal challenges against vaccine programs and mandates through high-profile attorneys. This includes undermining polio vaccination. Polio! Which can paralyze kids for life. Many of you from the older generations have seen this, and as a doctor I have several older patients whose lives were forever changed by partial paralysis. These are the ones who lived.

Part two dropped today. This one describes how the 1982 documentary "DPT: Vaccine Roulette" sparked an anti-vaccine movement that led to a surge in lawsuits against vaccine manufacturers, with damage claims reaching a staggering $3.2 billion by 1985, until the National Childhood Vaccine Injury Act of 1986 signed into law by President Reagan saved the industry by protecting manufacturers from litigation while establishing methods of compensation for those harmed. Our current vaccine programs could be dismantled by eliminating these legal protections, among the ideas RFK Jr has proposed. Turns out the pertussis vaccine is safe anyway, like originally tested.

Yesterday a related Op-Ed was published in The New York Times in which Dr. Offit lays out the self-evident case against RFK Jr. as potential head of Health and Human Services. He reminds us of the grave misunderstandings coming from RFK Jr., especially as it pertains to vaccination, and reminds us that:

In fact, everyone who serves with me on the Food and Drug Administration’s vaccine advisory committee is a vaccine skeptic. Pharmaceutical companies must prove to us that a vaccine is safe, that it’s effective. Then and only then will we recommend that it be authorized or licensed for use by Americans.

My job in primary care is supposed to incorporate a great deal of prevention. An ounce of prevention is worth a pound of cure. And so it is with great concern and daily exhaustion that I fight the good fight for my patients who decline, defer, and occasionally rant with passion against vaccines. I always acknowledge that vaccines are not 100% risk free, but that they are on balance much safer than the serious diseases they prevent or attenuate. In the 20 years I’ve practiced in the same community I’ve built wonderful relationships with patients. Yet even my patients’ implicit trust in me, built over those years, can be thoroughly damaged by the rise of anti-vaccination ideologies and identities. And once this bedrock of public health has been compromised, it’s tough to get it back.

Anti-vaccination sentiment often erodes people’s openness to consider other medical recommendations, too. They’ve been told doctors and nurses are ignorant at best, and part of a vast conspiracy at worst. This includes the humble family doctor they’ve otherwise known and trusted for those twenty years.

Dr. Paul Offit is a vaccine education soldier. He is a co-inventor of the rotavirus vaccine. He is a voting member of the advisory committee of the FDA for vaccine approval. He even voted against the bivalent Covid shots a couple years ago, citing concerns about antigenic imprinting and perhaps no advantage over the original monovalent Covid vaccines. Such is honest scientific debate in real time. Dr. Offit is the director of the Vaccine Education Center at Children’s Hospital of Philadelphia (click for an excellent resource online), and I’ve seen him around town here in Philly. He’s really a nice guy, too. But when he posts about vaccines on his Substack, a wave of very hostile commenters (and probably some bots) shows up with pretty nasty words, and the conversation devolves quickly into an ugly scene. Who wins in this devolution?

I need to keep doing my job. I believe in what the science and studies have shown: the benefits of approved vaccines outweigh the rare but sometimes serious risks. That’s what consensus panels of experts pouring over the data conclude. Even for Covid shots, the evidence keeps coming that staying up to date is good for reducing the number of infections we get, the severity of those infections, and the potential for long Covid. I need to keep doing my job by finding new ways to reach people. Maybe you need a helpful framework for family members who have incorporated distrust of vaccines and science into their very identities and communities?

Here’s what I came up with, followed by a look at the polio vaccine specifically, since it’s getting picked on. Concerned, open-minded people can inform themselves about all things vaccination by reading the good stuff at that Vaccine Education Center at Children’s Hospital of Philadelphia. If you have concerns about whether vaccines really work, and what the potential side effects and benefits are, please check it out.

Here’s a nice graph, too:

But facts are often not enough, and risks are hard to weigh against each other.

Understanding and Addressing Anti-Vaccination Motivations

Beneficence is what this is all about for doctors. Really. We lose money on vaccines we stock in our offices, and it’s a lot less work if we stop trying to educate. How many avaricious, malicious pediatricians or family docs do you know?

But understanding vaccine hesitancy requires looking beyond surface-level disagreements to examine the complex web of beliefs, fears, and values that drive anti-vaccination sentiments. In the framework below, I explore seven core motivations behind vaccine hesitancy and outline evidence-based strategies for addressing each one, recognizing that building trust and fostering open dialogue are essential.

1) Institutional Distrust Motivation: Deep skepticism of pharmaceutical companies, government agencies, and medical establishments.

Strategy: Emphasize diverse, independent global vaccine research/approval oversight systems that already exist. Share transparent safety monitoring data. Point to vaccine uptake among medical professionals and their families. I practice what I preach, and I’m up to 6 Covid shots already. Yearly flu shot. Tdap every 10 years. Looking forward to Shingrix and Prevnar soon…. We can highlight university and independent research roles in vaccine development and safety verification, not just big Pharma.

2) Personal Autonomy Motivation: Strong belief in absolute bodily autonomy and parental rights without government intervention.

Strategy: Present vaccination as an empowering health choice. Compare to widely accepted public health measures like seatbelts and food safety inspections. Demonstrate how vaccines enhance freedom by preventing disability and outbreak restrictions. Focus on informed decision-making while providing accurate information.

3) Alternative Health Beliefs Motivation: Preference for "natural immunity" and holistic approaches, viewing vaccines as artificial interference.

Strategy: Explain how vaccines enhance natural immune responses. Describe natural components in modern vaccines. Ironically, two Covid vaccines use mRNA. A typical human cell naturally contains around 200,000 to 300,000 mRNA molecules already. The human body has approximately 37 trillion cells. Do that math. Draw parallels between vaccination and natural immunity development. It is target practice before the battle. Show how vaccines complement rather than oppose holistic health practices.

4) Community and Identity Motivation: Finding belonging and purpose in shared beliefs, viewing themselves as enlightened truth-seekers.

Strategy: Build positive communities around evidence-based healthcare. Many of us are trying to do that online like here on Substack, despite much more profitable anti-vaccination/science communities developing to the opposite effect. Share stories of mind-changing experiences from former anti-vaccine advocates. Connect vaccine uptake to community care values. Engage trusted community leaders as advocates.

5) Fear and Control Motivation: Anxiety about modern medical interventions and desire to maintain healthcare decision control.

Strategy: Provide clear vaccine development and testing information. See those links above, and the polio history below. Compare actual disease risks versus rare vaccine side effects. Give agency in vaccination decisions while ensuring accurate information access. Address fears with factual reassurance and historical context.

6) Information Skepticism Motivation: Rejection of mainstream scientific consensus, preferring alternative information sources.

Strategy: Present complex science in accessible language. Provide access to primary sources and raw data. Teach scientific literacy and evaluation skills. Explain how scientific consensus emerges through independent verification.

7) Religious/Philosophical Beliefs Motivation: Opposition based on religious convictions or philosophical views about medical intervention.

Strategy: Partner with supportive religious leaders. Share major religious organizations' pro-vaccine positions. The Pope once called Covid vaccination “a moral obligation.” He was absolutely, infallibly right! Present ethical frameworks supporting community protection through vaccination. Discuss religious perspectives on medical advances as beneficial tools.

Core Implementation Principles

• Listen to concerns respectfully without dismissal

• Avoid confrontational responses

• Provide clear, accurate information

• Focus on shared values

• Combine personal stories with data

• Build trust through transparency

• Show how vaccines align with personal values

• Help people reach informed conclusions independently

The key is helping people feel heard while guiding them toward evidence-based conclusions that protect both the individual and public health. Rare adverse events do occur with vaccines. I think family doctors, pediatricians, and general internists do most of the nuance heavy lifting among doctors here. The increasingly Sisyphean nature of the work is exhausting, and we can’t be expected to bring the above tools to each and every tiresome day. But even Sisyphus did strike an existential victory in accepting the futility of his daily task, and then embracing it.

Just this morning I saw a 60 year-old woman for a preventative physical (and 5 other problems). She knows me, and trusts me. She declined the vaccines I recommended today. I spent about 8 minutes with some of the above strategies, and actually sent her a link to the CHOP Vaccine Education Center here in Philly that I’ve now linked to 3 times in this post! I asked for her feedback after the visit, and she stated that she felt respected and heard, and that she planned to honestly read through the educational material and rethink the vaccine reccomendations. Soon. Sincerely.

But what about the polio vaccine they are trying to undermine?

President FDR would be as disturbed as most of us are that Americans are even talking about cancelling vaccines, much less spending hundreds of millions to effect this. FDR was partially disabled from polio. So were these children.

Although it doesn’t often change hearts and minds to cite studies, I’ll drop this one anyway. “A major landmark study published by The Lancet found that global immunization efforts have saved an estimated 154 million lives – or the equivalent of 6 lives every minute of every year – over the past 50 years. The vast majority of lives saved – 101 million – were those of infants.” And that doesn’t even include devastating illness sequelae like paralysis from polio.

As Dr. Offit just detailed, they have already petitioned the FDA to withdraw or suspend polio vaccines. Why? They will say because they want proof of safety, but running more trials would be unnecessary and indeed unethical at this time. Here’s the history, with some help from Perplexity:

The 1954 Salk polio vaccine trial was a groundbreaking study in medical history, involving approximately 1.8 million children across the United States. This trial employed two distinct study designs:

1. Placebo-controlled areas: About 620,000 children participated, with 420,000 receiving the vaccine and 200,000 a placebo in a double-blind, randomized setup.

2. Observed areas: Approximately 1.2 million children were involved, with only second-graders vaccinated and first and third-graders serving as unvaccinated controls.

The trial results demonstrated high efficacy and safety:

• Efficacy: The vaccine was 80-90% effective in preventing paralytic poliomyelitis, with varying effectiveness against different poliovirus types.

• Safety: Only 0.4% of vaccinated children experienced minor reactions, with an even smaller percentage (0.004-0.006%) having major reactions.

The dual design approach allowed researchers to:

• Conduct a rigorous, randomized controlled trial in the placebo areas

• Include a larger population in the observed areas, addressing ethical concerns and maintaining public support

While the placebo-controlled design is considered scientifically superior, the inclusion of observed areas provided complementary data and helped with practical implementation on a large scale. The trial's success led to the vaccine's rapid acceptance and implementation, marking a significant milestone in the fight against polio. The results, announced on April 12, 1955, conclusively showed that the Salk vaccine was safe, effective, and potent in preventing paralytic polio, paving the way for widespread vaccination efforts.

And like many vaccines, success depends on enough children getting vaccinated to suppress community outbreaks. It is not 100% effective as we can see from the original study.

Does this post matter?

Vaccination beliefs have morphed into a core identity for many, as demonstrated by anti-vaccine dating sites. Vociferous voices will continue to pile on Dr. Offit’s site, unless he closes the comments section, adds a paywall, or moderates the section. Do loud, hostile voices work? Do they drown out voices of moderation and support?

A 2022 study published in Nature Humanities and Social Sciences Communications analyzed COVID-19 vaccine-related tweets to understand anti-vaxxers' behavior on social media. It found that anti-vaccine users were the most active in sending replies, particularly targeting neutral accounts and those with large followings. Their replies were significantly more toxic and negative compared to other groups. The research identified five distinct clusters: Pro-Vax, Anti-Vax, Political Left, Political Right, and Neutral groups.

To address these issues, the authors suggested two main approaches: First, social media platforms could adjust their algorithms to reduce the visibility of anti-vaccine replies without banning them outright, preserving freedom of expression while limiting exposure. This would reflect that these voices are still in the minority, though outshouting less strident voices. Second, pro-vaccine users should prepare for toxic responses by maintaining a calm, reasonable tone, recognizing that many people read but don't comment. The authors also recommended that fact-checking organizations develop specific guidelines for handling toxic anti-vaccine replies, focusing more on managing the spread of misinformation rather than changing beliefs directly.

Facebook is still standing up for truth against coercion and false narratives, right? They are still fact checking? No one is donating millions to inauguration funds, or bending truth to power, right?

It’s naive to think that a simple open competition of ideas, true or not, will result in a victory of facts over falsehoods, outrage and fear. The algorithms that feed our eyes with content are designed to maximize engagement and virality. Outrage, conflict, and fear work.

​​​​​​​​​​​Conclusion

The challenges facing healthcare providers in the era of rising anti-vaccination sentiment have become increasingly complex. As a primary care physician, I've watched with growing concern as anti-vaccine organizations have gained substantial financial strength, using their resources to mount legal challenges against established vaccine programs—including those for devastating diseases like polio. In my twenty years of practice, I've built strong relationships with patients, yet even these trusted bonds can be eroded by the surge of anti-vaccination ideologies. The issue runs deeper than simple hesitancy; it reflects a complex web of institutional distrust, personal autonomy concerns, and identity-based beliefs. While we have compelling historical evidence of vaccine success—like the groundbreaking 1954 Salk polio vaccine trials— the challenge now lies in addressing vaccine skepticism in an environment where anti-vaccine voices, though a minority, dominate social media discourse with particularly active and often toxic messaging.

This shift in public health dialogue represents a fundamental challenge to preventive medicine and the doctor-patient relationship. These are at the core of family medicine. I hope that doctors and patients, pro-vax and anti-vax thinkers, can understand some of the subconscious motivations at play, and revert to the cold calculations of risk versus benefit.

154,000,000 over 50.

FDR. Note upper and lower body musculature, and his smile and legacy for the ages.