One autumn afternoon in sun-drenched Mullumbimby, intensive care doctor Rachel Heap came across a crowd milling beneath a local telecommunications tower.
Heap was exhausted. She’d spent the day treating Covid-19 patients at Lismore Base hospital.
Near the Mullumbimby post office, she could see a group of protesters who were breaking Covid restrictions. The crowd wore no masks and there was little physical distancing. They were chanting opposition to the 5G waves Telstra planned to send from the tower overhead.
The scene wasn’t unusual in the northern New South Wales town, which is a counter-culture capital of Australia.
The same protesters have since marched through the streets with placards decrying “mandatory vaccination” on one side and 5G on the other, spreading wild conspiracies about Bill Gates. Similar rallies were held last weekend, when activists organised “Freedom Day” protests across the country, including in nearby Byron Bay, against lockdowns, mandatory vaccinations, perceived government repression and issues associated with the QAnon conspiracy theory.
Heap, a local vaccine advocate with the Northern Rivers vaccination supporters group, despairs: “That day was awful, it was awful, it was really distressing.
“I was vulnerable. Working with Covid-19 patients is a thing that we do, but it obviously carries risk to the healthcare worker, it carries risk to me, it carries risk that I bring it home to my family.
“So I’d been working in a high-stress environment … I’ve driven home past people who are hugging and standing close together with placards, fighting something that is a conspiracy theory.
“I’m not sure how you’re supposed to deal with that.”
Towns like Mullumbimby – where the childhood vaccination rate is a shockingly low 50% – are outliers. But the views of the protesters serve to remind the nation of its next great challenge”: if a safe and effective vaccine is found, how will the government convince hesitant Australians to take it?
The magic Covid vaccine number, the prime minister, Scott Morrison, says is 95%. That’s the coverage he believes Australia needs to build herd immunity and allow a return to relative normality.
The 95% target is the same as the childhood immunisation rate Australia strives to achieve. That rate is an aspirational goal, but Australia is closing in on it after decades of research, policymaking and strategising, which has taken coverage for one- and five-year-olds to 94.6% and 94.77% respectively.
Rolling out a Covid vaccine, though, is a different prospect.
Much of what is known about improving vaccine uptake is focused on parents and children. A vaccine would need uptake across a far broader range of society, including those who may have little engagement with the school or health systems.
Success will require careful planning on the practical aspects: ensuring widespread availability, ease of access, low cost barriers, incentives for use, and a high degree of public awareness.
It will also require the nation to confront vaccine hesitancy head-on.
Hesitancy – defined by the World Health Organization as the “delay in acceptance or refusal of vaccines despite availability of vaccination services” – has been associated with outbreaks of vaccine-preventable diseases, including measles and pertussis.
Last year the WHO included hesitancy in its top 10 threats to global health. In 2018 it set up a global expert group to better understand its drivers and potential solutions.
In Australia, Katie Attwell, a social scientist at the University of Western Australia, has spent much of her career studying attitudes to vaccines.
Attwell and her team have just embarked on a research project titled Coronavax, funded by the Western Australian government and Wesfarmers, to understand attitudes to Covid-19 vaccines and better prepare communities and governments for a nationwide vaccination program.
Data from previous studies, she says, suggests about two-thirds of Australians will take a Covid vaccine. The rest are split into two categories: the undecided and the outright opposed.
“We’re seeing some people who are saying no. Right now, those no’s are definitely larger than 5%,” she says. “Add the no’s and maybes together, and you’ve got your work cut out for you.”
Hijacking a mother’s grief
It was instinct that made Catherine Hughes take her baby boy to Perth’s Princess Margaret hospital in 2015.
At just three weeks old, Riley was not waking for his usual two-hourly breastfeed. A locum doctor who visited her home had assured her Riley was fine, despite a cough and cold-like symptoms.
Catherine thought differently. After four days at hospital, swabs confirmed Riley had whooping cough, a disease that he was too young to be vaccinated against.
He died in his mother’s arms the next day.
“We were left reeling after his death, absolutely devastated, but also determined to make sure this didn’t happen to other babies,” Catherine says.
Community-wide vaccination is critical to protect newborns. Babies receive their first pertussis, or whooping cough, vaccination at six weeks. Before that, they rely on the herd immunity of those they come into contact with.
In the weeks after Riley’s death, the Western Australian government introduced pregnancy vaccination to better protect newborns from pertussis. The federal government later followed suit.
Catherine and her husband Greg set up “Light for Riley”, a campaign to encourage pertussis immunisation, and established the Immunisation Foundation of Australia.
The abuse began almost immediately. A flood of hate and conspiratorial thought flooded her Facebook, both from anti-vaccination pages and individuals.
“What a fucking evil whore you are,” one wrote. Others called her a “fat attention seeker”. Another said Catherine and Greg were “exploiting the death of their child”.
“It was horrific,” Catherine tells Guardian Australia. “It began occurring as soon as we announced Riley’s death and implored people to vaccinate.”
It was just a taste of the sprawling, disjointed anti-vaccination ecosystem on platforms like Facebook and Instagram.
A study in the Lancet last year described media platforms, including social media, as being “enormously influential in the spread of vaccine hesitancy”. Similar warnings have been expressed by Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases in the United States.
There are few who understand Australia’s online anti-vaccination community like Timothy Graham, chief investigator with Queensland University of Technology’s digital media research centre.
Graham and his colleague Naomi Smith sifted through years of content posted in anti-vaccination groups on Facebook. They found vaccine misinformation being pushed at an enormous scale.
Over three years, the six biggest anti-vaccination pages delivered 14,736 posts, attracted 2,531,855 likes, 291,520 comments, and 2,024,672 shares.
Among the most common topics were anti-vaccine activism, media and censorship, vaccination as a form of “genocide”, Zika virus and the Gates Foundation, vaccine as a moral transgression, vaccine injuries, food as medicine, and chemtrails and agriscience.
The research built a clear picture of the common characteristics shared by posters.
“They do not trust the institutions of the state, they do not trust the scientific method, they do not trust scientists and people who are powerful and wealthy, like Bill Gates, who are involved in health and science,” Graham says.
“What they do trust, and in many ways this echoes QAnon and other conspiracy theories, is experiential wisdom over objective, scientific, rational knowledge.”
The same central threads wove their way through the discourse: moral outrage, oppression by institutional governments and the media, and conspiracy-style beliefs and thinking.
Facebook acknowledged the problem in September last year, declaring it would attempt to stamp out vaccine misinformation by reducing the ranking of anti-vaccination groups and pages in news feed and search functions, rejecting paid anti-vaccination advertising, and pushing people towards verified information.
Whatever Facebook has done, it hasn’t worked. Guardian analysis shows the Facebook page of the Australian Vaccination Risks Network, one of the country’s most prominent anti-vaccination groups, is growing.
In the year since Facebook’s announcement, its following has almost doubled from 10,773 to 17,834.
Its activity has become more frenetic since the start of the pandemic. Since March, the page has posted 400 times, attracted 36,962 likes and 32,350 comments. Those posts have been shared 29,429 times.
In the six months before the pandemic, it posted fewer than half that number, attracting 14,029 likes and 6,393 comments.
Instagram, owned by Facebook, has also provided a safe haven for anti-vaccination figures like celebrity chef Pete Evans and Taylor Winterstein.
Evans’ following has grown from 222,363 to 274,000 in the past year, data shows.
Anti-vaccination groups have, with apparent ease, avoided Facebook’s restrictions by simply altering the language they use – “vaccine” becomes “vak-seen”, for example.
It’s not only the growth of anti-vaccination groups that is troubling. Evidence suggests the online battle to convince the middle ground is being lost.
A landmark study published in Nature this year assessed 1,300 pages across the world engaged with the topic of vaccination, detecting 317 anti-vaccination pages with a combined following of 4.2m followers, 124 pro-vaccine pages with 6.9m followers, and 885 pages that were engaged but took neither a pro- or anti-vaccine stance.
The research found anti-vaccine pages were more numerous and growing at a faster rate. They were also more connected and engaged in discussions on undecided pages.
The paper concluded that anti-vaccine views would dominate online vaccination discussion within a decade if current trends continue.
Graham has a simple explanation for Facebook’s inability to rid its platform of such content.
“It’s basically good for business. Misinformation is good for business,” he said.
“All these workers who will produce all of this highly emotive content which we know, time and time again from research, people love to click on it, it gets much higher engagement on average than stuff that’s more neutral or objectively written.”
But social media doesn’t explain everything.
Opposition to immunisation has existed long before Facebook and Instagram, dating back to at least 1772 when English reverend Edmund Massey described vaccines as “diabolical operations” in a sermon titled “The Dangerous and Sinful Practice of Inoculation”.
Anti-vaccination movements have sprung up ever since, from opposition to the smallpox vaccination in the early 1800s to press-driven fears about the pertussis vaccination in the 1970s and 80s.
But Graham says social media has fundamentally rewired the way we access and verify information, build connections with peers, and treat dissenting opinion.
“It’s kind of two worlds,” he says. “You’ve got one world, where you’ve got these issues like communicable diseases and in modernity the prevailing way to approach this is to think about it scientifically and to measure it and understand it in that way,” he says.
“But on the other hand you’ve got these groups which essentially subscribe to a different church; it’s the church of thinking ‘Well, this person got autism, and it happened just after they got the needle, and I will thread together the evidence that I think supports this cover-up’, and the validation, for Facebook, comes through just the sheer amount of people, like-minded people, who click like and share it.
“In place of peer review, we have ratings, peer ratings, and peer shares.”
Morrison’s early blunder
All the evidence suggests that building confidence in vaccines is a complex, nuanced task requiring meticulous research and careful thought.
Last month Morrison took to it with a sledgehammer.
On talkback radio, while engaged in a public relations blitz spruiking the government’s efforts to secure the Oxford vaccine, he strongly suggested it would be mandatory.
“I would expect it to be as mandatory as you can possibly make it,” he said, while talking up his credentials as the minister responsible for the “no jab, no play” policy.
His ministers followed suit. “We are looking at it being a mandatory vaccine,” the industry minister, Karen Andrews, said.
Experts like Julie Leask, of the University of Sydney and the National Centre for Immunisation Research and Surveillance, were concerned. It was precisely the kind of statement that risked driving the most important group – the undecideds – away.
How could doubtful Australians be won over if they believed a vaccine was made mandatory before it was proved safe and effective?
“We can’t be playing political games with discussion about how we get high coverage of a Covid-19 vaccine,” Leask says. “We need to be as reasonable and careful as we possibly can.”
Attwell agrees: “It was just not helpful. This government loves to make vaccines mandatory … They like to use that really hard framing, and that’s their prerogative.
“But when state and federal governments made childhood vaccines mandatory, that was building on top of so many years of really good work in terms of communication, in terms of designing really good programs, in terms of designing really good systems … and the mandates were about getting it from 91% to 95% [coverage].”
Morrison quickly walked the comments back, saying it wouldn’t be mandatory, as did the health minister, Greg Hunt, who said the government would not “force vaccinations on any Australian”.
But the damage had been done. Anti-vaccination groups are already pushing out predictable messages about tyrannical governments and forced vaccinations.
In the face of such misinformation, howshould Australia address the problem of hesitancy?
It’s typically assumed that anyonewho doubts vaccines simply lacks understanding. But research has shown this is not the case.
“It’s not an information problem; it’s not an information deficit,” Attwell says. “It’s not that people don’t know enough, it’s not that they’re half-full of information and it’s all crappy and we can just fill them up with the good stuff.
“It’s very embedded in their values and identity, which makes it extremely difficult to engage with and shift.”
In a 2011 paper in Nature titled “Target the fence-sitters”, Leask argued that government efforts should focus on convincing the hesitant, not those who outright refuse vaccines.
Within that group, she argued, real gains can be made. She advocated for a three-step process to convince the fence-sitters.
First, remove structural barriers that work against vaccination – a lack of flexible hours at clinics or the distance travelled to obtain a vaccine, for example.
Second, tailor communication strategies directly to the fence-sitters, delivered by trusted peers and community leaders. Equip health professionals, for example, to “guide hesitant parents” into thinking about vaccines and motivating them to change while not forcing it upon them.
Leask argued social media strategies should be deployed to address rumours and promote vaccination, while peer-led, expertly resourced discussion groups were also effective.
Third, keep health professionals on side by deploying initiatives to improve their confidence in safe vaccines and give them the ability to address concerns raised by patients.
A critical need
Back in northern NSW, Heap and the the Northern Rivers vaccination supporters group have been deploying precisely that approach.
The group does not see its role as trying to counter professional anti-vaxxers or misinformation on social media, something Heap likens to a game of “whack-a-mole”.
“It’s endless and I don’t think countering it does anything other than give it oxygen,” she says.
Instead it works with a network of parents, nurses and midwives to equip them for the difficult conversations about vaccination.
Those conversations are inevitable in a town like Mullumbimby, she says.
“If you live in a culture around here you would have heard misinformation spread by professional anti-vaxxers that wrongly suggests vaccines might be dangerous, and you just want to find out more,” Heap says.
“That doesn’t make you an anti-vaxxer by any stretch of the imagination, and those are exactly the type of people that we hope to talk to – maybe not ourselves, but we hope to be able to enable or facilitate the practice nurses or the midwives to be able to talk to those families, to help alleviate their fears, answer their questions, help them know how to find good information.”
Heap knows how critical it is to get it right. Two babies she treated for whooping cough still stick in her mind.
One left the ICU after a prolonged period in hospital, still dependant on oxygen, with possible brain damage. The second didn’t survive.
“The ghosts of people I’ve looked after like that … you carry them,” she says. “It doesn’t overwhelm you all the time, but they’re always there, they’re there in the background.
“They’re there as part of my story.”