Exploring vaccination debates through corpus-assisted discourse analysis: The MMR vaccine debate and its relevance to the covid-19 pandemic

Front matter

Carlotta Fiammenghi Exploring Vaccination Debates through Corpus-Assisted Discourse Analysis The MMR vaccine debate and its relevance to the Covid-19 pandemic Exploring Vaccination Debates through Corpus-Assisted Discourse Analysis The MMR vaccine debate and its relevance to the Covid-19 pandemic Carlotta Fiammenghi This volume explores the discursive construction of debates around the topic of vaccination, with a particular focus on the hypothesis of a link between the MMR vaccine and autism. The research analyses the coverage of the debate in the British press up to 2019, through the tools of corpus-assisted discourse analysis and in light of the so-called “post-truth era”. The analysis focuses on the construction of medico-scientific debates in the media, in particular on issues of newsworthiness and polyphony. The discursive representation of evidence and the (de)legitimation strategies of social actors interacting in the debate are then explored. A large part of the volume is also devoted to the topic of argumentative narratives and the evidential value of personal experience. Each chapter of the monograph illustrates a connection between these aspects of the MMR vaccine controversy and the Covid-19 pandemic situation.

Cover photo: Casualità Controllata #33 – 2024, © Irene Costantino Carlotta Fiammenghi Exploring Vaccination Debates through Corpus-Assisted Discourse Analysis ISBN 979-12-5510-133-8 (print) ISBN 979-12-5510-137-6 (PDF) ISBN 979-12-5510-139-0 (EPUB) DOI 10.54103/milanoup.173

Carlotta Fiammenghi EXPLORING VACCINATION DEBATES THROUGH CORPUS-ASSISTED DISCOURSE ANALYSIS The MMR vaccine debate and its relevance to the Covid-19 pandemic

Chapter 1

Discourses of and about vaccines, the MMR vaccine, and the post-truth era 1.1. Discourses of and about vaccines Many studies have examined vaccination discourses from a variety of per - spectives; and it can be said that the advent of the Covid-19 pandemic spurred a further wave of studies on vaccine hesitancy and vaccine communication. The following is therefore not intended as a comprehensive and exhaustive over - view of such a fertile and interdisciplinary academic field, but a selection of the studies which most influenced the analysis expounded in this volume. 1.1.1. Vaccination discourses past and present Vaccination is an extremely complex and fascinating issue which stands at the intersection between the medico-scientific, the political, and the public sphere, in that it is a public health practice with direct consequences on the health of the individual who submits to it and of the community in which they live. It raises questions about freedom over one’s own body and responsibility towards one’s fellow human beings, often linked to overtly political stances, and consequently it may attract considerable hostility. Thoughts as to how to communicate effectively the science of vaccines recur frequently in science popularisation discussions, where anti-vaccination arguments are often interpreted as defying established knowledge and resisting recognised notions of expertise and authority. For these reasons, anti-vaccination arguments and conspiracy theories (CTs) seem to thrive in the contemporary, post-truth era, «the golden age of anti-vaccine CTs» (Stein 2017), because they often capitalise on emotion, personal beliefs, and anecdotes over hard evidence and facts (see also the following sections).

Nevertheless, it is the very nature of vaccination as a prophylactic medical practice which makes it particularly susceptible to criticism and scepticism, as is demonstrated by the fact that it has met with resistance and condemnation from its very invention. 1.1.2.1. Variolation and the origins of vaccination The origins of vaccination are to be traced back to the practice of variolation against smallpox, which was already widely performed in 16 th-century Turkey. This practice consisted in exposing the patient to material infected with a small amount of the smallpox virus, in the hope of inducing a mild form of the disease which would provide immunity from further infection. It goes without saying that the procedure carried some risks, but it was often effective in reducing fatal cases and controlling the rates of infection. The practice of variolation was introduced in England from Turkey by Lady Mary Wortley Montague in the 17th century. She was an English aristocrat and writer who followed her husband to Turkey once he was appointed Ambassador in Istanbul, where she learned the Ottoman practice of variolation which she then enthusiastically brought back to England. The introduction of the practice of variolation in England and Britain was at first accompanied by hostility and resistance from the medical class as well as from the general population, who were suspicious of the procedure because of its “Eastern” origin, and because it was promoted by a woman. Still, Lady Montague continued to ask for trials to be performed to demonstrate the safety and effectiveness of variolation, and finally, on 9 th August 1791 a Royal Experiment was carried out on six prisoners at Newgate, who were submitted to the practice, survived, and were then granted a full pardon. The procedure started to gain general acceptance after the two daughters of the Princess of Wales were successfully treated by Charles Maitland – then Embassy surgeon – on 17 th April 1792 (for a more detailed account of Lady Mary Montague and the practice of variolation, see for example: Halsall 1998, Grundy 2001, Kinch 2018).

The origins of the medical practice we now know as vaccination, however, are to be traced back to the experiments of the British doctor Edward Jenner in the late 17 th-beginning of the 18th century. Jenner learnt that milkmaids and farmworkers who came into direct contact with cows infected with cowpox did not contract human smallpox. He thus reasoned that cowpox provided some sort of protection against smallpox and tried injecting cowpox virus matter into the arm of a local child. Jenner afterwards deliberately exposed the same child to the smallpox virus, and he did not develop the disease (Riedel 2005). This and subsequent similar experiments resulted in the publication of an essay titled Inquiry into the Variolae vaccinae known as the Cow Pox (Jenner 1798), where Jenner exposed his theories about the benefits of the practice, which he termed “vaccination” from the noun vaccinia, the Latin word for cowpox. Although the paper was met with a mixed reaction by the medical authorities of the time, some of them ignoring or scorning the work, vaccination began to spread rapidly in England, thanks to mounting evidence of its effectiveness. By 1800, it had also reached most European countries (Willis 1997). Eventually, both the British medical community and the British Government became convinced of the necessity of vaccination to face the epidemics of smallpox that routinely devastated the country: in 1853, a first Vaccination Act demanded vaccination in England and Wales for infants up to three months of age; then, in 1867, a new Vaccination Act further enforced compulsory vaccination for all children under 14. The 1871 Vaccination Act mandated the employment of vaccination officers; and finally, the 1898 Vaccination

Bill introduced exemptions for conscientious objectors (Bennett 2020: 94-121). This was the result of years of protests from various organised anti-vaccination movements opposing both the practice and its compulsory enforcement (Durbach 2005) (see also Section 1.1.2.2. below).

The science behind this new medical technique was not fully understood, and therefore its potentials were not fully explored and implemented, until the discovery of the germ theory of disease by Louis Pasteur in the mid-19th century. This theory, too, encountered significant resistance and hostility both from the public and the established medical community, mainly because it was deemed implausible and counterintuitive: it required to believe that serious diseases were caused by invisible organisms – and vaccination required to understand that these diseases could be prevented by injecting the same organisms into the body (Lowry 2018). Nevertheless, the theory was eventually accepted by the scien - tific community, and the 20th century consequently saw the invention and vastscale administration of numerous vaccines which were fundamental in the fight against infectious diseases which had plagued humankind for centuries, such as smallpox, cholera, and poliomyelitis. Throughout the 1960s and the 1970s the coordinated, global effort launched by the World Health Organization (WHO) to eradicate smallpox effectively led to the last naturally acquired case of smallpox to be registered in Somalia in 1977; the world was officially certified free of naturally occurring smallpox in 1980. Nowadays, campaigns of mass vaccination, often implemented and coordinated by the WHO, have the objective of eradicating dangerous infectious diseases like polio (in 2014, for example, India received official polio-free status from the WHO), and research centres across the world are still studying to find effective vaccines against viruses and diseases like HIV/AIDS and tuberculosis (World Health Organization 2023b). The Covid-19 pandemic which hit the world in 2020 once again underlined the necessity to find effective vaccines against highly contagious infectious diseases. Despite what is largely recognised as one of the most important techno - logical and medical advances of all time, however, vaccination is often fiercely criticised and opposed by large portions of society, with anti-vaccination controversies regularly resurfacing; the Covid-19 pandemic has been no exception. The ensuing paragraphs are thus dedicated to the exploration of the history of anti-vaccination arguments and to the description of their characteristics, in the belief that it is crucial to understand and interpret anti-vaccination instances in a diachronic perspective, to understand them as socially situated and fundamentally cultural movements. 1.1.2.2. Anti-vaccination movements in Victorian England European anti-vaccination movements arose soon after the invention and introduction of the first vaccine against smallpox. 151. Discourses of and about vaccines, the MMR vaccine, and the post-truth era

Anti-vaccination movements in 19th century England were prevalent across the working classes and the less affluent layers of society, and indeed, according to Durbach (2005) they were part of a growing class consciousness and of more general demands for the working classes’ rights and dignity to be recognised. The bills rendering vaccination compulsory were onerous for the working classes. Moreover, they were seen as placing stigma over the poorest families and their ways of living, which were often considered as a threat to public health, especially in the cities. Consequently, anti-vaccination arguments were from the very start connected with political positions about dignity, freedom, and the need for recognition.

Anti-vaccinators united in formal, organised associations like the Anti- Vaccination League (established in London in 1853) and the Anti-Compulsory Vaccination League of Great Britain (established in 1867); the activities pro - moted by these movements were aided and influenced by social and techno - logical developments, as urban rallies were organised to protest compulsory vaccination, publicised through pamphlets that were written and distributed in great quantities, with the result that more than 100,000 people attended an anti-vaccination demonstration in Leicester in 1885 (Wolfe and Sharp 2002; on the Leicester anti-vaccination movement, see Swales 1992). The pressure from anti-vaccination groups was so strong that the question reached the government and influenced political decisions about vaccination laws; and indeed, following the Leicester demonstration, the Government appointed a commission to investigate the safety and efficacy of the smallpox vaccine. Note that this investigation had some legitimacy, as the process of vaccination at the time was still not closely regulated, and most importantly, rules of hygiene and sanitation were only then starting to be codified scientifically and to be applied consistently. What is more, not everyone could afford to be vaccinated at home; on the contrary, vaccination was often performed arm-to-arm in public vaccination stations, a practice that exposed children to the risk of blood infections, as the lymph used was sometimes impure and the stations themselves were often unsanitary (Durbach 2005: 113-149).

These incidents were widely reported in the anti-vaccination press, often in heart-wrenching tones (see, for example: Gibbs 1854, 1856). This kind of anti-vaccination rhetoric was so effective that the then editor of the British Medical Journal, Ernest Hart, lamented their «extremely energetic system of distributing tracts, inflammatory postcards, grotesquely drawn envelopes, and other means of disseminating their views» (quoted in Durbach 2005: 50). He also noted that «[t]here is nothing on the other side […] as an accessible antidote to these productions» (ibidem).

Although the report issued by the commission in 1896 unequivocally supported compulsory vaccination against smallpox, at the same time it tried to appease anti-vaccinationists by asking for the abolition of penalties for non-compliers.

A similar compromise between pro- and anti-vaccination stances was attempted with the 1898 Vaccination Bill, which introduced conscientious objection for anti-vaccinators. This clause was considered a victory for anti-vaccinators, because it considerably affected vaccine uptake in various regions of England: for example, magistrates in Oldham were said to have issued 40,000 certificates by December 1898, and in some districts like Southwark and Heywood coverage was said to have decreased from 95% to 2% following the introduction of the clause (see Durbach 2005: 186-187).

Controversies and protests against other vaccines followed the Victorian anti-vaccination movement, in many cases repeating similar claims and adapting them to the cultural, social, and political climate of the time. One such example is the polio vaccine. 1.1.2.3. The polio vaccine and the Cutter incident The development of a vaccine against poliomyelitis and the implementa - tion of mass vaccination campaigns led to the eradication of the illness in the Western Hemisphere; as to 2021, wild-type polio only remains endemic in Afghanistan and Pakistan (Bigouette et al. 2021).

The first licensed vaccine against polio was developed by the American virologist Jonas Salk in 1955 and used a formalin-inactivated virus (IPV); a second, live-attenuated oral vaccine was developed by the Polish-American medical researcher Albert Sabin in 1962. The history of the Salk polio vaccine, howev - er, was tragically marked by the Cutter incident which occurred immediately after the start of a mass vaccination campaign in 1955: a batch of the vaccine produced at Cutter Laboratories in the United States contained an incorrectly inactivated virus, which was inadvertently administered to 120,000 children before being withdrawn; as a consequence, 70,000 suffered mild polio, 200 were severely and permanently paralysed, and 10 died (Offit 2011; see also, and more specifically, Offit 2005). This disaster led to better vaccine regulatory systems but undermined trust in pharmaceutical companies. Although it did not spur significant anti-vaccine activity, and uptake of the polio vaccine remained high in the Western hemisphere, a general mistrust of the vaccine lingers in some African and Asian countries, sometimes incited by religious movements spreading claims that vaccination campaigns are part of a “Western plot” to sterilise non-White communities. Consequently, violent physical attacks towards vaccinators have also been reported (Warraich 2009). 1.1.2.4. The DTP vaccine and the VAERS The combined vaccine against diphtheria, tetanus, and pertussis (whooping cough) came into widespread clinical use in the 1940s, and it significantly reduced the incidence and mortality rate of said diseases (Centers for Disease Control and Prevention 2022). However, the vaccine was at the centre of a major health scare in Great Britain in the 1970s, and in the United States in the 171. Discourses of and about vaccines, the MMR vaccine, and the post-truth era

1980s. In 1974, a case series was issued from the Hospital for Sick Children at Great Ormond Street, which described 36 children who allegedly suffered se - vere neurological complications following their DTP immunisation. This case series received wide coverage in television documentaries and newspaper reports dramatizing tragic stories of severely neurologically impaired children, whose disability was linked by the authors to the vaccine. Moreover, their par - ents formed an advocacy group, named the Association of Parents of Vaccine- Damaged Children, which was very vocal in focussing public attention on the issue (Baker 2003: 4004). Consequently, and despite the fact that the Joint Committee on Vaccination and Immunisation (JCVI) endorsed it, uptake of the DTP vaccine fell dramatically in later years, a situation which was exacerbated by the fact that the British government did not launch any major campaign to restore public confidence in the vaccine at the outset. This caused a series of whooping cough epidemics sweeping Britain between 1977 and 1979. Public controversy and confusion were initially compounded by a division within the medical profession, with advisory bodies continuing to recommend the vaccine as opposed to general practitioners and home visitors who were hesitant and sceptical. A change occurred in 1981, when the National Childhood Encephalopathy Study launched by the JCVI concluded that the pertussis vaccine was not a significant risk factor for neurological illness. This study convinced the government and the mainstream media, which finally launched a major immunisation campaign in support of the DTP vaccine. Although there remains a portion of parents who are still convinced that the vaccine damaged their children’s health, DTP continues to be recommended and little debate accompanies it in Britain nowadays (Baker 2003: 4006). Scepticism and fear towards the DTP vaccine in the United States stemmed instead from a 1982 documentary titled DPT: Vaccine Roulette, which purported the same claims of vaccine-induced neurological damages and cover-ups by major pharmaceutical companies and governments. Following this documen - tary, many parents of allegedly vaccine-damaged children united to form advocacy groups: most notably, Dr Harris Coulter and Barbara Loe Fisher founded the National Vaccine Information Center and also authored a book titled DPT: A Shot in the Dark, which arguably influenced the imagery and vocabulary of the MMR vaccine-autism controversy.

Another important consequence of the DTP vaccine controversy in the USA was a significant rise in litigation, which led to the passing of the National Childhood Vaccine Injury Act in 1989 and to the establishment of the Vaccine Adverse Event Reporting System (VAERS), the National Vaccine Injury Compensation Program (NVICP), and the National Vaccine Program Office (Mariner 1992). The existence of the VAERS in particular is frequently mentioned by anti-vaccinators in the MMR controversy as proof of the reality of vaccine harm, although it actually is a free system allowing health professionals as well as the general public to submit reports describing alleged adverse reactions to vaccines, which then have to be scientifically scrutinised. In his historical assessment of the DTP vaccine controversy in Great Britain, Baker (2003: 4008) identifies several similarities with the MMR vaccine controversy: Any hopes that the pertussis vaccine controversy would prove to be an isolated episode on the British medical scene were dashed in 1997 when another routine childhood vaccine, MMR, became the focus of a new debate concerning whether it was linked to autism. […] The two controversies have shared a number of features. In each case, a routine vaccine has been linked to an unexplained yet devastating condition presenting at the same time in infancy or childhood. The MMR allegations have generated fierce debate in medical journals. […] The physician Andrew Wakefield has acted as medical spokesman […].

Anti-vaccine groups have played a yet more prominent role, now assisted by the powerful technology of the Internet. […] Immunization rates against measles are declining once again. […] From many perspectives history appears to be repeating itself. 1.1.2.5. The HPV vaccine and thiomersal Finally, another recent controversy was spurred by the human papilloma virus (HPV) vaccine, and thiomersal. The HPV vaccine protects against various types of cancer caused by the human papilloma virus, including cervical cancer, some mouth and throat (head and neck) cancers, and some cancers of the anal and genital areas; in the UK it is part of the National Health Service (NHS) vaccination programme, and is offered to both boys and girls aged 12 to 13 years (NHS 2019). Despite the fact that it has never been involved in major health scares the likes of the polio Cutter incident, uptake rates remain low because parents express concerns over its safety and efficacy, especially about its long-term side-effects; moreover, many believe that the vaccine encourages adolescents to become sexually active, which is still considered taboo in many cultures, including some European ones (Gilkey et al. 2017). This reluctance to vaccinate with the HPV vaccine can thus be interpreted as one possible manifestation of the widespread distrust towards the practice of vaccination. Indeed, it has frequently been said that vaccines are «victims of their own success» (Offit 2011: 174), meaning that anti-vaccination arguments tend to flourish when the remembrance of certain diseases fades, due precisely to their eradication through campaigns of mass vaccination. During the 20th century, vaccination was often met favourably by the general population, who was scared by the cyclical outbreaks of epidemics which left people – often children – dead or disabled (most prominently, the summer outbreaks of polio which killed young children, imprisoned them in iron lungs, or compromised their ability to walk and move unassisted; this fear was probably 191. Discourses of and about vaccines, the MMR vaccine, and the post-truth era the reason why even the Cutter incident did not significantly affect the uptake of vaccination). However, at the end of 20th-beginning of the 21st century concerns over the safety of vaccines began to re-emerge: although populations in industrialised countries now live longer and healthier than ever, they are para - doxically more concerned than ever about their health and safety, longing to return to a supposed naturalness, to a mythical unpolluted world following the rules of nature, a world in which vaccines often appear as a manufactured cocktail of poisoning chemicals (Clifford and Wendell 2016). Evidence of this forma mentis, and of the complex interaction between politics, science, and popular understanding, is the controversy surrounding thiomersal (also known as thimerosal, or sometimes thimerasol).

Thiomersal is an organomercury compound which used to be employed as a vaccine preservative. In 1999 (one year after Wakefield first proposed his MMR vaccine-autism hypothesis) and following a review of mercury-containing food and drugs, the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) mandated vaccine manufacturers to remove thiomersal from vaccines; this directive was soon imitated by Europe, too. However, they failed to communicate that this was a purely precautionary measure, and what is more, they based it on safety guidelines for methylmercury – while vaccines contain ethylmercury (note also that thiomersal was never used as a preservative for the MMR vaccine) (Offit 2008: 75-89; see also Baker 2008). Subsequent scientific studies proved that the amount of ethylmercury contained in recommended childhood vaccinations did not exceed safety measures and disproved its alleged link to autism (Doja and Roberts 2006; Gołoś and Lutińska 2015). However, the decision to remove a mercury-based preservative from all childhood vaccinations scared many parents, who were led to believe that the risk that their children had been poisoned truly existed. Note that this caused some parents to undertake potentially dangerous medical treatments, like chelation, to “remove the mercury” from their children’s bodies to “cure” their autism, in some cases with dire consequences for their health (Offit 2005). This episode demonstrates the importance of correct and precise scientific communication which highlights complexity and avoids simplifications that can lead to incorrect statements. It also underlines the importance of avoiding hasty political decisions which have the potential to undermine trust in scientific or - ganisations, often irremediably. Moreover, it is proof of the pervasiveness of the belief in a dichotomy between nature and technology, with nature being conceptualised as positive and technology being seen as negative for human health. This is also closely linked to questions about risk communication and the fact that we now live in what has been called a «risk society» (Beck 1999) where perceived risks far outweigh concrete risks, especially as far as diseases and hygiene are concerned (Wilkinson 2001).

1.1.2.6. The BSE crisis Concerns over the safety of vaccines which tap into wider discourses of wellness and wellbeing often appear coupled with wider concerns over pollution and food safety. One such concern indeed had profound implications on how the MMR vaccine was discursively constructed in the British press and public discourse, namely the BSE / CJD crisis.

The BSE and CJD crises refer respectively to the Bovine Spongiform Encephalopathy (also known as mad cow disease), a neurodegenerative disease of cattle, and its spread to humans, which is known as variant Creutzfeldt-Jacob Disease. Both BSE and CJD afflicted the UK in the 1980s-1990s, killing over four million heads of cattle and 177 human beings. The British government was harshly criticised for the way it managed the BSE crisis, particularly because at first it denied the danger it could pose for humans: for example, in May 1990 the then Minister of Agriculture John Gummer notoriously publicly fed his daughter a beef hamburger in an attempt to prove its safety – a strategy that later backfired as the incidence of both BSE and CDJ continued to rise, and the link between the two was scientifically established in the late 1990s (see also Kitzinger and Reilly 1997 for an account of the media’s coverage of the BSE crisis, and Jasanoff 1997 for a sociologist of science’s perspective on the controversy). This event severely undermined trust in the government and its officials, as was underlined also by Boyce (2007) who talks about a «BSE effect» in the subsequent media coverage of health and science: It was apparent in interviews with both sources and journalists that the BSE was a frame used by journalists and sources when deciding how to report the story. […] the production analysis in the MMR/autism story reveals the powerful frame the BSE crisis had over this story. With the BSE/CJD controversy not long from the top of the news agenda, journalists were quick to view the MMR/autism story as the next possible government cover-up, or “BSE part two”. […] Both sources and journalists continue to regard the BSE crisis as an influential frame in the reporting of science and health.

Scientific and government statements about the safety of the MMR vaccine were thus received with scepticism and suspicion. The BSE crisis, now more than 10 years old, continues to have considerable influence on how science and health stories are reported in the UK. (40-43) All the episodes briefly recounted in this section testify to the importance of previous health scares in the framing of subsequent debates over scientific and medical issues, suggesting that a correct managing of communication during health scares and controversies is crucial in order not to fuel the public’s 211. Discourses of and about vaccines, the MMR vaccine, and the post-truth era anxieties and suspicions, so as not to negatively prime their future responses to official communication. 1.2. The alleged link between the MMR vaccine and autism 1.2.1. The MMR vaccine Measles is a highly contagious, air-borne infectious disease whose typical symptoms are fever, cough, runny nose, inflamed eyes, and a rash covering the face and the body of the infected person. Its complications include diarrhoea, middle ear infections, pneumonia, and even seizures, blindness, and inflammation of the brain; measles can be fatal to both children and adults. Mumps is a viral disease whose specific symptoms include a painful swelling of the parotid glands (parotitis); its complications include deafness and a wide range of inflammatory conditions, in particular testicular inflammation which can result in reduced fertility or even sterility. Finally, rubella (also known as German measles) is an infection whose symptoms include a rash on the patient’s face and body; a fever, sore throat, fatigue, and joint pain are also common, while complications may include testicular swelling, bleeding problems, encephalitis, and inflammation of nerves. Most importantly, infection during early pregnancy may result in miscarriage or a child born with congenital rubella syndrome, which could affect its heart and brain and cause deafness (see, for example, Milner 2015: 24, 98, 100) 1.

The vaccine against measles, mumps, and rubella was developed by Maurice Hilleman and licensed for use in the USA by Merck in 1971. Nowadays it is widely used around the world, with 575 million doses administered since the vaccine’s introduction worldwide. It is routinely given to children around 9 to 15 months of age, with a second dose at 15 months to 6 years of age. After two doses, 97% of people are protected against measles, 88% against mumps, and at least 97% against rubella. Side effects of immunisation are generally mild and resolve without any specific treatment; these may include fever, pain, or redness at the injection site, while severe allergic reactions occur in about one in a million people. Because it contains live viruses, the MMR vaccine is not recommended during pregnancy; however, it may be given while breast - feeding and it is safe to give at the same time as other vaccines (Centers for Disease Control and Prevention 2021). 1 On the 25 th July 2023, the Regional Verification Commission of the World Health Organization (WHO) for the elimination of measles and rubella in the European Region declared that Italy has eliminated rubella, which is no longer endemic in the country; increase in vaccination coverage was linked to this result (Istituto Superiore di Sanità 2023).

In the UK, there is no law requiring vaccination for schoolchildren; how - ever, a suggested vaccine schedule is given by the NHS which also provides the recommended vaccines for free (Freed 2005). By way of comparison, all fifty states in the USA mandate immunisations for children to enrol in public schools, although they also offer exemptions on various (chiefly medical and religious) grounds. The issue of compulsory vaccination is not trivial and is strictly dependent on the social and cultural history of a country: in the UK, for example, anti-vaccinators in the Victorian era vocally protested mandatory, state-enforced vaccination, and since then, mass immunisations campaigns have relied on persuasion rather than compulsion (Colgrove 2004) (see also Section 1.1.2.2. in this chapter). Moreover, the availability of the triple vaccine freely provided by the NHS, as opposed to private clinics selling single injec - tions, also became an important element in the public debate on the MMR vaccine, especially for those parents who adopted a patient-as-consumer at - titude (Mold 2015), claiming to be willing to pay for separate vaccinations if these proved to be the safest option (see also the next section). On this subject, Tony Blair’s government was often accused of having ignored the parents’ fears in its refusal to provide single injections against measles (Stöckl and Smajdor 2017).

Finally, it is worth highlighting that the MMR vaccine is given to children, and therefore the decision (not) to vaccinate is taken by the child’s parents or caregivers. In this situation the patient – meaning the person potentially receiving the medical treatment – is oftentimes not the same person talking to the medical doctor and making decisions. Parents and caregivers are thus entrusted with another person’s health, and this may have repercussions on their feelings of responsibility and guilt as well as on the way the issue is tackled and communicated in different circumstances. This element may have facilitated the dissemination of very emotional arguments with a strong hold on the audience composed mostly of parents of very young children. 1.2.2. Timeline The MMR vaccine was first launched in Great Britain in October 1988 and began to attract sporadic court litigation in the early 1990s, as in February 1994 Jackie Fletcher, a British mother of an autistic child, became known as an anti-vaccination activist by launching a campaign claiming that MMR had damaged her son’s brain, also planning to sue the manufacturers. In September of the same year, lawyer Richard Barr decided to represent litigants in a potential class action lawsuit against MMR and hired Andrew Wakefield – then medical doctor who had already published a paper claiming to have found a link between the measles virus and Chron’s disease – with the aim of building a case against the triple vaccine. 231. Discourses of and about vaccines, the MMR vaccine, and the post-truth era