For example, in the Democratic Republic of the Congo during both the 20 Ebola outbreaks, disinformation campaigns argued that foreign medical workers were spreading the disease, contributing to attacks that killed or wounded dozens of medical workers. 19 20 These messages may be part of a broader effort to strategically undermine public health in both the developed and developing world. Research has shown that Russian bots and troll farms, in conjunction with Russia’s foreign broadcast network RT, have pushed anti-vaccination messages on a large scale on Western social media. However, the effect of social media is compounded by an additional factor: the intentional spread of disinformation in addition to misinformation. This leads to our first research question: does social media usage increase vaccine hesitancy in populations? More extreme propaganda of negative effects is incentivised, thus leading to a spiral of threat matched by public fear. In the case of anti-vaccination messaging, an effect similar to that of ethnic outbidding can emerge 18 in which a fringe group’s misinformation gains traction, not because it is considered credible but because, on the unlikely chance it is correct, the consequences would be horrific. 9–17 By drastically reducing the transaction costs associated with communication, social media has a 'long tail' effect in which the lack of any barrier to entry allows fringe groups to broadcast their message. Vaccine hesitant groups on social media have an alarming footprint, with studies from the early 2000s to the present showing that large proportions of the content about vaccines on popular social media sites are anti-vaccination messages. 1–8 This article fills that gap by addressing a pair of research questions tackling two dimensions of the proposed effect of social media. While there has been a great deal of work on the socioeconomic determinants of vaccine hesitancy ranging from qualitative single-country work to large scale surveys across dozens of countries, there has not been a global cross-national analysis of the effect of social media. Vaccine hesitancy is not a new phenomenon, but the proliferation of anti-vaccination misinformation through social media has given it new urgency, especially in light of the coronavirus pandemic and hopes for rapid development and deployment of a vaccine. Reconciling principles of free speech with the policing of social media for damaging falsehoods remains a conundrum for democracies. Social media, while providing an unprecedented capacity for the public to communicate, has also been a major factor in the rise of fringe opinions damaging to public health. Paradoxically though, contemporary anti-vaccination sentiment appears to be most concentrated in wealthy and highly educated democracies. Historically, democracies have been associated with improved health outcomes due to institutions being accountable to the public, increased levels of public education and generally higher levels of wealth. Last year the WHO listed vaccine hesitancy as one of the top 10 threats to world health.
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