A Critical Report About Emeritus Professor Timothy Noakes

This report will hopefully not only serve as evidence but provide a much deeper explanation about the situation. To avoid defamation or libel (as there is absolutely no intention of such acts), this letter will be as evidence-based as possible and in the interest of public and online safety. It will also avoid directly labeling without any substantial evidence. In a world where addressing is critical and should be done without further delay, this report should be perceived as responsible communication on matters of public importance. What is written (e.g. vaccine safety and the impact of misinformation) is based partially on my interpretation of the literature available to the public, as well as directly from the evidence cited and or from the professional discussion about the evidence. An in-depth play by play of events throughout the years will be given. All screenshots were collected on January 2, 2020 and are freely accessible using Twitter’s “Advanced Search” feature. This report will try to answer certain questions such as: 1. “Has Tim Noakes shared or expressed controversial claims in the past? If so, is this still continuing?” 2. “Are these claims, retweets and re-publications based on truthful, accurate, up to date scientific information?” 3. “If not, could these claims and re-publications be misleading, harmful or even a public health threat? Moreover, what is the true impact of such information?” 4. “Do people defend Noakes’ misinformation? If so, how trustworthy are these defenses, and do they resemble or amplify the original misinformation?” 5. “Is there any relationship between the leaders of online misinformation and Noakes’ Twitter account via their shared followers?” 6. “If such misinformation and untruthful re-publications exist, are there rules and regulations already in place that discourage these acts?” All of this will tie into one central question: “Is There Evidence to Suggest That Tim Noakes Might Be Truly Anti-Vaccine?” Properly Rephrased: “Collectively, do Tim Noakes’ verbal and online language, social engagements, shared information, retweets, likes, and behaviors coincide with those who are opposed to or hesitant of ?” This document will also try to follow closely to the World Health Organizations guiding principles on how to respond to vaccine misinformation and vocal vaccine deniers1:

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CONTENTS Introduction ...... 3 Background – Non-Vaccine Topics ...... 4 Background – Vaccines ...... 8 2014 ...... 8 2015 ...... 11 2016 ...... 12 2017 ...... 13 2018 ...... 18 Questionable Noakes Defender - Marika Sboros ...... 22 Cancer ...... 22 Vaccines ...... 29 Current 2019 Events ...... 39 Social Media’s True Impact ...... 65 Homogeneity of tactics, techniques and tropes ...... 65 Analysis of Tim Noakes’ Social Media ...... 73 Relevance and impact...... 79 Potential Rules & Regulations ...... 82 Discussion ...... 91 Conclusion ...... 111 References ...... 113

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Introduction

This is a separate issue from the original 4-year long nutrition trial with the HPCSA. The length of this past nutrition trial, it's coverage and negative impact on Noakes’ life adds further difficulty in writing this report and expressing its intent: that the 2014-2017 trial is a separate matter and the initial goal of writing this is not to amplify or continue the drama and personal attack that took place during the Low Carb High Fat Diet 2014-2017 trial. What is written is not an attempt to discredit the dietary advice given nor is it an attack on Noakes as a human being. Much criticism will be thrown at this report and some may think that this is connected to the previous trial, but that is not the case. What will be written is without preconceived opinions on that trial and thus does not compromise the intent or message of this report. Once again, what is written is with a non-malicious intent and should be perceived as in the interest of public health and online safety.

Professor Timothy Noakes’ previous trial brings to light the fact that many aspects of nutritional and dietary debate have grey areas, but topics such as do not have many. There is scientific consensus regarding safety, health effects, scheduling, etc., however, doubt about such topics is still spread through the online community and it is a matter of public, and worldwide, safety to lessen or remove misinformation. Noakes uses Twitter to educate himself, find new articles, share the information he has found and to “challenge conventional nutritional beliefs”.2 He also justifies “using Twitter because [he is] able to reach more people through the platform” – thus, it sounds like he uses his large social media following to his advantage, as many do. Writing about Noakes’ claims and statements is not out of the ordinary, with multiple blogs and posts from various professionals and members of the public doing so over the course of many years. In fact, quantifying and analyzing his tweets is also not a new task – as evident from a recent 2019 South African Masters Thesis dedicated to doing exactly this.2 Mr. Noakes has said in a December 2017 Tweet: “Let’s be certain of one thing: is one of the true successes of modern medicine and has probably saved more lives than any other treatment in the ”, however, his behaviors on social media seem to go in the opposite direction. The argument could be made that in public health, actions speak louder than words. We will come back to this claim later. Overall, the general narrative given is that Noakes expresses anti-vaccine narratives and concerns over vaccine safety, however, “vaccine-safety concerns … may snowball into societal tragedies when the media and the public confuse association with causality and shun immunisation.”3 It is a health professional’s responsible duty to emphasize “to patients [and the public] that there is a strong consensus in the medical community that vaccinations are safe, and that most doctors agree that adults and children alike should receive all recommended vaccines.”4 The majority of what Tim Noakes has shared contradicts that duty and diminishes this consensus.

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Background – Non-Vaccine Topics To begin, Timothy Noakes has promoted many topics in the past that some may believe are, to varying degrees, controversial. There is absolutely nothing inherently wrong with some controversy, but many problems arise when someone endorses sources that promote untruthful, potentially dangerous information – as we will see in this report. Tim Noakes expresses that he does not wish to be controversial5, however, it becomes problematic when some of the topics are indeed controversial and in some cases, untrue. One example is while addressing the topic of cancer, he recommends The Truth about Cancer. This book, conspiracy website, and documentary series make erroneous untruthful claims about cancer treatments, etc. This website also has an entire section of myths. ScienceBasedMedicine.org writers , MD and surgical oncologist, , MD, Ph.D., FACS, have detailed this misleading website and its creator.6,7 The fact that Noakes recommends this source is concerning.

This is not the first time Noakes has highlighted the topic of cancer, bringing up anecdotal cases of Complementary and Alternative Therapies (CAM).

But also implying that sugar causes cancer – a very popular narrative and topic of debate.

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This Tweet below received some criticism. It is quite clear that the husband of this woman did not also die of ovarian cancer because the man simply does not have ovaries, but Noakes implies that this may have something to do with her being vegetarian all her life. An anecdote without any causality or even scientific evidence in the tweet to back up the claim.

The spread of cancer misinformation continues in 2020.

Noakes has explicitly claimed that cancer, diabetes, and dementia “did not exist until we started eating highly processed foods.”9,10 There is evidence for how this claim is completely false.11–18 Multiple points of evidence in the literature show that these diseases existed before the rise of processed food consumption. Furthermore, there is reason to believe that these increased frequencies of modern disease may be more related to our higher life expectancy than genetics or our environment.19

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Mr. Noakes, on multiple occasions, has said or implied that carbohydrates are the “cause” of cancer. The specific details of debate are beyond the scope of this section but much of this direct singular causality is disagreed upon by oncologists and scientists. Of note, Noakes seems to continue to misinterpret and misrepresent Memorial Sloan Kettering’s CEO and President, Craig B. Thompson MD (tweet below). About 6 years after Thompson gave a talk titled “Why We All Don't Get Cancer”, Thompson was interviewed and he clarified that much of the increased risk of cancer comes from excess calories and obesity, not specifically carbohydrates and insulin.20 Furthermore, MSK clarified in the comments below that “it is not true that changing one’s diet by cutting out sugar will prevent cancer cells from obtaining glucose” and that regardless of a person’s diet, cancer cells will be able to obtain excess nutrients. The point here is not the debate about which nutrients cancer cells use, but that the misrepresentation of another academic’s work is highly irresponsible.

On that note, “Subsequent investigations showed that [cancer cells metabolic switch to glycolysis] actually stems from the very mutations that give rise to cancer – basically, [the changes in metabolism very well might be] a consequence of cancer rather than the cause.”21–23 More detail will be covered later and we will revisit this topic in the pages to come.

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A common theme, in my opinion, is Noakes’ statements of absolute certainty. In a broadcasted discussion between Prof. Noakes and Prof. Lionel Opie, which seems to be during Franschhoek Literary Festival 2014, Noakes makes a bold, but scientifically untruthful claim. At the time mark of 53 minutes and 16 seconds he says: “If you’re insulin resistant, you do not have to get any disease whatsoever. If you eat a high-fat diet all your life, you will not develop diabetes, you will not get cancer, you will not get dementia. That I can guarantee you”.9 - Can he indeed guarantee this? How?

Judge Davis says it’s a very extravagant claim, but Noakes responds with the quote I included before, “those diseases did not exist until we started eating highly-processed foods”. Which is not true. He tries to close this point off with: “Go into the traditional societies, you don’t find cancer.” This is also not true. While perhaps highly westernized societies have higher rates of cancer, cases of tumors date back to thousands and even millions of years ago. 12,13,24–29

When looking through social media one thing becomes clear, the people who follow and support Noakes rarely hold him accountable for misinterpreted claims. It is usually dismissed in many ways and sometimes people are selective with what he says; meaning that the apparent “good” things can somehow outweigh these misleading acts. This pattern follows as we transition to other areas of science and public health.

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Background – Vaccines Across the globe, vaccines have provided massive benefits for disease prevention and protection and have received a well-tracked safety record. “According to the Global Burden of Disease Study (GBD), between 1990 and 2010, there has been up to an 80% reduction in deaths from vaccine-preventable diseases,”30 writes pediatrician, scientist and Vaccinologist, Peter Hotez, M.D., Ph.D. There is some unfortunate irony when he talks about how can lead to outbreaks because it is so highly transmissible since we now are facing worldwide outbreaks two years later with a 300% increase in cases from last year.31 It’s highly relevant though when he mentions the movie tour and that he’s “especially concerned about the [influence it will have in] large middle- and low-middle income nations.” This topic has been followed for quite some time now and can provide an explanation as to how “western anti-immunization movements have taken root in South African communities resulting in some parents refusing to vaccinate their children.”32 With nearly a third of South African children not vaccinated, this places them at risk of catching serious diseases. Back in 2016, Charles Wiysonge, of the African Task Force on Immunisation of the World Health Organisation, explained that “this is, in part, because parents are hesitant to immunize, believing that vaccines are dangerous. A new phenomenon is emerging in well-served urban settings in known as 'vaccine hesitancy'…the anti-vaccination movement is growing in South Africa and we should be very concerned.”33 Almost a fifth of South African’s fear vaccines are unsafe.34 South Africa has indeed been a target of many anti-vaccination lobbying websites with claims and concerns regarding safety, the risk of adverse events, thimerosal, idiopathic illnesses including , and ‘vaccine-injured’ children.35 This seems to have contributed to the anti-immunization rumors and resistance from parents that challenges South Africa.36 Much can be learned about “vaccine hesitancy”37, as we will see in this report. The case with Tim Noakes acts as a vehicle to highlight and learn more about several aspects of vaccine hesitancy, the anti-vaccine movement, social media, and misinformation in general.

2014 The initial concern with Tim Noakes’ tweets all started on August 24th, 2014.

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The tweet first links to a YouTube video titled “CDC Whistleblower” posted by the AutismMediaChannel, which is a central video hub for Vaxxed content. This video attempts to, in a dramatic and fearmongering tone, uncover an apparent “whistleblower” (Dr. William Thompson, who’s comments were highly edited and disingenuously taken out of context38) in the US Centers for Disease Control (CDC) and show that they had identified a sub-group of individuals that were at a high risk for developing autism after the MMR vaccine. A connection that has since been widely disproven based on scientific evidence. The video is directed by non- other than anti-vaccine activist, .

When people questioned the post, Noakes suggested people watch it. He said that it was “about corrupt science and whistleblowing”.

Noakes says he has no opinion on the association between autism and vaccination and he said that “the tweet is not about vaccines but about bad (dishonest) science.” He says “as [a] layperson [he] promote[s] immunization of [his] family. As scientist [he’s] open to new data.” But as we will see in the many pages to come, the referenced data is not new nor up to date. Noakes has vaccinated his kids, and this fact is used by his supporters to suggest that he is not “anti-vaccine”.39 However, you can vaccinate yourself and vaccinate your children and still spread dangerous misinformation, as we have seen with Edwin Tamasese in Samoa.40 “[Tamasese is] willing to put others at risk while protecting his own family.”41 The defense for this 2014 tweet made by journalist and Noakes’ co-author, Marika Sboros, has been that “only one of his direct tweets (August 2014) indirectly included the topic of vaccines…any further tweets about vaccines have been simply reiterating the fact that he is NOT ‘anti-vaxx’.”42 So, the argument is that this tweet was only about the CDC covering up data about the proposed link between autism and vaccines. A link that has been completely disproven43–45 based on massive scientific studies, totaling over 3 million cases/subjects46–62, one of the studies concluding that “MMR vaccination does not increase the risk for autism, does not trigger autism in susceptible children, and is not associated with clustering of autism cases after vaccination.”46 To emphasize this one more time: Epidemiologic evidence supports a null association and there is a lack of mechanistic evidence to support this as well – “The evidence favors rejection of a causal relationship between MMR vaccine and autism.”55 With the last update occurring in 2018, The American Academy of Pediatrics highlights about 34 studies in detail related to autism and vaccines63, which further adds to the lack of association and causation of any link whatsoever.

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If Noakes is supporting the idea of a coverup, then he indirectly and unavoidably is supporting the belief that vaccines are associated with autism. In addition to this flawed connection in Noakes’ tweet, the video he shares also supports Brian Hooker’s work. Hooker has also been in the movie Vaxxed. His work, along with Noakes’ tweeted video, and any evidence of a true cover-up has been extensively written about and debunked.38,64–74 He defends his action (posting the video) by expressing three common anti-vaccine tropes: 1) The false CDC cover-up. 2) Comparison to the Tuskegee Experiment. And 3) Says the “mistake” was repeated more recently, in this context, the “mistake” was apparently MMR and autism.

According to Noakes, the tweet linking to vaccine hesitancy had nothing to do with whether to vaccinate or not. So, apparently, the tweet linking a video about vaccines…was not about vaccines?

Once again though, he brings up the wrongdoing by the CDC and increased risk of autism from exposure to Thimerosal. The big CDC “coverup” conspiracy has been debunked, disproven and a significant risk from Thimerosal is small or non-existent…which will be covered later in this paper. The study he provides is another Brian Hooker paper.75 In fact, several of the authors of this paper have controversial backgrounds, some have had trouble with legal authorities and it seems that the funding is from their own charity to write papers to use in court cases that they are involved in. Even the journal it was published in is questionable. This study has both been addressed and debunked on different blogs, one of them by Emily Willingham, PhD.76 Editor of the GroundUp news agency, Nathan Geffen, documented the 2014 Twitter exchange. “After recommending that his followers watch videos that cast suspicion on the MMR vaccine, it is disingenuous for Noakes to say he has no opinion. But even if we take him at his word, Noakes is a [retired] doctor who is outspoken on matters of public health.”77 Noakes has said that he has responded to this but his comment cannot be found at this time.78 Geffen makes the important point that even if Noakes turns out to be right about his dietary advice, “the measles

10 vaccine is a greater contribution to public health and the increase in human life-expectancy than his entire life’s work by a very long way. [Note: This is not meant to undermine Noakes’ work but it puts the global impact of the measles vaccine into perspective.] To spread doubt about the vaccine as he has done is not merely arrogant, it is irresponsible.”77

2015 In 2015, a health guru and follower of Noakes tagged him in a tweet.

The tweet includes a picture of a quote by a retired doctor who now uses “naturopathic and approaches” and is involved in selling disproven alternative treatments such as and Detoxes. More importantly, the quote is incredibly false, claiming that “almost all drugs are toxic and are designed only to treat symptoms and not to cure anyone.” It also claims that “Vaccines are highly dangerous, have never been adequately studied or proven to be effective, and have a poor risk/reward ratio.” Even going as far as to say that “most surgery [is] unnecessary and most textbooks of medicine are inaccurate and deceptive.” All of which is not true. The man on Twitter says that Tim Noakes and others are “trying to save your life”, which is then followed by this picture. The post is terribly misleading and untrue. Noakes retweeted this post and picture.

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When somebody replies to the post, discouraging this content, the person is told to read the book, Dissolving Illusions – we will come back to this book later. Instead of being alarmed by the misinformation, Noakes simply just asks if the person has read the book as if reading it will make a difference.

Later that same month in 2015, Marika Sboros warns somebody to be careful about saying negative things about the measles vaccine since “trolls” apparently don’t like that. She tagged Noakes as well.

2016 In 2016, Noakes questioned the ethics of the CDC and explicitly shared two extreme sources of “CDC Whistleblower” anti-vaccine misinformation/propaganda. He linked to an anti-vaccine Vaccine Whistleblower book. Kevin Berry and Robert F. Kennedy, Jr are two of the three authors. He also linked to a “CDC Whistleblower” YouTube video, another common anti- vaccine tactic.79 The video was also posted by an account that posts anti-vaccine content.

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2017 On November 22nd, 2017, Noakes says that he is interested in the claim that he is “anti- vaccination”.

He doesn’t “recall ever expressing that opinion either publicly or on Twitter.” He suggests that the term “anti-vax” is a smear towards those that read “science about [the] way in which [the] CDC conducts its vaccination research.” Not only does this wrongly imply that the vaccine- hesitant concerns about the CDC’s vaccine research (i.e. “cover-up”, MMR, etc.) are based on the “science”, he once again expresses the “CDC coverup” anti-vaccine trope. If he doesn’t recall expressing anti-vaccine-like opinions, then this report should benefit him and those who tend to agree with him. Mr. Noakes says that he has no opinion, but when asked for his opinion and more importantly, asked to expand his answer, it gives us a clearer view as to what his beliefs are. Gareth Cliff interviewed Noakes on November 29th, 2017. During this podcast, the topic of vaccines is discussed at the time mark of 44 min 07 sec. The back and forth conversation is included below because one must-see for themselves that Noakes’ first answer is positive, then there’s an “if” and a “but”, and it seems to get worse the more he explains. Cliff Interview:

Gareth: Do you believe in vaccination for children?

Noakes: That's a great question and the answer is yes of course I do, if the vaccination has been proved to be safe and effective. And that's the issue, you see. People -

Gareth: You aren't like that lunatic Jenny McCarthy who says that vaccination results in autism?

Noakes: But there is evidence for that. But it doesn't mean that everyone who is vaccinated has become autistic.

Gareth: *Slightly more assertive tone* Because the last thing we want is a whole bunch of Jenny McCarthy’s not vaccinating their children and starting Polio again. Noakes: But, but, but, you have to look into the hist- I don't want to get involved in this debate but there's a whole body of evidence that vaccination is being overused.

Gareth: But you do believe in vaccination? I'm trying to clear up a bunch of things -

Noakes: *Interrupts* Sure, sure, sure, sure. Of course. But I would minimize the amount of vaccination you do because...there's clear evidence that thimerosal ... is damaging to our health. And the CDC has suppressed information. Do you know that Robert de Niro who made this film "Vaxxed", he offered $100,000 to anyone who could prove that vaccination is safe? No one has taken him up on it. There is no evidence that vaccination is safe.

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Jacques Rousseau*, who teaches critical thinking and ethics at the University of , explains how this interview becomes a “Duck Test.”80 “The test implies that a person can identify an unknown subject by observing that subject’s habitual characteristics. It is sometimes used to counter abstruse, or even valid, arguments that something is not what it appears to be.” Rousseau provides a more detailed analysis. It is concerning that Noakes uses “much of the same misinformation they (McCarthy, Kennedy, Carrey, de Niro) do”80 and this can lead us to make assumptions or even a further quantified analysis about his beliefs, but more importantly, about the misinformation that fuels the anti-vaccine movement. Another concern and consideration is how the lay public would perceive what he says in this interview. “Even as he asserts that he supports vaccinations – he introduces sufficient qualifications and obfuscations that his pronouncements on the matter could plausibly lead to at least some of his followers choosing to not vaccinate their children.”80

* There have been multiple back and forth blogs and criticisms between Noakes’ work and Rousseau about various topics (e.g. diet), a lot of which are not about vaccines and are beyond the scope of this paper. It is not my intention to amplify the message of those writings.

“As discussed above, the idea of ‘over-used’ and ‘over-prescribed’ makes no sense here, because we want as many people as possible to be vaccinated. Noakes’ claim that thimerosal is the problem is, unfortunately, complicated by the fact that it hasn’t been used in childhood vaccines since 2001 [and is only in inactivated influenza vaccines]. Even when it was used, it was used in the production of vaccines, and then removed, with only trace elements remaining.”80 The American Academy of Pediatrics highlights about 15 studies in detail related to the various concerns about thimerosal63 – all of which provide scientific evidence against Noakes’ concerns or claims. Overall, the thimerosal argument is a reasoning flaw of miscommunication and misinformation. When it is used it has been considered safe, and there has been no significant association between thimerosal-containing vaccines and neurodevelopmental outcomes, autism or ill effects.81,48–50,52,82–89 Rousseau continues to write, “as for the ‘CDC suppressing information’, that’s a reference to the ‘CDC Whistleblower’ , again comprehensively debunked. As for Robert de Niro…[and] the $100 000 challenge, it’s easy to win a bet that’s designed to be impossible to lose. You can’t prove that ‘vaccination is safe’, because that’s an absolutist statement, rather than a scientific proposition.”80 Many things have risks, such as types of exercise, does this mean we shouldn’t do them? Absolutely not. What Noakes is doing becomes a perfect example of the Nirvana fallacy and is a clear anti-vaccine trope.90 This dichotomous thinking and craving for certainty quickly becomes unscientific and contradictory to what Noakes typically stands for. “…Given that any medication can cause adverse reactions in some humans, de Niro, Wakefield and Noakes can claim a victory. Science can’t offer such guarantees, and on that standard, we’d not be able to trust anything to be true. Meanwhile, we have an enormous preponderance of evidence that vaccines are low-risk and massively beneficial – and that it’s irresponsible to cast doubt on that, as Noakes is doing. Because subtle messages are usually lost in short interviews or social media, we need to be unambiguous about the positive value of vaccination, rather than casting doubt on it. Criticizing those who express skepticism is not an attempt to silence or

14 censor, but rather to ask Noakes whether ‘just asking questions’ is worth the risk of encouraging irresponsible – and harmful – choices, like opting-out of vaccination.”80

UK physician and author, Dr. Ellie Cannon, also raised concern with this, along with several others.

The day after this interview, Noakes was asked on Twitter to provide evidence for the link between autism and vaccines. His ultimate response is to refer to his 2014 “CDC Whistleblower” coverup tweet, which is clear misinformation as covered already in this paper. This sidesteps away from him having to provide credible, up to date scientific evidence.

Another remark Noakes makes is regarding “vaccine damage” apparently “proven” in court (US Office of Special Masters). As written in Times Magazine, this “has long been the kryptonite, the dropped mic, the rapped gavel of any rational discussion of vaccine safety.”91 The problem is that cases made in this court do not seem to provide proof and awards are given “with no determination being made about whether the vaccine even caused the claimed harm.” “…Claims may be settled for a lot of reasons, including ‘a desire by both parties to minimize the time and expense associated with litigating a case to conclusion; and a desire by both parties to resolve a case quickly and efficiently.’” The Times article goes into the numbers behind doses of vaccines and court injury claims made. It appears that the billions of dollars handed out from the National Vaccine Injury Compensation Program (NVICP) does not suggest that a ton of people are being harmed. Another issue with relying on NVICP cases is that because of their “no-fault” rule, they don’t seek proof of causation. Some cases have been controversial, but “what’s not controversial

15 is the far bigger picture, which is that medicine has never been about eliminating all risks, but about minimizing and balancing and coolly considering them.” “For the literal one in a million who are harmed, the NVICP stands by to help. For the rest, it’s the vaccines themselves that do the helping.”91 “To pretend that the existence of the NVICP proves vaccines are unsafe is either deliberately misleading or dangerously misinformed.”92 Both attempts by Noakes to redirect having to provide evidence, only to then recommend a flawed source, and use apparent, non- causal “vaccine damage” to instill doubt is irresponsible for public health. In a thread about the 2014 tweet, somebody suggested he should get a PR person, but he says the only defense he has is the “truth” and “the truth doesn't come from a PR agency/person.” When he is asked to provide evidence a month after the original 2014 tweet, he says he will only do so via direct/private message. He does not want to be transparent, claiming activists (assumingly those who are pro-vaccine), who do not want to know the “Truth”, will use the smear “anti-vax.” So, it seems that whatever he believes to be the “Truth”, he thinks it will be termed “anti-vax.” This may give insight into what he believes.

While defending himself 3 years later, Noakes uses the word “truth” again. Claiming “that activists who troll [him] have absolutely no interest in truth.” He recommends a book by Alice Dreger, who also may be a very misleading source when it comes to vaccines.93 He questions vaccine safety again to which he omits the several safety studies that exist within the literature. He may be falling prey to the “truth wins” assumption.90

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Noakes has denied that he is anti-vaccine or “anti-vaxx” and says that he is “about transparency and honesty in interpreting and reporting scientific data.”94 Although, as we have seen and will continue to see, Noakes is not transparent about what he believes about certain vaccines. Most of what he has shared about vaccines has not been honest nor has it been scientifically credible. We will continue to repeatedly see this contradiction throughout this report: claiming he is not anti- vaccine while expressing anti-vaccine views and spreading anti-vaccine misinformation. Naturally, his own foundation, The Noakes Foundation, also denies that he is anti-vaccine.

His explanation for why he thinks we should assess “all the evidence” gives false balance and is linguistically phrased just like common anti-vaccine rhetoric.

Here (above) he is defending his choice of words in the Cliff interview where he implied there is a vaccine-autism link and that vaccines aren’t safe. In this context, he seems to imply that those who say that there’s no link between and say that vaccines are safe (i.e. what is technically the “pro-vaccine” stance), are apart of “the marketing hype provided by those who stand to gain financially.” Apparently, he thinks this is a “problem caused by industry- driven ‘eminence-based’ misinformation.” So, not only does he suggest that the side that doesn’t question vaccines (which is technically the side that is not spreading misinformation) are apart of a marketing hype that gains financially, he suggests that it is industry-driven misinformation. So, if we take a step back for a second and look at this tweet one last time, he seems to suggest that the evidence showing there’s no link between vaccines and autism and that vaccines are mostly safe is industry-driven misinformation. This wording is incredibly unnerving, and we will see more of it to come.

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According to an analysis of Noakes’ tweets, truthfulness and honesty are very important to him. “[He] was raised by parents who were terribly honest, so [he] always [tries] to be as honest as possible.”2 He states that he tells the truth on Twitter, that he focuses on telling the truth and exposing untruths. The troubling reality is this completely falls by the wayside when it comes to vaccine information. One reason for this may be because “social media is not conducive to thinking analytically about truth and accuracy.”95 We will explore more reasons for this hypocrisy much later.

2018 In a series of tweets in April of 2018, Marika Sboros says that people are falsely claiming Noakes is “anti-vax.”96 She thinks it is an attempt to destroy Noakes’ reputation and she says that those who resort to the “anti-vax” term don’t have science on their side97 – although as we have seen and will continue to see, the science is not on Noakes and Sboros’ side in terms of vaccine information. Sboros goes on to say that “Desperate times call for desperate measures” and compares the apparent lies spread about Noakes to “Goebbels”, i.e. Joseph Goebbels, who served as minister of propaganda for the Nazi German government. Noakes replied…with more vaccine misinformation.

He quotes Brian Martin’s book, Vaccination Panic in , which uses some of the same language and tactics that Noakes and Sboros use, as will be mentioned later. Apparently, according to Sboros, Noakes’ response was not about anti-vaccination but about the suppression of opinion98 – but these opinions being suppressed are anti-vaccination. She once again says “Prof Noakes is NOT anti-vaxx! He has made that clear!” – while at the same time, Noakes’ post quotes and links to anti-vaccine misinformation.

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A day later Noakes shared the same book by Brian Martin and made the false comparison, as said in the book, between deaths associated with sugary drinks and deaths caused by vaccine- preventable diseases – which when digging deeper into what the book says, it demonstrates how vaccines have been a victim of their own success.99,100

Both topics of misinformation within this report, cancer treatment and vaccines, are two “topics that doctors discuss on social media at great personal risk”, according to Noakes in a May 2018 tweet.

This may only be true when such information about the topic is unconventional, misleading or out of the doctor’s scope of expertise. Noakes seems to think that a person is “safe from trolls only by making statements that support vested pharma interests.” If we break this language down further, what seems to be the “pharma interests” is conventional medicine, i.e. chemotherapy, radiation, surgery, pharmaceuticals, and vaccines. As we have seen in the past and will be covered many times hereafter, the term “troll”, as said by Noakes, is somebody who is not interested in the “truth” of vaccines – however, this “truth” happens to be misinformation. “Trolls” also apparently fire back at Noakes when his information is unconventional or misleading, as we’ve seen with vaccines or cancer treatment. Thus, what Noakes calls a “troll” is really somebody who doesn’t agree with his vaccine and cancer misinformation. “Vested”, in this case, is used as a negative connotation which frames these medical interventions as selfish and focused on personal and financial gain. Therefore, when we break things down further, what Noakes implies sounds something more like this: “Somebody is safe from the people who call out vaccine and cancer misinformation only by making statements that support conventional medicine, such as chemotherapy and vaccines. Challenging these topics with misinformation will cause personal risk because those who support conventional medicine disagree.” Of course, Noakes didn’t say this, but this seems to be a possible implied meaning. His tweet is so odd because there is some implied meaning which is hard to explain. Perhaps this can be discussed further as a response to this paper or section.

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Noakes has said that “You cannot talk about vaccines or chemotherapy without being destroyed and your reputation ruined.”2 This is simply not true. You can indeed freely talk about them, but you may not be able to cast doubt on vaccines and chemotherapy and spread misinformation without harm to your reputation. Doing so may be deemed as irresponsible, unprofessional and perhaps even against medical guidelines. The narrative under which the topic is posted tells us more than simply just “talking about it”, context is important – hence the need for this report.

A common theme when defending his position comes down to semantics. What is implied: “vaccines can cause autism”, versus what he actually says: “there is evidence for that” (i.e. that vaccinations result in autism). As said before, even though he claims to support vaccine success and he has not explicitly said they “cause” autism, through his posts and behaviors “he introduces sufficient qualifications and obfuscations that his pronouncements on the matter”80 could lead people to not vaccinate and believe the misinformation about vaccines.

Based on concerns such as this and accusations of being “anti-vax”, Noakes wrote a response in 2018.42,101 It starts with his tweet: “On December 1st, 2017 I tweeted the following on my Twitter feed: “Let’s be certain of one thing: Vaccination is one of the true successes of modern medicine and has probably saved more lives than any other treatment in the history of medicine”. In my opinion, these two positive points he addresses do not detail his true thoughts about vaccines as talked about above. Nearly identical language (i.e. general “medical success”) has also been used by anti-vaccine supporters.102 Regarding their success, he seems to specifically talk about smallpox and polio but has publicly shared doubts about other aspects of vaccines. Noakes continues in his response: “The source of my ‘contentiousness’ regarding vaccination is apparently my expressed concern on radio that is nothing more than a fundamental teaching to which all medical students are regularly exposed.” This teaching he says is that therapies are not without side-effects. This is exactly like what was said before and for that, I will repeat the following: “You can’t prove that ‘vaccination is safe’, because that’s an absolutist statement, rather than a scientific proposition.”80 “…Given that any medication can cause adverse reactions in some humans, de Niro, Wakefield and Noakes can claim a victory.” The fact that no medical treatment is 100% safe is taught in medical school, however, as far as I am aware, the vaccine misinformation and doubt Noakes expresses is not taught in medical school. A very questionable statement without any scientific foundation, in my opinion, made by Noakes is that we should consider long term consequences of “vaccinations for a range of illnesses that were not considered targets of immunization when [he] was growing up. And [he] and many in [his] generation appear to have survived quite well without them.” Long term consequences have been considered and just because Noakes survived without certain vaccines, doesn’t mean they shouldn’t be used. Also, when Noakes says that he is grateful for the vaccines he got as a child103, this might exclude the vaccines he casts doubt on, such as MMR. “When Tim Noakes was six years old, there were 693,803 cases of measles in the UK. Thanks to the vaccine, that number is now [in 2018], down to 1,642. Measles vaccination has resulted in an 84% drop in deaths between 2000 and 2016. Rotavirus was the number one cause of diarrhoeal disease in South African children. The new rotavirus vaccine has been estimated to have saved 170,000

20 deaths per year, with no significant side effects noted.”104 That’s just a couple examples out of many. Perhaps Noakes’ statement is an example of anecdotal survivorship bias. Ultimately Noakes’ question is: “do all of us need all of them all of the time?” This is just like the Cliff interview where he says that they are “overused.” The question to ask Noakes would be which vaccines he would exclude and based on what evidence. He has not responded when asked this as well as multiple other questions.105–107 This “Too Many, Too Soon” or “overused” way of thinking seems to be flawed based on the scientific evidence.63,108–112 His concerns are about “less obvious damage to health” that apparently impairs everyday wellness. For this, he cites another flawed and even retracted study by Mawson et al. comparing vaccinated and unvaccinated children. Of note, the link provided goes to the “Health Choice Vermont” website and it doesn’t take long to see that they have plenty of misinformation, myths and straight-up lies about vaccines…and this is the source Noakes directs readers to. Anyways, criticisms of the study have been that it wasn’t a representative sample, there were several limitations, conflicts of interest and the study did not set out to even test the association between vaccination and health.113,114 “To find any statistically significant, much less clinically significant differences in health outcomes between vaccinated and unvaccinated children would require huge numbers, and who knows if Mawson controlled for confounders properly.”114 The second study published using the same survey data was equally as flawed.115 Noakes’ rationale for citing a single associational study, which he even says might be quite wrong, is that “we do ourselves and our patients no favours by simply ignoring published evidence.” In my opinion, this is correct, but not about this study and not if the published evidence has been shown to be flawed. We do not do any favors by carefully selecting evidence that feeds our bias, especially if the balance of credible evidence in the literature suggests the opposition of our single study cited. Overall, comparing vaccinated and unvaccinated populations, those who are vaccinated seem to do better in many areas such as asthma116, allergies109, cognitive development117, birth outcomes118–121, serious effects from the flu122, adverse cardiovascular events123, clinical features and illness from measles124–126, and mortality127. Theoretically, a child would be able to receive 10,000 vaccines at once due to the immune system’s enormous capacity.112 Unequivocally, “current studies do not support the hypothesis that multiple vaccines overwhelm, weaken, or ‘use up’ the immune system.”110,112

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Questionable Noakes Defender - Marika Sboros One of the main sources of defense for Noakes is also questionable. Marika Sboros is a journalist and co-author of Noakes’ book Lore of Nutrition. The reason I bring her up in this report is that she has written multiple articles about Noakes, coming to his defense quite often, especially within the topic of vaccines — but she herself seems to have spread much misinformation. A note to the reader: this section unintentionally turned into a point by point evaluation of Marika’s claims but nonetheless it is still relevant to Tim Noakes, especially the section about vaccines.

Cancer We will first address various claims about cancer since this seems to be a commonality when it comes to misleading posts between Tim Noakes and Marika Sboros. While this does indeed trail away from the main topic of vaccines, it is apart of a larger theme of misinformation in general and demonstrates the convergence between misleading cancer and vaccine ideologies. Marika has several tweets about diet interventions as adjuncts for cancer treatment. Both her and Noakes continue to support specific narratives within this, mainly focused on low carb and ketogenic diets. Trends do exist which suggest that people with diabetes have an increased risk of cancer death128, however, this is often amplified by low carb and ketogenic diet advocates beyond what the cited evidence concludes – i.e. this does not automatically mean that these diets will prevent cancer, though research has been done, and is currently being done, with regards to the treatment of cancer. High-fructose corn syrup has been shown to enhance tumorigenesis in mice129, however, these findings cannot be extrapolated to humans, as explicitly said by the authors. Hyperinsulinemia has been shown to promote obesity-associated colon and in mice, this may be mitigated through exercise and weight loss, but since weight loss might not be a desirable outcome in cancer patients, pharmacological modulation with SGLT2 inhibitors may be a viable option. From this, some might assume that a diet that can lower glucose and insulin concentrations, such as a ketogenic diet, can also reduce or stabilize tumor growth. However, once these diets are implemented into a cancer patient’s regime during a or case study, this hypothesis starts to become quite shaky – evidence will be cited and explored that demonstrates this. While ketogenic diets can improve the response to PI3K inhibitors by reducing blood insulin in mice and exogenous insulin can “reactivate” the insulin receptor in mouse tumors130, short term infused glucose through total parenteral nutrition does not seem to metabolically stimulate human tumors.131 Furthermore, lipid supply (which is a major component in a Low Carb High Fat/Keto diet) does not seem to suppress the uptake of glucose by the tumor. Thus, the transition from mouse to human seems to be more complex than some make it out to be. Furthermore, some of the data in mice are also contradictory with regards to insulin. At least in Leukemia, “insulin does not function as a promoter for glucose utilization and cell proliferation”132, rather it is the cancer itself that induces an insulin-resistant phenotype via upregulated IGFBP1. (Of note, some Leukemias (CLL) do not follow the traditional Warburg Effect133 and many hematopoietic malignancies do not exhibit a fixed glycolytic phenotype.134) While ketogenic diets for cancer

22 remain controversial – since much of the scientific research is preliminary and in vitro or in vivo – some promise does show in animal models for certain cancers, while in others, it can make things worse. The current results, however, are quite contradictory between studies in cells and mice.135–141 We then run into the inconsistent comparison, and sometimes outright assumption, that in vivo studies translate to human cancer patients. It appears that this is the crux of the problem in the literature and in the reviews that report favorable results with ketogenic diets. A study done by Zahra et al. demonstrates this difficulty when comparing the efficacy in animal models to that of humans.142 NSCLC xenograft models showed promise when the ketogenic diet was combined with radiation and chemotherapy, however, in advanced pancreatic and NSCLC patients, dietary compliance was difficult and many prematurely stopped the ketogenic diet. While the KetoLung study was terminated and not powered to detect differences in survival, it is noteworthy that the differences in survival between groups did not favor the ketogenic diet. Only one patient who completed the KD had progression-free survival (PFS), this was 4.6 months. In comparison, those who prematurely stopped the KD had a median PFS of 7.5 months (range: 3.2 to 33). The median overall survival (OS) of those who completed the KD was 17.7 months (range: 9.4 to 26) and those who prematurely stopped the diet had an OS of 22 months (range: 3.7 to 33.3). There were no observed differences between groups, which contrasts with the claims made about the diet. Only a few very exceptional patient case reports exist from independent clinics which show prolonged survival and tumor shrinkage, however, these may be confounded by caloric and protein restriction, as well as standard treatment (drugs, radiotherapy, surgery) before, during and after the diet intervention.143–146 These cases are also uncontrolled and fail to show whether or not the experimental treatment actually does better than conventional treatment – this has been one criticism about these types of case studies.147 More importantly, they severely suffer from conflicts of interest, survivorship and publication bias, as well as other biases. One recent case report144 being circulated by low-carb and keto advocates is of a patient with glioblastoma multiforme who received treatment at one of the independent clinics. He received conventional treatment (subtotal surgery, radiochemotherapy with TMZ) but months later an MRI showed recurrence. After this, he decided to halt all standard treatment and go on a “Paleolithic Ketogenic Diet” (PKD). Follow up MRI scans showed no change in tumor size after starting the diet, however, there was also no change in size before the diet was started, thus, it is difficult to conclude the effect of the diet on the tumor. As described in the Macdonald criteria, “treatment response is defined as a minimum decrease of 50% in tumor area”148 – since there wasn’t any change in the tumor area, it’s quite possible the diet contributed to stabilization or there was little to no effect on the tumor. Limitations with MRI brain imaging do exist, so advanced imaging may be needed to give a more accurate interpretation of response and tumor activity. This patient has survived over three years which is being shared as a success for the diet intervention. While recurrent glioblastoma survival has been documented anywhere from 6 to 15 months149, long term survival is rare but not unheard of. About 2% of GBM patients, in general, survive over three years150–152, some even longer153. The PKD clinic has had about 10 GBM patients (confirmed by Clemens Zsófia, Ph.D.) so literally 10% (n=1) of them have survived for 3 years. In the past, combined GBM treatment with radiotherapy and TMZ has resulted in 16.0% of patients living at 3 years, 12.1% at 4 years, and 9.8% at 5 years compared to much lower survival rates with radiotherapy alone.154 In this PKD patient’s age demographic (>50 years), survival with combined therapy was 11.4% at 3 years, 8.2% at 4 years and 6.4% at 5 years. 15 patients that

23 were >50 years old were still alive at 4 years with combined therapy, 1 patient was alive at 5 years with just radiotherapy. In patients with first and second recurrence of GBM, 1 out of 12 receiving bevacizumab could be classified as a long responder (median PFS was 21.7 months, median OS was 31.1 months from the start of BV).155 Across the literature long term survival is not well understood and age, as well as biological, histological and genetic factors, may play a large role. While still controversial between studies, methylation status of the MGMT promoter has been related to improved prognosis.156 Tumor location might be another factor since the PKD patient had a cystic lesion that was localized in the right parieto-temporo-occipital region. Having no contact of the tumor at the subventricular zone and localization distant to the ventricle system has also been correlated to long term survival.157 All of this, mainly the various survival statistics cited above, is relevant because it seems to demonstrate that relying on a single patient’s case study makes it extremely difficult to sift out the effects of the diet and how it compares to standard therapy. It is also unknown how a larger sample size would affect the results. Adding further difficulty and publication bias, one of the clinics other GBM patients who was doing to diet adjunctly with radiotherapy, was stable for 2 months until the disease progressed and they died.158 The authors note that this man who is still currently on the PKD is the longest patient to live by just using the diet as a monotherapy, others have not been as lucky. Despite the commonly touted testimonials and case reports, we must be extremely cautious, and perhaps even disheartened, about these independent foreign keto cancer clinics.159–162 At one of the clinics, many of the patients have passed away but their testimonials are still on the website and are still being touted to convince people that the therapy works.162 The sheer and danger behind the use of additional alternative therapies163 (Mistletoe, Amygdalin/Laetrile, etc.) by independent “integrative” clinics that also use the ketogenetic diet are beyond the scope of this report. Other “integrative” clinics have been equally as ineffective and predatory.164–170 Cancer “” (i.e. unproven and disproven treatments) and “charlatanism” continues to be a major issue in the field of Oncology.170–172 Overall, there’s mixed evidence and a lack of well- designed rigorous trials in humans for ketogenic diets and cancer.173–178 Another consideration is that weight loss is frequently reported in ketogenic cancer trials177,179 and this may pose some risk if the weight loss grade is too high (grades 3 and 4).180 Marika does say that she has “not advised and [does] not advise patients to consider delaying chemo or radiation in favor of a ketogenic diet.”181,182 But she does say to “‘intelligently postpone” or “delay” in favor of diet with the approval of the patient's oncology team. However, some argue that this decision to “intelligently delay” may not be so intelligent after all.183 This would also depend on where the oncology team is located since patients have gone to independent foreign clinics that use the ketogenic diet and have had what is technically an “oncology team”, but the quality of life and survival outcomes continue to be quite awful.162 Marika uses the word “adjunctive” when introducing the ketogenic diet and cancer, but in the context and narrative in which she writes, it fails to meet the definition of adjunctive therapy as this would mean that the diet has been added on top of the conventional treatment and one would not replace the other, especially not in the characterization she uses to describe conventional treatment.

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One trauma surgeon was quite vocal.

However, Marika thinks that the potential harm caused by misleading claims doesn’t apply to her.

She has continued this in 2019:

Her and Noakes have also retweeted a post that wrongly suggests that is “free chemotherapy”184 despite the original study being much more nuanced and inconclusive. Much of the hype with fasting in oncology has been prematurely reported by the media and scientifically, the data is unclear. The promise of fasting and cancer is “devoid of clear clinical evidence and conflicts with recent recommendations from international scientific societies.”185 In addition, she has cited anecdotal stories (most times it’s one single story in particular – more survivorship and publication bias) of those who delay chemo for alternative therapies and glosses over the fact that they also had surgery to remove the tumor and organ.186 This can be quite misleading. Some alternative cancer therapies have even been shown to decrease survival rates187–189, but this is beyond the scope of this paper. Surgical oncologist, David Gorski, MD, Ph.D., would call this a “skipped adjuvant therapy testimonial.” “It is a subtype in which it was really the surgery that cured the patient, but [they] attribute [their] survival instead to the [alternative treatment they] chose.”190 “The conflation of adjuvant therapy after surgical extirpation of a cancer and chemotherapy as the primary therapy for such cancers is a common

25 theme in alternative cancer cure testimonials”191, writes Dr. Gorski. The point is that Marika has written about an anecdotal story of a man who is said to be cancer-free and attributes this success to the diet, fasting and supplementation whereas the more likely cause of success is the multiple surgeries the man had. It may be dangerous to call it, in Marika’s words, a “Revolutionary Survival Secret” especially if somebody also decided not to have surgery. Dr. Gorski expresses concern about a similar case, “as glad as I am to see a cancer patient overcome the odds and beat [their] disease, it’s truly depressing to see that same patient spread misinformation about the science-based medicine that saved [them] and then to promote all sorts of [risky alternatives]”.192 Of note, Noakes has retweeted a misleading and perhaps predatory book titled, How to Starve Cancer.193 Marika has alluded to the idea that there may be an “anti-cancer diet”.194 She follows this up by sharing the book Eat to Beat and the author, Dr. William Li. She has referenced his work multiple times. However, the scientific accuracy of such claims within the book seems to be quite weak with regards to human cancer and there is limited research on and diet.195 Marika promotes the book Tripping Over The Truth by Travis Christofferson196 which further pushes a single cause of cancer narrative, a dichotomist and simplistic view about cancer metabolism, and the idea that a keto diet will be effective and even possibly prevent cancer. Christofferson continues to promote and heavily support predatory integrative keto cancer clinics as well as other absurdity197 (cancer , toxic cell phone radiation, Burzynski protocol, etc.) through his Single Cause, Single Cure Foundation. “It is tempting to ascribe both increased aerobic glycolysis and apoptosis resistance (both hallmarks of cancer) to a single, central mechanism. However, empirically proving this hypothesis has proven elusive.”198 The behaviors at all levels of biochemical organization of different tumors are indeed heterogeneous.199 Given the complexity of the disease, discovering a “single cause” and “single cure” is likely impossible. Marika has included the claim in her blog that the ketogenic diet is a “cure” for cancer200 and she includes a quote that says ketones are “one of the keys to beating cancer”186 – both claims are misleading and, for the most part, goes against the current scientific evidence we have on the topic. Her sources of information196,200–202 (authors she puts in the spotlight) focus on the area of Complementary and and it is incredibly misleading.203–205 Some of which have breached the code of the Advertising Standards Authority of Ireland (ASAI) and it has been suggested that the claims are “misleading and unsubstantiated”.206 No citations to scientific research are given in Marika’s articles – thus there is no way to easily fact check them. Overall, placing trust into alternative diet therapies (keto, high fruit, supplements, hyperbaric oxygen, testimonials, etc.) are not without risk; the apparent benefits are being “massively oversold” and their promotion is misleading.147,207–209 Dr. Gorski also explains that when the risks of the alternative therapies are not covered in the articles, like the ones Marika writes and also in her tweets, it might not be “informed choice”, but misinformed consent. Like Noakes, she is excusing these actions by saying she has not told patients to avoid having chemotherapy. However, it’s concerning when her posts clearly cast doubt on chemotherapy.

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Here (above) she quotes a Naturopath that claims chemotherapy does not work and that it is only used because it brings in huge profits for doctors. Dr. Gorski covers this in a series of tweets.210 This level of fraudulence is beyond the scope of this paper. Hypocritically, in 2014 she wrote an article for BizNews211 about seven things you shouldn’t say to somebody who has cancer, one of them is recommending alternative therapies:

But literally, a month before that article was published, she wrote about “promising [cancer] breakthroughs, particularly in natural compounds, which are present in certain fruits and vegetables.”212 Specifically the dietary phytochemical Salvestrol, which also raises some flags as a cancer treatment.213,214 No clinical trials have been published and it seems as though it is used in the world of Complementary and Alternative medicine, along with other unproven or disproven therapies.215 This is concerning. Apparently, some patients have had worsening of disease while taking it, but Marika claims it can improve the quality of life of patients “long after orthodox medicine has given up on them.” No rigorous evidence on Salvestrol was found in the literature. Of important note, while the topic remains controversial, there seems to be a lack of survival or anti-cancer benefit from vitamins and antioxidant supplements. Mechanistic data216 and expert discussion allude to the idea that the “dose makes the poison”, as high doses may interfere with the cytotoxic mechanisms of cancer therapies. Associational data indicate no significant improved survival or reduction of adverse effects on chemotherapy with multivitamins.217 One recent observational study by Ambrosone et al. concludes that “associations between survival outcomes and use of antioxidant and other dietary supplements both before and during chemotherapy are consistent with recommendations for caution among patients when considering the use of supplements, other than a multivitamin, during chemotherapy.”218 It may be still too early to come to firm conclusions, but given the consistent result that antioxidants have at least a neutral effect in patients, there is doubt that they will independently contribute to increased survival and disease reduction. These claims and hype about vitamins, supplements, and antioxidants have a harsh history dating back to Linus Pauling in the 1960s.219 Another very concerning red flag is Marika’s support of “naturopathic oncology”.201 Or “master nutrition therapists who practice oncology nutrition therapy”, one of which comes from a controversial and questionable naturopathic university.220 One thing is for sure, the holistic “Nutrition Therapist Master” program is not a real Masters program and the two women Marika cites are not actual medical physicians, let alone specialized oncologists. One only needs to read articles from authors such as Edzard Ernst, MD, Ph.D., (an Emeritus Professor of Complementary Medicine at the Peninsula School of Medicine) or , Dr. David Gorski, Timothy Caulfield and the like to know that Naturopathic “medicine”, especially “naturopathic oncology” or “integrative oncology” should not be trusted, and its support should not go unscrutinized. With regards to CAM and integrative medicine, Li et al. conclude that “reducing the rigor of evidence in medicine will not improve the health of our population. Health care professionals must understand how deep CAM runs in their institutions and ensure that they

27 not only continue to provide the best, evidence-based care for their patients but also to advocate against the practice of non-evidence-based medicine.”170 Much like Noakes, Marika expresses the same dichotomous thinking flaws90 when writing about cancer. It’s also concerning that Marika includes descriptions of modern oncology, similar to “Chemo Truthers”191, as the “slash, poison and burn” treatment approach and “antiquated and largely ineffective”; but what also hasn’t been very effective, in most trials to date, is keto, showing a lack of survival benefit or lack of clear evidence to make claims about survival.177,179,208,221–226 Clinical promise may only be isolated for specific cancers, mainly glioblastoma227, however, for the time being, it is hard to evaluate the independent effects of the ketogenic diet. Even within glioblastoma trials, there seems to be mixed evidence.179,225,226 There are more clinical trials underway, but this fact does not yet change the evidence we have presently. There are still many challenges to be overcome regarding these clinical studies. So much focus is given by Marika on the Warburg Effect. However, as was already cited, further work by David Sabatini and Peggy Hsu22, as well a considerable amount of others23,138,140,199,228– 250, argue against a simplistic homogeneous approach and many “emphasize the need to explore beyond a glucose and -centric driven model of cancer metabolism to a broader one that encompasses all of the metabolic needs of a cancer cell. Perhaps it is time to step out from under Warburg’s shadow.”22 In short, the principal role of the original Warburg Effect, general mitochondrial disfunction and a “glycolytic switch”, is no longer consistent with the scientific evidence and appears to be incorrect.248 Thus, most of what keto diet and low carb/low sugar advocates propagate about cancer metabolism seems to be wrong. As Dr. Siddhartha Mukherjee clarified, the work using animal models looking at PI3K inhibitors and the keto diet130 “is not to be confused with the idea that this is a sugar feeding tumor idea. This is not a sugar feeding paradigm.”251 (As cited previously, results from cancer patients using glucose-based total parenteral nutrition also demonstrates this.131) Dr. Mukherjee specifically makes it clear that this was a “particular study and a very particular drug” and says, “folks don’t try this at home.” He emphasizes that the results do “not mean that the ketogenic diet is going to prevent cancer.” Currently, the effects of ketogenic diets on cancer are highly tumor dependent and there isn’t enough research to confidently advise, or indirectly imply, the diet for cancer patients.178,252–256 Its enthusiasm as a clinical therapy should be tempered and such an intervention should be done in close guidance with credible oncologists, physicians and dietitians – thus, it might be irresponsible at this time to publicly promote the keto diet, alternative therapies, anecdotal stories, preliminary studies, and naturopaths as a “survival secret” and a way to “beat cancer.”

Dr. Mukherjee echoed this on Twitter:

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As I digress, Marika’s narrative focuses only on the negatives of modern medicine regarding cancer, possibly to further the idea of the Metabolic Theory of Cancer, which in turn boosts the wow factor of the keto diet. Her language while writing as well as the sources used are of concern, though with a topic such as cancer, an entirely separate paper could be written. Thus, we will end the topic here. Of note, Marika has also been supportive of Homeopathy in her past writing257, which scientifically, is highly controversial and implausible.258,259 Some of her sources within her more recent articles and posts are also questionable.260–265 This reliance of controversial and questionable sources continues into other areas such as vaccines.

Vaccines As we get back on track here, the greatest concern out of all of this is her and Noakes’ similarities towards vaccines. She has indeed expressed and shared doubt about vaccines.

Describing the process as “injecting toxins into [children’s] immature immune systems.”266 She links to a video267 and says “the vaccine zombie video was made … by one of my favorite sources of health information: Mike Adams, AKA the Health Ranger.” This video does not need any further explanation, but it is extreme vaccine misinformation. From McGill’s Office for Science and Society, “Few alternative medicine proponents reach the near-operatic heights of Mike Adams, but his empire of misinformation has major ramifications. In the age of the digital echo chamber, his voice can be heard even if you don’t go searching for it.”268 His Twitter account had been suspended as of February 2019. “has become a hub for anti- vaxxers”269 and Adams’ page had been banned.270 This is a frightening source of misinformation to endorse.

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More recently, she liked a comment on Twitter which called Dr. David Brownstein, owner of the Center for Holistic Medicine in Michigan and someone who spreads anti-vaccine misinformation, a hero. Another concerning act of agreement online.

While writing articles that defend Noakes’ vaccine-hesitant behavior and covering/blogging the allegations that followed, several sources of vaccine misinformation are used.42,271 A common word she uses both on Twitter and in her articles is “bullying.” In Part 1 of her article42 about Noakes titled “Tim Noakes Really Anti-Vaxx? Fat Chance! Part 1”, she writes, “Noakes believes that the anti-vaxx campaign against him is yet another instance of the cyber and academic bullying or mobbing” and “Noakes has made it clear that he is not anti-vaxx”. The latter, Noakes’ hesitancy and what he has “made clear”, has been covered in the previous section. As for the former, while it can be argued that the situation has not been handled properly in the past, it is with this reports final attempt to uncover some of the truthful events and implicit motives without attacking or “mobbing”, thus highlighting the steady stream of misinformation over the years and the implications it can have on public health. Marika explains that this “bullying” all comes down to Noakes’ single 2014 tweet, but as this paper has tried to demonstrate, this situation is much, much more than a single tweet. To somehow provide evidence of the CDC’s “bad science”, Marika’s compares this to the terrible “Tuskegee experiment.” The events are not comparable, and this is a common vaccine- hesitant or anti-vaccine tactic since those who discourage the CDC or vaccines “use ethical misadventures and abuses as nothing more than a tu quoque argument; they delight in pointing out the gross ethical violations that are committed from time to time by science-based investigators while ignoring those committed by ‘their side’”.272 More importantly, this event does not validate vaccine or CDC misinformation. Also, in response to events like the Tuskegee experiment and World War 2, the Nuremberg Code was created, followed by The Belmont Report, the Common Rule and the Declaration of Helsinki.273 This comparison has been used by Andrew Wakefield himself and thus the “CDC whistleblower” conspiracy was born, which ended up comparing the CDC “coverup” to the Tuskegee syphilis experiment and even Pol Pot, Stalin and Hitler.274 The irony being that Wakefield makes claims about ethics but was then stripped of his license due to unethical actions. Noakes retweeted this Part 1 article by Marika multiple times. Marika seems to give her own exaggerated definition of “anti-vaxx” in her article when it is simply and informally defined as “opposed to vaccination.” In a separate and recent (July 2019) article, she says “Anti-vaxx is a defamatory smear that drug industry-led MDs and others resort to when they lack scientific, moral or ethical argument against a colleague. Ditto for anyone who dares to suggest that, like all pharmaceuticals, vaccines just may have a teeny, tiny downside.”275 (Response: Their upsides outweigh their downsides. What she says may give false balance.)

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Regarding the second article she wrote, “What’s Behind Noakes, Others ‘Anti-Vaxx’ Smear? – Part 2”, there are several points of misinformation.271 Marika seems to write in a tone that is sympathetic to Andrew Wakefield. While sympathy itself to the treatment of a human being is a matter of opinion, less of a concern and perhaps the right thing to do, she lessens the impact of Wakefield’s actions and is sympathetic towards those who support him. She explains the situation with Wakefield and how the autism link was an association and not causation, however, regardless of this distinction, there seems to be little difference in the public eye or when looking at the support Wakefield has gained. She tries to say that Wakefield himself doesn’t believe the link is causal – but this isn’t true since Wakefield has said multiple times that he thinks its causal. Even if it is phrased as an “association”, it has since been discredited and disproven, thus this is not up to date, accurate information. In fact, 10 out of the 12 authors said the original hypothesis had suggested a possible link, however, in the end, the paper “did not prove an association.”276 Thus, calling it an association may not be accurate either. She omits many details45 such as the admitted and proven “major public health implications” and “intense public and media interest the Lancet paper would attract” at the time.277 She leaves out that several points in The Lancet paper, on Wakefield’s part, were irresponsible, misleading, and “contrary to [his] duty to ensure that the information in the paper was accurate.”277 She also omits the fact that Wakefield’s MMR link was completely flawed and set up for a fixed outcome, as shown by Brian Deer.43 Marika says that Wakefield was 1 out of 12 authors of the autism link paper and that the “GMC chose to prosecute him alone”, along with Prof John Walker-Smith. Implying that Wakefield was targeted unfairly. However, the real reason for this might be the fact that back in 2004, 10 of the original 12 authors issued a partial retraction of the paper’s interpretations with Wakefield refusing to join the retraction.278 This then eventually led to the publication of a full retraction notice by editors of The Lancet in 2010. Marika accurately states that the concern by Wakefield at the time was single doses of MMR but fails to include the public health implications and that “this triggered a collapse in parental confidence in MMR”, resulting in uptake rates of the vaccine falling in the UK.276 She also fails to include up to date research that concludes no causal or associational link between MMR and autism, as previously cited. Wakefield’s study continues to be cited today, though most authors, before and after the retraction, have cited it in a negative manner.278 Marika cites the Vaxxed movie website describing the “two tales” of Wakefield and how he is viewed by different groups. She says that she is “simply stating facts about Wakefield's case that his detractors do not widely acknowledge.”279 This gives false balance. Implying people should watch the Vaxxed movie to view the “two tales” or “both sides” of the story, as well as selectively leaving out how flawed the study and the entire situation was, will result in people being misled and sent in the direction of clear vaccine misinformation. It is also worth mentioning that these omissions and flaws within the article are comparable to anti- vaccine websites.280 She then asks: “So why, when Noakes raises the issue of possible suppression of data in medical research, do his critics bring up Wakefield? And the MMR vaccine?” – Perhaps this is because there was no real suppression of data and when raising these issues, Noakes has cited Wakefield and other sources that spread doubt and fear about MMR. Marika describes the reactions and responses to Noakes’ vaccine-related posts as “attacks” and says that Noakes’ point is completely missed – which is that we shouldn’t ignore the evidence on health risks. She says Noakes is “brave” enough to say this. To quickly summarize and not get bogged down in details: her response is directed towards another Medical Brief article281, which cited WHO data and vaccine efficacy statistics, however, she completely takes the article out of context. One example is that she skips paragraphs. The original context when bringing up

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Noakes in this article is that it’s worrisome when respected scientists and nutritionists use social media to share content that can downplay vaccine use and cast doubt on their efficacy, citing the Cliff interview discussed above. In that Medical Brief article, it is also included that the anti-vaccine group, Vaccine Awareness South Africa (VASA), had written in response to the Cliff interview: “Brilliant! Thank you for being brave enough, Prof. Noakes, to venture into the contentious issue of vaccination too! We need more Academics in SA who are willing to really investigate the corruption behind this “holy grail” of the pharmaceutical industry!”282 VASA has also supported and posted the same Part 2 article written by Marika that I am addressing.283 On Facebook, Marika posted Part 1 of her Noakes article with several people posting comments that further spread misinformation about vaccines. One comment said “I’m pretty anti-vax. The promotion of vaccines for every damned thing is more to do with pharmaceutical company profits than public health. Since when has ‘anti-vax’ been such a bad thing?” This comment also included anecdotes about “vaccine damage”, fluoride and “destroying our immune system” …this comment was liked by Marika herself, which is concerning. Somebody else commented with a picture of the book, Dissolving Illusions: Disease, Vaccines, and the Forgotten History, by Suzanne Humphries, MD. Marika replied “I've heard of this book. Haven't read it yet. Thank for sharing.” Marika shouldn’t be thanking them for sharing since this book since it is full of misinformation, gross exaggerations and untruths - caution and concern is warranted.284 Back to Marika’s Part 2 article about Noakes.271 To demonstrate “open-mindedness” and acknowledging risks, she quotes a 2012 Cochrane report on MMR in children, which states that safety reporting for the vaccine is inadequate and separating adverse events from its beneficial role is difficult.285 However, I don’t think this means what she thinks it means. It does not mean that the vaccines aren’t safe or that we should decrease usage, indicated by the other part of the Cochrane conclusion not included by Marika: “Existing evidence on the safety and effectiveness of MMR vaccine supports current policies of mass immunization aimed at global measles eradication and in order to reduce morbidity and mortality associated with mumps and rubella.” In fact, this report she cites includes a section on the 1998 Wakefield paper and the disastrous consequences vaccine hesitancy caused, for some reason, this is also not included in Marika’s writing. The authors acknowledge that “improved and standardized definitions of adverse events should be adopted”, but these adverse events are certainly not autism since once again, an “association between autism and MMR exposure was not found”, as explicitly stated in the Cochrane report. Thus, the way she uses this Cochrane report in combination with the other text in her article is misleading. Next, Marika goes on to talk about “vaccine injury”, plus the non-causal vaccine court cited previously and the compensation case of Hannah Poling. “Mitochondrial disorders are increasingly being cited in vaccine court claims, but the conditions are not common and are poorly understood.”91 Marika makes it seem like we should question the US Government for “sealing” (hiding?) documents but either way it was clarified by the court and Special Master that this case did not confirm any vaccine link to autism. Once again, the court did not try and prove the association, as covered before in this paper. “The family was compensated because the Respondent conceded that the Poling child had suffered a Table Injury – not because the Respondent or the Special Master had concluded that any vaccination had contributed to causing or aggravating the child’s ASD.”286,287 “Because the case was settled, no evidence was presented, and it is difficult to ascertain the exact reasons for settling the case.”288 Causation was just

32 assumed and petitioners did not have to actually prove it. Notably, Dr. Paul Offit has gone into more specific detail on this case in The New England Journal of Medicine.289 “While the arguments may still not convince those who wish to believe, the conclusion is clear: The compensation of [Hannah Poling’s case], thus does not afford any support to the notion that vaccinations can contribute to the causation of autism.”287 Dr. comes to the same conclusion about a similar mitochondrial disorder case.290 After including this case, Marika cites evidence that is apparently “also worrying.” She cites the paper, Aluminium in brain tissue in autism, and despite the title, it’s the fact that this is another flawed study that makes it a concern. It should be noted that Marika goes on to talk about the aluminum study even going as far as to say, “scientists such as Exley (the study author) and Noakes are simply interested in promoting high-quality science. They see a need for evidence that could answer complex questions. Among these questions is the potential link between certain forms of vaccination and autism.” No, there is no link as concluded by a large consensus of massive studies already cited previously. Plus, this study she cites was anything but “high quality”. With an already questionable author291, this study was poorly designed, poorly executed, poorly analyzed, heavily debunked and even covered in Retraction Watch. “These kinds of deeply-flawed studies, lacking proper controls and driven by an ideology over the facts are dangerous because they prey on the meek and enrich modern snake oil sellers.”292–295 She for some reason includes Noakes’ belief that “the industry is also heavily conflicted because it benefits financially from our actions based on the medical and scientific myths that it carefully cultivates”. Here it seems that Noakes was talking about a different topic, but this article she is writing about is on vaccines and the quote is in the section about aluminum, so including this implies to readers that the topic of vaccines, or certain aspects of them, might be apart of apparent “medical and scientific myths” cultivated by industries. Including such a quote in the context and subject matter she is writing about seems, in my opinion, manipulative and deceitful. Marika continues to imply that Noakes, other doctors, and concerned patients are being silenced for questioning the “startling lack of actual science that proves (vaccines’) safety.” This is incredibly false. With this, she brings up misinformation about Gardasil. To be brief and not get deep into it, using the Japanese government and VAERS to attempt to justify a risk with the Gardasil vaccine is highly problematic and misleading.296–300 She appeals to the reader's emotions, suggesting that while conditions are rare, “some lives will be ruined forever” if doctors vaccinate millions of children for HPV. Several points of misinformation and lies regarding HPV vaccines, neurotoxicity, and aluminum are still spread by leaders in the anti-vaccine movement such as Robert F Kennedy Jr.301 The fact that Marika casts doubt on an intervention that can potentially eliminate cervical cancer makes her even more untrustworthy and feeds into the anti- vaccine movements next wave of “anti-scientific mumbo jumbo”302,303 Overall, Gardasil and all other HPV vaccines have shown to be safe, well-tolerated and effective in protecting against cervical precancer with “no consistent evidence of an increased risk of any adverse events of special interest such as autoimmune events, demyelinating syndromes or neurological conditions” – which includes the conditions Marika brings up, Guillain-Barre´ Syndrome and Acute Disseminated Encephalomyelitis.84,304–320 Marika further appeals to the emotion of readers by highlighting a “vaccine injury” case, though there’s no evidence that it was the vaccine that caused harm. She mentions Sudden Infant Death Syndrome, citing a single study. Overall, it seems like there’s no biological reason for a casual or

33 associational link between vaccines and SIDS321,322, and once again, compensation cases do not prove this.323–327 Immunization may even reduce the risk of SIDS.322 She links to data from the National Vaccine Injury Compensation Program, implying there are risks from vaccines but the source explicitly says: “Being awarded compensation for a petition does not necessarily mean that the vaccine caused the alleged injury.” She does not report accurate, up to date information that represents the truthful body of evidence. After this, Marika writes about Noakes and how critics “act as if asking questions about vaccines is a dangerous business.” Well… it can be if it leads to misinformation and can have the potential to influence others to make dangerous decisions like not vaccinating based on fear or false claims. Just “asking questions” is a common anti-vaccine talking point.92 In relation to “dangerous business”, the violent rhetoric of the anti-vaccine movement has also gotten worse.328 Marika once again brings up apparent bullying and the silencing of public vaccination criticism. For this, she cites Brian Martin, who describes this “silencing” in the same way that both Marika and Tim do by calling it bullying, mobbing or attacks. Similar between the three are the ideas of wanting to tell “both sides”, claiming suppression of data or opinions, bringing up what they call “heavily conflicted” pharmaceutical companies and more importantly, framing Andrew Wakefield’s characterization in a sympathetic, whitewashed tone. These resemblances are concerning. Unfortunately, Brian Martin has been a voice for those opposed and hesitant towards vaccines and has also been intellectual dishonesty when doing so.329,330 This explicit support made by Marika is also highly concerning. As she closes her article, she highlights Martin’s take on free speech, children’s health and the vaccine “debate”, though as expected, the evidence seems to be stacked against him on these topics. Noakes retweeted this Part 2 article by Marika.

On July 9th, Marika wrote an article that repeated Dr. Malcolm Kendrick’s blog and highlights what Marika calls the “great vaccination debate.”331 It is written with a tone that claims that doctors who don’t “question vaccines” are inferior or pretentious, e.g. “MDs’ knickers in self- righteous knots”, “self-righteous fury – usually in the form of an anti-vaxx smear” and “self- proclaimed medical ‘angels’”. Marika states that she “believes some vaccination works”, the problem is that she spreads doubt about the vaccines that do work, such as MMR or the HPV vaccine. Malcolm’s written piece is then included on the webpage, where he suggests vaccination and homeopathy fall under the same principles (wrong, they are not comparable332,333), he gives anecdotes, and says “research has clearly established that vaccination does not work in many people.” For this claim, a study is cited from 1987 looking at a measles outbreak which lasted no more than 46 days in a high school with those who received one dose of the vaccine. To summarize, the attack was highest in those who received the vaccine before they were 12 months of age (15%) compared to those immunized after their first birthday (1.3%). At this point in time the expected primary vaccine failure rate was 2-10%...in this study, it was 0.8%. “The infrequent occurrence of measles among highly vaccinated persons suggests that this outbreak may have resulted from chance clustering of otherwise randomly distributed vaccine failures in the community.” Overall, this study gives past evidence for the need for two doses of MMR at or after the age of 12 months. The Editors Note also states that since “measles transmission can occur among vaccine failures, [this] makes it even more important to ensure persons are adequately vaccinated. [In this case,] had there been a substantial number of unvaccinated or

34 inadequately vaccinated students in the high school and the community, transmission probably would have been sustained.”334 It is a common anti-vaccine tactic to misinterpret the studies on MMR and waning immunity.335 Interestingly, some researchers have suggested that a single dose “vaccine failure” can still improve the cases of severity and death from the infection.127 The age at which the first dose of a measles-containing vaccine is given is an important driver in determining vaccine effectiveness in both measles-endemic and eliminated settings.336 This point is further shown by the fact that an infant's humoral immunity from measles, via the past on from the mother, is waned earlier than previously thought.337 Thus, underscoring the importance of childhood vaccination and considerations for vaccine scheduling. It is studies like the one Malcolm cited from 1987 that act as a piece of history to learn how to improve scheduling and timing. Given that this study is 32 years old, the timing of vaccines has been widely studied since then. This does not strongly support Malcolm’s assertion that “vaccination does not work in many people” and is not based on up to date evidence. Furthermore, this 1987 study reporting a measles outbreak was in those who received only one dose of the vaccine, thus this article featured by Marika does not report the successful events that followed: “Within 20 years of vaccine introduction, measles incidence had been reduced by 99%, but transmission continued, particularly among school children who had received only 1 dose of vaccine. In 1989, facing a nationwide measles resurgence, the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics recommended that school children receive a second dose of measles- mumps-rubella vaccine (MMR) to provide protection to those who had an inadequate response to the first dose. Since then, the number of MMR doses administered annually has been enough to provide 2 doses to each child in the US birth cohort, plus catch-up doses to 4 million others. By 1993, viral transmission was interrupted and, by 2000, measles was declared eliminated in the United States, a historic achievement attributed to effective implementation of a routine 2-dose measles .”338

This heatmap graph339 shows measles incidence dramatically declining after the vaccine was created. We can even see further improvement after the second dose was recommended.

Malcolm falsely claims, without any evidence, that measles was becoming a “benign disease by the time vaccination came along”. Measles has never been a benign disease as will be covered later. The measles vaccine is not always 100% effective in every single person, that is recognized

35 in the medical community and is not “censored”. This is also like the “100% safe” argument/trope given by Noakes and is known as the “Nirvana fallacy.” This dichotomous view is unfortunately exactly the way anti-vaxxers think.90 Across the globe, it is recognized that science isn’t perfect, but this does not mean we shouldn’t trust it.340 Malcolm’s written piece (the one on his own website) was shared by the anti-vaccine group “Vaccine Choice ”.341 They thanked him and suggested it should get submitted as a speech against one of the Canadian mandatory vaccination bills. This is the content that Marika chooses to support. Furthermore, this article published by Marika on her website, which according to her, questions “the medical profession’s unquestioned faith in vaccination”, adds no useful information for readers other than deepening vaccine doubt with weak evidence. Noakes retweeted this article. The second article by Malcolm, published on Marika’s website275, includes more worries about vaccines. The example given by Malcolm, a recent rare yellow fever vaccine death, brings about false balance since it seems that causality has not been determined. In most people, the risk of the actual disease still outweighs the risk from the vaccine and the nuance regarding the rarity of serious side effects (i.e. 1 out of 100,000 recipients) is also not included by Malcolm.342–344 He references “vaccine damage” and autism in Germany without any citation. It is apparently from the Paul-Erlich Institute, but this cannot be found. The closest source, which is word for word what Malcolm writes, is from the site, VaccineInfo.com, which is full of anti-vaccine misinformation. Either way, the fact that the format and language are exactly like a vaccine misinformation website is concerning. Malcolm then references narcolepsy and Pandemrix, an H1N1 vaccine that was used in Europe. However, this was specific to this European brand of vaccine, and the incidence and association have been documented in the literature – thus, this isn’t some event hidden by the government. Malcolm finds the fact that there is a lack of association between modern vaccinations and serious neurological disorders hard to reconcile because of this narcolepsy case. But the study/review about neurological conditions that he finds troubling to reconcile with is talking about “Alzheimer's disease, multiple sclerosis, autism, epilepsy, schizophrenia, encephalomyelitis, encephalopathies, transverse myelitis and optic neuritis”345 – not narcolepsy. The review concludes that the associations between these conditions and vaccines are untrue. Malcolm cites the CDC but excludes the fact that upon closer investigation in the US, the CDC found “found no indication of any association between U.S.-licensed H1N1 or seasonal influenza vaccine and narcolepsy.”346 This led them to conclude that, “Vaccination with the influenza A(H1N1)pdm09 vaccine … does not appear to be sufficient by itself to increase the incidence of narcolepsy in a population.”347 The medical research community acknowledged the increase incidence with this specific vaccine and strain, however, “it is also important to state that seasonal influenza vaccines, which are given to hundreds of millions of individuals every year, have not been associated with narcolepsy.”348 Moreover, Pandemrix is no longer being used and similar vaccines have been created with no associated risk. Within this risk there are obviously several confounding factors, the epidemiology is unclear, different vaccines have not been associated with risk, and it may be important to note that along with the specific Pandemrix H1N1 vaccine, narcolepsy can be triggered from streptococcal infection as well as the H1N1 infection itself so avoiding the vaccine may not result in any benefit in terms of risk of narcolepsy.349–351 “The consequences of withholding vaccination should be weighed against the risk of potentially lethal H1N1 infections.”350 All of this freely public evidence is excluded by Malcolm and excluded by Marika.

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Malcolm continues to write about Hannah Poling and autism, which has been covered enough in this report. He suggests that the topic of vaccines and mitochondrial dysfunction should be an area of research – it is.

He then goes on to worry about safety and questions vaccine safety, in which some of his points are false since vaccines, their preservatives, and adjuvants are studied for safety. This is just like Noakes’ “100% safe” worry, and this worry is acknowledged and addressed within the medical and public health community.45,90,352,353

“Medicines have side effects. This is a well-known fact that is not disputed. Vaccines are medicines. This is also a well-known fact that is not disputed. Therefore, vaccines will have side effects, including serious side effects such as anaphylaxis. There is no way to predict who will develop such a reaction, so there is no way to make the vaccine safer in that regard. However, as we have learned above the risk of such serious side effects is about 1 per million doses, so the benefits far outweigh these risks.”354

“The ‘100% safety’ gambit is a variant of what is known as the ‘perfect solution’ or ‘Nirvana’ fallacy. It is an excuse for not doing something to fix or prevent a problem based on the assertion that the solution isn’t perfect. By any measure, vaccines are incredibly safe interventions, with a very low risk of complications. The risk, however, is not and never will be zero. Nothing is absolutely, positively 100% safe, including vaccines. However, they are certainly far safer than allowing children to be vulnerable to the diseases they prevent.”355

“It’s easy to make perfect decisions with perfect information. Medicine asks you to make perfect decisions with imperfect information.”356 ― Siddhartha Mukherjee, The Laws of Medicine

Dr. Gorski has also recently addressed this on Twitter:

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According to Malcolm, “there has never been a randomized controlled clinical study on the efficacy of any vaccine” – a quick look in the literature suggests otherwise, however, perhaps these are not up to Malcolm’s standard. This is a good example of the “No True Scotsman” fallacy.357 He describes the process of Phase III vaccine studies, questions their rigor and then doesn’t mention Phase IV, i.e. post-marketing surveillance, or any of the other information from the Vaccine Knowledge Project, which he cites.358 Several others have discussed this topic as well, the review by DeStefano and Shimabukuro45 is one example. It has been suggested by Dr. Christopher Johnson, a pediatric intensive care physician, that “demanding a randomized controlled trial for vaccines is disingenuous.”359 In fact, Malcolm cites this very article by Dr. Johnson and responds: “Without an RCT, how do you know that vaccines work? Where is your evidence?” This conversation about the time and place for RCT’s and the other forms of evidence that make up the body of literature on vaccines is best left for another time. Although, it is worth noting that this is a topic that the WHO360, the National Academy of Science, Engineering, and Medicine361, and others362–364 have already discussed. This demand for a specific study (RCT, Placebo, etc.) also happens to be another common anti-vaccine trope.364,365 Tim, Marika and Malcolm all have written about aspects of being a doctor and a medical scientist…ethical trials/treatment is one important aspect that should not be missed. Thus, they should know that such an intervention, that would give a 50/50 chance of not having access to a vaccine, would be unethical. The fact that the trial wouldn’t be passed by an ethics board doesn’t mean vaccines don’t work or aren’t safe. Malcolm continues to challenge vaccine efficacy and cites his previous article and the study about the 1987 school measles outbreak – which as we have seen, doesn’t strengthen his claim at all. Marika allows all this misinformation to be posted on her website. If these July articles tell us anything, it is that the spread of vaccine misinformation and doubt by Marika Sboros and Tim Noakes continue to persist and it is not ending anytime soon. With that I will once again quote Jacques Rousseau, whom Marika has seemed to also misrepresent in her writing366, “Criticizing those who express skepticism is not an attempt to silence or censor, but rather to ask Noakes, [and now Sboros], whether ‘just asking questions’ is worth the risk of encouraging irresponsible – and harmful – choices, like opting-out of vaccination”80, or providing narratives and sources that may cast doubt and influence people to do so.

Section Summary: Extreme caution is to be had when considering Marika Sboros as a source of defense for Tim Noakes.

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Current 2019 Events One main question when looking back at posts or claims from a year ago or more is whether such opinions and promotions have been updated, corrected or even retracted altogether. The reality of which is untrue since the posts have not been deleted as of writing this paper and more recent evidence shows us that Noakes’ beliefs and public promotions are still the same as they were years ago. In January 2019, the questionable “Weston A. Price Foundation” posted on Twitter about Dr. Andrew Zimmerman. Of note, according to their Facebook page, the Weston Price Foundation are also coalition partners with the anti-vaccine group, Children’s Health Defense. Dr. Zimmerman was the pediatric neurologist that diagnosed Hannah Poling (her case written about earlier) with a rare point mutation mitochondrial disorder. As the Weston Price Foundation writes it, Dr. Zimmerman “informed the government that vaccines can cause autism in certain cases” however his original statement indicates that this type of risk of regression can be triggered through environmental factors, which may include vaccines, but can also include several other factors that people are exposed to way more on a day to day basis. “Keep in mind that children are exposed to thousands of antigens every single day of their lives. Unless they are kept in a sterile bubble, the risk with these children is way higher with infectious diseases compared to vaccines.”367 Furthermore, “it’s not 100% clear that Hannah’s vaccinations even caused her regression, although it is certainly possible.” The “Division of Vaccine Injury Compensation concluded that [Poling’s] complex partial seizure disorder, is not related to a vaccine-injury.”368 Nonetheless, Dr. Gorski predicted in 2008 that “Anti-vaccinationists will try to torture the science into making it all about vaccines, just as they have always done, and that there will be a new round of autism quackery based on mitochondrial disorders.”369 It seems like he was right. The Twitter post also brings up one of the top vaccine misinformation promoters, Robert F. Kennedy, Jr, and links to an article on the subject which once again, includes vaccine safety “censorship” concerns/rhetoric. Mr. Timothy Noakes liked this post:

Based on this alone, it is unclear what Noakes’ opinions are about the post and there is some debate if Twitter “retweets” and “likes” are endorsements (will be covered later), however, given the current evidence, one can infer that Noakes agrees with this post. So, Noakes may not say vaccines “cause” autism, but he has at least liked and or agreed with a post indicating they do.

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Noakes continues this spread of vaccine misinformation in January.

The original tweet was from Sharyl Attkisson, who frequently posts misinformation. The post was once again about the false claim of a “CDC coverup” and once again the non-existent link between vaccines and autism. Noakes includes a quote from the video, calling it “One of the largest medical debates of our time.” To clarify, the so-called “debate” is about the link between autism and how apparently the CDC suppressed it, thus, Noakes still seems to be showing some support to this flawed belief. He says he is not primarily interested in the autism link, but whether there was a whistleblower that reported contradictory findings. This whistleblower story has been already covered and debunked multiple times – it continues to be a common anti- vaccine trope. He then calls Sharyl Attkisson “fearless.” Calling somebody who posts vaccine misinformation “fearless” for misreporting findings and conspiracies and furthering the spread of anti-vaccine misinformation about MMR and autism raises major red flags. Noakes uses the phrase “talking out of both sides of one's mouth” – which is to make contradictory or untruthful statements – and ironically, this is something Noakes continues and will continue to do. More ironies will be covered much later.

In March, Noakes responds to a clear anti-vaccine account on Twitter.

The person posted a “Measles Outbreak Quiz” that was originally shared by Toni Bark, another person who shares anti-vaccine misinformation. The “quiz” comes from the anti-vaccine website “Physicians for Informed Consent”. Noakes thanks the person for posting and says he took the

40 quiz. Some of the questions in the quiz are misleading, no evidence is cited for the claims and what is asked seems to be common anti-vaccine talking points aimed at either downplaying the severity of the disease and or giving reasons to doubt the MMR vaccine. Noakes says he got all the answers “correct” except for the last one. If Noakes took the quiz honestly then we can use this to figure out what misinformation he believes is true. One question was about the apparent decline in measles deaths before the vaccine was introduced. However, this uses a distorted and manipulated graph to give the impression that the vaccine had no role in improving measles mortality. The specific graph used by the “Physicians for Informed Consent” group has been analyzed and there are multiple reasons for why it is misleading.370–375 “It is true that death rates had declined prior to vaccines, but this was from improved medical practices and treatments, and actual infection rates had not decreased significantly.”372 Moreover, “mortality rates are the incorrect metric when evaluating vaccine effectiveness.”374 It would seem that Noakes also believes the false claim that “MMR vaccine has not undergone safety studies for its potential to cause cancer, genetic mutations, and impaired fertility.” The quiz uses scare tactics regarding package inserts, however, as explained and debunked by Dr. Vincent Iannelli, “if a package insert says that it has ‘not been evaluated,’ it is simply because it was not necessary or appropriate. It is not because they just didn’t want to do it and left those tests out. That doesn’t sound as scary though.”376 Using package inserts as evidence is also very misleading. When necessary, vaccines are appropriately evaluated for mutagenicity, carcinogenicity and impairment of fertility. Noakes was apparently misled into believing the contrary. There was a question that Noakes did get wrong though, which means that at the time he believed that the “MMR vaccine is safer than [the] measles infection”. This is indeed true. It is troubling, however, that Noakes shares sources of information or expressions that suggest the opposite of this claim. Another concern is that instead of discouraging this website of misinformation, Noakes took the quiz instead. Luckily, Noakes did not retweet this website so the misleading information was not spread, and thus he is still entitled to his own opinion on the matter. Not much can be concluded from this event except for the fact that the “Physicians for Informed Consent” group/website is very much a source of anti-vaccine propaganda.373,377–379

Regarding the use of the word “spread” – Noakes claims that he has not “spread” anything.

He suggests his followers ask questions about information from people “with a financial incentive to mislead them on the science.” If we take the time to unpack this, it seems that in this context, the people “with a financial incentive” would be pharmaceutical companies that make vaccines and or the scientists who make them and do vaccine research. As for “the science”, this

41 is open to one’s personal bias, so it is unclear exactly what “science” he is talking about. However, Noakes says that his followers will be misled by “the science” and that those who are doing the misleading will be those “with a financial incentive” – i.e. the vaccine scientists and pharmaceutical companies. This information from vaccine companies and scientists would most likely be pro-vaccine and would aim at promoting their safety, efficacy, usage, and reporting that there’s no link to autism, etc. So, what it seems like Noakes is implying is that the information from those who create vaccines – which would be about safety, efficacy, their usage, and perhaps disproving vaccine myths – is misleading. This focus on industry and the idea of being misled by those who profit is just like one of his 2017 tweets and resembles popular anti-vaccine content like the Vaxxed documentary.38 Back to the idea of the “spread” of misinformation – which perhaps can be defined as “communications that are not a fair representation of available evidence or communicate that evidence poorly”.380 Alternative ways to define this concept can be: exposed to inaccurate or misleading information as well as claims and stories that are diffused through the Twitter network. A cascade can begin “when a user makes an assertion about a topic in a tweet, which could include written text, photos, or links to articles online. Others then propagate the [information or claim] by retweeting it.”381 This results in direct (the post itself) as well as indirect (views on Twitter feed) spread of that information. False information is commonly spread this way.382 This is indeed what is happening with Noakes.

Starting in April is where things become a little more clear. When responding to a Twitter post about Dr. Zimmerman’s findings and possible “alarmism”, Noakes is asked to share his view on child vaccine schedules.

While saying that they are an “amazing medical contribution” for specific “fatal conditions like Rinderpest or Ebola”, he has a few questions to ask about the condition being treated. In this context, the condition is Measles. What is concerning is that he seems to question whether it is life-threatening or benign — the answer for this becomes simple. Noakes does reference smallpox when mentioning vaccine success, but he may not know that measles “was described by the Persian physician Rhazes in the 10th century as ‘more to be dreaded than smallpox.’”383 The public view might be that measles is benign due to its rarity. Perhaps even The Brady Bunch and other TV shows propagated this myth. Given the often forgotten large reductions in mortality seen after the introduction of measles vaccinations, the several complications measles

42 can have, as well as the overall impact of vaccines, measles is serious and not benign — it never has been benign.126,384–395 Noakes directly tweets about a so-called “Amish Paradox”, which cites the highly controversial, misinformation filled website, Natural News (author is Mike Adams as talked about previously).

The article contains more autism-vaccine misinformation and claims that since the Amish don’t use certain vaccines or eat GMOs, this results in Amish children not having any learning disabilities at all or diseases like cancer, heart disease, and diabetes. Some claims in the article are beyond the scope of this paper but nonetheless, these too are indeed false. Amish communities do have persistently lower immunization rates, but this seems to have resulted in outbreaks and increased risk and prevalence of vaccine-preventable diseases in Amish children, which have even required hospitalization.396,397 Of importance in this group, the vaccine hesitancy spread by both Natural News and Tim Noakes are part of the problem. The Amish do indeed vaccinate, but “fear, especially concern over too many recommended immunizations and immunizations overwhelming the child's system, are the most frequent reported reasons for not having children immunized according to recommendations.”398,399 Sharing false information that can impact the hesitancy and fear in other groups, such as the Amish, and the general public is concerning.

One reaction to this “Amish Paradox” tweet by popular food writer, “nutrition debunker” and chef, Anthony Warner, was as follows:

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Physicians and health professionals also discouraged the tweet, one such example:

Point being, nutritional information aside, Noakes is influential and should not be sharing this kind of misinformation.

Noakes has supported controversial topics in the past but recently has supported a long-time leader in the vaccine-hesitant and anti-vaccine community. If anybody has kept up with the “anti-vaccine” movement, then Robert F. Kennedy, Jr doesn’t need much of an introduction. He is co-author of the book, “Thimerosal: Let the Science Speak: The Evidence Supporting the Immediate Removal of Mercury--a Known Neurotoxin--from Vaccines”, and founder of Children’s Health Defense, formerly called the World Mercury Project. RFK Jr. spreads large amounts of misinformation about Thimerosal and autism, vaccine injury and safety, and has even tried influencing the Trump Administration/US government.400–404 It was recently shown that RFK Jr’s organization is also one of the two main buyers of anti-vaccine ads on Facebook.405 Despite all these red flags, Noakes shares posts by him and decides to call him brave for devoting his life to vaccine-induced/idiopathic conditions.

That same day, when asked if Noakes thinks the CDC is covering up a link between vaccines and autism, instead of replying with up to date truthful information, he suggests for the person to go and “interrogate” Robert F. Kennedy, Jr instead.

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The person says to just simply answer the question about the CDC video, to which Noakes replies, “Why should I? You do what I suggest… [then] we can discuss it…”.

When Noakes is called out for sharing and posting CDC “Whistleblower” conspiracy content, he says the person doesn’t want to research the topic because “[they] are scared of what [they] might discover.”

Unpacking this interaction: Noakes doesn’t answer the question about his own 2014 post, i.e. his own irresponsible actions, then directs the person towards a source of misinformation. His explicit suggestion, literally saying “do what I suggest”, is to go investigate the topic on their own, pointing them to RFK Jr. as a place to start. According to Noakes though, there is fear to be had behind the truth of information discovered and since the information might be from RFK Jr, what the person is going to discover is more misinformation and fearmongering about vaccines from leaders of the “anti vaxx” movement. Thus, Noakes once again promotes misinformation online and doesn’t take responsibility for his actions and the implications they can have on public safety.

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Entering the month of May, Noakes shares a quote by RFK Jr. on the familiar topic of “fighting bullies” while linking to the Children’s Health Defense and their focus on “vaccine injuries”. The fact that Noakes calls RFK Jr. “a hero for all generations” is concerning. Noakes also mentions JFK’s Ripple of Hope speech, so perhaps he is “striking out”, as phrased in the speech, against what he thinks is injustice but sharing misinformation about vaccines and casting doubt on the subject is not improving “the lot of others”.

On May 15th, Noakes once again defends his 2014 tweet about the false “CDC coverup”.

He does not understand how this makes somebody anti-vaccine and says it “goes beyond any reasonable logic.” To recap: he tweeted a video posted by an anti-vaccine account, that was directed by one of the most vocal anti-vaccine leaders. Noakes’ tweet was apparently about the “coverup” by the CDC, however, this “coverup” was about the false MMR and autism connection which is propagated by those who are anti-vaccine. The entire “coverup” story is also flawed and distorted by anti-vaccine members. So, to repeat one last time, the video is posted by an anti-vaccine account, which is directed by an anti-vaccine leader which claims there is a coverup in the CDC, which is an anti-vaccine trope, and the coverup is about a false association to autism, which also happens to be anti-vaccine. How Noakes doesn’t see that creating and sharing a post, which checks all the boxes for being “anti-vaccine”, doesn’t make one anti- vaccine in the eyes of viewers is, well, quite confusing.

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During more Twitter controversy and back and forth discussion, another reply by Noakes contains misinformation about vaccines.

He once again directs the public on social media to a video by “The Truth About Cancer” which further spreads fear and doubt. Moreover, Noakes uses the Japanese government as an example and asks for an “alternate explanation” for why the government withdrew MMR vaccines. In its full context, this is implying that they withdrew the vaccines in 1994 due to the link with autism. Vaccination rates did indeed decline in Japan, however, during the same period, ASD diagnoses increased. Leading this 2005 Japanese study to conclude that the MMR vaccine “cannot explain the rise over time in the incidence of ASD, and that withdrawal of MMR in countries where it is still being used cannot be expected to lead to a reduction in the incidence of ASD.”406 A similar finding was shown in the UK54 – autism risk increased between 1988 and 1993 but the MMR prevalence didn’t change. The authors suggested that the increased autism risk is “due increased awareness of the condition”, not vaccines. Furthermore, this autism connection has been vastly disproven through multiple studies as mentioned before in this paper.

Closer to the end of May, Noakes shared another quote about childhood inflammation and autism.

While the quote doesn’t seem to include anything about vaccines, the full context of the tweet indicates otherwise. Noakes responded to a tweet where somebody suggested that the term “anti vaxxers” was just an insult made by the “regressive left”, perhaps implying the views against anti-vaxxers are suppression of freedom of speech. Noakes questioned the causes of the “autism epidemic”, saying “there must be an answer.” In reply, somebody shared a video suggesting a few theories on the topic. The video was an interview with nonother than Dr. Suzanne

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Humphries, who “discusses the potential connection between vaccines and autism.” While she does say that there is a gut-brain connection to autism, ultimately this continues to make people question the disproven autism-vaccine link and it also does so in Noakes’ tweet by including: “you have to stir up that inflammatory profile in that child.” One of the ways this happens, according to Dr. Humphries, is via vaccines.

A quick Google Search is enough to show what she promotes.

Noakes also recommended her book in 2015 to “everyone with an opinion on vaccination debate.” His choice of words, “vaccination debate”, is also concerning.

As stated before, her book is full of misinformation and caution is warranted.284 Looking deeper, “her claims are often misleading and at times outright deceptive. The problem is that Dr. Humphries is so fervent in her belief that vaccines are evil that it ultimately ‘blinds’ her and leads her to become clumsy in her interpretation of studies, which in turn hurts her credibility. The more you delve into her work and consult her sources, the more you will find her guilty of:

48 cherry-picking isolated statements…aiming to confuse readers…ignoring data that are inconvenient to her claims and stripping numerous quotes off their context as an intentional means to mislead and deceive.”407 Quoting and sharing a video by her and the fact that Noakes’ tweet was further retweeted, liked and spread, is quite concerning.

Noakes and Sboros frame the current situation as a “vaccine debate” but to correct this further, there is no debate. There is no controversy. As Dr. Harriet Hall notes, “there is, however, a manufactroversy — a manufactured controversy — created by junk science, dishonest researchers, professional misconduct, outright fraud, lies, misrepresentations, irresponsible reporting, unfortunate media publicity, poor judgment, celebrities who think they are wiser than the whole of medical science, and a few maverick doctors who ought to know better.”408

Noakes replied to a tweet in which somebody suggested renaming “anti-vax” to “smarter-vax”. The person also mentioned whether we should question ingredients, timing, and safety. Noakes added that it’s about knowing which diseases are life-threatening and which are “best left alone.” I asked which vaccines he would exclude and which diseases we should leave alone…he did not respond. Somebody in the “anti-vax” camp responded with questions about safety, the vaccine court and MMR, as well as saying, “look at what chemicals can do to a child.” Noakes thanks the man and responds to that comment, adding that he has a responsibility to advise his children on what is best and says that he’s read all the literature, “not just that which is taught at medical schools.”

This ever so clearly implies that what is taught in medical schools is not all the literature, that something is missing and within this context, what is apparently missing is doubts about the safety and efficacy of vaccines. Not only does this cast public doubt on vaccines, but this also casts doubt on what is taught in medical school and decreases trust placed in doctors. This may weaken the reputation of other health professionals in the field, which is explicitly discouraged by the HPCSA. This also verges on the “maverick/brave” doctor anti-vaccine trope. Noakes says he has “read all the literature” and while he may have read it, he doesn’t seem to share it. With the overwhelming amount of evidence that contradicts the anti-vaccine movement and Noakes’ own views, he does not seem to establish public trust that is up to date, science-based and truthful. Nonetheless, Noakes’ tweet gains support from those who discourage vaccines and receives praise for his input. “Thank you for all you do. It’s for my children as well”, said a very evident “anti vaxxer” …or “smarter-vaxxer” as they like to call it.

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Somebody said that it’s not just about vaccinations, but the “safety” of them. To which Noakes redirected people to another promoter of vaccine misinformation.

He says to look at this person’s retweets, which is vaccine misinformation. He does say something very sneaky though, thus it is important to look at one’s actions, not just their words. He says, “Not saying I agree with any of these tweets.” This is where words start to contradict actions and analysis of one's intent would also be needed. Noakes is not saying he agrees, but he’s also not saying he disagrees. Noakes is not saying he agrees…but he directs people towards this source of misinformation and seems to value this person’s words/content enough to promote their account and to suggest they are worthy of providing useful information. According to “FollowerWonk.com”, this Twitter account that Noakes endorses (@LaLaRueFrench75) has one of the highest “social authority” (high number of combined tweets and followers) rankings among those who are anti-vaccine on Twitter. The women (@LaLaRueFrench75) promoting vaccine misinformation replies, “Bless you Professor Noakes”409, linking a video by Peter Aaby, who’s work has been used to cast more doubt on vaccine safety. At the time of writing this report, Noakes retweeted this post. At the time of editing this report, evidence that Noakes retweeted is no longer visible and thus he may have gotten rid of the retweet. Upon more Twitter controversy and debate, I questioned if this particular “anti vaxxer” or vaccine-hesitant promoter knew how the immune system worked. She accused me of spamming and not including scientific data, so I dove into the literature on what she was talking about (reports on Adverse Events Following Immunization, autism, MMR and autoimmunity) …she did not reply. But Noakes did:

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I, the author, do not claim to know it all, not even close. If defending truthful information about vaccines and discouraging misleading claims about vaccinations is “gross ignorance”, then I am very concerned with what Noakes thinks should be defended and encouraged. Several vaccine skeptics retweeted his comment. Noakes also liked and retweeted a comment in this Twitter thread about how pre-med students should be kept in a cage for their own, and others, good. This comment was also liked and shared by vaccine skeptics. *Update: The account has since been removed from Twitter; thus, a screenshot cannot be provided. The link is still included.* https://twitter.com/AlexBogdanov18/status/1131048059582857216 Noakes also said something similar in 2020:

The women promoting vaccine misinformation replied to Noakes’ Med Student comment, saying some medical students are on the “wrong side of history.” Assumingly this “wrong side” is the side that promotes certain vaccines. So, my speculation is that the “right side” is the one she agrees with…which happens to be the side with misinformation. She links to a video by “anti vax” misinformation leader, and his HighWire podcast. Noakes liked and retweeted this post…further spreading misinformation.

Perhaps Mr. Noakes doesn’t like what is taught to medical students, he seems to think they should be more focused on dedicating their lives “to finding causes for the autism epidemic* that is destroying the children of [the current] generation.”410 And as the mound of evidence has shown us, Noakes seems to think, based on untruthful, outdated and disproven evidence, one of those potential causes is vaccines. * (Side note: There is no autism epidemic.411–413)

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To note explicit promotion: On May 14th, Robert F. Kennedy Jr.’s Children’s Health Defense put out an article on chronic illness in millennials, glyphosate and that “vaccines represent one group of obvious suspects” – which is incorrect. Included were false claims about how the millennial generation “coincided with the end of manufacturer liability for childhood vaccine injuries and the beginning of the rush to pile ever-more vaccines onto the childhood schedule.” – this is also incorrect. Noakes retweeted this.

On June 18th, a tweet was posted which links to a video clip of a prominent anti-vaccine advocate and Hollywood actor who tells parents that he’s been saying that vaccines cause autism for 22 years. He suggests “the other side”, those who are pro-vaccine, are brainwashed and says to “be more like Andy Wakefield and less hot-headed like [he is].” The clip ends with him saying “if it’s not vaccines, then what is it?” This video clip is included in a Twitter post, which links to an anti-vaccine Twitter account and tags a vocal anti-vaccine proponent and RFK, Jr. This amplifies their voices. The post questions what has caused the rise in autism and grossly states that “Everyone is worried about the measles; that’s ” The emoji used insinuates that being worried about measles is laughable, a joke. Noakes retweeted this.

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A new follower of Noakes asked him to clarify his belief.

Noakes says there’s a “combination of very many factors” but does not deny his misleading views on vaccines and autism and doesn’t say that vaccines don’t cause autism – thus his answer is slightly untruthful and deceptively worded. It is hard to describe this technique that sidesteps away from what is asked while making it seem like the question has been answered. This technique can be further explained in point 4.2.4 in the review by Kata, A.414 He frames autism as a “crisis that is being ignored”, which continues to spread the misleading notion of an “autism epidemic”. Suggesting that rises in autism rates are “being ignored” gives the impression that medical orthodoxy is ill-informed and do not wish to investigate further, creating a false “us vs them” narrative.

On July 9th, a response to Dr. Ann Marie Navar’s JAMA editorial piece, Fear-Based Medical Misinformation and Disease Prevention - From Vaccines to Statins415, was posted on Twitter.416 Dr. Navar’s piece voices several of the same concerns (misleading websites, anti-vaccine misinformation, etc.) highlighted in this report. This report is mainly about vaccines and thus will not cover the information about statin therapy. The response post was written by Dr. David Brownstein, who is a family physician practicing “Holistic Medicine”. His website, the supplements and homeopathic products he sells, and the conditions he apparently treats are all red flags. He also hosted a viewing of the anti-vaccine film Vaxxed at his “Center for Holistic Medicine” and has multiple articles written in an anti-vaccine narrative – more red flags. Predictably, he includes misleading claims about vaccines and often omits important, context- dependent details. One such example is that he says that MMR vaccination does not guarantee a disease-free population. For this, he cites a 2015-2016 mumps outbreak among students at the University of Iowa.417 However, digging further, this gives evidence for the need for a possible third dose of MMR in young adults depending on when they received their second dose and of course taking the of the outbreak into consideration. This outbreak in those who did have their second dose of MMR brings to light the seriousness of high-density, close contact outbreaks. Demonstrating waned immunity and the drastic difference in effectiveness, MMR was 89.4% effective if the second dose was given less than 13 years before the outbreak (after 2002), and 31.8% effective in those who received their second dose 13 years or more before the outbreak (in 2002 or before). “Because the students in this outbreak were born in the 1990s, their exposure to circulating wild-type virus was probably minimal, given the level of mumps control achieved after the 1989 recommendation that two doses of MMR vaccine should be

53 administered. Therefore, opportunities for boosting immunity from wild-type virus exposure might not have occurred … The probability of remaining mumps-free was higher with receipt of the third dose for all time periods after vaccination.”417

Relevant to public health efforts, a third dose may be considered for outbreak control and this “data also showed the importance of waning immunity and of assessing the time since the last vaccination.” Why is this important? – because it is another example of those with anti-vaccine views distorting and omitting crucial facts in order to improve their narrative. Dr. Brownstein includes the classic CDC “cover-up” conspiracy, which as previously cited, is misleading and for the most part, untrue. Dr. Brownstein has been criticized before for his false anti-vaccine posts and rhetoric, as well as his alternative, and perhaps pseudoscientific, “holistic” treatments for conditions in which he profits from.418–421 Much of Dr. Brownstein’s content on his website can, in mine and other's opinions as well as based on the scientific evidence, be concluded as unscientific absurdity. Regarding Dr. Brownstein’s blog post with vaccine misinformation, Noakes retweeted this post.

In August, seen in the picture to the left, Noakes implied that a Low Carb High Fat diet can perhaps benefit a “vaccine damaged autistic kid.” Diet choice* aside, Noakes does not attempt to correct the original tweet which wrongly claims autistic children are “vaccine- damaged”.

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*(Diet and ASD. Maternal gestational diabetes has been associated with the risk of ASD in offspring422,423, and while a multitude of factors may influence the trajectory of fetal development424, there is increasing doubt about any causal environmental link to autism. Much of the associations seen may be heavily confounded by genetic factors that signal for and influence the same pathways as those suggested when discussing the environmental role. The very genetic risk factors that are seen in autism may also overlap in conditions such as diabetes.425 One single hypothesis that some, including Noakes (he retweeted the article), may want to grasp onto is that insulin could contribute to the development of autism via increased PI3K/mTOR signaling.426 This would bolster the case for using a Low Carb High Fat Diet. Increased IGF-1 levels are typically seen in hyperinsulinemia, IGF-1 also can signal mTOR, but contrary to the above hypothesis, some evidence has shown that both decreased IGF-I and mTOR signaling may be involved in the pathogenesis of ASD”.427,428 IGF-1 therapies are also being investigated for ASD and CNS disorders.429,430 In contrast, mTOR and IGF-1 inhibitors and other pharmacological agents are also an area of interest in mice, though there is debate as to whether animal models are comparable to humans.431 Given the vast complexity of the various pathways involved432, concise conclusions are unable to be made. Glucose abnormalities seem to have a role in ASD pathogenesis, however, the actual efficacy of “interventions aimed at maintaining glycemic control throughout pregnancy” remains unknown.433 Evidence points towards genetic modulation of these pathways (“autism-risk genes that regulate the structural stability of neurons”), rather than any specific role of diet.431 Specialized diets, such as a ketogenetic diet, have been reported to benefit children with ASD434–437, however, these trials either have a small sample size, low adherence, lack of relationship between serum lab measurements and symptoms, lack a control group or the evaluation of behavior and symptoms was unblinded. The impact of blinding and parental expectation bias may be a major factor in the positive results seen with different diets and ASD. In the early 2000s, gluten-free, casein-free (GFCF) diets showed promise438, trial methodology had been heavily criticized439 and upon blinded reanalysis, benefits for verbal communication were not statistically significant.440 Other trials have been equally as unsuccessful.441–444 These recent claims with the ketogenic diet are reminiscent of these previous nutritional attempts. Much of the special diet research in ASD has been seriously flawed.439,443,445 The American Academy of Pediatrics discourages the use of these elimination diets as an attempt to ameliorate core symptoms.446 In a recent 12-month follow up clinical trial, “a 6-month GFCF diet [did] not induce significant changes in behavioral symptoms of autism...”447 Overall, “There is little evidence to support the use of dietary therapies and supplements for children with ASD.”445 Based on previous history, it is doubtful that a Low-Carb High Fat diet will robustly improve ASD symptoms. Now, back to Noakes’ tweets.)

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As the days go by, on August 21st, more anti- vax misinformation is posted. Noakes shares a link to the flawed anti-vaccine website, “TheTruthAboutVaccines”, combined with the “pro-safety” anti-vaccine trope and a quote from Robert Kennedy Jr. In some ways, this adds even more explicit evidence since Noakes did not just click “retweet” or the like button, but he had to actually read through the article, reflect on it, copy and paste a quote and tweet this out to the public.

With more recent events and posts, while writing this, I am even more discouraged by Noakes’ ongoing support for RFK, Jr.

It’s agreed that Kennedy, Jr. is a major driver of the movement:

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On Oct 10th the Secretary of State for Health of the United Kingdom posted on Twitter that “vaccines save lives”, supporting the MMR vaccine and the Daily Mail’s campaign to raise the uptake of vaccination due to the UK’s failing immunization rates. One cardiologist replied, suggesting that the MMR campaign will fail unless the apparent “root cause” is addressed – i.e. that pharmaceutical industries and their scientists “commit corporate crime and continue to get away with it!” The reply was followed up by others commenting vaccine-hesitant concerns or anti-vaccine misinformation. Noakes retweeted this.

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Noakes explicitly posted a link to a “thoughtful review” on Oct 18th directed at those who are “vaccine-hesitant”.

The article is a Viewpoint piece published in JAMA from Dr. H. Cody Meissner which discusses the risk vs benefit of Rotavirus and Dengue vaccines, some challenges with them and safety monitoring and adverse reaction reporting.448 Dr. Meissner has a slight conflict of interest since he is the chair of the Vaccine Injury Compensation Program, but despite this, he includes recommendations for these two specific vaccines and highlights that the benefits outweigh the risks. Examples within the article would be that “intussusception following continued use of RRV-TV would [be] small relative to the reduction in the disease” and “a recommendation for … CVD-TDV in areas of high dengue seroprevalence where reliable serologic testing is not available could potentially benefit as many as 12 times more people than those who may experience dengue as a consequence of vaccination.” Ultimately, the article does a good job explaining the rigor at which vaccines are tested, monitored, and the considerations made by those producing and promoting them. The article also addresses misinformed parents, suggesting that they may be “unaware that remaining unvaccinated places their child at greater risk of disease than the risk of an adverse event following vaccination. Parents who choose not to immunize their children do not fulfill their parental obligation to protect children from disease.” Noakes believes that “at [a] population level, [the] advice is simple: Vaccinate everyone.”

This is good and quite different from anything we’ve seen him post. He includes that things get more complex at an individual level. He then says that the more interesting part is the quote about how the Vaccine Injury Compensation Program will compensate those who may be injured by a vaccine. A reference to another review by Dr. Meissner is included by Noakes449 – which also adds to the body of evidence that compensation programs do not prove that the vaccine

58 caused the injury. It could be argued that this nuance and lack of proof is not communicated sufficiently by Noakes. In fact, his other reference to “vaccine damage” in a previous tweet450 claims that it’s been proven in court, but this is not the case. Many claims come from shoulder injuries, “Dr. Meissner said public health authorities now emphasize training health providers to administer vaccines without hurting people’s shoulders.”451 Another central conflict we run into with Noakes’ Oct 18th tweet is that he does indeed say “vaccinate everyone” at a population level, however, he does not specify which vaccines – it is assumed that he is talking about Rotavirus and Dengue. When he expresses his opinion and information about other vaccines, such as MMR, he seems to cast doubt, post misinformation, say they are “overused” and asks if we need all the vaccines to begin with. As Dr. Meissner has said: “The overwhelming number of vaccine injections are completely safe and not associated with any adverse events. This is in marked contrast to what the anti-vaccine movement is trying to promulgate.”451 This October tweet is promising but perhaps we should not look at single tweets and focus on the totality of the evidence. That is, the misinformation and doubt that Noakes (and Sboros) have expressed contradict this tweet and vice versa. The caution and concern about vaccines that Noakes expresses also conflicts with his own citation and the words of Dr. Meissner.

On November 11th it was released that the Ebola vaccine, “Ervebo”, has been approved in Europe.452 Noakes retweeted this.

This is a positive finding with a pro-vaccine stance. However, as said before, Ebola is one of the diseases that Noakes thinks vaccines are an “amazing medical contribution” for. When looking at diseases other than Ebola (such as measles), he has shared doubt about the severity and the consequences of contracting the infection.

Near the end of November, Noakes shared a Twitter thread about how smallpox was eradicated, saying it was “well worth the read.” This post does lead to accurate information about vaccines.

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It can be concluded that Noakes shares pro-vaccine views about some diseases such as Ebola or smallpox and anti-vaccine views about others, such as measles or HPV. The belief that we should look at the summation and ratio of pro-vaccine to anti-vaccine views still stands.

Also, on November 11th, Noakes was tagged by somebody who is anti-vaccine in a post about “vaccine safety advocacy”. (Response: Safe vaccines already exist.) He was included in a Top 10 list of men and women who apparently fight for “safe vaccines”, however, multiple anti-vaccine accounts were tagged. It is concerning that online users include Noakes in this list of those who are technically anti-vaccine.

On December 8th, Noakes denies being an “anti-vaxer” again.

He claims that this (people calling him an anti-vaxer) “was part of a campaign to discredit [his] opinion.” He says to read his book Real Food on Trial, however, the word “vaccine” or “vax/vaxx” is not even in the book once. There is absolutely no way of knowing Noakes’ opinion and or the information he has shared about vaccines from this book. Moreover, he claims that this was an attempt to discredit his opinion, which is not at all the case. These are matters of professional responsibility and honesty as well as public safety, and thus Noakes should be held accountable.

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On December 12th, Noakes is tagged and engages in another Twitter thread of vaccine misinformation. The stream of tweets (not posted by Noakes) creates mistrust and places blame on the Samoan Government, claiming that the recent outbreak might have been caused by the vaccines and lack of Vitamin A – which is untrue. The measles virus causing the outbreak has a D8 genotype, all vaccines are genotype A453, therefore, the outbreak cannot be caused by the vaccine-like anti-vaccine proponents are claiming. Megadoses of Vitamin A may reduce mortality from the measles infection but it will not actually prevent the infection and won’t stop the virus.454 As said by Dr. Robert Linkins, CDC measles and global immunization expert, “the vitamin can’t be taken in place of the MMR vaccine.”455 Virologist Ian Mackay echo’s this, saying that the “anti-vax rhetoric about vitamin A peddled on social media is ‘not correct’.”456 The tweets continue to quote more of Malcolm Kendrick’s misinformation and claims about “vaccine damage”. Noakes then responds to somebody, going along with the idea that the strain could mutate.

However, it’s extremely unlikely that the virus will mutate and have a significant change. In this case in Samoa, the virus has not changed. According to Dr. William Schaffner, a professor of preventive medicine and infectious diseases at Vanderbilt University Medical Center, “Measles is solid as a rock. The measles virus that causes disease today is the same virus that caused disease in 1934.”457 This has also been said by the Chair of the International Committee to the World Health Organisation for measles and rubella, Dr. Nikki Turner.458 Put in scientific terms, the measles virus is an antigenically monotypic virus459 partly due to the fact that “the H and F proteins themselves are fundamentally unable to tolerate a large range of mutations.”460 There are many variables that contribute to the viruses' limited evolutionary rate.461 Despite this research, the idea of a “mutant strain” of measles is something now touted by Andrew Wakefield.462 It is concerning that Noakes does not correct the false information littered in this Twitter thread, though he says this is “not [his] battle.” Correcting scientifically false and misleading posts should be his battle if he is an advocate for “spreading scientific information”, as his Twitter bio indicates, as well as honesty and truthfulness as he had said in the past. Noakes did retweet a pro-vaccine correction to this idea of vaccine mutation a week later, which is commendable.

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However, when Noakes was asked if he thinks the strain could mutant along with the false conspiracy that the government had not released the strain, Noakes appeals to the idea of the “truth”.

He claims that “all [he] can guarantee is that the full truth of the matter – whatever it is – will not likely ever be exposed.” This wording is comparable to the idea that the “truth” is being suppressed and or covered up – thus, it can be labeled as a common anti-vaccine trope. He says that “The public deserves all the facts … Then the public can make informed decisions.” For this idea of “all the facts” and “informed decisions”, Noakes once again tags RFK, Jr, who has played a large role in causing the vaccine hesitancy in Samoa. This “truth” narrative and continued support for RFK, Jr, is concerning, and at this point, incredibly frustrating.

On December 20th, Noakes retweeted a Washington Post article that uncovered a health professional who sells “natural health” products and has given huge sums of money to anti- vaccine organizations. Ultimately, this was a pro-vaccine story. Noakes retweeted it.

The only concerning part is that there were online users who replied to Noakes’ retweet, tagging him, and claiming that it was “Fake News Pharma Propaganda”, etc. Somebody begged Noakes to read Suzanne Humphries's book, which is vaccine misinformation. This observation may

62 indicate that there is an echo-chamber within those who follow Noakes online and it is quite possible that these users have some influence on his views. On December 23rd, a post reshared originally from a very clear anti-vaccine account implied a financial connection (conspiracy?) between Merck the GAVI organization and the Ebola vaccine. The post was reshared by somebody who said, “Business as usual.” The user casted doubt on if we should trust these organizations. Noakes retweeted this post.

Finally, on December 24th, Noakes is more transparent about what he believes. He replies to somebody who asks if he is “anti-vax” because of this post he retweeted (above).

He is interested “purely in science and [the] way it is presented to [the] public.” The increasingly frustrating thing is that Noakes has almost never shared the actual, honest, scientific literature about vaccines. He is apparently concerned about the way it is presented to the public, however, there is almost zero doubt that he is apart of the problem when it comes to misrepresentation of vaccine science to the public. He says: “Increasingly the public is being told lies as if they are proven facts. If those of us with the training don't point out the lies, who will?” This implies that what the public is being told – that vaccines are safe, effective, do not cause serious side effects like autism, etc., and that there is not a pharmaceutical conspiracy – are lies. This once again resembles anti-vaccine conspiracy

63 content.38 He says they are being told as if they are proven facts - this is because based on the overwhelming amount of scientific evidence and analysis, they have been proven, at least within the constraints of the evidence we currently have. The fact that there is no such thing as absolute proof in science, especially medical and biological science, is a cornerstone of critical thinking. To echo Dr. Gorski, we discuss evidence, not proof.90 The next part of what Noakes says is especially troubling. It also plays into the “brave/maverick” anti-vaccine trope. He explicitly uses his past medical and science training as an appeal to authority, as a justification for “pointing out lies” which technically is a justification for “asking questions”, casting doubt, and further disseminating misinformation out to the public. This can substantially lower the dignity or damage the reputation of persons practicing the same profession, that is, health and medical professionals as well as scientists. This is explicitly emphasized in HPCSA ethical guidelines, which will be covered much later. Lastly, Noakes says that he’s “certainly not anti-vax” and is “just pro full disclosure.” Once again, the issue is that this linguistic choice of words and belief is anti-vaccine rhetoric. By “pro full disclosure”, based on his past expressions which are similar, this would mean disclosure of information that would ultimately be anti-vaccine in the eyes of the public and other health professionals.

Though the author of this report is sure that this won’t be the last expression of anti-vaccine rhetoric from Tim Noakes, the absurd amount of frustration over the months of writing this has made it hard to remain formal and professional, and thus this section will end here. This section was originally going to end in the month of October, but anti-vaccine misinformation kept being generated. The prediction would be that if nothing was done and this report was not created, this misinformation would continue for many months, perhaps years. It has lasted years. Over five to be exact. Some will read this and dismiss everything; some will read this and find it outrageous. In the end, honest evidence is the only thing that matters.

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Social Media’s True Impact As published in the journal of Vaccine, “the Internet acts as a postmodern Pandora’s box, releasing arguments that are not easily dismissible. The nature of the Internet allows any and all opinions to spread widely and instantaneously. Individuals and groups gain exposure online without being filtered or reviewed – and anti-vaccination advocates have taken advantage of this fact.”463 Even in the case of a few tweets, “these social groups exert considerable pressure on vaccination decisions by creating a ‘local vaccination culture’. With the prominence of the Internet in today’s world, the attitudes, beliefs, and experiences of that local culture can quickly become global.”463 This is seen even more today with the ever-growing networks of social media, however, the doubt, fear and opposition of vaccines is not a new phenomenon — going back to the 18th century when the “Anti-Vaccination League” was formed in London to combat Britain’s mandatory vaccination laws. Hussain A et al. highlight similarities during different time periods, such as how the fear of autism from vaccines is analogous to the refusal to vaccinate in the 1970s and 1980s when a report came out in 1974 linking neurological reactions and the pertussis vaccine.464 Much like the current measles situation, this caused a massive decrease in vaccine intake in the UK and eventually resulted in a pertussis outbreak. In today’s world, it is much easier to cover the masses with just one click. Hussain A et al. go on to explain the dangerous influence of social media and its repercussions on immunization rates. Common platforms are Facebook, Twitter and YouTube, with trends in anti-vaccination content closely following outbreaks. Misinformation is spread more often during the actual high crisis periods, such as during the H1N1 pandemic or recently, with measles.

Homogeneity of tactics, techniques, and tropes

Common places for parents to discuss vaccines and unfortunately fall into the trap of misinformation and myths are websites like Age of Autism, Say No to Vaccines, NaturalNews.com, and many others.465 Among these social platforms and discussions are the reoccurring themes of “worries over safety, encroachments on individual rights [and] distrust of scientific authority.”463 When evaluating vaccine-related websites, “anti-vaccination websites tended to reject scientific, clinical, and epidemiological studies demonstrating the safety and efficacy of vaccines. Pro-vaccination studies were criticized as unreliable, conducted by those with vested interests in vaccination.”463 The spread of these anti-vaccination websites is serious even for the occasional time somebody might see them. Timothy Caulfield, Canada Research Chair in health law and policy and author of The Vaccination Picture, has said that “just being exposed to a conspiracy theory, even if you’re not a conspiracy theorist yourself, can have an influence on vaccination hesitancy.”466 The argument could be made that a person who is hesitant or “sitting on the fence” about vaccines may be more influenced if they are spending a lot of time on dedicated websites compared to somebody briefly browsing the internet or scrolling through a social media feed. However, research out of Germany has shown that compared to a control site, viewing an anti-

65 vaccine website for just 5 – 10 minutes “increases the perception of risk of vaccinating and decreases the perception of risk of omitting vaccinations as well as the intentions to vaccinate.”467 This study also found that the influence on vaccine behavior continued to persist even 5 months after the original viewing, resulting in fewer vaccinations. Even when information is corrected, people often forget corrections faster than the original misinformation.468,469 Recently, it was shown that 12% of vaccine-related webpages posted on Twitter were of low credibility and they had the potential to produce 1.64 billion online public exposures/views.380 Thus, long term behavior changes may have started from just a quick glimpse online which further intensifies the importance of regulating misinformation. This short window of time that causes such an impact on parental decisions may be due to several techniques used to create a believable narrative. Dr. Natasha Crowcroft, chief of applied immunization research and evaluation at Public Health Ontario, explains, “if anybody is in doubt, and they start searching for information, it’s very easy to be pulled into reading stuff that really is anti-vaccine without knowing [because] it’s written in a way that’s very inviting.”466 Crowcroft continues by saying that the reason “anti-vax” groups have been so successful is that they also target those who have doubts or who are simply curious about the topic. In today’s ever-growing digital age, “the role of the online access to false anti-vaccination information just cannot be understated in examining the rise and spread of the anti-vaccination movement.”464 To create believable and convincing narratives, several techniques, rhetoric’s and tropes are used by “anti-vax” supporters which compile into common themes and tell-tale signs about a person’s or website’s intentions. Luckily, subjective interpretation of Noakes’, or anybody for that matter, use of language is not needed since the analysis of these specific themes have been published in the literature. Manipulation and false conclusions from research, using sources untruthfully, selectively describing data, using shocking images, focusing on individual and or free choice, and appeals to emotion via testimonials are just some of the online strategies. Nearly all “anti- vax” websites spread conspiracy theories; most commonly are accusations of an apparent cover- up by regulatory bodies. Claiming that motives are driven by profit is equally as common and many applaud Wakefield and others who have spoken out against vaccines. Some websites include the notion of “us versus them”, a battle between parents and supporters against physicians and the scientific establishment.463,470 Common language is the use of “freedom”, “informed choice” and “informed health decisions”, which then also targets parents' emotions and parental rights. Dr. Crowcroft notes that these very subtle “informed” parental narratives suggest to readers “that doctors or the government should not be the ones deciding whether or not they vaccinate”.466 The major problem with this is that it’s “a form of veiled or coded language, as it pushes anti-vax sentiments in a more subtle way than flat-out telling a parent to avoid immunization.” Personal testimonies are very common appeals and most narratives are about “vaccine-damaged” children. It is especially common to insist that they, the entity making or supporting the vaccine claims, are “not against parents choosing to vaccinate their children, so long as their decision was based upon proper information from both sides of the debate. However, the information they [provide tends] to be one-sided.”463 Making decisions based on the children’s “best interests” is also a way of phrasing messages to seem more subtle, often expressed as pleas directed at parents.463,466

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Indeed, using “freedom” to spread untruthful information and doubts just becomes an excuse:

Adding to the previous section regarding the support of Robert F. Kennedy Jr. and this notion of “medical freedom”, one might ask what the medical, science and public health communities have to say about it:

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Of note, now even RFK, Jr’s family disagrees with his misinformation:

The Anti-Defamation League has also disapproved of his statements:

A common way of rephrasing and masking moral conflicts is by reframing “Anti-Vax” as “Safe- Vax” since the argument is said to be more about vaccine safety. However, nothing in medicine and health is 100% safe. The benefits of vaccines outweigh the risks and this concern rides a lot on misinterpreted data, or misinformation all together, as covered already in this paper. It also becomes circular when this rephrasing has been shown to be a clear “anti-vax” technique, thus by saying “safe-vax”, one proves they are “anti-vax” even further. It is also never just the label that’s used, typically common anti-vaccine misinformation and unscientific concerns follow closely alongside the use of the “safe-vax” term. A perfect example of this is when one of the main voices of the movement, Jenny McCarthy, says “We’re not an anti-vaccine movement. We’re pro-safe-vaccine schedule.”471 She asks the same question that Noakes does: Do we need all of them all of the time? Just like Noakes, she thinks that children can skip some vaccinations they might not need. Robert F. Kennedy, Jr. has also said that he’s “pro-vaccine” but continues to spread unnecessary and untrue concerns and doubts about vaccine safety.401 Jenny McCarthy, like Noakes, implies that autism from vaccines is a concern, saying that parents “who have children with autism might take their chances on the measles after witnessing their children regress with autism.” McCarthy absurdly claims that “if you ask 99.9 percent of parents who have children with autism if [they’d] rather have the measles versus autism, [they’d] sign up for the measles.” McCarthy, like so many of those who are vaccine hesitant, including Noakes, “just want there to be some type of conversation” and their intentions are not to “[start] an epidemic of another disease.” Ironically though, this exact conversation is how epidemics can start and have started as we currently have seen with measles. Similarities between Noakes, his supporter and colleague Marika Sboros, and anti-vaccine leaders and vocal advocates exist through many themes. One of these themes is expressed by claiming suppression of data, silencing free speech and apparent bullying or attacks. There are plenty of examples, such as Brian Martin who was previously talked about, but also with Robert F. Kennedy, Jr. when he frames the term “anti-vaccine” as a “reflexive public relations ploy”. Sboros intentionally brings up in her writing how the term can stigmatize a person; just like when RFK, Jr. says that “it stigmatizes the mere act of even asking an open question about what

68 is known and unknown about the safety of vaccines.”472 However, time and time again the “open questions” tend to be completely one-sided and full of misinformation that can be refuted by current scientific data. Sboros says the criticisms about Noakes’ vaccine hesitancy are attacks and attempts to silence. In Noakes’ 2018 letter, which cited the flawed Mawson study, he implies that the concerns he expressed on the Cliff podcast about efficacy and safety – what is technically the use of a public platform “to disparage vaccine use or cast doubt on their efficacy”281 – resulted in “viciousness, name-calling, defamation and other markers of unprofessional conduct.”101 Overall, this phrasing in defense of Noakes is homogeneous with those who are anti-vaccine and or defend the movement. RFK, Jr. calls it a “derogatory attack designed to marginalize vaccine safety advocates and derail reasoned debate.”401 Mike Adams from Natural News has defended the Vaxxed documentary claiming that it's public exposure is “a crime in the eyes of the corrupt, fraudulent vaccine industry and all its arrogant zealots.” While calling it “one of the single most important documentaries of our modern age”, Mike Adams contests that its removal during a film festival was “participating in the censorship that was demanded by the vaccine totalitarians” and “pharma-funded media science trolls.”473,474 This strikes a very close resemblance to how Sboros and Noakes have also accused those who criticize the “vaccine safety” movement of being “in the thrall or pay* of pharmaceutical companies” or “trolls”** that fire off “venomous attacks”.42,271

* (Side note about all of the comments made by Noakes and Sboros regarding payment and profit: it seems that “many doctors who administer vaccinations lose money on them”.475 This is most likely because they are so expensive to produce. It can cost billions of dollars to create a vaccine476 and as of 2010, vaccines only account for 3% of the healthcare profit globally.477 More recent data shows that out of the countries selected, vaccines accounted for less than 2% of total healthcare spending.478 Another similar analysis of countries found that not one of them spent more than 0.5% of its healthcare budget on vaccines.479 Vaccine payments may not be enough to cover the costs of producing them and it was calculated that in the US, 79% of vaccination payments fell short.475 Several physicians and vaccine providers can vouch for the fact that they are not profitable.480,481 Either way, profit is not the main reason for creating and promoting vaccines.482 Thus, claiming vaccines, and the doctors and scientists who promote them, are driven by payment of industry (i.e. the “pharma shill gambit”) is not only inaccurate but it becomes just another anti-vaccine trope.38,414 Absurdly and ironically, Wakefield’s vaccine fear-mongering campaign has raised huge sums of money.483 Others () have made millions of dollars by selling fake vaccine alternatives and “natural” health products, all the while donating millions to anti-vaccine groups.484) ** (Side note about trolls: a 2018 study showed that Twitter bots are used to generate antivaccine messages and Russian trolls literally help propagate antivaccine discord and misinformation.485 However, of note, “false news spreads farther, faster, deeper, and more broadly than the truth because humans, not robots, are more likely to spread it.”381)

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It’s concerning when Noakes and Sboros as well as anti-vaccine advocacy groups, like the Age of Autism website, share the same narrative by calling it “censorship”. Prof. Yehuda Shoenfeld, another supporter of the anti-vaccine movement, frames his defense in a very similar manner to Noakes and Sboros – by saying that the medical community is trying to silence vaccine critics.102 When Sboros frames the situation as “silencing” or “being stomped into silence” and “shutting down debate”271, this is comparable to the response the General Medical Council’s findings got by Wakefield’s supporters who were frightened by “the silencing effect it could cause to scientists and researchers.” “These verdicts”, they claimed, “now prove that researchers who stumble upon science that is controversial have to worry about losing their licenses and careers.” Going as far as to say that it was a “mockery of the value of civil debate in an open society.”486 Yet as Dr. Gorski explains, “you can have all the ‘dialogue and discussion’ you want about a scientific topic, such as the question of whether vaccines cause autism, but at the end of the day there is a correct answer based on science.”487 The values and narratives regarding freedom of speech, censorship, attacks and vaccine safety that are shared by Timothy Noakes, Marika Sboros and anti-vaccine supporters are highly concerning.

As a side note, Andrew Wakefield and those who sympathize with him and his movement often claim they are being silenced. However, double standards exist within the anti-vaccine movement since Wakefield has also tried to silence critics: “Andrew Wakefield, the doctor at the center of the MMR vaccine controversy, was criticized by a high court judge for trying to silence critics by warning them that he was suing for libel while at the same time failing to progress the case.”488

Research has shown that online information does indeed influence decisions and perceptions about vaccination. Several tactics and tropes are used intentionally in writing, while some are unintentionally and indirectly used and serve as a quick blurb or repost at a passing glance. These “anti-vax” techniques include “actions such as skewing science, shifting hypotheses, censoring dissent, and attacking critics; also discussed are frequently made claims such as not being ‘anti-vaccine’ but ‘pro-safe vaccines’, that vaccines are toxic or unnatural, and more.”414 The rise in connectivity through social media and the internet allows marginalized groups, such as anti-vaxxers, 9/11 “Truthers”, or “Flat Earthers”, to “easily and uncritically interact with like- minded individuals online” and spread information through reaffirming techniques and websites.414 As mentioned before, such websites include but are not limited to: , Age of Autism, Autism Media, Children’s Health Defence, National Vaccine Information Center, Vaccination Risk Awareness Network, Natural News.com, and Mercola.com. (Of note is that some of these websites also spread misinformation about other health topics like cancer.)

The intent of including this section and the next one, coinciding with the 2012 review by Kata, A., is “not meant to belittle individuals with good-faith questions about vaccines, or those worried or swayed by what they find online” but to qualify and quantify anti- vaccination content and provide criteria that allows analysis on whether a person’s content is indeed “anti-vaccine”.414

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Previous work has been done to review and categorize anti-vaccination appeals and claims489:

At least nine other studies have quantified and described online anti-vaccine claims, patterns and have also done content analyses380,485,490–496.

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The way the movement operates is through common tactics414:

Several tropes and mottos are used within these tactics:

The ultimate relevance of this topic is through asking the question: Has Tim Noakes expressed or shared any of these? The answer is yes, yes indeed. We will use all of what we have covered thus far to analyze Noakes’ online expressions and social media.

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Analysis of Tim Noakes’ Social Media

Since the diffusion of information online can be governed by shared attributes and behaviors among users497, a concept formally known as homophily, it may be useful to identify shared connections within social media, perhaps through shared Twitter followers. Users with the same views or “belonging to the same echo chamber” (polarization)382,498 are a likely source of spread and this may explain why Noakes’ misinformation gets supported and retweeted. The content within the shared posts can then be analyzed for Anti-Vaccine versus Pro-Vaccine narratives, deriving a ratio and percentage of the overall narrative that is cast out to the public. The spread of misinformation can be estimated by calculating the maximum potential exposures on Twitter and can help demonstrate the impact one might have on social media. Each of these three techniques will be utilized to evaluate the vaccine-associated connections, narratives, and exposures within Tim Noakes’ social media.

Connections If Noakes was not “anti-vaccine” or vaccine-hesitant online and we had nothing to worry about, we would most likely see no relationship between these sides of social media. However, there is indeed a correlation between those who follow Noakes and those who follow vocal anti-vaccine proponents and leaders. On the date of June 17th, 2019, the website “FollowerWonk.com” was used to evaluate connections between the followers of 16 popular Twitter accounts that have spread anti-vaccine misinformation and Noakes’ 128,760 followers. After removing duplicates, 3744 of Noakes’ followers also follow anti-vaccine accounts. ~2901 accounts follow Noakes and at least one single anti-vaccine account. 851 of Noakes’ followers can be considered “true anti-vaxxers” since they follow all 16 accounts evaluated.

A brief visualization of the anti-vaccine accounts and how many of their followers also follow Noakes. Other anti-vaccine accounts did also share followers with Noakes, but these were not included.

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The largest number of accounts (2,220) come from those who are following both Noakes and Sharyl Attkisson. (As a simple and quick “health, diet & exercise science professional” control, only 359 people follow both Attkisson and Brad Schoenfeld, Ph.D. Accounting for the fact that Noakes has ~3 times as many followers, the relative number would still only be 1074.)

Attkisson is a former CBS reporter, but also an influential promoter of anti-vaccine myths and conspiracies with Wakefield and Age of Autism. She has been involved with such controversies and untruthful information for over a decade.499 She, just like Noakes, expresses multiple anti- vaccination tactics. Appealing to emotion, doubting safety, claiming “vaccine pharmaceutical activists” are trolls, and accusing “pharmaceutical interests and vaccine activists” of fighting “a PR campaign to squelch any discussion about vaccine safety and the autism connection.” However, since this follower number of 2,220 is quite large compared to the rest, perhaps we can consider it an outlier.

If we do so, Robert F. Kennedy, Jr. is the next anti-vaxxer that Noakes’ followers follow. This might make sense since Noakes has shared RFK, Jr’s content. (RFK, Jr. and Brad Schoenfeld, Ph.D. follower count is 80. Relative to Noakes’ total number of followers, this number is still 3-fold lower than Noakes’ and RFK, Jr’s shared followers.)

After RFK, Jr., is the account “@doctorsensation” or Toni Bark, MD. Bark turned her practice into what she called, “Holistic Medicine” and had a long history of homeopathy. She was a speaker, along with Andrew Wakefield, on a cruise ship dedicated to conspiracy theorists.379 She’s wrote the book Vaccine Epidemic and was co-producer of the documentary Bought - which apparently “Exposes Ugly Truth Behind Vaccines, GMO's and Big Pharma.”

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Toni Bark also made false claims in a court case and the judge refused to approve her as a vaccination expert, because, well, she isn’t one.500 She believed in “vaccine injuries” and has supported the Vaxxed company/movement.501 As a quick side note, Bark has unfortunately been diagnosed with cancer. Despite heavily promoting the Keto Diet for cancer and other alternative health options to, in her words, make her body “uninhabitable for cancer”, she developed cancer anyways. She implies that her “vaccine injury” might have caused her cancer, which is more misinformation. This becomes another example of cancer misinformation converging with vaccine misinformation. This blend between topics has also been extensively documented.90,191 *** 2020 Update: Sadly, Toni Bark has since passed away. Though the rest of the follower numbers are not as large compared Attkisson or Bark, this does not undermine the fact that some of Noakes’ followers also follow Children’s Health Defense, Generation Rescue, the Vaxxed accounts and Andrew Wakefield himself. If there was no relation between anti-vaccine supporters, we thus might be able to conclude that Noakes’ Twitter account is of minimal influence and we would see no crossover between social realms, however, this is unfortunately not the case. Whether the number we look at is the 851 “true anti-vaxxers” or the total 3744, the followers of Tim Noakes and the anti-vaccine movement do crossover. The question I had is not necessarily about how much, but about if there is any relationship at all. Indeed, as of June 17th, 3% of Noakes’ followers also follow anti- vaccine accounts.

Based on the mapped locations of Noakes' followers with a sample size of 5000 users, about 15.28% (n=764) are in the South African area as of the 17th of June. Based on this, a very oversimplified estimate can be made that >19,000 of his total followers are from South Africa. Perhaps this is not entirely correct, however, it gives an idea of the possible social media impact in South Africa. It is difficult to stay up to date on both the location and anti-vaccine follower trends since Noakes gains, on average, 49 new followers a day.

Update: An update on July 23rd shows us just how difficult it is to stay up to date with this follower correlation. Tracking from June 18th to July 23rd, Noakes had a net gain of 1726 followers in almost one month. Sampling two anti-vax accounts, Children’s Health Defense and Robert F. Kennedy Jr., follower counts rose from 305 to 330 and 844 to 871, respectively. On

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December 22nd, the followers of Children’s Health Defense, Robert F. Kennedy Jr, and Tim Noakes were analyzed again. Children’s Health Defense and Robert F. Kennedy Jr. follower counts rose from 330 to 429 and 871 to 1018, respectively. Increases from different accounts also existed (Table 1). The account “@teamvaxxed” was removed from Twitter as of December so the total account number became 15. Due to these increases in followers when looking at isolated accounts, the hypothesis was that there would be a significant increase across all accounts.

Table 1. Shared follower counts for Tim Noakes and popular anti-vaccine Twitter accounts.

Account June 17th December 22nd Children’s HD 305 429 RFK, Jr 844 1018 AndrewWakefield 291 324 Sharyl Attkisson 2220 2633 LaLaRueFrench75 252 307 Age of Autism 303 317 vaxxedthemovie 346 391 vaccineresist 195 222 Physicians for Info 176 269 ProAntiVaxxer 97 154 doctorsensation 590 680 GenRescue 165 173 JeffereyJaxen 299 369 avoiceforchoice 161 214

To evaluate the significance of this increase in followers from the 15 Twitter accounts from June to December, a Paired Samples T-Test was done (Table 2) using the software Jamovi.

Table 2. Paired Samples T-Test of June and December follower counts.

statistic df p Cohen's d

June 17th December 22nd Student's t -3.25 13.0 0.003 -0.870

Note. Hₐ Measure 1 < Measure 2

There was a statistically significant increase (p = 0.003) between the amount of anti-vaccine associated followers of Tim Noakes from June 17th to December 22nd. This was validated further by a Bayesian Paired Samples T-Test (not shown here) which indicated Strong evidence for the hypothesis and a Bayes Factor of 16.6.

Thus, we can conclude that over time, there is a significant increasing relationship between those who follow Noakes and those who follow anti-vaccine accounts.

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Narratives So far, we have established connections within social media, and we begun to introduce the impact social media can have with regards to vaccine information. Though there is an indirect relationship between those who follow Noakes and those who follow anti-vaccine accounts, this does not entirely address the information Noakes himself has shared. Upon reviewing his tweets about vaccines, not all of them contain anti-vaccine rhetoric and thus someone may be able to isolate one tweet and suggest that he has not cast doubt about vaccines or that he “is not anti- vaccine”. However, both Noakes and Sboros have suggested not to look at single tweets. Therefore, to determine the overall narrative Noakes has expressed to the public, it would seem reasonable to calculate the ratio of Pro-Vaccine VS Anti-Vaccine rhetoric in each online post (Table 3). Defining what is indeed “Anti-Vaccine” can be tricky, controversial and up for some debate; the criteria and examples, in this case, have been based on the tactics, tropes, techniques and rhetoric documented in the literature, particularly from Kata, A.414 and Davies et al.489 It may be important to note that total numbers are based on each individual trope within a tweet or retweet (i.e. a single tweet could have multiple tropes, consisting of only anti-vaccine, pro- vaccine or a mix of both.) For the sake of time and clarity, only tweets included in this report were analyzed. Noakes’ interview with Gareth Cliff and his 2018 written response about being called “anti-vax” were included. Both of Sboros’ articles defending Noakes along with her first article featuring Malcolm Kendrick were included since Noakes shared all of these online.

Table 3. Counts and proportions of vaccine tropes/expressions within this report.

Level Count Proportion

Anti-Vaccine 145 0.9006 Pro-Vaccine 16 0.0994

From the results in Table 3, we can clearly see the overall ratio of Pro-Vaccine VS Anti-Vaccine tropes and shared information online. 90% (145/161) of Noakes’ shared expressions were Anti- Vaccine in nature, while only 10% (16/161) were Pro-Vaccine. The claim that he “is NOT anti- vaxx!” is very difficult to reconcile with these findings. Thus, we can conclude that the overwhelming majority of Noakes’ rhetoric and information about vaccines is indeed anti-vaccine.

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Exposures These webpages and tweets that Noakes has shared are mainly a public health concern when other online users are exposed to the misinformation. In order to estimate potential exposures, we can use the method performed by Shan et al.380 and count the total number of followers for all tweets and retweets; this will give us an idea of the maximum possible audience. The method used was to take each post that Noakes explicitly tweeted that contained vaccine misinformation or rhetoric and take the sum of followers of each account that retweeted the post. Noakes’ own follower count was added to each post he created and retweeted, which would account for all of the people that follow him who’d see the post. Duplicate accounts were not a concern since what was being measured was each exposure to the content, not each user. Thus, a single user could have been exposed to the content multiple times. Posts were restricted to the content covered in this report. 35 posts were evaluated between 2014 and the end of 2019 with a total of ~272 retweets. The number of followers for each account was recorded on December 23rd, 2019. The primary limitation was that the number of followers for each user, including Noakes, was unknown at the specific original date it was posted; thus, the number of followers could have been much lower. Another limitation of counting these retweets was that, at times, Twitter wouldn’t display all the users (e.g. one tweet had 92 retweets, but only 45 were shown). Given that multiple counts were excluded due to hidden retweets, as described above, this lowers the total count and may balance out the primary limitation. The final count has also been rounded to the power of 106 which will further balance out the number. All this said, much like the limitations described by Shan et al.380, the number of likes and replies were not assessed. It is nearly impossible to count the exposures that would not have a number value assigned to them on Twitter, i.e. users can scroll past content that appears on their Twitter feed, which generates an exposure, but if the user does not engage with the post in any way then there is no way of measuring this. This specific limitation has been discussed elsewhere.502 These three additional limitations might balance out the estimate even further since it is quite possible that more people saw the content than what is indicated by the number of retweets and followers recorded. In 2019 alone, Tim Noakes generated a maximum of approximately 3 million (2,858,455) exposures to vaccine misinformation and or anti-vaccine rhetoric and narratives. Across all tweets from 2014 to the end of 2019, this number jumped to approximately 4 million (4,179,945) maximum exposures. Not only does this underscore the immense ability of misinformation and anti-vaccine rhetoric to spread and generate millions of views, which in turn can influence an individual’s decision, but this also shows that ~68% of these possible exposures were in 2019. Concluding this analysis of Tim Noakes’ social media with regards to vaccine content, there are multiple points of evidence to suggest an overall anti-vaccine narrative. There is, to some extent, a relationship between those who follow Noakes and those who follow anti-vaccine accounts. From June to December 2019 there was a statistically significant increase in the number of followers Noakes gained that also aligned with anti-vaccine views. As for the content that Noakes himself has shared and expressed, 90% were Anti-Vaccine in nature, while only 10% were Pro-Vaccine. The potential maximum number of exposures to this anti-vaccine misinformation and rhetoric are in the millions, with approximately 3 million exposures in 2019 alone and 4 million in total from 2014 to 2019. The claim that Noakes “is not anti-vaccine” and has not shared anti-vaccine misinformation is terribly weak and not based on the evidence.

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*January 2020 Update: (Narratives and Exposures have increased since writing this section. Additional increases in these results are taken into consideration in the Discussion, under Serious Social Media Analysis Considerations.)

Relevance and impact

Whether or not Noakes directly posted a statement or indirectly shared it might be up for debate. However, a person does not need to personally create a post to spread misinformation – retweets, shares and “likes” play into the social media algorithms that further popularize misinformation. “Each ‘like’ is an endorsement of the content of these anti-vaccine pages by an individual, often a parent, who has read through them. Each individual ‘like’ is then seen by - or promoted to - that person’s network of … friends.”465 The anti-vaccine tactic of appealing to a parent's emotions is concerning since we live “in an age where a parent can Tweet from the exam room or post links to any article on [social media and] these stories [about vaccine misinformation can] spread quickly.”465 Misinformation may spread even quicker since anti-vaccine tweets seem to attract more engagement than pro-vaccine tweets and are more likely to be retweeted.503 Though anti-vaccine tweet volumes have decreased since 2014, online users and the anti-vaccine community itself has doubled in the last three years.504 Perhaps we can entertain the idea that Noakes has been commenting and sharing more than directly posting; he does indeed acknowledge the fact that he comments and retweets more because he “want[s] to share insights that are important.”2 This may be slightly problematic as research has shown that online comments on scientific articles have a significant negative impact on scientific understanding.465 Low credibility, potentially anti-vaccine, Twitter content can also generate millions of online exposures through retweets and cumulative followers as we have seen in the analysis above.380 Beliefs are built within these Facebook groups, Twitter accounts, and online forums and they can “exacerbate misunderstandings about the science of vaccines — particularly risk-benefit analysis.”465

The question, asked by many anti-vaccine and hesitant supporters, including Noakes and Sboros, remains: “What is the harm in asking questions and being hesitant?” The World Health Organization has called “vaccine hesitancy” one of 2019’s Top 10 threats to global health,505 but where can this threat come from? “Anti-vaccination messages are more common on the Internet than in other forms of media, increasing the likelihood that vaccination decisions may be based on misleading information. Indeed, parents who exempt children from vaccination are more likely to have obtained information from the Internet than parents who have their children vaccinated; they are also more likely to have used certain antivaccination websites. This demonstrates the importance of understanding what messages are presented online and why they may be accepted.”463 Parents who are worried about vaccines and buy into the anti-vaccine rhetoric may feel like they are doing the right thing by participating in online causes and communities. Adding to those worries even more by sharing content about “vaccine injury” or Wakefield’s fraud study has created hesitancy which can result in delayed vaccine schedules and complete refusal of vaccines.465

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So, “asking questions” may result in hesitancy but does that lead to more people being unvaccinated, let alone lead to outbreaks of disease? Yes. “Parents hesitant to vaccinate their children may delay routine immunizations or seek exemptions from state vaccine mandates.”506 Anti-vaccine conspiracy theories can reduce the intentions to vaccinate507 and fake news about vaccines can cause parents to delay vaccinating their child or prevent them from ever vaccinating at all.508 Forward projections and mathematical models have shown that exemptions in schools might allow for large measles outbreaks.509 “A substantial proportion of the US measles cases in the era after elimination were intentionally unvaccinated. The phenomenon of vaccine refusal was associated with an increased risk for measles among people who refuse vaccines and among fully vaccinated individuals.”506 Parents have admitted to the influence that anti-vaccine social media posts have had on their decisions. One case was after a baby was rushed to the ICU after his parents refused to vaccinate, confessing their doubts afterward about the MMR vaccine and autism.510 Outbreaks have been caused by children who have not been vaccinated due to their parent's concerns about vaccine safety. If under-vaccinated populations exist, a preventable disease such as measles can spread quickly. The current Samoan measles outbreak is one example of this.511 “Health care providers, together with public health and community leaders, must address vaccine hesitancy to ensure high immunization rates in all communities, including subpopulations.”512,513 Based on the current evidence, Noakes fails to do this with specific vaccines. This is also concerning since Dubé et al. have shown that a health professional’s own beliefs might have an impact.37 “Parents may selectively choose providers who have similar beliefs to their own. Provider beliefs may contribute to parental decisions to accept, delay or forgo vaccinations.”514 This finding was also echoed in a recent Finnish healthcare worker survey.515 Of note, vaccine myths about autism don’t just impact immunization rates and outbreaks, but also the entire community of autistic people, including their younger siblings who don’t have autism.516 Buzzfeed has reported that “for autistic people, the claims, which have been repeatedly debunked, continue to be a source of frustration as people spreading vaccine misinformation play on fears and prejudices, often calling autistic children damaged.”517 This reinforces the false belief of “autism recovery” or “getting them out of that state”. When myths are spread it makes it “difficult to get people to calm down about autism.” “Falsely claiming vaccines cause autism also gives people a way out of actually accepting autistic people, said Morénike Giwa Onaiwu, co-executive director of the Autistic Women & Nonbinary Network.”517 Anti-vaccine parents often take the focus of trying to “fight autism” instead of “connecting with their autistic children, building on their strengths, and adapting.” It recently has been found that some autistic adults grow up believing they were “bad people”, referring to themselves as “alien”, “isolated” and “nonhuman”.518 Thus it is important that we do not negatively stigmatize autism and ASD as an “epidemic” we can “fight”. As said by Zoe Gross, operations director of the Autistic Self Advocacy Network, and of direct relevance to Noakes, “too often, experts focus on the deficits of autism or describe it as an epidemic, which only stokes people’s fears … Fake cures and skipping vaccinations won't help autistic kids…”517 The Twitter account for “Autistics 4 Autistics Ontario” also sums this up well:

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When posting online, a large degree of responsibility is needed as well as an understanding of how our digital decisions influence our surroundings. Dr. Jennifer Gunter explains in her latest article in The Lancet, “everything we read, and share builds the internet, so we in medicine should especially take that to heart. The more clicks the greater the chance that piece will appear favorably in an algorithm.”519 Dr. Gunter highlights “four basic rules of internet health hygiene”, with the most relevant being number two: “Avoid sharing bad information - even in jest. Sharing makes the bad content more popular algorithmically speaking.” And number four: “Steer clear of content from practitioners who are against vaccination or who recommend homeopathy.”519 Pediatrician, Dr. Eve Switzer, worries that “if we ignore these anti-vaccine people with all of the nonsense that they are putting on social media” it can give them a greater voice. “[She] thinks more pediatricians should be involved in putting stuff out on social media to counter the misleading and just blatantly false information that they use.”520 This fight against misinformation is difficult when some social media platforms won’t actually ban such content. Facebook and Twitter say they will try and “steer users toward scientifically sound information about vaccines, but both told CBC News that they won't go so far as to block and remove anti- vaccination material.”521 This may have improved since writing this paper. Jonathan Jarry, a biological scientist with McGill University's Office for Science and Society, has expressed great concern over the topic, asking the imperative question: “Where is the line between free speech and protecting the public?” He suggests that the biggest figures in the anti-vaccination movement should be banned from social media platforms “simply because the misinformation that they are pushing is having very, very concrete, dangerous and lethal consequences for the public.”521 Noakes and Sboros have casted doubt about vaccines while advocating for freedom of speech. Noakes states that “anything that takes away scientist's freedom of speech has to be anti- science.”2 According to Noakes, expression of his scientific opinion “is [his] right in the constitutional democracy in which [people] live in South Africa.” However, these doubtful vaccine-hesitant opinions, that can lead to unvaccinated children, now “constitutes a public health threat serious enough to outweigh freedom of speech on Facebook, Twitter and other social media platforms.”521 Jarry makes the point about how “maybe the public good outweighs the right for people to scream ‘Fire!’ in a theatre where there is no fire.” Dr. Gretchen LaStalle, a family physician who writes about vaccines, restates this point: “anti-vaccine articles that yell ‘conspiracy’ or ‘danger’ or ‘toxins’, when none of this has proven true, are putting the lives and the health of the people, particularly our children, at risk. This cannot stand.”522 But the problem we run into here, and the question I personally have, is what if the person untruthfully yelling “Fire!” ...is a firefighter? What if the firefighter was helping to build and stoke the fire? What if a police officer intentionally triggers a false alarm? What if a health professional was placing others at harm directly or indirectly, thereby not promoting health? What if a person failed to perform their professional duty by doing the opposite of what they are mandated to do: ultimately contradicting their colleagues, employer’s and regulator’s goals?

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Potential Rules & Regulations Among the several anti-vaccine tactics and tropes, the use of authority is used to somehow bolster the argument or position.465 Examples one might see online are “I’m a nurse”, or in Noakes’ case, “I’m a medical scientist.” Marika Sboros uses this appeal to authority in her writing when defending the 2014 “CDC Whistleblower/Coverup/Bad science” tweet: “…the tweet is not about vaccines but about bad (dishonest) science. But you’d know that if you were a scientist, which Noakes is … You would also know that Noakes is not just any scientist, but a world-renowned one.”42 Somehow this justifies the conspiracy: “If you were a medical scientist you’d know instantly why any hint of a CDC cover-up would raise red flags sky high” – a reminder that this “coverup” belief isn’t true. Also, a reminder that leaders in the anti-vaccine movement (e.g. McCarthy, Kennedy Jr., Bigtree) as well as those who will believe this “cover- up” are usually not doctors or scientists. Sboros goes on to say that having a debate about vaccines is frustrating when doctors “are not scientists, scientific in their thinking”, or the critics are sometimes not doctors at all (such as Rousseau who wrote about Noakes’ Cliff interview). The use of this fallacy implies that there is “significant disagreement about the safety of vaccination in the medical and healthcare communities…”465 when in fact, there is global consensus over the topic. It appears the goal is to further instill doubt and fear throughout the public. The question I have about these comments and about this entire situation in general, is: If one were an Emeritus Professor of UCT, a “world-renowned” A1 rated medical scientist and recognized as a world authority in science by South Africans, shouldn’t their claims and motives be subjected to scientific scrutiny in compliance with their professional and prestigious title? Such high praise from colleagues and the public merits further investigation of one’s recommendations, endorsements, and beliefs. In medicine, one may come into conflict between a patient’s beliefs and clinical decisions, this is especially true with vaccinations. The question might be, what is a medical professional to do? This is where the ethical theory and moral practice of Mill’s “Harm Principle” can come into play. My initial interpretation is that in certain cases, freedoms and liberties can be restricted if doing so will prevent the harm of others – “even expressive liberties can be restricted when their exercise poses a ‘clear and present danger’ to others”523 – there is, of course, lots of room for nuance. In the case of present-day vaccines, “patients are entitled to the right to refuse vaccination using ‘our children, our choice’ based on their autonomy, while health care providers are morally obligated to treat everyone with non-maleficence and avoiding harm to society at all costs. While exercising autonomy and refusing vaccination is valid for sensitive personal issues, it will cause more harm than good if a certain percentage of the population does not get vaccines, causing the immunization rate to fall below the threshold.”464 “The Harm Principle justifies interfering with autonomy and individual liberties, against their will, if it is done so as to prevent harm to others.” Some reiteration of this is emphasized in the HPCSA guidelines. The details of the South African laws and regulations are beyond my knowledge and the regulatory processing, independent expert analysis and ultimately, the decisions made hereafter, are out of my hands and beyond the scope of this report. This section is not meant to influence decisions, legal or otherwise, but to bring some of the already existing rules that are publicly viewable into focus.

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While Noakes has not practiced clinical medicine for many years, he is still an influential health professional. There seems to be, in my opinion, and based on the evidence, potentially two faults made by Noakes: 1) promoting and spreading misinformation and 2) not providing up to date evidence. “The Health Professions Act (No.56 of 1974) in South Africa defines unprofessional conduct as: … [I]mproper or disgraceful or dishonorable or unworthy conduct or conduct which, when regard is had to the profession of a person who is registered in terms of this Act, is improper or disgraceful or dishonorable or unworthy.”524 Providing truthful information based on up to date scientific evidence is well within the patients, or in this case, the public’s best interest, without the interference of the professional's own beliefs. As stated in HPCSA’s General Ethical Guidelines (Booklet 1)525, health professionals should follow these (but not limited to what is included here) core values: •

•

•

•

**(Since Noakes is no longer seeing patients clinically, the term “patient” or “patients” henceforth can refer to the social interaction as an authority figure with any person relating to the topic of health, or the sharing of information as an authority figure, perhaps online as a health professional.) Sections 2.3.7 and 2.3.12 suggest that one should be truthful, in the context of this report, about vaccines and continue to stay up to date on the science and update their knowledge on the subject matter. (If vaccines are not “within their area of practice” and thus they do not need to have continual competence and high levels of knowledge, then the question would be asked as to why they are providing information on vaccines in the first place.) Sections 2.3.2 and 2.3.3 justify the act of providing up to date information regardless of one’s interests and beliefs. Furthermore, sharing information about the need to vaccinate as well as the dangerous implications that vaccine misinformation can have are in the best interest of the patient and public.

Noakes has explicitly stated in his previous HPCSA Nutrition Trial526 that he values section “27A - d)” in Booklet 2.527 •

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He says that this drives him in all that he does in science.526 He uses this in his argument by justifying that he should be able to give all therapeutic options with regards to nutrition. Staying away from the previous trial and the topic of nutrition, we can still learn a few important points from Noakes’ deposition: 1. Noakes is indeed aware of the guidelines. 2. Noakes recognizes that health professionals have the ethical reasonability to provide all necessary information. Thus, omitting information about vaccines should be discouraged. 3. Noakes uses the guidelines in the context of providing information to the general public and not just to clinical patients or clients. Thus, it should be acceptable to do so here in this paper. While the guidelines may be focused on registered clinical professionals, we can still use them in the context of this paper, i.e. a health professional providing information to the general public. 4. Noakes uses this section in the guidelines to justify that he is allowed “to encourage people to think beyond what is the conventional” view. In my opinion, challenging the conventional view is highly context-dependent, and shouldn’t also conflict with other guidelines in place, among many other things. Thus, this argument would not justify challenging the conventional view on vaccines.

An influential health professional with a large following who shares sources of misinformation and continues to do so despite large amounts of opposing scientific evidence and critique might be abusing their power – not only based on their social media following but also as an authority figure. Withholding scientific information about vaccines, which further instills public doubt, and omitting the several research flaws and untruths that come with vaccine misinformation is not in the best interest of public health. Doing so goes against the HPCSA’s Ethical Guidelines, as implied in section 5: •

•

Regardless of one’s professional role and academic focus, “having a platform and a microphone does not make you an expert, but it does make you influential”, as said in a recent statement by 2019 president of the American Academy of Pediatrics, Dr. Kyle Yasuda.528 “How you talk matters, especially now when so much of our public discourse is distilled into sound bites and hashtags. It’s not just harmless entertainment when the takeaway message encourages people to question vaccines. Normalizing misinformation is dangerous.”

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The benefits and positive public health implications outweigh the risks of vaccines. The myths spread by anti-vaccine proponents about “serious harm” are flawed and are not a justification for vaccine omission; risks of omission and accurate evidence should be included when discussing vaccines. Moreover, discouragement of withholding critical information (in this context, the vast amount of evidence on vaccine safety and debunked myths) is more clearly stated in Booklet 4 529, section 3: •

•

There are and have been several serious consequences of vaccine myths. Decisions about vaccinations are weighed based on evidence, this also extends to posting vaccine content on social media. An example of a responsible, moral assessment, when posting or sharing online, might be from Booklet 1: • When making a moral assessment, as stated in the guidelines, two other important questions are asked: •

•

With the “particular circumstance” in this case being information about vaccines, the rational and perhaps obvious answer, in my opinion, to both questions might be: “The patient or practitioner would want to receive information that is based on the best available scientific evidence and not based on misinformation, myths or untruths.” Given the sum of Noakes’ vaccine hesitancy online, it remains questionable and unclear if any professional moral assessment was made.

As said above, health professionals should be up to date on the information they are providing and sharing. If the professional’s knowledge and expertise are not in the area they are promoting, and what they are sharing might be misinformation or incorrect, retracting potential misinformation and allowing those in the specific field to comment would be responsible and would follow HPCSA’s guidelines. This is explicitly stated in Booklet 1, section 8.1: •

•

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The importance of providing up to date information is further emphasized in Booklet 2 527, section 27A – “Main responsibilities of health practitioners”:

And in Booklet 7 530 – “Guidelines for The Withholding and Withdrawing of Treatment.” Of note in 5.1, is the fact that one should also refer to the clinical guidelines: •

•

There is reason to believe that Noakes is not following clinical or general health guidelines, including South African pediatric recommendations about vaccines. Such recommendations discourage common vaccine myths531 – “The combination MMR vaccine causes autism”, “Thiomersal in the vaccines, specifically the MMR vaccine, causes autism”, “Giving too many vaccines at one time will overload the system” – these are some of the very same myths that Noakes has explicitly and or implicitly shared. These myths and misinformation may go against the facts, standards, and goals of the Republic of South Africa's Department of Health.532 As well as the 's Vaccines for Africa Initiative (VACFA)533, South Africa's Centre for Vaccines and Immunology534 and even internationally from the World Health Organization. Seeing how measles outbreaks are increasing globally, it seems irresponsible to cast doubt on the measles vaccine. It seems oddly counterproductive to be an Emeritus Professor at the University of Cape Town who casts doubt on the measles vaccine when the university has encouraged getting the vaccine (when the Western Cape Department of Health reported a measles outbreak in 2017535). Given that South African researchers have been trying to address HPV vaccine acceptance and hesitancy536, it seems irresponsible to share misinformation and doubtful, hesitant wording about the HPV vaccine, as Sboros has done when defending Noakes; keep in mind that Noakes also shared those articles with that contained misinformation. It is especially counterproductive when the country of South Africa launched a national HPV vaccination campaign against cancer, as reported by the HPCSA.537 This campaign was back in 2014, in 2019 however, we are able to celebrate massive successes in which HPV vaccination is leading to significant drops in HPV-related infections, lesions and warts.538–542 It has been predicted that cervical cancer could even be eliminated by the end of the century.543 These are exciting times since the global prevention of cervical cancer is very near; not so exciting is the fact that some influential people cast doubt on this successful vaccine. The severity of the act of intentionally sharing and posting misinformation and failing to correct and retract misleading, untruthful content is obviously up for expert review. According to the Digital Media Law Project, which admittedly covers jurisdiction in the United States and not South Africa, in order to avoid online negligence, it is important to “act with a reasonable level of care in publishing the statement at issue. This basically turns on whether the defendant did everything reasonably necessary to determine whether the statement was true, including the steps

86 the defendant took in researching, editing, and fact-checking his work.”544 Given the series of events and posts, the case could be made that Noakes did not fact check information about vaccines before posting publicly online, nor have these errors been edited or retracted. The troubling fact is that Noakes had been corrected multiple times. Vast amounts of scientific evidence and analysis have been published that opposes Noakes’ content; the vaccine myths have been debunked, however, the hesitant phrasing and “anti-vaccine” tactics continue even years later after the original 2014 tweet – which also has not been deleted. Online negligence, within the context of posting online as a health professional, might be a claim to consider due to the various factors at question: “the trustworthiness of sources”, “attempts to verify questionable statements or solicit opposing views”, and “whether the defendant followed other good journalistic practices.” These are all highlighted in the book Editing for the Digital Age.545 Also, in question is the harm that vaccine misinformation can cause, as demonstrated in the previous section. All such questions and inferences on what the act can be called and if such acts exist are currently just speculative, inconclusive and the official regulatory nature of these acts are unknown at this time.

Some of these claims can also be turned around and said of me, the one writing this paper; one such claim being defamation, hence why I have included and acknowledged some of these issues and their uncertainties and have tried making this as evidence-based and truthful as possible, all the while writing in a frame of mind that urges immediate public safety. (Of note, Sboros includes that a statement is “really only defamatory if the claim is untrue or malicious. That is, if there is a deliberate intention to denigrate and damage the doctor’s standing and reputation.”42 Evidence has been provided for the justification of truthfulness of the claim and the intention of non-maliciousness has been emphasized.) Furthermore, regarding the truthfulness of the claims and evidence in this paper: if you post something online, it is valid for somebody else to point out that you posted something online. If it is, by definition, unprofessional to post or share such a thing, it is true and valid to point out that it is unprofessional.

When discussing defamation and freedom of speech, the HPCSA still states that “The freedom that individuals have to voice their opinions on forums and blogs, however, is not absolute and can be restricted by the need to prevent harm to the rights and reputations of others.”546 While preventing this report from being published might be justified by preventing harm to the reputation of Tim Noakes, this might come into conflict with the prevention of harm to those who might be exposed or influenced by the anti-vaccine misinformation shared. The public health threat of anti-vaccine misinformation, the possibility of unnecessarily putting others at risk, and the right to have access to an intervention that can prevent disease, may restrict the freedom to spread anti-vaccine information online. This is like other points made in this report.

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Under the section, “Advertising and Canvassing or Touting”, in HPCSA’s Booklet 2, they define “canvassing” as: •

And “touting” as: •

Both might include the various anti-vaccine advocates and voices that Noakes has echoed, however, that is not the original context of the document. Most importantly, it states that one can advertise their services “Provided that the advertisement is not unprofessional, untruthful, deceptive or misleading or causes consumers unwarranted anxiety that they may be suffering from any health condition.” A vital question is whether this applies to the health professional’s canvassing and touting of other people who’s claims are “unprofessional, untruthful, deceptive or misleading or causes consumers unwarranted anxiety that they may be suffering from any health condition.” An example of this would be how both the HPCSA guidelines525 and Noakes2 acknowledge that a professional cannot know everything, especially if the topic is outside of their expertise. Thus, as Noakes states, they should “immediately acknowledge [the other professionals] superior knowledge and refer people to them.” The problem with this is that, as the evidence has shown, Noakes has referred people to RFK, Jr. and other sources of misinformation. Furthermore, spreading vaccine misinformation, omitting credible and available scientific evidence, and casting doubt which may lead to the unvaccination of children is a public health risk and ultimately harms the reputation of regulatory bodies, which in this case, is the HPCSA. In their new Social Media Guidelines, the HPCSA specifically says that “doctors and medical students should consider whether the content they upload onto the internet could compromise public confidence in the medical profession.”547 This point cannot be emphasized more. If a professional was registered and the council went through with the decision, professional suspension may or may not be taken into consideration as stated in the “Regulations Relating To The Suspension Of Practitioners”548 in the Health Professions Act 56 Of 1974: •

•

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Claims made about vaccines and the misinformation that’s shared can get serious, if the regulatory bodies take action that is. As an example, former Halifax-based chiropractor, Dena Churchill, recently “has been ordered to pay her regulator $100,000 as part of a settlement agreement on charges of professional misconduct related to her sharing anti-vaccination views online.”549 Similar actions exist for Prof. Yehuda Shoenfeld, with Israel’s Association of Public Health Physicians calling for an investigation and for him to resign due to his support of the anti- vaccination movement.102,550 UK’s Society of Homeopaths also face serious regulatory action about their anti-vaccine stance and fake autism “cures”.551 To restate some of these important guidelines and responsibilities to follow when using social media as a health professional, the Association for Dietetics in South Africa also has several points552:

• Online credibility is essential for maintaining a professional perception of the healthcare professional. • Restrict yourself to your level of expertise or subject of interest. Ensure that all the scientifically correct facts are at hand before posting any information. • Take responsibility for the information posted. If an error was made, be the first to respond to the mistake. Acknowledge the error and correct it as soon as possible. • Do not engage in any behaviors that may harm the reputation of your colleagues or the profession … think before you post! • Avoid remarks that are negative, offensive, untruthful, threatening, discriminatory or demeaning. • The healthcare professional has a life-long responsibility to continue acquiring knowledge and skills consistent with professional standards. This means being up to date about the latest information about a subject area… • The user must, however, understand that the published information has meaning and consequence, despite the way in which it is expressed. Therefore, in essence, THINK BEFORE YOU POST, TEXT OR SPEAK! The relevance and importance of these points cannot be emphasized more.

When Marika Sboros was defending a tweet from Noakes about nutrition, she said, “The HPCSA has also not proven any harm or even the potential for harm to anyone from his tweet.”553 This may be true since this was a separate situation about food, however, the case could be made that harm or potential for harm to the public may come from Noakes’ untruthful 2014 “CDC Whistleblower” tweet, or the multiple tweets and claims thereafter. If Noakes claims that the HPCSA failed him by not providing guidelines on how to use social media as a health professional, as he did in his 2016 nutrition deposition526, then it would seem reasonable to argue that there are many resources available to him on the topic of medical and scientific professionalism on social media.547,554–557 Even before the HPCSA Social Media Guidelines came out in October of 2019, the topic of social media use among South African health professionals was still discussed. Back in 2017, it was concluded that “Professionals ought to ask themselves before posting on social media whether sharing certain information is legally and morally defensible, whether it reflects the professional conduct expected of them and whether it will benefit their patients, and importantly question their own intention for posting.”558 These points also cannot be emphasized more.

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If, emphasis on if, a legal or support team was created for Noakes for this possible case, the topic is not about nutrition and thus his previous expert witnesses may not be of help or credibility on the subject matter of vaccines. The question I am leaving open is: If the evidence is stacked against the doubtful, hesitant expressions about vaccines made by Noakes, who will he get to defend this flawed school of thought? Concluding this section on rules and regulations, which is partially hypothetical as this report awaits expert review, I’ll end with two quotes from the published literature about HPCSA health professionals and health misinformation, respectively.

559

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Discussion Across the scientific space, various levels of advocacy have created reductionism and false dichotomies, which has also led to intentionally degrading the public’s trust in science. As Nicola Guess, Ph.D. and Ethan J. Weiss, M.D. have written561, there is a certain tribalism when favoring a particular stance. Whether it be a medical intervention or a favorite diet, it is crucial that we “disentangle science from advocacy” and constructively criticize those who are avid cheerleaders for one narrative. Guess and Weiss both “believe that scientists, health care professionals, and journalists must avoid intentionally confusing or alarming the public in an attempt to discredit legitimate science, ultimately in the name of advocating for an agenda.” This advocacy can certainly be harmful to scientific and medical establishments and dangerous for public health, as we have seen with cancer misinformation and vaccine myths. The well-meaning but potentially useless alternative therapies that target vulnerable cancer patients are of increasing concern to doctors, and this, like the anti-vaccination movement, is a result of social media.562 Cancer researcher, physicist and science writer, David Robert Grimes, Ph.D., has also written extensively about how “both radiotherapy and chemotherapy are frequently dismissed as ‘poisons’, imperiling lives.”563 The fact that Marika Sboros echo’s this narrative about chemotherapy is disappointing. It is no wonder we see a crossover between topics of misinformation since these dichotomous “100% safety” and ”100% efficacy” narratives are almost identical between cancer and vaccine “quackery”.90 Perhaps Sboros hasn’t explicitly advised patients to consider delaying chemo or radiation in favor of a ketogenic diet, however, she also has not retracted misleading statements that may influence people to do so. Noakes implies that people will not get cancer or other diseases if they simply avoid sugar and processed food. If we embrace cancer’s vast complexity, this claim is wildly misleading. Grimes continues, “Whether born out of a desire to help, or naked charlatanism, the net impact of such misinformation is overwhelmingly negative. Patients engaged with unproven treatments for cancer are more likely to reject conventional treatment, or delay life-saving interventions.” … “Unscientific interventions can nevertheless come with substantial price tags.” … “The rise in cancer misinformation is part of a wider problem with online falsehoods. Like the equally dangerous explosion in anti-vaccine myths, cancer untruths have an impact on both our physical wellbeing and on the public understanding of science and medicine.”563 In order to systematically evaluate whether a person claims, re-publications, language and behaviors are considered “anti-vaccine”, we can look at research that has defined and quantified such tactics. We can also look at those who follow them on social media and whether there is any relationship to the anti-vaccine movement. This is possible since social media fosters “anti- vaccination connections and organization by facilitating the diffusion of centuries-old arguments and techniques. Arguments against vaccination are diverse but remain consistent within subgroups of individuals.”564 Moreover, those who deny or question the well established “pro- vaccination” science “use the same rhetoric across domains, [and it is suggested that] uncovering their rhetorical techniques is an effective and economic addition to the advocates’ toolbox.”565

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As reviewed by Hussain A et al., “online anti-vaccination authors use numerous tactics to further their agendas. These tactics include, but are not limited to, skewing science, shifting hypotheses, censoring opposition, attacking critics, claiming to be ‘pro-safe vaccines’, and not ‘anti-vaccine’, claiming that vaccines are toxic or unnatural, and more. Not only are these tactics deceitful and dishonest, but they are also effective on many parents.”464 Arthur Caplan, a professor of bioethics at New York University, also highlights just some of the many arguments brought forward by anti-vaxxers566:

- “Vaccines are not safe (such as concerns they are linked to autism, which study after study has debunked).”

- “It's a plot by big pharma (people are concerned pharmaceutical companies make big money off vaccines, but Caplan says companies don't make much profit off immunizations).”

- “It's about parental rights (parents don't feel people should be able to tell them what to do with their own children, but experts say this ignores community responsibility and other existing laws around child safety).”

- “Natural is good (the idea that vaccines are "toxic”, and it would be better to contract the disease and/or build resistance naturally, but Caplan says science does not support this).”

The World Health Organization also details these techniques of vaccine and science denialism567:

Various skeptical websites, such as the ones that Noakes and Sboros spread, use these techniques to their advantage. They focus less on “accurate transmission of evidence-based scientific research about vaccines and government-endorsed vaccination-related practices” and more on “creating communities of people affected by vaccines and vaccine-related practices.”568 But it is not just these websites, Noakes and Sboros themselves have used these tactics that are right out of the anti-vaccine handbook. One could only wish these instances were by accident or coincidence, perhaps a one-time thing, however, as the evidence and history have shown us, the spread of harmful, untruthful misinformation has persisted for many years. One such example is the notion of “vaccine injury/damage” and proof from compensation. In a recent New York Times

92 article, it is revealed that “vaccine skeptics and opponents sometimes claim that the existence of the [National Vaccine Injury Compensation Program] suggests that vaccines are more dangerous than medical evidence indicates. The likelihood of serious harm if a person contracts measles is much greater than the chance of being injured from the measles vaccine. The program can also settle cases without determining a vaccine caused the injury ... One condition that is not on the list of potential vaccine-related effects is autism.”451 Autism. A concern insinuated by Noakes and Sboros on multiple occasions. Whether it be Thimerosal, aluminum, a false “CDC Coverup”, or the dosing or “overuse” of vaccines, there is no link. Perhaps they are unaware of the large body of evidence on the topic, which calls into question why they are then providing information in the first place. “Eighteen studies done in seven different countries in three different continents involving millions have answered the question,” says Paul Offit, a pediatrician at Children’s Hospital of Philadelphia who specializes in infectious diseases and vaccines.569 “There’s no debate”, concludes Peter J. Hotez M.D., Ph.D. in another article. “Vaccines cannot and do not cause autism.”570 This out of date, debunked, support of Wakefield is flawed and also not consistent with the current neurobiology of ASD, which is that such genetic alternations occur during pregnancy, well before vaccination.571–573 In fact, the environment may play just a small role compared to genetics, with genetics contributing about 70 – 80%.574 Concluded in the largest study to date, “ASD occurrence is mostly owing to inherited genetic influences”, not vaccines.575,576 Another common tactic said by anti-vax activists, as well as Noakes and Sboros, is that they are for “safe vaccines” or “informed decisions.” Even claiming that they are skeptical about vaccines and their safety, unfortunately, supports “the false belief that such questions are still unresolved.”569 This focus on “safe vaccines” is now littered among the anti-vaccine movement, including the annual AutismOne conference. Those who attend will deny any claim that the conference is anti-vaccine, but at the same time, they state that “there’s no such thing as a safe vaccine” – and this so happens to be one of the most common anti-vaccine talking points. Anyone who questions it will be thrown out.577 This conference is relevant to this paper since Robert F. Kennedy Jr. was this year’s keynote speaker, among Andrew Wakefield and several others. “Robert F. Kennedy Jr., one of the leading lights of the anti-vaccine movement, recently published a lengthy article intent on scaring parents and teens away from the HPV vaccine”302 – which is similar to the content Marika Sboros has written in defense of Noakes. The HPV vaccine has now become the next target of the anti-vaccine community. Many health professionals have been concerned with RFK Jr’s misinformation including his own family, who “recently publicly called out his dangerous advocacy, which has included comparing vaccines to the Holocaust.”578 Exactly like Noakes and Sboros, he has also claimed that he is not anti- vaccine. The central problem with this is that saying “‘I’m not anti-vaccine’ is the fallback claim of every anti-vaccine activist.”578 This is where an analysis of language, social engagements, retweets, behaviors, etc. come into play – hence the need for this lengthy and in-depth paper. Perhaps Noakes and Sboros are not called “activists”, but as Tara C. Smith, professor of epidemiology at Kent State University has written about, there are still “hundreds of ordinary individuals and groups who similarly try to spin their anti-vaccine rhetoric into something more palatable for the general public. This means instead of anti-vaccine, they use such phrases as

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‘pro-medical freedom,’ ‘pro-vaccine choice,’ ‘pro-informed consent,’ ‘pro-vaccine safety,’ or characterize themselves as ‘anti-forced vaccination,’ ‘anti-vaccine mandate’ and ‘vaccine risk- aware.’”578 Smith suggests that the claim that somebody is “not anti-vaccine” just becomes a smokescreen. Overall, sharing Robert F. Kennedy Jr’s content and thus legitimizing the misinformation while increasing the man’s credibility is a concern that could be deemed as highly irresponsible. Expressing many of the same anti-vaccine talking points is also concerning.

Social Endorsement Any journalist or health professional online should “weigh the context of information shared against [their] public role as trusted, impartial sources of news and information”579, explains Brent Jones, the standards and ethics editor at USA Today. “It's an instinctive part of [their] job”. Sree Sreenivasan, former Chief Digital Officer and professor at Columbia University’s School of Journalism, echo’s the idea that a shared post or retweet is a form of agreement: “No one sees something controversial you've [retweeted] and says, ‘Gee, I wonder if this person agrees with that’…”579 In fact, a 2017 meta-analysis by Panagiotis Metaxas and the TwitterTrails Research Team concluded that “retweeting does indicate a level of endorsement of the message and/or the originator.”580 Some have argued that we shouldn’t assume an online user always believes in what they share and that this has more to do with social media’s poor effects on analyzing content accuracy and truthfulness.95 This nuance is indeed echoed by Metaxas. Both studies exclude modified/edited retweets because they want to take into consideration the context in which the original message was altered (i.e. constructive comments, debunking, critiquing, etc.). However, in this case, we are dealing with the amplification of the original message (i.e. direct quotes, praise given to the originator, etc.). It is particularly concerning with misinformation since “retweets … [allow] individuals to rebroadcast content generated by other users, thus raising the contents visibility.”580 In this context, it is not surprising that raising the visibility of untruthful vaccine misinformation is suspect and unsettling. Retweeting “empowers users to spread information of their choice beyond the reach of the original tweets followers … [and is] a way to incorporate information into your own existing belief system.”580 As we have seen, the impact of belief systems on social media and what is viewed online play a critical role in the anti-vaccine movement. Given the amount of evidence and the fact that retweeting has shown to be “a form of expression of agreement with the message, and endorsement – or even trust – of the message originator”, it is not unreasonable to conclude that Tim Noakes agrees with the anti-vaccine misinformation he has retweeted.

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False Balance David Robert Grimes, Ph.D., has written about important key principles that the media, journalists, scientists and health professionals should follow when forming a narrative. “When one tries to treat two opposing positions as equally valid when they are simply not”, this can create false balance.581

This is highly relevant to the spread of anti-vaccine misinformation.

In fact, false balance or “manufactur[ing] false debate and insist[ing] on balance” is something Sboros writes about and specifically discourages.582 But unfortunately when it comes to vaccines, using Sboros’ own article, both her and Noakes have indeed “create[d] the impression of a controversy” and have “maintain[ed] the controversy [to] keep the debate alive.” More of these hypocrisies are detailed in the pages to come. To completely contradict this discouragement of false balance, Noakes believes that “Science is about evaluating all sides of the argument. It's not about suppressing opinions that might be wrong. It should be about proving that those opinions are incorrect.”583 As far as vaccines go, it seems as though science has indeed teased out and disproven (based on the overwhelming amount of evidence) the side that continues to spread anti-vaccine misinformation. As we have covered, opinions may be suppressed if they have already been proven to be incorrect multiple times and continue to be a threat to public health. Continuing to share both sides creates false balance. Noakes agrees with this when the topic is nutrition.584 He explicitly agrees that if the opinion has been proven wrong multiple times then those holding the opinion should change their minds. Noakes thinks that the spread of that incorrect opinion will continue to misinform the public. The incredibility troubling fact is that Noakes expresses the complete opposite position regarding vaccines. If science is about “proving that those opinions are incorrect”, as Noakes suggests, then it’s a mystery as to why he values science but does not post and share the large amount of scientific evidence showing efficacy and safety of vaccines.

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To quote an article about broadcasting information to the public – that Noakes himself retweeted: “While the public is fed with questionable science on weak or null effects and questionable evidence is exponentially propagated, industries with calculated financial motives and non– science-based groups with harmful agendas deliberately communicate their messages in these same venues. While major disagreements about nutrition are expressed among public health experts for marginal issues that might be intrinsically impossible to settle with any certainty, social media spread misinformation from deniers of vaccination or . False news reports are more easily propagated than true reports.”585 “Once a fake story has spread, it becomes increasingly difficult to refute it. This principle is generally known as Brandolini's law, or the ‘Bullshit Asymmetry Principle': the amount of energy needed to refute bullshit is an order of magnitude bigger than that needed to produce it.”586 Wakefield’s fraudulent vaccine campaign is just one example. These journalistic problems are not new ones though. “As the World Health Organisation wearily notes, ‘How one addresses the anti‐vaccine movement has been a problem since the time of Jenner. The best way in the long term is to refute wrong allegations at the earliest opportunity by providing scientifically valid data.’”581 Hence this paper. “This is easier said than done because the adversary in this game plays according to rules that are not generally those of science”581, says Grimes. “There is ample evidence that anti‐vaccine campaigners are especially adept at spreading misinformation online, entirely unconcerned with the veracity of what they propagate.” With this “false balance” principle in mind, we can start to conclude that Noakes’, as well as Sboros’, narratives and reporting’s are largely problematic as they sacrifice accuracy for balance. Grimes quotes Boyce Rensberger and so will I: “Balanced coverage of science does not mean giving equal weight to both sides of an argument. It means apportioning weight according to the balance of evidence.”

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Questioning Authority Multiple times it is included that Noakes is a scientist, a “world-renowned” A1 rated medical scientist. While these prestigious credentials may be true, this appeal to authority is sprinkled throughout Sboros’ defenses, including posts regarding vaccines.

Since I, the author, am a student, and Noakes loves to point this out, an important point is this:

“Science, of course, is not an argument from authority; the hypotheses of even Nobel laureates can be utterly debunked by the experiments of the humblest student. Nor is it a popularity contest; scientific consensus is derived based on the strength of evidence for a given position. Scientists, when they are practicing science, only speak with any authority when they are reflecting best evidence. If they instead advocate a position unsupported by the evidence, their qualifications are utterly irrelevant.”581

A very important point within all of this is that since the 2014-2017 Nutrition Trial, Noakes has deregistered as a medical practitioner and thus the regulatory nature of this report may be weaker compared to a professional that is still registered.

What is concerning is that he apparently deregistered to “get back [his] freedom of academic expression”. This is fine. However, in the context of vaccines, this is concerning because it calls into question whether only registered medical practitioners should follow the rules and guidelines of the HPCSA and if being deregistered grants him permission to spread misinformation about vaccines. All things regulatory aside, these events still need to be brought to attention and called out.

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With regards to the role of being a prestigious scientist, a health professional, an Emeritus Professor, and a vocal, influential leader on social media, it would be of utmost importance to have accurate, robust and up to date facts and information. This is especially true when such information is being shared with the public and this is a responsibility that is talked about constantly with vaccines and vaccine misinformation. Noakes highlights that it’s important to express his scientific opinion2; however, this starts to become less valid if such opinions are based around untruthful, unscientific and potentially harmful information. “You can certainly opine or, you know, voice your opinion — that's freedom of expression,” said Fuyuki Kurasawa, director of the global digital citizenship lab at York University in Toronto, but “the fabrication of evidence and claiming that it is accurate — then that's when there's a problem.”587 Moreover, it seems like claiming that it is “informed choice” or “freedom of speech” is no longer a valid excuse when the totality of the person’s behavior is unacceptable. “Freedom of speech simply means you can't be arrested for your ideas. It's not freedom from consequence of speech.”588 “Everyone has a right to their own views…the crucial caveat is that this right does not shield one from being judged on content of those views”589, David Grimes writes in the Irish Times. “The laudable aim of free speech is predicated on an implication of good faith and honest engagement. Once this assumption is violated, it becomes a Trojan horse for the most terrible falsehoods”. Multiple anti-vaccine sources of information and websites “ostensibly aim to give parents ‘informed choice’ and ‘transparency’, in reality [they] merely provide unsubstantiated information which cannot lead” to informed choice.280 “Disagreement with proven facts is a choice that anyone can choose to make. Disseminating falsehoods, misinformation, and distortions of the facts about vaccines is not a choice that ought to go unremarked and unchallenged.” We can continue to base our conclusion about the notion of vaccines and freedom by learning from Germany’s recent national mandate and law for measles vaccination. Germany’s health minister, Jens Spahn, has “rejected criticism that the measure infringed on individual rights.”590 He says: “My understanding of freedom does not stop at my level as an individual. It is also a question of whether I am unnecessarily putting others at risk. Freedom also means that I will not be unnecessarily put at risk and that is precisely why, from the point of view of preserving freedom, this law is a good law, because it protects freedom and health.” Furthermore, regarding Noakes’ role as a health authority, it also can be seen as unprofessional and irresponsible to go against the international “Salzburg Statement on Vaccination Acceptance”.591 It is indeed true that “the risks to public health created by misinformation outweigh the right to free speech.”521 We should be asking ourselves, professionals and regulators: “Where is the line between free speech and protecting the public?”521

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Defining the Belief Over the years, much work has gone into defining the term “Vaccine Hesitant” as well as how vaccine experts and front-line vaccine providers perceive the term.592 Highlighted by the World Health Organization’s guiding principles and best practices for evaluating and confronting those who deny vaccines567, it is reasonable to suggest that Tim Noakes is not a “Vaccine Refuser”, as he does not refuse all vaccines. “However, this convinced refusal still permits the refuser to consider other opinions or arguments”, so this term may or may not still be valid. Tim Noakes, by definition, wouldn’t be considered a “Vaccine Skeptic” since it is clear he is not “willing to follow the facts wherever they lead”, as this would lead him to the overall body of evidence and consensus that contradicts what he has shared and posted about for many years. While the term “Vaccine Denier” refers to someone who is “not open to a change of mind no matter what the scientific evidence says”, it is reasonable to suggest and suspect that since Noakes has displayed the same narrative over approximately 5 years now, despite the contradicting scientific evidence and further analysis/debunking made by others, and has not changed his mind, this term may be best suited. A denier employs “rhetorical arguments to give the false appearance of legitimate debate”567 and also “criticizes the scientific approach as a whole” which has been a common theme throughout Noakes’ narrative. No matter how minuscule the controversy is, deniers continually point out areas of uncertainty while acting as if contradictory research doesn’t exist and “categorize the overall scientific status … as uncertain and controversial”.593 If anything, Noakes has supported the message spread by “Vaccine Deniers”, e.g. RFK Jr., and those who have “characteristics that are similar to religious and political fanatics, in that he or she adheres to a belief that is impossible to challenge”.567 The definitions given here are based on the evidence but are still speculative and a solid conclusion is unknown. All things considered, perhaps it’s best not to put a label on these actions just yet since the appropriate characterizations will ultimately be determined by the public and perhaps through expert review.

The Way Forward Given that cases of measles have tripled compared to last year in the USA, now at 1,276 cases (as of December 5th)594 compared to just 375 last year, with even more cases have been confirmed in other areas, it is obviously an increasing concern in North America. While writing this, the USA is at risk of losing it’s measles free status.595 Though the disease has hit harder in places like Africa, Ukraine and now Samoa. “Health workers in the Democratic Republic of the Congo have launched an urgent measles vaccination campaign in Ebola-hit regions, after [~5,700] deaths from the preventable disease”, 73% of deaths are in children under the age of five. Nearly [280,000] cases of suspected measles have been reported [as of December 23rd]. This well surpasses the deaths and cases of Ebola in the region. “The ‘unprecedented’ humanitarian crisis is putting the health system under strain, UN staff said.”596–598 Since 2017, Ukraine has also been devastated with over 100,000 cases.599 So far this year, there have been

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2172 cases in New Zealand.600 Albania, Greece, the Czech Republic, and the United Kingdom have lost their measles free status. As of December 24th, Samoa has reached 5,603 measles cases with 80 deaths and the WHO has said that anti-vaccine messages and fears are one of the main causes.601 The world “is facing an alarming upsurge in measles cases in all regions”, the WHO’s department director, Kate O’Brien, stated at a Strategic Advisory Group of Experts (SAGE) meeting on Immunization.602 Along with addressing gaps in vaccination coverage, the best way forward is to launch a “robust response to the anti-vaccine empire,” explained Dr. Peter Hotez.603 “We need to take aggressive steps to restore vaccine confidence and vaccine acceptance.” “From measles outbreaks in America and Europe to the spread of Ebola in central Africa, skepticism about vaccines has had a devastating impact. The anti-vax movement has exploited such skepticism to foster wild fears about vaccination. Trust, or, rather, the lack of it, clearly shapes much of our political landscape. But it can also have a direct impact on physical wellbeing. From America to the Congo, distrust without reason can be matter of life and death.”604 It is time we separate vaccine myths from reality, provide patients with truthful information and uncover those who influence the anti-vax narrative.605 How individuals, professionals, and organizations can combat and address vaccine misinformation is an ever-increasing area of research.560,606,607 There is some doubt, however, that the partial format and strategy of this report, i.e. “myths vs facts”, will be effective to counter vaccine misinformation since evidence suggests a backfire effect when repeating these myths.608 People do not process negatives well (e.g. “not”)468, and thus it is possible that not all individuals will resonate with the message that vaccines are not associated with specific risks. Frustratingly, “combating antivaccination arguments with more facts proving the safety and efficacy of vaccines will fail to persuade many since those very arguments are viewed, a priori, by vaccine skeptics as built on misinformation.”38 When countering misinformation, one should not “expect to counter the firehose of falsehood with the squirt gun of truth.”469 Nonetheless, anti-vaccine beliefs exist on a spectrum, from hesitant to complete anti-vaxxer. “It's incredibly unlikely that any strategy will change the mind of someone [deeply zealous in misinformation], but it is quite possible that one [strategy] or a combination of strategies could be potentially effective in persuading parents with much lower levels of fear and loathing of vaccines.”609 However, this mental conflict doesn’t just apply to parents – academics, scientists and doctors may also have a difficult time adjusting their beliefs. The “cognitive and behavioral science literature suggests that those who are highly educated, intelligent or rhetorically skilled tend to be significantly less likely than most to revise their beliefs or adjust their positions when confronted with evidence or arguments that contradict their priors. This is because, in virtue of knowing more about the world, or being better at arguing, they are better equipped to punch holes in data or arguments that contradict their prior views or to otherwise make excuses for ‘sticking to their guns’ regardless. And so, they do.”610 This seems quite relevant to the topic of vaccines. It has also been suggested that when “refuting antivaccination arguments on the basis of fact alone is insufficient, it may be possible to use similarly emotive tactics to promote immunization.”489 Unfortunately, allowing misinformation to spread via social media or trying to report “both sides”, for whatever reason, continues to be an issue since “research has shown that even parents favorable to vaccination can be confused by the ongoing debate, leading them to

100 question their choices.”464 Perhaps it is time for regulatory boards to come together internationally to remind health professionals – just as The Australian Health Practitioner Regulation Authority has done in a statement along with 16 other national boards611 – that they have a responsibility to promote evidence-based, truthful information that vaccines are safe and effective and to not spread anti-vaccination views that will contradict public health campaigns. “These outbreaks [as a result of public misinformation and unvaccination] not only put a strain on national healthcare systems but also cause fatal casualties. Therefore, it is of the utmost importance that all stakeholders in the medical world - physicians, researchers, educators, and governments - unite to curb the influence of the anti-vaccination movement targeting parents.”464 Verbal or online language, social engagements, shared information, retweets, likes, and behaviors from scientists and health professionals that go against that international mandate is of high concern, can be considered irresponsible, and a potential threat to public health.

Hypocrisies, ironies, and contradictions Noakes has pointed out many ironies and hypocrisies regarding nutrition and within the 2014 - 2017 nutrition trial.2 Despite this, there happens to be a large amount of irony when Noakes talks about the topic of science in general. With regards to the overall body of evidence on vaccines and the consensus among health professionals, there is an agreement, however, the content Noakes supports seems to refute this acceptance of vaccines. Thus, the South African term he tweeted, “The Bittereinders”, might be used in this context since it has become clear that he refuses to accept that the common vaccine safety concerns are not supported by the biological and epidemiological evidence.612

The anti-vaccination content he has supported contradicts his own words when he says his “tone on Twitter is … scientifically-based and credible.”2 He says he “want[s] to share evidence to convert the world, to make them realize that we have a real problem that needs to be changed.” The original context of the quote was about nutrition but applies to this report as well; we need to make people realize that we have a real problem that needs to be changed – that problem is vaccine misinformation. The very misinformation that Noakes has shared.

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As stated previously, health professionals and scientists should not carefully select sources that feed their bias, especially if the balance of credible evidence in the literature suggests the exact opposite of what is claimed and shared. As new evidence is published, which builds upon past research, it starts to form an accepted and robust consensus. The best thing to do is change your mind if this evidence and consensus contradict your view. Noakes agrees with this, as he writes in his and Sboros’ book Lore of Nutrition613 (now updated, revised and renamed to Real Food on Trial):

The irony, as well as hypocrisy, is that it appears that Noakes fails to do this when the topic is vaccines. He has indeed shared sources of misinformation and continues to do so despite overwhelming amounts of opposing scientific evidence and analysis, so it seems as though his own words contradict his actions. This may be because once false information has gained acceptance, false beliefs are also created and adopted by an individual and these beliefs, as well as the individual, can be highly resistant to correction.382 “Reflexive open-mindedness”, which is to be overly accepting of claims, weak claims in particular, is also another possible reason someone might fall for misinformation and fake news.614 A failure to think critically or “lazy thinking” might be another reason.615 A recent finding from Effron and Raj that cannot be emphasized more intensely, as it can also be applied to several points within this report, is that “repeatedly encountering misinformation makes it seem less unethical to spread-regardless of whether one believes it.”616 This finding, along with several other possibilities, might explain why Noakes claims to be grounded in honesty and ethical science, all the while continually spreading untruthful, unscientific, anti-vaccine misinformation. Both the sensitization through repeated exposure and resistance to correction, criticism and opposing evidence might be a perfect explanation of why Noakes’ words and actions contradict one another.

It is ironic that Noakes thinks that it might be “impossible for most professional people to change their minds on topics in which they've invested time, ego [and] professional credibility…”.

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He says that he’s learned this lesson over the last 5 years, however, over the last 5 years he has not changed his mind, as evident from his social media, about certain misinformed aspects with vaccines. Ironically though, this theme of changing your mind is focused in their book:

They also seem to contradict the idea of telling “both sides” of the story:

Along with contradicting her own words regarding false balance and telling “both sides”, Marika Sboros also republishes an article about tactics that are commonly used within industries to form a false narrative582:

• “Accuse science of deception, calling it ‘junk science’ or ‘bad science,’ claiming science is manipulated to fulfill a political agenda” • “Insist that the science is uncertain…” • “Using information in a misleading way” • “Exaggerate the uncertainty inherent in any scientific endeavor to undermine the status of established scientific knowledge” • “Make accusations using the rhetoric of political suppression” • “Constantly repeat the doubt” • “Use pejorative terms repeatedly such as ‘excessive’ regulation, ‘over’ regulation, ‘unnecessary’ regulation” • “Insist on personal or parental responsibility and insist that government should have no role in influencing individual health behavior” • “Admit that it is a serious problem, but not a life-threatening one” • “Admit that there may be a problem, but it is less severe than everyone says” All of which are highly relevant and identical to anti-vaccine tactics – both Noakes and Sboros have directly used these tactics and or indirectly promoted them. This expression of vaccine misinformation is contradictory to Sboros’ writing and is of concern.

These instances don’t stop there. In the book Tim Noakes: The Quiet Maverick, the author, Daryl Ilbury, has a short section on vaccines which details the whole destructive chain of events with Andrew Wakefield and the MMR vaccine. Ilbury gives this as an example of a “bad maverick”. He explains that Wakefield is a fraudulent scientist and someone who has been “burnt into the scientific consciousness for the damage [he] has done.” The fact that this book has been written positively about Tim Noakes, that it negatively characterizes Wakefield and the mistrust in the MMR vaccine etc., and that Tim Noakes himself has shared the content and behaviors of

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Wakefield and others who are hesitant of vaccines such as MMR may leave one perplexed by this irony. Noakes and Sboros have also retweeted a link to a video from the experimental psychologist, Steven Pinker, about academic freedom and freedom of speech.617 While some of Pinker’s claims, views and assertions have been criticized618, we can use his knowledge and his video to our advantage within the context of vaccines. He says when people “believe something that is not true and if people are punished for pointing out that it's not true”, a vicious circle of delusion can form. This also has to do with the idea of tribalism. If somebody continues to post harmful misinformation that is wrong, even if our intention is not to be a bully, we might feel morally obligated to point out that it is wrong even if it will be painful for the other person to hear: “It's annoying and upsetting, sometimes hurtful to hear ideas that you disagree with, that your tribe disagrees with. It might call into question your own credibility, your own competence but it ought to be aired for all that because if your feelings are hurt sometimes that's just too bad. You might be wrong no matter how painful it is for that fact to become known.”617

The contradiction of one’s actions is also evident when Sboros writes about the “perils of single tweets” and how we should not look at a single tweet in isolation, such as the original one in 2014 about the “CDC cover-up” conspiracy. However, Noakes continually refers his followers back to his one single tweet in 2017 about how he thinks “vaccination is one of the true successes of modern medicine.” When people ask questions online about his views or ask if he is “anti-vax”, he simply refers to the single 2017 tweet. But there is strong evidence to believe that we need to look deeper than just this single statement since a professional can deny being opposed to vaccination while at the same time support the anti-vaccine movement.

This concern has been intensified given the recent advancements in the case against Prof. Yehuda Shoenfeld102 and the nearly identical language used by him and Noakes.

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Sboros has also referenced the single 2017 tweet in her writing. In fact, Sboros repeats these various hypocrisies either by sharing an article on “why facts don't change minds”619 or quoting Richard Feynman, saying that good scientists don’t hold onto a hypothesis once it’s been proven wrong.620 Or by writing about Noakes in their book613:

Perhaps Noakes does value vaccination since he restates this on September 23rd.621 But again he says to “check [his] tweets”, which will result in somebody reading the vaccine misinformation he has posted in the past as well as his one single 2017 tweet. But both Sboros and Noakes say not to look at single tweets, so we once again run into a conflict. He is repeatedly asked about his views on the topic, but he does not give a clear answer. One might suspect that if he did give an answer, it may not truthfully reflect his actions and what he has shared.

Adam Pike, Noakes’ lawyer during the 2014-2017 nutrition trial, spoke on the Diet & Health Today podcast in 2018 622. Adam emphasizes (time mark 24:40) that the events from the last trial rested on a single tweet about nutrition and that looking at single tweets online is “flipping pathetic.” (Side note: this kind of thinking was the exact inspiration for the “true impact of social media” section in this paper.) He makes the point that there “were no dead bodies”, that nobody was sick, and it wasn’t life-threatening. But in the case of vaccine misinformation, there are multiple points of evidence to show the impact that social media and single tweets can have on the public and that it can potentially lead to life-threatening situations, i.e., increases in unvaccination, outbreaks and sickness. Adam Pike has also previously retweeted one of Noakes’ posts of vaccine misinformation623, which was unexpected and quite disappointing. This would also raise an eyebrow as to whether Adam Pike would be an unbiased form of defense for Noakes when it comes to vaccines; we have also seen this in more detail with Marika Sboros. Pike disagrees with the use of the terms “Anti-” and “Pro-”, as used in this report. Noakes seems to share the same attitude.624 Although the literature on echo chambers does indeed justify the use of these terms498, Pike says they are “lazy smears” and it “absolves the critic from engaging the argument.”625 This is context-dependent. If somebody just called Noakes “anti-vaccine” and that was it, i.e. there was no evidence cited, no point by point breakdown and no analyses of social media, and the claim was devoid of all scientific and analytical reasoning, then Pike may have a point about it being “lazy”. However, given the length of this report, it’s analyses, and the scientific evidence and expert discussion cited, including these prefixes are justifiable.

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Noakes believes that “In the end all that matters are the facts.” This is true.

However, it is unfortunate that these words do not follow Noakes’ actions within the context of vaccine information. He suggests that calling somebody a “quack” is “ALWAYS an attempt to hide inadequate/inconvenient evidence.” This may be true if there was unsubstantial evidence for calling someone a “quack”. On the contrary, “Quackery” might be defined as: “When an untrue or misleading health claim is deliberately, fraudulently, or pretentiously made…”, “the promotion of a medical remedy that doesn't work or hasn't been proven to work” or “the promotion of unproven or disproved” treatments.171,626 Much of the misinformation about vaccines that Noakes has supported might follow under the term “quackery”. That said, the aim of this report is not to label Noakes as a quack, rather investigate why some people have called him one.

Something that cannot be emphasized more, is that ironically, Noakes said this to somebody:

Noakes should not be surprised by this type of report since he seems to have encouraged the task of writing a paper on how one might define and demonstrate the term “anti-vaxxer”.

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Misinformation & rhetoric continues in 2020, past the year this report was meant to focus on On December 30th, 2019, it continues. Noakes replied to one of the tweets from 2017 from the back and forth conversations about the Cliff interview. Noakes once again frames this as an attack and once again says that “in the end it's the facts that matter.”

He has not shared the facts. The facts he shares are not accurate, up to date or based on the scientific evidence. It is wrong of him to claim that what he has expressed and shared are “facts” since based on the evidence, they are fabrications of the facts or sometimes outright lies. A day later, Noakes also says that “Twitter is one of the few hopes that remains to have the truth more widely known.” He once again alludes to some enlightened “truth”.

On January 2nd, 2020, somebody asks about Noakes’ views on vaccinations. Noakes says he’s answered this on numerous occasions in his Twitter feed, he says to “Please go and check”627. However, this will lead people to see the very few posts he has which are truthful as well as the many posts that are misinformation and or imply a view that is anti-vaccine, as evidenced by the various anti-vaccine rhetoric and analysis of his language. He once again says that “Vaccination is one of the greatest achievements of modern medicine”, however, the single 2017 tweet is similar and the majority of what he expresses seems to go in the opposite direction when he talks about individual vaccines. Noakes retweeted somebody who claimed vaccines cause harm and cause side effects. It is unclear what side effects the person is talking about and if the claim is at all backed up by scientific evidence; the person does, however, bring up compensation cases of side effects and deaths, but this does not mean, whatsoever, that the vaccines caused the adverse events. Also, the cited document explicitly states: “Being awarded compensation for a petition does not necessarily mean that the vaccine caused the alleged injury.” This was the exact issue we ran into with Marika Sboros. This misleading claim and rhetoric have been covered already. The debate about Noakes’ misinformation and views continues in 2020.628

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Marika Sboros has said in the past, “If you go up against a distinguished scientist on the evidence, you won’t win without all your scientific ducks in a row.”629 This has been duly noted while writing this report. Recently she has said, “When ‘experts’ lack solid science with which to debate Prof Noakes, they resort to false claims that he is antivaxx or a climate change denialist, etc.”630 In 2020, Sboros continues to defend Noakes and called me, the author, a “troll” and an “industry-led attention-seeker not interested in genuine debate [who] can't /won't stick to the science and the evidence.”631 The belief that I am “industry-led” is quite untrue. These three statements about “sticking to the science and evidence” genuinely have been the inspiration of the length and rigor of this report. It cannot be emphasized more that Noakes’, and sometimes Sboros’, biggest defense and narrative when having these continued discussions online, is the “Science was wrong before” trope or perhaps the appeal to “another way of knowing”.414 This involves pointing out examples of when science was either wrong or the scientific establishment made errors, and this somehow justifies going against consensus and minimizing or dismissing the current scientific data we have at this time. The best example is how Noakes challenged the HPCSA about nutritional advice, but this example of challenging the conventional belief about nutrition, as much as Noakes wants it to, does not translate well to other areas of medical science, such as vaccines. The “So many people can’t all be wrong” trope is also relevant when looking at this situation. This “wrong science” trope is discussed in more detail by Kata, A.414

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Serious Social Media Analysis Considerations These anti-vaccine tropes from Noakes (above) were not included in the social media analyses, however, his post gained retweets (one of them is from Marika Sboros) and he retweeted a post, and thus this would increase the amount of anti-vaccine tropes (~8 Anti, 1 Pro) he has expressed and would increase the number of exposures (4 retweets + 1 from Noakes, ~155,242 exposures). Noakes continues to defend his misinformation in 2020. **See 2020 Update**

Noakes disagrees with spreading untruthful information and says it is fortunate that if somebody spreads untruths, they can ultimately come back and explode in the person’s face.632 There is irony in this tweet but there’s also a certain level of mental exhaustion since we have seen time after time, Noakes has spread untruths about vaccines, and thus this tweet and his actions contradict each other once again. It is puzzling as to why he does not see this hypocrisy. We can perhaps refer to Brashier and Marsh’s review, Judging Truth, published in the Annual Review of Psychology, to get a better idea of the cognitive struggles when posting information and assessing the quality and trustworthiness of sources.468 Other sources of research may also be useful.382,614,616 We can use Noakes’ tweet to conclude that spreading untruths about vaccines may indeed come back and explode in someone’s face.

Noakes says he tries “not to embrace any narrative that is not supported by definitive evidence.”

If this is truly the case, then the question is why Noakes fails to follow through with this when the topic is vaccines. This claim contradicts every piece of anti-vaccine misinformation he has shared and expressed. This level of contradiction continues to be incredibly frustrating and disappointing.

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In a provisional monthly report by WHO, as of August, the first 6 months of 2019 have had more reported measles cases than in any year since 2006.633 With the constant push of anti-vaccine myths and hesitancy, measles outbreaks continue to spread. Once again, “these outbreaks not only put a strain on national healthcare systems but also cause fatal casualties. Therefore, it is of the utmost importance that all stakeholders in the medical world - physicians, researchers, educators, and governments - unite to curb the influence of the anti-vaccination movement targeting parents.”464 The historical impact that measles and other vaccine-preventable diseases have had is one that should be frequently reminded, and not in the form of misinformation that keeps setting back medical and scientific success. “The reality is that those peddling antivaccine falsehoods ultimately put others at risk of illness or even death,”634 says Dr. Grimes. A position statement by the American Society for Transplantation and Cellular Therapy was written with “tremendous sadness that despite the innumerable lives saved by vaccines, [physicians, researchers and scientists] once again find [themselves] needing to develop strategies to protect the most vulnerable against a disease that is preventable.”635 “The world before vaccines is a world we can’t afford to forget.”100 “There is too much at stake right now not to speak out when people in positions of power and influence spread misinformation”528, concludes 2019 president of the American Academy of Pediatrics, Dr. Yasuda. “Thinking outside of the box is one thing, thinking outside of the facts is another.”

In closing, we will end with an ironic and very fitting quote from Tim Noakes and Marika Sboros’ book613:

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Conclusion

(It should be noted that this conclusion cannot replace what has been written in each section, detail has been sacrificed for summarization.)

In conclusion, Tim Noakes has shared controversial and misleading online posts in the past and this continues to be the case as of writing this. Of interest to the fate of public health is the topic of vaccines and vaccine misinformation. Noakes has indeed shared expressions, claims, retweets and re-publications about vaccines that are not based on truthful, accurate or up to date scientific information. The misinformation about vaccines that Noakes has expressed, shared and or spread can be deemed as irresponsible, unscientific and a potential public health threat. Such information spread online can have and has had a major impact on critical thinking, vaccine acceptance, parental decisions, and even disease outbreaks. Nonetheless, followers and supporters of Noakes still continue to defend his actions. Many of these supporters, some of which have written articles defending Noakes’ views about vaccines, have published an incredible amount of vaccine misinformation which amplifies vaccine doubt, and thus the credibility of the source of defense, and the written defense itself, are no longer valid. Noakes denies being an “anti-vaxxer” and denies sharing anti-vaccine opinions and information, however, almost all of what he posts and expresses points in that direction and aligns with the anti-vaccine movement. Noakes has also supported leaders within the anti-vaccine movement and has amplified their voices on multiple occasions. Upon analysis of Tim Noakes’ social media, there is a substantial amount of evidence for concern. From June to December 2019 there was a statistically significant increase in the number of followers Noakes gained that also aligned with anti-vaccine views. As for the content that Noakes himself has shared and expressed, 90% were Anti-Vaccine in nature, while only 10% were Pro-Vaccine. The potential maximum number of exposures to this anti-vaccine misinformation and rhetoric are in the millions, with approximately 3 million exposures in 2019 alone and 4 million in total from 2014 to 2019. The claim that Noakes “is not anti-vaccine” and has not shared anti-vaccine misinformation is terribly weak and not based on the evidence. A substantial amount of evidence exists which may give reason to believe that Noakes is going against medical and scientific guidelines, particularly the official guidelines enforced by the Health Professions Council of South Africa (HPCSA). What is written in terms of ethical medical science, best practice towards patients and the public, and professional conduct on social media all can be applied to the current situation within this report. There also happens to be an incredible amount of irony, hypocrisy, and contradiction with regards to Noakes’ focus on truthful credible science and his complete opposite pursuit into the world of vaccine misinformation. There may be several critical thinking and belief conflicts taking place which can explain this. In the end, Noakes’ vaccine misinformation has continued online for over 5 years and Noakes has not corrected or retracted these public beliefs and claims, despite the overwhelming amount of opposing scientific evidence that stands before him. Given his stance on honest science, it is a complete contradiction to support the claims, tactics and

111 tropes of the anti-vaccine movement. Despite much frustration, and perhaps at times outrange, from the public and professionals in the medical and science community, Noakes seems to think he has not done anything wrong, and thus the misinformation and untruthful claims persist. Noakes has spread, expressed and supported unscientific, disproven claims and the majority of what he has shared about vaccines is dangerous to public health and can cause harm to the reputation of those in his profession. Continuing to do so, as he has done, is a complete contradiction to what Noakes stands for, what others in his profession stand for, and what his own country’s regulatory body, as well as international organizations, stand for.

Acknowledgments: For all who have been cited, whether it be a research article, an analysis, a blog post or tweet, thank you for your work.

Conflicts of Interest: The author declares no financial or non-financial conflicts of interest whatsoever.

Project Duration: May 23rd, 2019 to February 17th, 2020.

Edited on: July 26th, 2020.

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94. Noakes T. Suggest you read my response. I am not now, nor ever have been, anti-vaxx. I am about transparency and honesty in interpreting and reporting scientific data. As I am sure are you. @ProfTimNoakes. Published April 15, 2019. Accessed December 8, 2019. https://twitter.com/ProfTimNoakes/status/1117851015737253890

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96. Sboros M. Eish! Feel sorry for patients of Trump-like doctors who waste employer’s time, money trying, failing to defame, discredit @ProfTimNoakes with fake news! Falsely claim he is “antivaxx”. @HPCSA_ too busy/corrupt trying, failing to silence him on evidence for #LCHF! @janvyjidak. @MarikaSboros. Published April 13, 2018. Accessed October 5, 2019. https://twitter.com/MarikaSboros/status/984798014995861504

97. Sboros M. Yeah. Almost feel sorry for this doctor. Is obsessed with @ProfTimNoakes, has no science on his side. Desperate times call for desperate measures, resorts to canard that Noakes is “#antivaxx”. Reminds me of #Goebbels: tell a lie big enough, long enough, people will believe it?https://twitter.com/janvyjidak/status/984813677017739264 …. @MarikaSboros. Published April 13, 2018. Accessed October 5, 2019. https://twitter.com/MarikaSboros/status/984815892885377025

98. Sboros M. You genuinely can’t see the point he is making here? It isn’t about anti-vaccination but suppression of dissent. It’s an absolute no-no to REAL scientists! Prof Noakes is NOT anti-vaxx! He has made that clear! @MarikaSboros. Published April 15, 2018. Accessed October 5, 2019. https://twitter.com/MarikaSboros/status/985389522723762177

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103. Noakes T. I’ve already tweeted 1 such study in relation to CDC malfeasance in not reporting neg data. Interest solely in how science becomes corrupted by financial interests. Nothing to do with whether patients should receive all possible vaccines. Am grateful for vaxes I received as childhttps://twitter.com/poppy3872/status/936305946204221447 …. @ProfTimNoakes. Published November 30, 2017. Accessed September 24, 2019. https://twitter.com/ProfTimNoakes/status/936309525497438208

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106. Chrest B. So which need to be left alone....? Please specify. @Chrest_brett. Published May 15, 2019. Accessed September 24, 2019. https://twitter.com/Chrest_brett/status/1128687089791332355

107. McAlpine A. Instead of the bluster, can Prof answer some easy questions: 1) Does he agree with Jenny McCarthy that vaxes cause autism? 2) Which vaccines does he think are overused and over-prescribed? And why? 3) Does he stand by the Mawson study he published in his letter? @AlastairMcA30. Published April 23, 2018. Accessed December 3, 2019. https://twitter.com/AlastairMcA30/status/988370100796448768

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617. Pinker S. Academic freedom prevents us from getting trapped in circles of delusion. Big Think. Published October 2, 2019. Accessed October 5, 2019. https://bigthink.com/Stand-Together/academic-freedom-from-delusion

618. Steven Pinker, Sam Harris and the epidemic of annoying white male intellectuals. Salon. Published October 20, 2019. Accessed October 25, 2019. https://www.salon.com/2019/10/20/steven-pinker-sam-harris-and-the-epidemic-of-annoying- white-male-intellectuals/

619. Sboros M. Why facts don’t change minds ... new discoveries about the limitations of reason in the human mind.https://twitter.com/NewYorker/status/1139387355503063041 …. @MarikaSboros. Published June 14, 2019. Accessed August 10, 2019. https://twitter.com/MarikaSboros/status/1139515772303237120

620. Sboros M. Thank you, Prof Richard Feynman @ProfFeynman: the KEY to #science! No matter how beautiful your hypothesis or how smart you (think) you are, if it’s null, it’s null! Get over it and move on. That’s what good science does and good scientists do. Finish and klaar, as we say in SA.https://twitter.com/ProfFeynman/status/1186312751326433282 …. @MarikaSboros. Published October 21, 2019. Accessed October 22, 2019. https://twitter.com/MarikaSboros/status/1186490181932802048

621. Noakes T. Neither. Check my tweets on value of vaccination.If you label someone “denialist”, you’re talking religion, not science.I like to be able to argue both sides with equal conviction - until one argument becomes irresistible. And survives multiple attempts at disproof.That’s sciencehttps://twitter.com/jwcoetzee/status/1175899604098912262 …. @ProfTimNoakes. Published September 23, 2019. Accessed September 24, 2019. https://twitter.com/ProfTimNoakes/status/1176169584308752386

622. Diet and Health Today - Adam Pike, Tim Noakes’ Lawyer on “that trial” | Listen via Stitcher for Podcasts. Accessed November 14, 2019. https://www.stitcher.com/podcast/zoe-harcombe/diet-health-today/e/54999577

623. Noakes T. Please understand that activists who troll me have absolutely no interest in truth. Read @AliceDreger. Who ever said that vaccination is ‘not safe’? I said the question has not yet been studied properly. That is vastly different. Or at least it is to my understanding of logic. https://twitter.com/julieo_to/status/936317085365489664 …. @ProfTimNoakes. Published November 30, 2017. Accessed December 24, 2019. https://twitter.com/ProfTimNoakes/status/936319740187901958

624. Noakes T. What does it mean: To be for or against vaccination? It’s like are you for or against the prescription of aspirin. Well it depends. Aspirin can harm when given to the wrong patient - check Reye’s syndrome. That’s why medicine is a complex discipline. @ProfTimNoakes. Published January 2, 2020. Accessed January 2, 2020. https://twitter.com/ProfTimNoakes/status/1212782973738770434

625. Pike. Anti- neo- far- pro-... All lazy smears. Absolves the critic from engaging the argument. @MisterPikester. Published December 31, 2019. Accessed December 31, 2019. https://twitter.com/MisterPikester/status/1211950451685515264

626. Pray WS. Ethical, Scientific, and Educational Concerns With Unproven Medications. Am J Pharm Educ. 2006;70(6). Accessed December 18, 2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1803699/

627. Noakes T. I’ve answered that question on numerous occasions in my Twitter feed. Please go and check. It’s getting a bit tedious now. Vaccination is one of the greatest achievements of modern medicine. @ProfTimNoakes. Published January 2, 2020. Accessed January 2, 2020. https://twitter.com/ProfTimNoakes/status/1212776686837805056

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628. Venter   R. Oh, FFS. He’s said it many times. Are you feeling precious?pic.twitter.com/MR2XLPlOoj. @xeyedmess. Published January 3, 2020. Accessed January 3, 2020. https://twitter.com/xeyedmess/status/1213145530987094016

629. Noakes celebrates anniversary of victory against dietary dogma. FOODMED.NET. Published June 28, 2019. Accessed January 4, 2020. http://foodmed.net/2019/06/noakes-celebrates-anniversary-victory-dietary-dogma/

630. Sboros M. Here we go again! When “experts” lack solid science with which to debate Prof Noakes, they resort to false claims that he is antivaxx or a #climatechange denialist, etc. Simple, rank stupidity or worse? Do some basic research, Gerald! @MarikaSboros. Published January 3, 2020. Accessed January 4, 2020. https://twitter.com/MarikaSboros/status/1213185666428866573

631. Sboros M. Ignore him Rita. Clearly am industry-led attention-seeker not interested in genuine debate. Can’t /won’t stick to the science and the evidence. Troll in the making... @MarikaSboros. Published January 4, 2020. Accessed January 4, 2020. https://twitter.com/MarikaSboros/status/1213329064603373568

632. Noakes T. Fortunately if you spread untruths they ultimately come back and explode in your face. Jim Cameron may be a wealthy celebrity but his day of reckoning lies ahead. @ProfTimNoakes. Published November 4, 2019. Accessed January 2, 2020. https://twitter.com/ProfTimNoakes/status/1191352384699678720

633. WHO | New measles surveillance data from WHO. WHO. Accessed August 12, 2019. http://www.who.int/immunization/newsroom/new-measles-data-august-2019/en/

634. Grimes DR. David Robert Grimes: Vaccines—how can we counter misinformation online? The BMJ. Published November 6, 2019. Accessed November 6, 2019. https://blogs.bmj.com/bmj/2019/11/06/david-robert-grimes-vaccines-how-can-we- counter-misinformation-online/

635. Pergam SA, Englund JA, Kamboj M, et al. Preventing Measles among Immunosuppressed Cancer and Hematopoietic Cell Transplant Patients: A Position Statement by the American Society for Transplantation and Cellular Therapy. Biol Blood Marrow Transplant. Published online August 5, 2019. doi:10.1016/j.bbmt.2019.07.034

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