Lyme Disease Vaccines: A Cautionary Tale 271 associated with other nonsteroidal anti-inflammatory drugs) but that was undone by evidence that the same product imposed a small but real risk of increased cardiovascular disease. Risk-reducing products are especially vulnerable to actions that raise fear and damage trust and thus undermine the social efficacy of the product. LD activists were able to pollute the positive social and psy- chological efficacy with a small dose of personal anecdotes and theoretical concerns. This class of practices and products necessarily lives and dies by an “easy come, easy go” rule, that is, things that are easily and suc- cessfully promoted as relieving fear and reducing uncertainty can be just as readily undermined if they are shown—or believed—to be dangerous and risky. The relatively weak and hedged support for the vaccine by members of both the VRBPAC and the ACIP also followed from the vaccines’ identity as a risk-reducing product. While reducing fear, providing reassurance, and controlling uncertainty are valid consumer needs, med- ical experts were skeptical that they balanced out even a small health risk. Moreover, policymakers were concerned that even if safe, “yup- pie” or “personalized” vaccines might dilute trust in the entire vaccine enterprise through their marginal health impacts (see Sidney Wolfe’s testimony). LD activists asked whether scientific and clinical developments were “good or bad for the heterodox position” usually answered “bad” and acted accordingly. Some clinicians and scientists lived in a complemen- tary universe in which the vaccine might have contributed to a favorable end to the LD controversies by reducing the number of people who had, or could claim to have, LD. These fixed positions reflect a very long controversy that is ultimately about who gets to decide how LD is defined and, as a result, who ultimately gets the diagnosis (Aronowitz 1991). Policymakers, clini- cians, and vaccine companies failed to understand the central heterodox position that patients get to decide the diagnostic criteria. SKB ini- tially funded advocacy organizations and its DTCA campaign bypassed doctors, but the support these advocates craved was for the heterodox definition of LD, not an awareness of LD or a vaccine that stabilized the orthodox viewpoint and was created by the experts they loathed. With the benefit of hindsight, it might have made more market sense for SKB to have enlisted the support of more physicians and to have avoided any involvement with LD advocacy organizations.