Illusions should fall, but it's still good to be reasonable
Over the last few days, I have been sent a link by a number of people to a recent piece by the late-night talk show host. It is his take on the recent concern about the threat of measles, but also a very harsh attack on families who have struggled with the issue of immunization.
Given the number of people who have sent this clip to me, it is clearly catching a lot of attention, and I thought a response was in order.
The clip highlights two rather striking realities about our national conversation on immunizations:
1. A dramatic shift in our thinking and feeling on the measles vaccine is happening right now.
2. Much of the feeling associated with this shift is unnecessarily belligerent and mean-spirited.
Our Affair with False Claims
In 1998, a physician with transplant medicine experience published a paper in one of the world's oldest and most prestigious medical journals, The Lancet, in which he raised concern that the MMR vaccine caused autism. He later went public calling for the MMR vaccine to stop being used. Fairly rapidly, other scientists took a look at Wakefield's claims and found they had no basis in fact. The London Times conducted an extensive investigation and exposed Wakefield's work as fraudulent.
Science began exposing Wakfield's work as early as the year 2001, and by 2004, enough evidence to expose Wakefield has accumulated that serious steps began to be taken against his credibility.
In 2010, England revoked his license to practice medicine.
But none of the exposure of how fraudulent Wakefield's claims have been have had any impact on the public mood, until now, some 11 years after his work was first exposed.
For me, what is most interesting about the Wakefield hoax is not that it happened, but how we the public relate, because such processes are common when it comes to immunizations.
Some time ago, we posted a blog and post on the remarkable book, On Immunity, by Eula Bliss, a gifted writer. This is easily the most thoughtful and profound book on the issues we all face when considering medical decisions, and a tremendous reference on the story of immunizations. This story goes back well beyond Edward Jenner and his work on smallpox inoculation in 18th century England. The work of immunization can be traced to at least a century before that in India, thence to Turkey, and from Turkey, remarkable, to the United States via Cotton Mather whose family remains prominent in Cleveland to this day. The gift of immunization, namely the eradication of deadly diseases, has always been met with worry and resistance, now for centuries.
More recently, in modern America, the questions raised about immunizations have led to two movements against immunizations that each lasted about 15-20 years. One was quite strong in the 1970's and 1980's and it was based on the claim that the DTP vaccine caused mental retardation. As with our more recent movement against immunization, the claim was rapidly disproven, but it took nearly two decades for the claim to vanish. And this claim has clearly vanished. There is essentially nobody around today who really believes that if a child gets a tetanus shot it will cause them to become mentally retarded. But this was a hotly held feeling for a very long time, and it actually led to a change in the DTP, the creation of the now used DTaP, a weaker vaccine with fewer side effects.
And so it was with this current claim, that the MMR causes autism. Within a few years, evidence was at hand that the claim was untrue. But the power the claim had on our minds remained quite powerful for another decade.
Equally fascinating to us is how a very passionately held claim suddenly evaporates. No one knows what triggers the claim vanishing, but these false claims always end up collapsing. The fact that false claims collapse is no surprise, but it is intriguing that they persist, and intriguing that the moment of their collapse never bears any relation to any new facts emerging. It is as if the passion surrounding a controversial claim needs 10-20 years to go through its process, and only then will it collapse.
One dramatic illustration of what we are talking about is the fact that in 2000, measles had been eliminated from the US. In response to worries about MMR, the number of people protected by the MMR against measles began dropping, and measles outbreaks started up again in our country in 2007. From 2007-2014 there have been twenty measles outbreaks. But for 19 of these 20 outbreaks, the fact that measles caught fire again here had no impact. The outbreaks were reported, but essentially no one cared. During this time, in our public imagination, the worry that the MMR might cause autism trumped the worry that measles could cause harm.
Not this time. This 20th outbreak came after the claim that MMR could cause autism really began collapsing. And now this time, the measles epidemic has caused a furor, a firestorm.
As recently as early 2014, no late night comic would touch on public worries about measles, no one cared. But now, it is all the rage.
So, just as the claim that the DTP vaccine can cause mental retardation suddenly disappeared from public imagination in the United States, the claim that the MMR vaccine can cause autism is also, but it's happening right now.
Being Thoughtful During Reactions in Any Direction
And so, we are living through a very dramatic shift in public mood and perception.
Again, anyone really interested in this subject would greatly enjoy the masterful treatment of it in the book On Immunity.
Curiously, the shift has moved our country from one strongly held feeling to another. Initially the feeling was a sense of unease, and for many, a sense of dread that the MMR vaccine might cause autism. Now the feeling is a sense of unease, and for many, a sense of dread that measles could present a danger.
I would propose that at any time, no matter what the nation is upset or worried about, that a minimum of respect for the concerns of others be honored in practice as well as intent.
As the book On Immunity so beautifully illustrates, there is complexity in medical decision making, particularly when it comes to being a parent who imposes a treatment on their child.
Many parents over the years have expressed concern for the presence of various preservatives in immunization materials. These have included such ingredients as mercury. As a result of these concerns, nearly all immunizations used in our office arrive in single dose syringes that contain no mercury. Other ingredients of concern have included formaldehyde and aluminum. The aluminum is necessary to stimulate the immune system to react to the vaccine, no aluminum, no immunity from the vaccine. The formaldehyde is in extremely tiny amounts left over from the processing of the vaccine and not an active ingredient. Both the formaldehyde and aluminum have been studied and found not to cause harm since the amounts are so low.
The reason I review these three ingredients is twofold:
1. To let people know that the vaccines we recommend have been used after very careful scrutiny and enormous studies of risk, and found to be very, very safe.
2. The second is to let people know that people in the community who raise questions of course have a right, and duty as parents, to raise questions.
The swing from one strong feeling to another strong feeling has led to a shift from a very strongly held worry about vaccines, to a very strong held worry about those who do not vaccinate.
This swing has led to the emergence of a whole new discussion across the nation- should actions be taken against families that delay, or do not immunize their children? Some have even called for doctors to not see families who make these choices.
It is at this point that we call for calm and respect.
A closer look at the controversy about what doctors should do will hopefully encourage us all to be both calmer and more respectful.
As we think about it, several reasons come up, many of them compelling, for seeing the decision to exclude people for their medical choices from doctors' offices as not helpful to anyone:
1. The doctor's office is a place of help. The last thing a doctor should do is turn away someone who wants to be helped. Most families have questions about immunizations, it's one of the more helpful things pediatricians do, it does not make sense to turn away people looking for answers. Excluding people from care because others object to decisions or perceive harm could lead down a very odd road. Imagine doctors telling people who smoke that they can no longer come see them, or people with any complex health choices to weigh. Not only is that a bad idea, but it violates a very key principle of the profession: the doctor's office is a place of help.
2. If there is a disagreement or point of discussion around a subject, it usually does little good to respond to that by cutting off the conversation. For families that have concerns about immunizations, it does little good to respond by not allowing the conversation to take place. It doesn't help the doctor understand the concern, and it doesn't help the family explore their concern.
3. For those who feel strongly about everyone getting immunized, pursuing a policy of not allowing people who question immunization to come to the doctor actually will increase the number of children not immunized. Cutting people off tends to reduce opportunities to discuss options rather than expanding them.
4. The doctor's office is not the main source of exposure to any illness. Take the current measles outbreak. Most of the cases were caught in Disneyland, not the doctor's office. Many families are currently concerned that if unimmunized children come to the doctor's office, their child will be at heightened risk of catching preventable illnesses, like measles. But keeping access to a doctor limited to those unimmunized does not really change the risk of anyone catching those illnesses.
5. When an outbreak of a preventable illness occurs, immunized children spread it too. In the last measles outbreak, about 1 in 6 of those walking around with measles were immunized. When an outbreak occurs, there really is no safety in isolating those who are not immunized, we are all one community living together, whatever our choices are.
So, as one might suspect, it turns out the only way to protect a community from vaccine preventable, serious infectious diseases is to have as much of the community be immunized as possible. Infections spread across great areas, and that transmission can only be stopped if enough people are immune and unable to spread the illness.
Taking actions on an individual level has no impact, and the actions recommended all tend to be counter-productive as noted above.
BOTTOM LINES
1. We are all living through a rather amazing transition in perception. The MMR, and other immunizations, are moving from items of some worry, to highly valued protectors. Worry is shifting from the vaccine to the disease.
2. Right now, there is an incredibly sharp spike in feeling about immunization, this time the worry is with not getting immunized. Blogs, late night comedians, daily conversations are seeing a sharp rise in calls for action to demand everyone be immunized, including calls to restrict access to medical care.
3. It turns out the only way to keep one from catching a vaccine preventable disease is to have the whole population reach a safe level of rate of immunization. If a whole population dips below that rate, then everyone can spread it, even immunized people. There is no protection in trying to avoid people who have not been fully immunized.
3. As during the time when most worries were directed at the vaccine, this time calls for being reasonable and thoughtful. To that end, it is worth keeping in mind that our primary purpose as doctors is to help. And it simply does not help anyone to deny help to those with questions.
4. Those interested in perhaps the best, most thoughtful treatment of this issue might greatly enjoy On Immunity, a comprehensive treatment of the subject.
5. Putting it all together, we at Advanced Pediatrics will continue what we always try to do- be available, be helpful, answer questions, offer disease prevention. I have full confidence this approach is the safest, most helpful, and most informative approach we can imagine.
And to that end, we again thank you for the honor of being asked to help,
Dr. Arthur Lavin
*Disclaimer*
The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.
