http://www.nytimes.com/2008/03/21/us/21vaccine.html

I saw this article in the New York Times recently about a small measles outbreak in San Diego. In some ways that article was a typical pro-vaccine article, using certain techniques in order to give a slightly skewed view of the truth to make a stronger point. For example they cited statistics from around the world (242,000 children die annually from measles) instead of giving us statistics relevant to our lives. If children in third world countries are dying from measles, you could very reasonably conclude that this might not tell you much about what your child’s risk might be. There are obviously differences in circumstances, and at least some of those children might not have access to the healthy food, good sanitation and the excellent palliative care that we generally have available in the US. But there were two parts of the article I found more interesting than the rhetoric: the comment that many pediatricians view people who don’t vaccinate their children as “…parasites, of a sort, benefiting from an otherwise inoculated majority.” I suppose that they got a lot of mileage from calling people parasites instead of free riders, since it’s obviously a more upsetting, pejorative term. The other thing that was interesting was the fact that they got a mother to admit that she was more concerned about her child’s well being than those of other children.

But the most amazing thing about the article was the vitriol contained in the comments by people who think that vaccination should be forced on all children by the government. These people did a lot of name-calling of those who disagree with them, using inflammatory terms like “unscientific”, “poorly educated”, and claiming that non-vaccinators are unable to evaluate validity of reasoning because they don’t share the opinion of the particular comment’s author. It’s an important lesson for all of us to pay very little attention to the authority with which people speak on important matters, but instead to focus on the evidence which they present. This is especially true when the opinion is full of inflammatory, emotional language and is mostly rhetoric rather than evidenced reasoning, as are most of the comments after the article. If I didn’t know better, I would think it was a fervent flame war over religion and not a scientific disagreement.

Let me state my position point-blank, before I go any further: every person making a comment there that makes it seem as though this is a simple problem with an obvious answer (in either direction) does not know what they are talking about. That includes all the physicians and nurses who think that giving people shots for thirty years somehow confers upon them complex, otherwise-unknown scientific truths that have amazingly eluded everyone else. There is a reason that well-educated people around the world disagree in this problem-space: no one knows what the truth is. I maintain that anyone who tells you otherwise hasn’t looked at the problem and the studies very carefully, or has some sort of interest in the conclusion. And that interest may be as benign (and simultaneously malignant) as just assuming that when a lot of credentialed people say something is true, it must be.

Now, let me begin by saying something that I thought would be obvious to everyone: vaccines damage some children. (and this has nothing to do with the recent Hannah Poling case) It is pretty much true that everyone who knows about public health already knows this. This is the reason that vaccine court exists, and the reason that each shot costs a little bit more than it would otherwise; the money gets put into a fund to pay off those that have been hurt by vaccines. Again, it’s called PUBLIC health – it’s not about your child; it’s about the promotion of the healthy well-being of the society at large, knowing that along the way some people will probably be hurt. This is very simple public policy stuff about which it appears lots of people have their heads in the sand.

So far the lesson is that the pro- and anti-vaccine people agree about this general fact, and they’re now arguing about numbers. Pro-vaccine people think that you’re at much higher risk for being injured by illnesses, and the anti-vaccine people think you are at more risk for being harmed by vaccines. The anti-vaccine people are concerned that autoimmune diseases, allergies and autism are caused, at least in part, by vaccines and/or their component parts (meaning live viruses, adjuvants and/or preservatives, mainly) and that many of the illnesses for which we vaccinate are not serious. The pro-vaccine people think that vaccines alone keep us from reverting to the days when hospitals were full of people suffering and dying from diseases that we can now sidestep entirely because effective vaccines have been invented.

I have personally read all of the studies claiming to show that there is no connection between vaccines and autism, and would have read the studies showing that vaccines were evaluated in the long term, had anyone done those sorts of studies. And by that I mean that I have read the studies in their entirety, which means that I did not rely on information that I read about them in Time magazine, I did not have a conversation with someone (an MD or DO, or a medical student – lots of whom commented on the NY Times article) who claimed to have read the study, and lastly (and most importantly) I did not just glance at the abstract and pretend that I read the whole study, considered the methodology carefully and agree that the study actually demonstrates what it claims to show.

And even with all this study of the primary literature it’s the case that I still don’t understand what people are talking about when they say that vaccines have been proven to not cause autism. There are some epidemiological studies, but when I learned about biostatistics and scientific studies, population-based studies were used solely to help define more specific questions that could be investigated via experimental research. They are where one begins to define a medical inquiry, and are almost never used to prove/disprove anything (and certainly are not used to approve drugs or medical devices) because they fall prey to too many confounding factors.

The prior objection about the population-based studies doesn’t even begin to raise the questions about the legitimacy of the particular population studies that were done, and cited by the Institute of Medicine. In one case the children in the country where the study was done were administered half the thimerosal as children in the US, but somehow the study is still cited as perfectly applicable to US children. There was another study, done in the US, but it had a minor difficulty in that all the data that was analysed was “lost” (although individuals have testified that they were instructed to destroy the data), which would under any other circumstance result in the study being disregarded. High standards of proof in medicine usually require that the information used is available so that the results of the analysis can be checked and verified by other parties. In fact, the famous Wakefield study (that claimed an association between autism and measles vaccines by isolating measles in the gut of autistic children) is commonly discredited in this way. But somehow this protocol has been eschewed for studies on only one side of this debate. All this makes me feel a bit as though I’m living in the twilight zone; there’s one standard of proof when you’re discussing the claim that vaccines have no relation to autism, and a separate, more stringent standard of proof for the other side of the debate, and everything else.

But in spite of all these difficulties, every day people claim that there is no association between vaccines and autism. Go ahead and go back and count the number of comments after the New York Times article that claimed that the association between autism and vaccines has been disproven (bonus points for how many times this was said by physicians and med school students). These are the standards of proof being used by these commenters. (assuming they’ve read the studies at all and aren’t just relying on press releases or the likes of sciencedaily’s rubbish summaries that bear no relation to the study in question)

I believe that if someone could show people that do not vaccinate that vaccines were actually safe they might well reconsider; I think the uptake rates on vaccines would increase dramatically if people felt that they were safe and effective. So let me share some ideas that I have for things that could be done to get to get non-vaxers to reconsider, instead of using the brute force of law or personal attack, which a lot of the commenters seemed to be advocating.

Admit that no one has done any long-term study of vaccinations, and that certainly NO ONE has done a study to determine what happens when you give the many shots of the US recommended schedule in a short period of time (other than generate a lot of revenue).

Stop pretending that the thousands of families who have had normally developing children who went for a series of vaccines one day, then screamed for 24 hours (a not-uncommon vax side-effect) and then never uttered another word are imagining it. Science at its heart is all about observation, not fancy journals; so when many people tell a very similar story it certainly warrants real scientific investigation instead of a castigation that people are all collectively imagining things, and that it is a coincidence. I find it astounding that the people of medical science expect people to believe this. When you dismiss the reports and the very observational basis of science and instead engage in heated denial, you are simply extending an open invitation to people to wonder about cover-ups and conspiracies.

Acknowledge that vaccines do not seem to provide the same sort of protection that natural immunity does. There are almost no infections that humans routinely get that are not caused through contact with mucosal or digestive surfaces (malaria being the major exception that comes to mind). In lay-speak, our immune systems have various “layers” of immune globulins that have different roles in immunity – when we inject vaccines, we bypass some levels of immune response, and there is a good chance that this big difference is a factor in the shorter duration of protection that vaccines offer. Because vaccinations don’t seem to confer long-lasting immunity there seems to be an emerging trend where illnesses that used to mainly affect children are now affecting older people (sometimes only in their 20s), and the result has been atypical forms of the illness (like measles) that seem to be more virulent than when the illness is typically contracted as a child. A slightly different problem with the short-lived effect of vaccines is the fact that women used to contract rubella as children, and later, when they became pregnant, their immunity to it was practically assured. Now that we vaccinate against rubella, the immunity that waned, or simply never occurred (via vaccine failure) means that more fetuses are at risk of birth defects due to perinatal rubella infections. Stop pretending that these problems are due to non-vaccinators when vaccines and their incomplete, short-lived immunity contribute to the problem as well.

Stop claiming that practically everyone in the world died of chicken pox and measles ten minutes before the vaccines were invented. Go look have a look at the first hand statistics instead of just mindlessly repeating the propaganda.

Dispense with the arguments from authority such as “I am a physician and I think x.” or “My doctor, who went to Yale, says y.” – people with decades of experience and education have been, and will always continue to be mistaken about things. What matters are the studies and methodologies, and not who said what and what their qualifications are. How many people die each year due to physician error? The Institute of Medicine report from 1999 claimed that the figure is approaching 100,000 people per year. Those people were killed by doctors who made mistakes. Please let’s stop perpetuating the myth that doctors have some extra-human access to anything – they are just people who trade in medicine, and they are sometimes right, and sometimes wrong.

Now let me point out that this debate could be solved with an actual study, devoid of biased funding, done by researchers whose livelihood does not depend on paychecks from the manufacturers of vaccines, investigating the points that I mentioned above. It will be difficult to blind an actual experimental investigation of this sort, because of moral concerns. But there are already plenty of families in the US that do not vaccinate, and comparing rates of the various allergies, ADHD, asthma and autism in children who were and were not vaccinated certainly is a good place to start.

Once some reasonable scientific work has been done in this area, I think we could be on the way to refining our thoughts and concerns. It’s the reluctance to actually discuss the shortcomings and unknowns of vaccination, and instead derail the debate with over-emotionalism and insults that holds both public health and the well being of children back.

And as a private reply to comment #383, B. Pirkle, R.N., San Francisco: Non-vaccinating parents all over will be struck by the irony of your comment. They know all too well that there is no such thing as a free lunch; that’s exactly what they’re trying to get YOU to see. You can’t just inject a bunch of untested stuff into the body, hope it effects the immune system in the way you intend, and assume that there is no cost or downside – that sounds like free lunch idealism at its best. Maybe you should consider taking a little of your own medicine.

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