Sunday, June 21, 2015

Is there a need for more nuance in the vaccine "debate"?

Alice Dreger--an academic whose gutsiness in taking up controversial issues I have a lot of respect for--has recently written an article on yet another hot-button topic: A heretic in
the academy: What if not all parents who question vaccines are foolish and anti-science? on the book Vaccine, by Mark Largent.

Prof. Largent is basically in favor of vaccination and wants to increase coverage; however, he also criticizes some of the doctors, journalists and bloggers who have pushed the pro-vaccine line. Largent suggests that some of these people have made things more difficult by adopting all-or-nothing arguments about vaccination, as though refusing the chickenpox vaccine were the same as refusing the polio vax. He points out (correctly) that the US vaccination schedule is not based exclusively on medical evidence but is also influenced by commercial interests. He suggests a distinction between hard-core anti-vaccinators versus parents who are merely a bit anxious or who reject one or two vaccines, stating we might have more luck if we showed empathy with their worries. Dreger, describing Largent's ideas, also adds some personal stories about the gut-level fear she felt about the number of needles coming towards her child, in spite of her own strong conviction that vaccination is safe and necessary.

By using terms like "zealots" to describe some of the pro-vax people, Largent and Dreger aren't certainly out to win any friends, and both have already attracted some fierce criticism among science-based-medicine blogs on the grounds that they are going soft/pandering to parents who believe stupid things about vaccines. I do know what they mean, sort of. I personally was never one of those parents who felt gut-level "anxiety" about needles being stuck in my child, so Dreger's description of her own fears didn't resonate with me at all. The number of vaccines which are given to children in the United States certainly does sound like a lot at first glance... then again, I live in Japan with its relatively "light" vaccine schedule (Japan tends to be incredibly conservative about new vaccines and tends to panic and ban any shot that is even rumored to have created an adverse reaction); this has not been a roaring success. Japan has long been known as an "exporter" of measles due to frequent outbreaks--and as someone with no hearing in one ear due to mumps I was horrified to learn that the mumps vax is still not standard here, and that mumps regularly makes the rounds in Japanese universities.

And yet
That said, when the writer uses the phrase "vaccine zealot," honestly, I do know what she is talking about. Examples:

1) A mother posts online asking for advice about the chickenpox which her child has contracted. When it transpires that the mother had not vaccinated her child against this virus, a horde of posters descend on her and subject her to a lot of incredibly harsh, personal criticism faintly tinged with hysteria. After a while, another poster points out that there is a bit of controversy over the population-level effects of the chickenpox vaccine, which is why the British National Health Service (NHS) does not routinely offer it. The pro CP-vaccine posters, instead of admitting that the issue is somewhat nuanced, merely buzz even more angrily, all but accusing the original poster of wanting to murder immune-compromised children. 
2) A mum on a Facebook group announces that there have been a few cases of whooping cough in her state--the other side of her state from where she is living--and that she intends to avoid all unnecessary movement outside her home and stay indoors with her baby (not immune-compromised) for the immediate future. She receives responses of the "We are all praying for you!" type, as though the kid were already on its deathbed.
3) In an argument about the measles, mumps and rubella (MMR) vaccine, a poster correctly states that measles can potentially kill and cause serious complications--but cites statistics taken from developing countries, suggesting that a measles epidemic in the United States would kill up to 10% of those infected. The other posters on the discussion mostly know that this is bullshit but don't dare point this out, because this would risk giving ammunition to all the anti-vax posters who are on the same thread. (This article goes one further, claiming that more than half (!) of those infected with measles last year died of it, which if true would make measles deadlier than smallpox...!)

Okay, 1): Although the chickenpox vax is safe and effective, there's genuine concern that widespread vaccination of children against CP could be a factor behind recent increases in painful shingles among the elderly/immune-compromised in some countries (see here). Whether these things are really connected is very debatable; I personally decided to do the CP vax after weighing up the pros and cons. But "weighing up" is the key phrase here: I mean, I wouldn't spit venom at anyone who decided not to. If I had been some vaccine-hesitant parent reading through that thread, the overwhelming impression that I would have come away with would have been: "Vaccine-promoters are kinda selective with the truth and may cover up things which might call their case into question. Oh, and they also appear to be excitable and a little nuts."

Regarding 2): It's sensible and wise for parents to keep an eye on disease outbreaks in one's locality. On the other hand: if some lady announced that she was going to barricade herself in her home due to fear of child-abduction-by-strangers, I suspect that most of us would tell her ever-so-gently to "get a grip," and the risk of whooping cough multiplied by the disease's mortality rate has got to be similar. Worry about very small risks has to be balanced against the benefits of fresh air and having children spend time with friends and family.

3): Measles kills and blinds on an alarming scale in kids with Vitamin A deficiency and a heavy disease burden (chronic parasite infestations etc.). In developed countries, measles kills at a rate of perhaps 1 per several thousand cases. I know most pro-vax blogger etc. absolutely hate the "Brady Bunch" comparison, but honestly, there is some truth to the fact that by the 1960s and 1970s serious complications were rare enough that parents often didn't take measles all that seriously (hence it took quite a long time for the measles vax to catch on).

The reason why we should inoculate against measles is not because an outbreak would cause overflowing graveyards--it wouldn't. It's because nowadays we have very high standards for children's safety, so even a 1 in several thousand risk is worth eliminating, especially considering how incredibly safe this vax is. We wouldn't copy 1960s parents when it comes to car seat usage, either. And 1960s parents didn't know that measles may be connected to later illnesses in children due to "wiping clean" the body's immunity record (see below). Then you've got the issue of immune-compromised kids. There is no need for exaggerated figures when it comes to measles--the factual reality of the disease is already quietly worrying enough.

To be an activist, first be a "factivist"
As someone with a disability caused by a VPD, I feel a certain sense of urgency about the need to increase vaccination rates. If we want to do this, we need to make sure we're actually changing people's minds, not just grandstanding.

I don't know exactly what Largent says, as I haven't read his book. If he is descending into the nonsense of "let's present both sides of the argument" then he's talking out of his backside, because there is basically only one sensible argument here. But if he's talking about the need for sticking to the facts and maintaining a courteous tone in debate, then 
I'm with him.

As Andrew Maynard of the above linked blog post says "
[T]o use data that not only feel wrong, but are not backed up with evidence, only serves to undermines trust in public health experts. Anti-vaccine proponents are smart enough to realize this. Each time the data on infectious diseases and risk are spun beyond their legitimate bounds, anti-vaccine proponents are given a helping hand in winning the hearts and minds of concerned parents." When pro-vax people start to overreach--even by a little--it undermines the credibility of everything we say ever after.

"Courtesy" is important too--not frosty politeness through gritted teeth, but genuinely empathizing with people's worries. And for the love of God, please stop the aggressive dogpiling of people on discussion threads (I'm sure I've been guilty of participating in these in the past, too). Most people who hesitate about vaccination are not hardened anti-vax types, but worried parents who don't know who to trust. If we can talk to them as if we genuinely care about them and their kids, we might be surprised at how willing they are to listen.

Further reading:

A heretic in the academy: What if not all parents who question vaccines are foolish and anti-science? (Alice Dreger)  (Dreger's book, Galileo's Middle Finger, is worth a read too.)
Vaccine (Mark Largent): The subject of this post, but I haven't read this one yet, myself.
In which pro-vaccine advocates are inappropriately portrayed as frenzied, self-righteous “zealots” (Respectful Insolence): The counter-argument
Long-term measles-induced immunomodulation increases overall childhood infectious disease mortality (Science)
What is the risk of dying if you catch measles? (2020 Science)
Shingles & Chickenpox: What's the Link? Simple discussion
Why is measles still endemic in Japan? (The Lancet)