The vaccine debate — Could compassion and nuance be an antidote?

I’ve been thinking a lot about vaccines. As a learner, an observer of humans and our nature, a worshiper of the scientific method, a doctor, a new grandfather, and a member of society, few debates could be more compelling. The kerfuffle over vaccines has it all. It’s the Lance Armstrong story on steroids. (Grin.)

The spark for writing on this matter came from reading a mother’s impassioned call for reason. (Link at the end.) The author is a young lawyer who writes (skillfully) about being married to a young doctor. Her vaccine post went viral, garnering 483 comments—which, for a blogger, is akin to nirvana.

In what follows, I promise two things: brevity and candor. I’m just a cardiologist, so I claim no special knowledge on the biochemistry and immunology aspects of vaccines. I am, however, more than just an observer. I work in a healthcare setting, taking care of the vulnerable elderly. Other relevant facts: it’s flu season; I don’t like shots; I like the post-vaccine immune reaction even less; and, as an American, I hate being forced to do something. The latter fact should not be taken lightly when considering this debate.

Chapter one of the vaccine saga must start with efficacy. Here, let’s consider the childhood vaccines. It’s simply not credible to look at the resurgence of infectious diseases like whooping-cough and measles and then say vaccines do not provide protection. Smallpox was eliminated with vaccines, and in western countries, so was polio. These vaccines work.

But like all effective therapies in medicine, there are tradeoffs. Adverse effects from vaccines occur. This is where the story gets very interesting. Sparked by fraudulent science and downright maleficence, the notion that vaccines were overtly dangerous grew and grew and grew. Social media and the Internet provided the runaway train of misinformation monster tailwinds. Now, almost a decade later, the fraud exposed, vaccine doubters remain strong and united.

We must learn from this phenomenon. Taking the view that the millions of freethinking humans who doubt the “net clinical benefit” of vaccines are stupid or selfish is not productive. We need to look at why so many have these concerns.

Let me make an analogy to a clinical situation that I see nearly every week in the treatment of atrial fibrillation—my primary disease. In AF, the anticoagulant (‘blood thinner’) warfarin has been shown in clinical trials of thousands of patients to be effective in preventing stroke and lowering mortality. The data are crystal clear. Arguably, stroke and death are the worst possible outcomes of a disease. But yet, many AF patients are overcome with fear about taking warfarin.

The key, I believe, in both cases (warfarin and vaccines), is the issue of fear. Inherent in the definition of fear is unknowing. Lack of knowledge creates and fertilizes fear. Make no mistake, I’m not going to argue that overcoming the knowledge gap of vaccines is as easy as explaining the net benefits of an anticoagulant drug, but I believe we must continue to try. I’m optimistic that the message of “net clinical benefit” can be made. Maybe not tomorrow, but over time, reason will get traction.

Vaccines are especially important because unlike heart drugs, there is the matter of others’ health. When my daughter takes my granddaughter to play group, I’m hoping that other human beings have been considerate enough to have vaccinated their children against disease. The role of the social contract cannot be ignored. We expect things from fellow humankind. We expect people to not text (or drink) while driving; we expect etiquette with cellphones, and it’s expected that we not infect each other with infectious disease. Basic things.

The final point I’ll add is a word of caution to the medical world. The dynamic of the patient-doctor interaction has changed—for the better. Paternalism and hubris no longer work well in adult medicine, and such an approach likely won’t work in Pediatrics. We can’t say: take this… because I said so and I am a doctor. Good riddance with that BS.

Call me naïve, but I believe the most effective means to move the vaccine needle in the right direction is to do it gently and with compassion for others. Let’s see the fear in the doubters. Let’s see them as fellow humans trying to do what’s best for their children. They are like the AF patient frightened of a blood thinner. Acknowledging that taking a therapy does indeed expose one to risk is quite important. Dr Harlan Krumholz taught me that removing fear and ignorance is the way to better medical decisions. He’s right.

I will continue to watch this debate. How it goes will tell us a lot about us as a society and as a medical profession. I hope the needle moves in the right direction before major infectious diseases make a comeback.

JMM

The link to the viral post. Vaccination: A Layperson’s Perspective

12 comments

  1. John

    Nice article but, statistics are not always “crystal clear”.
    I have few issues with vaccines that have been around for a long enough period of time to prove their merit, but in this age of Pharma profits with vaccines being the new moneymaker, I do not trust their trials, outcomes and statistics. For that reason I rarely use new vaccines for reason already stated.

    I’m interested on your take about the following, http://www.thennt.com/nnt/warfarin-for-atrial-fibrillation-stroke-prevention/ ,. Is this enough overwhelming evidence?

  2. Some math types have suggested that probability and statistics should be the pinnacle of high school math instead of calculus. After all, everyone will buy insurance, have a chance to play the lottery, and need to decide the relative risk of alternative medical treatments.

    Along the same lines (the power of education for making sense of the modern world), how can you learn about Edward Jenner, Louis Pasteur, or even FDR without realizing the tremendous power of vaccines to prevent human suffering?

    On the flip side, like Doctorsh, I find myself wondering about the numbers that come out of industry when it comes to newer vaccines. How can one observe the medical-industrial complex of the last decade and not at least a little skeptical?

    Finally, I’m guess my personality is such that I’m sometimes willing to play the odds. After all, I ride my road bike knowing that I’ll eventually meet a car if I ride enough miles. I might skip the flu vaccine knowing that the consequence for an unlucky draw is likely measured in weeks and not years or decades. I’m not interested in gambling with Polio. I’ll gamble with the vaccine instead.

    There is more nuance than anyone can explain in a 15 minute visit of a 2 page magazine article. Surely if people knew more about statistics and the history of science, they would be better equipped to make their own decisions.

    Beware of the seductive simplicity of black and white, and beware the power of a good story (anecdote). Real life is seldom so simple. That’s part of what makes it interesting!

  3. I don’t think the issue of vaccinations is an “all or none”. I say this while fully believing that many vaccines have been instrumental in reducing morbidity and mortality from many diseases over many years. Clearly, life is easier raising a child if one goes through vaccination protocols as prescribed – rather than questioning each step of the way. That said – the assessment scorecard on vaccinations is not uniformly positive – with the assessment process being far from clearcut in my opinion given that: i) there are big bucks to be made; and ii) I have less faith than I used to in our regulatory agencies.

  4. Thanks for this commentary . Two comments : 1) do the ‘for profit medical industrial complex’ whiners think vaccines are big money makers- and, where will new vaccines come from. The ambulance chasing lawyers love both vaccines and vaxxers. As one of the hundreds of thousands who work for drug/device/imaging , I find the comments about ‘us’ ( with often many more years of education then physicians ,without high six figs docs ultimately get) insulting, ignorant and condescending ;
    2) my primary doc friends note it takes a major time allocation to go though the ‘education’ process of these folks – not possible. More ed time should be a charged fee.
    So, no vaccinations – no appointments; no school admittance ; increased insurance premiums ; healthcare professionals who advocate for the anti’s can & should be dis-barred and/de-licensed ; parents can be prosecuted .
    Harsh, I suppose, but , I do Not want my children & grandchildren any where near these people. I do not want them to be the sole decision makers. My bio Professor was old enough to describe in great detail the horrible results of a ‘no-vaccine’ era. And, today, we are revisiting potential epidemic issues ( helped by plane travel, social events, dense populations).
    Sorry for the rant. I have much more trust in vaccine researchers & docs than the anti’s. More of this ought to be in the lay press/broad-cast media.
    Sincerely,
    Jack

    1. Jack – Your rant has valid points. There is a counter. The “truth” lies somewhere in between, albeit probably a lot closer to net benefit for many (most) vaccines. But I don’t think net pros vs cons is uniformly positive for all vaccines for all people under all circumstances – and there are big bucks to be made and lack of pristine trustworthiness by our regulatory agencies … = just my 2 cents. I realize I’m speaking “against the Gospel”.

  5. Well said. My own experience with the regulators (20+ years in both devices and Pharma ) agree with your comment. Old world process; politics ; a significant reduction in quality of staff ; and, movement into using ‘costs’ in evaluations have greatly harmed the regulation process and results. Did I mention ambulance chasers?
    So, in an era which we should have a medical research enlightenment ( nano,genome directed diagnosis/treatment, discrimination algorithms , implantable monitors with 24/7 ‘yellow-red light capability ,3-D custom device allocation,,,,,etc.) we are stuck. Jeez, even the device tax has either shut down start-up money or, greatly delayed innovative programs from continuing to move forward. Would you invest in a ‘disruptive-technology ‘ start up??
    BTW, all one needs to do , is to read the many comments in the blog ,to realize how many of the well intentioned parents are using the internet to make very dangerous decisions about their own kids AND, the rest of the children. Sit in a peds office and see/hear the pile of crap some of these parents bring in for the poor ,time strapped MD/RN’s to deal with. Your points -well said. However, their comments and “proofs” must scare you, I hope.
    I sincerely hope these discussions become more public. The vast majority of parents will be outraged ,indeed.
    Regards to all,
    Jack

  6. I understand your medical views, but as a patient with many co-morbid conditions, people who refuse to get the flu shot annoy me. The shot that I get increases the chance that I won’t get the flu, but it isn’t a 100% foolproof protection. You may get the flu, come to the office and hack all over the place in a meeting. The flu is likely only make you feel bad. It’s almost a guarantee that I am going to spend a long amount of time in the hospital. I am certain that you never got the flu after getting the shot. Everyone knows that is a lie because everyone has told it. And when you tell me that you are afraid of needles I want to mock you. I know a 9 year old girl who gives herself a shot of insulin several times a day without complaining. Giving her the flu is a bad idea too.

  7. My older cousin wears a leg brace. I was fortunate to be in the first wave of Salk inoculations.

    I well remember my younger brother’s agonies as he contended with teenage mumps. Luck allowed him two lovely daughters nonetheless.

    My older sister suffered more than a year with the severe pain of shingles.

    I, myself, through daily visits by the family doc with his (large!) penicillin syringes, was able to escape death from measles complications at the age of seven. All I have to show for it now is progressive hearing loss.

    But these are merely anecdotes. Enormous volumes of research inform us that the benefit of most inoculations approaches 100 %. The risk of the inoculation is vanishingly small. Risking horrific diseases because of some misguided principles or beliefs gleaned from the web about the nature of vaccines is staggeringly foolhardy.

    Does one really have to have been there and tasted it to grasp the tragedy?

    So, do you have a new vaccine? Bring it on! Herpes zoster, a dozen different strains of pneumonia, this year’s flu, and all the other standards.
    If I had the youth, I’d have the HPV vaccine!

  8. Primary Care Physicians try to get patients to stop smoking, exercise, eat well and lose weight. I think you could say we are champions of difficult causes. All of the community pediatricians I know treat vaccine refusers with extra-ordinary kindness. They know that the only hope of convincing those parents lies in gaining their trust over time. Its also why Hopkins Vaccine people recommend a refusal form that has to be renewed annually with a visit to some sort of public health official (and maybe a physician as well) which creates an opportunity for education. They also require the parent to write a statement. (Never work harder than the patient.) Here’s a link to the recommended law for Arkansas: http://www.vaccinesafety.edu/DraftExemption.htm

    I think your example of fearful patients is not awful, but you forgot to point out that warfarin has very real risks of bleeding and that most vaccine risks are mild. I think some of the fear is related to a feeling of powerlessness in the face of society and physicians have to tread lightly not to be seen as “the man”.

    I’m not sure how to link this, but the CDC has a great page on common misconceptions. http://www.cdc.gov/vaccines/vac-gen/6mishome.htm

    I also recommend Paul Offit’s books: the one on Maurice Hilleman who developed many of our current vaccines, and gave them to his children and grand children; and Autism’s False Profits, although be prepared to be very angry while reading that one.

  9. John,

    Thanks for the post. As a primary care pediatrician I greatly appreciate your attention to the “Married to Medicine” blog post.
    Disclosure on my part I serve as a speaker for the PA chapter of the AAP for their Immunization Education Program. No pharma affiliations

    When the issue of a “new” vaccine comes up I am always puzzled as to what a person considers new. How may participants have to be in the phase 3 trials before it is no longer new or how many post licensure does have to be given. I do not mean to be sarcastic here but other than a gut feeling what do people base this on? During the H1N1 pandemic I had people even physicians say the vaccine was “too new” It was made the same way as all other flu vaccine it just used a different strain. From the perspective of “new” it was no newer than another flu vaccine.

    Dr Grauer, yes I would agree you are speaking against the Gospel. Of course there are contraindications to individual vaccines but the evidence is clear vaccine have had an overwhelmingly positive effect.

    Vaccines are among the safest things we put into our bodies.
    Post licensure there are multiple oversites, the passive VEARS but also more scientific over sight – Vaccine Safety Data Link, Clinical Immunization Sate Assessment project and the Brighton Collaboration.

    It does take time and effort to help parents understand the misinformation that is so readily available. While it is easy to scare people it is difficult to un scare them.

    Dr John, unfortunately we have seen outbreaks of vaccine preventable diseases in the US in particular measles and pertussis.

    I will second WomanWhoWeaves recommendation on Dr Paul Offit’s books. They are all very good.

  10. The issue of vaccines is not only an important topic in public health but also in terms of consistent or inconsistent quality control of pharmaceutical companies who create those vaccines. Diluent safety must be discussed and, eventually, pharmacogenetics will enter into the polemics to determine the interaction of genetics and types of tolerable vaccines. That infection control, clean water, better hygiene and improved nutrition have been the key determinants in preventing infectious disease epidemics, vaccines need to be scrutinized as to who, when, where and how.

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