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Vaccine anxiety… A teachable moment for doctors?

I’ve read and re-read Dr. Paul Offit’s WSJ opinion piece, The Anti-Vaccination Epidemic. Dr. Offit is a professor of Pediatrics at a leading hospital in the United States. He is also an author, a scientist, and a vaccine-developer. In short, he is a major physician leader. I’ll come back to that point in just a second.

His piece addresses the problem of pediatric infectious disease in the United States. Context is important here. Data from the CDC show that infectious disease is not in the top-five causes of death in children. In the US, children older than one are ten times more likely die from unintentional injury then they are from infection. Homicide and suicide kill many more young Americans than does infections.

But no one would argue pediatric infectious diseases aren’t important. One tool against infectious disease is vaccines. But for vaccinations to work effectively, populations must be vaccinated. Vaccines require a social contract. In some areas of the US, as in other countries, human beings are deciding to delay or withhold getting vaccines. Dr. Offit points out the curious fact that vaccine abstention clusters in populations of wealth and education.

I find the anti-vaccine movement an interesting human phenomenon. Why would it be that this many people, smart people, thinking people, loving parents, choose not to vaccinate? Why am I, a disciple of absolute benefits and risks, so squeamish about taking the mandated influenza shot? And, I’ve suffered through shingles in the past, but don’t plan to get the shingles vaccine.

Such disquiet is weird because you can’t look at population data on vaccines and not see overwhelming benefit for many diseases. The often fatal infection, epiglottitis, for example, has nearly been eradicated by Haemophilus influenzae type b vaccine. Polio is another example. There are other examples.

You know I don’t have the answers to such a complex human problem. I suspect fear, bias, loss aversion (good health at the moment), mistrust of the medical establishment and an increasingly skeptical population are all components.

But one thing that electrophysiologists know well is that if a strategy (in the EP lab) isn’t working, stop doing it, and try a different approach.

This is where I come back to Dr. Offit and the leadership thing. His tone was condescending and paternalistic. He had the statistics, which were quite clear, so it was unnecessary to euphemistically kick people in the shins. From my perspective, as a doctor who helps (mostly wealthy) people make preference-sensitive decisions about future and present risks, brow-beating and condescension are rarely effective strategies.

I realize I could be completely wrong about this, but I think part of the vaccine backlash relates to the means of delivering the message. It’s easy to blame social media and the Internet and celebrities and even journalists. That’s the fast-thinkers answer.

As medical doctors, professionals in the people business, I’d recommend slower thinking, and a tincture of looking inward.


16 replies on “Vaccine anxiety… A teachable moment for doctors?”

Hello Dr. John,

I think you are right on the money when you write that “fear, bias, loss aversion (good health at the moment), mistrust of the medical establishment and an increasingly skeptical population” are all components of the anti-vaccine movement.

I’m not a “pediatrician, an author, a scientist, a vaccine-developer or a major physician leader”. But even I know that Dr. Offit could have done a more convincing job in addressing the topic of vaccinating against pediatric infectious disease by simply showing this little video of an infant suffering with whooping cough.

I challenge anti-vaxxers to watch it and decide: “Yep, I want my child to go through this, too.”

Dr John
I sincerely appreciate your well written and thoughtful writing.

I am not anti-vaccine as I do get my kids vaccinated. However I am anti-Offit vaccination schedule.

Any medicine where anyone says “it is good for everyone” should be looked at with a critical eye. We are missing genotype/phenotype differences. Vaccines do not cause autism. But some cases of autism if you look at the data do appear to be directly related to vaccines. There are other well documented cases of vaccine injury as well. But statistically these are so tiny it doesn’t matter and vaccines do way more good than harm. Except if you are that parent.

In addition could the seemingly increase in autoimmune diseases be a result of T regulatory cell dysregulation as a result of many vaccines early in life? What impact do several vaccines given at the same time or closely together do to our immune system checks and balances? The issue is we do not know. So shouldn’t we first practice “Do no harm”? Why is a 2 month old in affluent suburbia getting a Hep B vaccine?

I hope that in the not too distant future we’ll identify children that may be susceptible to dysregulation or a cytokine storm because of a their genotype SNPs and offer different vaccination options.

George Mandler

As a physician and immunologist, I am an ardent supporter of vaccines–one of the best uses of our healthcare dollar. I have many patients who are anti-vaccination, and rather than be confrontational, it is best to open a dialogue and understand reasoning and motivation. Everyone wants what is best for their kids, and with no guarantees in life, it is difficult to reach certain decisions.

Your piece is at once thoughtful and on-the-mark. Too many professionals (and patients) are zealots who have their opinions written in stone. Medicine is still an art, although guided by science. and science can be incomplete.

Recommendations as opposed to mandates.
Discussions as opposed to confrontations.
Listening as opposed to lecturing.
Evaluations without judgement.

If more docs followed the above advice, there would be far fewer vaccine refusals.

Have you an example of where lack of mandates has lead to higher vaccination rates?
Public health mandates are always politically tricky. But anti-vaccine sentiment is of a very similar nature to the sentiment that gives credibility to snake-oil salesmen and bogus cancer cures.
Yes, the medical profession is sometimes guilty of hubris, paternalism, and even corruption. That doesn’t mean it’s OK to suspend disbelief or cease being an advocate for sound medical principles when considering fringe and other alternative remedies.

Even though herd immunity is a population issue, I’m not sure I can support mandates. In addition, the decision not to vaccinate may not be a choice of “alternative remedies,” but may represent fear of an adverse reaction in a loved one.

We know that there a National Vaccine Injury Compensation Program that reimburses patients and families for injuries caused by vaccines (it’s funded by a levy on all vaccine makers). These are not for controversial claims (e.g., autism) but rather for well-described adverse reactions. Who is culpable in the rare event that a child suffers a serious reaction from a vaccine in a “vaccine-mandated” society–especially where the parents may not agree with the policy?

Does the issue of culpability exist solely because the patient would rather not be vaccinated? Culpability generally implies deviation from the “standard of care”.
I understand and respect your position. Public health mandates are always tricky.

At our core, most people are both naturally cautious AND willing to follow those we trust.

Our brains are wired this way. It takes a lot of time and effort to analyze every decision we make, so we use shortcuts like paying attention to bad outcomes AND copying those we trust when we believe they know more about an issue than we do.

I can sense and understand Dr. Offit’s frustrations, but Medical professionals, Pharma, and Government Public Health officials need to look squarely in the mirror on this one.

Many people simply don’t trust the people giving vaccination advice. (just like they don’t trust police, schools, the church, and many other previously trustworthy social institutions).

Trust and confidence lay the groundwork for persuasion. If people aren’t persuaded by your argument, it’s not because they don’t understand the facts. A non-trivial number of people simply don’t trust the groups giving the recommendation.

It’s tough to admit, but understanding the lack of trust is the first step to fixing the problem.

Are people less trusting of the medical profession today than (say) 50 or 70 years ago?
I think people in general are less likely to blindly follow authority. This is probably a good thing.
I fear though that we are just a significant epidemic away from panic. I’m just old enough (at 62) to remember the iron lung–and that Jonas Salk was offered a ticker-tape parade in NYC.
People forget–and that is probably NOT a good thing.

I remember the iron lung, as well. I remember standing in line for the polio vaccine at the local high school. I also remember my parents’ relief that it wouldn’t happen to us. After watching my friends have shingles I could not get the vaccine fast enough. Annual flu shot? Sign me up. I wonder if the anti vax position or the squeamishness about vaccines is due to the fact that people don’t remember how bad things were. My grandmother just about died from tetanus. My Mom told us that story and we remember and are grateful for the protection.

Don’t get me wrong–we have a problem here, and I agree with almost all the points made by Dr. Mandrola. When he says:

“You know I don’t have the answers to such a complex human problem. I suspect fear, bias, loss aversion (good health at the moment), mistrust of the medical establishment and an increasingly skeptical population are all components.”

…I am inclined to agree totally. That vaccine refuseniks show up in highly-educated populations–I highly doubt that interesting statistic correlates with any of Dr. Mandrola’s suspect factors (with the exception perhaps of mistrust of the medical establishment).
That mistrust I’m afraid is often based on facts. Dr. Mandrola has written of his feelings about the scale of the use of ablation for cardiac arrhythmia; anyone stopping to think of Fen-phen, Vioxx. the perceived over-hyping of the coming bird-flu epidemic (not to mention the apparent revolving door between the pharmaceutical industry and the FDA) has got to be thinking twice.
A recent measles epidemic in Brooklyn apparently was related to the edict of a local rabbi in the Hasidic community. So there is trust in authority–but that trust is selective.
I agree with you–most people don’t remember what it is like to live with epidemics. That’s why (as Dr. Mandrola notes) infectious diseases are not in the top 5 causes of death in children.
In effect, vaccines (and antibiotics!) are victims of their own success. But that can change.
To paraphrase an old cliche, “there are no vaccine-atheists in epidemics”.

I didn’t swallow any of the new-flu hysterias because I am (if barely) old enough to remember the swine-flu hysteria. But if Ebola spreads widely, a lot of people who now think they are anti-vaccine will be trampling over each other to be first in line for the vaccine.

I use preservative free IV nutrients because I don’t want my patients to be exposed to the preservatives. There are preservative free vaccines available and we use those vaccines. Preservatives like thimerisol and aluminum may preserve the shelf life, which is convenient for industry and doctors, but patients pay the price for this convenience. Aluminum is also in anti perspirants and a lot of the same types of patients who don’t want vaccines choose to use anti perspirants free deodorant. Why would they trust a doctor who smells like old spice and toxic cologne and eats GMO carb bombs for lunch. Doctors just aren’t as hip as many patients and patients know it. As an informed doctor I completely understand where the skepticism comes from because most of my colleagues are clueless about the basics of what constitutes a healthy diet and lifestyle, even if they are very nuanced about their prescription of pharmaceuticals.

Most people don’t, indeed, remember how bad epidemics of the most serious vaccine-preventable diseases used to be. Rationally, vaccine developers targeted the diseases that did the most harm first, picking the low-hanging fruit so to speak, which means that the vaccines they’ve been rolling out in recent years are for diseases that are less often dangerous. Everyone my age had chickenpox, and few of us knew of any child dying of it. When binary-thinking vaccine advocates bellow about chickenpox and about polio as if they had identical risks, parents who are old enough to remember chickenpox but not polio may accept the claim and thereby lowball the risks of polio.

Also, some of the newer vaccines, particularly those for chickenpox and rotavirus, have questionable long-term risk-benefit ratios; they certainly will do more harm than good for some and may, depending upon issues that are hard to predict, end up doing so at the population level. Those who deny this possibility do so as a matter of belief or ignorance of the issues involved. If they deny it to parents in an abusive way, the parents may well assume that their promotion of more valuable vaccines is likewise driven by emotion or dogma.

I agree with you. There is no question that some doctors will take the dogmatic, “eminence-based” approach.
I’m sure most will not though. For example, our pediatrician counseled against giving our toddler the chickenpox vaccine–almost certainly because he’d done his own risk-benefit analysis. Our daughter subsequently suffered a mild case of chickenpox.
However, when Gardasil was approved, he had no trouble recommending she have the series promptly.
I certainly don’t take for granted that my doctors actually think for themselves. They are the flavor of doctors I try to have whenever possible

The chickenpox vaccine – unlike the rotavirus vaccines – hardly ever does serious harm directly. A greater concern is that unlike the disease, it does not confer lifetime immunity – at least this is what the manufacturer wants you to believe, that like the tetanus shot, you must keep going back for “booster shots” every ten years forever. Otherwise, you may well end up getting adult chickenpox, which is far more dangerous than chickenpox in children.

A lot of people even now don’t get regular tetanus boosters, and that is a more dangerous disease with a cheaper vaccine. The NYT recently ran a story on the “skyrocketing” costs of vaccines. Health care in the U.S. keeps getting harder to afford (and Obamacare has not solved the problem). If you are not a devout cornucopian, you probably have started to suspect that trends including limits to resource extraction, the imminent decline of America’s empire, and our increasing Gini coefficient at home are going to squeeze more of us harder in coming decades. So would you want to bet a working-class or poor baby’s life that if he is immunized today, he will be able to afford those boosters at every stage of life for the next seventy or eighty years, easily enough that he will always make getting them a priority? Because if he can’t or doesn’t, the number of complications he and others in the same boat will suffer if they get chickenpox as adults will be high enough to outweigh the relatively rare harms from a larger number of childhood cases.

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