“If you ask 99.9% of parents who have children with autism if we’d rather have the measles versus autism, we’d sign up for the measles, ” said Jenny McCarthy in 2010.
In 2015, the state of Washington reported the first U.S. measles death in 12 years.
Battleground #1: California: A Tale of Two Cities
“The Happiest Place on Earth”, otherwise known as Disneyland in Anaheim ironically served as the petri dish for the highly publicized measles outbreak in December 2014. While the origin of the measles outbreak was not identified, traveler/s could have arrived from any number of countries as Disneyland attracts visitors from around the globe. Thereafter, cases connected to the outbreak were confirmed in at least 7 other U.S. states as well as Canada and Mexico, thus demonstrating how rapidly and how far a measles outbreak can spread. Among infected California patients, 45% were unvaccinated, which enabled the outbreak to persevere.
A map of MMR kindergarten vaccination rates for the 2015-2016 school year across California counties reveals that it is the land of extremes and contradictions: a tale of two cities. While California is home to innovative tech startups, it also is a powerhouse of agriculture, an genesis of civilization. Billion dollar mansions with vaulted ceilings in Beverly Hills tower only a dozen miles from Skid Row, where tents, cardboard boxes, or simply the starlit sky serve as the roof for thousands of homeless. California boasts nature’s skyscrapers, the redwoods, which grow up to 250 feet tall, but never reside more than 50 miles inland from sea (level). Superimposing just about every demographic onto this map: net worth, income, political leaning, education, race, religion, work industry, etc. doesn’t recapitulate the MMR kindergarten vaccination trend. Because objections to vaccination seem convoluted, let’s superimpose some noteworthy (and partially tongue in cheek) commentary on to the vaccination map.
Not to exaggerate the lack of vaccination coverage, in 2015-2016, California (94.5%) matched the national average (94.6%) among children in kindergarten and was not the least vaccinated state, which was Colorado (87.1%). Despite high overall coverage, susceptible pockets still exist. California reported 19 kindergarten schools with less than 50% vaccination rate. Herd immunity is defined as the requisite ratio of a vaccinated populace to prevent an epidemic. In a population in which a large number of individuals are immune, chains of infection are likely to be disrupted, which delays the spread of disease. It follows that the greater the proportion of individuals in a community who are immune, the smaller the probability that those who are not immune will come into contact with an infectious individual. Measles, in particular, is a highly contagious disease that can live up to 2 hours in an airspace where the infected person coughed or sneezed. Due to such a high contagious rate, the herd immunity threshold for measles is likewise high: 90–95%. Although most demographics do not capture the vaccination compliance trend in California, one variable did emerge as a fairly accurate vaccination exemption predictor. Private kindergartens had a significantly higher percentage of both medical and philosophical exemptions from vaccines than public kindergartens.
The conjuncture of the infamous Disneyland outbreak and caches of kindergartens dangerously under-vaccinated by herd immunity standards prompted Richard Pan, a freshman Democratic Senator, and interestingly, also a practicing pediatrician, to introduce California Senate Bill 277. Signed into legislation in 2015 and enforced in 2016, SB277 effectively outlawed philosophical beliefs as a means to exempt children from school vaccinations. Only properly documented medical exemptions remain a viable option if you don’t want to home school your children.
As is a common combination, this measure was met with both immense success—vaccination rates skyrocketed—and passionate opposition—Senator Pan has since received death threats.
A Google search of the prominent figure on the opposing side of the vaccination debate, Andrew Wakefield, does not currently return any hits for death threats.
Battleground #2: Texas: Catalonia of America
Recall from Part I, Andrew Wakefield garnered international notoriety after publishing a henceforth-retracted paper that linked the MMR vaccine to autism. Years after the atypical retraction of a research paper and years after the ignominious revocation of his medical license, Andrew Wakefield still defends his anti-vaccination position—not from the pulpit of his hometown or former employment in Bath or London, respectively. Nay, Andrew Wakefield has since selected a residence that could not be more diametrically opposed to ancient Roman baths, fish and chips, and cold and moldy cobblestone streets. In 2007, Andrew Wakefield moved to Texas, the wide-open frontier of cowboys, BBQ, sunshine, and where the primary moisture source is now that which seeps out from the brim of a ten-gallon hat on a smoldering day.
Asked in 2011 by The New York Times if he still believed MMR causes autism, he was unequivocal. “Is that a serious question?” he asked. “Yes, I do still think MMR is causing it.” Wakefield has since appeared all over Texas at screenings of Vaxxed, a recent film he directed, and has testified at many city councils. “Wakefield doesn’t just have a dog in this fight; he is the dog,” said Indiewire’s review of the film.
“Texas is now the center of the antivaxxer movement,” said Peter Hotez, an infectious disease researcher at Baylor College. The Lone Star State (97.6%) exceeded the national average (94.6%) of kindergarten vaccine coverage, however, like The Golden State, contains worrisome pockets of low coverage. For example, one school in Austin reported 60% MMR vaccination coverage, which is well below the measles herd immunity threshold. Prior to the passage of SB277, California was the most populous of the 18 U.S. states that permitted philosophical exemptions from vaccines. Now Texas holds such a title with 27 million residents and boasts steadily increasing rates of philosophical exemptions.
In California, a Democrat, successfully introduced SB277. In Texas, Jason Villalba, a Republican, penned a bill just like California’s SB277. However, this bill was quickly scrapped and a newly energized PAC named Texans for Vaccine Choice sprung up in its wake. The PAC’s goal is to safeguard a parent’s right to opt out of immunization requirements and their website states, “Help us take a stand for liberty”.
Like Catalonia is to Spain, Texas has a history of threatening to secede and a culture of pride, independence, and liberty. The latter and its nuances are becoming more important in the vaccine discussion. Vaccination rights defenders frequently harbor a deep distrust of government. According to a Nature editorial, “They often suggest that vaccination is…an infringement of personal liberty and choice.” If one believes to have the moral right to philosophical exemptions to vaccines, do others, who are too frail to receive vaccinations like immune-compromised cancer patients or the elderly, have a moral right to the benefits of herd immunity?
Before we delve into philosophical ideals that underpin the vaccine debate, let’s zoom out from the big contenders of California and Texas and investigate any national trends as both Republicans and Democrats have been sponsoring vaccine-related legislation.
According to the Pew Research Center, older adults and Democrats, separately, are more likely to say that childhood vaccines should be required. As with all surveys, the wording of the question and whom you ask (this study has n = 1840) may affect results. Nevertheless, it is interesting that these differences across both age and party affiliation did not materialize back in a 2009 survey. What was happening around 2009? Wakefield’s seminal article was published in 1998, but then the vaccine debate in the U.S. was just barely a kindle. By 2009, the wild fire was roaring. In the year that followed, Jenny McCarthy gave her incendiary interview to Frontline and Andrew Wakefield’s paper was retracted and his medical license revoked.
With regard to the age dichotomy, it seems remiss not to remark that older adults are likely to have either witnessed or heard about someone with an infectious disease. Of course, until 1945, the United States of America had its most public of figures, a president, paralyzed from the waist down due to polio.
Gender, education, race, and ethnicity are not significant predictors of views on vaccines. According to the Pew Research Center, there is a slight trend that Hispanics believe vaccines should be required.
One cannot ignore the legacy of race and trust issues in the health care system dating back to the infamous Tuskegee clinical study conducted between 1932 and 1972 by the U.S. Public Health Service. With the concomitant discovery of WWII atrocities performed by Nazi doctors in the backdrop, several important bioethical standards arose during this time. In the U.S., the National Research Act of 1974 established institutional review boards (IRBs) that require that all patients involved in study be willing and voluntary participants. Mostly importantly, IRBs contain informed consent, which has since been the cornerstone governing ethical healthcare to date. Interestingly, informed consent is now often evoked in opposition to vaccination and is also related to the aforementioned notion of personal liberty.
For our final section, let’s scrutinize the primary pillars of vaccine opposition. Data will be cited for due measure, however, the focus will be on philosophies behind the objections, which is less often discussed, yet likely more requisite in order to string a productive dialogue between both sides of the debate.
Philosophical objections to vaccines
Vaccine Objection #1: Institutions/individuals in the vaccine business have dubious motives
“[There is] way too much conflict of interest [about private industry working with public health]. Like Paul Offit, who profits off of the vaccine he invented,” said Jenny McCarthy.
“When Jonas Salk invented the polio vaccine he was a hero — and I’m a terrorist?” said Paul Offit. Dr. Offit is a pediatrician at Children’s Hospital of Philadelphia and the co-inventor of a vaccine against rotavirus, a diarrheal disease that kills 600,000 children a year in poor countries.
Is the individual or the government responsible for maintaining health? If something goes wrong, is someone liable? If so, who? How much profit is acceptable in the healthcare field?
For physicians, it appears they are barely breaking even from vaccines as one study demonstrated that costs of vaccine administration exceeded reimbursement from some insurers and health plans. For pharmaceutical companies, the vaccine market is estimated as $24 billion, which is substantial, but only represents 1-3% of a trillion-dollar global pharmaceutical market. All 4 giants currently manufacturing vaccines (GSK, Sanofi-Aventis, Merck, and Pfizer) could stop making vaccines tomorrow and remain solvent. Vaccine production is a risky business in itself because the premise entails administering a drug to healthy people. If anything befalls an individual, it may be attributed (incorrectly) to the vaccine. Indeed, vaccines were the first group of medical products that were nearly decimated into extinction by lawsuits. In 1974, a British research team claimed the pertussis vaccine caused permanent damage in 22 children. Like the Wakefield article linking MMR to autism, this claim was scientifically debunked. Notwithstanding, a plaintiff in a lawsuit received remuneration from Pharma to the tune of $1.13 million, which was equivalent to more than half of the pertussis market at the time. Perceiving liability and a precarious change of winds, many risk-averse Pharma companies decided to abandon the vaccine business, which only comprised a small segment of their portfolio.
In order to stave off an emergency of vaccine shortages, Congress intervened by passing the National Childhood Vaccine Injury Act (NCVIA) in 1986, which included a program designed to protect Pharma from lawsuits. Because of the protections embedded the NCVIA, at least a few Pharma manufacturers remained in the business and a vaccine shortage crisis was averted. Those with vaccine objections view the NCVIA as a government-sponsored bribe shielding the pharmaceutical industry from liability. Perhaps, but without Congress’s intervention, Pharma companies seemingly would have been sued into oblivion. How then would you have obtained a vaccine if you so desired?
The healthcare field is rife with unique expectations unlike any other field. Physicians are expected to be benevolent while simultaneously shouldering liability. For example, when attendants on a plane ask for medical help, one expects a physician on board to nobly raise his or her hand, failing to realize that the situation is fraught with legal liability if anything goes wrong, or if the plane has crossed state or international borders.
In the United States, vaccines are generally accessible and affordable. In contrast, the diseases they prevent are costly and would exert an enormous strain on the healthcare system. If you contracted either diphtheria or tetanus, preventable by a DTaP for about $20 (or, a $51.67 vaccine, QuadracelTM, which also covers polio), your probability of hospitalization is 100%, which means you sitting in a hospital bed is inevitable. The inpatient costs are estimated as $16,982 for diphtheria and $102,584 for tetanus. It seems reasonable to speculate that Pharma companies could profit more if patients opted out of vaccines, contracted a disease, and were administered relevant other drugs in an inpatient setting. (The sky-high cost of our current healthcare system merits its own blog post.)
Vaccine objectors also allege that pharmaceutical companies instill dangerous excipients, such as thimerosal, into vaccines, which make people sick. Thimerosal is a mercury-containing compound that has been used as a preservative in vaccines since the 1930s to prevent potentially life threatening contaminations with harmful microbes. The FDA cites 27 publications from around the world that support the claim that thimerosal is safe. Furthermore, all vaccines routinely recommended for children 6 years of age and younger are already available in formulations that do not contain thimerosal. A common misconception is that Pharma companies sprinkle in a few toxic preservatives like consciously turning the wheel on a pepper grinder over a meal. In biology, one does not have the ability to check off a Santa Claus-like wish list of all the perfect desirable parameters. Rather, researchers scan thousands of options before selecting the best with which to move forward. Other times, researchers simply choose the solution they more or less stumbled upon, because, first and foremost, it worked. The origin of thimerosal was the latter: it worked by preventing contamination and researchers didn’t just throw in a splash of mercury for good measure. Optimization comes later through iteration…
In addition to concerns about thimersoal, vaccine objectors find the CDC’s recommended immunization schedule suspect. Since 1983, the CDC has significantly increased the number of recommended vaccines and shots. As one would expect, the CDC goes to great lengths to justify their recommendations, citing a dramatic decrease in the number of vaccine-preventable diseases. Despite being inoculated with more vaccines, children today are actually exposed to fewer antigens than ever due to Pharma’s optimization in manufacturing over the years. If you were shown the data, would you believe it?
Vaccine Objection #2: Increasing prevalence of autism is related to vaccines
Many researchers from around the world revealed there is nominal evidence linking the MMR vaccine to autism. One meta-analysis of over 14 million children found i) the MMR vaccine dose is at least 95% effective in preventing measles and ii) exposure to the MMR vaccine was unlikely to be associated with autism. So if MMR doesn’t cause autism, why is there a rise in autism?
Peter Bearman, a Columbia University sociologist, accounts for more than 50% of the observed increase in autism: 25% can be attributed to diagnostic accretion, 15% to greater awareness, 10% to parental age, and 4% to spatial clustering. To clarify, diagnostic accretion means that some children who would have been diagnosed as mentally retarded a decade ago may now be diagnosed with autism. Spatial or geographic clustering refers to a phenomenon, currently occurring in West Hollywood, wherein a neighborhood of parents and specialists spread awareness of a disease in a positive feedback loop, which produces more autism diagnoses. It is worth mentioning that diagnosing autism is inherently challenging because there is no definitive biomarker. Rather, physicians subjectively chronicle a child’s behavior and development. To wit, Leo Kanner, the first to describe autism in 1943, coined the term “refrigerator mothers” hypothesizing that cold, unloving mothers beget autistic children. With the prospect of such a hurtful stigma in the 1940s, do you think parents, especially mothers, would have visited a physician only to receive the blame for an autism diagnosis? Even today with the general cultural acceptance of autism, parents agonize over whether they could have done something to prevent it, hence the discussion of vaccine safety particularly among parents with an autistic child.
Approximately 46% of increasing cases of autism are unaccounted for and thus, likely ascribed to genetic and/or environmental factors. While autism, asthma, type I diabetes, and food allergies are all on the rise, only the increasing diagnoses of the former seem to be contentious. It is easy to conflate correlation and causation as the CDC’s increasing vaccine schedule is indeed concomitant with the rise of autism. However, such a theory conveniently ignores the fact that we are living in a very different world and engaged in very different activities than our ancestors. Namely, our eating habits have evolved and we are constantly exposed to pollutants and toxins. Decoupling all these variables in addition to the fact that autism may be multifactorial means a definitive simple answer for the rise in autism is challenging, if not unlikely.
In the meantime, on whom does the burden of proof lie? As it has already been determined that MMR is not the sole cause of autism, most vaccine objectors believe that the burden of proof rests on others to prove that something else definitively causes autism otherwise their vaccine suspicion stands.
“In science credit goes to the man who convinces the world, not the man to whom the idea first occurs.”
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