Please Vaccinate

Dear Parents (and others),

We write as concerned health professionals and community members. Our topic: Vaccination, or lack thereof, and risks to our health.

The urge to protect one’s children is one of the strongest known to humans (and other species, of course). Parents will sacrifice their own lives for their offspring, if needed. Thus it should not be so surprising that, when questions are raised about the safety of vaccines, many parents have concerns, and even forgo the shots—even though protecting children (and adults) from serious diseases is the reason that the vaccines exist.

This controversy has arisen ever since vaccines were first discovered, and is here again as infectious diseases such as measles and pertussis (whooping cough) reappear—following declines in vaccination rates in some communities, including in Northern California. While in the McCarthy-era 1950s vaccines could be derided as "communist', now there are strange bedfellows of boomers, new agers, and tea party politicos agreeing, mostly via the internet, that vaccines are both ineffective and dangerous, as well as only about profiteering. Accusations, blame and conspiracy theories abound. And thus in some areas, the percentages of unvaccinated children have increased to levels where real experts tell us that we are in danger of disease outbreaks otherwise considered to be threats from the past.

This is particularly important in the Bay Area, so much so that Jon Stewart recently mocked Marin County as being a center of “mindful stupidity” (ouch). The jab was spurred by a new California Department of Public Health report and database confirming that Marin’s rates of non-vaccination are among the very highest in the state. Stewart’s fellow television host Jimmy Kimmel then piled on, saying that some Californians seem "more frightened of gluten than smallpox.” Comedians Penn and Teller have a scathing video debunking anti-vaccination myths in profane terms. This month’s National Geographic magazine has the theme of “The War on Science,” with examples being climate change, evolution, the moon landings—and vaccination. Thus we become a laughing stock; but laugh as many might, the reality of the risk is not funny.

In some California schools, the percentage of kindergarteners who were vaccinated against the measles in the 2013-14 school year was lower than rates in the developing world. In Sudan, for example, 85 percent of 1-year-olds were vaccinated against measles in 2013, according to the World Health Organization. In our county of Marin that same year, only 54 percent of kindergarteners were immunized against measles at Bolinas-Stinson Elementary, and even less—2 students out of 11, or 18 percent, were reported as fully vaccinated. At the Bolinas Children’s Center, the rate was 35 percent fully vaccinated; At the Stinson Montessori School, one kid out of 13 (8 percent) was reported as fully vaccinated. In Marin overall, 84 percent of kindergartners are fully vaccinated; statewide, the rate is about 90 percent, with our neighbors to the north, Sonoma and Mendocino counties, higher than that overall. Anderson Valley Unified in Boonville reports 32 of 34 kindergartners fully vaccinated, or 94%; but in other places such as Fort Bragg, Laytonville, Ukiah, and Calpella, there are schools with much lower rates, down into the 50-60s % ranges.

Depending on factors such as the type of disease, most experts feel that vaccination rates should be at over 90 percent, with 95 percent or higher more optimal. "Reservoirs" of unvaccinated kids can be where outbreaks of diseases begin and spread. While confirmed medical exemptions are a tiny percentage of kids - less than half of one percent - the "personal belief exemption" rate rose for years, up to about 6% in 2013, with a bit of a decline last year, for multiple reasons, including a new law requiring a consult with an actual health professional before the "PBE" is granted. But it's still a problem.

We don’t expect to “solve” the vaccination controversies here—the arguments seem unresolvable to some, no matter how many facts are presented. We can only provide our own perspective, based on experience and training. And by way of disclaimer, it might be important to some readers to note that we are not “tools” of any organization or industry. As longtime medical and public health advocates, we offer our thoughts here as two who have adhered to no orthodoxy, choosing to challenge established thought and practice wherever we have hoped doing so would lead to better health. We have no financial interest in drug companies or anything else related to vaccines—in fact, one of us has developed policies to remove all pharmaceutical marketing in medical schools and hospitals, with some success so far. Again, we list this information only for those who might suspect our motives or orientation.

Here is our key point: Most medicine involves risk/benefit calculations. Virtually nothing is 100 percent risk-free, or 100 percent effective. Used wrongly, aspirin can kill. And yes, vaccines can have risks. But it is clear to us that, overall, the benefits far outweigh the risks both for the vast majority of individuals of all ages and for the community overall. Now, this can seem difficult to grasp—in part due to the success of vaccines over the decades, we don’t see the sickness and death that is being prevented anymore. With prevention, success means that something does not happen—and thus current generations have been fortunate to not live in continual fear of infectious diseases.

The Decline of Awful Diseases

One of us, Sadja, grew up in the 1930s, way before many vaccines were available. She distinctly remembers her mother’s fear of polio, the lack of understanding of its transmission, the avoidance of swimming pools, the iron lungs, the reliance on Sister Kenny’s methods of hot compresses and gentle movement of paralyzed limbs, our paralyzed President Roosevelt. When the Salk vaccine became available in the 1950s, it felt miraculous. That polio vaccinators are being murdered today in Pakistan and some African countries is horrible, as with universal vaccination, this virus could be eliminated.

While in medical school, she saw an 8-year-old boy die of tetanus, even though a vaccine was available but not widely used. She saw a child whose throat was clogged with diphtheria exudate, unable to breathe. She had whooping cough (pertussis) at age 11 and missed a half-year of school, as did many children, with convulsive coughing and vomiting. She saw desperately ill children with measles admitted to hospitals. She remembers the extreme fear of pregnant women who contracted ‘German measles’ (rubella) because of devastating birth defects that could ensue (women would sometimes say that they had German measles to qualify for an abortion, since this was the only way abortion could be legally obtained). Mumps can result in sterility for men, and also can affect a woman’s ovaries.

There are many other such examples of the painful and even lethal impacts of diseases that few people have encountered in recent years—fortunately for all of us. There are multiple reasons for this. As some anti-vaccination advocates note, many diseases have indeed declined in modern history prior to the introduction of the relevant vaccine (or other medical intervention). Contributors can include cleaner water and air, better food and better living conditions in general. But to sustain such healthy trends often takes both healthier communities and vaccination programs.

To give one striking example, the one disease eradicated by human effort in our time was smallpox, wiped out in Asia by a concerted, intense vaccination campaign. The experts there knew that they could not eliminate poverty, hunger, sewage and so forth in India, but that smallpox vaccination could interrupt the transmission of the horrible disease long enough for it to die out. After millions of vaccinations, it worked, even though the other conditions stayed the same. It was a targeted triumph that has prevented incalculable suffering and death since the 1970s. And there are other such examples; your other co-author here, Steve, has seen entire hospital wards in Asia and Africa that had been converted from infectious disease units, usually places of rampant death, into much less lethal places as those diseases became rare following international health programs with vaccination as their key weapon.

Measles is currently in the news. Yes, as with Ebola, some of the reporting has been sensationalistic and some political statements absurd. But think of this—throughout the world, measles kills about 400 children every day, and many more are made very ill, some with lasting problems. Historically it has been one of the most lethal infections affecting humans. The success of measles vaccination has made us either forget that or never know what this infection can do. Considering that, and that until recently there were hardly any cases at all in our country (as opposed to, say, a recent and ongoing outbreak of over 50,000 cases and many deaths in the Philippines), even the relatively small “Disneyland outbreak” we are seeing is very concerning to us - and it has now been traced to unvaccinated kids. Although it may be unlikely that a big outbreak will spread as in the past—primarily due to many people being vaccinated—it is a frightening reminder to us of the suffering of those times.

Ironically, one positive side-effect of the current measles outbreak and all the attention that it has garnered is a reported increase in parents asking more questions about vaccination and how they might best protect their children—this might result in increased vaccinations, but it is still too early to confirm that.

True Expertise—and Concern

Every pediatrician—every doctor, in fact—who we know, vaccinates themselves and their kids. They love their children as much as anybody. They tend to really like their young patients, too (OK, with maybe a few exceptions). They know, science, see the effects of their interventions and report the rare bad reactions when they do occur. And for doctors who give such shots, vaccines are rarely, if ever, moneymakers—sometimes the contrary, as insurers will reimburse so poorly that it actually costs a practice to administer the shots. But doctors provide vaccination anyway for any patient unless there is a medical reason not to do so, and that is because it works. To do anything other than what is best for the patient is rightly seen as a dereliction of duty.

The vast majority of scientists who have studied vaccines, support giving them. Large panels of scientists from far and wide and many disciplines have agreed. Even most who have questioned some aspects of vaccination still tend to favor vaccines. This is true for journalists as well—see, for example, Robert Kennedy, who favors making vaccines safer but is still pro-vaccine. Likewise, there has been much online talk of a possible Centers for Disease Control “whistle-blower” who has come forth to question research and practices done while he was at the CDC—but who still says, “I want to be absolutely clear that I believe vaccines have saved and continue to save countless lives. I would never suggest that any parent avoid vaccinating children of any race. Vaccines prevent serious diseases, and the risks associated with their administration are vastly outweighed by their individual and societal benefits.”

But research has shown that for some reason, many people give equal weight to nonscientific, unsupportable sources, such as online comments and editorials by self-appointed advocates with little or no scientific background. This reminds us of the climate change debate. More than 95 percent of the real experts agree that humans are causing global warming, but a small percentage get “equal time” in the media and even influence policy and behavior (and of course, there is big money behind “climate denial”). In the case of vaccine denialism, it seems that mistrust of authority (not always a bad thing!), a lack of science education and the parental instinct we started with above play into non-vaccination. A certain small number of crusaders presume to know more than almost everybody else, even though most of them have little to no training in relevant disciplines. Try, for a moment, to imagine how it feels for well-motivated scientists and doctors, who have spent many years learning how to understand and apply science to improve human health, to be attacked by those who, like anti-vaccine activist and actress Jenny McCarthy, proudly admit that, “The University of Google is where I got my degree from.”

The Autism Non-Connection

Based on many discussions we’ve had, parents in Marin and elsewhere express concerns not only about links to serious conditions like autism or cancer, but about the general issue of possibly overloading a child’s immune system with too many vaccinations in too short a time, or even “poisoning” them with toxins that they have heard are in vaccinations. But many who once believed that an autism connection existed are backing away from that position, convinced by evidence. There are many nuances in this debate, and even some reputable researchers who allow that in some limited cases, older vaccines might have “tipped” some children towards problems in the past—although the vaccines in question have been made even safer now.

Extensive analysis of all available good studies has not supported the fears that vaccines have contributed to the rise in autism and similar conditions. The most recent “meta-analysis” of many studies found, like all the others, that “vaccinations are not associated with the development of autism or autism spectrum disorder. Furthermore, the components of the vaccines (thimerosal or mercury) or multiple vaccines (MMR) are not associated with the development of autism or autism spectrum disorder.” On the other hand, the most recent study purporting to link autism to vaccines has been withdrawn, since the author used bad methods and had conflicts of interest—much like the original study that started this debate.

Autism Speaks, the nation’s leading autism advocacy group, just released a statement saying, “Vaccines do not cause autism … We urge that all children be fully vaccinated.” Which is what every medical group which has closely examined this issue has concluded as well, and again, the researcher who first brought it up has been wholly discredited and sanctioned, his medical license revoked. Something else is going on, causing the rise in autism. In addition to possible culprits like advanced maternal and/or paternal age at pregnancy, various infections, maybe even antidepressants taken during pregnancy, and more, there might indeed be environmental factors in autism—chemical pollution, for example.

Regarding risk in general, again, almost nothing is totally risk-free. With respect to vaccines, very rarely, the side-effects from a vaccine can be severe. Some people are likely more susceptible to bad reactions, and vaccines carry warnings to evaluate patients for such known risks, but not all can be prevented. About one person per million will have a severe allergic reaction to the MMR vaccine. Mostly, though, it’s a mild reaction, if anything. Such statistics are true for most vaccines, and researchers are continually trying to make them even safer, as they should.

Thin Conspiracy Theories

For those who think that the medical/scientific “establishment” has conspired to hide the ill effects of vaccines for profit or other reasons, again, we are not always fans of “big pharma,” but cannot support that allegation. First, there would be much more potential financial profit for drug companies and the medical industry from sick people than from preventing diseases. For even the biggest vaccine manufacturers such as Merck, vaccines make up only about 10% of their business, and are one of the less profitable sectors (and thus the need for protection from lawsuits, or few if any companies would make vaccines at all).

Also, scientists are trained to be competitive and to debunk theories and discoveries; reputation is everything in both science and medicine. The idea that tens of thousands of scientists from all over the world would collaborate on such a vast hoax to sell bad vaccines and hide ill effects is less believable to us than most anything else in this debate. And we must observe, again, that some of the most prominent anti-vaccine figures have been discredited, even convicted, of the very kind of transgressions they have alleged that thousands of others have done. Some have tried to profit from the uncertainty they create by selling questionable “cures” for diseases. Now that is shameful.

For those who believe/hope that optimal nutrition and “natural” foods, supplements, etc., will make one and one’s kids immune from disease—and that “big medicine” or “big pharma” repress such products to keep them from competing—there is really no good evidence of that. We, as longtime proponents of healthy eating and nutrition, wish it were true that such good practices could protect us from infections. But it is not. General immunity might well be improved by smart diet and exercise, but the kinds of diseases that vaccines prevent respect no such robust health. Likewise, there is no evidence that “alternative” approaches such as chiropractic, etc., can make one immune to such infections. And frankly, it is unethical to claim they do, as misleading people in this manner—usually done by people who themselves have a financial interest in selling something—can endanger both individuals and others in the community.

Vaccination and Community Solidarity

On a somewhat more philosophical note, effective vaccination requires a form of solidarity—meaning, community consciousness and action. “Herd immunity,” wherein protection for a community comes from most people being vaccinated, is a complex but very real phenomenon. It takes all of us doing our part, vaccinating our children and ourselves where indicated. Relying on others to make our community, schools and kids safe by vaccinating, even if you don’t believe in it yourself, is just not in the collective spirit that has made our communities the great places they have long been.

One should not be using others’ kids as a sort of “human shield” to keep your own safe. Babies who are still too young to be vaccinated are put at risk. Plus, it simply doesn’t work to try to “self-quarantine” oneself and hope the broader hazards won’t impact you and your loved ones. As Dr. Phil Landrigan, one of the best environmental scientists and pediatricians around recently said, “Rather than worry about a vaccine-autism connection that has been proven not to exist, parents should be banding together and writing their elected officials to insist that chemicals be properly tested for toxicity to children before they are allowed to enter the American market. The Europeans have passed such legislation. We should, too.”

We agree. We believe that policies have made it not only too easy for pollution of all kinds to affect our health and environment, but also for parents to be overly influenced by bad information and to opt out of vaccination due to unfounded fears. Proposals are now being made to make it much more difficult to opt out, to ban unvaccinated kids from schools and so forth. Some of these might make sense, some less so. We do not believe in taking away parental rights, but parents who do vaccinate, who have kids with immune problems or other medical conditions that put them at risk, and so forth have rights, too. There should be reasonable consequences for not doing the right thing, such as less access to schools, public spaces, and the like. The UC system will soon require that all students are vaccinated; would a parent be well advised to eliminate their kids’ chance of going to a UC campus because of bad advice from the Internet? We wish that every parent would avail themselves of solid scientific information and a sense of communal responsibility that good public health requires.

Dr. Mike Witte, family practitioner and pediatrician since 1981 with the Coastal Health Alliance in West Marin, says, “There are still too many vaccine holdouts to ensure overall protection of our communities. Will legislation at the state level change this? Maybe. We would be relieved to have this decision made firmer under the law. But our job as healthcare professionals, and as a society, is in finding much better ways to communicate this real science so that it can be heard and trusted by many more of the vaccine doubters.”

We agree, and that is our intention here as well—not to force vaccination but to show that it is the right thing to do. We should not go back to the time when now-preventable diseases were prevalent: It seems tragic that so many people are not taking advantage of the amazing gifts of vaccination. We hope that every parent—every adult—who has kids who are not fully vaccinated, or who are not vaccinated themselves, will consider the facts, the health of their kids, and of the community, and seek advice from their pediatricians and doctors. If they go in with an open mind, and with the kind of trust they otherwise likely place in them, they might be surprised. They will work with people to confront their fears, and the misinformation that they might have heard elsewhere. You might well check to see if your own adult shots are up to date as well. And then—vaccinate.

We thank you for your attention. Good health to you and yours.

Sadja Greenwood is a retired physician and public health advocate who writes a health column for the ‘Bolinas Hearsay News’ and the ‘Point Reyes Light’. She was an Assistant Clinical Professor in the Department of Obstetrics, Gynecology and Reproductive Sciences at UCSF. Steve Heilig is a veteran health advocate trained in epidemiology, environmental and public health, and medical ethics. He works at Commonweal in Bolinas and with the San Francisco Medical Society (which accepts no pharmaceutical industry support) and is an editor of both the Cambridge Quarterly of Healthcare Ethics and the ‘Bolinas Hearsay News’. Different versions of this plea recently appeared in Marin's Pacific Sun, the Bolinas Hearsay News and the Point Reyes Light.

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