Vaccines: There’s No Controversy

Parents are nervous about vaccines. They involve needles, for crying out loud! (Babies literally cry out loud when they get them.) And aren’t vaccines full of toxins? Well… no.

There is no controversy

Many parents believe that there is a controversy about vaccine safety. The truth is that there is no controversy, despite what you may have read, here and elsewhere. Vaccine safety has been investigated ad nauseam, and in very large population studies (sometimes entire countries). No study, published in a reputable, peer-reviewed journal has been able to find any negative health consequences of vaccines. None.

The truth is that, apart from synthetic fibers and indoor plumbing, vaccines are the single greatest public health triumph in human history.

Do vaccines cause Autism?

No. They do not. This is one aspect of vaccine lore which really needs to be abandoned. Not only do vaccines have nothing to do with the autism spectrum, vaccines have not been associated with any bad neurodevelopmental outcome of any kind. A few years ago, the anti-vaccine movement (including RFK, Jr) blamed the mercury-containing preservative Thimerosal for causing autism.  The journal Pediatrics published three reviews showing that Thimerosal had nothing to do with autism. That was back in 2004. It shouldn’t be a surprise that no one talks about Thimerosal any more.

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The dose makes the poison

Yeah, but vaccines are chock full of poisonous preservatives, aluminum and whatnot, am I right? Aluminum and other things, yes. Chock full, no. Something the anti-vaccine movement does not understand is that miniscule amounts of any compound are generally harmless. How much arsenic do you consume every day? Serious question. On the other hand, large amounts of “harmless” substances can be lethal. Drinking excessive amounts of water all at once will kill you (from brain swelling). Seriously, don’t try it – you’ll die.

Are vaccines a “public good”?

By definition, a public good is something that is non-excludable and non-rival. They are non-excludable because the non-vaccinating crowd cannot be excluded from benefitting from the herd immunity that the vaccinated majority provides. Vaccines are non-rival because my getting my kid vaccinated does not prevent another kid from getting vaccinated.

Having said all that

vaccines
I’m goin’ back to Cali, to Cali, to Cali

Now, anti-vaxxers do have a point about some things. Universal vaccine programs tend to employ the coercive power of the state to get to vaccinate your kids.  In California right now, you can’t get into school without being vaccinated, and religious exemptions no longer work, as of January 2016. That’s a shame. There are extremely few things that are so good that the government has to force you to do them. Unfortunately, vaccination is one of them. There ought to be a better way to persuade folks to do the right thing, short of bringing down the “benevolent” hand of the State.

Extremism 2 – Nuance 0

The other problem with the entire vaccine debate is that nuanced arguments get drowned out by all the screaming from the Pro and the Anti camps. That too is a shame, because there is a great deal of nuance to be explored between the extremes.

Most parents are concerned that vaccines are toxic. I’m concerned that they won’t work. If all people scrutinized everything else that happens in medicine as closely as some people scrutinize vaccines, the world would be a better place. But people don’t scrutinize everything that happens in medicine. This is an even bigger shame.

vaccines
Now, turn your head and cough

Some vaccines are better than others, in many ways. The Whooping Cough vaccine, DTaP, sucks. It simply sucks. The effect lasts 5 years, maybe. The Smallpox vaccine on the other hand, is great. I should say was great. You see, Smallpox was wiped out world-wide because of the vaccine, in 1977.

And polio vaccine is about to do what Smallpox vaccine did 40 years ago. And when that happens, it will represent an even greater public health victory than the Smallpox win. Why? Smallpox you could only get from another person you got close to. You can get Polio from infected water, like in a swimming pool. It’s much much harder to eradicate. But we’re very close.

There’s lots more nuance to discuss, but I’ll mention only one more: Tetanus vaccine. There’s no reason why you should keep a kid out of school for not having a Tetanus vaccine. Why not? Because Tetanus is the only infectious disease we vaccinate against that you can’t catch from another person. You get it from a bacterium that lives in dirt. But it’ll kill you if you get it. There’s no cure for Tetanus. Get the vaccine. For the love of God, get it.

 

 

Rush

When I was growing up, the expression “emergency room”, was always appended to the expression “rushed to”, as in “he was rushed to the emergency room”. It was always rush.

Of course you got rushed to the emergency room: There was some kind of emergency going on! Either you were having a seizure, or you fell off a ladder and broke several bones, or you were having crushing chest pain radiating down your leftrush arm… And virtually always you were rushed to that emergency room in an ambulance.

Emergency rooms back in the day didn’t look like they do today. There was very little regular staff, certainly no dedicated emergency room doctors.  An excellent picture of the 1960’s emergency room is drawn by the film Parkland , which tells the story of the doctors of Dallas’ Parkland Hospital on November 22, 1963, the day JFK was assassinated.  Every physician called to the emergency room that day (and by the looks of it, by the end, every physician in the house was in that room) had been elsewhere in the hospital prior to the President’s arrival.   None were dressed in scrubs or operating room gear. Each was wearing white shirt, tie, and black pants. And each was fairly drenched in the President’s blood by the end of the code (which is wrenching to watch).

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Where’s the rush?

A lot has changed in 52 years. The expressions “emergency room” and “rushed to” have been separated. Ambulances often bring people there, but more often than not people are driven there by family, or drive themselves (presumably not in mid-seizure).

The expression “emergency room” itself has evolved to “Emergency Department”, to reflect the fact that these formerly empty, intermittently used spaces are now fully functional, fully staffed parts of a hospital.

Sometimes the word “emergency” is dropped entirely when one talks about a medical misadventure. The word “hospital” is substituted. “I went to the hospital”. “We took her to the hospital”.  Well of course, the individual went to the hospital, but not exactly.  They went to the emergency room of the hospital. This may be because of tacit acknowledgment that there was no true emergency, but I cannot be sure.

Why does all this matter?

As I hope to describe in future posts, the transformation of the emergency room into the Emergency Department is central to the story I am trying to tell in this blog. It is a multi-layered and nuanced story and by no means do I intend to distill the many issues down to One Big Thing.

For now, I will observe only that the disappearance of the expression “rushed to” is a symptom of our culture of over-treatment, about which I will have much to say later. There are two foci in the universe of over-treatment: one is the private doctor’s office, and the other is the Emergency Department.  How the universe of over-treatment came into being is a long story with many parts.

Stay tuned.

Over-Treatment

Our culture of over-treatment is the subject of one of the main arguments I make on this blog. To discuss it properly we need to define our terms.

Over-treatment…

over-treatment
according to the Free Dictionary is “the treatment of clinically insignificant disease, that is, minor or indolent illnesses that do not require aggressive or invasive therapy.” Reilly and Evans, writing in the Annals of Internal Medicine, refer to the phenomenon as “unnecessary care”, and define it as “diagnostic or treatment service that provides no demonstrable benefit to a patient.” They argued that 30% of all medical care in the United States (in 2009) might have met their definition.

My Definition

I tend to employ a broader definition that encompasses what I have already referred to as The Culture of Over-Treatment: Over-testing, over-medication, over-referral (to specialists), and over-hospitalization. The common feature of these four “overs” is that they satisfy Reilly and Evans’ condition of failing to provide demonstrable benefit to a patient. The “culture” of over-treatment refers to the institutions, practices, and mind-sets that propagate unnecessary care.

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Harm

And I take the argument further. I claim not only does over-treatment fail to provide benefit, but that over-treatment does harm. Always. Sometimes the harms are small – the recipient of over-treatment isn’t physically harmed but treatment cost money that didn’t need to be spent. Or the treatment did nothing but cause anxiety. This is difficult to measure but cannot be discounted – in future posts I hope to deal more fully with the “anxiety factor.” And finally there is physical harm.  It’s bad enough when people are harmed in the course of treatment that threaten life or limb: when injuries happen in the course of over-treatment, it is doubly catastrophic.

Measurement of harm in medicine is a relatively new phenomenon. Harms studies are different from mere complication rates after surgery or rates of readmission after hospitalization. Today, more attention is paid to adverse outcomes from tests and treatments previously thought to be innocuous, such as routine blood tests, or antivirals for the treatment of Influenza.

But the harms that interest me the most are more difficult to define and quantify, but are no less devastating, and these are harms related to the ways we think about ourselves: our lives, our health and wellness, and particularly the way we experience our children.

There are several excellent books on the subject, especially “Overtreated” by Shannon Brownlee, about which I have a personal story that will have to wait for a future post.

I hope the tide is turning away from the culture of over-treatment but I see no solid evidence of this happening.  Talking about it is the best way I know how to buck the trend.  Read on.

The Myth of the Unhealthy Child

My mother once told me that when she and my father were starting our family in the mid 1950’s, she never imagined that she would give birth to unhealthy children. As it turns out, she was right: between 1956 and 1964 she gave birth to four healthy babies. My mother’s expectations were not all that unusual: Sixty years ago, most parents expected that their children were probably going to be born healthy and grow up to lead healthy lives.

Infant Mortality

Most parents believed this despite the fact that the infant mortality rate was 26 per 1000 live births, over four times what it is today. Polio was still a threat, and public swimming pools were regularly closed during the summers of the 1950’s for fear of polio. As if polio weren’t scary enough, twice as many children were dying of Measles as from Polio in 1956. We were years away from an effective Measles vaccine.

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And in an age where car seats were never heard of, and seatbelt laws did not exist, four times as many children died in accidents in 1956 compared today.

And yet, our parents believed we would probably be born healthy and grow up safe and sound. They believed that children were essentially healthy human beings. That is to say, it is an element of their essence that children are healthy.  Sure, things would happen: they’d catch the flu, they’d fall down and break a bone, but the children were essentially healthy and they’d recover.

Fast forward to 2016

The mindset that was common among my mother’s peers has been turned on its head. Instead of believing that their children are essentially healthy, it is common today for parents to believe that their children are essentially un-healthy. A version of this mindset is that their children are potentially unhealthy, one sniffle away from certain doom.

The facts suggest the complete opposite.  Babies born in 2016 in the United States belong to a cohort of human beings who are the healthiest that have ever lived on planet Earth. That is not just pie-in-the-sky optimism: that is demonstrable fact. And yet parents are more worried than ever that their children are sick or will become sick.

It is the aim of this blog to explore this phenomenon of the “Essentially Unhealthy Child”: to test the truth of the hypothesis; to examine the possible reasons we’ve come to the pass; and to explode the myths that have come to surround the institution of parenthood.

We really that unhealthy?

There are several consequences of The Myth of the Unhealthy Child that I believe are at best counter-productive to the enterprise of raising healthy, happy children. At worst, the consequences threaten our very self-concept of our health and well-being as adults.

I hope you’ll join me on this journey – I look forward to hearing your contributions.