Thursday, January 19, 2012

Unavoidably Unsafe: vaccine truths in the information age

Well, it’s 2012 and I’ve made some resolutions. I like to make a lot of them every year, because statistically I can probably manage to stick to one or two just by virtue of having about fifty. Some of them are pretty easy, like “Don’t drink drain cleaner,” and “try and avoid contracting a heritable disorder,” but some of them, like “Don’t use hand sanitizer to get drunk in prison” are tougher. Some things are just beyond my control.

One thing that I have actually committed to doing is to write more about issues that matter to me. It’s super easy for me to craft a post for the sole purpose of referring to Daniel Quinn as a total asshole, but not so easy for me to deliberately confront my own defensible truths. And so in my first post this year, I want to write about something that I think is really important to a lot of people, and that’s a frank discussion of the doctrine of fear surrounding vaccinations.
I have been flippantly censorious of the vaccine phobia more than once on this blog, and I unequivocally stand by my position that exposure to Jenny McCarthy should result in a quarantine. I will, admit, however, that statements like that don’t really serve to educate or conciliate people who don’t already agree with me, and I’m not sure that it’s not an irresponsible application of my education in health sciences to alienate people who have legitimate curiosities about the dangers of vaccines.

Historically, the implementation of all public health interventions has been characterized by a conflict between personal autonomy and public benefit. This poses a formidable dilemma. The ethical execution of public health should always take into account the fact that implementing public health programs creates a palpable tension between individual autonomy and perceived population benefit. While it is, of course, requisite that there always be an explicit respect for persons inherent in every public health action, there are instances in which the overarching principle of beneficence takes precedent. Those instances must be carefully analyzed and objectively evaluated, and they are rare and far between. Newborn screening programs, childhood vaccinations and water fluoridation are three of relatively few such programs ever implemented in the United States. The conflict is not one that policy makers underrate; it’s difficult to minimize the impact of what might be characterized as a transgression on personal freedoms in a society as committed to individual liberty as ours.
This is especially difficult when policy dictates that we impose a measure in the name of public health that is perceived as dangerous, and potentially harmful. Vaccinating children is such a measure, and the controversy generated by state laws mandating these vaccinations has been prodigious.
It is really easy for those of us in public health to dismiss dissenters as lunatics and morons. It is really, really easy to wax lyrical about the fatuity of this movement, to make fun of the maniacs who commit violations of federal laws to expose their children to infected candy mailed to them by a stranger from the internet, OH MY GOD. 
But it is ultimately not very helpful.

It is irresponsible and harmful to dismiss this population as imbecilic or insane. I realize that it’s simpler, and I’ve been guilty of it myself, but in many ways that behavior reduces you to the practice of blaming the victim. The central tenet of public health is not that we show respect only for the people who agree with us. Public health requires a necessary element of education, because you are not dealing with a horde of scientific practitioners, you are dealing with the public. IT SAYS SO RIGHT IN THE FUCKING NAME. Public health. And public opinion matters, especially in a case like this.

So in my opinion, it is far more efficacious to acknowledge that these fears exist, and that the potential impact of these fears on the overall health of our population is significant. And that, whether or not we believe wholeheartedly that these fears are ignorant, or wrongheaded, or pernicious, we do not fulfill our duty to one another by deriding those beliefs. So here are some facts.

Vaccines work by providing the body with an ersatz version of the disease in question, and allowing the body an opportunity to mount a response to the fascimile, without exposing the individual to the whole package. Diseases are neutralized for vaccines in different ways. Often, the infectious agent is killed by heat or other chemicals. sometimes, the virus' ability to reproduce is destroyed, meaning that the disease cannot mulitply in the body. For some diseases, like hepatitus, it is enough to simply expose the immune system to an associated protein. Once a virus has been killed or neutralized, it cannot hurt you. The illness that people feel after receiving a vaccine is not the virus contained in the vaccine, it is your immune system responding to a foreign agent, memorizing it, and mounting a response designed to remove it. Once your immune system has recognized something as harmful, it can be destroyed. And given another exposure, your body will simply annihilate the intruder without the necessity of a full scale immune response. This is why people only get the chicken pox once - your body won't be fooled twice by the same trick. Colds and influenzas are slightly different, since those viruses are always changing and adapting. This is why some people get a flu shot every year.

The truth is that vaccines are not always 100% safe. They contain some preservatives that look and sound alarming. They occasionally precipitate an immune system response that can be unpleasant. Other safety concerns have revolved around mercury and Thimerosal, which is a compound containing organomercury, historically used as a preservative in vaccines and other medications. Over the course of the last decade, safety concerns about the use of Thimerosal (also known as Merthioloate, the trade name of the compound developed by Eli Lilly) have prompted the FDA to phase out its use from vaccines given to children under six. That means that the Measles, Mumps and Rubella vaccine, traditionally given at 18 months, does NOT contain Thimerosal.
It is worth noting that all of the multiple trails testing the safety and efficacy of Thimerosal have suggested that the compound is safe for the controlled uses to which it is put. However, public opinion and preference has guided the evolution of policy on this issue; and the development of more acceptable compounds has made the substitution much easier.

One exceedingly harmful myth about vaccines is that the government requires them simply because the government is in business with big pharma. THAT IS FALSE.

Vaccines themselves reside in a nebulous legal category known as "Unavoidably Unsafe." This is a designation given to drugs that are deemed necessary for population health, but which cannot be designed to be entirely innocuous. This label means that there is a certain amount of risk inherent in the treatment, but that the benefits outweigh the harms so significantly that there can be no question about the propriety of administering it.
If a company were to be held responsible for every adverse side effect resulting from a drug, there would be an enormous economic disincentive to making that drug. This is why safety trials are necessary. If, however, the product is considered necessary, the companies that create these products are allowed a certain amount of indemnity from litigation, in order to assure that access to these necessary treatments is retained.
Products  must meet very, very specific criteria in order to be considered "Unavoidably Unsafe." The product must be produced to the standard specifications, meaning that there must be no error or negligence in the actual production of the product that caused the damage. If a company were to make a mistake in a batch of vaccines, for instance, and accidentally add a bunch of rat poison, the product would not be considered "Unavoidably Unsafe," it would be considered "Shitty." Secondly, the marketers of the product must be transparent about the potential known risks. The product must, as discussed above, have a clinical utility that greatly overrides the potential for harm, and there must be no other alternative to the product available.

As it stands, we don't have a better alternative for vaccines. They can sometimes cause our immune systems distress. Care providers are honest about those potentials, and vaccines have proven to be so advantageous and beneficial that those risks have been deemed acceptable. And all of this would be ok, if it weren't for our 21st century witch hunt for the causes of Autism.

An additional truth is that the vaccine schedule is, in fact, kind of arbitrary. Vaccines are scheduled at 18 months because they will conform to the changes in a child's immune system as they acquire their own resistance, and so they will coincide with established wellness checkups. That is convenient, and in the consumer driven medical market that we have created for health care, convenience is king. It is also true that 18 months is the time that many symptoms of disorders on the autism spectrum become apparent. It’s understandable that this connection might be where we start to look for a causal relationship.

What it is imperative to remember is that correlation is not causation. A 1998 study published in the British Medical Journal, The Lancet, claimed to have demonstrated a causal link between vaccinations and the onset of traditional symptomology pathognomonic of autism. This study terrified people, and caused a widespread panic. Consequentially, many people refused to vaccinate their children, and the findings were widely publicized by the media.  Over the subsequent decade, follow-up studies failed to replicate the results, all of the co-investigators of the study dissociated themselves from the paper, and in 2010, the Lancet itself withdrew the publication. What this means is that the information and the associations supported by the data collected in the study have proven to be spurious. As it turned out, the lead investigator was found to have fabricated those data, and was forced to acknowledge the fraud in ignominy. The twist here is that this retraction was not as widely publicized as were the initial study findings. The NIH and the WHO did not embark on an aggressive media campaign, trusting that every mom in the world had nothing better to do than refresh the lancet website daily researching ethics violations. Even I only do that when I’ve been drinking cooking wine and thinking bitter thoughts about Anthony Bourdain.
So what we’re left with is a significant proportion of the population that have been grievously misinformed by a primary source, which was subsequently interpreted and disseminated by innumerable other sources and inadequately refuted by organizations that should have made it a top priority. By then it was a little late; the damage was widespread, and the consequences are becoming apparent.

The concept of population health is in a way self-sustaining, in that we rely heavily on acquired or achieved immunity in others to protect ourselves. We call this “herd immunity,” and we base our assumption on the principle that diseases rely on susceptibility in their target organisms to spread. reducing the overall susceptibility in a population provides less opportunities for infection, thereby reducing the rate of incidence. When a large cadre of people fail to acquire immunity through vaccination, an infected agent’s ability to spread is greatly increased. Already in the United States we are seeing the consequences of the reluctance to vaccinate, in resurgences of diseases we had previously suppressed, such as whooping cough, and Rubella.
the vast majority of opposition to vaccinations is predicated on information that was fraudulently derived, and irresponsibly disseminated. I think that frustration with this misinformation is driving a large proportion of the intolerance that many medical professionals are demonstrating when people express their concerns, but I don't feel that that frustration gets us anywhere.
Our society places a high value on the principle of autonomy. And if you are an advocate of autonomy, it's important to realize that the option of choice should be exercised responsibly, and on the basis of the best information available.  Fear and tenuous supposition are poor substitutes for ratiocination and primary source material.
So let's be excellent to one another. And don't eat shit you bought on ebay. Jesus Christ, guys.

1 comment:

  1. It's the tragedy of the commons: you can piggyback your child on herd immunity without exposing him or her to any perceived risk of side effects. Very sad, especially when based in hysteria, but completely understandable.