On measles.

With the outbreak of measles originating at Disneyland in California, and the few cases here in Toronto, media - both commercial and social - have lit up with the often vicious debate between those "pro" and "anti" vaccine.  I struggle with it because that polarization reduces the issue to a black and white argument about who's fear is more warranted and who's health rights trump who's.  The issue of whether vaccines are indisputably a good public health measure is much more complex than that, although most discussions come back to a primal hysteria of either the risks of the disease or the risks of the vaccine.  

I wrote a brief article for a parenting magazine last year on why I have chosen to not vaccinate my children at this time.  Producers of CBC's "The Current", in preparation for a piece on the subject, tracked me down to inquire whether I would be open to being interviewed on the radio show.  I had a lovely conversation with one of the producers, explaining my rationale, responding calmly and (I think) intelligently to her rebuttals, and acknowledging weaknesses in my position.  She told me that she would get back to me before the segment this week.

Apparently I wasn't what they were looking for.  The segment aired last Monday morning, with the "anti-vax" position being represented by an "energy healer" who made me squirm with her lack of information and her simplistic perspective.  I didn't inherently disagree with the points she made, but it was disappointing that she was unaware of some basic elements - for example the ease with which one can access the Canadian vaccine adverse event reports.  It struck me that the show was a set-up ... the producers seemed more interested in putting someone on the air who would not stand up to the host's scrutiny than someone who could intelligently engage in a discussion on the topic.  This disappointed me greatly, coming from our national public broadcaster - I was optimistic that the CBC would provide a more neutral opportunity for the exploration of the subject.  It seemed sneaky and underhanded.

So here is what I would have said had I "passed" my pre-interview with "The Current".  I'm not inherently "anti-vaccine" and I acknowledge that my thoughts aren't without fault.  However, although some would argue that the vaccine debate isn't a debate at all - that it's quite a simple public health measure with obvious benefit to society - I'm convinced that it's far more complicated than that. 

Do vaccines prevent disease and promote health?

Vaccines may be largely effective at preventing the individual diseases they were intended to prevent BUT they do little to promote health.  The slew of vaccines - 16 now recommended for children in Ontario -  in addition to fever suppressing medications, over-enthusiastic use of antibiotics, environmental exposure, poor quality nutrition and excessive hygiene are shifting our ecology and the epidemiology of many conditions, both infectious and non-infectious.   Increasing rates of allergies, obesity and superbugs can be directly attributable to this.   Low-grade inflammatory, chronic conditions have increased over the same period of time that heroic measures have increased; we don't have direct evidence of causation, but some combination of factors is responsible for it.  

The "risks" oft cited by the "anti-vax" crowd focus almost exclusively on immediate adverse events.  While the risks of these events are low, we can't ignore that they exist - it is cruel to malign parents with children adversely affected by a vaccine, or who fear intentionally doing something to their child that could cause them harm (the dilemma of error by ommision vs. commission).  I have been unable to find any evidence that vaccines promote population health  in the long run, nor that they don't cause long term harm.  A long term study of vaccinated vs. unvaccinated populations comparing rates of all-cause mortality and overall health would have to be observational, as it would face tremendous ethical challenges as a controlled trial.  Such a study would give us some insight into whether the sum of vaccines to which our kids are now exposed (with their immunological effects and myriad adjuvants and preservatives) have any significant impact (positive or negative) on long term health.  

The ecology of disease

We evolved with infectious agents; we developed mechanisms to cope with them given otherwise good health otherwise.  Unfortunately, we don't always respond perfectly - organisms interact with each other and the most able survive, keeping populations in check.  However, the anthropocentricity of our species is such that we aim to "eradicate" and conquer diseases and to override nature's mechanisms.  We are experiencing the consequences of this, in the way of overpopulation, destruction of the environment, loss of biodiversity, climate change - I worry that we aren't seeing the forest for the trees.  I realize this is an unpopular line of discussion; it sounds heartless to suggest that we shouldn't keep everyone alive at all costs.  But I have to wonder - is remarkable progress and discovery in such fields as medicine, agriculture and fuel liberation always for the better?  It seems as though we are simply shifting the burden of morbidity and mortality from acute infectious disease to chronic conditions on both a personal and population level.

Am I willing to take the risk of my child acquiring measles?

There is about a 0.1% chance that if my child encountered the measles he would have serious consequences, although those numbers don't differentiate between kids who are well-nourished and otherwise healthy vs. kids who aren't.  Vaccines do work to reduce the incidence and the severity of disease, but other factors such as good nutrition and effective management also contribute to the reduction in severity and outcome of infectious disease.  In the short term, motor vehicle accidents and drowning are far more likely to harm or kill my kids than any infection - I place them at risk each and every time we get in a car, despite wonderful developments in car safety.  Few people would prevent their children from travelling in a car - we take calculated risks every day.  Over their lifespan, obesity and lack of physical activity are more likely to cause my child's poor health and ultimate death, which is why I emphasize good nutrition, active lifestyle and minimal time being sedentary.  However, nearly one third of our children are overweight or obese; fewer than 7% of them get as much physical activity on a daily basis as is recommended; kids spend an excessive number of hours each day engaged in sedentary activities with devastating consequences to their health.  Somehow there is no hysteria about this, despite the fact that these are the indisputable causes of lifelong morbidity and mortality (including increased susceptibility to infectious diseases).  The consequences of these behaviours will cost the healthcare system significantly more money than any infectious disease.  The approach being considered in Puerto Rico to target childhood obesity seems to me to be a more timely and appropriate health promotion measure than debating mandatory vaccination programs.

Do I expect the healthcare system to help me if my child were to contract measles?

It is most likely that if my child acquired measles we wouldn't require access to OHIP-covered healthcare.  My children are well-nourished, have robust immune responses, and with conservative care, high dose vitamin A and lots of rest, chances are excellent that they would recover at home just fine.  However, given the fact that I pay my taxes, I have the right to access the healthcare system for my children if they require it.  Frankly, I would argue that overall we save the healthcare system money.  They have been to our family doctor for check-ins on a next-to-minimum basis; they are not the children sitting in waiting rooms with uncomplicated upper respiratory infections unnecessarily inocculating everyone around them; they have never had antibiotics.  Doctors should be teachers and engage in disease prevention and health promotion, but are burdened and limited in their time and ability to do this well.  Our healthcare system is strained with concerns and conditions that are preventable and/or manageable through non-reactive measures.  I acknowledge that many would put choosing not to vaccinate in this category ... however, eating poorly and not moving our bodies have much deeper, broader and longer-lasting consequences - and cost the healthcare system significantly more money.  My preference for myself and my loved ones is a response to illness that leaves us healthier and more capable of handling other illnesses as opposed to suppressing fevers and aiming to avoid every possible infection out of fear and/or convenience.  Vaccinating for as many conditions as possible while neglecting other health measures is not true "preventative" medicine.  In fact, it may leave us more susceptible.

What about the vulnerable in our population - the very young and the very old? 

Much has been made of the concept of herd immunity, and the responsibility of all capable members of a community to contribute to it.  In a community in which a disease is endemic, we can also attain herd immunity, although the immunity acquired is somewhat different from that developed through vaccination.  It is mediated by a different mechanism, in part due to the antigen entering the body through different pathways (in the case of measles, via the mucus membranes of the respiratory tract vs. the current method of direct inocculation via the sub-cutaneous tissue.  Breastfed infants benefit from antibodies to diseases passed on to them through the placenta and breastmilk from their mothers.  Antibodies to measles developed through vaccination are not transferred to the same degree, leaving infants of vaccinated mothers more susceptible.  Adults who have been vaccinated have declining titers over time, whereas naturally-acquired immunity seems to protect longer.  In a community in which the disease exists, constant low-grade exposure to the virus provides a natural booster, keeping antibody levels sufficiently high to protect.  One could thus argue that the vaccine program actually puts folks at risk.  I could argue that the vaccination program puts my children at risk since they are unlikely to ever encounter the diseases that the public health program is trying to eradicate, including such relatively benign conditions as measles and chicken pox.  The older they get, the more serious the manifestation of a disease like measles.  The program has painted those of us who don't fully agree with it into a corner; I may soon be in a position where having my child vaccinated makes the most sense when ideally, I would have rather he encounter these organisms naturally.

What about the immunosuppressed individuals for whom vaccination is contraindicated? 

This is the point at which my argument falters, and I struggle with that.  It's a tricky one because my priority is my own children's health - that's each of our biological imperative.  However, as a member of society, what's best for most is ideal.  This is complex, because while I sincerely empathize with families caring for ill members, I remain unconvinced that the vaccination program ultimately promotes health.  An immunosuppressed individual is vulnerable to all infectious agents; my child's immunization status against measles is unlikely to significantly modify their overall risk.  

Increased rates of cancer (one cause of immunosuppression due to chemotherapy) in recent years have in part been attributed to increased exposure to environmental toxins.  The impact of environmental exposure on children alone (the group most vulnerable to the consequences) is tremendous.  This is yet another threat to population health about which we aren't nearly as hysterical as we should be.   One societal choice creates a consequence which requires another intervention, which creates further consequences ... and is our population really healthier overall at the end?

What happened to choice?

Thus far - although some argue that this should change - vaccinating in Ontario is a choice.  However, many parents aren't truly given that choice.  Physicians have the responsibility to obtain informed consent for every procedure they recommend:  "Patients must always be free to consent to or refuse treatment, and be free of any suggestion of duress or coercion." (The Canadian Medical Protection Association).  For a variety of reasons, this isn't happening in many offices.  Parents aren't always informed of the low but real risk of adverse events; they aren't educated about the role of scary-sounding adjuvants found in vaccines (many aren't even given the opportunity to look at the pharmaceutical insert); they aren't asked if they consent.  I hear from many parents that they are told their child will receive the vaccine of the day with no discussion and no tolerance for questioning.  True informed consent should allow consideration of the risks and benefits of the procedure, of not doing the procedure and of alternatives.  This happens in few medical offices, and parents who question are often maligned.  This is unacceptable and is counter to core expectations and ethics of medical practice.  

Hesitancy around vaccinating does not  necessarily equate to a universally "anti-vaccine" or "distrust-of-medicine" stance.  Each recommendation, each procedure, and each vaccine needs to be individually considered in consultation with one's healthcare provider.  In the case of vaccines, each vaccine and the disease it can prevent must be assessed individually according to the understood risk of both the disease and the vaccine (short and long term).  The individual health status of the child and the community in which she lives (nutrition, access to health care, etc.) should also be taken into consideration.  Maligning parents for making thoughtful, intentional choices for their children (calling them ignorant and moronic, for example) does not encourage them to vaccinate.  Providing an opportunity for an open and thoughtful discussion is more likely to put everyone in a better position to make the best potential choices for our children and our society.