Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Saturday, December 23, 2006

Darwin and Vaccines

(Note: this post is written partly to avoid exacerbating Flea's burgeoning comment trail, and partly to address an issue that got buried in it; but mainly to offer my support to the noble Flea.)

Flea is in the process of writing a wonderful series of posts about vaccine-preventable diseases, and of course in the process has been subjected to the attack of the wingnuts. Now at 121 comments and counting, there were a few along the lines of "Just let them die" (ie, let natural selection kill off the anti-vaxers by allowing them to contract the diseases in lieu of receiving the vaccines to which they so object.) Although I know (or sincerely hope) that these comments were tongue-in-cheek, I would like to address the question -- perhaps unasked in precisely this form -- "Why bother fighting them if it's only their children they're putting at risk?"

First of all, I am not agreeing with the second part of that statement. Herd immunity is real but fragile. Nevertheless, it must be agreed that unvaccinated children are at much more immediate risk from their status than are their innoculated peers.

So what's the harm? They may be whack jobs, but it's a free country. And in America, the most treasured right is the right to be stupid. Why should we waste our time and effort trying to convince delusional science-illiterates?

The answer is similar to that given by the senior OB resident during my third year med school rotation during the particularly hectic treatment of a drug addict in labor. I forget who raised the issue, but the question was asked, essentially, "Why are we bothering?" If the mother didn't care enough to take even the slightest care of herself all through the pregnancy (as I recall, she kept getting herself pregnant so she could shoot up in the dilated veins of her breasts) why should we be putting in all this effort to care for her now? The answer -- which I know comes as no surprise to any pediatrician or ethical OB reading this -- was that it wasn't the baby's fault its mother was a drug addict. Whatever your belief in "original sin" from a theological standpoint, it is never medically appropriate to punish one patient -- the baby -- for the sins of another.

The same issue holds in pediatrics. By and large, the ideal of the "best interests of the child" is seen similarly by loving parents, who want to do everything that can be done to keep their children as healthy as possible, and physicians with our armamentarium of vaccines.

Conflict arises when parents object to standard medical treatment -- whether they be paranoid, anti-vax wingnuts, or thoughtful, religious Christian Scientists. We may question the intellectual stands they take, but I don't think it's fair to impugn their feelings for their children. Still, we are left with the conundrum that has led to court orders overriding parental wishes in life-threatening medical matters. Although we cannot draw the line directly enough from "refusing to vaccinate" to "immediate threat of death" to justify that degree of intervention, it is still the innocent children whose interests we must keep striving to represent, even if it means dealing with irrational people.

That is why these discussions -- futile as they may seem -- deserve to continue.

There's also another side to this.

A few months ago, I saw a new patient in my office. This lovely, intelligent 14-year-old had received no immunizations at all. Having now done the research for himself, this boy was requesting all age-appropriate vaccinations. To his parents' credit, although they disagreed with his decision, they respected his wishes and brought him to see me. We (he and I) sat down together and set up an appropriate schedule. I administered the first set of vaccinations; he returned as requested, and all went well.

I have another family in my practice who just had their first child. They had "concerns" about the vaccines and came to see me before the birth to discuss these issues. They ended up deciding to forego Hepatitis B, but so far their 2-month-old is otherwise "on schedule." They don't want her to get MMR or Chickenpox vaccine, but every time I see them we discuss it some more. I try to provide more information and address their concerns with respect. I'm optimistic that when the time comes, the kid will end up fully vaccinated. And even if she doesn't, there's always the possiblity that she, like the young man above, will transcend her parents' limitations and eventually choose vaccine protection for herself.

So hang in there, Flea. Even though the crazies may come out of the woodwork, you never know who else is listening.


At Sat Dec 23, 10:32:00 AM, Anonymous Anonymous said...

Great story about the 14 year-old boy!

I have ongoing dialogues with my no-vax parents about immunizations, and I try to be encouraging rather than pushy. Many times, we eventually agree to disagree. Other times, they leave my practice. Usually, the baby gets immunized according to the parents' wishes--maybe on a different schedule or, like your patients, skipping a few of them.

The bottom line, to me, is that I'm an advisor, not a dictator.

At Sat Dec 23, 09:41:00 PM, Blogger Big Lebowski Store said...

Hanging in, Sir!

Thanks for the link.



At Sun Dec 24, 07:28:00 AM, Blogger Unknown said...

Excellent story, Dinosaur.

Regards - Shinga

At Sun Dec 24, 08:38:00 AM, Blogger Cathy said...

2 things I don't understand. Am I so OLD that things have changed so much in the past 20 years? I really had no understanding of this lack of vaccines. When my children were small (granted they are now in their 30s) it was required to enter grade school that vaccines had to be done and up to date. We actually had to take their vacinne record into the school for them to copy and put in the childs school records. If you were not up to date and your child was not vaccinated against all these illnesses then your child was not permitted to go to school until you had proved they had been done.

Do school systems not require this anymore?

I know my grandchildren have receieved all their vaccinations. Don't know though if the records have to be taken to school.

Also, as for some of those commenters at Fleas. They have wondered over there from one other med blog, where they troll around making remarks of very similar nature.

Making children suffer for their parents mistakes is just wrong on so many levels.

At Sun Dec 24, 04:32:00 PM, Anonymous Anonymous said...

Although I am only a med student here in Israel (Hebrew U), I've had these discussions with married friends with kids - some of them are anti-vaccines.

A few months after having a particularly annoying argument with the wife of a good friend of mine, I attended a wedding with my friend, and he made a comment to the effect of "My kid got shots b/c of you". I almost fell off my chair I was so shocked - the mother was adamantly against vaccinations (b/c of autism etc....)

The moral of the story - you never know when you have an affect on people - sometimes they never even mention it to you. Keep on trying and doing what you can!


At Mon Dec 25, 12:01:00 AM, Blogger Katie said...

Well, since you linked over you think it is EVER ok for parents to NOT vaccinate their child?

Here's the thing...we have food allergies (among other allergies--but that's beside the point) in our family...I'm VERY allergic to we weren't even going to introduce eggs to our son until he was 2-3 and UNDER medical supervision (my allergist made that suggestion). My son's pedi brushed off our concerns for allergen possibilities. *I* had adverse events (which are described in VIS and vaccine package inserts) when I received my childhood vaccinations...and since my son is 1/2 my genetic material...I feel/felt he is predisposed for allergens and similar reactions to what I had. Again, our concerns about this were dismissed and ignored. She completely cut off (which, by the way, is against what the AAP/AFP suggests doing) our family because we wanted to DISCUSS a delayed schedule--possibly order allergy testing (which typically isn't done until after 1 year--and even then it isn't so reliable--until the child is older--just repeating what my allergist said)'s just as well that we were "fired" because I believe that parents and pedi's should be PARTNERS in the child's healthcare.

Another thing, my son was exclusively breastfed for a year (and then with "solids" and breastmilk until 18 months--now, just shortly after 18 months he's completely on solids). Honestly, Hib is pretty much impossible for breastfed children--so I saw no reason for Hib. My son has never had an ear infection--rarely is "ill" and when he has been feeling's very short and he's back to his normal self in no time...

Oh, not to mention, I'm religiously opposed to aborted fetal tissues being used in vaccines and I would NEVER inject that into my son (now, if ethical vaccines were available, I'd research it and make and educated decision about it at that point)...

And chickenpox...seriously...why do I need to vaccinate my son against CHICKENPOX...I realize that people *DO* die from complications from chickepox (just as people can die from complications from the common cold or from infections from a wound)...

And the more I researched and looked, the more I saw that the danger (for our family--I'm not saying for everyone--but for our family) was heavier on the vaccine side.

So do you feel it is ever appropriate for families to choose not to vaccinate at all or not to vaccinate with some of the vaccines?

PS I got a I'm not anon Katie anymore...

At Mon Dec 25, 03:12:00 AM, Anonymous Anonymous said...

How is Hib pretty much impossible for bf children?
Pretty curious since I'm bf-ing my son as well and haven't gotten the Hib vax yet.


At Mon Dec 25, 03:23:00 AM, Anonymous Anonymous said...

Good post dino - it is definitely fair to impugn these morons' feelings for OUR vaccinated children , however.
The unadulterated , pseudoscientific B/S that they continually spout makes me think that supratentorial prefrontal protoplasmic deficiency and functional inadequacy disorder is spread via the internet and of particular danger to the progeny of the protoplasmically adequate!

At Mon Dec 25, 01:05:00 PM, Blogger Katie said...

Just about failure of Hib vaccine: "Meningitis Risk Seen from Use of Vaccine" (St. Paul Pioneer Press Dispatch, April 21, 1987)

At Mon Dec 25, 01:38:00 PM, Anonymous Anonymous said...

Thanks Katie

At Tue Dec 26, 01:05:00 AM, Anonymous Anonymous said...

Katie: If allergies are your legit reason for NOT vaccinating, then you should be making sure everyone around IS vaccinated. You need to be sure to keep herd immunity up.

My son has never been vaccinated against pertussis because of a history of seizures (and at that time the seizures precluded that particular vaccine). Since the county I was living in was experiencing a pertussis epidemic (about the same time measles returned to the USA, killing over 120 people)... I made sure to know the vaccine status of any new playmates.

So you really need to champion vaccines for EVERYONE who can be vaccinated!

At Tue Dec 26, 08:40:00 PM, Blogger Alyson said...

Another post that makes me wish you could be our Doc. Although I have to admit that our pediatrician is doing the same with us on a delayed schedule and discussions with more info at every appointment. And I'm definately not a rabid anti-vaxer and I don't care what other's do when it comes to vaccines and their children. I just want to be sure that I'm doing the right things for my child. And there is a lot of misinformation out there, as well as people who think I don't care about my child because I've delayed the MMR. Seriously, how do you have an intelligent discussion with either side when they are so vehement in their positions? Long winded I know, but all to say, you are still my favorite Dinosaur!

At Sat Jan 06, 12:17:00 AM, Anonymous Anonymous said...

I think sometimes patients just want the information to make an informed decision. When I had a kid I asked my doc about the effects of getting vaccines. She gave me straight information. Not just the good stuff but the possiblity of the bad as well. Because she does this I always go with her prefered choice of treament. It's becasue she has enough respect for me to explain why she is doing what she is doing and I have enough respect for her and her abilities as a doc. It is nice to have a doc who takes the time to explain things.

At Sun Jan 07, 10:29:00 PM, Blogger Northwoods Baby said...

Conflict arises when parents object to standard medical treatment -- whether they be paranoid, anti-vax wingnuts, or thoughtful, religious Christian Scientists.

What about those of us who are thoughtful, educated, non-religious, selective/delayed vax parents? You say Christian Scientists are thoughtful. Perhaps, I Have no personal experience to determine the case one way or another. I'm sure they would appreciate the sentiment. I don't understand, however, how not citing religious reasons makes other parents "paranoid ... wingnuts". If God says not to do it, you're thoughtful. If your research/gut/whatever says not to, you're a wingnut? Whu? Actually, it's a refreshing change of attitude, in many respects, but not entirely helpful to the cause, wouldn't you agree?

FWIW, my daughter is fully vaccinated, and my son will be by the time he starts school. But eight at a time seems a bit excessive to me. Does that make me a paranoid wingnut or thoughtful? I like to think the latter but perhaps I am wrong. Then again, perhaps you are.

At any rate, I enjoy your blog, despite the insults ;)


At Wed Mar 05, 08:53:00 PM, Blogger Hypothetical said...

So, what kind of schedule did you set up with the 14 year old boy to get him caught up? I'm also curious about the comments above where the vaccines happen "on a different schedule".


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