Vaccines and Their Critics



This year we witnessed a lot of contentious debate in newspapers and on television shows about the safety and efficacy of vaccines. Recently, for example,
the actor and anti-vaccine activist Jim Carrey spoke out against a new law in California that eliminates personal-belief exemptions from mandatory vaccination. Carrey tweeted: “California Gov says yes to poisoning more
children with mercury and aluminum in manditory [sic] vaccines. This corporate fascist must be stopped.” Carrey received Twitter support from other
celebrities including Kirstie Alley, Selma Blair, and Erin Brockovich.
Meanwhile,

a woman from Washington state died of measles in June
, reportedly the first measles death in the United States in a dozen years. And,

in Seattle, only 81 percent of kindergarten students have been vaccinated against the polio virus, a rate “lower than the 2013 polio immunization rates for 1-year-olds in Zimbabwe, Rwanda, Algeria, El Salvador, Guyana, Sudan, Iran, Kyrgyzstan, Mongolia and Yemen, among other countries.”

In a 2014 post on this blog, I told the
story of a child in the hospital who nearly died from whooping cough. I pointed out that vaccine critics today make
similar objections to vaccine critics from the eighteenth and nineteenth centuries. But why has this criticism persisted such that outposts of communities still refuse to vaccinate their children? Why does the vaccine controversy continue to resurface?

I have since followed up on this subject with a full-length essay in The New Atlantis, now available online: “Vaccines and Their Critics, Then and Now.” If
you’re at all interested in the topic, or if you’re interested in history and public health policy, this piece worth your time. I argue that
vaccine criticism has a long and robust history. And historical vaccine criticisms repeat themselves today, though they are voiced by new anti-vaccinationists and
shaped by cultural trends like feminism, environmentalism, and radical patient autonomy.

What exactly do these critics say? And how do we confront such a persistent and unyielding group of arguments? It’s all there in the essay. Here is a taste:

It is true that high vaccination rates are important for public health, and when people make false claims about the dangers of vaccines it is the
responsibility of scientists, journalists, and politicians to criticize and refute them. But calls to ostracize and ridicule vaccine critics may be as likely to harden hearts as they are to persuade. For
example, in a recent article in the journal Pediatrics, researchers studying the effects of different communication strategies reported, somewhat counterintuitively, that giving vaccine-hesitant parents more information about
the safety of vaccines, or telling them about the risks of vaccine-preventable disease, whether through scientific information, dramatic narratives, or
arresting images, were not effective at persuading them to vaccinate their children. And yet, another recent study in Pediatrics suggests that parents are less likely to vaccinate their children if
physicians ask them what they want to do about vaccinations (as opposed to taking a presumptive approach and asserting that the children will receive their
shots).

Given this impasse, where ought we to turn? Perhaps what is needed is a better understanding of the long history of vaccine critics’ objections, going back
to the very origins of vaccination. This will help us not to bemoan, accuse, or fight but to educate, persuade, and vaccinate.

The whole essay is online here.

Image via Shutterstock

Practicing Medicine Turns One

As I look back on the first year of this blog and reflect on my four years of medical school, I am amazed at how much I have learned and how much
I have seen. All of it has informed what I have written about here on Practicing Medicine. And many of the issues I have raised remain vital to my experience within the hospital.
Medicine forces physicians to ask questions; questions beyond which IV fluids to give or which antibiotic to use. Medicine demands that we ask the same
questions that any student of human history might ask: What makes us human? What is so humorous about human suffering and pain? Why
do we become numb to human forms of sufferingWhat is the process by which we die? And is it dignified?

How should we view the place of the mentally ill in our society
?

I have also made other, perhaps less broad and less grand, attempts at explicating the practice of medicine. My first post explained why I decided to blog and the awkward place
of medical students within the medical field. This piece
discussed the potent smells of the hospital — they are unavoidable and yet we adjust to them. Stepping into the ED for the very first time, I
explained how a trauma code works and the horrors that
trauma patients face. The kidney-failure patient also faces difficulties,
but they are of a chronic nature due to dialysis, a miracle of modern science with its own drawbacks.

I compared
George Orwell’s experiences in a French hospital in the early twentieth century to my own experiences in a hospital in the early twenty-first; yes, there are major differences, but there are also similarities. This is a pragmatic post on how we ought to think about
scientific studies and evidence-based medicine. I have written about depression and schizophrenia. And, in a more recent post that would have
pleased me greatly as a younger reader, I wrote about Sir Arthur Conan Doyle’s eponymous detective, Sherlock Holmes — it turns out his methods are relevant to physicians today.

Over the next year I hope to continue to write about the big questions and bring up others in relation to what I see and do. I also have a few bigger writing projects in the works, which I will mention here on the blog. If you have suggestions or
comments, please feel free to send them my way. My e-mail address and Twitter handle can be found at the right.

In the Clutches of Depression

Oh, that this too, too sullied flesh would melt,

Thaw, and resolve itself into a dew,

Or that the Everlasting had not fixed

His canon ’gainst self-slaughter! O God, God!

How weary, stale, flat, and unprofitable

Seem to me all the uses of this world!

Fie on ’t, ah fie! ’Tis an unweeded garden

That grows to seed. Things rank and gross in nature

Possess it merely. That it should come to this.

Hamlet

I need not speak to him to know he is not well. A simple glance tells me all. The patient’s unshaven face wears no smile and, at once, no frown. His vapid gaze
lingers longer than it should on various objects or people or nothing at all. The slippers, pajama pants, and torn t-shirt express the disposition of their
owner, unkempt and exhausted. His visage is neither pale nor tan nor some variation on one of these — it is like a bare tree on a late and chilly fall day.
His brow barely responds even when he speaks and his susurrant replies to our questions are scarcely audible over the ambient sounds in the room. In
conversation he rests his hands on his knees, palms up as if hoping to receive something to make this all end. I can only claim that he exists in physical
form.

We, the psychiatry team, confronted in this patient a true disease of the mind; unchecked and unmitigated depression, eating away at the soul and
destroying its possessor. One doesn’t require the Diagnostic and Statistical Manual of Mental Disorders
(DSM) of the American Psychiatric Association to diagnose this young father with depression. But if we wanted to, we could look through it for criteria on diagnosis and treatment of this disease. A
diagnosis of Major Depressive Disorder requires five of nine specific symptoms,
which include depressed mood, decreased pleasure, change in appetite, change in sleep, and others, present nearly every day for more than two weeks. This
makes the diagnosis “official,” though the definition and the name of the diagnosis lack the descriptive power to characterize its severity (and perhaps also a crispness that one wants out of any definition). Algis Valiunas, a
fellow at the Ethics and Public Policy Center and a contributing editor to this journal, points this out in a wonderful 2007 essay in The New Atlantis, “Melancholy’s Whole Physician.” He writes that the term “depression” was “never appropriately ferocious to begin with, suggesting a mere dip in the road rather than the sulfurous sinkhole that engulfs you and all
you love and sends you into infernal freefall like the host of wicked angels, plummeting in terror with no end in sight, no hope of seeing the beautiful
face of God again.”

Still, we’ve chosen “depression” as the name for it and unfortunately this gives a false sense of innocuousness to the whole experience. We also, frankly,
overuse the term which may contribute to that perception. Whenever we feel down or something hasn’t gone our way we claim depression, as if getting a flat
tire marks a trough in our lives. But to see someone truly depressed gives new meaning to the word.

There was no triggering factor for this particular patient. He had dealt with depression his whole life. He never attempted suicide but his illness waxed
and waned, sometimes waxing so powerfully that he could not work, love, or live outside of the pseudo-security of a dark room under his blanket.

Nobody is sure about the exact pathophysiology of depression, but physicians suspect it has to do with an imbalance of neurotransmitters, small molecules that
bind receptors in the brain affecting happiness, sadness, and desire. Specifically, depressed patients often lack the neurotransmitter called serotonin, which functions in many different biological activities including vomiting, memory, blood
pressure, pain, and others. Therefore, psychiatrists often begin treating depression with an SSRI (Selective Serotonin Reuptake Inhibitor) as well as
cognitive behavioral therapy, which in combination are better than either alone. SSRIs work by preventing neurons from absorbing serotonin after they have transmitted a neural impulse, which allows serotonin to remain active for a longer period of time. And there is a

60–70 percent response rate
to initial therapy with antidepressants. Other medications can be tried if these fail, including multiple SSRIs, tricyclic antidepressants, monoamine oxidase inhibitors, and others.

After seeing multiple psychiatrists the patient had unsuccessfully tried many of these medications. Dr. Paul McHugh, former psychiatrist-in-chief at Johns Hopkins Hospital, describes the
kind of hopelessness a patient like this feels when confronted with depression in a wonderful essay for Commentary Magazine. (A collection of his essays can be found in The Mind Has Mountains, a fascinating
collection reviewed here in The New Atlantis). “You cannot choose for
or against this disease. It chooses you, just as does epilepsy, cancer, or heart disease. It turns you into a stereotyped copy of every other person
afflicted with it. You are not in charge of it, you are not to blame for it, and you can do little about it except seek the help that may enable you to
escape its clutches.” When the medical help fails as it had for this patient, imagine the tightening of clutches, the sheer hopelessness compounded with
the underlying pathology.

Image via Shutterstock

The next option for this patient was Electroconvulsive Therapy (ECT). This is
an effective last-ditch possibility for some patients with intractable depression as well as some patients with schizophrenia. (I will write about a schizophrenic patient in the next
couple of posts.) The side effects of ECT include some ephemeral cognitive decline and memory loss. Anesthesiologists sedate the patient and the psychiatrist
hooks the patient up to a machine and sends a series of electrical waves through the patient’s brain. The response to this therapy, which is relatively
safe despite the possible conception of it as some barbaric torture method, depends on the individual. Some patients respond and feel better after one
treatment. Others may need multiple treatments. Psychiatrists don’t fully understand why this works. Also, ECT does not always permanently fix depression; it often merely
gives a brief respite, sometimes half a year, before the disease comes roaring back.

And this persistence of disease leads to even more problems, as Valiunas explains in his essay — it actually causes anatomical changes that further
exacerbate depression, a vicious cycle. Examples of changes include destruction of glia, which supply
nutrients to neurons and clean up their garbage, and atrophy of the hippocampus
and amygdala, parts of the brain involved in memory and emotion.
This, of course, is why
treatment of depression is so important and it explains why this disease, as Dr. McHugh points out, is not due to some “great personal or moral flaw, one
that can be corrected if only [patients] would not let their emotions run amok.” No, the disease is very real and vicious.

I don’t know if ECT ever worked for this particular patient because, as seems to be so common a trope in this blog, I left the psychiatry service before I
got to see the procedure performed on him. But I cross my fingers that when I run into him again I won’t recognize him at all.