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.

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

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

The Purpose of Medicine

American medicine is not well. Though it remains the most widely respected of professions, though it has never been more competent technically, it is in
trouble, both from without and from within.
—Dr. Leon R. Kass

As a newly minted medical school graduate, I am suddenly faced with much more responsibility. Now I must write prescriptions for patients, write notes
on patients, and know what to do during an emergency. It is all very daunting. While anxious and excited about these new responsibilities, I am also
confused about what I’m doing it all for.

I don’t mean that I’m confused about why I chose medicine. True, medical school was incredibly difficult, but there will be many rewards down the road. I
mean to ask: What is the purpose of medicine? It is queer that one should spend four years learning medicine and not know one’s purpose. But no one ever
discussed this question in medical school. Now, after graduation, the question’s importance is suddenly apparent. My future actions depend on the answer to

Some answers are implied during our schooling. The purpose of medicine that seems obvious is to cure the patient of disease. After all, this is
why patients come to the doctor. But sometimes, we also attempt to make people happy. I’ve seen patients receive IV fluids because it will
“make them feel like they’re getting treatment.” I’ve seen children receive antibiotics even when they didn’t need them, simply because the parents wanted
something done for their children. I’ve also seen a patient receive a “therapeutic” EKG — his chest hurt and despite the fact that there was no way he was
having a heart attack, he received an EKG to “calm him down.” The goals of medicine, according to my own limited experience then, are at least twofold: the
elimination of disease and, more broadly, patient satisfaction even when it has nothing to do with disease.

Dr. Leon Kass, a teacher and bioethicist trained as a physician (and a New Atlantis contributor), wrote about the purpose of medicine in the 1975 essay “Regarding the End of Medicine and the Pursuit of Health”
in The Public Interest (available here as a PDF). Though written forty years ago this summer, the essay is as relevant and necessary as ever. I’ll highlight some of Kass’s major points to help us think through my
question about medicine’s purpose.

The fact that the purpose of the medical profession is not often considered is, Kass points out, deeply troubling. Indeed, without an
answer to the question, Kass writes, “medicine is at risk of becoming merely a set of powerful means, and the doctor at risk of becoming merely a
technician and engineer of the body, a scalpel for hire, selling his services upon demand.” This would spell the end of medicine, Kass believes — “there
will be an end to medicine unless there remains an end for medicine.”

Kass proceeds to tackle the issue by critiquing some of the goals of medicine that people sometimes assume. Happiness, he argues, should not be the
purpose of medicine. Kass offers some examples of physicians attempting to make patients happy: a surgeon might remove a woman’s breast so she can improve her
golf swing, or a family physician might administer amphetamine injections to people who want to
feel good. These interventions are aimed solely at gratification and thus are not even concerned with pathology.

Even the prolongation of life or the prevention of death per se should not be the goal of medicine, Kass argues. This, perhaps, is difficult for us to understand. Indeed,
doctors daily witness death and terminal illness. If we know CPR,
do we withhold it because it’s not our job to prevent death or prolong life? Not at all, but if we believe that the goal of medicine is the
prevention of death, then the logical endpoint of this must be “bodily immortality.” Kass observes that “to be alive and to be healthy
are not the same, though the first is both a condition of the second, and, up to a point, a consequence.”

Anyone’s life can be prolonged now. Machines
breathe for patients. Machines oxygenate patients’ blood. Machines pump blood into the circulatory system. All this occurs regularly in the intensive care unit. But if physicians put patients on these machines indefinitely
solely to keep blood flowing through arteries regardless of the patient’s condition, the mere preservation of life, and by extension the job of medicine,
is meaningless.

The goal of medicine, according to Kass, is the preservation of health. The word “health” in English means “wholeness.” It is derived from the
Old English hal, which is also the origin of “whole.” For Kass “wholeness” involves a “fully formed mature organism … composed of parts. It is a structure and not a
heap.” Additionally, wholeness includes the “working-well of the work done” by a person’s body. Thus, health consists of a proper balance of parts that
make up the whole and the workings of the whole human being. In order to demonstrate his point, Kass takes the example of a squirrel. A healthy squirrel is
not just a squirrel with a normal digestive tract, it is a squirrel who acts and looks like a squirrel. It leaps from tree to tree, runs, gathers, and
buries. All of these characteristics tell us that this is a fully-functioning, whole squirrel—a healthy squirrel. Similarly, a healthy human being acts
and looks like a human being. While this concept may seem vague, Kass’s point is well-taken; a healthy human is “recognizable if not definable.”

A good example of preserving health is the well-child visit in a pediatrician’s office, where physicians check for normal growth and development. This
demonstrates that “health is a good in its own right, not merely a privation of one or all evils.” In other words, pediatricians don’t just see children
who are sick (though they do that, too); they also see children who are healthy. And in doing so they help make sure that these children remain healthy. Family medicine physicians do something similar with adults. They see their patients on a regular basis
to ensure that patients are exercising, eating right, and have no abnormal blood counts or cholesterol numbers, and that they are otherwise doing well.

Check-ups like these are as important as giving a patient antibiotics for pneumonia. Medicine involves figuring out how to maintain the excellent functioning of a human
being. It necessarily includes what today we call preventive medicine: vaccines, cessation of smoking, a healthy diet, an active lifestyle. This view of medicine necessarily involves the patient as a partner to the physician: both work together to help maintain the health of the patient.

Many of the things we expect from medicine today do not fall under Kass’s definition of health. The injection of Botox to make one look younger, for example, does not
involve health in any way whatsoever. Having wrinkles in one’s face does not affect the excellent functioning of a person. Endocrinologists, plastic
surgeons, psychiatrists, and many other specialists and generalists all deal with patients who request the kinds of procedures that go beyond health. Whether these procedures ought
to be available is a completely separate question from whether these services fall under the purview of the physician. If physicians perform them for
patients, then physicians, I think, become service providers to the highest bidder. They become technicians at the whim of patients. (Kass addressed some of these same themes about the difference between therapy and enhancement in his 2003 New Atlantis essay “Ageless Bodies, Happy Souls.”)

To be sure, Kass’s 1975 essay does not go into the kind of detailed, philosophical argument that we might hope for. Kass himself admits this when he writes,
“large questions still remain” and “I am not seeking a precise definition of health.” But he gives us a basic and firm outline of the purpose of medicine
and we would be remiss if we didn’t study this purpose carefully. Without a purpose,
medicine lacks moral certainty or a soul. None of us, within medicine or without, can afford that.

Whooping Cough and the Anti-Vaccination Movement

Pediatrics rounds are similar to what I described in one of my initial posts. We spend most of the morning
visiting each pediatric patient with the attending physician and deciding on a treatment plan with the parents. Frequently we encounter patients on
“contact precaution,” which means they have a highly communicable infection. In order to reduce the transmission of infection, before we enter the room we
put on disposable gowns that cover the arms, torso, and upper legs, as well as gloves, and a face mask if the infection is communicable via the air. We
fumble around outside the patient’s room, handing gloves, gowns and masks out to each other, donning them as we would some radiation suit. Upon exiting the
room, we remove these protective accoutrements and put them in the trash. The

CDC recommends this practice
, though in certain cases the efficacy of it is unclear.

One morning we saw a six-month-old child on contact precaution with whooping cough, a respiratory sickness caused by
the Bordetella pertussis bacteria. We stood outside the child’s room putting on masks
before we entered. Inside, the baby’s mother paced back and forth, holding and rocking her son as the infant experienced a series of coughing fits and
struggled for the air even to cry. Bacteria had attached to the cells of his upper airway and produced a toxin that prevented those cells from sweeping
foreign particles and dirt up out of his throat. Thus, he coughed in order to clear these alien elements that we normally clear silently. He coughed so
hard and for so long that he barely had time to breathe in and was perpetually short of breath. At times, he looked and sounded like he was about to die. This not-uncommon response to the infection disturbs us as we must watch an infant struggle for each breath without any effective treatment. We sit back with horror, anticipating the moment
when the child ceases to inhale.

At this point, he had already experienced the first stage of the whooping cough sickness, the catarrhal stage. This lasts for the first couple of weeks and
presents merely like a common cold, making it unrecognizable from a benign respiratory infection. But this is also the stage at which the bacteria are most
contagious, and the only stage at which antibiotics work in preventing progression of the sickness. Many parents unknowingly take their
children out into the community without being treated, thus spreading the infection.

The second stage of the disease is the stage our patient was struggling through — it’s called the paroxysmal stage. Though children or adults are less
contagious at this stage, their symptoms are far worse and this is the stage with the infamous whooping cough. Patients cough so forcefully that, desperate
for air, they take in a huge and sudden inspiration (the whoop) in order to compensate for lost breathing time. Antibiotics only prevent
the disease from spreading but have no mitigating effect on symptoms. During the second month of the infection, the disease resolves with the convalescent

Though the eventual outcome sounds benign, the disease does not always resolve as we expect. In fact, the sequelae of this disease are costly and deadly. Half of infants less than one year
old with this infection are hospitalized. And among those, 23% get pneumonia, 1.6% will have convulsions, 67% will have apnea (cessation or slowing of
breathing), and 1.6% will die. In adults who get pertussis, weight loss, loss of bladder control, syncope (passing out), and rib fractures from severe
coughing are also common. But a patient need not experience any of these symptoms, mild or severe, if he or she receives the vaccination against Bordetella pertussis.

Why, if we have a perfectly good preventable measure against these bacteria, do we have six-month-olds gasping for air in the hospital? Unfortunately, in
recent years, a

popular anti-vaccine movement perpetuated by celebrities and based on shoddy science
 has discouraged many parents from vaccinating their children and made all of us, including the child I saw on rounds, more susceptible to infection with
these bacteria. Last year, Julia Joffe wrote an incisive and frightening piece in The New Republic about this issue. She explains the gravity of the problem:

Vaccinations work by creating something called herd immunity: When most of a population is
immunized against a disease, it protects even those in it who are not vaccinated, either because they are pregnant or babies or old or sick. For herd
immunity to work, 95 percent of the population needs to be immunized. But the anti-vaccinators have done a good job undermining it. In 2010, for example,
only 91 percent of
California kindergarteners were up to date on their shots. Unsurprisingly, California had a massive pertussis outbreak…. 
From 2011 to 2012, reported pertussis incidences rose more than threefold in 21 states. (And that’s just reported cases.
Since we’re not primed to be on the look-out for it, many people may simply not realize they have it.) In 2012, the CDC said that the number of pertussis cases was higher than at
any point in 50 years. That year, Washington state declared
an epidemic; this year, Texas did, too. Washington, D.C. has also seen a dramatic increase. This fall, Cincinnati reported a 283 percent increase in pertussis…. 
study recently published in the journal Pediatrics indicated that outbreaks of these antediluvian diseases clustered where parents filed non-medical
exemptions — that is, where parents decided not to vaccinate their kids because of their personal beliefs. The study found that areas with high
concentrations of conscientious objectors were 2.5 times more likely to have an outbreak of pertussis.

But these “personal beliefs” are not part of some novel and modern ideological movement. In fact, the arguments of the anti-vaccination movement of today
closely resemble those perpetuated when Europe first used vaccines in the 18th century. And when we consider the six-month-old in the hospital
and our current predicament outlined by Julia Joffe, this fact should give us hope.

The Chinese first used vaccines, inhaling powder from smallpox scabs on deceased patients, a method which eventually moved west to Britain
during the 18th century — the British rubbed scabs of smallpox victims into newly created scratches on their skin. And most of the time this
worked, even if there were risks involved. In fact, as

Dr. William R. Clark
, a former Professor of Immunology at UCLA, writes in his book on the immune system,

At War Within,

even in that era, “from a public health point of view, inoculation made great sense.” Nonetheless, many physicians and religious leaders at the time opposed this
method of preventive care for a few different reasons.

First, religious leaders spoke out against vaccination because they thought it interfered with God’s plan. In July 1722, Reverend Edmund Massey argued
in St. Andrew’s Church that humans were punished for their sins with illness, and that attempting to prevent these diseases with vaccines was a “diabolical operation.”

But that wasn’t all. According to some, the government and the wealthy used vaccines to subject, or profit from, the populace. As Clark recounts in his book, William Wagstaffe,
a physician at the time, wrote the following about Britain’s female ruling class, which first began to use the vaccines:

Posterity perhaps will scarcely
be brought to believe, that an Experiment practiced only by a few Ignorant Women, amongst an illiterate and unthinking People, shou’d on a sudden, and upon
a slender Experience, so far obtain in one of the Politest Nations in the World, as to be receiv’d into the Royal Palace.

In other words,
ignorant leaders practicing inoculation took advantage of the ignorant citizens. J. M. Peebles, an American physician, wrote a book in 1900 entitled

Vaccination: A Curse and a Menace to Personal Liberty, with Statistics Showing its Dangers and Criminality
. In it, he explained, “The vaccination practice…has not only become the chief menace and gravest danger to the health of the rising generation, but
likewise the crowning outrage upon the personal liberty of the American system.” Further, the “vaccination syndicate” is “continually lobbying our
legislatures for an extension of privileges on the pretense that the public welfare will thereby be enhanced.” So, the pro-vaccine “syndicate,” using the
American government, forces its mendacious ideas upon American citizens.

And the harmful medical effects of the inoculations bothered scientists at the time who, according to Dr. Clark, “were concerned about the
risk, and not completely convinced that the protection was genuine or long lasting.” Peebles covered the vaccine’s deleterious effects in his book, too. The
“vaccine-poison,” he asserted, will take its time in killing its victim or do little to prevent death, “one year, ten years, this generation or the next; no matter, death has a mortgage
on the premises and will claim his own and receive it on demand.”

These objections sound entirely familiar. Dr. Suzanne Humphries, a nephrologist and homeopath,

has recently rewritten the religious argument for the International Medical Council on Vaccination
: “Vaccines are the template for the fear-based belief system that those who don’t know their history will easily fall for. The trajectory of fear removes
God from the picture. A fear-ridden populace couldn’t possibly credit God with any usefulness once the medical/pharmaceutical industry sets itself up in
God’s place.” This claim echoes Reverend Massey.

Professor Daniel A. Salmon, of the Johns Hopkins School of Public Health,

quoted in a New York Times article
, discusses many of the groups who refuse to vaccinate their children. He explains that some oppose vaccines because they distrust the government or
believe that government is in bed with the big pharma vaccine industry. Moreover, in an editorial post on the Alliance For Natural Health website, the group claims that the “cozy relationship of government with the drug companies may be why the CDC
is now recommending a cocktail of over ten different vaccines.” William Wagstaffe or J. M. Peebles could have written this.

And, of course, detractors argue that the side effects of the vaccines are too dangerous and may even cause autism. Jenny McCarthy, in a similar vein as J.
M. Peebles, made this argument. (She recently

attempted to paint herself as “pro-vaccine,”
 which is simply not true.)

But why should we be comforted by this current of familiar anti-vaccination arguments? Because despite the historical resistance to the smallpox
vaccination, eventually the vaccine was successful — so successful, in fact, that the World Health Assembly declared smallpox eradicated in 1980. Therefore, the
vaccine movement has won out in the past against similar arguments and can do so again. Will whooping cough be eradicated with successful vaccination? I
can’t say, but even a minute sway in opinion can make the difference between herd immunity and an epidemic. And that would decrease the number of six-month-olds and their parents who must suffer in anguish through those frightening moments on the precipice of breathlessness.