Fall 2019 - Vol. 14, No. 3



 
NO SIMPLE MATTER
When you think of a proverb like “people in glass houses shouldn’t throw stones,” you know that its meaning goes deeper than simply “don’t throw a rock at glass, it will break.” Likewise, measles’ resurgence tells us much about our country beyond the simple fact that more parents are refusing to vaccinate their children. What does it mean that a disease we declared eradicated in the year 2000 rebounded to cause almost 1,200 cases in 30 states in the first seven months of this year? *

Forty years ago, social critic Susan Sontag said that the way a society views illness is an indicator of not just its physiological health, but its cultural and political health. Our initial reaction to the AIDS epidemic, for example, revealed much about homophobia in America.
 
THREE OBSERVATIONS ABOUT AMERICA
In an article titled “Measles as Metaphor” in the August issue of The Atlantic magazine,¹ Peter Beinart posits three major cultural reasons why so many parents are refusing to have their children vaccinated.

First, Americans have dangerously poor historical memory. Most parents today do not remember life with measles (or polio, or other contagious childhood diseases), and don’t realize that it used to kill around 500 children in the United States every year. Beinart links this amnesia to a broader societal forgetting of lessons of the past that aren’t health-related, such as the trade war that followed passage of the 1930 Smoot-Hawley Tariff Act and deepened the depression.

Second, the impact of this ignorance of history is magnified by the current ethos in which individuals think that — thanks to the internet — they know more than the experts; indeed, that Google can make anyone an expert. Undeniably, the internet is a valuable source of information, but it is also a minefield of disinformation — some of it benign and unintentional, and some intentionally misleading. Churchill famously said that one can “trust Americans to do the right thing after they’ve tried everything else,” but what does that mean in an era when specious objections to “the right thing” (i.e. logical and evidence-based) are always a click away. Indeed, they may even be posted by a mischievous foreign power bent on sowing discord by stirring up what has been termed the “anger industry.” The very concept of “truth” is now regularly challenged by cunning deceit and “alternative facts.”

Columnist Tom Friedman bemoaned the loss of societal cohesion in a New York Times column titled “Where Did We the People Go?” ² He expresses the fear that we’re seeing the end of truth — that we simply can’t agree any more on basic facts.

It should concern us all that resistance to vaccines, which have proven benefits for the individual and for society, is inimical to a sense of communal responsibility. One hears concerns about a “nanny state,” but a government that prevents you from harming others is simply doing its job. To be a nanny state, government must intercede to prevent you from harming yourself, such as by hypothetically outlawing smoking even in private. Herd immunity is rendered impotent if too many people are unvaccinated (>5% for measles, according to the World Health Organization).

Third is the rising distrust of Washington, which has misled the public on so many issues within recent memory. First there was Iran-Contra, then the Vietnam War, Watergate, the Bush/Cheney administration’s false justification for invading Iraq, and, finally, the current administration's river of falsehoods and conspiracy theories about matters great and small.
 
A BIPARTISAN ISSUE
Another reason the misconceptions about vaccines have tenaciously resisted debunking is that they have supporters on both sides of the political landscape. On the left there is distrust of Big Pharma that manufactures the suspect vaccines, because their behavior so often seems to place profit over responsibility to the public. Also, the left argues for control of one’s own body because it is an essential part of the argument for abortion rights.

On the right there is a hoary distrust of government, and an entrenched insistence that individual liberty is the highest good — even, it seems, when it might be at the expense of the commonweal. The most salient example currently is the right to own assault weapons. (Parenthetically, it must be noted that the right’s emphasis on individual liberties is highly conditional, some would say hypocritical. It is strongly in favor of the individual right to own assault weapons, but strongly against the individual right to an abortion, or — in the extreme — even to have contraceptives paid for by health plans.)
 
DO MINORS HAVE ANY RIGHTS TO HEALTH CARE?           
This Journal has previously discussed the rights of minors to make health care decisions.³ In most states, parents can legally make all decisions regarding health care for their children until they reach the age of majority at 18. Some states’ courts have adopted the mature-minor doctrine, under which a minor with enough maturity to understand and appreciate the nature of treatment and its risk and consequences can have the capacity to consent. (Pennsylvania courts have not expressly adopted the doctrine.)

To my knowledge, the mature-minor doctrine has not been tested anywhere by a minor seeking vaccination. In an extensively reported case,⁴ however, Ethan Lindenberger, an 18-year-old high-school student in Ohio, got vaccinated against his mother’s wishes, and became an outspoken advocate for vaccination, even speaking at a United Nations conference hosted by UNICEF. He explained that most of his mother’s misinformation came from Facebook, and she was unmoved by any scientific information he presented to her, telling him: “That’s what they want you to believe.” Her refusal to be dissuaded proves yet again that you can’t reason a person out of something they didn’t reason their way into.

HOW EXTREME IS ANTI-VAXX BEHAVIOR?
As a staunch advocate of vaccination, Lindenberger has been harassed intensely on social media. He’s been accused of being in “Big Pharma’s pocket,” and even received death threats.⁴ UNICEF was inundated with hostile phone calls when he spoke there.

Parents will go to extremes to avoid vaccinating their children. Five states have eliminated personal (i.e. non-medical) exemptions for vaccination of school-age children — California, New York, West Virginia, Mississippi, and Maine, where the law won’t take effect until 2021.

In California, anti-vaxx parents are so numerous and so determined that a new industry has arisen — doctors who, for a fee, will write a medical exemption for any child. The Associated Press reports that the rate of kindergartners with permanent medical exemptions has quadrupled since California banned personal exemptions, and more than 100 schools have medical exemption rates exceeding 10%. ⁵

An analysis by a newsgroup in the Bay Area found that half of the 180 exemptions filed in area schools were written by just five doctors.⁶ A committee hearing on a bill in the California legislature that merely sought to provide a mechanism for oversight of these “exemption doctors” was nearly disrupted by raucously outspoken opponents of the measure.
 
SUMMING UP
Even aside from its physical harms, the resurgence of measles should concern every physician because the anti-science attitudes it reflects are a threat to evidence-based medicine and should not be ignored. The current societal war on science encourages acceptance of pseudo-science and non-compliance with allopathic therapies, while billions of dollars are spent on worthless nostrums. Though we as physicians are usually powerless to dissuade patients from their fundamentally irrational belief in these substances, we can at least avoid encouraging such behavior, or — as in California — participating in it.

Measles has much to teach us as metaphor.


* The misinformation about the harms that vaccines supposedly cause needs no repetition here. The fallacies in those arguments, and the irrefutable scientific evidence about the benefit of vaccination for measles, is reviewed on page 94 of this issue by Dr. Alan Peterson in his Choosing Wisely article.


REFERENCES
1. Beinart P. Measles as metaphor. What the disease’s return tells us about our ailing culture. The Atlantic. August 2018.

2. Friedman TL. Where did we the people go? New York Times. Pg. A23. June 21, 2017. https://www.nytimes.com/2017/06/21/opinion/where-did-we-the-people-go.html

3. Browne MR. Minors rights to make health care decisions. J Lanc Gen Hosp. 2016; 11(1): 24-26. http://www.jlgh.org/Past-Issues/Volume-11---Issue-1/Minor-s-Rights-to-Make-Health-Care-Decisions.aspx

4. https://www.statnews.com/2019/06/28/ethan-lindenberger-vaccines-harassment/

5. Associated Press. June 20, 2019. https://www.apnews.com/e82739a3289647d39b0cf1c791628e17

6. California’s vaccine battle: Here are the doctors behind Bay Area students’ medical exemptions. Mercury News. June 20, 2019. https://www.mercurynews.com/2019/06/20/these-anti-vaccine-doctors-are-signing-a-ton-of-bay-area-medical-exemptions/