Vaccine Objector Backlash

In March, a version of the following article appeared in Lacamas Magazine, a local lifestyle publication. It was very well received, and attracted an enormous number of hits. I need to rework something for the local daily paper, The Columbian. Until then, I offer you an opportunity to review and comment; it is a controversial topic but I believe science is the benchmark, not conspiracy theories. We are one epidemic away from the ostracization of people who object to vaccines. This is why my original title is somewhat inflammatory. It was softened for the actual publication.  

Many of the digital back-issues are online, but not the one containing this article. I will link to it if it comes back live.

Vaccines are the most effective tool of medical science to decreasing the burden of human disease since Edward Jenner in 1798 described a method of inoculating healthy people with cowpox to prevent smallpox. Countless lives have been saved worldwide with a record of remarkable safety and a miniscule degree of adverse reactions given the magnitude of the benefit. Despite the incontrovertible weight of the evidence, there remains an anti-vaccine movement and a persistent fear of immunizations of all sorts.[1]

Opposition to vaccines can be found as far back as 1905 when the case of Jacobson v Massachusets went to the Supreme Court. In that case, a father refused to be forced by the state to vaccinate his daughter in the midst of a smallpox epidemic. The Supreme Court found that despite a legitimate libertarian argument, there was a compelling reason to over-ride the rights of the individual when fighting an epidemic because there was direct link between the number of people who were immunized and the total spread of the epidemic. It turns out that interrupting transmission was a function of reducing the number of people who could transmit the virus. The benefit to the person was magnified when the effect on the community was examined.

More recently opposition started with Andrew Wakefield, an English surgeon, who became interested in vaccines and published a study that claimed to show a link between MMR (measles, mumps and rubella) and autism in 1996. Understandably, this captured the imagination of parents everywhere. Can anyone imagine causing brain damage to their children by accepting an injection which was supposed to protect them against a deadly disease? Emotions run high with autism; parents wonder if they did something wrong and grasp at any potential cause to explain he unexplainable.

There were problems with the hypothesis from the start. First, the assertion of a link between immunizations and autism rested on the observation that the increase in the occurrence of autism ran parallel to the increase in vaccinations. Of course many other things also increased in the same interval; there was also an increase in the number of doctors available who could diagnose autism and better diagnostic criteria to distinguish autism from other forms of developmental problems. One can make an argument that anything else that increased over the prior several decades was linked, but a link is not a cause. The number of cars on the road has also increased parallel to the increase in autism, and the lead in automobile emissions is actually biologically active when ingested in the form of dust by an infant. It is more plausible than mercury as a cause, but nobody would take the idea seriously.

The vaccine link was supposed to be thimerosal, a mercury-containing preservative in the MMR vaccine. Mercury is indeed neurotoxic, but not all forms of mercury are active when absorbed into the body. For example, it is the fumes that are the best absorbed and the most active. Inorganic mercury is found almost universally in the soil and water in nature and poses no hazard. Theoretically, someone could swallow elemental mercury and not suffer any effects, because it cannot be absorbed that way (of course fumes may be released before, during or after digestion, so no one will say swallowing mercury is safe.) The mercury in thimerosal is very tightly bound and probably inert. The same way, mercury in the soil behind dams cannot be released into the food chain until bacteria convert it into a form that can be absorbed by eating fish. But mercury in fish is a well-recognized problem and there is no connection between autism and ingesting mercury-containing fish. It is difficult to think about how a relatively inert form of mercury can have any biological activity when injected. In fact, it was found that babies excrete thimerosal much faster than would be expected from our knowledge of how the body handles the toxic forms of mercury. This is one more small piece of evidence suggesting that mercury in thimerosal does not have time to interact with tissue. Nonetheless fear and controversy won out and vaccine manufacturers responded to the concerns. Thimerosal was never universally present in all vaccines and has since been removed in most every vaccine available today, except where it is impossible to use something else for technical reasons. Rates of autism continue to increase.

Then Wakefield’s study blew up! The co-authors smelled something fishy in the results especially when information emerged that proper methods in conducting the study were not followed. Eventually, it became clear that the data had been falsified, Wakefield was accused of fraud and he lost his license to practice medicine. It is believed that he falsified data so that he could profit from being a consultant on all the lawsuits that would follow. He currently lives in Texas.

The damage he caused was in stirring up a controversy that was not based in any sort of fact, in spreading false information and fear leading people to refuse vaccination and suffer the burden of increased vaccine-preventable disease making a come-back, in intense efforts to remediate a problem that did not exist and untold research dollars that would have been better spent seeking the real cause of autism. We can see the traces of his misinformation when someone like Congresswoman Michelle Bachman says that she knows people who got autism from the HPV vaccine. The statement is appallingly ignorant, brutally stupid and horribly violent for the children who would benefit from the vaccine.

Some people seem to feel that the number of vaccines is an overwhelming assault on the immune system. The problem with this notion is that in each vaccine there are a handful of highly purified proteins designed to arouse a strong immune response. Purification may always introduce trace chemicals, but at levels less than the neighborhood pool. A bowl of chicken soup probably contains an order of magnitude greater number of proteins that the entire set of childhood vaccines from birth to the teen years. It seems much more likely that prematurely feeding an infant adult food would be more harmful.

The number of needles required frequently comes up with parents. It is easy to understand how five injections at one time can be heartbreaking, especially as the child begins to wail. Older doctors however remember the days that circumcisions were done on infants without anesthesia. Without condoning what seems like a barbaric procedure to some, there is some dissonance between insisting on a circumcision on one hand and worrying about an extra needle on the other. The pain is limited. The benefit is huge.

The immunization regimens are constantly being revised and changed as circumstances permit, including the increasing availability of combination vaccines to reduce the number of individual injections. We must also remember that vaccines have become victims of their own success. When polio is fresh in people’s memory -- the paralysis, death and suffering wrought by a horrible disease -- it is easy to convince parents that the vaccine is necessary. When the disease has become rare because of the widespread use of a vaccine, the benefit does not seem as significant. Until the disease starts coming back, that is.

Other accusations thrown around about vaccines are that they represent a conspiracy on the part of pharmaceutical companies. This is laughable to people who have been interested in vaccines since the decades that research had stalled. In the 80’s, fear of litigation led most manufacturers to withdraw from vaccine research and development and shortages were looming. In 1986 Congress created the National Vaccine Injury Compensation Fund so that people who were injured by vaccines could be compensated publicly  After all, there is a societal good to vaccination that makes even the rarest adverse reaction doubly tragic. Two things happened after establishing the fund; first vaccine manufacturers reinvested in developing vaccines and lawsuits plummeted. It seems the new fund was more rigorous in making awards, not subject to the vagaries of the “jury lottery” of super-sized awards and nuisance claims. In other words, vaccines do not have a history of being particularly profitable, at least until the past couple of years when prices have started to sky-rocket. In the mean-time the compensation fund is one government program that is significantly over-funded because there have been so few claims made.

Incidentally, the body that makes vaccine recommendations is the American Committee on Immunization Practices, set up by the CDC at arm’s length. It has representation from numerous medical, public health and consumer groups and has remained stubbornly independent. It accepts no money from industry, works only peripherally with the FDA, limiting its recommendations to FDA approved parameters and constantly weighs the risks and benefits of any immunization. All their deliberations are public, transparent and available online. With the National Science Foundation and The Institute of Medicine, the ACIP is one organization that is least likely to be swayed by the big pharma’s financial interests.

Clark County’s Public Health Officer Alan Melnick is fond of saying that “vaccines prevent diseases that kill kids.” This is also true for adults. The ACIP makes recommendations based on the best science and evidence available with the aim of saving as many lives as possible with the lowest risk of any adverse events. The science and the evidence demonstrate that there is a community benefit that exceeds just the individual protection. Diseases like whooping cough and measles can still occur in an immunized population if enough people remain uncovered. It is not enough to immunize your own kids if neighbors and schoolmates refuse their immunizations; your kids can still get sick. The risk is small but probably greater than the risk of a serious reaction to a vaccine. It is an inflammatory statement that may yet prove true; that not immunizing your own kids can allow diseases to spread that potentially can kill other kids as well as your own. Vaccine objectors have not yet faced this backlash, but it remains that human beings living in communities have a responsibility first to themselves and their families, but then also to the communities which sustain them.

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[1] An immunization is an intervention designed to increase an immune response to a specific agent. Vaccines have come mean the same thing although historically the word vaccine refers to vaccinia, the cowpox virus used to prevent smallpox.

Family Medicine in the New Healthcare Landscape

A couple of weeks ago, I was invited to our local residency graduation party to give a few words on behalf of the Clark County Medical Society. It was more of a party than anything else, but there was so much I wanted to say. It was supposed to be about the residents, they had a keynote speaker, and I had five minutes to promote the society. I also kept getting ideas right up to the time of the speech. I cannot tell you how many rules of public speaking I broke. I read most of the speech, way too fast, couldn't keep eye contact with the audience and improvised on the fly... not really sure if the main points came through. It was probably more of an essay, probably more multi-layered than it should be for a simple five minute talk.

So here it is in blog format.

You are graduating into the single most exciting period in the past century of medicine. Sweeping changes to how healthcare is delivered is being contemplated and actually being enacted.

The last time this much change was going on at the same time was.. well, it was when I was graduating. They told me the same thing. From my  In the late 1980's and early 90's, a pharmaceutical revolution had reduced hospital stays and the technological revolution of minimally invasive surgery was about to threaten the need for beds across the country. HIV had been isolated and drugs were emerging that could potentially provide hope for a treatment. The practice of medicine was coming to be viewed more and more as a business and restrictions on physician advertising were being rolled back, along with the introduction of pharmaceutical direct-to-consumer advertising that was just starting at the time. Managed care was growing, HMO's were felt to be the inevitable wave of the future and the first wave of integrated health systems was about to begin, with physicians selling their practices to hospitals that were reaching out blindly to won as many practices as they could.

Since then, we saw the boom of primary care in the HMO era, the consumer backlash that followed, and the unwinding of integrated health systems. It was painfully apparent by then that FP's did not always have a good business sense and many lost money taking on capitated patients with exposure to too much risk. The hospitals realized they needed to pay attention to what they were buying when they bought a practice and for more than a decade, they were very cautious in such enterprises. The pharmaceutical industry seems to have split in two: the “me-too” drug manufacturers and the biotechs. The success of specialty drugs is perhaps nowhere felt more than in oncology where survival started increasing in the most stubborn of cancers like lung and pancreas. Indeed breast cancer is now more of a chronic disease than an acute illness and this may yet occur with other conditions. In fact, think of HIV/AIDs which is a persistent, annoying and important public health problem, now also best managed as a chronic disease. Some of our internal medicine colleagues, not known for being well remunerated have entered a golden age of their own, think of rheumatologists and the spread of biologicals in lupus and RA.

So maybe I'm wrong, maybe every age is the most exciting age in the history of medicine and the pace of change is merely accelerating. That means you will have to be accustomed to constant change throughout your careers. Such a thought can be a little sobering, because we all need some constants in our life. Living with constant change sometimes feels like living in the eye of a hurricane.

On the other hand, consider the following... no matter how much the content and context of medical care changes around you and your patients, some things do not change... a physician and a patient behind a closed door discussing their health. The generalist physician, in particular, is the one who does the troubleshooting. This never changes. Family medicine defined this way, is an integral part of the health care system. Worldwide, many experiments are under way in horizontal care with nurse practitioners, physician extenders, community health workers and the like... At the center of any program is a generalist physician who encourages, fosters and actively participates in caring professional relationships with people who may or may not know what kind of healthcare they need.

A mature specialty does not ask for the respect of its colleagues; it merely acts knowing that it is contributing to the well-being of everyone it touches by the individual acts of its practitioners.

A mature specialty does not criticize its colleagues for acting according to their immediate pecuniary interests. It recognizes its inherent power to guide and direct patients to where they will get the greatest value for their money. It also recognizes that much of its credibility in the eyes of the populace rests in the network of specialists to which they have access. People see value in getting to the right specialist quickly.

Primary care will be at the center of the future healthcare system and the fact that family physicians alone see all patients along the age spectrum provides a huge market advantage. I speak as an employer now. I have asked family physicians to step aside if they were uncomfortable with caring for certain age groups to step aside. I'd rather have an internist.

So how about some free advice to be valued as such from a doc who is now old enough to be looking downfield for a Hail Mary pass:

Family Medicine will be fine as long as you focus on certain things:

1. Focus on the health of the population. In so doing, you will always be able to see the amount of value you are contributing to the communities where you work, no matter how little you actually get paid!
2. Focus on the fact that without generalist physicians, the goal of a safe, efficient, effective health care system cannot be achieved.
3. Focus on the fact that you need to work well with everyone in the allied health fields: PA's, NP's, pharmacists, home health aides, radiology technicians, lab porters... Medicine was never supposed to be a turf war and what you do depends on the contributions of so many, it is best to remember them in everything you do.
4. Remember that nothing makes competition irrelevant than a change in the landscape. Your competition is not against PA's, NP's, specialists and the like... it is with them you must work to improve the health of populations.
5. It is OK to say no to working more for less. There are settings where you can deliver better care with less effort and mean more to people. (And maybe make more money.)
6. Stay involved.
   Medical and specialty societies are both important. In this county the WAFP is not as strong as the WSMA, but there are other counties where the opposite is true. Get involved in both. It's not about how they represent you, but rather that when you get involved, you start driving how it represents you. There is nothing more important to understanding how a new relationship between family medicine and the rest of medicine will work until you see how family physicians are getting involved all the way up to the AMA.

I would like to leave you with this one final thought on how important your contribution is

“Family physicians are the guardians of the House of Medicine; the last credible proponents of sensible care.”

First Post

I used to write a blog several years ago under a pen-name. I became disillusioned around that time; not with blogging as much as with my job. I stopped writing as my anger was leaking into my writing. I was supposed to be "The Physician Executive" but found myself unable to hold a job, buffeted by my own ego and surrounded by some more than disingenuous people. Nothing in my career as a physician, teacher, manager or self-described policy commenter had prepared me for the foulness of the human struggle.

Yes, I got involved in a political battle at work and found myself oddly unprepared for the interpersonal and political battles which presented themselves. The blow to my confidence was such that my next job, accepted mostly because I needed a job, went just as badly. Well, 'nuff said.

I have since gotten back on my feet.I worked my way into a private practice, where I am now a principal and am working on developing a medical home and honing our quality performance. During my Master's, I particularly honed interests in Outcomes and Management with a view to quality management. I feel reasonably well-integrated in the community; I get along with most people, but am already aware of some people who stand in opposition to my ideas, attitudes and practices. That's OK, nobody in the world only makes friends without being a little obtuse.

Over time, I have regained confidence in my insights and my ability to communicate them. I no longer intend to write just about health care, management and policy items. This is not a blog with its own brand identity. Writing for a local magazine, I requested republication rights. Everything I publish should eventually come under the umbrella of dinoramzi.com.

My wife and I have started two companies, one was a consulting company that took in some revenue between jobs, and is now a small holding company with investments in several healthcare (and non-healthcare) fields. SanZoe Health is in pursuit of ideas that can improve the delivery of primary care, because it is the best way to improve the health of populations (at least as far as health services are concerned). SavingHealth.com is a web site that will deliver evidence-based medicine (EBM) insights from the perspective of a practicing physician. There was a time I would perform reviews for the teaching program when I was involved in teaching at Emory. I have published an evidence-based review in a large circulation continuing education journal. Now that I am in practice, I find I still use the skills. These skills may be scarce, but they are definitely not unique but nobody is actively blogging them. So we'll get this one up when we get the time... between patients, you know.

We also started PanZoe, which should begin accepting donations within a month or two to help deliver innovative primary care to uninsured or underinsured Americans. We will begin locally, in the Camas/Washougal area, suburbs of Portland Oregon. This is our status as of June 2013 and I do not intend to update this first entry.

At this time I am also the President of the Clark County Medical Association, an alternate delegate to the Washington State Medical Association, and an active member and delegate to the Washington Academy of Family Physicians.

Politically, I am conservative, but you might not recognize my ideas as conservative given that the current crop of right-wingers are merely radicals to my eye. Many of them would call me a liberal. At the end of the day, I am an Independent who supports No Labels and the Congressional Problem-Solvers. Being a bit of a gadfly and calling out inconsistencies on both sides, I could be regarded as uniter of the parties; both sides can always rally behind the idea of throwing me out of the room!

The simple and effective communication of complex ideas is not at easy thing to do. It is a skill that requires a great deal of practice. I have not invested enough time in doing this, but have become aware that my head is exploding with innumerable multi-step ideas. There is no way to describe the role direct-primary care combined with reinsurance and a disappearing deductible for employers to avoid the Obamacare tax and improve the health of the population without building ideas one by one. I need this venue to develop the articulation of these ideas.

The greatest paradox and struggle of my life is that an intellectual path eventually takes you to a place of uncertainty, unknowing and doubt, which inevitably leads to either a sort of intellectual nihilism or on the other hand, to a succumbing to faith. I came backwards to the faith of my ancestors, to the world of Eastern Orthodoxy, mostly as a cradle Greek Orthodox. I accepted this world because of its inherent mysticism; although there is dogma in this church, there is much we acknowledge as unknown. All revelation is short of the blinding reality of God. I find echoes of Orthodox Christianity in the non-religious methodology of mindfulness meditation and most recently in "happiness" research and the concepts of "flow" and "social altruism." My old professors are guffawing as I write, but this too is something by which I stand.

If by way of advocating for the things I am most passionate about, I run into something offensive, please forgive me in advance. It is not my primary purpose to advocate for any single entity; not for primary care or family medicine, not for the Clark County Medical Society, the AMA, the AFP or its state affiliates, my wife's for-profit holding company or my non-profit foundation, EBM, mindfulness meditation or the Orthodox Church. But these things are reflections of who I am and what I care about.

I hope you will enjoy the blog and follow its evolution.