The Third Rail of Pediatrics

Is discussing the safety of vaccines the third rail of pediatrics?

I have begun to think so, and stated this during my address at the recent Forum on Vaccines hosted by Deirdre Imus at Hackensack University Medical Center. The point of the Forum was to bring together doctors and other health care practitioners, NJ legislators and public health officials, and parents to try and find common ground in what I think is the public health debate of our times. It was clearly stated at the outset that none of the speakers were anti-vaccine, and that we were there in fact to figure out how to help rebuild trust in a system that is clearly broken. As with so many of our American institutions designed to protect public good (CDC, EPA, NIH, FDA), the immunization program that is called a “miracle” by public health figures and most doctors may in fact be a victim of its own success. By that I mean we have eliminated or vastly reduced most of the vaccine-preventable diseases that plagued our country in the 20th Century. The last case of naturally occurring paralytic polio in the United States was in 1979, and in fact, the vast majority of non-naturally occuring polio cases from 1980-1999 (144/152) were vaccine-associated paralytic polio which affected some who received the oral Sabin vaccine. This vaccine was discontinued in the U.S. when it was discovered that the risk of polio from vaccination outweighed the natural risk of contracting polio – the risks outweighed the benefits; now we use the inactivated injectable Salk vaccine (the original polio vaccine) exclusively in our country. So parents today are similarly trying to weigh risks vs. benefits regarding vaccine efficacy and safety.

Is this a radical statement? Shouldn’t parents have a role in this decision? Isn’t vaccination a medical procedure guided by the ethical principles of informed consent? I understand there are other ethical principles in play here – what role does the child have in this decision (i.e. in NJ now, it is mandatory for those entering 6th grade to have a meningococcal meningitis vaccine and a diptheria-tetanus-pertussis booster)? And what about individual health vs. public health? These are complex ethical principles and deserve measured, careful debate. But as someone who has even entertained the idea that 100% of vaccines may not be safe and effective for every child all of the time (no different than any other medical intervention, I might add), I have been labeled as “anti-vaccine.” That makes me mad.

Does it make me naive? No, I get it. I don’t have to like it, though. I have been visibly, publicly in favor of vaccination as public health policy. I vaccinate in my practice, and of greater importance, I have vaccinated my children. But simply because I am willing to publicly question (imagine that?) the rhetorical safety and efficacy of immunizations, special interest groups with lots of political power and money would like to shut me up. After all, if a board-certified pediatrician, a former Chief Resident at NY’s Mount Sinai Medical Center, and a Fellow of the American Academy of Pediatrics and vice-chair of one of the AAP’s Sections (on Integrative Medicine) is voicing concern, well, I guess that’s threatening. Is this not America?

In a country where we as a people are mired in one of the greatest economic debacles of all times due to lack of regulatory oversight, is it wrong to want to be careful? We live in a cynical age. Trust in public institutions is at an all time low. We have seen once again this week that bodies like the FDA are fallible – witness the whole BPA mess . When one government regulatory agency – the CDC – is charged with both promoting vaccines and monitoring their safety, we have a big potential conflict of interest. What I have simply argued is that in order to save the vaccine program, we need transparency and open dialogue (sound familiar?), not cloak-and-dagger policies. If parents are forced to choose between giving all currently mandatory vaccines on a strict schedule based more on insurance company recommendations (“come get your shots at 2-4-6-9-12 months, because those are the # of well visits covered by your HMO”) than on current scientific rationale, especially when you now throw in required influenza vaccination for preschoolers and infants in daycare, more are going to choose none and opt for religious exemptions. It is anecdotal, and I would love to study this, but it is my observation that most parents who are avoiding vaccination altogether would like to vaccinate their children against most illnesses, but have reservations about 1 or 2. In NJ, they are left with one option – religious exemption, and thereby effectively closing the door to any vaccines. Is this what we want? A system of fear and forced choices? I don’t think so. Especially when there are legitimate concerns raised by cases such as that of Hannah Poling, the young autistic girl with mitochondrial issues and vaccine-related neurodevelopmental disorders (autism, seizures). We need to ask these hard questions – are immunizations in some way related to the epidemics of autism, food allergies, ADHD and asthma afflicting our children? Are we trading off a reduction in acute, infectious-disease illnesses for a surge in chronic neurodevelopmental and atopic/autoimmune disorders? It will only be through open, scientifically-based debate that we will discover what is truly in the best interest of our public’s health.

“The best way out is always through.” – Robert Frost, “A Servant to Servants” from “North of Boston” (1915)