Forum: What Do Doctors Think About America’s “Vaccine War”?

When the FRONTLINE investigation, The Vaccine War, first aired in 2010, doctors across the nation were increasingly hearing from worried parents with questions over just how safe vaccines were for their children. It was an issue that caught many physicians by surprise, given the role that vaccines have played in eradicating a myriad of life-threatening diseases, from smallpox to polio to diphtheria.

How were physicians meant to respond? We put that question to three doctors and experts in the field of vaccine safety.

Sigall Bell, M.D. is an assistant professor of medicine at Harvard Medical School and a member of the Division of Infectious Diseases, Beth Israel Deaconess Medical Center. She is the director of the BIDMC travel medicine clinic and the mother of two young children.

Eileen Costello, M.D. is a pediatrician in Boston and co-author of Quirky Kids: Understanding and Helping Your Child Who Doesn’t Fit In. She has completed an autism fellowship at Boston Medical Center and is the mother of three children.

Tom Delbanco, M.D. is a professor of medicine at Harvard Medical School and a primary care physician at Boston’s Beth Israel Deaconess Medical Center, he also served as senior consultant for The Vaccine War.

Here is what they wrote around the time of the film’s premiere back in 2010:

Tom Delbanco | April 19, 2010: Fear rules three memories of infections and efforts to avoid them in my childhood. My first experience with prevention taught me how to faint gracefully. As a child in England in the 1940s, we would get periodic Schick Tests, an injection testing whether we had antibodies against a dread disease, diphtheria. For some reason, I’d faint right after the needle was withdrawn, but I quickly learned to take it sitting down.

Next, F.D.R was the family hero; he had helped save us Jews, and after arriving in America in 1948 a few years after the war, my parents quickly took my brother and me to pay respects at Hyde Park, the Roosevelt family home. But my mother turned pale when she saw the crowd of visitors, and we never entered the gates. The threat of our contracting infantile paralysis, now known more benignly as polio, trumped the purpose of the visit.

And my third memory is my brother’s struggle with the measles: shades pulled down to protect his eyes and the worried look on our pediatrician when he first heard a heart murmur, signifying possible structural damage to a heart valve.

Today, my grandchildren don’t run such risk. Moreover, young doctors and young people in America haven’t seen these and other illnesses for which we have vaccines. So thoughts turn to benefits versus risks, to possible vaccine interactions with devastating disabilities, and to individual versus social responsibility.

And how the rules for debate have changed! Violent exhortations highlight how Googling, Twittering, YouTubing, Facebooking and blogging have transformed the way we gather, disseminate, consider and discuss all kinds of information.

The Vaccine War addresses complicated issues. Joined by Sigall Bell and Eileen Costello, two doctors both young mothers and expert in this area, I look forward to my first experience blogging and, at times, debating.

… A good book, debate, or film makes one think, and perhaps even alter one’s views: Will your understanding and/or opinions have changed? It’s generally true that “Where you sit is where you stand.” But if the film, fortified by this website, makes you shift in your seats a little bit, it will have been worthwhile!

Sigall Bell | April 22, 2010: Asked in a survey whether they thought vaccine decisions should be made by parents or government, focus group participants told political scientist Hank Jenkins-Smith they wanted to make their own decisions. Even those who agreed with vaccines wanted to be in charge. I’m not surprised. When it comes to my kids, I want to vote with my own feet too. And I do that with school choices, TV rules, video games, etc. But when you say “No” to vaccines for you, you are also saying “No,” to some degree, for me.

We’ve long known that children in the same community belong to a shared pool of infection risk. If I pay insurance but you don’t, both of our kids are at increased risk. This is because while very protective, vaccines are not 100 percent effective. Some children may not mount a full immune response after vaccination. Some children can’t get vaccinated because they are not old enough or because they have underlying health conditions that preclude safe vaccination. If enough kids lack protective immunity and the illness enters the community, it’s not just the unvaccinated child that gets sick. In fact it is often the vulnerable children who couldn’t get vaccinated that are at greatest peril.

Now researchers tell us that so-called “herd immunity” travels even farther. A unique study published in JAMA a few weeks ago compared 22 small communities in Canada where kids were influenza vaccinated to 24 similar communities where they were not, examining rates of influenza in the whole community. Here’s what they found: Total community influenza rates were more than double in the unvaccinated group. Immunization of children conferred a large (61 percent) protective effect for the entire community, providing clear-cut evidence that the benefit of vaccines extends beyond the recipient. Considering that approximately 30,000 people die each year in the U.S. from influenza, this is not trivial.

So now we parents have yet another string of social responsibility to consider: if we forego vaccination for Bobby, what does this mean — not only for Bobby’s classmates — but also for his grandmother?

Eileen Costello | April 23, 2010: As a pediatric resident in Boston in the 1980’s, I spent a lot of time caring for babies and young children with critical infectious diseases that we no longer see.

Two bacterial organisms were especially common, household words among pediatricians: Haemophilus influenza type B (HIB) and Strep pneumonia (Pneumococcus). Both could cause infections in the blood, meningitis, pneumonia, bone infections, and abscesses in the brain and other organs.

If the children were lucky enough to live close to the hospital and come in early in the course of their illness, they might do well with aggressive treatment and antibiotics. If they weren’t so lucky, or if their illness seemed at first like a run-of-the-mill childhood illness, they may not do so well. In my practice now, I follow kids who suffered deafness or other long term learning or developmental disorders as a result of these illnesses.

Within a few years of starting practice we began routinely vaccinating babies against these two organisms, and suddenly the practice of pediatrics was so different! Babies with fevers who were fully immunized had a dramatically lower likelihood of a serious bacterial illness, and this was such a relief. Many fewer babies were hospitalized for the possibility that their fever represented a serious and potentially devastating bacterial illness. Perhaps this is why it seems so terribly ironic that parents are refusing these very vaccines.

The Vaccine War is a timely examination of just this paradox, and an issue whose time has come.

Tom Delbanco | April 23, 2010: Several respondents comment here about the (apparent) increase in the prevalence of autism. Two questions about it, and the film addresses both: 1) Is it real? 2) If it is, why is it happening? I’ll offer a few observations …

Suffice to say that measuring prevalence (how many people have condition x at a given point in time) has never been easy, and there have been some real goofs along the line. For example, acute rheumatic fever (ARF) was a common illness in this country in the 1950s, and systemic lupus erythematosus (SLE) was rare … until investigators began to decide that quite a few patients labeled with ARF were afflicted with SLE … AND penicillin began killing streptococci that caused ARF. So: ARF began to disappear, SLE grew … and who knows exactly what meant what?

Autism brings up the same issues. As a medical student at Columbia, my first patient on my psychiatry rotation was an autistic child who collected newspapers and was obsessed by the subway gratings on New York’s streets. A talented young boy with a brain that did many things marvelously, he was spooky, fascinating, and tearing his family apart. His parents were in agony: guilt-ridden, angry, grateful that their two other children were fine, and seeking answers to why … and where do they go next …

Almost 50 years later, I don’t think we’re a lot closer to the answers, and as the definitions shift, it remains difficult to measure prevalence. My own suspicion is that it has indeed increased, and I come to that conclusion in a highly un-scientific way. We have friends who are teachers in elementary schools, and they really know kids. They are convinced they’re seeing more autism … full blown.

Why? More later …

Sigall Bell | April 24, 2010: Thanks for the contributions, here are a few responses:

[One commenter] questions the efficacy of vaccines since many of the persons affected by the current mumps outbreak in New York and New Jersey were already vaccinated. That’s true, TJ, and an unfortunate reality in vaccine medicine: despite ongoing efforts, vaccines aren’t 100 percent effective. This is particularly true for mumps vaccine, which has a more variable efficacy rate in the literature. Compare that to recent measles outbreaks where 91 percent of the people who got measles were not vaccinated or had unknown vaccination status, and only 5 percent of those who got sick received the recommended two doses.

Even though vaccine effectiveness is not 100 percent, vaccination is still worthwhile. Why? Even in those who get the disease, prior vaccination can decrease the severity or duration of the illness.

[A second commenter] states that herd immunity has no scientific basis — the Loeb article suggests otherwise. Several people also commented about how vaccinated kids should be fine if there were an outbreak, so why all the hubbub? That brings us back to the mumps situation above … vaccinated kids are not always fine, unfortunately. [A third commenter] wonders can’t we do more bloodwork to figure out who is immune? Absolutely! … In the travel clinic where I work, we do this all the time. For people who aren’t sure if they got two doses of MMR, or were born before 1957 and can’t recall if they had the diseases, we routinely check blood titers. …

A few of you asked about vaccine spacing. Stay tuned, I’ll write about that next…

Eileen Costello | April 25, 2010: Many posts have included references to the increased prevalence of autism.

There are several aspects to the autistic disorders that make this question especially interesting. First, the autism “spectrum” refers to children with a wide range of ability and disability, and this is quite new.

If we compare the current estimates with those of even 20 years ago, before Asperger’s syndrome or high functioning autism were commonly described, we will of course see much higher rates of “autism” now. At the Asperger’s Association of New England where I have been on the board and am currently on the executive advisory committee, we see a great number of adults come to us seeking help after a new diagnosis on the autism spectrum. Most have no previous diagnosis, but have had a lifetime of difficulties in educational, occupational, and social situations despite normal or above normal intelligence. These are not the autistics of 20 or 30 years ago, a good proportion of whom met criteria for a diagnosis of mental retardation, or intellectual disability, as we would call it today.

Thus, the widening of the “spectrum” contributes, at least to some degree, to the confusion about the numbers. There is little question in the minds of most developmental and behavioral pediatricians that terminology plays a part in the apparent increase in prevalence of autism.

Tom Delbanco | April 25, 2010: From the first days of medical school, we’re taught to stay away from anecdote. “When you see a patient with symptom x, consider the possibilities carefully, but you’d best ignore what the last patient with the same symptom turned out to have. If you assume this is the same illness, time and again you’ll find yourself misled by anecdote.”

But fervent beliefs growing out of a singular experience seem to be spreading. Today, more and more people are convinced that Diet A, Pill B, Activity C, or Potion D has transformed their lives, and that their experience must apply equally to everyone else. Aided by the Internet and its electronic relatives, new authorities appear instantaneously, and their convictions spread like wildfire. But recall Virginia Woolf’s admonition: “Literature is strewn with the wreckage of those who have minded beyond reason the opinion of others.”

Scientific medicine struggles to counteract that phenomenon. But it has its own troubles. It’s rare that we really prove cause and effect; penicillin definitely kills certain bacteria, but not many other phenomena are so clear. Relatively new research tools, such as clinical epidemiology, decision analysis, and controlled trials, make us better at estimating probabilities and establishing associations, but quicksand abounds and we keep changing our minds as new data are collected and new analytic tools are applied. So one year vitamin D’s not so important, this year it’s vital. One year, freezing stomachs cures ulcers; the next year it kills people. The PSA helped us chart the future, now it breeds chaos, and so on.

So as we confuse people with our flip-flops, what right do we have to decry anecdote? And it’s not always so bad. We’ve learned a lot from close observation of interventions with individuals or small groups of patients. It took just a few to teach us that penicillin cured disastrous infections. Isoniazid transformed tuberculosis. And it was immediately clear that a vaccine could prevent smallpox. Was that not anecdotal medicine?

Not so easy. Americans pay millions for homeopathy: pills soaked in water so dilute it lacks even one molecule of the dead spider that’s purported to make it a powerful medicine. And what about the placebo effect: how often does your headache clear before the pill dissolves?

Pretty confusing stuff. No wonder we find a “vaccine war!”

Tom Delbanco | April 25, 2010: When you’re nervous about vaccines — and many of the diseases they target have disappeared from sight or certainly don’t seem nearby — it’s easy to understand hesitancy about piercing a baby’s skin again and again.

When I discuss the relatively new vaccine against shingles with my aging patients, it’s simpler. Among those “of a certain age,” almost everyone has seen shingles, and many know friends or acquaintances knocked for a loop by that virus, with more than a few left with ugly scars or chronic pain. So it’s much easier for my patients to consider the risks vs benefits because they have some firsthand knowledge of the risks. And of course the perspective is quite different when you’re thinking about yourself at age 70, rather than about another person – a newborn with a whole life ahead (though even in the shingles example, you need to consider others because you need to stay away from people with damaged immune systems while the vaccine is settling in, and several posts in this discussion have rightly pointed out that it’s very hard to know who may be at risk in that respect, whether adults or infants).

So the dilemma is much more difficult for a parent with a baby who already cries enough. Who’s seen diphtheria recently? Am I in a community or circumstance where hepatitis B is a real risk? How should I weigh the common good versus my child’s unique interests?

These decisions aren’t easy, and anyone who claims they are sells the value of individual perspectives short. The survey we display shows that “different strokes for different folks” is still the American way!

Sigall Bell | April 25, 2010: [A commenter] asks why researchers used the hepatitis A vaccine for the control group instead of just placebo in the JAMA study I recently blogged here about. Great question …

The methods section states that hepatitis A vaccine was chosen for the control group “because it is well tolerated and provides a potential health benefit given reported outbreaks of hepatitis A on Hutterite colonies” (the communities studied). Since studies have to be approved by the Institutional Review Board, which looks hard to protect human subjects, an intervention with potential benefit may have seemed like a better choice than a shot of nothing as the placebo.

I contacted the lead author, Dr. [Mark] Loeb, who told me the potential benefit was the main reason. He also pointed out that hepatitis A vaccine was previously used as a control in a CDC [Centers for Disease Control and Prevention] pediatric influenza study, so there was good precedent.

Here’s my take: you can use placebo (like salt water) or you can choose something that might more closely mimic the experience of an actual vaccine. In general, scientists try to keep as much as possible the same for the two groups, except for the precise thing they are testing — in this case, influenza immunity itself.

For example, let’s imagine that getting the hepatitis A vaccine revved up the immune system, even in a non-specific way, such that vaccine recipients were able to fight off other infections more effectively. If this were true, it would potentially affect the study, because even those receiving hepatitis A might be less likely to get (or get sick from) influenza, and therefore less likely to pass it on. It didn’t turn out that way – the herd immunity was specific to those in the community where kids got influenza vaccine – but using actual vaccine for the control group in the study design might make it even harder to show that difference. It’s my own curiosity talking here, so I asked the lead author, Dr. Loeb, to join our conversation. Let’s see if he chimes in!

Eileen Costello | April 25, 2010: Some parents have asked how we help them think about the wildly different information they hear about vaccines, and how they are supposed to make an informed decision about what is best for their baby or toddler. This is a common occurrence in our pediatric practice.

Most parents come to their first visit to the pediatrician armed with questions. The majority have done their research on the Internet, and anyone who has googled “vaccines” or “vaccines and autism” knows it’s overwhelming and very frightening to new parents of young babies. We recognize that anxiety and work with parents to help them understand why we think that vaccinating their babies is in their best interest and in the best interests of the community they live in.

One truth new parents may find hard to accept is that there is no such thing as a risk-free life, and we cannot protect our children from all potential harm. I had the privilege recently of meeting with Dr. T. Berry Brazelton, a pediatrician in his 90’s. He is recognized as the father of developmental and behavioral pediatrics.

Asked what he sees as the major difference between today’s parents and those in his practice 60 years ago, he commented about the anxiety of today’s parents. He noted that we as a group seem committed to preventing any harm from befalling our children, and we feel like failures if we cannot. This plays into the fear that we are harming our children by vaccinating them.

No one can “prove” that vaccines are completely without risk. But history and science do tell us that the diseases they prevent are dramatically more risky. The post from the mom who lost her one month-old son to pertussis (whooping cough) is an excellent case in point. Pertussis kills very young infants. When a newborn is in my waiting room with unvaccinated children who are coughing, I cannot help but worry that I am exposing that baby to a potentially life threatening disease unnecessarily.

So I talk with parents about the diseases, which most of them are fortunate enough to have little or no experience with. Sometimes I tell them about outbreaks in our own community of vaccine-preventable illnesses — for example, an outbreak at a daycare center here in the 1990s of strep throat and chicken pox at the same time.

The strep bug took advantage of the break in the skin to cause “flesh-eating strep” in a number of kids, several of whom were hospitalized and required surgical treatment of their wounds. The myth that chicken pox (varicella), for example, is always a harmless childhood disease, contributes to the belief of many parents that a vaccine is more dangerous than an illness.

It’s difficult in a busy pediatric office, where visits run about 15 minutes each, to spend the time to review this information. But I do it. Because I remember that it’s the delightful, adorable, beloved infant that is my patient and my job is to protect him or her to the best of my ability. For me, that means vaccinating.

Eileen Costello | April 26, 2010: [A commenter writes] that infants do not need hepatitis B vaccine because the only way that one can contract the virus is through needle sharing and sexual intercourse.

In fact, in fully one third of cases of hepatitis B, the exposure is completely unknown. Exchange of blood or semen is not required to transmit hepatitis B. The reason to vaccinate as early as possible is because the earlier a child contracts hepatitis B, the more likely he or she is to develop chronic hepatitis and hepatocellular carcinoma, a liver cancer.

Children can be exposed to the virus simply by eating in a restaurant. The food industry is well known as a potential source of hepatitis B. That’s one reason why there are signs in every restaurant restroom reminding employees to wash their hands before returning to work.

There is plenty of hepatitis B around the world and lots more in the U.S. than we realize. Every pediatrician in America cares for internationally adopted children, a proportion of whom are infected with hepatitis B because they are from countries where it is rampant and have not been vaccinated. Those children attend school and play sports with our children. The risk is there. It’s not zero. And the risk to your child’s health, should he or she contract hepatitis B, is greater than the risk of the vaccine.

Over the years I have received a number of calls from parents who are discovering for the first time that a close relative has previously undiagnosed chronic hepatitis B. They wonder what the risk to their child is if, for example, they take a family vacation or go to a reunion or picnic. If the child in immunized I can reassure them that the risk is extremely low. If not, the risk is very likely greater. Of course we can’t quantify the risk, but we do know it’s there.

Sigall Bell | April 26, 2010: A few months ago I got an email from my cousin. “Should I really be giving my baby all these vaccines at once?” Spacing vaccines is now a hot topic among young mothers. Why do them all at once when you can spread them out over several visits?

Curious, I raised the question with my own pediatrician. “I can do that if you want, “she said, “but I feel bad for my relationship with the child.” How can they grow to trust their doctor if every visit comes with a needle? And they learn fast. With just a handful of words under her belt, my daughter mustered up “Oh-oh!” as soon as we checked in for her 12 month visit.

So then I researched the issue and discovered something surprising: Despite routinely vaccinating our infants and toddlers against 14 pediatric diseases (15 if you count H1N1), compared to the single smallpox vaccine kids got a century ago, their immune systems get less of a workout. How can that be?

Vaccine biology is much improved today. With purified proteins and recombinant DNA technology, we can target the desired antigen — that component that we want the immune system to “see” and remember — much more specifically. So while vaccines of the past may have had hundreds of antigens, today’s vaccines can have as few as one. Here’s the take-home: kids today get many more vaccines than the children who got the solitary smallpox vaccine, but they actually receive less immunologic triggers (approximately 150 versus 200 antigens from smallpox, according to researchers).

Here are some more interesting numbers: using conservative estimates of immune system capacity, scientists estimate that infants could theoretically respond to about 10,000 vaccines at any one time. No one’s going to do that, but it does put things in perspective. For those who worry that multiple vaccines “overwhelm” the immune system, these researchers suggest that even 11 vaccines given at once only occupies about 0.1 percent of the immune system’s attention.

I fully confess that I’m the parent who has to leave the room when our kids get vaccinated (my husband is the official “holder”). Spacing sounds very rational. But there are a few poorly publicized arguments against it that are worth considering when you make your decision. Even beyond the pediatrician relationship issue, and the overall lower antigen load, I just can’t bear the thought of putting them through more total vaccine visits than we need to. For others, the scales may tip in the other direction. At this point, I think the spacing decision is best made by weighing your own pros and cons. Talk it over with your pediatrician. My personal feeling is get it over with, until there is more compelling evidence that spacing works. That’s what I told my cousin. What would you say?

Eileen Costello | April 27, 2010: Because there have been many posts relating stories about children who regressed after receiving their vaccines, I would like to address what the community of clinical autism specialists have come to believe, based on many years of observation and analysis of children on the spectrum.

Autism is largely believed to be a biologically based neurodevelopmental disorder, which in most cases means a child will or will not develop autistic features based on their biology at birth and their genetic heritage.

A developmental regression is a very alarming thing to see. Pediatric residents are taught to ask about it and look for it in very young children because it often represents something truly awful, like a genetic syndrome with a poor prognosis, or a serious underlying medical condition. I recently saw a 10 month-old boy who had been happily pulling up to stand for a month and suddenly stopped. He had a serious bacterial infection in the vertebra of his spine, for which he was hospitalized and treated, and completely recovered.

There have been a number of fascinating studies of children diagnosed with autism who were felt who have undergone a developmental regression. About a quarter of parents of autistic children report that their child had a regression of development. Many experts believe that regression is simply part of the process for many cases of autism. When first birthday videos made by families were reviewed with expert eyes — but blinded to which children were ultimately diagnosed — there were indications that those children had early, though often subtle, indications of developmental differences.

Similarly, infant sibling studies which are following the younger siblings of children already identified as autistic, demonstrate that some signs are evident to experts as early as six months of age. So while we may think the child has regressed, it isn’t always the case.

The reason the infant sibling studies are so critical is because of the recurrence rates in families. When asked by parents with one child what the likelihood is that a second child would be affected, we generally quote about a 6 percent to 8 percent recurrence rate. Among identical twins both are affected about 90 percent of the time. I always suggest genetic testing if couples are considering having another child, and follow a good number of families with multiple affected children (some vaccinated and some not, in a few families), as well as some families where a gene was unexpectedly identified as the culprit.

I have certainly received calls from parents about babies screaming or having high fevers after their vaccines. In those cases, we carefully plan out how to administer the rest of the series. In my practice we have not seen dramatic negative outcomes with long term significance in any of our patients. Babies do have medical problems sometimes. Babies can have seizures, babies can get and do get fevers. Sometimes it’s simply impossible to know if a baby with a fever or a seizure shortly after a vaccine may have had the fever or seizure without the vaccine.

I hope this helps to answer how we think about some of these important and difficult questions. I am deeply indebted to the parents of autistic children for helping us investigate the causes of the autism spectrum disorders. I am including a few links to studies of interest:

  • Adrien JL, Lenoir P, Martineau J, et al. Blind Ratings of Early Symptoms of Autism Based Upon Family Home Movies. J Am Acad Child Adolesc Psychiatry 1993; 32:617-626.
  • Adrien JL, Perrot A, Sauvage D, et al. Early Symptoms in Autism From Family Home Movies: Evaluation and Comparison Between 1st and 2nd Year of Life Using I.B.S.E. Scale. Acta Paedopsychiatrica 1992; 55:71-75.
  • S. J. Spence, “The Genetics of Autism,” Seminars in Pediatric Neurology 11
    (2004): 196-204;
  • R. Muhle, S. V. Trentacoste, and I. Rapin, “The Genetics of Autism,” Pediatrics
    113 (2004): 472-86;
  • M. T. Miller, K. Strömland, L. Ventura et al., “Autism Associated with
    Conditions Characterized by Developmental Errors in Early Embryogenesis: A Mini
    Review,” International Journal of Developmental Neuroscience 23 (2005): 201-19.

Tom Delbanco | April 27, 2010: Assuming a) that you have now watched The Vaccine War, that b) some of you have been watching or took part in the discussion/debate/arguments that have marked this forum for the past several days, or c) that you are looking into this for the first time, let us welcome you (back)! Sigall Bell, Eileen Costello, and I are three doctors who come to this with rather different backgrounds, although we share grounding in “scientific medicine” (here come the next brickbats!).

In order for you to take stock of where you sit on some of the issues touched in the film, we invite you first to address (perhaps once again) the five questions posed on this page. Please compare your responses a) to what you felt if you “surveyed yourself” before watching the film, and b) to what a national survey conducted recently revealed about the views of our citizenry.

As I note in my welcoming comments to this discussion, while most often “Where you sit is where you stand,” we hope the film made you wiggle in your seats a bit. At the very least, we trust you’ll agree that you’ve met some stimulating folk, each with considerable experience in the area, convictions strongly-held and articulated, and good intentions.

You can now read more from several of them in extended interviews. You may want also to take a look also at our preceding commentary, along with the often heated and illuminating response it triggered. In no particular order, we’ve addressed so far anecdote’s pitfalls and power, individual decisions versus the public health perspective, the rationale for hepatitis B vaccination in early age, the argument for spacing vaccinations differently from the national recommendations, control groups in clinical studies, why measuring the prevalence of conditions such as autism is so complex, a young (doctor) mother’s views about vaccinating her own children, a pediatrician’s management of individual choice … and other themes that intertwine.

Far more to come! Join us. As my grandkids would say, bring it on!

Tom Delbanco | April 29, 2010: From the words flying back and forth, The Vaccine War has got more than a few people riled up. Infections, tragedies, and public health debates rarely lack controversy. But recall also that a few months ago the world was in uproar about Swine Flu. How bad would it be? How widespread? Would the vaccines work? When would they arrive? Who should get first crack at them … the elderly, the young, pregnant women, health workers? Everyone was on edge, including us, the primary care doctors who’d help deliver the goods once they arrived.

I can’t remember pundits asking a question that proved at least as important: Who’d say “yes” or “no” once my needle was ready? Turns out an awful lot of people refused the shot, and that wasn’t limited to parents who believe vaccines mean trouble. It included more than a few health professionals. I have several in my practice: brilliant scientists, analytic thinkers, professors … I asked them to explain their saying no, but most refused to give a reason.

I met with Norman Letvin, a famed vaccine scientist at my hospital who leads a large team of talented scientists working feverishly to prevent HIV infection. He startled me: A majority of his younger colleagues were avoiding flu shots despite his urgings and our hospital’s fervent efforts to vaccinate its entire workforce. He smiled, looked frighteningly scholarly, and asked me why I thought this was happening.

First, I guessed fear of serious side effects, such as Guillain-Barre syndrome: enormously rare, but frightening as paralysis spreads (usually self-limited, with most recovering fully over time). Wrong. Next guess was lack of efficacy; his colleagues understood vaccines better than I ever could and didn’t think this one would work. Wrong. I tried again: they thought the flu would be milder than most expected. No. What about quiet rebellion against authority’s urgings? Wrong again. I gave up.

To paraphrase his highly scientific insight: “People are afraid of shots. Shots hurt. No one likes a shot!”

He may be right. Not only do parents (and clinicians) hate watching kids cry as the needle goes in, but I struggled and failed again recently to convince one of my long-term patients to switch to insulin injections. In his 50s, with more than 15 years of diabetes, a history of ineffective pills and unpleasant side effects, his blood sugars are much too high and his kidneys are becoming damaged. Yet he refuses shots that might both help him feel better now and turn things around long-term.

I’d love to hear Freud and Pavlov speculate about shots. Is the fear genetic (why are many terrified of snakes right from the start)? Is it conditioned by early childhood vaccinations? Deep down, are people afraid of crying? Are shots assaults? Do we believe the arm or buttock will hurt forever?

I suspect Norman may be right, but if so, why? What do you think?

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