Vaccines: The Blind Men and an Elephant
by MATT CHRISTENSEN
In a well-known Indian parable, a group of blind men are walking together and come upon a strange creature in their path. Using their sense to touch, they each try to describe what they have found. The first one feels a leg and argues that the creature is like a pillar. The second feels an ear and argues it is like a hand fan. The third feels its tail and argues it is like a rope.  There are a few different versions of the parable, but generally the blind men argue on and on about which one is right until either a god enlightens them to the complete truth or they learn to collaborate and discover that they were all correct—the creature was simply an elephant. No blind man was wrong per say, but rather all were only partially correct about the properties of the elephant. Largely, the parable functions to highlight the manifold nature of truth, and the shortcomings of not seeing the ‘whole-picture.’ Likewise, in recent decades, there has been much careful (and some not so careful) discussion about vaccinations, but most of the debate has only centered on whether or not they are safe. Yet, perhaps we haven't yet seen the whole elephant, as it were.
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This past July, the California state government passed a law (bill SB277) that eliminated personal belief exemptions for childhood vaccinations. Once the law goes into place a few months from now in July of 2016, it will remove the major mechanism by which California parents could choose to not vaccinate their children.  For some, this law comes as a welcome measure to counter falling childhood vaccination rates.  For others, many in the anti-vaccine camp, it is an outrage.  The potential impact of the law is uncertain, but has certainly added yet another twist to the on-going debate.
Before diving in further, it's worthwhile to review the context of the anti-vaccine movement. Although there has been legislation and some debate over routine or compulsory vaccination since the mid-1800s  the modern anti-vaccination movement was really born on February 28th, 1998 with the publication of a study by Andrew Wakefield in The Lancet. In some of the press conferences at the time of publication, Wakefield suggested that there might be a link between the routine childhood vaccination for MMR (Measles, Mumps, and Rubella) and autism.  This study is commonly credited as being the spark for the anti-vaccination movement. The Lancet is a prominent medical journal and the story got broad coverage on U.K. and U.S. news streams.  Public concern grew over time even as researchers pointed out obvious flaws in Wakefield's argument, notably a very small sample size of only 12 patients. The anti-vaccine movement then reached full national attention in the U.S. when Jennifer McCarthy, former Playboy Playmate, publicly blamed the MMR vaccine for the onset of autism in her son.  McCarthy made numerous television appearances and many parents, particularly in California, began to opt out of recommended childhood vaccines due to concern for their safety.
Since then, the anti-vaccination movement has remained strong despite strong scientific evidence that refute the vaccine-autism connection. Multiple studies re-confirmed the safety of vaccines and failed to find a link between the MMR vaccine and autism and the editors of The Lancet retracted the Wakefield publication in 2010 after and investigators revealed that Wakefield had manipulated his data.  There is even a growing literature in the medical community on how best to respond to concerns based upon misinformation and convince parents to vaccinate their children. One medical trial even found that dialogue between a parent and a health professional might actually make a skeptical parent less likely to vaccinate their child.  This research and overall lack of public response demonstrates something we already intuitively know: it's very difficult to change someone's mind, even more so when it's in relation to what's best for their child and fear  is involved.
One medical trial even found that dialogue between a parent and a health professional might actually make a skeptical parent less likely to vaccinate their child.
On the other side, the major concern behind falling vaccination rates is that potentially lethal diseases could resurface. For vaccination to be effective at preventing the spread of disease in large outbreaks, about 95% of a community must be vaccinated and develop immunity to the viruses that cause the disease.  This is commonly known as “herd immunity.” Without herd immunity the virus can spread, even through those who have been vaccinated, and infect vulnerable individuals who either have some other medical reason for not being vaccinated or have a weakened immune system from old age or immune-system-suppressing medications. Indeed, since 2000, the rate of cases of the Measles and small pox outbreaks has been steadily increasing.  Just as some parents fear vaccines, others have begun to fear the increasing risk of an outbreak due in part to those who have not received vaccines.  An outbreak of the measles in December 2014 spreading into January 2015 was ultimately linked to an exposure at Disneyland in Southern California and the California Public Health Department partially attributed the outbreak to lower vaccination rates.  Although this outbreak can only provide partial evidence of causation, it was a major factor motivating the passage of bill SB277  and subsequent counter-debate and calls for repeal. [15, 16]
There is certainly more detail and nuances to the anti-vaccination story than I've presented here. However, even at the level of an overview, the vaccine debate bears a fair resemblance to a group of blind men struggling to comprehend an elephant. The players are not blind and not stupid but the ongoing squabble doesn't appear to be very productive.
To widen our scope on vaccines, it may be helpful to consider a seemingly unrelated law that was passed just a few months earlier from SB277. In early April of 2015, while the rest of the nation was absorbed in the final game of college basketball’s March Madness, Arizona passed a law that removed the requirement for a doctor's order to request a blood test.  Previously, an individual had to speak with a doctor to obtain this kind of medical testing. Now, a blood test can be ordered by any individual. The law specifies that health insurance will not be required to cover any of these tests and that medical professionals are not obligated to independently follow and respond to abnormal results.  One might consider it a nice personal liberty, but does the law suggest something more? Although the Arizona law has little to do with vaccines directly, it is interesting to consider in relation to the anti-vaccine movement. Thus, the parallels and contrasts between these two new laws might strongly suggest that the anti-vaccine movement, at its core, may have little to do with vaccination and fear thereof, and much more to do with power and individual agency.
At face value, opening up access to blood tests seems reasonable. Much of the medical and scientific research that lead to the development of these blood tests was funded by the U.S. government through the National Institutes of Health and there aren't any obvious concerns of national security and defense. Some medically relevant tests, such as blood pressure cuffs, thermometers, and pregnancy tests are already directly available for sale to the public. How different, really, is a blood test from a home urine pregnancy test? One might argue that people should have the ability to access information that is literally in their blood regardless of whether or not a doctor thinks it is needed. Given that the individual themselves pays the cost, is not harming others in the process, and that the other regulations on lab testing centers ensuring safety are still in place, there aren't any glaring reasons why individuals shouldn't be allowed to test themselves. However, that doesn't mean that allowing individuals open access to blood tests is a good idea.
Although the Arizona law has little to do with vaccines directly, it is interesting to consider in relation to the anti-vaccine movement. Thus, the parallels and contrasts between these two new laws might strongly suggest that the anti-vaccine movement, at its core, may have little to do with vaccination and fear thereof, and much more to do with power and individual agency.
Consider, for example, the test used in prostate cancer screening which is no longer recommended. Research has found that screening otherwise healthy men more often lead to unnecessary surgical treatment with associated harms than it lead to a saved life. Note that screening healthy men is different from diagnosing and treating men who come to the doctor with symptoms suggestive of prostate cancer. What happens for some of the cases of prostate cancer identified by screening is that some are actually harmless and would never have lead to symptoms or death. The problem is that it's impossible to tell which will develop into aggressive cancers and which will never cause any issue at all. And although physicians know that it's an issue of probability, having a diagnosis of cancer makes people more likely to want to treatment. Overall, for those who have no symptoms, even if they do in fact have prostate cancer that would be detected on screening, therapy is more often harmful than helpful so it's better not to screen at all. And this is just one example where the results of a blood test can be more harmful than helpful. Physicians tend to believe that discussing this matter with a professional is crucial because, as one can see, the topic is quite complex and the reasons to test or not are subtle. This suggests that obtaining a blood test on oneself without the proper medical knowledge might actually be quite dangerous. And our society generally accepts that individuals should be allowed to choose to expose themselves to risks. However, making it easy for individuals to harm themselves when understanding the risks involved without a case-by-case consultation with a medical professional is not a good idea.
The Arizona law therefore contrasts with the California law in an interesting way. Both laws have very much to do with how people make decisions about their health and either access or refuse healthcare resources. Both share an inherent tension between what decisions can and should be allowed and regulated and what actions are medically advisable. The distinction between making a decision for a minor (California), and making a decision for oneself (Arizona) is a major one worth keeping in mind. In oversimplified terms: The Arizona law represents a situation that is a bad idea but perhaps should be allowed. Conversely SB277, represents something that seems like a good idea but might overstep individual rights.
Research has found that screening otherwise healthy men more often lead to unnecessary surgical treatment with associated harms than it lead to a saved life.
From a public health standpoint, increasing rates of vaccination to decrease the overall rate of vaccine-preventable deaths makes sense. The only way to achieve protection from outbreaks of the measles, for instance, is to vaccinate enough of the population to reach herd immunity. Since some individuals have medical reasons they cannot be immunized, they are particularly dependent upon others to contribute towards herd immunity. If the disease cannot survive in the herd, then it cannot afflict the weakest ones in such herd. Yet, given how outbreaks of vaccine-preventable diseases are starting crop up in part due to voluntary non-vaccination, it is easy to see why some could be concerned. If all parents chose to vaccinate their children (except when contraindicated), then the population as a whole—and particularly the vulnerable individuals—would be better off. Laws that enforce restrictions on personal liberties in order to protect the rights and safety of others are common. Thus it's not that surprising that SB277 was pushed through in the wake of a scare following the Disneyland outbreak. However, the appropriateness of restricting individual freedom in the case of vaccines is a bit muddled. First, with vaccination, the relationship between self and other is not direct. We could not place the blame for a death from a measles outbreak on an individual or group of individuals that chose not to vaccinate. An outbreak, as a physical phenomenon, is not directly due to the action of any of the individuals. In a sense, all are attacked. Yet, the degree of environmental risk of an outbreak is comprised in part by the individual's immune systems. The link between not vaccinating a child and increasing the risk that another becomes infected with the measles is not direct.
These two seemingly unrelated laws represent two sides of the same coin. Medically one should be done while the other may inadvertently cause harm. Ethically one seems quite reasonable while the other is controversial and may be stepping over the line. Both center on how we regulate decision regarding medical care. Whereas the Arizona law seeks to shift power to the individual, the California law seeks to place tighter regulations on individual choice. Although the political climates may have differed—and the situations are of course different—that these two laws came to be in the same time frame is perhaps not entirely coincidental. So what does this tell us about the anti-vaccination movement?
Perhaps, at its core, the anti-vaccination movement has little to do with vaccines at all. The concerns for safety, the continued insistence of links to autism, the bickering about cause and effect are all just the foot, the ear, and the tail. The elephant is power and trust. Who should have the power to decide when one can and cannot refuse medical treatment? Who should a parent trust about the safety of vaccines? At what point does benefit of the whole overstep sanctity of the individual? We should understand, that not only do most parents want to protect their child, but perhaps what those against vaccination really want is agency. That the same common desires that lead people to want to access medical knowledge on their own also leads others to want to be able to refuse treatment speaks to this idea. Instead, we should strive to encourage critical thinking and healthy skepticism. Sometimes true risks are missed. The clue, then, is to see the other viewpoint and ask not how to convince, but how to more effectively get to the elephant of the matter.
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Matt Christensen is a Guest Contributor at Aesir Lab. You can reach him at firstname.lastname@example.org.