Thursday, September 27, 2012

A Non-Inflammatory Article About Vaccinations

Last week, the New York Times published an article about Washington state’s efforts to increase vaccination rates, which include a new law that would require parents to get a physician’s signature should they choose to opt out. Interestingly, the article quoted a naturopathic physician who supported vaccination and talked about some of the reasons parents avoid them, rather than opposing vaccinations, as NDs are often accused of doing. It always makes me happy to see NDs portrayed positively in the media, but on this topic in particular I was glad that an ND got a voice.

Let me put it in simple terms right here at the beginning: in a conversation dominated by loud voices at either end of the spectrum, the naturopathic profession should promote a moderate point of view, one the resonates with what the majority of parents and healthcare providers understand, and that respects the needs of both the population as a whole and individual children. Both the movement against vaccines, as well as physicians who ‘fire’ patients for refusing vaccination have major failings. Rejecting vaccines ignores the tremendous victories over infectious diseases that we’ve seen in the past century, and allows for the re-emergence of diseases that are currently well-controlled. On the other hand, firing patients who decline vaccination alienates people from the healthcare system and is self-defeating in the effort to increase vaccination rates.

As healthcare providers and as good scientists, NDs understand the important role that vaccinations have played in the history of disease. Smallpox, a disease which in the 20th century alone killed over 300 million people worldwide, has been eradicated in the wild since 1979. Polio, a disease that affected even the future President of the United States, has been nearly eradicated, save for isolated regions in Nigeria, Afghanistan, and Pakistan. Many potentially fatal diseases, such as pertussis and diphtheria have been curbed, primarily due to vaccination. Clinical success of this magnitude is undeniably important.

Vaccines are sometimes called victims of their own success – their importance is easily forgotten because, when successful, nothing happens. To draw modern analogies, imagine that we were able to completely eliminate smoking, or Type II Diabetes, or Breast Cancer – the effect on public health would be massive. To prevent these illnesses through a public health campaign would save millions of lives and prevent suffering on an enormous scale. This is the same type of effect that vaccinations have had. To be able to continue to eradicate these infectious diseases, and prevent future epidemics, is a great opportunity for our profession.

At the same time, because of our attention to individual needs and individual cases, NDs understand that some patients have needs or desires that must be respected. A growing number of physicians are ‘firing’ patients who decline vaccinations, and while this is not without reason, I think there are serious problems behind this practice. Firing patients (or more specifically parents) who refuse vaccinations alienates these families from the healthcare system, and may result in these families seeking out providers who agree with them regarding vaccination, but who may not be fully qualified to deal with the ramifications of non-vaccination. Additionally, firing patients loses the battle for vaccination – while parents may not be willing to have their child fully vaccinated at 2 years old, they may be persuaded to do so a few years later, with the birth of a second child, for example. Vaccination is not an on-or-off switch, and catch-up schedules do exist for children who are not vaccinated on the first pass. It’s important to keep these families in the conversation, and at least under medical supervision.

I should note here that the American Academy of Pediatrics’ official position is that physicians should respect parents wishes, but continue the conversation on vaccination. The American Association of Naturopathic Physicians has a similar position. Of course, these moderate points of view don’t make headlines, as it’s the loudest, most extreme voices that make it into newspapers.

My last note today is simple: we need to understand more. One of the primary concerns raised by vaccine objectors is the proposed link to autism. I’m not going to make a comment on that proposed connection, but what I will say is that we need to understand autism better than we currently do – we can describe it quite well, and have diagnostic criteria for it, but still have little understanding of why it occurs in the first place, and are still scraping the surface of how to treat it. There are treatments and theories out there, but nothing has really come to the fore as a unifying explanation of autism. Autism can be a very scary disease for parents, and it’s not surprising that parents are frustrated with physicians’ lack of answers; a better understanding of the cause and treatment of this disease would almost certainly take some pressure off vaccination.

Additionally, we need to understand more about vaccines and adverse events. We know that they happen, we know the basics of preventing them, but we haven’t fully eliminated them. Some are minor, like pain and redness around the injection site. Some are more serious, including neurological damage, high fevers, and other issues. Vaccines have improved over time, even in the past few years, so that they are far more targeted, with less likelihood of side effects – even so, though, their near universal use necessitates that we understand why adverse events happen in isolated cases. Unfortunately, this will take some time to determine, as these events are rare enough that it takes significant amounts of time for enough cases to accumulate to make conclusions.

The system isn’t yet perfect, but efforts are being made. In the interim, consumers should work with qualified healthcare providers who are willing to have a conversation about vaccines and supply information. Likewise, providers shouldn’t alienate skeptics, but rather keep them in the conversation. A moderate course of action, based on advancing public health and respecting individuals is currently the best solution to this slightly thorny issue, and it’s no surprise that both the AAP and AANP have advocated for this approach.