Hakuna Matata: Being Anti-vaccine in an Outbreak

Another measles outbreak has hit the United States, this one traced back to California’s Disneyland theme park, spreading to multiple states, and causing a series of headlines with ironic, corny allusions about “the happiest place on earth” not being so happy and how highly infectious disease makes it “a small world, after all.”

Another outbreak. Another opportunity for the medical and media communities to remind people of the dangers of measles and the dangers of anti-vaccine misinformation.

Angelina caught measles at 7-months-old. She developed SSPE (subacute sclerosing panencephalitis), an incurable, progressive brain disorder that leads to seizures, loss of cognition and motor skills, and, eventually death.

Another outbreak. Another opportunity for this mother of an infant too young to be vaccinated to try in vain to banish the stories of Angelina and Sarah to the farthest recesses of my mind.

It’s been interesting to see the reaction of the anti-vaccine contingency in the wake of this outbreak. The old canards of sanitation and diet, not the vaccine, causing measles’ elimination in the United States or of the vaccinated, not the unvaccinated, being the real threat fly in the face of the reality staring us in the face. The sanitation at Disneyland is as first-world as it’s ever been, and no one reasonable people aren’t going to believe that the residents of Orange County are suddenly stricken with malnutrition and their unvaccinated status is just an inexplicable coinky dink.

The most striking consistency among the whole lot, though, when approaching the topic of measles is summed up by one (annoying) Disney phrase: “Hakuna Matata.” (“It means no worries.”)

I get very annoyed that atheists have subsumed the word “skepticism” and conflate it with rejecting (usually out of hand) theism, certain philosophical or moral arguments, and scientific propositions outside the mainstream. Ironically, I’ve seen many Christians accept the atheists’ paradigm as true and reject authentic skepticism as a result. But, as Christians, we shouldn’t fear objective reason and skepticism! Fides without ratio would just be that silly caricature of religion that atheists rightly reject. Skepticism, like science, is for everyone. This post is going to look at how anti-vaccine apologetics fall apart with a little bit—say, just a spoonful— of skepticism and critical thinking.

I realize that most (normal) people don’t use their free time delving into vaccine science/pseudoscience. Going through these posts, I saw right away the same errors, obfuscations, and “arguments” I’ve seen many times before. But if vaccines aren’t your “thing”, these wouldn’t jump out as red flags. What is there for us, then, when we are not experts, don’t have time to verify or acquire a lot of information, but still don’t want to submit to a kind of scientific clericalism where a white lab coat means that not only the scientific evidence, but also the interpretation and application of such, are above reproach?

The answer: skepticism. Real, authentic skepticism that actively questions what might make something misleading, incomplete, or wrong.

Look at these five online responses, one from an anti-vaccine website, two from “mommy bloggers”, and two from medical doctors who have made their fame and fortune thumbing their noses at the mainstream. You can read them here:
“Measles at Disneyland!” by Marcella Piper-Terry on Vaxtruth.org
“Measles Schmeasles Goes to Disneyland” by Jessica Gianelloni*
“A Response to One Dead Child, Two Foolish Parents” by Megan Heimer
“DR. BOB’S DAILY: JUST HOW DEADLY IS MEASLES?” by Dr. Robert Sears
“Natural Treatments for Measles Symptoms” by Dr. Aviva Romm (reposted on Facebook 1/14/15)
* Gianelloni’s blog has been taken down. This links to a .pdf of cache screenshots

 
• Why this photo? How is the picture influencing my perception?
Let’s start simple with picture manipulation. Consider this screen shot of Aviva Romm’s article, “Natural Treatments for Measles Symptoms.”

This Caucasian girl with her braided, blonde hair sits on a fuzzy white couch looking sad. Don’t you just kind of want to go make her a pot of chicken noodle soup? I might feel a little sad for that girl, but I’m not worried about her. Of course, all I need are natural treatments! Compare that sentiment, now, to when we replace Romm’s generic illness stock photo with pictures of actual measles.

Not one of those pictures should leave a person with a comfortable feeling. I don’t want to make chicken soup; I want to cry. How can there be such disconnect?

Pictures convey emotion and emphasis; they are windows to the author or editor’s mind. This is not a bad thing, per se, but it is not trivial. The skeptical mind must always ask if the picture, rather than emphasizing or adding to the writing, distorts or distracts from it.

It is very telling that Romm uses a stock photo of a generic illness and not a photo of measles. Measles, even without complications, should not give you warm fuzzies. And, if you’ve been led to have a hakuna matata image of measles, you might not see Romm including the word “death” as something particularly noteworthy. You might gloss over the complications and not be inclined to wonder what this undefined, unlinked “Subsclerosing panencephalitis [sic]” might be. But if you’re looking at this post skeptically, you wonder. You look it up. You, then, quickly realize that Subacute Sclerosing Panencephalitis (SSPE) is the thing of nightmares… a nightmare that is not just some nebulous specter of the past.

 
• Looking back—Is it accurate and relevant? Why might it be different?
Invoking the past is always tricky. Sometimes a person with an agenda can (without even knowing it) play to historical ignorance, myths that “everyone knows” are true, and nostalgia about “the good old days.” This is especially true in terms of science and medicine because of new information generated, new discoveries made, and there is a disconnect between the professionals generating the science, the professionals disseminating the science, and the layman whose opinion needs to be informed by the science.

Gianelloni and Sears say:

Heck all you have to do is watch tv episodes from back in the day when measles was a laughing matter on tv and referred to by the CDC as ‘a mild childhood illness’? –JG

Nobody knows measles anymore, and when we are ignorant of something unfamiliar, we fear it until we understand it. –RS

Ask any Grandma or Grandpa (well, older ones anyway), and they’ll say ‘Measles? So what? We all had it. It’s like Chicken pox.’ –RS

These statements imply that because people in the past considered measles to be no big deal, we should not either and “they” are stirring up unnecessary concern.

But, really, what does that matter? Catholics should be particularly receptive to the fact that even if an idea were popular, that does not make it right. Smoking tobacco was popular, even among physicians, in the past. Yet, an increasing body of scientific evidence revealed its associations with health maladies prior to the 1930s. Still, it took decades to shift popular perceptions about the risks of cigarette smoking, and, to this day, you will find smokers downplaying the seriousness of the risks. As for measles, Dr. J. Mayer notes this very point in his address to the State Society of California:

It is hard to combat the old notion that measles is something akin to a common cold with a rash…. The truth is that we, ourselves, too often encourage indifference by some such remarks as “It is only measles.”…

In conclusion, perhaps I can do no better than quote, with due acknowledgment to ‘Twentieith Century Practice of Medicine,’ some extracts from a pamphlet which, during an epidemic of measles in Glasgow, was distributed to the people by the health authorities:

‘Measles is a dangerous disease—one of the most dangerous with which a child under five years of age can be attacked….It is therefore a great mistake to look upon measles as a trifling disease.’

Mayer said this in 1904. Even at the beginning of the last century—decades prior to a vaccine— the medical community was trying to combat a nonchalant approach to measles. Those who made light of measles back in the “good old days” were wrong, even according to their contemporaries. So, in a sense, maybe Dr. Bob is right— maybe we do “fear” measles because we don’t “know” measles anymore. But this isn’t because measles isn’t inherently dangerous; it’s because we can see measles for what it is without having anecdote or inevitability cloud our perception. Popular notions don’t obfuscate our judgment.

We also cannot allow ourselves simply to be led to the author’s conclusion. We have to question why something might be different today beyond what the author implies. Sears, and Heimer state:

[Death from measles] hasn’t happened here in at least ten years…–RS

Everything can be potentially deadly but is measles inherently deadly? Absolutely not.
Did you notice that the case mentioned above was from 1990? That was 25 years ago people. It makes perfect sense though. One couldn’t use a case from 2014, 2013, 2012, 2011, 2010, 2009, etc. because not a single child died from measles. –M

Therefore, hakuna matata, measles isn’t a real danger here.

But is there a way that measles can be both inherently dangerous and go decades without a fatal case? Of course! In fact, this is exactly what we expect when there is extensive uptake of an effective vaccine for a disease. Thank God, death from measles is rare (1-5 deaths per 5000 cases) and the 2-dose MMR vaccine schedule has kept measles epidemics at bay, with only a handful of imported cases and outbreaks in unvaccinated clusters.

You’re more likely to land on “36” if you spin the roulette wheel 1,000 times instead of 100. Likewise, if you only have 100 cases of measles, the odds are good that none of those cases will land on “death.” So, of course we have to look farther back into the past to find a death, yet measles’ inherent mortality rate remains whether we have 100, 1000, or 3 million cases. As we’ve had larger and less isolated pockets of unvaccinated, the cases rise. The roulette wheel is spun more and more times, increasing the likelihood of landing on death.

 
• Statistics—How could it be misleading? Is it a relevant statistic for the argument? What happens when it applies to populations?
Statistics. Yeah… Heimer says:

According to the CDC’s 1990 MMWR data, there were a reported 27,672 cases of measles. There were 89 measles deaths. Fifteen of those deaths occurred in infants under 1 year of age, twenty-seven deaths occurred in people over the age of 20, and 19%+ of the deaths occurred in vaccinated individuals.

Let the record reflect that prior to vaccines, adults and infants were not the at-risk population, and thank goodness because measles is more severe in both babies and adults. These deaths can be directly attributed to the MMR vaccine.

Let’s think about these “statistics”: what they say, what they don’t. I put the word “statistic” in quotes because there is a significant error that you can easily find when you wonder where the statistic came from. “19%” of cases were vaccinated, not deaths; the actual statistic for death was 9% But, even taken at face value, they are misleading… and contradictory. (Remember, Megan Heimer said measles is not “inherently deadly”, especially in the first-world, yet she acknowledges that 89 people died in one year of the last major measles resurgence.)

Do the deaths of infants and adults demonstrate that the vaccine made things worse? No. When you think about it, if we had the first measles vaccine in 1963 and an even more effective pediatric measles vaccine licensed in 1971 (which we did), this is exactly what we would expect. Those who had been the primary at-risk group, young children, became essentially not at-risk because of their immunization. But the adults who had spotty measles immunity and infants too young to be immunized would have had no such reduction in risk. They take up a larger percentage because deaths in the child demographic fell, not because theirs increased. In fact, if we look at the “other side” of the story, we see that all deaths have declined after the advent of vaccination.

One “trick” for trying to see if a statistic is misleading is to present it in a different way. A ratio instead of a decimal fraction or percentage. Raw numbers instead of relative/absolute risk and vice versa. The odds in the opposite scenario. That last option shows how Heimer’s conclusion lacks merit on the most basic level. Being vaccinated doesn’t sound as inconsequential when you flip it around and say “80%+ of the cases occurred in unvaccinated individuals.” It sounds a lot scarier to be unvaccinated when you say “91% of the deaths occurred in unvaccinated individuals.” And those are just raw numbers, not even taking relative risk into account. Even with her error of substituting the word “cases” with “deaths”, Heimer’s “statistic” would mean 4 out of every 5 dead were unvaccinated! But she doesn’t present the statistics that way because it does not support her conclusion.

When it comes to the risk of death, Sears and Piper-Terry state:

The risk of fatality here isn’t zero, but it’s as close to zero as you can get without actually being zero. It’s 1 in many thousands. –RS

The statement that 1 out of 1,000 ‘children’ who gets measles will die from it is misleading…. Here is a photo Dawn used in her article, to demonstrate a more likely estimate of the risk of U.S. citizens dying of measles. [screen shot of 0.00015] –MPT

Dawn writes: ‘Also, consider that in 1963, the population was 189,241,798. That means that prior to the vaccine, the percentage of the entire US population that died from measles was .000237%.’ .000237% is a very small number…. Are you feeling a little better now about the “outbreak” of measles at Disneyland? I hope so. –MPT

“1 in many thousands” might look close enough to zero if you put it as a percentage (1: 5000 = 0.02%); “0.00015” is a very small fraction. “.000237%” looks positively minute. But what do these statistics actually mean? The person who wants to believe the hakuna matata narrative of measles takes it to mean just that. However, the medical community, without denying these statistics, says they mean we should be vaccinating, quarantining, and seeking to eradicate measles globally. Why might that be? Translating these risks to populations and raw numbers gives us an idea. Suppose we had 3 million cases of measles annually, which would be a good year in a world without a vaccine. With a 0.02% (1:5000) mortality rate, Sears’s “1 in many thousands” would translate into 600 deaths. 600 flesh-and-blood people, 600 lives lost annually are “close to zero”? 0.00015 would be 450 deaths per year. And, while 0.000237% might be the most impressive for its smallness, if we lost 0.000237% of our population annually to measles today, that would mean 749 people would die every year. When statistics apply to a large population with actual lives on the line, small fractions aren’t so small, but can be useful to those who want to obfuscate a rare event’s real-world impact. (And if hundreds of people dying needlessly is no big whoop to you… well… you have problems.)

 
• The citation— Is it applicable? Is it current? Is there context? (i.e. Click the link.)
One of the great oddities I’ve encountered is how often the anti-vaccine proponents provide links that refute their claims. I don’t know if they purposefully do this, hoping people will just be impressed by their bibliography salad, or if they just copy and paste from someone they trusted to be accurate who was not. Regardless, a lot can be revealed when you click the links from the position of skepticism.

Heimer believes in the order of wild infection and breastfeeding as preferable to vaccination for the protection of infants:

Before the MMR vaccine, mothers acquired natural exposure to measles and passed on this protection to their infants via breast milk. This passive immunity protected them for their first year of life and (for some children) up to 10 years thereafter….Today, vaccinated mothers only pass on protection for a mere 2-3 months (if any) leaving our most vulnerable at risk.

She then cites the Journal of Infectious Disease:

Children of mothers vaccinated against measles and, possibly, rubella have lower concentrations of maternal antibodies and lose protection by maternal antibodies at an earlier age than children of mothers in communities that oppose vaccination. This increases the risk of disease transmission in highly vaccinated populations.

But does the study actually imply that maternal antibodies are superior to vaccination? To the contrary, even if you only view the abstract, you see that maternal antibodies only protected “2 months longer for infants born in the orthodox communities, most of whom had unvaccinated mothers.” Wild or vaccine-acquired immunity in the mother, most children will be completely vulnerable by 6 months of age. As the study’s authors note in the full text, “The average age at which a child loses the protection of its maternal antibodies and becomes susceptible to measles, mumps, and rubella lies well before the age of first MMR vaccination.”

Piper-Terry, also believes that the natural order is better and that vaccination is ineffective, and she goes on to list an impressive bibliography salad. However, the skeptic notices right away that almost every one of her studies is old. Like really old in terms of medicine, which is constantly evolving. Remembering to question what might be different today than in the past, we quickly find that the situation in the past isn’t really relevant to us today: the MMR vaccine wasn’t licensed until 1971 and the current 2-dose schedule wasn’t implemented until the 1990s.

The first study she cites is quoted as follows:

The phenomenon of declining vaccine efficacy may have become more pronounced in recent years because there has been less exposure to measles infection; we have found that exposure to natural measles is important in maintaining protective antibody levels among vaccinated children.

Cherry picking quotes from legitimate sources is a favorite tactic of those with an agenda. This applies in many disciplines—Satan employed this cherry-picking tactic with scripture— but especially in science. When you actually click the link, you see the title of the study is “Waning of Vaccine-induced Immunity: Is It a Problem in Africa?” Well, we’re not in Africa—certainly not Africa at the end of the twentieth century— but let’s see if the context makes it applicable here… nope:

The phenomenon of declining vaccine efficacy may have become more pronounced in recent years because there has been less exposure to measles infection; we have found that exposure to natural measles is important in maintaining protective antibody levels
among vaccinated children (4).

We readily agree that the major priority in measles control is provision of the first dose of vaccine to unvaccinated children.

Reading a little further, you see that the whole point was that because the measles vaccines had been effective at reducing the prevalence of measles in Africa, waning immunity might need to be considered for the vaccine schedule in Africa.

Sears and Heimer also appear to believe that nutrition is basically all you need in preventing severe measles complications:

Deadly? Not in the U.S., or any other developed country with a well-nourished population. -RS

Even the World Health Organization says severe measles can be prevented by vitamin A. Get on board with the science my friends. -MH

Sears doesn’t provide a citation. This isn’t terribly surprising since “well-nourished” is a vague term— I mean, are Europeans not well-nourished?— and I’d wager it merely serves to give his “well-nourished” following, particularly his privileged O.C. clientele, the warm fuzzies that they are not in any danger from measles. Heimer, on the other hand, does provide a link to the World Health Organization. But when you search for “vitamin A”, you find that the WHO says no such thing:

Severe measles is more likely among poorly nourished young children, especially those with insufficient vitamin A…. Vitamin A supplements have been shown to reduce the number of deaths from measles by 50%.

Notice how it says “more likely” and “reduce”, not “only” and “eliminate.” Further, on the topic of who is at risk, the first thing they say is, “Unvaccinated young children are at highest risk of measles and its complications, including death.”

 
• The alternative— Is it viable? Is it proportionate? Is it more reasonable?
We see a failure to give due consideration to the alternative(s) all the time in politics. Politicians often seem more concerned about towing the party line or saving face, usually by focusing on why the opponents’ ideas are wrong, instead of seriously seeking the best answer to a problem. It’s an appropriate comparison because, really, there isn’t a “scientific” debate with measles vaccination; it’s a debate dealing with personal convictions, personal biases and supporting different agendas.

But everyone wants his “side” to have the weight of evidence, even if it is lacking or disproportionate. Piper-Terry lists a long list of “articles from the peer-reviewed medical literature” talking about the dangers of vaccination. (The merit of some of these articles is put into perspective here). However, after noticing how many of these articles are single case reports, I clicked a study (Landrigan, P.J., et al. “Neurological disorders following live measles-virus vaccination.” JAMA, 1973) that provides a perfect example of why vaccine refusal is not reasonable: the alternative— risking infection with the actual disease— is not proportionate in any way to vaccination.

[This] clustering suggests that some [cases of encephalitis] may have been caused by vaccine. From 1963 through 1971, 50.9 million doses of measles vaccine were distributed, and, therefore, incidence of the reported neurologic disorders was 1.16 per million doses. Risk of encephalitis following measles infection is one per thousand cases. [emphasis mine]

Put another way, the anti-vaxxer’s own cited article states that you are about 1000 times more likely to suffer encephalitis with natural measles infection as you are from that vaccine.

I’ve noticed, too, and this applies to other disciplines as well, that the person in the position of weakness will focus on anything that can go wrong with their opponents’ plan, but then selectively will focus only on those things in their plan that can be mitigated or rationalized. Why do Gianelloni, Piper-Terry, Sears all have such a focus on the risk of death from measles infection? It is the smallest risk so they rationalize that it isn’t worth concern. But what of the other complications? “Treatable” says Sears, or at least “extremely rare”, so we can rationalize that they aren’t of concern, either.

But if there are substantial risks— costs, pain and suffering, loss of life— it behooves us to look at all options with the same scrutiny. If you are so convinced that you are “healthy” and “well-nourished” enough to come out of measles unscathed, why would you expect different from the vaccine? If you aren’t concerned about the causally-linked, quantifiable chronic sequelae of measles, why in the world are you concerned about the unsupported or exponentially rarer ones of the vaccine? If death is all you care about with measles, why do the parameters change to non-fatal, recoverable events with the vaccine? If you are singing “Hakuna Matata” with measles infection, why do I hear a dark, foreboding “O Fortuna” when the topic changes to measles vaccines?

 
• Skepticism—It’s okay to change your mind.
I get it. I’ve been there. Embracing skepticism is hard. It is unsettling to challenge your ideas. It is uncomfortable to consider that your “side” might be the wrong side. It is gut-wrenching to seriously consider that a cherished belief might not be true. And it’s even harder to actually change your mind.

True skepticism, not the atheist brand of pompous snark-on-a-stick (though sometimes that is accurate and hilarious), requires humility. You have to recognize your own biases and limitations. And, truth be told, most of us want to compartmentalize humility to the confessional. Outside, we want to be the intelligent righteous who can say, “O God, I thank you that I am not like the rest of humanity.”

We’re flawed and limited creatures. It would be impossible to be completely skeptical and completely thorough with every topic that we encounter in life. However, when the stakes are high, as is the case with an infectious disease like measles, and someone is trying to tell you to go against scientific consensus, we would do well to remember the incredibly ironic words of Dr. Bob Sears:

“They don’t have to tell you the whole truth, just the part of the truth that they want you to believe.“