Immunizations

This is a thinking out loud/stream of consciousness post.

A common dichotomy in the conversation revolving around vaccinations is personal freedom and public harm.

We generally engage in cost-benefit analysis. We weigh the benefits of vaccinations with the risks of vaccinations.

Anti-mandatory vaccination

Some physicians are anti-mandatory vaccination.  Vaccines are complicated. Children may receive as many as 69 doses in the first 6 months of life. Informed consent for the patient should be prioritized, but the Medical Board of California does not always exercise its authority well.

Medical exemptions can be defined too narrowly for the good of the patient. Patients may have very severe brain damaging neurological injury or they go into anaphylactic shock and nearly die.  Physicians may be afraid to write medical exemptions, even when warranted, because they may lose their licenses if the Medical Board does not consider their medical exemptions appropriate.

Physicians consider some of the following for vaccine safety evaluations: genetic risk and family history of vaccine reactions.  However sometimes the only vaccine reactions that warrant exemption are CDC contraindications: severe brain injury or anaphylactic shock. So the question becomes “Is the limit for medical exemption set too high or defined too narrowly?”

What do physicians do in the grey areas where we try to distinguish between a moderate allergic reaction and a terrible one?

Ideally, physicians are given the freedom to selectively and carefully vaccinate an exempt patient based on need.  But mandatory vaccination policies can take this judgment away from doctors. Instead of a bilateral dialogue between doctors and their patients, a unilateral decision is made by the public health department or a bureaucrat. The decision making process is moved away from the doctors and their individual patients. 

The MMR vaccine can cause very severe brain injury reactions. There have been 48 confirmed cases.  The health care consumer and patient should be able to have conversations with their doctors and assess all the data and kind of make these decisions for themselves.  Other individuals would say the government should step in and make this decision for you and make it mandatory for the sake of  the collective public health.

Personally, I wish patients were free to ask their questions without fear of being ruthlessly ostracized.  They should be free to ask “What’s in the vaccine?” and “Are there any adverse reactions?” without being ostracized as a hippie. 

Now measles, polio, and whooping cough are real dangers.  There is real fear.  But parents that talk about vaccine injuries also have real fears too.  Everyone is weighing the risks and they come up with their own decisions.  They should be free to do so without intimidation or stifled conversations.

In an environment that mandatory vaccination policies create, doctors may kick patients out unless they comply with the full vaccine schedule.  Doctors may also falsely believe that vaccines are so critically important that there is only one right answer.  They start developing tunnel vision and downplay or ridicule looking for and developing viable alternatives.  They commonly believe vaccine reactions are not real and only coincidental.  Yet while vaccine injury may not be common, it does exist. 

Parents may be kicked out of school for not getting vaccines.  The common argument for this course of action is to prevent the risk of their kids spreading vaccine-preventable diseases to other kids.   For physicians who want to adopt a more moderate approach to vaccination, they risk their license and reputation. Malpractice insurance may double or insurances may refuse to contract with them even when physicians seek legitimate medical exemptions for their patients.

In addition, a world where vaccination is mandatory can create a system that is very difficult to remove once in place.  Insurance contracts could state that for every MMR and chickenpox vaccination, a 150 dollar year end bonus will be added.  Sensible reforms from politicians may be difficult to put in place and enforce.  Legislators who want a more moderate approach to vaccination, even when warranted, than their more hardline colleagues may lose the support of their fellow party members. 

Big business donates to legislators.  Legislators are beholden to those who donate to them.  In 1986 a Vaccine Injury Compensation Act was passed.  This law effectively takes away liability for big pharmaceutical companies.  There is a pro and con to this law.  One could say that removing liability allows pharmaceutical companies to make their products without fear of lawsuits, but at the same time, it puts a lot of faith in the pharmaceutical companies that they will not take advantage of the public trust. 

Congress did Pharma a favor to take away liability.
Pharma returned the favor by donating billions of dollars.
Congress returns the favor by mandating liability free products.

For some individuals, this sequence of events looks fishy.  There appears to be a conflict of interest just as bribes distort justice. 

The philosophical assumption behind the vaccination debate is again freedom versus public harm.  We basically have a bureaucrat deciding if a child was injured enough to be exempt from the vaccine as opposed to the physician.  There should be patient autonomy: just as private decisions can be made between an OB and a woman, so there should be private decisions between a pediatrician or family physician and parents.

Mandatory vaccinations does not seem a wise course of action so long as we have a system where large corporations can exert unduly large influence over the government.  Pharmaceutical companies can use the force of law to bully parents asking about vaccine risks into silence.  Physicians seeking a moderate approach such as delayed vaccination or parents with severely vaccine injured children may face segregation or discrimination from the system.

Pro-vaccination

People who are pro vaccination believe vaccines prevent suffering, hospitalization, and death.  Pharmaceutical companies have the resources and expertise to make the vaccine. Usually 1.2 billion dollars are spent on the company’s part to make a vaccine.

Some physicians want to follow the CDC schedule for vaccinations as the benefits outweigh the risks. They acknowledge that vaccines can cause type 1 allergic hypersensitivity but vaccines only prevent vaccine preventable diseases and not everything else.  

They favor the HPV vaccine because it is a cancer preventing vaccine.  They favor the flu shot because the flu normally kills 30,000 to 40,000 people, from the very young to the very old and the flu shot is 40 to 60 percent effective.

They admit some vaccinations are made from the two cell lines from elective abortions in England and Sweden in the 1960s: chickenpox, hep A, rubella/German measles, one of rabies. 

Some physicians believe good information leads to good decisions, but some parents will put their children or the children of other parents in harm’s way.  They cite the measles outbreak as an example. They say 500,000 children cannot be vaccinated because they are immunocompromised.  If we have bad information, bad decisions will be made. Parents who refuse to vaccinate their children are effectively making decisions for other people’s children. 

Vaccination has no link to autism.  Quality studies prove shots are the best way to deliver those vaccines. The season we give flu shot is also the season we get colds and other viruses. Correlation is not causation.  The amount of aluminum in the first six months from vaccines is less than that in diet.  The usual side effects from vaccination would be redness, swelling in injection site, and mild fever.  Anaphylaxis is 1 in a million, and reversible by epinephrine. Vaccinations are the best treatment we have given the information we have.

Physicians who favor vaccination also care about informed consent. They would say there is a lot of statistical evidence.  Statistics, studies, and research.  Yet there is a micro issue: each vaccine should be evaluated. Each set of vaccination has different set of adverse reactions.

For the child that has an adverse vaccine reaction, the physician would ask what about the children that have an immunodeficiency and a non-immunized child spreads deadly illness to them.  A child may have an adverse reaction to vaccine, yet the doctor may say continue getting vaccines to protect all of us.  He is also engaged in risk benefit analysis and says herd immunity exists.

Some physicians want to make sure parents are giving quality care to their child.  Just because they’re your child does not mean they can do whatever.  If the child does not get vaccinated, it is medically and statistically proven that the parents are endangering their child to develop these deadly diseases.

The axiom: “Parents know their children best” may indicate that bias will play a role in judgment and decisions.  It helps to share personal stories, relate emotionally and reasonably to your patients.  People who are hesitant about vaccinations may find themselves isolated by family, the medical community, and society.  We should find common ground.

The Collection of Private Information

 

I do find this meme humorous, and it raises an important issue.

Some thoughts that came to my mind when I saw this:

Information is power. There are questions about how that information is obtained, who accesses it, and how that information is used.

The Dark Knight (2008) had an excellent scene regarding this issue of invasion of privacy vs public safety: Batman used Lucius’ sonar idea on the people of Gotham’s cell phones to locate the Joker. https://www.youtube.com/watch?v=Kr7AONv3FSg

The government may invade our privacy for a stated purpose of protecting the public from potential terrorists among us. Or it may use that knowledge to manipulate us into supporting its agenda.

Mark Zuckerberg may invade our privacy and give that data to a political data firm for an efficient marketing strategy. However he is somewhat better than the government, since he generally gives potential Facebook users a notice beforehand that our data may be collected and thus there is more of an emphasis on consent.

So both the government and Mark Zuckerberg are guilty of invading the people’s privacy, albeit for different reasons.

Generally, our privacy should be protected, but there are times when an invasion of privacy is warranted if it is done for noble pursuits. It is similar to how HIPAA permits a covered entity to disclose protected health information to law enforcement if there is a serious and imminent threat to the health or safety of the patient or others.

Collecting our private information for marketing purposes is a little different. Ideally the collector would be transparent about the gathering of data and ask for permission to collect said data. They also need to be careful about how they use that data. They may obtain it for research/academic purposes or to subtly manipulate public opinion and behavior.

All in all, transparency and accountability are key.

Generally, private information should be obtained by consent.
There are exceptional times when invasion of privacy is warranted, as in the case of public safety, for example.
There is a moral expectation that the information gathered should be used in a responsible manner and respects the autonomy of others as much as possible.

Whether it be the government, Mark Zuckerberg, political data firms, marketing firms, and the like, these are some of the guidelines that should be followed.