Vaccines: In Offit, We Do Not Trust

I could probably write a post a day about vaccines if I wasn't busy taking care of families with babies who have real-life questions about vaccines.   

I pretty much said what I had to say in this post in October, 2008.  But today's profile of Dr. Paul Offit in the NYT Science Times coupled with his recent editorial/book review of Dr. Bob Sears' "The Vaccine Book" in January's Pediatrics bothered me enough to write some more.

Let me be very clear about this: I am in favor of vaccination as a public health policy.  I am not anti-vaccine.  Some of my colleagues have been branded as such, and I'm sure behind closed doors, I have been branded the same.  Why - despite our honest claims to the contrary?  Because our views are not mainstream pediatric views, and we dare to question standard vaccine policies.

So, I am pro-vaccine.  This will not make anti-vaccine folks very happy.  But let me also be very clear: I am not pro-vaccine for all children all of the time.  This will not make my fellow members of the AAP very happy (or at least not most of them).  I do believe that each and every child must be considered as an individual and that the timing, dose, and number of vaccines given must be determined on a case-by-case basis.  I do not believe this is an unethical or radical perspective.  We individualize medical care all the time.  And informed consent regarding medical procedures is the standard.  Most other countries, including those with lower rates of vaccine-preventable diseases, do not mandate vaccination.  They rely on the general population to weigh the risks and benefits of vaccines and diseases and make decisions that are rationale.  And you know what?  Just as with polio epidemics in the 1940's-50's, people will line up down the block for a vaccine for their kids if they believe it is in their best interest.  Are vaccine rates in the U.S. declining due to parent concerns?  Not according to the CDC:

Sept. 4, 2008 -- Childhood vaccination rates are at or near record highs, the CDC announced today.

Most parents are vaccinating their kids, with less than 1% of children not getting any vaccines by age 19-35 months, according to a new CDC report.  "The ongoing success of our nation's immunization program is largely dependent on the trust that parents put in the safety of vaccines and in those caregivers who administer them," CDC Director Julie Gerberding, MD, MPH, says in a news release. "I want to encourage parents to continue to be informed and to ask their pediatricians about the safety of vaccines or any other concerns they may have about their child's health."

Well, Dr. Gerberding is now gone; she certainly didn't engender any trust in the system during her tenure at the CDC.  And I think Dr. Offit has to go, too - whatever role he serves for the AAP as vaccine watchdog is certainly now backfiring.  Look, it is absolutely horrible, but no one wants to hear anymore about his death threats and how he can't go to sign books in bookstores.  He has made himself the story - cardinal sin.  All the while, trust - the key to the success to our vaccine program - is eroding.  As long Paul Offit is the one the AAP trots out to send the pro-vaccine message, many parents on the fence will continue to opt out.  My letter to the editor (fully excerpted below) in Pediatrics points this out:

"Whether we want to admit it or not, public trust in the immunization program and in pediatricians in general is eroding. And while we can debate whether aluminum and mercury in vaccines is the same or different as what we eat/drink/breathe (my personal bias is that we should reduce all exposures when possible), we must all agree that the only way to save the U.S. vaccine program - and trust in our profession by the families who need us most - is to encourage public conversation in a non judgmental manner. And it has to start here, with us."

Now, I realize I am in the minority.  Most pediatricians expect to tell parents what to do and then have them follow suit.  And most parents do this.  But more and more families today are struggling with whether or not to vaccinate their kids.  Until we support open and honest dialogue, these families will continue to walk out of pediatricians' offices never to return.  And I do not (and I know the AAP does not) believe that is what's best for our children.

-------------------------------------------------------------------------------------------------------------------------------------------------

The Third Rail 30 December 2008
Lawrence D. Rosen, Pediatrician The Whole Child Center	I read with great interest Dr. Offit's editorial/book review of Dr. Sears' The Vaccine Book. As a "front-line" pediatrician seeing many new families and babies each day, as a parent of young children, and as an active, concerned citizen of the U.S., vaccines of course are a daily part of my life. I welcome these conversations with families, as I am encouraged they are comfortable enough to discuss their fears and hopes with me. My strong belief is that by allowing these conversations, more families actually vaccinate than would have otherwise. Would it be better that they seek non pediatric primary care in support of no vaccination or would it better for me to tolerate their concerns and "allow" them to vaccinate flexibly? What is the "right thing" to do? This is what many of us struggle with. As I become more involved in the AAP at a leadership level, I become more and more aware of the divide between pediatricians. What I fear is that we as a profession and the AAP as an institution may be discouraging honest and open dialogue about one of the most important public health issues of our times. I find it highly unusual that a fellow AAP pediatrician is roundly critized in Pediatrics (the flagship journal of the AAP) without a chance to address the claims. Perhaps some at the AAP find his book that threatening. Is fear of information the direction we want to support? Should we not be using this as an opportunity for discussion? Whether we want to admit it or not, public trust in the immunization program and in pediatricians in general is eroding. And while we can debate whether aluminum and mercury in vaccines is the same or different as what we eat/drink/breathe (my personal bias is that we should reduce all exposures when possible), we must all agree that the only way to save the U.S. vaccine program - and trust in our profession by the families who need us most - is to encourage public conversation in a non judgmental manner. And it has to start here, with us. - A plea for intentional dialogue.

Comments

[jmalak]

Alexa tells the story of what people think of the AAP. Look at the numbers. In the last week, AAP ranked as the 86,000th most popular site on the web. Not very flattering, esp when you consider that probably 95% or more of the visits are from doctors, not parents. See http://www.alexa.com/data/details/traffic_details/aap.org

Compare that with Dr. Sears, at position 26,000. Then look at site like NaturalNews or Mercola that routinely castigate the AAP. They are ranked at 6,500 and 13,000 respectively.

[playdough]

As I've said before: you are the most sensible doctor I know, and it's hard for me to understand why some of your fellow colleagues don't recognize that. Don't let them stress you--we need you healthy and well! "Many men, many minds"--what are you going to do... Keep spreading your word--we always learn from you! By allowing the parents of your patients to be more "flexible" with the vaccination plan, you've created an incredible atmosphere of trust and comfort, because it IS a painful and stressful issue for a lot of parents!