So how does one solve the problem of the growing rift between parents who are concerned about the safety of vaccines and doctors who are worried about the reemergence of infectious diseases? The solution may not be easy; but it’s there.
CHAPTER 11
Trust
Leave the gun. Take the cannolies.
—PETER CLEMENZA,
THE GODFATHER
W
e’ve reached a tipping point. Children are suffering and dying because some parents are more frightened by vaccines than by the diseases they prevent. It’s time to put an end to this. Several solutions have been proposed. The first would be effective but is too awful to imagine; the second, given the history of the American legal system, will never happen; the third, while possible, would require a sea change in our culture.
In 1998, Robert Chen, then head of immunization safety at the Centers for Disease Control and Prevention, created a graph titled “The Natural History of an Immunization Program.” Chen described what happens when vaccines are used for a long time, partitioning the public’s reaction into distinct phases.
In the first phase, people are afraid of infections. In the 1940s, parents readily accepted the diphtheria and pertussis vaccines because diphtheria and pertussis commonly killed young children; and the tetanus vaccine because many people died of tetanus, especially during World Wars I and II. In the 1950s, parents rushed to get the polio vaccine because they saw what polio could do; everyone knew someone who had been paralyzed or killed by the virus. In the 1960s, parents gave their children measles, mumps, and rubella vaccines because they had witnessed firsthand the devastation wrought by those diseases: pneumonia and encephalitis from measles, deafness from mumps, and severe birth defects from rubella. During this phase of Chen’s graph, immunization rates rise.
In the next phase, as vaccines cause a dramatic reduction in disease, a new line appears: “Fear of Vaccines.” Vaccines become a victim of their own success. Now the focus is on vaccine side effects, real or imagined. Immunization rates plateau.
In the next phase, as fear of vaccines continues to rise, immunization rates fall. And preventable diseases increase. It’s in this phase that America now finds itself. When Chen showed this graph to colleagues at the CDC, he used statistics to support his argument. And, like most thoughtful scientists, he remained dispassionate, referring to children as numbers on a graph. But there was emotion in those numbers. (“Statistics are people with their eyes wiped dry,” said former Surgeon General Julius Richmond.)
The last and most disturbing phase of Chen’s graph offers a solution to the problem posed by unvaccinated children. In this phase, the incidence of preventable deaths becomes so high that parents again seek solace in vaccines. Immunization rates rise. In a more perfect world, we would never get to this part of Robert Chen’s graph. We would learn from history—learn from the smallpox deaths in England in the late 1800s following widespread anti-vaccine activity, learn from pertussis deaths in England and Japan in the mid-1970s following unfounded fears that the vaccine caused brain damage, learn from measles deaths in England and Ireland in the late 1990s caused by the false notion that MMR caused autism, and learn from bacterial meningitis deaths in Minnesota and Pennsylvania in 2009 caused by the fear that children were getting too many vaccines.
Although renewed fears of fatal infections caused by the reemergence of these diseases would undoubtedly increase vaccination rates, the price is far too great.
Another solution to the problem of unvaccinated children would be to eliminate religious and philosophical exemptions.
Religious exemptions would be impossible to eliminate. That’s because parents have been letting their children die in the name of religion for decades, without consequence. And these children have been denied treatments that
would
have saved their lives, not vaccines that
might
have saved their lives. For example:
• In the late 1890s and early 1900s, many children of Christian Scientists died from diphtheria, even though diphtheria antitoxin was widely available. Christian Science healers were unrepentant, one stating, “We do not feel bound to the laws of hygiene, but to the laws of God.” Several parents were charged with manslaughter, none successfully.
• In 1937, Edward Whitney, a widowed insurance salesman, left his ten-year-old daughter, Aubrey, in the care of her aunt in Chicago. Aubrey was a diabetic. The aunt, a Christian Scientist, took Aubrey to her practitioner, William Rubert, who immediately took her off insulin. On December 10, 1937, Aubrey Whitney died in a diabetic coma; Rubert wasn’t held accountable for her death. Twenty-two years later, Edward Whitney walked into Rubert’s office, pulled out a 32-caliber handgun, and shot him at point-blank range.
• In 1951, Cora Sutherland, a fifty-year-old Christian Scientist who taught shorthand at Van Nuys High School in Los Angeles, argued successfully that she should be exempt from the periodic X-rays required by her school to detect tuberculosis. Three years later, in March 1954, she died of tuberculosis, but not before exposing thousands of students. The health department petitioned the board of education to eliminate religious exemptions, without success.
• In 1955, seven-year-old David Cornelius became ill; his parents, Edward and Anne Cornelius, took him to a doctor who diagnosed diabetes and started insulin. Later, a Christian Science clinician stopped the insulin, causing David to die in a diabetic coma. The district attorney indicted Edward and Anne Cornelius for involuntary manslaughter, but dropped the charges when a senior church official persuaded him that the Corneliuses “had sincerely believed that they could save their son through prayer.”
• In 1967, Lisa Sheridan, the five-year-old daughter of Dorothy Sheridan, contracted strep throat. For the next three weeks Lisa found it harder and harder to breathe. Dorothy, a Christian Scientist, prayed but to no avail; Lisa Sheridan died of pneumonia on March 18, 1967. At autopsy, the pathologist found a quart of pus in Lisa’s chest that had collapsed her lung—pus that could have been removed easily had Dorothy sought medical attention. Sheridan was convicted of manslaughter and sentenced to five years in jail. The church, frightened by the verdict, issued a scathing rebuke: “We must not yield to the mesmeric claims of medicine by calling a doctor and being forced to worship a false God.” Christian Science officials successfully lobbied the Department of Health and Human Services to exempt faith healers from prosecution. In 1974, when the federal exemption was made, eleven states already had a religious exemption statute; ten years later, all fifty states and the District of Columbia had it.
• In 1977, Matthew Swan, the second child of Rita and Douglas Swan, had a high fever. The Swans asked their Christian Science practitioner, Jeanne Laitner, to treat him. Laitner complied; sitting next to Matthew’s crib she said, “Matthew, God is your life. God didn’t make disease, and disease is unreal.” Matthew continued to scream in pain. On July 7, Matthew Swan was pronounced dead from bacterial meningitis. Unlike other Christian Science parents, Rita Swan saw the death of her son as a wake-up call. She founded Children’s Health Care Is a Legal Duty (CHILD), an organization devoted to changing religious exemption laws.
But the neglect continued:
• On March 9, 1984, Shauntay Walker died of bacterial meningitis. Her mother, Laurie, a Christian Scientist, had kept her home for seventeen days. At the time of death, Shauntay, who was five years old, weighed only twenty-nine pounds. In 1990, Walker was convicted of manslaughter, but the conviction was overturned with the help of her lawyer, Warren Christopher, who would later become Bill Clinton’s secretary of state.
• On April 8, 1986, Robyn Twitchell—the two-year-old son of David and Ginger Twitchell—died of a bowel obstruction. David and Ginger had graduated from a Christian Science college in Missouri. After the bowel obstruction ruptured, Robyn vomited stool and portions of his bowel. He died in his father’s arms. At trial, Dr. Burton Harris, chief of surgery at Boston’s Floating Hospital for Infants and Children, testified, “It’s beyond comprehension that the parents of a child who’s vomiting stool wouldn’t seek medical help.” The Twitchells were found guilty; the verdict was overturned on appeal.
• On June 5, 1988, twelve-year-old Ashley King died of bone cancer. The only child of John and Catherine King, Ashley lay at home for months without medical care. At the time of her death, the tumor was the size of a watermelon; her hemoglobin level was incompatible with life, and she was covered with bedsores. John and Catherine King each pleaded no contest to one charge of reckless endangerment: a misdemeanor. They were sentenced to three years’ probation.
• On May 9, 1989, eleven-year-old Ian McKown—the son of Kathleen McKown—died in a diabetic coma. Doctors testified that insulin given even two hours before his death could have saved his life. The police officer called to the house said that the child was so emaciated that “he didn’t even look human.” Kathleen McKown was protected from prosecution by Minnesota’s religious exemption law.
Despite deaths at the hands of faith healers, religious exemptions have remained intact, causing prosecutors either to decline to file criminal charges or to lose in court. Only three states—Massachusetts, Hawaii, and Maryland—have repealed their religious exemption health laws; the rest continue to offer protection to parents who medically neglect their children in the name of God.
The notion that U.S. courts would eliminate religious exemptions to vaccination, when they haven’t eliminated religious exemptions to lifesaving medicines, is fanciful.
Philosophical exemptions, which have become increasingly more popular, would also be difficult to eliminate.
In the 1990s, philosophical exemptions were available in only a handful of states; now, they’re available in twenty-one. Alan Hinman, the CDC official interviewed for
Vaccine Roulette
who actively promoted state mandates in the 1970s, doesn’t see any hope of eliminating philosophical exemptions. “I don’t think that one would win the battle in the legislature on getting rid of philosophical or personal belief exemptions,” he said. “Looking at the trajectory of our society over the last several years, I find it hard to imagine. If anything, we’re going the other way.” Walter Orenstein thinks philosophical exemptions at the very least should be much more difficult to obtain. “I believe that a decision
not
to vaccinate is of equal gravitas to [the decision]
to
vaccinate,” he said. “And there should be a procedure whereby people have to read information, understand information, and sign that they understand the risks they are putting that child through. Right now, in some places, it’s a hell of a lot easier to get an exemption than to get your child vaccinated.” Orenstein sees his proposal as of value only for those who choose what he calls “exemptions of convenience.” “For people who are adamantly opposed to vaccines,” he says, “I don’t think this will make that much difference.”
Another solution would be for the medical community to respond more directly to the threat of decreasing immunization rates.
Recently, hospital administrators have been mandating influenza vaccines given yearly for healthcare providers. Regarding influenza, certain facts are unassailable: people sickened by influenza come into the hospital, healthcare providers can spread influenza virus from one patient to another, patients who catch influenza in the hospital can suffer severe and fatal illness, and hospitals with higher rates of immunization among healthcare providers have lower rates of influenza. Despite these facts, influenza vaccination rates among healthcare providers have been woeful—hovering around 40 percent. So, in the name of patient safety, hospital administrators are doing something about it.
In 2009, eight hospitals in the United States mandated influenza vaccine for their employees. Some took a softer approach: if a healthcare provider refused vaccination, administrators required a surgical mask to be worn throughout the day. Others took a harder line. At the Children’s Hospital of Philadelphia healthcare providers who refused influenza vaccination were given two weeks of unpaid leave to think about it. If they still refused, they were fired. As a consequence, immunization rates among healthcare providers at the hospital rose from 35 percent in 2000 to 99.9 percent in 2010. Administrators at Children’s Hospital knew they were responsible for a vulnerable population; so they stood up for them.
Doctors are also doing something that decades ago would have been unthinkable: they’re refusing to see parents who won’t vaccinate their children.
For doctors, it’s a lose-lose situation. Doctors who refuse to care for unimmunized children are sending a strong message. They’re saying vaccines are so important that they cannot be asked to withhold them. The problem with this approach is that by refusing to see unimmunized children, doctors lose any chance of convincing parents of the value of vaccines; worse still, these children will likely remain unimmunized and vulnerable. On the other hand, if doctors continue to see unimmunized children, they’re sending a tacit message that it’s an acceptable choice. And it’s not a choice that parents are making for their child only; it’s a choice they’re making for other children, including those in the doctor’s waiting room. The measles outbreaks in 2008 are a perfect example of how parents’ choices for their children affected others. When unimmunized children developed fever and a rash, parents brought them to their pediatricians’ offices, where other children, some too young to be immunized, were exposed. Doctors’ offices became epicenters of measles transmission. Now, doctors are asking: who will stand up for children in our waiting rooms if not us?