Time out at Taghazout

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Its a long gradual descent from the mountains to the Moroccan coast. The landscape becomes greener and we pass through an extensive area of citrus and olive orchards before arriving in Agadir 9 hours later. In 1960 this city was devastated by a large earthquake and it has been rebuilt to create one of the premiere coastal resorts in the country. Its just a brief stop for us here as 14 foot waves

Oktoberfest in Mexico City

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Als wir es von Daian erfahren koennen wir es zunaechst gar nicht glauben es gibt ein Oktoberfest in Mexico City Am Sonntag dem 4. Tag unserer Reise erleben wir Unglaubliches. Aufbruch mit yu erwartender Verspaetung von Daians Wohnung um ca. 12.00 Uhr. Ihr Freund Udi mit dem wir uns yuvor treffen wollen kommt nach. Er verlaesst seine Wohnung der Haustuerschluessel nicht. Er muss auf den Sch

Lots of traveling Prague and Dresden

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Prague I arrived with my parents on Thursday afternoon and as we waited for my grandparents to arrive we did a lot of walking around. One of the first things we were surprised at was the number of pickpockets and other various types of unusual people. It was definitely a lot rougher than germany. But it was a beautiful day and we saw a lot of things even in the short time that we walked around.

Druk druk druk

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Het is al weer even geleden maar hier is mijn nieuwe berichtje uit NicaraguaVorige week had ik voor het laatst spaanse les en toen heb ik mijn diploma ontvangen. Ik had toen ook al een paar keer gewerkt met Ritmo en los Barrios De organisatie waar ik werk en daarmee muziekles geef aan kinderen op verschillende scholen. De mensen daar zijn echt heel erg aardig en het is allemaal goed geregeld. Z

School van driver died of injuries – Pittsburgh Post Gazette

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Pittsburgh Post Gazette
School van driver died of injuries
Pittsburgh Post Gazette
An autopsy done by the Allegheny County Medical Examiner's office shows the driver of a school van died of injuries. The office released a report on Russell ...
Coroner: School van driver died from blunt traumaPittsburgh Tribune-Review
Police probe fatal school van accidentPittsburgh Post Gazette

all 20 news articles »

Improving Our Response to Anti-Vaccine Sentiment

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As Vaccine Awareness Week draws to a close, I thought it might be instructive to step back and look at the tactics, impact, and successes of the anti-vaccine movement. Yesterday, Orac questioned the best approach to counter the anti-vaccine movement. With today’s post, I’ll summarize two pertinent papers on the effectiveness of their tactics, and suggest some possible approaches.

There’s overwhelming evidence that vaccines have provided us with tremendous health benefits. Smallpox has been eliminated (except, apparently, for homeopathic nosodes), polio is almost gone, and occurrences of diseases like measles or rubella are now rare. In use for over a century, they are a public health triumph: diseases that terrified us a generation ago are now never seen.  Epidemiologic evidence demonstrates that vaccines have a remarkable safety record, and are exceptionally cost-effective interventions. Yet in spite of this, concerns about vaccine safety seemingly continue to mount.  And as we see time and time again, when vaccination levels drop, diseases reappear. So what’s driving anti-vaccine sentiment, and why is it successful?

The H1N1 pandemic of 2009/10 is now about a year past its peak, and is instructive as a case study on communication on  vaccine safety and efficacy. Remember the H1N1 vaccine? Judging by the anti-vaccine rhetoric of just last year, by now we should all have been rounded up by the army, given forced injections, and if the vaccine didn’t kill us right away, or make us walk backwards, we’d be immunosupressed (from the aluminum adjuvant), or have Gulf War Syndrome (from the squalene). And not only did it not work, it doubled our odds of getting H1N1.  All we needed was vitamin D and a proprietary supplement formula to avoid the flu, they said.

There’s a new paper that attempted to evaluate population-level sentiment about the vaccine, as well as the key sources of antivaccination information that circulated at the time. Neil Seeman, Alton Ing, and Carlos Rizo recently published Assessing and Responding in Real Time to Online Anti-vaccine Sentiment during a Flu Pandemic in the journal Healthcare Quarterly. The authors had two objectives: evaluate Canadian attitudes about the safety of the H1N1 vaccine during the fall of 2009; and to aggregate and quantify the vaccine-related information that was being circulated online.

Percieved Safety of the H1N1 Vaccine

The authors wanted to understand how perceptions of safety were changing during the flu season by surveying Canadians on a daily basis. They used a commercial program that redirects visitors to nonsense URLs that would be reached by random accidents in entering web addresses. URL names used had no commercial or English name. This process is similar to random-digit dialing for internet users, as any user could conceivably enter an incorrect web address and land on a tracked site. There was no intent to track users seeking vaccine information – the process would simply identify a random sampling of internet users. Users that landed on a tracked site were asked “Is the H1N1 flu vaccine safe?” and answers were restricted to “yes”, “no”, “I don’t know”, or “skip”. Basic demographic information was also collected. Only Canadian IP addresses were exposed to the survey.

Over 27,000 respondents (1,141 visitors per day) completed the survey out of 175,000 that landed on a URL, a decent response rate of 15.6%.  Response was evenly distributed from across Canada, but was predominately female (61%) and, compared to known internet user demographics, skewed towards younger Canadians, with older adults significantly underrepresented.

Here’s how vaccine safety was perceived by the survey population over time:

 

There’s no statistical analysis conducted, but it seems reasonable to assume that concerns about the vaccine’s safety were substantial, and possibly even increased slightly over time. During the survey period, 23.4% of Canadians considered the vaccine safe, compared to 41.4% who indicated it was unsafe, and 35.2% who expressed no opinion.

What Drives Perceptions of Safety?

In the second part of the paper (unrelated to the survey) the authors describe their attempts to understand information being circulated online about H1N1 vaccine safety. They identified and tracked over 17,000 Google search results based on (English language) Google searches, and then ranked them based on how frequently the information was shared via social networks like Digg, Facebook, YouTube and Twitter. On a daily basis, trending articles were reported and ranked in real time in their Flu Chat Lab. The authors aggregated the most shared links overall in an appendix to the paper.

Here are the results. Round up the usual suspects:

  1. YouTube video: Convenience store clerk touting Vitamin C and fish oil
  2. YouTube video: “Girl gets ‘Flu’ shot & now can only walk backwards”
  3. Mercola article: “Critical Alert: The Swine Flu Pandemic – Fact or Ficton?”
  4. Atlantic article: “Does the Vaccine Matter?”
  5. Prison Planet article: “CDC warns neurologists to watch for nerve disease following swine flu shots”
  6. Informationisbeautiful.net: “Is the H1N1 swine flu vaccine safe? What if I’m pregnant?”
  7. Mercola article: “Swine Flu – One of the Most Massive Cover-ups in American History”
  8. Flu.gov article: Assistant Surgeon General Dr. Anne Schuchat dispels myths about the H1N1 flu virus on The Doctors
  9. Mercola article: “Warning: Swine Flu Shot Linked to Killer Nerve Disease”
  10. Mercola article: “Alert: Special Swine Flu Update”
  11. Newscientist.com article: “Swine Flu: Eight Myths That Could Endanger Your Life”
  12. CDC.gov article: CDC’s Questions and Answers: “Vaccine against 2009 H1N1 Influenza Virus”
  13. Mercola article: “Squalene: The Swine Flu Vaccine’s Dirty Little Secret Exposed”
  14. Mercola article: “Flu Vaccine Exposed”
  15. Mercola article: “CBS Reveals That Swine Flu Cases Seriously Overestimated”
  16. Natural News article: “Ten Swine Flu Lies Told by the Mainstream Media”
  17. Mercola article: “Expert Pediatrician Exposes Vaccine Myths”
  18. WebMD article: “Swine Flu FAQ”
  19. Natural News article: “”Vaccine Revolt! Swine Flu Vaccine Support Crumbles”
  20. “Fact sheet” from the Arizona government’s news release on H1N1

Not very inspiring, is it?

Now there’s inadequate information in the paper to evaluate how accurately the survey method used tracked actual sites shared. But based on the methodology used, articles questioning the safety of the H1N1 were circulated widely, and anti-vaccine articles and sources dominated.

Are the anti-vaccine tactics effective?

If we accept that decisions to vaccinate are based on an evaluation of the risks of both commission and omission, then we should ask if exposure to anti-vaccine information has a meaningful impact on perceptions of the safety of vaccines. There is some literature that has studied this question. An interesting paper published earlier this year by Betsch and colleagues set out to prospectively measure the impact of anti-vaccination websites. They recruited 517 internet users (from sites for parents or those interested in medical information) and compared risk judgment and vaccination intentions before and after viewing different websites. (The evaluation was in German and used German websites. ) Users were directed to view a vaccine-critical website, or a neutral website, and then evaluated again.  The authors found that viewing anti-vaccine material for only five to ten minutes increased the perception of risk of vaccination, and decreased the perception of risk of omitting vaccines, compared to viewing neutral websites. It also lowered vaccination intentions.

Overwhelmingly, policy analyses of the anti-vaccine movement have centered on the need to address fears by providing reliable, accurate understandable information. But if H1N1 taught us anything, it’s that traditional public health advocacy and messaging is probably insufficient to deal with anti-vaccine tactics used today. We believe that providing the facts alone will be effective, but this tactic is probably ineffective when responding to unfounded fears. Providing factual information, and correcting misinformation needs to be at the core of our advocacy, but it alone does not address the strategies used by anti-vaccine advocates.  It’s the reality we need to accept if we’re going to effectively counter these messages.

Conclusion

One of the biggest drivers of health behaviors is risk perceptions. Anti-vaccine information effectively shapes this, and science advocates need more effective responses. The opportunity to get a real-time understanding of popular anti-vaccine sentiment could help us improve our responsiveness. But unless we focus on prospectively influencing the key factors that drive decisions about vaccination, we’ll continue to struggle.

 

 

A Shot in the Dark Revisited

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Most shots in the dark miss. Scientists learn this early in their career – most of the guesses we make as to how things work will turn out to be wrong. In fact, a proper understanding of science requires thorough knowledge of all the ways in which humans deceive themselves into believing things that are not true. In fact, most shots in well-lit conditions (informed by prior knowledge) miss. Ignoring prior knowledge results in chances that are all but hopeless.

Therefore the title of the 1985 book DPT: A Shot in the Dark by Harris Coulter and Barbara Loe Fisher, is perhaps unintentionally ironic. The book sparked the first modern popular concern about the risk of neurological damage from vaccines, in this case the pertussis vaccine that is part of the DTP vaccine.Fisher, of the National Vaccine Information Center (NVIC) still promotes the book and its content, even though the science has progressed in the last 25 years.

At the time the whole cell pertussis vaccine was part of the diptheria, tetanus, pertussis vaccine (DTwP). This combination has been largely replaced with the DTaP vaccine, which contains an acellular pertussis component. This change was partly due to safety issues, rare cases of neurological disease (seizures and encephalopathy) following DTwP being given. DTaP has a lower incidence of fever, seizures, and other side effects.

In the 1980s reports were surfacing of seizure and encephalopathy following DTwP. A 1991 review of these reports concluded that there was a possible association, but there was insufficient data to establish causation. It was also unclear if these reactions were causing any long term consequences. The safety of DTwP was therefore further studied, and as the evidence was examined it did not appear to support an actual link between DTwP and neurological injury. A 1990 review found:

There clearly is an increased risk of a convulsion after diphtheria-tetanus-pertussis immunization but no evidence that this produces brain injury or is a forerunner of epilepsy. Studies have also not linked immunization with either sudden infant death syndrome or infantile spasms.

In 1993 the Institute of Medicine conducted their own review of the evidence and concluded.

The committee concluded that the evidence is insufficient to indicate either the presence or absence of a causal relationship between DTP vaccine and permanent neurological damage.

But a later (1994) extensive population-based case control study found:

This study did not find any statistically significant increased risk of onset of serious acute neurological illness in the 7 days after DTP vaccine exposure for young children.

The DTwP has largely been replaced by the DTaP vaccine, and so there is little research into DTwP safety in the last decade. However, there is still some data from countries other than the US, that continued to use the DTwP after it was abandoned in the US. A 2008 Polish study, for example, compared reported side effects following DTwP and DTaP and found:

Comparisons done in children less then 2-years-old show in general about twice as high incidence of adverse effects following the whole-cell than the acellular vaccine. The biggest rate of proportions (RR = 4,75) was observed for high pitch cry. There was no significant difference in incidence of the most severe reactions, including encephalopathy and nonfebrile seizures, and there was no significant difference in allergic reactions.

So while there were more minor reactions to DTwP, there was no increase in seizures or encephalopathy compared to DTaP, which supports the conclusion that DTwP does not increase the risk of these neurological events. However, a Canadian study found a decrease in hospital admissions for febrile seizures following the transition to DTaP, suggesting that DTwP did increase the risk of febrile seizures. It should be noted, however, that febrile seizures do not generally increase the risk of developing epilepsy or permanent neurological damage.

Researchers are not done with the whole cell pertussis vaccine question. It is the nature of research to continually ask questions, to take shots at the truth (in whatever lighting conditions are available). A 2010 paper argues:

We argue that these reactions may have occurred in metabolically vulnerable children, specifically those with defects in fatty acid oxidation. In these children the combination of anorexia and fever that could be caused by the vaccine may have resulted in hypoglycemic episodes and possibly death. We believe that this association was not detected because these conditions were not recognized at the time and because these conditions are uncommon. Nevertheless, at a population level, enough events could have occurred to cause concern amongst parents.

This is a typical follow up question after negative findings – perhaps the effect (whether good or bad) exists only in a subpopulation and therefore was statistically missed by studies of the general population. This is a common question that can be applied to any negative study, and therefore is a fairly generic alternate hypothesis, which most of the time turns out to be false.

Conclusion

The DTwP story is a fairly typical one in the world of medicine. Anecdotal reports indicated a possible adverse reaction to the whole-cell pertussis vaccine. Researchers therefore looked at the question in various ways and eventually concluded that no significant signal or pattern could be detected. In short, there does appear to be an increased incidence of adverse events, such as irritability and maybe even febrile seizures, but no evidence of long term neurological harm. Never-the-less, a newer safer version of the vaccine, the acellular pertussis vaccine, became available and was adopted because it was probably safer. Even still researchers continue to drill down into the question of pertussis vaccine safety.

It is not possible to ever prove zero risk from any medical intervention. The data will always be limited. But we can demonstrate that the risk must be below certain upper limits, and that benefits outweigh risks – that net outcomes are improved with the intervention.

What we also see in this story is that anti-vaccine activists, like Fisher, froze their opinions about DTwP back in the early stages of anecdotal reports. The book, Shot in the Dark, was written prior to the informative research as to the safety of DTwP. The same appears to be true for those who continue to promote the myth that vaccines (MMR or thimerosal specifically) are associated with autism. The science has spoken even more clearly on this question – there is no detectable link between vaccines or mercury toxicity and autism. But the myth persists.

Skeptically Speaking with Dr. Gorski

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I have been very, very remiss about this, but I totally forgot to pimp my appearance a week and a half ago on Skeptically Speaking. Part of the reason was that I tend to be rather shy about interviews, and part of the reason was that I just plain forgot. Given our having dedicated this week to the discussion of vaccines on Science-Based Medicine, I thought it would be the perfect time to point out to Skeptically Speaking #82 Vaccines.

Why science reporters should do their homework

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One of the most significant medical advancements of the last few decades has been the use of cholesterol-lowering medications called statins.  These drugs, when used properly, have been shown over and over to lower the risk of heart attacks, strokes, and death.  But like all drugs, they have many effects, both those we like (preventing heart attacks) and those we don’t (in this case, rare liver and muscle problems); the latter we call “side-effects”.  Studies done on drugs before they hit the market can identify common side-effects, but it’s not until many more people are exposed for a long period of time that rare side-effects show up.

A recent Scientific American article wondered if one of these rare side-effects could be memory problems.  At first glance, the idea seems pretty improbable, but the SI article takes some sketchy anecdotes and runs with the idea, managing to cobble together an interesting hypothesis:

It is not crazy to connect cholesterol-modifying drugs with cognition; after all, one quarter of the body’s cholesterol is found in the brain. Cholesterol is a waxy substance that, among other things, provides structure to the body’s cell membranes. High levels of cholesterol in the blood create a risk for heart disease, because the molecules that transport cholesterol can damage arteries and cause blockages. In the brain, however, cholesterol plays a crucial role in the formation of neuronal connections—the vital links that underlie memory and learning. Quick thinking and rapid reaction times depend on cholesterol, too, because the waxy molecules are the building blocks of the sheaths that insulate neurons and speed up electrical transmissions.

It’s not crazy to connect cholesterol-modifying drugs with cognition, but it’s quite a stretch.  We do know that statins affect the central nervous system.  They’ve been proven to reduce the risk of stroke, a devastating central nervous system disease.  If they can prevent brain disease, might they also cause it?  We have some ideas about why statins prevent strokes: they lower cholesterol and stabilize arterial plaques, perhaps by reducing inflammation in these plaques.  They can even cause plaques in some arteries to shrink.  Is there a plausible hypothesis as to why statins might cause memory problems?  What is being posited is that statins actually reduce cholesterol levels so much that cell membranes are damaged and neuronal saltatory conduction* is impaired.  If this were the case, we might also expect to find cognitive differences  when comparing people with high and low cholesterol levels, or to see cognition affected by cholesterol-lowering diets.  This is not the case.

Still, dementia—the most common and severe form of memory loss— is a devastating disease, so if there is even a chance, maybe we should ask the question.   A large  cohort study published in Archives of Neurology in 2005 looked into whether statins might actually help prevent dementia.  They groups of elderly patient who took statins, and those who did not and compared the incidence of dementia in each group. There found neither a protective effect nor a harmful effect.

The idea that lipids (fat molecules) can affect brain function has been supported by certain epidemiologic studies and some animal models.  Omega-3-fatty acids have been touted for possible use in preventing and treating dementia.  Last week, a randomized controlled trial of a particular omega-3-fatty acid was published in JAMA.  The study design was strong, and the study found no evidence that this particular molecule helped dementia patients.

The two most common types of dementia are vascular dementia and Alzheimer’s disease.  The cause of Alzheimer’s disease isn’t known, making prevention difficult.  Vascular dementia, however,  is to a certain extent preventable.  It is caused by a variety of factors that affect blood vessels such as hypertension, and studies have shown that many of the same interventions that prevent stroke can help prevent vascular dementia.  One of the most potent risks for vascular disease is cigarette smoking, so it would make sense that smoking would be a risk factor for vascular dementia.  A surprising result of a study recently published in Archives of Internal Medicine was that smoking is a risk factor not only for vascular dementia but also for Alzheimer’s dementia.

The story of dementia risk is complex, and there is a rich vein of literature to mine.   I was disappointed that the SI article presented anecdotes rather than data, case-reports rather than good studies, and highlighted “experts” who presented fear-mongering testimony rather than the measured caution that we can expect from real experts.

___________________________________

*“Saltatory conduction” describes a way that nerve signals travel quickly.  Nerve cells can function as a sort of wire for electrical signals, and the myelin sheath allows electrical signals to jump from node to node, increasing the speed of conduction when compared to an un-myelinated neuron.  Certain diseases, such as multiple sclerosis, involve destruction of the myelin sheath, decreasing nerve conduction velocity, leading to weakness and other symptoms.    Myelin contains cholesterol, among other things.

References

Rusanen, M., Kivipelto, M., Quesenberry, C., Zhou, J., & Whitmer, R. (2010). Heavy Smoking in Midlife and Long-term Risk of Alzheimer Disease and Vascular Dementia Archives of Internal Medicine DOI: 10.1001/archinternmed.2010.393

Quinn, J., Raman, R., Thomas, R., Yurko-Mauro, K., Nelson, E., Van Dyck, C., Galvin, J., Emond, J., Jack, C., Weiner, M., Shinto, L., & Aisen, P. (2010). Docosahexaenoic Acid Supplementation and Cognitive Decline in Alzheimer Disease: A Randomized Trial JAMA: The Journal of the American Medical Association, 304 (17), 1903-1911 DOI: 10.1001/jama.2010.1510

Rea, T. (2005). Statin Use and the Risk of Incident Dementia: The Cardiovascular Health Study Archives of Neurology, 62 (7), 1047-1051 DOI: 10.1001/archneur.62.7.1047

Forette F, Seux ML, Staessen JA, Thijs L, Birkenhäger WH, Babarskiene MR, Babeanu S, Bossini A, Gil-Extremera B, Girerd X, Laks T, Lilov E, Moisseyev V, Tuomilehto J, Vanhanen H, Webster J, Yodfat Y, & Fagard R (1998). Prevention of dementia in randomised double-blind placebo-controlled Systolic Hypertension in Europe (Syst-Eur) trial. Lancet, 352 (9137), 1347-51 PMID: 9802273

Vaccine Wars: the NCCAM Drops the Ball

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If you go to the website of the National Center for Complementary and Alternative Medicine (NCCAM), you’ll find that one of its self-identified roles is to “provide information about CAM.” NCCAM Director Josephine Briggs is proud to assert that the website fulfills this expectation. As many readers will recall, three of your bloggers visited the NCCAM last April, after having received an invitation from Dr. Briggs. We differed from her in our opinion of the website: one of our suggestions was that the NCCAM could do a better job providing American citizens with useful and accurate information about “CAM.”

We cited, among several examples, the website offering little response to the dangerous problem of widespread misinformation about childhood immunizations. As Dr. Novella subsequently reported, it seemed that we’d scored a point on that one:

…Dr. Briggs did agree that anti-vaccine sentiments are common in the world of CAM and that the NCCAM can do more to combat this. Information countering anti-vaccine propaganda would be a welcome addition to the NCCAM site.

In anticipation of SBM’s Vaccine Awareness Week, I decided to find out whether such a welcome addition has come to fruition. The short answer: nope.

Go where the Money Is(n’t)

I looked on the NCCAM website in places where common sense would dictate that such content might be found:

In each case I searched for the terms “vaccine,” “vaccination,” “immunization,” “autism,” “MMR,” “thimerosal,” “mercury,” and variations of those words. No dice. I found a couple of mentions of vaccinations by using the general NCCAM website search function; Drs. Novella, Gorski, and I had been aware of these when we visited Dr. Briggs in April, but for completeness’ sake I’ll cite them here. One is in an essay titled Colds and Flu and CAM: At a Glance, dated January, 2010. It states, correctly, that “Vaccination is the best protection against contracting the flu,” but it offers no further comment. There is no rebuttal of vaccine myths, nor even an acknowledgment that such myths exist. Another is in a Message from the Director from October, 2009, which appears to be the precursor of the “Colds and Flu” essay. Here, Dr. Briggs briefly acknowledges vaccine myths:

Vaccination is the best protection against contracting the flu. I know that many people are very concerned about the safety of the flu vaccines, but let me echo the Centers for Disease Control and Prevention, as well as other prominent public health leaders, in assuring you that the vaccines for both the seasonal flu as well as H1N1 have a very good safety track record. Over the years, hundreds of millions of Americans have received the flu vaccine, and the development of the H1N1 vaccine followed the same path of safety and effectiveness testing and approval.

One wonders why that language is absent from the subsequent, larger essay. Not that including it would have addressed the problem of vaccine myths in general, as suggested by the search terms that I chose.

“Whole Medical Systems” lack Whole Discussions

On the NCCAM website there are other notable failures to respond to public misinformation about immunizations. In the Homeopathy treatise there is no mention that homeopaths have famously railed against vaccinations ever since Constantine Hering, the “father of American homeopathy,” called them “always a poisoning.” Nor is there any mention of Hering’s invention, “homeopathic nosodes,” also called “homeopathic vaccinations,” which homeopaths such as Dana Ullman claim to be effective in preventing infectious diseases.

A similar failure exists in the Naturopathy treatise. Many influential naturopaths are anti-vaccine; they advocate “homeopathic nosodes” or other implausible measures. I wonder if Dr. Briggs had any inkling of this when she flattered the American Association of Naturopathic Physicians—whose Position Paper on Childhood Vaccinations is certain to mislead and frighten parents—with her presence at their annual convention in August.

Credentialing Nonsense

Linked from the “Be an Informed Consumer” page on the NCCAM website is an essay titled Credentialing CAM Providers: Understanding CAM Education, Training, Regulation, and Licensing. In it we are told that

A physician’s credentials—the licenses, certificates, and diplomas on the office walls—tell us about that person’s professional qualifications to advise and treat us. We seek similar assurances when we choose a complementary and alternative medicine (CAM) practitioner…

The essay hedges a bit, but is careful to suggest that “CAM” credentials are every bit as trustworthy as those held by real doctors:

Regulations, licenses, or certificates do not guarantee safe, effective treatment from any provider—conventional or CAM.

We are told that “naturopathic physicians” are licensed in 15 states and the District of Columbia, that they have undergone apparently rigorous training in “natural sciences and clinical sciences,” and that they have passed an apparently rigorous, standardized exam offered to “graduates of accredited programs” by their national organization, the American Association of Naturopathic Physicians. The essay makes similar statements about homeopaths and chiropractors—another group with a well-documented distaste for vaccinations.

Such claims of training and credentialing are deceptive, because the fields are bastions of pseudoscience. In the words of Edzard Ernst, “the most meticulous regulation of nonsense must still result in nonsense.” Yet an unsuspecting person looking for responsible information about “CAM” on the NCCAM website would be led to believe, along with all the other nonsense, that the anti-vaccination views of naturopaths, homeopaths, and chiropractors are valid and based on science.

It is no surprise that the NCCAM “Credentialing” essay relies heavily upon the writings of attorney Michael H. Cohen, a champion of quackery about whom we’ve heard before on SBM.

Why?

I used to suppose that the NCCAM website ignoring vaccination hysteria was a matter of naïveté: most NCCAM functionaries know little of the practices and practitioners with which they are expected to be familiar. This probably remains true to a large extent, but we know that Dr. Briggs, at least, is aware of the intimate relation between “CAM” advocacy and the anti-vax movement. Perhaps she hasn’t got around to making the promised changes on the website, but if so, why not? Widespread fear mongering about vaccines being poisons and causing autism is a far more important public health issue than whether or not glucosamine is useful for osteoarthritis, or whether acupuncture might be useful for fibromyalgia, or any of the rest of the standard, breezy, NCCAM fare. The refutation of dangerous myths about vaccines ought to be a priority.

During our visit, Dr. Briggs, who has been at the NCCAM only since 2008, made a point of denying that she feels pressure from Congressional “CAM” demagogues such as Dan Burton and Tom Harkin. That may seem true in the day-to-day grind of her job, but such pressure has permeated the culture of the NCCAM since before its formal inception, as documented many times here on SBM and elsewhere. Rep. Burton conducted numerous pro-quack hearings during his tenure as chairman of the House Committee on Government Reform. His bullying of NIH directors is largely responsible for two of the most unethical trials ever funded by the NCCAM, the Gonzalez trial for cancer of the pancreas and the Trial to Assess Chelation Therapy. Burton is also a champion of quacks who claim that vaccines cause autism.

Sen. Harkin was the creator of both the NCCAM and its predecessor, the Office of Alternative Medicine (OAM). He famously stacked the OAM advisory panel with four pseudoscientific zealots who would be become known as “Harkinites.” He worries that the NCCAM hasn’t spent its time “seeking out and approving [alternative methods].” He hypes “integrative medicine” as the Next Big Thing, the answer to

the dogmas and biases that have made our current health care system – based overwhelmingly on conventional medicine – in so many ways wasteful and dysfunctional.

In particular, assert Sen. Harkin and other advocates, “integrative medicine” will mean preventative medicine. I’ve discussed this deception previously: it’s worse than a Damned Lie. I can’t help but restate, for the occasion of Vaccine Awareness Week, an unending source of ironic amusement for your SBM bloggers and for rational thinkers everywhere: immunizations, also called vaccinations (for the first of their kind, made from cowpox exudate), are the most effective preventative health measures ever devised; yet “alternative medicine” pushers of every stripe, who claim special, proprietary knowledge about achieving ‘wellness,’ can dependably be counted on to oppose them.

A Web of Misinformation

The NCCAM, whether Dr. Briggs would like to admit it or not, is heavily influenced by such sentiments. We’ve already seen how the Center’s website whitewashes naturopaths, homeopaths, and chiropractors. We’ve seen how Dan Burton has single-handedly forced the NCCAM to fund horrible trials and to employ investigators who are charlatans and even criminals. We know that National Advisory Council for Complementary and Alternative Medicine (NACCAM) has been and continues to be, as a matter of law, a bastion of naturopaths, chiropractors, and other quacks.

“Wait a minute,” someone might be thinking, “you can’t conclude from your cited evidence that Harkin himself is anti-vax.” That’s true, but it doesn’t matter. What’s important, for the purposes of this discussion, is the company that he and the NCCAM keep. Let’s illustrate this by citing an example from the current membership of the Advisory Council.

Janet Kahn is the Executive Director of the Integrated Healthcare Policy Consortium (IHPC). The organization was founded in 2001 at the completion of the “National Policy Dialogue to Advance Integrated Health Care: Finding Common Ground,” whose report was co-authored by two naturopaths. As was true of that report, the IHPC agenda and beliefs are exactly in line with those of Harkin and other “integrative medicine” enthusiasts. The IHPC has a Federal Policy Committee whose goal is to fearlessly and tirelessly “transform the very architecture of the US healthcare system.” This, the IHPC intends, will be accomplished by legislative fiat: practitioners of implausible methods will simply be shoehorned into mainstream health care, bypassing science and rational practice standards.

Now let’s close the anti-vax/NCCAM circle. If you’ve looked at the many documents linked from this post, you might have noticed the name Michael Traub. He is a naturopath and homeopath who is on the IHPC’s Board of Directors, Federal Policy Committee, and Steering Committee. He was co-author of the “National Policy Dialogue” report cited just above. He is a past-President of the American Association of Naturopathic Physicians, and last summer shared the podium with NCCAM Director Briggs.

In 1994, Traub published an article, titled “Homeopathic prophylaxis,” for the Journal of Naturopathic Medicine. As previously explained,

[The] article suggests that homeopathic products are safer and more effective than vaccination for preventing disease. The article’s author (Michael Traub, N.D.) taught public health at the National College of Naturopathic Medicine and helped formulate the AANP’s position papers on immunization and homeopathy. He recommends tetanus vaccine but advises against measles, mumps, rubella, and diphtheria. After paying homage to a homeopathic treatise on “vaccinosis” published more than 100 years ago, Traub’s article details the use of homeopathic nosodes for preventing diphtheria, whooping cough, polio, influenza, tuberculosis, and pneumoccal pneumonia. Nosodes are products made by repeatedly diluting samples of pathological tissues, bacteria, fungi, ova, parasites, virus particles, yeast, disease products (such as pus), or excretions. The protocol Traub describes uses “200C potencies” which means that the nosodes are made by serially diluting the original substance 1-to-100 a total of 200 times. (After the 12th dilution, no molecule of original substance remains.) Traub states that he no longer recommends nosodes but uses other “preventive” homeopathic strategies.

That Traub hasn’t substantially changed his tune since 1994 is suggested by the title of a 2004 article, “Alternatives to Flu Shots”—I won’t pay to read it, but you can find it linked from here—and by Traub’s recent report of his own bout with apparent H1N1 flu, which can most generously be described as ditzy. Circle closed; there are many more.

Conclusion

Is it possible that the ubiquitous influence of “CAM” and its fellow traveler, anti-vaccination hysteria, is the real reason that the NCCAM website lacks responsible, definitive information about immunizations and pseudo-immunizations? If this is not the case, and if Dr. Briggs reads this, I hope she’ll be reminded of our discussion in April and consider this a challenge to show us that she is a player. I also hope that she’ll remember that her constituents are approximately 300 million American citizens, not merely tiny fringe groups of homeopaths, naturopaths, and Jenny McCarthy.

Homeopathic Vaccines.

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It is probably of no surprise to anyone who has read my blog entries, I am a proponent of vaccines.  They give the most bang for the infection prevention buck, and many of the childhood illnesses covered by the vaccine are now so rare that many physicians, even in Infectious Diseases, have never taken care of cases of measles or mumps or German measles, etc.  It is  a remarkable triumph of modern medicine.  Of course, the decline of infectious diseases is always multifactorial: good nutrition, understanding of diseases epidemiology, and good hygiene all have contributed to the decline of many diseases, vaccine preventable or not,  The application of science has resulted in an almost inconceivable decline in contagions that have killed and injured millions.

It is always better to prevent an illness than to have to treat it.  An ounce of prevention is worth a pound of cure.  Even those who erroneously believe that standard vaccines are not effective and/or dangerous understand that it is better to prevent illness with some sort vaccine.  But rather than use an effective vaccine, they choose, instead, other options.  Like homeopathic vaccines.

Vaccines offer a small, fixed amount of a pathogen (antigen)  to the immune system.  A touch of  bacterial carbohydrate here, a smidgen of viral protein there.  Something that the immune system can recognize and respond to, so that when the patient is exposed to the real infection, with its relatively massive amounts of antigen, the immune system is prepared and can react immediately to minimize the damage, rather than the usual delay it takes before immunity kicks in.  You know, like FEMA and New Orleans.  Or maybe not.  Perhaps my metaphorableness is lacking today.

There has to be something there, a real molecule of some sort, for the immune system to recognize and respond to. There is a threshold below which foreign material will not be recognized.  Tetanus is an interesting example.  An  impressively awful disease in those suffering from it, with every muscle contracting due to the tetanus toxin.  But interestingly, there is sometimes not enough toxin causing the disease to result in  an immune response, and those who get tetanus still need the vaccine after they recover to prevent recurrence.

Homeopathy is the art of giving absolutely nothing and believing that it is something. Kind of like election year promises.  A reader sent me an article on homeopathic vaccinations, which is one of the more bizarro concepts I have yet to discover in my wanderings in SCAMs.  I sometimes feel like someone is pulling an elaborate prank on me.

The first ‘law’ behind vaccines and homeopathy is the same: like cures like. Vaccines are the only medical validation of the first  ‘law’ of homeopathy of which I am aware.  It is the second ‘law’ of homeopathy where medicine, and reality, part company with homeopathy, the ‘law’ of dilutions.  Where vaccines are given with a well characterized concentration of antigen, homeopathic nostrums are often diluted long past the point where anything remains behind.  If a homeopathic nostrum is  20X, then there is no longer even a molecule of the original substance in the mixture.   Which can be a good thing, since homeopaths  use nosodes as their vehicle for imaginary vaccination.

A  nosode “is a homeopathic remedy prepared from a pathological specimen. The specimen is taken from a diseased animal or person and may consist of saliva, pus, urine, blood, or diseased tissue.”

And people complain about the alleged toxins in real vaccines.

Nosodes are cargo cult medicine at its finest. The trappings of real medicine with none of the efficacy. Thank goodness they are diluted to the point of nothingness.  At least with serial dilutions, HIV, Hepatitis B and C are unlikely to be  spread from injecting the patient with concoctions derived from various and sundry body fluids.  At least we left the techniques of Jenner behind with modern medicine.   Fortunately nosodes are used primarily in veterinary homeopathy.

One can purchase nosodes for human use for everything from Anthrax to Variola (smallpox) at either 30 or 200 dilution.  In a rare burst of honesty, one site notes

There are no whole molecules of the actual substance in 30C potency” and another notes “(homeopathic vaccines) do not contain Thimerosal, Aluminum, Borax (used to kill ants) and other chemical elements. Also in the studies that have been able to proceed, no child has had a any severe side effects from the homeopathic vaccines given.

Since they contain nothing, it would seem unlikely that they could have any side effects at all.

And they have a nosode for smallpox?  It is supposedly derived from the ripened pustule of a smallpox patient and I have to wonder about their source.  There has been no smallpox in the world since the mid 1970′s,  either they have a stock of smallpox that they feed like sourdough starter or they are not really selling the real deal.  Although even Twinkies have expiration dates, I guess the ‘energy’ in homeopathic remedies lasts for decades, with the smallpox nostrums maintaining their potency through the ages.

Are there any studies or case reports  to support the use of nosodes? As best I can discover there are two clinical trials in animals of nosodes: one in calves that did not show benefit and one in mice that did, and both are in journals too obscure for my library to have subscriptions. There are two cases of fatal polio after receiving homeopathic vaccinations. That is it in Pubmed.  Not a convincing literature for effectiveness.

One site does recognize that homeopathic vaccinations do not work like standard vaccines: by leading to the development of antibodies

Homeopathic preparations have not been shown to raise antibody levels. Smits tested the titre of antibodies to diphtheria, polio and tetanus in ten children before and one month after giving homeopathic preparations of these three vaccines (DTPol 30K and 200K). He found no rise in antibody levels (Smits, 1995). He speculates that protection afforded by a homeopathic remedy acts on a “deeper” level than that of antibodies. Other homeopaths have stated similar opinions. Golden says, “unlike conventional vaccines, the Homeopathic alternative does not rely on antibody formation.

Of interest, homeopaths argue the validity of the homeopathic vaccinations, since their nostrums are classically supposed to be effective only after symptoms have occurred.  It does make for a curious reading, one group of nonsense arguing that another group of nonsense is, well, nonsense.

The sad thing is parents will be fooled into thinking that their children are protected from infectious diseases, when, in fact, they are not.  Vaccines do not provide perfect protection; neither do seat belts.  But a vaccine is superior to the nothing of homeopathy and I would bet that parents would not rely on a child car restraint made by the same process as homeopathy.

What does “anti-vaccine” really mean?

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We write a lot about vaccines here at Science-Based Medicine. Indeed, as I write this, I note that there are 155 posts under the Vaccines category, with this post to make it 156. This is third only to Science and Medicine (which is such a vague, generic category that I’ve been seriously tempted to get rid of it, anyway) and Science and the Media. There is no doubt that vaccines represent one of the most common topics that we cover here on SBM, and with good reason. That good reason is that, compared to virtually any other modality used in the world of SBM, vaccines are under the most persistent attack from a vocal group of people, who, either because they mistakenly believe that vaccines caused their children’s autism, because they don’t like being told what to do by The Man, because they think that “natural” is always better to the point of thinking that it’s better to get a vaccine-preventable disease in order to achieve immunity than to vaccinate against it, or because a combination of some or all of the above plus other reasons, are anti-vaccine.

“Anti-vaccine.” We regularly throw that word around here at SBM — and, most of the time, with good reason. Many skeptics and defenders of SBM also throw that word around, again with good reason most of the time. There really is a shocking amount of anti-vaccine sentiment out there. But what does “anti-vaccine” really mean? What is “anti-vaccine”? Who is “anti-vaccine”?

Given that this is my first post for SBM’s self-declared Vaccine Awareness Week, proposed to counter Barbara Loe Fisher’s National Vaccine Information Center’s and Joe Mercola’s proposal that November 1-6 be designated “Vaccine Awareness Week” for the purpose of posting all sorts of pseudoscience and misinformation about “vaccine injury” and how dangerous vaccines supposedly are, we decided to try to coopt the concept for the purpose of countering the pseudoscience promoted by the anti-vaccine movement. To kick things off, I thought it would be a good idea to pontificate a bit on the topic of how to identify an anti-vaxer. What makes an anti-vaxer different from people who are simply skeptical of vaccines or skeptical of specific vaccines (for instance, the HPV vaccine)? I don’t pretend to have the complete answer, which is why I hope we’ll have a vigorous discussion in the comments.

Believe it or not, I’m actually a relative newcomer to the task of taking on the anti-vaccine movement. Ten years ago, I was blissfully unaware that such a movement even existed; indeed, I doubt the concept would even have entered my brain that anyone would seriously question the safety and efficacy of vaccines, which are one of the safest and most efficacious preventative medical interventions humans have ever devised, arguably having saved more lives than any other medical intervention ever conceived. Even six years ago, although I had become aware of the existence of the anti-vaccine movement, I considered them a small bunch of cranks so far into the woo that they weren’t really worth bothering with. Yes, I was a shruggie.

All of that changed not long after I started my first blog in December 2004. Approximately six months later, to be precise. That was when someone as famous as Robert F. Kennedy, Jr. published an infamous screed simultaneously in Rolling Stone and Salon.com entitled Deadly Immunity that was so full of misinformation, pseudoscience, and conspiracy mongering that it altered the course of my blogging forever. Although I had already been becoming less and less of a “shruggie” about the anti-vaccine movement before RFK’s propaganda piece, “Deadly Immunity” resulted in a significant percentage of my blogging turning to discussions of the anti-vaccine movement and the scientifically-discredited myth that vaccines cause autism.

Anti-vaccine, not pro-safe vaccine

Before I try to define “anti-vaccine” in more detail, I should take a moment to point out that, if there’s one thing I’ve learned in nearly six years blogging about vaccines and the pseudoscience used to attack them, it’s that no one — well, almost no one — considers himself “anti-vaccine.” This is very easily verifiable in the outraged reaction elicited from people like J.B. Handley (who simultaneously gloats about the decline in confidence in vaccines among parents), Jenny McCarthy, and Dr. Jay Gordon when they are described as “anti-vaccine. Jenny McCarthy, for instance, will reliably retort, “I’m not ‘anti-vaccine.’ I’m pro-safe vaccine.” An alternative response is, “What I really am is ‘anti-toxins’ in the vaccines.” Meanwhile, Dr. Gordon will say the same thing while simultaneously saying that he doesn’t give a lot of vaccines and foolishly admitting in the comments of a blog post that some parents have actually had to persuade him to vaccinate “reluctantly.”

The rule that those holding anti-vaccine views will rarely admit that they are anti-vaccine is a good one, although there are exceptions. It is not uncommon to find in the comments of anti-vaccine propaganda blogs like Age of Autism and anti-vaccine mailing lists comments proclaiming explicit anti-vaccine views loud and proud, with declarations that “I am anti-vaccine.” This dichotomy has at times caused problems for the more P.R.-savvy members of the anti-vaccine movement, as demonstrated two years ago at Jenny McCarthy’s “Green Our Vaccines” rally, where images of vaccines as toxic waste and weapons of mass destruction were commonplace. Even so, the “Green Our Vaccines” slogan and coopting the “vaccine safety” mantle have been very effective for the anti-vaccine movement. In particular, Barbara Loe Fisher has successfully portrayed her National Vaccine Information Center (NVIC) as being a “vaccine safety watchdog” group looking out for parents’ rights, this despite hosting an online memorial for vaccine victims and a deceptive and disingenuous vaccine ingredient calculator.

“I know it when I see it”

In a concurring opinion in Jacobellis v. Ohio, regarding possible obscenity in a movie, Justice Potter Stewart once famously wrote:

I shall not today attempt further to define the kinds of material I understand to be embraced within that shorthand description ["hard-core pornography"]; and perhaps I could never succeed in intelligibly doing so. But I know it when I see it, and the motion picture involved in this case is not that.

From my perspective, defining what is “anti-vaccine” is a lot like defining obscenity: I know it when I see it. However, as in the case of pornography, even though it’s quite true that what is anti-vaccine is in general easily identifiable to those of us who pay attention to such matters, it’s much more difficult to define in a way that those who don’t pay attention to the issue can recognize. This difficulty is complicated by the fact that there are a number of different flavors of anti-vaccine views ranging from (I kid you not) the view that vaccines are a tool of Satan to depopulate the earth to much milder views. It’s also important to realize that most parents who buy into anti-vaccine views do so out of ignorance, because they have been misled, rather than due to stupidity. When I “go medieval” on anti-vaccine activists, my ire is almost always reserved for the leaders of the anti-vaccine movement, who spread misinformation.

When I’m actually in an exchange with someone whom I suspect of having anti-vaccine views, one rather reliable way of differentiating fear from real anti-vaccine views is to ask a simple question: Which vaccines do you think that, barring medical contraindications, children should receive? If the answer is “none,” then I’m pretty much done. I know I’m almost certainly dealing with an anti-vaccinationist. Be aware that this question may require some pushing to get an answer. Rarely am I able to get a definitive answer on the first try, because most anti-vaccine advocates are cleverer than that. They realize that I’m trying to get them to admit that they are anti-vaccine. Even so, if I ask something like, “If you had it to do all over again, would you vaccinate your child?” or “If you have another child, will you vaccinate that child?” I will usually get the candid response I’m looking for.

“Vaccines don’t work”? “Vaccines are dangerous”? They’re both!

If you look at the types of arguments used to oppose vaccination, they will almost always boil down to two different flavors, either that vaccines don’t work or that vaccines are somehow dangerous. Of course, we discuss the latter argument here all the time when we point out studies that refute the alleged link between vaccines and autism. Like the slogan “Tastes great, less filling,” both of these claims often co-exist to differing degrees, with some anti-vaccinationists arguing that both are true: Vaccines don’t work and they are dangerous.

This being the real world, one has to remember that vaccines are not perfect. They are not 100% effective, and there can be rare serious side effects. What differentiates anti-vaccine cranks from, for example, scientists who deal with issues of efficacy versus side effects and potential complications all the time, is exaggeration far beyond what the scientific data will support. For example, if the influenza vaccine is less efficacious than perhaps we would like (which is true), then it must be useless. This is, in essence, the Nirvana fallacy, wherein if something is not perfect it is claimed to be utterly worthless. Part and parcel of this approach involves the complement, namely vastly exaggerating the potential side effects and complications due to vaccines to paint them as being far more dangerous than the diseases they prevent. In addition, anti-vaccine activists frequently attribute harms to vaccines that the existing scientific data definitely don’t support as being reasonable or legitimate. The claim that vaccines cause autism is the most famous, but far from the only one of these sorts of claims. It’s not uncommon to hear fallacious claims that vaccines cause autoimmune diseases, asthma, and a general “weakening” of the immune system, among others.

One of the most famous examples of exaggerated harm or nonexistent risks is the infamous “toxin” gambit. This fallacious argument claims that there are all sorts of scary chemicals in vaccines. Of course, there are all sorts of chemicals with scary names in vaccines, just as there are all sorts of chemicals with scary names in almost everything, from food to clothing to household cleaners, among others. The dose makes the poison, and the amounts of these chemicals, such as formaldehyde, are tiny. As we’ve pointed out time and time again, for instance, the amount of formaldehyde in vaccines is so tiny that it’s overwhelmed by the amount of formaldehyde made as a byproduct of normal metabolism. Then, of course, there are the chemicals claimed to be in vaccines that are, in fact, not in vaccines. The most famous of these is undoubtedly the infamous “antifreeze in vaccines” gambit. Finally, there is the claim that there are “aborted fetal parts” in vaccines. This particular claim comes from the fact that, for some vaccines, the viruses used to make the vaccines are grown in a human cell line derived from an aborted fetus.

Overall, the “tastes great, less filling”-type anti-vaccine claims that vaccines are dangerous and don’t work, can be differentiated from scientifically valid concerns about the efficacy and safety of vaccines on the basis of how evidence is treated and the types of arguments that are used. Scientists, of course, tend to be a lot more measured and express the level of uncertainty in their claims; anti-vaccine activists are under no such constraints. When, for example, scientists debated how to respond to the H1N1 pandemic last year, there was considerable uncertainty about how to do it, when to do it, and how to formulate the vaccines. Which adjuvants? Should we use squalene in order to decrease the amount of antigen used? Contrast this to the anti-vaccine arguments, which tended to argue that H1N1 wasn’t harmful, that the vaccine was toxic and wouldn’t work, and even that it was a New World Order plot.

Approaching the evidence

If there’s one thing that distinguishes science from the way movements like the anti-vaccine movement approach evidence, it’s that the anti-vaccine movement values anecdotes over careful science. If you check out Generation Rescue’s website or any of a number of anti-vaccine websites, you will find numerous stories using the classic post hoc ergo propter hoc fallacy that in essence argues that, because one thing happened before another, that thing must have caused it. Because Generation Rescue preaches that its various forms of biomedical woo can “recover” autistic children, not surprisingly, there are a number of testimonials on its website touting stories of children who regressed after vaccination and then appeared to recover after whatever woo du jour was tried on them. On the surface, these testimonials seem convincing. However, given that millions of children who undergo vaccination each year, the number of vaccinations in the currently recommended schedule, and the fact that approximately 1% of children will eventually be diagnosed with an autistic spectrum disorder, it is not surprising, given the law of large numbers, that there will be a significant number of children who regress in fairly close temporal proximity to a vaccination by random chance alone. Even though such cases are random, though, to a single observer, they appear all the world as though the vaccine caused the regression. What’s difficult for non-scientists (and even many scientists) to accept is that it’s impossible to tell if vaccines are actually correlated with regression unless careful studies are done comparing large populations to determine whether children who are vaccinated really do have a higher chance of autism. Those studies have been done, and the answer is a resounding no. To the anti-vaccine movement, anecdotes trump evidence. Indeed, even physicians, like Jenny McCarthy’s son Evan’s pediatrician Dr. Jay Gordon, fall for touting their own anecdotal experience over careful epidemiology and science.

Perhaps one of the most characteristic aspects of the anti-vaccine movement is the same one that is shared by virtually every denialist movement, be it denying the science of climate change, evolution, or scientific medicine. That is the use of logical fallacies, cherry picking of the evidence, and distortion of the science. Perhaps the best example of cherry picking and distortion of evidence engaged in by anti-vaccine activists is a set of graphs I discovered earlier this year by a man named Raymond Obomsawin, in which he tried to represent as “proof vaccines didn’t save us.” As I pointed out in my response, this was intellectual dishonesty at its most naked. Basically, Obomsawin deceptively conflated mortality and incidence. Worse, he also chose his graphs in a way that parts of the data were left out. Indeed, less than a month ago, the Australian anti-vaccine activist Meryl Dorey approvingly cited Obomsawin’s graphs. When it was pointed out how Obomsawin had cherry picked his graphs to deceptive purpose, his response was beyond pathetic:

The software that I was using to create the graph did not allow for the creation of either a blank space or a dotted line between 1959 and 1968. There was no intent to be dishonest about this, and thanks to your blog, I will make it a point to specifically note on the graph that there is an absence of incidence data in this period.

I note that, not only have the graphs not been changed as far as I can tell, but Dr. Obomsawin is going to be giving a webinar tomorrow in which he is apparently going to argue the same nonsense. I’m half tempted to sign up and see what he says. It’d make for more blogging material, and an update to the Obomsawin Technique of vaccine denialism (yes, I named it after him) is probably overdue anyway. After all, I never took on several other of the graphs he included in his collection. My guess is that Obomsawin won’t change his graph. Obomsawin’s disingenuous approach to the evidence is mirrored by naturopath David Mihalovic, who wrote the infamous 9 Questions That Stump Every Pro-Vaccine Advocate and Their Claims. Dr. Crislip answered each and ever one of these “nine questions” without difficulty. The result was that Medical Voices (which published Mihalovic’s post) challenged us to a “public debate.” We said we’d be happy to debate them in blog posts but that a “public debate” would be counterproductive and allow them to engage in the Gish Gallup. The result? Like Brave Sir Robin, Medical Voices bravely turned its tail and fled. “9 Questions” remains on the impressively named International Medical Council on Vaccination’s website, formerly known as Medical Voices.

Another example of how anti-vaccine activists approach the evidence landed with a huge thud in the blogosphere last year when the Jenny McCarthy-fronted anti-vaccine group Generation Rescue decided to try to discredit the studies that show no link between vaccines and autism. As Steve Novella, Mark Crislip, and I all showed, Generation Rescue’s arguments were fallacious at best and deceptive at worst. The result was that J.B. Handley launched a broadside at Steve Novella.

Which brings us to another characteristic of the anti-vaccine movement.

Conspiracy mongering and reaction to criticism

Science is, if you’ll forgive the term, a highly Darwinian process. To be a scientist, you have to have a thick skin, because you’ll need it. Reviewers, mentors, other scientists, and virtually anyone to whom you present your results will be picking away at them, looking for flaws, looking for reasons to invalidate your conclusions. There’s nothing personal in it (usually); it’s how the process of science works. Similarly, those who have an appreciation for science understand that it’s a rough-and-tumble world where scientists have to be able to defend their work. Yes, it’s messy as hell, but it works. It may take a lot longer than we’d like and be a lot more confusing than the public likes, but over time hypotheses that don’t hold up are weeded out, to be replaced by those that do. Scientists understand this, and most know not to become too distressed by criticism. True, scientists are human too and can’t always separate themselves from their science; sometimes they lash out at criticism. However, for the most part, they don’t react the same way as denialists do when criticized. More importantly, contrary to scientists, it’s very rare indeed for an anti-vaccinationist to change his mind due to the evidence.

The anti-vaccine movement shares another characteristic with denialists of all stripes, and that’s an intolerance to criticism. Instead of answering it with science (which they can’t do), they tend to answer criticism with vitriol and conspiracy mongering. After all, when it’s all a conspiracy between the government and big pharma to “suppress” the data that allegedly show that vaccines cause autism, then anyone who speaks out for that viewpoint must be a pharma shill. If that critic is a woman, then she must have been the victim of a date-rape drug. Or he must be hopelessly compromised by relationships between big pharma and his university, even if such relationships need to be made up or extrapolated beyond all relationship to reality.

Perhaps the best way of describing how anti-vaccine groups react to criticism is to point out that their first response tends to be to try to suppress criticism rather than to answer it. Usually, this is accomplished through ad hominem attacks and poisoning of Google reputations. One particularly egregious example occurred when Age of Autism Photoshopped the faces of Steve Novella, Trine Tsouderos, Alison Singer, Paul Offit, Amy Wallace, and Tom Insel into a photo of people sitting down to a Thanksgiving feast of dead baby. Yes, likening enemies to cannibals wasn’t going too far. Sometimes attacks on critics can escalate to legal thuggery, which happened when the British Chiropractic Association sued Simon Singh and Barbara Loe Fisher sued Paul Offit. That such lawsuits nearly always fail, at least in the U.S., where the libel laws aren’t as draconian as in the U.K., doesn’t matter. The goal is not to recover damages; it’s to intimidate critics into silence. Unfortunately, even I’m not immune to being at the receiving end of this tactic.

Conclusion

Distinguishing true anti-vaccine rhetoric from cluelessness is not always easy. To help, I’ll recap the eight characteristics I’ve just discussed:

  1. Claiming to be “pro-safe vaccine” while being unrelentingly critical about vaccines
  2. The “vaccines don’t work” gambit
  3. The “vaccines are dangerous” gambit
  4. Preferring anecdotes over science and epidemiology
  5. Cherry picking and misrepresenting the evidence
  6. The copious use of logical fallacies in arguing
  7. Conspiracy mongering
  8. Trying to silence criticism, rather than responding to it

Someone who is anti-vaccine will almost certainly use at least three or four of these techniques. The cranks at Age of Autism use all eight and then some. Indeed, when these eight techniques fail to suffice, they make up more.

One other thing that’s important to mention, particularly since I’ve been guilty of this sin on occasion, is that we have to be careful about leaping to the conclusion that someone is anti-vaccine. That’s where the “I know it when I see it” test can backfire. For example, I was quite distressed at some of the statements coming from Dr. Marya Zilberberg on vaccines, in particular her referring to defenders of the current vaccine schedule as “rabid” and arguments that are reminiscent of the same sorts of arguments that the anti-vaccine movement uses for the HPV vaccine and the chickenpox vaccine, mixed with a question about combinations of vaccines being of concern that sounded uncomfortably like the “Too Many Too Soon” slogan beloved of Generation Rescue. Although I did not explicitly call her “anti-vaccine” in another forum and even went out of my way (as did Steve) to point out that I don’t think she’s anti-vaccine, I did try to point out to Dr. Zilberberg that, if you’re skeptical of some aspect of our current vaccination schedule, it’s important to be aware of how anti-vaccine cranks argue, so that you don’t inadvertently sound like one.

In the end, the anti-vaccine movement is another denialist movement, very similar to denialists of global climate change, science-based medicine, and evolution. As such, it uses many of the same fallacious strategies and distortions of science to promote its agenda and reacts the same way to criticism. Similarly, in the end, the anti-vaccine movement is also far more about ideology rather than science, which is why it remains so stubbornly resistant to reason and science. Finding an effective means to counter its message will likely require developing effective general strategies to counter science denialist movements of all types.

Let the discussion begin! What are the characteristics of anti-vaccine arguments and organizations that allow us to identify and characterize them as “anti-vaccine”?

Journal Club Debunks Anti-Vaccine Myths

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American Family Physician, the journal of the American Academy of Family Physicians, has a feature called AFP Journal Club, where physicians analyze a journal article that either involves a hot topic affecting family physicians or busts a commonly held medical myth. In the September 15, 2010 issue they discussed “Vaccines and autism: a tale of shifting hypotheses,” by Gerber and Offit, published in Clinical Infectious Diseases in 2009.  

The article presented convincing evidence to debunk 3 myths:

  1. MMR causes autism.
  2. Thimerosal (mercury) causes autism.
  3. Simultaneous administration of multiple vaccines overwhelms and weakens the immune system, triggering autism in a susceptible host.

Gerber and Offit reviewed 13 large-scale studies that demonstrated no association between the MMR vaccine and autism. These included ecologic studies, retrospective observational studies and prospective observational studies.  The findings were consistent; the only outlier in all the studies of MMR was Dr. Andrew Wakefield’s small, discredited 1998 study, which was fully retracted by The Lancet in early 2010.

They reviewed 7 large-scale studies (again, ecologic, retrospective, and prospective) that consistently demonstrated no association between thimerosal and autism. They showed that the hypothesis was not biologically plausible, since the symptoms of mercury poisoning are distinct from those of autism and are not produced by the thimerosal in vaccines.

They showed that the overload hypothesis is not credible because

  1. The immunologic load has dropped from 3000 components in the 7 vaccines used in 1980 to less than 200 in the 14 vaccines recommended today.
  2. An infant’s immune system is capable of handling the thousands of antigens it is exposed to early in life.
  3. Vaccinated children are not more susceptible to infections.
  4. Autism is not an autoimmune disease.

The discussants ask “Should we believe this study?” and their answer is a resounding “yes.” They say “This month’s article clearly provides the science and statistics to dispel the theory that childhood vaccinations induce autism. A Cochrane review came to the same conclusion in October 2005.”

They ask “What should the family physician do?” They point to evidence that information and assurance provided by health care professionals can make a difference. They even suggest that physicians get a copy of the Gerber/Offit article and keep it handy for when parents are apprehensive about immunizing their child.

The Journal Club doctors evaluated the evidence rationally and accepted the logical conclusions. The anti-vaccine activists didn’t: instead, they have endangered our public health by rejecting or postponing immunizations and repeating myths. Shame on them!

Mayor Kitty Piercy and Envision Eugene

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Oregon is famous for its land use policies known as urban growth boundaries, or UGB’s. It is one of the few states in the country to require UGB’s by law. They are a regional boundary, set in an attempt to control urban sprawl by mandating that the area inside the boundary be used for higher density urban development and the area outside be used for lower density development. An urban growth boundary encompasses an entire urbanized area and is used by local governments as a guide to zoning and land use decisions.

Some of the benefits of having urban growth boundaries among others are:

  • protects farmland and forests from urban sprawl
  • promotes efficient use of land
  • motivates redevelopment of land and buildings in the urban core, helping keep core “downtowns” in business
  • provides assurance for businesses and local governments about where to place infrastructure (such as roads and sewers), needed for future development.

    • Envision Eugene is a collaborative public planning process that will help shape the future of the Eugene, Oregon for the next 20 years. Envision Eugene is a 2030 plan for a Eugene-Only UGB. The discussion varies from regional transportation plans, 20 minute neighborhoods, mixed use centers, and small scale infill projects.

    Mayor Kitty Piercy of Eugene, is a voice at the table who believes in the Envision Eugene process and has kindly answered our questions below:

  • What does Envision Eugene mean for the future of mass transit for the city? Expanded EMX throughtout the city and county? Streetcar?
  • Does Envision Eugene see transit oriented development as part of its core mission to promote density and livability?
  • As Oregon and the Pacific Northwest prepares for highspeed rail in the future, what role does the UGB play in planning for possible future economic expansion around a proposed High Speed Rail Line?
  • How difficult is it to plan the balance of setting enough land aside for industrial and commercial uses while trying to promote density in Eugene?
  • Does not setting enough land aside for industry and business use dampen job growth and opportunity for the Lane County region?


    • Envision Eugene is in planning process right now so I cannot yet answer your question specifically but in our discussions there is general recognition of transportation corridors with transit oriented development around them and mass transit through them. Our current Transplan already commits to a build out of EmX and we are on the third leg discussion.

    From my perspective, it is important for us to tie all the needed tranportation elements together. We are not yet a big city but we still need real choices for people to move about including bike, ped,car, bus, mass transit, and street car is being discussed. Each has a different functionality within the city.

    We had news this week that we will received grants of 4.3 million for the environmental studies for the section between Portland and Eugene, 80,000 for the state rail plan, and another 3+ m for the Portland area. In addition there are much larger sums for continuing to build a real high speed segment from Portland on up to BC. We certainly have higher speed rail in our vision that offers on time, reliable, more frequent, and faster rides up the corridor. That would be a great start for us.

    I was just saying to staff this week that we need some transit oriented planning around our depot. It is not going to be one of those huge high speed stations but we ought to really think about how our depot area should grow with a better rail system that will accommodate many more riders. As you know our depot area really connects to our downtown and offers real opportunity.

    Certainly the EmX and HSR offer the ability to plan for higher density urban centers that can allow us to stay within our UGB.

    We have long had battles over the UGB. There are those who believe expansion is necessary for economic development and those who believe we have plenty of room within our UGB to meet needs of the next 20 years. We have a group of community leaders who represent both of these points of view working together on Envision Eugene. We are trying to have a more productive discussion about how we want our community to be in the future and how we best achieve that, rather than a simplistic argument which gives no one any space to be creative. All of these people seem to value the livability of our area and to understand the fundamentals of transit oriented development. They also worry about our economic viability and the future of our children. No its not easy but it is important.

    I would not be participating in Envision Eugene and advocating for this process if I did not believe we were capable of finding a future for our community that preserves what we care about most and better prepares us for a more stable future with a more robust economic foundation. We need to be able to support our schools, human services, and to provide jobs and opportunities for our families.- and we need to do that while preserving this special place with its farm lands, forests, rivers, neighborhoods, and general health and beauty.