The public controversy about a possible link between vaccines and autism—which I want to again state exists in the face of powerful scientific evidence to the contrary—concerns me. Over the last two decades we have seen a rapid escalation in both the number of vaccines administered to the average U.S. child and the intensity of the standoff between the U.S. medical community and opponents of mandatory vaccination. Parents are caught in the middle of this increasingly passionate debate. Issues involving individual liberties and public health require a subtle balance of competing goals. In this controversy subtlety has been lost, and the battle of harsh words will likely escalate. Peter Hotez, president of the Sabin Vaccine Institute, has said, “If the surgeon general or the secretary of health or the head of the CDC [Centers for Disease Control and Prevention] would come out and make a really strong statement on this, I think the whole thing would go away.” In my view, as I hope this book has shown, a “really strong statement” is hardly what is needed, and it certainly would not make the problem disappear. Public health officials, researchers, and physicians must look beyond the vaccines-cause-autism debates to confront the foundational issues causing so many parents such great concerns. What are these issues?1
Problems with the modern vaccine schedule have been oversimplified and bundled into the claim that vaccines cause autism as parents’ fears have been supported by the views and efforts of anti-vaccinators. Unfortunately, the scientific and medical authorities have been content to wage their battle in support of universal vaccination within the confines of the vaccines-cause-autism claim. It is certainly reasonable for them to do so. The assertion that vaccines do not cause autism (or, we do not see evidence in our studies that vaccines do cause autism) is much more limited, and it allows them to engage in the debate on the basis of their authority in the realm of science and to use their impressive capacity to analyze the problem scientifically. The result is a very public battle that avoids addressing the essential problems with our vaccine regime. Here, then, are some of the underlying problems.
In Washington, DC, in 2008, Jenny McCarthy led 7,000 demonstrators all chanting “Too many, too soon.” By the start of the twenty-first century, a fully vaccinated six-year-old U.S. child received almost three dozen inoculations containing about fifty vaccines against fourteen communicable diseases. This number grows far higher when influenza vaccines are included, because each year’s flu vaccine contains at least three different influenza vaccines, and sometimes additional influenza vaccines are recommended, as happened in the 2009-10 influenza season. Over half of these vaccines are given in a child’s first eighteen months of life. Again and again throughout their babies’ first years of life, many parents watch carefully in the days and weeks that follow each vaccination for adverse effects.
Childbirth and child rearing have become medicalized in the United States. Parents are expected to bring their children into their pediatricians’ offices for a series of appointments that are called “well-child visits.” These visits happen at regular intervals, typically within the baby’s first week and then at one, two, four, six, nine, twelve, fifteen, and eighteen months, and every year after that up to age six. They typically involve a general physical exam, discussions about development and nutrition with the parents, and vaccinations. Most insurance companies fully cover the scheduled well-child visits, and many uninsured children have access to some sort of state-sponsored health care to allow for them. Well-child visits are essential to the modern U.S. immunization schedule because pediatricians’ offices have become the location for almost all routine childhood immunizations, and a sick child cannot be vaccinated. To insure that babies receive all of the required and recommended vaccines in the first years of their lives, parents have to be compelled to bring them into the doctor’s office when they are healthy enough to be vaccinated.
Unfortunately, the large number of vaccines given in a child’s first year, combined with the relative infrequency of well-child visits, means that many children receive multiple vaccinations at key office visits. At the six-month visit, for example, the CDC recommends children be vaccinated against rota-virus, seasonal influenza, diphtheria, tetanus, pertussis, Hib, pneumococcus, and polio. Parents may find themselves leaving their pediatrician’s office with a child who has gotten one nasal spray vaccine (against rotavirus), an oral vaccine (against polio), and four shots (seasonal influenza, DTaP, Haemophilus influenzae type B, and pneumococcus), all combined containing as many as ten different vaccines. The number grows even higher when a child misses one or more of the expected well-child visits because of illness or scheduling difficulties, as was the case with Representative Burton’s grandson.2
One of the public health community’s strategies for universal vaccination leads to the vaccines being given long before there is any reasonable risk that a child could actually contract the diseases against which they are being vaccinated. In the case of the hepatitis B vaccine, for example, U.S. children—regardless of their level of risk for contracting the disease—must be vaccinated within the first days or weeks of their life. Why? Because public health officials want to eliminate the disease and, to do this, nearly universal vaccination against hepatitis B is necessary. Millions of parents fail to bring their children to pediatricians’ offices, either because they lack adequate health insurance or because they do not see any need to bring healthy children to the doctor’s office. Hepatitis B is one of those diseases—like polio—that once no living person has it, will join smallpox on the list of diseases that vaccines have triumphantly exterminated. Unfortunately, our current strategy to achieve universal vaccination against hepatitis B requires that Annabelle and millions of other newborns receive the vaccine within hours of their birth regardless of whether or not they are at any immediate risk for contracting it. The potential of such a strategy for raising alarm among vaccine-anxious parents—and the ammunition it provides anti-vaccinators—is tremendous.
A substantial part of the problem we have drifted into not just with vaccines but with all drugs, derives from the awkward distinctions we draw between medical therapies and medical enhancements. Generally speaking, we consider a medical intervention to be therapeutic (to be a therapy) if it attempts to return a patient to health following the diagnosis of a disease, an injury, or some sort of condition that is easily recognized as problematically abnormal. Vaccines are generally classified as preventative therapies, because they are given to healthy people in an attempt to preserve health or normalcy by preventing a disease or condition from appearing.
Medical enhancements, however, refer to attempts to overcome normal human limitations by using medical interventions for nontherapeutic purposes. The most notorious human enhancements are in the realm of sports and include steroids, human growth hormones, and supplements like creatine. Lately, nootropics—drugs that improve mental functions like memory, intelligence, motivation, and attention—have come under criticism as a form of human enhancement. If it is ethically problematic for an athlete to use performance-enhancing drugs, it is perhaps equally wrong for someone participating in competitive intellectual activities to use drugs like Ritalin or Adderall to improve their cognitive abilities. Most Americans approve medical interventions for therapeutic ends, but we have significant angst over the use of medical technology for enhancement purposes, either physical or cognitive.3
Vaccines tickled the line between therapy and enhancement even before we extended the vaccine regime beyond immediately threatening communicable diseases. They allow us to resist diseases beyond our normal capabilities to do so. We are now so dependent on vaccine technology that without it many of us would not live as long or as healthily as we do. As vaccines are used with increasing frequency to combat a growing list of natural ailments, they are ever more open to being criticized on the grounds that they have become enhancement technologies.
The path from therapy to enhancement is well worn, so it should not come as a surprise that vaccines have followed it. Among the examples of therapies that have become common enhancements is plastic surgery, which was developed to help people who had been burned, had birth defects, or had other disease-or accident-related physical and aesthetic problems. It evolved into nose jobs, breast augmentation, liposuction, and labiaplasty. Long before they were used by athletes to gain weight, size, and strength, steroids were developed to supplement normal hormone levels, to help people overcome injury or disease, and to regain or maintain weight during recuperative periods. Drugs like Adderall were originally created to treat attention deficit hyperactivity disorder and narcolepsy but are now widely used by college students as a study aid. As a prevention against disease, vaccines have been safely ensconced within the realm of preventative therapies, but as new vaccines increasingly allow us to avoid what many parents see as natural aspects of childhood (like contracting the chickenpox) or to avoid the consequences of unprotected sexual activity (as with the long-promised vaccine against HIV/AIDS), we are on the verge of seeing vaccines follow that path from therapy to enhancement.
In the future, we will face even more trouble from the reasonable assertion that vaccines are enhancement technologies and as such are subject to all the criticisms launched against enhancement technologies. A new class of vaccines is emerging that will prevent someone from being capable of getting high from legal and illegal drugs like nicotine, cocaine, methamphetamines, or heroine. Addiction vaccines are being developed as therapies for people who are addicted and want relief from the urges to partake. As with many other therapies-turned-enhancements, the enhancement uses lurk just beneath the surface. Imagine being able to take your child into your pediatrician’s office to be vaccinated against addiction to illegal drugs, something that British health ministers have already considered making mandatory. In the 1990s, when addiction vaccines were only theoretically possible, some medical and legal authorities argued that it would be appropriate to add them to the list of mandatory vaccines once they were developed, because addictions are medically classified as diseases. Like smallpox or polio, addictions are essentially communicable because a cluster of addicted people provides the basis for previously unaddicted people to become addicted. Put another way, if no one was addicted to cocaine, there would be no supply of cocaine and no new addicts having access to illegal drugs. Today, as vaccines for the treatment or prevention of certain addictions are under review by the FDA, U.S. law journals publish articles explaining how anti-addiction vaccines could be incorporated into the existing compulsory immunization schedules.4
Clustering vaccines around well-child visits represents a practical challenge for vaccine-anxious parents who watch their very young children receive multiple vaccinations and worry about the emergence of adverse side effects. There also exists a much more deeply philosophical challenge to the number of vaccines that we give children. There are a great number of new vaccines on the horizon, and authorities have heralded their potential to allow us to vaccinate larger numbers of people against larger number of diseases. Moreover, recent advances in microbial genetics and immunology have opened the door for another wave of new vaccines. As one researcher noted, “Both infectious and noninfectious diseases are now within the realm of vaccinology.” There are now vaccines for twenty-seven different diseases, and the number of diseases, ailments, and even behaviors that can be treated or avoided by vaccines is continuing to grow rapidly. As of January 2009, the U.S. National Institutes of Health were tracking over 650 different active clinical trials of new vaccines. Even the most ardent proponents of widespread vaccination programs must admit that our future holds a number of complicated political, medical, and ethical issues as we invent and mandate more and more vaccines each year.5
As it is, over the last twenty years we have doubled the number of diseases against which we vaccinate, and we have tripled the number of inoculations a child receives. How many more vaccines shall we add to the long list of diseases against which we vaccinate? What exactly is our goal here? The complete elimination of all illness? Would such an objective be possible? What would it mean for how we live, how we think about illness, what we expect from our physicians and scientists, and how we deliver health care within a system that already has such gross inequities? Some prominent philosophers and theorists have started thinking about the consequences of our current biotechnological revolution. While some have celebrated the potential of our technology to help us overcome our natural limits, others have described the threat posed by contemporary biotechnology to “alter human nature and thereby move us into a ‘posthuman’ stage of history.” Clearly, these are not simply scientific questions, even if they do have substantial technical components. They require a thoroughgoing analysis by thoughtful, well-trained professionals drawn from a variety of humanistic and scientific disciplines and a careful weighing of our scientific and medical capabilities against other social needs and wants. Unfortunately, we have ignored the difficult questions inherent to biotechnology and have instead engaged in heated arguments around the claim that vaccines cause autism. Thus we have drifted into our current situation.6
A number of indicators suggest there might be some gender issues at play in modern U.S. tensions over vaccines and the current vaccine schedule. First, even a casual examination of the makeup of the anti-vaccine community demonstrates intense concern among women about vaccines, and at the popular level vaccine anxieties are most frequently presented by women, to women. Certainly, a substantial portion of the gender imbalance is because women take primary responsibility for routine health care and decisions about children’s medical care. A 2005 report by the Kaiser Family Foundation found about eight in ten mothers “take on chief responsibility for choosing their children’s doctors (79 percent), taking them to appointments (84 percent), and ensuring they receive follow-up care (79 percent).” Disproportionate gender representation is also seen in the children about whom there is so much concern regarding the risk of autism—boys are four to five times more likely than girls to be diagnosed with autism. This gender imbalance means that we frequently see mothers campaigning for their sons, and much more rarely do we see fathers or daughters involved in the debate.7
In addition to mothers’ shouldering the bulk of responsibility for their families’ medical decisions, it may also be the case that, on average, men and women think and act differently about issues of disease. A large and growing body of research has shown that men and women receive different treatment for similar ailments. Some recent literature has demonstrated that this disparity results in part from the different ways in which men and women describe their conditions to physicians and the generally different level of expectations they have for remedying ailments, all of which combine to lead to lower levels of medical intervention on average for women. But there may well be more to it.8
It might be that men and women have—or are represented to have—very different notions about the capacity of humans to overcome disease. These potential differences were illustrated nicely in a recent story in the New York Times about cryogenics, the low-temperature preservation of people’s bodies or brains after death in hopes that one day advanced medicine will be able to revive them. Three times as many men as women pay to have themselves frozen after death. The article focused on the tension between men who intend to be cryogenically preserved and their wives, who find their aspirations after death at best fanciful and at worse insulting. We see that these men who have adopted transhumanist aspirations to use technology to conquer death are often at odds with their wives, who appear much more willing to accept the natural limits and the unavoidable eventuality of death. How might these differences between how the men and women in this story think about life, death, and medical technology—if the differences indeed exist—impact the public’s anxieties about vaccines and the conduct of the modern American vaccine controversy? Is the apparently unrelenting effort to add more and more vaccines to the routine schedule a sort of technological hubris, a self-assured component of a transhuman effort to avoid all illness and death?9
Putting aside speculation about gender differences, we see that two very different visions for modern medicine are evident in these discussions. The first perspective imagines modern science and medicine as being capable of heroically conquering all ailments, eventually insuring universal health and extending life indefinitely. The other sees science and medicine as, at best, capable of working in concert with the body’s natural processes to aid healing, maximize quality of life, and ultimately accept our mortal limitations. The two perspectives demand different approaches to balancing the economic and political demands of science and medicine with the many other human expectations, so there are frequent conflicts when they meet in policy deliberations. These two competing worldviews also think about vaccines in two very different ways—and increasingly the average American is compelled to line up on one side or the other.
A vaccine comes to market only after it has undergone a thorough prelicen-sure testing to establish both its safety and its efficacy. The testing begins with computer modeling of how the vaccine will work, followed by testing on animals. If these tests suggest that a vaccine will be safe and effective, clinical trials proceed to test first the safety of the vaccine, then its efficacy in preventing particular diseases. Clinical trials proceed in three phases. The first phase typically enrolls less than twenty volunteers and looks for common adverse events. Phase two can include several hundred individuals to determine any general side effects that occur after the vaccine is given. Finally, in the third phase, researchers continue to watch for adverse events while they also determine the efficacy of the vaccine in preventing diseases. Once a vaccine is released, its safety cannot be measured directly; instead, as the Centers for Disease Control explains, its safety is estimated by examining the reported number of adverse events, then a formal scientific study is conducted to distinguish between coincidental adverse events and true reactions. “It is rarely possible to say, whether a vaccine caused a specific event,” the CDC concludes.10
Post-licensure surveillance of vaccines is conducted by the Vaccine Adverse Event Reporting System (VAERS), which is cosponsored by the Food and Drug Administration and the CDC. It collects information provided by patients and physicians about adverse side effects that show up after a patient is vaccinated. Of the ten million vaccinations given each year, VAERS receives about 11,000 reports, 13 percent of which are classified as serious because they are associated with disability, hospitalization, or life-threatening illness. Two percent (220 people) are reports of death. Of the reports received by VAERS, 85 percent to 90 percent describe mild adverse events, like fever, fretfulness, or limited reactions at the injection site. The system also offers a database that researchers can use as an early warning system, as it served for RotaShield when a small number of cases of intussusception appeared among recently vaccinated infants.11
Especially considering how intensely health officials rely on VAERS, there are a number of worrisome shortcomings with the system, primary among them concerns about underreporting of adverse events. Officials explain, “ ‘Underreporting’ is one of the main limitations of passive surveillance systems, including VAERS.” The degree of underreporting is difficult to ascertain. For example, one study estimated that only about 33 percent of the cases of vaccine-associated polio are reported to VAERS, but that over 95 percent of measles, mumps, and rubella vaccine (MMR)-associated thrombocytopenia (low platelet levels) are reported. We also know that newly released vaccines seem to have higher levels of reporting than do vaccines that have been on the market for some time, a phenomenon that has been called the Weber effect. From another perspective, the voluntary basis for reporting adverse effects to VAERS raises significant concern by health officials because plaintiff attorneys have encouraged their clients to file reports in preparation for going to trial. Paul Offit asserted, “Public health officials were disappointed to learn that reports of autism to VAERS weren’t coming from parents, doctors, nurses, or nurse practitioners; they were coming from personal-injury lawyers.”12
Critics of vaccines have long argued that VAERS, by virtue of being a passive surveillance system, is too slow and too inaccurate to depend upon for the safety of the many millions of vaccines we administer each year. Why, given the tremendous health importance of vaccines and the potential damage that can be done by a faulty vaccine, do we rely on a passive surveillance system? The answer is simple: there is no other practical or theoretical way to monitor vaccine safety. By the very nature of vaccines and the functioning of science itself, one cannot say that any vaccine is perfectly safe. That is, we can never rule out with complete confidence the risk of side effects from a vaccine, so there must be in place some sort of continuing surveillance of vaccines as they are administered. Moreover, we must be constantly watchful for the possible future adverse effects of combining vaccines with one another or with some other drug, food, condition, or situation. Short of constantly running and rerunning clinical trials over and over again—something no reasonable person would demand—a passive system is the only method for discovering any long-term adverse effects, and it comes with certain shortcomings. They must be recognized and accepted for what they are.
Vaccine-anxious parents’ concerns about the safety of vaccines is based partly on the claim that officials allow vaccines to come to market without adequate testing and, under pressure from lobbyists, too quickly adopt them as part of the vaccine schedule. By moving vaccines too quickly from active investigation in clinic trials into the passive surveillance system, critics worry, short- and long-term side effects are easily overlooked. Recently, this claim has been especially common in the criticisms of Gardasil, the Merck company’s vaccine against the Human Papilloma Virus (HPV). Even proponents of the vaccine have expressed these concerns. For example, Diane Harper, an expert on HPV and one of the scientists that Merck employed to conduct the clinical trials of Gardasil, told a reporter recently that she believed that much of the public controversy around the vaccine was the result of a rush to mandate it for very young girls. “It went too fast, it went too fast without any breaks.” She believes that Gardasil is safe, but she thought that more time was needed to watch for potential side effects in larger numbers of girls before any consideration should have been given to mandating the vaccine. “The vaccine has not been out long enough for us to have post-marketing surveillance to really understand what all the potential side effects are going to be.” It is easy to understand why Merck, after investing so much money in the development of a new vaccine, would want to begin selling it in large quantities as quickly as possible. However, in the context of a public health concern that rests precariously on a willing public’s shoulders, corporate profit motives must be tempered by other concerns.13
There is a striking incongruence in the public debates about vaccines: critics attack particular vaccines—such as the vaccines against the chickenpox or HPV—and health officials respond with blanket arguments about the vital importance of vaccines generally. The approach allows authorities to respond to parents’ concerns without addressing them. It is based on the notion—repeatedly expressed—that the decision about the value of a particular vaccine is best left to the officials at the CDC’s Advisory Committee on Immunizations Practices.
There are two net effects of this disconnect in the rhetoric over vaccines, both of which are problematic. First, it signals to parents that the vaccine schedule is an all-or-nothing affair. You either accept that the mandated vaccines are all equally valuable and comply with the entire vaccine schedule, or (if you have concerns about one or more vaccines for any reasons) you reject the schedule in its entirety. Nowhere is this as evident as in the response by Paul Offit to the alternative vaccination schedule offered by Robert Sears, popularly known as Dr. Bob. Sears is a member of a family of pediatricians who have published the widely read Sears Parenting Library. In The Vaccine Book: Making the Right Decision for Your Child, Sears offered two revised vaccination schedules, one that spread out vaccinations over a longer time period and another that allowed parents to skip the vaccines for milder or lower risk diseases, like hepatitis B and rubella, while maintaining something similar to the recommended vaccination schedule for more problematic diseases, like diphtheria and pneumococcal disease. He also suggested that parents could delay vaccinating their children against diseases like measles, mumps, rubella, and chickenpox until ten years of age, when a blood test would be done to see if the child had acquired natural immunity; only then would a decision be made about whether to vaccinate the child against any or all of these diseases. In an article in the American Academy of Pediatrics’ journal Pediatrics, Offit took Sears to task for increasing the time during which children would be susceptible to vaccine-preventable diseases. “In an effort to protect children from harm,” Offit concluded, “Sears’ book will likely put more in harm’s way.” For the most ardent vaccine proponents, the current vaccine schedule is the only way to vaccinate children, and any deviation from it is a threat to the public health. Offit’s article initiated a wave of responses, both within the journal and online, in which authors lined up on either side of the debate and characterized the two pediatricians’ dispute in much the same way others had described the stand-off between Jenny McCarthy and Amanda Peet.14
The second negative effect of the all-or-nothing approach to vaccination is produced when officials, in promoting the recommended and mandated vaccine schedule against any threat of alteration, make equivalent all of the diseases against which we routinely vaccinate. In this regard, their efforts to get parents to comply with the vaccination schedule effectively holds the chickenpox vaccine equivalent to vaccines against other, much more deadly and debilitating diseases, like diphtheria and pertussis. In their public rhetoric, they disparage anti-vaccinators’ claims, asserting that by questioning the need for a vaccine against chickenpox, anti-vaccinators are asking for the return of childhood scourges like polio. In addition to being logically incoherent, this tactic actually empowers the anti-vaccinationists. By making all the vaccines on the schedule of equal importance, anti-vaccinators can sway vaccine-anxious parents over to their side of the debate by taking advantage of the weak basis upon which we vaccinate against diseases like chickenpox. That is, if (as vaccine proponents claim) every vaccine on the schedule is equally vital to the health and well being of children, then parents who have serious reservations about vaccinating their children against a disease that they see as a childhood rite of passage may come to see all the vaccines on the schedule as unnecessary. The bundling of vaccines—such as the combining of the vaccine against chickenpox with the MMR vaccine to create the MMRV—perpetuates the all-or-nothing approach. It also further reduces parental choice and fuels their concerns about the vaccine schedule.
Short of an extraordinary public health emergency, the likes of which we almost never see, no one can be legally compelled to be vaccinated. However, you may need to be vaccinated if you want to keep your job (as has been the true of members of the military and first responders like police officers and fire fighters) or, absent a medical, religious, or philosophical exemption, if you want to attend a daycare or school. Since the vast majority of U.S. children attend daycare or school, this arrangement means that our current vaccine policy places the duty of policing vaccine compliance on daycare and school administrators and staff. Thus, a parent who—by choice, oversight, or lack of access—has failed to have their child fully vaccinated will be confronted by an administrator or staff member and threatened with the child’s expulsion from that daycare or school. Why exactly am I forced to negotiate the details of my daughter’s medical records with the receptionist at her daycare? As I explained in the introduction, I have found myself caught between the bureaucratic demands of the Michigan State Health Department and our pediatrician’s overbooked schedule, which has led me to take advantage of my state’s philosophical exemption to mandatory vaccinations.
In recent years, citing the limitations of the current system, legal and medical authorities have been seeking ways not just to encourage, but to outright force, parents to vaccinate their children. Faced with increasingly popular religious and philosophical exemptions for childhood vaccinations, some officials have become especially aggressive in enforcing compliance. For example, in 2007 Judge C. Philip Nichols Jr. of Prince George’s County Circuit Court in Maryland mailed letters to 800 households “strongly recommending that the children be immunized” and threatening fines and jail time if parents refused to comply. Similarly, Alexandra Stewart of the George Washington University Medical Center published an article in 2009 in the Michigan Law Review in which she argued that “public-nuisance law may offer a legal mechanism to hold vaccine objectors liable for their actions.” Moving from persuading to coercing to compelling compliance with vaccine policy mirrors the broader trend in twentieth-century public health policy where the imminent threat of contagion brought widespread compliance through persuasion alone, whereas more tenuous disease threats required much more aggressive compulsory measures, like fining or jailing parents or preventing them from sending their children to school or daycare.15
Pediatricians have discussed ways in which they can press parents to overcome concerns about vaccines and compel them to allow their children to be vaccinated. Over the last several years, they have debated the wisdom of refusing to treat children who are not fully vaccinated. In 2011, the Chicago Tribune reported that the Northwestern Children’s Practice in Chicago sent letters to parents stating that it would no longer see those children whose parents had chosen to forego any mandated or recommended vaccine. Doctors at the practice based their decision on the assertion that vaccines were both safe and necessary to protect the public health. Scott Goldstein, one of the physicians in the practice, stated, “All of the available research shows that the safest and most effective way to vaccinate children is on the schedule set by the CDC and the American Academy of Pediatrics (AAP). To go against that schedule goes against proven scientific research and puts patients who do follow the schedule at risk.” Nationally, between 5 percent and 10 percent of pediatricians had reported discharging families who, despite physicians’ recommendations, had refused to allow their children to be fully vaccinated. The AAP does not think that such efforts are appropriate, and it encourages pediatricians to continue to provide care to children whose parents are unwilling to follow the vaccination schedule. Research published in the AAP’s journal Pediatrics has demonstrated that continued dialogue between a physician and parent is the most effective way to increase vaccine uptake. While it might seem reasonable to deny access to health care in order to coerce parents into following the routine vaccination schedule, doing so only drives them further from mainstream medicine.16
The pressures on pediatricians to fully vaccinate children become even clearer when one realizes that pediatricians make little or no money when they vaccinate their patients, and many actually lose money in the process. A study that appeared in Pediatrics in 2009 examined the financial and operating records of about three dozen private medical practices. It reported, “More than one half of the respondents broke even or suffered financial losses from vaccinating patients.” The average loss was 7 percent for the practices. The economic burden is made greater because practitioners must keep between $250,000 and $1.9 million tied up in their on-hand inventory of vaccines, a substantial sum for any small business. The price paid by private practices for vaccines varies wildly, and the average reimbursements pediatricians receive from insurance are almost always less than the upper end of that range, which makes it necessary for offices to buy in bulk to keep their costs as low as possible.17
To make matters worse, especially in the context of the anxieties that so many parents feel about giving children multiple vaccinations at the same time, insurance companies’ vaccine administration fees are not sufficient to cover the overhead associated with administering vaccines unless a child receives two or more inoculations at a single visit. There is, in fact, little or no money to be made by most pediatricians in vaccinating, unless they can give multiple vaccinations in a single visit or they can vaccinate children assembly-line style and spend as little time as possible discussing the benefits and potential adverse side effects of vaccines with parents. The article explains that the counseling time associated with vaccines increases when media coverage of controversial issues, “such as autism,” increases, and as one pediatrician commented in a letter to the AAP’s journal, Pediatrics, “time is often our enemy in general pediatrics”18
What are the sources of anxiety for parents as they confront the modern American vaccine controversy? Parents worry about the high number of vaccines that the vaccine schedule prescribes, especially in their children’s first year of life. They see that vaccines are increasingly crossing the line from therapies to enhancements, especially the newest vaccines and the addiction vaccines that are on the horizon. Parents frequently express concerns about the increasingly common intrusions of biotechnology into their lives by advocating for lifestyles that they deem “natural.” They do not trust the passive surveillance system that is used by public health officials to watch for problematic side effects from vaccines, and they worry about inappropriate corporate influence in the testing and implementation of vaccines. Health officials’ all-or-nothing approach to the vaccine schedule makes parents feel disempowered and often resentful of the vaccine schedule, especially when they find themselves negotiating their children’s medical care with school and daycare administrators. Finally, the economic realities of the modern American health system prevent pediatricians from devoting the time and resources that are necessary to allay parents’ concerns.
Individually, any of these problems can be addressed, and parents often seem willing to overlook them in analogous situations. Combined, the problems represent a serious threat to U.S. parents’ willingness to allow their pediatricians to vaccinate their children. The collective weight of the concerns is simply too much for many parents to bear, as evidenced by the high and growing numbers of parents who opt out of one or more vaccines for their children. We may begin to find our way out of the modern American vaccine controversy only by identifying these problems, admitting they are a basis for concern, engaging cooperatively with parents, and directly addressing as many of these problems as possible.