Philip Alcabes discusses myths of health, disease and risk.

Vaccines & Autism: News?

Fascinating.  You can’t look at a newspaper or news feed without seeing today’s AP story on the finding of fraud in Andrew Wakefield’s vaccine-autism study.  CNN is into this story in a big wayHuffington Post ran the AP report.  Amanda Gardner at HealthDay picked it up, which means it will go into further syndication.  I can’t help wondering why it’s so important to put another nail in Wakefield’s professional coffin.

Or is it the vaccine-autism connection that’s supposedly being interred?

Probably both.

The BMJ opened the proceedings this week by publishing journalist Brian Deer’s investigative piece on the original Wakefield study of MMR vaccine and autism (Wakefield’s study was published in Lancet in February 1998).   That report had already been repudiated by Wakefield’s coauthors, and retracted in 2010 by the Lancet‘s editors after investigation of Wakefield’s procedures.  Wakefield is no longer allowed to practice medicine in the UK.   The Deer article was a parting shot.

An accompanying editorial by Fiona Godlee, Jane Smith, and Harvey Marcovitch, BMJ editors, was a well-taken and circumspect attempt at restoring confidence in measles immunization — on which, in their view, the work of Wakefield and colleagues had cast a shadow.  The editors might not be right in blaming the 1998 Wakefield study for contemporary parents’ reluctance to get their kids immunized, but their aim is to make a reasonable, if arguable, public health point.   To my reading, they haven’t got much of an axe to grind.

But then the whetstones began to turn.  Jonathan Adler at Volokh cheers, wondering if now the “vaccine-autism charade” will end.  Nick Gillespie is also celebratory, albeit more sedately, at Reason‘s blog.   

At Age of Autism, John Stone tries to undermine the journalist (Deer) who wrote the fraud story.  Stone is so rabid, and so ad hominem, in his attempts to destroy Deer that he manages to touch on not a single one of the reasons why it remains impossible to rule out a link between vaccines and autism.   Elsewhere at AofA, the UK group CryShame’s response is published; it too focuses on Deer’s methods, not the substance.

Evidently, substance is nobody’s concern here.  It’s about how news gets made.  Gary Schwitzer, a really sharp observer of the journalism scene, notes that journalists made Wakefield’s reports newsworthy back in their day, and are now “playing a key role in uncovering and dismantling” the story.

The vaccine-autism connection is news because it continues to get everyone riled up.

The defenders of vaccination (to judge by their vigorous celebration every time some further insult is visited on Andrew Wakefield) keep hoping that the suspicions of such a connection will go away.

The skeptics about governments’ medical policing of private lives invoke the possibility that vaccines are associated with a really high profile Bad Thing — like autism — to further their case.

The people who are crying out for an explanation for why so many kids function autistically remain unsatisfied.  (It’s not hard to see why they can’t get satisfaction:  policy makers, invested in mass immunization, don’t want to do the studies that would really find out whether or not the multiple vaccinations that kids are supposed to undergo today might be related to neurological changes.)

Of course, all of that has to do with the substance of the problem.  And what we’re seeing here, with Wakefield, with the revocation of his medical license last year, with this week’s fraud charge, and so on, isn’t substance at all.  It’s gloating or it’s grumbling.  Really, it’s not new.  But it’s news.

Why Vaccinate Children Against Flu?

Scientists shill for vaccine manufacturers in doing routine research.  This week, HealthDay reports that University of Rochester researchers found lower flu-immunization coverage in states with less Medicaid coverage for vaccination.   Instead of asking whether pediatric flu immunization has any public health value, research like this assumes that flu immunization is useful.  It helps make sure the vaccine manufacturers sell more flu vaccine.

What is the value of mass immunization of children against flu?

CDC claims that flu is dangerous for children and recommends immunization.  This claim seems to be based on the 50 to 150 pediatric deaths attributed to flu each year.  Preventing children’s deaths is a good reason to immunize those who might get very sick were they to be exposed to influenza.

But to translate a small number of possibly preventable deaths into a national policy of mass immunization?  That takes a special relationship with the vaccine manufacturers (see here and here and here and here for my comments on the collusion of officials with pharmaceutical interests).

The evidence that flu vaccine is effective in children is shaky, as Dr. Tom Jefferson’s exhaustive scrutiny of study data reveals.  Immunization of children seems to be weakly effective at reducing influenza-like illnesses in a general population, as Ritzwoller et al. showed in a study published in Pediatrics in 2005.  Partial immunization was ineffective — an issue worth considering if more than a single dose is required.

A few studies suggest that mass immunization of children is a way to prevent flu among young adults.

A community trial of immunization of children against flu, published in Vaccine in 2005, showed the ineffectiveness of immunizing children:  there was no reduction in acute respiratory illnesses among children in the concurrent or subsequent flu seasons, compared to communities where kids were not immunized.  There were slight reductions in ARI incidences among adults in the community where children were immunized — but this study wasn’t designed to show whether it was the immunizing of kids that protected the adults, or something else.

Similarly, a 2000 study published in JAMA by Hurwitz et al. showed that flu immunization of children in day care had the effect of reducing acute febrile illnesses among household contacts, compared to household contacts of daycare attenders who were not immunized (abstract here, full article requires subscription).  So immunizing children in daycare might help their parents to avoid getting sick.

In general, there’s suggestive evidence that mass immunization of small children against flu lessens the impact of flu outbreaks among young adults.

But few young adults die of flu.  It’s an annoying and sometimes serious illness.  The reason the public health authorities are interested in preventing flu among young adults isn’t to reduce suffering; it’s to keep them from staying out of work.  Should we immunize children so that the nation’s economic machine doesn’t slow down?

To put it a little differently:  should we shift large amounts of taxpayer money into the hands of pharmaceutical and vaccine manufacturers for the purchase of flu vaccine for children, basically in order to spare employers the loss in profits that would arise when workers stay home?

The news from ProPublica this week, that they and associated journalists found many cases of physicians taking money from big pharmaceutical companies, is alarming but comes as no surprise.  ProPublica’s new searchable database shows that the seven pharmaceutical companies (collectively accounting for 36% of market share) that provided data together made $257.8 million in payments to physicians.

What’s more alarming is that pharmaceutical companies often don’t even have to bother paying to push their products.  That’s especially true when the product is a vaccine.  Even flu vaccine, despite its limited and highly variable effectiveness.  Policy decisions made by the Advisory Committee on Immunization Practices and CDC, practice decisions by medical organizations, research-grant funding, and so on are thoroughly organized around immunization.  Despite the evidence.

A Blog Worth Following

If you haven’t already, put Crawford Kilian’s H5N1 blog on your regular reading list.  There, while you’ll still get updates on the H5N1 avian flu virus and occasional pieces on H1N1 flu (and you can see a multitude of archived posts from 2009  filled with international material on the progress of last year’s flu — and the reaction to it), you now get a much-expanded scope, including news and commentary on the spread of infectious diseases of different sorts.

What I value about H5N1 is the tracking of the mosquito-borne viral diseases, like dengue and chikungunya as well as H1N1, that reveal the effects of the elision of ecosystem boundaries; the close attention to outbreaks that stem from changes in human-animal interactions — like the recent outbreak of plague in Tibet and, of course, H5N1; and the watch it keeps on the vaccine trade, as in yesterday’s post picking up a report in The Nation on the purchase of flu vaccine from France and one last week on a US tech company’s trials of a new flu vaccine (which won’t help the public but is, apparently, already helping the company to get richer).

The kind of close attention to the details of complex interactions amongst humans, animals, and both the natural environment and the economic one that H5N1 shows is indispensable.   It should spur more interest in wresting public health away from the simple-minded mass-vaccination schemes of medical officials in the U.S. and other wealthy countries — the point of which is usually to transfer public monies into the hands of pharmaceutical companies.  And move us to toward a more complex and inclusive view of the nature of health.

Public Health Priorities: Follow the Money

Thanks to Crof at H5N1 for bringing to our attention a strong editorial in yesterday’s Bangkok Post.   The editorialists note that H1N1 preparedness efforts were not always successful and that WHO, fresh from announcing that the H1N1 pandemic is over, is now promoting fears of renewed outbreaks of H5N1 (avian) flu.  The editorial continues:

While it would be foolish to dismiss such warnings as this latest one on bird flu, it is important we keep a sense of proportion and not let them distract us from countering the unfashionable but widespread potential killers such as tuberculosis, HIV/Aids, diabetes, cancer, dengue and malaria. These are the diseases already causing widespread illness and economic harm….

Rather than competing for cash, the threat from newer diseases should serve as a catalyst to combat existing epidemics.

Competing for cash is key.

Funding for TB languishes, dengue incidence expands, more people with the AIDS virus are getting treated but new infections continue to occur, water scarcity (and displacement because of wars and natural disasters) makes diarrheal illness a persistent problem, and malaria transmission continues to threaten billions of people who live in tropical and subtropical regions — but flu preparedness dominates the public health scene.   Why?

Here’s the infernal logic of WHO and the public health officers of wealthy countries (U.S., U.K., etc.):  (a) At the start of the H1N1 outbreak in 2009, a sensible worst-cast forecast was about a million deaths worldwide; the more likely scenario was well under 500,000 deaths.  (b) TB + malaria + diarrhea + AIDS together kill 6 or 7 million people a year.   (c) Immunization against flu is notoriously variable in its effectiveness and mass immunization is almost never effective (except if instituted in an isolated population well before the flu virus makes inroads into the population).

Sounds like it would be worth it to pump lots of resources into reducing the incidence of malaria, TB, AIDS, and diarrhea.  But that’s hard.  It takes political will.  Whereas immunizing against flu is easy: it just takes money.  And national health officials were eager (it turned out) to transfer billions of dollars, pounds, and euros into the hands of vaccine manufacturers in order to be able to immunize their populations against H1N1 flu.

To an official whose job is to watch out for the needs of the economic machine, immunization pays.

One flu vaccine manufacturer estimates that in the U.S., employers lose $2.1 billion each year in productivity because of flu-related absences from work.  Let’s be skeptical about this estimate, coming as it does from one of the beneficiaries of federal largesse in response to flu fears.  But the point is clear enough:  it was a great boon to the private sector to have the federal government spend $1.6 billion of taxpayer money on flu vaccine in 2009 even though the outbreak was mild and vaccine did virtually nothing to stop it.  Because with the feds footing the bill, the burden on corporations was slight, whereas the private sector would have lost a lot of money if many Americans had fallen ill with flu.

It’s not just the vaccine manufacturers and pharmaceutical companies who stand to capitalize on the absurd calculus of protecting American businesses instead of poor people’s lives:  scientists do, too.

Robert Webster is an eminent virologist who has become dean of those American scientists who purport to be able to foresee a future flu catastrophe.  Perhaps he’s right, but of course nobody knows.  So when Webster says

We may think we can relax and influenza is no longer a problem. I want to assure you that that is not the case,

as he just did in a meeting in Hong Kong, it’s a good sign that the preparedness crusaders are worried about their funding.  They should be.

The preparedness crusaders have been unmasked as shameless shills for the private sector,  even if the vaccine and antiviral manufacturers aren’t paying them directly.  And the ones who are scientists have been revealed as self-important promoters of their own research — so fiercely protective of their own turf that they might use their prestige and the imprimatur of science to hoodwink officials into ignoring the more serious, and more certain, problems of the developing world.

Let’s hope that more opinion makers take the stand that the editors in Bangkok just did.

Transparency on Pandemics

How bad would it be for officials to be more open about how they make decisions on “preparedness”?  Should the public know more about how so-called experts forecast coming danger?  What’s the influence of media reports, like the coverage of last year’s flu outbreak which suggested, from day one, that it would resemble the 1918 flu?  How influential are the pharmaceutical companies and other vaccine makers?

At H5N1 yesterday, Crof picked up the U.K. government’s announcement that it would sponsor an independent review of decision making in response to H1N1 swine flu last year.  The U.K.’s Minister of Health, Liam Donaldson, told WebMD that it is

vital that we learn from what we have seen in this pandemic, for the sake of those who find themselves tackling … the next. It is likely to be worse.

Anybody who claims to know what the next pandemic will be like is asserting a special ability to read mysterious auguries that nobody else can see.  So it’s all the more shocking that Donaldson goes on to obfuscate his own failure to ask critical questions by claiming to have been using expert predictions:

Would it have been acceptable to hide and conceal statistical projections provided by statistical modellers of international standing, even though releasing them publicly caused alarm in some quarters?

As if the flak he had taken last July were for a perfectly rational assertion, not an apocalyptic forecast — when he said that there could be 65,000 deaths from flu in Britain.  Donaldson later dropped the forecast to 19,000 deaths.  (The actual number was less than 400 during 2009, 457 to date.)

And as if Donaldson had not made the same off-base prediction back in October 2005, when he said that there would be an avian flu outbreak in the U.K. with 50,000 deaths.  That was Donaldson’s excuse to use public money to purchase two and a half million doses of antivirals for stockpiling.

As if, that is, the problem were that people are just benightedly opposed to science — not genuinely concerned about malfeasance.

To its credit, the Parliamentary Assembly of the Council of Europe continues its investigation of decision making around the H1N1 outbreak response, holding a second public hearing on Monday.  Briefs of experts’ statements at the first hearing, back in January, are available here, and links to full statements and video are at the PACE site here.

Some of my friends and colleagues in public health wonder if this kind of questioning comes from misunderstanding the seriousness of flu and others are fearful that it will diminish the authority of public-health physicians.  A few, but too few, back the redoubtable Tom Jefferson, who has been questioning the reliance on flu vaccine for a long time.  Shouldn’t scientists — especially scientists — question authority?

Officials’ legitimacy ought to be diminished if they’re not serving the public.  Particularly when their decisions mean that private companies benefit from taxpayers’ monies.  Clearly, the transfer of funds is what happened with the H1N1 flu response.  Was it based on sound decision making?  More transparency would be a good thing.

Now that the Council of Europe and the U.K., are investigating official responses to H1N1 flu, could we please hear from the United States?