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Needling Worry

Why are we so crazy when it comes to vaccines?

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I’ve been writing about parenting for eight years. And for eight years I’ve joked that if you want to make readers crazy, you only need two words: “vaccines” and “breastfeeding.” So I shouldn’t have been struck by the passionate rantings on Facebook following my colleague Allison Hoffman’s story on how anti-vaccine fears caused a rise of measles in the ultra-Orthodox community. And I shouldn’t have been surprised by the blog world’s responses to my story on the venom aimed at women who don’t breastfeed. Anything we put in our children’s bodies—milk (whatever its mammalian origin), medicine, McNuggets, high-fructose corn syrup, petrochemicals leaching out of baby bottles—it’s all a huge source of anxiety for modern parents.

Back in the day, of course, we just wanted our kids to survive childhood. I once wrote a piece for the Forward theorizing about why Judaism historically didn’t address stillbirth or miscarriage. Why weren’t babies who lived less than 30 days given funerals? Why weren’t they attended with the rituals associated with mourning? I’m guessing it’s because attitudes were different in a time when an infant’s death was a regular occurrence. It was better to move on, push past grief, plan for the next kid. Today we have the luxury of neurosis. We get to dwell. We have fewer kids, and we not only expect them to survive to adulthood, we expect them to go to Yale and become gastroenterologists and program our TiVos. We get worked up about vaccines and breastfeeding because we can. But it’s more than that. I’ve been pondering why vaccine advocates can cite reputable studies until the cows come home, insisting with ever-increasing vehemence that Legitimate Science does not show that vaccines cause autism and let us explain the concept of herd immunity and you put all our children at risk if you don’t vaccinate yours and do you know that People Used to Die of Measles—and the anti-vaccine folks come back just as forcefully with anecdotal evidence and studies that the Friends of Science see as substandard.

Meanwhile, I wave around studies showing that once researchers correct for maternal age, income, smoking, intelligence, and education levels, the evidence is inconclusive about whether breastfeeding is better than bottle-feeding with modern formula—but lactivists continue to hurl insults at bottle-feeders and insist they’re harming their children and society. Why do we talk such different languages, at such cross-purposes?

I thought about this while sitting in a school meeting that turned into a heated referendum on the H1N1 vaccine. Like all New York City public schools, my kids’ school is making the vaccine available, but the Department of Education has been surprised by how few parents want it. Current estimates say that 25-35 percent of families want it for their kids, far below the original 50 percent estimate. Why? “There are still a lot of parents who want the vaccine for their kids, but many really don’t,” said Neal, my brother-in-law and a pediatrician who runs school health programs in the Bronx. “No one is lukewarm about it.” In my kids’ school, one person ranted about how a holistic doctor told her sister’s friend that the vaccine can eat the lining of the heart and kill you as two other mothers campaigned furiously to get the vaccine sooner rather than later and to be called to hold their child’s hand in the nurse’s office while it was administered.

So why the passion? I think it’s because we’re terrified of an unknowable future. Parenting is about making choices—how to feed a newborn, whether to work or stay home (if you’re an upper-middle class Jewess who is fortunate enough to have that choice), whether to vaccinate. We hope that what we do provides a magic bullet that keeps our kids safe and healthy in a terrifying, uncertain world. And yet, we’re supposed to let our kids disappear into a mysterious school nurse’s office, to be jabbed or made to snort something, some substance provided by a government we haven’t trusted since Watergate? Can’t I just let my kid wear a hamsa and feed her organic bananas?

“I think the anxiety about vaccines and breastfeeding is about seeking a false sense of control,” said Kiki Schaffer, director of the Parenting & Family Center at the 14th Street Y in Manhattan. “You can’t be anxious about everything, because it’s too much, so you pick a few manageable things to get really, really upset about. A few years ago it was asbestos, then alar in apples. But picking one or two things feels safer than having anxiety about the whole world.” And I think part of making your choice about what to get worked up about involves slamming the choices of others. Because what if they’re right? What if you’re the one who’s screwed up when it comes to your kid? Nothing could be more horrible to contemplate. Better to close your eyes and go on the attack. At this point, the notion of kids dying of old-school diseases seems far more remote than the notion of your specific kid getting autism or an immune disorder. We don’t know any kids with rubella. We know lots of kids with autism.

Next year, I’m going to have to decide whether to allow Josie to have the vaccine that protects against the human papillomavirus. The idea of 9-to-11-year-old girls getting vaccinated for a sexually transmitted disease is a certainly discombobulating. Jojo’s a baby! She’s not going to have sex until she’s at least, I don’t know, 35.

Indeed, many parents are opting out. Some worry that the vaccine will encourage promiscuity; others have concerns about the contents of the vaccine itself. Yet the Centers for Disease Control and Prevention believe that the vaccine is safe. (So do my kids’ pediatrician, my own G.P., and my brother-in-law.) The fact that 11,000 women are diagnosed with cervical cancer every year and 3,700 die is a compelling argument for the vaccine. The fact that 70 percent of American girls have had sex by age 18, while the vaccine is most effective among people who have not yet have sex and thus haven’t been exposed to any strain of this very common virus, is a compelling argument for giving a kid the vaccine while she’s young. (Should boys get the vaccine? Good question.)

Neal thinks that the HPV vaccine offers an important opportunity for pediatricians. “From a clinical perspective, I like the idea of using a discussion about the vaccine as an opportunity to talk to parents about how they’re going to keep communication channels open as their kids get older,” Neal says. “We need to acknowledge parents’ emotions and anxieties. Just offering and re-offering the vaccine is not the only intervention we should be doing.”

Would reframing the public health concerns around pediatric immunizations increase the numbers of kids getting vaccinated? Do we have to wait for more massive outbreaks, along the lines of the ones in ultra-Orthodox communities, perhaps involving even scarier diseases? Perhaps if we stopped treating opt-out parents as if they were stupid and instead treated them as though they were frightened for their own children’s welfare, it would color our approach and let us communicate more effectively. Or maybe we should make it harder to opt out. Or both.

All I know is that judgmental eye-rolling doesn’t help anyone. Not kids, and not parents.

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Marianna says:

Judgmental eye-rolling may not help but it’s so much fun! (plus, it’s a whole lot easier than genuinely engaging with the other side’s arguments and trying to figure out what’s driving them and finding common ground and . . . )

I know other people have made this point–but maybe vaccines have worked too well. Very few of us who aren’t pediatricians have seen a child with the diseases we immunize against. And every year children die of the chicken pox. But who sees chicken pox that are that bad? So vaccinating feels like something that can be opted out of because very few people have seen the real diseases they protect against or can imagine the worst case scenario of them. Meanwhile, the fake scary scares of autism are worse than a case of measles, from which, the argument must go, a child can recover, mostly. Right? No? For me the vaccine question was decided by the holistic pediatric medicine book Healthy Child Whole Child. The doctor authors said unequivocally, if you’ve ever seen a case of whooping cough, you’d know you have to immunize and we recommend it.

Michele says:

Marjorie does it again! What a timely, insightful article that I think really gets to the heart of what may be going on here – pick the thing you want to go nuts over and stick with it! I definitely agree that people slam others to make themselves feel better about their own choices. On both of these issues, the rabid criticism flies both ways. Not to say I haven’t been guilty of some judgmental eye-rolling, but still … (to be fair, it usually is in direct response to someone carrying on at me that I am somehow harming my kids … usually …but isn’t that how this craziness keeps going?) I am a mom who breastfed and vaccinates – on the breastfeeding I was more live and let live (at least I like to think I was) but I have to admit I am very worried about the ramifications of parents opting out of vaccinating.

Elizabeth says:

The most compelling example I witnessed around the “should we vaccinate or not?” question was in our co-op preschool. All us parents watched one of our four-year-olds suffer through whooping cough. There were weeks and weeks of this recurring, whole-body cough, even after the child was non-contagious and well enough to be back at school. It was terrifying, and even his mother agreed that the experience changed this happy, outgoing kid into a gun-shy little guy. I’ve never been happier to know that my child’s DPT booster was current.

I keep trying to stop my eye-rolling response to the anti-vaccination crowd, but I suspect I do not succeed.

Wonderful article, Marjorie. I fully support your plea for parental tolerance — why judge other families’ decisions? I also appreciate Kiki’s point about how we want to feel in control of our world, but that’s impossible. So instead, we obsess about whether to breastfeed or vaccinate or whatever.

Jacob Davies says:

Tolerance is generally a virtue, but in some cases objective reality demands judgment based on the best available evidence and the need to head off disasters with fatal consequences.

If your neighbor decides to build a 20-story building without an engineer, tolerance does not demand that you say “Hey, well, we all have to do our own thing, right?” until the day the tower falls over and crushes your house.

Well, that’s pretty much how I feel about vaccination. It’s not a question of “everyone’s choice is as good as everyone else’s”. It’s a question of whether 20-story buildings should be designed by engineers and whether medical treatment should be guided by the best available science. I don’t necessarily think vaccination should be absolutely compulsory (for one thing that would probably drive the conspiracy theorists even more nuts than they already are), but that doesn’t mean I think we need to politely accept those who avoid it. I don’t think drinking to excess in the privacy of your own home should be illegal either, but that doesn’t mean I think it’s a very good idea.

On breastfeeding, the other side of saying that modern formula is as good or nearly as good as breastmilk (which may well be true) is the recognition that it is only decades of forceful resistance to marketing and pseudoscience (put out by formula manufacturers) by advocates of breastfeeding that got the manufacturers to do the work required to make formula as good as breastmilk.

They had – still have, just not so much in first-world countries – a habit of telling uninformed people that formula was better than breastmilk, with serious consequences for millions of people, if nothing else the economic consequences of spending a lot of money on a product that was inferior to what was – for many, not all but many people – available at a much lower cost.

So we should remember how we came to the situation where the advantages of breastmilk over previous types of formula were recognized, and how it came to be that it was perhaps remedied by formula manufacturers. That was through the forceful activism of people not motivated by personal profit, standing against powerful multinational corporations. Were they angry, judgmental, and outspoken in their advocacy? Well, yes. You don’t win arguments with Nestle’s marketing budget by being meek. It may be true now that formula is just about as good, I’d be willing to accept that. But whether we like it or not, it will remain a battle in which one side is well-funded, aggressive, and relentless. Even if formula appears to be just as good, it would not be a good idea to let the marketing budgets of formula manufacturers drive the discussion.

All of that said, the difference for me between the two issues is that breastfeeding truly is a personal decision without significant health consequences for other children (and quite possibly without any dire consequences for the child in question either), and vaccination is not. Not vaccinating means children will die who didn’t need to, including children who were vaccinated but did not gain immunity and who were later exposed to unvaccinated children infected with a preventable disease. That’s already happening, and it’s not okay.

But I think you’re entirely right to highlight these as consequences of the fear that is pounded into parents. That fear is driven by marketing – whether it’s products or books or alternative therapies – and the marketing of fear is relentless. The truth is that you can do something to reduce the occurrence of certain kinds of accidents, generally boring things like car safety and smoke alarms, but very little about most of the causes of death & illness for children. It’s not only uncomfortable (nobody likes to think that the most serious risks to their children are completely random and out of their control) but also fails to sell any product. Which is why you don’t hear much about it.

jennifer says:

I must be the only lukewarm parent out there. It doesn’t seem like it’s going to kill them (any more than the usual flu) and I can’t quite figure out where to get the vaccine (I just moved to another country). if someone showed up on the front door I would be very happy to have the kids get it, but can’t quite get around to actually going to look for it.

Jacob Davies says:

There’s a big difference between the vaccines for seasonal flus (even including this H1N1 strain) and major childhood diseases. The flu vaccines are a good idea, but not 100% effective, and there is always a rush to get them because they have to be made new every year. And their effectiveness is pretty much limited to the year you get it anyway – so missing one has no long-term consequences. This year the seasonal and H1N1 vaccines have both been in short supply anyway – for instance I can’t currently get either one through Kaiser.

The vaccines for serious childhood diseases are completely different. They are widely available, give long-lasting protection, and are extremely effective at preventing diseases that have pretty high mortality. It’s unfortunate that the difference between the two kinds of vaccine is not more prominent.

I’m sure you’re right — it IS fear, not anti-science knownothingism, that makes people so rabid about vaccines. But we also know that people’s fears are often exaggerated or misplaced, that they fear things unlikely to happen but don’t take action against things more likely to.

It helps to be older, and to remember when parents feared polio outbreaks.

Why judge other families’ decisions? Because unlike decisions about nursing versus bottles, vaccinating versus not affects everybody, including adults.

Patricia says:

A similar issue–about controlling children’s environment and keeping them safe is in how we supervise play. Children who are driven to and from school and activities are (perhaps) marginally safer than children who walk. But they are likely less healthy and less competent to navigate the world.
To drive or not seems like an individual choice. It is not–when most children are driven, it increases the danger for those who walk, both due to traffic and because the few children on the street stand out.
In addition, the culture around walking changes–it becomes negligent for parents to send a six-year-old to school alone–yet at other times and in other places, this is the norm.

thanks for the comments, all.

WE NEED PARAGRAPH BREAKS!

right now it’s really easy to opt out of vaccines for religious, ethical or moral reasons. i’m curious whether making it harder to opt out — and saying you MUST be vaccinated to attend public school in the USA — would have a meaningful impact on vax rates. among the orthodox community in allison’s story, probably not; those kids don’t go to public school. and i suspect a lot of anti-vaccine parents homeschool or send their kids to hippie private schools.

i do think we live in a culture in which all science seems equal. thanks to books and lack of science education and the interwebs, people don’t differentiate between a poorly designed study in Dr Joe’s Autism Journal and the NEJM. and of course people pick the science that backs up their own positions. furthermore, we associate with people who share our politics and our beliefs. we don’t tend to interact with folks who disagree with our positions, and that helps them ossify. so again, it’s hard to learn where others are coming from and find a good way to educate them. i do understand from talking to kiki that acting like they are morons and only talking LOUDER AT THEM! AND EXPLAINING BASIC SCIENCE, HI! does not help them see the error of their ways and make jenny mccarthy go away.

patricia, i want to do a piece at some point on letting josie walk to school alone (it’s only a block away, but she has to cross a street and an avenue, with a crossing guard) at age seven. oh my lord, you would have thought i was sending her to a porn expo from the way people were horrified.

Yes, there have been several studies in the past couple of years showing that more lenient exemption policies (allowing “philosophical” rather than strictly religious exemptions) are associated with lower immunization rates, and higher rates of vaccine-preventable diseases.

I’m not sure I agree that anti-vaxers segregate themselves. They may not announce themselves, but they’re everywhere. The other day I was leaving school with a dad I know, and I idly asked how his daughter had done with the H1N1 vaccine they gave the day before (mine had a fit). He calmly told me that he and his wife had “done some reading” and decided to pass on it. “There are risks either way, right?” I’m not sure if he’s really aware that I work in public health, and we only had half a block to walk together, so I nodded and smiled, rather than asking what risks he saw in a flu vaccine that is basically identical to the one given to 90 million people every year, and how those risks, whatever they are, can possibly be greater than that of a pandemic flu that has killed 500 kids so far this year. But no eye-roll, I promise.

I think the anxiety stems from general mistrust of sectors that historically were perceived as being driven by something like the public good and are now perceived and being driven by profit. It is hard for many people to trust powerful groups of people who perhaps have much to gain — that said, I vaccinated my kids – but I did so with trepidation. We have lost faith in our doctors, our government, certainly our banks (assuming we ever had faith in them) I can only hope we don’t lose faith in ourselves to rectify the damage of the last 30 years of pilfering of the public trust.

I work at Georgetown; a Georgetown medical professor invented the HPV vaccine– Dr. Schlagel (and we’re a Jesuit institution– love irony in life).

It is a conundrum what to do…vaccinate or not. I’ve gotten my kids poked and prodded and inoculated. My ex is adamant about the H1N1. I’m not so hardcore; my kids are really healthy kids, but the hype has sunk in-I do want them to have it. I cdo think for the kids it’s a wise move. He and his wife are getting it too, but I don’t think I will — not in the target risk group. I think the hysteria swirling around all this is outrageous. Hysteria breed erroneous thinking; erroneous thinking leads to panic and distorted views. It’s hard to sort through all the hype-rubble sometimes.

I spent 25 years in public health trying to convince Chassidic families to vaccinate their children. There is a lack of concern among Jewish parents for the greater good of the community – achievment of “herd immunity” that requires 90% coverage of all eligible children and protects the few children who cannot be vaccinated, is not a motivator. Conditions as diverse as autism, allergies, and Downs Syndrome are all blamed on immunizations. It is very frustrating.

I understand the fear about vaccinating at school, as well as about the HPV shot. It’s about relinquishing control: giving your kids up to the school for inoculation in one case and giving your prepubescent girls up to a sexual world (even if it’s in your own mind) in the other. What I don’t get is the trend away from vaccinating. I can’t help but be judgey because it strikes me as one of those very western, very privileged positions. “Oh, those diseases aren’t that bad!” Actually, they are, or were, until vaccines came along. And H1N1 may be shark-attack hype, but the numbers do bear some cause for concern. Seasonal flu kills elderly; this flu is killing children. Thus the public health response for massive vaccination among children. I was so happy to give my 5 y.o. the vaccine at school, better yet it was the mist, not a dreaded poke.

Great article, as usual. And a great discussion. I don’t know what to think about the vaccine issue, and I too am amazed by the heat and passion it generates.

I’m 66 and grew up in the era when the discovery of the polio vaccine was the biggest relief ever, because we were all so terrified of even leaving the house when summer came. As kids we regularly visited a second cousin who lived 24/7 trapped in an “iron lung” because she couldn’t breathe on her own, thanks to polio – completely terrifying!!

I also note the confusion about what it is about kiddy vaccine that’s potentially harmful. The theory keeps changing, because we just don’t know. For a while people were sure it was the mercury. Then it was the piling on of too many at once – and lots of parents mediate this by insisting the doc deliver each shot sequentially with spaces in between. (One Israeli vet told me that they’d never give so many vaccines to an animal at one time, because they feared kicking off an overblown autoimmune reaction.)

All I can say is, I’m kind of sneakily grateful that when my kids were at these ages, it wasn’t an issue. You just did it and checked off one more parental responsibility taken care of.

Why is everything so much harder for parents now? Good grief, it’s hard enough as it is without all this worry about doing something relatively small wrong and messing up your kid forever. I remember the cheese scare for pregnant women with the same bafflement. But I got no answers.

A timely article! We had H1N1 in our household this summer and fortunately both my daughter and I made a complete recovery. We have had several kids/grandkids in our shul who are very, very ill as a result of the virus. One teen’s H1N1 virus has developed itno both meningitis AND enchephalitis and it is not known when he will be well enough to return home.

The unknown factor really makes parents nuts. And so we try to control those things that are, in fact, out of our control. And we seek blame wherever it can be placed in order to come to terms with life’s hardships.

Our son has autism. He had it before his vaccinations and he has it after his vaccinations. What he hasn’t had is pertussis, diphtheria, or any of the other potentially fatal childhood diseases that have been eradicated in this country thanks to the aggressive inoculation program we are fortunate to enjoy.

We are vaccinating all three kids against seasonal flu and H1N1 (with the exception of our daughter who is now immune to H1N1!) and hope that others will do so as well.

Thanks for addressing the tough issues.

I have to agree with Jacob Davies when he points out that there is a difference between vaccines for seasonal flu and those to combat major diseases. Seasonal flu changes from year to year and will not be entirely eliminated, while things like Polio and Small Pox have been virtually wiped out.

— That being said, I think between the unknown of a new vaccine (whether a legitimate fear or not) and the fact that this year kids are expected to receive 2 different flu shots (and H1N1 having 2 doses) it becomes something parents question. Next year H1N1 will be rolled into the seasonal flu shot, and the hype will disappear. Those who normally get the flu shot will automatically get H1N1 and not think twice about it.
–Something to consider when wondering why parents start questioning inoculations is that in the ’70s kids were recommended to vaccinated against 7 different diseases, today it is 14 plus HPV for tweens. So when ‘we were kids’ it really was a simpler situation and easier not to question.

Excellent blog you have here. You’ll discover me looking at your stuff often. Saved as a favorite!

fantastic post, very informative. I wonder why the other specialists of this sector do not notice this. You must continue your writing. I’m sure, you’ve a huge readers’ base already!

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Needling Worry

Why are we so crazy when it comes to vaccines?

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