Homebirth Debate

Vaccine rejection: a flat-earth theory for the 21st century

Salon Magazine, an online magazine, has started a new blogging platform to publicize bloggers. I posted on vaccine rejectionism to give the site a try: Vaccine rejection: a flat-earth theory for the 21st century.

Labels: vaccine rejection

posted by Amy Tuteur, MD @ 9:00 AM

The link between homebirth and vaccine rejectionism

A number of people have asked why a blog about homebirth has posts about vaccine rejectionism. The reason is that homebirth advocacy and vaccine rejectionism are linked. I am not the only one who think so. At the recent 42nd annual National Immunization Conference sponsored by the CDC, officials of the Oregon Department of Health Services presented an educational session on The Association between Birth Place, Birth Attendant, and Early Childhood Immunizations.

Objectives:
The objective of the present study is to assess the association between type of birth attendant, place of birth, and immunization seeking.

Methods:
Oregon birth records for 2002, 2003 and 2004 were matched with the Oregon ALERT immunization registry. Shots in a 4:3:1:3:3:1 series received by age two were used for estimating population based rates. Birth location, such as in-hospital, at home, or birth center, and birth attendant were compared to rates of population capture into the registry by age two, and against UTD rates.

Results:
Overall 132,473 Oregon births were included in this study. While 97.9% of births were in hospitals, 82.7% had a M.D. as the attendant. The 2,200 children who were born in locations other than a hospital or freestanding birthing center were 8.8 times more likely not to be seeking or receiving immunizations than those born in hospitals. Those with a direct-entry or non-certified midwife in attendance were 7.4 and 8.8 times more likely to not be shot seeking as those with an M.D. However the 19,600 children born with a certified nurse midwife in attendance at a hospital were 1.1 times more likely to be shot seeking than those with an M.D. Similar results were obtained for UTD rates for these groups.

Conclusions:
A birth outside of a hospital is a strong factor both for not seeking immunizations, and for not completing series for those that do seek immunizations.

In other words, parents who chose a direct entry midwife were approximately 8 times more likely to reject vaccines than the average parent. Interestingly, those who chose a certified nurse midwife for their care did not share in vaccine rejectionism.

This finding is not surprising. Homebirth advocacy and vaccine rejectionism are linked by fundamental traits. Both depend on a lack of understanding of basic science. Both depend on a lack of understanding of statistics. Both depend on a lack of understanding of the subject matter, childbirth or immunology. Because of this lack of basic understanding, both groups of parents are easily manipulated and misled by "alternative" practitioners. Moreover, both groups have a reflexive distrust in authority, and a belief that rejecting authority is, in itself, a mark of being "educated". In other words, neither homebirth advocacy nor vaccine rejectionism is based on scientific facts. Both are philosophical orientations that have more to do with the parents' views of themselves than with the actual risks and benefits.

Perhaps the most important way in which homebirth advocacy and vaccine rejectionism are linked is that both place young children at increased risk of death or disability as a result of parental ignorance.

Labels: vaccine rejection

posted by Amy Tuteur, MD @ 7:11 AM

More on the free-rider problem

Vaccine rejectionism involves three all too human tendencies: fundamental misunderstanding of scientific principles, irrational risk perception, and selfishness. Vaccine rejectionists lack even the most basic understanding of immunology and epidemiology. Vaccine rejectionists have no concept of risk. They grossly overinflate the risk of vaccine complications and grossly underestimate the risks of vaccine preventable diseases. What is particularly ironic about vaccine rejectionism is that parents who are busily congratulating themselves on avoiding the risks associated with vaccines are doing so by being free-riders and taking advantage of everyone else.

Thomas May, a bioethicist, has written an excellent exposition of the free-rider problem in the article Public Communication, Risk Perception, and the Viability of Preventive Vaccination Against Communicable Diseases. The article appeared in the journal Bioethics in 2005. This article also includes one of the best explanations of vaccination I have read. On the results of vaccination programs:

Since its inception, the program of mandatory childhood vaccination for children entering the U.S. public school system has been remarkably successful – widely recognized as one of (if not the) most successful public health programs in history. The program has resulted in the eradication of smallpox, the elimination of polio, and a radical reduction in the number of cases of diphtheria, measles, pertussis (whooping cough), rubella, mumps, and a number of other serious diseases. For example, diphtheria has dropped from a peak of 206,939 cases in 1921 to only 4 cases in 1990, and similar drops in cases have occurred for measles, mumps, pertussis, and rubella. The success of the childhood vaccination program, however, faces threats from an increasingly visible anti-vaccination movement, and from visible (though extremely rare) cases of adverse reactions to vaccination. The DTP vaccine results in adverse events such as convulsions or shock for 1 in 1,750; acute encephalopathy for 0–10.5 in 1,000,000; and the MMR vaccine results in encephalitis or severe allergic reaction for 1 in 1,000,000. These risks are extremely low when compared to the adverse consequences from contracting vaccinepreventable disease (for pertussis, encephalitis for 1 in 20; death for 1 in 200; for measles, encephalitis for 1 in 2,000; death for 1 in 3,000) ...

On how vaccines work:

No vaccine is 100% effective. The success of vaccination programs relies on a concept known as 'herd immunity,' wherein protection is achieved through attaining a high enough level of immunity to a disease so as to make exposure to the organism that causes the disease extremely unlikely. If a critical mass of people is immune, then, those who are not immune are protected through 'herd immunity'... The actual level of vaccination necessary to maintain herd immunity is different for each potential disease (depending on the rate of effectiveness for the vaccine in question), but generally ranges from 83%–94%.So long as this level of vaccination is attained, those who refuse to be vaccinated are nonetheless protected through the unlikelihood that they will ever be exposed to the disease... If exemptions to vaccination should be great enough to threaten herd immunity, however, significant harms through exposure to vaccine-preventable disease could result not only for those exempted, but for those who are excluded from vaccination for medical reasons, and for those who are vaccinated yet remain susceptible to the disease (since, again, vaccination is not 100% effective).

This is precisely what has happened in the recent measles epidemic. The level of vaccination had decreased to the point where herd immunity was compromised. As a result the children of vaccine rejectionists got measles, as predicted, and children who were too young to be vaccinated got measles as well, also as predicted.

On the logic of free-ridering:

... [T]he action of any one individual will have a nearly imperceptible effect on the achievement of a collective goal, motivating free-riding behavior that seeks to garner the collective good at no cost to the individual in question. This will be true so long as an individual cannot be excluded from the collective good (as exemptors cannot be excluded from the protection provided when herd immunity is achieved), no matter how agreed upon the desirability of the collective good. However, widespread noncompliance with behavior necessary to achieve the collective good can result in loss of the good entirely – even for those who comply – a phenomenon often described as a 'tragedy of the commons.'... [I]ncreases in exemption rates have occurred in several other states, most notably in Utah, where exemptions to mandatory vaccination rose high enough to threaten herd immunity and result in a measles outbreak where half of those contracting measles had been vaccinated but had not achieved immunity (not surprising, since the rate of exemption was roughly equal to the rate of vaccine ineffectiveness).

Vaccine rejectionism is more than a demonstration of ignorance on the part of vaccine rejectionists, and vaccine rejectionism harms others in addition to the children of vaccine rejectionists. Vaccine rejectionism is unethical because vaccine rejectionists implicitly or explicitly seek to enjoy the benefits of vaccination programs without sharing the risks. Vaccine rejectionism is unethical because it harms innocent others who have taken steps to protect themselves. Vaccine rejectionists need to take a closer look at their own behavior. Rather than congratulating themselves on their selfishness, they should be apologizing to the rest of us.

Labels: vaccine rejection

posted by Amy Tuteur, MD @ 1:55 PM

Measles outbreak a direct consequence of vaccine rejectionism

Exactly as predicted, in exactly the way predicted, there has been an outbreak of measles in the US. According to the CDC, the disease was brought into this country by travelers, and caught by children whose parents had rejected measles vaccination. Of note, almost a third of the cases were in babies who were not yet immunized. This is precisely what one would expect as a result of vaccine rejectionism: a substantial proportion of the victims are infected by exposure to children who should have been vaccinated. In other words, the decision by vaccine rejectionists to be free riders, taking the benefits of mass vaccination without partaking of the risks of individual vaccination, victimizes other people's children.

Prior to 1963 when the measles vaccine was introduced, there were 3-4 million cases of measles per year, 48,000 hospitalizations, and 400-500 deaths per year. Measles had been effectively eliminated in the US by the year 2000. Measles still exists in other countries and can easily be imported by travellers. Of course, it always could be imported by travellers, but herd immunity prevented spread of the disease. Now, as a result of vaccine rejectionism, herd immunity has been reduced and the disease can take hold and spread. Of the 64 documented cases thus far, 63 occured in individuals who had not been vaccinated.

It would be bad enough if vaccine rejectionists were harming only their own children, but a substantial proportion of the cases have occured in children who are too young to be vaccinated. The youngest members of society are protected from vaccine preventable diseases by the fact that everyone else is vaccinated. When the disease cannot take hold in the population, there is virtually no chance for a baby to be exposed to that disease. Out of the 64 documented cases of measles, 20 occured in babies and toddlers who had not yet been vaccinated.

Where did the exposures take place? Evidently vaccine rejectionists took their ill children to pediatricians' offices where they infected babies who were there for well baby visits. Think about that for a moment: babies whose parents were doing everything possible to keep them healthy caught a life threatening disease because of the ignorance of parents who don't understand immunology, don't understand statistics and don't understand risk.

To date, 14 of the 64 patients have been hospitalized, most with pneumonia. Fortunately, there have been no deaths yet. In addition to the 64 reported cases, 8 unvaccinated siblings in one family have contracted measles within the past week, and 3 appear to have pneumonia.

Vaccine rejectionism is dangerous. It harms the children who are not vaccinated, and it harms unrelated children who are too young to be vaccinated. Make no mistake about it, vaccine rejectionism is unethical as well as the result of scientific ignorance. Parents who reject vaccines implicitly rely on other people being vaccinated. They are willing to accept the benefits, without partaking of the risk. They expose their own children to life threatening illness, and they expose other people's children to life threatening illness. The government should act to restrict vaccine waivers to only those with medical indications for forgoing vaccination. The right to indulge one's philosophical beliefs ends at the point where it threatens the life and health of other people's children.

Labels: vaccine rejection

posted by Amy Tuteur, MD @ 11:26 PM

Flaws in reasoning

Both lack of basic knowledge about childbirth, and lack of understanding of statistics contribute to the belief in the myths and falsehoods of homebirth advocacy. There is another factor, as well: flaws in reasoning. A recent article on the flaws in reasoning of vaccine rejectionists gives us insight into the flaws in reasoning of various "natural" health movements.

According to A taxonomy of reasoning flaws in the anti-vaccine movement, flaws in reasoning can be divided into two types: cognitive determinants such as the difficulty in detecting and correcting biases in incomplete and unrepresentative data and motivational-social determinants such as wishful thinking and self-serving distortions of reality and exaggerated impressions of social support.

For example:

One can readily point to two of the most common misconceptions regarding vaccination used by the anti-vaccine movement in its literature. The first is that the diseases against which we vaccinate had already begun to disappear before vaccination and were going to disappear anyway regardless of the adoption of routine vaccination. The second is that vaccine-preventable diseases are no longer threats from which one must protect oneself.

These twin misconceptions are commonly said to be the product of vaccination’s own success. By reducing the risk of the disease, the occurrence rates of that disease drop dramatically. As a result, over time, new generations of parents are vaccinating their children against diseases for which the parents lack direct experience or even awareness. For example, it has been generations since the vast majority of parents in highly developed countries have experienced a case of diphtheria, infantile pertussis, or tetanus. Contemporary parents may incorrectly presume from the absence or reduced occurrence of disease that the disease is no longer circulating and hence is no longer a threat...

A very similar phenomenon occurs among homebirth advocates. Because of the success of modern obstetrics in lowering mortality and complication rates, "new generations of parents lack direct experience or even awareness" of the inherent dangers of childbirth. Because it has been generations since parents in highly developed countries have had direct experience with neonatal or maternal death, contemporary parents incorrectly assume that the risk of neonatal or maternal death has virtually disappeared. However, the inherent risks remain the same. Modern obstetrics has modified the outcome.

As the authors write in regard to vaccine rejectionism:

These beliefs represent cognitive flaws arising from the difficulty in detecting and correcting biases in incomplete and unrepresentative data. The absence of disease does not mean the virus or bacteria is eradicated or that the disease is not a threat.

Similarly, the beliefs of homebirth advocates "represent cognitive flaws arising from the difficulty in detecting and correcting biases in incomplete and unrepresentative data." Low neonatal and maternal mortality rates do not mean that childbirth is not inherently dangerous.

In addition:

Mistaken beliefs arise not just from cognitive flaws in reasoning, but also from motivational and social determinants of questionable belief...There are three major forms of this ... the first of which is wishful thinking and self-serving distortions of reality... [such as] the anti-vaccine movement’s belief in a vast conspiracy of physicians, public health officials, and the pharmaceutical industry. The argument goes that this triad will of course suppress information regarding ... adverse events ... When a public health official or a physician or an industry representative defends vaccines, the believer in this conspiracy senses a cover-up...

Other common themes of the anti-vaccine movement readily play to this motivational determinant. A Dutch survey ... described a pair of prevalent negative beliefs among parents regarding vaccines that influences their decisions to allow vaccination of their children. Parents in this survey commonly held the belief that children receive
too many vaccines at once and that the vaccinations interfere with natural development...

The belief that vaccines interfere with natural development appeals to an attractive logic that medical interventions in general, and vaccinations in particular, are artificial and therefore unnatural, unwelcome, and unnecessary. Thus, that a medical intervention and especially a combination of medical interventions might overwhelm one’s system is that much more unnatural, unwelcome, and unnecessary.

These motivational and social determinants have parallels in homebirth advocacy. Homebirth advocates constantly claim that doctors are motivated by desire for profit above safety, that there are "too many" interventions and that these interventions "interfere" with the maternal-infant bond.

Lastly:

The third of these motivational and social determinants of
questionable beliefs is the exaggerated impression of social support.

Homebirth advocates repeatedly claim that homebirth is a growing movement despite the opposition of doctors. The fact is, however, that homebirth with direct entry midwives is a fringe movement, accounting for less than 1% of births in the US, the rate remaining unchanged over the past 25 years.

Homebirth advocacy is based in large part on a myriad of erroneous beliefs. In attempting to correct these erroneous beliefs, it is important to understand the flaws in reasoning that lead homebirth advocates to accept claims that are patently untrue.

Labels: vaccine rejection

posted by Amy Tuteur, MD @ 8:55 AM

Cultural attitudes, vaccine rejection and homebirth

A recent article in the journal Sociology of Health and Illness explores the cultural attitudes that lead to vaccine rejection. This is relevant for an understanding of homebirth advocacy, because promotion of the same cultural attitudes undergirds homebirth advocacy as well.

It is important to understand that both vaccine rejection and homebirth advocacy are not based on science. There is no scientific data that supports vaccine rejection. Indeed vaccines are one of the greatest public health achievements of all time and virtually every accusation about vaccines by vaccine rejectionists is factually false. Despite the fact that vaccine rejectionists have been 100% wrong in their understanding of vaccines, statistics, risks and claims of specific dangers, they still have a large following. In large measure that is because the cultural claims of vaccine rejectionists resonate with prevailing cultural assumptions. Vaccine rejection (and homebirth advocacy) are social constructs that have little if anything to do with objective reality or science.

'Trusting blindly can be the biggest risk of all': organised resistance to childhood vaccination in the UK (Hobson-West, Sociology of Health & Illness Vol. 29 No. 2 2007, pp. 198–215) explores these cultural attitudes. The first social construct is a re-imagining of the meaning of risk:

A primary way this is achieved ... is to construct risk as unknowns... [This] serves as an example of how the realist image of risk as a representation of reality is undermined. In the realist account, uncertainty and unknowns may be recognised but are usually framed as temporary phases that are overcome by more research. For the [vaccine rejectionists], there is a more fundamental ignorance about the body and health and disease that will not necessarily be overcome by more research. Interestingly, this ignorance is constructed as a collective – ‘we’ as a society do not know the true impact of mass vaccination or the causes of health and disease.

The problem that vaccine rejectionism is based on false premises is elided by ignoring the actual scientific data and focusing instead on whether parents agree with health professionals or refuse to trust them. Agreement with doctors is constructed as a negative and refusal to trust is constructed as a positive cultural attribute:

Clear dichotomies are constructed between blind faith and active resistance and uncritical following and critical thinking. Non-vaccinators or those who question aspects of vaccination policy are not described in terms of class, gender, location or politics, but are 'free thinkers' who have escaped from the disempowerment that is seen to characterise vaccination...

This characterization of vaccine rejectionists can be unpacked even further; not suprisingly, vaccine rejectionists are portrayed as laudatory and other parents are denigrated.

... instead of good and bad parent categories being a function of compliance or non-compliance with vaccination advice ... the good parent becomes one who spends the time to become informed and educated about vaccination...

... [vaccine rejectionists] construct trust in others as passive and the easy option. Rather than trust in experts, the alternative scenario is of a parent who becomes the expert themselves, through a difficult process of personal education and empowerment...

The ultimate goal is to become "empowered":

Finally, the moral imperative to become informed is part of a broader shift, evident in the new public health, for which some kind of empowerment, personal responsibility and participation are expressed in highly positive terms.

So vaccine rejectionism (like homebirth advocacy) is about the mother and how she would like to see herself, not about vaccines and not about children. In the socially constructed world of vaccine rejectionists, risks can never be quanitified and are always "unknown". Parents are divided into those (inferior) people who are passive and blindly trust authority figures and (superior) rejectionists who are "educated" and "empowered" by taking "personal responsibility".

These social constructs on on display in homebirth advocacy as well: The "risks" of hospital birth are "unknown". Women who trust their doctors are passive, sheep like beings who cannot think for themselves. In contrast, homebirth advocates are "educated", "empowered" and taking responsibility for their own health.

This view depends on a deliberate re-definition of all the relevant terms, however, and that re-definition is unjustified and self aggrandizing. The risks of hospital birth are not unknown. Believing that doctors lower neonatal and maternal mortality is not a matter of "trust", it is reality. Questioning authority is not the same as being "educated"; indeed, it isn't even related. Lacking even basic knowledge childbirth and rejecting medical facts is not a sign of education, independent thinking or taking personal responsibility. It is a lack of education at best, and self serving, self aggrandizing ignorance at worst.

Labels: feeling superior, pseudoscience, vaccine rejection

posted by Amy Tuteur, MD @ 8:02 AM

Homebirth advocacy and vaccine rejection

It is not surprising that homebirth advocacy and vaccine rejection go hand in hand. They are based on similar factual errors and errors in thinking. A list of these errors is instructive:

Lack of historical knowledge: Both homebirth advocacy and vaccine rejection are based on the fact that if ordinary people haven't seen something, they feel free to assume that it doesn't exist. The average person living in a first world country has no direct experience with birth prior to modern obstetrics and no direct experience with the major infectious diseases. Since they are also unaware of historical evidence, they feel free to pretend or even believe that childbirth is inherently safe or that major infectious diseases do not pose much of a risk. There is no homebirth advocacy in countries with high neonatal and maternal mortality rates and there is no anti-vaccination movement in countries that still suffer from major infectious diseases. Individuals with direct experience of childbirth in nature or with direct experience of major infectious diseases would never claim that childbirth is inherently safe or that major infectious diseases do not pose much of a risk.

Lack of knowledge about science: Both homebirth advocacy and vaccine rejection involve ignorance of basic principles of science and statistics. Proponents of homebirth and vaccine rejection have no way to independently evaluate the claims that they read. They decide what to think based on how much they like or admirer the person who is telling them what to think. If that person is lying, they have no way to know.

Misperception of risk: Both homebirth advocacy and vaccination rejection are based on misperception of risk. Proponents of homebirth and vaccination grossly overestimate the risks of hospital birth and grossly underestimate the risks of forgoing modern technology. They even appear to have trouble understanding the actual numbers. The fact that homebirth has a much greater risk of death than epidural anesthesia does not stop homebirth advocates from claiming that homebirth is safe and epidurals are dangerous. The fact that the risk of severe injury or death from a major infectious disease is literally more than 1000 TIMES higher than the risk of major injury or death from the vaccine. Yet that reality does not stop antivaccine proponents from asserting that not vaccinating is safer than vaccinating.

Homebirth and antivaccination advocates take advantage of these three serious deficiencies in knowledge and thinking (lack of historical knowledge, lack of scientific knowledge and misperception of risk) to convince well meaning parents to expose their children to increased danger.

Labels: pseudoscience, vaccine rejection

posted by Amy Tuteur, MD @ 3:05 PM