Vacinacao: a irresponsabilidade de pais que nao imunizam seus filhos- NY Review of Books

Eu me pergunto se pais irresponsáveis que não vacinam seus filhos perguntam a eles se preferem ficar doentes ou ser vacinados.
Paulo Roberto de Almeida

There’s No Way Out of It!

Jerome Groopman

The New York Review of Books

March 5, 2015 Issue

On Immunity: An Inoculation

by Eula Biss

Graywolf, 205 pp., $24.00

Bad Faith: When Religious Belief Undermines Modern Medicine

by Paul A. Offit, M.D.

Basic Books, 231 pp., $27.99

Collection of the John and Mable Ringling Museum of Art, State Art Museum of Florida, Florida State University Peter Paul Rubens: Achilles Dipped into the River Styx, circa 1630–1635

Even many years later, when my mother told the story, fear still showed on her face. One morning in 1954, at the age of two, I awoke and told her that my head hurt. I had a fever, and she put me to bed. Over the next days, my temperature rose, and my headache worsened. My parents called our pediatrician, who came to our small apartment in Astoria, Queens. He found that my neck was stiff and my legs were weak. Polio, he said, was a possible diagnosis. There were tens of thousands of cases of the paralytic illness each year in the United States. The doctor insisted that I be hospitalized in an isolation unit in upper Manhattan. My parents readily complied.
After a week in the hospital, my temperature fell and my legs became stronger. Tests showed that it was not polio; the infection was never identified.¹
My mother and father feared debility and death due to pathogens. They were raised in immigrant New York neighborhoods at a time when diphtheria, typhoid, and tuberculosis were rife. My parents also knew that microbes were not restricted to the newly arrived and poor. Polio had struck the patrician FDR in his prime.
The world of my parents, and that of their children, dramatically improved in the latter half of the twentieth century as modern medicine introduced an array of effective vaccines and antibiotics. When the Salk vaccine against the polio virus became available a few years after my mysterious illness, I was inoculated, along with my siblings. The idea of preventing or curing dreaded infectious diseases “naturally,” relying on the body alone, hardly entered our minds.
But two generations later, such ideas have considerable traction in our society. Eula Biss, a writer who teaches at Northwestern University, seeks to understand their appeal, and whether they should be given credence. On Immunity is an effort to reconcile her divided feelings, fearing both infection and the imagined risks of vaccination. Her book weaves metaphor and myth, science and sociology, philosophy and politics into a tapestry rich with insight and intelligence.

In 2009, Eula Biss gave birth to her first child and became fixated on the many ways he might be harmed—poisoned by chemicals in his plastic bottles or suffocated in his crib by lying incorrectly. Her intense concern about such dangers coincided with the appearance of a new strain of H1N1 influenza in the United States. Much of the country was in a panic: some churches were serving wafers at Mass on toothpicks, and airlines removed pillows and blankets from their flights. “What surprises me now is how unremarkable this seemed to me at the time,” Biss writes.

It all became part of the landscape of new motherhood, where ordinary objects like pillows and blankets have the power to kill a newborn…. It was as if the nation had joined me in the paranoia of infant care.

The strain of the virus was potent for children and teenagers, not only those who typically suffer severe cases of influenza, like the elderly and diabetics. Public health officials recommended widespread vaccination. But among her group of new mothers, “every exchange about the new flu vaccine was an extension of the already existing discussion about immunization, in which all that is known of disease is weighed against all that is unknown about vaccines.”
Biss reflects on the myth of Achilles, and the profound maternal desire to make a child impervious to harm. Achilles’ mother dipped him into the river Styx, but holding him by his heel, which left him vulnerable:

Immunity is a myth, these stories suggest, and no mortal can ever be made invulnerable. The truth of this was much easier for me to grasp before I became a mother. My son’s birth brought with it an exaggerated sense of both my own power and my own powerlessness. I found myself bargaining with fate so frequently that my husband and I made a game of it, asking each other what disease we would give our child for prevention against another—a parody of the impossible decisions of parenthood.

For Biss, decisions about which, if any, vaccines should be given to her son were made “impossible” by allegations on the Internet and anecdotes from other mothers about their long-term risks:

We fear that vaccination will invite autism or any one of the diseases of immune dysfunction that now plague industrialized countries—diabetes, asthma, and allergies. We fear that the hepatitis B vaccine will cause multiple sclerosis, or that the diphtheria-tetanus-pertussis vaccine will cause sudden infant death. We fear that the combination of several vaccines at once will tax the immune system, and that the total number of vaccines will overwhelm it. We fear that the formaldehyde in some vaccines will cause cancer, or that the aluminum in others will poison our brains.

Her anxiety is amplified by a larger culture of suspicion. In contrast to my parents, who put complete trust in the integrity and authority of their doctor, Biss and her fellow mothers distrust government, pharmaceutical companies, and journalists who seek to inform and reassure the public:

The fact that the press is an unreliable source of information was one of the refrains of my conversations with other mothers, along with the fact that the government is inept, and that big pharmaceutical companies are corrupting medicine. I agreed with all these concerns, but I was disturbed by the worldview they suggested: nobody can be trusted.

One of her efforts at calm is to understand how emotions color perception of risk. Scientists typically present the risks of a vaccine by citing the numbers of people suffering side effects against the total numbers given the treatment. Reviewing the work of the scholars Paul Slovic at the University of Oregon and Cass Sunstein at Harvard Law School, Biss notes:

Risk perception may not be about quantifiable risk so much as it is about immeasurable fear. Our fears are informed by history and economics, by social power and stigma, by myth and nightmares. And as with other strongly held beliefs, our fears are dear to us. When we encounter information that contradicts our beliefs,…we tend to doubt the information, not ourselves.

How should she keep herself informed? Should she give weight to the anecdotes told by fellow mothers? Listen to mainstream doctors, among them her father, a blunt-speaking man dismissive of her crowd? Or should she trust the antiestablishment clinicians on the Internet? And might there be ethical tenets to help her make a sound choice to vaccinate, or not?

As a writer and teacher, Biss is primarily concerned with language, specifically how metaphor sculpts thought and feelings:

“Our bodies prime our metaphors,” writes James Geary in I Is an Other, his treatise on metaphor, “and our metaphors prime how we think and act.” If we source our understanding of the world from our own bodies, it seems inevitable that vaccination would become emblematic: a needle breaks the skin, a sight so profound that it causes some people to faint, and a foreign substance is injected directly into the flesh. The metaphors we find in this gesture are overwhelmingly fearful, and almost always suggest violation, corruption, and pollution.

Biss moves from the power of language to the demographics of sociology. She cites a 2004 analysis of data from the Centers for Disease Control and writes: “Unvaccinated children…are more likely to be white, to have an older married mother with a college education, and to live in a household with an income of $75,000 or more—like my child.” Such unvaccinated children generally live near one another, which means that if they contract a disease, it can be readily passed on to others. Then there are so-called undervaccinated children, those who have received some but not all of their recommended immunizations. They “are more likely to be black, to have a younger unmarried mother, to have moved across state lines, and to live in poverty.”
These demographic distinctions inform Biss’s understanding of the scientific concept of “herd immunity”:

If we imagine the action of a vaccine not just in terms of how it affects a single body, but also in terms of how it affects the collective body of a community, it is fair to think of vaccination as a kind of banking of immunity. Contributions to this bank are donations to those who cannot or will not be protected by their own immunity. This is the principle of herd immunity, and it is through herd immunity that mass vaccination becomes far more effective than individual vaccination.

Her physician father articulates the value of herd immunity in public health, and Biss extends his analysis to a political principle she holds dear:

“Vaccination works,” my father explains, “by enlisting a majority in the protection of a minority.” He means the minority of the population that is particularly vulnerable to a given disease. The elderly, in the case of influenza. Newborns, in the case of pertussis. Pregnant women, in the case of rubella. But when relatively wealthy white women vaccinate our children, we may also be participating in the protection of some poor black children whose single mothers have recently moved and have not, as a product of circumstance rather than choice, fully vaccinated them….

Immunity…is a common trust as much as it is a private account. Those of us who draw on collective immunity owe our health to our neighbors.

But do we owe so much to the collective that we should sacrifice our autonomy? I learned in On Immunity that the term “conscientious objector” came out of resistance to a British law passed in 1853 requiring the vaccination of all infants. Forty-five years later, the government added a “conscience clause,” allowing parents to apply for an exemption. The exemption clause was rather vague, requiring only that the objector satisfy a magistrate that it was “a matter of conscience.”
Biss turns to her sister, a philosophy professor at a Jesuit college who studies Kant. She explains Kant’s contention that we have a duty to ourselves to examine our conscience, the “inner judge” that unites thoughts and feelings. An individual might resist flaws in the dominant moral code and thus create the possibility for reform, or conscience can be what keeps your actions in line with publicly defendable moral standards.
Biss, while aware that a conscientious objector to vaccination may contribute to an epidemic, affirms that “our laws allow for some people to exempt themselves from vaccination, for reasons medical or religious or philosophical. But deciding for ourselves whether we ought to be among that number is indeed a matter of conscience.” Yet this seems too facile a conclusion, since the freedom to exempt oneself negates a responsibility not only to society, but to one’s own children who do not have the agency to decide for themselves.

Paul Offit, a professor of pediatrics at the University of Pennsylvania and the head of the Division of Infectious Diseases at the Children’s Hospital of Philadelphia, is one of the most courageous and sober voices arguing to protect children from exemptions made by their parents.² Biss draws from one of Offit’s books, Autism’s False Prophets, in her examination of the ideas of the British gastroenterologist Andrew Wakefield.

In 1998, Wakefield published a study in The Lancet of twelve children indicating that vaccines caused autism. The publication was accompanied by a promotional video of a press conference in which Wakefield supported the suspicions of parents who already believed what the study suggested. Although there were caveats in the Lancet paper, it resulted in a sharp drop in vaccination against measles. Later, when the study was discredited and shown to be sloppy, Wakefield portrayed himself as the victim of establishment persecution.
Another vaccine opponent is Dr. Joseph Mercola, who heads the Mercola Natural Health Center in the Chicago suburbs. Mercola offers information on a website about the dangers of water fluoridation and metal amalgam in dental fillings, as well as speculation that AIDS is not caused by HIV. Biss notes that the site is visited by nearly two million individuals a month, and “products available for purchase range from tanning beds to air purifiers to vitamins and supplements. The website and Mercola LLC generated an estimated $7 million in 2010, and in 2011 Mercola donated $1 million to a number of organizations” that oppose vaccination.
Offit’s book debunks the claims of such antiestablishment clinicians. But his criticism extends to the morality of parental “conscience” when imposed on the health of children. Offit recounts painful tales of children dying from diseases that could be easily prevented or cured if parents had accepted the advice of doctors. In his most recent book, Bad Faith, he argues that we fail minors by giving permission to parents who seek exemptions from vaccination on religious grounds. Sacrificing the lives of vulnerable minors, he contends, negates God, since all human beings are created in His image. But, to date, legislatures and the courts have been loath to override religious beliefs that reject life-saving treatments for children.

On Immunity follows the ebb and flow of Biss’s mind, sometimes taking up a point, like herd immunity, first from a scientific perspective, then a political one, then a philosophical. Interspersed are her stories as a new mother. When she searches for a pediatrician, she is referred by her midwife to one who appears to share her “left of center” mindset:

When I asked the pediatrician what the purpose of the hep B vaccine was, he answered, “That’s a very good question,” in a tone that I understood to mean this was a question he relished answering. Hep B was a vaccine for the inner city, he told me, designed to protect the babies of drug addicts and prostitutes. It was not something, he assured me, that people like me needed to worry about.

Biss’s pediatrician may be left of center, but she discovers that he is not reliable in his reply. Biss won the 2009 National Book Critics Circle Award for Notes From No Man’s Land, a collection of essays on race, and she is alert to suggestions of stigma. She cites epidemiological data indicating that there is a decline in the incidence of hepatitis B only when all children are vaccinated against the infection:

One of the mysteries of hep B immunization is that vaccinating only “high risk” groups, which was the original public health strategy, did not bring down rates of infection. When the vaccine was introduced in 1981, it was recommended for prisoners, health care workers, gay men, and IV drug users. But rates of hep B infection remained unchanged until the vaccine was recommended for all newborns a decade later. Only mass vaccination brought down the rates of infection, and it has now virtually eliminated the disease in children….

This is a radical inversion of the historical application of vaccination, which was once just another form of bodily servitude extracted from the poor for the benefit of the privileged. There is some truth, now, to the idea that public health is not strictly for people like me, but it is through us, literally through our bodies, that certain public health measures are enacted.

Still, Biss wonders if there may be reasonable alternatives to vaccination that effectively protect children:

Some parents feel that the immunity produced by the chicken pox vaccine is inferior to immunity by natural infection because it does not last as long. To carry immunity through adulthood, when chicken pox can be quite serious, one must get a booster in adolescence. “So what?” my father says. I am trying to explain the phenomenon of chicken pox parties to him. I say, “Some people want their children to get chicken pox because,” and pause to think of the best reason to give a doctor. “They’re idiots,” my father supplies.

But Biss understands what appeals to these mothers: “I do not think they are idiots. But I do think they may be indulging in a variety of preindustrial nostalgia that I too find seductive.”
Then there is “Dr. Bob” Sears, who hews to a supposed middle ground. In The Vaccine Book, he claims to offer a compromise between vaccinating and not vaccinating. Sears endorses changes in the schedule of childhood vaccination for parents worried about overtaxing the immune system. He proposes a selective vaccine schedule, so a parent can provide only the vaccines that Dr. Bob believes most important. But Biss notes his omission of vaccines against hepatitis B, polio, measles, mumps, and rubella. Another strategy of Dr. Bob is to spread out over eight years all the vaccines a child typically receives in two years.
Biss rightly takes him to task, disputing his claims that tetanus is not a disease that affects infants and that measles is not that bad: “He does not mention that tetanus kills hundreds of thousands of babies in the developing world every year,…and that measles has killed more children than any other disease in history.”
After much indecision, the altruistic principle of herd immunity and its benefits for children of all socioeconomic and racial groups ultimately moves Biss to embrace vaccination.

We no longer see children stricken with polio in wheelchairs or hear of those suffocating from diphtheria, of babies born to mothers with rubella whose eyes are clouded by cataracts and hearts deformed. The success of protecting against such pathogens has removed a sense of their immediacy and caused many to forget their horror. But that may change, as we receive reports of outbreaks of infections due to unvaccinated children and mothers. In January, California health officials reported an infant death from pertussis and a measles outbreak among children who visited Disneyland. Currently, some 8 percent of children in California kindergartens are not adequately vaccinated.

The infection has now spread beyond California to Utah, Washington, Oregon, Colorado, and Mexico. Last year, California made the “personal belief” exemption law more stringent, requiring parents to submit a form signed by a health professional. But Governor Jerry Brown, at the last minute, added a religious exemption, so that parents who object to vaccination as a matter of faith do not need a physician’s signature.³
Countering such actions by state officials, the father of a six-year-old boy who had leukemia and still suffers from reduced immunity has asked the superintendent of his Marin County school district to keep unvaccinated children out of the classroom, since they pose a significant threat to his own son. The county health officer expressed sympathy for the father’s concern, but would not enforce such a ban on unvaccinated pupils.⁴
Measles in particular is one of the most contagious viruses, causing illness in more than 90 percent of those who are exposed to it. There is legitimate concern that the outbreak, which originated in California, will spread throughout the nation, particularly in locales where parents have sought exemption from vaccinating their children. Those at greatest risk for debility and death from measles have impaired immunity, like the child in remission from leukemia, or newborns whose immune systems are not yet strong enough to resist the virus. The outbreak, which is said to affect more than a hundred people in some fourteen states as of the beginning of February and is getting increasing public attention, will force the issue around parental choice and social responsibility. Governor Chris Christie of New Jersey waffled when asked whether vaccination should be mandated, asserting that there should be room for parents to choose. President Obama strongly supports the science behind vaccination, but it will take more than statements from a bully pulpit to safeguard the nation from epidemics that would be prevented through vaccination. Ultimately, either lawsuits or legislation will be needed to protect the health and welfare of children in schools and other public institutions.
My wife and I are physicians. We are acutely aware that every clinical intervention carries a potential downside. We also question clinical data from research studies and challenge the idea of a single authority that always wisely weighs risk and benefit. But we also know firsthand what infectious diseases can do. When our children were born, we vaccinated them. The natural world of unopposed pathogens is full of danger; it should not be presented as idyllic.

1. Last autumn, there were more than a hundred reports of unexplained paralysis following viral infections in the US. See Catherine Saint Louis, “After Enterovirus 68 Outbreak, a Paralysis Mystery,” The New York Times, January 12, 2015. ↩
   
2. See my “Libertarian Medicine: And Why It Doesn’t Work,” a review of Paul Offit’s Do You Believe in Magic? The Sense and Nonsense of Alternative Medicine, The New Republic, October 21, 2013. ↩
   
3. Adam Nagourney and Abby Goodnough, “Measles Cases Linked to Disneyland Rise, and Debate Over Vaccinations Intensifies,” The New York Times, January 22, 2015. ↩
   
4. Tamar Lewin, “Sick Child’s Father Seeks Vaccination Requirement in California,” The New York Times, January 29, 2015. ↩