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I’m ba-ack.

As I announced three weeks ago at the end of my last blog post before going on medical leave, I underwent surgery. In the nearly three weeks that I’ve been away, I thought about just how much to reveal and how much not to. Basically, I developed a pretty nasty cervical radiculopathy, complete with pain and some weakness. Conservative management, including steroids followed by two steroid injections, helped some, but I hit a plateau where I wasn’t improving any more. The pain was still quite bad, to the point where it was still interfering with my work; so I decided not to bother with a third steroid injection and went for surgery. Fortunately, I was a good candidate for a foraminotomy (enlarging the foramen, or hole, through which the affected nerve passes) and didn’t need removal of the disc and fusion of the two involved vertebrae. Thus far, the results have been good, although I do remain surprised at how much such a small incision can still hurt after nearly three weeks, but such is life. Now it’s on to physical therapy.

So what to write about for my return? This post might be a little disjointed and shorter than my usual logorrhea, because I’ll probably need a bit of time to get back up to speed. However, it’s pretty hard not to take note of all the vaccine-related stories that have been going on in my absence. For instance, thanks largely to the antivaccine movement, there are multiple measles outbreaks around the country. According to the CDC, as of April 4 there were 465 cases documented in 19 states, more than the total number of cases recorded in the last three years, and we’re only one quarter of the way through 2019. At this pace, we’re unfortunately currently on track to surpass 2014 nationwide total of 667 cases—and by a huge margin.

By far the largest of these outbreaks is centered in Brooklyn and Queens, with 285 cases since October (229 so far in 2019), most of which involved members of the Orthodox Jewish communities in those boroughs. Further up the Hudson River, in Rockland County, NY, there’s another outbreak ongoing, whose 2018-2019 total is up to 184 cases, which the Rockland County Department of Health breaks down this way:

Vaccination rates for confirmed measles cases in Rockland County as of April 12, 2019:

  • 81.0% have had 0 MMRs
  • 4.3% have had 1 MMR
  • 3.3% have had 2 MMRs
  • 11.4% unknown status

It is, of course, not at all surprising, as most of the cases have been associated with failure to vaccinate. Elsewhere another large outbreak is in progress centered in Clark County, WA just across the Columbia River from Portland, OR. There, they’re up to 74 cases. Not surprisingly, a prominent antivaxer, Dr. Paul Thomas, whom I’ve called a “rising star” of the antivaccine movement, practices in Portland and is making claims that he has almost no autism among his unvaccinated patients.

Unfortunately, we in southeast Michigan are not immune to this problem. We have a measles outbreak that’s currently up to around 40 cases, again associated with lack of vaccine uptake and international travel. (Indeed, I called it when I said that the first outbreaks in Michigan would occur in Oakland County, which is densely populated and antivaccine-central for the Detroit metropolitan area.) Considering all these measles outbreaks, I wanted to discuss two things: first, how these outbreaks have been shaping our conversation about vaccines, and, second, how they are interrelated. To discuss the second point, I will look at a news story that appeared yesterday in my local newspaper, The Detroit Free Press, entitled “How Oakland Co.’s Orthodox Jewish enclave became the epicenter for Michigan measles outbreak“. (I like to discuss local issues that are related to broader concerns, because, hey, how many skeptics and bloggers with a special interest in the antivaccine movement are based in the Detroit area?)

Antivaxers react to the backlash

If there’s one thing that’s been happening as a result of the ongoing and growing measles outbreaks throughout the US, it’s been a backlash against antivaccine viewpoints. It’s the same phenomenon that we observed after the Disneyland measles outbreak four years ago. It was that very backlash that provided the political will in California to pass SB 277, the law that eliminated nonmedical personal belief exemptions to school vaccine mandates. It’s a law that’s worked so far, with significant increases in vaccine uptake observed. Unfortunately, it became clear that SB 277 has a significant flaw. It’s a flaw that I pointed out soon after its passage, namely that any physician can write a medical exemption for basically any reason, regardless of whether that reason has a basis in science and clinical evidence. As a result, soon after SB 277 passed, a cottage industry of selling medical exemptions popped up, pioneered by antivaccine-friendly pediatrician Dr. Bob Sears, who was observed selling them online.

Unfortunately, after the measles outbreak abated, so too did the political will to pass further legislation making exemptions to school vaccine mandates more difficult to obtain. Here in Michigan, the Department of Health and Human Services did it administratively by requiring parents seeking personal belief exemptions to go to their county health department to undergo an educational course by a public health official before being granted an exemption. Even that small measure, although successful, resulted in a backlash among antivaxers, who successfully conflated the ability of parents to refuse vaccines for their children with issues of personal freedom and parental rights to persuade conservative legislators to try to pass legislation to make measles great again in Michigan. The bill, if passed, would have stripped from the Michigan Department of Health and Human Services the power to require parents to attend an educational program before being granted a nonmedical exemption for school vaccine mandates, but it’s even worse than that. The law, if passed, would have made it much more difficult to exclude unvaccinated children from school during an outbreak of vaccine-preventable disease. Meanwhile, in 2018 several Republicans actively campaigned on antivaccine-friendly promises in my state.

If there’s a good thing about this measles outbreak, it’s that the backlash against the antivaxers who contributed to it has once again forged the political will in several states to propose measures to tighten up the requirements for medical and non-medical exemptions. For instance, in California Senator Richard Pan, who co-authored SB 277 and lobbied to get it passed, has recently introduced a bill (SB 276) that would address the loophole allowing physicians to use any reason in justifying a request for a medical exemption by requiring the state health department to vet each medical exemption form written by physicians. The department would also maintain a database of exemptions that would allow officials to monitor which doctors are granting the exemptions, and the state would rely on federal guidelines to determine which reasons are valid for vaccine exemptions. This is the same approach that West Virginia uses.

Meanwhile, other states, including Washington and Maine, are considering bills that would end nonmedical exemptions to school vaccine mandates, while New York Mayor Bill DeBlasio issued a mandatory MMR vaccination order for the affected areas of the city. In Rockland County, a measles emergency was declared that barred children and teenagers who are not vaccinated against measles from public places. It was halted through a preliminary injunction soon after, but the fact that public health officials and politicians are now willing to go that far to control measles outbreaks is a sea change in attitude from even a year ago.

In response to the backlash, antivaxers have, predictably, dug in their heels and become even more intransigent. Perhaps the best example of this occurred a couple of weeks ago in Texas, when antivaxer Del Bigtree, who produced the antivaccine propaganda film disguised as a documentary (or, if you prefer, the antivaccine quackumentary), VAXXED, held up a handmade Yellow Jewish Star of David in “solidarity” with the Orthodox Jews of Brooklyn where a large outbreak of measles is currently centered.

Condemnation was swift:

This time, he had a prop: Near the end of his speech, he affixed a yellow Star of David to his coat with the words “No Vax” across the center. It was a symbol, he said, of solidarity with New York’s Orthodox Jewish community, which is in the throes of a measles outbreak.

Condemnation of the stunt—from the Auschwitz Memorial Museum and the Anti-Defamation League, among others— was swift. But Bigtree said he wasn’t worried about the criticism.

“Honestly, I was doing what I thought I was raised to do, which was stand up for minorities,” he told The Daily Beast in a recent interview. “A Jewish community was going to be quarantined and not allowed to go into their own synagogues during Passover. To me it seems so obvious that smacks of the issues in Germany.”

Bigtree’s explanation for why he used the Yellow Star of David is transparent, disingenuous nonsense. He’s never shown evidence of standing for minorities that I’m aware of other than in the context of the antivaccine movement. Indeed, he arguably exploited the distrust for the medial system held by African Americans in his use of Brian Hooker’s bogus “reanalysis” of a study that purportedly showed that the MMR vaccine was associated with an increased risk of autism in African-Americans. He’s gone to Compton to preach the evils of vaccination, not unlike the way that Andrew Wakefield went to Minnesota to fuel the measles outbreak among the Somali immigrant community there.

I’ve written about the penchant of prominent antivaxers to liken school vaccine mandates to the persecution of Jews by the Nazis. Indeed, RFK Jr. himself once likened vaccination to the Holocaust. (But don’t call him antivaccine!) This isn’t even the first time that antivaxers have misappropriated the symbol of the Nazi persecution of the Jews, the Yellow Star of David that the Nazis forced Jews to wear in order to be instantly identifiable. During the political battle in 2015 over SB 277, an antivaxer named Heather Barajas made a badge with a syringe on it. True, it wasn’t yellow, and it wasn’t a Star of David, but her intent was explicit in the Facebook post in which she showed off her new badge with her child in a photo with photos of Jews during the Holocaust wearing Yellow Stars of David. She deleted it, but I preserved it (unfortunately I did not preserve the text):

That was 2015. In 2019, everything’s been amped up, leading to Del Bigtree’s appropriation of the idea of a yellow star badge. Bigtree’s not the only one, either. Here’s a version that’s been popping up on social media all over the place:

As the measles outbreaks continue to grow and the backlash against antivaxers grows with it, I fear even worse reactions from antivaxers. After all, Del Bigtree has been known to say that “now’s the time for guns“, and during a trip to Michigan in 2016 said this in a speech to antivaxers:

If we do not fight now, then there will be nothing left to fight for. And I think that is where everyone in this room, I pray you realize how important you are in this historic moment. We will never be stronger than we are right now. We will never be healthier than we are right now. Our children are looking like this, a generation of children, as we’ve said on The Doctors television show this is the first generation of children that will not live to be as old as their parents. Are we going to stand…are we going to sit down and take it? Or are we going to stand up and say: This is a historic moment, that my forefathers, those from Jefferson all the way to Martin Luther King, the moments where people stood up and something inside of them said I’m going to stand for freedom and I’m going to stand for it now. That is in our DNA. It is pumping through me, and I pray that you feel it pumping through you, because we must look back. Our grandchildren will look back and thank us for having stood up one more time and been the generation that said, “We the People of the United States of America stood for freedom, stand for freedom. We will die for freedom today.

Yes, I know that Del Bigtree is a blowhard. I know that he is likely just playing to his audience with hyperbole. Even so, I’m not exaggerating when I say that I fear violence is not an impossibility. Antivaxers are already busy harassing physicians who speak out against antivaxers and for vaccines in order to intimidate them into silence. Online, they are arguably winning, because pro-science, pro-vaccine groups are only recently organizing more effective countermeasures against the threat, and Hollywood is starting to feature storylines illustrating the threat of the antivaccine movement. Even Saturday Night Live featured a sketch making fun of Jenny McCarthy and antivaxers the other night.

We’re all in this together, or: The narrative is more complicated than you think

The US is not the only place where there are ongoing measles outbreaks. Indeed, the outbreaks here pale in comparison to outbreaks elsewhere, particularly Europe, where there have been massive outbreaks including deaths, Israel, and the Philippines. In our local Sunday Free Press, there was an interesting story illustrating how vaccine hesitancy and antivaccine views must be combatted around the world. It’s by Kristen Jordan Shamus and it’s entitled “How Oakland Co.’s Orthodox Jewish enclave became the epicenter for Michigan measles outbreak“:

It was a traveler from Israel, state health officials say, who unknowingly brought the measles to Oakland County in early March, and sparked what has become the largest measles outbreak in Michigan in 28 years.

Before he came to visit an Orthodox Jewish enclave in Southfield and Oak Park, the man spent some time in New York, where an unrelated and fast-spreading measles outbreak among mostly unvaccinated children led the mayor last week to declare a state of emergency.

Once he got to Michigan, the man spent his time at Jewish synagogues and institutions to pray and study every day from March 6-13, unaware that he was spreading the virus along the way.

And:

Eliav Shoshana, a father of six from Southfield, didn’t know that the traveler had exposed him to the measles at Congregation Yagdil Torah in Southfield on March 9, said his wife, Henny Shoshana.

“My husband was sitting in a synagogue and studying Torah and praying” that day, Henny Shoshana said. “He realized in retrospect there had been a person there who seemed sick and was coughing a lot. He was covering his mouth. … I am sure he was horrified when he realized what had occurred. He probably had no idea that he had measles and that it is so highly contagious, even covering your mouth can allow some droplets to escape.”

What’s particularly interesting about this story are a couple of things. First, what got the measles outbreak going was a “perfect storm”:

“There was this perfect storm that led to the outbreak in the Michigan Orthodox community,” Henny Shoshana said. “In the run-up to this holiday, which as you can imagine takes a lot of preparation … people were contagious but not aware yet they were sick — either entirely asymptomatic or maybe feeling a little under the weather.

“Because it happened over Purim, the breadth of the exposure was enormous, obviously. That’s really the story of what happened over here.”

She recalls celebrating Purim at parties on the evening of March 20 and continuing until March 21.

“We went to this big party that had at least 150 people there, including infants and pregnant women,” she said. “And again, we went not knowing he was sick at all, and certainly not with the measles. Then, that night, he came home, and it was very clear he had a fever. So he stayed in bed.”

More importantly, it shows that it’s not just antivaxers that fuel outbreaks. Contrary to the Orthodox Jewish community in Brooklyn, where there is an even larger outbreak of measles, the Orthodox Jewish community in Michigan is pro-vaccine. What facilitated the spread of measles within the community was that there was a larger number of susceptible people than known. There were many adults who thought they were immune who turned out not to be:

“The quick spread of the virus,” said Lynn Sutfin, a spokeswoman for the state DHHS, “had more to do with how many places he visited, the number of people exposed initially (the couple weeks before Purim), and subsequent exposure of close/household contacts to confirmed cases.

“The other thing that played a role in this is the number of individuals who were susceptible to measles. Unfortunately, there were many adults who thought they were immune to measles but ultimately were susceptible.”

The result? The Council of Orthodox Rabbis of Greater Detroit issued a statement:

The response was immediate and striking. Members of the Orthodox Jewish Community turned out in droves to be vaccinated. In just three days, the health division administered 970 MMR vaccinations, and in one week the health department gave over 2,000 doses of MMR, not counting the hundreds of vaccine doses administered in private doctors’ offices to babies, children, and adults for whom documentation of measles vaccination could not be found.

Which brings me to another point. The narrative is not as simple as saying that antivaxers are solely responsible for measles outbreaks. They are, without a doubt, a major factor, but other factors contribute as well. Antivaxers are an easy scapegoat, the more so because they most definitely do contribute to outbreaks of vaccine-preventable diseases. However, they could not be so effective if there were not other factors that leave people unvaccinated and other situations. Combatting antivaccine misinformation is still critical, but it is not enough.

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Posted by David Gorski

Dr. Gorski's full information can be found here, along with information for patients. David H. Gorski, MD, PhD, FACS is a surgical oncologist at the Barbara Ann Karmanos Cancer Institute specializing in breast cancer surgery, where he also serves as the American College of Surgeons Committee on Cancer Liaison Physician as well as an Associate Professor of Surgery and member of the faculty of the Graduate Program in Cancer Biology at Wayne State University. If you are a potential patient and found this page through a Google search, please check out Dr. Gorski's biographical information, disclaimers regarding his writings, and notice to patients here.