Given the ongoing (and increasing) measles outbreak linked initially to Disneyland, it’s hard for me not to revisit the topic from time to time. This time around, there are two issues I wish to discuss, one political and one that is a combination of medical and political. After all, it was just one week ago when New Jersey Governor Chris Christie stepped in it by advocating parental choice in vaccines, as if parents don’t already have a choice. He rapidly had to walk it back, and his ill-considered remarks were almost certainly not evidence that he is antivaccine. They are, however, evidence that he doesn’t understand that we do not have “forced vaccination” in this country (we have school vaccine mandates). Parents already have choice in 48 states, given that only two states (Mississippi and West Virginia) do not allow belief-based non-medical exemptions, be they religious exemptions, personal belief-exemptions, or both, to school vaccine mandates. It also came out that in 2009 while running for Governor, Christie met with Louise Kuo Habakus (who is antivaccine) and the NJ Coalition for Vaccine Choice, a very vocal NJ antivaccine coalition whose member organization list reads like a who’s who of the national antivaccine movement and includes Life Health Choices, the antivaccine organization founded by Habakus. He even wrote a letter promising that as governor he would stand with them in “their fight for greater parental involvement in vaccination decisions that affect their children.”
It’s also evidence that vaccine mandates are becoming even more politicized. Indeed, Senator Rand Paul, on the very same day, provided more such evidence when he claimed on a conservative talk radio show that he’s seen children with severe neurological problems after vaccination, the implication being that he believed these children’s problems were linked to vaccination. Later, in a testy exchange with a CNBC reporter, who asked him whether he had really said that he thought vaccines should be voluntary, Paul sarcastically replied, “I guess being for freedom would be unusual.” Later in the exchange, after repeating the same antivaccine talking points that he had related earlier in the day, he said, “The state doesn’t own the children. Parents own the children, and it is an issue of freedom.” You get the idea. He, too, ultimately had to back off a bit, famously showing himself getting vaccinated for hepatitis A, but given that Paul has had a long history of making similar comments, this was almost certainly strategic.
What is happening is that refusal to vaccinate is being painted, instead of as a public health issue with potentially dire consequences, as an issue of “freedom.” Rand Paul’s statements are health freedom rhetoric packaged toxically with “parental rights” rhetoric in which children are viewed as the property of their parents and the parental choice always trumps the child’s right to good medical care. It’s the same sort of rhetoric I’ve decried before in the cases of children whose parents refuse chemotherapy, such as the two 11-year-old aboriginal girls in Canada (one of whom has already died) or Jann Bellamy and Harriet Hall have while discussing cases of faith healing and lack of parental accountability. No wonder the antivaccine crank blog Age of Autism loves Rand Paul.
Politicians will be politicians, of course. They go where they think there’s support and say whatever message they perceive to be advantageous to them politically. Also, Rand Paul has long been known for saying dumb things about vaccines, things no doctor should be saying. What was more disturbing was that a relatively moderate Republican as nationally prominent as Gov. Christie would think that pandering to the health freedom and antivaccine movements might be good for him politically. On the other hand, the rapidity with which these two were slapped down by the media and prominent Republican politicians rushed to support vaccines was reassuring to me that antivaccine beliefs haven’t become as prevalent as I had perhaps feared.
Of course, politicians spouting antivaccine nonsense can often be dealt with through public opinion and shame. It doesn’t always work (witness how long Dan Burton was in Congress), but they, at least, are public.
Less well known but even more pernicious are antivaccine doctors, such as pediatricians Dr. Jay Gordon and Dr. Bob Sears. If there’s one salutary effect of this outbreak, one silver lining in a dark cloud of measles suffering, it’s that the question of what to do about antivaccine physicians has come to the fore.
An even bigger problem: What to do about antivaccine doctors
As bad as the conflation of “vaccine choice” with freedom is by some politicians, what’s more difficult to fathom is how pediatricians could be antivaccine (or antivaccine-sympathetic). Given that the ongoing measles outbreak started in southern California at Disneyland and has affected mostly unvaccinated children, it’s not surprising that two of SoCal’s own antivaccine pediatricians have featured prominently in the news. I’m referring, of course, to Dr. Jay Gordon, the Santa Monica pediatrician to the stars’ children (most famously, to Jenny McCarthy’s son Evan) who has a long history of appearing with antivaccine groups, and Robert “Dr. Bob” Sears, the Capistrano Beach pediatrician known for his antivaccine-sympathetic and misinformation-packed The Vaccine Book. There is a third doctor, who is not a pediatrician and not based in southern California, who was in the news over the last couple of weeks. His case is interesting for the consequences he might suffer for his promulgation of antivaccine views.
What do I mean? The entire issue came up when former SBM contributor Peter Lipson wrote a post for his Forbes blog entitled “Anti-Vaccine Doctors Should Lose Their Licenses“, in which he argued:
State medical boards are notoriously toothless but doctors speaking out against vaccination in the midst of an ongoing outbreak should be investigated, warned, and censured. They should have their licenses suspended until undergoing 150 hours of continuing medical education on public health and infectious diseases (except that cardiologist–he should just lose his license).
As doctors we have sworn an oath to protect our patients, and if our ideologies and skills prevent this, it’s time to hang up the stethoscope.
Of course, the problem is just how toothless state medical boards are. (More on that near the end of this post.) Let’s recap what these doctors have said that might warrant such action, starting with the third (and most despicable) one, Dr. Jack Wolfson, a “paleo-cardiologist” from the Phoenix area. I start with him because his statements are the most egregious, and he has been featured all over the media, starting with the local NBC affiliate in Phoenix. (I’m not embedding the video because it autoplays and I hate that.) Upon seeing this interview, all I could think was: Wow. I’m glad this guy doesn’t treat children. Then I thought: But he does treat adults and no doubt tells his patients not to get the flu vaccine every year or other vaccines recommended for adults, such as the Tdap and the every ten years Td booster, or the varicella or zoster vaccines. I’m also guessing that he doesn’t recommend the pneumococcal vaccine to his heart failure patients, even though pneumonia, even your run-of-the-mill community-acquired pneumonia, is a life-threatening illness in such patients and the pneumococcal vaccine (PPSV23) is recommended for all adults 65 and over and for adults younger than 65 with heart or lung disease (among other indications). Instead, the ignorance flowed:
“We should be getting measles, mumps, rubella, chicken pox, these are the rights of our children to get it,” said Dr. Jack Wolfson of Wolfson Integrative Cardiology in Paradise Valley.
Wolfson does not believe in vaccination. “We do not need to inject chemicals into ourselves and into our children in order to boost our immune system,” he said.
The cardiologist also believes the key is to have a healthy immune system. In order to have that, he says, you have to avoid chemicals, get enough sleep, exercise, take good supplements, and have proper nutrition.
“I’m a big fan of what’s called paleo-nutrition, so our children eat foods that our ancestors have been eating for millions of years,” he said. “That’s the best way to protect.”
Yes, this is where Wolfson’s national notoriety began. He believes it’s your children’s right to get measles, mumps, rubella, chicken pox. Their right? But, as he goes on in the video, never inject “chemicals” into your child’s body to “boost their immune systems”? Geez, I thought cardiologists tended to be smarter than that. It does, after all, take four years of medical school, three years of internal medicine residency, and at least three years of fellowship (more for interventional cardiology or electrophysiology) to become a cardiologist, but apparently it is possible for someone as scientifically ignorant as Dr. Wolfson to become board certified in cardiology. Of course, if Michael Egnor can become a neurosurgeon while apparently understanding so little about neuroscience, then I guess I shouldn’t be surprised that Dr. Wolfson is so ignorant about vaccines, given that that’s not his area of expertise, but truly his ignorance is staggering, as he demonstrated in his response to criticism of his television appearances.
From that local interview, Wolfson rapidly landed an interview for USA TODAY:
He also did a segment for CNN in which he “debated” Dr. Armand Dorian about vaccines. I’ll warn you before you click the link that it was truly painful to watch. (Sorry, CNN doesn’t allow embedding.) Dr. Wolfson even pulls the “aborted fetal proteins” gambit. I will give Dr. Dorian credit for being suitably aggressive and doing an OK job countering Wolfson, but he seemed insufficiently familiar with how to counter antivaccine misinformation in succinct soundbites for television. But that’s not really what it’s about. What it’s about is that CNN fell into the trap of false balance, and put a particularly virulent antivaccine kook to “debate” things that, from a scientific standpoint, are not debatable.
It’s not enough to be just antivaccine for Dr. Wolfson, though. Oh, no. He has to be boorish and unconcerned about children who rely on herd immunity to protect them from measles. He was interviewed again by CNN for the article entitled, “Arizona measles exposure worries parents of at-risk kids“. Yes, it’s a story similar to another one from a couple of weeks ago in which the parents of a child with leukemia discuss how terrified they are that their child will be at risk for the measles. It’s a very understandable and reasonable fear. The reason is this. MMR is a live-attenuated virus vaccine, and live virus vaccines are contraindicated in cancer patients who are immunosuppressed due to chemotherapy. Such children have a legitimate medical contraindication to vaccination and therefore rely on herd immunity provided by having a high level of vaccination in the population of children with whom they come into contact.
If there’s one thing I’ve noticed when I describe selfishness as being one of the core motivators of the antivaccine movement, basically a lack of concern about other people’s children built on the false notion that others shouldn’t need to worry about their unvaccinated children if their own children are vaccinated, it’s that people unfamiliar with the antivaccine movement have a hard time believing it. They don’t think that people can be so callous or that such callousness is baked into their antivaccine philosophy. For those people, I present to you Dr. Jack Wolfson’s response to these parents:
But Dr. Jack Wolfson said it’s the Jacks family who should keep themselves at home, not him.
Wolfson, an Arizona cardiologist, refuses to vaccinate his two young sons. He said the family that didn’t vaccinate and endangered the Jacks children did nothing wrong.
“It’s not my responsibility to inject my child with chemicals in order for [a child like Maggie] to be supposedly healthy,” he said. “As far as I’m concerned, it’s very likely that her leukemia is from vaccinations in the first place.”
“I’m not going to sacrifice the well-being of my child. My child is pure,” he added. “It’s not my responsibility to be protecting their child.”
In other words, screw you. I got mine, and I don’t care about anyone else and am perfectly satisfied to sponge off of herd immunity. Even worse, he’s blaming cancer on vaccinations without a shred of evidence to support his viewpoint. That this man is an actual cardiologist is a profound embarrassment to the specialty of cardiology. No, it’s a profound embarrassment to all physicians. I can understand (sort of) the sentiment of some antivaccine parents that their child should be their first concern and that they are not responsible for other people’s children. I can (sort of) understand it, but I still find it to be an abhorrent attitude. However, as much as I can somewhat at least understand the roots of such an attitude, even as I disapprove of it, what I can’t understand is how someone like Dr. Wolfson takes that attitude and cranks it up to 11 and beyond:
CNN asked Wolfson if he could live with himself if his unvaccinated child got another child gravely ill.
“I could live with myself easily,” he said. “It’s an unfortunate thing that people die, but people die. I’m not going to put my child at risk to save another child.”
He blamed the Jacks family for taking Maggie to the clinic for care.
“If a child is so vulnerable like that, they shouldn’t be going out into society,” he said.
This is not the first time Wolfson has been so vile. This is not an isolated incident. It’s a pattern, as readers of my not-so-super-secret other blog pointed out to me. Indeed, this is not the first time Dr. Wolfson has blamed parents of a child with leukemia for their predicament. Interestingly, the original post referenced has been removed from Dr. Wolfson’s website. Fortunately, the Wayback Machine remembers all, and the post is archived and reprinted in full elsewhere. In the post, Dr. Wolfson responds to a story about a child with leukemia who died of complications of chicken pox and approvingly quotes his wife Heather, who is a chiropractor, who blames the mother for the loss of her child. In particular, the “Doctors Wolfson” claim that the child probably lived longer because she wasn’t vaccinated and probably gave her child Tylenol, which “depletes glutathione and is a sure fire way to allow your child to succumb to such a benign childhood illness,” concluding:
If this mother would have sought out chiropractic care, gave just two simple vitamins A and C, she would have never developed pneumonia. Also, mom fed her garbage food and exposed her to thousands of chemicals. This little girl is dead, not from chicken pox, but from chemicals and poor nutrition. Additionally, she probably had at least one vaccine, hepatitis B, when she was first born in the hospital which would have destroyed her immune and nervous system from the start.
The mother is ignorant, uneducated, and a danger to all other parents and children. She should spend her time learning how the human body works instead of spreading her deadly advice to the rest of the world.
What a lovely couple. Personally, my response to the last sentence is:
Now, Dr. Wolfson is under investigation by the Arizona Board of Osteopathic Examiners and is no longer eager to speak with CNN.
Is this right? Should Dr. Wolfson be sanctioned? Let’s revisit Dr. Jay and Dr. Bob briefly before returning to that question.
What about the antivaccine pediatricians?
You might recall that a couple of weeks ago, I discussed Dr. Bob’s Facebook activity, in which he went through numerous contortions of logic and science to try to argue that the measles isn’t that bad. (So why worry?) It’s a longstanding trope of the antivaccine movement that I’ve sarcastically labeled argumentum ad Brady Bunchium, after its frequent appeals to a 1969 episode of The Brady Bunch in which everyone in the family except Carol got the measles. (Carol, it’s revealed at the end, had had the measles before.) In the show, the disease is portrayed as mild, with the six kids relishing their time off school and playing Monopoly.
Dr. Jay couldn’t resist the same arguments, first on Twitter:
Yes, there have been cases of Disney spread from Measlesland. I will give MMRs to kids 3 yrs+ if parents are worried. http://t.co/c8plVwmRlN
— Jay Gordon, MD, FAAP (@JayGordonMDFAAP) January 8, 2015
Of course, the CDC recommends that children receive their first dose of the MMR vaccine between age 12 and 18 months. So what’s this with Dr. Jay’s obfuscating? People on Twitter wanted to know:
.@JayGordonMDFAAP You should be giving MMR to kids according to the @CDCgov recommendation, not "because parents are worried.
— David Gorski (@gorskon) January 10, 2015
Dr. Jay responded:
@scottmyers20 @gorskon @cdcgov The MMR vaccine may not be inherently unsafe but it appears safer to give it after age three years.
— Jay Gordon, MD, FAAP (@JayGordonMDFAAP) January 10, 2015
To which I responded:
.@JayGordonMDFAAP @ScottMyers20 @CDCgov That's nonsense, but assume for 1 min. it's true. Do you recommend MMR for all your patients over 3?
— David Gorski (@gorskon) January 10, 2015
Dr. Jay responded:
@gorskon @scottmyers20 @cdcgov Great question, David. My thoughts have changed because of colleges requiring MMR and travel while pregnant.
— Jay Gordon, MD, FAAP (@JayGordonMDFAAP) January 10, 2015
Which wasn’t an answer. Finally, after more pestering, he said:
@doritmi and if the parent, worried about this outbreak, wants MMR for their one year old?___I give them the MMR. My reluctance is secondary
— Jay Gordon, MD, FAAP (@JayGordonMDFAAP) January 10, 2015
@doritmi But I don't fee; great about the timing. I think the MMR risk is minimized by waiting until age three. But parents decide, not me.
— Jay Gordon, MD, FAAP (@JayGordonMDFAAP) January 10, 2015
So, as has been observed before, Dr. Jay won’t give the MMR (or, it would seem, any vaccine) unless the parent badgers him to do it. Basically, like Dr. Bob, he washes his hands of the decision (and therefore responsibility) to vaccinate, justifying it by saying he’s just letting the parents choose. The problem is that he’s “letting them choose” based on misinformed consent, in which his copious statements expressing “concern” about vaccines, invoking the “toxins” gambit, and likening vaccine manufacturers to tobacco companies, as he states unequivocally that vaccine cause autism.
Lately, Dr. Jay has been popping up in the national and international media, for example on an Australian radio show, The World Today, where he says:
This measles outbreak does not pose a great risk to a healthy child and quite frankly I don’t think it poses any risk to a healthy child.
They would get measles, not meningitis, not the plague, not Ebola – they would get measles. Measles is an almost always benign childhood illness
Dr. Jay has also appeared in the New York Times, where he says that he believes the measles vaccine is risky under the age of three, cheerfully admitting that he has no evidence to back up his claim. He was even interviewed on the CBS Evening News with Scott Pelley:
In it, he says:
This is definitely being over-promoted as a large and dangerous outbreak. It’s an outbreak of measles. If you have millions of cases of measles, there’ll be complications and fatalities. Right now we don’t have that many cases of measles, and we should speak a little more quietly, we’re actually panicking people.
So, yes, Drs. Jay and Bob are actively promoting misinformation about the measles and fear of the vaccine. Of note, in response to a measure being considered in the California State Assembly to eliminate non-medical exemptions, Dr. Bob took to Facebook in outrage:
The other issue is that of informed consent. This is a sacred right among Americans. Any medical treatment or procedure has risks and benefits, and parents have the right to make healthcare decisions for their children. We know that each vaccine has a very small risk of a severe side effect. The CDC makes this very clear. Because of this risk, informed consent must be given.
Except, as I’ve explained time and time again, what antivaccine pediatricians like Dr. Bob and Dr. Jay are doing is not giving informed consent. Far from it! They are, in fact, giving misinformed consent that grossly exaggerates the risk of vaccines (and makes up risks that aren’t supported by science), irresponsibly downplays the risks of the diseases vaccinated against, and also downplays the efficacy of the vaccines, all the while misrepresenting the science of infectious disease and vaccines.
But is that enough to justify sanctions from medical licensing boards?
Policy and regulation versus antivaccine doctors
I started this post describing a bit how politics collides with public policy with respect to vaccination, with a minority (but, unfortunately, not a small enough minority to ignore) of people conflating freedom with the freedom not to vaccinate their children and caring little about others. Dr. Jack Wolfson is a particularly odious example of this tendency, but Dr. Bob exhibits it too—in spades. Indeed, Dr. Bob recently wrote a post in which he tried to play both sides against the middle, so to speak, but, more explicitly, blew on what I like to call the antivaccine dog whistle. In politics, a “dog whistle” is when a politician uses terminology that is only well-known within a specific group of people but cloaked as supporting things people generally find good or noble (such as freedom, tradition, and the like), so that the politician can let them know that he is one of them and on their side. In antivaccine circles, I define a dog whistle similarly: It’s rhetoric that antivaccinationists will recognize as antivaccine but that most other people who are not invested in the issue will see as being about something else, something desirable, usually freedom to choose for one’s child or suspicion of pharmaceutical companies. In Dr. Bob’s case, the dog whistle is “parental choice” and “health freedom,” often with some downplaying of the seriousness of diseases vaccinated against. (In this, Dr. Bob’s Facebook post and Rand Paul’s rhetoric are astonishingly similar; astonishing, at least, if you’re not familiar with antivaccine dog whistles.)
So what can be done? Personally, I’m starting to agree with Peter Lipson that it is appropriate for medical boards to investigate doctors like Drs. Sears, Gordon, and Wolfson, but I recognize that there are a lot of problems with taking this course. First, as Dr. Lipson pointed out, state medical boards are notoriously toothless. Think about it. How many times has the Texas Medical Board gone after Stanislaw Burzynski over the last 38 years and failed? Or what about the quack whose friendship with the town sheriff led to the identification of the nurses who complained about him and their suffering severe professional and legal consequences as a result? Or what about the neurosurgeon who can’t operate and injured many patients? Or what about the oncologist who administered chemotherapy to patients without cancer and administered medically-unnecessary chemotherapy to patients with cancer? So bad was his behavior that a nurse interviewing for a job noticed that the chemotherapy was being mixed up incorrectly and complained to the state medical board with no result. This oncologist was only brought down when the feds investigated massive Medicare fraud. Second, medical boards need a concrete complaint, and that concrete complaint usually has to be about the actual practice of medicine. The Arizona Board, for example, might list 49 definitions of unprofessional conduct, but try fitting speaking out about vaccines into any of them. In Dr. Wolfson’s case, one might tag him under #19, “any conduct or practice contrary to recognized standards of ethics of the osteopathic medical profession.” Maybe.
The bottom line is that state medical boards tend to be toothless, underfunded, and overwhelmed. That’s why the only physician behaviors very likely to result in strong action consists of running a prescription mill, diddling patients, or practicing while impaired by abuse of alcohol or illicit substances. It’s a matter of resource allocation and prioritization. State medical boards tend to react primarily to what they perceive to be the most immediately and obviously dangerous behaviors. Practicing quackery rarely makes the cut, because medical boards are loathe to make value judgments about medical practice, and proving quackery is way harder and more resource-intensive than proving a doctor is an addict practicing while impaired or that he’s diddling patients. Even horrible surgeons like Dr. Duntsch, whose epic incompetence in the operating room resulted in multiple “clean kills” and so-alarmed colleagues that they actually took the rare action of complaining about him, all too often take a long time to take down.
On the other hand, medical boards have to investigate if they receive a complaint. It might not be such a bad idea to use. Also, any physician who is publicly spewing antivaccine views, like Dr. Sears, Dr. Gordon, and Dr. Wolfson, is almost certainly not practicing good medicine with respect to vaccines. And if that doctor is not practicing good medicine with respect to other things… This would be facilitated if laws were passed to define not following the CDC-recommended vaccine schedule without medically accepted reason not to as practicing substandard medicine potentially subject to sanction: Maybe not delicensing, at least not the first offense, but required remedial education, as Dr. Lipson suggested. While I’m dreaming, I might as well dream big and wish for more resources, more authority, and more ability to state medical boards to allow them to go after quackery as well. It’s a disgrace that a physician like Stanislaw Burzynski, for instance, or Rashid Buttar can practice for decades and have little or nothing to fear from the state medical board. I know that the Texas Medical Board is going after Burzynski again, and I wish it nothing but the best. Maybe this time it’ll finally succeed in stripping Burzynski of his medical license. But it would not surprise me if it did not.
The bottom line is that practicing medicine is a privilege, one of the highest privileges society can grant to a human being. It is not a right. Unfortunately, all too often the law treats it more like a right, with state medical boards being loathe to strip quacks and other doctors practicing inarguably substandard medicine of their privilege to practice.
Finally, on another note, sanctioning antivaccine physicians is likely not by itself going to have a huge effect on this problem. That’s why I think the time has come to eliminate non-medical exemptions to school vaccine mandates, as some legislators in California are trying to do. The political opposition will be fierce, and they might well fail, but if they can at least make such exemptions much harder to get, then there is the potential to eliminate these pockets of low vaccine uptake.
Now if only we can think of something to do about antivaccine comedians like Bill Maher using his show as a platform to preach antivaccine pseudoscience.