The Home Birth, "Natural" Child Birth, and U.S. Hospital Birth Debate Part I: Hospital Safety, C-Section Rates, and Paternalism

Aaaaah friends.  Just when I vowed to extricate myself from the black hole of vaccine debates and finally start going to bed on time, along came a parallel and equally frustrating universe:  That of the home birth (HB), "natural" child birth (NCB), and U.S. hospital birth debates.  Without further ado, here's what I think you should know about all this:

In direct contradiction to what you might have heard, U.S. hospitals have excellent safety stats.

Although it seems incredible, there is no shortage of NCB/HB proponents who will tell you that "infant mortality" in the U.S. is very high, as if that's a reason you should birth at home and/or live in fear of your healthcare providers.  Alarmingly, many of the people spouting this nonsense are paid birthing "professionals" ("childbirth educators," "doulas," and even so-called CPM "midwives" - paraprofessionals, really).  Here's the deal:  Infant mortality is a statistic counting every baby born alive who dies before 12 months of age.  Ours is high compared to other first-world nations because we lack universal health care coverage and we have bigger pockets of poverty.  

The relevant statistic is perinatal mortality.  Perinatal mortality counts deaths during labor (intrapartum deaths - stillborn babies) and deaths within a week of birth.  Guess what?  We are not too shabby.  The World Heath Organization gives us a rate of .7%, comparable to other Western nations and better than many of them - better than the U.K.   Other Western nations that have us beat generally have a rate of .6%, so just a .1% difference.  You can check out the WHO's report on perinatal mortality here.  And keep in mind that maternal obesity increases the risk of perinatal death by about 20% per every 5 BMI points… so really, our safety stats are actually pretty darn phenomenal.  And that's without universal coverage too!

On our c-section rate.

Speaking of comparative statistics, here's a fact you won't hear from NCB/HB advocates:  Yes, Canada (for example) has a lower c-section rate than we do (22.5% versus 33%).  But their rate of operative vaginal birth (OVB), meaning forceps and vacuum-assisted deliveries, is much higher.  Theirs is 14.9% versus ours, which recently dropped again to 3.5%.  Guess what that means?  It means that our rate of unassisted vaginal delivery is actually just about the same, or higher, than theirs.  And this is true of other comparable nations as well.  Check out the U.K. (12.8%; 25.5% c-section rate), Australia (11.1%), and Ireland (16%).  None of those other nations have our legal climate, and none of them have our (alleged) profit incentives, either.  What gives?  Probably that doctors fear hypoxic brain injury whether or not they also fear a law suit, and whether or not they can charge extra for a c-section.  

Why have our doctors essentially replaced OVBs with c-sections?  It's a complex topic.  If you're interested, I would encourage you to read "The Score" by Atul Gawanda - a fascinating article on the history of childbirth in the U.S.  You should also be aware that there is a new movement to bring back more OVBs - check out the ACOG's press release about the new c-section reduction guidelines.

So why is our c-section rate high, other than our OVB rate being so low?  Here are a few other reasons.

And for the record, I'm not arguing that our c-section rate isn't "high."  I don't know what an "ideal" c-section rate would be for our demographics, and neither does the WHO; the oft-quoted 10-15% is a 27-year old statement that was retracted in 2005.  I'm simply pointing out that our c-section rate is not as comparatively "high" as it's made out to be and that there are many legitimate reasons behind it … reasons you never hear about from NCB proponents or uber-crunchy "mommy blogs."

• Obesity.  As is commonly known, the U.S. obesity rate is the highest in the world.  Nearly 33% of U.S. adults are obese - about 10-12% higher than any other comparable country.  Obesity significantly increases your risk of the following conditions that in turn make it more likely that you'll need a c-section:  (1) high blood pressure; (2) preeclampsia; (3) gestational diabetes; (4) preterm birth; and (5) other complications during labor and birth.  In particular, having a BMI greater than 30 - the technical definition of "obese" - doubles your chance of having a macrosomic baby (a baby 8 lbs 13 oz or more) which, in turn, doubles your chance of needing a c-section.  And as I mentioned above, it significantly increases the risk of perinatal death.  It's a sensitive subject for both patients and doctors but one that cannot be left unaddressed; click here for a thoughtful commentary written by an OB.   
• Herpes.  Genital herpes is significantly more common in the U.S. than in other comparable nations, and it poses serious risks to a baby.  While about half of babies who contract Neonatal Herpes will have no permanent damage if treated with antiviral medications, others will suffer serious neurological damage, mental retardation, or even death.  For that reason, a c-section is standard procedure for any mother with an active outbreak of herpes at time of delivery (10-14% of women with herpes).  Where one in six adults in our nation has herpes (and other sources I checked said higher, 20-25%), this means that herpes alone probably accounts for 2 - 3.5% of our 33% rate of c-sections.  And none of these women are going to tell you the real reason for the c-section.  So next time you hear a suspect reason, keep in mind that you might not know the whole story.
• Advanced Maternal Age Pregnancy.  The younger a mother is (obviously, to a certain point), the less likely she is to need a c-section or an assisted vaginal delivery, and mothers 34 years of age and older are at a significantly increased chance of needing a c-section delivery.  This remains true when we control for the fact that older moms are more likely to electively induce; even naturally occurring labors in older moms are more likely to fail to progress and/or result in a c-section for fetal distress - and moms over 40 are more than twice as likely to have a breech baby (see also this CDC chart, showing c-section rate by age of mother).  Here in the U.S. about 14% of birthing mothers are 35+ years of age - and that was true even back in 2008.  Compare to 11% in Canada and fewer still in most other Western nations.  I suspect that, if anything, our rate has continued to increase over the past six years; indeed, rates did continue to rise in 2013.  Advanced maternal age in pregnancy (and advanced parental age in pregnancy - dads too) also increases the risks of other complications and of certain birth defects including Down syndrome and autism.  So the next time someone tries to tell you that autism is caused by "interventions" like pitocin (or by vaccines), you can remind them that correlation is not the same thing as causation; births to older parents are more likely to produce autistic children and they are more likely to involve complications.  There is no reason to believe that the complications "cause" the autism.
• Multiples.  As maternal age goes up, fertility goes down.  That - coupled with advancements in fertility treatments for couples of all ages - means that multiples are far more common now than they used to be, especially in the U.S. where lots of couples have the resources to pay for them (or health insurance companies are legally required to cover them, as is the case in my state Massachusetts).  While protocol for twin births has recently changed to encourage attempting vaginal birth in situations that meet certain criteria (first twin head down, babies at a healthy weight for their gestational age, and delivery occurs between 37w5d and 38w6d of gestation), 44.2% of attempted vaginal twin births still end either in a c-section (40%) or in a combination vaginal and c-section birth (4.2% - yeeeowch).  To say nothing of triplets, etc.  Check out this article on "The Problem with America's Twin Epidemic." 
• Other Speculative Reasons.  I haven't seen any studies on this but it does seem to make sense that a "melting pot" nation might entail more c-sections or OVBs.  Different races have different builds, and if you mix a larger skull with a narrower pelvis, it does seem like you'd be more likely to run into difficulty (whereas the opposite wouldn't change anything).  I'm thinking of my sister-in-law who, like my husband, is half-Asian and very petite.  She and her much taller, bigger-boned (not a euphemism) Scandinavian-descent husband made a pretty big baby who was delivered with forceps.
• Epidurals.  Nope!  I was just as surprised as you are, but epidurals given at 4 cm dilation and beyond do not increase your chance of having a c-section.  You can read a more thorough discussion of this in my other blog entry "Five Mommy Myths I Believed."  And be aware that many NCB courses teach completely outdated information on pain relief methods.  Did you know that you can now control your epidural such that you can still feel your contractions?  I didn't get an epidural with my #2 until I was over 9 centimeters, and I clicked just enough to make my experience pleasant.  Which it really, really was.  Nor will it make your baby groggy.  I had an epidural for 18 hours with my #1 - he was not groggy and nursed just fine.  The medicine doesn't go into your blood stream; it goes into your spinal cord fluid.  And an epidural can actually relax your pelvic muscles so that you dilate faster.

On the alleged "Paternalism" of U.S. OBs and whether you can expect your hospital experience to be miserable.

If you're following this topic at all, you've likely heard that U.S. hospital births are miserable experiences in which women are utterly disrespected, to the point of being "birth-raped."  Here's what I think is worth noting on this issue:

• It's definitely true that some physicians have terrible bedside manners and/or are incompetent - not even following the current ACOG guidelines themselves.  All professions have incompetent practitioners, midwifery and nursing included.  As someone who sacrifices every day so that my perfectionistic husband can offer the best care possible to his oncology patients, I have to say that I find incompetent and/or slacking doctors really reprehensible.  Physicians who short-change their jobs are not only endangering their own patients, but they are making it more difficult for other people to trust and feel comfortable with medical providers; they are directly fueling the anti-vaxx and the home birth/NCB movements.  Plus, their slacking is making more work for dedicated physicians like my husband - physicians who do care and who will take the time to explain everything to the questioning, misled patient.  
• All that said, many NCB/HB courses and proponents give a highly skewed idea of what a typical hospital birth is like.  This sets women up not only to go into their births with fear, but also to find things wrong with their experiences that are not, in fact, wrong.  Here's an article with statistics on that, but possibly more compellingly, here is my friend Dani's blog that describes what she was led to expect from a hospital birth versus what her experience actually was, when she ended up unable to avoid one.  She's a doula, by the way, and remains supportive of natural child birth… but she's science-based and she doesn't inflate the "benefits."  
• On "pushing interventions" - I really think it's of utmost importance that physicians explain why they are "pushing" an intervention; if they don't, they're leaving the door WIDE open for some new mom's friend to tell her that her birth was "ruined" for no reason - and that will happen.  I hear so many stories where (allegedly, anyway) all the OB says is "I feel strongly that we should do X right now."  No.  If studies show that given the conditions presented, there would be a 5 per thousand (.5%) increase of perinatal mortality if, for example, labor continues past a certain time, tell the patient!  Tell them that since you deliver an average of 500 babies per year, you WILL SEE babies die or be born damaged who didn't have to be, if you aren't risk-averse!  Admit to them that yes, not intervening might significantly increase their chance of a vaginal delivery… but tell them that in your opinion, even a small risk to the baby's life or long term health isn't worth even a significantly greater chance of a vaginal birth!  And please be sure to also tell the women who are not fighting or questioning you!  They are questioning in their minds but too polite and/or overwhelmed to ask, and they deserve to know.
• Meanwhile, some patients need to realize that the laboring mother is NOT the OB's only patient. The baby is equally the OB's patient and the OB's highest duty is to protect life, not to avoid c-sections.  
• Did you know that over 80% of current OB residents are female, and OBs as a demographic are getting younger?  These women are feminists and trail-blazers ... they're strong and dedicated women who usually care deeply about getting it right.  They're not out to cut you open for money.  When I asked my OB about an induction at 39 weeks with my second baby (because of my first baby's macrosomia) she strongly discouraged it.  Now… compare all that to the roots of the NCB movement:  Male physicians deciding that childbirth pain was all in women's heads.  And to the current NCB movement - paraprofessionals feeding women inaccurate, misleading, and false information in order to make their system look more necessary than it actually is - see my other post on myths about epidurals and 41 week inductions.  Who's paternalistic now?  And whose business is completely dependent on all this ... and who has the luxury (and the scientific resources) to simply seek truth?  I'll give you a clue:  Home births represent .5-1% of all U.S. births - ZERO impact on any OB's salary.  But they represent 100% of the revenue for home birth practitioners.
• I often see the idea perpetuated that OBs will perform a c-section because it's "better for their schedule."  ????  Are you living in a rural area?  I labored 15 hours at home and 18 more at the hospital.  I went through at least two OBs; when their shift was over, they left.  My labor didn't make any difference to anybody's work schedule.   

I have to cut this off for tonight.  But here's some food for thought:  If you didn't like your attorney, or you suspected that he or she was incompetent, would you replace your attorney with a paralegal or a legal secretary?  Why not just find a better attorney?  CPMs (lay midwives) and "childbirth educators" are not professionals.  No professional organization is holding them accountable for anything they say or present to you.  Compare that to OBs and hospital-based CNMs (nurse midwives) who function as part of a team under layers of accountability in hospital settings - oversight boards, patient satisfaction surveys, safety protocols, and potential legal action.  It's cost-prohibitive to sue CPMs or "lay midwives" because they don't carry malpractice insurance … more on that later.

Like vaccines, the best answer here is to find a physician or hospital-based CNM you trust.  Just as surely as you cannot adequately represent yourself in court (or fly your own airplane), you cannot be your own "best" physician via google, mommy blogs, or any other non-science based source.  

Part II discusses the dangers of U.S. home birth and how NCB propaganda fuels home births.

My first baby was 9 lbs 10 oz and at a bad angle for pushing, as seen in his swollen-shut eye.
As with many macrosomic (8 lbs 13 oz+) babies, my labor (NOT induced) was protracted -
15 hours at home to get to a 4, 18 more before he came out.
His head was 99/100th percentile circumference, and It.  Was.  Stuck.

My second baby was a full 3 lbs lighter and with a much smaller head.  She came out in 5 pushes.

My OB is a mom herself.
She strongly discouraged my request for a 39-week induction with #2,
which I made because of #1's macrosomia.
… was that "paternalistic" of her?
… did she "push" a natural childbirth on me??
(Irony intended).

Click HERE for Part II.

Five Mommy Myths I Believed.

Looking back at the start of my motherhood journey, I could have saved myself some stress by doing a little fact-checking.  Even though I'd cross-examined plenty of witnesses during my lawyering years, I started motherhood out pretty much believing everything I heard or read from other moms.  See, to a new mom (or at least to this new mom), experienced moms are like gods.  (Or goddesses).    

Most of these experienced moms are well-intentioned; they believe what they heard or read somewhere and are just passing it along to be helpful.  Or perhaps they did "verify" their information... but they were looking at a non-scientific, biased source.  Either way, there are quite a few Mommy Myths floating around out there that simply aren't true.  Here are five of them:    

1.  Getting an epidural increases your chance of having a c-section.  

I give myself a pass for having believed this one because it does seem to make a lot of sense.  If you're able to get up and walk around throughout labor, and try out different pushing positions, wouldn't that make your pushes stronger?  Or wouldn't an epidural make them weaker?  Or something?

As it turns out, there is no dispute that once you hit 4 cm dilation, an epidural doesn't increase your chance of having a c-section.  Here's a brief overview of the "gold standard" on this topic, a 124-page meta analysis (meaning, a study of studies - in this case, a study of 38 other studies).  It came out in December of 2011 and was provided to me by a friend who holds an MD and a PhD in anesthesiology; I wish I could provide you with the full text but I'd be infringing copyright.  My friend's career will be anesthesiology research and Harvard wanted him for residency, and he's a super nice guy.  And he was looking into this for his pregnant wife - who did get an epidural - that makes him my gold standard.

It is also not clear that epidurals have any impact on your chance of successful breastfeeding, which makes sense since the medication goes into your spinal fluid, not your blood stream - I was on an epidural for 18 hours with my first and he was not groggy and nursed just fine.  But this topic is probably too nebulous to really be a complete "myth."  

Please see my own comment to this post, below; I am not arguing that there is no benefit whatsoever to not getting an epidural, I am simply dispelling the myth that you increase your chance of a c-section by doing so; you don't.  

2.  You must have a supply issue if [insert any number of things].

You must have a supply issue if (a) your child loses interest in nursing before turning two (or three... or thirty); (b) your child starts sleeping through the night (better wake up anyway ... and pump!); (c) Your boobs feel flat; (d) you don't get much when you pump; (e) your child ever cries ...

Nope.  The truth is that the only way to tell you have a supply issue is if your baby stops gaining or starts losing weight.  With both my babies I went through phases of being positive I had major supply issues... my breasts felt totally flat, I only got 1-2 ounces when I pumped (even if it was time for a feeding), and my child was only nursing 1-3 minutes per side, 3-4x/day, and not at night.  But thanks to KellyMom I just kept on keeping on and I nursed both babies, waxing and waning (probably depending on their growth spurts) until about 15 months.  At that point they lost interest.  Even in the morning, which was the only time of day it actually was clear that I had some milk.

It's strange to me that many of the people who so strongly believe that almost all moms are capable of exclusively breastfeeding their babies are also hyper-obsessive about supply maintenance... 

3.  Inductions should be avoided at all costs; your OB is only trying to up her chances of a lucrative c-section!  

When I got to be 38 weeks along and my OB wanted to schedule an induction for 41 weeks, I knew just where to go for some "real" medical advice:  My local mommy list serve, of course!  I asked, and I read the archives, and it didn't take me long to find plenty of threads amounting to "I learned in my 'natural childbirth' class that you should almost never allow induction" and "my midwife says inducing before 42 weeks increases your chance of c-section" etc.  Now there was one comment by a mom saying that she pushed her OB to wait until 42 weeks and it backfired, since by then her baby was too big to deliver vaginally.  But I discounted her opinion since everybody knows that the size of the baby doesn't matter, duh!

But seriously, I was completely distraught; did I need to find a new OB or switch to a midwife this late in the game?  Would my insurance even cover that??  It's humorous in retrospect but it was downright miserable at the time.  Thankfully my (physician) husband was able to research the issue for me... and find that induction at 41 weeks does not increase your chance of c-section like earlier inductions do - and in fact, it's safer than waiting!  This is presumably because having a macrosomic baby (8 lbs 13 ounces or more) actually does double your chance of a c-section - along with other complications - and your baby is only getting bigger the longer he cooks.  I never did need that induction, but when my OB told me she was impressed that my macrosomic son came out vaginally (he was 9 lbs 10 oz, 99th/100th percentile head ... and I'm 5'3" and petite; he was delivered with forceps assistance) I secretly thought she was just saying that to pad my ego or something.  Because at that point, I still knew that "the size of the baby doesn't matter."

You can click here for a list of 124 peer-reviewed studies on Fetal Macrosomia.  Or click here for an excellent article by a renowned obstetrician that will probably clear up some other misconceptions you might have, too.  If you've seen "The Business of Being Born," click here and here. 

Actually, size does matter.  This was me somewhere around 40 weeks with my first.
(Please, I beg you:  Ignore the shoes).

After laboring at home for 15 hours overnight, I looooOOOooved me some epidural!

I just want to thank my OB, the hospital staff, and the scientists who made my birth as unnatural as possible.
They saved my baby's life and my own life, and saved me from what would have been unimaginable pain.
With my #2 I got past a 9 before they got my epidural in... it was a breeze.
And seriously - check out his head - he was 6 weeks in this pic, his head not all that much smaller than ours!!

4.  If you're doing it right, nursing shouldn't hurt.

Being the ever-diligent, slightly-crunchy mom that I was, I obviously signed up for a breastfeeding prep course taught by a Certified Lactation Consultant ("CLC").  Adorably, my husband even came with.  There, I learned that breastfeeding was nothing but dreamy - unless you were doing it wrong.  No problem, how could I possibly do it wrong after learning about something so "natural" for three solid hours ... to the tune of $70.00??

Fast-forward to the birth of my son.  Nursing in the hospital was pain free and my milk came in right away.  My son was a great nurser and the only problem was getting myself positioned in a way that wasn't excruciatingly painful to the nether-regions that delivered him.  All the nurses were so impressed, one even told me that "my problems [with delivering a huge baby] were ending, right when all the problems usually begin."

Then I got home.  And holy MOLY did it start to hurt.  It hurt so badly that I walked around for days - weeks even - in a nursing tank with the flap pulled down.  I even answered the door that way, it was so second-nature to me (thank God it was a female neighbor).  People:  I flashed my father-in-law.  There were lotions and soothies and "airing out" and everything else I could possibly think of or get my hands on.  I called pretty much every other mom I knew, even though I am a professed phone-hater.  The worst part was, I lost a lot of the intense bliss I was otherwise feeling and a lot of the family time I'd have had on my husband's 2-week paternity leave (which was pretty much the last time I ever saw him awake until residency was over) frantically trying to figure out "what I was doing wrong" - because I was so worried that I was sabotaging my nursing.  I watched youtube videos, I googled, I emailed, I even drove to a friend's house to show her my nipples, and I went all over town to "nurse teach-ins" with CLCs.  At the nurse "teach-ins" all I got was further confirmation that it shouldn't hurt, and the suggestion that my son was likely tongue-tied ... so I had better set up a private consult, stat!

I was on the verge of caving even though we could not afford a private consult at the time when I thankfully asked my son's pediatrician about it.  In under 10 seconds he gave me the best advice I'd yet received.  He said "I really think there's too much 'dogma' out there about nursing; The proof is in the pudding, and he's clearly getting plenty of milk."  Then my own OB gave me a script for APNO (a prescription nipple ointment for nursing - that was never once mentioned in my $70 CLC class) and it rocked my world.  As it turns out, I was doing it right all along - it just still hurt like a mother!  (no pun intended).  And it hurt even more with my second born!  Maybe because she was born tiny (6 lbs 10 oz) and gained weight at lightening speed?  The postpartum hospital nurses and the hospital CLC were all scratching their heads about why my nipples were so torn up.  I nursed through all the pain and nasty scabbing, and some thrush, and eventually it all came along.  I've always had really sensitive skin.

My experience made me really skeptical of some CLCs:  Pay lots of money to learn about nursing, learn that it shouldn't hurt, when it hurts, be told to pay more money for a private consult.  I have no doubt that there are amazing CLCs out there doing a world of good for new moms, but my particular experience seemed kind of like a racket.  And my dad told me that over the course of his (40-year) career as a pediatrician, he's found the lactation world a bit "trendy."  For example, he said tongue tie is the current hot ticket, whereas it was all but unheard of until recently - and so now he's gets lots of patients who have been told their child has or might have a tongue-tie, where that's clearly not the case.

And so yeah, vulgarity aside I pretty much completely agree with this Jezebel article:  Far from blissful, nursing is often excruciating.  Physically, mentally, and emotionally.

5.  Any of this really matters.  

It's really easy as a new mom to get all wrapped up in the first few parenting choices we make.  You're overwhelmed with the newness of being responsible for another human being, and you want to get it right.  Plus, there's an enticing sense of "safety" in every decision you can convince yourself is monumental.  "Well, I don't have to worry about obesity/ADHD/allergies because I did X, and 'studies' show that X blah blah blah blah blah."

But the truth is that ten years from now we'll hardly remember or care about fleeting things like whether we birthed vaginally (well, unless we're still peeing when we cough) or even whether we nursed.  By then, we'll have made approximately 1.3 billion other parenting decisions; parenting is decision-making, it's hundreds of mostly small decisions day by day and hour by hour, and even minute by minute, that add up to your relationship with your child.

This isn't to say that you shouldn't be proud of the struggles and sacrifices made for your baby, whatever they may be; I am, and you should be too.  But if you do find that new-mom stress is getting to you, it might help to envision that fast-forward button for some perspective.  Ask yourself whether you ever suspected that the success of an adult you admire was due in any part to having been born vaginally.  Query whether you've ever watched someone accept an award and thought "That's totally because his mother nursed him the full twelve months."  And if your grown son needs therapy one day, do you think it will have anything to do with exactly when and how you introduced solids - or even whether you circumcised?  These baby-days might seem the be-all, end-all but in reality they fade quickly as our children grow and develop.  At that point, it becomes obvious what really matters:  How we raise our children and how we love them - in other words, how we parent (not how we birth).  The memories we make with them.  How we function as a family.  And who we are - who we model for our children to be.

This super boring video shows all you need to be an amazing mom:  Love.  That's it.

Why The Press Shouldn't Be Your Source For Medical Advice

Perhaps you read the Huffington Post article "Why The Press Shouldn't Dismiss Vaccine Skeptics" by Lawrence Solomon.  In it, Mr. Solomon concludes with the worthy (if not lofty) goal that we should spend a lot of research dollars "identifying vulnerable populations" so that "all can be confident when vaccines are administered."  (Lofty I say, because study after study has shown that vaccinated children are at no higher risk for autism than are unvaccinated children, and severe vaccine reactions - or reports alleging the same - remain almost entirely without causal verification and number fewer than one per million for most childhood vaccines).

The rest of his article drops a few names, and attributes a few out-of-context quotations.  For example, he claims that Dr. Diane Harper, one of the lead developers of Gardasil, "believes [the vaccine] is less effective than the common pap smear, and that it may harm more children than it helps."  He doesn't link to any transcript of her saying any such thing, and as far as I can tell from Snopes there's a pretty good reason for that [Correction:  Since I first published this entry, he changed his hyperlink to direct to an article by a known anti-vaxxer who seems to parrot the debunked statements].  Let's look at what Dr. Harper actually says about the vaccine versus what Mr. Solomon says she "believes."  It's classic anti-vaxx twisting:

According to Snopes, and to another more in-depth discussion here, Dr. Harper has said:  "Cervarix is an excellent choice for both screened and unscreened populations due to its long-lasting protection, its broad protection for at least five oncogenic [read: cancer-causing] HPV types, the potential to use only one dose for the same level of protection, and its safety."  She did speculate that cervical cancer screening may be just as effective in preventing cervical cancer, and she expressed concern that vaccinated women would fail to use other protection and/or to follow-up with annual pap smears, which would remain important for detecting rarer strains of HPV not covered by the vaccine.  She finally went on to recommend expanding the guidelines for HPV vaccines for older women (in other words, using it more often).  And yes, there is continued confusion over Dr. Harper's views on the effectiveness of the vaccine 5+ years after it is administered (because current research shows that it is highly effective longer-term - see the link and the comments section).

Hmmm.  A pretty far cry.  Any innocent reader who didn't dig beyond Mr. Solomon's article would walk away thinking "The very creator of the HPV vaccine doesn't think it's the most effective option and thinks it may harm more children than it helps.  Guess I won't be using that!"  In reality, Dr. Harper's statements have been a ringing endorsement of the vaccine.  Plus, anyone with a little medical knowledge will tell you that even if pap smears are highly effective at detecting precancerous cervical cells, they cannot be done to detect and prevent the oral, penile, or anal cancers also caused by HPV.  Oral HPV-acquired head and neck cancers are fast becoming a major concern; when my husband did his head-and-neck cancer rotation back in 2006, already about half the patients were tobacco users and half had oral HPV-acquired cancer.  To say nothing of the idea that perhaps preventing HPV in the first place is more appealing than acquiring it and catching precancerous cells at one's annual pap smear - and continuing to spread it.

That twisting alone made me highly suspicious of the article and its author.  That's why I want to share with you the exchange I had with him in the comments section.

Commenter A:  When 97 scientists say these vaccines are better than no vaccines, and 3 scientists say no to vaccines, I don't think we need balanced reporting or respect for the no-side. They are simply wrong with potentially dangerous effects.

Mr. Solomon:  Can you point me to the survey or study that indicates a 97%-3% split among scientists? Was the question as black and white as you suggest or could a scientist have answered that some vaccines help some populations but not others?

Me:  Here's a study that shows that 97% of physicians vaccinate their own children:  (This study shows that 95+% of pediatricians polled in Switzerland - which included a 95% response rate among pediatricians there - vaccinate their own children, and that physicians are more likely than non-physicians to vaccinate still more for other diseases not included on the schedule, like Lymes Disease).

http://pediatrics.aappublications.org/content/116/5/e623.full.pdf

Mr. Solomon:  Thank you very much for this 2004 study, which I had not seen. It shows that pediatricians in Switzerland generally follow the recommended schedule, but not slavishly. And other physicians (non-pediatricians) are less likely to do so. 

In the case of vaccines that are not recommended by the authorities (the Swiss vaccinate much less than we do), the majority of pediatricians and non-pediatricians stay away from most of the vaccines.

Me:  Actually, that is not true. We have one extra Hep B and one extra PCV, and we vaccinate for Hep A. But the Swiss show 2 more IPVs and 1 more MMR. Did you see a vaccine "not recommended by the authorities" in Switzerland that we do vaccinate for other than Hep A? I didn't.

Mr. Solomon:  You'll find the World Health Organization's immunization schedules for every country here: http://apps.who.int/immunization_monitoring/globalsummary/countries?countrycriteria%5Bcountry%5D%5B%5D=CHE

You'll see that the vaccination schedules for both Canada and the US are much longer than in Switzerland.

Me:  This is a good example of why non-physicians and non-scientists have difficulty assessing the vaccine situation. The tables above are confusing because of overlap; if you look carefully you will see that the only diseases we vaccinate for that they do not vaccinate for are:

(1) Rotavirus and Hep A, which are a concern for nations including significant migrant and inner-city poor populations - a good example of how, far from mindless and unmonitored, each nation accounts for its population when its experts come out with their best schedule; and

(2) They don't recommend the flu vaccine until the age of 65. Surely though, the current news in the U.S. is enough support for our schedule here.

The other differences are minor differences I already listed above. The Swiss actually give two different meningococcal vaccines whereas we give 1. We give 1 extra HPV but are considering reducing to 2 as more evidence emerges that 2 is safe. We give one more pneumoccocal. 

The point being that the study I provided shows that 95+% of pediatricians vaccinate their children. I don't know of a similar study done in the US but it seems anti-vaxxers are more likely to trust physicians of other nations anyway. Do you have a study showing anything otherwise? My father is nearing retirement as a physician/professor at UW-Madison and has seen tens of thousands of vaccinations. He has never once seen a dangerous reaction, and he hasn't seen HIB deaths since we started vaccinating for it.

So there you go.  Perhaps the press shouldn't dismiss vaccine skeptics.  But they should certainly do a better job of presenting their misleading, distorted, and in some cases simply false "information" as factual and objective.  The above exchange shows the classic twisting of anti-vaxx logic.  A study showing near unanimity in physicians supporting their nation's vaccine schedule that is nearly identical to ours - and is identical on the controversial vaccines - is made out to be a potential reason not to vaccinate.  And the fact that physicians are more likely than non-physicians to add still more vaccines (like the Tick-Borne Encephalitis vaccine) is twisted to somehow say something alarming about our own vaccine schedule.  It's almost amazing, really!

Here is an excellent response to the article, from the professor who runs "Informed Parents of Vaccinated Children" ("like" the Facebook page to get the most recent vaccine news coverage and studies in your Facebook feed ... or ask them your questions, she'll respectfully respond).

Asking questions about vaccine safety is both important and appropriate - and done by scientists and the public alike. That's not why anti-vaccine activists are dismissed. They're dismissed because they reject valid answers because of conspiracy theories. They're not interested in improving vaccine safety, but in getting rid of vaccines - based on false information and unsupported fears - without proposing an alternative to protect children from disease. They ignore the data. They resort to conspiracy theories and personal attacks.

When serious scientists point out real problems with vaccines, they are not dismissed - like the recent narcolepsy connected to H1N1 or the problems with the first rotavirus vaccine. When scientists or others misrepresent data, do flawed research, when others reject abundant data based on global conspiracy theories, they are appropriately marginalized and criticized.

Last, please note that Mr. Solomon's article cites with approval a research team funded by wealthy anti-vaccine foundations.  The papers produced by Chris Shaw and Lucija Tomljenovic have been rejected by mainstream scientists as remarkable for sloppy methods and weak non-scientific reasoning.  See the first comment below for more information and sources.

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The Top Six LEAST Logical Anti-Vaxx Arguments

After a little rant I wrote went viral, I found myself mired in the black hole of vaccine "debates."  And I'm putting "debates" in quotations because it pains me to even elevate much of what is being said to "debate" where so many "points" and "counterpoints" make no sense whatsoever.  It was hard to narrow it down but I think I've found the six least-logical anti-vaccination points of all.  Here they are, in no particular order.

1.  We can't trust the researchers or the doctors because they're all part of a vast "Big Pharma" conspiracy to make money off of vaccines.

There are at least five good and obvious reasons why this is clearly not true, but I'll make room here for just one:  The "naive" parent who didn't "do her homework" by running a google search or listening to her friends is not, in fact, the one paying for her child's vaccines.  Vaccinations are paid for largely by private health insurance companies and, for uninsured children, the government.  Hopefully we can all agree that health insurance companies are not an innocent, naive, duped party in this or any other equation.  Not only is the health insurance industry a major political powerhouse, but health insurance companies employ hundreds of physicians whose sole jobs are to find ways to deny coverage for any medical care that is even arguably not "medically necessary."  If you must have a conspiracy theory, and you really don't believe vaccines work, maybe you should consider the idea that the "Big Health Insura" put out all the anti-vaxx internet quackery so that fewer people would vaccinate.  *I* know that's not true, because *I* know that health insurance companies don't want to pay for babies hospitalized with pertussis.  But if you're a vaccine-denier, then I have to tell you that my conspiracy theory is far more likely than yours.

2.  They've never done a study of vaccinated versus unvaccinated children and autism rates.

They have, in fact, plenty of them!  Can you imagine if we'd been debating this for as long as we have been and nobody had ever bothered to check?!  Here's one out of Denmark, published in the #1 leading medical journal NEJM.  It used data from all children born in the country of Denmark from 1991-1998.  Spoiler:  There is no difference in the rates of autism when comparing vaccinated to unvaccinated children.  Update:  Here's another such study, this one a massive new study this year, out of the U.S.!  What they haven't done is a double-blind study.  And that's not because Big Pharma is preventing one - it's because it would be considered unethical to randomly assign babies to not be vaccinated.

3.  It's actually the vaccinated children who are dangerous - they are the ones most commonly infecting other people.

One good argument against that is that it's factually not true.  See also this, this, this, and this:

Most of the 288 measles cases reported this year have been in persons who were unvaccinated (200 [69%]) or who had an unknown vaccination status (58 [20%]); 30 (10%) were in persons who were vaccinated. Among the 195 U.S. residents who had measles and were unvaccinated, 165 (85%) declined vaccination because of religious, philosophical, or personal objections, 11 (6%) were missed opportunities for vaccination, and10 (5%) were too young to receive vaccination (Figure).

But let's imagine it were true, and vaccines were only ("only"), say, 85% effective.  Now imagine a town of 100 people.  Ninety of them are vaccinated and ten are not.  Everyone is exposed.  If this were to happen, in theory, 10 unvaccinated people would contract the illness, but thirteen vaccinated people would.  It's simple math.

Oh yeah, the pertussis vaccine.  That one has its own ironic twist.  In 1997 we switched over to an acellular vaccine formula in order to appease vaccination fears.  The cellular formula was more effective but it had more side-effects - more fevers, and thus more febrile seizures.  But febrile seizures are not actually dangerous and if you're prone to them, you're not going to avoid them by not getting vaccinated.  My 13-month old inherited them from her father and while she never experienced one after a vaccination, she had one anyway when she caught a simple passing illness that spiked her fever.  She's perfectly fine and was never in any danger.  So now to avoid a false danger we've increased the real danger:  a less effective vaccine where vaccination rates are declining.

**Even at that, though, studies show that even in populations including non-infants (so people far removed from their infant pertussis vaccines), the unvaccinated are 2.5 times as likely to catch (and potentially spread) the disease.  And as for infants - the people most likely to die from a pertussis infection - our current vaccine is still 90+% effective.

4.  If vaccines are actually effective, vaccinated people shouldn't care whether some people don't vaccinate.

Is this how you feel about hand-washing?

5.  It's better to be "naturally" infected than to receive a vaccine.  

This reasoning is so circular it makes my head hurt:  It's better to risk death, brain damage, paralysis, birth defects, and various kinds of cancer by getting a full-blown "natural" case of one or more of these diseases because... because it's a more effective way of making sure you don't ever get the disease you already had.

And if you do subscribe to this theory, I certainly hope you're formula-feeding.  Antibodies passed to your infant through your breast milk won't be quite as effective or long-term as the antibodies your baby's own body would produce in response to full-on "natural" infections of various illnesses.  You wouldn't want to jeopardize his developing immune system by nursing, would you?  (Disclaimer:  This is sarcasm; I'm nursing my 13 month old through this winter JUST to - maaaaybe - give her any antibodies I happen to acquire).

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6.  We shouldn't blindly trust our doctors.

Agreed.  Physicians make mistakes, and we as patients can optimize our medical care by staying informed and by self-advocating where appropriate.  Thankfully, though, we have very little such work to do when it comes to vaccination.  Contrary to what anti-vaxxers would have you believe, vaccines are some of the most thoroughly studied medications out there and there is not just a national but a global consensus on their safety and efficacy.  Really, people, you might find my vaccination posts a little too snarky for your tastes.  But at least admit that it's not exactly humble to ignore the consensus of every legitimate medical and public health group in the world.

Vaccination: A Layperson's Perspective

Needles:  Scary.  No medication - not even Tylenol - is 100% safe or side-effect free. 

Neither is highway driving, for that matter.  

But vaccines are a thousand times safer than driving.  

Watching your baby struggle with or die of suffocation by whooping cough:
Much, MUCH Scarier.
Did you know that
kids who miss doses of their DTaP vaccine are 18x as likely to get it?

Fulminant Meningococcemia:  I'll take the needle, please!

Polio:  A vaccine success story; completely eradicated in the U.S. (though not globally, yet).  Smallpox too; Smallpox eradication has been so successful that
we no longer vaccinate for it.

Even though there's an alleged pharmaceutical conspiracy forcing us to get vaccines we don't need...

If this guy found out that you could vaccinate your children but chose not to... 

NPR article from 9/30/2013:  Study confirms that a recent whooping cough epidemic in California that killed ten babies was due to failure to vaccinate and receive boosters. 
People who lived in areas with high "personal belief exemptions" from public school vaccination requirements were 2.5 times as likely to live in areas with high incidents of whooping cough.
Link to original study appearing in Pediatrics.

As a medical "layperson," it's ironic that I'm blogging about vaccination - or at least I think it is.  While my husband slaved away on all the pre-med courses in college, I avoided science like the plague (terrible pun, I know.).  When he scored within the top 2% of MCAT takers I was pretty impressed, but truthfully I don't know much about the MCAT.  While he busted his butt - to put it politely - through four years of medical school and two years of grant-funded medical research, I studied the health care system... in law school.  And over the past 4.5 years that he's been putting in 60-100 hour weeks in medical training at the #1 hospital in the U.S., I've thankfully managed to continue to ... not study or practice any medicine.  That means that he has 14.5 years of grueling medical training that I don't have.  And - conservatively estimated - 28,160 hours.  My father has infinitely more; he's seen tens of thousands of patients over the course of his forty-year career as a pediatrician.

Clearly, I can't run a google search on a complex medical topic and eventually cobble together a better answer on it than these two can.  Not even if I spent ten hours on it.  Not even if I spent forty.  Not even if I spent weeks.  They don't hand out medical degrees for running google searches.  Or for talking to non-nurse (home birth) midwives... or doulas... or anybody else.  Imagine if they did though, and you got in a car accident or you had a heart attack, or you needed a liver transplant or something.  Um... yikes.

But the problem is that lay people are blogging about vaccination.  And they're meeting up and talking about "vaccine choice."  They're imagining conspiracy theories and refusing to trust anyone other than each other.  And they've managed to convince others of their "practice of medicine" to the point where there are schools at which only about half of the children are vaccinated and many states are falling below vaccination levels considered to provide herd immunity.  "Herd immunity" is real and it protects us all (see this explanation by an immunologist mom), especially those who are too young to receive their first vaccines or who are immunocompromised because of a childhood illness like cancer (see the comments for further discussions on this).  Herd immunity even protects the vaccinated, as vaccines are "only" 90+% effective, not 100%.  Herd immunity is the reason we're not currently in this situation (or this one, or countless others).  Would anti-vaxxers still refuse vaccines if they had to travel to one of those nations? And if not, are they only refusing them here since the rest of us do vaccinate?  

This topic is so vast and so complex that I'm not going to pretend to be able to address it in single coherent blog entry (unlike so many anti-vaxxers).  But I do want to put together a bullet-pointed list of what I, as a layperson with personal access to the medical community, believe that you, as a layperson without that same access (clearly - if you're considering not vaccinating) might want to know.  I've followed and participated in many discussions on this topic and there are some repeat misconceptions or missed points that are worth cobbling together.  Here are a few of them:

(1)  Vaccines do not cause autism.  See also this, this, this, this, this, this and this.  Kudos to Dr. Andrew Wakefield for getting published in a legitimate medical journal, since everything else on this topic either wasn't, or has been misleadingly taken out of context and interpreted by non-medical minds to mean something it doesn't mean to any other physicians, who are also parents themselves.  Too bad though - after other labs were unable to get any results by repeating his study, and after he was unable to reproduce the results himself, the original study was found to have fraudulently falsified its data (this "caught ya!" process is called peer review, and it's why we can rely on science).  He made millions and children died.  Not sure what that makes him in your book, and I don't want to mention what that makes him in mine.  Maybe we should honor those deaths... by vaccinating.  Here's some more persuasion though, if that's not enough:

• We've been vaccinating since the 1950s, so we vaccinated for many decades before autism rates went up.  The spike has been most significant over the past five years, in spite of the decline in vaccination rates.  Hmm.  Doesn't seem that vaccines are the cause, does it?
• Maybe you know or have heard about someone who went from "normal" to autistic right after his shots.  Well, autism is an early-childhood onset condition, and it happens that we vaccinate early in childhood.  There are lots of children out there whose symptoms started shortly BEFORE their shots, too; they're just not organizing themselves and speaking out about their experiences.  Anecdotal evidence, while compelling to those personally experiencing it, does not show or prove correlation (let alone causation).  Medical studies do, but they have repeatedly disproven that vaccines have any relation to autism - every single legitimate, peer-reviewed study (see the links above).  If that weren't true, and this was, then your pediatrician wouldn't be vaccinating his or her own children - at rates even *higher* than the official recommendations.  
• Okay okay, you still can't be convinced, and perhaps you would like to speak at the next national AAP conference on this topic, and present to them the articles you found on the internet.  Well how about the point that my friend made?  Her brother is autistic.  She loves him just the way he is, and would much rather an autistic brother than a dead one; she takes more than a little offense when people don't vaccinate for fear of autism.  I'd rather an autistic child than a dead one myself, personally.  But thankfully, we don't have to choose ... because vaccines do not cause autism! 

(2)  On "alternative schedules."  Some people acknowledge that vaccines don't cause autism, but remain convinced that all those pediatricians out there who are vaccinating their own children "on time" - meaning, on the schedule created and monitored by the AAP and the CDC, among other professional organizations - are sadly mistaken.  They believe there is a "true" best vaccine schedule out there but that pediatricians aren't recommending it - or using it on their own children - because:

(a) it's more convenient for doctors to lump the shots together; or

(b) the U.K. doesn't vaccinate for chicken pox so perhaps the U.S. is "shot-happy" since we're "for-profit"; or

(c) they read one book by one physician, Dr. Sears, the "schedule" in which has been completely discredited (see also this, this, this and this for further confirmation of the safety of the current schedule); or

(d) they think we are vaccinating too early because we want to get kids vaccinated before irresponsible parents stop bringing their children to medical checkups.

Well, (a) and (b) cannot possibly both be true, since more visits means more money.  So pick just one first, please.

(a) is not true.  Doctors wouldn't care if people came in a few more times to get shots; what's it to them?  And again, they vaccinate their own children on the AAP/CDC recommended schedule.  It's actually more convenient for your child to be poked less with a needle.  But none of this is about convenience; vaccines are simply given as early as they can be, because the sooner a baby is vaccinated, the sooner he or she is safe.  Just last winter a baby boy at Boston Children's contracted whooping cough from an unvaccinated toddler.  He died - just days away from his first vaccination.  So did this child, and many others.  Pediatricians are now advising parents on how best to protect their newborns, until their babies are vaccine-eligible.  

(b) Different nations have only very minor differences in their recommended vaccine schedules, and that should help make it clear that vaccines aren't a "Big Pharma" conspiracy.  Indeed, if our vaccines weren't medically necessary, our insurance companies would be the first to let us know by not covering them - they LOVE to do that, and they employ hundreds of physicians whose sole jobs are to review claims so that they can deny coverage for any medical care that is even arguably unnecessary.  You can also check out this story about a mom in the UK whose daughter died of chicken pox, not having been vaccinated since the chicken pox vaccine (Varicella) isn't on on their vaxx schedule.  And this BBC story wherein cost and a flawed fear of increased shingles were given as the UK's reasons for not including varicella.  As it turns out, that particular US/UK difference probably does come down to money - not that we're "for-profit" but that they aren't, and in this particular case they cut costs in an unfortunate way.

(c) why are you trusting someone with whom no other expert agrees, and who is making millions off of this, instead of your own moderately-salaried pediatrician(s)?  Okay I get it - you've had a crappy doctor (or doctors) before.  Me too.  Not everyone is willing to bust their butt like my husband does.  But this debate isn't pediatrician-to-pediatrician.  This debate involves a clear, essentially unanimous medical consensus among all our leading experts.  See, also cited above, this, this, and this.  When you vaccinate on time, you're not "just" trusting your pedi; you're trusting all the top experts on topics including virology, immunology, microbiology, statistics, epidemiology, pathogenesis ... and of course, medicine and pediatrics.  We're talking the guys who went to Harvard and the like, and got MD's and PhD's and devoted their careers to research, which generally pays much less than private practice.  These tend to be, FYI, super nice and super nerdy guys (and gals) - and most of them are also parents.  They make up the AAP and the CDC and other organizations that put their heads together and come out with the schedule.  I truly hope that you don't think that you or I could come up with a better answer than they have, by googling or by doing other layperson "research."  If we were so capable, then what's preventing us from coming up with the next curative cancer treatment, which is another thing we can expect of Md/Phd medical researchers (like the husband I've barely seen for the past decade)?  See also this article - delaying vaccines can increase the chance of a "reaction" (benign, but who wants one?) because older infant bodies are better able to mount stronger immune responses; see this, too, for a further discussion.  See also this video on the dangers of under-vaccination - children who skip doses of their DTaP vaccine are 18x as likely to get whooping cough.

(d)  We aren't vaccinating earlier than "we should" just because some parents might "flake out" on later appointments; we're vaccinating as early as possible because unvaccinated newborns are unprotected and they could, and do, catch things like whooping cough in hospitals and at checkups (and from relatives and friends - especially those who haven't had their boosters) and die.  Do you really think that the CDC, AAP, etc., came out with a "truly ideal" schedule, but are keeping it secret because of flakey parents?  If so, why do you think that all these physicians and experts follow the recommended schedule on their own children?  Again, pediatricians are now advising parents on how to protect their newborns until they are vaccine-eligible.

What about Hep B, they give that one at birth, why??  That's because the Hep B vaccine also protects against "vertical" transmission, meaning transmission from the mother (or father ... or father to mother to child), which usually (but not always) occurs perinatally (meaning at birth).  Because there's no risk in giving this vaccine at birth (none *proven*, other than the mildest of reactions for this vaccine - see discussion in comments below and what I quote from UpToDate, and ignore what you read on non-reputable websites), and because doing so for the entire population will prevent cases of this terrible disease (and probably eventually eradicate it), that's standard procedure.  Studies on this topic have shown that prenatal maternal testing is not a good way of preventing or predicting perinatal transmission, or childhood acquisition of unknown origin (think a bite from another child, or perhaps food prepared for you or your child by someone with an open cut who gets careless about hygiene) - this is discussed in greater detail in the comments following the post, and this article discusses the topic in-depth.

(3) Won't breastfeeding offer the same or better protection?  No.  How would there have been polio epidemics in the early and mid-1900s if that were true?  Polio (as one example) was eradicated in the 1960s as we started vaccinating for it.  People actually nursed less in the 1950s and 60s than they do now; nursing fell out of favor when commercially marketed formula was presented as and believed to be "better" than breastmilk.  My mother-in-law was breastfed but she still remembers how horribly sick she was with the measles.  Check out this woman's story about how extended breast-feeding and all the crunchiness in the world didn't save her from multiple illnesses when her parents failed to vaccinate.  And no, these diseases didn't just disappear because of clean water and sanitization - things we had for decades while we still had epidemics.  Here's a great article debunking that myth.  

(4) What if you keep your kids largely at home with you, should you still vaccinate?  Yes.  You and your children could end up in a medical waiting room at any time, and that's where the sick kids will also be.  See the story above, about the boy who died last year here in Boston.  Plus, even if you home school, your kids will be at museums and basically, in public.  These diseases are highly contagious - much more so than a common cold or GI bug.  You don't have to share a toy or even a doorknob to catch some of them.

(5) But my pediatrician approved my proposed alternate schedule.  Ask your pediatrician:  How would he or she vaccinate his own children?  That's the truth of the matter.  Delaying a vaccine leaves you vulnerable until you take it, while offering no proven benefit whatsoever.  It's a small chance, but it's getting bigger as we've seen in the news lately.  Skipping doses is even worse - again, see this video on the dangers of under-vaccination - skipping a DTaP dose makes your child eighteen times more likely to get whooping cough.

(6) But what if it's just a hoax that vaccines are even effective at all?  I mean why else would vaccinated people care whether I vaccinate?  Vaccines do not offer 100% protection (more like 90+% depending on your age, when you had the vaccine, and which vaccine we're talking about).  They don't work for everybody, and they can wear off.  That doesn't mean that they don't work at all.  We've already seen what happens when nobody vaccinates.  And if you happen to be one of the people for whom a particular vaccine doesn't work, you'll much prefer to be surrounded by vaccinated people than by unvaccinated people.  That's called herd immunity.  You know what else offers herd immunity?  Hand-washing.  Washing your own hands is great, but you're far better off if everybody else washes their hands too.

(7) Medical Malpractice.  Here's another point, since I'm a lawyer and I studied health law:  Physicians these days practice medicine defensively, in fear of getting sued.  Yet they continue to advise their patients to vaccinate and to vaccinate on time.  Don't you think that pediatricians would stop recommending vaccinations if vaccinating was anywhere near as dangerous as not vaccinating?  Or perhaps their liability carriers would force them to do so, or jack up their premiums??  Instead, doctors are increasingly fearing a new kind of lawsuit:  Lawsuits from their immunocompromised patients and newborns who might come into contact with infected, unvaccinated children in their waiting rooms.  They're discussing a new ethical dilemma:  Do they deny care to the unvaccinated, or do they risk creating a highly contagious, potentially lethal waiting room for their other patients?

Ah, and yes, there DOES exist a fund to compensate people for ultra-rare severe reactions to vaccines.  Want to know why they need a fund for that?  Because it's still safer TO vaccinate, so those (VERY rare - far, FAR more rare than people dying of vaccine-prevantable illnesses) people could never win any money by suing their doctors.  You can't sue someone who made the safest possible choice for you - not even in the good old U. S. of A. - so we've established a fund to compensate those children anyway.  AND we've even lowered the standards for getting the money:  Whereas in a law suit you have to prove legal ("proximate") causation, to recover from the fund you just have to prove that your "symptoms" happened within a certain timeframe and that the vaccines in some way contributed to your final condition.  Because of this, and because there are very rare people born with conditions in which a simple fever will set off a chain of reactions in them resulting in cognitive decline, there are a few cases in which claimants have recovered lots of money from the vaccine fund even though all the vaccine really caused in them was a fever, and they would eventually have had a fever from another source - you can't escape life without a fever, unless you literally live in a hospital bubble.  (One last side-note - as a plaintiff's attorney I only accepted about 1 in 5 calls we got, the others were too bogus to take ... so take the alleged vaccine injuries and get rid of 80% of them to give yourself a better estimate of whether vaccines are dangerous... or don't, because even if every claim were true it would still be far safer to vaccinate than not to vaccinate).

(8) False Sense of Control.  I see a lot of anti-vaxxers say "You can always vaccinate later, but you can't take a vaccine back."  Of course, the problem with this thinking is that you cannot vaccinate yourself after you get sick.  In this way, the vaccination fears are much like fearing flying more than driving.  Driving is far, far more dangerous than flying, but people are more comfortable driving because driving gives them the false sense that they will be able to prevent or minimize any collision because they are in control of their own car.  Another good analogy for vaccination is seatbelt wearing.  In almost all situations, it is far safer to wear a seatbelt, and seatbelts have saved hundreds of thousands of lives since they became standard in all cars in the early 1960's.  But there are occasional cases in which a seatbelt causes injury ... probably even cases where a seatbelt effectively traps someone in a burning car, causing death.  That doesn't make it safer to never wear your seatbelt - or to "selectively" wear it!

(9) Social Contract.  Anti-vaxxers get really offended when you try to appeal to their sense of social justice.  (Note:  If social justice on a certain topic offends you, you might be on the wrong side of things.  Just sayin'.).  But the fact is that the choice not to vaccinate is at best paranoid and at worst selfish (the choice... not the person... I'm sure some really good, smart people get fooled by anti-vaccination quackery); anti-vaxxers only have the (false) luxury of not vaccinating because the rest of us continue to vaccinate, thus keeping epidemics back in the history books where they belong (herd immunity).  Meanwhile, anti-vaxxers are endangering not only their own children, but they are especially endangering children who are already suffering from childhood illnesses and conditions like cancer and HIV.  Those children cannot safely be vaccinated with any live vaccines; their immune systems are compromised, so they would risk contracting the illness rather than having a successful vaccination.  And non-live vaccines are less likely to work for them - plus, they have less of a chance of fighting off any serious illness they contract.  I'm sorry, but how would you feel if your paranoid choice resulted in the death of a child who was trying to fight cancer??  Plus, like I said before, vaccines can fail - whether you're immunocompromised or not.  Could you live with yourself if your paranoid choice killed someone else's child, or your own?  Because it happens a lot more often than even just the the alleged internet "vaccine deaths."  And I think it should be considered negligent homicide.  (See this for a discussion of the potential legal ramifications for failure to vaccinate your child).

I'm not writing this blog entry to convince the unconvinceable - and that's why I'm not sugar-coating it.  I'm writing it for the people who are on the fence:  the middle ground that we've been losing by being too nice about this because there is such an outrageous amount of false and misleading information on the internet that appears reliable.  I have absolutely no bias or financial gain in this equation (neither, by the way do the salaried pediatricians or pediatricians in small practices that sometimes lose money on vaccines, or the history textbooks).  I'm not a physician and my husband is going into cancer research.  My father is nearing retirement.  I have nothing to gain but what I do have is access to two brilliant medical minds who carefully considered this issue when choosing to vaccinate their own children.  My father and my husband have heard, through me, all the arguments brought up against vaccines and expertly batted them away.  Perhaps your pediatrician isn't taking the time to do so with you; that may simply be because there is not enough time built into a well-child visit for it, and you probably don't want to pay out of pocket for 30-60 minutes of your pediatrician's time and expertise (much as you're willing to spend hours of your own time googling).  Or perhaps your pediatrician has simply given up because it's so rare that he or she changes anyone's mind - see this recent article on the frustrations physicians are facing out near me in Western Massachusetts.

What I would love to see happen is for each pediatric office to publish a brochure on vaccines that answers the most common questions and addresses the most common misconceptions.  Until then, here's a brief list of resources for the curious.

** And I'd like to just note here that I am unable to "link to" a lot of the sources provided to me for this blog entry.  That's because you have to have to pay for a subscription to a lot of the major medical journals and other legitimate scientific sources - or make the big trek to your nearest medical school's library.  In other words, a lot of the best stuff out there isn't available by googling the internet.  And in fact, some of the very worst stuff is - check out this recent sting operation that found that some of the online journals will actually publish fake science for a fee.  See also this December 2016 NYT article ("There are real, prestigious journals and conferences in higher education that enforce and defend the highest standards of scholarship. But there are also many more Ph.D.-holders than there is space in those publications, and those people are all in different ways subject to the 'publish or perish' system of professional advancement. The academic journal-and-conference system is subject to no real outside oversight. Standards are whatever the scholars involved say they are.")

** Also, comments will be disabled as of Friday, October 18th.  With nearly 500 comments, I can't imagine we haven't covered it all... and I need to get back to doing other stuff with the limited free time I have as a busy mom of two healthy, vibrant, fully vaccinated children.  Many of the comment threads are fascinating and informative, with lots of physicians and other experts responding.  A Command+Find search *after* you scroll and upload to the end of all the comments - which you now have to do several times to reach the end - might help you find threads that are of interest to you.  I took care during the nearly one full month since this was originally published not to delete a single comment.  So you can rest assured that the integrity of the comment threads is fully preserved.

1. AAP article discussing the problems with alternative vaccine schedules and the concerns vaccine-hesitant parents have.
2. "Do You Believe In Magic?  The Sense and Nonsense of Alternative Medicine"
3. "Deadly Choices:  How the Anti-Vaccine Movement Threatens Us All."
4. How to Protect Your Newborn from Whooping Cough by Dr. Wendy Swanson.
5. Vaccine FAQ's from The Children's Hospital of Philadelphia.
6. How Physicians Immunize Their Own Children:  Differences Between Physicians and Non-Physicians from the AAP.
7. Excellent article on the Chicken Pox vaccine from "Seattle Mama Doc" Wendy Swanson.
8. NPR article from 9/30/13 confirming by location that failure to vaccinate and failure to get boosters caused California's recent whooping cough epidemic that killed ten infants in 2010.  Link to the original study, which just came out in the journal Pediatrics.
9. On whether vaccines are made from aborted fetal tissue.
10. On the safety of the current vaccine schedule.  See also this.  And this.
11. NPR article on a recent sting operation that found that some of the online journals will actually publish fake science for a fee.
12. NYT article on the online world of "Fake Academia" (studies that appear reliable but are not)
13. Interview with Dr. Paul Offit, Chief of the Division of Infectious Diseases at Children's Hospital of Philadelphia and co-inventor of the Rotovirus vaccine, credited with saving hundreds of lives daily.
14. Excellent explanation of what vaccines are, what they're made of, and how they work, given by experts interviewed by Real Simple Magazine.
15. Many states are falling below vaccination levels considered to provide herd immunity.  
16. Video on the dangers of under-vaccination.
17. Two articles (this and this) discussing studies that have found that delaying vaccines increases your child's chance of having an adverse reaction (but note that all but ultra, ultra rare adverse vaccine reactions are fairly benign).  
18. On the lack of profit margins because vaccines are so expensive to produce.
19. Discussion of potential legal ramifications for failing to vaccinate your child.
20. More on the fake science used in the past to propagate the damaging - indeed, deadly - myth that vaccines cause autism.  If you've stumbled across any work by Mark or David Geier, you need to read this.
21. Pakistan polio outbreak puts global eradication at risk - "Health teams in Pakistan have been attacked repeatedly since the Taliban denounced vaccines as a western plot to sterilize Muslims and imposed bans on [them] in 2012 ... dozens of children, many of them under the age of 2, have been crippled by this disease in the past six months." 
22. On vaccine package inserts:  "Inserts are a problematic source of information for a number of reasons. They are legal documents, not scientific documents. They do not include science done after the insert was approved. They include ingredients, but do not show you that you are already exposed to those ingredients naturally and how tiny the amounts in vaccines are. They have to report on every adverse event that allegedly happens after a vaccine, whether or not causally related. In short, they are usually more misleading than useful, and my experience is that most readers get them wrong. My favorite was the anti-vaccine proponent who insisted that the vaccine insert said a child cannot eat fruit and vegetables for six weeks after getting the vaccine."
23. Brand new study this past summer:  "The Number of Antigens in Early Childhood Vaccines and Neuropsychological Outcomes at Ages 7-10 Years."         
24. Want to be "educated" on vaccines (and all these citations aren't enough)?  Well, "A new report found that parents wishing to exempt their children from required vaccinations due to personal beliefs should first be educated on immunization, the Colorado Department of Public Health said . . .  The stakeholder report was led by three partner organizations, the Colorado Children’s Immunization Coalition, the Colorado Department of Public Health and Environment and the Keystone Center, a neutral, third-party facilitator. The report studied the state’s personal belief exemption policy in an effort to update the policy."  Full article here.
25. On whether we were magically saved from all these diseases right at the same time vaccines came out, but not from the vaccines themselves.  (Yes, that really is a common allegation).  
26. The whooping cough vaccine does not increase your chance of getting whooping cough, see this and this.          
27. Excellent explanation of herd immunity and fantastic information on each of the vaccines by an immunologist who is also a mom, here.   
28. In-depth discussion of the Hep-B vaccine.      
29. Statistics on 2014 measles, showing that almost all victims were unvaccinated or of unknown vaccination status (89% - versus 10% of the vaccinated). 
30. Yet another study finding no link between the MMR vaccine and autism.  
31. But what about all the "vaccine injury"stories I've heard on the internet and from my neighbor's second cousin once removed?  Read more on those here.        
32. Excellent explanation of whether the current vaccine schedule is "too much, too soon."