Every pediatrician, each in his or her own way, faces those few parents who are afraid to immunize their children. It’s not a dramatic moment. Fairly early in the process of getting to know who this patient is, a parent will say, “It’s too much.” Or, “It will overwhelm his immune system.”
This opens up a new window into who they are, along with a question — will I be able to convince them or not? In a way, it’s basic medicine: You find out something new about someone, and now you have to figure out what it means and what they will need from their doctor.
The measles virus, like the polio virus, only lives — in the strange way that viruses live — in people. These viruses are part of the natural world. We aim to improve upon nature by getting rid of these illnesses, thereby making this virus extinct, without apology. Smallpox was eradicated in the 20th century. The eradication of polio was a goal within reach, though now it seems to be slipping further from our grasp.
My father had polio before it was preventable. Both of his legs were paralyzed. In his childhood, he got around on a kind of homemade skateboard, or he was carried like Dickens’ Tiny Tim. After many surgeries a long train ride from home, he got around quite well with a brace and crutches. His handicap was an important part of my formative experience, 30 years after the polio virus had done its damage to him. Of course, I got the polio shots as soon as they were available. And soon after that, I got the oral vaccine too, just to be sure.
Lots of things are complicated, but why is the immunization of children against measles one of them? It should be a no-brainer. Measles is a serious illness, bad enough that it’s worth preventing.
Antibiotics don’t do anything against measles. Treatment is “supportive,” meaning watch and wait, managing complications as possible. Days of fever of 104 degrees and higher, maybe pneumonia, maybe hospitalization — burning through your deductible — and sometimes permanent consequences. I saw a patient once who was having seizures every minute for years after measles.
Around the world, measles is still a major cause of mortality in children. Almost all of us over 60 are “survivors”; we had measles when we were little. I had measles and got over it. And I rode around in a car without a car seat or seat belt and survived that, too. Not everyone was so lucky.
Seat belts and car seats save lives. And immunization works. It works so well that U.S. cases, which used to number in the hundreds of thousands every year, have been knocked down to fewer than a hundred, until recently. The MMR vaccine prevents measles, mumps and rubella. Incidentally, we don’t see as much infertility from mumps as we used to. And congenital rubella — a much worse illness than measles — has mostly disappeared from this part of the world, for now. I’ve seen congenital rubella with my own eyes: a frail blind girl, with a tiny brain that didn’t work very well.
Most of the people in the world live in places where measles is seen all the time. Mainly, it’s just one, and not the worst, feature of poverty. Since the continuous circulation of measles ended in the U.S. in 2000, we have had occasional measles outbreaks, each starting with an importation. Since then, measles in the U.S. has mostly been imported by Americans returning from Europe and Asia. Someone inhales the measles virus in the course of his or her adventure. Later, safe at home, a nasty “flu” with “pink eye,” fever and cough ensues. Days pass in misery without any rash. Friends, classmates, co-workers, health care workers are exposed. With every cough, he is spreading measles virus generously around; it lingers for an hour or two wherever he’s been. No one has figured out he has measles yet because the rash comes later.
Now we come to “herd immunity.” No vaccine works perfectly, meaning that some people get measles when exposed in spite of having been immunized. But for each individual, the chance of getting it is very much reduced by having been immunized. The fewer the people in the “herd” — more felicitously known as the community — are vulnerable, the lower the chance that the “index patient,” the importer, will be able to infect someone else. For those who cannot be immunized — especially babies, people with HIV or on chemotherapy — “herd immunity” means they hope to get away with being vulnerable because measles won’t start going around if all the contacts of the index patient are immune.
And because the vaccine isn’t perfect, even those of us who are immunized benefit from the herd, because the fewer people around us have measles, the lower our chance of being in the 1 or 2 percent “vaccine failure” group.
So why is there so much push back? Stumbling blocks were deliberately placed in front of the blind: False and fraudulent assertions of a link between the MMR and autism were made. Although the claims were finally and definitively debunked several years ago, spinoff descendants continue to appear. In the American spirit of “Don’t Tread on Me,” parents — like physicians — don’t want government telling them what to do. And some people believe they can protect their children from all harm if they avoid “toxins” and “chemicals” — never mind the “toxicity” of the diseases themselves to muscles, fertility and sometimes to the brain. Others are leery of “Big Pharma” and the Medical-Industrial complex. And not a few parents are just anxious.
Should a pediatrician refuse to take care of children whose parents refuse immunizations? Should a doctor refuse to see people who are sick? We routinely treat folks who eat too much, watch too much TV, don’t exercise regularly, smoke or drink and put others at risk, and even who ignore good medical advice. Why should some absurd ideas about immunization be a disqualifying condition for having a doctor?
Very few of us are completely rational, and for those who are, it’s usually seen as a disability. Our judgments of priority are colored by our experiences. I didn’t need medical school to know that polio was bad. Everyone sees the world from a different point of view. The physician has to start by listening to the patient. Immunizations are important; lots of things are important.
To what extent is the pediatrician, an agent of the state, charged with enforcing some standard? Our primary obligation is to the children in our care, but we rely on the parents to provide it; there is rather little we can do without their active participation. So pediatricians perform a delicate dance — we have to convince the parents to see it our way.
But now measles is here. This week, I began requiring my patients who can be immunized to be immunized against the contagious illnesses that could jeopardize my other patients.
I have to take care of the patient that I have in the family that he has, in the context where I find him. Being invited to enter into that world is a privilege, and it’s my main tool. It’s also where the real drama is, and where both healing and prevention begin. But I am reminded that the context of the physician-patient relationship includes the community of my practice — my “herd.”
David H. Keene, M.D. is a pediatrician in Los Angeles.
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