Vaccination for H1N1 “swine” flu: Do The Atlantic, Shannon Brownlee, and Jeanne Lenzer matter?

I had meant to address this topic last week, but the whole Suzanne Somers thing bubbled up and overwhelmed my blogging attention. Regular readers of this blog probably realize that I tend to live and die as a blogger by the maxim that if some is good more must be better. So I clobbered the topic with three posts in rapid succession. Now that that’s out of the way, I can address topics that readers have been bugging me about sending to me.

At or near the top of the list has to be a biased and poorly framed article that appeared in The Atlantic this month. I tell ya, I’ve been a subscriber to The Atlantic for at least 25 years, and for the first time ever I’m seriously tempted to let my subscription lapse when it expires early next year. In the 25 years I’ve been a subscriber, I’ve never seen such a credulous, irresponsible piece of “journalism” appear in The Atlantic.

I’m referring to the recent article by Shannon Brownlee and Jeanne Lenzer entitled Does the Vaccine Matter? The article takes doubts about the efficacy of the seasonal flu vaccine, conflates them with an entirely different situation, namely the pandemic of H1N1 (a.k.a. “swine”) flu that we are currently experiencing, mixes them with the cliched trope of the brave maverick doctor and scientist bucking the status quo and being reviled for it, and serves a steaming, stinking mess of confusion that puts the worst possible spin on the evidence. It’s a perfect storm of obfuscation. Indeed, I can picture the pitch for the story to the editors of The Atlantic. “Conventional wisdom” found to be overoptimistic? Check. Brave maverick doctor fighting a lonely battle against scientific and medical dogma? Check. Scientific dogma overturned and a major public health strategy shown to be useless? Check. Well, not exactly. Only seemingly so as framed in the article. My guess, though, is that that last part of the pitch was indeed pitched that way, with the tagline, which I quote directly from the article:

But what if everything we think we know about fighting influenza is wrong? What if flu vaccines do not protect people from dying–particularly the elderly, who account for 90 percent of deaths from seasonal flu? And what if the expensive antiviral drugs that the government has stockpiled over the past few years also have little, if any, power to reduce the number of people who die or are hospitalized? The U.S. government–with the support of leaders in the public-health and medical communities–has put its faith in the power of vaccines and antiviral drugs to limit the spread and lethality of swine flu. Other plans to contain the pandemic seem anemic by comparison. Yet some top flu researchers are deeply skeptical of both flu vaccines and antivirals. Like the engineers who warned for years about the levees of New Orleans, these experts caution that our defenses may be flawed, and quite possibly useless against a truly lethal flu. And that unless we are willing to ask fundamental questions about the science behind flu vaccines and antiviral drugs, we could find ourselves, in a bad epidemic, as helpless as the citizens of New Orleans during Hurricane Katrina.

Journalists do so love that cliché, don’t they? It’s an irresistable hook, cliché or not. People love reading about issues that we thought to be true but–surprise! surprise!–turn out not to be true. It was also sheer genius to compare the issue vaccination for influenza to that of New Orleans before Hurricane Katrina. What a striking visual image of a city being leveled by flooding due to a hurricane because of neglect and the failure to listen to lone voices in the wilderness warning that the levees couldn’t hold against a major storm! I suppose I should be grateful that she didn’t also use images of engineers warning about the O-rings before the Challenger disaster. In any case, just Google the phrase “What if everything we think we know about is wrong?” (I left out the topic in order to pull in pretty much all topics.) As of Sunday afternoon, Google returned 90,700,000 hits on that search. Put the word “vaccine” after the word “about” and do the search, and guess what came up number one in a Google search? Well, at least as of Sunday in my location at the time I did the search, it was Shannon Brownlee’s Atlantic article. I sense serious Google optimizing going on. And, yes, I’m including that phrase in order to see if I can fire up some Google mojo for myself. Whether it works or not, who knows? Probably it won’t. But I think I’ve made my point. Framing an issue as arguing that conventional wisdom is wrong and highlighting a couple of “lone voices in the wilderness” warning, Cassandra-like, of impending disaster represent a time-honored journalistic trope, not to mention a story structure that goes back thousands of years to, well, Cassandra at least. Add a healthy dollop of “skepticism” about big pharma and the government, and you definitely have a winner. I can see why the editors of The Atlantic bit.

Now, it’s time to move on to the meat of the Atlantic article. Before I do, let me just point out that revere addressed many of the factual issues with the article in his analysis, and Mark Crislip did an excellent job reviewing the data for and against the efficacy of flu vaccines, which is largely shades of gray. I encourage you to read those posts, because I’m not going to go into as much detail as they did over that issue. The other thing that I like to point out is that Shannon Brownlee is a senior fellow at the New America Foundation and is best known for her recent book Overtreated: Why Too Much Medicine Is Making Us Sicker And Poorer. Jeanne Lenzer is a freelance journalist who, it would appear, frequently shares bylines with Shannon Brownlee. As revere noted, both appear to have made their names promoting the contention that we are “overtreated” as a society. As Steve Novella once noted, Brownlee rather credulously fell for the alt-med myth that only 15% (or even less than 50%) of current medical treatments are based on valid scientific evidence in an article she published for The Washington Monthly. While it is arguably true that in many areas we are overtreated and it isn’t hard to find examples, vaccination is arguably not one of those areas. Among medical interventions, vaccines arguably have saved more lives and prevented more suffering than every other medical intervention combined. Moreover, choosing the flu vaccine as an example in the middle of a pandemic borders on–hell, is–the height of irresponsibility.

In any case, as Mark Crislip pointed out, vaccines for seasonal flu are suboptimal for a variety of reasons. For one thing, health officials have to make educated guesses every year about which strain(s) of influenza virus will be circulating each year. Sometimes they guess correctly, and in those years the vaccine is very effective. Sometimes, to paraphrase the Knight guarding the Holy Grail in Indiana Jones and the Last Crusade, they choose poorly. In those years, the flu vaccine doesn’t work very well. Also, the elderly, the ones most likely to die of complications after the flu, tend not to develop as robust an immune response to the vaccine. This is not new news, although Brownlee and Lenzer trumpet it like some sort of revelation. Of course, what they fail to emphasize sufficiently is that H1N1 is actually a strain that is more likely to cause serious complications in those who are under 60. Moreover, the strain match for H1N1 is excellent. Consequently, this year for this pandemic, the H1N1 vaccine is likely to be highly effective. Of course, we won’t know this until this flu season is further along, but confusing seasonal flu with pandemic flu is not a productive way of bringing clarity to the issue of whether flu vaccines work, which is, to lay people at least, surprisingly difficult to figure out.

I think the thing that most annoys me about this article is how it uses the cliché of the “Brave Maverick Doctor.” In this case, it’s Tom Jefferson of the Cochrane Collaboration, who, if you believe Brownlee and Lenzer, is the only researcher who knows anything about the flu and the only one who has ever actually examined the literature in detail. Like all Brave Maverick Doctors, he is portrayed as reviled by the medical community:

The most vocal–and undoubtedly most vexing–critic of the gospel of flu vaccine is the Cochrane Collaboration’s Jefferson, who’s also an epidemiologist trained at the famed London School of Tropical Hygiene, and who, in Lisa Jackson’s view, makes other skeptics seem “moderate by comparison.” Among his fellow flu researchers, Jefferson’s outspokenness has made him something of a pariah. At a 2007 meeting on pandemic preparedness at a hotel in Bethesda, Maryland, Jefferson, who’d been invited to speak at the conference, was not greeted by any of the colleagues milling about the lobby. He ate his meals in the hotel restaurant alone, surrounded by scientists chatting amiably at other tables. He shrugs off such treatment. As a medical officer working for the United Nations in 1992, during the siege of Sarajevo, he and other peacekeepers were captured and held for more than a month by militiamen brandishing AK-47s and reeking of alcohol. Professional shunning seems trivial by comparison, he says.

Of course. Not only is he a Brave Maverick Doctor, but he’s a Outcast Brave Maverick Doctor, if you know what I mean. Of course, I’ve gone to meetings where no one greeted me, where I had no one to talk to, and where I had to eat some of my meals alone–even at one where I had had an abstract accepted and was going to speak. Help! I’m being shunned! Well, no, actually. The reason was because these were huge meetings where I didn’t really know any of the attendees. Because I tend to be a bit on the shy side in person, I tend not to introduce myself and insinuate myself into conversations with my colleagues. Of course, it’s quite possible that Dr. Jefferson’s colleagues were shunning him, but one wonders if he may not be a particularly enjoyable dinner companion. Who knows?

But this is a relative quibble compared to what really bugs me about Dr. Jefferson, namely the disconnect between what he says in public to journalists and what he writes in various Cochrane Reviews about influenza for which he is a coauthor. First, a couple of samples straight from Brownlee and Lenzer’s article. Here’s sample 1:

“Tom Jefferson has taken a lot of heat just for saying, ‘Here’s the evidence: it’s not very good,'” says Majumdar. “The reaction has been so dogmatic and even hysterical that you’d think he was advocating stealing babies.” Yet while other flu researchers may not like what Jefferson has to say, they cannot ignore the fact that he knows the flu-vaccine literature better than anyone else on the planet. He leads an international team of researchers who have combed through hundreds of flu-vaccine studies. The vast majority of the studies were deeply flawed, says Jefferson. “Rubbish is not a scientific term, but I think it’s the term that applies.” Only four studies were properly designed to pin down the effectiveness of flu vaccine, he says, and two of those showed that it might be effective in certain groups of patients, such as school-age children with no underlying health issues like asthma. The other two showed equivocal results or no benefit.

Ah, yes, the Brave Maverick Doctor encounters pushback by the “dogmatic” and close-minded medical community that obviously cannot see his brilliance. And here’s sample 2:

In a phone interview, Fauci at first voiced the opinion that a placebo trial in the elderly might be acceptable, but he called back later to retract his comment, saying that such a trial “would be unethical.” Jefferson finds this view almost exactly backward: “What do you do when you have uncertainty? You test,” he says. “We have built huge, population-based policies on the flimsiest of scientific evidence. The most unethical thing to do is to carry on business as usual.”

Wow. “Rubbish” and “the flimsiest of evidence.” Strong stuff. I wonder. Does Dr. Jefferson say the same things in his Cochrane Reviews? Well, no, as revere pointed out. Take a look at the Cochrane Reviews page for flu vaccines. Then take a look at the conclusions he makes in Cochrane Reviews about the flu vaccine. As revere says, they are–shall we say?–considerably weaker than what Dr. Jefferson says in public to journalists, including the extra bonus example I included after stealing revere’s examples:

  • In long-term care facilities, where vaccination is most effective against complications, the aims of the vaccination campaign are fulfilled, at least in part. However, according to reliable evidence the usefulness of vaccines in the community is modest. The apparent high effectiveness of the vaccines in preventing death from all causes may reflect a baseline imbalance in health status and other systematic differences in the two groups of participants. (Rivetti D, Jefferson T, Thomas R, Rudin M, Rivetti A, Di Pietrantonj C, Demicheli V, Vaccines for preventing influenza in the elderly, Cochrane Database Syst Rev. 2006 Jul 19;3:CD004876)
  • We concluded that there is no credible evidence that vaccination of healthy people under the age of 60, who are HCWs [health care workers] caring for the elderly, affects influenza complications in those cared for. However, as vaccinating the elderly in institutions reduces the complications of influenza and vaccinating healthy persons under 60 reduces cases of influenza, those with the responsibility of caring for the elderly in institutions may want to increase vaccine coverage and assess its effects in well-designed studies. (Thomas RE, Jefferson T, Demicheli V, Rivetti D, Influenza vaccination for healthcare workers who work with the elderly, Cochrane Database Syst Rev. 2006 Jul 19;3:CD005187)
  • Influenza vaccines are efficacious in children older than two but little evidence is available for children under two. There was a marked difference between vaccine efficacy and effectiveness. No safety comparisons could be carried out, emphasizing the need for standardisation of methods and presentation of vaccine safety data in future studies. It was surprising to find only one study of inactivated vaccine in children under two years, given current recommendations to vaccinate healthy children from six months old in the USA and Canada. If immunisation in children is to be recommended as a public health policy, large-scale studies assessing important outcomes and directly comparing vaccine types are urgently required. (Jefferson T, Rivetti A, Harnden A, Di Pietrantonj C, Demicheli V. Vaccines for preventing influenza in healthy children. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD004879)
  • Inactivated parenteral vaccines were 30% effective (95% CI 17% to 41%) against influenza-like illness, and 80% (95% CI 56% to 91%) efficacious against influenza when the vaccine matched the circulating strain and circulation was high, but decreased to 50% (95% CI 27% to 65%) when it did not. Excluding the studies of the 1968 to 1969 pandemic, effectiveness was 15% (95% CI 9% to 22%) and efficacy was 73% (95% CI 53% to 84%). Vaccination had a modest effect on time off work, but there was insufficient evidence to draw conclusions on hospital admissions or complication rates. Inactivated vaccines caused local tenderness and soreness and erythema. Spray vaccines had more modest performance. Monovalent whole-virion vaccines matching circulating viruses had high efficacy (VE 93%, 95% CI 69% to 98%) and effectiveness (VE 66%, 95% CI 51% to 77%) against the 1968 to 1969 pandemic. Influenza vaccines are effective in reducing cases of influenza, especially when the content predicts accurately circulating types and circulation is high. However, they are less effective in reducing cases of influenza-like illness and have a modest impact on working days lost. There is insufficient evidence to assess their impact on complications. Whole-virion monovalent vaccines may perform best in a pandemic. (Jefferson TO, Rivetti D, Di Pietrantonj C, Rivetti A, Demicheli V., Vaccines for preventing influenza in healthy adults, Cochrane Database Syst Rev. 2004;(3):CD001269.)

Pretty wishy-washy, full of the usual cautious wording that scientists expect and use, wouldn’t you say? I would. I also note that that last quote indicates to me that the flu vaccine is actually pretty darned good, with 80% efficacy when the vaccine matches the circulating strain. The H1N1 vaccine matches the strain quite well; so we should expect that it will be quite efficacious.

In any case, so why does Jefferson go all full mental jacket negative when he’s speaking with journalists? Why does he do what irritates the crap out of me and many other advocates of science-based medicine when it’s done by researchers, be they legitimate scientists or mavens of “alternative medicine” whose statements in press releases and in public are far stronger (and often more inflammatory) than anything one can find in their scientific papers? The answer is obvious. It’s because he can! Dr. Jefferson can’t say stuff like “rubbish” and “the flimsiest of evidence” in scientific papers because peer reviewers will quite properly shoot it down, but he sure can say what he really thinks to reporters. Moreover, Jefferson wouldn’t be the first scientist to fall for the blandishments of fame and a public reputation as bucking the establishment, something the media loves. Being an “iconoclast” or a “maverick” is very seductive. It brings attention and fame. In recent years, Dr. Jefferson has become the go-to vaccine scientist for the “skeptical view” on the flu vaccine whenever a journalist is doing a story, and he appears only too happy to oblige these days with juicy quotes.

He’s also become so attractive as a quote source because journalists tend not to like nuance. With only a limited space to say what they have to say and ubiquitous deadline pressures, explaining nuance is hard. That’s why they tend not like statements like the ones in the Cochrane Reviews co-authored by Dr. Jefferson cited above. They like concrete statements, especially if they are pith, juicy, or controversial, statements like calling the evidence base for flu vaccines “rubbish” and the basis for flu vaccination the “flimsiest of scientific evidence.” There are many reasons to be cautious when discussing the efficacy of flu vaccines and many shortcomings to how scientists make and use flu vaccines. In short, there are many legitimate issues to debate about flu vaccines and our policies for combatting the H1N1 pandemic. Inflammatory statements, such as the ones Jefferson is fond of making, however, shed far more heat than light on the legitimate issues and problems surrounding vaccination against influenza and the murky evidence regarding its efficacy.

I also have to wonder if this celebrity effect was responsible for Dr. Jefferson’s initial acceptance of an invitation to speak at the annual conference of the oldest and largest anti-vaccine organization there is, the National Vaccine Information Center (NVIC), where he was to receive the NVIC Courage in Science Award. (No, I am not saying that Jefferson is anti-vaccine.) True, he did ultimately bow out and refuse to attend after he found out that he would be sharing a stage with Andrew Wakefield, who was slated to receive the NVIC Humanitarian Award. That is to Jefferson’s credit. However, it only partially absolves him. After all, that Jefferson ever accepted the invitation in the first place tells me that he is either clueless about the ramifications of his stance about the flu vaccine and how it is used by anti-vaccine activists as part of their overall war on vaccination programs or he doesn’t mind. That’s not to say that skeptics of current flu vaccination policies shouldn’t speak out, either. What I do argue is that skeptics like Tom Jefferson, who holds a prominent position in the Cochrane Collaboration, has a special responsibility not to make his message too easy for antivaccine advocates to coopt and especially not to lend his name to their message. That is something he has failed at utterly. Yes, Jefferson did ultimately withdraw from the NVIC meeting less than a month before it was scheduled, but he did not, as far as I know, ever make a public statement about why he withdrew, which is why I don’t consider him completely absolved. Maybe he was embarrassed; if so, he should be.

Moreover, I have to wonder if it was more Jefferson’s contempt for Andrew Wakefield that was responsible than anything else and whether he would have minded sharing the stage with the other NVIC award recipients, such as that promoter of quackery and anti-vaccine nonsense Dr. Joe Mercola, who received the NVIC Visionary Award; Peggy O’Meara, founder of that repository of anti-vaccine “mommy instinct,” Mothering Magazine, who received the NVIC Courage in Journalism Award; or Vicky Debold, who sits on the board of NVIC and received the NVIC Parenting Leadership Award. Without Wakefield, it wouldn’t surprise me if the blandishments of Barbara Loe Fisher, stroking Jefferson’s ego with the words “iconoclast”, “maverick,” and “visionary,” would have led him to participate in a pure crank anti-vaccine conference. Jefferson’s agreeing to appear at the NVIC was, from my perspective, still more evidence that Jefferson has drifted too far beyond reasonable skepticism about the boosterism surrounding flu vaccine programs and an “outlier” viewpoint. He’s now flirting dangerously with becoming a crank himself.

This is the hero of Brownlee and Lenzer’s article.

As I said before, I agree that, even more than most Cochrane afficianados, Jefferson does indeed fall prey to the sin of “methodolatry,” which is, as revere puts it, the “profane worship of the randomized clinical trial as the only valid method of investigation.” While it is true that RCTs are the gold standard for many areas of medical investigation, they can’t be done for many areas, either for practical or ethical reasons. I work in just such an area, namely surgery, where it is, with few exceptions, impossible to blind researchers to experimental groups and is often very difficult to randomize to different operations. These are just practical, logistical considerations, too. Does that mean that surgical research is bogus and we can’t know what operations do and do not work? Of course not!

There are also ethical grounds. Brownlee and Lenzer write:

Demonstrating the efficacy (or lack thereof) of vaccine and antivirals during flu season would not be hard to do, given the proper resources. Take a group of people who are at risk of getting the flu, and randomly assign half to get vaccine and the other half a dummy shot. Then count the people in each group who come down with flu, suffer serious illness, or die. (A similarly designed trial would suffice for the antivirals.) It might sound coldhearted, but it is the only way to know for certain whether, and for whom, current remedies actually work.

This statement is the purest rubbish (to paraphrase Tom Jefferson himself). Indeed, such a statement is pure methodolatry. That’s because an RCT is not the “only” way to know if a flu vaccine works. It may be the most rigorous way to determine if a flu vaccine (or any other intervention) works. It may be the methodology that would provide the clearest answer (assuming the RCT is properly done). It may be the methodology that allows researchers to control variables the best. However, it is most definitely not the “only” way to know if an intervention works. There are numerous other strategies, and they are all being used. Moreover, such an RCT would not necessarily be nearly as easy to do as Brownlee naively thinks.

When doing clinical trials, one of the most important principles is clinical equipoise. What that means is that, to the best of the knowledge of the investigators running a trial, there truly must not be known difference between the interventions being tested. In other words, RCTs are only acceptable from an ethical standpoint if we truly do not know whether one treatment is superior to another (in the case of trials of one treatment versus another) or a treatment is better than a placebo (in the case of testing a single treatment). There must be genuine uncertainty, even if the investigators believe strongly in the treatment being tested. After all, that’s why we do the trial, to try to eliminate that uncertaint. If there is good reason to believe that one arm will be receiving inferior care, then an RCT is not considered ethical because it would be randomizing patients to a treatment (or lack of treatment) that is either inferior or potentially harmful. Here’s a hint that neither Jefferson nor Brownlee seems to get: That evidence suggesting superiority of one arm or another does not have to come from RCTs. It can come from observational studies, preclinical studies, and other sources. In the case of the influenza vaccine, there is more than enough convergence of evidence to suggest that leaving a placebo-control group unvaccinated against the flu does not meet the standard of clinical equipoise. As revere points out:

The bottom line is this. There is excellent and credible evidence in the scientific literature that vaccination against influenza reduces infections in people under 60, evidence that even Dr. Jefferson accepts. For those over 60, there are legitimate questions that were raised by others about the extent of the benefit of seasonal flu vaccine, but they were raised before Jefferson got into the act. The argument put forward in this piece is a straw man argument as far as pandemic influenza is concerned (and in which context it was placed).

Given this background evidence, at the very least leaving a control group unvaccinated leaves them more likely to get the flu–a definite potential for harm even if it ends up being true that differences in death rates due to vaccination may be small or nonexistent. Thus, a truly randomized trial would very likely be unethical and violate the Helsinki Declaration. At the very least it would be highly suspect from an ethical perspective.

As a breast cancer surgeon, I found one passage most telling:

The annals of medicine are littered with treatments and tests that became medical doctrine on the slimmest of evidence, and were then declared sacrosanct and beyond scientific investigation. In the 1980s and ’90s, for example, cancer specialists were convinced that high-dose chemotherapy followed by a bone-marrow transplant was the best hope for women with advanced breast cancer, and many refused to enroll their patients in randomized clinical trials that were designed to test transplants against the standard–and far less toxic–therapy. The trials, they said, were unethical, because they knew transplants worked. When the studies were concluded, in 1999 and 2000, it turned out that bone-marrow transplants were killing patients.

Well, yes and no. First off, the evidence was not quite as flimsy as Brownlee and Lenzer paint it, although I can see why it is necessary for her to portray it that way in the context of how she is framing her story. There were a couple of phase II trials showing of a benefit, but they were not large and it was unclear if selection bias was playing a role. Second, comparing the evidence base for bone marrow transplantation (BMT) for breast cancer to the evidence base for the flu vaccine is disingenuous at worst and ignorant at best. There are numerous studies, a confluence of evidence from various sources, that attest that the flu vaccine does, in fact, prevent the flu. The point of contention is for what groups it reduces mortality and by how much. Moreover, having lived through the era of BMT for breast cancer, I get the impression that Brownlee overstates the use of the ethical argument against doing a randomized trial of bone marrow transplant versus standard high dose chemotherapy. Indeed, throughout the 1990s, numerous oncologists argued for and ultimately pushed for just such a study because of a distinct feeling that BMT had become popularized before the evidence base supported it. More than ethical concerns, what stood in the way were more political considerations. No, I’m not saying that some oncologists hadn’t come to believe in BMT passionately enough to make that argument. I’m saying that, more importantly, the public had come to believe that BMT worked and lobbied the government and insurance providers to pay for BMT for breast cancer.

The whole mess is well summarized in this article by Michelle M. Mello and Troyen A. Brennan entitled The Controversy Over High-Dose Chemotherapy With Autologous Bone Marrow Transplant For Breast Cancer. Basically, the controversy over BMT for breast cancer was far more complex than Brownlee and Lenzer portray, with patient advocacy groups demanding insurance coverage for BMT for cancer absent phase III trial evidence and lawsuits against insurers, which were also partially egged on by some researchers and oncologists who should have known better. Indeed, the experience has led at least one patient advocate to adopt a more cautious approach to clinical research. Moreover, flu vaccines are not BMT, which is a risky procedure full of toxicity. A large benefit is required to justify such a risk. In contrast, the risk from a flu vaccine is minimal; hence the benefit does not have to be as great to justify it from an ethical standpoint.

Come to think of it, it’s about as simplistic as the way Brownlee and Lenzer portray the state of evidence for flu vaccination and the use of anti-viral drugs. But, then, a Brave Maverick Doctor story using a heroic martyr as the protagonist does not leave room for nuance, which would put a damper on the drama. Better to have a dogmatic establishment persecuting the heroic visionary whose genius they can’t comprehend and don’t accept. It’s much more interesting. Sadly, there was a germ of a decent story buried within Brownlee and Lenzer’s article. There are real problems with the use of the flu vaccine and its shortcomings, but it is the best vaccine we have at the moment, and other public health interventions that could help have been de-emphasized in favor of vaccination. Unfortunately, Brownlee and Lenzer saw the issue through the simplistic lens of the hoary old story of the prophet of doom whose message is rejected due to dogma.

Does the vaccine matter? Brownlee and Lenzer ask. More like: Does The Atlantic matter any more, to me at least? Unfortunately, Brownlee, Lenzer, and The Atlantic do matter, but in this case they matter in a negative way. Maybe I will just let my subscription lapse without renewal. Clearly, its editorial standards have fallen, and I hate to be reading a magazine whose latest article is being passed around anti-vaccine circles as “vindication” that the flu vaccine doesn’t work. If Brownlee and Lenzer happen to read this, given that they’ve shown up on revere’s blog, I would ask them to consider this: Their article is being touted by one of the most notorious anti-vaccine crank blogs there is, Age of Autism, and at repositories of pure quackery and anti-vaccine insanity that exists on the Internet, namely Mike Adams’, in an article entitled Flu vaccines revealed as the greatest quackery ever pushed in the history of medicine. Yes, I realize that cranks will be cranks, and that cranks can misuse even reasonable denialist objections to science, but Brownlee and Lenzer made it just so incredibly easy for the anti-vaccine movement to hold up their article as “proof” that flu vaccines don’t work.

If I were a journalist, that’s not something I’d be proud of.