Now what? Will SB 277 enrich antivaccine doctors?

My original intention was to write about something entirely different today, but, really, how could I, given that SB277 has become law in California and non-medical exemptions to school vaccine mandates are a thing of the past? The topic I had in mind for today can easily keep for a day or two anyway. Besides, what I want to contemplate now is how SB277 will work in practice. Sure, it’s fun to watch the antivaccine fringe completely lose it as SB 277 got closer and closer to passing. Indeed, if you want to experience a combination of amusement and revulsion, just peruse the comments of this post on the antivaccine crank blog Age of Autism announcing that Governor Jerry Brown had signed the bill. It’s full of outraged antivaccine activists shouting about how Gov. Brown “has blood on his hands,” how his entire legacy will be defined by this single act of signing SB 277 (really, they do have a vastly inflated view of their own importance), and rants about medical tyranny and how there will now be armed revolution. The #SB277 hashtag on Twitter is similarly depressing and entertaining.

As an aside, at this point I can’t resist pointing out briefly that perhaps the most hilariously unhinged reaction to the passage of SB 277 comes from Jon Rappaport, where the derp is so strong that it’s hard to believe that a human being can be so ignorant about science. Let’s just say the title of his rant is Mandatory vaccination: California is ordering genetic alteration. His argument? Epigenetics man. As I like to say: Epigenetics. You keep using that word. I do not think it means what you think it means. Rappaport’s rant is so unhinged that it’s basically self-refuting, which is why I didn’t construct an entire post around it. True, it’s not as utterly vile as Kent Heckenlively’s post yesterday likening SB 277 to the Fugitive Slave Act of 1850, because, apparently, vaccine mandates are the equivalent of making slaves of parents, but it is a masterpiece of quackery.

Oh, and Jim Carrey is still antivaccine. I had thought that was just a momentary affectation due to his dating Jenny McCarthy, but apparently the antivaccine views have been internalized so that he’s still spouting them years later.

There. I’ve gotten that out of my system. Now what about SB 277 in practice? SB 277 is a major improvement in the law regulating vaccination and vaccine exemptions in California that protects children from infectious disease. However, it is not perfect. For example, a question came up for me reading Gov. Brown’s signing message:

The Legislature, after considerable debate, specifically amended SB 277 to exempt a child from immunizations whenever the child’s physician concludes that there are “circumstances, including but not limited to, family medical history, for which the physician does not recommend vaccination.”

Thus, SB 277, while requiring that school children be vaccinated, explicitly provides an exception when a physician believes that circumstances — in the judgment and sound discretion of the physician — so warrant.

What does this mean? I went and took a look at the text of the bill as passed, specifically, Section 5:

SEC. 5. Section 120370 of the Health and Safety Code is amended to read:

120370. (a) If the parent or guardian files with the governing authority a written statement by a licensed physician to the effect that the physical condition of the child is such, or medical circumstances relating to the child are such, that immunization is not considered safe, indicating the specific nature and probable duration of the medical condition or circumstances, including, but not limited to, family medical history, for which the physician does not recommend immunization, that child shall be exempt from the requirements of Chapter 1 (commencing with Section 120325, but excluding Section 120380) and Sections 120400, 120405, 120410, and 120415 to the extent indicated by the physician’s statement.

What does that mean? It’s hard not to suggest that it means that antivaccine pediatricians in California, like Dr. Bob Sears and Dr. Jay Gordon, are already putting money down on a new Lamborghini. No, that’s not my joke; I saw it on Twitter:

That might be going too far, but it does bring up a point. The biggest weakness in SB 277 is that it appears to leave it pretty much up to a child’s pediatrician regarding whether a medical exemption to the school vaccine mandate is medically indicated. In that, it is similar to the Mississippi law. In contrast, in West Virginia, it isn’t just the word of the child’s physician that matters; all requests for medical exemptions are reviewed by an Immunization Officer, who determines if they are appropriate “based upon the most recent guidance from the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP) with respect to medical contraindications or precautions for each vaccine.”

On the surface, it would indeed seem to be a godsend to antivaccine pediatricians, who will likely see their business boom in the wake of SB 277, as parents, no longer able to get nonmedical exemptions, start looking for medical exemptions, much the way parents in states that allow religious exemptions but not personal belief exemptions, suddenly found religion and used it as a justification for not vaccinating. Resistance will flow wherever it can. I’m just happy that, in this case at least, only letters from a physician will be valid for obtaining a medical exemption; one could only imagine what would happen if letters from naturopaths and chiropractors, who, unfortunately, are licensed “health care professionals” in the state of California, were permitted.

Indeed, Dr. Jay himself wrote yesterday:

Governor Brown signed this law because of the strong medical exemption provisions. He recognized that parents with reasonable medical objections—as opposed to personal or religious objections—must still have access to exemptions for their children.

Consult with a physician who knows your child and your family.

No one should scare you into or out of vaccinating.

This is the sort of thing that irritates me about Dr. Jay. He knows damned well that the parents of some of his patients are antivaccine activists. Heck, he was the pediatrician who took care of Jenny McCarthy’s son Evan back when she was emerging as America’s foremost (if you can call it that) antivaccine celebrity activist. Does he ever, in the privacy of his office, suggest to them that maybe—just maybe—it’s not such a good idea to spread misinformation demonizing vaccines as toxin-laden poison causing autism, autoimmune diseases, neurodevelopmental disorders, SIDS, and even shaken baby syndrome? Only he and his patients’ parents know for sure, but I doubt it. Certainly, he rarely, if ever, publicly calls out people on “his side” for promoting such misinformation. Instead, he falls back on a vague false equivalency that paints pro- and anti-vaccine activists both as irrationally trying to frighten people to their position. Of course, even if that were true, there would still be a big difference. What pro-vaccine activists say about the dangers of vaccine-preventable diseases is true. What antivaccine activists say about the dangers of vaccine is almost always untrue. In fact, Dr. Jay himself engages in such fear mongering just a few months ago when he declared that The MMR is not controversial because of Wakefield.

His protestations otherwise (which, to be fair, I really think he believes, thanks to massive cognitive dissonance), we know what side Dr. Jay is on.

But back to Twitter. There was an exchange yesterday in which Dr. Jay asserted:

Dr. Jay replied about “family history” in SB 277 and was asked:

He was therefore asked how he, as a pediatrician, would decide whether to recommend a medical exemption to school vaccine mandates, now that SB 277 basically gives him the power to do that. At first, he said, simply, “Nope”:

After some prodding, he did get one thing right:

Which is a relief.

However, elsewhere, he remained maddeningly vague, going on about “family history” of reactions to vaccines, even though he admits that the AAP does not consider this a contraindication. He sparred with a couple of doctors, who asked him what specific medical conditions he’d consider a contraindication to vaccination. Oddly enough, he didn’t mention any of the contraindications that no one disagrees about, such as the accepted contrindication that children with severe immunosuppression (such as due to chemotherapy or illnesses that compromise the immune system) should not receive attenuated live virus vaccines. It would have been so easy to say that, because such a contraindication is on firm medical ground. But instead, Dr. Jay went here:



So what does this mean? The cynic in me thinks it might mean this:

Certainly, for some physicians, that will be the main criterion. The question will come when it is parents who have a perfectly healthy child with no accepted contraindications to vaccination (such as immunosuppression) or even typical “contraindications” promoted by the antivaccine movement, such as a sibling who had an adverse reaction to vaccination, a sibling with autism, the child having autism himself, and the like. How far will pediatricians like Dr. Jay go to give their patients’ parents what they want? It will be a fascinating question, something to keep an eye on as SB 277 is implemented. One thing that I expect to happen is for dubious laboratories, like Doctors Data, to come up with more (and ever more bogus) panels of laboratory tests purported to predict “sensitivity” to adverse reactions from vaccines. Just you watch.

One comforting observation is that there doesn’t seem to be much of a problem with pediatricians writing up dubious recommendations for medical exemptions in Mississippi, whose law doesn’t require review of doctors’ requests for medical exemptions for their patients by an Immunization Officer. But Mississippi is not California, and the law has been in place there for many years. People are used to it. Also, California is one of the great paradises for the many “alternative” practitioners there, including physicians who have gone to the dark side, making the supply of physicians willing—shall we say?—to stretch the boundaries of indications for a medical exemption to vaccines likely much greater in California than it is in Mississippi.

Perhaps the most effective means of making sure that doctors sympathetic to antivaccine parents don’t come up with excessively creative rationales for recommending medical exemptions is vigilance by the state medical board, the federal government, and insurance companies. For instance, one quality metric that is being increasingly examined among pediatricians is the percentage of children who are up-to-date on the recommended vaccines. Pediatricians who fall short on that measure because they issue way more medical exemptions than average could well come under scrutiny. At the very least, they might be risk losing pay-for-performance bonuses. (Not all antivaccine-sympathetic pediatricians are in concierge practices like Dr. Jay and Dr. Bob.) Unfortunately, state medical boards tend to be toothless; so I have little hope that complaints about a physician to the Medical Board of California will have much of an impact.

Don’t get me wrong. The passage of SB 277 is a major victory in the struggle to protect children from the ravages of infectious disease and a major defeat for the antivaccine movement, which marshaled pretty much everything it had to defeat it and still came up short. The California legislature and Governor Jerry Brown are to be commended, as are the innumerable advocates for children “on the ground” who worked tirelessly for its passage. But it is not perfect. It’s politics. Compromises had to be made. SB 277 makes the situation in California much better than it was before with respect to child health and should serve as a model for the remaining 47 states that allow religious and personal belief exemptions. It is a beginning, not an end, and part of what needs to be done now is to keep an eye on its implementation. While I suspect that there will be some doctors who profit as a result of the law, fortunately I also suspect that the number of doctors who will be willing to go much beyond the CDC/AAP guidelines for medical contraindications to vaccination is and will remain small.