Conflicts of interest among vaccine advocates: The Law of Contagion

I didn’t think I’d be revisiting this topic again so soon, but damned if Alice Dreger didn’t write something that comes pretty close to demanding that I do so. I tried to resist, but unfortunately could not. Basically, I’m getting really, really tired of Dreger. Why do I say that? It’s because I’m having a harder and harder time not thinking that she has antivaccine proclivities. I don’t want to. I really don’t. But, damn, if she doesn’t keep sounding like a blogger on Age of Autism or The Thinking Moms’ Revolution. The echoes are unmistakeable and appeared again just yesterday.

I first encountered Dreger’s ambivalence about vaccines over a year ago, when I first encountered an article by her entitled What if not all parents who question vaccines are foolish and anti-science? that basically painted those of us who advocate for science and vaccines as frenzied, self-righteous zealots who are incorrect (and disrespectful to parents, to boot) when we point out that most fears of vaccines are rooted in pseudoscience and, for the most part, baseless. More importantly, Dreger painted us as incapable of the nuance that she so clearly thinks she brings to the discussion. In contrast to her recognition that it is not necessarily irrational to have fears about vaccines and her oh-so-”reasonable” refusal to take a side on the issue, she portrayed pro-vaccine advocates as the unreasonable and dogmatic ones.

Oddly enough, she seemed oblivious to antivaccinationists who liken vaccines to the Holocaust, relentlessly attack pro-vaccine advocates like Dr. Paul Offit as “Dr. Proffit” and a “pharma shill.” (More on that a bit later.) Many of these same people declare themselves to be “not antivaccine,” and Dreger seemed to take them at their word. She also seemed oblivious to the fact that most pro-vaccine advocates recognize why many parents are afraid of vaccines, actively try to understand, so that we can allay those fears, and try our best to be respectful to genuine doubters. Unfortunately, she also seemed incapable of distinguishing between parents with fears, who can be persuaded with reason, respect, and patience, and hard core antivaccinationists, who cannot be persuaded and whose beliefs are indeed rooted in pure pseudoscience, along with many of the cognitive quirks we humans have in determining causation.

Then, a mere three weeks ago, Dreger wrote a very misguided post, Beyond Vaccine Exceptionalism. In it, whether she knew it or not, she basically parroted the familiar antivaccine trope that that vaccines cannot be criticized. In fact, she stated it explicitly in a way that would have made her statement quite at home on any antivaccine blog, referring to “the attitude among many science and public health advocates, that approved and recommended vaccines are never to be questioned or doubted,” an attitude that she referred to as “vaccine exceptionalism.” It’s a common trope among antivaccinationists that liken belief in vaccines to religion or ideology more than science. Unfortunately, the level of ignorance on display with respect to the antivaccine movement in her article was simply staggering. At the same time she slimed bioethicist Arthur Caplan as hopelessly compromised because his foundation has apparently accepted grants from vaccine manufacturers. I can’t help but note at the time that the evidence she presented to support her charge that Caplan can’t be trusted or is some sort of massive hypocrite was thin gruel indeed.

Yes, there was the germ of a good point behind her warnings about undisclosed conflicts of interest (COIs). I’ve said similar, but less radical things myself. Unfortunately, her utter lack of a sense of proportion and her dismissal of anyone who’s ever had a commercial or financial interest in vaccines as hopelessly compromised bordered on the pharma shill gambit. So what compelled me to revisit Dreger and her antivaccine-friendly, if not actually antivaccine, ramblings? Yesterday she dropped all pretense of nuance and dove headlong into flinging the pharma shill gambit at two people I admire, Dr. Paul Offit and Dr. Arthur Caplan, while condescendingly lecturing journalists, including one whose work I admire, Tara Haelle, in a post entitled Reporters Need to Avoid Experts with Vaccine Industry Funding; Here’s Why, and Here’s Help. The premise of her article is that reporters should never, ever interview vaccine experts who have ever received funding from a vaccine manufacturer or that, if they must, they must “disclose” to her standards.

Dreger uses as her jumping off point a story in the New York Times about an article in JAMA Internal Medicine that found that the sugar industry sought to influence the scientific debate over the causes of coronary heart disease (CHD) to play down sugar as a cause and blame the cause on fat. It’s actually a fascinating article. Basically, the authors examined internal documents of the Sugar Research Foundation (SRF), whose first research project resulted in a literature published in the New England Journal of Medicine in 1965 that singled out fat and cholesterol as the dietary causes of CHD and downplayed evidence that sucrose consumption was also a risk factor. This was back in the days before journals required authors to disclose COIs and the ethical standards for disclosure of links to industry were basically nonexistent.

Now, there is no doubt that this is a disturbing story, reminiscent of what the tobacco companies did to try to suppress or counter research showing that tobacco was a major health hazard, the cause of lung cancer and heart disease. To be honest, what surprised me the most about this article is how cheaply some of these researchers were bought, at least initially. For instance:

On July 13, 1965, 2 days after the Tribune article, the SRF’s executive committee approved Project 226,31 a literature review on “Carbohydrates and Cholesterol Metabolism” by Hegsted and Robert McGandy, overseen by Stare.10 The SRF initially offered $500 ($3800 in 2016 dollars) to Hegsted and $1000 ($7500 in 2016 dollars) to McGandy, “half to be paid when you start work on the project, and the remainder when you inform me that the article has been accepted for publication.”31 Eventually, the SRF would pay them $6500 ($48,900 in 2016 dollars) for “a review article of the several papers which find some special metabolic peril in sucrose and, in particular, fructose.”

So we can all agree that this is a deplorable incident, just as what the tobacco companies did to try to counter the growing evidence of just how dangerous tobacco was to public health. It’s also clear that this effort, as disturbing as it was, was nowhere near as extensive and pervasive as that of the tobacco companies. Basically, what the SRF got for its efforts was a single review article. Yes, it was a review article published in the New England Journal of Medicine (NEJM) in 1967 that was highly influential. That’s bad enough, but even the authors state that there is “no direct evidence that the sugar industry wrote or changed the NEJM review manuscript; the evidence that the industry shaped the review’s conclusions is circumstantial.” Reporting of the story makes it sound as though the sugar industry was as bad as the tobacco industry. (It did spend $600,000, or $5.3 million in 2016 dollars over the course of many years.) Whether that’s true or not, it’s impossible to tell from this single historical analysis, which is only about one review article and one industry group. As Steve Novella and Scott Alexander point out, the JAMA Internal Medicine article fails to put its finding into the context of the “diet wars” of 50 years ago, when it was debated whether it was sugar or fat that’s the worst culprit in promoting CHD. As Alexander put it:

In any case, claims that the sugar industry sponsored one study back in the 1960s, and this means everything we’ve ever thought is wrong and biased against fat and in favor of sugar, miss the point (especially since there are probably problems with both sugar and fat). Whatever study the New York Times has dredged up was one volley in an eternal clandestine war of Big Fat against Big Sugar, and figuring out who’s distorted the science more is the sort of project that’s going to take more than one article.

I went on this diversion mainly because it is relevant, but also because I found the article describing this incident interesting. So does Alice Dreger, who takes a germ of a reasonable point and runs right off the deep end with it:

This is exactly the kind of history that I am talking about when I write, as I did for New Statesman magazine, about how not all parents who question some vaccines are “anti-vax.” Some are well read; they know about the bad behaviors and troubling power of the pharmaceutical industry, and they know the same industry produces many of our vaccines.

This is why editors should refuse to accept pro-vaccine articles from individuals who have been funded by the vaccine industry without full disclosure of that funding history; better yet, don’t allow them. Get someone who hasn’t been paid by the industry. It is also extremely important that reporters working on stories about vaccines consult physicians, epidemiologists, and ethicists who do not have histories of being funded by the vaccine industry.

This is what I like to refer to as the “contagion” concept of COIs. Basically, Dreger appears to think that it’s not enough just to disclose COIs. (What, exactly, constitutes a reportable COI in any given situation is not even considered carefully—or even really at all.) Rather, to her, just being touched by that evil, evil, big pharma money, particularly if it’s a vaccine manufacturer, is apparently enough to taint forever any expert who partakes of the tainted sustenance, no matter how distant in the past, no matter what the situation was, no matter how much funding was received. None of that matters. To Dreger, if you’ve ever accepted any funding from a vaccine manufacturer, you’re forever blacklisted. She starts out saying that such people should have their COI disclosed, which is generally what is done and should be done. Take Dr. Offit, for instance. I’ve never seen a pro-vaccine article by him that doesn’t mention that he’s a Professor of Pediatrics at the University of Pennsylvania and that he was the co-inventor of a Rotavirus vaccine (RotaTeq), usually with his connection to Merck mentioned as well.

Dreger goes beyond just disclosure, though. To her, disclosure of COIs is not enough. Instead, she advocates censorship—yes, censorship—in the name of “intellectual honesty” and rooting out COIs. Dreger is basically arguing that publications should not accept pro-vaccine articles from any expert with a COI and, even beyond that, journalists should not consult with such experts at all! Helpfully, she provides a list of experts that are acceptable to her because she finds them clean of any taint of vaccine money. I recognize some of them, such as Dr. Daniel Flanders, Dr. Jamie Friedman, and Alison Bateman-House, PhD, MPH, MA. Most of the others, I don’t recognize. The reason, of course, is that most of these doctors and academics, although pro-vaccine, are not actually, strictly speaking, vaccine experts. Dr. Flanders runs Kindercare Pediatrics. Dr. Jaime Friedman is a practicing pediatrician, as well. I worked my way down the list and found precious few whom I’d consider bona fide scientific experts on vaccines. Only a couple appear to have done significant work related to vaccines as part of their professional career. That is not a knock on any of them. After all, I’ve never done significant work related to vaccines either, but I sure have picked up a lot of knowledge about them. I could just as easily been on that list. So could Steve Novella, Harriet Hall, Mark Crislip (who, as an infectious disease doctor, has at least as much claim to expertise on vaccines as any pediatrician), John Snyder, or Clay Jones.

Now, don’t get me wrong. I have nothing against the experts on Dreger’s list. Clearly, they have been active enough for vaccines to have earned plaudits and suggestions. For instance, I’m a big fan of Dr. Jen Gunter and admire her standing up for science. However, Dr. Gunter is not really a vaccine expert, at least not in the formal sense. She is an OB/GYN and a pain medicine physician with an interest and expertise in the HPV vaccine. This is not a criticism. I also point out I’m not a formal expert in vaccines, either. I’m a breast cancer surgeon. Indeed, when journalists contact me, I generally make it a point to tell them that I am an expert in neither autism nor vaccines, although I do know a lot because of my long term interest in combatting antivaccine pseudoscience. Basically, like me, Gunter developed her expertise in writing about vaccines, primarily Gardasil. Let’s put it this way, neither Dr. Gunter nor I are a Dr. Paul Offit. Neither, as far as I can tell, is anyone else on Dreger’s list. Again, that is not a knock, nor is it to say that Dreger’s experts aren’t experts. Dr. Flanders, for instance, is an expert in dealing with parental fears of vaccines. They are all very accomplished experts in many different areas, all with some experience related to vaccines. It’s just that Dreger, in her zeal to find people clean of any perceived taint of big pharma, is willing to throw more compelling experts under the bus.

Like this:

Reporters should always be careful, when reporting on vaccines, to specifically find out whether a source has vaccine industry funding in their history. Avoid people like Arthur Caplan who has said that he doesn’t get vaccine industry funding because “the checks aren’t written to me”; in fact, his Center for Vaccine Ethics and Policy specifically seeks and takes vaccine industry funding. He even offers “development of articles for peer-reviewed journals positioning the underlying issues involved to contribute to the field overall,” but don’t expect Caplan to disclose that when he publishes; he doesn’t. (It’s kind of hilarious the folks at Caplan’s center call themselves “an independent voice” on vaccine policy while offering to do political consulting for the vaccine industry. For more on Caplan’s troubling history, see the last chapter of Carl Elliott’s excellent White Coat, Black Hat.)

I discussed last time the bug up her butt Dreger seems to have for Caplan. For whatever reason, she seems to think he has an irredeemable COI. What stood out about Dreger’s targeting Caplan was a very remarkable absence. Namely, I don’t recall ever having read anything on an antivaccine website about Caplan being a pharma shill (and, make no mistake, Dreger is pulling the pharma shill gambit on Caplan in a way that would make Jake Crosby blush). Given that Caplan is a high profile vaccine advocate, I find it hard to believe that, if he truly had received as much pharma funding as Dreger implies, antivaccinationists wouldn’t have been all over it for years now. In any case, I discussed last time why I found Dreger’s accusations against Caplan rather…underwhelming. In any case, this is what Caplan’s Center for Vaccine Ethics and Policy does:

Beginning in 2008, the Center for Vaccine Ethics and Policy began to respond to request for ethics and policy consultation by state and local government, major NGOs in the public health sphere, vaccine makers and corporations. These consults have included ethical issues around pandemic preparedness planning; H1N1 vaccine deployment; clinical trial design for novel vaccines; informed consent issues around vaccine clinical trials and immunization campaigns; pre-licensure access to vaccines in development, and targeted market withdrawal of specific vaccine products.

These consults are typically confidential in nature but have included PATH, The Wistar Institute; the Commonwealth of Pennsylvania, the City of Philadelphia, Merck, Novavax, and Goldman Sachs, among others.

OK, so Caplan’s group does consulting work for a whole bunch of interested parties, responding to requests. That’s a bit different than what Dreger describes.

Dreger also goes off the deep end here:

The issue of avoiding vaccine commentators with CoI’s arose for me anew yesterday after reading Tara Haelle’s astonishing and important account of why the famous Dr. Bob Sears may lose his medical license. (It’s not just that he’s irresponsible around vaccines.)

In that article, Haelle quoted Dr. Paul Offit as an expert—which he most certainly is—but did not mention his history of industry funding. Note: I incorrectly tweeted yesterday that Offit’s center takes industry funding; his current center at Penn, which replaces the one Caplan took with him to NYU, does not. I apologize for that mistake but note that my point about his history stands: for years, Offit helped co-lead Caplan’s Center for Vaccine Ethics and Policy and there’s no question Offit has a long history of industry funding of the sort that leads to skepticism.

Yes, and in her article, Haelle quite appropriately pointed out that Offit is “co-inventor of the rotavirus vaccine, director of the Vaccine Education Center and a professor of pediatrics in the Division of Infectious Diseases at the Children’s Hospital of Philadelphia.” Uh, hello. He invented a vaccine! That’s a pretty good indication that he’s invested in vaccines. Could Haelle have disclosed more, such as how Offit sold his interest in the vaccine? Sure. Was it necessary? I’m not sure in this case, because in this case Offit was commenting on Dr. Bob Sears’ history, in particular his “delayed” vaccine schedule), and, compared to every single other of Dreger’s suggested experts, Dr. Offit has way more scientific authority when discussing vaccine schedules.

Haelle, not surprisingly, was not pleased with Dreger’s attack. She launched an epic Twitter storm in which she schooled Dreger. Some of my favorites:

Exactly.

There’s more, much of which echoes what I just wrote above, something like 40 total.

I know Dreger says she’s pro-vaccine. I even believe that she probably is. However, she is even more anti-pharma than pro-vaccine, to the point where it warps her perception and that some of what she writes would be right at home on antivaccine blogs and websites. Basically, her thinking reminds me of the Law of Contact or Contagion in James George Frazer’s The Golden Bough. Basically, the idea behind the Law of Contagion is that, once two people or objects have been in contact, a magical link persists between them unless or until a formal exorcism or other act of banishing breaks the non-material bond. You get the idea. In Dreger’s world, if you’ve ever touched pharma money, even indirectly, a magical link persists forever. You are tainted forever. In my younger days, I accepted pens and the occasional tchotchke from Merck and other pharmaceutical companies that make vaccines. By Dreger’s definition, I guess I, too, am tainted forever. At least I’m in good company.

I wonder if the Law of Contagion applies to those on the “vaccine safety” (in reality, almost always antivaccine) side, many of whom make quite a pretty penny from selling various supplements and various quack treatments, ranging from hyperbaric oxygen to chelation therapy, to MMS (a.k.a. bleach) enemas to many others. Many on the antivaccine side have lucrative businesses devoted to speaking, selling books and DVDs, and the like. Dr. Bob Sears, for instance, sells medical exemptions to vaccines based on what parents submit on an online form.If she did, then say goodbye to Dr. Bob, Andrew Wakefield, Del Bigtree, Polly Tommey, and many other antivaccine activists disguised as “autism advocates.” There are a lot of other examples just as blatant, if not as militantly antivaccine. One wonders if Dreger applies her same absolutist definition of a financial COI to these people when it comes to vaccines. We don’t know. She doesn’t say. I wonder why.

As I said last time, with friends like these, who needs enemies?