Inauguration day: How President Trump could undermine trust in vaccines

In a (very) few short hours, Donald Trump will take the oath of office and become the 45th President of the United States. I realize that I don’t normally blog about politics, at least other than that related to medicine, but I make no bones about it. I’m dreading 12 Noon ET on January 20, 2017. There is more than enough reason for dread given the likely effect on medical science, at the very least. Also, Donald Trump is antivaccine. He’s shown it through meetings with Andrew Wakefield and Robert F. Kennedy, Jr, the former of whom spoke a year ago on a “Conspira-Sea Cruise” and the latter of whom is slated to speak at an anti-vaccination, chemtrails, chiropractic and conspiracy theory event later this year.

That’s just medicine. Don’t even get me started on the ignorant things Trump believes about, for example, climate science, the anthropogenic climate change denialists he’s appointed, how he’s appointed someone as Secretary of Education who is so clueless that she was completely blindsided by a simple question on one of biggest debates in education, whether to assess educational achievement by proficiency or by growth. There’s just too much antiscience to go around now. That’s why I’ll concentrate mainly on what I know, which is medicine, and what I’ve been interested in, high on the list being vaccine science. After all, antivaccine activism is every bit as much a form of science denial as anthropogenic global climate change denial.

One of the retorts I heard when I wrote about Robert F. Kennedy Jr. meeting with Donald Trump a week and a half ago was that the commission on vaccine safety and/or autism that he might or might not have been asked to chair, was that this wouldn’t matter. That federal vaccine policy is based in law and regulations, and that unless Trump spends political capital changing those we don’t have any reason to be worried. Of course, that’s only partially true. Yes, Trump can’t just replace members of the Advisory Committee on Immunization Practices (ACIP) with Andrew Wakefield, Robert F. Kennedy, Jr., Barbara Loe Fisher, and a gaggle of other prominent antivaccine activists because there is a rigorous nominating process for membership, and vacancies are staggered, so that it takes several years to turn the membership over. It’s also true that school vaccine mandates are a matter of state, not federal, law; Trump can’t change 50 state laws. On the other hand, as was noted on STAT News, Trump can appoint a CDC director and agency staffers who have antivaccine proclivities, and such a director could change CDC priorities and policies. If he’s willing to spend political capital, he could conceivably work with Congress to change or eliminate the Vaccine Court. He could cut back funding for the Vaccines For Children program or Section 317, a CDC-administered federal program that pays for vaccines, epidemiology, science, surveillance, the management of outbreaks, and more and has been called the “backbone of the US Immunization Program.”

So, what Trump can do to vaccine policy is limited, at least initially. However, that doesn’t mean he can’t still do enormous damage. There’s a reason why public health officials were appalled at his having met with RFK Jr. and would have been appalled had they known about his meeting with Andrew Wakefield before the election, and it’s Presidential bully pulpit that Trump will have beginning this afternoon. As Olga Khazan wrote the other day in The Atlantic, there is a shadow network of doctors who encourage vaccine hesitancy who could be empowered by a President who openly questions vaccine safety based on no evidence. Her article brings up some excellent points, but unfortunately starts out with a massive fail that I have to point out because it irritates the crap out of me. The article begins:

When Andrew Brandeis encounters patients who are skeptical about vaccines at his family-practice clinic in San Francisco, he doesn’t toe the typical pediatrician party line—that the standard vaccine schedule is a must-do. Instead, he might help the patient delay or space out their child’s shots beyond the recommendations of public-health agencies, if they so desire.

“The earlier you introduce a vaccine to a kid, there is evidence suggesting various adverse reactions,” he said. He believes early administration of the Hepatitis B vaccine is linked to allergies, asthma, and multiple sclerosis—something doctors and health agencies vehemently deny. “The parents might say, ‘I’m just going to wait on that one,’ I’d say that’s okay.”

He doesn’t actively promote this delay strategy, and he said he administers more vaccines than he avoids. Still, his own 2-year-old daughter is unvaccinated, since as Brandeis sees it, “the risks outweigh the benefits.”

Most readers who see this would assume that Brandeis is a pediatrician or family practice doctor. Certainly I did. It’s not until well into the article, the beginning of the second section actually, that we learn:

Brandeis is a naturopathic physician, or ND, a type of alternative medicine specialist who uses herbs, supplements, and lifestyle counseling alongside standard medical treatments. Most NDs get thousands of hours less formal training than do traditional family doctors, and 20 states license them to practice. Brandeis says other than the focus on holistic health, his practice resembles that of any other family physician—except that he doesn’t accept insurance.

Brandeis told me he has no opinion on Robert F. Kennedy or Trump’s vaccine commission, but “I’m looking forward to seeing if any new science is exposed. It’s really hard to get to the bottom of this one.”

Naturopaths are not physicians. They should not be called physicians. Their training does not warrant it, and naturopathy is a cornucopia of quackery mixing everything from homeopathy, traditional Chinese medicine, functional medicine, a variety of dubious medical tests and devices, and basically any form of quackery you can imagine. Yes, it is correct to point to naturopaths and other alternative medicine practitioners as a concerning source of antivaccine beliefs and the encouragement of vaccine hesitancy among parents. No doubt about it. However, contrary to the title about a “shadow network of underground antivax doctors,” these are not real doctors and, compared to the number of pediatricians practicing, there aren’t that many of them. That’s not to say that there isn’t a “”shadow network of underground antivax doctors” that includes naturopaths and their ilk. It’s just that many of these “underground antivax doctors” are not so underground and are actually real pediatricians, family practice doctors, and physicians of other specialties who have embraced “holistic medicine” that includes antivaccine beliefs and thereby betrayed their patients. I’m talking “Dr. Bob” Sears and “Dr. Jay” Gordon, as well as “integrative” pediatricians who imbibe all sorts of quackery about “detox” to which antivaccine beliefs are a kissing cousin. Think of the physicians, such as Dr. Bob Sears, in California who are selling bogus “medical exemptions” to parents so that they can evade the vaccine requirements of SB 277.

In fairness, Khazan does come around to mention real antivaccine physicians, but it comes across as an afterthought when in reality it should have been the focus of the story:

And yet, it’s not just naturopathic doctors who doubt vaccines. Earlier this month, Daniel Neides, a medical doctor and director of the Wellness Institute of the Cleveland Clinic, wrote a column for the news site Cleveland.com that questioned the safety of vaccines, saying they come “at the expense of neurologic diseases like autism and ADHD.” After a PR firestorm, the Cleveland Clinic disavowed the column and said it would stop selling homeopathic treatments in its gift shops. (Neides declined to comment further.)

Jay Gordon, a board-certified pediatrician in Santa Monica, California, estimates that about 90 percent of his patients are not on a typical vaccine schedule. “I get vaccines,” he said, “but I don’t believe that the vaccine schedule that we have now is the best way of doing it.”

He said that he would, after a discussion, support a patient who didn’t want to vaccinate at all, though he realizes the patient would be contributing to the erosion of herd immunity. “One reason the risk [of infectious disease] is small is because of vaccines, and I don’t want things to change overnight,” he said. “I don’t want to abandon all vaccines, and I don’t like the anti-vaccine agenda.”

“It gives me the luxury of being disliked by both ends of the spectrum,” he added.

Here’s a hint, Dr. Jay: Just because “both ends of the spectrum” don’t like you doesn’t mean that you’re correct. Thats the fallacy of moderation. Sometimes there is a right and a wrong answer, and placing yourself in the middle between the two makes you still wrong. I also call bullshit on your “not liking the antivaccine agenda, given how much you align with it. You were Jenny McCarthy’s son’s pediatrician, for cryin’ out loud, and you’ve spoken at antivaccine rallies and shown up as the “vaccine skeptic” in innumerable news stories. Yes, it’s disappointing to see Dr. Jay still parroting the same antivaccine nonsense (and, yes, “too many too soon” is a familiar antivaccine trope) while, in a true Dunning-Kruger fashion shared by Dr. Bob Sears, placing his expertise above that of ACIP to determine a safe and effective vaccine schedule.

Dr. Jay aside and my irritation with missing the target on which medical professionals have more influence and are more responsible for fomenting antivaccine beliefs, Khazan does get it right near the end:

The Kennedy news sparked worries among some doctors that Trump will wrench responsibility for vaccines away from the CDC and hand the reigns to a pseudo-scientific panel, or that he will dismantle programs that protect vaccine makers from frivolous lawsuits.

In the meantime, he risks shaking the public’s trust in a vaccination schedule that has saved millions of lives and allowed Americans to live 30 years longer. As the recent wave of anti-vaccine alarm has shown, confidence in vaccines works similarly to herd immunity. It takes a universal acceptance of fact, and a rejection of conspiracy theories, to get every parent’s buy-in.

Last week, Kennedy told reporters, “Everybody ought to be able to be assured that the vaccines that we have … [are] as safe as they possibly can be.”

But doctors say even the hint that patients need such “assurance” is toxic. After all, people question vaccines because authority figures raise questions about them. Patients don’t question whether it’s the right choice to eat apples, because doctors and politicians have never suggested that the jury is still out on fruit.

Exactly, so much so that I mostly forgive Khazan and her editor for focusing on naturopathy way, way more than antivaccine pediatricians like Dr. Bob Sears. Naturopaths are still fringe, as much as they like to represent themselves otherwise, and they don’t have nearly the cachet in medicine as real pediatricians because they are quacks. However, whether it’s real doctors or quacks taking care of patients, it is quite reasonable to fear that Donald Trump will, just by questioning vaccine safety based on no good evidence and by cozying up to antivaccine activists prone to conspiracy theories like RFK Jr. will spread antivaccine ideas and give them the imprimatur of the President of the United States. No wonder antivaccine parents are furiously working to get their message to Trump using anecdotes and pseudoscience.

They see a kindred spirit in the White House, one with the power to give them at least some of what they want, fantasies that date back many years.