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Thanks for the measles yet again, Andy

Yet another population is learning why you shouldn’t trust Andrew Wakefield. There is a large Somali immigrant population in Minnesota, and unfortunately they’ve been targeted by antivaxers. As a result, their MMR uptake has plummeted, and now they’re in the midst of another measles outbreak. Andrew Wakefield screws yet another group.

There are many harms attributable to the antivaccine movement and its promotion of antivaccine beliefs. Certainly, the harm those of us who have been combatting antivaccine misinformation fear is the return of vaccine-preventable diseases, which is something we’ve seen in the form of outbreaks, such as the Disneyland measles outbreak two years ago and, in my own state, pertussis outbreaks. The Disneyland outbreak was a wake-up call to California legislators, who in its wake passed SB 277, a law that eliminated personal belief exemptions (PBEs) to school vaccine requirements. Now, only medical exemptions are permitted, and so far the law has worked well. In Michigan, we’re still struggling. The Michigan Department of Health and Human Services issued a new rule that requires parents seeking a PBE to attend an education and counseling session at a local county health office before the PBE is issued. Not surprisingly, local antivaxers are not happy and have managed, by painting this rule as a horrific affront to “freedom” and “parental rights,” to persuade legislators to try to pass a law that would not only revoke the rule and explicitly bar MDHHS from issuing similar rules in the future, but it would prevent local health officers from barring unvaccinated children from school during an outbreak. The law failed to pass the first time it was introduced, but Michigan legislators are nothing if not extremely persistent in pursuing harmful policies, and a new version of the same old bill is again under consideration. It matters not one whit to our stupid legislators that the rule change is starting to work to increase vaccine uptake. Unfortunately, we have a fair number of antivaccine and antivaccine-sympathetic legislators.

Although the antivaccine movement in the US has classically been associated with upper middle class and affluent white people, they are not the ones who are likely to suffer the most when herd immunity breaks down. I’ve written extensively here about how the newest (and perhaps most pernicious) antivaccine conspiracy theory, the so-called “CDC whistleblower” conspiracy theory promoted by Del Bigtree and Andrew Wakefield’s propaganda film disguised as a documentary VAXXED, explicitly targets the African-American community, complete with promotional visits featuring the Nation of Islam going to speak in Compton and being involved in protests outside the CDC. Wakefield, as you recall, is the British gastroenterologist who in 1998 published a case series in The Lancet linking MMR to autism. It has since been retracted and shown to have been fraudulent, and Wakefield has had his UK medical license stripped from him. Unfortunately, that only makes him more of a hero to the antivaccine movement, and he’s spent the last 19 years playing that role to the hilt.

The “CDC whistleblower” conspiracy theory is based on the story of CDC scientist William Thompson, who in 2013 apparently contacted biochemical engineer turned incompetent antivaccine epidemiologist Brian Thompson to vent about a study he co-authored in 2004 that examined whether there was a correlation between vaccination with MMR and subsequent risk of autism. Not surprisingly, the study failed to find a correlation. However, there was one subgroup, African-American boys, in which the unadjusted data showed a 3.4-fold increased risk of autism. (I’m simplifying for space considerations in providing background, obviously; if you want the gory details, read here and here for a contemporaneous account of the origin of a new conspiracy theory, as well as my review of the book Vaccine Whistleblower and Andrew Wakefield’s fraudumentary VAXXED.) Thompson had had disagreements with how the data were presented and how he thought the CDC has “suppressed” the unadjusted data. Unfortunately for him, Thompson didn’t realize that Hooker was recording their conversations, and Andrew Wakefield found out about it. Thus, he became the “CDC whistleblower” who seemingly validated what I like to call the central conspiracy theory of the antivaccine movement, specifically that the CDC “knows” that vaccines cause autism but covered it up. It didn’t matter one whit that the correlation was found only in a small subgroup (African-American boys), but it did matter because African-Americans already have reason to distrust the medical community based on history. The “CDC whistleblower” myth feeds into that sad history, which is why Wakefield loves to invoke the Tuskegee syphilis experiment.

This is also not the first time Andrew Wakefield has targeted people of color with his pseudoscience. By any objective measure, for the most part the CDC whistleblower conspiracy theory and VAXXED have not had much resonance in the African-American community other than in the Nation of Islam and among a handful of parents like Sheila Ealey who really believe vaccines caused their children’s autism. The first time around, unfortunately, Wakefield was much more successful. Now, nearly a decade after he first started targeting the community, they are continuing to suffer measles outbreaks. I will begin with the story as it stands now and then go back and look at how it got to this point. The story takes place among a seemingly unlikely group of people in an unexpected location. It’s also a story that I can’t believe I’ve never blogged about before, given how long it’s been going on.

Measles outbreaks among Somali immigrants in Minnesota

Before I first encountered this story several years ago, I had no idea that there was a large community of Somali immigrants in Hennepin County in Minnesota, but there is. In fact, it’s the largest community of Somali immigrants in the US that began forming over a quarter of a century ago and now numbers in the several tens of thousands. Right now, the community is the center of a new measles outbreak, which is just the latest. From the StarTribune a week ago:

As a registered nurse and a consultant to the Minnesota Department of Health, Asli Ashkir has spent nearly a decade talking with Somali parents about autism, vaccines and the importance of getting their children immunized.

Last week she redoubled her efforts. A measles outbreak in Hennepin County has sickened 12 children — all of them unvaccinated and all of them from Somali families, according to the department — throwing a spotlight on low immunization rates among Somali children.

Now state and county public health workers are doing their best to contact Somali parents and underscore the value of immunization. “I know when parents have facts, they do the best they can to make the right decision,” Ashkir said.

I note that the total number of children sickened had reached 32 by the weekend, and the toll is still growing.

The story shows why the Somali community in the Twin Cities area is so susceptible to measles outbreak. All you have to do is to look at this graph of MMR vaccine uptake by year:

MMR uptake among Somali immigrants in Minnesota: This is the effect of nearly a decade of antivaccine propaganda.
MMR uptake among Somali immigrants in Minnesota: This is the effect of nearly a decade of antivaccine propaganda.

The graph above shows what can only be described as a catastrophic plunge over the course of just one decade in MMR uptake among American-born children of Somali descent, from 92% to 42%. There is, for all intents and purposes, no herd immunity in this community. The interesting thing here, though, is that this plunge is very specific. It’s noted in the story that there is not a fear of vaccination in general among the Somali immigrant population. Rather, it’s fear of just one shot: the MMR. It is a fear that antivaxers stoked, beginning sometime around 2008, and they have unfortunately been wildly successful in inculcating fear of the MMR in Somalis in Minnesota. Indeed, a 2014 study examined attitudes towards the MMR vaccine in Somali and non-Somali children in Minnesota and found:

Somali parents were more likely than non-Somali parents to have refused the MMR vaccine for their child (odds ratio, 4.6; 95% confidence interval, 1.2–18.0). Most of them refused vaccines because they had heard of adverse effects associated with the vaccine or personally knew someone who suffered an adverse effect. Somali parents were significantly more likely to believe that autism is caused by vaccines (35% vs. 8% of non-Somali parents). Somalis were also more likely to be uncomfortable with administering multiple vaccines at one visit (odds ratio, 4.0; 95% confidence interval, 1.4–11.9) and more likely to believe that children receive too many vaccines.

It was a small survey, but it was the only one I found in the peer-reviewed medical literature thus far. Its results are not surprising, however, to anyone directly involved with the Somali community, particularly public health officials. There haven’t (yet) been studies published about this latest measles outbreak, but there was a study about the 2011 measles outbreak in Minnesota, which, to that point, was the largest such outbreak in 20 years, with 21 cases identified. Its conclusions were also unsurprising. The source was found to be a 30-month-old US-born child of Somali descent infected while visiting Kenya and then spread to the Somali and non-Somali population primarily through the unvaccinated:

Three case-patients had unknown vaccination status, 1 was vaccinated before the recommended age (11 months), and 1 was a health care worker who was thought to be immune (IgG-positive documented >10 years previously). Sixteen of 21 (76%) were unvaccinated; 7 of 16 (44%) were too young for routine vaccination. Nine (56%) children were age-eligible for routine vaccination but unvaccinated, 7 because of safety concerns owing to the misinformation that MMR vaccine causes autism; 6 of these children were of Somali descent. Two other children did not refuse but were behind on immunizations.

This is how the outbreak spread:

This outbreak began with an unvaccinated US-born child who was exposed to measles in an endemic region of Africa and developed disease on return to the United States. Low vaccination rates in the local Somali community, and subsequent exposures among susceptible homeless shelter residents, fueled ongoing transmission of measles. Delay of the source case-patient’s measles diagnosis also may have contributed to transmission before public health interventions. Although post-exposure prophylaxis, vaccination, and voluntary isolation and quarantine were implemented after the first known case, there was ongoing transmission in 1 of the 2 affected shelters. This transmission was attributable to several factors, including exposures that occurred before the first identified case, an exposure of an infant too young for MMR vaccine according to the routine schedule, as well as exposure of an infant who was too young for the early MMR vaccine outbreak recommendation. Other contributing factors were caused by the challenges of quickly assessing and documenting immune status in a large group of individuals living in a temporary, communal setting. These challenges allowed transmission to individuals who initially were assumed to be immune, but who lacked documentation. After ongoing transmission was seen, immune status testing was implemented for those who lacked documentation.

Notably, two-thirds of the cases in this outbreak were hospitalized, and many of these were hospitalized for respiratory complications in addition to dehydration, highlighting that measles is a severe infection even in well-resourced countries.

If measles is as harmless as antivaxers claim that it is, then why were two-thirds of the people stricken with measles in this outbreak hospitalized for complications? That’s a rhetorical question for antivaxers, obviously.

The first question that faces Minnesota public health officials is, of course: How did we get here? The second is: What can be done to combat MMR fear-mongering? I can’t help but note that the fear of the MMR that is so prevalent among Somali immigrants in Minnesota, while primarily about the MMR, is bleeding over to other vaccines. Some Somali immigrants are starting to show susceptibility to the “too many too soon” myth and, as a result, spacing out the remaining vaccines other than the MMR that they are willing to administer to their children, believing that early vaccination can “damage an infant’s language skills.” Basically, if you live in Minnesota, combatting antivaccine and anti-MMR views in the Somali immigrant community is imperative. Even if you don’t live there, given that the Twin Cities area is a hub of national and international transportation, measles could be as short as a quick plane flight to where you live.

So let’s look at how we got here. Andrew Wakefield has his fingerprints all over this, but it didn’t start with him. As is his usual MO, he opportunistically took advantage of a situation, as he did when he discovered that Brian Hooker had been recording telephone conversations with a disgruntled CDC scientist.

2008: Autism in the Somali immigrant community

The story of how the myth that MMR causes autism became so firmly entrenched among Somalis living in Minnesota began sometime around 2008, with a cluster of autism cases among the community and a news story, as described by Bahta et al. in Minnesota Medicine:

Parents in Minnesota’s Somali community have voiced concern that their children are disproportionately affected by autism spectrum disorder (ASD) compared with children of other ethnicities. Many in the community blame the MMR vaccine. In an August 2008 news story on WCCO-TV, one parent was quoted as saying, “It’s the vaccines.”

Shortly after the story aired, the Minnesota Department of Health reached out to members of the Somali community to gather more information. Health department staff attended meetings with Somali parents, many of whom were unfamiliar with ASD. Repeatedly, they stated that they don’t even have a word for autism in their language. In telling her story, one mother reported that in their attempt to understand ASD, she and others discovered groups that supported the claim that vaccines, particularly MMR, cause autism. Misinformation can spread rapidly in the Somali community, which has a rich oral tradition of passing information to one another. It is now widely accepted among Somali Minnesotans that MMR is to blame for autism.

The antivaccine movement was all over this story in 2008. For example, David Kirby, author of the book Evidence of Harm: Mercury in Vaccines and the Autism Epidemic: A Medical Controversy, which was one of the early works using pseudoscience to link thimerosal in vaccines to autism was writing articles like ‘Autism May Be Caused By “Chemical Exposures”‘ specifically about the Somali community in Minnesota, with a “wink, wink, nudge, nudge” that the “idea that ‘chemical exposures’ (vaccine related or otherwise) might cause autism still brings virtual apoplexia to certain scientific circles.” He had previously hammered the same theme on the antivaccine blog Age of Autism, noting from the data presented that “rate of autism among Somali children in the public schools had been reported at 1 in 28 kids” and that the “80 or so Somali parents who attended were disappointed, by all accounts, that Dr. Punyko had no way to tell them if autism among their children was, as they strongly suspect, more common than among non-Somalis the same age.”

But was autism more than twice as common among the American-born children of Somali immigrants, as the data linked to above suggest? In early 2009, the Minnesota Department of Health released a study of autism among Somali immigrants. It is a substantial read. Here are a couple of key findings, which, as is often the case in studies of autism compared to parental perception of autism prevalence, are not as clear as the prevalent belief among the Somali community in Minnesota or as the antivaccine movement latched onto:

  • The administrative prevalence for three and four year old Somali children was significantly higher than for non-Somali children. This is consistent with the perceptions of the community that a larger number of Somali children were participating in ASD programs. Because of the study’s limitations, it is not proof that more Somali children have autism than other children; however, it does raise an important question about why Somali children are participating in this program more than other children.
  • The relative difference between Somali and non-Somali administrative prevalence decreased markedly over the three years covered by the study. It is unclear if this is an identification issue, a change in parental awareness for the need for developmental screening or some other issue.
  • Administrative prevalence rates for the Asian and Native American groups were found to be “strikingly low.” The reasons for these low rates are unknown, but they could be important to understanding whether the rate of ASD is higher among Somali children or underestimated among other children. In other words, the seemingly low prevalence rate among Asian and Native American children may artificially boost the comparative rate among Somali children, distorting a true understanding of all groups involved.

So, yes, administrative prevalence of autism was higher among Somali-Americans in Minnesota, but there were a lot of issues that made it difficult to use these data to determine for sure whether actual autism prevalence was higher, not the least of which was that as was noted in Left Brain, Right Brain, Department of Education data are not reliable for tracking autism. Jim Laidler made the same point in a publication in Pediatrics in 2005. Indeed, the most recent study of autism in the Somali-American community in Minneapolis was published in 2016 and found that Somali children were as likely to be identified with an autism spectrum disorder (ASD) as white children but that Somali children with ASD were significantly more likely to have an intellectual disability than children with ASD in all other racial and ethnic groups. Meanwhile, Steve Novella examined the cluster and proposed other potential causes for it, if even there was a cluster, such as vitamin D deficiency or a founder effect. Of course, as I pointed out above, it appears that children born to Somali immigrants are no more likely to be diagnosed with autism than white children; so there wasn’t even a cluster there. Unfortunately, it took eight years to figure that out.

By long before then, the damage had been done and the seed of distrust in the MMR and other vaccines had been planted by antivaxers. Over the next several years, as you will see, antivaxers nurtured that seed until it blossomed in the form of measles outbreaks.

Enter Andrew Wakefield

It’s not clear exactly when Andrew Wakefield first made contact with the Minnesota Somali community, but I do know that Age of Autism was on the case as early as August 2008 and that the founder of the antivaccine group Generation Rescue J.B. Handley published “An Open Letter to the Somali Parents of Minnesota” in which he told them it was the vaccines and that they can’t trust the local health authorities. He even went so far as to urge them to declare a “state of emergency within your community and create a new vaccine schedule for your kids.” Meanwhile, also as early as August 2008, David Kirby had been writing stories like ‘Is Autism an “American Disease?” Somali Immigrants Reportedly Have High Rates.’

I do know for sure from media accounts and triumphant blog posts in Age of Autism that he met multiple times with the community and its leaders between 2010 and 2011 and that he appears to be still intermittently in contact. For instance, here is one contemporaneous account in local media from 2010. It was a time when he proposed as “study” of autism in Somali immigrants and promised to raise funds for it, something he appears never to have done. At the same time he sold the study this way:

Minnesota Somalis worried about autism rates among their children recently invited controversial British researcher Andrew Wakefield to Minneapolis to talk to their community.

At a Somali community meeting in Minneapolis, Wakefield asked his audience to participate in a study. He told about a hundred people gathered at a Somali-owned restaurant that they could help find the cause of autism.

“It is solvable, it has a cause, it had a beginning and it must have an end,” Wakefield said. “We cannot accept the damage that is being done to all of these children. It is completely unacceptable and the suffering you’re going through.”

At the same talk, Wakefield claimed that there were no known cases of autism in Somalia, characterized in the story as an “anecdotal observation many Somalis confirm.” It staggers the mind that Wakefield would make such a claim (OK, actually, it doesn’t, given how big a liar Wakefield is), but it does not stagger the mind that Minnesota Somalis would find such a claim credible. Somalia is a poor country, and it does not stretch the imagination to speculate that most people living there are unfamiliar with autism. Nor does it bend credibility too much to observe that a Third World country is unlikely to have the same sort of screening and support programs for autism that we have in the US and other developed countries and that in such countries most cases of autism other than the most severe would go undiagnosed. Indeed, even the severe cases might well be diagnosed as mental retardation rather than autism.

Be that as it may, the cluster of autism in 2008 led to perceptions like this one:

She recalled a Somali mother who spoke at a public health meeting at the Brian Coyle Community Center some years ago. She had given birth to several healthy children in Africa, but her first child in the United States showed autism symptoms at an early age.

Wakefield visited Minneapolis again right in the middle of the 2011 measles outbreak to give a talk at a Somali restaurant. It was noted at the time that there were “a number of vocal pediatricians and doctors of Somali descent trying to speak out about this” but that distrust of health authorities was very high and local antivaccine groups like the Vaccine Safety Council of Minnesota were actively influencing Somalis. They still are. In 2016, for instance, the VSCM board member Patti Carroll published a warning to Somali parents that the Minnesota Department of Health “schools professionals to persuade Somali parents to give their children the MMR vaccine, despite clear opposition.”

Gee, you say that as though it were a bad thing.

That’s the problem, of course. Antivaxers are opportunistic in the extreme. If they see a population who are vulnerable to their disease-promoting message, they will pounce, and it’s always about the vaccines. They saw a story of a possible autism cluster among the children of Somali immigrants in Minnesota. Where scientists see such a story and ask “Is the cluster real and not spurious?” and “If it’s real, what might be causing it?” antivaxers see such a story and assume it absolutely, positively must be the vaccines. In this particular case, they took advantage of a newly arrived immigrant community’s lack of knowledge about autism and vaccines, its tradition in which information is primarily transmitted orally, and the distrust some of its members had for the local health authorities. The results are still playing out in catastrophically low MMR uptake and measles outbreaks.

Over the weekend, it got even worse, as a coalition of antivaccine groups gathered together to tell the Somali immigrant population that the “the epidemic is autism, not measles”:

As Minnesota confronts its second measles outbreak in seven years, public health officials are battling to contain the disease while also trying to educate parents in the face of an organized opposition.

As happened in 2011, anti-vaccine activists are reaching out to Minnesota’s Somali community, where both outbreaks have been centered, with messages that reinforce the discredited belief that vaccines cause autism.

On Sunday afternoon, a coalition of anti-vaccine organizations plans a meeting at the Brian Coyle Community Center on Minneapolis’ West Bank in an effort to bring their message to Somali families, saying “The epidemic is autism, not measles.”

Just what the Minnesota Somali immigrant community needs.

What can be done?

As every source I’ve read over the years about the Minnesota Somali community and vaccines has stated, suspicion and fear of the MMR vaccine are now very much entrenched and will be very difficult to reverse. Indeed, it’s been pointed out:

Minnesota Department of Health staff found that fear of autism was often the reason for parents’ refusal to have their children vaccinated. Highly educated Somali Minnesotans are not exempt from this fear. As one Somali educator admitted, “My children did not get the MMR; my evidence is the Somali children I see who have autism.”

Parents who cited fear of autism as the reason for their vaccine hesitancy told health department staff that they received their information mostly from other Somali Minnesotans. Being told that MMR does not cause autism was not satisfactory for many parents because no one could tell them what does cause autism. Yet, when asked whom they would trust for health information, nearly all said they trusted their health care provider. And a significant number who refused vaccinations said they would reconsider their decision if they were given more information.

Parents of children diagnosed with ASD were articulate about their belief in an association between MMR and autism and sometimes also implicated receipt of multiple vaccines as the cause of their child’s autism. Some Somali parents have come to realize that autism and vaccines are unrelated, but they are in the minority.

Vaccine hesitant Somali parents thus resemble our own native-grown antivaxers and vaccine hesitant parents in many ways. Many are highly intelligent and educated. They get their misinformation about vaccines and autism from their peers more than from medical authorities. Also, it is the parents who have children diagnosed with ASD who are the most passionate and persuasive in arguing that vaccines are linked with autism, and, because of the low rate of measles (thanks to the MMR) many Somali parents view autism as a greater threat to their children than the measles and base their decisions about vaccines on that misperception. One difference is that, unlike many of our native antivaxers, Somali immigrants generally hold the medical profession in high esteem and are thus more open to being influenced by physicians and other clinicians. Actually, I should be a bit more clear. American antivaxers generally distrust the medical profession, while American parents who are vaccine-hesitant tend to hold the medical profession in higher esteem.

Be that as it may the Minnesota Department of Health has been trying to meet the challenge of reaching Somali parents through outreach programs in the schools and day care centers aimed at increasing awareness of Somali children’s growing vulnerability to vaccine-preventable diseases. Bahta et al note:

Finding ways to leverage the respect Somalis have for doctors and other health care professionals is challenging. In studies examining how clinicians can provide effective care to Somali patients, building trust has been identified as important. Two things that contribute to trust that are repeatedly cited in the literature are the availability of a competent interpreter and not feeling rushed by the clinician. Clinic policies such as ensuring that a professional interpreter is available, adding time to appointments when interpreters are needed, and consistently scheduling families with the same clinician can support efforts to build trusting relationships with Somali patients.

At their heart, strategies like these are no different than techniques used with the vaccine-hesitant of any race or nationality, adapted to Somali parents by including an interpreter. There’s one area where the Minnesota Somali community might be a bit different, though:

They also want clear direction from their physicians. Providing parents with options may confuse them. A statement such as, “We can give your child the vaccine today, or if you want, we can wait,” may be perceived by the parent as meaning that the clinician also has reservations about vaccines or thinks that either choice is acceptable. One Somali interpreter described an interaction this way: “When the mother told the doctor that she did not want her child to get the triple-letter vaccine, the doctor said, ‘OK.’” The interpreter was worried that the parent thought the doctor agreed that the MMR vaccine wasn’t needed or that he, too, was worried about its effects.

This is different from American parents, who tend to resent being told too firmly what to do and want to make their own decisions. Again, what this shows is the importance of flexibility in dealing with vaccine hesitant parents and how strategies and messaging, although generally sharing the same broad themes, have to be adapted to the specific population being targeted. It’s also important to remember that Minnesota Somalis are not monolithic. Although anti-MMR views predominate and antivaccine views have become common, there have been (and still are) members of the community who are joining forces with Minnesota health officials to push back.

Unfortunately, progress is likely to be slow, as changing entrenched beliefs is difficult and requires a sustained, targeted effort. In the meantime, the children of the Minnesota Somali community will remain vulnerable to measles and potentially other vaccine-preventable diseases and are likely to serve as the nidus for further outbreaks until the MMR uptake rate can be raised back to what it was in 2004. Remember, it took the UK many years to lift its MMR uptake level back to somewhere near where it was before Wakefield, aided and abetted by the tabloid press, caused the MMR panic. There’s no reason to expect that a similar recovery will take any less time in Minnesota.

Sadly, measles is the gift that keeps on giving, and nobody is better than giving it than Andrew Wakefield and his acolytes. The Somali immigrant community in Minnesota is now finding that out.

By Orac

Orac is the nom de blog of a humble surgeon/scientist who has an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his copious verbal meanderings, but just barely small enough to admit to himself that few probably will. That surgeon is otherwise known as David Gorski.

That this particular surgeon has chosen his nom de blog based on a rather cranky and arrogant computer shaped like a clear box of blinking lights that he originally encountered when he became a fan of a 35 year old British SF television show whose special effects were renowned for their BBC/Doctor Who-style low budget look, but whose stories nonetheless resulted in some of the best, most innovative science fiction ever televised, should tell you nearly all that you need to know about Orac. (That, and the length of the preceding sentence.)

DISCLAIMER:: The various written meanderings here are the opinions of Orac and Orac alone, written on his own time. They should never be construed as representing the opinions of any other person or entity, especially Orac's cancer center, department of surgery, medical school, or university. Also note that Orac is nonpartisan; he is more than willing to criticize the statements of anyone, regardless of of political leanings, if that anyone advocates pseudoscience or quackery. Finally, medical commentary is not to be construed in any way as medical advice.

To contact Orac: [email protected]

258 replies on “Thanks for the measles yet again, Andy”

Wakefield claimed that there were no known cases of autism in Somalia

The reasons you cite for this claim being not the whole truth, that Somalia is a poor third world country, are valid, but Somalia isn’t just any third world country. It’s a failed state. That’s a major reason why there are Somali communities in places like Minneapolis and Lewiston, ME: cold winters are less of a challenge than what they had to deal with in the old country. There are lots of third-world countries that may be less than rigorous about identifying autism cases, but at least some of the infrastructure is there, at least for the country’s elites. Somalia doesn’t even have that.

I invite Andrew Wakefield to book the next available flight to Mogadishu to investigate for himself why there are no known cases of autism in Somalia.

“Notably, two-thirds of the cases in this outbreak were hospitalized, and many of these were hospitalized for respiratory complications in addition to dehydration, highlighting that measles is a severe infection even in well-resourced countries.”

In light of this, the relatively high hospitalization rate during the Disneyland measles outbreak and my perception that in the “old days” hospitalization for measles was less common, are we seeing 1) more medical caution now related to clinicians’ unfamiliarity with measles, 2) greater virulence of modern measles strains, or 3) hospitalization for measles really was this common in the 1950s-60s and I just didn’t realize it?

The community center ended up cancelling the event and it was held in a restaurant, and appears sparsely attended. Mark Blaxill claimed that the government admitted vaccines cause autism by compensating such cases (using the old Holland et al article that claimed that cases compensated on other theories are compensated for autism).

He referred to cdcwhistleblower and worked hard to create fear and doubt.

Because 29 cases and 11 children hospitalized in that community isn’t enough for the anti vaccine activists.

What will it take for medical groups and health departments to call out by name the anti-vaccine/pro-disease groups for their lies they tell and the threat they present? Not one large medical group such as the AMA, AAP, AAFP has been willing to call Wakefield the fraud that he is. Even simply the local HD holding a press conference to state that Blaxhill has no medical experience/authority and is not to be believed could help. I don’t get this.

Sorry you’re still butthurt Andy got exonerated and met our pres.

Good to know you blame him for measles, though, of course you’d be dumb enough to conflate speech with actions. I will blame you for every case of vaccine injury since you started blogging then. What’s fair is fair.

How’s that dating scene going for you, Jake? You’re as knowledgeable about women as you are about measles, vaccines, and causes of autism. As an epidemiologist, you’re a disgrace.

I think I’ll go with Orac’s description – yes, the Gnat is butthurt that he’s obliterated any chance of a real job & obviously set himself up for life-long celibacy.

And for what is happening in Minnesota, there is a direct link between Wakefield’s visit & the drop in vaccination rates – which means that he is, indeed, now directly responsible for this outbreak (of course, the initial case isn’t his fault, but that he prepared the ground for mass infection to occur among a vulnerable population – he is 100% culpable for that).

If any of those kids die, I hope they sue the crap out of him.

Eric, I think Jake should join Wakefield on that investigational trip to Somalia . . . .

“Andy got exonerated”

So, where is he licensed to practice medicine now? I must have missed that stunning development.

“…butthurt that he’s obliterated any chance of a real job & obviously set himself up for life-long celibacy.” – So that’s what you were afraid would happen to you when I posted a link to your linkedin profile. No wonder it disappeared so fast!

The infant at the beginning of the post is adorable.

In the future, it is my wish that vaccines will be free of packaging warning-labels and every Somalian child is fully vaccinated and healthy.

So this is the best that the anti-vaccine attack gerbil can come up with? I think Orac gives you far too much credit as a serious threat to vaccination. Your attacks on people are as feeble as your arguments that vaccines cause autism. As others have stated, please feel free to travel to Somalia and look into the lack of autism. Maybe even wok in a trip to North Korea, Oman and Afghanistan where there is very low reported cases of autism as well. It’s almost like poor and failed nations don’t do much research on things they view as unimportant. Try to read this link ( and educate yourself on reality and not your safe little fantasy world.

Jake, you seem to agree with BS Hooker that the Bonferroni correction is not a good way to adjust for multiple tests within one dataset. Why don’t you ask your advisor about it? She’s in genetic epidemiology, isn’t she? Genetic epidemiologists use it a lot. Are they all wrong?

While we’re at it, what kind of biostats are you using on your doctoral thesis? Me? I’m using GLM with Poisson distribution. Should probably use multi-level modeling, but GLM is more “elegant,” in the words of BS Hooker.

Jake, in between complaining that he can’t get any woman to pay attention to him (which is surprising given how well he speaks of women on his blog), criticizes the very biostatistical methods he’s going to need to use for his work in public health. Because you ARE going to work in public health after the PhD, right?

[email protected]: In addition, when was the retraction issued for the retraction of Wakefield et al. (1998)? The Lancet‘s investigation found that the data were fraudulent and that Wakefield had an undisclosed conflict of interest (remember that at the time he was an expert witness for a company offering a competing vaccine to MMR). To paraphrase Arthur Dent, this is some usage of “exonerated” of which I was previously unaware.

I’ll agree that the Gnat should join Wakefield on that field trip to Mogadishu.

“…when I posted a link to your linkedin profile.”

That’s journalism in Crosby’s Labyrinth. Reveal your sources, doxx your commenters, and use foul language.

It’s so nice that Jake can doxx people. Shows what high quality morals he has. /sarcasm.

Different statistical tests are appropriate for different measures.

“complaining that he can’t get any woman to pay attention to him”

Other topics include: the autistic knight, the short bus that now regularly stops at Sesame Street and my Kekistani citizenship (Praise Kek).

I didn’t dox him. His information was already online and public.

“Different statistical tests are appropriate for different measures.”
Next, you’ll tell me that water is wet and the sky is blue. Way to put a truism into words, Jake.

Other topics also include your nascent racism. Tell me, Jake, am I a cancer also? After all, I’m an immigrant AND I support Black Lives Matter, AND I don’t think women are property there to be raped at will. Those are your qualifications to call someone or a group a cancer.

It’s nice to have a conversation with Jake here, in the open. As opposed to having my comments edited or outright deleted from his site.

Crosby’s Labyrinth:

“His information was already online and public.”

Yeah, but he was commenting anonymously (at least by first name only) on your blog. A reasonable person could not have put two and two together. That is, until you outed him.

“…AND I don’t think women are property there to be raped at will.” – What are you talking about? I haven’t converted to Islam.

Also, I’ve approved five consecutive comments of yours on a fairly recent AI post. Don’t pretend that you’re not allowed to comment at AI. You’re more than welcome to now.

It’s nice to have a conversation with Jake here, in the open. As opposed to having my comments edited or outright deleted from his site.

And, of course, I let The Gnat’s comments through because they reveal much about his character.

I really just wanted to see if he was man enough to put his name to his own shit-posting. He failed miserably.

I really just wanted to see if he was man enough to put his name to his own sh*t-posting. He failed miserably.

What are you talking about? I haven’t converted to Islam.

That’s a Suspiciously Specific Denial if I ever heard one. While undoubtedly there are some Muslims who consider women to be chattel, there are many others who don’t, and many non-Muslims who do. In particular, Men’s Rights Activists (a group that AFAICT has little if any overlap with Muslims) seem to behave in ways that are indistinguishable from considering women as property.

Statistically, there have to be children who are Autistic who’ve never been vaccinated. What are the anti-vaxerss excuses for them? Or are those kids just not being diagnosed?

“I haven’t converted to Islam.”

Ah, there it is. There’s the nascent racism. More than nascent, really.

And you must think I’m stupid if you think I’m going to comment on your teenage fan fiction blog given how you’re editing comments and people’s names, and doxxing. And, no, my comments on “recent” posts are not mine. I haven’t commented on your blog since September of last year. If that is “recent” in Crosby’s Labyrinth, then I’d hate to read your lit review section.

You know, Gnat, not that you ever had any journalistic integrity to start, but the fact that I could get that far under your skin by merely pointing out that your choice of topics and tone would have serious repercussions on future employment opportunities, just shows how ill-prepared you are for the real world.

Security settings are a wonderful thing, as are privacy settings.

“What are the anti-vaxerss excuses for them?”

In the case of Kim Stagliano, who has an autistic child who, as far as I know, is unvaccinated, the autism was the result of Kim’s vaccines. That is, if I remember correctly.

Islam isn’t a race.

I maintain the integrity of comments, except when it’s Brian Deer trying to sign off as “Becky”. Everybody already knows who you are anyway, Ren. You have nothing to be afraid of, unless it’s of being wrong.

Islam isn’t a race, but many believers – the majority – belong to races that can be painted as others.

We can point out that you are biased and prejudiced unfairly against a religious group, if it makes you feel better, and reduced to making generalized hate-filled statements against them.

Your posts about women are troubling, disrespectful, and should give any woman considering being alone with you – let alone creating a relationship with you – pause. Maybe you should consider what you said and why it’s an issue, rather than lashing out at Muslims.

Nothing wrong with being afraid of being wrong, Jake. It’s called maturity and integrity. One must check himself before he wrecks himself, so to speak.

People who are not afraid of being wrong have a personality disorder of one type of another. They can also be described as “a-holes, not otherwise specified.”

If I’m wrong in a statement of fact, not opinion, then I’ll correct myself. I won’t do an Andy and claim persecution. Heck, Andy would have become more credible had he accepted the retraction and then worked to correct his mistakes.

“Islam isn’t a race” <– Another truism aimed at deflecting from the xenophobia.

In the case of Kim Stagliano, who has an autistic child who, as far as I know, is unvaccinated, the autism was the result of Kim’s vaccines. That is, if I remember correctly.

Thank you! I should have guessed; after all, everyone knows that vacinations are inherited. /s

“Islam isn’t a race” <– Another truism aimed at deflecting from the xenophobia.

Indeed. While I agree with certain New Atheists that “Islamophobia” is the wrong word for anti-Muslim bigotry – Islam is a religion, an idea, and should be criticized – criticism of the term is often used as a smokescreen to hide clear anti-Muslim bigotry.

@Dorit: I’ve stood up for women against a vaccine that’s made them infertile, paralyzed and dead. I’m a way bigger advocate for women than you’ll ever be.

especially since I’m not blind to oppression of women in Islamic countries

@39 (Gnat)

I’ve stood up for women against a vaccine that’s made them infertile, paralyzed and dead.

No, you haven’t. You’ve stupidly attacked a safe and effective vaccine that protects women from potentially fatal cervical cancer because, for you, it’s always the vaccines, toxic boy.

Oh, look at the big Gnat, trying to claim that espousing anti-vax views against a vaccine that prevents cervical cancer (among others) is “fighting for women’s rights.

Sorry, but I’m sure the 6000 or so women that die every year from HPV-derived cervical cancer would tell you go to hell, if they were able.

“especially since I’m not blind to oppression of women in Islamic countries”

And ONLY Islamic countries, amirite? Because, according to you, “rape culture” is not a thing in America… Well, privileged frat boy America.

Yeah well those women wouldn’t have been saved by the HPV vaccine even if it is effective. The data just isn’t there yet. The only deaths related to the vaccine are the deaths caused by the vaccine, but I’m not here to open that front in this flame war.

I’m only saying that if I really didn’t like women, I wouldn’t give a f*ck. I actually do.

He’s beyond hopeless. Since AoA kicked him to the curb, he’s been looking for another group to attach himself to – and obviously he’s found it.

And it represents the literal worst of the alt-right.

I’m a way bigger advocate for women than you’ll ever be.

See if the Geiers can score you some Lupron, and then we’ll talk.

And obviously hopeless when it comes to epidemiology, since he doesn’t appear to understand that if someone isn’t infected with a strain of HPV that causes cancer, they can’t get that cancer….and since we’ve already seen an over 60% reduction in cancer-causing HPV strains since the vaccine came out, the evidence is already apparent that lives will be saved.


It’s clear the results of this past election still have not fully registered with you. Trump supporters are not “alt-right”, we’re THE Right.

“The data just isn’t there yet.”

Here’s where that lack of fear to being wrong comes into play. Obviously, there are plenty of data to support the use of the HPV vaccines (all the formulations), from safety and effectiveness studies to observable declines in rates of abnormal Pap smears and ensuing malignancies. It’s all there in the literature, but, since “recent” to Jake means last September, and he’s still suckling from the anti-vax teet of a case series from the late 1990s, I guess he’s not quite through catching up to the current decade.

I guess the 32 references on this page from the National Cancer Institute are not really data. In Crosby’s Labyrinth, we’re seeing things.

While there are, naturally, internet stories of deaths happening after the HPV vaccine, I have yet to see real evidence of deaths caused by it. I have seen several cases of clear other causes, like heart conditions or, in one case, a Benadryl overdose.

HPV infections kill thousands. Each year. And the vaccine is increasingly shown very, very effective in preventing them.

@Jake Crosby #5:

and met our pres.

Given that your president has a truly amazing capacity for surrounding himself with incompetent arseholes, that’s not exactly a badge of honour.

And any president – even a more conventional one – could slip and meet with someone with a bad past if a donor suggested it. That by itself isn’t suggestive.

The meeting with RFK jr. was more a cause of concern, though the administration does not seem to be continuing down that weird path.

There are “Trump supporters” and then there are the ilk that you’ve decided to align yourself with. I won’t tar the majority of people who support the current President, but the “alt-right” – merely another name of ultra-right wing racist xenophobes, deserve all of the derision they get.

Islam is a religion, an idea, and should be criticized – criticism of the term is often used as a smokescreen to hide clear anti-Muslim bigotry.

My only quibble with this is that Islam is not a monolithic religion. Some versions, like Wahhabism, are indeed toxic, but many others allow their adherents to take a live-and-let-live attitude toward their neighbors. I know a few Muslims (at least nominal Muslims–some of them drink beer on occasion, and not all of the women wear the hijab) through work, and they aren’t out to convert me, let alone kill me if they fail to convert me.

That same wide range of interpretations holds among those who call themselves Christian. Southern Baptists and Wahhabists have much more in common than either group would like to admit, and more in common with each other than with either the Muslims of my acquaintance or most non-evangelical Christians.

My only quibble with this is that Islam is not a monolithic religion.

Oh, absolutely. I hadn’t meant to imply otherwise.

I know a few Muslims (at least nominal Muslims–some of them drink beer on occasion, and not all of the women wear the hijab) through work, and they aren’t out to convert me, let alone kill me if they fail to convert me.

Indeed, I had many friends of Lebanese descent back in Ann Arbor. Not all of them were religious, but some were, and were perfectly lovely people who never really brought up their religion, let alone tried to convert me. And yeah, even some of my more religious Muslim friends drank.

Hell, even most of the guys who ran the liquor stores in Ann Arbor spoke Arabic, although I guess that doesn’t necessarily mean they were Muslim; I never asked, but I did often greet them in Arabic.

I replied to Eric Lund and it seems to have disappeared into the ether. I shall try again.

My only quibble with this is that Islam is not a monolithic religion.

Oh, absolutely. I hadn’t meant to imply otherwise. I still think even moderate religion can be criticized, but there is no need to be obnoxious about it.

I know a few Muslims (at least nominal Muslims–some of them drink beer on occasion, and not all of the women wear the hijab) through work, and they aren’t out to convert me, let alone kill me if they fail to convert me.

Indeed, many of my friends in Ann Arbor were of Lebanese descent. Not all were religious, but the ones who were were apparently very moderate, since some of them drank, and they never brought up their religion, let alone tried to convert me.

Heck, even most of the guys who ran the liquor stores in Ann Arbor spoke Arabic, although I suppose that doesn’t necessarily mean they were Muslim; I never asked. I did learn Arabic greetings from them, though.

^ Ah, I see that the original comment appeared. I guess there was a swear in it or something.

“there are the ilk that you’ve decided to align yourself with…ultra-right wing racist xenophobes”

Some accusation to make against a Jewish scientist’s autist grandson.

“I’m talking mortality Mr. Johns Hopkins.”

I guess you really haven’t been reading the literature at all, then. You’ve missed the analyses where younger women are not dying from cervical cancer as much. I guess in Crosby’s Labyrinth the “yeah, the cohort is still alive after age 60, but give it some time. They might still get cervical cancer and die” paradigm is in full effect.

How do you plan to write-up shifting of goalposts on your thesis, Jake?

I continue to maintain that putting on a tux and going to one of a dozen inauguration parties is not the same as getting a meeting with the President. Wakefield didn’t meet with Trump, at least not since he was elected. If he did, we’d have pictures. I’ve seen pictures of Wakefield in his tux outside a party, not inside it and not meeting with the President.

And shaking hands in a reception line is not meeting with the President, either.

And Jake, spare me your “help.” Blocking the prevention of cervical cancer is not the kind of help I need as a woman.

“…younger women are not dying from cervical cancer as much.”

For a guy whose ilk loves to lecture the autism community on the ecologic fallacy, you sure do fall for it.

There is obviously no accounting for taste – because it isn’t an “accusation” it’s just a fact.

^ Ah, I see that the original comment appeared. I guess there was a swear in it or something.

Most cuss words send a comment to automatic moderation. I usually let them publish after review, but I like to try to keep this blog PG13 rated rather than R or X.

I’m a way bigger advocate for women than you’ll ever be.

Good grief he’s even stealing Trump’s lines. The little gnat isn’t at UT-Austin anymore?

On topic, Mark Blaxill and Jennifer whatshername, the anti-vaxxer who is always by Blaxill’s side are beneath contempt for showing up continuing to scare the Somali Community amidst a measles outbreak which they directly contributed to.

Most cuss words send a comment to automatic moderation.

I think the strongest word in the comment was “hell,” so I was a bit bemused. 🙂

Maybe I did something else to trigger automatic moderation, I dunno

Here in Minnesota, there is indeed considerable concern. The recommended age for completing MMR vaccination was lowered, and they are advising vaccination at 6 months for high risk groups and those intending international travel. But it’s a little like closing the barn door after the cows have gone; hopefully the current outbreak will burn out soon, but with the low uptake in the Somali community, that’s very uncertain.

BTW, as to mental health records in Somalia, one only has to see the state of mental health care to know that autism would not be something anyone would pay attention to. Not merely because they had bigger problems, like finding food and not getting killed in the fighting, but also because as in much of the world, mental illness of all kinds has a gigantic stigma. The mental hospital (and I use that word lightly) in Mogadishu did what it could, but they basically only took the ones who were completely incapable of caring for themselves, or who were a danger to those around them, and whose families had abandoned them. They were kept in chains, because the staff had nothing else they could use to control them. Warehousing them, in essence. A lot of that was doubtless due to the general breakdown of order; we’re talking a population that has not had a stable government in two generations. Anyone attempting to care for the mentally ill there has few resources beyond their own wits.

When that’s all you look at as mental illness, you are not going to even notice autism as a condition. When your treatment options consist of a choice between “suck it up” and “chained to a wall”, fine distinctions like actual diagnoses are simply not going to happen.

This, of course, made the Somali community perfect targets for Wakefield, and he cynically exploited that. Not even for financial gain — for his own personal aggrandizement. He disgusts me.

Given that even when Somalia had a government, it didn’t act in the best interest of its people (and of course, much worse since then), I can understand why this minority group would be very susceptible to the idea that the government was intentionally trying to harm them.

Sad, really.

Ah, I see that Jake has moved the HPV goalposts. It’s not enough that fewer women (and now men) are being diagnosed with HPV and needing treatment. It’s that “we don’t know if fewer will die of cervical cancer”. I almost regret that Jake isn’t a woman – I’d have great trouble NOT wishing him the experience of a colposcopy and loop procedure. Then he’d understand the issue, perhaps.

And Jake: can you give us the numbers of women who have ACTUALLY died from a HPV vaccine? IIRC, it’s a very low number (single digits in VAERS), and all related to allergic reactions. Also, as an epidemiologist (you ARE an epidemiologist, right? Right???), you can obviously show the numbers that prove the HPV vaccine is causing more problems with infertility, premature ovarian failure, etc, above baseline from reliable sources that have been peer-reviewed.

Some accusation to make against a Jewish scientist’s autist grandson.

You can invoke all the minorities you want, that doesn’t give you a pass for being a bigoted and repugnant areshole.

Some accusation to make against a Jewish scientist’s autist grandson.

When something looks like a duck, quacks like a duck, and waddles like a duck, it is rational to conclude that the thing in question is in fact a duck.

“For a guy whose ilk loves to lecture the autism community on the ecologic fallacy, you sure do fall for it.”

For the uninitiated — and we are initiated, aren’t we, Jake? — the ecological fallacy is when one attributes to an individual the characteristics of the larger group. For example, when Jake is told by his friends on xenophobe chat rooms that Islam devalues and denigrates women, Jake thinks that the Muslim person sitting next to him at lecture devalues and denigrates women.

What Jake tried to hit me with is the opposite of this fallacy, the atomistic fallacy, where one attributes to the larger group the characteristics one sees in an individual. For example, if Jake is rejected by a woman, then he sees all women as being rejecting of him.

When I told you, dear Jake, that fewer women are getting cervical cancer and that deaths from cervical cancer are on the decline as a natural effect of lower incidence of cervical cancer in the population, I did neither the atomistic nor ecological fallacy.

So what does Jake engage in when he sees a handful of deaths in individuals who get the HPV vaccine but then extrapolates those outcomes to all who get the HPV vaccine? Atomistic or Ecological fallacy?


Ren, I’ll freely admit I’m not an expert in epidemiology but it sure sounds like the atomistic fallacy to me.

And I can certainly see that if how he writes about women is how he interacts with them, atomistic doesn’t become such a fallacy in his case.

I’m autistic too, Jake . . . Asperger’s. I take ownership of my words and deeds. If I’m out of line, I encourage people around me to hold me accountable. So do NOT sit there and make excuses for your racism, xenophobia, and misogyny and cry autism as a defense.

Only a matter of time now before the Gnat chimes in that you’re obviously a lesbian….per his own writings.

That’s the standard defense of many a loser who can’t get a girl to go out with them, much less sleep with them.

The only thing I look for in a guy is that he’s a nice person. The Gnat doesn’t qualify.

The gnat seems to have directed the comments away from what this blog entry is about; a possible higher rate of autism in Somali children living in MN.

If my member of my anthropology days serves me correctly; the nation of Somali is made of many of what we would call clans. These clans tend to inter-marry so they are genetically very similar.

It is possible that the MN Somali population came from only a few of these clans and therefore maybe genetically very similar.

If this is the case; it would make a great epi study. If autism is genetically linked then the link maybe found more easily (scientifically) in population that is genetically than looking in a diverse genetic population.

Gnat your supposed to be an epi grad student and I probably know more than you do as an EHS,

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