Barbara Loe Fisher: Well baby visits are vaccine battlegrounds!

Yesterday, I discussed how antivaccine activists have increasingly been trying to make life miserable for pro-vaccine advocates such as Dr. Paul Offit, who’s been putting up with their harassment for decades now. Along with that, they’ve been making lives miserable for pediatricians. To be clear, I’m not blaming vaccine-averse parents, most of whom aren’t antivaccine but rather concerned or scared, thanks to the misinformation promoted by real antivaxers. I’m blaming the real antivaxers, the leaders of the antivaccine movement, the ones who run blogs, form antivaccine groups like Texans for Vaccine Choice or Michigan for Vaccine Choice, lobby government for loosening of school vaccine mandates or even primary Republican candidates whom they perceive as too pro-vaccine. As a result of the barrage of misinformation, many parents question vaccines, leading to prolonged, sometimes contentious, conversations with pediatricians during well baby visits about vaccines, leading some pediatricians to take a harder line on parents who don’t vaccinated, with some even “firing” parents who won’t vaccinate their children from their practice.Not surprisingly, Barbara Loe Fisher, the grande dame of the antivaccine movement, does not approve.

I don’t know how I missed it, but last week the founder and president of the Orwellian-named National Vaccine Information Center (NVIC) posted a video bemoaning how pediatricians are turning well baby visits into “vaccine battlegrounds”:

Ms. Loe Fisher apparently has a different definition of “battlefield” than I do, and she definitely has a different perception over whose fault it is that pediatricians have to spend so much time trying to persuade vaccine-averse parents that vaccines are safe and effective and that they should adhere to the standard of care and vaccinate their children according to the CDC-recommended schedule. First, she takes us on a journey to forty years ago:

I remember when I took my first-born baby to the pediatrician for his first checkup 40 years ago. Like most young Moms, I looked up to my pediatrician and completely trusted him. I did everything he told me to do, never questioning his expertise or doubting him, believing that he would never recommend or do anything that would put my baby in harm’s way.

Much has changed since 1978. Back then infants and children were getting half as many vaccines as they do today. Parents had no information at all about vaccine risks and failures. We just followed the doctor’s orders.

Ve vere just following ze orders! (Sorry, given Ms. Loe Fisher’s history of Nazi analogies with respect to school vaccine mandates, I couldn’t resist.) At least she’s not claiming that babies are now getting ten times the number of vaccines now as they did 40 years ago, as many antivaxers do by taking multivalent vaccines like the MMR (which covers measles-mumps-rubella) and counting each disease vaccinated against in the vaccine as a separate vaccine.

Not surprisingly, she most strongly disapproves of doctors’ efforts to persuade hesitant parents to do the best thing for their children and vaccinate. What doctors view as trying to hew to the standard of care and protect babies and children from vaccine-preventable diseases that were once deadly but are rarely so any more, thanks to vaccines. So it’s not surprising that Ms. Loe Fisher bemoans the situation, referring to vaccination as “most often discussed health topic in America.” Not surprisingly, the references she cites to back up the claim that vaccination is the “most discussed” health topic don’t really support her assertion. One’s a link to the CDC-recommended schedule for children and adolescents. Another’s a link to an article reporting a survey of pediatricians and family physicians about requests by parents to spread out the vaccine schedule, and the last is an article about the moral dilemma of “firing” vaccine-averse parents who won’t come around and vaccinated from pediatrics practices. I guess Ms. Loe Fisher isn’t the greatest at making sure her references actually support her arguments. Whatever.

Consistent with her previous Godwins (but without actually invoking Hitler or the Nazis this time), Ms. Loe Fisher views the CDC-recommended vaccine schedule as a “commandment”:

These days, that CDC vaccine schedule is no longer being viewed simply as a recommendation, it is being treated as a commandment. We are told it is our patriotic civic duty to get our children vaccinated and ourselves, too. The implication is that we are committing treason if we don’t.⁵

These days, a well baby checkup can be a frightening and gut-wrenching experience for a new Mom bringing her baby to the pediatrician’s office. That is because, with the approval of the American Academy of Pediatrics (AAP), many pediatricians have taken the hardline position that they do not have to discuss vaccination with parents or, if they do, they can threaten them with dismissal from the practice for not obeying a direct order.^{6 7 8}

Not exactly. First of all, nowhere in the article cited to support Ms. Loe Fisher’s claim that it’s implied that we are committing treason if we don’t get our children vaccinated according to the CDC schedule. Read it for yourself if you don’t believe me, particularly this passage:

The report urges pediatricians to:

• Listen to parents patiently, address concerns and correct misperceptions.
• Explain that vaccines are rigorously tested for safety and effectiveness.
• Present all vaccinations as required rather than optional.
• Personalize the positive message about vaccines.

Pediatricians can also note that they receive regular flu vaccinations to protect their patients, and that they’ve had their own children vaccinated as recommended, said Edwards, who is pediatrics chair at Vanderbilt University School of Medicine in Nashville.

That hardly sounds judgmental. Here’s probably the passage that provoked Ms. Loe Fisher’s ire:

Pediatricians also should remind parents that vaccination is something of a civic duty. If large numbers of parents refuse vaccines, the herd immunity that occurs with widespread vaccination can be compromised, McCarthy said.

“Vaccination is not just about you and your kid,” she said. “It’s about your neighbor’s newborn. It’s about your grandmother. It’s about the kid at school who can’t receive a vaccine because he’s on chemotherapy.”

All of this is, of course, true, but I don’t see any implication that a nonvaccinating parent is “committing treason.” The only way one can make that sort of conclusion is if one views failing to live up to one’s civic responsibility as “treason.” It’s not. Treason and not being civically responsible are two very different things. However, it serves Ms. Loe Fisher’s agenda to conflate them in order to anger vaccine-averse parents by claiming that pediatricians through the American Academy of Pediatrics are calling them “traitors.” It’s a very dishonest strategy, but, then, this is Barbara Loe Fisher.

Similarly, although the new policy allows pediatric practices to dismiss patients whose parents won’t vaccinated, as is usually the case, it’s way, way more nuanced than Ms. Loe Fisher portrays it. For example, it expresses tolerance for diverse professional approaches, which is unlike the earlier guidance, which promoted a unified response to vaccine refusal. Indeed, the resolution presented at the AAP’s Annual Leadership Forum that led to the clinical report also called on the AAP to “to continue to support pediatricians who continue to provide health care to children of parents who refuse to immunize their children.”

Basically, what Ms. Loe Fisher is doing is obvious. She’s portraying the AAP and pediatricians as dogmatic paternalistic authoritarians who won’t listen to the legitimate concerns of parents. Of course, pediatricians have always listened to the concerns of parents. Indeed, it is the job of a physician to counter medical misinformation that their patients (or parents of their patients) might have, particularly when that misinformation interferes with the patient’s getting proper science-based medical care. Contrary to Ms. Loe Fisher’s assertion, nowhere in any of the references she cites does the AAP (or anyone else) say that pediatricians don’t have to discuss vaccination with parents or that they can, as Ms. Loe Fisher seems to be saying, do so in the context of threatening to fire them from their practice if they don’t knuckle under. In reality, the AAP encourages pediatricians to discuss vaccination with parents and has always viewed firing parents as a last resort. What the new policy recognizes is that there eventually comes a time when parents who won’t vaccinate and won’t listen to the pediatrician take up so much time and effort on the part of the pediatrician and his or her staff that it becomes clear that the parents should find a pediatrician with whom they’re more comfortable.

One area where Ms. Loe Fisher is not entirely incorrect is in her assertion that the trust between pediatricians and mothers is broken. No, it’s not broken between all (or even most) mothers and pediatricians. It’s just that it’s fairly inevitable that trust between parents who are absolutely convinced that vaccines are potentially harmful and not worth the risks and pediatricians who want to treat their children according to the science-based medical standard of care will inevitably erode. Of course, Ms. Loe Fisher, being the grande dame of the antivaccine movement that she is, presents this case in a manner distorted by the not-so-funhouse lens of her antivaccine beliefs:

Pediatricians’ offices have become ugly battlegrounds. Intelligent, well-informed and loving parents asking legitimate questions about vaccination are being belittled and treated with disrespect and contempt by too many pediatricians robotically implementing the CDC’s inflexible vaccine schedule in clear violation of the informed consent principle.

Don’t take my word for it, go to NVIC’s Cry for Vaccine Freedom Wall and read report after report of just how terrifying pediatric check-ups have become. The sacred trust between mothers and pediatricians fostered by mutual respect and shared decision-making has been broken. Sadly, the admiration and trust that mothers used to have for family pediatricians is melting away and being replaced by fear.

Doctors are not our masters. We pay them well to do a job, not to exploit and terrify us. Discrimination, coercion and force have no place in modern medicine or in public health policy.^{19 20 21 22 23 24}

Let me start with that last bit first. True, doctors are not patients’ masters, but neither are they their servants or paid lackeys, either. Physicians are hired to exercise their professional medical judgment and deliver the best science-based care that they can. While I agree that coercion is to be avoided, I also assert that if a patient will not allow a physician to do what he considers to be best for the patient—or even to compromise and do something that might not be optimal but is still not outside a reasonable standard of care—then the patient has in essence fired the physician. Of course, Ms. Loe Fisher wants to portray physicians as “robotically implementing the CDC’s inflexible vaccination schedule.”

I also can’t help but note how Ms. Loe Fisher slipped the bit about “violation of the informed consent principle” in there. Misrepresentation of “informed consent” is stock and trade of antivaxers. What they portray as “informed consent” is, in fact, misinformed consent. Antivaxers both make up (e.g., autism, which vaccines don’t cause) and vastly exaggerate potential risks from vaccines while downplaying their benefits, and that is the body of information that they want to see presented to parents. Naturally, if that misinformation were the basis of informed consent, few parents would agree to vaccination, which is why I refer to this deceptive technique as “misinformed consent.” Ms. Loe Fisher, of course, is a master of misinformed consent.

As for the “Cry for Vaccine Freedom Wall,” I perused a few of the stories featured there, and saw that these are just the sort of parents who are basically begging to be “fired” from any pediatric practice.

For example, here’s one from two days ago:

I was in my pediatricians office and I was asked if I was going to get my sons vaccines yet since I’ve told them I was delaying previously. I used this technique in fear I would get kicked out like I’ve heard many have. This time, I said “no” to any vaccines. The nurse told me that I would have to sign a refusal form. I told her I would read it first. When I read the form I quickly felt that I was being told I’m a bad mom and that I’m aware I was endangering my child and others for declining shots. I did not agree so I crossed out certain sections and initialed. I gave the form back to the nurse and then my pediatrician came in and gave me a new form. She told me that I could not alter the form in anyway and that I needed to resign. I told her I didnt agree with what the form stated and that I also didn’t receieve full informed consent about the vaccines either. She came back with papers I assume they hand out to patients who ask. Knowing that they are provided by the CDC, I quickly told her these papers are not true informed consent and that I wanted the vaccine inserts that come with the vaccines themseleves. She then had her nurse come back in with the little packets. My pediatrician came in shortly after and I told her I’m still not signing because I dont agree with this refusal form and explained why. She said if I didn’t sign then I could no longer attend her office. By this point we were talking loudly (arguing) in the room with the door open. She then started yelling at me saying I am lucky to have her because she is the only pediatrician in the area that accepts non vaccinated children. She also stated that they just had a meeting with the CDC and she is in trouble because not all her patients are vaccinated so she is doing me a favor by still seeing my child. She also explained that the refusal form is just something they put in their system to show that in case something happened with my son like he contracted a disease, I cant come back at her for not offering the vaccine. This spoke volumes and confirmed everything I’ve heard that pediatricians are pressured to administer these vaccines. Needless to say after this happened I never went back. This is a true battle ground for parents and if not educated these pediatricians know how to bully a parent. It’s not easy arguing with a white coat even when you are educated.

First of all, I concede that this pediatrician probably should not have let this mother get under her skin like this. Doctors are human, though, and sometimes have bad days too. Also, given the millions of children and patient encounters with pediatricians, it’s inevitable that some will be bad and that some subset of those unpleasant encounters will involve vaccine-averse parents. Of course, this is not an vaccine-averse parent. This is clearly an antivaxer. In any event, the pediatrician raised her voice and said some things that were probably not the greatest idea. On the other hand, this mother’s entitled attitude would probably try the patience of a saint, with her nonsense about “informed consent” (really misinformed consent) and her demanding nature. I also note that blowups like this rarely occur on a first visit. Usually, when there is an argument like this between parent and pediatrician, it’s only after multiple attempts by the pediatrician to assuage the parents’ fears. Moreover, it is not at all unreasonable to want a parent to sign a refusal form in which they acknowledge the risks of not vaccinating. Who wants the liability of not vaccinating if there’s no clear record of the fact that the parent refused vaccination. The pediatrician is correct: How does the pediatrician know that a nonvaccinating parent whose child came down with measles and suffered encephalitis from it or contracted Hib and died wouldn’t sue her for not having pushed to vaccinated strongly enough?

Finally, Ms. Loe Fisher frames her struggle as a social justice struggle, a framing by antivaxers that never ceases to bug the hell out of me:

Every social reform movement in history has been shaped by injustice and suffering. Suffering is often the greatest catalyst for change, and change will come if we believe it is possible. Working to successfully reform vaccine policies and laws that cause suffering is not an impossible dream.²⁵ It will be done if we believe it can be done.

It is time to let our elected representatives know that we want them to put legal boundaries on the authority that doctors and public health officials wield in our society.

I felt the bile rising in the back of my throat as I read this nauseatingly self-righteous attempt to tie antivaccine activism to social justice movements of the past. I suppose I should be grateful that Ms. Loe Fisher resisted the temptation to invoke the Nazis, their medical experimentation, the Holocaust, and the Nuremberg declarations. I know she wanted to.