Years ago, when I was less flexible, I took up Pilates. My instructor, Jim, a charming chap with an infectious laughter, was a 9/11 truther. I’d egg him on to hear about his conspiracy theories. Jim believed that 9/11 was concocted by Bush and Halliburton so that the U.S. could invade Iraq to capture their oil. He thought that United Flight 93 never took off. Whatever happened after 9/11 became the motivation for 9/11. He was the sort of person who would have concluded that Mahatma Gandhi plotted the World War II to free India from British rule.
I began to suspect that Jim was, to put it charitably, nice but dim. But he wasn’t that dim. He corrected me when I once, innocently, underpaid him. He was also smart at advertising. And when he met my wife, he told her that she should join me for Pilates because it would strengthen our marital bond. My wife politely declined the bond strengthening. He was also very cued up with the nutritional sciences and warned me, without leaving a trace of irony, “don’t believe everything you read about diets.”
9/11 truthers remind me of anti-vaxxers. They share a deep paranoia which is impervious to logic and science and which becomes stronger when confronted with logic and science. What doesn’t change their minds, and little does, makes their beliefs stronger.
Recently, Dr. Daniel Neides from Cleveland Clinic opined about the risks of immunization. Writing in the local newspaper, which I wouldn’t have known about if it weren’t for Twitter’s enthusiastic crowd, he cautioned his readers about the industry and toxins. He said, “We live in a toxic soup.” He alluded that vaccinations cause autism. For good scientific measure, he threw in the microbiome — an entity which will lead to much confusion before clarification.
The history of the anti-vaccination movement is the history of paranoia in the developed world. People in developing places don’t fear vaccinations — they have genuine fears to contend with. Vaccine phobia, though a marker of scientific illiteracy, can be traced to heavy paranoia of industry and a belief in environmental utopianism. Only once in history has there been purer environmentalists — the Digambar sect of Jainism who believed that wearing clothes harmed the environment (don’t go looking for them — they no longer exist).
With a bit of historical reflection, you can see how “vaccines cause autism” got out of hand. I highly recommend Paul Offit’s “Autism’s False Prophets.” Andrew Wakefield’s now-discredited research linking MMR with autism made social justice warriors positively tumescent. It’s easy to see why — greedy industrialists and greedy doctors polluting little, unsuspecting babies is candy for righteous rage. It’s no surprise that Wakefield’s research was funded by trial lawyers — a profession which makes a lot of money exploiting paranoia about greedy capitalists. Wakefield’s discredited findings moved the FDA and the Congress. Both right and left wing publications warned people of the dangers of immunization. It is possible that Cherie Blair, Tony Blair’s chakra-believing wife and gifted lawyer, also fell for the paranoia.
The tide has turned. It is vaccine skepticism which evokes considerable rage. Fighting anti-vaxxers is now the lowest common denominator of intellectual probity. No doubt the fight is important and it seems to be seen fighting is also important. To me, the anti-vaxxers, one of the most demonized constituencies, evoke pity rather than anger. I feel that if I shouted “boo,” they’d collapse into a pile of liquid. But shaming them by calling them selfish for free-riding herd immunity and putting immunosuppressed people at-risk or stupid or scientific illiterates will unlikely persuade them to get vaccinated. Nor will they be persuaded by reams of data or a Powerpoint showing that the confidence intervals for the likelihood that vaccinations cause autism, as the point estimate, is zero.
But doctors should know better. Should the anti-vax physician have his medical license revoked? Should his employer fire him? The near-unanimous view of physicians on Twitter was affirmative for the latter and a desirability for the former. But once you think beyond stage one, you’ll realize the matter isn’t so simple.
Let’s explore the case for revoking his medical license. The logic is taut. His piece advising against immunization is jeopardizing patients’ lives. But is that true? I mean is it true that there were people undecided about vaccinations or felt that they should be vaccinated who, after reading his piece and persuaded by his credibility as a doctor in the prestigious Cleveland Clinic, have decided against being vaccinated? Plausibly yes, but arguably no. Anti-vaxxers reject vaccination despite the evidence, and despite persuasion from mighty Ivy League doctors to get vaccinated. Their sensitivity to doctor’s advice to get vaccinated, whether positive or negative, is likely zero. They’d stay unvaccinated despite his piece, not because of it.
Thus, it’s likely that he was preaching to the choir and unlikely that the net mass of unvaccinated people changed by his forgettable piece. And if you’re going to make an empirical case that he led to net harm, you’d also have to blame the social media which, in a “Streisand effect,” helped his piece reach people who wouldn’t have read it.
How about this rationale: Physicians skeptical in the public domain about mass immunization, an indisputable standard of care (SOC), are unfit to practice? The rationale appeals because doctors with such scientific illiteracy so as to peddle fears about vaccination may be clinically incompetent. But let’s parse the issue because there are two problems. The first is that the anti-vax sentiment of doctors might not affect their clinical work. If they were radiologists, for example, adept at detecting acute pathology, it would scant matter what they thought about immunizations. You might find them annoying, but if they quietly cranked through the list, never missing important findings, would it matter to a medical tribunal if they believed in Santa Claus, or that the moon landing was a hoax, or that immunizations cause autism?
The second problem is that anti-vax doctors might not practice what they blog — that is they may still offer their patients vaccinations. Furthermore, they may resort to that capacious formulation called shared decision making, to show that the patient’s decision not to be vaccinated was the patient’s decision not theirs. How will you prove that this was not so, particularly if the patient was an anti-vaxxer?
I’m unable to find any legal precedence of a physician found guilty of malpractice or who has lost his or her medical license, for merely questioning an indisputable SOC in the public domain — if you know of such a case, please let me know. It will be a tough case to try because it would, in effect, censor skepticism and in a country with a strong tradition of free speech would likely reach the Supreme Court. Anti-vaxxers would be emboldened, and the anti-vax doctor would become a martyr. Vaccinations would become even more politicized than they are today.
There is clearly legitimate and illegitimate skepticism — skepticism of statins for primary prevention, now endorsed by the USPSTF and, therefore, standard of care is legitimate, and skepticism of vaccinations is illegitimate.
This begs the question: How do we define legitimate skepticism? To that, I can offer no better answer than Potter Stewart’s. When asked to define pornography, he said: “I know it when I see it.” You could argue that vaccinations are different from statins because not being vaccinated has negative externalities as it endangers others and that vaccinations have the same effect across the whole group — neither of which is true for statins. However, these are post hoc rationalizations why skepticism of vaccinations should be censored. There’s no formalized framework for what’s legitimate skepticism of standard of care which impugns skepticism of vaccinations but doesn’t impugn skepticism of statins.
Censoring skepticism of vaccinations is a slippery slope which could be applied to any standard of care. Don’t think of the present, think what might happen 50 years from now. Science progresses when someone questions the status quo. Do we really wish to endanger this avenue for the sake of one physician?
Silencing skeptics in the U.S. is never a good idea as climate scientist Michael Mann has found. He sued writer Mark Steyn for calling his research fraudulent. Whatever the outcome of the trial, Steyn has far from been silenced — he has upped the ante in his derision of Mann, and he has even written a book solely devoted to ridiculing Mann. The suit has become an avoidable own goal for Mann. Climate science is already excessively politicized to the detriment of the science, and Mann’s lawsuit doesn’t help. Even if Mann wins, climate science loses.
The Cleveland Clinic, a private entity where the First Amendment doesn’t apply, can dismiss the physician. But they may not wish to. Dr. Neides heads their Wellness Unit. Cleveland Clinic is the premier center, it seems, not only for mitral valve repair but Reiki and other para-medical phenomena. It’s likely that his views — specifically, his morbid fear of industry and toxins — comport nicely with the mumbo-jumbo ethos of wellness programs. Those programs are an initiative and are the mother of quackery. They’re also enshrined in Obamacare, and their provenance is, amongst other things, a study by preeminent economists. To put it bluntly, he’s quite possibly a cash cow for the clinic. The brouhaha over his anti-vax piece is likely to draw even bigger crowds enamored by chakras and complementary and alternative medicine, meaning it won’t have harmed the Clinic’s bottom line. Physicians on Twitter just gave the Clinic’s Wellness Institute free publicity — congratulations.
Were I the Health care Czar, I’d throw wellness programs into the Potomac. But I’m not the Czar, and there are no Czars in the U.S. who can tell a hospital not to offer aromatherapy. Will the Clinic lose credibility for employing a physician with anti-vax views? I doubt it. The rich oil sheiks from the Gulf countries couldn’t care less about a doctor in charge of aromatherapy with crank theories about immunizations. Just because something bothers the medical commentariat, doesn’t mean it bothers patients.
To save science, you need skepticism. To save skepticism, you must tolerate stupidity. But there are other lessons. Vaccination phobia is the perfect storm of paranoia. We’re conquering hype. We’re not doing too well with paranoia. Evidence and science won’t reduce paranoia. It is the culture which begets paranoia which should be addressed. Perhaps we should think twice before we demonize, whether it be doctors, industry, regulators, lawyers, insurers, government or markets as we can so easily excessively and irreparably demonize.
The lesson I’ve drawn from conspiracy and non-conspiracy theorists is that crank can coexist with competence, and competence can coexist with stupidity. Maybe if we treated the anti-vaxxers with a smidge of respect they might, just might get over their vaccination phobia.
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