embracing uncertainty in vaccine policy
DRUG BUST by Alan Cassels
• The people’s briefing note on prescription drugs
I have to make an admission: I’m somewhat of a coward in that I’m not particularly crazy about getting in the middle of a war. That’s why I don’t really like writing about vaccines; there are few things in healthcare as polarizing, fiercely debated and spiked with invective as the topic of vaccines. As I write this, Israel is bombing Gaza and militants are firing missiles back into Israel.
Makes one wonder if there can ever be a peaceful resolution to a situation marked by so much hatred. So, too, in the vaccine world it sometimes seems that even when people say they want peace, it’s hard to conceptualize what that would look like with the acrid smell of burnt gunpowder hanging in the air.
There are clearly two warring camps in the vaccine arena and, like any war, it sometimes looks so bleak one wonders if there will ever be an end to the fighting.
On one side, you’ve got the very positive, pro-vaccine promoters who claim near-miraculous effects of vaccines. They like to point to the great strides made over the last half-century in the war on deadly vaccine-preventable illnesses. They support more aggressive, broader-based vaccine policies that they believe can only benefit the entire population because, well, “Better safe than sorry.” These folks believe that if we follow the precautionary principle, we need to be expanding our use of vaccines to provide the greatest benefit to mankind.
On the other side, you’ve got a very strident, anti-vaccine camp, whose proponents seem to find fatal faults with every vaccine ever devised, have deep concerns about vaccine safety and vigorously oppose mandatory vaccine policies that they believe will hurt the entire population, because, well, “Better safe than sorry.” These folks believe that if we follow the precautionary principle, we need to be restraining our use of vaccines to provide the greatest benefit to mankind.
So which camp are you in – restraining or expanding our use of vaccines? Let’s just say I’m in the camp of John Lennon, who famously sang, “All we are saying is give peace a chance.” Ok, vaccine lovers and haters, let’s put down the weapons for a second and at least try to find some points on which we can both agree.
The good thing is that both the pro and anti-vaccine camps want the same thing, at least ostensibly: they want what’s best for the population – some kind of preventive treatment that is effective, not wasteful, safe and proven to do what it is designed to do: prevent illness. But how does one get to that middle ground? Especially when we’re in love with our own ideas and most comfortable sticking firm in our entrenched positions?
Let me propose a mediating force, a kind of middle ground. For the lack of a better name, let’s call it uncertainty. This could apply to most vaccines currently being promoted to the wider population, but because we’re in flu season, let’s focus on the hotly debated BC policy of mandatory flu vaccinations for healthcare workers. You’ve got the health authorities on one side claiming the policy is right and some healthcare unions on the other claiming it is wrong. How to decide?
Let’s be adults here and agree on the following: what is known and true, what is known and false and what is unknown and which hints at where we need to go for more and better information.
Sound like a tall order? How do we amass all that information and dissect it so that the true, the false and the unknowns drop in our laps? Thankfully, many researchers around the world are systematically collecting and synthesizing evidence, finding the best quality research and sifting that evidence in a clear and rational way that gives weight to the best studies and weeds out ones likely to be biased. They are taking all of the evidence and crafting a coherent picture so that people can learn what has been discovered and how they went about finding it.
Systematic reviews of evidence are produced by many groups around the world, the most famous being the Cochrane Collaboration whose Database of Systematic Reviews holds around 5,000 reviews and forms part of The Cochrane Library, which can be seen at www.cochrane.org
My feeling is that, whenever a new health question arises, the first question any person should ask is not “What does the research say?” but rather, “What does the systematic research say?” Better yet, “What does the Cochrane Collaboration say?” Because most of us have neither the time nor the expertise to sift through hundreds of studies, the Cochrane group is providing a valuable service to humankind.
Much controversy has arisen here in BC concerning the province’s mandatory flu shot, where BC’s healthcare workers are told to either get the shot or wear a mask and to wear a badge indicating their status. (We don’t have to go too far back in history to a time when the wearing of a badge was a mark of shame and ostracism, but opposition to the policy comes down to two things: the science behind the policy and the coercion with which it is applied.
On the science front, thankfully, we do have systematic evidence that shows the policy to be perhaps more political than proven, which is to say the highest quality evidence suggests there isn’t much to be gained by having healthcare workers immunized. We hope it works, but hope and expectation don’t cut it when we’re talking about mandatory policies. The Cochrane review of flu vaccine research finds that many of the studies are biased, incomplete or of poor quality, which makes conclusions hard to draw.
Systematic evidence can help mediate conflicts – between those who advocate for stronger vaccine policies and those who oppose them. But often that systematic evidence says we need better evidence.
There is plenty of emotion around BC’s flu vaccine policies where the province is accused of enforcing Nazi-like anti-flu policies and the anti-vaccine tribe is accused of being uncaring and insensitive to the needs of patients. Wouldn’t it be more satisfying if both sides resisted the urge to question each other’s motives and call each other names, agreeing instead on a game plan to do better research?
Wouldn’t it be better if we collectively focused our energies on the quality of the science behind the flu shots and came to a mutually agreed upon understanding of what we know and what we don’t know, in terms of the flu shot’s effectiveness and safety? How about that as a way to go forward?
Better research doesn’t have to be expensive, but it would have to be well designed. We could start by simply determining how big the flu problem is in BC (and stop guessing at the actual rate of flu deaths each year) and whether vaccinated people did better than the non-vaccinated (by proper monitoring and follow-up of individuals) and collecting data on those harmed by the vaccine.
When I talk or write about flu policies, people often share their stories. The one I hear the most is where the person who got a flu shot says that he right away came down with the nastiest flu ever. And he then blames the shot. The authorities universally say this is biologically impossible. The problem is we don’t know in the ‘real world’ how often a flu jab leads to people getting sick. Without collecting those data, we will never know.
Despite the warring factions of the pro and anti-vaccine mobs, we hear a lot of angry rhetoric, but only occasionally do we hear demands for better science, better monitoring and more assurances that better data need to be collected.
Why not start by all of us agreeing there are things we know and things we don’t know. That there is uncertainty. And that we might get along better if we collectively embraced this uncertainty. Is this the beginning of a peaceful resolution? I hope so. Peace on Earth.
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Alan Cassels is the author of Seeking Sickness: Medical Screening and the Misguided Hunt for Disease. Follow him on Twitter @AKECassels or www.alancassels.com
If it weren’t for the immunocompromised we could go with the ‘do what you like’ position. But what about the parents of kids who are trying to allow their kids to live the most normal life possible, by going to school or by being able to go out in the world like other children? The children who are in years long chemotherapy, the children with severe chronic asthma, or other health issues, as well as adults similarly affected. The freedoms could well cost people their lives. I still see people coughing into their hands and then touching common objects, like door handles, when surely we all, by now, know how cold and flu germs are passed along. And the people who are sick who get bored of staying home when sick, and reassure us that they aren’t contagious any more, as thought they have expertise on the subject. I do believe in a healthy immune system, which yes can be built up by living in the real world, playing in the dirt: building up immunity. But I do not believe we have the right to risk others, especially those who are unable to protect themselves. Every day on the road I see people whose driving practices make clear they are willing to endanger others; if caught, they are ticketed, but too often they are not caught. People who are not vaccinated are invisible to those who might be harmed, and the people in danger usually wear that invisibly as well. I agree that good science is imperative, and part of that is impartiality on the part of researchers, as opposed to sponsored research. But meanwhile, yes, I do get flu shots, update my tetanus vaccine, and polio. How many of you, as adults, have had your childhood vaccines updated? My father had polio as a young adult, but I am one of few people I know who had their vaccination updated as an adult. These diseases are not gone. There are periodic outbreaks even in North America. A friend of mine’s aunt came down with tetanus, with consequences that changed her life. Yes, you should be able to gamble with your own life, but, like dangerous drivers, there should be consequences for people who endanger others. Wearing something that indicates you are not vaccinated? That just doesn’t seem as harmful to the people who have made that choice as it could be for those they might endanger.
I agree with CATT. Let adults decide for themselves, and parents decide for their children. Anything else makes a mockery of living in a “free” country.
Perhaps the best possibility would be to agree to disagree, meaning allowing every adult to address the question of having themselves inoculated, or not. And, thus allowing their decision to stand without repercussion. Also, allowing adults, in charge, of children to make the same decision without reprisals from their doctors (throwing them out of their practice) or the school system. It should never be the business of anyone other than the individual as to what is done to or put into their own body.