Candle in a Breeze? HPV, Measles and the Public Health in an Anti-science Era

Imagine this.  You tune in to the evening news and hear that a new virus has been discovered.  What's more, it has infected over 80 million Americans.  Is there good news?  Just that most people don't know they have it, simply because they have no symptoms at all.  On the other hand, this new virus will cause 300,000 precancerous conditions in women, and every year 31,000 men and women will develop one of six kinds of cancer caused by this infection.  This year, next year and each one after. 

I believe that mayhem would follow.  And then a call that government and medical scientists DO something about it.  

As it happens, this is not science fiction, except for the part about the virus being new.  Rather, this is a description of the human papillomavirus, or HPV, discovered in 1956 and first linked to human cancers more than 30 years later.  In 2006, a highly effective vaccine against HPV was licensed by the FDA.  It was felt to be so important for cancer prevention that a year later the federal Centers for Disease Control and Prevention (whose Advisory Committee for Immunization Practices writes the national guidelines that undergird vaccine use in our country) called for the addition of HPV vaccine to the list of recommended childhood immunizations at the 11 or 12 year old visit.  


Why are cervical cancer and other HPV malignancies still with us?  For that matter, why is measles making a comeback after all these years? In the first instance, it is because uptake of the vaccine in the US has been unusually slow.  In the latter, there is actual backsliding, with previously high rates of immunization eroding in pockets from New York to the Pacific northwest. Other countries, like Australia, are on track to completely eliminate HPV cancers in less than a decade.  But not us.  Why? It's not lack of access.  In fact, in communities like ours across the country, those who a economically disadvantaged are MORE likely to be up to date with their immunizations, including these.  Those at greater risk - for HPV, measles and other preventable infections - are the well off and the (otherwise) well educated.  

Pediatricians like me approach the problem of immunization with great empathy for parents, who face a terrifying array of viewpoints in the marketplace of ideas.  "Getting natural diseases is better than immunization." (This is such an odd idea.  Behind my wife's ancestral, 19th century home in Riverhead there is a small, lovely graveyard.  We walk there sometimes and linger at the tiniest tombstones, perhaps a dozen in all. They belong to those who did not survive infancy due to fatal infections like diphtheria and whooping cough that were once a commonplace in our towns.)  "Vaccines overwhelm the immune system - especially when we keep adding new ones." (Children immunized now receive far FEWER antigens - the vaccine building blocks that create immunity - than they did in 1970, even after accounting for the longer list of conditions prevented. This is due to continuous improvement in vaccine design.)  


"Vaccines cause autism." This deserves more space than we have here.  In the 90s, concerns were raised about a widely used mercury preservative - the so-called smoking gun. Experts noted that the form of mercury was different from the biologically active kind that we should worry about.  As a cautionary measure, the mercury was removed in 1999.  However, the reported prevalence of autistic spectrum disorders did not decline thereafter - it increased.  Then, in 1998, the Lancet published a paper by Wakefield et al describing 12 children with GI symptoms and autism following administration of MMR vaccine.  At first thought to be provocative, and then just bad science, it was disclosed by 2010 to have been a conscious fraud, intended to support a malpractice claim by a UK firm.  His medical license was revoked as a result. Since that time, 56 studies have been published internationally evaluating the hypothesis that vaccines are linked to neurodevelopmental conditions like autism, focusing on the MMR-autism issue and others.  None of the 56 showed an association.     

Let me be quite clear on one point.  There are many controversies in Medicine - on diagnostic tests, on the best treatments for a host of conditions...but immunization is not one of those controversies.  Among experts in pediatrics, infectious diseases and public health, the safe and effective vaccines listed by the ACIP and endorsed by the AAP and AAFP as recommended for all healthy children constitute a vital strategy for keeping our patients from harm.  

Many have noted that new information is not of interest to those who are most staunchly opposed to childhood immunization, unless it reinforces their pre-existing bias - which is essentially the definition of a "cult."  Where have we seen this before?  This is a matter not for immunologists to decipher, but for social scientists.  It is about an unravelling of trust - in doctors, in the methods and practitioners of science, and in the legitimate functions of governments in protecting the public welfare.  

It is certainly about libertarianism, at least in some locales.  Politicians have gone on record with the position that the science doesn't even matter.  Instead, they argue, this is about the parent's right to be wrong.   

Some feel that the most important contributor to skepticism is incomprehension.  The notion that association between two events may not mean causality is just too abstract-sounding to be trustworthy, especially in an era when scientific literacy is in decline.  Two decades ago, Cornell astrophysicist Carl Sagan expressed his serious concern that we were entering a new Dark Age.   In his last book, "The Demon Haunted World - Science as a Candle in the Dark," this is what he said:

“I have a foreboding of an America in my children's or grandchildren's time when...people have lost the ability to set their own agendas or knowledgeably question those in authority; when, clutching our crystals and nervously consulting our horoscopes, our critical faculties in decline, unable to distinguish between what feels good and what's true, we slide, almost without noticing, back into superstition and darkness... 

The dumbing down of America is most evident in the slow decay of substantive content in the enormously influential media, lowest common denominator programming, credulous presentations on pseudoscience and superstition, but especially a kind of celebration of ignorance...”

God save our children.