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March 26, 2008

On Vaccinations

I recently had an interesting conversation with guest-blogger extraordinaire and friend Kelly Hills on the current brouhaha regarding vaccinations.  I thought I'd share some of my thoughts, as I think they implicate some concerns fairly within the domain of the medical humanities.

BLOGVERSATION: Prettier than Napoleon, and Law and Letters.

First, the history of opposition to vaccinations is both important and instructive here.  The literature on this subject is immense, and I don't have the time or space to go into it here.  Suffice it to say that, as usual, we can learn much about the present by reflecting deeply on the past, in large part because the past continues, in dialectic fashion, to shape and mold the present (and the future, for that matter).  Opposition to vaccination is most assuredly not novel.

Second, the thimerosal issue is something of a red herring.  There is currently no evidence whatsoever that thimerosal has any causal link with any kind of disease, syndrome, or illness.

The reason this is a red herring is because it masks the deep and inherent uncertainty that characterizes much epidemiologic and disease causation.  Having practiced pharmaceutical litigation, written on scientific causation, and thought about these issues for some time, it seems difficult to contest the notion that medical and disease causation is an extremely tricky concept.

Who, for example, would have seriously entertained the notion prior to 2002 that hormone replacement therapy may actually cause or at least increase the chances of developing certain kinds of cancers? In pharmaceutical litigation, causation is typically where the most significant fight is: we know the plaintiff took the drug, we know the plaintiff got injured, the question is whether the drug caused the injury.  And this is an extremely difficult question to resolve to our satisfaction.

(Though, for the record, Kelly and I both happen to believe that part of our problems in assessing epidemiologic causation arise from a fundamental reduction and misconception of the ways in which complex systems behave, in which they produce effects.  This, of course, is the subject of another post or posts).

495pxdavid_hume So, the fact that thimerosal does not seem to cause disease does not imply that there is no other causal agent or set of agents that can cause disease.  Of course, it is entirely legitimate to note that, at present, there is not a shred of evidence causally linking vaccines to illness.  But, as the venerable Mr. Hume would remind us, beware of the principle of uniformity; the future does not always resemble the past.  Just because we have not found the link does not mean there is no such link (i.e., epistemology vs. ontology).  Prior to 2002, we had not found any link between hormone replacement therapy and increased risk of cancer, either.  Few even imagined such a link existed, and so we were not even looking for a link.

While we have no good scientific evidence, we have an abundance of anecdotal evidence that I, as a new father, find to be quite frightening.  From a MH perspective, the question becomes how does one square the legitimate notion that anecdote is poor evidence, if it is evidence at all, with the crucial proposition that narrative evidence is most assuredly evidence, and vital evidence, at that.  Stories matter, especially as to human suffering, health, and illness.

So, what are the possibilities? Future work could demonstrate that the likelihood that there are any causal linkages between vaccines and disease is vanishingly small.  In this scenario, the hue and cry over the potential linkage is simply another instance of the awesome pattern recognition capacities of the human mind, one that all too often, as Mr. Hume would also note, attributes causation where only correlation obtains.

Alternatively, future work could demonstrate that, once again, narratives of illness, especially persistent ones, demonstrate amazing prescience and wisdom, and that they capture phenomena and relationships that are at present blind to the investigating, scientific Eye/I.

Of course, I don't have any of the answers, but these remain difficult questions, though this is not necessarily to suggest the decision of whether to vaccinate one's own child is of comparable difficulty. 

Finally, I'd like to remind again that in thinking about issues of mortality, one could do worse than to attend to Nietzsche, who reminds us of the power and importance of the guilt and responsibility narrative in the Judeo-Christian ethos.  The thought of being a parent who is responsible for a treatment decision that immediately, irrevocably and dramatically alters my child's life course and development into adulthood is, in many ways, quite frightening.  (Of course, one could quite reasonably argue that deciding not to vaccinate one's child is also just such a decision.  This is in part why the foregoing should not be taken as an argument for or against vaccination).

I think it was Freud who said it best: all our fears are mortal.



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1: Toxicol Sci. 2003 Aug;74(2):361-8. Epub 2003 May 28. Links
Thimerosal induces DNA breaks, caspase-3 activation, membrane damage, and cell death in cultured human neurons and fibroblasts.Baskin DS, Ngo H, Didenko VV.
Department of Neurosurgery, Baylor College of Medicine, 6560 Fannin Suite 944, Houston, Texas 77030, USA.

Readers who are interested in this topic that Daniel goldberg has framed nicely may want to see the vaccine debate at www.health.mil.
Ward Casscells,MD

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