Should a doctor fire an anti-vax patient?

The anti-vaccination movement continues to grow, despite the retraction and thorough discrediting of the 1998 scientific study that spurred much of its growth.  The stubborn persistence of anti-vaxxers shows how difficult it is to dispel misinformation once that information is out there, even after dozens of new studies and millions of dollars in research that demonstrate that vaccines are safe.

One of the most dangerous trends is the growing number of parents who refuse to vaccinate their kids, or who choose "alternative" vaccine schedules, such as the one promoted aggressively by Robert Sears (who goes by "Dr. Bob").  Sears appears to have simply invented this alternative schedule without bothering to conduct any scientific studies, in part to promote sales of his 2007 book, The Vaccine Book: Making the Right Decision for Your Child.  Vaccine expert Dr. Paul Offit explained, in a 2009 article in the journal Pediatrics, why Dr. Sears' schedule was a very poor choice for children and for the public health.  After thoroughly dismantling Sears' anti-science positions, Offit concludes, "Sears has a poor grasp of the scientific method."  That's an understatement.

Other doctors, perhaps jealous of all the attention that Sears has gained through his anti-vaccine writings and television appearances, have created their own alternative vaccine schedules.  One of them, Donald Miller, even goes so far as to say that vaccines cause childhood cancer, despite the complete lack of evidence for this wild claim.  Somehow Sears, Miller, and others like them have managed to convince many parents that their children don't need vaccines.

In response to parents who don't want to vaccinate, many of whom show up with Dr. Bob's schedule in hand, pediatricians have struggled to find an effective response.  Parents can be utterly convinced by the misinformation they find on the Internet, which is all too easy to find.  (For example, Googling "vaccine" brings up the National Vaccine Information Center, a hotbed of anti-vaccine propaganda and pseudoscience, on the first page of hits.)  By the time parents arrive with their babies for the first vaccine, convincing them to change their minds can be nearly impossible.

Perhaps in frustration, doctors have started to "fire" their patients if they refuse to vaccinate.  As reported by Shirley Wang in The Wall St. Journal last week, 20-30% of doctors in two different surveys, in Connecticut and the Midwest, reported having to kick patients out of their practices because of vaccine refusal.  These numbers have roughly doubled over the past ten years, according to the American Academy of Pediatrics.

Is firing a patient the right thing to do? It's a difficult question.  On the one hand, doctors should do everything they can to make sure kids are vaccinated.   If a doctor kicks a parent out, that parent may find another doctor who doesn't insist on vaccinating children, which ultimately harms the children.  Doctors have to spend more time educating parents about the tremendous benefit of vaccines, about the very strong evidence (based on tens of millions of doses) for vaccine safety, and about the frightening consequences of infection with meningitis, hepatitis, measles, polio, and other vaccine-preventable diseases.

On the other hand, unvaccinated children bring diseases into the pediatrician's office, where they can spread them to other children.  Some of these other children are too young to be vaccinated, and childhood infections can be extremely dangerous, even fatal, in the very young.  From this perspective, "firing" a patient might be the only responsible action, after first trying to convince the parents to vaccinate.  I know that I wouldn't want to bring my child to a doctor's office where unvaccinated children were in the same room.

I understand how nervous a parent can be about vaccinations.  I will never forget the day my older daughter got her first vaccine: the needle looked huge compared to her tiny leg, and she screamed when the doctor gave her the shot.  But she was fine a few minutes later, and she'll be protected against a dangerous infection for her entire life.  Vaccines have been so successful at eliminating childhood infections that parents no longer see these infections as a threat.  Ironically, the very success of vaccines has allowed the anti-vaccine movement to sway so many people.

Doctors may have to keep firing the parents of their young patients, but I hope they'll first make every effort to educate them.  They need to explain that vaccines do not cause autism, nor do the ingredients in vaccines, and that scientific studies involving hundreds of thousands of patients support these conclusions.  They should also explain that many of the anti-vaccination claims on the Internet started when Andrew Wakefield published one small study of 12 patients, now retracted, claiming a link between the MMR vaccine and autism.  Investigations later revealed that he was paid by lawyers to recruit patients for a lawsuit against vaccine makers, that he didn't reveal these payments to his co-authors or the patients, and that he manipulated the data.  Since then, the anti-vaccine movement has exploded and we've experienced multiple outbreaks of measles, mumps, and other illnesses linked directly to unvaccinated children.

Doctors interviewed by the Wall St. Journal reported that they had convinced at least some parents to follow the recommended vaccine schedule.  Perhaps that's the best we can hope for.  If we're going to avoid a return to the era when children routinely died from infections, we must keep trying.

An Alzheimer's disease breakthrough?

We all hope to get old one day.  But if we do, our chances of getting Alzheimer's disease increase dramatically as we move into our 80s.  As many as 50% of people over age 85 may be affected.  Much progress has been made in understanding the disease, which appears to be caused by "plaques" forming in the brain, but we have no treatment and no cure.

But maybe - just possibly - a dramatic new study offers the first real hope for a treatment.  In a paper published today in the journal Science, a team of researchers led by Gary Landreth at Case Western University and his graduate student Paige Cramer found that an orphan drug called bexarotene has a remarkable affect on mice afflicted with a condition similar to Alzheimer's in humans.  These mice have similar plaques in their brains, compose of beta-amyloid proteins, and they show behavioral and cognitive impairment similar to some of the problems experienced by Alzheimer's patients.

Within just hours of administering bexarotene to these mice, the plaques started to clear.  If that weren't amazing enough, within a few days the mice also recovered cognitive abilities that they had lost.  In particular, they regained the ability to make nests, a behavior that normal mice have and that the Alzheimer's mice had lost.  They also regained at least some of their sense of smell.

Bexarotene (TargretinTM) is an orphan drug that is approved for use in humans to treat cutaneous T-cell lymphoma, a rare skin cancer.  It works by inhibiting a gene, RXR, that is involved in the production of beta-amyloid proteins.  Cramer, Landreth, and colleagues hypothesized that because bexarotene can cross the blood-brain barrier, it might just help to clear out the plaques associated with Alzheimer's.  It seems that they may be right.

A huge caveat here is that many promising drugs seem to work in mice but fail when used in humans.  This drug is different, at least in the sense that it is already approved for human use, but no one has tested it on Alzheimer's patients.  Studies are likely to begin very very soon, but it will take time - possibly years - before we know if it can slow the progress of Alzheimer's.  But for a disease that affects a huge percentage of the population, with no current treatment, this could be a huge breakthrough.

Indiana's clumsy attempt at theocracy

An edible FSM

Those state legislators are meddling with science again.  This time it's Indiana, trying to promote their religious views in public schools by dictating what science teachers will teach.  As usual when legislators try to do science, they messed up badly.

What happened?  Just a few days ago, the Indiana state Senate passed a bill, sponsored by Republican Dennis Kruse, that required the teaching of creationism.  Actually, the original bill called for schools to teach "creation science," but then the Senate amended it to make it much funnier.  Thanks Indiana!

The amended bill, which was approved 28-22, says:
"The governing body of a school corporation may offer instruction on various theories of the origin of life. The curriculum for the course must include theories from multiple religions, which may include, but is not limited to, Christianity, Judaism, Islam, Hinduism, Buddhism, and Scientology."
Holy cow!  I can't wait to see what Indiana students will be spouting when they go on to college.  Maybe they'll learn Scientology, which is one of the religions listed in the new law.  Scientologists believe that life on Earth started 75 million years ago, when an evil galactic warlord named Xenu brought 13.5 trillion of his people to Earth in a spaceship, stacked them around volcanoes, and vaporized most of them with hydrogen bombs.  (No, I'm not making this up.)

If I were teaching in Indiana schools, I'd be sure to cover the Church of the Flying Spaghetti Monster, which has a wonderful theory about the origin of life:
"We believe the Flying Spaghetti Monster created the world much as it exists today, but for reasons unknown made it appear that the universe is billions of years old (instead of thousands) and that life evolved into its current state (rather than created in its current form). Every time a researcher carries out an experiment that appears to confirm one of these “scientific theories” supporting an old earth and evolution we can be sure that the FSM is there, modifying the data with his Noodly Appendage. We don’t know why He does this but we believe He does, that is our Faith."
Now that's a theory you can sink your teeth into.

Finally, a little bit of science education for Indiana's legislators.  The next time you write a law trying to force the teaching of creationism instead of evolution, get the wording right.  You see, you wrote the bill incorrectly, because evolution is not a theory of the origin of life, as any good high school science teacher could have told you.  (Note to Indiana teachers: I've no doubt that you tried to teach these legislators back when they were in school. Apparently they're still not listening.)  Instead, evolution is a theory that explains how species arise: how a single species can evolve into many, through the process of natural selection.  You might have guessed this from the title of Darwin's book: The Origin of Species.  Scientists do have theories about the origin of life, but evolution isn't one of them.

Two years ago, South Dakota's legislature declared that astrology can explain global warming, which gave the rest of the country a bit of entertainment. Last week, it was Indiana's turn to look foolish.  After a huge flurry of embarrassing publicity, it appears that Indiana's legislature has changed its mind, and the bill will not become law.  But if they try again, I'd be happy to send them some materials on the Flying Spaghetti Monster.

[Note: I also recommend the blog posts by PZ Myers at Pharyngula and Jen McCreight at BlagHag.]