Category Archives: NaBloPoMo

Recentering—Vaccine post #3

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NaBloPoMo 2018:  What I’m Learning

When you buy a red car suddenly you notice so many red cars on the road.  I write two posts on vaccines, and now I see all these vaccine posts on my Facebook feed. One made me sad for multiple reasons.

Dr. Jennifer Chuang , a pediatrician who ran for the state legislature in New Jersey, posted this:

In 2017, I was moved to run for office in the NJ State legislature because of bills being introduced that were harmful to public health. Among the areas that I stood firm on were the importance and safety of vaccinations, and I was harshly attacked for that, even threatened.
However, NJ should not be proud of introducing the most pieces of legislation that would have made our children at risk for vaccine preventable illnesses. The current measles outbreak in New Jersey has now grown to 18 cases. Legislative decisions have consequences, especially to public health.

“From 2011 to 2017, New Jersey lawmakers introduced the most pieces of legislation that would make it easier for children to skip vaccines, according to a new study by Drexel University researchers.”

She linked to this article, detailing the anti-vaccine legislative history in New Jersey and lawmakers’ rationale, compared to the scientific literature.

I’m sad that there is such a fight against proven public health initiatives, and I’m sad that legislative bodies, who write our health and medical policies, include remarkably few clinicians.  But I’m most sad at the meanness in the fights.

A woman immediately commented, “Shut up already” on Dr. Chuang’s page.  When challenged benignly by others, she replied telling them to fuck off and calling them assholes.  Her page is apparently public, so I visited.  The posts that I could see were vehemently opposed to vaccines of all kinds, at least in 2016 and 2017.  She apparently lost a son this year, in his 24th year of life.  She has posted about eating healthy, self-care, and seeing intelligence as ‘not because you think you know everything without questioning, but rather because you question everything you think you know.”  So while I feel acutely put off and dismissive of her vile reaction to Dr. Chuang’s post, I also imagine that she and I may have things in common and might even be friends, if circumstances facilitated.

Somehow I came across another woman’s page tonight, similarly militantly anti-vaccine.  She and the first woman both posted a lot of memes and sayings implying that people who advocate for vaccines are brainwashed and ignorant, and not worthy of engagement.  Huh.  Sounds to me just like many of the ad hominems hurled by vaccine advocates against women like them.  It’s exhausting.  Who does it help, this mutual shit-flinging?  In Rising Strong, Brené Brown points out the pitfalls of false dichotomies and binary decision trees.  If you hear people shouting that you have to choose one side or another, that it’s all or nothing, be suspicious.  Look for the beneficiaries of that feud.  Often it’s the politicians who leverage our warring tendencies to stay in office.  Or maybe it’s physicians who, when they refuse to care for patients who decline vaccines, can feel decisively self-righteous rather than uncomfortably ambivalent.  Or maybe it’s the anti-vaccine parent, who feels embarrassed to express fear and uncertainty (because she has been shamed too many times for questioning a sanctimonious medical community), and so finds her voice in combative rage instead.  And could it be that anytime one of us shows up in attack mode, we incite our counterpart to take a mirroring stance, even if that was not their original intent (this is a rhetorical question)?

Regardless, I’m tired.  Social media and loud, mean, public debate are not venues that yield any meaningful interactions (I see the irony of my writing this on a blog).  It feels too slow, but experience teaches me that we win hearts and minds face to face, quietly, intimately.  Nothing good ever comes from a collision of two oncoming bullet trains.  It’s wildly destructive more than anything else.

Thankfully, my good friend posted Max Ehrmann’s poem “Desiderata” tonight.  I first read, transcribed, and posted this poem on my wall in high school, and have not seen it in a couple decades.  It really captures the essence of inner peace and right relationship, with self, humanity, and the earth, and it soothes me.  It’s a late Thursday night of another long week.  I leave you with Mr. Ehrmann’s master work below.  Good night.

Desiderata

Go placidly amid the noise and haste,
and remember what peace there may be in silence.
As far as possible without surrender
be on good terms with all persons.
Speak your truth quietly and clearly;
and listen to others,
even the dull and the ignorant;
they too have their story.

Avoid loud and aggressive persons,
they are vexations to the spirit.
If you compare yourself with others,
you may become vain and bitter;
for always there will be greater and lesser persons than yourself.
Enjoy your achievements as well as your plans.

Keep interested in your own career, however humble;
it is a real possession in the changing fortunes of time.
Exercise caution in your business affairs;
for the world is full of trickery.
But let this not blind you to what virtue there is;
many persons strive for high ideals;
and everywhere life is full of heroism.

Be yourself.
Especially, do not feign affection.
Neither be cynical about love;
for in the face of all aridity and disenchantment
it is as perennial as the grass.

Take kindly the counsel of the years,
gracefully surrendering the things of youth.
Nurture strength of spirit to shield you in sudden misfortune.
But do not distress yourself with dark imaginings.
Many fears are born of fatigue and loneliness.
Beyond a wholesome discipline,
be gentle with yourself.

You are a child of the universe,
no less than the trees and the stars;
you have a right to be here.
And whether or not it is clear to you,
no doubt the universe is unfolding as it should.

Therefore be at peace with God,
whatever you conceive Him to be,
and whatever your labors and aspirations,
in the noisy confusion of life keep peace with your soul.

With all its sham, drudgery, and broken dreams,
it is still a beautiful world.
Be cheerful.
Strive to be happy.

Max Ehrmann, Desiderata, Copyright 1952.

 

Talking to the Opposed About Vaccines

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NaBloPoMo 2018: What I’m Learning

Go figure, I’m having conversations about flu and vaccines every day right now.  Today I described my post from yesterday to a new friend.  He stands firmly in the ‘vaccines are good’ camp.  His sister, however, does not.  Her son has autism.  After hearing about my post, he asked me what I would say to her, if she told me she would not vaccinate her child ever again.  It was a great opportunity to think and practice, and I’m grateful that he asked.  I had already thought earlier today about writing a separate post on communication around vaccines.  So here goes!

First I would tell her that I understand why she would not want to vaccinate, if she blames vaccines for her son’s autism.  I don’t know any kids with autism, but I have friends whose kids are autistic, and I see how stressful and exhausting it can be.  As a mom of kids with anaphylactic food allergies, I also know the feeling of absolute guilt for being the one who gave my kids the things that made them sick.  If I were a mom whose kid was diagnosed with autism after receiving vaccines that I consented to, and I were convinced that the latter caused the former, I would definitely want to protect my kid from anything else that might hurt him, especially anything that I have control over.

Some additional background:  We are a lot better at recognizing and diagnosing autism spectrum conditions now than a few decades ago.  That diagnosis is commonly made in the toddler years, also around the time kids have received a boatload of vaccines.  So it’s easy to see a correlation, but causation cannot be proven.  One could argue that it also cannot be totally disproven, but given the number of children who receive all of their vaccines and the very small proportion of them all who go on to be diagnosed, the evidence definitely leans away from vaccines causing autism.  That is little comfort for a family and a child affected with the disorder, who may always wonder.  As humans, we naturally look to assign blame; vaccines are an easy target.  And why on earth would we repeat actions that have previously caused us trauma, real or perceived?

This year I read an article about a mom of three.   She had vaccinated her two elder children as per guidelines.  After her third was born, however, she started to read lay literature online stoking fear of vaccines.  She had no negative experiences herself, but started to wonder, what was really the best thing to do for her family?  She decided to stop vaccinating when her son was 6 months old.  At 18 months, he got pertussis, or whooping cough.  He almost died.  She posted videos of him coughing and turning blue, captioned with a heartfelt mea culpa, urging other parents to vaccinate:

“This is whooping cough,” she wrote. “This is Brody. An 18-month-old boy. Our third child. Our first son.

“This is a mother that sees ‘anti-vaxx’ all over social media and becomes terrified. Unsure whether or not to give vaccines (even though she did for both of her girls). Terrified to ‘pump her baby with poison’ … so she stops vaccinating after six months.”

“This is pure hell. This is guilt. Guilt of putting not only my son at risk, but my community too …This is embarrassment.”

She wanted to impress the fact that she’s not “bashing” the anti-vaxx community – or blaming or judging anyone.

“The decisions I made were MY decisions. Based purely on my lack of knowledge and fear,” she said.

“This is to show the consequences of not vaccinating my child correctly.”

I wonder about her conversations with her son’s doctors.  Did they try to shame her into vaccinating when she initially expressed a desire to stop?  If so, could this have just made her more resistant?  It could easily look something like a conversation that I would bet happened all over our country today:

Doctor:  Have you gotten your flu vaccine yet?

Patient: I don’t do flu vaccine.

Doctor: Seriously?  Why not?  It’s perfectly safe, you know, and tens of thousands of people die every year from flu.  If you don’t get vaccinated, you could pass it on to everybody you know.  Aren’t your parents elderly?  Don’t your kids have asthma?  You’re putting them at risk for serious illness or death, you know that, right?  And you don’t get flu from the vaccine, that is a total myth.  (Insert list of facts and evidence for benefits of flu vaccine here.)  Really, you should get it (suppressing eye roll).

Patient:  No, no thanks.  Can I go now?

I see and hear my colleagues complain all the time about vaccine-resistant patients.  When they are particularly tired or moody, they can get judgmental and even a little mean.  I understand.  It’s frustrating to watch people we care about making choices we think are against their best interests, especially when it also puts the community at risk.  I fear for my kids if their classmates are not vaccinated—both of my kids have asthma that’s triggered by respiratory infections.  Even if our whole family is vaccinated, they are still exposed to hundreds of snotty, sneezy, coughing faces every day at school.  Flu season is essentially six months long, most of it when we are all stuck inside basically slobbering all over one another.  High. Risk.

But does it really help for me to come at my patients with my ‘advice’ before I understand the origins of their decisions?  What are my assumptions about them when I do that?  Some patients claim science as the basis of their refusal; others admit that it’s totally irrational.  Regardless, how can I best conduct myself?  Here is my current approach:

Cheng: Do you do flu vaccine?

Patient: No, not really.

Cheng: Can we talk about that?

Patient: Do we have to?

Cheng: I would really appreciate it.  I won’t try to pressure you, I just want to understand your rationale.

Patient:  Gives their reasoning.  If it’s like my friend’s sister above, or I otherwise understand that they are resolute in opposition, I thank them for sharing, shift to strategies for illness and transmission prevention (see yesterday’s post), and ask permission to talk again next season.  This happens in a minority of cases, actually.  Most often they say something like, “Well, I just don’t really think about it, I feel like I don’t need it, I think it’s strange that it’s recommended every year, it doesn’t really seem to work from what I hear, and what’s the big deal about flu, anyway? …Do you really think I should get it?”

Cheng: Yes, I really recommend it.  Can I tell you why?

Patient: Okay, sure.

This is when I go through all the evidence that I reviewed yesterday and the rationale above.  If I know something meaningful to them that relates, I make sure to highlight the connection.  At the end I make sure to reiterate that they are free to vaccinate or not; I am honestly unwedded to a particular decision. I invite them to consider and let me know, or just show up to a pharmacy clinic if they decide to get it.  Most people are appreciative of the time spent; many say they learn something they did not previously know.  We end the conversation at least with no hard feelings, and often with positive ones (at least on my end).

It occurred to me this morning, what is my primary objective when I conduct these conversations this way, coming alongside my patients rather than coming at them?  Initially I thought it was to keep people healthy, to prevent death, serious illness, and suffering.  But now I think my primary objective is actually to cultivate our relationship.  I usually have this conversation with new patients, because if I know them already then I know their vaccine patterns and I don’t have to ask, “Do you do flu vaccine?”  If they refused last year I can simply start with, “Can we please talk about flu again?”  When we are new to each other, the way I present sets the tone for our relationship and has an outsize impact on patients’ receptivity to my advice.  The flu vaccine conversation is a prime opportunity to prove that I can listen to, empathize with, respect, and honor their values and autonomy.

On the contrary, when I come at them, bent on convincing them to vaccinate now, what is my primary objective?  Thinking of other times I present this way, if I’m being honest, I’m just trying to prove I’m right and win an argument.  I don’t think that approach has ever really helped anybody.

 

 

What Doesn’t Kill Me

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NaBloPoMo 2018:  What I’m Learning

What does your doctor tell you about flu vaccine?  What about shingles vaccine?  Antibiotics?  This week I have had a series of both unifying and gratifying conversations around these topics.  I thank my patients for sharing their opinions and questions, which stimulate and sharpen my thoughts and expressions, all in service of making us healthier.

People have a lot of reasons for declining flu vaccine.  It’s usually something around not believing it does any good (it does), feeling they don’t need it and are not at risk for serious illness or death (we all are), and a general aversion to ‘putting something in my body that isn’t natural.’   Most people who decline flu vaccine still accept tetanus/diphtheria/pertussis, hepatitis, meningitis, or other vaccines.  I find this interesting.  The rationale behind all vaccines is the same—saving lives and minimizing serious illness and complications, especially for vulnerable populations like babies, the elderly, and people with immune-compromising conditions (pregnancy, cancer, diabetes, autoimmune disorders).  We are contagious before we feel sick—this is the natural genius of viral survival and spread.  So this flu season, cover your face with your arm when you sneeze, wash or sanitize your hands after every encounter with any surface, and don’t share drinks or utensils with anybody.

Shingles is interesting.  You cannot get shingles unless you have had chicken pox or the chicken pox (varicella zoster) vaccine (though shingles after vaccination is rare).  After the acute illness (and sometimes after vaccination), the virus does not go away.  Like other herpes viruses, it lives in your body permanently and reactivates under certain conditions.  In my experience the most common trigger for shingles (zoster) is stress, either physical (eg sleep deprivation) or mental and/or emotional—often both.  The virus resides in the spinal cord and reactivates usually along a single nerve root, hence the typical pattern of a band of blisters on one side of the body.  For someone who has not had chicken pox or the vaccine, infection occurs through contact with respiratory droplets from someone with either chicken pox or shingles illness.

Here is my best analogy for how vaccines work:

Think of your immune system as law enforcement or a military operation.  Its job is to hunt down offending agents, apprehend them, subdue them, and kill them, if possible.  All such operatives need training to be effective.  Vaccines are like battle simulators.  We deploy them into circulation and trigger a drill response from immune system troops, making mobilization for the real, live attack more efficient and successful.  In the case of flu, offenders are shapeshifters, constantly changing their outward appearance to evade capture.  So simulators must be updated annually to prepare the troops in kind.

For shingles, think of varicella zoster virus (VZV) as the prisoner, your spinal cord as the prison, and your immune system as the prison guards.  Usually VZV breaks and enters when we are young, when our guards are also young, fit, and agile.  Over the years, our guards age.  With age comes sluggishness, memory loss.  The prisoner, however, remains as virulent as ever.  So it looks to escape through one window or another—maybe a left thoracic nerve root this time, a right lumbar next.  Shingles vaccine takes our dad-bod prison guards back to boot camp and reminds them what the enemy looks and acts like, so they may better thwart any escape attempts.  The new shingles vaccine, Shingrix, is recommended at age 50.

So, vaccines are basic training for our immune system soldiers.  I’ve never been anywhere near the military (God bless all of you who serve, and does residency count for something?).  For those who have, do you agree that there may have been times during training when you questioned your likelihood of survival?  And when you did survive, did you not emerge stronger and more confident for the experience?  What doesn’t kill me…

It’s the same for bacteria exposed to antibiotics.  There is no question, we use antibiotics too much.  Now think of bacteria as a horde of enemy invaders.  Our immune military wages war with these throngs at every orifice and mucus membrane of our bodies every day.  Every time we take antibiotics, however, it’s like coming over the battlefield with an imprecise explosive device aimed at the bad bacteria, but that also can cause collateral damage (eg friendly fire on our good gut bugs).  The problem with antibiotic overuse (and, in theory, shortened or incomplete courses of antibiotics) is that the bacteria who were already equipped to survive the blast now make up the majority of the surviving invasion party who can procreate.  They will pass on these survival traits to their progeny, and voila, antibiotic resistance.  The next time you have a respiratory infection, do not automatically assume you need antibiotics.  Talk to and/or see your doctor.  If it’s an uncomplicated viral illness, ask what else you can do to suffer less while your troops battle this transient, non-lethal invader.  Support them by hydrating, sleeping, eating healthy, and avoiding caffeine and alcohol.  Support yourself by medicating for the symptoms.  You’ got this.

What does not kill me makes me stronger.

It works both ways.