Response to Matthew Baral’s Perspective on the Measles Outbreak

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Response to Matthew Baral on writing about the measles vaccine:

http://www.azcentral.com/story/opinion/op-ed/2015/02/09/vaccines-measles-facts/23142469/
http://drmatthewbaral.com/archives/1699

Matthew Baral’s recent blog post and corresponding opinion piece in the Arizona Republic highlights a trendy and inappropriate naturopathic stance on vaccinations. He claims that because he has 15 years of experience practicing as a naturopath seeing numerous patients with autism spectrum disorder he can assert objectivity and scientific acumen. He maintains that a cautious approach to the CDC recommended vaccination schedule is scientifically sound and states that arguments from the both the pro-vaccine and anti-vaccine camps need clarification in order for parents and patients to make informed choices. He further suggests that there are effective natural vaccine alternatives to prevent infectious diseases, like the measles.

It is typical for naturopaths to promote and administer vaccines but frequently deviate from the established immunization schedule and write exemptions for personal beliefs instead of medical necessity. These naturopaths call themselves vaccine neutral, or vaccine impartial, and preach about parental choice dominating in the vaccine debate. (I am not even going to mention the far greater number of naturopaths who fully reject vaccinations and who also  write personal belief exemptions.)

It is as if naturopaths are making up their own standards of care. They use buzzwords like “individualized” or “compassionate” and arguments that vaccines contain many toxins, that vaccines are linked to developmental disorders, that vaccines can overload a child’s immune system, and that vaccine-preventable diseases can be fought or prevented with natural medicines. I can put my weight behind the scientific consensus to say that healthcare practitioners who use these points are doing everyone a dangerous disservice.

I focus on what Matthew Baral wrote about vaccines because he is the president of the Pediatric Association of Naturopathic Physicians and chair of the Department of Pediatrics at Southwest College Naturopathic Medicine. I find it deeply troubling that he does not advocate the widely accepted medical standards of care when inoculating children against communicable diseases. This disconnect between being a leader in the naturopathic community and a self-proclaimed medical expert is unfortunately quite characteristic of the naturopathic profession. I’ll break down how Baral’s writing on vaccines misinterprets scientific facts, confuses causality and correlation, and blatantly ignores the opinions of real experts and dedicated scientists.

I want to start with what it actually means to be “pro-vaccine.” You cannot be pro-vaccine simply because you agree with administering some vaccines, to some children, under some circumstances. Such reasoning is a major cop-out. I understand this error because I used to make it myself. I used to believe that a delayed vaccine schedule was medically appropriate in any case. I used to believe that some vaccines should not be administered in the presence of developmental delays. I used to space out vaccines across many office visits. I didn’t trust research that debunked the link between vaccines and seemingly unrelated diseases. To make a long story short, I now question everything I was taught in naturopathic medical school. And I mean everything. When I read Baral’s arguments, I understood why I used to believe what I did.

The main problem with Baral’s position is that he uses the argument of false equivalency. His strategy is to present his views as a middle ground between two extreme positions that are not equal: 1) vaccine proponents want to silence or jail those who are “anti-vax” and 2) “anti-vaxxers” denounce all inoculations and therefore cause harm to society. It is also possible to consider his position a straw-man argument, in which he misrepresents his opponents’ positions in order to clear a path for his own argument that seems attractive because it is not prejudicial or aggressive. In reality, vaccine advocates want everyone to be healthier, and they arrive at their decisions based on science. This is the definition of “pro-vaccine.” The anti-vaccination camp cannot be equated to the scientific community. Therefore, Baral’s middle-ground reasoning is false.

A few important things need to change when we discuss vaccinations and the opinions and research that underlies how they are used. First, Baral argues that the American Association of Naturopathic Physicians (AANP) is pro-vaccine. I can see how he might have gotten confused as the AANP provides vague and incomplete recommendations.

The AANP Position Paper on Immunizations that Baral mentions does not advocate the administration of routine childhood vaccines. The paper does not mention any vaccine schedule specifically nor does the paper recommend a standard of care. The paper instead clearly leaves room open for exemptions and custom inoculation schedules between parents and practitioners “within the range of options provided by state law.” Since many states have major loopholes in public health law regarding vaccine exemptions, this statement basically means vaccinate as you like or even not at all.

The AANP paper also talks about the “moral obligation and legal mandate to uphold and carry out public health mandates” but stops short of clearly stating how to make such an obligation effective. A step in the right direction would be to recommend that in order for such public health mandates to be effective, vaccines must be administered according to the US Centers for Disease Control and/or World Health Organization recommendations. Furthermore, the AANP paper states that “agents” in vaccines “have been associated with significant morbidity and are of variable efficacy and varying necessity.” Basically, the AANP says that 1) vaccines are scary and may not work 2) naturopaths have a lot of wiggle room as afforded by state laws; 3) and parents have a lot to bring to the discussion, all while weakly nodding to public health mandates.

In contrast to the AANP paper, the AAFP Immunization Recommendations firmly anchors decisions to administer vaccines within a clinical setting by the family physician based on the “best understanding of the science of medicine.” AAFP’s policy is presented alongside a schedule for vaccination and a clear statement that in order to improve the healthcare of America, “these recommendations must be met.”

Second, Baral states that the discussion regarding autism and the MMR vaccine “is a debate that will never end” but in my opinion, it needs to end. One does not need expert knowledge in order to discover reliable sources that point at the science. There are reputable organizations that clearly spell out the evidence and consensus of family physicians, epidemiologists, and immunologists. The criticism found on the internet of this consensus is driven by a belief in conspiracy theories. There is no conspiracy.

The MMR vaccine does not cause autism. There is no evidence that is does, but there are lots of conspiracy driven ideas. In fact, in order to claim that the vaccine causes autism, one must carry the burden of proof. Show the evidence, if there is any. Remember, Wakefield’s paper was retracted and his medical license in the UK was revoked for his professional misconduct. Subsequent research was performed and turned up no link. None.

Furthermore, Autistic children should be vaccinated according to the regular schedule because, contrary to Baral’s claim, their immune systems do not behave abnormally when inoculated. Baral’s citation of Singh’s research does not bring into the discussion that his work has been discredited by the scientific community. In a controlled analysis of titers (antibody levels) to the MMR vaccine, autistic children showed identical immune responses to control groups. For further reading, examine this document published by the American Academy of Pediatrics.

Also, this paper beautifully outlines the history of the autism-MMR myth and research discrediting both Wakefield’s 1998 study and Singh’s subsequent research suggesting a relationship between measles vaccination and central nervous system autoimmunity.

Patients with mitochondrial diseases should indeed receive vaccines, and no scientific evidence exists to the contrary. Baral cites the case of Hannah Poling as evidence that patients may suffer from a vaccine-induced mitochondrial disease as if this is another form of autism. In fact, mitochondrial disorders are not linked to autism, but can be confused with autism because they share clinical features but rarely share autistic-like features alone. Patients with mitochondrial disorders are much more susceptible to complications and disease exacerbations from viral infections that cause fevers, like influenza and the measles. Thus, it is very important for these patients to be immunized on schedule to avoid contracting an infection which causes a life threatening fever.

There is no need for Baral to even mention the possibility that any parent has to decide when the time is right to perform a muscle biopsy to definitively diagnose a mitochondrial disorder. Most typically, patients present with a constellation of symptoms that indicate the need to test further, in which case vaccination against fever-causing diseases is prudent. For further reading regarding this topic, please reference this Mitochondrial Disorder Overview published in 2014 and also Dr. Paul Offit’s case analysis on Hannah Poling.

Third, Baral is wrong in his descriptions of the efficacy of vaccines in terms of recent disease outbreaks. His discussion needs to include the fact that vaccination exemption is a significant contributing factor. Factually, there were over 9,000 cases of pertussis in the 2010 California outbreak, and yes, 9% of these were unvaccinated, but this glosses over geographic distributions and epidemiology. An examination of the clusters of communities with higher than average vaccine exemptions for non-medical reasons was found to have contributed to the outbreak. The geography of disease is important because pathogens can spread rapidly through undervaccinated communities and persist, from which others can be infected.

Lastly, Baral grossly misrepresents how vitamin A and measles infection are linked. He assumes that children are susceptible to measles infection when they are also vitamin A deficient. He states that we currently do not know which “came first, the low vitamin A or the measles?” Well, this is easily answered, because measles obviously occurs in populations who are not vitamin A deficient. The chances of being infected by the measles does not depend on one’s vitamin A status. The science is clear and remarkable however, that vitamin A given in two super doses, to patients who are very deficient in vitamin A and who also already have an advanced measles infection will reduce their risk of death and complications.

Baral’s presentation of this important public health discovery seems to be pushing for vitamin A supplementation for all and probably testing vitamin A levels. For measles, vitamin A should be taken only by patients with the disease to reduce the risk of death. Naturopaths erroneously believe that supplements are essential for health, and in some, limited cases, it can be (i.e., folic acid during pregnancy). Vitamin A does not prevent the measles. It can prevent death and severe complications only in the presence of already being infected with the measles.

Baral’s arguments have taken the reader on quite a journey. He began by setting himself up as a middle-path seeker, but he gave too much legitimacy to the anti-vaccine position. This sort of pandering is unethical for any healthcare professional. It is important to note that the AANP does not advocate for vaccines in any way similar to all other major health organizations. Next, he takes the reader through a misrepresentation of disease causality with the MMR vaccine, autism, and mitochondrial disease. The reader leaves this topic with the impression that parents should be vigilant about such purported side effects of the vaccine and practice discretion when deciding what vaccines to allow and when. From here, he takes the reader to the idea that not all vaccines are really that effective when juxtaposed against the general statistics of whooping cough outbreaks. The problem here is that geography and clustering are very important variables for how and why communicable diseases spread. Finally, Baral leaves the reader with much doubt about the risk factors of contracting the measles when he misrepresents the science on vitamin A as a treatment.

Baral ends his articles with another fashionable naturopathic declaration: we all “want our children to be healthy and happy.” Usually this statement is followed with an explanation of how vaccines are just one of many ways to achieve this goal. Baral suggests that “it is imperative to keep the passion in our debates focused not on clenching to our position, but to ask every question possible.” Ironically, Baral’s article shows profound bias that exhibits deeply flawed reasoning. He also doesn’t ask a lot of relevant questions. When writing his articles, Baral clearly avoided research that challenged his viewpoint, cited discredited research, and brought his readers to believe in ideas that actually work against his claimed goals.

To the scientifically untrained reader, and those who are not thinking critically, Baral’s arguments seem objective because he presents a false middle-ground perspective. However, when his arguments are fact-checked and examined for logical fallacies, one finds deluded science and faith-based medicine. Sadly, Baral’s critical thinking and interpretive mistakes in research are common in naturopathic medicine. I hear these faulty arguments from naturopaths frequently. This reality has created a thriving environment to perpetuate biases through communal reinforcement. Instead of claiming objectivity and reinforcing the biases of worried parents, naturopaths should be directing parents towards health decisions that are justified with scientific evidence and medical consensus. Otherwise, they should step aside.

Image credit: Sanofi Pasteur under a CC License