FW Parents who refuse vaccination for their children

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http://www.theatlantic.com/issues/2002/09/allen_a.htmBucking the Herd Parents who refuse vaccination for their children may be putting entirecommunities at risk by Arthur Boulder, Colorado, a university town of 96,000, lies in a sequestered valleyon the western edge of the Great Plains. Both geographically and culturallyit is a place apart. Ralph Nader won more than 10 percent of Boulder's votein the most recent presidential election. Natural-food groceries outnumberSafeways; chiropractors' offices line the main drag; and the city councilrecently declared that dog owners would henceforth be referred to as "dogguardians." A popular bumper sticker reads, WELCOME TO BOULDER, 20 SQUAREMILES SURROUNDED BY REALITY. Boulder is, in short, an experiment-orientedcity.A particularly interesting experiment, from a public-health perspective, hastaken shape at the Shining Mountain Waldorf School, a campus of one-storywooden buildings set amid cottonwood and willow trees hard by the foothillsof the Rockies. By their parents' choosing, nearly half of the 292 studentsat Shining Mountain have received only a few, and in some cases none, of thetwenty-one childhood vaccinations mandated by Colorado state law inaccordance with federal guidelines. The shunning of one of the vaccines,against diphtheria, tetanus, and pertussis, has resulted in a revival ofwhooping cough, the illness that occurs when colonies of the bacteriaBordetella pertussis attach to the lining of the upper respiratory passages,releasing toxins that cause inflammation and a spasmodic cough. Thehigh-pitched whoop is a symptom heard mainly in younger children; it's thesound of a desperate attempt to breathe.Shining Mountain exemplifies a growing movement in American life: thechallenge to childhood vaccination. According to a survey published in theNovember 2000 issue of Pediatrics, one fourth of all parents are skepticalof some or all of the standard vaccines. Some states grant exemptions to thelaw so that parents can refuse vaccinations for their children. In Coloradoparents who don't want their children vaccinated have only to sign a cardstating as much. In Oregon the rate of religious exemptions‹which aregranted to all parents who choose not to have their children immunized forphilosophical reasons‹tripled, from 0.9 percent in the 1996- 1997 schoolyear to 2.7 percent in 2001.Those skeptical of vaccines have various reasons. Some believe that vaccinesare responsible for otherwise unexplained increases in conditions such asautism, asthma, and multiple sclerosis. Others, including the conservativeactivist Phyllis Schlafly, see government attempts to track and enforceimmunization as an intrusion on privacy. Still others‹parents whoserecollections of their own bouts of chickenpox or measles are bathed innostalgia‹argue that the elimination of traditional childhood illnesses isan attack on childhood itself. The parents at Shining Mountain areinfluenced by the philosophy of Rudolf Steiner, a turn-of-the-centuryAustrian philosopher who founded the Waldorf movement. Steiner (who was nota medical doctor) believed that children's spirits benefited from beingtempered in the fires of a good inflammation.The critics have concluded that the dangers of vaccination outweigh therisks of vaccine-preventable disease. Like all medical interventions,vaccination entails some risk, although the extent and gravity of potentialside effects are matters of debate. For example, febrile seizures occur inroughly one in 10,000 children‹perhaps 1,000 a year in the United States‹whoreceive the current whooping-cough vaccine. Such seizures rarely, if ever,lead to permanent brain damage, however, and in any case febrile seizuresare triggered just as easily by a run-of-the-mill infection as by a vaccine.Suspicions that mercury preservatives used in vaccines inflictedneurological damage on children are worrisome but unproved (mercury haslargely been phased out of vaccines over the past three years).To some extent vaccination is a victim of its own success. Owing tovaccination campaigns, smallpox no longer exists in man, and polio has beendriven from the Western Hemisphere. Measles, diphtheria, and invasivehemophilus bacterial disease (such as meningitis) are rare in the UnitedStates, and even whooping cough is unusual enough that few parents considerit a threat. All these diseases, with the exception of smallpox, stillinfest various corners of the world, but in most of the United States eventhose who have not been vaccinated against them, or in whom the vaccine isnot effective, are protected, because most of the people we meet have beenvaccinated. Epidemiologists call this phenomenon "herd immunity": the morevaccinated sheep there are, the safer an unvaccinated one is. Whenvaccination rates drop, disease returns.Precisely at what point herd immunity fails is difficult to calculate, butthere is ample evidence that it does. Since the collapse of the Sovietpublic-health system diphtheria has returned to Russia with a vengeance,killing thousands. Sweden suspended vaccination against whooping cough from1979 to 1996 while testing a new vaccine. In a study of the moratoriumperiod that was published in 1993, Swedish physicians found that 60 percentof the country's children got whooping cough before they were ten. However,close medical monitoring kept the death rate from whooping cough at aboutone per year during that period.Boulder, which has the lowest schoolwide vaccination rate in Colorado, hasone of the highest per capita rates of whooping cough in the United States.The problem started in 1993, when fifty-two people in Boulder Countycontracted the disease. Since then the county has seen an average ofeighty-one cases a year. Although unvaccinated children are six times aslikely as vaccinated children to get whooping cough during an outbreak,about half the cases in Colorado have involved vaccinated children; thewhooping-cough vaccine sometimes fails to produce effective immunity, andeven successful pertussis immunity generally wanes by age ten. "At first wecalled it an outbreak; then we started calling it a sustained outbreak; nowwe just say it's endemic,'' Ann Marie , the county nurseepidemiologist when I visited Boulder last year, told me.To many in Boulder, endemic pertussis is no cause for alarm. ShiningMountain's director, Schiappacasse, says that his daughter, who hadbeen immunized, got whooping cough but suffered no lasting effects. Hebecame a little concerned, he told me, when the baby of one of the school'ssecretaries "coughed himself into a hernia" after visiting the school duringan outbreak. Still, "parents here," Schiappacasse said, apparently includinghimself in the category, "are more likely to be worried about fumes from anew carpet than they are about any infectious disease."I also spoke with nie Egars, a Shining Mountain parent whose threechildren, all unvaccinated, got whooping cough in 1994. Her youngest childwas particularly sick. Egars's description of the experience was harrowing."It was a loud cough that went down to her toes, and the whoop was a sharpintake of breath," she recalled. "She coughed and coughed until she threwup; then she slept an hour or two. Then she'd wake up and start over again."The daughter, who was two at the time, was undergoing treatment for cancer;she was hospitalized for three days in the infectious-diseases ward ofChildren's Hospital in Denver. Nonetheless, Egars is comfortable with herdecision not to vaccinate her children. A niece was hospitalized withfebrile seizures following a pertussis vaccination, and in her view,"immunization just weakens the immune system." She adds, "We have a historyof cancer in my family, so we try to do everything we can to strengthen theimmune system.">From its reservoir in the undervaccinated population of Boulder pertussishas branched out: neighboring Jefferson and Denver Counties had more casesin 2000 than Boulder did. Some of the people who live near Boulder areangry. "There is a constant presence of whooping cough here, and it'sbecause of Boulder Valley," says Kathy Keffeler, the chief school nurse forLongmont, a growing city just north of Boulder.Pertussis is on the rise not just in Colorado but across the country: therewere 7,600 cases last year, as compared with 4,600 in 1994. It can be fatal,especially in countries‹like ours‹with spotty health-care coverage. In 2000it killed seventeen people in the United States, including two Coloradobabies, both of whom were taken to the hospital too late. "It was very sad,"Tina Albertson, a pediatric resident who cared for one of the infants, toldme. "She was a six-week-old girl with a sister and a brother, four and six.The family had chosen not to immunize, and the week she was born, hersiblings both had whooping cough. When they're real little, the babies don'twhoop‹they just stop breathing. This little girl was septic by the time theygot her here."Like most in Boulder, Ann Marie , the nurse epidemiologist, istolerant of the alternative health-care scene; she cedes nonvaccinatingparents the right to decide what's best for their children. But she gentlypoints out that they're fooling themselves if they think no one else isaffected by their decisions. "We've been able to show very definitely thatwhooping cough spreads from these pockets in small communities. If theylived in a vacuum at Shining Mountain‹if they never went out to go swimmingor to church or the YMCA or the Boy Scouts‹it would be a different ballgame," she told me.Jia Gottlieb, a family practitioner who offers acupuncture and breathingexercises along with traditional medicine, said, "When I get parents whodon't vaccinate, I tell them, 'When your boy gets a vaccination he takes ona risk for the public good, just like the firemen [at the World TradeCenter] who went back into the buildings.'" But Gottlieb's words usuallyfall on deaf ears. "These are probably people who donate a lot of money togood causes," he said, "but their view is 'I'm going to let everyone else'schild take a risk but not my own.' That's not avant-garde. That's notenlightened. It's pretty primitive. And ironically, in a town like Boulderthe selfish strategy is probably not in the best interests of your childeither."