Its one of life’s universal rules: Emergency Departments are situated in the basement. No matter the city, the country, the healthcare system, the age of the building itself: Emergency Departments are almost wholly subterranean. One unfortunate upshot of this is that, when you’re working in one of these EDs, you generally have no idea what the weather’s like outdoors: that is, until the broken bones roll in. This is the fourth patient with a nasty fracture I’ve seen in as many hours, which pretty much narrows it down, weather-wise, to treacherous snow and hail, or glorious sunshine. It’s July. Even in England, my suspicions are that, up in the outside world, this would be a lovely afternoon to while away an hour or two in a beer garden.
Sitting in front of me, the four year old girl being cradled close to her mother has started to calm down. The intranasal diamorphine has kicked in. She has spent the afternoon performing acrobatics on her cousin’s trampoline and now she has a very bendy arm. Before we get round to fixing that I just need a little more information.
‘And are her immunisations up to date?’
‘No. She hasn’t had any of her immunisations.’ Breathe, I tell myself, just breathe. Poker face. Do I challenge this?
‘Right, okay. Could I ask why?’
In truth, now’s not the time. This is a family unit in distress and I don’t want to add to that. This mother has other things on her mind. I’m almost certainly not the first doctor to discuss this with her and I doubt I’ll be the last. That said, if I say nothing at all, if I don’t explore even a little, then I run the risk of normalising her choice and I conspire with her in making a very poor decision for her daughter and each and every one of my patients. Put bluntly, choosing whether or not to vaccinate your child is not the same as choosing whether or not to let them drink artificially sweetened drinks or play with toy guns: it’s far, far bigger. In terms of the impact of this mother’s decision, its not even confined to solely affecting her daughter. Whether I like it or not, right now, in this conversation, I must act as an advocate for the little girl in front of me, for every child I’ll see in my career and for you and me.
Given what’s at stake, this is a conversation where physicians might be tempted to wade in with all guns blazing. I’ve seen that conversation play out before and, unsurprisingly, it never goes well. That’s because, whatever answer this mother gives me, and I feel like I’ve heard them all, this is simply an issue of trust.
During the 20th century one disease killed five times more people than the combined total of deaths resulting from World War One and World War Two. This terrible disease had been a scourge of mankind for over twelve thousand years; it was the cause of a third of all blindness; and, it killed four out of every five children it infected. But these days most people couldn’t tell you much about it, because, in 1977, as a result of a concerted worldwide vaccination effort, mankind was able to completely eradicate smallpox. One of the worst diseases in our species’ history vanished without a trace. Buoyed by success, the same was attempted for polio, but, although that disease has essentially been eliminated from the Western world, occasional outbreaks still persist. To understand why, you must understand the concept of herd immunity.
Contagious diseases require a natural reservoir of hosts to survive. Herd immunity is the idea that, as more of a population becomes immune to an illness, the chances of a non-immune individual coming into contact with an infected individual greatly reduce. When enough members of a population are immunised then a contagious disease can no longer spread. If a population sustains that herd immunity for long enough then a contagious disease will no longer have a reservoir: the disease will become extinct. Even if you are vaccinated, you are not necessarily completely protected if there’s not sufficient herd immunity, because they are not always 100% effective. This has been understood for a long time and it’s why in 1853, the British government passed a law making it compulsory for all infants to be vaccinated against smallpox, thereby inspiring an anti-vaccination movement and forever conflating vaccination with civil liberties.
Polio has never been completely eradicated because small pockets of non-immunised people, reservoirs, have remained – in many cases due to fears surrounding the vaccine rather than any inability to reach areas and to administer it.
Herd immunity is why choosing not to immunise your child affects the whole population: the overall level of immunity is reduced, a natural reservoir for disease persists and contagious diseases we could otherwise be in the process of dispatching, linger. So there are mumps outbreaks at universities, outbreaks of measles in Disneyland and babies born blind, deaf and with holes in their heart from congenital rubella. Gallingly, the most appalling argument I’ve ever heard from ‘anti-vaxxers’ is that these diseases are relatively trivial. I would like them to come and say that to the face of the young men rendered infertile by mumps, the parents of children who’ve suffered a brain injury from measles or the surgeons repairing the tiny heart of a baby that has suffered congenital rubella syndrome. That’s why this is an emotive issue for doctors. They’ve seen the toll these decisions take.
But it’s an emotive issue for parents, too. An emerging pattern in these past years has been of increasing distrust and scepticism toward experts in all fields. Parents receive mixed messages and are inherently suspicious of things apparently unnatural. They are acutely aware of medical mistakes and failures, and grossly under-informed about medical successes. Resourceful, and wanting what’s best for their children, naturally many explore and research only to find a cacophony of voices – from news media that treats scientific issues as though they are differences in opinion rather than a simple matter of fact versus fiction, to internet sites full of spurious or misleading information, and online forums suffused with those with an axe to grind: in this environment, it’s difficult for doctors to shout the loudest.
Sometimes doctors themselves perpetuate the mistrust surrounding immunisation. Doctors offering to administer separate measles, mumps and rubella jabs, rather than the standard combined vaccine imply, by association, that concerns regarding combined vaccines are well-founded. Doctors offering delayed immunisation schedules to parents worried that the standard evidence-based schedule is ‘too much’ for their children’s immune system ignore immunological fact and leave children unprotected at their most vulnerable ages, all the while fanning the flames of mistrust towards the larger medical body’s recommendations. These doctors may not be heinously publishing fraudulent data, like that of the disgraced Andrew Wakefield’s since debunked link between the MMR vaccine and autism, but they are complicating an already difficult situation.
‘Okay. Today’s not the day to talk about this, but would you like to come back and speak with a paediatrician sometime about vaccinations? Maybe answer any questions you might have?’
I make the appointment. Maybe she’ll go, maybe she won’t. Arguing won’t help, but trying to rebuild that trust might. All in all I can’t help but feel that there’s more riding on her decision than she probably knows.