Vaccines, the Public Trust, and the Importance of the Medical Home

I thoroughly enjoyed the articles "Anti-Vaccine Media: Its Impact-and Strategies to Combat It" by Linda Nield, MD, and "Vaccinations: Immunizations Do Not Cause Autism Spectrum Disorder . . . They Prevent Disease" by Golder Wilson, MD, PhD, and Miranda Ramirez, MD (both of which appeared in the Special Issue on Vaccines that accompanied the September 2008 issue of CONSULTANT FOR PEDIATRICIANS). The authors did a nice job covering the advent of misguided theories linking autism and vaccines and the growth of anti-vaccine sentiment in the media over the past 10 years.

 As a pediatrician and the father of a 12-year-old son with autism, I have been in the proverbial "thick of it." With previous scourges essentially relegated to the status of case reports because of the success of vaccines, the public is now frequently misled by a litigious, media-saturated culture that tells us we should be living in a "risk-free" environment. When the rates of autism skyrocketed, we were told by the media that we were in the midst of an epidemic. Epidemics must have a cause, and the multitude of scheduled vaccines, which had increased from 11 to 23, was the perfect scapegoat.

Autism and vaccines-my personal experience. My son was officially diagnosed with autism in 1998. That same year, Andrew Wakefield was getting media hype for his Lancet article on the measles-mumps-rubella (MMR) vaccine and autism.¹ I was perplexed, because I knew that my son had signs of autism prior to his first birthday-and before he received his MMR shot.

Patients coming into my practice would ask about the article, the media coverage, and how I felt about their children getting the vaccine. I would tell them that I really did not think the vaccine was causally related to autism, even though I could not prove it. To underscore my conviction, I would tell them that my son's younger sister, who had just had her first birthday, had received her MMR vaccine on time. Obviously, some parents were still nervous and would ask about separating the components of the MMR vaccine and/or delaying the vaccination altogether, but many trusted me and had their children immunized in the normal fashion.

Soon after this, the theory that mercury (thimerosal) in vaccines caused neurodevelopmental problems surfaced and put our system on trial again. Parents' trust in the vaccination system had been shaken hard by the media twice; the duty of the pediatrician was to hear them and to acknowledge that we don't know everything-but also to reaffirm that vaccines are inherently safe.

What wins parents' trust about vaccines? One reason many parents trusted me and my colleagues and accepted that immunizing their child was the right thing to do was that we were providing a stable medical home where they knew they could rely on our expertise. Moving forward, as more unproved theories about the safety of vaccines arise, what will happen if the medical home has been allowed to decay? With insurers and the government threatening to decrease payments to primary care providers, the medical home as we now know it may be replaced by vaccine outlets at WalMart and convenient "doc-in-the-box" clinics with no actual doctor and no real oversight. Parents may no longer have a reliable, trusted source to turn to when they have questions or fears.

Preserving trust in the pediatric medical home. We cannot afford any further erosion of trust in the medical home. The financial crisis on Wall Street demonstrates what happens when trust is lost in a market. If people can be emotional about money, they can also become irrational about their child's health and perceived injury. That is why the recent developments in the Hannah Poling case should give healthcare providers pause. Theodore C. Eickhoff, MD, pointed out, in a recent article for Infectious Diseases in Children, that the court's ruling in that case was based on the plausibility of vaccines having caused the child's injury, not on a preponderance of evidence.² If the 5000 other cases of alleged vaccine-related autism are subjected to the same scrutiny and are decided in favor of the plaintiff, then the trust in the pediatric medical home may have as much meaning as a safe investment in Lehman Brothers.

-- John W. Harrington, MD
Associate Professor of Pediatrics
Eastern Virginia Medical School
The Children's Hospital of the Kings' Daughters
NorfolkREFERENCES:

• Wakefield AJ, Murch SH, Anthony A, et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet. 1998;351:637-641.

• Eickhoff TC. Preponderance of evidence versus plausibility: the Hannah Poling case. Infect Dis Child. 2008;21:31.

I appreciate Dr Harrington's perspective as a physician and a father, and I admire his honesty in counseling for vaccination while admitting that there is much to learn about autism. As a sub-specialist in genetics who does some general pediatrics, I further applaud his recognition that practitioners must protect the medical home, which provides perspective and expertise well beyond what a WalMart outlet can offer.

Trust is indeed fundamental to the patient-physician partnership: patients must trust their physicians to protect their vulnerability during examinations, to respect the confidentiality of their medical records, and to have adequate experience and competence. Key to preserving this trust is a health care system that recognizes clinical expertise and rewards practitioners for time needed to explain and promote vaccinations.

 --Golder N. Wilson, MD, PhD
Clinical Professor of Pediatrics
Texas Tech University Amarillo