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Argument for Big Pharma

Not a big fan of big pharma. Not a big fan of big insurance. Come to think of it, I’m not a big fan of anything big: government, hospitals, or anything else for that matter. This bias is evident in this post from The Physician Executive.

 

Peter Pitts appears to be a very intelligent person. As a former head of the FDA, he knew how to find the money and took off to run the Center for Medicine in the Public Interest, generally recognized as a front for Big Pharma. I like reading his posts, for the same reason I like reading the Cato; I am always looking for good arguments on the side of any position.

So I came across this interesting article suggesting that we need to stop insurance companies from switching people to generics all the time. This was published the same day that Wal-Mart added terbinafine, once $300 a month, to it’s $4 generic list.

As a clinician, my frustration is that insurance companies, or more specifically the pharmacy benefit managers, forcing patients to change meds. They insist that a certain medication in a given class is not covered and the patient must change to a different drug in the same class. It’s like don’t take amoxicillin, you have to take penicillin. Alternatively, the physician can somehow demonstrate or certify an adverse reaction or lack of effect before they authorize going back to the original drug. I already know drug A doesn’t work, from experience on the previous insurance. The insurance requires that we try Drug A again, before they reimburse for Drug B, which the patient has been taking for a long time.

I understand the complications of dealing with expanded formularies and the inefficiencies of having to stock so many similar drugs. I also understand the value of the discounts available when you order in bulk.

I just don’t think it’s a good idea to swap chemical entities because I have a healthy respect for the risks of consuming anything on a regular and ongoing basis. Once you have a functional and safe regimen, it is unwise to change.

Here’s the bone I’m going to throw to Big Pharma; sometimes a softer argument makes a greater effect than one so strident, the bias encourages the reader to discard it without a thought.

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Finding a match in your doctor.

From The Physician Executive in 2007, but I could have written it last week.

CNN had an article on how to fire your doctor.

I agree. Sometimes it’s about chemistry. Some patients and I are like oil and vinegar, others like fire and gasoline. I have always invited these patients to seek care elsewhere with no hard feelings.

Somewhere in the corporate transition, this message got lost. My previous employer almost had a hissy fit.

The alternative is an unhappy patient who doesn’t trust their doctor, who doesn’t really like their patient but is seeing them begrudgingly out of some kind of moral obligation.

If that isn’t a recipe for a lawsuit, I don’t know what is.

Each physician-patient relationship is different. You are looking for a match. This applies to the patient, but is also good practice for the organization.

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Health Care: The Blind Men and the Elephant

From The Physician Executive in August of 2007.

In health care, management and policy are a couple of steps removed from patient care. Physicians and other health care workers have insights that sometimes fall on deaf ears. But this is the era of Babel in health care; I don’t believe we have a common language yet, so we can actually understand what each of us are saying.

Health policy is a large enough field that, as in medicine, specialties are starting to emerge. When I speak with health policy types and health economists, they often see the world through the glasses of their area of interest. I know of an economist who specializes in transplant allocation. Another health economist is a state secretary of health (how rare is it that government hires a real specialist for any post, instead of a politician?) Some people are dedicated to providing care for the poor, other would like to preserve choices and options, which are usually relevant to the wealthiest and most privileged.

These different perspectives yield emphasis by turns on primary care or specialties, ambulatory or hospital care, cognitive versus procedural practitioners… Health wonks are like blind men trying to figure out what an elephant looks like.

Biological organisms are not mechanical, and this has an impact in various aspects of the health system. I recall an Operations Manager who couldn’t understand why the clinical staff didn’t follow medical guidelines the same way his computer staff created patient files. (This represents the mis-application of Six-Sigma to the wrong level of outcomes.) One of the most dynamic classroom discussion I experienced was when a bunch of mid-career professionals tossed around my assertion that “protocols” and “guidelines” are not the same thing. We settled on protocols for processes and guidelines for diagnosis or treatment. It’s too bad that medicine cannot be based entirely on empirical evidence, as an epidemiologist (I think) commenter to this blog asserts.

The complexity of people as biological and social organisms leaves us with so many unknowns, I am amazed at how much information we have that is actually actionable. But health care remains governed by careful judgment informed by some data, to help navigate the unknowns.

Experience can be a fickle teacher. So much of our perceptions are shaped by personal experiences, and then confirmed by the consequent bias. If we have a bad experience a physician, we are looking for confirmation in any trace of behavior of every subsequent interaction. So outliers can begin to distort our opinion of things: the greedy doctor, the uncaring insurance company, the bean-counting administrator, the abusive patient or the ignorant bureaucrat… These people exist for sure, but the vast majority are working stiffs who show up for work and try to do the best they can before getting home to their families and an over-leveraged mortgage.

In all this, it is the emotional context of health care that is the most ignored. The fear and despair that physicians and nurses see is forgotten in epidemiologists’ regressions, economists’ differentials and executives’ spreadsheets. No, the golden age of medicine is gone and good riddance, but something else this way comes and we don’t yet know what it looks like. Let’s just make sure it works for the middle: the normal patients, health care workers and administrators who show up every day and stay for every shift, no matter how terrible the things they see.

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Underfunded, undervalued

This is one of my favorite posts from The Physician Executive, which is especially relevant today as we enter the conversation of reforming payment from our current fee-for-service model to a pay-for-value system in which primary care may finally get the recognition it needs to actually serve its role within the health system.

 

Funny that people complain about how hard it is to get a good doctor. Sometimes it is important to ask why things are as they are, rather than complain about why they are not better.

I remember a conversation with an internist a couple of years back, who was complaining about how her family physician was so useless…it takes forever for the office to get back to her, appointments are a bear to get, refills take forever and it’s like getting teeth pulled to get him to call her back.

If a primary care doc is running all day trying to get patients through, then I assume he’s busy. That’s good thing. I’ve never waited for reservations at a bad restaurant. A good rule of thumb is that the better doctors’ offices are more crowded.

I know some physicians who have also had the business sense to build incredible systems that can get 30 patients or more in and out daily and still do a good job at it. Not everyone has the administrative skills to do that, even if they are excellent doctors. If the doctor doesn’t spend enough time to listen, the question must turn to what they’re paid for.

Generally, I view phone calls as a waste of time, because they frequently represent an inappropriate service to deliver by phone. Some advice can be safely dispensed at a distance, but nothing is certain without a proper examination. Oh, and that’s what usually what physicians are paid for. They are not paid to dispense advice, provide basic health education, prescribe medication without an assessment, complete forms for patients who haven’t been seen in two years and coordinate referrals for patients who bypassed them entirely and went straight to the specialist. They are paid by the visit, where an examination frequently takes place.

Our physicians at a facility for low-income individuals are allocated fully 20% of their time to do unremunerated administrative functions, only some of which ethically seems appropriate. We stretch the rules in recognition of our patients’ socioeconomic constraints and only because we receive sufficient grant income to support the loss. In private practice… fuggedaboudit. The only reason to do it, is to preserve goodwill, which doesn’t really pay the bills. (This only applies to traditional fee-for-service environments. More about capitation some other time, because that’s a whole different ball of wax.)

Why do physicians with very busy offices have to be so busy? I mean, are they just greedy, churning people like so many little factory widgets? I suspect, while there are some bad apples in the barrel, the majority are skating trying to cover their overhead, payroll, malpractice and hopefully come close to the national average of $150,000 in income. Remember the big bucks are usually reserved for cardiologists, neurosurgeons and other proceduralists, without which no health system would have credibility (source: healthcareerexplorer.com/salaries/neurosurgeon/). What’s the use of preventive services if there is no available curative services should prevention fail?

My friend, the internist completed her rant by saying there was no value to primary care since her family doctor couldn’t provide the service she required.

I wondered out loud if that was the way the world always worked, “Underfund the service you need so that it can’t do the job and then complain that it has not value.”

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Employed Physicians Becoming More Common

I am on a roll finding old posts from The Physician Executive that are still relevant today. In fact, this post is more relevant today than it was in August 2007.  We now must need to be concerned about how physicians are being managed and in the face of large integrated health systems with an incentive to encourage increased testing and referral. This will still be a major policy issue for the next decade.

Interesting post by Dr. Reece about physician-hospital collaborations at medinnovationblog. There is no question that community hospitals exist in a challenging environment, but each specialty now has its own financial realities that can color the relationship between physician groups and hospitals. My comment, is the most recent trend towards hospital-employed physicians accomplishes two things:

1) it puts physician executives in greater demand
2) it may put more hospital functions under greater physician influence or control.

Surely there are numerous other forces at work here and only the smartest and best informed physicians will win. I don’t believe the golden age of medicine was very good for patients, at least on a population basis. However physicians are often well-positioned to consider the patients’ best interests. Hopefully, the current grass-roots push towards more accountability and better quality-of-care data will combine with a strong physician perspective and professional management skills at hospitals to improve health outcomes overall.

Then again, the landscape may prove just too complex to navigate.

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Envelopes and the Greek Medical Business

This post on informal payments from The Physician Executive was one of my most popular. Originally published Aug 15, 2007. Dangerously, I have to note it is one of my favorite jokes. 

 

If you think we have problems in the US, you should try Greece.

There had been talk of a socialized system several years and a couple of prime ministers ago. There seems to be a modicum of a centrally funded, insurance-based system now. However, the WHO’s description of Hellenic healthcare tells me it still runs the old-fashioned way:

[Informal payments] are especially prominent in the case of in-patient care, and are made to doctors, mainly surgeons, in public but also in private hospitals. These payments are also made in the case of outpatient care. The rationale is to jump the queue or to secure better quality services and greater personal attention by the doctor. Unofficial payments are considered to be a major problem in the Greek health care system. It is estimated that about half the total private expenditure on health care involves informal payments. There is no really reliable estimate of the size of the unofficial market, partly because it is so widespread, and partly because of the complexity of the Greek health care system.

Almost 60% of total out-of-pocket payments (official and unofficial) are made to doctors and dentists (especially those in charge of facings), 20% go toward pharmaceuticals, with the rest being mainly expenditures on private diagnostic centres and private clinics. Out-of-pocket payments (both official and unofficial) represent roughly 6% of household income (1990 figures).

So these informal payments are made under the table, usually cash stuffed into an envelope and they are fairly common, even in the out patient arena. Traditions die hard, and the tradition of the “fakelaki” (the Greek word for envelope) is alive and well. I believe these payments are outlawed in the government-run clinics, but common prejudices take effect: Greeks are nearly Italian in their disregard for authority and let’s face it, doctors can’t be any good if they works for the government! You and I may know it’s not true, but there’s no accounting for consumer decisions.

My suspicion is that the lowest risk way of buying a stake in Greek Healthcare is to buy a stake in an envelope factory.

Aide, gela!

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Vaccinate, Support Local & Subscribe

Our clinic, Lacamas Medical Group, runs a couple of free immunization clinic for kids in Camas and Washougal who could not ordinarily pay for their pre-school physicals and vaccines. The Camas-Washougal Post Record, supports us in this endeavor, once running a free ad and this year sending a reporter. This is a link to her story on the web, but they held back a significant chunk for the print edition i wish it had all been online, but I understand why they do that.

I think this may convince me to subscribe. It is a very good publication by the standards of a local weekly newspaper. Moreover it is local, with local news and full of information about local businesses. We can complain about the lack of ethics in corporate America all we want, but without supporting local business, like the Post Record and the businesses that advertise in it, all is for nought.

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Breast Feeding: Froelich & CDC

This is another old post from The Physician Executive that I expect is still relevant because old habits like supplemental feeding in hospital nurseries die a hard death when they are the path of least resistance. It was originally published on June 16, 2018

Edwina Froelich, founder of La Leche League, passed away last week. La Leche League used to state that the three main obstacles to successful breast-feeding were doctors, hospitals and social pressure.

My experience has been one of utter frustration with maternity nurses, who should know better, but frequently feed their wards sugar water for no reason. Some kids can get hypoglycemic, but certainly not three quarters of the nursery. Some kids may lose weight, but that is a normal phenomenon, with the natural history of birth being a decline in weight and return to birth weight by day 10. It is not abnormal to lose weight, but it is abnormal to get formula or D5 on day 1.

These practices appear to me (on an anecdotal basis) to be widespread in places I have worked in the US, but they would be unacceptable in other places of which I have some knowledge: Montreal, England, or France. I understand from a cousin in Dubai that at least one hospital reflects the US’s breastfeeding dysfunctions, so I am sure there is tremendous variation from country to country, especially by socio-economic class.

The harm done is that by allowing alternatives to breast feeding, we don’t give a woman a reasonable chance of establishing her breast milk in the first place. To establish breast feeding, you need an infant sucking on a nipple, which provides the hormonal stimulus to produce milk in the first place. The more concerned you are that the breast milk may “not be enough”, the more you assure the fact.

The problem with personal observations is the tendency to generalize. Finally, the CDC surveyed hospital infant feeding practices, as reported in MMWR. American hospitals persist in providing alternatives to breast feeding to infants, such as sugar water and formula. I am sure that most well-meaning maternity ward nurses will explain that they are trying to make sure babies gain weight or not become hypoglycemic. Unfortunately, entire wards of infants are not likely to suffer from the risk factors for hypoglycemia and weight loss in the first three days is a natural phenomenon that does not get babies in trouble if skilled observation and timely intervention is available.

So breast feeding suffers for entire populations as we chase the shadows of unusual and uncommon poor outcomes that rattle us to the point that it is easier to just chuck formula into every crying newborn’s mouth.

Hopefully there will be more Edwinas around to take up the cause.

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Are You At The Table?

In case you’re wondering, this is my piece for the Clark County Medical Society newsletter, summer 2013.

There are just under 900,000 licensed physicians in the U.S. Current AMA membership numbers about 224,500, rising up to levels not seen since 2009 when the AMA’s endorsement of Obamacare apparently precipitated a 5% drop in membership. Local Medical Societies are often loosely affiliated with the state and national medical association and can compare themselves to the national benchmark. Clark County has a better percentage than the national average, but barely. Nearly a quarter of the county’s physicians belonging to the medical society.  
In my few months as President of the CCMS I have watched with interest as some counties struggle without any physician cohesion as others have active and dynamic medical societies that contribute much to their communities’ well being.  It would be enlightening to understand what accounts for low membership in the AMA and local county societies.
The most significant drivers of membership seems to be related to the employment status of a growing number of physicians.  In the much storied  past of American Medicine it was necessary to belong to a local medical society as a source of referrals and recognition within that local medical community. As more and more physicians find themselves employed by large multispecialty groups, the relevance of a medical society diminishes. In addition most specialists seem to believe that their interests are better represented by their societies.
Perhaps at some point in the past couple of decades, the House of Medicine lost its ability to extract growing concessions from the rest of society and thus external conflicts became intra-professional conflicts. Despite the larger world relying on progressively greater degrees of specialization, it seems unwise to perpetuate internal conflicts. We each have a role to play in the larger system, including the generalist role in primary care and care coordination.
What seems self-evident is that a fragmented medical profession is easier to control and manipulate than a united one.  There was a time when a nationwide group of educated, professional healers were felt to be the best hope for advising on the population’s health. Some social theorists have suggested that the medical profession squandered its social capital on protecting its economic welfare. I would argue that a small minority of narrow-minded and short-sighted physicians temporarily hijacked an organization whose role has always been nobler than its own economic welfare.
We all have colleagues who will not join the AMA because of positions it had taken in the past. Well, the trouble with that is that no one has a voice who is not at the table. There should be no illusions about how political organizations work and how advocacy comes about; we may lose the occasional internal battles but still fight for common goals. A medical society works for the interests of its members but it would be a mistake to take a shortsighted view of what that means. Medicine based on scientific proof still safeguards the public’s health. Thus, there is no way of continuing to safeguard the public’s health, either by prevention or treatment  without a highly trained, professional force working to create a health system that is both effective and efficient improving the health of the entire population.
Health care has a knack of exposing the weaknesses of a free market system but I have also worked in a socialized health system that shared different weaknesses, but of equal magnitude.  It seems the US medical system is evolving into some sort of hybrid system midway between different ideologies. Anxiety comes with any change and we are being presented with a major change in the environment of medical practice.
Whatever your politics and personal philosophical structure, much of this change has happened with nominal input from organized physicians groups. It is important for the House of Medicine to speak with one voice whenever it can come to a consensus. My thoughts and opinions have been well-received at the state level where they have differed from the official position of the WSMA. Clark County has been particularly active at the state level, especially when it comes to advocating for the health of the Medicaid population. We have been involved in discussions regarding CUP, physician wellness programs, Prescription Monitoring Program funding (in the future, it will no longer be from your license fees), exempting physicians from the state B&O tax, the role of physicians in the state disciplinary body MQAC, and disseminating information about the upcoming state health insurance exchange.
We need to focus on what is best for the health of our population and not just what is best for ourselves. However, we must also stand up for ourselves because without a professional workforce, the population will suffer. We must face the fact that the industry of which we are an integral part extracts $2.7 Trillion from the general economy and we are being held accountable for the value we return in exchange for our share.  

One thing is sure. This is no longer your father’s AMA! It is YOUR AMA! And its actions depend on your participation at the local level in your County Medical Society.
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Vaccine Objector Backlash


In March, a version of the following article appeared in Lacamas Magazine, a local lifestyle publication. It was very well received, and attracted an enormous number of hits. I need to rework something for the local daily paper, The Columbian. Until then, I offer you an opportunity to review and comment; it is a controversial topic but I believe science is the benchmark, not conspiracy theories. We are one epidemic away from the ostracization of people who object to vaccines. This is why my original title is somewhat inflammatory. It was softened for the actual publication.  



Many of the digital back-issues are online, but not the one containing this article. I will link to it if it comes back live.

Vaccines are the most effective tool of medical science to decreasing the burden of human disease since Edward Jenner in 1798 described a method of inoculating healthy people with cowpox to prevent smallpox. Countless lives have been saved worldwide with a record of remarkable safety and a miniscule degree of adverse reactions given the magnitude of the benefit. Despite the incontrovertible weight of the evidence, there remains an anti-vaccine movement and a persistent fear of immunizations of all sorts.[1]

Opposition to vaccines can be found as far back as 1905 when the case of Jacobson v Massachusets went to the Supreme Court. In that case, a father refused to be forced by the state to vaccinate his daughter in the midst of a smallpox epidemic. The Supreme Court found that despite a legitimate libertarian argument, there was a compelling reason to over-ride the rights of the individual when fighting an epidemic because there was direct link between the number of people who were immunized and the total spread of the epidemic. It turns out that interrupting transmission was a function of reducing the number of people who could transmit the virus. The benefit to the person was magnified when the effect on the community was examined.

More recently opposition started with Andrew Wakefield, an English surgeon, who became interested in vaccines and published a study that claimed to show a link between MMR (measles, mumps and rubella) and autism in 1996. Understandably, this captured the imagination of parents everywhere. Can anyone imagine causing brain damage to their children by accepting an injection which was supposed to protect them against a deadly disease? Emotions run high with autism; parents wonder if they did something wrong and grasp at any potential cause to explain he unexplainable.

There were problems with the hypothesis from the start. First, the assertion of a link between immunizations and autism rested on the observation that the increase in the occurrence of autism ran parallel to the increase in vaccinations. Of course many other things also increased in the same interval; there was also an increase in the number of doctors available who could diagnose autism and better diagnostic criteria to distinguish autism from other forms of developmental problems. One can make an argument that anything else that increased over the prior several decades was linked, but a link is not a cause. The number of cars on the road has also increased parallel to the increase in autism, and the lead in automobile emissions is actually biologically active when ingested in the form of dust by an infant. It is more plausible than mercury as a cause, but nobody would take the idea seriously.

The vaccine link was supposed to be thimerosal, a mercury-containing preservative in the MMR vaccine. Mercury is indeed neurotoxic, but not all forms of mercury are active when absorbed into the body. For example, it is the fumes that are the best absorbed and the most active. Inorganic mercury is found almost universally in the soil and water in nature and poses no hazard. Theoretically, someone could swallow elemental mercury and not suffer any effects, because it cannot be absorbed that way (of course fumes may be released before, during or after digestion, so no one will say swallowing mercury is safe.) The mercury in thimerosal is very tightly bound and probably inert. The same way, mercury in the soil behind dams cannot be released into the food chain until bacteria convert it into a form that can be absorbed by eating fish. But mercury in fish is a well-recognized problem and there is no connection between autism and ingesting mercury-containing fish. It is difficult to think about how a relatively inert form of mercury can have any biological activity when injected. In fact, it was found that babies excrete thimerosal much faster than would be expected from our knowledge of how the body handles the toxic forms of mercury. This is one more small piece of evidence suggesting that mercury in thimerosal does not have time to interact with tissue. Nonetheless fear and controversy won out and vaccine manufacturers responded to the concerns. Thimerosal was never universally present in all vaccines and has since been removed in most every vaccine available today, except where it is impossible to use something else for technical reasons. Rates of autism continue to increase.

Then Wakefield’s study blew up! The co-authors smelled something fishy in the results especially when information emerged that proper methods in conducting the study were not followed. Eventually, it became clear that the data had been falsified, Wakefield was accused of fraud and he lost his license to practice medicine. It is believed that he falsified data so that he could profit from being a consultant on all the lawsuits that would follow. He currently lives in Texas.

The damage he caused was in stirring up a controversy that was not based in any sort of fact, in spreading false information and fear leading people to refuse vaccination and suffer the burden of increased vaccine-preventable disease making a come-back, in intense efforts to remediate a problem that did not exist and untold research dollars that would have been better spent seeking the real cause of autism. We can see the traces of his misinformation when someone like Congresswoman Michelle Bachman says that she knows people who got autism from the HPV vaccine. The statement is appallingly ignorant, brutally stupid and horribly violent for the children who would benefit from the vaccine.

Some people seem to feel that the number of vaccines is an overwhelming assault on the immune system. The problem with this notion is that in each vaccine there are a handful of highly purified proteins designed to arouse a strong immune response. Purification may always introduce trace chemicals, but at levels less than the neighborhood pool. A bowl of chicken soup probably contains an order of magnitude greater number of proteins that the entire set of childhood vaccines from birth to the teen years. It seems much more likely that prematurely feeding an infant adult food would be more harmful.

The number of needles required frequently comes up with parents. It is easy to understand how five injections at one time can be heartbreaking, especially as the child begins to wail. Older doctors however remember the days that circumcisions were done on infants without anesthesia. Without condoning what seems like a barbaric procedure to some, there is some dissonance between insisting on a circumcision on one hand and worrying about an extra needle on the other. The pain is limited. The benefit is huge.

The immunization regimens are constantly being revised and changed as circumstances permit, including the increasing availability of combination vaccines to reduce the number of individual injections. We must also remember that vaccines have become victims of their own success. When polio is fresh in people’s memory — the paralysis, death and suffering wrought by a horrible disease — it is easy to convince parents that the vaccine is necessary. When the disease has become rare because of the widespread use of a vaccine, the benefit does not seem as significant. Until the disease starts coming back, that is.

Other accusations thrown around about vaccines are that they represent a conspiracy on the part of pharmaceutical companies. This is laughable to people who have been interested in vaccines since the decades that research had stalled. In the 80’s, fear of litigation led most manufacturers to withdraw from vaccine research and development and shortages were looming. In 1986 Congress created the National Vaccine Injury Compensation Fund so that people who were injured by vaccines could be compensated publicly  After all, there is a societal good to vaccination that makes even the rarest adverse reaction doubly tragic. Two things happened after establishing the fund; first vaccine manufacturers reinvested in developing vaccines and lawsuits plummeted. It seems the new fund was more rigorous in making awards, not subject to the vagaries of the “jury lottery” of super-sized awards and nuisance claims. In other words, vaccines do not have a history of being particularly profitable, at least until the past couple of years when prices have started to sky-rocket. In the mean-time the compensation fund is one government program that is significantly over-funded because there have been so few claims made.

Incidentally, the body that makes vaccine recommendations is the American Committee on Immunization Practices, set up by the CDC at arm’s length. It has representation from numerous medical, public health and consumer groups and has remained stubbornly independent. It accepts no money from industry, works only peripherally with the FDA, limiting its recommendations to FDA approved parameters and constantly weighs the risks and benefits of any immunization. All their deliberations are public, transparent and available online. With the National Science Foundation and The Institute of Medicine, the ACIP is one organization that is least likely to be swayed by the big pharma’s financial interests.

Clark County’s Public Health Officer Alan Melnick is fond of saying that “vaccines prevent diseases that kill kids.” This is also true for adults. The ACIP makes recommendations based on the best science and evidence available with the aim of saving as many lives as possible with the lowest risk of any adverse events. The science and the evidence demonstrate that there is a community benefit that exceeds just the individual protection. Diseases like whooping cough and measles can still occur in an immunized population if enough people remain uncovered. It is not enough to immunize your own kids if neighbors and schoolmates refuse their immunizations; your kids can still get sick. The risk is small but probably greater than the risk of a serious reaction to a vaccine. It is an inflammatory statement that may yet prove true; that not immunizing your own kids can allow diseases to spread that potentially can kill other kids as well as your own. Vaccine objectors have not yet faced this backlash, but it remains that human beings living in communities have a responsibility first to themselves and their families, but then also to the communities which sustain them.

[1] An immunization is an intervention designed to increase an immune response to a specific agent. Vaccines have come mean the same thing although historically the word vaccine refers to vaccinia, the cowpox virus used to prevent smallpox.