Thursday, May 16, 2019

From "Forced Injections" to "Sorcery," - More Examples of Partisan Ideology and Religious Sectarianism Trumping Evidence in Health Policy and Public Health

Evidence-based medicine (EBM) is about medical-decision making based on critical review of the best applicable evidence from clinical research informed by knowledge og biology and medicine, of the patient's biopsychosocial circumstances, the patient's values, and of ethics and morality.  Advocating EBM, and evidence-based health care, public health, and health policy was sometimes slow going, but at least health care professionals often seemed open to these ideas.

Now we seem to be in an alternate universe.  We have discussed the rising tide of health care and public health policy unsupported by evidence, and sometimes supported only by nonsense.  This tide seems driven by ideology, partisanship, and religious sectarianism.  Furthermore, we see more and more examples of political leaders embracing such policies apparently without any input from health or public health professionals.  We discussed several relevant cases in March, and then April, and included them in an interval summary of the "new (ab)normal in health care dysfunction" in May.

Less than 10 days later, we have accumulated enough new examples to be worth summarizing, presented in alphabetical order by state.

Arizona Republican State Legislators Push Vaccine Exemptions in the Face of a Measles Outbreak, While Decrying Pornography as a Greater Public Health Hazard

In February, 2019, Arizona state legislators were pushing to further relax requirements for and even discourage vaccination.  According to CNN,

Arizona lawmakers voted last week to advance three bills that would make it easier to get exemptions from the state's vaccine requirements, and which would require doctors to provide much more information to patients and families about potential harms that vaccines pose.

The bills cleared the House's Health and Human Services Committee on a 5-4 GOP-led, party-line vote, and head to the Rules Committee on their way to the floor.

HB 2470 adds a religious exemption to the existing law requiring vaccinations, and carries an amendment that would eliminate the requirement for parents to fill out an exemption form that informed them of potential consequences of not vaccinating their children. Those consequences can include requirements to keep children who haven't received vaccinations out of school during disease outbreaks.

HB 2471 requires medical providers to give detailed information about vaccines, including the prescription's package insert, to parents.

It was not clear that any of the legislators pushing these measures based their arguments on evidence about vaccines, the diseases they may prevent, or public health in general. Instead, for example:

the bills' sponsor, Rep. Nancy Barto ... told Capitol Media Services: 'These are not, in my view, anti-vaccine bills. They are discussions about fundamental individual rights.'

In this case, was she expousing a fundamental right of a parent to increase the likelihood that the parent's child would get an unpleasant, and dangerous disease, and to transmit such a disease to others?  Soon after, in March Arizona recorded its first case of the measles, affecting an 11 month old child.

Meanwhile, Arizona state legislators decided to worry about the public health hazards, not of the measles outbreak, but of ... pornography.  We had noted also  in March that Republican legislators were pushing the notion, unsupported by evidence, that pornography is a public health crisis.  In May, CBS reported,

A Republican-backed measure in the Arizona State Senate to formally denounce pornography as a public health crisis has passed. The resolution, which does not require the governor's signature for approval, will now go to the secretary of state to be certified. According to text of the bill, the legislation claims that pornography 'perpetuates a sexually toxic environment that damages all areas of our society.'

It goes on to claim, without any medical citation, that pornography is 'potentially biologically addictive and requires increasingly shocking material for the addiction to be satisfied' leading to 'extreme degradation.'

Again, the resolution seemed to have only Republican support. It was "Introduced by Republican Rep. Michele Udall and backed by six other Republican co-sponsors...."

While there is very good evidence that measles vaccination prevents the disease, that the disease can have serious, sometimes fatal consequences, and that measles is easily transmitted to others; and there is no good evidence that pornography is harmful, the legislators treated the latter is a more serious threat.  I saw nothing to suggest they had any personal experience in medicine, health care, or public health, or that they consulted anyone with any expertise in their areas.  Although they cited "individual rights" to support vaccine exemption, they were silent about rights to free expression that might have been affected by their crusade against pornography.  Finally, all the legislators prominently involved in these moves were from one party.  

Oregon Republican Party Derides Vaccinations as "Forced Injections"

This story comes via Vice News on May 8. In response to a bill sponsored by Oregon Democrats that would remove the "moral exemption" for vaccination,

Oregon’s Republican Party isn’t on board with this whole 'forced injections' thing — otherwise known as mandating kids get their shots against life-threatening illnesses like measles, mumps and rubella.

'Oregon Democrats were just joking about 'my body, my choice' while rammimg (sic) forced injections down every Oregon parent's throat,' the state’s official GOP account tweeted Monday night, apparently referencing the Democrats’ argument that Republicans shouldn’t interfere with a woman’s ability to access abortion.

Note that parents are making decisions about measles vaccinations, which are injections, for their children, not themselves in this context.  Although Oregon apparently has not had its own measles outbreak, there is one in neighboring Washington state.  According to Vice News, the vaccination rate in some parts of Oregon may be as low as 80%, reducing herd immunity and making the risk of an outbreak high.  Again, I could find nothing to suggest whoever in the state Republican party coined the perjorative "forced injections" had any understanding of the data about vaccine effectiveness versus adverse effects, or the severe consequences and transmissability of measles.  Finally, again this seems to be making a discussion of public health partisan.

Texas Republican State Legislators Also Advocate More Vaccine Exemptions, While One Accuses Public Health Authority of "Sorcery"

In April, the Corpus Christi, Texas, Caller-Times reported that four Texas state legislators were introducing bills to make it easier to avoid vaccination,

H.B. 3857: by Rep. Tony Tinderholt, R-Arlington, would prohibit doctors from refusing to see unvaccinated patients. Pediatricians tend not to want unvaccinated children in their waiting rooms, exposing other children and their parents to preventable deadly diseases like measles. Pediatricians are kind of funny that way. So are parents who believe in vaccination.

H.B. 1490: by Rep. Matt Krause, R-Fort Worth, would make it easier for parents to opt out of vaccinations. But perhaps of bigger concern is that it would prevent the Texas Department of State Health Services from tracking non-medical exemptions. This would make it harder to respond to outbreaks and certainly harder to predict them by identifying potential hotspots.

H.B. 4274: the 'informed consent' bill by Rep. Bill Zedler, R-Arlington, would require doctors to explain the benefits and risks in detail, including ingredients in the vaccines. That may sound like a good thing on face value. But this is technical information that is more likely to cause confusion and fear than understanding and appreciation. It's like telling someone what's in menudo first, then trying to get them to eat it.

H.B. 4418: by Rep. Jonathan Stickland, R-Bedford, would let nurses rather than only doctors sign off on vaccination exemptions.

The reporters tried to understand the rationale for these bills.  The best they could do was to write

that it appears to be a mix of political opportunism and ignorance. Suspicion of vaccinations is suspicion, period, and suspicion helps drive votes. The ignorance part is best summed by Zedler, who told the Texas Observer that concerns about measles are overblown because it's beatable 'with antibiotics and that kind of stuff.' The punchline is that antibiotics don't kill viruses and measles is a virus.

Note that we had discussed Rep Zedler's remarkably wrong headed statement that measles can be treated with antibiotics here.

The Caller also noted that

not one of these bill sponsors is a medical professional or scientist. Nor are they acting on the advice of medical professionals or scientists. If they had listened to and heeded medical advice, they would not have filed these bills.

In May, a follow to this story was a bit wilder.  The Washington Post reported on the latest antics of Rep Strickland, who introduced the fourth bill in the list above,

 A Texas state legislator unleashed a vilifying attack on a leading vaccine scientist Tuesday, accusing the doctor of 'sorcery.'

It started with a report published Monday by the Texas Department of State Health Services that noted the state recorded a 14 percent rise in parents opting out of their children’s vaccinations. It was a new statistic that alarmed Peter Hotez, professor and dean of the National School of Tropical Medicine at Baylor College of Medicine.

'We have more than 64,000 kids not getting vaccinated in the state of Texas, and that doesn’t account for the over 300,000 home-schooled kids,' Hotez said during an interview with The Washington Post.

Hotez took his concerns about the report to Twitter. And then he received an unexpected, seething personal attack from the Republican state legislator, Rep. Jonathan Stickland.

New school #vaccine exemption numbers reported yesterday by @TexasDSHS. Now >64,000 kids not vaccinated, with #Austin schools, which can no longer be considered safe for kids. All to benefit outside #antivax groups from CA NY DC monetizing the internet. Where is our leadership? — Prof Peter Hotez MD PhD (@PeterHotez) May 7, 2019

'You are bought and paid for by the biggest special interest in politics,' Stickland wrote. 'Do our state a favor and mind your own business. Parental rights mean more to us than your self enriching ‘science.’'

In a tweeted response, Hotez, a pediatrician and vaccine scientist, noted to Stickland that he does not receive money from the vaccine industry; instead, his work focuses on 'neglected disease vaccines for the world’s poorest people.'

Stickland, who told The Post he is 'not anti-vaccination,' tweeted his response to Hotez.

'Make the case for your sorcery to consumers on your own dime,' the Republican, who represents an area of suburban Fort Worth, snapped back Tuesday. 'Quit using the heavy hand of government to make your business profitable through mandates and immunity.'

(Hotez is not part of a for-profit business, either as a dean at the Baylor College of Medicine or as an endowed chair at the nonprofit Texas Children’s Hospital.)

What was the rationale for Strickland's position?

'It comes down to whether the government should be mandating what’s right for us,' Strickland said. 'I side with the individual.'

So note that Rep Strickland not only apparently falsely accused Dr Hotez, a recognized public health expert, of a conflict of interest, but of "sorcery," that is, witchcraft  The latter was apparently not clearly satirical, or metaphoric.  This suggests that underlying the ideology may be some very extreme religious sectarianism.  It looks like the idea of a witch hunt is not dead.


As we noted above, here are three more cases in which politicians in three states, all Republican, none of whom had any obvious background or expertise, in medicine, health care, or public health, pushed public health policies that were unsupported by evidence and poentially harmful.

Their rationale seemed at best ideological, based on "individual rights."  Yet while focusing on the rights of parents to not vaccinate the children, they ignored how these rights could adversely affect the children, and anyone who might be exposed to disease the children might acquire.  In the case of Arizona, they also simultaneously ignored rights of free expression while they denounced pornography.

Since all the polticial leaders involved were Republicans, and in some cases their advocacy was in the context of deriding their Democratic political opposition, it seemed that their public policy stances were also partisan.  Such ideologically based and partisan arguments should alarm health care professionals who are sworn to put the patients' and the public's health ahead of other concerns, including political ideology.

Finally, the last case, which included a state legislator accusing a physician and public health expert not only of having a conflict of interest (which he apparently did not have), but of "sorcery," their public health stances also seemed to come from religious sectarianism, at its most extreme. Such  arguments are also concerning because they seem to be an attempt to use the govenrment to promote a particular set of religious beliefs ahead of patients' and the public's health, and to impose these beliefs on people of other faiths.  This apparently contradicts the US constitutional prohibition against governmental establishment of religion.

True health care reform would require government officials to use evidence, rather than personal ideology and particularly rather than their own religious beliefs when making health care and public health policy. 


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