Paul Offit, M.D., chief of infectious diseases at the Children’s Hospital of Philadelphia and professor of pediatrics at the University of Pennsylvania School of Medicine. He is frequently quoted regarding the controversy over a vaccine-autism link; he emphasizes the importance of vaccines for public health. Dr. Offit is, accordingly, not exactly a beloved figure among those who claim that there is a link between autism and vaccines and has even been the recipient of death threats.
In the May 15th New England Journal of Medicine, Dr. Offit revisits the case of Hannah Poling in light of the recent history of the Vaccine Injury Compensation Program (VICP). With the start of another case in “Vaccine Court” on Monday, Dr. Offit’s essay is certainly timely, though I’m sure he’ll receive merciless “jabs” (may as well use the pun at this point) on the web and elsewhere by those who believe that there is, beyond a doubt, a link between autism and vaccines.
Dr. Offit states that the VICP’s consession to Hannah Poling—that vaccines aggravated her underlying mitochondrial disorder and caused symptoms of autism—-was “poorly reasoned” for four reasons:
- “…whereas it is clear that natural infections can exacerbate symptoms of encephalopathy in patients with mitochondrial enzyme deficiencies, no clear evidence exists that vaccines cause similar exacerbations.” It is even recommended that children with these deficiencies receive all their vaccinations, as they are especially susceptible to infections.
- “…..the belief that the administration of multiple vaccines can overwhelm or weaken the immune system of a susceptible child is at variance with the number of immunologic components contained in modern vaccines.”
- “…although experts testifying on behalf of the Polings could reasonably argue that development of fever and a varicella-vaccine rash after the administration of nine vaccines was enough to stress a child with mitochondrial enzyme deficiency, Hannah had other immunologic challenges that were not related to vaccines. She had frequent episodes of fever and otitis media, eventually necessitating placement of bilateral polyethylene tubes.” As Dr. Offit notes, this is not an atypical medical history for a child; just reading “otitis media” reminded me of my son’s ear tube operation, just over nine years ago.
- “…without data that clearly exonerate vaccines, it could be argued that children with mitochondrial enzyme deficiencies might have a lower risk of exacerbations if vaccines were withheld, delayed, or separated. But such changes would come at a price. Even spacing out vaccinations would increase the period during which children were susceptible to natural infections,” including such diseases as chicken pox, pertussis, and pneumococcus.
Dr. Offit compares the concession in the case of Hannah Poling to two earlier cases in which “the VICP seems to have turned its back on science”: In 2005, Margaret Althen was successful in claiming that a tetanus vaccine had caused her optic neuritis; in 2006, Dorothy Werderitsch successfully claimed that a hepatitis B vaccine had caused her multiple sclerosis. Even though the scientific literature did not provide evidence of such claims,
VICP ruled that if a petitioner proposed a biologically plausible mechanism by which a vaccine could cause harm, as well as a logical sequence of cause and effect, an award should be granted.
“apparently reasonable and valid, and truthful”
—-and apparently reasonable and valid, and truthful, is not the same as something (a hypothesis of autism causation, for instance) being actually reasonable and valid, and truthful. And perhaps this is why the fate of the vaccine-autism link is being tested, and perhaps decided, in the courtroom rather than the lab. If it’s “a logical sequence of cause and effect” that is needed to explain that “biologically plausible mechanism,” those who can construct the most forceful (but not necessarily true) arguments—those who know best to use language to build a case for a purported vaccine-autism link—have something of an advantage. It seems that it is not science that is going to be the decisive factor here, but the power of argument, and, too, of rhetoric.
It is precisely language that is that has become problematic for scientists in disputing the claims of those who contend that there is a link between vaccines and autism. As Dr. Offit writes at the end of his article:
After the Polings’ press conference, Julie Gerberding, director of the Centers for Disease Control and Prevention, responded to their claims that vaccines had caused their daughter’s autism. “Let me be very clear that the government has made absolutely no statement . . . indicating that vaccines are a cause of autism,” she said.5 Gerberding’s biggest challenge was defining the term “autism.” Because autism is a clinical diagnosis, children are labeled as autistic on the basis of a collection of clinical features. Hannah Poling clearly had difficulties with language, speech, and communication. But those features of her condition considered autistic were part of a global encephalopathy caused by a mitochondrial enzyme deficit. Rett’s syndrome, tuberous sclerosis, fragile X syndrome, and Down’s syndrome in children can also have autistic features. Indeed, features reminiscent of autism are evident in all children with profound impairments in cognition; but these similarities are superficial, and their causal mechanisms and genetic influences are different from those of classic autism.
The CDC did not immediately send out a message proclaiming that “this concession does not mean that the government says that vaccine cause autism”: By not sending out such a clear and direct statement, a great deal of debate arose, and is still raging, about the government “conceding” regarding Hannah Poling’s case.
And, as Dr. Offit points out, what exactly is meant by “autism” in regard to Hannah Poling is not entirely clear, due to what is known about her “global encephalopathy” that was “caused by a mitochondrial enzyme deficit.” While she displayed the “difficulties with language, speech, and communication” that are regularly noted as pointing to an autism diagnosis, the causal mechanisms and genetic influences” for those difficulties are “different from those of classic autism,” as Dr. Offit writes. If the level of autism awareness were not as high as it is now, and if autism were not being said to be more and more common, would Hannah Poling still have been said to display symptoms of autism? Or would some other disorder or dysfunction be emphasized?
And, if the VICP had “more rigorously” defined what it means by a vaccine causing harm, perhaps there would not be such grounds for the cases of Margaret Althen, Dorothy Werderitsch, and Hannah Poling. Dr. Offit indeed calls on the VICP to create such criteria, or further risk eroding “public confidence in vaccines and hurt those whom it is charged with protecting.” Dr. Offit is well aware of the popular press’ and the internet’s role in fanning and refueling the flames of vaccine misinformation. A few days ago, Dr. Offit was quoted in the Washington Post as saying
“I think that what’s so endearing to me about the anti-vaccine people is they’re perfectly willing to go from one hypothesis to the next without a backward glance.”
And, it seems, quite willing to change how “autism” is referred to: As Kev at Right Brain/Left Brain has been noting in his coverage of the latest round of “Vaccine Court,” the lawyers for the petitioners and an expert witness have been carefully defining autism into sub-groups such as “regressive autism” and “clearly regressive autism“: Does this mean there is also “unclearly regressive autism” or “clearly progressive autism”?
These shifts in theories of what causes autism can become the basis for new treatments that are said to potentially “cure” autism. For instance, chelation, in which the body is “detoxified” of “heavy metals” and of mercury via medicines and “chelating agents,” is said to be a treatment specifically for autistic children. As Orac points out in a recent post, chelation has also been suggested as a treatment for other conditions, including atherosclerotic coronary artery and peripheral vascular disease. There’s a multimillion dollar “clinical trial” on chelation as a treatment for coronary artery disease being sponsored by the National Center for Complementary and Alternative Medicine (NCCAM); Orac points readers to an article about Why the NIH Trial to Assess Chelation Therapy (TACT) Should Be Abandoned—they don’t, as he writes, call it “cheat-lation” for nothing.
And more and more one wonders if, when the last of the 4900 cases in the “Vaccine Court” has been closed, will anyone feel just a little cheated for having made this their focus.