Tom’s Dumb Vaccine Argument
Last week I got into a heated argument with my friend Tom over vaccines. Now, normally Tom is a very logical fellow. But I should have been prepared for the discussion to turn ugly– vaccines being so pregnant with issues about justice, public goods, the role of the individual in society, and the role of government in our lives. He even warned me going in about how he has soured friendship. Hagwash I thought. Any reasonable person could see the logic of my argument. But nooooo.
I am going to recapitulate the argument here to the best of my recollection to calmly deconstruct why it is that vaccines get temperatures to rise.
It started with a long rant by Tom about crazy vaccine refusers like Jenny McCarthy who continue to propagate the link between MMR and autism in the face of overwhelming evidence to the contrary. I assumed, given that I believe in evidence-based medicine, that we would be in radical agreement about vaccine policy. But then I discovered that Tom was faulty for some of the very logic he was criticizing, fundamentally by taking an ideological line of reasoning. There are both philosophical and logical flaws to his arguments.
Tom’s first error was to lump together all vaccines as being good and necessary. Some vaccines are more effective than others. Some vaccines have more deleterious effects than other. Some diseases are transmitted in different ways from others. Tom argues that these distinctions are so marginal they are meaningless.
Well let’s explore if this is true.
Vaccine effectiveness and side effects
Take Pertussis. It is highly contagious. It is estimated that 50-80% of unvaccinated children exposed in a daycare scenario would contract the disease. It is fatal in one in every 200 cases. I for one would not want to be playing those odds. The vaccine is 59-89% effective in preventing infection – thus in this instance, heard immunity becomes essential in preventing outbreaks. At the same time, there are side effects. 1% have significant side effects such as a fever of 105 or higher, seizure, or becoming limp. These are significant with possible long-term implications.
What about Hepatitis B? If a child’s mother is not infected, infants are at very low risk. While the vaccine is 95% effective, there are also some side effects. A low 1 in 10,000 have anaphylaxis shock. High effectiveness, low risk of side effects, but also virtually no benefit to the vast majority of low-risk children.
So there is a lot of variation on both effectiveness and potential side effects. Are these meaningless in relationship to the public good they create? What about the nature of the contagion? Hep B is on the CCD schedule and mandated on many areas of the country. Unless a parent has Hep B, the child can only contract the disease via sexual activity or intravenous drug use, and can only transmit it to other kids through the same mechanisms. Where is the great risk to the vulnerable unvaccinated toddler in the pediatrician’s waiting room from the heathen kids who are not vaccinated? The CDC decided to put Hep B on the child vaccination schedule because people who were high risk were unlikely to get vaccinated, also putting at risk the infants of those who engage in high-risk behavior. So while I understand the desire to promote public-health by implementing strategies that result in high-risk populations getting immunized – at birth, in the hospital, no matter what your socioeconomic level. The problem is that these policies become mandated and therefor impinge on the civil rights on those who really are not at risk. What cost the vast majority of the population have to absorb to protect a small population of at risk children? This vaccine can be free and require some opt out after informed consent is requested, but this is radically different than mandating it.
Now there are lots of other vaccines that are not on the childhood vaccine schedule recommended by the CDC and enforced by different state and local governments. I have personally been vaccinated for Yellow Fever and Typhoid. Why don’t we vaccinate most kids in the US for there infectious diseases as well? Exactly because the side effects are not worth the reduction of risk for protracting against the disease. I can’t image Tom arguing that every child in the US get every possible vaccine, but each time I tried to get him to separate his argument about vaccines in general to individual vaccines, he reverted to the previous position. So I am going to give him the benefit of the doubt here and assume that he means every CDC recommended vaccine, with the belief that the CDC vaccine policy is what he means by “vaccine.” But really it totally undermines his argument.
Tom’s other argument is about the importance of public good. He argues that even if it is in the parents’ own interest to defect from the common good and free-ride on the herd immunity of the community, the government should step in and enforce vaccination for the good of all.
My response to Tom is twofold, one philosophical and one practical.
Philosophically I would agree with Tom to an extent. I also advocate for a helmet law and a seatbelt law, because the cost of exercising your rights to not wear a helmet and getting into an accident are shared by all, by-and-large. That said, if someone wanted to purchase optional additional insurance to cover the cost of the head injury they incur when they choose to not wear a helmet, I do not see any reason not to allow the behavior. Likewise if an individual could guarantee they were going to live in the hinterlands and not expose the public to a possible disease they contract, I would be fine with that. Of course, diseases are much more difficult to isolate than the costs associated with not wearing a helmet.
As mentioned above, there are diseases like Hep B which in a sense, do not pose a big public risk in the form of an epidemic. So why is the government mandating them and forcing people to absorb the risk of the side-effects? On the other hand, I do feel that mandatory Pertussis vaccines may indeed be warranted, allowing for very specific exemptions where it is contra-indicated.
The question I posed to Tom, was about how to we calculate the cut off between the benefit to public health, and the need to enforce through law the injection of vaccines? I would argue that there would have to be very strong evidence that the threat to public health was sever in the absence of vaccination before it became mandatory. It would be a function of the rates of contagion, the chance of mortality or sever health complications, the cost to the public health system, etc. Polio, for instance, is a devastating disease with mortality rates between 2-30% depending on age. It would be difficult to argue against a public health policy that mandated polio vaccination.
Chicken pox, in contrast, has a mortality rate of 0.0014% in adults, and lower in children. Should the government, in this case, be able to mandate injection of the vaccine in this case? There is evidence that the chicken pox vaccine policy has actually hurt public health be creating a large spike in the number of Shingles cases. 1 2 3
My point is simple, the question about vaccines is not about the abstract benefit and role of vaccines in a public society. There are some public goods that we should as a community be forced to observe via coercion. We all know that cooperation exists because of “TiT-For-Tat with Moralistic Retribution”… As Tom pointed out, the entire rule of law is grounded in this social fact. Where vaccines are involved, few parents would take a staunch libertarian view and argue the government should have no say in public health or vaccine policy at all. Nor would many people argue that the government should not have the capacity to quarantine someone who suddenly became ill with Typhoid and imposed a devastating risk to public health. Nor would many people argue that the state should not have the capacity to incarcerate homicidal murderers. My point is that it is all in the particular details. I guess in some way it parallels some of the arguments about legalization of marijuana, alcohol, or cigarette smoking.
When I raise the issue that delegalizing alcohol would do more for public health than mandating the chicken pox vaccine, suddenly Tom shifts the issue to the social ills of prohibition and the difficulty with enforcement and compliance. Prohibition caused more problems than it solved…. That did not seem to inform his opinion on vaccine policy. Hmmm.
What happens in real life is only partially impact by the ideology and ideals. Government policy is impacted not only by science and the public good but my money and politics. It gets corrupted by other interests.
Tom argues that no pharmaceutical company or patent holder benefits from the sale of vaccines. In fact, he argues,they lose money and are forced to produce vaccines by the federal government. Let’s look at this claim.
While vaccine production is not the most profitable element of a pharmaceutical companies portfolio, they do indeed produce profit. He is right, in that they would focus their attention on more profitable business. But this impacts more the development of new vaccines due to the high upfront costs of R&D and not the existing vaccines which have high fixed costs and where the initial investment has been made.
What about patent holders? There is a lot of conspiratorial material floating around the internet about the CDC and FDA advisory panel’s financial interests in the vaccines they evaluate. The reality, like always, is complex and less definitive.
The House conducted an investigation in 2000 and did find substantive conflicts of interest. Members own stock in the pharmaceutical companies. Some had patents on drugs they were evaluating. These conflicts of interest, however, were to a degree vetted. Waivers are provided . Others were excluded from specific votes. You could argue that there was probably a quid-pro-quo within the committee driven both my personal profit motives but also due to a common world-view about the role of public policy in driving public health.
Since that time, a number of steps have been taken to address the public outcry.
The point I am making is this — people who are making the CDC vaccine schedule recommendations are driven by a number of forces, including what they think are the key variables in defining public health, their criteria on the definition of a cost and the level of acceptable cost each individual should absorb to maintain the herd immunity, and their beliefs on the role of government vs individual choice in driving optimal behavior. As I have mentioned before, the CDC’s model has been antithetical to the model of the Treasury, where in the past Allan Greenspan argued that individual interests in the market always drive optimal results. If you follow this paradigm of human behavior, you should let the vaccine market move toward a Nash Equillibrium where the benefits of vaccine equal the benefits of not vaccinating given the benefits, the die effects, and the size of the population that refuses to vaccinate. Such a system is more stable than one driven by enforcement. And probably more in line with the basic American ethos about the role of government in private life. This would be the market of vaccination.
What would the Nash Equilibrium be for vaccines like pertussis? Probably most people would still vaccinate. Chicken pox? I bet a lot of people would no longer vaccinate and chicken pox parties would reappear.
He thinks that parents refuse to vaccinate because they do not have personal experience with the horrors of the diseases like small pox and polio. The lack of saliency of the diseases no doubt have some influence on choice – just as the behavioral economists have demonstrated. But so to does the feeling that, as a parent, your primary responsibility lies in protecting your child not the public.
This leads me to the second major plank in my argument with Tom. Even if everyone agrees that individuals should assume some cost in the form of possible vaccine side effects to maintain the overwhelming benefit to the population, you have to operate from the knowledge that common pool resources are always subject to the tragedy of the commons. Individual interests erode over time the cooperation of the group for the common good, unless you have draconian enforcement.
Just like the rule of law about stop signs and speed limits, there is a distinction between coordination and cooperation. People drive they way they do partly due to enforcement and partly because of aligned self-interests. We all in a sense are partial free-riders in that we may speed a few extra miles or don’t come to a total complete stop at a stop sign. We are trying to get where we are going as quickly and painlessly as possible. So people may run a red light at 2 am on a deserted street partially because they are less likely to get caught but mostly because they are much more certain that they won’t get killed trying to do it. My point is simply that you cannot discount self-interest in the crafting of public policy if your ultimate goal is optimizing the public good. Those systems that align individual interests with public interests will get higher compliance. Once you start to impose costs to the individual with little or no public benefit, you get defection in the absence of high degrees of law enforcement.