Americans go to the doctor far less than their foreign counterparts. The most likely reason? It’s expensive. While the quality of healthcare in the U.S. might be high, it does little good if citizens can’t afford to go. (I’m also going to guess that most workplaces are not keen about handing out sick days so employees can visit a doctor.) It will be interesting to see if the average number of visits per year increases with the ACA in effect.

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We don’t take advice from celebrities on many issues, like how to avoid scandal or how to turn down Oprah’s request for an interview. Why? Because celebrities are renowned for both scandalous behavior and illuminating Oprah interviews. But it’s surprising what we do take advice from celebrities about and increasingly, that is whether or not to vaccinate our children.

There are a lot of wacky theories surrounding immunizations, from secret government microchips transmitted through vaccination shots to the effectiveness of faith-only “medicine”. Faith-only “medicine” is the practice of using religious devotion and prayer in place of real medicine to cure disease and heal the afflicted. While there is an abundance of evidence favoring science-based medicine with predictable results, faith-only “medicine” requires…well, faith; most often with unfavorable results, as in Texas right now. By the way, if this practice sounds medieval, it’s because it is.

However entertaining (or scary) the hokier theories sound, by far the anti-immunization myth with the most traction out there is the claim that immunizations cause autism. Because the idea is so popular, it is also the most damaging to children and public health.

Where the autism myth comes from

It all seemingly began in 1998. A study by discredited British doctor Andrew Wakefield was published in the medical journal The Lancet. In the paper, Wakefield suggested a link between autism and the MMR (measles, mumps, rubella) vaccination. For the study, skillfully summarized here, the former doctor scrutinized a dozen children with “chronic intestinal disorders” and “severe mental regression”. He posited that the MMR vaccine could have caused an intestinal infection, and further, that infection instigated damage to the brains of his subjects.

After the paper was published, large numbers of fearful parents from the UK and Australia to the United States refused to have their children immunized. Preventable infectious disease, once all but eradicated from these countries, began to spread anew. When the vast majority of the public is immunized against deadly disease, a few people without the immunities are protected. This is called herd immunity. When the number of people without immunities grows, as it did following Wakefield’s paper, a large number of people are at risk of infection and that measure of protection disappears.

Another theory behind the immunizations-cause-autism myth is the idea that the preservative thimerosal, once used in vaccinations, caused autism. Due to this concern and a fear that another unfounded theory would prompt an even greater decrease in immunized children, thimerosal–which contains mercury–was removed from nearly all vaccinations well over a decade ago.

The science-based reality

Not only is there no causal evidence that merits debate on this issue, the elimination of thimerosal from vaccinations in 2001 has had no statistical effect on occurrences of autism. The Centers for Disease Control has a fairly extensive review of this and other autism-related subjects. Thimerosal is still used in one type of influenza vaccine, but according to the CDC, there is a non-thimerosal alternative available.

Three years ago, the journal that originally published Dr. Wakeman’s ill-devised study retracted the paper. The reason? It turns out Dr. Wakeman had treated the children he used in his study unethically and harmfully, subjecting them to invasive and unnecessary tests. Britain’s General Medical Council found that he “showed a callous disregard” for the pain of the youths he and his colleagues studied.

Furthermore, he had a ton of financial incentive to make his assertions: a year before the paper was published, he had patented his own measles vaccine that could be used in the event the MMR vaccine he was studying was discontinued. Additionally, his study was partially funded by attorneys representing a group of parents hoping to be paid damages in a lawsuit against vaccine makers. Given the council’s findings, Andrew Wakeman’s medical license was summarily revoked.

Despite the scandal—or maybe because of it–Dr. Wakefield now insists that he never suggested a link between autism and the MMR vaccination. Just so, considering a laudable number of subsequent studies have found no causal link between autism and the MMR vaccination. Most pediatricians—including my children’s own, in the interest of full disclosure—continue to recommend life-saving vaccinations for infants and children.

A lack of evidentiary findings doesn’t necessarily mean definitive proof, as any scientist can tell you. Scientific theory changes when new evidence presents itself. That is the crux of the issue; there has been no corroborating evidence. Lack of evidentiary findings in addition to an inability to replicate Wakeman’s discredited assertions makes an autism-immunization link not only highly unlikely but has compelled general consensus in the medical community.

The bad news

The evidence, or lack thereof in this case, hasn’t stopped stars like Jenny McCarthy and Jim Carrey from using their celebrity status and whatever soapbox they can borrow to disseminate these harmful anti-immunization theories. Jenny McCarthy has made many public appearances and wrote a book about her son’s experience with autism. Jim Carrey famously wrote an article that was published on the Huffington Post website. Both stars are part of a growing movement to resist vaccinations and were part of a “Green Vaccine” rally in 2008.

Meanwhile, preventable infectious diseases like measles and whooping cough are spreading; with deadly consequences. The number of people endangering the public’s health and helping to eliminate herd immunity has risen to such an extent that some areas of the country are revising immunization policy.

Even though we are only 99.9% sure vaccinations do not cause autism, the jury is not still out. Medical professionals and science-based medicine agree: immunizations save lives. So long as infectious disease exists, it is vitally important to immunize against it.

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One afternoon last week, I walked into the pharmacy in my local supermarket. Twenty minutes later, I left after receiving a needle’s worth of this season’s influenza vaccine. The cost? $20.  For those in line behind me (lucky enough to have better insurance than I have), the cost was nil or $5.

When I first walked in, I was asked to fill out the necessary forms.  While completing them, I noticed that my fellow vaccinees seemed, like me, to be quite relaxed and even a bit jovial. And why wouldn’t we?  No waiting on hold at home to make an appointment weeks in advance. No sitting in stuffy waiting rooms—breathing in germs spread by the coughing and sneezing of fellow patients—just to see the blur of an over-scheduled doctor for a few moments.

My pharmacy visit spared me all that. The experience revealed something that deserves our attention and should be celebrated:  a health-care success story and an example of good government.

It took all of a minute for the pharmacist to swab my arm and administer the shot.  When I left, I found myself wondering just how such an effective innovation—now generally taken for granted—had come about.

Expanding access to healthcare

If you ask whether I was surprised to discover that the initial push for offering an alternative to vaccination at a doctor’s office had its origins in a Democratic administration, my answer would be “of course not.”  Since the days of FDR’s New Deal, Johnson’s Great Society, and now Obamacare, progressive Democrats have been at the heart of the fight to expand access—whether in the workplace, health care, or civil and legal rights.

This latest expansion originated during the Clinton administration, when then–Secretary of Health and Human Services, Donna Shalala, proposed to the American Pharmacists’ Association (APha) that the organization develop a plan to train pharmacists across the country to deliver immunizations.  At the time, Shalala and others in the administration were alarmed by low vaccination rates, particularly among the uninsured and rural populations underserved by the medical community.

Remember that 1993 was the year in which President Clinton focused his domestic agenda on health care and unleashed a task force (headed by First Lady Hillary Rodham Clinton) that tried nobly—and failed miserably—to take on the entrenched interests of a health-care industry that was (and is) costing the public and private sectors dearly and delivering poorly on services.

Shalala, one of the unsung crusaders of the Clinton administration’s focus on health care, hoped that convenience and lower cost might boost vaccination rates and provide a more broadly based entry point to the front lines of preventive health care—the vaccination.

Secretary Shalala’s efforts paid off when her proposal was embraced by APha.  The organization responded by developing a rigorous program to train and certify an army of pharmacists who would be available to administer vaccinations.  Although at the time a few states already had existing laws on the books allowing vaccination in pharmacies, implementation had been slow or nonexistent. Shalala was determined to change that.

Although the Clinton administration laid the groundwork, administering vaccinations in pharmacies really began to take off in the 2006–2007 influenza season.  The number of vaccines delivered by pharmacists that year comprised seven percent of total vaccinations.  By 2011 the rate had increased to eighteen percent.

Lest this seem like a success story unmarred by controversy, it’s important to remember that doctors were hardly on board.  Their lobby pushed back and pushed back hard. Even today, state medical societies continue to fight against ceding vaccination delivery to pharmacists.  Their objection holds that vaccination by pharmacists disrupts the doctor/patient relationship and complicates record keeping in doctors’ offices. Talked about less often is the loss of doctors’ fees from patients, insurance companies, and Medicare and Medicaid.

State-by-state

Which vaccines may be administered by pharmacists continues to be controversial as well.  Each state determines its own regulations, and those regulations are all over the map.

It was not until 2009 that all fifty states allowed some or all of the CDC-recommended adult vaccinations to be delivered by pharmacists. (Maine being the last state to pass the necessary laws.) Only six states—Massachusetts, Washington, Connecticut, Colorado, Minnesota, and Kentucky—have passed regulations allowing all CDC-recommended adult vaccinations to be made available at pharmacies, supermarkets, and big-box stores.

In New York State, pharmacists are authorized to administer the adult influenza, pneumonia, and, just this year, shingles vaccinations but have not yet been authorized to administer the adult whooping-cough vaccination.

(In an unexpected move on January 12, 2013, Governor Cuomo, responding to an influenza rate of infection of epidemic proportions in the state, issued an executive order permitting pharmacists to temporarily administer seasonal influenza shots to children between the ages of six months and eighteen years.)

Pro-active, good government

There’s another important dimension to this story that goes beyond health benefits. And this brings me back to the concept of good government (an idea nearly extinguished by conservative Republicans but, thankfully, robustly revived by President Obama in his recent inaugural speech).

The success story of pharmacist-delivered vaccinations is an example of what can happen when a government agency pro-actively identifies a problem and then works aggressively, innovatively, and nimbly to craft a solution that yields results not for a single special-interest group but for the benefit of all.

And so I find myself asking: How many of the cheerful vaccinees that day in my local pharmacy realized that they should be thanking former President Clinton and Donna Shalala for sparing them time out of their busy days and saving them money by going to the pharmacy rather than a doctor’s office? In fact, every day in pharmacies, supermarkets, and big-box stores in cities, suburbs, and rural areas, individuals are unknowingly experiencing up close the intersection of their daily lives with the benefits of good government.

How altered our political discourse would be if only we all realized it.

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“Adding fluoride to drinking water is among the greatest public health achievements of the 20^th century,” says the Centers for Disease Control and Prevention.  The benefit of fluoridated water is one of those issues that, until recently, seemed settled.  But in the right-wing-fomented political free-for-all that is 21^st century America, many seemingly long-settled issues [women’s rights, collective bargaining, voting rights] are up for grabs. And fluoridation is one of them.

Pevely, Missouri offers the most recent example. Apparently, the tooth-saving benefits of fluoridation are outweighed by the $8,000 to $10,000 annual cost of adding it to the municipal water system. [Fluoridation costs about $1 per person-year.] According to the St. Louis Post-Dispatch, “the cash-strapped city ran out of fluoride at the end of May 2012, and isn’t buying more.”

That’s sad, because dentists and public health pros can cite decades’ worth of evidence that fluoride saves teeth—resulting in significant savings for families.

Fluoride basics

According to the Centers for Disease Control,

Nearly all naturally occurring water sources contain fluoride—a mineral that has been proven to prevent, and even reverse,tooth decay. Tooth decay is caused by certain bacteria in the mouth. When a person eats sugar and other refined carbohydrates, these bacteria produce acid that removes minerals from the surface of the tooth. Fluoride helps to remineralize tooth surfaces and prevents cavities from continuing to form.

Water fluoridation prevents tooth decay mainly by providing teeth with frequent contact with low levels of fluoride throughout each day and throughout life. Even today, with other available sources of fluoride, studies show that water fluoridation reduces tooth decay by about 25 percent over a person’s lifetime.

In the early years of water fluoridation, studies showed that adding fluoride led to reductions of 50–60% in childhood cavities.  More recent studies show lower reductions (18–40%), likely due to increasing use of fluoride from other sources, notably toothpaste, and also to the halo effect of food and drink made in fluoridated areas and consumed in areas where there was no fluoridation.

Fluoridation became an official policy of the U.S. Public Health Service in 1951, and by 1960 water fluoridation had become widely used in the U.S., reaching about 50 million people. By 2006, 69.2% of the U.S. population using public water systems were receiving fluoridated water, amounting to 61.5% of the total U.S. population.

Throughout its history, though, fluoridation has met opposition—typically from anti-government activists who call it “forced, mass medication,” conspiracy theorists, and people who doubt the validity of science and medical research. The reasons to oppose fluoridation seem to match the political climate—as exemplified by the Cold War meme that fluoridation was part of a world-wide Communist plot to control America.

Today, the conspiracy theorists are still out there, as are ideologically driven anti-government, anti-science activists. And they’ve won in many towns. Fluoride Action Network, an anti-fluoridation group, lists more than 100 towns in North America [interestingly, many of them are in Nebraska] that have voted to end fluoridation since 1990.

You can’t help but feel sympathetic to city councils whose revenues have tanked in recent years and who are looking for ways to balance their local budgets. It’s also a fact that, with the availability of fluoride toothpastes and mouthwashes, many people are getting some fluoride benefits from sources other than their drinking water. And both CDC and the Department of Health and Human Services have recently revised downward their recommendations for the most effective levels of fluoride in public water sources, but they’re far from recommending a cessation of fluoridation.

It just doesn’t seem right to balance a government’s budget on the dental health of the citizens it serves. Maybe fluoridation is low-hanging budget fruit that’s out of sight and easily cut—especially if you’re under pressure from local people with an anti-fluoridation agenda.  One can’t help but notice, though, that when the budget axe falls, it rarely chops publicly financed sports stadiums or tax-increment financing  for corporations and developers. And, of course, there’s never a discussion of raising revenue as a way of balancing the municipal budget–or the national budget, for that matter–in order to attend to government’s main reason for being–enhancing the common good and collectively doing for individuals what they can’t do individually. Like improving public health. But I rant.

I can’t say with any certainty that’s there’s a trend toward eliminating fluoridation. I can only observe that the arguments against fluoridation seem to fit the right-wing’s anti-government and anti-science agenda–a philosophy that turns individual citizens against their own self-interest and toward a rejection of the common good–in this case, public health and their own personal health.

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