This article is by Dorit Rubinstein Reiss, Professor of Law at the University of California Hastings College of the Law (San Francisco, CA), is a frequent contributor to this and many other blogs, providing in-depth, and intellectually stimulating, articles about vaccines, medical issues, social policy and the law.
Professor Reiss writes extensively in law journals about the social and legal policies of vaccination. Additionally, Reiss is also member of the Parent Advisory Board of Voices for Vaccines, a parent-led organization that supports and advocates for on-time vaccination and the reduction of vaccine-preventable disease.
Today, on Friday, January 16, 2015, Dr. Robert (Bob) Sears, a California pediatrician and author of a controversial book on vaccines (critiqued here, pdf, or here by the fine folks at Science Based Medicine) wrote in his Dr. Bob’s Daily and published on his Facebook page that measles is only rarely fatal in developed countries and that serious complications are rare. (In the likely event that Dr. Sears decides to delete his misleading comments, it’s archived here permanently.)
Dr. Sears’s comments were false. And they were irresponsible. In a way that can put people – including children, including his patients – at serious risk. This is not the first time Dr. Bob Sears has made inaccurate claims about a vaccine preventable disease, but on the background of the current measles outbreaks, the risk from his behavior is more imminent and more obvious. It is appropriate to react.
Duties, Responsibilities, and Ethical Failures
Dr. Bob’s home base–Orange County, CA–has seen over 21 measles cases during 2014, of which seven were hospitalized. As of now, a large and expanding measles outbreak has centered that part of California.
Dr. Robert Sears vaccine reputation is considered friendly to parents who delay, skip or refuse vaccines–his patient population includes many such parents. At least some of his young patients were not given the MMR vaccine (for measles, mumps and rubella) or the MMRV vaccine (MMR plus varicella, also known as chickenpox), and are thus at high risk of measles. Children under five are at higher risk of measles complications than older children. By inaccurately downplaying the risks of measles, Dr. Sears is reaffirming these parents’ decision to deny their children the MMR. He is actively supporting leaving those children unprotected against measles, when there is an extremely effective, simple preventive medication at hand–the MMR vaccine.
Dr. Bob is not just another commentator on the web, or just another anti-vaccine activist. He is a pediatrician. This means two things. First, he has ethical responsibilities to his patients. His patients are the children whose welfare is entrusted to his care, and who deserve to be protected against diseases according to the universal recommendation of all professional bodies.
He also owes a duty to the parents who are their guardians: he owes them accurate information, and he owes them his best expert advice. Not catering to their misconception: he owes them the truth. When he says things that are false, he is failing his duty to them. He is undermining informed consent, because informed consent can only be based on true information. And he is failing his little patients by misleading their guardians about the risk of a disease they can prevent.
Second, being a pediatrician means that his opinions carry clout beyond what a lay commentator’s would–even when, as here, they are plainly wrong and against the evidence. He may not have an official ethical duty to those who read his comments on the web. But he has a moral duty not to mislead those who trust his professional accreditation and expertise.
How are the claims false?
Some of Dr. Sears’ claims are quoted below (in italics):
“…the lie is that measles has a high rate of serious complications. It doesn’t. It CAN, but it rarely does.”
“Potentially fatal? Technically true, but herein lies the lie. It’s been publicized as “the deadliest of all childhood fever/rash illness with a high rate of complications.” Deadly? Not in the U.S., or any other developed country with a well-nourished population. The risk of fatality here isn’t zero, but it’s as close to zero as you can get without actually being zero. It’s 1 in many thousands.”
In other words, Dr. Bob is claiming measles only rarely has serious complications, and is very, very rarely fatal. What does the data show?
The CDC has scientifically established the rate of complications from measles at 30% (pdf). That includes 6% of people getting pneumonia, about 1 out of 1000 get encephalitis, and around 2 out of 1000 die. Those numbers are not from the 19th century–they are based on the years 1985-1992, which included the latest large scale measles outbreak the United States has seen (since then cases have been rare, thanks to the MMR vaccine, and the free availability of children’s vaccines through the CDC’s Vaccines for Children Program).
In recent years, Europe has seen a large-scale measles outbreak–mostly in unvaccinated children–literally, thousands of cases. One article from France puts the death rate there at 3 out of 1000. Death rates from vaccine preventable measles is scary. In 2011, Europe saw nearly 29, 000 cases of measles (pdf). Over 80% of those 29,000 cases were in the unvaccinated. What were the rates of complications? One table from the article provides the breakdown, though the article makes it clear the reporting of complications is incomplete:
So, we have 8 deaths, or about 1:3500; close to 1:1000 that got encephalitis, 4% that got pneumonia. I don’t know about you, but that doesn’t seem like good odds to me.
And the results in 2011 are not the end of the story, because SSPE can appear years after the fact. In Germany during the last 6 years, there were 31 cases of SSPE, for a risk of 1:1700-1:3300 in children under five. SSPE, or subacute sclerosing panencephalitis, is always fatal. And it’s a slow, lingering death in which the child slowly loses her capacity ( other stories here, here and here).
But the risk of fatalities is close to zero? One in many thousands? Not generally, and especially not if you’re under five.
Look at what is happening in the United States right now. As of January 13, there were 26 cases linked to the Disney outbreak, and out of those 6 were hospitalized–a rate of 23%. Complications are higher in adults and children under five.
But serious complications are rare? I guess it depends how you define serious and how you define rare. Raise your hand if you’d be happy with seeing your three year old in a hospital.
“Complications? … Pneumonia is next – also treatable.”
Dr. Paul Offit, Director of the Vaccine Education Center in the Children’s Hospital of Philadelphia and an attending physician in the Department of Infectious Diseases, an expert on vaccines and infectious diseases, disagrees. “You can support people with measles pneumonia (by ventilating them and giving them oxygen), but there is no treatment.”
Encephalitis? That’s much worse. Fortunately it’s extremely rare in well-nourished people.
Deadly? Not in the U.S., or any other developed country with a well-nourished population.
The numbers repeated in this article are taken from the United States and from Europe, certainly not undeveloped areas of the world with chronic malnutrition. Between the two, Europe has less income inequality and lower rates of poverty than the United States – and it has seen encephalitis and deaths. Roald Dahl’s daughter, Olivia, who died from measles encephalitis, was well nourished.
What basis is there for Sears claiming that these complications are extremely rare in the well nourished? He provides none, and his claims contradict the view of experts. Says Dr. Offit: “Sears implies that complications from measles can be avoided by being well nourished. This is certainly untrue. Measles hospitalizations and deaths in the US typically occurred in previously healthy children.”
“Ask any Grandma or Grandpa (well, older ones anyway), and they’ll say “Measles? So what? We all had it. It’s like Chicken pox.””
Dr. Offit points out that the 400-500 people who did not survive their infection with measles each year are unlikely to agree. Unfortunately, interviewing those who aren’t alive to tell their stories may prove a bit challenging. But one parent who lost his precious, well nourished child–author Roald Dahl–eloquently disagreed.
[infobox icon=”quote-left”]“I was sitting on her bed showing her how to fashion little animals out of coloured pipe-cleaners, and when it came to her turn to make one herself, I noticed that her fingers and her mind were not working together and she couldn’t do anything.
“Are you feeling all right?” I asked her.
“I feel all sleepy,” she said. In an hour, she was unconscious.
In twelve hours she was dead.
The measles had turned into a terrible thing called measles encephalitis and there was nothing the doctors could do to save her. That was twenty-four years ago in 1962, but even now, if a child with measles happens to develop the same deadly reaction from measles as Olivia did, there would still be nothing the doctors could do to help her.”[/infobox]
Roald Dahl called on parents to protect their children against this illness, which Sears dismisses as “so what”.
This news story, published in the 1950’s well before the existence of the vaccine, disagrees with Dr. Sears’ off-handed dismissal of the dangers of measles’ epidemics.
[infobox icon=”quote-left”]Two research teams, a continent apart, are hot on the trail of poles-apart methods of combatting measles. Traditionally one of the “inevitable” childhood fevers, measles is widely underrated as a health menace. For children under three and for adults, it is a threat to life itself; at any age it can cause brain inflammation, which now (since Salk vaccine) kills more victims than does polio and handicaps about as many by damaging the brain.[/infobox]
And is measles like chicken pox? Let’s compare harms pre-vaccine:
|Deaths per year||450 on average||Average of 103|
|Hospitalization per year||48,000||11,000|
Chicken pox can harm you; but measles is much more likely to.
Dr. Bob is right that measles won’t spread through the United States and “kill people left and right”–mostly because most children are vaccinated. Get enough cases, however, and it will kill, and cause additional extensive suffering. Suffering that is preventable. Not giving his patients the full facts about that suffering – in fact, downplaying the rate of complication and the risk of death – is unfair towards them. It’s actively misleading them.
Dr. Bob is also failing his duty by not reminding his patients that this suffering can be prevented. We have an extremely effective–99% of people who get two doses will have long term protection (pdf)–and extremely safe vaccine against it. A vaccine many of Dr. Bob’s patients choose to delay or not get for their young children – something his post will encourage them in.
What can you do about it?
Dr. Sears’s actions are irresponsible. They are a failure of his professional and ethical duty as a physician, and they actively mislead people.
There are a number of things you can do to respond.
A. File a complaint with California’s medical board. Here is the link for complaints:
And here are Dr. Bob Sears’s details (all publicly available with easy searches – nothing here violates his privacy).
Sears, Robert William
License number: 60936
26933 CAMINO DE ESTRELLA
CAPISTRANO BEACH, CA
B. File a complaint with the FTC. In response to a comment highlighting the inaccuracies and omissions in his claims on his Facebook page, Dr. Bob said:
“Thanks for posting. Realize that this post was far from a complete discussion. It only focused on the topic in the title. That’s it. There’s no way for me to write a complete post on mealses [sic] – don’t have that much time. That’s what the measles chapter in the book is for”
When promotion of misleading claims is tied to the sale of a product – his book – there’s a colorable claim that he is using misleading and unfair practices in trade. This may justify filing a claim with the FTC. And to remind you, Dr. Bob Sears also sells medical services – and as the post demonstrates, makes untrue claims while doing so. In a previous post, our gracious host provided a step-by-step guide on how to complain with the FTC about a different promoter of misleading claims.
The same steps can be used here.
C. Spread the word, and ask professional organizations to act. Write letters to the editor, and speak up in any forum you can, saying clearly that misleading claims of this sort, by a doctor, are inappropriate. And even more inappropriate when they put children, adult and the public health at risk.
This is not just an abstract failure of duty. I’m a California parent. Dr. Bob’s actions are increasing the risk of preventable disease and making my state less safe for my children. In 2015 my children should not have to worry about a preventable disease. Nor should the children of other parents. And parents shouldn’t have to see their children suffer from it, not the parents misled by Dr. Sears, not the parents who made the error of not vaccinating by falling for misinformation from elsewhere and are encouraged in their error by Dr. Bob, and not the parents of other children that may be infected because they’re too young, have medical conditions that prevent vaccinating, or suffer vaccine failure.
We all deserve better.