On Immunity : An Inoculation (9781555973278) (12 page)

Surgery struck me as overkill, and I was not eager to have part of my son’s lymphatic system removed from his body. When I researched the procedure, I was disturbed to discover that it was performed widely in the early 1900s as a kind of cure-all for childhood ailments. My father was sympathetic to my concerns. He himself no longer has his tonsils because a traveling doctor removed the tonsils of all four children in his family on a single visit. This was, at the time, a standard preventive measure against rheumatic fever, which ceased after research revealed that the dangers of the surgery outweighed its benefits. As a rule, it is wise to be wary of overtreatment, my father told me. But if the alternative to surgery in my son’s case was the ongoing use of antibiotics or other drugs, surgery might be the more conservative option.

I delayed making a decision for well over six months, all the while trying everything else. A friend suggested an expensive air filter, which I bought. The allergist recommended that I keep our floors clean, a Sisyphean task, considering that microscopic allergens were constantly circulating through the air and settling on the floors. But I mopped the invisible dirt and I changed my son’s sheets and pillowcases daily. Despite his protests, I flushed his sinuses with salt water every evening. I gave him a prescription nasal spray. I fed him raw honey and nettle tea. Then his breathing, already loud, became irregular at night. I crouched next to his bed, holding my own breath during the pauses in his breathing to gauge how long he was going without air. After particularly long pauses he woke, gasping and coughing. I scheduled the surgery.

The surgeon reminded me, on the day of the surgery, not to expect dramatic or instantaneous results. She had already been over this with me, and had already warned me that my son might continue to get infections despite the surgery. I was most hopeful not that the surgery would enact a miracle, but that it would simply do no harm. It was an easy, routine surgery, she assured me. The most dangerous part was the anesthesia.

While we waited in a room full of toy stethoscopes and toy syringes, the anesthesiologist arrived and asked if I had any questions. I told him that I would like to be with my son while he was put under and while he came back to consciousness. The doctor stiffened at this suggestion. Studies had shown, he told me, that the body language and facial expressions of anxious mothers can cause children to fear surgery and resist anesthesia. It seemed there were two ways to interpret those findings, I told him—one could determine that the mother’s presence is not good for the child, or one could conclude that ensuring the confidence of the mother is essential to the well-being of the child. We began to argue in low voices, while my husband and my son applied toy bandages to each other on the other side of the room. The implication that I was a hysterical woman and a threat to my child was making me so angry that it seemed possible I might actually become hysterical. Finally, we compromised. I would be allowed to hold my son’s hand while he was put under anesthesia if I agreed to position myself so that he could not see my face.

In the operating room I talked to my son from beyond his range of vision until the anesthesia took effect. Watching the muscle tone leave his face and body was disturbing, like seeing a rehearsal of death, and I was eager to go back to the waiting room as soon as he was unconscious but the anesthesiologist called after me. “Don’t you want to give him a kiss?” he asked, to my disgust.

A smiley-face balloon bobbed mutely against the ceiling of the waiting room. It had been trailing us ever since my husband untied it from the stuffed pig that was given to my son by the child life specialist, who assured me that the pig could accompany my son into surgery. All the doctors were very pleased about this, even the stern surgeon. They seemed convinced that the pig would be a source of great comfort to my son.

Perhaps as a punishment intended for me, or perhaps as the result of an error or just a matter of routine, my son woke from anesthesia before I was summoned to the recovery room. I could hear him screaming “Mama! Where’s my mama?” all the way down the hallway. I knew from my own experience with surgery that the moment before anesthesia takes effect and the moment after it loses effect can seem to be the same moment—in my son’s mind I had vanished. When I reached him, he was thrashing in confused panic, trying to rip the IV line out of his body. I climbed up on the gurney to hold him and stroke his hair and keep his hands away from his IV while he wailed. “He won’t remember any of this,” the anesthesiologist assured me nervously. I was busy calming my son, but I looked up just long enough to say, “I will.”

My father suggests that the time has come for another version of
Dracula
in which the vampire serves as a metaphor for medicine. Because, he says, “medicine sucks the blood out of people in a lot of ways.” The cost of my son’s surgery, which was considerably more than the cost of his birth, would have made it an impossible decision for many families. I was reminded of this in the days immediately after the surgery, when my son’s breathing became easy and quiet. He slept better, he put on weight, and he stopped getting sinus infections. I now regret waiting to give him the surgery, but my husband does not. It was responsible of us, he says, to be skeptical.

Either despite or because of his training, my father is himself fairly skeptical of medicine. He once joked about the two-sentence textbook he would like to write for physicians: “Most problems will get better if left alone. Those problems that do not get better if left alone are likely to kill the patient no matter what you do.” This is as much an argument for preventive medicine as it is a sigh of defeat.

I remain grateful for my son’s surgery, just as I remain furious with the anesthesiologist and dismayed with myself for trusting my child to someone I did not myself trust. “Where there is trust, paternalism is unnecessary,” the philosopher Mark Sagoff writes. “Where there is no trust, it is unconscionable.” And so we are caught in a double bind.

T
HE MAGAZINES I PAGED THROUGH in my midwife’s waiting room when I was pregnant with my son ran advertisements for disturbing little sculptures that could be made from ultrasound images of my developing fetus, as well as ads for the equally mystifying services of private cord blood banks. My midwife had already informed me that I could donate my son’s cord blood to a public bank where it would be available for transplants in people with leukemia and lymphoma, among other conditions. The private banks advertised in magazines were offering, at a cost, to preserve my child’s blood not for anyone who needed it, but exclusively for my child or a close relative. It was banking against future knowledge, I would discover, since the ways in which having access to one’s own cord blood might be advantageous later in life are still fairly limited in practice and promising only in theory.

Interested in the transformation of a public fund into a private account, the hoarding for unknown future benefit of something that could be donated for known benefit now, I tore an ad for a private cord blood bank out of a pregnancy magazine shortly after my son’s birth. That ad features a large photo of a sleeping infant next to an advice column titled Ask Dr. Sears, with the question “Should I bank my baby’s cord blood?” The response from the expert, Robert Sears, is unsurprising, considering that the advice column is actually an advertisement and Sears is a consultant for the cord blood bank being advertised. “As new treatments develop,” Sears writes, “having cord blood on hand may be invaluable.” The fine print at the bottom of the ad clarifies his equivocation: “There is no guarantee that treatments being studied in the laboratory or in clinical trials will be available in the future.”

I had not yet read Sears’s best seller,
The Vaccine Book
, when I tore out this ad. But I recognized the Sears brand, I had seen Sears endorsements on products for infants, and I knew that Robert Sears, or “Dr. Bob,” as he calls himself, was the son of William Sears, a popular source of parenting advice and probably the most well known pediatrician in the United States. The widespread appeal of
The Vaccine Book
, I would come to understand, lies mainly in the compromise it offers between vaccinating and not vaccinating. For parents who fear both vaccines and infectious diseases, Sears offers two clear courses of action. One is “Dr. Bob’s Selective Vaccine Schedule,” a plan that provides only the vaccines Dr. Bob deems most important—leaving children unvaccinated against hep B, polio, measles, mumps, and rubella. The other is “Dr. Bob’s Complete Alternative Vaccine Schedule,” a plan that provides all the vaccines a child typically receives in two years on the standard schedule, but spread out over the course of eight years.

“It’s the best of both worlds of disease prevention and safe vaccination,” Dr. Bob writes of the alternative schedule. Because the schedule delays some vaccinations that are intended specifically to protect very young children, it is unlikely to offer the best of disease prevention. And it is unlikely to offer the best of safe vaccination in that there is no credible evidence, beyond Dr. Bob’s personal speculations, that spacing and delaying vaccinations minimizes the incidence of side effects. The alternative schedule is, optimistically, the
most
of both worlds. By following this schedule, parents can secure most of the benefits of disease protection—though not at the most crucial age for that protection—while risking all of the potential side effects of vaccination.

The extra time and trouble required to follow Dr. Bob’s alternative schedule are hard to justify unless the dangers of contracting infectious diseases early in life are minimized and the dangers of vaccinating early in life are exaggerated. Much of
The Vaccine Book
is devoted to this minimization and exaggeration. Tetanus is not a disease that affects infants, according to Dr. Bob, Hib disease is rare, and measles is not that bad. He does not mention that tetanus kills hundreds of thousands of babies in the developing world every year, that most children will encounter the bacteria that causes Hib disease within the first two years of their lives, and that measles has killed more children than any other disease in history.

The idea of a middle ground on vaccination is appealing, if elusive. Competing claims to expertise countered by accusations of conflicts of interest have bred a hunger for the kind of impartial authority Dr. Bob promises in the preface to his book. But
The Vaccine Book
is not even-handed so much as it is equivocal. “Vaccines don’t cause autism,” Dr. Bob writes, “except when they do.” And he concludes his discussion of the lack of evidence supporting a causal relationship between vaccines and certain side effects by asserting, “I’m sure the truth of the matter is somewhere between causality and coincidence.”

What it might mean for a vaccine to neither cause an effect nor be simply coincidentally associated with it is unclear. There are a number of indirect side effects associated with vaccines. The measles-mumps-rubella vaccine, for example, can cause a high fever that may then cause a seizure in an infant who is prone to febrile seizures. It is the fever, not the vaccine, that causes the seizure—and the same child would be likely to suffer a seizure from a fever brought on by natural infection—but most discussions of vaccine side effects, including Dr. Bob’s, do not bother with this distinction. Indirect causation is typically considered causation. And so it is here, between causality and coincidence, that I begin to fear Dr. Bob’s middle ground may be a fictive location.

Dr. Bob maintains his middle ground in part by recalibrating the conversation around vaccination so that positions more cautious than his appear extreme. “I’m not sure where this hard line comes from,” he writes of pediatricians who dismiss from their practices families who refuse to vaccinate their children. As Dr. Bob is probably aware, some pediatricians do not treat unvaccinated children because of the possibility that those children might expose infants in their waiting rooms to diseases that those infants are too young to be vaccinated against. In fact, the unvaccinated child who returned from a trip to Switzerland in 2008 with a case of measles that infected eleven other children was Dr. Bob’s patient. It was under Dr. Bob’s care that he was not vaccinated, though it was not in Dr. Bob’s waiting room that he spread measles to three babies too young to be vaccinated.

“I was NOT the pediatrician who saw the measles patient and let him sit in my office,” he wrote of the incident. “I was not involved in that at all.” When pressed, he added, “I have simply been the family’s pediatrician over the years, but I practice far away from them, so they went to a local ped for THIS problem.” In Dr. Bob’s world, another doctor’s waiting room is not his concern and public health is entirely independent of individual health. “This is an important vaccine from a public health standpoint,” he writes of the hep B vaccine, “but it’s not as critical from an individual point of view.” In order for this to make sense, one must believe that individuals are not part of the public.

Public health, Dr. Bob suggests, is not
our
health. “It is safe to say that we don’t give this vaccine in order to protect each individual child from catching polio,” Dr. Bob writes of the polio vaccine. “Rather, we do it to protect our nation as a whole in the event an outbreak does occur.” As he acknowledges, “If we stop using this vaccine, polio may come back. Anyone who is over fifty knows just how scary that would be.” He himself is too young to remember polio. And he has never treated a child with diphtheria or tetanus. “Hopefully, someday we will have a better way to know for sure which side effects are truly vaccine related,” he writes. He is banking against future knowledge, again—using the limitless promise of scientific discovery to disguise a gamble as a prudent investment.

M
Y GRANDFATHER LOST HIS FATHER to tuberculosis when he was ten. On the other side of my family, both my grandmother and my grandfather lost siblings to infectious diseases. One family lost a toddler to measles and a teenager to sepsis, and the other family lost a toddler to pertussis and a teenager to tetanus. When my father was a boy, his brother was bedridden for six months with rheumatic fever. He lived, but he suffered permanent heart damage and died young of heart failure.