The Global Experience

Please join me in welcoming Dr. Atoosa Kourosh who is providing us with a guest blog this week!   Dr. Kourosh is a board-certified Pediatrician with a Masters Degree in Public Health. She received her Bachelors degree in Middle Eastern Studies from the University of Texas at Austin and then attended the University of Texas Southwestern Medical School where she received her medical degree. After completing her residency from Baylor College of Medicine and Texas Children’s Hospital, Dr. Kourosh also obtained her MPH at the University of Texas School of Public Health. She has been actively involved in public health development in both the US and abroad, and has served and studied in Europe, Asia, the Middle East, Africa and South America.  She has served internationally with International Medical Corps, Health for Humanity, Curamericas and the Hope Alliance. Her unique experiences serving those in need both here and abroad give her a distinct and valuable perspective on the topic of vaccinations. Welcome to MOMmunizations Dr. Kourosh!

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Accessing Global Experience and Generational Memory of Epidemics to Promote Vaccination: What Each of Us Can Do Every Day

When I was growing up, the calling I felt to become a physician was almost inseparable from the desire to work internationally. I’ve been lucky to have had many opportunities to work, study and serve overseas and have always enjoyed being a doctor in the developing world. My international health work has often afforded me indispensable learning experiences, at once uplifting and humbling. But sometimes, the experiences can be unpleasant – and I don’t mean because of the rough conditions, or even the many dangers of traveling to remote areas of the globe, but because these experiences bring into sharp relief how much we have here in the US comparatively, and perhaps how little we appreciate and utilize those many gifts.

One of the more embarrassing moments I can recall occurred during my first trip to Bolivia some years ago. I was with a group of Curamericas volunteers who were serving in Montero in the rural lowlands of Bolivia, and we had the opportunity to visit Nur University in nearby Santa Cruz. Nur is renowned for its innovative programs and for graduates who are dedicated to public service. We were on a tour of the main building when a group of Public Health students heard we were on campus and asked to meet with us. After a short dialogue during which we answered some questions about the public health infrastructure in the United States and discussed their experience with epidemic investigations in the Andean highlands, one of the students asked a penetrating question that left us all speechless for a minute:
“How is it that in a poor country like ours, we have a 96% vaccination rate, while in the US, it’s at best 80%? You have so many resources…. how can it be that you cannot vaccinate your children?”

One of my colleagues answered that in many cases, vaccines were offered but people refused to vaccinate their children because they feared vaccine side effects or believed misinformation about vaccines rather than the advice of their health care providers. The student then responded that the diseases were so much worse than the side effects, that she didn’t understand how parents could make that choice.

“That’s just it,” I said. “Most people in the United States and many other countries in the North and West have no idea how bad these vaccine preventable diseases can be. The resistance to vaccination comes from the luxury of never having seen the disease in its epidemic state.”

In my years of working overseas, I’ve never seen a parent refuse a vaccination. There are, of course, rare instances of scares and misinformation in the developing world like the Oral Polio Vaccine scare in Nigeria in 2003 when parents were led to believe by local leaders that the vaccine was a Western plot to sterilize their children to control the Muslim population. The low vaccination rate that resulted from that unfounded scare then decreased herd immunity to the point that there was an outbreak of polio the following year. But such misguided anti-vaccine campaigning is not a typical occurrence in developing countries, such as it is in the US or the United Kingdom where immunization opponents command the spotlight.

There was a time in the not so distant past when epidemics still raged in the US and other industrialized countries and parents saw vaccines as the life-saving miracle they truly are. When many early vaccines – like those for Diphtheria and Polio – were first made available, people stood in line for hours to make sure their children were protected. They had witnessed epidemics, seen the devastation these diseases could cause, and would not risk their children’s health for another day if they could help it. That generational memory has faded with herd immunity and the decreasing frequency of even small scale outbreaks. In short, our success at controlling epidemics through vaccination has created an obstacle to future vaccination in the minds of those who don’t know how lucky we are to have vaccines.

Nowadays I have often heard those who are wary of vaccines speak of measles, mumps and chicken pox as benign childhood diseases, almost rites of passage for a child to catch and suffer through. I have shuddered at hearing of “pox parties” where people deliberately expose their children to vaccine preventable diseases hoping they will get infected. If people truly saw these diseases for the dangerous contagions they are, I doubt they would risk their children’s health in such a manner. Aside from the suffering the infection entails for the child and family, these “childhood” diseases can cause serious and even life-threatening effects. Most people don’t realize that chicken pox can sometimes cause life threatening pneumonia, or that measles can in some cases lead to a devastating, usually fatal neurological disorder called subacute sclerosing panencephalitis (SSPE). These are just a few examples of the potential harm and mortality vaccine preventable diseases can cause.

The fact is that these vaccines were developed because these diseases are dangerous, devastating, and in many case, have no good definitive treatment……or they can cause catastrophic outcomes even when treated promptly and definitively, as in the case of bacterial meningitis.

The risk of getting the disease, and the risk of a bad outcome if the child gets the disease far outweigh any risk from vaccination. The science is clear on this. So why don’t parents see it that way in the case of vaccine hesitancy?

In looking for the answer to that question I ran across some fascinating work done by Dr. Chris Bauch and his team at the University of Guelph in Canada. Dr. Bauch is a mathematician, and he applied the principles of Evolutionary Game Theory to the behavior of vaccine resistance to see why parents make the decisions they do, even as they often agree with the medical community that we need to protect these vulnerable young children.

Because immunization programs are largely successful and epidemics in the West are rare, parents usually don’t personally know anyone who has lost a child to a vaccine preventable disease, so they grossly underestimate the risk of contracting the disease. The perception in the US is that the risk of contracting these diseases is low – even if that perception is absolutely wrong (as with Pertussis, for instance), and celebrity anti-vaccine campaigners are loud, so parents get scared hearing their testimonials and refuse vaccination – thinking erroneously that they are protecting their children from potential harm when they are in fact putting them at risk of serious disease.

Anti-vaccine activists hold up their anecdotes of supposed vaccine induced harm as proofs of the dangers of immunizations. Parents who have seen even minor vaccine side-effects sometimes go to the media and scare others into not vaccinating. Those who are sharing these negative experiences present them as the norm rather than the rare exception, and their anecdotes somehow take on the same weight as the science, as if they are now experts on vaccine effects. Christine Vara, the moderator of Shot of Prevention (an online forum about immunization) says that we have to help parents distinguish between “experience” and “expertise.” We should acknowledge that vaccine related side-effects are an unfortunate– though rare–possibility, but emphasize that the risk of not vaccinating is far greater – and that the true experts are unequivocal about this fact.

On a more encouraging note, Dr. Bauch also found that the vaccination behavior of the hesitant parents’ peer group influenced their decisions about whether or not to vaccinate. So if most of their friends were vaccinating their children, they were more likely to be open to vaccination as well, even when they had initially expressed reservations.

So what can you do to help?

You can talk to the hesitant parents in both your professional and personal spheres about why you vaccinate your own children, and share with them the video recently produced and distributed for free by the Texas Pediatric Society that addresses vaccine hesitancy and shares the experience of two Texas families who lost children to vaccine preventable diseases:

http://txpeds.org/vaccine-information

Research has shown that personal stories have more impact on behavior change than statistics, and that’s why the anti-vaccine campaigns have been so successful.

What else can we do to help save children’s lives through vaccination?

Remember all those little ones all around the world whose parents eagerly vaccinate them? The reality of infant and child mortality in the developing world, the daily agony of witnessing the death of a child on a regular basis, provides more than enough motivation for those parents to do all they can to prevent ANY disease that CAN be prevented. And yet, not all those children get the vaccines they need due to resource scarcity and lack of access to immunizations. Every 20 seconds, a child dies of a vaccine preventable disease – and most of these deaths are in the developing world, where the children who fall ill won’t be able to call an ambulance or access lifesaving care.

During World Immunization Week at the end of April, the Shot at Life initiative was launched in partnership with the United Nations Foundation to help mobilize a grassroots movement in the United States advocating for global vaccine delivery, so that every child anywhere in the world can have the same fighting chance. Check it out and lend your support:

http://shotatlife.org/blog/shotlife-blog-carnival-global-vaccines.html

So each of you reading this can make a difference every day, by encouraging hesitant parents to protect their children by immunizing them according to recommended vaccine schedules, by helping improve access to immunizations all over the world, and by speaking out in support of vaccination whenever the opportunity arises.

“Your life begins to end the day you stop speaking out about things that matter.” Christine Vara (Shot of Prevention http://shotofprevention.com/)

C.T. Bauch, S. Bhattacharyya (2012). `Evolutionary game theory and social learning can determine how vaccine scares unfold’. PLoS Computational Biology, in press.

M. Ndeffo, J. Liu, C.T. Bauch, Y.I. Tekel, L.A. Meyers, A. Galvani (2012). `The impact of imitation on vaccinating behavior in social contact networks’. PLoS Computational Biology, in press.

S. Bhattacharyya, C.T. Bauch (2012). `Mathematical models of the interplay between individual vaccinating decisions and disease dynamics: a need for closer integration of models and data’. Human Vaccines and Immunotherapeutics, in press.

A game dynamic model for delayer strategies in vaccinating behaviour for pediatric infectious diseases.
Bhattacharyya S, Bauch CT- J Theor Biol – 7-DEC-2010; 267(3): 276-82

Social contact networks and disease eradicability under voluntary vaccination. – Perisic A, Bauch CT – PLoS Comput Biol – 01-FEB-2009; 5(2): e1000280

http://www.scientificamerican.com/article.cfm?id=how-anecdotal-evidence-can-undermine-scientific-results

One thought on “The Global Experience

  1. Dr. Kourosh, It was such a pleasure to have met you on my trip to TX and I’m thrilled to be reading this post that we had started discussing that day. You’ve done a wonderful job in providing readers with a better understanding of your perspective as both a doctor and a concerned global citizen. It’s clear that you are already committed to taking the definitive action that you suggest others take in an effort to address the vaccine hesitancy we are witnessing in our privelaged country. I’m encouraged by your words and hope others will be as well. Thanks for all your support of Shot of Prevention and Shot@Life and for all your hard work in trying to ensure that children everywhere are protected from vaccine preventable diseases.

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