Peter Hotez is dean of the National School of Tropical Medicine at Baylor College of Medicine in Houston, Texas. He has worked on developing vaccines for hookworm and schistosomiasis, and is a vocal opponent of the anti-vaccine movement. His daughter Rachel is autistic and he has written a book, Vaccines Did Not Cause Rachel’s Autism, in which he describes her illness and tackles the newly resurgent anti-vaccine movement.
Why did you decide to write this book through the prism of your own child?
Well, I felt called to do it. I’ve written books about neglected tropical diseases, and here I was seeing these terrible things happening in Europe and the US, and if I didn’t do it – a vaccine scientist, paediatrician and autism dad – who else would?
You cite Andrew Wakefield, the discredited British gastroenterologist, as the founder of the modern anti-vaccine movement. What kind of responsibility does the Lancet bear for publishing his erroneous report and disseminating what the BMJ called an “elaborate fraud”?
Ultimately the Lancet did the right thing in retracting the paper. It’s unfortunate that it took 12 years for that retraction. But I think it’s important to mention that Wakefield is not the only individual who’s alleging vaccines cause autism. So this whole movement may have started in 1998, but it has grown so much beyond him.
Cases of measles reached a 13-year high in 2008. What’s the situation today?
I can bring up the numbers of the European centres for disease control. You have around 50,000 cases of measles in Europe in 2018. So it’s very concerning. There have been 1,019 cases in the UK between October 2017 and September 2018.
Is there an established mortality rate for measles?
There is, but it varies depending on underlying nutrition. But remember, it’s not just mortality; there’s also permanent injury due to measles encephalitis, measles pneumonia, hearing loss, affected vision… The overall picture of measles goes beyond the fact that children can die.
But the anti-vaccine movement says the threat from measles is overstated.
Exactly. They actually mock me. There are memes about me. They call me the boy who cried wolf. They claim I’m exaggerating measles. But if you look at it historically, after smallpox was eradicated in the late 1970s, measles became the leading killer of children in the world: two-and-a-half million children died annually of measles. Now, through aggressive vaccination programmes, we’ve brought that down to under 60,000-70,000 deaths a year – still a lot of deaths, but more than a 90% reduction. Now I’m worried we’re going to reverse those gains because of this anti-vaccine movement in Europe and the US. That’s going to extend elsewhere.
Thimerosal, a preservative with a tiny amount of mercury, has been removed from child and baby vaccines in the US and the UK, although there is no evidence supporting a link to autism…
After the Wakefield paper was retracted, the new allegation that popped up came from Robert F Kennedy Jnr and others, claiming that it was the thimerosal. But it was removed from childhood vaccines and the rates of autism did not decline. There are also large-scale epidemiological studies showing that there’s no link between autism and thimerosal. What the anti-vaccine movement does is play this game of whack a mole: you knock one down and a new one pops up. It shifts from MMR to thimerosal to spacing vaccines too close together, to aluminium in vaccines, and it’s all garbage. None of those things cause autism. We’ve learned a lot about the neurobiology and genetics of autism to know that this is beginning prenatally, well before children ever see vaccines.
So what does cause autism?
There was a paper released just last week in bioRxiv identifying 99 genes associated with autism. Autism has a very strong genetic basis, which is not to say that there is no environmental impact, because we still have this phenomenon of epigenetics; but if there is any environmental trigger it’s happening very early on in pregnancy, around the time of conception. This is not something that’s happening after children are born. These genes involved in creating autism are causing very complex rearrangements of the anatomy of the brain. The idea that a vaccine would do that is really just absurd.
Is autism growing?
The problem is that the diagnostic criteria for autism also shift. And then you have the added complexity that, often, for children to get special services from the school system they have to have the autism label. What used to be diagnosed as all sorts of things back in the 60s and 70s is now labelled as autism. The numbers are going to go up a lot more, because we’re getting much better at diagnosing girls and women with autism. We used to say it was 10:1 boys to girls, but now we’re recognising that many girls and women are on the autism spectrum but often it’s more subtle, because they’re more socially adept; they can camouflage their autism better. But they have very high rates of co-morbidities like OCD or ADHD, or even eating disorders. A lot of girls with eating disorders may in fact be on the autism spectrum.
Wakefield has relocated to Austin, Texas and there has been a drop in vaccination rates in Texas. Are those facts in any way related?
It’s hard to know. Certainly this terrible false documentary that he’s been involved with – Vaxxed: From Cover-up to Catastrophe – hasn’t helped. How much Wakefield is a factor is difficult to estimate, because it’s grown so much bigger than Wakefield. We now in Texas have a whole political action committee (PAC) that’s anti-vaccine and raising money for candidates to run on anti-vaccine platforms. It’s happened in multiple states in the US. There are more than 480 websites that are anti-vaccine.
The anti-vaccine movement has been focused on California and Texas. What’s the difference in approach?
In the US, the anti-vaccine movement really took off first in California, having come from Europe. It was one of 20 states that allowed non-medical vaccine exemptions for reasons of personal or philosophical belief. Then there was a terrible measles outbreak in 2014-15 in southern California and the Californian legislature responded by closing that loophole. If you want to go to public [state] school, you have to get vaccinated. That largely ended the problem. Then it shifted to Texas, which is the largest state that allows philosophical exemptions. In Texas it’s very much libertarian; in California, there’s a libertarian element as well, but it’s interesting that it’s coming both from the political left and right.
There is evidence to suggest that it’s educated people who are leading this movement.
As I like to say, educated enough to do a Google search, not quite educated enough to know what the hell they’re Googling.
What’s driving it?
That’s the most important question, and it’s one I can’t answer. There’s a lot of money behind this. Who’s paying for all this? It takes a lot of money to make PACs effective and put up all these anti-vaccine legislators.
Is there evidence that the anti-vaccine movement is targeting vulnerable communities?
Well, certainly we saw this in Minnesota last year, where they were absolutely predatory on the Somali immigrant community. They convinced them that vaccines cause autism and caused a horrific epidemic of measles.
You suggest that the anti-vaccine movement is undermining care for autism. How does that work?
One of the problems is that when the term autism is discussed in state legislatures in the US, and presumably in European parliaments, one of the first topics that then arises is vaccines. It distracts from the things we really need to focus on for kids and adults on the autism spectrum. Are they getting the special services they need? And then as adults, adequate job placements? Instead, the energy gets shifted to these false arguments about vaccines. So I think it’s been harmful to the autism community.
You’re not sure whether Donald Trump has galvanised the anti-vaccine movement. But would you say he hasn’t supported the vaccination argument?
He’s certainly not supported vaccinations, but in fairness to President Trump we didn’t get a lot out of the Obama administration and the Bush administration before that. Why have the US federal agencies been so silent about promoting vaccinations? I think when the anti-vaccination movement started in 1998 the federal agencies saw it as a cult movement and they thought it was best to ignore it. Unfortunately, they’ve largely continued that position even though the anti-vaccine movement is no longer fringe… it’s a full-blown movement affecting public health.
How do you win an argument when empirical facts and scientific expertise are seen as inherently suspect by your opponents?
There is a vacuum out there. While the anti-vaccine movement is very well-organised, well-funded, very adept at the use of the internet and social media, there has not been a response on the pro-vaccine side. So your question remains untested. I believe if there was a more active pro-vaccine lobby, most parents would listen to it. There are diehards who fully believe the conspiracy theory and you’re not going to reach those individuals. But I think for the majority, you can reach them. That’s my motivation for writing the book.
How do you see things developing with measles and other vaccines?
Unless there is a well-focused and effective response, this thing is not going to get any better. All the signs are that it’s going to get worse. My big worry is that this is going global. The US and Europe are very good at exporting their culture, and now we’re exporting this garbage. What happens when the anti-vaccine movement moves into India?