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One of the oddest things to have come out of the first two rounds of Democratic Presidential debates was the inexplicable prominence of one candidate, Marianne Williamson. Indeed, she was the most Googled candidate after the second debate last week. A New Age self-help guru who got her start over 30 years ago peddling her own interpretation of A Course in Miracles , an unholy fusion of New Age woo and Christian beliefs, she rose to prominence, thanks to several books and becoming Oprah Winfrey’s “spiritual advisor” and has a bevy of celebrity friends and admirers ranging from Elizabeth Taylor to the Clintons to Alyssa Milano, the last of whom is fundraising for her. It also came out over the last couple of months that she harbors antivaccine views and has some very Scientology-like views towards mental illness. True, she’s tried to backpedal as much as she can, imitating antivaxer Robert F. Kennedy, Jr., who has risibly called himself “fiercely pro-vaccine” by proclaiming herself “pro-science and pro-vaccine.” There’s always, however, a “but,” as in “but big pharma and the opioid crisis”:

I’m pro-vaccine & pro-science! Also pro-responsibility on part of Big Pharma & independent govt oversight. We’re currently indicting Big Pharma execs for opioid crisis. In every other area we should just assume they’re a paragon of pure intention and concern for the common good? — Marianne Williamson (@marwilliamson) July 24, 2019

Or it’s “but childhood chronic illness”:

Jonas Salk was a great scientist. The polio vaccine did and does save lives. The current controversy about vaccines is not about their inherent value. It’s about the rise in chronic illnesses (from 12% to 54%) among American children since the “Vaccine Protection Law” in 1986. — Marianne Williamson (@marwilliamson) July 24, 2019

Marianne Williamson has a number of horribly denialist views about medicine, particularly about vaccines and psychiatry and antidepressants (about which she sounds rather Scientology-like). She routinely takes a criticism of medicine that has a grain of truth (e.g., regulatory capture at the FDA and other regulatory agencies) and then runs right off the cliff with it (and has been at it for a long time), even having gone so far as to confuse correlation with causation regarding celebrities on antidepressants who commit suicide:

How many public personalities on antidepressants have to hang themselves before the FDA does something, Big Pharma cops to what it knows, and the average person stops falling for this? The tragedies keep compounding. The awakening should begin. — Marianne Williamson (@marwilliamson) June 5, 2018

My primary purpose in this post is not to deconstruct all of Marianne Williamson’s pseudoscientific beliefs about vaccines and medicines. That’s been done more extensively here, here, here, here, and here. Rather, my purpose is to hone in on one very specific one. It’s one she’s Tweeted about and has repeated in nearly every recent media appearance that I’ve seen her on, including interviews with Anderson Cooper of CNN and Ari Melber of MSNBC. It’s also one that I’ve been meaning to address for a long time because it’s a frequent talking point used by antivaxers. Here’s a quote from her interview with Melber, in which Melber asked her, “Do you think vaccinations are contributing to things being worse now? Is that what you’re suggesting?” Looking a bit flustered, Williamson responded:

No, no, what I’m saying is that in 1986 there was this vaccine protection law. There was, and there have been $4 billion in vaccine compensation payments that have been made. There was much less chronic illness. There was something like 12% chronic illness in our children previous to that law, and there’s 54% now. I don’t see why in a free society. I mean, what is going on here? When you look at the fact tha big pharmaceutical companies lobbied Congress to the tune of $284 million last year alone, as opposed to oil and gas, which has lobbied Congress to the tune of $125 million last year, when you look at all the money that is spent by pharmaceutical companies even on our news channels, when you look at the fact that there are two pharmaceutical lobbies for every member of Congress, and even when you look at the tens and even hundreds of millions of dollars that have been paid into the coffers of even Presidential campaigns, why are we so okay with complete shutdown of any conversation about this topic?

The above response is, of course, a pastiche of antivaccine talking points, including calling the Vaccine Court, which was mandated by the National Childhood Vaccine Injury Act of 1986, the “vaccine protection court”; harping on the $4 billion in payouts over the last three-plus decades (which, when taken in context of the billions of doses of vaccines given to hundreds of millions of children during that time is not really that large a sum of money); and, the topic of this post, her claim that 54% of American children now have a chronic disease. She even uses a typical form of antivax sleight of hand to imply without saying directly that the increase in prevalence of chronic disease is due to the expansion of the vaccine schedule in the wake of the NCVIA, while recounting big pharma’s lobbying influence. It’s JAQing off at its finest.

The claim that over half of our children are chronically ill is a variation of what I like to call “the sickest generation” trope, often used by antivaxers and quacks to claim that their favorite bogeyman, be it vaccines, GMOs, wifi, or whatever, is making our children sick. Does the claim stand up to scrutiny?

The sickest generation?

Before I discuss whether, in fact, 54% of our children have one or more chronic illnesses, it is useful to take note of where that claim came from. The first time I heard Williamson make it a month or two ago, I immediately recognized it as an antivaccine talking point. Even though I don’t recall Williamson ever using the term, it is a variation of “the sickest generation” trope, a trope frequently invoked by antivaxer Robert F. Kennedy, Jr., such as when he referred to this generation of children as the “sickest generation in history.” Indeed, although the term didn’t originate with RFK Jr., as far as I can tell he is the first to have fused it with the very specific claim that 54% of children have some chronic illness or other. Basically, the first instance of the claim that I could find (and, I concede, I might have missed earlier instances, but I doubt it) was on RFK Jr.’s Childhood Health Defense website in a post “Too Many Sick Children” posted last December, complete with a video:

It opens with a simple statement, “The health of our children has declined dramatically over the past few decades.” After a list of prevalences of health problems among children, the video concludes, “VISION: A world free of childhood chronic health conditions caused by harmful environmental exposures” and:

Get involved. With your help and support, Children’s Health Defense will defend the health of our children in American and around the world, tackle the known exposures that are harming our children, hold those responsible accountable for their actions, and establish safeguards to prevent theses injuries from ever happening again.

Translation of “exposures”: Vaccines.

In any event, in the link above you can sign up for an e-book entitled The Sickest Generation: The Facts Behind the Children’s Health Crisis and Why it Needs to End . I took one for the team and entered a throwaway email address to sign up to get a link to the ebook. Fortunately it’s only 29 pages. It does, however, pack a lot of antivaccine tropes into its thin pages, including the bogus claim of an “autism epidemic” that ignores the effects of diagnostic substitution, broadening of the diagnostic criteria, and more intensive screening.

Indeed, there’s so much deceptive weaving of statistics in the ebook that it might take multiple posts to unpack it, which is why for now I’ll stick with discussing the primary claim parroted by Williamson that 54% of our children are chronically ill. I will, however, show you just where this report is coming from by showing you a screenshot of a graph in the ebook. It’s about the most obviously deceptive attempt to confuse correlation with causation I’ve seen in antivaccine propaganda.

Back to the claim that 54% of our children have chronic illness. The primary study cited to back that figure up is a 2011 study based on the 2007 National Survey of Children’s health. The aims of the study were:

to evaluate national and state prevalence of health problems and special health care needs in US children

to estimate health care quality related to adequacy and consistency of insurance coverage, access to specialist, mental health and preventive medical and dental care, developmental screening, and whether children meet criteria for having a medical home, including care coordination and family centeredness

to assess differences in health and health care quality for children by insurance type, special health care needs status, race/ethnicity, and/or state of residence.

Basically, the investigators used the 2007 NSCH to derive national and state level estimates of prevalence of health problems.

The 2007 NSCH included 91,642 children aged 0–17 years. The key graph is here:

There are several things to note, The study found that, overall, 19.2% of children met the criteria for Children with Special Health Care Needs, defined as children who “have or are at increased risk for chronic physical, developmental, behavioral or emotional conditions and who also require health and related services of a type or amount beyond that required by children generally.” That is, of course, a rather broad definition and would be expected to produce larger estimate. As was pointed out at Vaccines Work, the estimate that 54% of children have chronic illness of some sort includes children who are obese (which has nothing to do with vaccines, although occasionally antivaxers will claim obesity is related to vaccination) and have risk of developmental delay, which is likely correlated with the number of premature babies surviving birth and the number of drug-addicted babies surviving birth, not vaccines. (We already have numerous studies that do not support a link between developmental delays and vaccines.) It was also noted that the children in this study were born before specific vaccines were routinely recommended during pregnancy; so that can’t be a factor either. In addition, we have numerous studies showing no link between vaccines and allergies and asthma, the latter of which far more likely to be associated with pollution and lack of exposure to the microbiome. In fairness, RFK Jr.’s report does mention pollution as a potential contributor to childhood chronic illness. (He was an evironmentalist before he became an antivaxer. How could he not mention pollution?) However, vaccines are by far the “potential cause” of chronic childhood illness given the most verbiage in this ebook.

Basically, the claim that 54% of children in the US are chronically ill takes the most inclusive definition of chronic illness. The comparison to a figure of only 12.8% of American children having a chronic illness before the NCVIA is also a deceptive sleight-of-hand. For one thing, the study upon which that estimate was based was an entirely different study published in JAMA in 2010 using a different data source and different methodology. The authors of this study used the National Longitudinal Survey of Youth–Child Cohort (1988-2006) of 3 nationally representative cohorts of children, an ongoing survey that collects annual data from a national probability sample of youth aged 14-21 years in 1979 regarding their health, education, and employment. The study focused on three cohorts of children aged 2-8 in the years examined: 1988 (Cohort 1); 1994 (Cohort 2); and 2000 (Cohort 3). The authors also asked about a different set of chronic conditions. The finding was that the end-study prevalence of any chronic health condition was 12.8% for cohort 1 in 1994, 25.1% for cohort 2 in 2000, and 26.6% for cohort 3 in 2006.

The authors noted:

Many factors may have contributed, including environmental changes, which may affect rates of chronic respiratory conditions46 and obesity,47 better survival rates of conditions such as prematurity,5 and the development of “late effects” of some treatments, such as chemotherapy.34 Medicaid expansions and the State Children’s Health Insurance Plan (S-CHIP) increased access to health care during the time this study was conducted,48,49 and children in later cohorts would have had greater opportunities for diagnosis and ongoing treatment of their chronic conditions. This may be especially true for less severe conditions that rarely flare to the point of needing emergent care. The push for increased surveillance for behavior/learning problems in children may have identified cases that would have previously gone undiagnosed. For some behavior/learning problems, patients qualify for therapies only with a diagnosis; thus, diagnosis may be influenced by pursuit of treatment.

Yes, you don’t diagnose what you don’t look for, especially milder conditions, and access to care will produce more diagnoses of chronic conditions. S-CHIP, as you might recall, was passed into law in 1997 and provided insurance to uninsured children in families with incomes that are modest but too high to qualify for Medicaid. Indeed, I can’t help but point out that the 1994 cohort was roughly around the time that the vaccine schedule started to expand and right when the diagnostic criteria for autism were broadened in the DSM-IV, also published in 1994. If you look at the percentage changes between the 1994 and 2000 cohorts, you’ll see that it’s not nearly as impressive. Indeed, even the change from the 1988 and 1994 cohorts isn’t as impressive as comparing the 12.8% prevalence of chronic illness in the 1988 cohort to the estimate of 54% in the 2011 study. It’s almost as though RFK Jr. and Children’s Health Defense were going out of their way to produce the largest increase in prevalence they could find that almost perfectly correlated with the introduction of the Vaccine Court the year after the NCVIA was passed, differences in methodology and databases be damned. After all, antivaxers wouldn’t play fast and loose with studies, would they?

The authors also noted:

A surprising finding is that many children with a reported chronic condition at ages 2 through 8 years did not have the condition 6 years later. Additionally, most chronic conditions at the end of each study period represented new conditions that developed in the previous 6 years. This dynamism challenges the notion that chronic conditions persist without change. Although having a chronic condition in childhood is a risk factor for having the same chronic condition later, many chronic conditions appear to remit for a significant period before relapsing or resolve completely. After cancer treatment, a child may no longer fit criteria for having a chronic condition, although late effects can result in other conditions.34 Many young children with developmental delay receive therapy during critical years before catching up.35,36 A child’s natural development helps resolve conditions such as chronic constipation. For conditions where symptoms wax and wane, mild cases may be more common and likelier to remit, while severe cases may persist.17

This brings up another point. Unlike the case in adults, the prevalences of individual chronic illnesses in children are dynamic, as discussed above. A significant portion of children with developmental delay “catch up” and lose the diagnosis. This makes a blanket statement about the prevalence of “chronic illness” of the type that RFK Jr. is making incredibly simplistic. Just to illustrate, I further note that in 2007 a whole issue of JAMA was devoted to children’s health, in which one systematic review reported that the definition of chronic illness was very critical in estimating prevalence, listing estimates of the prevalence of chronic illness in children ranging from 0.22% to 44%, depending on specific operationalization of the definition. Another review from that issue estimated that the 1994-1995 National Health Interview Survey on Disability indicated that chronic conditions of any type affect 15% to 18% of US children and adolescents but also noted that “these estimates substantially undercount some prevalent conditions, especially obesity and mental health conditions.” This was over 20 years ago.

So what is the actual state of our children’s health?

There is no doubt that the prevalence of chronic illness among children is higher now than it was 30 years ago. At the very least, changes in diagnostic criteria and more intensive screening for some conditions would have changed the apparent prevalence of common conditions even in the absence of changes in the “true” prevalence. Moreover, if you count obesity as a chronic illness you’ll definitely find a large increase, given the more than tripling in the prevalence childhood obesity over the last 40 years.

Dr. Vincent Ianelli, a pediatrician who runs Vaxopedia, tried to put things in perspective:

If you have only been listening to the alarmists who talk about the unhealthiest generation all of the time, you likely wouldn’t know that: while 2.6% of kids were thought to be in fair or poor health in 1991, that is down to just 1.8% today (2015)

fewer kids today (4.5%) report having had an asthma attack in the previous year than they did in 1997 (5.4%), and that fewer kids have asthma today (8.5%) than in 2003 (8.7%)

since 1997, fewer children, whether or not they have insurance, are visiting the emergency room

fewer children are requiring overnight hospital stays, down from 5.5% to just 2.1% today (2015)

rates of hay fever or respiratory allergy are down since 1997, from 17.5% of kids to 15.6% of kids today (2015)

rates of epilepsy have been stable in children for at least 40 years

fewer kids have multiple ear infections since 1997, when 7.1% of kids had 3 or more ear infections, to just 5% of kids today (2015)

fewer kids are being prescribed antibiotics

childhood cancer rates have been rising, but only slightly, and mortality rates have been declining

suicide rates are rising, but only from historic lows – they used to be about the same or higher in the early 1990s

He does concede that the prevalence of some conditions is on the rise, including ADHD, type 1 diabetes, food allergies, eczema, obesity, and most autoimmune diseases. Why might that be? Perrin et al. commented on this in that 2007 issue of JAMA on childhood chronic illness:

A few conditions have decreased because of prevention (eg, lead encephalopathy), a few represent relatively new conditions (eg, human immunodeficiency virus type 1 infection), and some have increased after dramatic improvements in survival for individually low-prevalence childhood conditions that previously had high fatality rates (eg, leukemia, cystic fibrosis, congenital heart diseases).6 Most growth, however, reflects dramatic increases in incidence of a few high-prevalence conditions.

These high prevalence conditions include mainly obesity and associated type II diabetes, asthma, attention-deficit/hyperactivity disorder (ADHD), and autism. Perrin et al. also note that for ADHD and autism, diagnoses have definitely increased, although it’s not clear that actual prevalence has. (For instance, there was no entry for ADHD in the American Psychiatric Association manual until 1968). Even so, according to the 2015 National Health Interview Survey, among those under 18, more than 85% are in excellent or very good health, which is roughly in line with what we would expect if around 15% (or even a little more) of children had chronic health problems.

So are our children the “sickest generation”? My conclusion is that it’s highly unlikely that they are. At the very minimum, ironically enough, vaccines have prevented many sources of illness, including chronic illness. For example, polio is no longer paralyzing thousands of children every year. While it is true that there has been a rise in the prevalence of certain high prevalence chronic conditions, many of them are well-managed and it’s not clear for every illness or chronic condition how much of the observed increase in prevalence is due to increased diagnosis of previously undiagnosed conditions versus an actual increase in prevalence. More importantly, estimates of chronic illness in childhood are highly dependent on the operational definition of chronic illness. Worse, the claim that 54% of our children have some sort of chronic illness is based primarily on a single cherry-picked study that is compared with another cherry-picked study for the pre-NCVIA estimate of chronic illness used by antivaxers to make it look as though the overall prevalence of childhood chronic illness has increased more than four-fold in the last 30 years. Even more deceptive is the linking of that dubious estimated increase in childhood chronic illness to a timeline that allows antivaxers to spread a narrative that it’s vaccines causing it. Thus, even if we concede that today’s children represent “the sickest generation,” we already know that vaccines aren’t the cause, the efforts of RFK Jr. and his fellow antivaxers to promote the narrative that vaccines are the cause notwithstanding.

Finally, I’ll conclude by saying that we don’t need another President who spouts dubious statistics from conspiracy mongering websites.