It always irritates me when I discover a new antivaccine crank in my state; so you can imagine how irritated I become when I discover one right in my very city (OK, metropolitan area). When that happens, it becomes a bit more personal than my usual mission to refute antivaccine misinformation. So I was most alarmed when I discovered just such a beast because a former ScienceBlogs colleague now writing for Forbes, Dr. Peter Lipson, took the time to deconstruct a very ill-informed piece of antivaccine propaganda. The offending post appeared on the blog of a "holistic" physician named Dr. David Brownstein, and in it he complained about new vaccine requirements at a summer camp. Apparently, Dr. Brownstein was not at all pleased at being publicly taken to task for spreading antivaccine misinformation, leading him to write a deceptively titled post using a title that I've seen antivaccinationists use, in one form or other, many times during the eleven years I've been in the blog biz. Yes, Dr. Brownstein entitled his post The Great Vaccine Debate, but in reality it was more or less a heapin' helpin' of the "toxin gambit," anti-big pharma ranting, and a whole lot of tone trolling complaining about how Dr. Lipson had been so very, very mean to him, because he had called Dr. Brownstein's arguments "bullshit." Specifically, he referred to them as "total bullshit. It’s not even good bullshit, but bullshit that has long been known to be, well, bullshit."

Oh, dear. Poor Dr. Brownstein. Did Dr. Lipson hurt his widdle feelings? Too bad for Dr. Brownstein that his arguments are indeed bullshit—in both of his posts. If Dr. Brownstein wants to vie for the title of the "Dr. Bob" Sears of southeast Michigan, he needs to have a thicker skin and be better prepared to defend his statements; unfortunately for him, his arguments and responses to Dr. Lipson's spot-on criticism can only be described as pathetic. Let's just put it this way. Respect is earned, and Dr. Brownstein clearly failed to earn Dr. Lipson's respect.

In any case, perhaps it was incorrect to say that Dr. Lipson's post at Forbes led me to "discover" Dr. Brownstein. I actually have heard of him before. Indeed, I had placed his blog in my folder of woo as potential subject some day and forgotten about him. So I'm happy that Dr. Lipson's little tussle with him brought him back to my attention. First, a little background is in order. This is what set Dr. Brownstein off:

As a child, I attended sleepover camp as many Jewish children did. Camp Tamarack is the largest (or one of the largest) Fresh Air Society camps in the U.S. Some of my favorite memories from my childhood occurred at Camp Tamarack. I still have many Tamarack friends that I still connect with. This summer, I hosted a reunion for my Tamarack friends and it was truly a wonderful, memorable evening. Yesterday, (12.30.15) Tamarack Camps put out a vaccine edict that mandates, “No child, camper, staff, artist in residence, volunteer, doctor, nurse, and their families will be allowed to come to camp without documentation of complete immunization according to the policy.” The immunization policy states that everyone is to have age-appropriate vaccines according to the CDC which includes: DTaP, DT, Td, or Tdap

IPV

HIB

PCV 13

Rotavirus vaccine

Hepatitis B

Hepatitis A (strongly recommended)

MMR or serologic evidence of immunity

Varicella vaccine (chicken pox)

Menactra

Flu vaccine (strongly recommended)

Of course, this sounds like an eminently reasonable policy to me. After all, summer camp is not unlike school in that there are a lot of children frequently crammed into relatively small areas, such as the cabins. Sure, the kids will be off doing summer camp things, but a lot of other activities involve being in close-in quarters, particularly at night in the sleeping area, which are usually bunk beds in a large cabin. So it would make sense for camps to require the same vaccines required to enter school. Dr. Lipson explains why camps like Tamarack Camps are important to the large Jewish population in the northern suburbs of Detroit:

Dr. Brownstein practices in the heart of Michigan’s Jewish community. Among American Jews, summer camping has been an important part of childhood for nearly a century. In the early part of the 20th century, it was felt that city children would benefit greatly from exposure to nature. Jews were not allowed to attend most camps and started their own. The tradition has remained strong. I spend a week every summer helping to keep an eye on the kids at one such camp. During the flu epidemic of 2008–09, I watched as dozens of kids came down with a new flu strain, one for which a shot had not yet been developed. It was a frightening lesson in what can happen in unvaccinated populations. Thankfully, the strain wasn’t deadly in this population. Among the hardest hit were pregnant women.

I did not know this bit of history about Jewish camps in southeast Michigan, but then I'm not Jewish. Still, it makes sense to me. In particular, though, I like the reasoning behind this new vaccine requirement at Tamarack Camps:

In the letter I received, the Tamarack-Powers-That-Be state, “Given the overriding Jewish value of Pikuach Nefesh (saving a life), that puts a premium on maintaining health, including taking preventive measures, along with the clear public health based need to protect the camp community as a whole, and those unable to receive vaccines in particular, we are requiring that all campers, staff, artists in residence, volunteers, doctors, nurses, and their families planning to attend/participate in any Tamarack Camps programs be immunized…”

As regular readers know, I'm not particularly religious (an understatement). However, this policy and the rationale for it demonstrate that in some cases religious principles can certainly be a force for promoting science-based health care. In this case, it's a principle of promoting saving lives, and being vaccinated is a simple and effective way not only to maintain one's own health through protection against vaccine-preventable diseases but by contributing to herd immunity that protects the vulnerable who, for whatever medical reason, cannot be vaccinated. The rant that Dr. Brownstein follows up his introduction with is indeed, as Dr. Lipson correctly characterized it, bullshit. It's antivaccine bullshit of the lowest, easiest to refute order, and Dr. Lipson did an admirable job. Even so, before I move on to Dr. Brownstein's counterattack, I can't resist having a little swipe myself at things at the scraps Dr. Lipson left behind.

First up, Dr. Brownstein delivers up a hunk of burning stupid:

Perhaps Camp Tamarack is unaware that over $3 billion has been awarded by the Federal Government to children and adults injured by vaccines. Maybe Camp Tamarack can assure all who will have to be fully vaccinated to attend camp that it is safe to inject numerous doses of neurotoxins like mercury, aluminum and formaldehyde into any living being. As far as I am aware, there are zero—ZERO—safety studies on injecting a neurotoxin into a living being. I would like to see where Jewish law says it is safe to inject a neurotoxin into a baby or any living being.

So much antivaccine misinformation, so little time. I give Dr. Brownstein credit for combining the "toxins gambit," common misinformation about the National Vaccine Injury Compensation Program used by antivaccinationists as propaganda, and the claim that there are no safety studies of thimerosal. The last one is particularly amusing because thimerosal was removed from most child vaccines in 2001; the only vaccine left that has thimerosal is the flu vaccine, and even then most flu vaccines are thimerosal-free. As for safety studies of thimerosal, how about these big studies that show no link between thimerosal and neurodevelopmental disorders or autism? No doubt Dr. Brownstein will dismiss them because they were done by the CDC (antivaccinationists are very predictable that way) or will claim that they are not the "right kind" of safety study, but they were done specifically to try to detect correlations between the use of thimerosal-containing vaccines and adverse neurological outcomes. That's a safety study in my book. I also remind Dr. Brownstein that he said that there were no safety studies on thimerosal. No, he said that there are "zero—ZERO—safety studies," a claim he doubled down on in his second post. I just showed that there are at least three. There are, in fact, more than that that I could list, had I a mind to. On this issue, Dr. Brownstein's claim is clearly incorrect, as it's easy to demonstrate. If he had tried to argue the strengths and weaknesses of the existing safety studies, then there might have been a productive discussion (that is, assuming he could resist dismissing studies just because the CDC or a pharmaceutical company had anything to do with them). Heck, he could even have cited some execrable Mark Geier studies claiming to have found various dangers due to thimerosal in vaccines, but he didn't, even though those bits of pseudoscience could easily be considered safety studies too. Unfortunately, like a five year old not liking what he hears Dr. Brownstein simply denied that there were any such studies at all.

Then he even invokes the "CDC whistleblower" manufactroversy:

Maybe Camp Tamarack should take notice that there is a whistle blower at the CDC—a senior scientist who authored research papers on childhood vaccinations—who has stated that the CDC has hidden and altered data that confirmed a link with the MMR vaccine to autism.

Um, no. Just no. This "CDC whistleblower," a rather confused CDC scientist named William Thompson, showed nothing fo the sort. If anything, the antivaccine "reanalysis" done on his data proved Andrew Wakefield wrong yet again. There is no association between MMR and autism. Brownstein also mentions the so-called "Merck whistleblower." Let's just say there's a lot less to that story than meets the eye, certainly less than antivaccine "holistic doctors" like Dr. Brownstein would like you to think. Let's also just say that, even if everything both "whistleblowers" said were true, it would not prove that vaccines are unsafe, because there are many other studies that show them to be safe and effective.

Elsewhere, Dr. Brownstein trots out familiar (and easily refuted) antivaccine propaganda talking points, in particular the myth of the "autism" epidemic and an "epidemic" of chronic illness and how these "epidemics" supposedly correlate with the increase in vaccines in the recommended vaccine schedule. Cementing Dr. Brownstein's status as seemingly being a Dr. Bob wannabe, Brownstein then invokes the antivaccine dog whistle of "parental rights" and "health choice" near the end of his first post. He even parrots the antivaccine myth of viral shedding in which children vaccinated with attenuated live virus vaccines are portrayed as a danger due to "viral shedding." The truth is much different.

Amusingly, Dr. Brownstein's response to Dr. Lipson's critique of his collection of discredited antivaccine talking points is even more pathetic than the original post that provoked Dr. Lipson in the first place.

He begins with a straw man:

Dr. Lipson must be poorly informed here as there has not been a single flu vaccine—and the flu vaccine has been around for over 70 years–that has been shown to work for the elderly. In the best of the flu studies (which are hard to find), the efficacy for younger people is around 7-10%. That means the vaccine fails nearly all the elderly and fails around 90% of younger subjects. Dr. Lipson might want to review the research on the flu vaccine for the elderly. A 2005 study of a 33-season national data set found the “…national influenza mortality rate among seniors increased in the 1980s and 1990s as the senior vaccination coverage quadrupled.” (Arch. Int. Med. 2005;165:265-272). A 2012 systemic review found the original recommendation to vaccinate the elderly was made without data for vaccine efficacy or effectiveness. (Lancet Infect. Dis. 2012;12:36-44). Nothing much has changed since then. And, injecting the elderly with mercury? Nonsense. More about that later.

Of course, Dr. Lipson didn't claim that the flu vaccine was great in the elderly. He simply pointed out that his elderly patients who got serious cases of the flu might not have gotten it if others around them had been immunized against the flu. Annoyingly, Dr. Brownstein didn't include the link to PubMed entries for these studies, necessitating my manually looking them up. (Hint: it's good form to link to studies you're discussing to make it easy for people to look them up and compare them with how you're characterizing them. I always do it.) For instance, this first study does seem to indicate poor vaccine efficacy in the elderly, and yes, the Lancet systematic review did note that evidence was lacking for flu vaccine efficacy in the elderly while noting that it does provide moderate protection in everyone else. Of course, one notes that Dr. Brownstein ignored a more recent study that found that flu vaccines were effective in the elderly. The point is not to argue about the flu vaccine in the elderly, however. Again, that's a straw man, and we know that the flu vaccine's efficacy in the elderly is not what we'd like it to be, hence efforts to design more immunogenic flu vaccines for people over 65. We know that the flu vaccine is not the best vaccine, but we do know that it is efficacious enough to recommend to most people and that vaccinating younger people does protect older people from the same strains, as Dr. Crislip explained in his review of the evidence for flu vaccine efficacy.

Next up, this is how Dr. Lipson criticized Dr. Brownstein's argument that if Camp Tamarack hadn't had an outbreak of vaccine-preventable disease, then there's no point in mandating vaccines:

I call this the “seat belt” argument. I’ve never been in a serious crash, but studies clearly show that if I were, wearing a seat belt could make the difference between life and death. The same is true for vaccination. While we may not see a lot of tetanus in this country, we still need to protect ourselves. Tetanus is a particularly hideous death, and we see so little precisely because of our vaccination efforts.

Here, Dr. Brownstein engages in a little misdirection. Ignoring Dr. Lipson's broader point about vaccine protection, he latches on to the example that Dr. Lipson chose, that of tetanus:

As far as I know, tetanus is not a communicable disease. Therefore, I am not sure why Dr. Lipson is arguing this point. How much tetanus do we see? According to the CDC, from 2001-2008, there were 233 cases of tetanus out of 322 million people. The annual incidence is 0.1 per 1,000,000 population. During this time period, among 92 subjects, out of the 233 reported cases where the vaccination status was available, 60% were vaccinated. In other words, the majority who got tetanus were vaccinated. Do we need to give routine tetanus shots to 322 million people to prevent about 30 cases of tetanus per year? Will that work? Those are questions that need to be answered. Moreover, the Td vaccine (Tetanus vaccine in multi dose vials) still contains mercury. Dr. Lipson is fine injecting mercury into people, but I am not.

Ugh. The stupid, it burns us. (No doubt Dr. Brownstein, if he sees this post, will howl with indignation that I characterized his argument as "stupid." He can either just deal with it or stop making stupid arguments. His choice.) It apparently never occurs to him that the reason that the incidence of tetanus is so low is because of high uptake of the tetanus vaccine in the DTap and Tdap vaccines, where the "T" stands for tetanus. Tetanus incidence began falling after the vaccine was introduced in the 1930s and 1940s, with incidence having fallen by 95% and deaths by more than 99%. In any event, the reason Dr. Lipson used the tetanus vaccine as an example is to explain why just because there hasn't been a major outbreak at a Camp Tamarack isn't a reason not to act to protect against one. This is particularly true given the recent Disneyland measles outbreak.

Dr. Brownstein then goes on to make a rather astonishing claim, namely that the "U.S. vaccine market is projected to rise to $100 billion dollars by 2025. While this is true based on a WHO report, one thing Dr. Brownstein neglects to point out is that this is total revenue, not profit. If you look at the profitability of vaccines critically, you can see that vaccines tend to be less profitable because non-vaccine pharmaceuticals have a lower cost of goods because of fewer returns due to spoilage and distribution is a lot more expensive because they need to be shipped more carefully to avoid spoilage. But, for the sake of argument, let's assume vaccines have, after not being very profitable in the past (which they weren't) become wildly profitable. They're still only around 3% of the pharmaceutical market, and they are worth the cost.

Much of the rest of Dr. Brownstein's "rebuttal" is more of the same antivaccine talking points: the "toxins" gambit on steroids, with a particularly mind-meltingly silly variant:

Formaldehyde is a known carcinogen. Yes, it is produced in tiny amounts in the body. As with injecting anything, there is 100% absorption of formaldehyde via injection. There are reports of inflammatory diseases developing after injection of formaldehyde in vaccines. (Cutan. Med Surg. 2015 Sep-Oct;19(5):504-6) Formaldehyde is a direct acting genotoxic compound that affects multiple gene expression pathways including those involved in DNA synthesis and repair.

The stupid, it still burns! Yes, formaldehyde is a carcinogen, but only at orders of magnitude higher and longer exposures than vaccines could ever achieve! Otherwise, it is a normal product of metabolism, and the amount of formaldehyde found in an infant's circulation is at least five times more than an infant would encounter due to vaccines. As for that case report, it describes a man with an allergic reaction to formaldehyde causing contact dermatitis. The report goes on to note: "A review of the literature revealed 2 cases of systemic contact dermatitis from formaldehyde derived from aspartame and 1 case from a thimerosal-containing influenza vaccine. No cases caused by formaldehyde in influenza or other vaccines were found." In other words, this phenomenon is incredibly rare, so rare that it merited a case report! I do give Dr. Brownstein credit for his mad cherry picking skillz, though.

It's really scary to see a primary care physician with such ignorance of science and such obvious antivaccine proclivities. No antivaccine trope seems to be too pseudoscientific for him, it would seem, not the "toxins" gambit, not the ranting about thimerosal and aluminum, not the whole scale buy-in to the latest antivaccine conspiracy theory, the CDC "whistleblower," not fear mongering about formaldehyde, not the abuse of the "science was wrong before" trope through liberal mentions of Vioxx, not outrageous conspiracy theories about big pharma. Indeed, Dr. Brownstein's ranting about big pharma's supposed vaccine profiteering strikes me as particularly hilarious given that a glance at the front page of his very own website reveals that he is not at all adverse to a bit of profit himself. Yes, he sells all manner of books and DVDs with titles like Drugs That Don't Work and Natural Therapies That Do, The Miracle of Natural Hormones, The Statin Disaster, and several others. He has a supplement store that sells Celtic Sea Salt and Iodoral, and many others through his Center for Holistic Medicine. He even sells what I consider to be The One Quackery To Rule Them All, homeopathic remedies. Elsewhere, he claims he identifies "heavy metal toxicity" in over 80% of his patients using provoked urine tests, which involve administering a chelating agent before collecting urine for the test. One notes that such "challenge tests" were specifically mentioned by Choosing Wisely as a test that should not be done and has no value because it will result in seemingly elevated urine levels of heavy metals even in patients with no disease.

Sadly, after perusing Dr. Brownstein's site, it's hard for me not to conclude that he is antivaccine to the core. He doesn't even put up much of a pretense of claiming to be a "vaccine safety activist" rather than "antivaccine," particularly when posts by him having to do with vaccines buy into even the most idiotic antivaccine tropes and bear titles like:

I mean, seriously. There were times when I was having a hard time telling whether I was reading something by an actual doctor or one of the screeds over at that wretched hive of scum and antivaccine quackery, Age of Autism. That Dr. Lipson annoyed ticked Dr. Brownstein off enough for him to go on the attack is a badge of honor for Dr. Lipson, for which I congratulate him. Dr. Brownstein should also be profoundly embarrassed, as it seems as though he's been reading from a list of spectacularly bad antivaccine arguments. Heck, he even looks to be trying to contribute to the list himself. Finally, the management of Tamarack Camps is to be commended for requiring that its campers and staff be vaccinated. It's the right thing to do.