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Regular readers of my not-so-secret other blog are probably aware that a week and a half ago I went undercover, into the belly of the beast so to speak, to an antivaccine panel discussion held by a local candidate for Congress and featuring my state representative, Jeff Noble. They also know that last week antivaxers were trying to entice me into appearing on a panel with antivaxers as the token pro-science skeptic. (I declined, but did get a fun blog post out of it.) These two recent events got me to thinking—or perhaps I should say “thinking again”—about the tactics and tropes favored by the antivaccine movement. This thinking came into relief when I came across this not so little gem of antivaccine misdirection by an old “friend” of mine, J.B. Handley.

J.B. Handley and I go back a long way. He first appeared on my not-so-secret other blog as a commenter sometime in 2005, if I recall correctly, but quickly disappeared when he realized that his antivaccine pseudoscience wasn’t persuading anyone, least of all me. You might recall that Handley and his wife founded the antivaccine group Generation Rescue, which later became Jenny McCarthy’s antivaccine group when she became its president. (She’s still on the group’s board of directors.) Generation Rescue began primarily as a flagbearer for what I used to like to call the “mercury militia,” a branch of the antivaccine movement whose central belief was that the mercury in the thimerosal preservative that was in some childhood vaccines until 2002 was the primary cause of the so-called “autism epidemic.” However, as it became clearer and clearer after the removal of thimerosal from childhood vaccines that autism rates were not declining, meaning that there was no link between mercury in vaccines and autism, Handley pivoted to claiming that autism and other neurodevelopmental disorders are caused by “an overload of heavy metals, live viruses, and bacteria,” and that the primary causes of the alleged autism epidemic “[included] the tripling of vaccines given to children in the last 15 years (mercury, aluminum and live viruses); maternal toxic load and prenatal vaccines; heavy metals like mercury in our air, water, and food; and the overuse of antibiotics.” In other words, he switched from a hypothesis that was rapidly being falsified to one that is damned near unfalsifiable.

Since then, I’ve mentioned Handley’s activities from time to time, such as when he gloated over the decline in confidence in vaccines among parents, in essence taking credit for it; attacked Steve Novella; launched a misogynistic attack on a female journalist who had written a pro-vaccine article; and in general demonstrating a high level of Dunning-Kruger effect.

This time around, he reminded me of one of the two main tactics of antivaxers, a tactic that isn’t covered enough. Basically, there are two central tenets of antivaccine pseudoscience. The first, of course, is that vaccines are harmful because they’re chock full of toxins and cause all sorts of horrific health problems. Skeptics refute this type of misinformation quite well. However, the second tenet of antivaccine pseudoscience is that vaccines don’t work (or don’t work very well) and as a result are not nearly as beneficial as vaccine advocates claim. One variety of this “vaccines don’t work” trope is what I like to refer to as the “vaccines didn’t save us” gambit, which is essentially the claim that vaccines had little to do with the decline in infectious disease over the last century. You can tell that’s the trope by the title of Handley’s blog post, “Did vaccines save humanity?” I will give Handley credit for one thing. This is a wrinkle on this hoary old bit of antivaccine intellectual dishonesty that I haven’t seen before.

Handley attacks a massive strawman

You know Handley’s argument is going to be dicey right from the opening passage of his blog post:

Since 1900, the mortality rate in America has declined by roughly 74%, creating a dramatic improvement in quality of life and life expectancy for Americans. The simple question is, “Why?” Why did the mortality rate decline so precipitously? If you listen to vaccine promoters, the answer is simple: vaccines saved us. What’s crazy about this narrative is how easy it is to disprove, the data is hiding in plain sight. The fact that this easily-proven-false narrative persists, however, tells us a lot about the world we live in, and I hope will encourage parents to reconsider the veracity of many of the narratives they’ve been fed about vaccines.

Can you spot the straw man? It should be fairly easy for SBM readers. Basically, no scientist I know of is claiming that vaccines are responsible for all or most of the 74% decline in mortality observed over the 73 year period that Handley references in his post. Basically, what he’s doing is what we call inflating the denominator, which means making the denominator as huge as he can in order to make the percentage that he gets when he divides the numerator by it as small as possible. Of course, you know what the numerator is going to be. That’s right, deaths prevented by vaccines.

But does Handley have a point? Not really, as you will see. Rather, what he does is to cherry pick and misinterpret a handful of studies, take some not unreasonable cautioning by some scientists in the past, and mixing them together to make the deceptive claim that vaccines do very little good.

Edward Kass in 1970

The first piece of evidence that Handley cites is a speech by Edward Kass, MD, who at the time was President of the Infectious Diseases Society of America. Now, Mr. Handley might be forgiven if he doesn’t realize that speeches that the outgoing President of a medical society give are not the same as peer-reviewed evidence. I’ve been to a lot of these speeches, and one thing I’ve realized over the years is that there is a subset of them in which the society’s president is trying to tweak his membership, to challenge them with a controversial viewpoint. Dr. Kass’ speech, which was published in The Journal of Infectious Diseases in January 1971, strikes me as just that variety of presidential speech. In it, he cautioned his fellow infectious disease doctors and researchers that what they do didn’t have as large an influence as they like to think on mortality. Indeed, the title of the speech is telling, “Infectious Diseases and Social Change“. Using Kass’s speech, Handley invokes the “vaccines didn’t save us” gambit based on the observation that the mortality from various infectious diseases had been declining for decades before the vaccines were introduced for them and how mortality from scarlet fever (for which there has never been a widely used vaccine) was also in decline.

Handley again beats the straw man:

At the time, Dr. Kass was actually the President of the organization, which made the things he had to say about vaccines and their impact on the reduction in American mortality rates even more shocking, at least by today’s standards. Forty-eight years after Dr. Kass’ speech, vaccines have taken on a mythological status in many corners of our world, hyped up by the people who benefit the most from their use. Of course vaccines saved the world. Of course every child should get every vaccine. If you don’t vaccinate, you will enable the return of deadly childhood diseases. If you don’t vaccinate, your child will die. If you question vaccines, even a little, you’re an “anti-vaxxer” who should be shunned and dismissed!

Reading over Dr. Kass’s actual speech, I noted right away that it was not an antivaccine speech. Far from it. Handley opines that Kass “never referred to vaccines as “mankind’s greatest invention” or one of the other many hyperbolic ways vaccines are described all the time by vaccine promoters in the press today”, but, then, why would he have? His speech wasn’t about vaccines. Handley, of course, is very impressed by this particular quote from Kass:

…we had accepted some half truths and had stopped searching for the whole truths. The principal half truths were that medical research had stamped out the great killers of the past —tuberculosis, diphtheria, pneumonia, puerperal sepsis, etc. —and that medical research and our superior system of medical care were major factors extending life expectancy, thus providing the American people with the highest level of health available in the world. That these are half truths is known but is perhaps not as well known as it should be.

Of course, I can’t help but point out that, even if you accept the premise that these are “half truths,” that doesn’t mean medicine doesn’t work, and it doesn’t mean that vaccines weren’t important. Quite simply, Dr. Kass was pointing out that a lot of the improvement in our health has been due to improved socio-economic conditions and then went on to speculate about potential mechanisms. Handley quotes the first, but not the second, part of this passage. Here’s what Handley quoted:

This decline in rates of certain disorders, correlated roughly with socioeconomic circumstances, is merely the most important happening in the history of the health of man, yet we have only the vaguest and most general notions about how it happened and by what mechanisms socioeconomic improvement and decreased rates of certain diseases run in parallel.

Which is true but incomplete. Here’s what Kass said next:

We know that for many infectious diseases, such as poliomyelitis and perhaps infectious hepatitis, the trend is opposite, and for some there is little or no socioeconomic status.

So the relationship, while common, is not absolute. He also noted that there is little evidence that nutritional improvements account for the decline in mortality from common infections. So what does account for the differences? Kass speculated:

What other explanations are there for the effects of being poor? One explanation was developed in England more than 40 years ago (figure 6). It was shown that rates of rheumatic heart disease were almost linearly related to crowding at home. This is understandable since spread by droplet infection is greatest in a narrow radius around an infected source and the home is, particularly for children the place in which most prolonged contact will occur.

Kass also cited data from World War I that showed that when beds in barracks were placed too close together rates of meningococcal infection among troops rose abruptly and a study from Baltimore that showed in African-American children that attack rates for rheumatic behavior were not related to low income or lower educational attainment, but were directly related to the number of people per bedroom.

Of course, what Kass was really showing was that there are more ways to prevent disease than just vaccines, and this is hardly a message that anyone in public health would dispute. Nor is it a message that shows that vaccines don’t work. I’ll elaborate more as I discuss the next reference cherry picked by Mr. Handley.

“McKinlay & McKinlay”, or: Look how J.B. Handley had to go back 40 years to find a paper supporting him

Mr. Handley refers to his next piece of evidence as the “the most famous study you’ve never heard of”. I wouldn’t quite say that. For one thing, it’s not a study, but rather an opinion piece that reads like a book chapter more than anything else. Naturally, as I always do, I read all 23 pages of the article, entitled “The Questionable Contribution of Medical Measures to the Decline of Mortality in the United States in the Twentieth Century“. Unlike Mr. Handley, I didn’t find it a difficult read at all, although I did think that at points John and Sonja McKinlay (the authors were a husband-and-wife team of epidemiologists) overstate their case. Certainly, whenever I see a paper start with a subsection title of “Introducing a Medical Heresy”, my skeptical antennae start twitching a bit. I also couldn’t help but think “Grandiose, much?” when I read the first paragraph:

The modern “heresy” that medical care (as it is traditionally conceived) is generally unrelated to improvements in the health of populations (as distinct from individuals) is still dismissed as thinkable in much the same way as the so-called heresies of former times. And this is despite a long history of support in popular and scientific writings as well as from able minds in a variety of disciplines. History is replete with examples of how, understandably enough, self-interested individuals and groups denounced customs and beliefs which appeared to threaten their own domains of practice, thereby rendering them heresies (for example physicians’ denunciation of midwives as witches, during the Middle Ages). We also know that vast institutional resources have often been deployed to neutralize challenges to the assumptions upon which everyday organizational activities were founded and legitimated (for example, the Spanish Inquisition).

Because nobody expects…the Spanish Inquisition!

Sorry, I couldn’t resist. However, I must say that my skeptical antennae started twitching so mightily when I saw McKinlay and McKinlay invoke the Spanish Inquisition as an appropriate comparison to medical orthodoxy. Comparing medicine to religion, no wonder Handley liked this article so much:

The study clearly proved, with data, something that the McKinlay’s acknowledged might be viewed by some as medical “heresy.” Namely: …that the introduction of specific medical measures and/or the expansion of medical services are generally not responsible for most of the modern decline in mortality. By “medical measures,” the McKinlay’s really meant ANYTHING modern medicine had come up with, whether that was antibiotics, vaccines, new prescription drugs, whatever. The McKinlay’s 23-page study really should be read cover to cover, but in a nutshell the McKinlay’s sought to analyze how much of an impact medical interventions (antibiotics, surgery, vaccines) had on this massive decline in mortality rates between 1900 and 1970:

And here’s the graph:

So, yes, there was a remarkable decline in mortality from 1900-1973. Of course, once again, this is inflating the denominator, because this is all mortality, not just mortality from vaccine-preventable diseases or childhood mortality. In a later graph, he looks at what proportion of the total mortality reduction was represented by various infectious diseases, finding that only the declines in tuberculosis and pneumonia mortality were fairly large percentages of the overall decline 1973 (16.5% and 11.7%, respectively) and that the percent of the total decline in mortality from the other eight conditions examined (scarlet fever, diphtheria, influenza, whooping cough, measles, smallpox, polio, and typhoid) combined was less than 12%.

This leads McKinlay and McKinlay to conclude:

Even if it were assumed that this change was entirely due to the vaccines, then only about one percent of the decline following interventions for the diseases considered here could be attributed to medical measures. Rather more conservatively, if we attribute some of the subsequent fall in the death rates for pneumonia, influenza, whooping cough, and diphtheria to medical measures, then perhaps 3.5 percent of the fall in the overall death rate can be explained through medical intervention in the major infectious diseases considered here. Indeed, given that it is precisely for these diseases that medicine claims most success in lowering mortality, 3.5 percent probably represents a reasonable upper-limit estimate of the total contribution of medical measures to the decline in mortality in the United States since 1900.

Of course, I can’t help but point out that, even if this pessimistic estimate were accurate, that would still be millions of lives saved over that 73 year period. There’s also another problem, and McKinlay and McKinlay themselves note it. Mortality statistics over such a long time period are fraught with difficulties. For instance, there were changes in registration areas in the US in the early 20th century. Also, often no single disease, but a combination of conditions, is responsible for death. Moreover, studies show considerable inaccuracies in reporting the cause of death, and, just as relevant, there are changes over time in what is fashionable to diagnose. Add to that how some conditions cause immediate death, while others don’t. For example, consider scarlet fever. Untreated, it can result in rheumatic heart disease, but that usually doesn’t kill for decades. Indeed, my grandmother was an example. She had rheumatic heart disease after having had scarlet fever as a child. Eventually she needed a valve replacement. So if someone dies of rheumatic heart disease at age 60, is the cause of death heart disease or scarlet fever? Also, there are a lot of conditions that are debilitating but don’t cause immediate death. It’s true that over the last 50 years reporting has become a lot more standardized, but if you’re looking at statistics going back into the 19th century, you have to wonder how accurate they are.

Here’s another issue. Everybody dies. I like to say that life is a sexually transmitted terminal disease. If you don’t die of an infectious disease, you’ll die of something else eventually. That’s just the way it is. Heck, even McKinlay and McKinlay show that in this article with a graph showing the decreasing percentage of people dying of infectious disease being compensated for by the increasing percentage of people dying of chronic diseases and diseases of aging. In other words, it’s complex.

Of course, as I said the last time I discussed the “vaccines didn’t save us” gambit, there’s another problem with the use of mortality statistics über alles. They completely ignore incidence of the disease being prevented by vaccines. For instance, yes, mortality from measles was falling long before the vaccine—decades in fact. However, incidence, albeit fluctuating yearly, remained roughly the same until the measles vaccine was introduced, after which the incidence fell precipitously. And that’s the problem. Consideration of mortality alone as the be-all and end-all of whether a vaccine works completely ignores all the morbidity, all the suffering caused by infectious disease. By this analysis (and to J.B. Handley), none of that matters.

Vital statistics abused

The next paper used and abused by Handley is a paper published in 2000 by epidemiologists from both Johns Hopkins and the Centers for Disease Control entitled “Annual Summary of Vital Statistics: Trends in the Health of Americans During the 20th Century“. You can see why from the selective quote he chooses to highlight:

Thus vaccination does not account for the impressive declines in mortality seen in the first half of the century…nearly 90% of the decline in infectious disease mortality among US children occurred before 1940, when few antibiotics or vaccine were available.

No one ever said that vaccination did account for the impressive declines in mortality seen in the first half of the 20th century. Antivaxers like Handley like to make that claim, either explicitly or implicitly, but that doesn’t make it so. In fact, what’s interesting about this paper is that it actually explains the likely reason why mortality due to infectious diseases declined in the first half of the 20th century:

The major declines in child mortality that occurred in the first third of the 20th century have been attributed to a combination of improved socioeconomic conditions in this country and the public health strategies to protect the health of Americans. These public health measures included the establishment of local health departments in nearly all of the states. State and local health departments implemented these public health measures, including water treatment, food safety, organized solid waste disposal, and public education about hygienic practices. These improvements in water and food safety and purity are linked to the major decline in diarrheal diseases seen in the early years of the century. Similarly, improvements in housing and decreased crowding in US cities are linked to the reductions in mortality from tuberculosis and other diseases attributable to person-to-person airborne transmission.

The paper also notes:

Thus, vaccination does not account for the impressive declines in mortality seen in the first half of the century. The reductions in vaccine-preventable diseases, however, are impressive. In the early 1920s, diphtheria accounted for 175,000 cases annually and pertussis for nearly 150,000 cases; measles accounted for about half a million annual cases before the introduction of vaccine in the 1960s. Deaths from these diseases have been virtually eliminated, as have deaths from Haemophilus influenzae, tetanus, and poliomyelitis.

In other words, socioeconomic changes decreased mortality from vaccine-preventable diseases before the actual vaccines were developed, but the vaccines were important and remain important in preventing diseases and the morbidity and mortality from those diseases. Funny how J.B. Handley neglected to mention this part of the paper.

The Aaby Study

The hits keep coming from J.B. Handley, as anyone who knows him would expect. Next up:

Published in the peer-reviewed journal EBioMedicine in 2017, the study is titled, “The Introduction of Diphtheria-Tetanus-Pertussis and Oral Polio Vaccine Among Young Infants in an Urban African Community: A Natural Experiment.” Researchers from the Research Center for Vitamins and Vaccines, Statens Serum Institut (Denmark), and Bandim Health Project looked closely at data from the West African nation of Guinea-Bissau. The scientists in this study closely explored the concept of NSEs, “nonspecific effects” of vaccines, which is a fancy way of saying vaccines may make a child more susceptible to other infections. They found that the data for African children who had been vaccinated with the DTP vaccine: was associated with 5-fold higher mortality than being unvaccinated. No prospective study has shown beneficial survival effects of DTP. . . . DTP is the most widely used vaccine. . . . All currently available evidence suggests that DTP vaccine may kill more children from other causes than it saves from diphtheria, tetanus, or pertussis. Though a vaccine protects children against the target disease, it may simultaneously increase susceptibility to unrelated infections.

Wow. Sounds damning.

Not surprisingly, it’s not. As Skeptical Raptor noted, the study was tiny, and the number of deaths studied was even tinier. Also, the deaths were not categorized. Basically, this was a typical small study with questionable results.

What J.B. Handley missed.

I could go on and on and on about how Handley has weaponized the Dunning-Kruger effect to cherry pick articles that he can spin to make it seem as though vaccines are not effective. More recent studies show that vaccination does indeed save lives. For example:

Childhood vaccination, and in particular measles and tetanus vaccination, is associated with substantial reductions in childhood mortality. We estimated that children in clusters with complete vaccination coverage have a relative risk of mortality that is 0.73 (95% confidence interval: 0.68, 0.77) times that of children in a cluster with no vaccinations. Although widely used, basic vaccines still have coverage rates well below 100% in many countries, and our results emphasize the effectiveness of increasing coverage rates in order to reduce child mortality.

Meanwhile, the dreaded CDC notes:

Strategic vaccination campaigns have virtually eliminated diseases that previously were common in the United States, including diphtheria, tetanus, poliomyelitis, smallpox, measles, mumps, rubella, and Haemophilus influenzae type b meningitis (8). With the licensure of the combined diphtheria and tetanus toxoids and pertussis vaccine in 1949, state and local health departments instituted vaccination programs, aimed primarily at poor children. In 1955, the introduction of the Salk poliovirus vaccine led to federal funding of state and local childhood vaccination programs. In 1962, a federally coordinated vaccination program was established through the passage of the Vaccination Assistance Act–landmark legislation that has been renewed continuously and now supports the purchase and administration of a full range of childhood vaccines.

Precisely.

The use of mortality as the be-all and end-all of vaccine efficacy is an intentional strategy of the antivaccine movement. This strategy completely ignores the morbidity and suffering due to vaccine-preventable diseases.

J.B. Handley, on the other hand, thinks this (if you can call it thinking):

So am I saying no one should vaccinate? No, I’m not. Vaccines provide temporary protection from certain acute illnesses. Some matter more than others. I think we give way too many vaccines, and I think the risk/benefit equation of each vaccine is never properly revealed to parents. Worse, the lie that vaccines saved humanity in the twentieth century has turned many vaccine promoters into zealots, even though their narratives are simply not supported by the facts.

As a counter-point:

A greater than 92% decline in cases and a 99% or greater decline in deaths due to diseases prevented by vaccines recommended before 1980 were shown for diphtheria, mumps, pertussis, and tetanus. Endemic transmission of poliovirus and measles and rubella viruses has been eliminated in the United States; smallpox has been eradicated worldwide. Declines were 80% or greater for cases and deaths of most vaccine-preventable diseases targeted since 1980 including hepatitis A, acute hepatitis B, Hib, and varicella. Declines in cases and deaths of invasive S pneumoniae were 34% and 25%, respectively.

And, from the World Health Organization:

Ehreth estimates that vaccines annually prevent almost 6 million deaths worldwide. In the USA, there has been a 99% decrease in incidence for the nine diseases for which vaccines have been recommended for decades, accompanied by a similar decline in mortality and disease sequelae.

No, the only one spreading lies here is Mr. Handley, who is also attacking an obvious straw man. Vaccines work.

The bottom line is that vaccines are safe, effective, and prevent disease. Yes, sanitation and public health measures decreased mortality from infectious diseases before vaccines for them were developed, but that doesn’t mean that they don’t work or aren’t important. The “vaccines didn’t save us” gambit, as demonstrated by J.B. Handley, remains intellectually dishonest.