Why I support ABA Insurance Billing Changes

I am aware there is some concern over proposals in various States to force insurance providers to cover ABA as it relates to autism. I am going to take what may be an unpopular position and argue in favor of such. I understand this may frustrate some of my fellow bloggers; and while this is unfortunate, I think most of our peers at the hub will at least hear my reasons. Maybe a question-answer format will best address this?

Q. Why support the proposals regarding Insurance support for ABA and autism?
A. All students have a right to an educational method that actually can successfully teach them. The idea of what constitutes appropriate goals of education is in debate. Regardless, the zeitgeist in the human service field is toward evidence based practice. This concept props up research based teaching and begins to fade pure theory based teaching.

Currently there are four methods of teaching relative to autism that have some level of support. One is ABA, also TEACCH, Occupational therapy, and speech therapy. That is it…. There is nothing else with an evidence base beyond quasi-experimental designs. I will advocate for any of these four, although speech and OT are often alreadt covered under insurance.

Q. But ABA has been called into question?
A. The groups designs have been questioned to a degree, not the single case designs, of which there are multiple examples and which are consistent and well designed for a number of techniques. ABA literature in autism has developed to the point where there are often multiple research based techniques available for teaching the same skill. This is not opinion, it is fact.

Q. So, why support the law if it only supports ABA?
A. I am all for allowing TEACCH to written in as well, but I am not going to pull my support for that reason. It is not personal; I would still support this proposal even if it was TEACCH that was being promoted.

Q. But ABA targets autistic behaviors, not just academics, right?
A. Yes it does…. so advocate for a focus on academics and what you believe to be more appropriate behavioral goals. I am not unsympathetic, but I will not pull my support for what would have to be a shift of the whole human service field. If you think that general eclectic or Floortime programs are somehow even one mote more respectful of inherent autistic differences then you are simply wrong. In fact I cannot think of any programs that can be considered exemplary in this regard, not even Montessori schools. If that changes I am happy to revise my opinion.

Q. This medicalizes autism, don’t you think?
A. Autism is already deeply medicalized. It is a billable code for many… many services. The services range from the evidence based to Jungian/Tibetan sand play therapy, under the guise of counseling for teens with autism.

Q. Well, then we shouldn’t feed further into the medicalization of autism, right?
A. Fine, so advocate that terms be changed to better fit the view of autism you wish to promote. The reality is some autistic students need tutoring or additional educational work, just like some typically developing students do. They still have a right to have substantiated practices used to educate them….again… just like their typically developing students do.

Q. Then why not put them into standard tutoring, just like their typically developing peers?
A. Do not confuse equality and equity. They are not the same thing.

As always, comments welcome below.

Using the Word “Retard”

It is disappointing for me whenever I hear someone use the word “retard” as an insult. I am sure this is not a unique experience amongst hub bloggers. Nor are we likely to be the only ones who feel this way. The Special Olympics has even come out with an r-word petition.

But in some ways… maybe many ways, this isn’t going to change things. I am prepared to argue that the use of word “retard” as a pejorative is most common (although grown ups make this sort of error too) among teens. I want to focus on that in this post. In my view, there are rather unique motivation factors that influence teen behavior and make this behavior particularly likely.

There seems to almost be a mystique attached to teenage verbal misbehavior by our culture. References are made to hormonal imbalances and changing brain structures as if layman’s appeals to the medical model are somehow a sufficient answer in and of themselves.

In contrast I tend to look at the fact that teens are by definition at a point of transition. The simple and often direct contingencies of behavior management that have governed their lives up till this point are being faded and more cognitive or delayed rule-based-behavior contingencies are replacing them. Concepts, memes, and ideals become increasingly important. As these shifts take over, the teens become more able to discriminate contradictions, exceptions, and inconsistencies.

However, until these discriminations are firm, there will be uncertainty as to what constitutes acceptable limits of a given contingency. The teens will, as we say “test the boundaries”. Moreover, if a teacher or caregiver adds in a simple contingency to counter this, there may well be an inadvertent counter contingency. This happens all the time with swearing. It is punished when emitted in front of a teacher, but reinforced in the presence of peers. This reinforcing aspect is possibly increased by aggression reinforcers, based on a time when emitting the same word was punished. In other words, the more it is punished in one situation the more reinforcing it is in another.

I have spent a fair amount of time working with teens both with and without disabilities. It seemed the more I discouraged the use of this term the more the teens employed it. Some used it, I think; to get a reaction out of me. So, I made a classic mistake. I increased the severity of my reaction. Whereas before, I gave a verbal reprimand, I now gave written write-ups. This did eliminate the behavior around me, but it continued when I was not around. I wonder in the end, if my actions made a lick of difference in this regard.

Upon reflection maybe there was another strategy. Maybe instead of punishment I could have employed a specific explanation illustrating the rule based contingencies that controlled my own behavior. In other words, I could explain why I chose not to use the word “retard” as a pejorative. This may or may not result in a shift in the contingencies.

Ultimately, if I am correct about the managing contingencies, then strategies where the use of the word “retard” is turned into the equivalent of a swear word, will only increase the usage of this expression.

There is yet another strategy too. I think it is inevitable that many teens are going to at one point or another emit comments that are rude, cruel, or derogatory toward an entire classification of people. Perhaps then, another strategy is to tolerate the misbehavior to degree. This does not imply acceptance, it implies that we understand that this is likely to be an age specific misbehavior that will be intrinsically countered as maturation occurs. If this is true, then our duty is then to provide appropriate models of the verbal behavior employed by adults in our society.

A Review of Insidevaccines’ “Scary Stats IV: Polio”.

I would like to take this opportunity to review “Scary Stats IV: Polio”. This is my third review of an article from the Insidevaccines blog. Some might wonder why I am reviewing a science issue not related to autism. Well, as said before, Insidevaccines is sometimes described as a model of good science. They are quoted on occasion by those advocating a vaccine etiology theory of autism.

I was very interested to see how well this claim held up. Vaccines are by no means perfect, they do cause injury, and it is possible that they cause at least some cases of autism. Any clarity on vaccine science, even if it points toward an uncomfortable truth, is a good thing. However, one will not find that at Insidevaccines. The first two articles I reviewed had rather remarkable errors of logic and science, this one was no different.

The worst problem in the article is the graph of polio over the years that appears early in the article. It correlates polio with DDT and other chemicals. This is cherry picking on an absolutely epic level. The authors at Insidevaccines state that the discussion will not address the relationship between DDT and polio. The authors give their rationale for using this graph as being that it begins earlier and gives a more accurate picture of the pattern and extent of disease notifications prior to the Salk vaccine. Further, Insidevaccines links to the same or similar graph stretching back further into the 1800s and based on general historical commentary to produce the data points.

The source of the graph is a New Age site promoting a range of metaphysical ideas and alternative medicine, complete with advertising tours for sacred places of power. However, what is interesting is that the site author does not even get simple ideas like incidence correct. Further still, the site author doesn’t mention how s/he obtained the data for the first half of the 20th century.

So, this is what Insidevaccines leaves us; a graph the veracity of which we cannot check, which attempts to correlate DDT and other chemicals to Polio. I argue that their choice was an inappropriate and ill served their readership. That they did not address the argument for DDT as a cause of polio is no excuse. In the realm of science, even in the realm of popular science you present what you mean. If the authors at Insidevaccines do not agree with the DDT argument then they should have created their own graph. Or if they did agree they should have offered their support for this idea. By leaving it as is, their actions do lend themselves to charitable description.

The authors write (references removed):

“Depending on whether you consult the CDC data compiled for parents or the CDC data compiled for medical professionals, the fatality rate for paralytic polio is between either 2-5% or 5-10%."

If one journeys to the source one will see that the CDC is providing a general rate and then a rate for a specific age group.

“The actual historical data from the peak years: 19,794 avg. acute cases in 1941-1950, which is 0.6% of the total average births for the US from 1941-1950”

Actually, based on the sources the authors’ provide, they miscalculated here. It should be 1.0% of the total average births.

“In 1951-1954, an avg. 16,316 paralytic cases (notice that this data conveniently stops at the time of the definition change and the introduction of the Salk vaccine, thus implying that subsequent reduction in incidence is due to the vaccine. Unfortunately for this hypothesis, the Salk vaccine was shown to have very little positive effect, prompting the switch to the Sabin vaccine)”

A lesser effect is not the same as “little positive effect”. In fact in the field trials, the Salk vaccine was found to be over at least 60% effective for all subtypes of polio and often more than 90% effective (Smith, 1990).

“Based on Table 1, using the hypothetical birth cohort of 3,803,295 infants as stated in the article, we get 1,179 paralytic cases per year, with an estimated 23 (2%) to 118 (10%) deaths. For 60,974 cases of polio, using CDC metrics of 200:1 inapparent:paralytic (leaving aside how they can project an estimate for an inapparent infection), we would get 3,048 cases of paralytic polio, resulting in 61 (2%) to 305 (10%) deaths, rather than 723.”

The Insidevaccines authors are taking a rate from a single age group and trying to apply it across ages. This comparison has no validity.

“So, what can we conclude from these discrepancies and contradictions? The data doesn’t support the headlines. The numbers presented by vaccine defenders do not stand up to scrutiny.”

Actually it is the poor mathematical practice used by Insidevaccines that is the problem here.

“Our analysis above shows that data are not consistent within an individual publication, or from one publication to the next.”

Offering different rates based on age cohorts or via total should not be a problem for a careful reader. The authors at Insidevaccines have failed to exercise this concept.

“Sometimes, they do not even correlate with numbers from the CDC, an organization whose primary objective appears to be the defense of vaccines!”

This is a ridiculous claim. One does not have to like the CDC or even think they are good people, to recognize this claim as absurd.

“Is their work just sloppy, erroneous, or intentionally misleading? Are they so focused on marketing the vaccines that they are unwilling to critically parse the data? Perhaps they think parents aren’t paying attention.”

Insidevaccines has made basic errors in mathematics, reasonable comparison, data checking, and graphical presentation. Are they prepared to argue that they are paying attention?

In the first article I reviewed from Insidevaccines the authors note that many who advocate for vaccines want nothing to do selective or delayed vaccinators. The authors challenge this stance, as delayed or selective vaccinators may be allies who advocate for certain vaccines. In response, I wrote a number of concerns I think should be addressed before any collaboration was considered. I would like to add a few more.

I think potential allies:

Should accurately quote science

Should not pull graphical shenanigans

Should not mis-compare data

There is room for disagreement and debate in the world of vaccines and autism. Any site that offers science or criticism that illuminates the issue is a blessing. Unfortunately, it is clear that this role will not be fulfilled by Insidevaccines.

Reference

Smith, Jane S. (1990). Patenting the Sun: Polio and the Salk Vaccine.

Mercury challenge misunderstandings: A guide especially for parents new to autism

Making decisions as a parent of a child diagnosed with autism can be tough. This doesn’t mean it has to be, just that it can be. One of the reasons it can be tough is that popular culture or the internet will bombard you with a variety of education plans, treatments, or therapies, many of which will claim to be scientifically proven or evidence based, but very few of which even come close.

One of the popular theories in the US, is that autism is caused by one or more forms of mercury. Where the mercury comes from depends on who you talk to, vaccines, dental fillings, fish, lights, computer screens, forest fires, and cremations have all been named as suspect. That may seem tricky enough, but the real question is in how children diagnosed with autism deal with the mercury.

Some sources claim that children diagnosed with autism are poor excretors of mercury. In other words for some reason they don’t get rid of the mercury their body accumulates (either in a fast or slow way) and that it poisons them and results in autism. For this group the advocates claim that mercury poisoning is difficult to assess. They may recommend assessing other biological factors as evidence. Or they may recommend a challenge (provoked) test for mercury.

Just to be clear, a provoked test is when a chelating agent is given to the patient and then the mercury test is administered. Some chelating agents bind to mercury and/or other heavy metals making it much more likely that they will be cleared from the body. This step is important for advocates of the poor excretor hypothesis, because they argue that the chelating agent captures mercury in the body. An increase between a non-provoked test and a provoked test is evidence of this according to certain parties. Or even without this non-provoked test, a provoked test that comes back in an elevated range can be evidence of this all by itself. However, others who advocate a mercury etiology of autism theory do not seem to put stock in the poor excretor theory. They advocate straightforward testing without a provoked test.

For a parent considering heavy metals testing a good first step is to decide which variant you believe in. These theories cannot both be true, they are exclusive. Children with autism are either poor excretors or they are not. And while some might try to be ingenious and claim that sometimes it is one and sometimes it is the other, I would ask the reader to decide whether this is truly a valid argument.

If a parent decides that the poor excretor hypothesis is unlikely, then there is no need for a provoked test.

If on the other hand a parent decides the poor excretor hypothesis is valid then a provoked test may seem reasonable. This is where my concerns begin.

My core concern is this; there is no mercury scale that was normalized with participants who were first given a provoking agent. This means that any of the provoked measurement will have to be compared to a scale established only with non-provoked samples. This is innately invalid, and yes, invalid is the right word here.

This is why: When one wants to establish a statistical scale, one must first create the conditions under which data will be collected. After data are collected a mean (average) is determined as is the standard deviation, which is simply a statistical way of determining how far away (in either direction) a given score is from the average. However, if you try to compare a given score taken under different conditions from how the scale was formed, it is no longer meaningful.

These data taken under different conditions were not included when the mean or standard deviations were calculated. For them there is neither mean nor standard deviation. The comparison is meaningless, and there is no way right to compensate for this problem at the moment. And while this may be a standard practice for many labs and practitioners, anyone who tells you these tests can be used to determine mercury poisoning is not using any recognized standard of science or statistics.

If you are a parent please be aware of these facts when you consider a provoked test.

Mercury Autism Tests Are Flawed

Please everyone go read the Quackwatch article on urine metal testing. The article makes it crystal clear what the problems with this technique are. If you are a parent of a child diagnosed with autism who is considering or has done heavy metals testing you will especially find this article interesting.

Confusing Literary Criticism for Science

Continuing to read up on the Insidevaccines group blog I decided to search their blog on my own interest which is Autism. I then found and read Helen Tucker’s “Bad Writing Can’t Save a Bad Study” published by Insidevaccines under a new title of “Vaccine Science??? Part II”. Having read Tucker’s piece, I read the article she reviewed, and then re-read Tuckers criticism. There are indeed a number of problems with Barlow et al. (2001), but what is remarkable, is that Tucker cannot seem to correctly identify a single one of them. Instead what Tucker offers us might be called a form of literary criticism.

“The entire paper was a convoluted description of how Barlow et al whittled the 679,942 children they said they studied in the abstract, to the 624 children they actually did study. The procedure was so complex that they used up most of the “Methods” section to explain it, and then resorted to a flow chart to present the final sample size as one of the results of the study.”

First, the entire paper is not a description of the ascertainment procedure, but instead contains all the appropriate components we should expect to see. Anyone who has thirty seconds can verify this. Second, saying the authors “used up” the methods section is silly. The methods section is as long as it needs to be. In fact in some research with complex procedures, the methods section is notably longer than what we find here. What is an actual concern in writing up research is a page limit for a given journal. This means authors must sometimes weigh what get the most attention. However, this is not the same thing as what Tucker describes.

Continuing, in the methods section the authors do describe a complex procedure. They are both scrupulous and clear in the description of ascertainment. This does not mean they lack the necessary parts. They have headings for (1) Study Sites, Sources of Data, and Identification and Classification of Cases, (2) Data on Immunization, (3) Statistical Analysis, and (4) Follow-up Study. Moreover, in the results section the authors do use a flow chart to present data on what they found in terms of unanalyzed data for seizures. Frankly, so what? Tucker’s criticism here has absolutely zero bearing on statistical problems or internal validity.

“They did not find any increased risk for nonfebrile seizures for either vaccine, compared to the control group (the non-recently-vaccinated). Any increased risks were then downplayed by comparing study seizure rates with “background” seizure rates obtained from the same HMO’s.”

No, they didn’t downplay increased risk. The authors are very clear here; there is no room for confusion and no reason to state that risks were downplayed. Here is what the authors actually said:

“Using the background rates of seizure in the Group Health Cooperative, we found that there were 5.6 and 25.0 additional febrile seizures per 100,000 children receiving DTP and MMR vaccines, respectively. Using published background rates of seizure from Kaiser Permanente of Northern California, we found that there were 8.9 and 34.2 additional febrile seizures per 100,000 children immunized with DTP and MMR vaccines, respectively.16 For these calculations, we used the estimated relative risks in Table 1 for each period of exposure, since these are the best estimates.”

“This paper is so muddled that it is tempting to suspect that it is muddled on purpose, as if to obscure fundamental flaws in its design. However, in the end, the flaws are too monumental to hide behind a fog.”

And yet Tucker never seems able to cogently present what flaws these might be.

“A relative risk study should have never been retroactive in the first place–it would have been easier and more scientifically valid to follow children who were either vaccinated or not vaccinated.”

Again, Tucker misses the boat. Relative risk studies can be, and are indeed done all the time using databases that were already in existence. That data have already been collected is in itself a frivolous criticism. The actual concern should be how well the given database controls for the 6 types of random and systematic statistical error and how well the authors collect those data. Building a case for how they collected data from the Vaccine Safety Database (VSD) is something the authors spend a fair amount of time doing in their methods section.

“The risk ratios are meaningless without knowing how many study and control children did not have seizures.”

Huh? Yes they did! The way data were collected there is a bias towards missing seizures that did not require hospitalization. However, there is no reason to think that severe seizures should bias the association, as the authors themselves note. Based on what the data indicate the authors can calculate how many children did not have seizure… at least severe enough to warrant hospitalization.

“The control group itself was poorly distinguished from the study group (recently vaccinated vs. non-recently-vaccinated), especially in a long-term study.”

From the article:

“The reference group at the time of the seizure was composed of children matched for
age, calendar time, and HMO but who had not had a vaccination in the preceding 30 days.”

So, actually the difference was between groups was quite clear. As to the long-term follow up why would it be different if not explicitly stated? The authors noted at least one such explicit difference in their description of the follow-up study.

“Inclusion in and exclusions from the study were inadequately justified, yielding a sample that cannot be considered representative–of anything.”

The authors explicitly describe who was included and who was not. As to her comment about not representative, I have no idea what logical process she took to reach such a conclusion.

From the article:

“716 were confirmed to have had a first seizure during the study period. The primary
reason for nonconfirmation was the identification of an earlier seizure.”

So, the author didn’t include kids who had an earlier seizure. In other words the study is representative of kids who didn’t already have seizures at the time of their DTP and MMR…. seems pretty fair to me.

“And perhaps the most glaring of all, the follow-up study excluded the most widely reported neurobehavioral diagnoses temporally associated with vaccines: non-infantile autism and pervasive developmental disorders. Murkiness on details can’t hide errors this egregious.”

The authors use the clinical manual of the ICD-9, this is appropriate as this is what the doctors used to report to the HMOs in the United States. And while some of the PDD criteria are used in current autism epidemiology via the ICD-10, the practical everyday reporting happens with the ICD-9-CM. However, most of the recent autism epidemiology in the West is done using the DSM-IV-TR, a completely different manual altogether.

Tucker’s criticism here is unfortunate, because at the year of publication there was little evidence that other PPDs and specifically PDD-NOS make up the majority of the PDDs in the epidemiology. In fact the good epidemiology such as Bertrand et al. (2001) and Chakrabarti & Fombonne (2001) used to help establish this fact would first appear in the same year as Barlow et al., but wouldn’t receive confirmation until Chakrabarti & Fombonne (2005) several years later.

In summary, Tucker indentifies no statistical problems, nor concerns with instrumentation, history, or selection bias. In fact Tucker identifies no threats to the validity of Barlow et al. I like reading science criticism and I like reading literary criticism, but I prefer a cleaner delineation between the two.

Further, some criticism needs to be directed at Insidevaccines. This may not have been their article, but they selected to reprint it in full with author permission, but without comment and give it blog-time on their site. Again they are the ones promoting it and so can be held in part accountable for its lack of quality. That one or more of them didn’t write it is irrelevant; it is re-printed in full on their blog, this is what matters.

For a blog that gets promoted as a model of good science I have thus far been very disappointed by Insidevaccinesm both in the current post and in the one I reviewed the other day. More time will be needed to see if some of their other “heavy science” articles are better than this. And while forming a group that looks at vaccine issues from a variety of viewpoints might be a good thing, sacrificing science in the process is not.

References

Bertrand, J., Mars, A., Boyle, C., Bove, F., Yeargin-Allsop, M., & Decoufle, P.(2001). Pediatrics, 108, 1155-161.

Chakrabarti, S., & Fombonne, E. (2001). Pervasive developmental disorders in preschool children. Journal of the American Medical Association, 285,3093-3099.

Chakrabarti, S., Fombonne, E., (2005). Pervasive developmental disorders in preschool children: confirmation of high prevalence. American Journal ofPsychiatry, 162(6), 1133-1141.

A Review of “Vaccines? Safe. Parents? Dangerous”.

“Inside Vaccines” is an interesting blog that offers views from a variety of standpoints concerning vaccines issues. Like many group blogs the articles differ massively in quality. This blog is seen by some as a model of good debate and scientific advocacy and is promoted by certain parties as such. For my part, I think someone really ought to systematically review “Inside Vaccines” and see how well this claim holds up to scrutiny. Some of the articles seem a bit creative in their interpretation of epidemiology.

Relative to our topic today, I would like to review “Vaccines? Safe. Parents? Dangerous”. I cannot determine whether this post has one or many authors. This is of no concern. What is a concern is the attitude toward science promoted within the posting. I will quote large chunks of the post and my reply to them below.

“Lately I’ve been noticing an increasing number of journal articles, blog articles and opinion pieces on a terrible problem: Parents have questions about vaccines.”

This is not a problem. It is reasonable and perhaps necessary to inspect both current health issues and older science from time to time. Scouring for merit and questioning are the tools by which correction of science may occur. However, what is a problem is the promotion of pseudo or anti-science under the guise of self-correction. For many of us, this is our concern, not the legitimate questioning of science.

“You would have to look far and wide to find anyone who thinks that these questions are valid and should be taken seriously.”

Perhaps the author(s) of the post have done neither.

“Common explanations are:1) It is all about the parents who think they are really smart.2) It is all about the parents who are very stupid and read stuff on the Internet.3) It is all about the bad stuff on the Internet which is deceiving the parents who aren’t very smart and who think they are smarter than doctors. And infinite variations on this theme, which is really one argument…and the real argument is (drum roll)…vaccines are perfect and parents are the problem.”


And do we see this among the science based bloggers or scientists that are well known? Or is this a reference to Mr. Haggen-Daas, your grumpy and opinionated old neighbor down the street. If you mean the former, I think I am going to have to ask for quotes or call straw argument at this point.

“Oddly, however, the number of parents with questions seems to be increasing. Perhaps the vaccine defenders need to reconsider their approach.”

Yes, the numbers do seem to be going up. That is okay, questioning is not the problem. I don’t think science has anything to fear from questions. On the other hand, there is a big problem when information is dressed up as science, but is actually.... not science.

Let me be direct here. I do not care if people question vaccines. For that matter I do not care if the majority people hear a variety of argument and adopt a very different view from the one I hold. What I do care about is the consistent application of science; this is a concern based on logic. What I also care about is that people have a right to be given accurate even if emotionally hurtful information; this is a concern based on ethics.

“Here are some suggestions, kindly meant, from an admirer of their efforts. These guys have put a lot of sweat equity into defending vaccines and they ought to be getting better results”

Why so? People exposed to our arguments will still make up their own minds. Our efforts do not somehow intrinsically merit the greater popularity. Of actual concern to me and those like me is how science is used and promoted.

“One argument which comes up over and over again is herd immunity.”

This actually seems to be a talking point of the vaccine etiology of harm theory advocates, not of those bloggers who hold a similar view to myself. I am not saying that it is never used, but that it is rare. In fact, I would argue that herd immunity is one of the favored whipping-boys of those who advocate a vaccine etiology of harm theory and that mention of it is disproportionate. I think a great little “study” would be to look at the Autism Hub and look at the Age of Autism blog and see how many times “herd immunity” pops up and who uses it. The results could be quite interesting no matter what they find.

“In addition to the defenders acting as though all vaccines are identical in their efficacy, safety and relevance, they also tend to act as though all vaccine questioners are identical. Anyone who has a question, is, in the defenders view, anti-vaccine.”

You treat us as monolithic; moreover you offer no quotes or references for such an opinion. Your comment here should not be mistaken as being logically sound.

“And people who are anti-vaccine are bad people. As a result the defenders respond with sarcasm, rudeness and repetition.””

There are indeed people who are largely or wholly anti-vaccine. They are not the majority, but they are out there. I do not think of them as bad people. I do not think of them as fools. I understand too, that all people are going to occasionally land on a stupid, illogical, or anti-scientific comment, perhaps in spite of their general inclinations. To counter-act this, I select to make my own arguments which attack and correct the errors that I see. Some people may be hurt by the information I provide or by the questions I pose. Even so, I am obligated to speak up if I see a problem, this is the same for anyone and everyone. I would cite failure to do so, as a form of unethical behavior.

“Some parents who raise concerns are just raising concerns. They haven’t gone over to the dark side. But with enough rudeness and sarcasm from the vaccine defenders they will definitely be moving in that direction.”

They may, but that is their choice. Do not misplace their decision on others. Please note, I am advocating neither the appropriateness of rudeness nor sarcasm, but only that people can select a course based on what they value. In my view however, this course of action is particularly illogical. It is not their emotions or desire to be treated with respect that is illogical, but their decision based on their emotions. Most of us will have had a teacher at some point in our lives we could not stand. Does this somehow make what they taught us untrue? Do we now have license to reject fact, because we were mistreated?

“Which leads me to the next problem. It is not, absolutely not, all about autism and vaccines.”

True, but for many of us coming from many views, this is indeed the main bone in contention.

“Try being polite and sympathetic. I know this is tough and doesn’t come naturally, but it is absolutely essential if the vaccine defenders want to get anywhere in this battle.”

I understand polite, but what do you mean by sympathetic? Do you mean that I should:

A) Consider the author’s view and try to understand their feelings?
B) Accept (or at least avoid questioning) certain accounts that my inclination towards science has taught me to question?
C) Both A and B
D) None of the above

There are two choices above that I am going to reject as being unethical.

“The articles on this blog provide good models for a sympathetic, thoughtful and scientifically oriented approach.”

I would be interested to know which of the above your particular post models.

“Vaccine defenders need to deal with the science. Saying that the science is all on the vaccine side, without actually presenting said science is a hollow argument.”

Here we stumble upon some agreement.

“A sub-point on science: the scandals about faked science in medical journals are undermining people’s faith in doctors and science in general. If Merck did some bad stuff with Vioxx, is it unreasonable to have questions about their trustworthiness when it comes to Gardasil? The defenders need to be able to explain why vaccines are an exception to dirty dealing from the pharmaceutical companies. I’m wondering about this one myself and look forward to seeing what the vaccine defenders come up with.”

It has been tackled before…. multiple times in fact. The blogosphere is a big place, no doubt explaining why you missed it. The answer is this; vaccines should not be a special case, but the general case. Because companies are run by imperfect beings they occasionally deal dishonestly. This is a very good reason to be careful, scientifically conservative, to expect replication, and to revisit old issues. This is no excuse at all to offer a carte blanche dismissal of well designed science.... no matter who funded it.

“Calling people anti-vaccine isn’t actually an argument.”

Exactly, it is a description that may or may not be accurate.

“Selective and delayed vaccinators are potential allies who will fight for vaccines, but currently the vaccine defenders want nothing to do with them. Some of these parents are quite knowledgeable and have done extensive research into vaccines. They know more of the science than the defenders, frankly.”

If you are going to offer an argument, then offer an argument please.

“But defenders want nothing to do with them, because in a black and white world you are either with us or against us and there is no middle ground. Pushing away allies is dumb.”

If we both advocate for certain vaccines then we are already allied on this particular issue, right? If this is the goal then we simply press on. But if what you mean is actually mutually coordinated advocacy then I would want to know to what extent you will be simultaneously advocating your other views that I do not agree with. And to what extent will I be creating a platform for you to advocate such views. Also, I would want to know whether I am expected to put aside our disagreements, because of our coordinated advocacy. Based on this cost-benefit analysis I may or may not see our collaboration as the best option. Perhaps too, the people who want nothing to do with the selective and delayed vaccinators see a proposed collaboration as creating more problems than it solves. I think mutually coordinated advocacy is possible, but a number of issues would have to be resolved first.

“Now comes a truly tough one: The vaccine defenders should be strongly, passionately, in favor of a philosophical exemption to vaccines.”

I am in favor of such, but not for scientific or practical reasons. My agreement here is based on an ethical reason, the right to self-determine, in this case via proxy. My agreement here is neither strong nor passionate. Instead it is tentative, quite possibly to be removed. The post author(s) predict that this would actually increase the vaccine rates. I see zero evidence for that. It may be true, but then maybe not. If not and certain vaccine rates plummet, then one or more very serious health issues could arise. If so, then I would argue that a significant amount of parents have failed to be a reasonable proxy for their child in this regard, and that philosophical vaccine exemptions should be removed.

“Now, listen carefully, because this is the most important point of all. Defenders should stop denying vaccine damage.”

Illness or injury from vaccination happens. A new or newly modified vaccine may not be as safe as initial tests suggest. A batch may go bad. An individual may have a unique or rare reaction. Although there may very well be disagreements about rates of injury, that fact that injury itself occurs is not a point of contention among any players in the debate.

“When a parent testifies that their child was damaged by a vaccine they should fall all over themselves to acknowledge what happened, to agree that vaccines can, indeed cause injuries, to encourage the parent to report what happened to VAERS, to sympathize if they say the doctor denied the incident and refused to report it.”

Wouldn’t this depend on the case? If you said that your child regressed a month after her MMR and now meets criteria for Autistic Disorder, I am probably going to question whether there is a connection. These events are not that close in proximity. I have reason to question and/ or to suggest that you question your assumptions. If I offer nothing but sympathy, then I am probably helping you feel better, but I am also engaging in enabling behavior towards anti-science. It seems to me that the author(s) try to assume the mantle of science, but reject it when expedient.

“They even see, as I recently did, a vaccine defender proclaiming gleefully that the VAERS system is useless and cannot be used as a source of information about the risks of vaccines. What sort of message are vaccine defenders sending out to the public? Clear enough, unfortunately.”

The VAERS does a good job doing what it was designed to do. Being a rapid and ongoing system to monitor and hopefully detect problems with vaccines. It is an imperfect system, but it does the job it was designed for. When it is forced fit into epidemiology then the VAERS has very little utility. It is a database that controls for none of the 6 types of statistical threats. It has been used this way by a variety of people working on a variety of issues. The VAERS data are un-refereed and uncontrolled. Don’t confuse monitoring and formal epidemiology, and don't twist a data set into something it is not.

“On the same note, a good study comparing vaccinated and unvaccinated populations will obviously prove that vaccines are safe, right? So why don’t the vaccine defenders fight for such a study? Vaccines make children healthier and the evidence should be easy enough to find. Yes?”

I have no problem with additional research. However, since this is what you are calling for, this is your burden.

“Are they really fighting to defend vaccines or are they just out there to tell everyone how smart they are? Some of us are wondering.”

Using an ad hominem to close I see.

Well, thank you for the advice. I would like to reciprocate your gesture and offer some advice too.

1) Do not claim to be an admirer of our efforts and then slander us with ad hominem arguments, we will note the inconsistency.

2) Do not claim your blog as a model of science then abandon it when an emotive issue arises, we will note that your work is not as scientifically oriented as you claim.

3) Do not claim your advice is kindly meant and then deploy arguments that are really quite snotty. We will question your work's intellectual integrity.

Thank you for your time.