In this debunk of Chapter 8, we talk about how the book authors feel the need to distort the history of public health in order to show their point. I help you undistort their assertions.

1. The actual claims of Thomas McKeown – he was an Irish physician who worked in many areas, but his core thought in the world of public health is that the decrease in mortality due to infectious diseases is primarily due to improved sanitation, better food quality regulation, and better food supply (along with broad improvements in economic and social conditions). He believes that vaccinations only played a minor issue. In order to make this proposition, one has to make multiple logical mistakes.

Firstly, it is true that mortality of each of the major vaccine preventable diseases started declining before the major vaccines were made available. The isolated point that vaccines cannot improve mortality before they existed, is in fact true – vaccines back in the olden days could not time travel, just in the same way that COVID vaccines cannot time travel. In order to dismiss the role of vaccinations, one has to dismiss the role they played in morbidity – which is actually clearly delineated in the original McKeown book (that the Turtles authors either didn’t read or chose to willingly hide). A common antivax strategy used is to display only the mortality charts used in the book and refrain from discussing morbidity – on this point I can give the Turtles authors a bit of credit from refraining from using this antivax logical fallacy.

Next, the decrease in mortality does not compete with the need to decrease morbidity from these diseases. Specifically, newborn infections with hepatitis B still leads to chronic, lifelong hepatitis B infections, and potentially liver cancer, in modern, real infants, who are unvaccinated due to the choices of their parents. Hepatitis B carries no cure at current – and it is well worth the newborn’s time and effort to give him/ her essentially decades-long or lifelong protection against hepatitis B. Some congenital infections like Rubella, can create hearing loss and blindness in affected babies – both of which are impossible to cure (they can only be mitigated somewhat by vision aids and hearing aids). That infants are not dying in large numbers anymore from vaccine preventable diseases is excellent, but this does not give us a free pass to stop helping improve morbidity. McKeown shares similar views about tuberculosis, but recall that there is a vaccine against tuberculosis and an effective antibiotic regimen against tuberculosis (I acknowledge the existence of tuberculosis antibiotic resistance but that problem in itself requires entire graduate school programs to discuss thoughtfully). They too, are not in competition with one another. In vaccine preventable disease, small numbers of morbidity and mortality are not sufficient, alone, to stop trying to make things better.

Next, with modern infections, while physicians would always advocate for a complete intake of all the essential vitamins and minerals, no physician would advocate for vitamins and minerals as the agent responsible for curing bacterial or fungal infections – this has been below standard of care for a long time, as we have antibiotics now. Next, if you review McKeown’s original analysis, he combines what we would now understand as multiple variables, under the analysis of “standard of living”. This could mean cleaner streets, horses no longer pooing on the cobblestone, fresh peppers, boiled water, and many other things. Such a practice would be recognizeable to a modern epidemiologist as not effectively treating confounding variables. The main thrust of his argument was reasonable, in that he praised better economic and social conditions – but due to the non-exhaustive list of reasons above, the core argument does not logically end in “stop the vaccinations” as the Turtles authors think it should. Remember, for the Turtles authors, no other answer other than “vaccines are unsafe” is acceptable. This is not a rational viewpoint for a scientist to take – even the editor, Mary Holland, preaches to be ready to overturn a paradigm (but not when it is her paradigm evidently).

2. Misquoting the conclusions from an article by Guyer – For this part of the chapter, they focus on another author who wrote a sentence saying that vaccines cannot take full credit for the decrease in morbidity and mortality from the 1700s-1900s. They then take this to mean that vaccines weren’t important. The previous two sentences convey different information. While it is true that Guyer said the sentence, in order to arrive at this conclusion, the authors of the book need to actually misquote the entire conclusions of the article they quoted – which for the reader’s reference is below.

“For this article, we have selected a number of major indicators that have been available for most of the century. In particular, we focus our attention on measures of the health of children and women of reproductive age. The findings point to the challenges that lie ahead in the 21st century.”

Proficient scientists shouldn’t need to misquote and distort isolated sentences to prove their point.

3. Most of the major infectious diseases of the 19th century are no longer considered significant public health threats, and vaccines played a prominent role in reducing morbidity for some of them – In a general sense, the first part is true; the second part of the sentence is definitely not true. For each of the vaccine preventable diseases, the morbidity was decreased by vaccines. Although the mortality had fallen significantly, the mortality was decreased even further by vaccines. It is great that we do not have to deal with outbreaks of vaccine preventable disease on the same scale as we used to 300 years ago. This does not mean on its own, that the major vaccine preventable diseases are eradicated (only smallpox is). Public health agencies are constantly on the lookout for new infectious diseases and outbreaks of well known vaccine preventable disease so that they can help control the breakouts. It would not be accurate to consider these diseases “no longer significant public health threats”, as when the outbreaks happen, people get hurt or die. As a reminder, Robert Kennedy Jr directly contributed to a measles outbreak in Samoa.

4. Other diseases, for which no effective medical preventive or intervention was developed, have also been largely eradicated: malaria and syphilis morbidity decreased significantly from the late 1940s onwards – this is code for a frequently used antivaxxer strategy, the hygiene hypothesis. This is essentially saying the same things as points 1-3, that hygiene is responsible for the decrease in morbidity and mortality of most infectious diseases. Again, one has to make several logical mistakes to subscribe to this hypothesis. On syphilis – it is common to initially have no symptoms, and not seek out treatment until the disease has done some damage to the body. Malaria is still a major issue in regions that have mosquitos that carry malaria, despite the advent of better hygiene (of course some countries with limited economic means still struggle in the economic and social arenas). Malaria has only carried a cure in the age of modern antibiotics – something hygiene was not able to accomplish by itself. Also – malaria has recently expanded its reach to first world countries. Finally, malaria now has an active vaccine called Mosquirix that is being rolled out.

5. Scurvy and pellagra, lesser-known historical diseases caused by nutritional deficiencies, were almost completely eliminated in the first half of the 20th century
Again, the importance of a balanced diet is not in competition with the importance of the major childhood vaccines and their protection against vaccine preventable disease. Vitamin deficiency can be prevented by vitamin replacement, and vaccine preventable diseases can be mitigated or prevented by vaccines.

6. To their credit, vaccines were also responsible for a considerable decline in morbidity of some of the milder diseases (mumps, rubella).
Appreciate one of the few times the authors actually praise vaccines. However, they manage to downplay some of the serious health consequences of measles and rubella, which may include subacute sclerosing encephalitis (an irreversible brain damage leading to death) and congenital blindness/ deafness (for rubella).

7. Rise of chronic disease… public health officials prefer to keep underscoring the threat posed by diseases of the past, while concealing the immense damage inflicted by those of the present and future. Two of their biggest contentions in this chapter are the rise of asthma and allergy. While most physicians would agree that we would love not to have so much asthma and allergy, it would be better to reach for people who actually study these topics to learn where they are coming from.

First off, an increase in diagnosis is not purely a bad thing – identifying more children who are having medical problems allows them to get help for those problems. Next, even a simple 1 minute Google search reveals that all national public health agencies (not just the United States CDC) has a large variety of public health campaigns on various issues that are not related to infectious disease. For example the CDC alone has ideas on how to mitigate the affects of gun violence, car accidents, drunk driving, and pollution. This is a big logical hole in the assertion above.

Next, a public health agency campaign does not conflict with the campaign to vaccinate against a vaccine preventable disease. One is perfectly capable of doing both. One of the biggest contributors (but not the only contributor) to obesity in the United States is the increasing consumption of highly refined and processed foods/ simple carbohydrates. Telling patients to make the change is theoretically easy, but practically speaking, it is hard. One has to change habits, make sure the environment is supportive of the change, make sure the family can afford it, and make sure it is sustainable (a nonexhaustive list of the social determinants of health). Physicians try to do the counseling all the time, but sometimes if a corner bodega doesn’t have a lot of fresh food and vegetables, the family can’t do it. The chapter is curiously silent on this issue (but any physician who has attempted to wrangle with these issues can explain it in detail).

Let’s move on to asthma and allergy. This particular university group, did the necessary basic science work to show one of the reasons why some patients with asthma don’t respond well to medication. This group found a molecule, that when blocked, was able to return asthmatic mice to baseline mice without asthma. Other groups are focusing on the genetic and immunologic causes of this very complex disease. This group found a potential way to block life threatening peanut allergy in a mouse model, rather than treating it with epinephrine (the current standard of care) after the allergic reaction already started. This represents the vast difference between writing a book criticizing vaccines, and doing the actual research that may alleviate eventual patient suffering. The act of having better diagnostic techniques and bring more patients to care is not in itself a harm – more patients are getting the opportunity to have less suffering. By the way, there is no relationship between vaccines and allergy – this has been looked at from multiple perspectives.

8. Drugs for chronic conditions, especially due to their routine and long-term use, usually come with their own side effects, which have the potential to create new health problems that may require even more medications and treatments
No medical professional denies that. This is why a big part of medical school is devoted to both the benefit and side effects of modern medication. Medical students spend a lot of time learning about drug-drug interactions, and are encouraged to collaborate with pharmacists on this exact issue. Medical professionals spend a lot of time training on polypharmacy and how to avoid it. Some health problems do not yet have cures, and despite the antivax ecosystem’s exhortations that there is a conspiracy to prevent a cure, there is no cure because in certain instances science has not advanced far enough to figure it out. For example, we only recently in the last few years figured out that the Ebstein-Barr virus is causative of a large portion of multiple sclerosis. This development was welcomed by the world of neurology, but it took this long not because of a lack of trying, but that the granular details of the science were difficult. Some very common conditions like high blood pressures, sometimes need both lifetyle modification and medication. Despite the best efforts of an adult with a blood pressure of 150/100, that adult might still need medication to prolong both quality and quantity of life. There are black-and-white risks to letting high blood pressure go untreated – there is no shame in needing blood pressure medications (nor is there a conspiracy to hide a permanent cure). If cardiologists had an overall cure that could fix hypertension in everyone, they would give it out. Physicians are also quite capable of finding blood pressure medication side effects, and changing course if needed. Diet and lifestyle change may work in many people – and for this reason, a physician will still counsel to improve lifestyle choices. For those who don’t get relief from high blood pressure with lifestyle change alone (which is a lot of people), medical care is available. A discussion on how to cut down on total medicines taken is always welcome in a physician office – it just may take some time.

Overall, this chapter engages in misquoting, conflating public health vaccine initiatives with other types of initiatives, and distortion of the history of public health. A proficient scientist should not need to engage in misquoting to show their point. A public health agency is more than capable of conducting one initiative at a time. There aren’t physician groups attempting to hide the side effects of medications – if the reader believes hiding is going on, then just ask for a separate comprehensive discussion on side effects during the office visit or another visit. Lastly, all the logical fallacies committed by the authors in describing historical public health initiatives can be revealed… by simply reading about what actually happened in the first vaccine initiatives.