Per-Hour Learning Potential / Utility: ★★★★★★ (6/7)
Readability: ★★★★★ (5/7)
Challenge Level: 2/5 (Easy) | 214 pages ex-notes (304 official)
Blurb/Description: Dr. Paul Offit, a pediatrician specializing in infectious diseases and the co-inventor of a rotavirus vaccine, explores the science on vaccines and the psychological phenomena that lead well-intentioned parents to make the brutally misguided – and profoundly dangerous – decision to delay, or skip, their kids’ vaccinations.
Summary: Cults and conspiracy theories are rich ground for understanding human psychology. Fortunately, they usually stay pretty self-contained and harmless: if you want to believe that the government is hiding UFOs in Area 51, knock yourself out. It may even make for an amusing conversation (for a few minutes, after which I’ll lose cell connection because I’m going through a tunnel, on an airplane, and my battery’s dying).
But the anti-vaccine conspiracy theory is different: it’s one with real health consequences, not just for kids too young to protect themselves from their parents’ empirically indefensible decisions, but also for immunocompromised kids (some with leukemia, for example) who can’t be vaccinated and thus rely on herd immunity to protect them from deadly diseases. Then, of course, there’s the small percentage of kids (and adults) who – despite being properly vaccinated – will still contract communicable diseases from unvaccinated vectors (as vaccines provide strong, but not always impenetrable, protection.)
This book is thus of practical interest to me from a public-health perspective, as well as from a psychology perspective: how can one of the safest, cheapest, most effective medical interventions in human history face such absurdly irrational resistance from small pockets of the population – often pockets that are highly educated and should know better?
Dr. Paul Offit answers that question, confirming the salience x n-order impacts hypothesis I’d come up with after reading “Polio: An American Story” (PaaS review + notes) and “The Vaccine Race” (TVR review + notes). As I discuss in depth in the salience mental model, in the absence of kids dropping dead every day from terrifying diseases, it’s easy for people to view diseases as “not a big problem,” and follow a chain of flawed logic from there that leads to them not vaccinating their kids.
(Public service announcement: if you’re in your teens/20s, or if you’re older and have kids, make sure you or your child gets at least two doses of the HPV vaccine, because it provides meaningful benefits. It wasn’t a standard part of the immunization schedule when I was growing up, so I got my doctor to write me a prescription.)
Highlights: Before we even get to the mental models learning, there’s a hugely important practical public-health tip from this book: don’t take your young kids (infants/toddlers) to a pediatrician who accepts unvaccinated children as patients. It’s an unnecessary risk factor that you can easily avoid. (Also: don’t take your kids to daycares that accept unvaccinated kids.)
As Offit explains, many pediatricians refuse to cater to parents who won’t vaccinate their kids properly. These pediatricians have a good reason: their waiting rooms can become disease transmission vectors, with older (unvaccinated) kids harboring diseases that younger (can’t-yet-be-vaccinated) kids can contract and suffer greatly or die from.
This is not a theoretical concern, but a real one: there are documented cases of kids dying of diseases they haven’t been vaccinated against yet, because usually well-intentioned but profoundly deluded anti-vaxxer parents are so prevalent in some areas (such as one wealthy suburb of Seattle) that herd immunity has been compromised. I’m a long way away from having kids, but this is clearly a “dealbreaker” question for any potential pediatrician when I’m in the market for one.
Anyway, beyond that, Offit does a great job of using scientific thinking and disaggregation, presenting the data and reviewing the safety record of vaccines, noting the rare instances where they did cause real negative effects – which aren’t the ones anti-vaxxers talk about – and how quickly those cases were dealt with, and how the review process works today.
Lowlights: I’d like to make it clear that, as always, I’m reviewing/rating this book from a mental-models-learning perspective. As a public health book, this is A+ and tremendously important, but also (other than the above tip about pediatricians) probably an issue of self-selection where you won’t learn anything you don’t already know.
That is, anyone who isn’t vaccinating their kids probably isn’t going to be convinced by the rigorous science and thoughtful analysis presented in this book (indeed, Offit has received death threats from anti-vaxxers, and apparently has to have his mail screened.)
And on the other hand, the vast majority of us, at least the type of people who are interested inmental models, already understand that vaccines are awesome and indispensable, and don’t needthis book to tell us that.
So the learning comes down to the psychological angle, and in that sense Deadly Choices has a somewhat narrower scope than, say, David Oshinsky’s “ Polio: An American Story” ( PAAS review + notes – my favorite science-history book of all time), which touches on many of the same mental models but also provides terrific broader context with a similar amount of time investment to read.
While Deadly Choices is a fantastic exploration of scientific thinking and disaggregation, contrasted with the anti-vaxxers’ psychological mechanisms and faulty thought processes, like salience, storytelling, ideology, and misunderstanding of probabilistic thinking / control groups / correlation vs. causation, it doesn’t delve into the vaccine origin story the way Polio or Meredith Wadman’s “The Vaccine Race” (TVR review + notes) does.
Additionally, some of the writing (though not most of it) is a bit dry, and parts of the book (such as Offit’s thorough dismantling of every argument and every anti-vaccine source) start to seem repetitive and intuitive: every time, it basically boils down to the same idea.
Mental Model / ART Thinking Points: salience, priors, intellectual humility, dose-dependency,storytelling, sample size, n-order impacts, local vs. global optimization, multicausality, a/b tests,correlation vs causation, margin of safety, incentives, activation energy, probabilistic thinking,desire bias
You should buy a copy of Deadly Choices: How The Anti-Vaccine Movement Threatens Us All if: you’re interested in the topic of vaccines or public health, and want a good scientific analysis that step-by-step deconstructs the science behind vaccines and the psychology behind anti-vaccine conspiracy theories.
Reading Tips: This isn’t a book you need to read page for page. For example, the “Past is Prologue” chapter, about early public response to vaccines in England, wasn’t very interesting to me. Additionally, the thorough deconstruction of anti-vaxxer sources – while well-researched – wears on after a while (yes, they’re all kooks, we know that.) Skim these parts of the book and focus more on the parts discussing the science and the psychological mechanisms.
“Polio: An American Story” by David Oshinsky (PaaS review + notes). This is a wonderful pairing, particularly if you read Polio (my favorite science book) first – you get to compare/contrast salience across eras through the fascinating lens of vaccines.
Reread Value: 2/5 (Low)
More Detailed Notes + Analysis (SPOILERS BELOW):
IMPORTANT: the below commentary DOES NOT SUBSTITUTE for READING THE BOOK. Full stop. This commentary is NOT a comprehensive summary of the lessons of the book, or intended to be comprehensive. It was primarily created for my own personal reference.
Much of the below will be utterly incomprehensible if you have not read the book, or if you do not have the book on hand to reference. Even if it was comprehensive, you would be depriving yourself of the vast majority of the learning opportunity by only reading the “Cliff Notes.” Do so at your own peril.
I provide these notes and analysis for five use cases. First, they may help you decide which books you should put on your shelf, based on a quick review of some of the ideas discussed.
Second, as I discuss in the memory mental model, time-delayed re-encoding strengthens memory, and notes can also serve as a “cue” to enhance recall. However, taking notes is a time consuming process that many busy students and professionals opt out of, so hopefully these notes can serve as a starting point to which you can append your own thoughts, marginalia, insights, etc.
Third, perhaps most importantly of all, I contextualize authors’ points with points from other books that either serve to strengthen, or weaken, the arguments made. I also point out how specific examples tie in to specific mental models, which you are encouraged to read, thereby enriching your understanding and accelerating your learning. Combining two and three, I recommend that you read these notes while the book’s still fresh in your mind – after a few days, perhaps.
Fourth, they will hopefully serve as a “discovery mechanism” for further related reading.
Fifth and finally, they will hopefully serve as an index for you to return to at a future point in time, to identify sections of the book worth rereading to help you better address current challenges and opportunities in your life – or to reinterpret and reimagine elements of the book in a light you didn’t see previously because you weren’t familiar with all the other models or books discussed in the third use case.
Page ix: Offit identifies the same salience issue as Wadman re: adenovirus in “The Vaccine Race” (TVR review + notes). Offit notes on the very first page, discussing the biggest measles epidemic in twenty years:
“The reason these children were unimmunized was that their parents had chosen not to immunize them. And the reason they’d made that choice was that they no longer feared the disease.
But they should have feared it. Because before the measles vaccine was first introduced in the United States, every year about three to four million children would catch measles, forty-eight thousand would be hospitalized, and five hundred would die.”
Page x: Offit here mentions the HPV vaccine, which is shamefully underselected (see my public service announcement).
In some tony parts of LA, immunization rates are similar to Chad and South Sudan; Offit also notes that in some states, more than 5 percent of parents opted out of vaccinations, which puts us at risk of highly contagious diseases (we’ll get into this).
But let’s face it – no one actually forms their beliefs this way. If an experiment […] slowed the growth of […] cancer […] by putting patients inside a plastic replica of Stonehenge, would you grudgingly accept that [vibrational earth energy was curative?]
You would not, because that’s nutty. You’d think Stonehenge probably got lucky.
You have different priors about those two theories, and as a result you interpret the evidence differently, despite it being numerically the same.”
Offit essentially makes a similar point about vaccines:
“[Seth] Mnookin argued that the anti-vaccine movement’s desire to have a seat at the table in discussions about vaccines is analogous to the Ku Klux Klan wanting to have a seat at the table in discussions about race relations.”
Page xvi: The real victims here are kids who risk death and disease because of their parents’ (usually well-intentioned) ignorance.
Pages xvii – xviii: In the interest of salience and stories being more impactful than statistics, Offit brings up the example of a mother whose son died of Hib (Haemophilus influenzae):
“Honestly, I never really understood how severe the risk [was] that we put our son at.”
Offit notes that:
“Before the vaccine, Hib caused meningitis, bloodstream infections, and pneumonia in twenty thousand children every year, killing a thousand and leaving many with permanent brain damage.”
Page xx – xxi: Measles is alarmingly infectious… also, 89% of vaccinated people exposed to a carrier (in a 35-person sample) were infected, while only 3 of the 465 vaccinated (0.6%) were infected.
One of the challenges that Offit here notes are n-order impacts: doctors of the current generation have really never had experience with (and probably much training on) Hib, measles, etc, because, you know, the vaccine fixed ‘em.
Now that they’re back, thanks to anti-vaxxers, doctors don’t know how to deal with them, and in some cases (not their fault) don’t take appropriate precautions to prevent others from being infected.
Pages xxii – xxiii: Why is this a public health issue and not a personal liberty issue? Externalities (a subset of local vs. global optimization). Offit notes that:
“for highly contagious infections – such as measles or pertussis – the immunization rate needs to be about 95 percent [to achieve herd immunity].”
To this point, see also research cited by Dr. Matthew Walker in “ Why We Sleep” (Sleep review + notes) on sleep’s modulation of antibody response to the flu vaccine… the takeaway: make sure kids get a good night of sleep before immunizations. (No sleepovers!)
Page xxiv: Offit overviews some of the various diseases that vaccines have eliminated. Again, see David Oshinsky’s “ Polio: An American Story” ( PaaS review + notes) and Meredith Wadman’s “ The Vaccine Race” ( TVR review + notes), both of which are wonderful (especially Polio.)
Pages 3 – 5: The start of the anti-vaxxer movement was “DPT: Vaccine Roulette.” These pages are a great example of salience.
Page 8: Barbara Loe Fisher becomes a key player…
Page 10: Paula Hawkins, a Republican senator from Florida, who chaired a congressional hearing in response to the documentary (seemingly to reassure public confidence):
“It would be tragic if efforts to eliminate or control communicable disease were to become hampered because the public’s confidence was so eroded as to cause frightened segments of the population to oppose and reject vaccines.
Neither can we afford revival of serious childhood epidemics because a complacent and apathetic public, with a diminishing memory, forgets the iron lung.”
Unfortunately, that’s what happened…
Pages 11 – 12: At this time, it was assumed by physicians that the “P” component in the DTP vaccine did, in fact, have a small risk. (We later find out this wasn’t the case.)
Pages 14 – 16: More on the power of salience: similar TV programs in Britain had previously caused immunization rates to drop from 79% to 31% in a year (presumably not among the whole population, as that would be nonsensical, but among children who were slated to get the vaccine.)
What happened? 100K kids got whooping cough; 36 died.
Page 17: Also an interesting bit here about selection bias: statistics on pertussis deaths were likely underreported because, per Dr. James Cherry:
“[Doctors] didn’t want [parents or themselves] to have guilt[y] feelings. So they were reporting [pertussis deaths] as other things.”
Desire bias here too.
Pages 19 – 22: N-order impacts: successful vaccine lawsuits led to the cost of one dose of DTP vaccine increasing from $0.12 to $4.29 in less than three years. Companies also started dropping out of the market.
Lederle (remember them from “The Vaccine Race” – TVR review + notes) basically threatened to stop producing the vaccine (they were the only one left) after being sued, successfully, for something that had nothing to do with their vaccine.
In response, the government established the National Childhood Vaccine Injury Act, which included the Vaccine Injury Compensation Program. Counterintuitively, this saved the vaccine makers…
Pages 22 – 23: the act also created a reporting system – VAERS
Pages 27 – 29: was the Pertussis vaccine safe? Some studies found surprising results.
Offit starts to examine the causality and finds the mechanisms were suspect: the mechanism by which the vaccines could’ve caused brain damage would’ve caused other symptoms that were not seen in the affected kids. Nor did large sample size epidemiological studies find any impact.
Page 30: Natural experiments – a/b tests – are cool. Offit notes that one such experiment in Denmark, due to a shift in the vaccine schedule, saw no change in seizure onsets related to the pertussis vaccine.
“Analysis of the recent literature, however, does not support the existence of [a pertussis-caused encephelopathy] syndrome, and suggests that neurological events after immunization are chance temporal associates.”
Or, in other words, post hoc ergo propter hoc
Page 32: They did find that there are elevated risks of seizures post DTP, but no long-term adverse consequences.
Pages 37 – 39: Justice Stuart-Smith ruling on the Miller study: he quotes Samuel Johnson:
“It is incident I am afraid, in physicians above all men, to mistakes subsequences for consequences.”
It seems that there was inappropriate margin of safety here: Offit notes that Miller:
“didn’t want to appear to have whitewashed the issue,”
which led to – “if there is doubt, code the worst picture” being in the instructions. So many of the cases that appeared to be present were, in fact, not.
Page 42: Another scientist, Samuel Berkovic, notes in a paper that many of the children had a defect in the SCN1A protein that would cause seizures and mental retardation regardless of the vaccine.
Pages 46 – 47: Lea Thompson got basic facts wrong in Vaccine Roulette, like the prevalence of whooping cough.
Pages 48 – 51: Her sources were wildly uncredible as well in addition to bashing vaccines, they expressed other incoherent, credulity-straining beliefs like, in the case of Gordon Stewart,
“AIDS was caused by the gay lifestyle, not HIV […] HIV [didn’t] cause immune deficiency… sperm in the rectum did.”
Okay, sure, right. </sarcasm>
Pages 54 – 55: Offit here very briefly reviews the FDR, the March of Dimes, Jonas Salk, and the Cutter incident. Again, see Oshinsky’s “Polio: An American Story” (PaaS review + notes) and Meredith Wadman’s “The Vaccine Race” (TVR review + notes).
Pages 57 – 59: Offit here does note some of the historical side effects of some vaccines, including the Sabin polio vaccine, as well as gelatin’s potential for allergic reactions (as well as that of egg proteins). He notes these would have been reasonable consumer-safety targets for Barbara Loe Fisher, but she went a different direction, fighting against good vaccines like Hib.
Epiglottitis is a thing I did not know about and it is terrifying. Hib can infect the epiglottis, cause it to swell, and basically suffocate the kid like a pillow…
Pages 62 – 65: Fisher then went after Hep B…
Page 71: Fisher tried to block the pneumococcal vaccine, which has saved lives…
Pages 72 – 73: Offit notes that when there’s actually a problem with a vaccine – as there was with the rotavirus vaccine – it’s responded to. The CDC, via VAERS, discovered this problem, and pulled the vaccine. (Note that Offit himself later co-developed another rotavirus vaccine.)
Page 76: Worth calling out, because it’s a surprisingly prevalent view, expressed by at least two reasonably intelligent people I know:
Here, Barbara Loe Fisher is quoted as hankering for the good-ole Mayberry days:
“We have gotten into a mindset where there is an abject fear of disease. In the ‘50s, everyone had measles and mumps, and there wasn’t this drama attached.”
Yes, and hundreds of thousands of people were hospitalized every year, with hundreds of deaths.
Offit also does a great job here of exploring herd immunity: for example, with the flu vaccine, while it’s true that someone young and in good health is unlikely to suffer severely (though it’s not impossible), it’s totally possible to be a carrier and pass it along to an elderly or immunocompromised person – who subsequently dies. We’ll see that this applies later to some kids who can’t get vaccinated thanks to conditions like leukemia.
Offit notes that it’s safer to be unvaccinated living in a fully vaccinated community than it is to be fully vaccinated living in an unvaccinated community.
Pages 77 – 81: Offit points out John Salamone as an example of a thoughtful vaccine safety advocate; Salamone helped shift the U.S. from the Sabin vaccine (which has a small risk of causing polio) to the currently-used Salk vaccine (which does not).
Page 91: Myelination sighting!
Page 92: Andrew Wakefield pops up here… his fraudulent paper caused a lot of parents to forego the MMR vaccine.
Note that the sample size was tiny – only eight kids with autism – een if the paper hadn’t been fraudulent, that’s a red flag…
Page 96: Offit notes, in response to conspiracy theories, that plenty of scientists not named Wakefield published papers demonstrating the negative safety effects of vaccines and weren’t forced into hiding – because their papers were not fraudulent, and highlighted real problems.
Thimerosal doesn’t cause autism; rates have continued to climb even after thimerosal was removed from vaccines.
Pages 98 – 99: From a court decision on MMR:
“To conclude that Colten’s condition was the result of his MMR vaccine, an objective observer would have to emulate Lewis Carroll’s White Queen and be able to believe six impossible, or at least highly improbable, things before breakfast.”
Pages 102 – 103: on incentives: there was money to be made from peddling the MMR-causes-autism lie… which is ironic, because that’s what the anti-vaxxers always accuse the scientists/drug companies of, despite the fact that vaccines are not a particularly big moneymaker.
Pages 106 – 107: Nice scale comparison:
“Smallpox killed more people than the Black Death and all the wars of the twentieth century combined.”
Also a nice brief overview of the invention of the smallpox vaccine.
Page 118: On why chiropractic has no causal mechanism…
“it was a miracle – a miracle that would have made infinitely more sense if the cochlear nerve … actually passed through the neck.”
Page 119: Offit has a book on alternative medicine, too.
Pages 120 – 121: Again, the basic logic here is excellent:
“The notion that a single viral protein could [cause strokes, blood clots, heart attacks, paralysis, seizures, and chronic fatigue syndrome] when the whole natural replicating virus can’t do any of this was illogical.”
This book is a clinic in disaggregation.
Page 128: incentives again
Page 130: Why did SCOTUS rule that the right to refuse vaccination wasn’t guaranteed by the Constitution? Externalities, basically. Social contract theory.
Pages 131 – 133: The story of Typhoid Mary!
Page 138: Another wonderful natural experiment / a/b test: an outbreak in Texarkana was 96/4 weighted to TX vs. Arkansas; the latter required vaccinations for school entry.
Pages 139 – 140: Again on externalities:
“The right to practice religion freely does not include liberty to expose the community or the child to communicable disease or the latter to ill health or death.”
Prince v. Massachusetts
Pages 141 – 142: if you thought “pray the gay away” was bad, now introducing: pray the smallpox away!!! (In case you were wondering, they are both equally ineffective.)
And here’s a wonderful example of internal inconsistency: one couple didn’t want to vaccinate their child because it “represented an unwanted intrusion into the body” – but the court pointed out, sensibly, that Sherr “had circumcised his son and allowed dentists to fill his son’s cavities.” Awkward.
Page 143: A great example of activation energy:
“Children in states with easy-to-obtain [vaccine] exemptions (granted by the simple signing of a form) were almost twice as likely to suffer outbreaks of whooping cough.”
Pages 144 – 147!: Offit does a great job of explaining externalities here, building on Garrett Hardin’s 1968 paper, “The Tragedy of the Commons.”
There’s also an awesome example of salience here, as well as the very real cost of the anti-vaxxer movement: Offit cites Stephanie Tatel’s article “My son has cancer. He can’t go into daycare because of unvaccinated children.”
Offit notes that:
“like Stephanie Tatel’s son, hundreds of thousands of people in the United States cannot be vaccinated, forced to depend on those around them to be protected.”
Pages 150 – 152: Jenny McCarthy… after Googling and Wikipedia-ing, I still have no clue what an “indigo” adult or “crystal child” is. It sounds like the sort of hippie nonsense that Dan Harris is allergic to. (“ 10% Happier” – 10H review + notes.)
And in another wonderful example of what Thaler might call “dynamic inconsistency” (not really, I just like to name-drop Thaler):
“McCarthy later undercut her stop-injecting-toxins-into-our-bodies message by saying, “I love Botox. I absolutely love it.””
Botox – botulinum toxin – as Offit points out, is one of the most powerful toxins known to man… I truly have difficult deciding whether this or the circumcision-and-cavities bit is more amusing.
Page 153: again on incentives: Offit points out that supplements, with unproven (often disproven) health benefits, are an $80B/yr industry; vaccines (with benefits proven beyond all reasonable doubt) are a $17B/yr industry.
Pages 155 – 157: more irrationality. I actually watched this on Youtube before the book mentioned it.
Pages 160 – 161: Offit actually cites a paper on the economics of vaccines by Patricia Danzon of Wharton. I didn’t read all of it (skimmed) but kinda interesting.
“would be, of course, an entirely unethical experiment. No investigator could prospectively study children who are denied a potentially lifesaving medical product. And no university’s or hospital’s institutional review board worth its salt would ever approve such a study.”
Page 164: Shingles sounds scary.
Page 167: PSA: get your flu vaccine.
Pages 173 – 174: Again, Offit’s great at disaggregation:
“It’s not the number of vaccines that counts; it’s the number of immunological components contained in vaccines […]
the total number of immunological components in today’s fourteen vaccines is about a hundred and sixty, fewer than the two hundred components in the only vaccine given more than a hundred years ago […]
arguably, a single infection with a common cold virus poses a much greater immunological challenge than all current vaccines combined […]
babies could theoretically respond to about a hundred thousand vaccines at one time […] the notion… shouldn’t be surprising. In a sense, babies are doing that every day.”
Page 176: Why is it important not to make up your own vaccine schedule? Because maternal antibodies fade over time, and many dangerous diseases appear in the first year of life.
“Vaccines against Hib, pneumococcus, and pertussis are given at two, four, and six months of age so that when the mother’s antibodies wear off, children will have acquired their own protective immunity.”
Pages 177 – 178: Offit here on dose-dependency (as it relates to aluminum.) The aluminum in all childhood vaccines = 4 mg; babies will have ingested 10 – 120 mg of aluminum by six months of age.)
Similar arguments are made for formaldehyde.
Page 181: Offitt notes that vaccines go through more testing than drugs.
Page 187: again… stick to the schedule
Page 197: incentives: threatening to fire healthcare providers at the Children’s Hospital of Philadelphia if they didn’t get their flu shot increased immunization rates from 35% in 2000 to 99.9% in 2010
Page 203: on conspiracy theories…
Page 205: … and the heroes who create vaccines.
Page 209 – 214: don’t take your kids to pediatricians who accept unvaccinated kids. Just don’t do it…
First Read: summer 2018
Last Read: summer 2018
Number of Times Read: 1
Planning to Read Again?: maybe
Review Date: summer 2018
Notes Date: summer 2018