Dr. Robert Sears' "The Vaccine Book" is slim, hugely popular with parents -- and the bane of pediatricians' existence.
Published in 2007, "The Vaccine Book" has sold nearly 180,000 copies and been an Amazon top seller in the parenting section since its debut. Its timing was perfect: For nearly a decade, a small but highly visible army of anti-vaccinationists waged an all-out war to persuade parents that vaccines cause autism -- resulting not only in anxiety but also, thanks to vaccine refusal, the re-emergence of virtually extinct diseases like whooping cough and measles. Amid the polarizing debate, Sears appeared to offer a middle ground. The book's centerpiece is "Dr. Bob's Alternative Schedule,” a vaccine regimen for parents nervous about the traditional timetable to give kids their shots. The schedule departs radically from the one vetted by the CDC and used by physicians, spacing out vaccines over 21 visits, as opposed to the standard 13.
The book has been skewered by the medical community, most notably respected vaccine developer Dr. Paul Offit, who called it a "misrepresentation of vaccine science" that "misinforms parents trying to make the right decision for their children" in the Journal of Pediatrics. And yet, as a pediatrician myself, I have seen an increasing number of caring, reasonable parents hold it up like a bible in my practice (and that of my colleagues).
I initially dismissed the book after reading Offit (and others') criticism, but I wanted to understand its appeal. And I wanted to hear from the author himself, who agreed to answer questions via email. In his book and his responses, I found a physician who is articulate and persuasive -- but whose understanding of vaccines is deeply flawed.
Before I get to that, it's worth understanding why Sears drew crowds to his work in the first place. The surname "Sears" is to pediatric medicine what the surname "Bush" is to politics. Sears' father, Dr. William Sears, is a Harvard-educated and -trained pediatrician who has authored more than 30 books. You've probably seen Sears on TV or read his advice in parenting magazines. Three of Sears' eight kids are physicians. (Bob Sears and his brother Jim practice with their father in affluent Capistrano Beach, California, just north of San Diego. Peter Sears practices family medicine.) And dad's telegenic quality runs in the genes: Jim co-hosts the popular afternoon TV show "The Doctors.” Together, Sears and Sons have built a celebrity brand as "America's Most Trusted Name in Pediatrics." The family even boasts their own line of infant vitamins.
From early in his career, Bob Sears wanted to bring the family brand to bear on the controversial topic of childhood vaccines. It’s clear from our correspondence that Sears long had a sympathetic ear for parents concerned about vaccine safety, though he admits early in his book that he didn't learn much about vaccines in medical school or during his residency. Instead, faced with questions from concerned parents in his private practice, he researched vaccines by reviewing package inserts and studies. Based on his diligence, Sears positions himself as an authority, promising parents "open, honest, complete and accurate information" about childhood immunizations, with the hope that they can then make their own choice.
Paul Offit isn’t convinced that Sears deserves to called a vaccine expert. "Sears has never conducted any original vaccine research or been asked to approve a biological agent," he told me. Offit has done both on numerous occasions. Readers, however, are likely to forgive that shortcoming because Sears provides them with something more critical: a choice. "Vaccination isn't an all-or-nothing decision,” Sears writes. At a time when patients feel anxious about the medical practice, Sears' book gives them something they sorely want -- autonomy.
But it doesn't take long to see the fault lines in "The Vaccine Book," making that choice a false one. Sears uses maddening circular logic in his recommendations. Take the chapter on the MMR vaccine (used against measles, mumps and rubella), where Sears implies that skipping the vaccine is OK because "measles is now extremely rare and in most cases harmless. The chance that a child will catch measles and be one of the rare fatalities is extremely low."
But the near-zero risk of contracting measles, mumps or rubella happened thanks to vaccinations. Before introduction of the MMR in the United States in 1963, measles caused an estimated 4 million cases, with 48,000 hospitalizations and 500 deaths reported annually. Because of mass vaccination, measles were wiped out of the United States in 2000. But in 2008, a large measles outbreak occurred in San Diego, just south of where Sears practices.
I asked Sears about the outbreak, which he seemed to downplay. "Realize," he told me, "that the measles outbreak is nothing new. Every year for the last couple of decades we have had between 50-100 cases of measles each year in the U.S., just like we did in San Diego."
What Sears didn't acknowledge is that Patient Zero in the San Diego outbreak was the child of vaccine refusers who contracted measles on vacation in Switzerland and brought it back home. A recent study by researchers on the role of vaccine refusal in this outbreak was staggering: 839 people were exposed, 11 additional measles cases were reported (all in unvaccinated children); one infant, too young to be vaccinated, had to be hospitalized. At a time when the state of California is in devastating financial straits, it cost San Diego serious health care dollars: $10,376 per case, for a total of $124,517 (and the hospitalized infant's bill was nearly $15,000). Forty-eight children too young to be vaccinated were quarantined for several weeks, meaning parents had to miss work and wages at an average cost of $775 per child.
When I asked Sears about balancing patients' needs against those of society at large, he told me he believes vaccine-averse parents usually aren't persuaded by doctors' appeals to community health. "Most parents are selfish -- not in a negative way, but in a realistic way," he said. I'm inclined to agree with him: That argument has rarely worked for me in the exam room with a vaccine-ambivalent parent. But we can't just ignore public health, telling parents they make their own choice as long as they keep it to themselves.
But that's what Sears does, making the indefensible suggestion that vaccine refusers simply hide in the herd. In advising parents who refuse the MMR, he writes, "I also warn them not to share their fears with their neighbors, because if too many people avoid the MMR, we'll likely see the diseases increase significantly." Does he really think parents won't share their stories about taking their kid to the doctor with others? Sears justified this statement to me with more circular logic. "My purpose for this statement was to discourage people from spreading their own fears about the vaccine … This is very pro-vaccine," he said. And yet, it's the kind of advice that will make another San Diego-like outbreak inevitable.
Sears' arguments crumble further when we turn to his alternative vaccine schedule, which remains the book's biggest sell. He told me he wanted "balance between making sure infants get vaccines in a timely manner without making the parents feel that their babies were getting overloaded with too many shots at once." The word "overloaded" is key, because Sears' advice is based on avoiding ingredients used to keep vaccines safe and effective, especially aluminum, used in small quantities to help stimulate the antibody response and ensure immunity. Without it, many vaccines would be useless. It has received increased scrutiny only because anti-vaccine folks blamed it for causing autism after studies showed their first two biological scapegoats -- the MMR vaccine and another preservative, thimerosal -- do not.
While the notion of injecting a metal like aluminum into a baby isn't appealing to anybody, it has gone on for almost six decades. And it's worth putting that aluminum in context. By 6 months, according to Paul Offit, breastfed babies take some 6,700 micrograms of aluminum. Formula fed babies take almost 40,000 micrograms (116,600 micrograms if they drink soy formula). In that same period of time, the cumulative dose of aluminum from vaccines on the schedule I use to immunize kids in my office is a mere 4,575 micrograms.
Sears justifies his attack on aluminum by exploiting research that has nothing to do with vaccines. He draws on studies in two different groups of patients: premature babies NICUs and adult patients with kidney disease who received regular, prolonged amounts of aluminum in IV nutrition and in dialysis fluid. In both those cases toxic effects are well-established. But Sears' comparison is apples-to-oranges.
What is reassuringly well-established -- after six decades of experience -- is an infant and child's ability to tolerate and metabolize small doses of aluminum in vaccines. But Sears waved away a single study that showed aluminum was safe in vaccines, one which suggested no further study needed be undertaken. "Most researchers will make a conclusion on research findings, but it's unusual to go so far as to say no one else should do research on the matter," he writes. What he doesn't clearly explain is that this single study is a "meta-analysis"-- a "study of studies" -- that draws a conclusion based on the breadth of available evidence. That one study is far more compelling compared to the several unrelated studies Sears exploits to justify his special vaccine schedule.
Sears goes further awry when he addresses the question of whether vaccines cause chronic diseases like arthritis, multiple sclerosis or diabetes. When I asked him about this, he sought to clarify a criticism by Paul Offit that accuses Sears of stating that vaccines cause chronic disease. "I discuss the MYTH (emphasis his) that vaccines are linked to ADHD and other chronic diseases." But Sears doesn't use the word "myth" in his book -- and certainly not in capital letters -- when discussing vaccines and chronic disease at all. Doing so would have helped put the issue to rest. Instead he muddles in the middle ground: "I haven't found any solid research to support the connection [between vaccines and chronic disease]. When I reviewed numerous studies, I did find some that show a possible link between a vaccine and a chronic disease … However, I also found many studies that conclude there isn't enough evidence to prove a link." How is a worried parent supposed to unscramble that?
Sears sent me a list of 14 studies linking vaccines and chronic diseases. But a close examination shows he is on shaky ground. Eight of those 14 "studies" are case reports -- where doctors describe what they see in a patient or group patients who, in these cases, may have had an untoward reaction to a vaccine. They are meant to raise awareness and questions and not to draw conclusions. One study was an opinion piece full of speculation. For the remaining studies that suggested links -- between diabetes and immunizations, for instance -- current studies have put these concerns to rest.
As if all of these shortcomings weren't enough, "The Vaccine Book" is peppered with misleading innuendo and factual errors. "In truth, tetanus is not an infant disease," Sears writes. In fact, neonatal tetanus is one of the most serious forms of tetanus known to us. Another error involves, again, the MMR vaccine. Paul Offit shows that Sears is wrong when, in his book, he writes that the vaccine contains protein derived from human blood. It actually contains protein made in a lab to help keep it stable. When I asked Sears about who was right (and only one of them can be) he waffled.
"We are both right," he wrote. "When the book was published in 2007, this ingredient was used. In 2007 the company changed the process … I didn’t find out about it in time to change the book.” Yet, three years later, Sears has left the passage unchanged and uncorrected. That’s odd given at least one other update to his book, like the one he made in 2009, to point out that the MMR vaccine is no longer available as three separate injections.
In his chapter on the Hepatitis B vaccine, Sears conducts sloppy arithmetic to punch holes in the reason we want babies vaccinated against this disease (best explained here). But perhaps the most chilling example of the way Sears misleads parents is his coy mention of children taken away from home after their parents refuse to immunize them.
When I asked Sears about this, he began defensively. "Allow me to quote from page 218. 'I've heard rumors that state child protective services take children away … I find that hard to believe.' In my opinion, I am stating that this has not happened. That it is only rumor," he wrote.
In his opinion? It either has or has not happened. Why didn't Sears do more research to find out? But the passage on page 218 is not as simple as he suggests. Here it is in its unedited form. (Sears is referring to two states: Mississippi and West Virginia.)
"I've heard rumors that state child protective services take children away from parents if they don't immunize. I find it hard to believe, but if you live in one of these two states and don't want to vaccinate, it might be time to move (or hide for a really long time)."
His advice borders on something Orwellian.
It's hard to point out just how many times Sears uses the same tactics: soft science, circular logic, reporting rumors and outright falsehoods. Paul Offit is quite convinced that Bob Sears has written nothing more than an anti-vaccine book blanketed in a soft, sympathetic and homespun style.
Sears insists otherwise. "Probably the harshest critics have come from [the anti-vaccine] crowd for not joining their side," he told me. On the other hand, it's worth noting that Sears has been what's known as a "DAN! Doctor" for almost 10 years. DAN! stands for "Defeat Autism Now!," an autism advocacy group with strong anti-vaccine views and one that "certifies" doctors to use therapies that treat autistic children as if vaccines poisoned them. And if the anti-vaccine movement hasn't embraced Sears, it's hard to believe otherwise when you look at this picture of Sears arm in arm with the leader of the modern anti-vaccine movement, Andrew Wakefield, at a conference of anti-vaccine types. Recently, Sears appeared on Fox News to answer questions about vaccines, which was really just an opportunity to promote his book and vaccine schedule. Early in the interview, he referred to "my colleagues at Safe Minds," another autism advocacy group with strong anti-vaccine prejudices. Finally, Sears himself blogs about vaccines at -- well, where else but that asylum for junk science: the Huffington Post.
If there is one thing Sears gets right, it is the fact that doctors need more education about vaccine science from the get-go. Parents do feel lost in the confusion and hysteria, and they are right to demand more information and reassurance from their children's doctors. To that end, Paul Offit has created a curriculum for medical students at the University of Pennsylvania to set the facts straight.
It's safe to say Sears could learn something from it.